Reaching for Goal: Incorporating the Latest Hypertension Guidelines Into Practice

Reaching for Goal: Incorporating the Latest Hypertension Guidelines Into Practice Bridget Shoulders, MS, ACNP-BC, and Laurie Powell, MSN, AGNP-BC ABSTRACT

Hypertension accounts for more cardiovascular disease deaths than any of the other modifiable risk factors. Despite the known benefits of lowering blood pressure, more than half of adults taking antihypertensive medications have blood pressures above current treatment goals. The purpose of this article is to inform nurse practitioners of the key highlights in the updated hypertension guidelines and provide guidance on incorporating the best available evidence into hypertensive care management. Keywords: high blood pressure, hypertension, hypertension guidelines, hypertension management Ó 2018 Elsevier Inc. All rights reserved.

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here are more cardiovascular disease (CVD) deaths attributed to hypertension than any of the other modifiable risk factors. Antihypertensive therapy not only decreases blood pressure (BP) but also reduces the risk of CVD, cerebrovascular disease, and death.1 Despite the known benefits of lowering BP, more than 50% of adults taking antihypertensive medications have BP above treatment goals.2 Numerous patient, provider, and environmental factors influence the high incidence of poorly controlled hypertension. These factors range from suboptimal doses of medical therapy, complex regimens, affordability, lack of adherence, to time constraints that do not allow providers to adequately address the individual needs of each patient. Most nurse practitioners would agree that these obstacles present a challenge in achieving goal BP. The purpose of this article is to inform nurse practitioners of the key highlights in the latest hypertension guidelines, in addition to other supplementary findings in the literature, and to provide guidance on incorporating the best available evidence into hypertensive care management. HIGHLIGHTS OF THE GUIDELINES

The American Heart Association (AHA) and American College of Cardiology (ACC) partnered with 9 www.npjournal.org

organizations and a panel of experts to develop the 2017 hypertension guidelines. The guidelines are intended to provide a comprehensive resource for clinicians, with the aim of improving outcomes through early detection and effective management of hypertension.1 Key highlights include new lower targets for diagnosing hypertension, incorporating risk assessment into determining the need for medical therapy, diagnostic and treatment algorithms, pharmacological and nonpharmacological strategies, accuracy in BP measurement, and emphasis on teambased hypertensive care. In addition to the comprehensive document, there is a simplified version available, “Guidelines Made Simple,” that provides clinicians with easy access to the diagnostic and treatment algorithms.3 The revised BP classifications are based on interpretation of related CVD risk and benefits of BP reduction in clinical trials. The increased risk in patient with stage 2 hypertension was already well established.1 Recent studies have revealed progressively higher CVD risk as elevated BP advances to stage 1 hypertension. The Systolic Blood Pressure Intervention Trial (SPRINT) provided substantial evidence for the modifications outlined in the updated guidelines.4 This large randomized trial found that lowering systolic BP to The Journal for Nurse Practitioners - JNP

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a target goal of less than 120 mm Hg, compared with the standard goal of less than 140 mm Hg, resulted in significantly lower rates of fatal and nonfatal cardiovascular events and deaths from any cause. This trial also provided significant evidence of the benefits of lowering systolic BP in older adults. The definition of hypertension is divided into 4 categories: normal, elevated, stage 1, and stage 2 (see Figure). Prehypertension was replaced with the category of elevated BP, reflecting the increased

CVD risk, compared with normal BP.5 Stage 1 hypertension is now defined as systolic BP 130e139 mm Hg or diastolic BP 80e89 mm Hg. This lower threshold increases the number of adults diagnosed with hypertension. An analysis of data from the National Health and Nutrition Examination Survey revealed that the prevalence of hypertension increased to 45.6% using the 2017 ACC/AHA guidelines, compared with 31.9% using the previous Joint National Committee 7 guidelines.6

Figure. Blood pressure thresholds and recommendations for treatment and follow-up. Reprinted with permission from ACC/AHA Guidelines for Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, by Whelton PK, Carey RM, Aronow WS, J Am Coll Cardiol. 2017;71(19): e127-248. Copyright 2017 by American College of Cardiology.

