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Steichen O. [Hypertension: Who to treat, to what extent and how?]. Rev Med Interne 2023; 44:158-163. [PMID: 36710087 DOI: 10.1016/j.revmed.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/18/2022] [Accepted: 01/08/2023] [Indexed: 01/30/2023]
Abstract
Hypertension is the modifiable risk factor causing the largest loss in healthy life-years. The risk of cardiovascular events increases exponentially with the level of blood pressure (BP), starting from 115mmHg for systolic BP. Out-of-office BP measurements (self-measurements or ambulatory BP measurements) are now preferred for the diagnosis and follow up. In the absence of a preferred indication, antihypertensive treatment is based on thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. These treatments are associated with a significant reduction in morbidity and mortality in people with office BP ≥ 140/90mmHg (self-measurements ≥ 135/85mmHg). For people at high cardiovascular risk, especially those with a history of cardiovascular disease, starting the treatment for an office BP ≥ 130/80mmHg is also beneficial (self-measurements ≥ 130/80mmHg as well). It is now common to start treatment with half-dose dual therapy, which is more effective and better tolerated than full-dose monotherapy. The clinical effect is assessed at 4 weeks and intensification, if required, is then usually done by switching to the same dual therapy at full-dose for both components.
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Affiliation(s)
- O Steichen
- Sorbonne université, Inserm, institut Pierre-Louis d'épidémiologie et de santé publique, équipe Sentinelles, 75012 Paris, France; Assistance publique-Hôpitaux de Paris (AP-HP), Sorbonne université, CHU de Tenon, service de médecine interne, 4, rue de la Chine, 75020 Paris, France.
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Daniel RC, Atzema CL, Cho DD, Davis PJ, Costello LL. Which Recommendations Are You Using? A Survey of Emergency Physician Management of Paroxysmal Atrial Fibrillation. CJC Open 2022; 4:466-473. [PMID: 35607488 PMCID: PMC9123374 DOI: 10.1016/j.cjco.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/16/2022] [Indexed: 10/29/2022] Open
Abstract
Background Both the Canadian Cardiovascular Society (CCS) and the Canadian Association of Emergency Physicians (CAEP) have published documents to guide atrial fibrillation (AF) management. In 2021, the CAEP updated its AF checklist. Prior to this update, the recommendations of the 2 organizations differed in several key areas, including the suggested cardioversion timeframe, the factors determining cardioversion eligibility, and anticoagulant initiation after cardioversion. Whether emergency physicians (EPs) are aware of, or adhering to, one, both, or neither of these documents is unknown. Methods We assessed document awareness, adherence, and EP practice using a piloted questionnaire administered to EPs at 5 emergency departments in 3 provinces. Results Of 166 survey recipients, 123 (74.1%) responded. The majority (64.7%) worked at an academic site, 38.8% identified as female, and median years in practice was 10.0. Most (93.1%) were aware of at least one of the documents; 45.7% were aware of both. Reported awareness was higher for the CCS (77.6%) vs the CAEP (61.2%) guidelines. Respondents varied in their adherence, with 40.5% using parts of both documents. Considerable practice variability occurred when recommendations conflicted. Despite its use not being recommended by either organization, half of respondents (50.0%) reported using the CHA2DS2-VASc score as their stroke-risk assessment tool. Conclusions Although most surveyed EPs were aware of at least one organization's AF documents, many reported using parts of both. When recommendations conflicted, EPs were divided in their decision-making. These findings emphasize the need to improve consensus between organizations and further improve knowledge translation.
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Affiliation(s)
- Ryan C. Daniel
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clare L. Atzema
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Dennis D. Cho
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Philip J. Davis
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lorne L. Costello
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Commodore-Mensah Y, Loustalot F, Himmelfarb CD, Desvigne-Nickens P, Sachdev V, Bibbins-Domingo K, Clauser SB, Cohen DJ, Egan BM, Fendrick AM, Ferdinand KC, Goodman C, Graham GN, Jaffe MG, Krumholz HM, Levy PD, Mays GP, McNellis R, Muntner P, Ogedegbe G, Milani RV, Polgreen LA, Reisman L, Sanchez EJ, Sperling LS, Wall HK, Whitten L, Wright JT, Wright JS, Fine LJ. Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension. Am J Hypertens 2022; 35:232-243. [PMID: 35259237 PMCID: PMC8903890 DOI: 10.1093/ajh/hpab182] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 11/28/2021] [Indexed: 01/09/2023] Open
Abstract
Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, it remained stable through 2013-2014 and declined to 43.7% in 2017-2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community-clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control.
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Affiliation(s)
- Yvonne Commodore-Mensah
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Fleetwood Loustalot
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cheryl Dennison Himmelfarb
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Vandana Sachdev
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Kirsten Bibbins-Domingo
- Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Steven B Clauser
- Patient Centered Outcomes Research Institute, Washington, District of Columbia, USA
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Brent M Egan
- American Medical Association, Greenville, South Carolina, USA
| | - A Mark Fendrick
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith C Ferdinand
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | | | | | - Marc G Jaffe
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Glen P Mays
- Department of Health Systems, Management and Policy, Colorado School of Public Health, Aurora, Colorado, USA
| | - Robert McNellis
- Agency for Healthcare Research and Quality, Rockville, Maryland, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama, USA
| | - Gbenga Ogedegbe
- New York University Grossman School of Medicine, New York, New York, USA
| | - Richard V Milani
- Department of Cardiology, Ochsner Health System, New Orleans, Louisiana, USA
| | - Linnea A Polgreen
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, USA
| | | | | | - Laurence S Sperling
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hilary K Wall
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lori Whitten
- Synergy Enterprises, Inc, Silver Spring, Maryland, USA
| | - Jackson T Wright
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Janet S Wright
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lawrence J Fine
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
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