How well are we managing and monitoring high blood pressure?

Major inducing factors of hypertensive complications and the interventions required to reduce their prevalence: an epidemiological study of hypertension in a rural population in China

Background

The complications of hypertension cause severe health problems in rural areas in China. We (i) screened the major factors inducing hypertensive complications and provided intervention measures; and (ii) verified the efficacy of the New Rural Cooperative Medical Scheme (NRCMS; a medical insurance scheme for rural residents) for hypertension management.

Methods

A survey was conducted in the villages of Yunnan (an underdeveloped province in southwest China). The NRCMS was initiated there in 2005. Data were collected through questionnaires, physical examination, electrocardiography, as well as blood and urine tests. To detect factors inducing hypertension complications, a generalized estimating equations model was developed. Multivariable logistic regression was used to analyze influencing factors for hypertension control.

Results

Poor management of hypertension was observed in women. Being female, old, poorly educated, a smoker, ignorant of the dangerousness of hypertension, and having uncontrolled hypertension made patients more prone to hypertension complications. Combination therapy with ≥2 drugs helped control hypertension, but most rural patients disliked multidrug therapy because they considered it to be expensive and inconvenient. The NRCMS contributed little to reduce the prevalence of complications and improve control of hypertension.

Conclusions

The present study suggested that the NRCMS needs to be reformed to concentrate on early intervention in hypertension and to concentrate on women. To increase hypertension control in rural areas in China, compound products containing effective and inexpensive drugs (and not multidrug therapy) are needed.

Characteristics, and Disease Control and Complications of Hypertensive Patients in Primary-care – A Community-based Study in Singapore

Introduction: Hypertension is a common chronic condition usually managed by primary-care practitioners in Singapore. This study assessed the characteristics, control and complications of non-diabetic hypertensive patients managed at government primary healthcare clinics. Materials and Methods: A cross-sectional study involving 9 clinics was conducted over 1-week in 2006. Five hundred and six non-diabetic hypertensive patients were systematically sampled from all clinic attendees. Data relating to socio-demographic, lifestyle factors, treatment and complications were collected by interviewer-administered questionnaires and review of clinic medical records. Blood pressure (BP) measurements were taken with validated automated sets following a standard protocol. Results: The prevalence of good BP control (<140/90 mmHg) was 37.7% (95% CI: 33.6% to 41.8%). Ninety seven percent were on medication with about half on monotherapy. Seventy percent of patients had a body mass index (BMI) of 23.0 kg/m2 or higher, 64% did not exercise regularly and 8% were current smokers. After adjusting for age and lifestyle factors, male hypertensive patients had poorer BP control compared to females. Nineteen percent of patients reported at least 1 complication of hypertension, especially cardiac disease. After multivariate analysis and duration of disease, age and the male gender were associated with the presence of hypertensive complications. Conclusions: More than half of the patients were not controlled to target levels. Male patients were more likely to have poorer control of hypertension and significantly higher risks of complications. Control of BP could be further improved by lifestyle modifications – weight reduction, promotion of physical activity, healthier eating habits and smoking cessation. Key words: Blood pressure, Cross-sectional, Prevalence

Achieving blood pressure goals globally: five core actions for health-care professionals. A worldwide call to action

The prevalence of hypertension continues to rise across the world, and most patients who receive medical intervention are not adequately treated to goal. A Working Group including representatives of nine international health-care organizations was convened to review the barriers to more effective blood pressure control and propose actions to address them. The group concluded that tackling the global challenge of hypertension will require partnerships among multiple constituencies, including patients, health-care professionals, industry, media, health-care educators, health planners and governments. Additionally, health-care professionals will need to act locally with renewed impetus to improve blood pressure goal rates. The Working Group identified five core actions, which should be rigorously implemented by practitioners and targeted by health systems throughout the world: (1) detect and prevent high blood pressure; (2) assess total cardiovascular risk; (3) form an active partnership with the patient; (4) treat hypertension to goal and (5) create a supportive environment. These actions should be pursued with vigour in accordance with current clinical guidelines, with the details of implementation adapted to the economic and cultural setting.

Total cardiovascular risk management

Hypertension usually clusters with other cardiovascular risk factors, such as insulin resistance, visceral obesity, and dyslipidemia, greatly increasing an individual's risk for cardiovascular morbidity and death. Despite universal recognition that reduction in blood pressure and other cardiovascular risk factors is essential to improving long-term cardiovascular health, <25% of patients diagnosed with hypertension have adequate blood pressure control. Total cardiovascular risk is increased in the presence of risk factors, target organ damage, comorbid conditions, and the metabolic syndrome and may, to some extent, be prenatally determined. Individuals with "borderline" normal blood pressure and blood glucose are also at increased risk for cardiovascular disease, giving rise to the concept of individuals with "prehypertension" and "prediabetes." International treatment guidelines are now incorporating the concept of global cardiovascular risk assessment and management to improve long-term outcomes. Multifactorial intervention has proved to be highly effective at reducing cardiovascular risk and events in patients with type 2 diabetes mellitus, and studies suggest that reducing an array of risk factors by relatively small amounts can be more beneficial than achieving large reductions in a single risk factor. Clearly, isolated treatment of hypertension is no longer sufficient; risk factors and target organ damage need to be actively searched for and treated if long-term cardiovascular health is to be improved.

High prevalence of newly detected hypertension in hospitalized patients: the value of inhospital 24-h blood pressure measurement

OBJECTIVE

Screening for hypertension in hospitalized patients could reduce the number of individuals with unrecognized hypertension. We hypothesized that 24-h blood pressure monitoring is an adequate tool to detect unrecognized hypertension among inpatients.