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ASSESSING RISK USING THE ASCVD RISK ESTIMATOR

The recently updated ASCVD (atherosclerotic cardiovascular disease) Risk Estimator plus tool is used to calculate 10-year risk for CVD. This tool was initially developed as a point-of-care resource for clinicians to estimate cardiovascular risk and need for risklowering interventions, in patients without known CVD.7 The upgraded version incorporates recommendations from the 2017 hypertension guidelines to assist the clinician in making pharmacological treatment decisions for adults with stage 1 hypertension.8 A risk score of 10% or greater is associated with higher CVD risk. In addition to the risk score, the risk assessment provides a treatment advice summary for clinicians and patients. The ASCVD Risk Estimator Plus tool can be accessed on the web (http://tools.acc.org/ASCVD-RiskEstimator-Plus/#!/calculate/estimate/) or as an app on iTunes and Google Play. RECOMMENDATIONS FOR PHARMACOLOGICAL MANAGEMENT

Major changes in the guidelines include the use of BP-lowering medications for primary prevention in adults with stage 1 hypertension and high ASCVD 10-year risk scores, and recommendations to consider initiating 2 first-line antihypertensive therapies in patients with stage 2 hypertension.1 The first-line antihypertensive agents include thiazide diuretics, calcium channel blockers, and angiotensinconverting enzyme inhibitors, or angiotensin receptor blockers. The decision on which agent and whether to start with 1 or more agents depends on a number of factors, including the stage of the hypertension, comorbid conditions, age, adherence, cost, and patient preferences.1 The guidelines include a comprehensive table that list primary and secondary oral agents used for management of hypertension.1,3 The importance of regular follow-up to determine the effectiveness of interventions is emphasized in the guidelines. Adults initiated on pharmacological therapy should have repeat BP evaluation at monthly intervals to assess response to treatment, need for adjustments in dosages, and adherence with medical therapy and lifestyle changes, until control is achieved.3 A repeat BP assessment for low-risk adults with stage 1 hypertension is recommended in 3e6 www.npjournal.org

months, and an annual evaluation is advised for normotensive adults. NONPHARMACOLOGICAL STRATEGIES FOR HYPERTENSION MANAGEMENT

Nonpharmacological strategies are recommended for all patients with elevated BP. There are a number of nonpharmacological interventions with reported benefits in lowering BP; however, many have not been sufficiently supported with scientific evidence.1 The guidelines primarily focused on 6 strategies that have shown the greatest impact on BP reduction: weight loss, heart-healthy diet, sodium reduction, potassium supplementation, reduction of alcohol consumption, and increased physical activity. The BP-lowering effects associated with each of these interventions3 are summarized in Table. There is a strong relationship associated with obesity at a young age and over time and the future risk of hypertension.1 Even a small reduction in weight can improve BP. The patient’s goal should be Table. Impact of Nonpharmacological Strategies on Reducing Blood Pressure3 Nonpharmacological Strategy

Approximate Reduction in BP

Weight loss

1 mm Hg decrease in BP with each kilogram of weight loss

DASH diet

3e11 mm Hg reduction in systolic BPa

Sodium reduction to <1,500 mg/day

2e6 mmHg reduction in BPa

Supplemental potassium, 3,500e5,000 mg/day

2e5 mm Hg reduction in BPa

Moderation in alcohol intake

3e4 mm Hg reduction in BPa

Regular exercise for a period of 3 months: Aerobic

2e8 mm Hg decrease in systolic BP

Resistance training

2e4 mm Hg decrease in diastolic BP

Isometric exercises

4e5 mm Hg decrease in diastolic BP

BP ¼ blood pressure; DASH ¼ Dietary Approaches to Stop Hypertension. a The greatest reduction is seen in hypertensive adults.

