The Evolving Clinical Management of Hypertension

The management of hypertension has continued to change during the past 5 decades. We have seen progressive improvements in the number of patients being treated and achieving control of their blood pressure (BP). A large part of this clinical success can be linked to the widening array of effective and inexpensive drugs that are now available to clinicians. In addition, the medical community has become highly knowledgeable about the management of hypertension, although, despite our therapeutic advances, a meaningful number of patients still do not have adequate access to care. The Journal of Clinical Hypertension has become a major resource for practitioners and investigators in the field of hypertension practice, and this brief review will take a look at a small selection of interesting articles published by the Journal last year that addressed this area. One of the major cornerstones in the history of clinical hypertension in the United States was the creation of the National High Blood Pressure Education Program (NHBPEP). In an eloquently written editorial to celebrate the 40th anniversary of the NHBPEP, Dr Marvin Moser and Dr Edward Rochella described the genesis of this remarkable program.1 Among other things, the program was responsible for creating the Joint National Committee (JNC) reports that guided clinical practice over several years and for stimulating efforts by the National Institutes of Health to conduct meaningful clinical trials in the field of hypertension.2 Dr Moser deserves much of the credit for the NHBPEP and remained its champion during many fruitful years of contributing to America's public health. Dr Rochella, a distinguished scientist at the National Heart, Lung, and Blood Institute, played a major role in the activities of the NHBPEP and particularly in the arduous work of producing the JNC reports. Our Journal was delighted to publish this brief article by Drs Moser and Rochella, and we believe that readers will have enjoyed its fascinating insights into the progress of hypertension care in this country. A current area of attention in our field is treatment-resistant hypertension. This condition reflects the fact that some patients, despite being prescribed apparently effective multidrug regimens, continue to have uncontrolled BP. In an editorial, Dr Suzanne Oparil and I reviewed a report that evaluated the emotional responses of patients to this condition.3 Schmieder and colleagues4 had reported that a survey of patients with treatment-resistant hypertension revealed that these individuals had serious emotional consequences associated with their poor BP control. For instance, the patients were fearful of imminent major events such as strokes and heart attacks. They were pessimistic about their future health and in many cases expressed concerns that they might not live long enough to see their children or grandchildren grow up. It is likely that many people with apparent treatment-resistant hypertension may not, in fact, truly have this condition. In some cases, the patients may have high office BP caused by white-coat hypertension; in other cases, there may be hidden or unsuspected secondary hypertension or the use of other drug types that could interfere with hypertension treatment; or, in many cases, there could be a lack of compliance by the patients with their prescribed treatment. One of the major arguments put forward by Dr Oparil and myself was that high BP, regardless of whether an explanation can readily be found, remains a major risk factor for strokes and other serious outcomes. So, without trying to apportion blame for poor treatment results to patient behavior or inadequate clinical management, the overriding need is to identify these patients and find solutions—with traditional or newer modes of treatment—that can bring their BPs into a safer range. There are still deficiencies in the overall management of hypertension in the United States. An article by Dr Adesuwa Olomu and colleagues5 reported on BP control in a Federal Qualified Health Center (FQHC) in Michigan. Although the overall control of BP in the United States has continued to improve during the past several years,6 the findings in Michigan revealed that the patients who qualified for care in this type of facility had lower rates of BP control than the national average. The report indicated that 75% of the patients seen in the center were on Medicaid. Overall, women achieved better BP results than men, but there was no difference between patients categorized as white or black. The control rates in patients with diabetes were particularly poor. The explanation for this result is not easily apparent because it suggests that simply providing standard resources for medical care may not be sufficient. Future strategies may require the introduction of programs to proactively educate and support patients whose BPs are not responding adequately to treatment. Although traditional hypertension guidelines use a BP threshold (typically 140/90 mm Hg) to diagnose hypertension, an article by Drs Brent Egan and Yumin Zhao7 has drawn attention to the fact that a large number of patients, typically young, are diagnosed with hypertension based on the fact that they have been told on at least two occasions by medical personnel that they have this condition. This is a meaningful consideration because the American Heart Association includes these patients in its statistical reports of cardiovascular conditions.8 The report by Egan and Zhao indicates that when such individuals are included in hypertension statistics they can influence public health policy and reporting since they may have nonhypertensive BPs (<140/90 mm Hg) when re-checked, yet still be counted among the hypertensive population. Of