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Who fails to achieve blood pressure
and lipid targets – patients or doctors?
Francesco P Cappuccio MBBS MD MSc FRCP FFPH FAHA
Professor of Cardiovascular Medicine & Epidemiology, Warwick Medical School
Consultant Cardiovascular Physician, UHCW NHS Trust, Coventry
CV Mortality Risk
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Doubles with each 20/10 mm Hg BP increment
CV mortality:
-fold increase
8
7
6
5
4
3
2
1
0
115/75
135/85
155/95
BP (SBP/DBP mm Hg)
175/105
Lewington S, et al. Lancet 2002; 60: 1903-1913
Long-term antihypertensive
treatment reduces CV risk
0
CV event
Stroke
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CHD
−10
−20
−30
20–21
21–28
−40
30–39
−50
Relative risk reduction (%)
Risk of CV event with ACEI or CCB relative to placebo
CV: cardiovascular
CHD: coronary heart disease
Neal B, et al. 2000
Uncontrolled BP results in major CV
events*
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DBP/SBP uncontrolled
Major CV events/year*
50 000
DBP uncontrolled
SBP uncontrolled
40 000
30 000
20 000
10 000
0
Medicated
Unmedicated
Total
Uncontrolled BP results in major CV events
(myocardial infarction [MI], stroke or CV-related death)
*Study of the US population
Flack JM, et al. 2002
Serum Total Cholesterol and Blood Pressure
strong determinants of cardiovascular risk
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Erhardt LR et al. Atherosclerosis 2008;196:532-41
Evolution of guidelines on lipid
management
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Erhardt LR et al. Atherosclerosis 2008;196:532-41
Large numbers of patients are still not
reaching cholesterol targets
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Erhardt LR et al. Atherosclerosis 2008;196:532-41
One conclusion from an expert panel …
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• Harmonise guidelines
• Focus on common areas of consensus
• Remove boundary between primary and
secondary prevention
• Focus on level of risk
• Help policy makers to understand the different
component of CVD
• Include professional societies from different
specialties in guidelines development and
implementation to increase ownership and
decrease fragmentation
Erhardt LR et al. Atherosclerosis 2008;196:532-41
BHS NICE Guidelines
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Potential barriers to BP control in
patients with inadequately controlled
hypertension in primary care
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• Jan-Mar 2004: 110/155 (71%; 27% A/C) patients (50-80 yrs)
with last recorded BP >150/90 mmHg (>140/85 mmHg if
diabetic) seen in a nurse-led clinic
• Standardised measurements plus questionnaire (including lifestyle, compliance and awareness)
• 53% still had inadequate BP control
• Of those on Rx, 94% reported taking tablets at least 6
days/week
• Only 9% knew their target number
• Only 39% knew the purpose of BP management and control
• Patients with diabetes were more likely to have BP > audit
standard (79% vs 42%; p<0.001)
Dean SC et al. Fam Pract 2007; 24: 259-62
NSF for CHD progress report: “new
drugs and policies of reform and
investment have helped to reduce CVD
deaths in the UK by more than 23%”
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Erhardt LR et al. Atherosclerosis 2008;196:532-41
Q.O.F. Blood pressure (audit) targets
Most deprived
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Least deprived
90
85
75
70
65
Hypertension
Diabetes
Stroke & TIA
C.H.D.
07
20
06
20
05
20
07
20
06
20
05
20
07
20
06
20
05
20
07
20
06
20
05
60
20
%
80
Data on >8,000 General Practices in England (>97%)
Modified from Ashworth M et al. Br Med J 2008;337:on-line November
A more aggressive strategy for the
treatment of hypertension is needed
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Patients with hypertension control (%)
70
63
60
50
46
40
40
40
31
36
30
20
10
0
France Germany
Italy
Spain
UK
USA
Hypertension control defined as:
systolic BP <140 mmHg and diastolic BP <90 mmHg
Wang, Y. R. et al. Arch Intern Med 2007;167:141-147.
