Patterns of hypertension management in Italy: results of a pharmacoepidemiological survey on antihypertensive therapy. Scientific Committee of the Italian Pharmacoepidemiological Survey on Antihypertensive Therapy

OBJECTIVE: To collect statistically significant information on patterns of antihypertensive therapy in medical practice, with particular attention to the drugs used in the pharmacological management of hypertensive patients and the reasons for the limited achievement of therapeutic goals during treatment DESIGN: A survey conducted among general practitioners, specialists, and hypertensive patients. METHODS: A total of 28,000 physicians were contacted by letter and 3,394 declared their willingness to participate and received a questionnaire. Subsequently, 1,255 questionnaires suitable for analysis (corresponding to 37.0% of adhering physicians) were received. In addition, 4,612 questionnaires completed by patients were pooled and evaluated. The prevalence of hypertension was calculated from a base of 254,192 patients, seen by general practitioners. RESULTS: The prevalence of hypertension, defined as systolic blood pressure > or = 160 mmHg or diastolic blood pressure > or = 95 mmHg, or current treatment, was 19.7%. The average number of hypertensive patients in each general practitioner's file, covering the previous 12 months, was approximately 230. Physicians reported a 66% rate of discontinuation of treatment or switching to another drug. Physicians and patients both considered inadequate blood pressure control and side effects to be the two main reasons for switching antihypertensive therapy, but in opposite order. Furthermore, physicians indicated a prevalence of drug side effects between 10 and 20%, according to class of drug used, whereas 69% of patients reported to have experienced side effects. In the doctors' opinions, there were many reasons for poor patient adherence: complexity of the drug regimen, appearance of side effects, forgetfulness, reduced patient understanding of the need for long-term continuation of treatment, and refusal to accept a chronic pathological condition. CONCLUSIONS: The survey showed awareness of the disease among physicians and provides a representation of the experiences of both general practitioners and specialists, in addition to that of their patients. During antihypertensive therapy, a disconcerting degree of discontinuation and switching of drugs occurred. Insufficient blood pressure control and side effects accounted for most of the observed treatment changes. This survey revealed the existence of a gap between the physicians' perception of tolerability and the real experience of patients, a clear need for greater tolerability of treatments, and a need for an enhancement of patient-physician communication.     

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.     

Improving patient compliance: a major goal in the management of hypertension

The primary goal in the treatment of hypertension is to reduce the incidence of cardiovascular events in hypertensive patients. Studies performed to assess the impact of treating hypertension have revealed very disappointing reductions in the incidence of coronary heart disease. There are several reasons for these poor reductions in the incidence of cardiovascular disease; however, the most important is related to the fact that worldwide less than one quarter of hypertensive patients are adequately controlled for hypertension. Again, there are multiple reasons for these poor blood pressure (BP) control rates; however, most physicians would agree that patient compliance with their antihypertensive treatment is a major contributing factor. This is an area that we need to re focus on in our management of hypertensive patients. Issues such as safety, convenience, polypharmacy, cost, and education in the selection of antihypertensive agents are all critically important issues in the treatment of hypertensive patients. In addition, the level of patient involvement in their treatment seems to be essential in obtaining goal BP. Newer approaches to the management of hypertension such as earlier control of BP and the more aggressive use of low-dose combination therapy as first-line treatment of hypertension also need to be considered in our effort to improve BP control rates. Achieving goal BP in hypertensive patients is one of the most important clinical dilemmas facing physicians. There is little doubt that an improvement in control rates will result in substantial reductions in cardiovascular disease.     

Adherence to antihypertensive treatment: a critical factor for blood pressure control.

BACKGROUND: To compare rates of blood pressure (BP) control with the level of adherence to antihypertensive treatment and factors influencing compliance in Greek patients. DESIGN: An observational cross-sectional study on 1000 consecutively treated hypertensive patients, admitted to a University department of general surgery in a Greek hospital. METHODS: Patients were interviewed by the same doctor using pre-coded questionnaires with questions on demographic data, health and treatment status. Blood pressure was measured using a standard mercury sphygmomanometer. Treatment of hypertension was defined as current use of antihypertensive medication. Compliance was defined as an affirmative reply to a number of questions regarding regular use of antihypertensive medication according to the physician's instructions. RESULTS: Satisfactory BP control (levels <140/90 mmHg) was documented in only 20% of the treated hypertensives. Compliance to antihypertensive treatment was found in only 15% of the patients. Control of BP was positively associated with compliance. Compliance was more common among patients aged <60, city dwellers, the better educated, those more adequately counselled by their physicians and those followed by a private doctor. As regards treatment, compliance was better among those taking one antihypertensive tablet per day, those who had never changed their antihypertensive regimen and those who had never changed their doctor. CONCLUSIONS: Compliance is associated with more effective BP control. Physicians can enhance patient compliance and hypertension control by devoting more time to counselling, avoiding unnecessary changes in drug regimens and restricting the tablet numbers.     