course, it could be argued that for young adults, a value below 140/90 mm Hg (eg, 130/80 mm Hg) might be more appropriate for diagnosis, and indeed this has been suggested as an expert opinion in the hypertension guidelines published by the American Society of Hypertension (ASH)/International Society of Hypertension.9 In a multicultural country it may be important to modify predictors of cardiovascular risk according to ethnicity. For instance, a paper by Dr Nam-Kyoo Lim and colleagues10 based on the Korean General and Epidemiology Study constructed a formula for predicting the probability of patients with a variety of demographic and clinical characteristics to become hypertensive. They compared their Korean-based formula with the Framingham Hypertension Risk Score11 and found that the findings in their own derivative and validated patient sets were clearly more reliable than the Framingham model in identifying Asian patients likely to become hypertensive. It will be interesting to see whether similar risk models can be established for other ethnic groups as well. It is logical to assume that poor adherence or compliance to treatment will increase the risk of uncontrolled hypertension and the probability of adverse cardiovascular outcomes and increased hospitalizations.12 How common is the problem of nonadherence? In a report by Dr Larissa Grigoryan and colleagues,13 120 primary care patients with uncontrolled hypertension were evaluated for drug adherence by electronic monitoring. Of these patients, 74% had at least one day during which their drugs were omitted. Almost 30% of these patients with uncontrolled hypertension had treatment gaps of at least 4 days during the 30-day period of monitoring. Dr Grigoryan and her colleagues speculate that the use of long-acting antihypertensive drugs could help cover the gaps in treatment, but the large number of people who omit their treatment for multiple days at a time would obviously require a different kind of intervention to improve their BP results. It is not always the patient, however, who is responsible for inadequate treatment results. Hypertension is often affected by so-called clinical inertia, a situation in which physicians fail to intensify treatment despite observing that their ongoing therapy is not being effective in achieving the desired results.14 Despite this apparent failure on the part of clinicians, there may at times be good reasons why they do not increase the dosage of drugs or add new ones. In a report by Dr Nayan Desai and colleagues,15 charts were reviewed in 429 patients in an academic chronic kidney disease clinic. Of these patients, 263 had not achieved target BPs. In this uncontrolled group, treatment had been intensified in 81 patients and in another 67, physicians acknowledged the lack of BP control but gave reasons for why they were not adjusting the drug therapy at that time. However, in 115 of the 263 uncontrolled patients, there was no reason offered for a failure to change the therapy, indicating that 44% of patients with inadequate BP control probably represented true therapeutic inertia. Of course, it may still be possible that in these patients there was a plausible reason for not adjusting therapy, but these findings still point out that even among clinicians regarded as experts in BP management there may be excessive caution in upgrading hypertension treatment in appropriate patients. In view of these reports indicating that both patients and clinicians may share responsibility for poor BP results, it is interesting to consider the article by Dr Ivo Abraham and colleagues16 that looked at a meta-analysis of 14,646 patients to evaluate whether physicians or patients might be primarily responsible for inadequate responses to treatment. As already discussed, hypertension is an asymptomatic disease and is particularly susceptible to nonadherence, which has been reported in up to 50% of patients with this condition.17 Using hierarchical modeling of physician and patient characteristics that might be predictive of BP outcomes, Abraham and colleagues found—not surprisingly—that BP control was better in treatment-adherent patients. What was particularly important was that the vigilance by physicians in checking BP and adjusting treatment was clearly a beneficial factor in achieving BP control. Similarly, it was noted that the patients with greatest adherence to therapy were those with a history of prior cardiovascular events, suggesting that adverse cardiovascular outcomes of hypertension provide a strong incentive for more rigorous compliance by patients with prescribed antihypertensive therapy. Although none of these findings could be regarded as unexpected, they nevertheless provide useful information in helping us understand what might underlie good or poor treatment results. A similar look at physician and patient characteristics in determining the outcomes of BP treatment was conducted by Dr Christopher Harle and colleagues.18 Again, this study was motivated by previous evidence that failure by practitioners to increase treatment when BP goals are not met is a major cause of poor results.19 The study comprised an evaluation of 5 years of electronic health records from a multispecialty group practice. The investigators found that 66% of their patients experienced clinical inertia or an inadequate response to unsatisfactory BP control. Interestingly, when evaluating physician performance, only one characteristic appeared to indicate clinical inertia: patient volume. Perhaps it could be speculated that physicians with a long list of patients to see may not have sufficient time to deal with inadequately controlled BP, although making treatment adjustments not be a major Among patients, there were major predictors of poor the of a health