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NEW ORLEANS -- The hypertension guidelines are there. Now the questions are how to convince clinicians in primary care to trust those new blood pressure (BP) targets and how to help patients achieve them.

Steady gains in BP control (to a 140/80 mm Hg target) were observed in the U.S. from 1999 to around 2014, when the control rate started falling back down from a high of over 53%, according to NHANES data cited by Brent Egan, MD, of the University of South Carolina School of Medicine-Greenville.

"It really looks like we've plateaued in the past decade," said Egan, who advocated "recognizing these battles are won and lost in the trenches of primary care" at the American Heart Association (AHA) annual Hypertension meeting.

Yet the American College of Physicians or the American Academy of Family Medicine are two groups that have come out to say they disagree with the 2017 blood pressure guidelines from the American College of Cardiology and AHA, which recommend 130/80 mm Hg as the new threshold for hypertension.

Clearly, such disagreement leads to confusion and less action in primary care, Egan said.

It's also not as simple as getting everyone under the BP target: the bell-shaped curve to achieved BP suggests that if the goal is for 90% of the population to have systolic BP less than 130 mm Hg, it would require a mean BP around 114 mm Hg, which may be lower than one would like, according to session co-chair Michael Bloch, MD, of Blue Spruce Medicine Consultants in Reno, Nevada.

Then again, if clinicians want to control most patients to <140 mm Hg systolic, they wouldn't want many of them ≥130 mm Hg -- avoidance of which would require working with patients to assess the right therapeutic intensity for each person, Egan noted.

A major question is whether to start patients off with monotherapy or combination therapy.

"There's therapeutic inertia from both the patient and the provider, and it's easier to uptitrate combination therapy than its single components," Egan said.

He said once-daily single-pill combinations are an opportunity to boost adherence to antihypertensive medications among patients, as they have also been linked to better cardiovascular outcomes.

However, Egan said they are not being prescribed as much as they could be. After all, not everyone is a believer in this approach, given the increased difficulty of medication titration.

"I don't believe in combination therapy," said David Hyman, MD, of Baylor College of Medicine in Houston, who cited clinician non-adherence as the problem in hypertension control during the session Q&A. "Most of my patients are taking nine or 10 pills. If you're already taking nine, does it matter if you're taking seven? You're either into it or not."

Yet uptitration doesn't have to be so hard: 15 Kaiser medical centers in California have succeeded in BP control by starting hypertensive patients off with a half tablet of lisinopril-hydrochlorothiazide, another member of the audience reported during the Q&A.

"From the patient's point of view, it's half of one medicine when it's really two medicines. Uptitration doesn't require a trip to the pharmacy. When we add amlodipine, in theory, the patient could get to maximum dose, three meds, in two pharmacy visits. It removes a whole lot of complexity to implementation," he said.

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