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ideal body weight, but setting short-term goals may be a more realistic approach. Weight loss through calorie reduction and increased physical activity is an effective method to achieve sustainable weight loss. The DASH (Dietary Approaches to Stop Hypertension) eating plan is low in saturated fat, cholesterol, sodium, and sugar, and high in potassium. It is rich in fruits and vegetables and includes low-fat dairy products, whole grains, fish, poultry, and nuts. A clinical trial evaluating the long-term effect of the DASH diet found that systolic BP was significantly lower at 1 year, in those assigned to the DASH intervention groups.9 The combination of weight loss and the DASH diet can have a substantial effect on lowering BP.1 Reducing sodium in the diet can significantly decrease BP in adults with hypertension. When sodium reduction is combined with weight loss, the BP reduction may be doubled.1 Patient education should include limiting sodium intake to less than 1,500 mg/day, avoiding processed foods, and including more fresh fruits and vegetables. Reading labels, preparation of meals at home, and encouraging the use of fresh spices and herbs to flavor food, can result in more control of the sodium content in meals. Consumption of potassium-rich foods (eg, fruits and vegetables, low fat dairy products, fish, and soy) decreases the incidence of hypertension. The BP-lowering effect is similar whether achieved through diet or potassium supplements. Because potassium-rich foods tend to be healthy, they are preferred over supplements.3 Four to 5 servings of fruits and vegetables per day can typically provide the recommended goal amount of 3500e5000 mg per day. Although potassium has BP-lowering benefits, supplemental potassium should be avoided where there is an increased risk for hyperkalemia (eg, in patients with significant kidney disease or heart failure patients taking aldosterone antagonist). Another key strategy in lowering BP is reducing alcohol consumption. Alcohol may account for close to 10% of the population burden of hypertension,1 with the impact on BP depending on the amount consumed. There is a strong correlation between alcohol consumption and hypertension, especially when 3 or more standard drinks are consumed per 4

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day.1 Men should be encouraged to limit their alcohol consumption to no more than 2 drinks per day and women to no more than 1 drink per day. There is a considerable body of evidence supporting the BP-lowering effects of exercise, including aerobic, resistance training, and static isometric exercises.1 There are a variety of ways to meet physical fitness goals, such as walking, biking, tennis, swimming, pilates, and power yoga. The AHA recommends a minimum of 150 minutes of moderate exercise per week. Regular exercise for a period of 3 months can contribute to a decrease in systolic and diastolic blood pressure, with greater effects seen in those with hypertension.10 COMPLEX ISSUES IN HYPERTENSIVE MANAGEMENT

The prevalence of resistant hypertension is estimated to be 17% of the adult population with high BP, based on the new lower targets.1 In patients with chronic kidney disease, the percentage has been reported as high as 40%.11 Patients with resistant hypertension fall under 2 categories: (1) inability to achieve goal, despite concurrent use of at least 3 antihypertensive agents of different classes and (2) requiring at least 4 antihypertensive agents to achieve target BP.12 True resistance is confirmed after adherence with optimal antihypertensive therapy is determined. Based on the recently revised resistant hypertension guidelines, optimal therapy should include a long acting calcium channel blocker, ACE inhibitor or angiotensin receptor blocker, and a diuretic, at maximally tolerated doses.12 Since the etiology of resistant hypertension is often multifactorial, effective treatment is dependent on identifying and treating various contributing factors. The diagnostic and treatment recommendations include verifying accurate blood pressure measurements, screening for secondary causes, discontinuing agents or other substances (eg, nonsteroidal anti-inflammatory drugs, or NSAIDS) that may contribute to hypertension, identifying and addressing contributing lifestyle factors, and maximizing pharmacological therapies.1 In the absence of a secondary cause, referral to a hypertension specialist is recommended if BP remains elevated, despite maximally tolerated medical therapy.12 Volume