and One of the useful results of this work by Dr Harle and colleagues is that by identifying some of the for poor results it might be possible to strategies to The of clinical in the clinical management of hypertension, particularly in a with has been to be highly A report by and has evaluated the by outcomes based on BP Using the of were to be part of the other were to as a control. of the In for the BP, there was a difference of mm Hg the there was a Hg during and a Hg at the in BP associated with the in the patients by the there was an of patient during the treatment as compared with only in the control group, indicating the to BP control by the There was a use of in patients by the The of clinical in clinical to the problem of clinical inertia. to achieving BP outcomes has been reported by and from a major model health were that a variety of strategies have been to improve patient or to increase patient at investigators this one and the value of to their patients. they compared the results in patients who a to to a for a BP with the BPs in patients their care. The patients responding to the achieved clearly better BP those patients with a of cardiovascular or kidney disease or It was interesting that predictors of better results were and a than the As noted in other these investigators that women achieved better BP results than This and inexpensive use of to have results. It is that American patients are more likely to have hypertension and to its cardiovascular consequences than people of other it is to the management of patients with hypertension and to provide support in helping control of their BP. In a report by Dr and the value of for American patients was were based on patients being into hypertension and was with a control group without access to these the patients had in their and BPs and there was a for these patients to a of BP Using to be a good to particularly in up these as in a or other be and into the of the patients. A beneficial for BP control is the use of BP This has become to in years as a result of the of inexpensive and BP It is the hypertension community that patients to become in their own care BP in to better adherence to treatment and better BP results. Dr and colleagues at the for and the of primary care physicians to the use of BP They found that about one of primary care physicians BP in their patients. the other about one of primary care physicians this in than of their patients. Interestingly, practitioners were more likely than physicians to use BP to why they were not BP the common reason offered by physicians was that patients with would not easily be to the However, it that BP could be a part of hypertension care and be as a There is a on the resources of primary care in this country. Hypertension in is now common that it a and it has been suggested that may be a good for this might be particularly for patients in who find it to with their In a study by Dr and the on BP outcomes of during an period were compared with care in patients at or than or more than from their point of care. investigators found that there was no difference in BP findings between the and the care suggesting that can be a useful when are not This is a useful although those of us who have traditional may as to the of to One of the of effective hypertension management, particularly in the primary care is an effective but for high BP. In an that for patients different and would be highly There is good evidence that logical such as or are effective in In a written Dr BP control results in a large health by the standard use of an This out at and is increased to over a period of to BP control. is from a to a or a can be Of course, this of an be in patients who are or might become In addition, patients with for other as for patients with a history of or heart require different As some of the more than a to be in with an or clinical trials to of this in cardiovascular outcomes. There is that and the drug types that be regarded as the which treatment is and Dr major success in achieving high control rates is a that this to therapy be The clinical of hypertension experts are by readers of this and a by Dr and Dr is an important part of the In a these experts evaluated a report from the with reasons for poor BP In the reported that of individuals with uncontrolled hypertension had health and of had office medical care. The that we are observing a major for primary care physicians to improve hypertension care in the United the from the support the that access to care is not the explanation for poor BP particularly when many of these patients have medical there is an to improve outcomes by the of medical care. the other we that in many particularly in there is access to health care BP results are still not as good as in the United it is to with Drs and that efforts at the primary care be to improve outcomes in this country. practitioners are of to as a for BP control. The Health with a that a of in BP as compared with and it was that increased in increased the risk of strokes and heart In a argued Drs and the for of the of the and other for below It is that on an patient can be often because the in is not clearly or the for are progressive in the of and This be over a period of years and by or There are of course, in the and even some that can be This is probably not a and as Dr and colleagues point one of the in the role of in hypertension is that many have been based on The of is a for the Hypertension This the of that be this important in to it has long been argued that in or patients would be beneficial in BP. this has been although there have been some concerns that BP responses to can be over Dr and her colleagues have reported results from the a study of the BP of Using different strategies for these investigators