Optimizing hypertension management in clinical practice

A clear relationship exists between elevated blood pressure (BP) and various manifestations of cardiovascular disease. Despite the availability of numerous treatment guidelines, hypertension remains inadequately controlled, with only a small proportion of patients achieving target BP levels. Many factors, both patient and physician related, contribute to this poor level of hypertension control. Major determinants include the implementation of inappropriate treatment regimens that do not enable patients to achieve goal and poor patient compliance. For example, it is widely acknowledged that most patients require two or more antihypertensive drugs to achieve BP goal; however, physicians may be reluctant to employ such treatment strategies. The aim of this review is to explore factors that contribute to poor hypertension control rates and how to overcome these, including the rationale for selecting combination therapy, with particular reference to angiotensin II receptor blocker combinations.     

Improving blood pressure control and clinical outcomes through initial use of combination therapy in stage 2 hypertension

Poor control of clinic and 24-h blood pressure (BP) is associated with enhanced risk of all cardiovascular disease events. Certain patient groups including the elderly, African-Americans, and those with hypertension and comorbid disease are difficult to control, as are patients with stage 2 hypertension (systolic BP>or=160 mmHg or diastolic BP>or=100 mmHg). It has been estimated that more than two-thirds of high-risk hypertensive patients with stage 2 hypertension and all hypertensive patients with diabetes mellitus or kidney disease will require two or more antihypertensive agents from different therapeutic classes to reach BP goals. Combining agents with distinct and complementary modes of action can address different pathophysiologic mechanisms involved in hypertension and may lead to more complete and prompt reductions in BP. Tolerability may also improve, as certain classes of antihypertensive agents ameliorate adverse effects associated with other agents. Patients may benefit from fixed-dose combinations of drugs as this simplifies the regimen and may improve adherence with therapy, control of BP, and ultimately lead to reductions in cardiovascular events. Recent data and treatment guidelines support the use of a combination strategy as 'initial' antihypertensive therapy in high-risk patients with stage 2 hypertension.     

Moving beyond guidelines: Are report cards the answer to high rates of uncontrolled hypertension?

Hypertension control rates remain alarmingly low worldwide despite the extensive evidence for decreased rates of cardiovascular, cerebrovascular, and renal events in response to blood pressure (BP) lowering to recommended targets. Several classes of antihypertensive drugs are available, which in combination can produce major decreases in BP, with minimal side effects. Moreover, most patients only have mild hypertension and, in general, can be controlled to < 140/90 mm Hg by proper combinations of two antihypertensive drugs. Although patient-related factors clearly contribute to poor control of hypertension, physician-related factors, particularly “passive” therapeutic inertia, are as responsible if not more so. Recent studies clearly indicate that monitoring performance of individual physicians and providing feedback on the care delivered by them can move treatment of hypertension to BP control rates in the 60% to 70% range. If health care organizations would implement this approach, enormous benefits could be expected for the prevention of cardiovascular and cerebrovascular disease.     

Reasons for Switching Antihypertensive Medication in General Practice: A Cross-Sectional Czech Nationwide Survey

To improve blood pressure (BP) control of their patients, physicians either adjust or switch antihypertensive medication. Currently, there is only limited information available on why physicians decide to switch antihypertensive medications.A questionnaire-based survey was performed between November 2011 and March 2012 in the Czech Republic. General practitioners were asked to fill in questionnaires about their hypertensive patients whose antihypertensive medication they were planning to change. These questionnaires recorded data about patient demographic information, cardiovascular risk factors, BP values, and reasons for switching antihypertensive medication.Two hundred eight-six general practitioners surveyed a total of 4341 hypertensive patients. The mean age of the patients was 59.8 years, 68.9% of patients were overweight or obese. Uncontrolled office systolic and diastolic BP >140/90 mm Hg was present in 89.6% and 81.5% of patients, respectively, despite the fact that 49.4% of patients used a combination of 2 or more antihypertensive drugs. The most common reasons for switching medication were insufficient BP control (73.7%), followed by aiming for a better 24-hour effect (38.4%) and increased cardiovascular risk of the patients (37.7%).The major reason for switching antihypertensive treatment in general practice was insufficient BP control. Switching medication because of adverse drug effects is less frequent than reported a decade ago.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in Singapore