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Secondary hypertension has an identifiable cause and accounts for up to 10% of the population with high BP.13 Screening is indicated when there is evidence of severe elevation or sudden uncontrolled hypertension, resistance to medical therapy, onset at a younger age, and target organ damage out of proportion to the severity and duration of the hypertension.1 Identifying and correcting the cause of secondary hypertension could result in either a cure or significant improvement in BP.1 The guidelines include a comprehensive table that provides direction for the clinician to evaluate secondary causes of hypertension. The most common chronic condition contributing to secondary hypertension is obstructive sleep apnea (OSA), with the prevalence ranging from 25% to 50%.3 Use of continuous positive airway pressure (CPAP) is an effective treatment for OSA, but its effect on BP reduction has been variable in trials.14 The magnitude of reduction may depend on compliance with CPAP, severity of OSA, or incidence of daytime sleepiness. A systematic review and meta-analysis of randomized controlled trials evaluating the effect of CPAP on OSA patients with resistant hypertension revealed a significant decrease in BP.15 A meta-analysis of randomized controlled trials found that CPAP reduced severity of OSA but did not have an overall beneficial effect on BP in patients with minimally symptomatic OSA.16 Patients who used CPAP for greater than 4 hours per night seemed to benefit from a small decrease in diastolic BP. CONSIDERATIONS IN MANAGEMENT OF HYPERTENSION IN THE ELDERLY

According to the Heart Disease and Stroke Statistics 2018 Update, the prevalence of hypertension among adults at least 60 years old was 67% between the years of 2011 and 2014.2 The age-related increase in hypertension is mostly attributed to changes in arterial structure and function that accompany aging.17 Both systolic and diastolic BP increase linearly up to the 5th and 6th decade of life, at which point systolic pressure continues to rise with a gradual decrease in diastolic BP.1 As a result, there is a high prevalence of isolated systolic hypertension in the elderly. The recommendation for goal BP of less than 130/80 extends to the elderly. Studies have www.npjournal.org

demonstrated that lowering BP in the older adult is effective in decreasing cardiovascular events. Although the SPRINT trial did show benefit of intensive BP-lowering in older adults, 38% of the participants experienced adverse events (eg, hypotension, syncope, acute kidney injury).4 A metaanalysis and systematic review looking at the benefits and harm of intensive BP treatment in the older adult revealed similar findings; lower treatment targets were associated with reduced mortality, stroke, and cardiac events, but there was an increased risk of short-term harm (eg, hypotension).18 The elderly tend to be frail, at increased risk for orthostatic hypotension, falls, and mental function impairment. The concern for potential harm can unfortunately lead to undertreatment. The goal to achieve target BP must be balanced with careful titration and close monitoring. Consideration in older adults includes using lower initial doses of antihypertensive therapy to minimize the risk of adverse events.17 Caution is advised in starting 2 antihypertensive agents simultaneously in older adults.19 ACCURACY OF BP MEASUREMENT INSIDE AND OUTSIDE THE OFFICE

The mercury sphygmomanometer and the aneroid manual auscultatory BP methods have been replaced by automatic oscillometric devices as the primary means of BP measurement. These monitors use a sensor to detect oscillations in pulsatile blood volume during cuff inflation and deflation. The point of maximal oscillation corresponds to the mean arterial pressure (MAP). The systolic and diastolic pressures are indirectly estimated, using a derived algorithm, which varies from one manufacturer to another.20 Office BP measurement is the first step for diagnosis and management of hypertension, so accuracy is critical for making appropriate treatment decisions. Periodic BP readings in the office setting may provide an incomplete picture of real-life BP levels.21 White-coat hypertension usually comes to mind. There are procedural-related factors that can also contribute to inaccuracies. Measurement errors can occur with incorrect performance of the procedure. This problem can be minimized by ensuring that there is standardized training of staff in the proper The Journal for Nurse Practitioners - JNP