Role of organizational factors in poor blood pressure control in patients with type 2 diabetes: the QuED Study Group--quality of care and outcomes in type 2 diabetes

BACKGROUND: A large body of evidence supports the need for reducing the cardiovascular burden of diabetes. Only indirect and occasional data describe the adequacy of routine management of hypertension in patients with diabetes. The aim of this study was to explore the interplay of some potential key determinants of quality of antihypertensive care, including the settings, physicians' beliefs about blood pressure (BP) control, and patient-related factors. METHODS: We evaluated physicians' beliefs about BP control using questionnaire responses at study entry. A sample of 3449 patients with type 2 diabetes mellitus, of whom 1782 (52%) were considered to have hypertension, was recruited by 212 physicians practicing in 125 diabetes outpatients clinics (DOCs) and 106 general practitioners (GPs). We evaluated the type and number of antihypertensive agents used and the BP values at study entry and after 1 year of follow-up. We used multilevel analysis to investigate correlates of poor BP control (> or =160/90 mm Hg). RESULTS: Only 16% of GPs and 14% of DOC physicians targeted BP values of less than 130/85 mm Hg. At study entry, 6% of the patients had values below 130/85 mm Hg, whereas 52% showed values of 160/90 mm Hg or greater. Only 12% of subjects were treated with more than 2 drugs at study entry, compared with 16% at the 1-year follow-up (P =.001). Multilevel analysis showed that patients attending DOCs had a more than 2-fold increased risk for inadequate BP control, compared with those treated by GPs. The risk for poor BP control was 2 times higher for patients treated by male physicians compared with those treated by female physicians, and it was halved when the physician responsible for the diabetes care specialized in diabetology or endocrinology. CONCLUSION: In a model situation of comorbidity, the overall quality of care depends on structural and organizational factors, which are likely to be more influential than existing guidelines.     

Risers and Extreme‐Dippers of Nocturnal Blood Pressure in Hypertension: Antihypertensive Strategy for Nocturnal Blood Pressure

There is increasing evidence that disruption of diurnal blood pressure (BP) variation is a risk factor for hypertensive target organ damage and cardiovascular events. Especially, the risers (extreme non‐dippers), who exhibit a nocturnal BP increase compared with daytime BP, have the worst cardiovascular prognosis, both for stroke and cardiac events. On the other hand, extreme‐dippers (with marked nocturnal BP falls) are at risk for non‐fatal ischemic stroke and silent myocardial ischemia, particularly extreme‐dippers complicated with atherosclerotic arterial stenosis and excessive BP reduction due to antihypertensive medication. Extreme‐dipping status of nocturnal BP is closely associated with excessive morning BP surge and orthostatic hypertension. Hypertensive patients who have these conditions and exhibit marked BP variations are likely to have silent cerebral infarct and to be at high‐risk with regard to future stroke. Individualized antihypertensive medication targeting disrupted diurnal BP variation might thus be beneficial for such high‐risk hypertensive patients.     

Risers and extreme-dippers of nocturnal blood pressure in hypertension: antihypertensive strategy for nocturnal blood pressure

There is increasing evidence that disruption of diurnal blood pressure (BP) variation is a risk factor for hypertensive target organ damage and cardiovascular events. Especially, the risers (extreme non-dippers), who exhibit a nocturnal BP increase compared with daytime BP, have the worst cardiovascular prognosis, both for stroke and cardiac events. On the other hand, extreme-dippers (with marked nocturnal BP falls) are at risk for non-fatal ischemic stroke and silent myocardial ischemia, particularly extreme-dippers complicated with atherosclerotic arterial stenosis and excessive BP reduction due to antihypertensive medication. Extreme-dipping status of nocturnal BP is closely associated with excessive morning BP surge and orthostatic hypertension. Hypertensive patients who have these conditions and exhibit marked BP variations are likely to have silent cerebral infarct and to be at high-risk with regard to future stroke. Individualized antihypertensive medication targeting disrupted diurnal BP variation might thus be beneficial for such high-risk hypertensive patients.     