Despite reductions in hypertension prevalence and improvements in control rates in recent years, almost one‐third of all deaths in Singapore are due to cardiovascular disease and that proportion is growing. Ischemic heart disease is the most common cause of cardiovascular death, ahead of stroke. Local data suggest that awareness and support for home blood pressure monitoring (HBPM) is good, but there are reservations about the accuracy of HBPM devices and physicians cited a lack of time and resources to educate patients about HBPM. In addition, there was a knowledge gap around use of HBPM for evaluating treatment response. This is consistent with the emphasis of using HBPM for the diagnosis, rather than monitoring, of hypertension in the Singapore hypertension guidelines. In the absence of specific HBPM thresholds and targets, it is suggested that HOPE Asia Network consensus documents provide the most locally relevant guidance of the use of HBPM. Calcium channel blockers and angiotensin receptor blockers are the most commonly used antihypertensive agents in Singapore, and monotherapy was relatively uncommon (24%) of patients. Overall, more needs to be done in detecting and managing hypertension in Singapore to address rates of cardiovascular disease and cardiovascular disease mortality. Use of HBPM needs to be encouraged to improve adherence to treatment and optimize BP targets according to Asian perspectives and data.     

Prevalence,awareness, and control of arterial hypertension in Denmark

Hypertension is an important modifiable risk factor for cardiovascular disease. Risk is reduced by reduction of blood pressure (BP). The present survey estimated the prevalence of hypertension, awareness, treatment, and BP control in Denmark. BP was measured three times on one occasion in a representative sample (n = 7,767) of the Danish population ages 20 to 89 years. Persons with screening BP ≥140/90 mm Hg also measured BP at home. Participants with home BP ≥135/85 mm Hg in general and ≥125/75 mm Hg for patients with diabetes or renal disease were categorized as hypertensive together with those already on antihypertensive treatment. Awareness was registered by questionnaire. Treated patients with BP below relevant limits were categorized as controlled. Age-adjusted prevalence of hypertension was on the basis of screening BP 25.7% and by home BP 22.3%. Seventy-two percent of patients found hypertensive by home BP were aware of it, 64% were treated, and 57% of those treated were controlled by office BP and 68% by home BP. One-fifth of the adult Danish population was found to be hypertensive, Awareness and control of hypertension was better than in most previous reports. Control rates similar to those of clinical trials are achievable in clinical practice.     

The heart,kidney, and brain as target organs in hypertension

The heart, kidney, brain, and arterial blood vessels are prime targets of hypertensive damage. Uncontrolled hypertension accelerates the damage to these organs and results in eventual organ failure and cardiovascular death and disability. Current guidelines for the appropriate treatment and control of hypertension requires an assessment of the presence of target organ damage. When present, evidence of target organ damage determines the urgency and intensity of drug treatment and may also dictate the choice of initial antihypertensive drug class. Thus, evaluation of persons with suspected or established hypertension must include a meticulous search for evidence of target organ damage. Fortunately, treatment with all antihypertensive medications that results in significant BP reductions also reduces fatal and nonfatal hypertensive complications and significantly slows down the progression to organ failure. Because of the important role that adverse activation of the renin-angiotensin-aldosterone system plays in target organ damage, drugs that antagonize this system have provided consistent and compelling proof of organ protection in both primary and secondary prevention of adverse outcomes. The challenge now is to use these and all other antihypertensive agents effectively to control BP to target levels in patients with hypertension. Continued emphasis on the adoption of lifestyle changes for prevention of hypertension in the first place or as adjunctive therapy in hypertensive patients is essential.     

