Cross-sectional survey evaluating blood pressure control ACHIEVEment in hypertensive patients treated with multiple anti-hypertensive agents in Belgium and Luxembourg

Unravelling the Belgian cascade of hypertension care and its determinants: insights from a cross-sectional analysis

BACKGROUND

Hypertension is a major risk factor for cardiovascular disease and all-cause mortality worldwide. Despite the widespread availability of effective antihypertensives, blood pressure (BP) control rates remain suboptimal, even in high-income countries such as Belgium. In this study, we used a cascade of care approach to identify where most patients are lost along the continuum of hypertension care in Belgium, and to assess the main risk factors for attrition at various stages of hypertension management.

METHODS

Using cross-sectional data from the 2018 Belgian Health Interview Survey and the Belgian Health Examination Survey, we estimated hypertension prevalence among the Belgian population aged 40-79 years, and the proportion that was (1) screened, (2) diagnosed, (3) linked to care, (4) in treatment, (5) followed up and (6) well-controlled. Cox regression models were estimated to identify individual risk factors for being unlinked to hypertension care, untreated and not followed up appropriately.

RESULTS

The prevalence of hypertension based on self-reported and measured high BP was 43.3%. While 98% of the hypertensive population had their BP measured in the past 5 years, only 56.7% were diagnosed. Furthermore, 53.4% were linked to care, 49.8% were in treatment and 43.4% received adequate follow-up. Less than a quarter (23.5%) achieved BP control. Among those diagnosed with hypertension, males, those of younger age, without comorbidities, and smokers, were more likely to be unlinked to care. Once in care, younger age, lower BMI, financial hardship, and psychological distress were associated with a higher risk of being untreated. Finally, among those treated for hypertension, females, those of younger age, and without comorbidities were more likely to receive no adequate follow-up.

CONCLUSION

Our results show that undiagnosed hypertension is the most significant barrier to BP control in Belgium. Health interventions are thus needed to improve the accurate and timely diagnosis of hypertension. Once diagnosed, the Belgian health system retains patients fairly well along the continuum of hypertension care, yet targeted health interventions to improve hypertension management for high-risk groups remain necessary, especially with regard to improving treatment rates.

Lipid-lowering therapy and risk-based LDL-C goal attainment in Belgium: DA VINCI observational study

BACKGROUND

Cardiovascular disease (CVD) is one of the leading causes of death in Belgium. Current strategies for the prevention and management of CVD focus on reducing low-density lipoprotein cholesterol (LDL-C) levels. This analysis assessed whether LDL-C goals, recommended by the European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines, were being achieved in a Belgian study population.

METHODS

The cross-sectional, observational, DA VINCI study enrolled patients prescribed lipid-lowering therapy (LLT) between 21 June 2017 and 20 November 2018. Data for patients from Belgium were extracted for this country-specific analysis. Primary endpoint was the proportion of patients who achieved 2016 ESC/EAS risk-based LDL-C goals; attainment of 2019 risk-based LDL-C goals was evaluated post hoc.

RESULTS

Of 497 enrolled patients, 41% were female and mean age was 68 years. Among subjects with an LDL-C measurement on stabilised LLT, moderate-intensity statin monotherapy was the most prescribed LLT regimen (59%). Overall, 63% of patients achieved their risk-based LDL-C goals according to the 2016 ESC/EAS guidelines. Among patients with established ASCVD, risk-based LDL-C goal attainment was higher in patients with peripheral arterial disease (53%) than patients with coronary (37%) and cerebrovascular disease (42%). According to the updated 2019 ESC/EAS guidelines, less than half (41%) of patients achieved their risk-based LDL-C goal. The proportion of primary and secondary prevention patients who achieved 2019 risk-based LDL-C goals was 59% and 18%, respectively.

CONCLUSION

These findings reveal a large gap between the LDL-C goals advocated by the ESC/EAS and the levels achieved in routine clinical practice in Belgium.