METHODS

Clinically stable inpatients in the Department of Internal Medicine, Department of Visceral Surgery and Department of Orthopaedics were included in the cross-sectional study. Every patient underwent inhospital 24-h blood pressure measurement. Previously unknown hypertension was defined as 24-h blood pressure of at least 125/80 mmHg in the absence of known hypertension. Forty-two patients had an additional 24-h blood pressure measurement after discharge, to compare mean inhospital and outpatient 24-h blood pressure values.

RESULTS

In 314 consecutive inpatients, 24-h blood pressure measurement was performed. Among 139 patients without known hypertension, 53 were hypertensive. The mean routine and 24-h blood pressures in these patients were 135/77 and 137/82 mmHg, respectively. Thirty-seven of these patients had normal routine blood pressure and could be detected only by 24-h blood pressure measurement. Patients with unknown hypertension had a marked cardiovascular risk profile, 26 being at high or very high cardiovascular risk. However, documented cardiovascular disease was present in only seven patients, suggesting that effective treatment could prevent a considerable number of cardiovascular events. The agreement between inhospital and outpatient 24-h blood pressure measurement in 42 patients was good.

CONCLUSIONS

By performing inhospital 24-h blood pressure measurement, a considerable number of patients with previously unknown hypertension can be detected.

Detection and treatment of hypertension in general health-care practice: a patient-based study

The aim of this study was to describe the pattern of blood pressure (BP) distribution in a multiethnic primary care practice in relation to sociodemographic characteristics, lifestyle and risk factors. Another aim was to analyse the quality of diagnosis and effectiveness of hypertension (HT) treatment. In all, 470 adult patients (> or =16 years old) who visited the Jordbro Health Centre (JHC), Haninge Municipality, participated in this study. A general questionnaire with questions about sociodemographic characteristics, lifestyle, health status and chronic disease was used. Medical records: information on consultations with the general practitioner and prescriptions were collected from the medical records for the year 2001. Furthermore, a medical examination was performed: this consisted of weight, height, systolic (SBP) and diastolic (DBP) blood pressure, and laboratory analyses including fasting blood glucose, serum cholesterol, serum triglycerides, electrocardiogram and spirometry. Out of 464 patients, 114 (24.6%) reported HT. Among the HT patients, 93 (81.6%) had SBP > or =140 mmHg and 52 (45.6%) DBP > or =90 mmHg. Among the nonhypertensive patients (n=350), 120 (34.3%) had SBP > or =140 mmHg and 50 (14.3%) DBP > or =90 mmHg. Furthermore, there are some patients with high BP who are unknown or undetected. HT treatment among this population is unsatisfactory and greater efforts are required to identify people with high BP and to ensure that they are managed according to the best available evidence.

Angiotensin II receptor antagonists alone and combined with hydrochlorothiazide: potential benefits beyond the antihypertensive effect

Angiotensin II receptor antagonists (angiotensin receptor blockers; ARBs) and thiazide diuretics have an accepted place in the management of hypertension. Most patients require combination therapy with two or more drugs to adequately control blood pressure to targets recommended by European and international guidelines. ARBs and the thiazide diuretic hydrochlorothiazide have complementary modes of action. Fixed-dose combinations of an ARB and low-dose hydrochlorothiazide provide a convenient and effective treatment option for patients who do not achieve blood pressure targets on monotherapy, without compromising the placebo-like tolerability of ARBs. In Europe, fixed-dose combinations with hydrochlorothiazide currently are available for the ARBs candesartan, eprosartan, irbesartan, losartan, telmisartan, and valsartan. Recently, a number of studies have focused on the use of ARBs in monotherapy and in combination therapy, in conditions including congestive heart failure, post-myocardial infarction management, hypertension with cardiovascular risk factors, and diabetic and non-diabetic nephropathy. Evidence from these studies suggests a beneficial role beyond the antihypertensive effect of these therapies in providing protection against cardiovascular, renovascular, and cerebrovascular events.

Relationship between blood pressure measurements recorded on patients' charts in family physicians' offices and subsequent 24 hour ambulatory blood pressure monitoring

Background

In most western countries 20% of adults have hypertension. Reports in the literature suggest that from 31 to 86% of treated patients are not at recommended target levels. However it is important to consider how we are determining whether targets are unmet and the degree to which they are unmet. Our underlying hypothesis is that white coat effect is partially responsible for the reported low rates of control of hypertension by primary care practitioners.

Methods

The study population consists of 1142 patients who are being assessed for enrolment in two community-based randomized controlled trials. Patients must have essential hypertension, be on antihypertensive medication, and must not have met their blood pressure targets. We are reporting on the proportion of patients who have not achieved target, and the degree to which they have not achieved their target. We also report on the mean daytime blood pressures on 24 hour ABPM and compare these to mean blood pressures found on the patients' charts.

Results

We identified 3284 patient charts of patients with hypertension. Of these, 1142 were determined to be "out of control" (did not achieve target) and 436 agreed to undergo 24 hour ABPM for final determination of eligibility. Overwhelmingly (95.8% of the time) it was the systolic blood pressure that was not under control. However, most of the patients who had not achieved target according to our criteria were within 10 mmHg of the recommended targets. Isolated systolic blood pressure was the best predictor of elevated mean daytime blood pressure on 24 hour ABPM.

Conclusions

At least 35% of patients had not achieved target blood pressure levels and this is primarily due to lack of control of systolic blood pressure. The best predictor of continuing hypertension on 24 hour ABPM was the mean systolic blood pressure on the patients chart. However, only 69% of patients who were uncontrolled according blood pressures recorded in the chart were uncontrolled according to 24 hour ABPM criteria. This suggests that the white coat effect makes blood pressure measurements in the doctor's offices, at least as currently done, not sufficiently accurate for determining treatment endpoint.