PA Helps to Revise Hypertension Guidelines

By Eileen Denne, CAE, APR

Sondra DePalma, MHS, PA-C, CLS, DFAAPA, AACC
Sondra DePalma, MHS, PA-C, CLS, DFAAPA, AACC

The American Heart Association (AHA), American College of Cardiology (ACC), AAPA, and several other health organizations released a new prevention, diagnosis and treatment guideline that redefined high blood pressure, or hypertension (HTN), in November 2017. The guideline addresses blood pressure management for a broad spectrum of causes and complications, such as kidney problems, heart failure, and diabetes.

Through her service on the writing committee for the new HTN guideline, Sondra DePalma, MHS, PA-C, CLS, DFAAPA, AACC, helped to encourage PA involvement in an important healthcare issue and reminded other professionals of PAs contributions to patient care and the clinical management of HTN. DePalma is AAPA’s director of regulatory and professional practice.

The ACC and AHA requested the AAPA’s involvement on the writing committee because they recognized the contribution of PAs in medicine – both in primary care and specialty care.

PA DePalma Selected for Writing Committee
According to DePalma, who was not on the AAPA staff at the time, she was asked to apply to represent AAPA on the writing committee and was selected as one of two candidates by the AAPA, with final selection by the Chairs of the writing committee and the ACC Task Force on Clinical Practice Guidelines.  Per the guideline:

“The writing committee consisted of clinicians, cardiologists, epidemiologists, internists, an endocrinologist, a geriatrician, a nephrologist, a neurologist, a nurse, a pharmacist, a physician assistant, and 2 lay/patient representatives. It included representatives from the ACC, AHA, (AAPA, Association of Black Cardiologists (ABC), American College of Preventive Medicine (ACPM), American Geriatrics Society (AGS), American Pharmacists Association (APhA), American Society of Hypertension (ASH), American Society for Preventive Cardiology (ASPC), National Medical Association (NMA), and Preventive Cardiovascular Nurses Association (PCNA).”

The committee convened in November 2014.  During the 3-year guideline development, there were several in-person meetings, monthly conference calls, and numerous electronic communications and evidence reviews. Multiple stakeholders did extensive peer reviews of the document prior to final approval. AAPA’s Board of Directors endorsed the guidelines in October 2017.

New Guideline Meets PA Approval
Sondra DePalma at the clinicViet Le, current co-chair of the ACC’s PA Work Group, welcomes the news guideline, which he says provide a rational approach to diagnosis and management of hypertension and addresses the issues of blood pressure measurement inaccuracies as well as improved engagement of the patient in their own health.

“The new guidelines help bring to light more formally (by lowering the diagnostic criteria) a larger group of individuals who the data show are already at risk. Identifying them more formally allows clinicians to potentially address the risk sooner. Notably, our medical infrastructure will be strained. We will need to think outside of the box in order to create more space in our clinic schedules to have in-depth lifestyle conversations, to follow-up with these patients more frequently, and to better manage their medications and blood pressure in real time, not three months after the fact when they can finally get in our clinic,” Le said.

DePalma expects the new guideline to help lower the incidence of cardiovascular events (as well as the associated morbidity and mortality) and improve the health and quality of life for patients.

“Evidence shows that a lower systolic blood pressure goal of under 130 compared to under 140 is associated with decreased fatal and non-fatal cardiovascular events, with about half the risk heart attack and stroke.”

Contribution to Patient Care
As the only PA on the writing committee, DePalma felt the greatest value she added was reminding the committee of the contribution PAs make to patient care and the clinical management of HTN.

“I think my presence also influenced the guideline language – only once in the document is the term “physician” used; in all other instances, recommendations are for “clinicians” and involve “clinician management”. I think it was also important for national researchers, clinicians, and thought-leaders involved in the guideline writing and development to recognize the value PAs can bring to the process and to encourage inclusion in future documents,” DePalma said.

Sondra DePalma with a patientDePalma is a cardiology PA of 15 years, a Certified Hypertension Clinician, and Clinical Lipid Specialist with unique knowledge and experience in cardiovascular risk reduction. She worked with ACC on other patient-centered and prevention tools and served on the writing committee of the ACC’s 2016 and 2017 Focused Update of the ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk.

“These experiences taught me the importance of analyzing and synthesizing scientific evidence while focusing on the risks and benefits of recommendations to patients – as patients’ health and quality of life is the main focus of guidelines.”

Writing the guideline itself provides an example of how collaboration and team-based medicine can improve patient care, DePalma said. “The members of the writing committee were very respectful and inclusive of all committee members regardless of credentials or experience and appreciated everyone’s contribution. It was great to see that the chairs and all members of the committee valued my input and that of the NP and pharmacist.”

DePalma encourages other PAs to try to be added to writing committees: “It is important that PAs contribute to guideline development and add their perspectives to patient care. It is also important for PA advocacy that leaders in clinical fields experience the value of PAs in clinical guideline development, health advocacy and management, and patient care.”

Le agrees with DePalma. “This demonstrates to all Advance Practice Providers (APPs) that physicians and cardiology societies recognize the value of APP input and of team-based care. It is so important to have members of the team represented in guideline writing, in particular, when these guidelines are also implemented by those team members,” he said.

More Details at AAPA 2018 Presentation
DePalma will present The Hype on Hypertension: An Overview of the 2017 Guidelines for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adultson the history, evolution, controversy, and contemporary evidence of blood pressure guidelines and hypertension management to improve patient outcomes, on Monday, May 21, 2018, from 1:00 to 2:00 p.m. during AAPA 2018 in New Orleans.

According to DePalma, the presentation will help PAs understand the strengths and limitations of current evidence-based hypertension management recommendations. She will review the definitions and rationale for blood pressure classifications and blood pressure treatment goals. The presentation will provide a comprehensive overview of nonpharmacologic and pharmacologic blood pressure treatment, including pharmacologic recommendations in special populations. She will also emphasize strategies to promote medication adherence and lifestyle modification.

Eileen Denne is director of corporate communications.  Contact her at [email protected].

Learn more about the impact of the new guideline.