Effectiveness of Hypertension Treatment and Intervention at the Community–Level is Poorly-Cont

Two studies presented today at the American Society of Hypertension’s Twenty Fourth Annual Scientific Meeting (ASH 2009) underscore the importance of addressing racial disparities in treatment provided by community-based practices (CBP) and suggest more intensive practical studies are needed.

Researchers at the Medical University of South Carolina analyzed data collected by the Hypertension Initiative of South Carolina to determine the rates of control of several cardiovascular risk factors at the community level. The goal of the Hypertension Initiative is to help transition South Carolina and the Southeast from a leader in cardiovascular disease to a model of heart and vascular health. The Initiative simultaneously promotes effective primary care management of major modifiable risk factors including hypertension, hyperlipidemia and diabetes and encourages healthy lifestyle, especially good nutrition and physical activity.

Multiple Risk Factor Control in Diabetic, Dyslipidemic, Hypertensive Patients
Research has shown that diabetes constitutes a significant risk factor for coronary heart disease and that the majority of diabetic patients are also hypertensive and dyslipidemic. Additional clinical trials document that controlling these multiple risk factors in this high risk population can significantly reduce cardiovascular and renal events.

In this study, researchers evaluated the control of diabetes, hyperlidipemia (elevated fats in the bloodstream) and hypertension, collectively and individually, in more than 96,489 diabetic, hypertensive patients (ages 41 – 81) seen at 150 CBPs between 2006 and 2008.

Despite comparatively high control rates for individual risk factors in this CBP, only 17 percent, or 1 in 6, patients with diabetes, hyperlidipemia and hypertension attained simultaneous control of all three. Overall, control rates were lower for African-Americans than Caucasians. A blood pressure goal for these risk patients of < 130/80 mm Hg remains challenging and failure to meet this one target was a driving force behind many patients’ failure to attain simultaneous control of all three risk factors.

“These results show that we have a lot of work to do to translate the success we see in clinical trials into real results at the community level, especially for those clinics that serve disproportionately minority and low income patients,” said Brent Egan, M.D., director of the Hypertension Initiative, Medical University of South Carolina, Charleston, SC. “Practical clinical trials are urgently needed to address the burden of preventable cardiovascular disease and reduce health disparities among the growing population of patients with diabetes.”

Treatment-Resistant Hypertension in Community-Based Practices
Treatment resistant hypertension (TRH), defined as blood pressure above goal on three or more medications or at goal on four or more medications, occurs in 20 – 30 percent of patients in clinical trials; however, the prevalence in community-based practices is not known.

In 2007, the Hypertension Initiative obtained data, mainly from electronic medical records, from 264,967 hypertensives seen at 150 CBP. In 64 percent of patients without diabetes, blood pressure was controlled to < 140/90 mm Hg and in 40 percent of patients with diabetes and/or chronic kidney disease, blood pressure was controlled to < 130/80 mm Hg.

Patients with diabetes and chronic kidney disease received more medications and achieved lower blood pressure, even though they were less likely to be controlled to the more stringent goal. African-Americans were comparatively over-represented in the uncontrolled group. Overall 16.2 percent of patients met the definition of TRH, with 12.7 percent uncontrolled on more than 3 medications and 3.5 percent uncontrolled on more than 4 medications.

The high proportion of untreated and under-treated patients (those receiving less than 2 medications) likely explains the lower rate of TRH than the estimated 20 – 30 percent in clinical trials, as some patients would remain uncontrolled despite additional medications.

“These data suggest therapeutic inertia remains an obstacle to better BP control, as many uncontrolled hypertensives are receiving below recommended number of medications,” said Dr. Egan. “Improvement in care is urgently needed to address the burden of uncontrolled blood pressure and reduce racial disparities in order to realize more cardiovascular benefits.”

About the American Society of Hypertension
The American Society of Hypertension (ASH) is the largest U.S. professional organization of scientific investigators and healthcare professionals committed to eliminating hypertension and its consequences. ASH is dedicated to promoting strategies to prevent hypertension and to improving the care of patients with hypertension and associated disorders. The Society serves as a scientific forum that bridges current hypertension research with effective clinical treatment strategies for patients. For more information, please visit http://www.ash-us.org.

Source: American Society of Hypertension (ASH)

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