Tolerability and treatment compliance with angiotensin II receptor antagonists

Several studies and intervention trials performed during the past 30 years have provided evidence that hypertension-related cardiovascular risk is not irreversible. This is because the reduction in blood pressure (BP) induced by antihypertensive drugs has been shown to be accompanied by a clear-cut decrease in the rate of cardiovascular events and complications. There is also evidence that BP control in the population is far from being optimal, and that no more than one quarter of treated hypertensive patients display BP values <140/90 mm Hg. The reasons for inadequate BP control are multiple, involving a combination of factors such as inadequate compliance with treatment, intolerance to side effects of currently prescribed drugs, and insufficient clinical use of combination drug treatment.

This article focuses on three major areas. It first provides an overview of the current status of BP control in treated hypertensive persons. It then examines the factors potentially responsible for this phenomenon, with particular emphasis on the relevance of the so-called “compliance factor.” Finally it provides an overview of the tolerability and compliance profile of the angiotensin II receptor antagonists, a new class of antihypertensive drugs characterized by an efficacy and safety profile.     

Hypertension management: results of a new national survey for the hypertension education foundation: Harris interactive

A new national online survey by Harris Interactive of 1245 hypertensive individuals indicates that >90% were aware that elevated blood pressure (BP) is a major risk factor for cardiovascular disease. The majority discovered that they had elevated BP levels as a result of a routine examination. More than two thirds of persons identified 120/80 mm Hg as an optimal BP level; only 6.0% stated that the Internet was their primary source of information about high BP. More than 60% of respondents had a body mass index >30 kg/m(2), and >50% had other cardiovascular risk factors. More than 50% were involved in some lifestyle change to control BP, and >90% were taking medication. More than 60% reported that BP was controlled (<140/90 mm Hg) at the last visit, although approximately 50% were told that their BP was high at some time. The survey results suggest that >90% of hypertensive patients are aware of the risks of elevated BP and that a high percentage of hypertensive patients are being treated with medication. Control rates as reported by respondents were >60% based on last BP recorded; however, between 31% and 40% of patients (based on differences in ethnic groups) were continued on the same therapy despite elevated BP levels. The survey suggests a high degree of risk awareness and treatment, and what appears to be an increase in control rates among hypertensive patients.     

Application of French guidelines in newly diagnosed hypertensive patients managed by general practitioners

The French guidelines of the 2000 ANAES indicate that the management of patients with hypertension should not be based only on the level of blood pressure, but also on the presence of other risk factors and/or concomitant diseases such as diabetes or target organ damage. OBJECTIVES: To evaluate if the 2000 ANAES Guidelines concerning the initiation of antihypertensive treatment are applied by general practitioners. METHODS: Seventy new diagnosed hypertensive subjects, never treated by antihypertensive drugs, managed by 13 general practitioners were included in the study. From the data of the general practitioners medical report, the cardiovascular risk have been retrospectively recalculated for all the subjects. The concordance between the Guidelines and the clinical practice in term of institution of treatment have been evaluated. RESULTS: In this population of mean age 58 +/- 15 years, a concordance of 64% between the 2000 ANAES Guidelines and the clinical practice was observed (45/70 subjects). Among the discordant subjects (36%, [25/70]), the treatment was instituted by excess in 88% of cases (22/25) although it was not recommended. In contrast, in the remaining 12% of cases, only lifestyle measures have been proposed although an antihypertensive treatment was recommended. The discordance concerns essentially subjects with medium cardiovascular risk (84%). The principal determinants of this discordance were the grade 2 of hypertension and the presence of few risk factors (1 or 2), where the cardiovascular risk have been overestimated. CONCLUSIONS: Guidelines concerning the initiation of antihypertensive treatment in new diagnosed hypertensive subjects are more often applied by general practitioners. It is particularly in subjects with medium cardiovascular risk that the decision of the initiation of treatment is taken by excess in comparison to guidelines.     

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.     