evaluated the in BP in patients into outcomes or They that in BP to a with and of BP mm Hg) in the group 5 and in the There was no change in BP in the results that even when over a period of not to BP in a However, it would be that during a the increase in BP associated with could at least these apparently of management on BP. It be noted that other cardiovascular risk type diabetes or be or by providing to BP in these hypertensive patients. We still consider and its as of hypertension There has been the of BP in the of BPs. A report from the that there was no evidence that for hypertension in children cardiovascular events in However, in a written editorial by Dr and this was experts in hypertension point out the of hypertension with excessive cardiovascular such it would be to conduct for which is clearly a and However, these experts point out that we already have good evidence for BP such that BPs in children to be into and to identify more likely to have hypertension at an As the editorial out that even in children it is possible to find evidence for target indicating that high BP in children be regarded as a important cardiovascular The from these was that for hypertension in children is important and be on a BP in children can be multiple have been to an of their Dr and from from the National Health and Interestingly, of these young patients their BP or when their BPs were Of the patients who their the of appeared to be a major factor in this it is that children who are have their BP with increased to an of their BP it is more there has been in BP as an to traditional for BP in Dr and colleagues have compared the use of an and an for BP in They found that the two not particularly as as BPs were is that a hypertensive be on several occasions a of hypertension is In an Dr argued that despite their apparent may BP results. It be noted that in young people the BP is of meaningful in to the and it is a characteristic of that BPs are by that are to Dr that a high BP in a is with an that this be an In addition, Dr a useful clinical for the of high BP in the of hypertension in a Dr and a study of children to years in a large health Using standard from hypertension they found that of these young people had of and and had hypertension BP However, these investigators noted that of this large had two of their BP the in a of of this had or to evidence for hypertension. This to be a remarkable of hypertension in this young and attention to the of BP in children and to on a In a Dr and her the of patients to the of hypertension with This was an interesting to because previous indicated an between hypertension and in Using the of their health large patient these investigators compared the of hypertension in individuals as or be noted that of in children by and other and a of this is in the Dr and colleagues found compared with children of the of hypertension was in was in patients with and in patients with was that children be for hypertension. to strategies for their would be an important part of these One of the interesting in hypertension in is the high of strokes in the to as the It is that uncontrolled hypertension a major part in this and particularly in Dr and have reported from their to In this risk factor and these investigators on patients. They that 44% of this had uncontrolled BP and had uncontrolled BP. The control rates were lower in American patients than with the that American patients have a risk of particularly in the of the not that the two that uncontrolled hypertension in this of patients were and to treatment. findings clearly help an for work in in this of the United States. In another study on American patients with hypertension, Dr and her reported results from the Heart They reported findings in treated that the target BP of mm Hg was achieved by 66% and of patients at the two during this for many other the control of BP in was than in The investigators noted that the use of appeared to be associated with the results in these patients, with previous that are effective in BP in American guidelines have suggested that when their strategies for hypertension are not practitioners consider their patients to practitioners who are in hypertension. Dr and at the of reported on BP control results year patients were to their because of uncontrolled hypertension. are a group of hypertension a review of patients in they had year of the BP in these patients was during this period from mm Hg to mm this result was achieved on a number of than were already in use at the time of patient How these hypertension such a good result without of antihypertensive primary was to the of a by Dr This for a more of drugs to the of hypertension, and it is of that these academic hypertension experts of and to help in the effective treatment for their patients. This is a fascinating and be into consideration as for in to clinical practice in the years a new medical clinicians who had appropriate and an as Hypertension are to have many among the to deal with hypertension, one of the common and serious in primary care clinical Hypertension be effective in colleagues in achieving BP control as a part of the both in and of heart and Dr and a group of other of have put forward an to why hypertension now be regarded as a part of the cardiovascular and why to their in better care of hypertension be and now on the of good hypertension and it is to be that of clinicians in is probably the common chronic condition in medical consider qualified as Hypertension Overall, it has been to see in this small selection of from last of this Journal such and strategies for the management of hypertension. that what has been in this brief is truly only a small of the of information published in the of this I our list of Our published articles are readily available