Contribution of single-pill combinations in the management of hypertension: perspectives from China, Europe and the USA

Uncontrolled hypertension is associated with an increased risk of adverse clinical vascular outcomes and death. Hypertension management guidelines from China and the USA recommend initiation of antihypertensive pharmacotherapy with a single drug for patients without severe hypertension at presentation. Current European hypertension guidelines take a different approach and recommend the use of combination therapy from the time of diagnosis of hypertension for most patients. This article reviews the burden of hypertension in these countries and summarises the evidence base for the use of antihypertensive combination therapy contained within a single tablet (single-pill combinations, SPC). Typically, half or less of populations from China, Europe and the USA who were found to have hypertension were aware of their condition, less than half of those receiving treatment, and fewer still achieved adequate blood pressure (BP) control. The reasons for the unaddressed burden of hypertension are complex and multifactorial, with contributions from factors related to patients, healthcare providers and healthcare systems. The use of SPCs of antihypertensive therapies helps to optimise adherence with therapy and is likely to result in superior BP control. There is a strong evidence base to support current European guideline recommendations on the initiation of antihypertensive therapy with SPCs for the majority of people with hypertension.

Identification of patient-related, healthcare-related and knowledge-related factors associated with inadequate blood pressure control in outpatients: a cross-sectional study in Serbia

OBJECTIVES

To determine rate of blood pressure (BP) control and to analyse patient-related, medication-related and healthcare system-related factors associated with poor BP control in outpatients with hypertension (HT).

DESIGN

Cross-sectional study.

SETTING

Two study sites with different levels of healthcare (primary healthcare (PHC) and secondary level of healthcare (SHC)) in Vojvodina, Northern Serbia.

PARTICIPANTS

A total of 581 patients (response rate 96.8%) visiting their primary care physician between July 2019 and June 2020 filled out a pretested semistructured questionnaire and had a BP reading during their regular appointments.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data on demographics, medication, BP control (target systolic BP≤140 mm Hg and∕ or diastolic BP≤90 mm Hg) and knowledge on HT was collected. Based on the median of knowledge score, patients were classified as having poor, average and adequate knowledge.

RESULTS

Majority of the respondents (74.9%) had poorly controlled BP and had HT longer than 10 years. Larger number of patients at PHC site was managed with monotherapy while at the SHC majority received three or more antihypertensive drugs. Respondents from SHC showed a significantly lower knowledge score (9, 2-15) compared with the respondents from PHC (11, 4-15, p=0.001). The share of respondents with adequate knowledge on HT was significantly higher in the group with good BP control (26% and 9.2%, respectively). In a multivariate regression analysis, factors associated with poor BP control were knowledge (B=-1.091; p<0001), number of drugs (B=0536; p<0001) and complications (B=0898; p=0004).

CONCLUSIONS

Poor BP control is common in outpatients in Serbia, irrespective of the availability of different levels of healthcare. Patients with poor knowledge on HT, with complications of HT and those with multiple antihypertensive drugs, were at particular risk of poor BP control. Our study could serve as a basis for targeted interventions to improve HT management.

Cardiovascular drug interventions in the cardio-oncology clinic by a cardiology pharmacist: ICOP-Pharm study

Background

Cardio-oncology is a rapidly growing field that requires a novel service design to deal with the increasing number of patients. It is reported that the volume of patients at the cardio-oncology clinic in the United Kingdom is 535 patients/5 years and in Canada is 779 patients/7 years. The pharmacist has a role in reducing the consultation time of physicians.

Objective

To identify the role of a qualified cardiology pharmacist at the cardio-oncology clinic using a new paradigm based on complementary interventions with the cardiologist for the management of patients with cancer and cardiovascular risk factors and/or cardiovascular diseases (CVRF/CVD).

