Tackling a Fundamental Disease:
Multiple Disciplines Take on Hypertension
A multidisciplinary clinic at Stanford is redefining what it means to live with hypertension.
About one in every three American adults has the condition, generally known as high blood pressure. It’s difficult to detect because it typically has no symptoms or warning signs. What’s more, a significant proportion of patients aren’t fully treated despite taking multiple medications, says Vivek Bhalla, MD, assistant professor of nephrology and co-director of Stanford’s Hypertension Center.
The Hypertension Center encompasses 12 specialties including renal, endocrine, and stroke medicine; preventive cardiology; and sleep medicine.
“Treatment always involved multiple specialists, but in the past we never really got together to talk about it. Instead we would view isolated aspects of the problem from different angles,” Bhalla says. “But that’s not what’s best for the patient.”
Teaming up with colleagues like center co-director Robert Isom, MD, clinical associate professor of nephrology, Bhalla realized that Stanford had the resources to gather all the necessary experts under one clinical roof.
“There seemed to be somebody in every corner with expertise and/or interest in hypertension,” Bhalla says. “So we tried bringing together physicians from these different specialties to create an infrastructure for clinical care of hypertension patients as well as to propagate clinical, translational, and basic research based on shared interest.”
For Bhalla, the center’s most important feature is having different specialists looking at the same patient and offering various opinions — which results in better overall care. For physicians, trying to lower a patient’s blood pressure requires not only medication, but also management of risk factors and secondary causes and consequences of hypertension, like obesity, sleep apnea, or kidney disease.
Center clinicians, along with colleagues in surgical specialties, are conducting a range of studies about hypertension. One study involves correlations between obesity and insulin resistance in patients with high blood pressure. Other research projects, with vascular surgeon Jason Lee, MD, and general surgeon Electron Kebebew, MD, have looked into the viability of surgical treatments.
The center’s research legacy also includes SPRINT — a national systolic blood pressure interventional trial — which focused on whether then-current blood pressure goals for patients with hypertension were insufficient. Led by Glenn Chertow, MD, professor of nephrology, and Randall Stafford, MD, professor of medicine, the trial was supposed to run from 2013 to 2018, but it was halted after just three years because the data so convincingly showed that lower blood pressure targets overwhelmingly improved health.
New methods raise new questions about the best way to measure hypertension, and how often, which ultimately improves treatment
Just five years ago, guidelines set the upper limit of acceptable blood pressure at 140/90 mm Hg. Bhalla says these conservative guidelines meant that people with moderate hypertension weren’t being identified or treated.
“But SPRINT really tested and challenged the prevailing law of the land, showing that a target for systolic blood pressure of 120 mm Hg — versus 140 mm Hg — resulted in an almost 25 percent relative risk reduction in cardiovascular events and mortality,” he says.
Inspired in part by SPRINT’s success, Bhalla is working with Tara Chang, MD, assistant professor of nephrology, on better tools to measure blood pressure like the AOBP, or automated office blood pressure. This technique reduces sources of measurement error and provides clinicians with a more accurate picture of patients’ blood pressure health, enabling them to make informed decisions regarding diagnoses and therapy plans.
“Not all methods are created equal,” Bhalla says. “New methods raise new questions about the best way to measure hypertension, and how often, which ultimately improves treatment.”
Members of the center are also working with several Silicon Valley start-ups on novel devices for measuring blood pressure at home.
“We know that monitoring of blood pressure at home can help control hypertension, and newer devices may facilitate the accuracy and frequency of data that we doctors have to treat our patients,” he says.