Current status and characteristics of hypertension treatment by primary physicians in Korea: data from Korean epidemiology study on hypertension (KEY study)

BackgroundThis study was designed to investigate the characteristics, control rate, and factors affecting BP control in hypertensive patients treated by primary physicians in Korea.MethodsThe study was a multicenter, nationwide, cross-sectional, population-based survey conducted to identify the current status of hypertension treatment in Korean patients. A direct mail survey was sent to a random sample of 800 primary-care clinics across the nation. A total of 529 physicians in 510 clinics agreed to participate in this study (63.8%). Among the recruited 13,452 patients, 13,184 were included in the analysis.ResultsBP was controlled in 6,723 patients (51.0%). However, the control rate was lower in patients with diabetes (21.6%) or chronic kidney disease (CKD) (19.9%). Furthermore, the mean systolic and diastolic BP levels were higher in patients with diabetes and/or CKD. The mean BP level was higher in patients undergoing combination therapy than those undergoing single-drug therapy. Male gender, cardiovascular comorbidities, long duration of hypertension, and unhealthy lifestyle were associated with poor control of hypertension. In multivariate analysis, diabetes (odds ratio: 5.57; 95% confidence interval: 5.05-6.13) and CKD (odds ratio: 3.40; 95% confidence interval: 2.54-4.54) were the most significant independent factors related to poor BP control.ConclusionBP control is still largely unsatisfactory, especially in patients with diabetes and kidney disease, who could benefit the most from effective BP control. The reasons for poor BP control and high BP levels in those patients need to be investigated to improve BP control in Korea.American Journal of Hypertension (2008). doi:10.1038/ajh.2008.191American Journal of Hypertension (2008); 21, 8, 884-889. doi:10.1038/ajh.2008.191.     

The heart,kidney, and brain as target organs in hypertension

The heart, kidney, brain, and arterial blood vessels are prime targets of hypertensive damage. Uncontrolled hypertension accelerates the damage to these organs and results in eventual organ failure and cardiovascular death and disability. Current guidelines for the appropriate treatment and control of hypertension requires an assessment of the presence of target organ damage. When present, evidence of target organ damage determines the urgency and intensity of drug treatment and may also dictate the choice of initial antihypertensive drug class. Thus, evaluation of persons with suspected or established hypertension must include a meticulous search for evidence of target organ damage. Fortunately, treatment with all antihypertensive medications that results in significant BP reductions also reduces fatal and nonfatal hypertensive complications and significantly slows down the progression to organ failure. Because of the important role that adverse activation of the renin-angiotensin-aldosterone system plays in target organ damage, drugs that antagonize this system have provided consistent and compelling proof of organ protection in both primary and secondary prevention of adverse outcomes. The challenge now is to use these and all other antihypertensive agents effectively to control BP to target levels in patients with hypertension. Continued emphasis on the adoption of lifestyle changes for prevention of hypertension in the first place or as adjunctive therapy in hypertensive patients is essential.     

Reasons for therapeutic inertia when managing hypertension in clinical practice in non-Western countries

Insufficient awareness of hypertension guidelines by physicians may be an impediment to achieving adequate blood pressure (BP) control rates in clinical practice. We therefore conducted an open intervention survey among primary care physicians in 1596 centres from 16 countries in four different continents to prospectively assess what is the BP goal defined by physicians for individual patients and what are the reasons for not intensifying antihypertensive treatment when BP goals are not achieved. Enrolled patients (N=35,302) were either not treated to goal (N=22,887) or previously untreated (N=12,250). Baseline systolic and diastolic BP averaged 159/95+/-15/12 mm Hg. BP goals defined by physicians averaged 136+/-6 mm Hg for systolic and 86+/-5 mm Hg for diastolic BP. Patients' individual risk stratification determined BP goals. At last visit BP averaged 132/81+/-11/8 mm Hg and values of 相似文献   

Women and hypertension: what did we learn from the Women's Health Initiative?

The Women's Health Initiative (WHI) provides valuable data on blood pressure (BP) and on the prevalence, treatment, and control of hypertension in the largest multiethnic, best characterized cohort of postmenopausal women ever studied, including 98,705 women aged 50 to 79 years. Hypertension prevalence was high (38% overall) and directly related to age. Major determinants of hypertension prevalence included black race, history of cardiovascular disease (CVD), and concomitant CVD risk factors of physical inactivity, overweight/obesity, and excess alcohol consumption. Menopausal hormone treatment had little effect on BP. BP control rates declined dramatically with age. Interestingly, participants who were insured by Medicaid had significantly higher treatment rates and tended to have better BP control than those with Medicare only, perhaps reflecting differences in drug coverage and/or age. Inadequate intensity of antihypertensive treatment contributed to poor BP control: approximately 60% of participants were treated with a single drug; 30% with 2 drugs; <10% with 3 or more drugs, and the number of medications used was similar across age groups despite the age-related increase in the severity of hypertension. This treatment pattern is inconsistent with current treatment guidelines, which stress the need for 2 or more antihypertensive medications to control BP in most older hypertensive patients. The take-home message from WHI is that more effective strategies, including more efficient and cost-effective systems of healthcare delivery, are needed to control BP and prevent CVD morbidity and mortality in older women, a group characterized by severe, treatment-resistant hypertension and high risk for CVD events.     