Methods

A prospective observational study was conducted at the cardio-oncology clinic in the Medical City in Baghdad, Iraq between December 2020 and December 2021. Patients with CVRF/CVD were registered. The Iraqi Cardio-Oncology Program-Pharmacist (ICOP-Pharm) paradigm was designed to involve a qualified cardiology pharmacist for initial cardiovascular (CV) drug interventions.

Results

Among 333 patients who attended our clinic over the 1-year interval, 200 (60%) CVRF/CVD cases were enrolled in the study, and of them 79 (40%) patients had CV drug interventions. A total of 196 interventions were done, including 147 (75%) cases performed by the cardiology pharmacist, and 92 (63%) of the latter were CV drug initiations. Among the total CVRF/CVD treated initially by the cardiology pharmacist, hypertension 32 (26%) and cancer therapy-related cardiac dysfunction 29 (24%) were the main types.

Conclusion

The qualified cardiology pharmacist was responsible for three-quarters of the initial CV drug interventions at the cardio-oncology clinic in a complementary approach to the cardiologist. The role of the cardiology pharmacist in the ICOP-Pharm paradigm may be one of the reasons for the ability of the heart team to manage 3-fold of the patient volume when compared with those in the United Kingdom or Canada.

Antihypertensive treatment in a general uncontrolled hypertensive population in Belgium and Luxembourg in primary care: Therapeutic inertia and treatment simplification. The SIMPLIFY study

BACKGROUND

Despite effective treatments, blood pressure (BP) control remains suboptimal.

OBJECTIVE

The SIMPLIFY study aimed at identifying key factors related to therapeutic inertia in Belgium and Luxembourg, and evaluating how uncontrolled treated hypertension is managed in primary care.

METHODS

In a 2017 cross-sectional survey, 245 general practitioners (GP) collected routine clinical data from 1,852 consecutive uncontrolled (Office SBP/DBP ≥ 140/90 mmHg) hypertensive adult patients taking at least one antihypertensive drug.

RESULTS

Patients were 64 years old on average, 48% were women, 61% had dyslipidemia, 33% had diabetes mellitus and 22% had established cardiovascular disease. Half of the patients had 2 or more comorbidities. Patients had been treated for hypertension for an average period of 8 years, 40% of patients were in hypertensive stages 2-3, 44% were treated with monotherapy only, 28% with free combinations and 28% with at least one single pill combination (SPC). Therapeutic adherence was rated as 'good' in 62% of patients. AHT treatment was modified in 84% of patients. In the group of patients with stage 2-3 hypertension, treatment remained unchanged in 5%. In the group of patients with stage 1 hypertension, treatment remained unchanged in 23% of patients. Patients treated for longer than 10 years were less likely to undergo treatment change (81%) compared to patients treated for less than 10 years (87%). Patients with 1 or 2 comorbidities were more likely to have their treatment modified (87%) compared to those with no comorbidities (61%) and those with ≥ 3 comorbidities (79%). If treatment was modified, a SPC was introduced in 90% of cases; 91% in stage 1-2 hypertension and 84% in stage 3 hypertension. SPCs were less frequently initiated in patients without comorbidities. Main reasons for the GPs to switch from a free association towards SPC were 'better BP control' (55%), 'better therapeutic compliance' (53%) and 'simplicity for the patient' (50%).

CONCLUSION

The SIMPLIFY study confirms therapeutic inertia in hypertension management. After an average of 8 years hypertension treatment, almost 1 in 2 uncontrolled treated patients are on monotherapy. The key inertia drivers seem to be age, mild grade hypertension, isolated systolic hypertension, longer duration of antihypertensive treatment and better therapeutic adherence. When treatment is updated by the GP, the currently preferred strategy is switching towards SPC based therapy to improve BP control, and enhance therapeutic compliance by simplifying treatment for the patient.

TRIAL REGISTRATION

pharma.be visa number: VI 17/01/20/01 ISRCTN registered study: ISRCTN16199080.