Neurologists urged to take on a bigger role in managing hypertension


By Sunalie Silva

12 Sep 2019

Neurologists are being called on to play a bigger role in diagnosing and managing hypertension in a bid to stem the tide of stroke and cognitive decline associated with the condition.

Writing in JAMA Neurology, US neurologists, who have investigated antihypertensive prescription patterns in primary care and neurology clinics for patients diagnosed with a stroke, found that while total antihypertensive prescriptions were increasing over time, 50.9% of primary care visits involved the prescription of an antihypertensive compared with only 26.2% of neurology visits.

Neurologists should find these numbers ‘shocking and unacceptable’ say the authors, noting that neurologists may be seeing patients as frequently as primary care physicians do for certain neurological diseases, such as epilepsy, multiple sclerosis and migraine. Visits that represent potential missed opportunities for counselling patients and primary prevention, they argued.

Speaking to the limbic about the commentary Professor Stephen Davis, director of the Melbourne Brain Centre and Neurology at the Royal Melbourne Hospital, said the message was an important one that already underscores Australian practice.

“I think most neurologists in Australia would regard measurement of blood pressure as being one of the important aspects of examination. Australian neurologists are probably much more competent in general medical treatments than American neurologists because we have quite extensive general medicine training before we go into neurology.

“We all recognise the importance of hypertension in neurological diseases so we’re very familiar with the treatment of hypertension – that it has to be aggressively treated – and most of us are comfortable deciding which of the blood pressure drugs to use.”

But charging neurologists with initiating hypertension treatment is problematic, argues Professor Davis, who is the Immediate Past-President of the World Stroke Organisation.

“The problem is this: hypertension usually requires more than one measurement of blood pressure to establish that the patient truly has hypertension. If a high blood pressure reading is picked up in an outpatient setting then usually the neurologist will advise the GP to recheck the blood pressure and to institute anti-hypertensive therapy.”

The authors of the commentary conceded that a number of challenges and barriers would need to be overcome before neurologists could become more involved in managing hypertension – fear of overstepping boundaries with general practitioners, for instance.

And with neurologists in short supply, patients and primary care physicians may prefer that neurologists focus on ‘the active neurologic issue at hand rather than preventing potential future neurologic conditions’, they wrote.

But the problem of limited neurologist time when it comes to actively diagnosing and treating hypertension could be helped along with the use of existing practice team members, they suggested. Medical assistants performing intake blood pressures could use a hypertension algorithm and relatively simple electronic health record interventions, such as after visit summaries explaining the importance of blood pressure control and automated messaging to primary care physicians could promote primary prevention efforts.

Meanwhile hypertension clinics run by advanced practice physicians or pharmacists could represent alternative solutions in situations where neurologists can’t personally manage hypertension, they added.

“Neurologists are not the sole answer to stemming the tide of hypertension, but it is necessary to increasingly recognise the role hypertension plays in the lives of patients and the spectrum of neurologic disease that matters to them. This specialty should feel obligated and empowered to become a bigger part of the solution.”

The viewpoint was published in JAMA Neurology.

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