Variations in blood pressure and lipid goal attainment in primary care

Goal attainment, medication adherence and guideline adherence in the treatment of hypertension and dyslipidemia in Irish populations: A systematic review and meta-analysis

Background

The appropriate treatment high blood pressure (BP) and low-density lipoprotein cholesterol.(LDL-C), according to clinical guidelines, reduces a patient's risk of a cardiovascular event.

Aim

This systematic review aims to evaluate the attainment of BP and LDL-C goals among the Irish population in both primary and secondary prevention of cardiovascular diseases, the level of adherence to prescribing guidelines by doctors and the level of medication adherence among patients.

Methods

Five databases were searched in March 2024. Quantitative articles reporting levels of goals attainment, medication adherence or guideline adherence for LDL-C and BP among Irish adults aged ≥18 years were included. The proportion of patients attaining their LDL-Cor BP goals were statistically combined using the random effect model.

Results

Following screening, 23 eligible articles were identified. The achievement of LDL-C <1.8 mmol/L was 41 % (95 % CI 31,52), compared to 69 % of people (95 % CI 62,76) reported to have achieved the less stringent goal of LDL-C < 3 mmol/L. The achievement of BP < 140/90 mmHg was 56 % (95 % CI 46,65). Medication adherence levels ranged between 27 % and 92 %. Guideline adherence findings demonstrated that not all patients who should be on lipid-lowering therapy are and that choice of antihypertensive is not always in line with the guidelines.

Conclusion

Approximately one-third of deaths in Ireland annually are caused by cardiovascular disease, despite being preventable. There is room for improvement in goal attainments in people at risk of CVDs and optimization of medication adherence and guideline adherence may be beneficial in this population.

Blood pressure and lipid target adherence in Korean patients receiving angiotensin II receptor blockers/statin regimens

OBJECTIVES

Hypertension and dyslipidemia are important cardiovascular risk factors. Simultaneously controlling blood pressure (BP) and lipid levels is effective in preventing cardiovascular events and premature death. This study investigated the association between adherence to angiotensin II receptor blocker (ARB)/statin regimens and BP or low density lipoprotein-cholesterol (LDL-C) target attainment in Korean patients with concomitant hypertension and dyslipidemia.

METHODS

In this retrospective, multicenter study, we collected case report forms (CRFs) of hypertensive patients with concomitant dyslipidemia who were prescribed an ARB/statin regimen between 1 April 2014 and 31 March 2015 from 51 outpatient clinics. A total of 672 and 609 patients were eventually included for statistical analyses of BP and LDL-C, respectively. Adherence was measured by medication possession ratio (MPR) for 6 months following the index date.

RESULTS

The overall rates of attaining BP and LDL-C targets were 75.6% and 81.1%, respectively. The mean value of MPR for patients attaining target BP or LDL-C was significantly higher than that for those not attaining target BP or LDL-C. After adjustment for all covariates, increases in the quartiles of MPR were significantly associated with an increased probability of attaining target BP or LDL-C in all models (all p-trend <0.05). Attaining of BP control was significantly higher in quartiles 3 and 4 of MPR (MPR >0.95) than the lowest MPR (quartile 1), whereas attaining LDL-C target was associated with quartile 4 of MPR (MPR >0.97).

CONCLUSION

We identified a strong correlation between medication adherence and BP or LDL-C target achievement in Korean patients with concomitant hypertension and dyslipidemia. The adherence for reaching targets could be different between BP and LDL-C levels.

Severity of obesity and management of hypertension, hypercholesterolaemia and smoking in primary care: population-based cohort study

Obesity and obesity-associated cardiovascular risk are increasing worldwide. This study aimed to determine how different levels of obesity are associated with the management of smoking, hypertension and hypercholesterolaemia in primary care. We conducted a cohort study of adults aged 30–100 years in England, sampled from the primary care electronic health records in the Clinical Practice Research Datalink. Prevalence, treatment and control were estimated for each risk factor by body mass index (BMI) category. Adjusted odds ratios (AOR) were estimated, allowing for age, gender, comorbidity and socioeconomic status, with normal weight as reference category. Data were analysed for 247 653 patients including 153 308 (62%) with BMI recorded, of whom 46 149 (30%) were obese. Participants were classified into simple (29 257), severe (11 059) and morbid obesity (5833) categories. Smoking declined with the increasing BMI category, but smoking cessation treatment increased. Age-standardised hypertension prevalence was twice as high in morbid obesity (men 78.6% women 66.0%) compared with normal weight (men 37.3% women 29.4%). Hypertension treatment was more frequent (AOR 1.75, 1.59–1.92) but hypertension control less frequent (AOR 0.63, 0.59–0.69) in morbid obesity, with similar findings for severe obesity. Hypercholesterolaemia was more frequent in morbid obesity (men 48.2% women 36.3%) than normal weight (men 25.0% women 20.0%). Lipid lowering therapy was more frequent in morbid obesity (AOR 1.83, 1.61–2.07) as was cholesterol control (AOR 1.19, 1.06–1.34). Increasing obesity category is associated with elevated risks from hypertension and hypercholesterolaemia. Inadequate hypertension control in obesity emerges as an important target for future interventions.

Total and low-density lipoprotein cholesterol in high-risk patients treated with atorvastatin monotherapy in the United Kingdom: analysis of a primary-care database

OBJECTIVE

British clinical guidelines recommend statins as first-line lipid-modifying treatment (LMT) for patients at high risk of cardiovascular disease (CVD). We undertook an observational study to assess total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) levels in high-risk patients who were treated with atorvastatin monotherapy by UK general practitioners.

METHODS

This retrospective database study included patients with a prescription for atorvastatin monotherapy between November 30, 2008, and November 30, 2011, with the index date defined as the first atorvastatin prescription during this period. Eligible high-risk patients with evidence of coronary heart disease (CHD), atherosclerotic vascular disease (AVD), diabetes mellitus (DM), or familial hypercholesterolemia (FH) were required to have ≥1 TC and LDL-C measurement between 3 and 12 months after the index date, and continuous enrollment 1 year before and 1 year after the index date. Cholesterol levels were assessed using the National Institute for Health and Care Excellence (NICE) guidelines: TC <4.0 mmol/L or LDL-C <2.0 mmol/L.

RESULTS

Of 2999 high-risk patients (60.2% men; mean [SD] age = 67.9 [10.6] years) meeting selection criteria, 23.9% 28.2%, 36.2%, and 11.6% received prescriptions for atorvastatin 10, 20, 40, and 80 mg, respectively (percentages do not sum to 100 because of rounding). Across all doses, the mean (SD) follow-up TC was 4.08 (0.80) mmol/L and LDL-C 2.08 (0.65) mmol/L. A large proportion of patients (88.8%) had TC < 5.0 mmol/L. However, only 45.8% had TC < 4.0 mmol/L, and 46.5% had LDL-C < 2.0 mmol/L. Although a larger proportion of patients with CHD/AVD + DM reached guideline-recommended lipid levels, only 63.7% of such patients had TC < 4.0 or LDL-C < 2.0 mmol/L, which are the current targets for this subgroup as recommended by NICE.

CONCLUSIONS

Less than half of UK high-CVD-risk patients receiving atorvastatin monotherapy achieved guideline-recommended treatment targets for TC, and less than two-thirds of patients with CHD/AVD + DM had values below TC (4.0 mmol/L) or LDL-C (2.0 mmol/L) targets. More effective lipid-lowering strategies may be warranted to optimize cholesterol lowering and target attainment in high-risk patients. Limitations of this study include its retrospective, observational nature.