Swiss Hypertension and Risk Factor Program (SHARP): cardiovascular risk factors management in patients with type 2 diabetes in Switzerland

The prevalence of hypertension in type 2 diabetics is high, though there is no published data for Switzerland. This prospective cohort survey determined the frequency of type 2 diabetes mellitus associated with hypertension from medical practitioners in Switzerland, and collected data on the diagnostic and therapeutic work-up for cardiovascular risk patients. The Swiss Hypertension And Risk Factor Program (SHARP) is a two-part survey: The first part, I-SHARP, was a survey among 1040 Swiss physicians to assess what are the target blood pressure (BP) values and preferred treatment for their patients. The second part, SHARP, collected data from 20,956 patients treated on any of 5 consecutive days from 188 participating physicians. In I-SHARP, target BP?135/85 mmHg, as recommended by the Swiss Society of Hypertension, was the goal for 25% of physicians for hypertensives, and for 60% for hypertensive diabetics; values >140/90 mmHg were targeted by 19% for hypertensives, respectively 9% for hypertensive diabetics. In SHARP, 30% of the 20,956 patients enrolled were hypertensive (as defined by the doctors) and 10% were diabetic (67% of whom were also hypertensive). Six per cent of known hypertensive patients and 4% of known hypertensive diabetics did not receive any antihypertensive treatment. Diabetes was not treated pharmacologically in 20% of diabetics. Proteinuria was not screened for in 45% of known hypertensives and in 29% of known hypertensive diabetics. In Switzerland, most physicians set target BP levels higher than recommended in published guidelines. In this country with easy access to medical care, high medical density and few financial constraints, appropriate detection and treatment for cardiovascular risk factors remain highly problematic.     

中国门诊高血压患者治疗现状登记研究

目的 了解我国门诊高血压患者血压达标率及其影响因素.方法 采用多中心横断面临床流行病学调查,在我国北京、上海、广州等分布于不同地理位置的22个城市中,选择92家三甲医院,于2009年4月20日至5月31日,对就诊于心内科、肾内科、内分泌科门诊的18岁及以上高血压患者进行流行病学调查,收集研究对象的一般人口学资料、疾病史、患者的血压控制情况、患者的心血管危险因素、患者的降压药物应用情况和患者关于高血压治疗的认知状况等信息.该项目经伦理委员会审核,所有患者签署知情同意.每个中心连续入组至50个及以上的病例.结果 本次共调查5086例患者,其中心内科2032例,内分泌1510例,肾内科1544例.研究对象在各不同科室间的身高、体重、体质指数(BMI)均数及性别、学历构成等均衡;全体研究对象中2和3级高血压分别占27.1%(1380/5086)和25.3%(1285/5086);伴发冠心病、糖尿病和肾功能不全的患者分别占22.4%(1139/5086)、37.2%(1891/5086)和18.4%(936/5086),且伴发疾病的百分比在各科室间不完全相同(P均<0.01).调查人群血压达标率为30.6%(1554/5086)[血压达标标准:糖尿病或肾病患者血压<130/80 mm Hg(1 mm Hg=0.133 kPa),其他患者<140/90 mm Hg],其中单纯高血压患者的达标率为45.9%,伴发冠心病、糖尿病及肾功能不全时达标率降低,达标率分别为31.3%、14.9%和13.2%.钙通道阻滞剂(CCB)和血管紧张素Ⅱ受体拮抗剂(ARB)为最常用的降压药物,分别占调查人群所用降压药物的56.6%和32.0%.全体研究对象中,平均服用1.73种降压药物,其中54.1%的患者联合应用2种或2种以上降压药物.起始降压治疗中,采用联合治疗或服用复方制剂的比例较低,分别为8.3%和12.7%.对血压达标产生影响的因素中:不饮酒、公费医疗、无糖尿病史、无肾功能不全史、合用降脂药物、平均就诊时间间隔短、从不漏服降压药物、具有适当体力活动的患者血压达标率高;而BMI增加、有糖尿病史、有肾功能不全史、不合用降脂药物、经常漏服降压药、第1次服用降压药物用药不详等的患者血压达标率降低.结论 China STATUS是中国第一个在三甲医院中进行的大规模、跨科室的多中心横断面临床流行病学调查;我国门诊高血压患者达标率较过去的调查结果有所上升,但仍然较低.BMI增加、伴随疾病、联合治疗比率低、患者依从性差为达标率低的主要原因.因此,提高联合治疗及复方制剂的应用比率,可有助于改善我国高血压控制现状.     