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technique of BP measurement. Another source of error is using the incorrect cuff size. Morbidly obese patients often have very large arm circumferences with short upper arm length, which makes it difficult to find a suitable cuff size. In this case, BP may be measured with the cuff on the forearm, supported at heart level.20 Keep in mind that this method may overestimate systolic BP. It has been suggested that cuff size criteria may not apply with use of the oscillometric method.22 The purpose of the cuff with the auscultatory methods is to compress or occlude the artery to determine systolic BP. With the oscillometric method, the cuff serves as the signal sensor. The reference point is not the artery occlusion, but the peak signal that is equivalent to the mean BP.20 A number of patient-related factors need to be taken into consideration when determining accuracy of BP measurement. When the heart rhythm is irregular (eg, atrial fibrillation), BP varies beat to beat. Rapid cuff deflation in the presence of marked sinus bradycardia can underestimate systolic and overestimate diastolic BP.20 A reliable BP may not be obtainable in an extremity with occlusive arterial disease. Out-of-office measurements are recommended to confirm hypertension and monitor effectiveness of medical therapy. Ambulatory BP monitoring (ABPM) has been used widely in research and in hypertension clinics but has been underutilized in general practice.21 This technique uses a cuff and small wearable monitor to automatically obtain BP readings, at set intervals as patients go about their normal activities, over a 24-hour period. This method can be useful when diagnosis is uncertain, resistance to treatment, concern about variability, and to evaluate for white-coat hypertension. Home BP monitoring (HBPM) is a cost-effective and convenient method for assessment of BP at specific times of the day.23 Although there is a smaller evidence base compared with ABPM, HBPM is widely used and is a means to enhance patients’ engagement in their hypertension care. To ensure accuracy with HBPM, it is essential that patients are provided instructions on the proper technique for measurement of blood pressure. The Preventative Cardiovascular Nurses Association website (pcna.net) 6

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has a downloadable home BP monitoring instruction sheet available that can be used to supplement patient education on the proper technique for home BP measurement. Both ABPM and HBPM provide lower BP values than office BP measurements.21 Current evidence suggests that ABPM and HBPM are valid oscillometric options, but they are not interchangeable. The use of ABPM may be more appropriate for the initial diagnosis, whereas HBPM may be more suitable for long-term follow-up of treated BP.22 The findings of a systematic review to assess whether BP measurements from ambulatory monitoring or home monitoring is more consistently associated with CVD events and/or mortality were inconclusive due to the small number of cohorts comparing the 2 methods.23 On the basis of the current data available, the authors concluded that there is limited evidence to support recommendations of ABPM over HBPM. TELEHEALTH AND DIGITAL TOOLS TO IMPROVE HYPERTENSION MANAGEMENT

Telehealth strategies and innovative digital tools can facilitate management of patients with hypertension. These technologies offer opportunities to improve patient access via the Internet, e-mail, text messaging, and other electronic means.24 Use of BP monitors in combination with tablets, smartphones, and other mobile applications have the potential to enhance hypertension management.21 User-friendly applications can provide medication reminders, monitor medication compliance, and monitor refill needs. Communicating BP measurements remotely is one strategy to address the guideline recommendations for regular follow-up to evaluate the effectiveness of interventions. A randomized clinical trial to determine the effectiveness of remote patient monitoring and physician care revealed that remote monitoring of BP alone or in combination with remote physician care was as efficacious as usual office care for reducing BP in patients with hypertension.25 Another study evaluating the effectiveness of a remote home-based telemetry monitoring program found that 71% of the patients with poorly controlled hypertension achieved BP control at 90 days compared with the usual care group.26 Volume

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Although digital technology is evolving and there have been a wide variety of applications developed, there are limited empirical data evaluating the effectiveness of many of these products. The AHA Scientific Statement on Current Science on Consumer Use of Mobile Health for CVD Prevention emphasized that the lack of evidence does not necessarily mean these products are ineffective and encouraged more studies to determine their effectiveness.24 TEAM-BASED APPROACH TO HYPERTENSIVE MANAGEMENT

