Study: Aggressive approach to hypertension needed

Doctors aren’t being nearly aggressive enough in treating hypertension, according to a recent study which tracked patients at Veterans Affairs (VA) clinics in Virginia.

The study found 40% of patients had unacceptably high blood pressure despite frequent office visits documented through clinical records. Physicians’ orders, progress notes, and pharmacy records show patients were compliant in taking prescribed medications.

"Doctors have gotten sloppy in treating a serious disease that is not as sexy as some others," says the study’s lead author, Mark Moskowitz, MD, professor of medicine and public health at Boston University School of Medicine. "It’s lost its sexiness. Now we focus on cholesterol or we talk about diabetes and other conditions that need to be treated aggressively. This paper is an awakening call."

Hypertension affects 50 million Americans, and about one-third of the victims don’t know they have the disease. It is the direct cause of about 40,000 deaths a year and contributes to 190,000 more deaths, according to the American Heart Association (AHA).

What’s more, the AHA says 52% of those diagnosed with hypertension are not on any drug therapy, 27% are on inadequate therapy, and only 21% are being adequately treated.

Nancy Houston-Miller, RN, associate director of the Stanford Cardiac Rehabilitation Program in Palo Alto, CA, and a frequent spokeswoman for the National Heart, Lung and Blood Institute in Bethesda, MD, echoes the sentiment. "We have to do a better job. People have told me it’s the physicians I need to talk to. It’s an issue of physician compliance."

Change medications

The key? If the patient’s current medications do not keep blood pressure below 140/90 mm Hg, try different drugs, a combination of medications, or increased dosage.

It’s precisely because high blood pressure was hot news nearly half a century ago that physicians are becoming lax in its treatment, Moskowitz says.

Researchers initially thought the issue was patient compliance, but Moskowitz says they were surprised to find that despite an average of six office visits a year and the anti-hypertensive drug therapy, 40% of the 800 elderly male patients studied had blood pressure that remained above 160/90 mm Hg.

In addition, they found those who made the most frequent clinic visits had the worst control, indicating that physicians did not take advantage of ample opportunities to improve control by changing medications.

Researchers said patient compliance is certainly an issue, but the VA study was particularly significant because patients had virtually unlimited access to medical care and to drug therapies.

"It’s a simple solution," Moskowitz says. "If doctors change blood pressure medication when it’s high, their patients get much better control and better outcomes."

Moving goalposts

Moskowitz and his colleagues admit it’s hard to keep on top of the latest thinking about hypertension management.

One reason, Houston-Miller acknowledges, is the goal posts keep moving. "Ten years ago, a blood pressure of 160/90 was considered good. The bottom line is that there’s an increased risk of heart disease and stroke even at 140/90. Thirty percent of MIs develop at 140/90. Some nephrologists say 120/70 is ideal," she explains.

In February, the World Health Organization/ International Society of Hypertension lowered its target goals for hypertension in overweight, sedentary, hypercholesterolemic patients to 130/85 mm Hg.

Houston-Miller also says hypertension is a difficult disease to control and compliance may be more difficult to obtain on the part of both patients and physicians because of the side effects associated with many medications.

"There are more than 100 anti-hypertensive drugs that can be used very effectively, some in combination with others and with ACE inhibitors and diuretics," Houston-Miller says.

She also said doctors frequently do not question patients thoroughly enough about their problems "because they don’t have the time in a visit that lasts only seven to 10 minutes and they have to deal with acute problems first," even though blood pressure problems are the most common reason for all outpatient visits.

"We need to change the message to doctors and the public," says Houston-Miller. "The No. 1 cause of death in the United States is heart failure, caused in a large part because of lack of control of blood pressure."

The problem may be doctors don’t prescribe enough antihypertensives because "they know a lot of patients won’t take them," says Lee Green, MD, MPh, a family practitioner in Ann Arbor, MI, and professor of family medicine and assistant chair for research programs at the University of Michigan, also in Ann Arbor.

Green says the kind of study conducted by Moskowitz is based on scientific evidence, but that’s different from "face-to-face encounters with patients."

"Let’s say Joe comes into the office, and he’s got hypertension, but he doesn’t have any symptoms. He feels fine," Green says. "Now, as the doctor, I tell Joe this is a life-threatening illness that he needs to take these medicines. He’ll say, Yeah, right, Doc,’ and I’ll write him a prescription. I know and he knows that he’ll never get it filled."

Green says patients do not want to "adopt a sick role, take medicines, and change their concept of themselves as healthy."

"We have to sell them on taking the drugs," Green says. "Now it’s easy to sell a patient with a broken ankle with the idea he needs a cast. But for a patient with hypertension who has no symptoms, who tells you everybody in his family lived to the age of 90, he’s not likely to be very receptive to the idea he needs to take pills to avoid a heart attack, stroke, or congestive heart failure."

Some practitioners argue with Moskowitz, contending compliance is more difficult to monitor than by simply accessing pharmacy records.

"If prescriptions are being filled and they aren’t responding, I would wonder if they really are taking their medications," says Stephen Spann, MD, chairman of the Department of Family and Community Medicine at Baylor University Medical School in Houston.

Spann suggests that looking for markers in urine or taking actual pill counts are better ways to determine if patients are complying.

Then, he says, "Maybe we can look at whether they should be on additional medications or on higher doses."

Mark Moskowitz can be reached at (617) 638-8030; Nancy Houston-Miller at (650) 725-5008; Lee Green at (734) 998-7120; and Stephen Spann at (713) 798-7788.