Prevalence and therapeutic control of hypertension in 30,000 subjects in the workplace

-To assess blood pressure (BP) control in a French working population through the use of a careful assessment of BP based on 2 different visits in 1 month, 17 359 men and 12 267 women were evaluated from January 1997 to April 1998. The initial phase was a cross-sectional analysis of a cohort study designed to assess the incidence of arterial hypertension in a French working population. Information was collected by the work-site physician during the annual examination. BP was measured with a validated automatic device. Among subjects with BP >/= mm Hg, patients not treated with antihypertensive drugs were invited to have an additional BP measurement taken 1 month later. The prevalence of hypertension (BP >/= mm Hg) based on 2 visits was 16.2% in men and 9.4% in women. When the diagnosis of hypertension was based on 2 visits, its prevalence was 41% lower in men and 36% lower in women compared with that of a diagnosis based on a single visit. Accordingly, the awareness of hypertension was 49% higher in men and 40% higher in women. Overall, 12.5% of hypertensive men and 33.2% of hypertensive women taking antihypertensive medication had their BP levels lowered to < mm Hg by treatment. Although the percentage of hypertensive men and women under current treatment who were aware of their hypertension increased with age, BP control among treated subjects decreased with age. Ineffective BP control with treatment accounted for 33% of BP levels >/= mm Hg in men and 40% of those observed in women. In this large French working population, estimates of hypertension therapeutic control depend heavily on the number of BP measurements. Despite these methodological precautions, insufficient awareness of BP and insufficient BP control through treatment remain 2 major public health problems.     

Registry of the Egyptian specialized hypertension clinics: Sex‐related differences in clinical characteristics and hypertension management among low socioeconomic hypertensive patients

Hypertension is a major modifiable risk factor for cardiovascular disease (CVD) which is a leading cause of death in developing countries affecting both genders. Gender dissimilarity in clinical characteristics and hypertension (HTN) management among hypertensive patients has been reported in several reports before. The aim was to detect sex differences in clinical characteristics and HTN management among Egyptian hypertensive patients. Data from 4701 hypertensive patients attending 9 university located Specialized Hypertension clinic (SHC) were collected from October 2014 to September 2017. The collected data included demographics, cardiovascular risk profile, hypertension‐related history, anthropometric and blood pressure (BP) measurements, antihypertensive medications used, number of patients attending the follow‐up visits, and HTN control rate. Females represented 58.5% of the recruited patients, they were younger, with higher BMI, lower education level, and employment rate compared with males. Females had lower mean office systolic and diastolic BP than males (144.2 ± 22.6 vs. 146.5 ± 22.0 mmHg and 88.1 ± 13.0 vs. 89.9 ± 12.6 mmHg, respectively) and lower rate of uncontrolled BP (54.8% vs. 61.1% in males P < .001). Antihypertensive drugs were comparable among both sexes except for angiotensin converting enzyme inhibitors which were more prescribed in males. Compliance to antihypertensive medications was better in females (63.6% vs. 60.1% in males, P = .015). To conclude, Egyptian hypertensive females have different clinical characteristics as compared to their counterpart males with better BP control, adherence to antihypertensive medications, lower systolic and diastolic BP, and no major differences in the prescribed antihypertensive distribution.     

Overall cardiovascular risk still ignored in general practice care of hypertension

BACKGROUND: Recent guidelines for the management of arterial hypertension have emphasized the importance of total cardiovascular risk for setting the blood pressure (BP) goal to be achieved and the intensity with which it should be pursued. DESIGN: To assess the degree of BP control in hypertensives receiving long-term antihypertensive treatment according to the presence of major cardiovascular risk factors or diseases and the level of individual total cardiovascular risk, a large sample of general practitioners throughout Italy had to evaluate a random sample of their hypertensive patients. METHODS: A clinical history was collected for each patient and BP was measured three times using a reliable automatic instrument. To stratify the cardiovascular risk we used the criteria suggested by the 1999 WHO-ISH guidelines. RESULTS: Among the 1204 patients recruited (mean age 64.2 +/- 11.4 years, 663 females), only 399 patients (33.1%) had a BP lower than 140/90 mmHg. Except for male sex and previous myocardial infarction, the concomitant presence of major cardiovascular risk factors or diseases was never associated to a better control of hypertension. BP control was unrelated to individual overall cardiovascular risk: BP was < 140/90 mmHg respectively in 44.0, 37.7, 33.5 and 42.1% (P for trend = 0.54) of people aged less than 65 years with low, medium, high and very high risk and in 27.7, 25.9 and 27.1% (P for trend = 0.91) of people aged more than 65 years at medium, high and very high risk. CONCLUSIONS: BP control in Italian hypertensives is still unsatisfactory, even in patients at high and very high cardiovascular risk.     