Evidence for improvement in survival with antihypertensive combination treatment

Hypertension constitutes a major risk factor for an array of cardiovascular diseases. Rates of morbidity and mortality related to its complications are high and remain an important concern in terms of public health. Improvement in cardiovascular outcomes and survival is an ultimate goal of the antihypertensive treatment. However, despite the wide range of available antihypertensive drugs, the rates of BP control are still insufficient. In most hypertensive patients, more than one antihypertensive compound is necessary to achieve goal levels of blood pressure. Assuming a greater antihypertensive effect may be obtained from two or more agents given in association, many combination therapies have been proposed and tested in a number of studies. The best clinical trial evidence comes from large outcome studies with an ACE inhibitor and dihydropyridine calcium antagonist combination, that of perindopril/amlodipine in the ASCOT trial in particular.     

Why is blood pressure so hard to control in patients with type 2 diabetes?

Resistance to antihypertensive drugs is common in hypertensive patients with type 2 diabetes. This is unfortunate because hypertension is one of the most important risk factors for development of cardiovascular events, and the goal blood pressure level is set lower in diabetic subjects than in nondiabetic subjects. Previous outcome trials in diabetic subjects have mainly focused on end points such as microalbuminuria or the incidence of cardiovascular events rather than on reduction of blood pressure; some reports, however, have suggested mechanisms for the drug resistance. These include several clinical conditions known to be associated with difficulty in reducing blood pressure specifically in diabetes mellitus: change in the renin-angiotensin system and chymase, volume overload, central sympathetic hyperactivity, sleep apnea, secondary hypertension, pseudoresistance (white coat hypertension), and poor compliance related to subclinical depression. In this review, the authors focus on the mechanisms of resistance to antihypertensive therapy (particularly for monotherapy with either angiotensin-converting enzyme inhibitors or angiotensin II antagonists) in the treatment of diabetic hypertension.     

Hypertensive heart disease.

Left ventricular hypertrophy (LVH) and diastolic dysfunction (CHF-D) are the early manifestations of cardiovascular target organ damage in patients with arterial hypertension and signify hypertensive heart disease. Identification of hypertensive heart disease is critical, as these individuals are more prone to congestive heart failure, arrhythmias, myocardial infarction and sudden cardiac death. Regression of left ventricular (LV) mass with antihypertensive therapy decreases the risk of future cardiovascular events. The goal of antihypertensive therapy is to both lower blood pressure (BP) and interrupt BP-independent pathophysiologic processes that promote LVH and CHF-D. The purpose of this review is to summarize current and emerging approaches to the pathophysiology and treatment of hypertensive heart disease.     

