Associate feature: Giving high blood pressure the attention it deserves

High blood pressure is a huge problem for the health of the nation, affecting 1.3 million people in Scotland – around 30 per cent of all adults and 40 per cent of over-65s – but despite the serious and potentially life-threatening health effects, it’s one that has not had as much attention as many others.

“I suppose it’s been a bit of a Cinderella condition because directly people don’t actually suffer from it,” Professor Brian McKinstry, Professor of Primary Care eHealth at the University of Edinburgh, tells Holyrood.

“There’s no symptoms of high blood pressure as such, it’s just consequences of being untreated.

“So you’re not really getting the sort of people who are marching for breast cancer or prostate cancer, these sort of things that really, really excite people. It’s not really happening with blood pressure.

“And I think maybe that’s why it’s not had the sort of attention it should have had over the years – despite being extremely important.”

High blood pressure is one of the biggest preventable causes of heart attack, stroke, peripheral vascular disease and renal failure, but most people with high blood pressure have no symptoms at all and it is found by chance.

A blood pressure monitor - Image credit: British Heart Foundation

However, a cross-party group in the Scottish Parliament is aiming to push the issue higher up the health agenda. Last week, the parliament’s Cross-Party Group on Heart Disease and Stroke published its report, ‘Beating High Blood Pressure: Scotland’s Silent Killer’, setting out recommendations that could be life-changing for the health of this country.

Key among the recommendations is to create a high blood pressure taskforce that would raise awareness of high blood pressure, ensuring it gets the attention it deserves, and create a coordinated response to improve blood pressure levels across Scotland.

As well as preventative measures around health issues such as diet and exercise, the two key changes that would make a difference are increasing detection and scaling up self-monitoring and self-management of the condition once it has been diagnosed.

Because people will not experience any symptoms of high blood pressure, measuring someone’s blood pressure is the only way to pick it up, and one of the report’s recommendations is to expand blood pressure testing into a wider range of community settings.

In particular, this could ensure that people who might not usually have their blood pressure checked would be more likely to be reached.

McKinstry explains: “We need to get more people checking it in lots of different places and then deciding whether it’s a genuine raised blood pressure – as I’m sure you’re aware, individual blood pressures are seldom that helpful, you need to check it a few times to make sure that someone has got raised blood pressure because it tends to go up and down – but if you’ve got these blood pressure machines in lots of different places, like pharmacists and gyms and places like that where people can get checked, if they get a high figure, they can follow it up.”

Normalising blood pressure checks and having more machines available, including in the home, could have a snowball effect of others also checking theirs too, McKinstry suggests.

He explains: “I think making blood pressure machines a lot more available than they are currently will increase the number of people getting their blood pressure checked.

“So if we have them in lots of different places, if people, for example, [who] have blood pressure have their own machines at home, then other members of the family may check out their blood pressure as well.

“It’s just like having a set of scales in the house, everybody jumps on them.”

But testing for high blood pressure is only the beginning; alongside this is a need for awareness raising about what is normal and what to do about an abnormal result.

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McKinstry says: “[People] don’t quite know what the figures means, so there perhaps needs to be more in the way of an educational campaign as to what’s not normal and when it’s worthwhile to act on this.

“And acting on it isn’t always just drugs, you can make a big difference by losing weight, by taking more exercise, by eating less salt, these things can all make a bit of a difference to blood pressure.

“And if your blood pressure’s borderline, these simple things – we say they’re simple, they’re quite hard to stick to sometimes – but if you can do these things, you can make a difference. And we’ve seen that.

“But having said that, we know that there are really good drugs which work well and that most people tolerate really well and they reduce the risk of stroke and heart attack. We know that. The evidence is incontrovertible.”

Both the Scottish and UK governments are already taking action on some of the causes of high blood pressure, with the UK now having the lowest salt intake in the OECD, and attempts are under way to decrease the country’s intake of sugar and promote exercise, so why is a specific taskforce on high blood pressure so vital if preventative action is already being taken?

McKinstry explains: “One [reason] is to increase awareness of blood pressure itself. I think that would be a big plus.

“The other thing I think we need to do is that although we’ve got effective treatment for it, only 27 per cent of people with high blood pressure have it controlled to recommended levels.

“So it’s really, really important to get across this idea that it’s not enough to know you’ve got high blood pressure, you have to have your blood pressure controlled, and trying to get that across to people.

“The other thing that I think would make a big difference to this is for the taskforce to determine whether we could prescribe blood pressure machines in the same way as we can prescribe peak flow meters for people managing their asthma… because we do know that when people have self-monitoring, particularly if it’s monitored self-monitoring, like telemonitoring, of blood pressure, it definitely reduces blood pressure quite considerably. It’s something that really improves control.”

Telemonitoring works by patients checking their own blood pressure on a regular basis at home and texting in the result, with the collated figures passed to their GP on a regular basis.

The benefits of telemonitoring are that it gives a more reliable result than occasional monitoring by a doctor and it can also help encourage people to keep taking medicine.

The report highlighted that this is often a challenge in treating blood pressure, and that the taskforce should address this.

McKinstry led a trial of telemonitoring of blood pressure in NHS Lothian, Scale Up BP, but there have been similar trials around the world and they have found a much greater reduction in blood pressure than check-ups at a doctors’ surgery.

“You get across this idea that you really need to check the numbers rather than how you feel and that’s something that having a machine does,” McKinstry says.

Having these numbers tends to encourage people to continue with treatment, where they otherwise may stop because they believe they have got better.

McKinstry says: “That’s our fault as doctors because we don’t make it clear that this is something you’re on for life.

“This isn’t something that you’re going to get this blood pressure controlled and then you can just stop the tablets after two months, you have to keep taking this.

“And, again, having a machine is a good thing because people check their blood pressure and they think, ‘I can do without these tablets’, and then they check again and the blood pressure’s gone up.”

Regular home testing also does away with any excuses that high blood pressure is just a one-off on the day of the test, which can happen in a clinical setting.

“This person will come in and they’ll say, I just had a row with my daughter this morning, the bus was late, and [the GP will] say, yeah, yeah, we’ll just check it again in three months, but if you’ve got 20 blood pressures taken at home, all of which are high, you can’t really argue with that.

“Both the patient and the clinician know there’s something wrong here and you have to do something about it.”

And the evidence from elsewhere suggests that increasing the blood pressure diagnosis followed by better self-management of the condition through telemonitoring could have a dramatic effect on the rate of serious life-threatening diseases in Scotland.

McKinstry explains: “Certainly if you look at randomised controlled trials, and you look at the amount of blood pressure lowering that occurs in that, the average is round about four millimetres of mercury, which does not sound like very much, but that would lower the stroke rate by 15 per cent and the MI [heart attack] rate by ten per cent, so that small reduction would make a huge difference… even very small lowering of blood pressure has dramatic effects.”

The report highlights Canada as a case study, showing the significant improvement in blood pressure detection and control, and the corresponding decrease in rates of heart attack and stroke that occurred once a coordinated approach to tackling blood pressure was taken.

With significant changes in detection and management models on the horizon, the report suggests that it’s an opportune time to bring key stakeholders together to drive forward with these changes, and ensure that everyone in Scotland benefits.