Reducing therapeutic inertia to improve blood pressure control

Effective clinical management and control of hypertension remains a major challenge for physicians operating in different clinical settings, worldwide. Despite the majority of physicians reporting relatively high rates of perceived blood pressure control [1], over the past decade, observational studies and epidemiological surveys still have consistently and systematically showed relatively low proportions of hypertensive patients who attained the recommended blood pressure targets [2–6]. Several factors have been claimed to explain this gap between perceived and attained blood pressure control, among which some are related to patients (e.g. lack of adherence and frequent discontinuations from prescribed antihypertensive therapy due to drug-related side effects or adverse reactions) and some others to physicians (e.g. use of inappropriate therapeutic regimens, extensive use of monotherapy, complex combination therapies, and association of nonsynergistic antihypertensive drugs) [7]. Mostly, therapeutic inertia – that is the lack of therapeutic intervention in the presence of treated uncontrolled blood pressure levels – has emerged as a frequent and potentially modifiable factor for improving blood pressure control in daily clinical practice. In this issue of the Journal, a study by Escobar et al. described the main findings of a systematic and comprehensive analysis performed on the PRESión arterial en la población Española en los Centros de Atención Primaria [PRESCAP] databases, which collected data on temporal trends on blood pressure control rates achieved in Spain (three dataset of studies performed in 2002, 2006 and 2010), reporting that 36.1, 41.4 and 46.3% of the included patients achieved the recommended blood pressure targets [8]. This analysis focuses on therapeutic behaviours of physicians involved in the clinical management of hypertensive patients, with a particular emphasis on therapeutic inertia. The main findings of this analysis are, in our opinion, of particular relevance because they provide a clear example and useful information for improving blood pressure control rates in a setting of primary care practice in a Western country. In those patients with uncontrolled blood pressure levels, in fact, Spanish physicians modified the treatment in 18.3, 30.4 and 41.4% of the cases, respectively (P = 0.0001). The most frequent action taken was the change to another drug in the first analysis of PRESCAP 2002 (47.0%), and the addition of other antihypertensive agents in subsequent analyses of PRESCAP 2006 and 2010 (46.3 and 55.6%, respectively). Predictors of therapeutic inertia were the physician's perception of blood pressure control, being on treatment with combined therapy, and the absence of risk factors or cardiovascular disease. Similar findings have been also reported in other European countries, including Italy. For example, in the REassessment of Antihypertensive Chronic Therapy (REACT) study [9], which included about 1500 treated hypertensive adult patients, relatively small proportions of physicians modified antihypertensive medications in the presence of uncontrolled blood pressure levels. In particular, when investigators were asked how they would modify therapy, the dosages and the prescription of calcium antagonists, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (alone or in fixed-combination therapies) were only partially increased, whereas diuretics and beta-blockers remained almost the same. In a similar analysis from the Brisighella Heart Study database [10], which included 940 hypertensive patients from the original cohort of otherwise healthy adult volunteers, the increased use of combination therapy, the reduced use of diuretics and the increased use of calcium channel blockers and ACE inhibitors as first-line drugs were paralleled with an improved blood pressure control and lower rates of fatal and nonfatal cardiovascular events in a setting of primary care practice. Although therapeutic inertia has decreased in the past years in primary care setting in Spain, as well as in Italy or in other Western countries, nowadays, in nearly 60% of patients with uncontrolled blood pressure, no therapeutic action is actually taken. This clearly supports the need for improving educational and behavioural interventions for reducing physicians’ inertia and increasing patients’ adherence to prescribed medications at both national and local levels, as recently promoted by several national societies for hypertension management and control [11]. ACKNOWLEDGEMENTS Conflicts of interest The authors have no conflict of interest to disclose.