The guidelines present a paradigm shift from fragmented care to a team approach aimed at improving the quality of hypertensive care management. Teambased care involves a multidisciplinary group of clinical and supportive staff with the goal of providing a comprehensive patient-centered plan of care.1 The team would ideally include physicians, nurse practitioners, physician assistants, clinical pharmacists, nurses, dieticians, social workers, case managers, and clinical psychologists. Patients should be active partners, working with the rest of the team to create an individualized treatment plan. For the team-based concept to be viable, organizations must be committed and willing to allocate the necessary resources, to enable this process.1 IMPLICATIONS FOR PRACTICE

The real-life application of the hypertension guidelines presents a challenge for nurse practitioners, in terms of the ability to achieve lower targets, when BP goals were not being met with the previous higher targets. To help overcome this concern, it is essential that nurse practitioners are not only familiar with the latest guidelines but that they incorporate the recommendations into practice. The guidelines are not intended as a substitute for clinical judgment, so tailoring the strategies to each individual patient’s situation is necessary to ensure optimal hypertensive care management. Practicing based on the best available evidence will ultimately translate into positive patient outcomes. Another important implication is the role of nurse practitioners in closing the gap between research and practice. The lack of sufficient data related to the www.npjournal.org

efficacy of nonpharmacological interventions and the limited evidence supporting innovative technologies are examples of topics where nurse practitioners are ideally suited to contribute to the existing body of evidence. We enhance our practice as nurse practitioners not only through research utilization but also by actively participating in research. References 1. Whelton PK, Carey RM, Aronow WS, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;71(19):e127-e248. https:// doi.org/10.1016/j.jacc.2017.11.006. 2. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics 2018 update. A report from the American Heart Association. Circulation. 2018;137:e1-e134. https://doi.org/10.1161/CIR.0000000000000558. 3. American College of Cardiology. Guidelines Made Simple. 2017 Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 2018. https://www.scribd.com/document/365805717/ Guidelines-Made-Simple-2017-HBP. Accessed November 12, 2018. 4. Wright JT, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103-2116. https://doi.org/10.1056/NEJMoa1511939. 5. Carey RM, Whelton PK. The 2017 American College of Cardiology/American Heart Association hypertension guideline: a resource for practicing clinicians. Ann Intern Med. 2018;68:359-360. https://doi.org/10.7326/M18-0025. 6. Muntner P, Carey RM, Gidding S, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. Circulation. 2018;137(2):109-118. https://doi.org/10.1161/CIRCULATIONAHA.117.032582. 7. Kullo IJ, Trejo-Gutierrez JF, Lopez-Jimenez F, et al. A perspective on the new American College of Cardiology/American Heart Association guidelines for cardiovascular risk assessment. Mayo Clin Proc. 2014;89(9):1244-1256. https:// doi.org/10.1016/j.mayocp.2014.06.018. 8. American College of Cardiology. ASCVD Risk Estimator Plus. 2018. https:// www.acc.org/tools-and-practice-support/mobile-resources. Accessed November 12, 2018. 9. Hinderliter AL, Sherwood A, Craighead LW, et al. The long-term effects of lifestyle change on blood pressure: one-year follow-up of the ENCORE study. Am J Hypertens. 2014;27(5):734-741. https://doi.org/10.1093/ajh/hpt183. 10. Wasfy MM, Baggish AL. Exercise dose in clinical practice. Circulation. 2016;133:2297-2313. https://doi.org/10.1161/CIRCULATIONAHA.116.018093. 11. Braam B, Taler SJ, Rahman M, et al. Recognition and management of resistant hypertension. Clin J Am Soc Nephrol. 2017;12:524-535. https:// doi.org/10.2215/CJN.06180616. 12. Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: detection, evaluation, and management. A scientific statement from the American Heart Association. Hypertension. 2018;72:e000ee000. https://doi.org/10.1161/HYP .0000000000000084. 13. Rimoldi SF, Scherrer U, Messerli FH. Secondary arterial hypertension: when, who, and how to screen? Eur Heart J. 2014;35:1245-1254. https://doi.org/10 .1093/eurheartj/eht534. 14. Ahmad M, Makati D, Akbar S. Review of and updates on hypertension in obstructive sleep apnea. Int J Hypertens. 2017:1-13. https://doi.org/10.1155/ 2017/1848375. 15. Lei Q, Lv Y, Li K, et al. Effects of continuous positive airway pressure on blood pressure in patients with resistant hypertension and obstructive sleep apnea: a systematic review and meta-analysis of six randomized controlled trials. J Bras Pneumol. 2017;43(5):373-379. https://doi.org/10.1590/S1806 -37562016000000190. 16. Bratton DJ, Stradling JR, Barbé F, et al. Effect of CPAP on blood pressure in patients with minimally symptomatic obstructive sleep apnoea: a metaanalysis using individual patient data from four randomised controlled trials. Thorax. 2014;69:1128-1135. https://doi.org/10.1136/thoraxjnl-2013 -204993. 17. Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA expert consensus document on hypertension in the elderly. A report of the American College of Cardiology Foundation Task force on clinical expert consensus documents. Circulation. 2011;123:2434-2506. https://doi.org/10.1161/CIR.0b013e31821daaf6. 18. Weiss J, Freeman M, Low A, et al. Benefits and harms of intensive blood pressure treatment in adults aged 60 years or older. Ann Intern Med. 2017;166(6):419-429. https://doi.org/10.7326/M16-1754.

