Department of Veterans Affairs hypertension meeting : a proposal for improved care

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

METHODS

Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.

CONCLUSIONS

The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Improving survival of malignant hypertension patients over 40 years

BACKGROUND

To examine changing demography and survival of patients with malignant phase hypertension (MHT) over 40 years.

METHODS

Patients from our MHT registry whose survival status on 31 December 2006 was known were included, with analyses conducted based on decade of MHT diagnosis.

RESULTS

Four-hundred and forty-six patients with MHT (overall mean (s.d.) age 48.2 (12.9), years; 65.5% male; 64.7% white-European; 20.4% African Caribbean, and 14.8% South-Asian) were included. No significant demographic differences at diagnosis were evident over the 40 years, with the exception of a significant increase (P = 0.001) in the proportion of MHT among ethnic minorities (South-Asian and Afro-Caribbeans). There were no significant differences in mean systolic blood pressure (SBP) at presentation but baseline diastolic BP (DBP) was significantly lower after 1976 (P < 0.0001). The total number of person-years of observation was 5,725.5 years, with a median (interquartile range (IQR)) length of follow-up of 103.8 (31.3-251.2) months. Overall 203 patients (55.6%) died, 125 (32.0%) within 5 years of diagnosis. There was a significant improvement in 5-year survival from 32.0% prior to 1977 to 91.0% for patients diagnosed between 1997 and 2006. SBP and DBP improved significantly during follow-up (P < 0.0001). Multivariate analyses revealed that age, decade of MHT diagnosis, baseline creatinine, and follow-up SBP were independent predictors of survival (all P < 0.0001).

CONCLUSIONS

Demography and number of new cases of MHT have not changed dramatically over the past 40 years. Five-year post-MHT survival has improved significantly, possibly related to lower BP targets, tighter BP control, and availability of new classes of antihypertensive drugs.

Computer confirmation of improved blood pressure control in diabetic patients

In order to evaluate efforts to improve blood pressure (BP) control in veterans with diabetes, the authors performed a retrospective review of computerized health records in the Veterans Affairs Northern California Health Care System (VANCHCS). A total of 6624 diabetic patients with BP data were identified and a comparison was made to earlier surveys. There was an overall improvement in BP control. In a cohort of 1791 patients followed since 1999, there was a progressive improvement in both systolic BP (patients at goal increased from 28% to 35%; P<.001, chi(2)) and diastolic BP (patients at goal increased from 69% to 79%; P<.001). There was a corresponding increase in both number of drug classes used and use of antiangiotensin treatment. The authors conclude that the improvement in BP control in these veterans with diabetes was temporally associated with intensification in antihypertensive pharmacotherapy and sustained provider education and patient-specific computerized reminders.

Physician-nurse team approaches to improve blood pressure control

Hypertension is an asymptomatic chronic disease that contributes to the development of serious health problems including coronary artery disease, chronic renal failure, and stroke. Despite published guidelines addressing goals for the treatment of hypertension, control rates (defined as a blood pressure <140/90 mm Hg) have not increased in recent years, and uncontrolled hypertension remains a serious public health issue. Both patient- and provider-related factors contribute to these poor control rates, and new approaches to the management of hypertension must be sought. In this review, we describe unique physician-nurse team approaches to improve the control of hypertension both in a subspecialty hypertension practice and in a primary care clinic setting. By implementing practice models that result in sustainable improvements in blood pressure control rates, the morbidity and mortality resulting from target organ damage and ensuing costs to society may be expected to decline as well.

Prospective surveillance of hypertension in firefighters

The authors evaluated blood pressure and antihypertensive medication use in 334 firefighters in an occupational medical surveillance program. Firefighters received written summaries of their examination results, including blood pressures, and were encouraged to see their personal physicians for any abnormal results. The mean age of the participants was 39 years, and the vast majority were men (n=330). The prevalence of hypertension was 20% at baseline (1996), 23% in 1998, and 23% in 2000. Among firefighters with high blood pressure readings, only 17%, 25%, and 22% were taking antihypertensive medications at the baseline, 1998, and 2000 examinations, respectively. Medical surveillance was effective in detecting hypertension in firefighters; however, after 4 years of follow-up, only 42% of hypertensives were receiving treatment with medications, including only 22% of firefighters with hypertensive readings. Overall, 74% of hypertensives were not adequately controlled. Possible reasons for low treatment rates may be the inadequate recognition among primary care physicians that mild hypertension is a significant risk factor for cardiovascular disease.