Hypertension and antihypertensive treatment in HIV-infected individuals. A longitudinal cohort study

Abstract Objectives. Hypertension is a significant contributor to cardiovascular disease in HIV-infected individuals. The purposes of this study were to assess the development of new-onset hypertension and the use of antihypertensive treatment and blood pressure (BP) control. Methods. In a longitudinal study of 434 HIV-infected individuals (43±11 years, 72% males, follow-up 3.4±0.8 years), standardized BP recordings were undertaken at three clinical visits both at baseline and at follow-up, and cardiovascular risk factors were monitored. Adjusted odds ratio (OR) for new-onset hypertension (systolic BP≥140 and/or diastolic BP≥90 mmHg or initiation of antihypertensive treatment) was calculated using multiple logistic regression analyses. Results. New-onset hypertension occurred with an incidence of 29.8 per 1000 person-years (95% CI 20.3-42.2). HIV duration (OR=1.10, 95% CI 1.01-1.20), mean BP (1.24, 95% CI 1.13-1.35) and abnormal urinary albumin excretion (OR=5.47, 95% CI 1.07-27.85) were independent predictors for new-onset hypertension after adjustment. Use of antihypertensive treatment increased threefold from 17% to 49% in hypertensive patients. Adequate BP control was obtained in 22% of patients on antihypertensive therapy. Conclusions. HIV duration predicted new-onset hypertension, which could suggest involvement of low-grade inflammation; this hypothesis needs to be further explored. Despite increased use of antihypertensive treatment, enhanced awareness and adequate treatment of hypertension are still warranted in HIV-infected individuals.     

Hypertension among Tunisian adults: results of the TAHINA project

We performed a national survey to determine the prevalence, awareness, treatment and control of hypertension, one of the main cardiovascular risk factors, among the adult population in Tunisia. A total of 8007 adults aged 35-70 years were included in the study. Blood pressure (BP) measurements were taken by physicians with a mercury sphygmomanometer, and standard interviewing procedures were used to record medical history, socio-demographic and cardiovascular disease (CVD) risk factors. Hypertension was defined as a systolic BP ≥140?mm?Hg and/or diastolic BP ≥90?mm?Hg or current treatment with antihypertensive drugs. The prevalence of hypertension was 30.6%, higher in women (33.5%) than in men (27.3%). Multiple logistic regression analyses identified a higher age, urban area, higher body mass index, type 2 diabetes and family history of CVD as important correlates to the prevalence of hypertension. Only 38.8% of those with hypertension were aware of their diagnosis, of which 84.8% were receiving treatment. BP control was achieved in only 24.1% of treated hypertensive persons. Women were more aware than men (44.8 vs. 28.8%), but the rates of treatment and control of hypertension did not differ between the two genders. Higher age, being female, lower education level and urban area emerged as important correlates of hypertension awareness. The study highlights the hypertension problem in a middle-income developing country. There is an urgent need for a comprehensive integrated population-based intervention program to ameliorate the growing problem of hypertension in Tunisians.     

Treatment and blood pressure control in isolated systolic hypertension vs diastolic hypertension in primary care

Cross-sectional surveys on prevalence, treatment and control of hypertension could not satisfactorily distinguish between diastolic hypertension and isolated systolic hypertension because the definition of hypertension included patients under pharmacological treatment. We assessed the situation in the two types of hypertension in general practice in Belgium, based on current blood pressure (BP) measurements and on BP prior to the initiation of drug therapy. Participating physicians enrolled the first 15 at least 55-year-old men visiting the surgery, measured their BP and recorded data on medical history including pretreatment BP, drug utilization, cardiovascular risk factors and target organ damage. Diastolic hypertension was defined as diastolic BP> or =90 mmHg, irrespective of systolic BP, and isolated systolic hypertension as systolic BP > or =140 mmHg and diastolic BP < 90 mmHg. Among 3761 evaluable patients, 74% were hypertensive. Among the 1533 hypertensive patients in whom blood pressure was known prior to treatment (n=965) or who were untreated at the study visit (n=568), 1164 had diastolic hypertension and 369 isolated systolic hypertension. The prevalence of antihypertensive treatment was, respectively, 75 and 25% (P<0.001) in these two types of hypertension. The odds of being treated were independently determined by type of hypertension, severity of hypertension and level of risk (P<0.001). BP was controlled in 25% of all patients with diastolic hypertension and in 13% of all patients with isolated systolic hypertension (P<0.001). About half of the treated patients with systolic hypertension were on a diuretic and/or a calcium-channel blocker. In conclusion, isolated systolic hypertension is less frequently treated than diastolic hypertension, overall BP control is poor and actual drug therapy diverges from recommendations based on placebo-controlled intervention trials.