Reasons for not intensifying antihypertensive treatment (RIAT): a primary care antihypertensive intervention study

OBJECTIVE: Hypertension is often poorly controlled, despite its importance and despite the availability of very effective treatments. An under-recognized problem is the failure of consensus guidelines to acknowledge the important difference between efficacy in clinical trials and effectiveness in clinical practice. The present survey was designed to prospectively assess what is the target blood pressure (BP) goal defined by a general practitioner (GP) for an individual patient, and what are the reasons for not modifying an antihypertensive drug regimen, when pre-defined individual BP goals are not achieved. DESIGN: Family practice based, open intervention survey. SUBJECTS: Participating GPs enrolled 2621 hypertensive patients. At the first visit each physician was required to assess the cardiovascular risk profile of each patient and to define individual BP targets. INTERVENTIONS: Treatment was started with irbesartan alone or in fixed combination with hydrochlorothiazide. Follow-up visits were suggested after 1 month, 2 months and 4 months. Physicians were asked to report BP values under the new treatment regimen and to indicate whether in their opinion pre-defined BP targets set at baseline were achieved or not and whether the antihypertensive regimen was modified or maintained in relation to whether target BP was reached or not. MAIN OUTCOME MEASURE: To provide reasons for not changing the treatment even though BP goals were missed. RESULTS: Average target BP values defined by the physicians at baseline were 138 +/- 8 mmHg for systolic and 84 +/- 5 mmHg for diastolic BP. Among GPs, defined target BP values did not depend on individual risk stratification, but rather depended on baseline BP values. At baseline systolic and diastolic BP averaged 165/97 +/- 17/10 mmHg, while at the last visit achieved BP averaged 140/84 +/- 14/8 mmHg. There were three main reasons for not intensifying antihypertensive treatment when BP targets were not achieved. These reasons were: (1). the assumption that the time after starting the new drug was too short to appreciate its full effect (44% at first, 14% at last follow-up), (2). that there was a clear improvement or the target BP was almost reached (24% at first, 34% at last follow-up) or (3). that self-measurements were considered satisfactorily (10% at the last visit). CONCLUSIONS: Failure of physicians to follow guidelines is apparently dependent on the belief that baseline BP dictates the target, that a clear improvement in BP might be sufficient and that the full drug effect may take up to 4 months or more to be attained.     

Hypertension in high-risk patients: beware of the underuse of effective combination therapy (results of the PRATIK study)

OBJECTIVE: To determine whether blood pressure control in a general practice setting is influenced by the presence of additional risk factors, and to analyse the role of antihypertensive therapy in this relationship. DESIGN: A cross-sectional study was conducted with a sample of 3153 general practitioners. SETTING: Primary care. PARTICIPANTS: The first five hypertensive patients presenting at the practitioner's office were included. MAIN OUTCOME MEASURES: Cardiovascular risk factors, antihypertensive drugs and cardiovascular history were reported. Blood pressure was measured. The analysis was conducted in treated patients who were divided in three groups: no other risk factors (group I); 1-2 risk factors (group II); 3 or more risk factors or target-organ damage or diabetes or associated cardiovascular disease (group III). RESULTS: Data were available for all variables in the 14 066 treated hypertensive individuals who form the basis of this report. Blood pressure control had been achieved in a lower percentage of individuals in group III (27%) than in group I (42.9%). To control hypertension, combination therapies were more frequently required in group III (55.8%) than in group II (43.5%) or group I (34.2%). Among individuals with uncontrolled hypertension, about 39% of patients in group III were receiving monotherapy and the percentage receiving two-drug treatments identified as effective in the 1999 WHO guidelines was significantly lower in group III. CONCLUSION: The study shows that, in general practice, control of blood pressure decreases as the number of risk factors present increases. An underuse of combination therapy, especially effective two-drug treatment in patients with several risk factors, may account for this finding.     

A cross-sectional study of blood pressure control in hypertensive patients in general practice (the I-TARGET study)

Introduction

Despite the availability of multiple effective antihypertensive drugs, hypertension control rates remain poor. The reasons for this are complex, but increasingly, physician inertia has been identified as a crucial factor. In this study we attempted to define the level of blood pressure (BP) control and reasons for not achieving control in a survey of selected general practices within South Africa.

