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Who fails to achieve blood pressure and lipid targets – patients or doctors?

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. 8. 7. 6. CV mortality:

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Who fails to achieve blood pressure and lipid targets – patients or doctors?

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  1. 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

  2. 8 7 6 CV mortality: -fold increase 5 4 3 2 1 0 115/75 135/85 155/95 175/105 BP (SBP/DBP mm Hg) CV Mortality RiskDoubles with each 20/10 mm Hg BP increment Lewington S, et al. Lancet 2002; 60: 1903-1913

  3. 0 −10 −20 −30 −40 −50 Long-term antihypertensive treatment reduces CV risk CV event Stroke CHD 20–21 21–28 30–39 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

  4. DBP/SBP uncontrolled Major CV events/year* DBP uncontrolled 50 000 SBP uncontrolled 40 000 30 000 20 000 10 000 0 Medicated Unmedicated Total Uncontrolled BP results in major CV events* 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

  5. Serum Total Cholesterol and Blood Pressure strong determinants of cardiovascular risk Erhardt LR et al. Atherosclerosis 2008;196:532-41

  6. Evolution of guidelines on lipid management Erhardt LR et al. Atherosclerosis 2008;196:532-41

  7. Large numbers of patients are still not reaching cholesterol targets Erhardt LR et al. Atherosclerosis 2008;196:532-41

  8. One conclusion from an expert panel … • 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

  9. BHS NICE Guidelines

  10. Potential barriers to BP control in patients with inadequately controlled hypertension in primary care • 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 life-style, 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

  11. 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%” Erhardt LR et al. Atherosclerosis 2008;196:532-41

  12. Diabetes Stroke & TIA Hypertension C.H.D. Data on >8,000 General Practices in England (>97%) Q.O.F. Blood pressure (audit) targets Modified from Ashworth M et al. Br Med J 2008;337:on-line November

  13. A more aggressive strategy for the treatment of hypertension is needed Patients with hypertension control (%) 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.

  14. Prevalence, awareness, treatment and control of hypertension* in Europe Awareness** (%) Prevalence** (%) Treatment** (%) Control** (%) * ESH criteria **adjusted for age, sex and SES Costanzo S et al. J Hypertens 2008; December (in press)

  15. 2000 Population with hypertension (%) 26 28 24 2025 Overall Men Women The global incidence of hypertension in the adult population is predicted to exceed 29% by the year 2025 30 The incidence of hypertension is predicted to increase dramatically Kearney PM, et al. Lancet 2005

  16. Discordance between increase in use of medications and failure to control BP 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

  17. Patients with hypertension have additional co-morbidities, making treatment difficult Men Women 0 0 Obesity Glucose intolerance Hyperinsulinaemia Reduced HDL-C Elevated LDL-C Elevatedtriglycerides Left Ventricular Hypertrophy 1 1 19% 17% 26% 27% 12% 4+ 4+ 8% 22% 20% 25% 24% 3 3 2 2 >50% have two or more comorbidities Kannel WB, 2000

  18. Multiple antihypertensive agents are needed to reach BP goal 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

  19. Achieved BP in trials in hypertensive diabetics and number of drugs needed G Mancia J Hypertens 2002;20:1461-4

  20. Predictors of target failure Nilsson PM, J Hypertension 2005

  21. 24-hour control of BP is a vital consideration for treatment of hypertension patients • 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 ofnon-compliance in patients with hypertension3 1. ESH/ESC guidelines. J Hypertens 2003;21:1011–1053 2. Elliott WJ. Am J Hypertens 2001;14:291S–295S3. Burnier M, et al. J Hypertens 2003;21(Suppl 2):S37–S42

  22. Incidence of CV events per 1000 person-years 30 25 20 15 10 5 0 <140 mmHg 140–159 mmHg ≥160 mmHg Clinic systolic BP 24-hour ambulatory SBP <135 mmHg 24-hour ambulatory SBP ≥135 mmHg Greater 24-hour ambulatory BP control is associated with fewer CV events Adapted from Clement DL, et al. N Engl J Med 2003;348:2407–2415

  23. Cross-national differences in the use of 7 antihypertensive drug classes and combination drug therapy among treated hypertensive patients Still significant variations in the use of drug classes and combination therapy Wang, Y. R. et al. Arch Intern Med 2007;167:141-147.

  24. Physicians often underestimate their patients’ CV risk Comparison of actual vs perceived 10-year risk among 80 Swedish GPs Erhardt LR et al. Atherosclerosis 2008;196:532-41

  25. ‘Clinical Inertia’ 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.

  26. 10 steps before you refer for hypertension • Check that the measurement is correct [standardised procedure; validated electronic device] • Check compliance, establish concordance [agree with patient and warn of side effects] • Encourage weight loss and salt reduction [inform patients (www.bhsoc.org & www.salt.gov.uk)] • 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] • Establish that better control is required [clear, written plan] • Ensure that other preventive measures are in place [multi-factorial approach] • 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

  27. What are the barriers to an effective management of hypertension? • 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 • 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

  28. 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?

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