Prevalence, awareness, treatment and
control of hypertension* in Europe
Awareness** (%)
Prevalence** (%)
40
70
35
60
30
50
25
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40
20
30
15
20
10
5
10
0
0
All
Men
All
Women
Treatment** (%)
Men
Women
Control** (%)
60
70
50
60
50
40
40
30
30
20
20
10
10
0
0
All
Men
Women
All
Men
Women
* ESH criteria **adjusted for age, sex and SES
Costanzo S et al. J Hypertens 2008; December (in press)
The incidence of hypertension is
predicted to increase dramatically
Population with hypertension (%)
30
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2000
2025
28
26
24
Overall
Men
Women
The global incidence of hypertension in the adult population
is predicted to exceed 29% by the year 2025
Kearney PM, et al. Lancet 2005
Discordance between increase in use of
medications and failure to control BP
I (1995-1996)
II (1999-2000)
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III (2005-2007)
100
90
80
70
(%)
60
50
40
30
20
10
0
Hypertension
Raised TC
Raised LDL-C
Diabetes
Hypertension: >140/90 mmHg or >130/80 mmHg in diabetics
Raised TC: >4.5 mmol/L
Raised LDL-C: >2.5 mmol/L
EUROASPIRE Surveys - E.S.C. Vienna 2007
Patients with hypertension have
additional co-morbidities, making
treatment difficult
Men
Women
0
1
19%
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0
Obesity
1
17%
Glucose intolerance
26%
27%
Hyperinsulinaemia
4+
8%
Reduced HDL-C
4+
12%
Elevated LDL-C
22%
3
Elevated
triglycerides
25%
2
Left Ventricular
Hypertrophy
20%
3
24%
2
>50% have two or more comorbidities
Kannel WB, 2000
Multiple antihypertensive agents
are needed to reach BP goal
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Trial (SBP achieved)
ASCOT-BPLA (136.9 mmHg)
ALLHAT (138 mmHg)
IDNT (138 mmHg)
RENAAL (141 mmHg)
UKPDS (144 mmHg)
ABCD (132 mmHg)
MDRD (132 mmHg)
HOT (138 mmHg)
AASK (128 mmHg)
1
2
3
4
Average no. of antihypertensive medications
Adapted from Bakris et al. Am J Med 2004;116(5A):30S–8
Dahlöf et al. Lancet 2005;366:895–906
Achieved BP in trials in hypertensive
diabetics and number of drugs needed
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G Mancia J Hypertens 2002;20:1461-4
Predictors of target failure
Nilsson PM, J Hypertension 2005
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24-hour control of BP is a vital consideration for
treatment of hypertension patients
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• Treatment guidelines recommend use of antihypertensive agents that
provide 24-hour efficacy with once-daily dosing1
• Sustained, 24-hour BP control is important in prevention of CV events1
– the risk of MI and stroke is greater in the morning than at other
times of day2
• Control of BP beyond 24-hours is useful in preventing the
consequences of an occasional missed dose3
– occasional missing of doses is the most common form of
non-compliance in patients with hypertension3
1. ESH/ESC guidelines. J Hypertens 2003;21:1011–1053
2. Elliott WJ. Am J Hypertens 2001;14:291S–295S
3. Burnier M, et al. J Hypertens 2003;21(Suppl 2):S37–S42
Greater 24-hour ambulatory BP control is
associated with fewer CV events
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Incidence of CV events per 1000 person-years
30
25
20
15
10
5
0
<140 mmHg
140–159 mmHg
Clinic systolic BP
≥160 mmHg
24-hour ambulatory SBP <135 mmHg
24-hour ambulatory SBP ≥135 mmHg
Adapted from Clement DL, et al. N Engl J Med 2003;348:2407–2415
Still significant variations in the use of
drug classes and combination therapy
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Cross-national differences in the use of 7 antihypertensive drug classes and
combination drug therapy among treated hypertensive patients
Wang, Y. R. et al. Arch Intern Med 2007;167:141-147.
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Physicians often underestimate
their patients’ CV risk
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Comparison of actual vs perceived 10-year risk among 80 Swedish GPs
Erhardt LR et al. Atherosclerosis 2008;196:532-41
‘Clinical Inertia’
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Multivariate-Adjusted, Cross-National Differences in the
Likelihood of Hypertension Control and Medication Increase
for Inadequately Controlled Hypertension* (Cardio-Monitor)
Wang, Y. R. et al. Arch Intern Med 2007;167:141-147.
10 steps before you refer for hypertension
1.
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Check that the measurement is correct [standardised procedure;
validated electronic device]
2.
Check compliance, establish concordance [agree with patient and
warn of side effects]
3.
Encourage weight loss and salt reduction [inform patients
(www.bhsoc.org & www.salt.gov.uk)]
4.
5.
6.
Stop drugs that raise blood pressure [NSAIDs; OC; ciclosporin]
Maximise medication using ACD [BHS-NICE algorithm]
Spironolactone [low-dose (12.5mg) to start; watch U+E’s and for postural
hypotension]
7.
8.
Establish that better control is required [clear, written plan]
Ensure that other preventive measures are in place [multi-factorial
approach]
9.
10.
Are there any investigations that might be useful for the
specialist? [TFTs; ECG; Echo-cardio; U/S kidneys; Ur Na, K, Albumin, VMA;]
Are you referring to the correct consultant? [Hypertension clinic in
local hospital; European Hypertension specialists; ESH Centres of Excellence
for Hypertension (BHS website)]
McCormack T & Cappuccio FP. Br J Cardiol 2008;15:254-7
What are the barriers to an effective
management of hypertension?
• Patient
– Life-style
– Poor compliance (and
concordance)
– Ineffective drugs
– Missed doses
– Side effects or Adverse drug
reactions
– White coat
– Need for additional agents
– Resistance to treatment
– Loss to follow-up
– Lack of awareness of targets
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• Physician and health-professional
–
–
–
–
–
–
Attitudes
Training
Knowledge and awareness of guidelines
Measurement issues
Clinical inertia
Reluctance to change treatment despite
failure to achieve targets
– Lack of regular review
– Co-morbidity
• Organisation
– Lack of follow-up
– Migration
– Failure to refer to specialist centres
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Doctor - Try this. If it doesn’t work, come back and I will give you something else
Patient - Wouldn’t it be better if you gave me that something else right now?