Methods

This was a multi-centre, cross-sectional disease study involving 15 selected general practices throughout South Africa. Treated hypertensive patients over 18 years old were eligible for inclusion. The study was approved by Pharma Ethics, and after informed consent, consecutive hypertensive patients at the participating general practice centres were included, with each centre enrolling 30 patients.

Results

A total of 451 patients, from 15 sites in South Africa, were entered in the study. The mean age of the patients was 60.7 years, 56.3% were female and 15.7% were current smokers. The BP was reduced by 26.4/17.6 mmHg (p < 0.001) in 220 patients with a documented initial BP. Co-morbidities were present in 322 (71.4%) patients and overall, 37.9% had more than one co-morbidity. Lifestyle modification was not uniformly applied, with only 46.1, 59.6 and 56.8% receiving advice about weight loss, exercise and diet, respectively. Less than a third (30.7%) of patients were on monotherapy, 42.8% were on two drugs (25.9% on fixed-drug combination and 16.9% on free combination) and 26.5% were on more than two agents. Most (86.9%) practitioners used either international or local guidelines to determine target BP. Overall, 61.2% of patients were at goal (BP < 140/90 mmHg). If a stricter target BP (BP ≤ 130/80 mmHg) is applied to patients with co-morbidities, as recommended by the guidelines, 60.6% of patients did not reach goal. Of the 175 patients not at target BP, there was no action plan in 22.9%, while 39.4% were advised to undertake lifestyle changes only.

Conclusions

Control rates were quite good in comparison with other surveys within and outside South Africa. However we were able to define several important deficiencies: there was evidence of physician inertia and also practitioners need to be more cognisant of local and international guidelines to optimise treatment.     

Awareness of Hypertension and Proteinuria in Randomly Selected Patients in 11 Italian Cities. A 2005 Report of the National Kidney Foundation of Italy

Arterial hypertension and proteinuria are risk factors for chronic kidney disease. A mobile clinic was parked in a central plaza of 11 Italian cities to check blood pressure (BP), prescribe antihypertensive drugs, assess for proteinuria, and provide awareness about hypertension. Among 3757 patients, 56% were hypertensive, 37% were not diabetic nor proteinuric with BP ≥140/90 mm Hg, 17% were diabetic or proteinuric with BP ≥130/80 mm Hg, and 11% were on treatment with BP at target. Among 1204 treated patients, 400 (33%) had controlled BP. Among all 2114 hypertensive patients, only 1344 (64%) were aware of their hypertension. Awareness was greater among treated patients at target (99%). As many as 523 (14%) patients had proteinuria ≥30 mg/dL. The authors conclude that awareness of people walking in the street about their BP and proteinuria is insufficient. Mobile screening clinics may increase public awareness and detection of hypertension and proteinuria in the general community and detect patients at risk for chronic kidney disease.     

Arterial hypertension management in general practice in France according to global risk factors

OBJECTIVE: The absolute benefit of antihypertensive medications increases with the level of cardiovascular risk. Moreover in high risk groups, it has been demonstrated that tight blood pressure (BP) control conferred a substantial reduction in the risk of cardiovascular events compared to less tight BP control. Taking into accounts these data, the WHO guidelines recommend to achieve normal BP in high risk subjects. The aim of the study was to assess BP control in a large population of hypertensives (HT) after stratification by cardiovascular risk. METHODS: 15,514 HT defined as office BP > or = 140/90 or the presence of antihypertensive treatment were recruited in France by 3,152 general practitioners. Cardiovascular risk factors and office BP were recorded. Controlled hypertension was defined as a BP < 140/90 mmHg. In patients free of cardiovascular disease, 10-year cardiovascular risks were calculated on the basis of the equations derived from the Framingham Study. RESULTS: 10-year risks were available in 13,560 HT. Those in the highest quartile had greater body mass index (BMI) and the highest concentration of diabetics and current smokers (upper quartile versus lower quartile: BMI: 28.15 vs 26.51 kg/m2; diabetics: 45% vs 3%; current smoking 32% vs 12%; p < .001). [table: see text] Increasing quartiles of risk were associated with the prevalence of uncontrolled hypertension and at a lesser extent with the use of combination therapy. Subjects in the upper quartile had more frequent calcium-blockers, ACE inhibitors and diuretics use and a less frequent betablocker use. CONCLUSION: In general practice, 85% of hypertensives at highest risk are uncontrolled whereas half of them are under monotherapy. An antihypertensive strategy based on global risk may improve BP control in high risk patients.