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19. Cushman WC, Johnson KC. The 2017 U.S. hypertension guidelines: what is important for older adults? J Am Geriatr Soc. 2018;66:1062-1067. https:// doi.org/10.1111/jgs.15395. 20. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005;111(5):697-716. https://doi.org/10.1161/01.CIR. 0000154900.76284.F6. 21. Parati G, Ochoa GE, Bilo G. Role of office blood pressure in diagnosis and treatment of hypertension. Moving beyond office blood pressure to achieve a personalized and more precise hypertension management. Which way to go? Hypertension. 2017;70:e20-e31. https://doi.org/10.1161/HYPERTENSIONAHA .117.08250. 22. Stergiou GS, Palatini P, Asmar R, et al. Blood pressure monitoring: theory and practice. European Society of Hypertension working group on blood pressure monitoring and cardiovascular variability teaching course proceedings. Blood Press Monit. 2018;23(1):1-8. https://doi.org/10.1097/ MBP.0000000000000301. 23. Shimbo D, Abdalla M, Falzon L, et al. Studies comparing ambulatory blood pressure and home blood pressure on cardiovascular disease and mortality outcomes: a systematic review. J Am Soc Hypertens. 2016;10(3):224-234. https://doi.org/10.1016/j.jash.2015.12.013. 24. Burke LE, Ma J, Azar KM, et al. Current science on consumer use of mobile health for cardiovascular disease prevention: a scientific statement from the American Heart Association. Circulation. 2015;132(12):1157-1213. https:// doi.org/10.1161/CIR.0000000000000232.

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25. Kim YN, Shin DG, Park S, et al. Randomized clinical trial to assess the effectiveness of remote patient monitoring and physician care in reducing office blood pressure. Hypertens Res. 2015;38(7):491-497. https://doi.org/ 10.1038/hr.2015.32. 26. Milani RV, Lavie CJ, Bober RM, et al. Improving hypertension control and patient engagement using digital tools. Am J Med. 2017;130(1):14-20. https:// doi.org/10.1016/j.amjmed.2016.07.029.

Bridget Shoulders, MSN, ACNP-BC, works as a cardiology nurse practitioner in the Cardiology Department, James A. Haley VA Hospital, Tampa, Florida. She is available at bso1029@ aol.com. Laurie Powell, MSN, AGNP-BC, is a nurse in the Electrophysiology Section, James A. Haley VA Hospital, Tampa, Florida. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/18/$ see front matter © 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.nurpra.2018.09.011

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