Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Men, Leaner Folks Less Likely to Be Treated for High BP

By Kristina Fiore, Staff Writer, MedPage Today
Published: August 10, 2011
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Action Points
Note that this report reviewed NHANES surveys to identify clinical characteristics associated with untreated hypertension, uncontrolled hypertension and apparent treatment-resistant hypertension.


Consider that this study found that in the years 2005 to 2008, more than half of uncontrolled hypertensives were untreated and unaware of their hypertension. Also note that the prevalence of apparent treatment-resistant hypertension increased significantly in the last survey and appeared to be associated with aging, obesity and diabetes.

Men and patients who are leaner and generally healthier are less likely to have their hypertension treated, researchers said.

Male sex, body mass index (BMI) below 25 kg/m2, lack of chronic kidney disease, lower heart disease risk, and making fewer visits to the doctor were associated with high blood pressure going untreated, Brent Egan, MD, of the Medical University of South Carolina in Charleston, and colleagues reported online in Circulation: Journal of the American Heart Association.

When patients were treated, those whose hypertension remained uncontrolled on one or two medications were more likely to be older and have a greater risk of heart disease, while those who were treatment-resistant (uncontrolled on three drugs or more) also had a higher risk of heart disease; but they went to the doctor more frequently, were obese, and had chronic kidney disease, too.

Defining the characteristics of these uncontrolled hypertensive patients may facilitate efforts to improve blood pressure control, the researchers said.

"Overall, physicians are doing a very good job treating and controlling hypertension," Egan said in an email to MedPage Today. "Yet there is still room for improvement."

Although the proportions of untreated and uncontrolled hypertensive patients have fallen in recent years, more than 30 million hypertensive patients remain uncontrolled in the U.S., they said.

In order to define the characteristics of both groups of patients, the researchers looked at data on 13,375 hypertensive adults from three periods of the National Health and Nutrition Examination Survey (NHANES): 1988-1994, 1999-2004, and 2005-2008.

Overall, the proportion of uncontrolled hypertensive patients fell from 73.2% in 1988-1994 to 52.5% in 2005-2008.

Clinical factors linked with untreated hypertension included male sex, infrequent healthcare visits, BMI of 25 kg/m2 or below, absence of chronic kidney disease, and 10-year Framingham heart risk below 10% (P<0.01 for all).

Egan and colleagues said that infrequent healthcare visits is a major issue in this population, with a mean of more than 40% of untreated hypertensive patients in all survey periods reporting none or just one trip to the doctor annually.

This finding suggests that increasing health care use in all settings "is critical in reducing the burden of untreated hypertension," they wrote. "Raising the perceived value of regular preventive health care services among those without clinically overt disease emerges as an important complementary educational strategy."

About a third of all uncontrolled patients reported taking one or two antihypertensive medications in all three study periods, the researchers said. These patients were older and had higher Framingham risk scores than those who were controlled on this number of medications (P<0.01). In two of the study periods, uncontrolled patients were also more likely to be male, have Hispanic ethnicity, and fewer healthcare visits.

A "logical option," Egan and colleagues wrote, would be to add an additional antihypertensive to these patients' drug regimens, as the majority "appear to be seen frequently enough to allow treatment intensification."

Said therapeutic inertia, or the failure to further treatment when patients are uncontrolled, appears to reflect a patient-provider interaction.

"In addition to provider interventions," the researchers wrote, "educating patients, especially those at higher risk, on the importance of blood pressure control may facilitate efforts to overcome therapeutic inertia."

They said the data also suggest that medication selection affects control. Those uncontrolled on one or two medications were less likely to report taking a diuretic, an ACE inhibitor, or an angiotensin receptor blocker than those who were controlled on this number of drugs -- which "aligns with the efficacy of diuretics and renin-angiotensin system blockers, especially in combination, for blood pressure control," the researchers wrote.

Apparent treatment-resistant hypertension -- disease that was uncontrolled with three or more drugs -- increased from 15.9% to 28% of treated patients between 1988 and 2008 (P<0.001).

"The rise in treatment-resistant hypertension is of real concern, and reflects a population which is aging and more obese with more diabetes and chronic kidney disease," Egan said in an email to MedPage Today.

Indeed, the clinical characteristics associated with treatment-resistant disease included obesity, chronic kidney disease, more frequent healthcare visits (four or more per year), and Framingham risk scores above 20% (P<0.01).

Infrequent use of aldosterone antagonists among this group of patients was notable, the researchers said, as several trials have shown that adding one of these agents to treatment regimens lowers systolic blood pressure by 20 to 25 mm Hg and diastolic blood pressure by 10 to 15 mm Hg in refractory patients.

Egan and colleagues added that personalized medicine -- such as hemodynamic and renin-guided therapeutics -- and genetic testing may be effective complementary approaches for treatment-resistant patients.

Though the study was limited by a relatively small sample size, self-reported data, and hypertension defined by a single measurement, the researchers concluded that national efforts to increase healthcare insurance coverage and use of primary care services may be a boon to hypertension awareness, treatment, and control.

Egan said in order to improve control among their own patients, physicians should continue to encourage health lifestyle changes and promote medication adherence. He also urged an increase in dose or number of medications when treatment goals go unmet.

For those who are still uncontrolled on three or more drugs, he said, document blood pressure outside the office to evaluate a "white-coat" effect -- though he noted that this is a "controversial area" -- to confirm resistance. Then, consider either intensifying diuretic therapy or, "while not an established part of current guidelines," hemodynamic- or renin-guided treatment changes.