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Assessing Guidelines, Strategies, and New Drugs to Get Patients to Target

Authors: Linda Brookes, MScFaculty and Disclosures

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Introduction

New data highlighted this month reveal that hypertension control appears to be better in the United States than in Western Europe -- but unfortunately the latest US hypertension guidelines fail to substantially affect blood pressure control in diabetic patients, whereas the new Canadian hypertension guidelines highlight for the first time the dangers of "high normal" blood pressure. Two new reports further confirm that there is a higher rate of incident diabetes with diuretics and beta-blockers, and beta-blockers are less effective than diuretics, calcium channel blockers, or angiotensin blockers as first-line therapy for elevated blood pressure control. Finally, the first clinical trials with new second-generation renin inhibitors and a small catalog of new combination antihypertensive pills coming soon in Europe, the United States, and, as a polypill, in India are reported.

Hypertension Control Appears Better in the United States Than in Western Europe

An analysis of survey data appears to confirm previous population-based studies showing that patients with diagnosed hypertension in the United States have lower blood pressure levels and better hypertension control than patients in Western European countries. The results of the analysis are published in the January 22 issue of Archives of Internal Medicine.[1] The US investigators attribute the difference to lower treatment thresholds and more intensive treatment set out in the most recent US hypertension management guidelines. However, in their analysis, almost half the US patients did not achieve their goal blood pressure as recommended in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7),[2] so "better blood pressure control in the United States should not be too quickly praised," they caution.

The study, which was supported by the MacLean Center for Clinical Medical Ethics, the National Institute of Aging, and the Agency for Healthcare Research and Quality, used patient data collected from surveys conducted in 2004 in France, Germany, Italy, Spain, and the United Kingdom, as well as the United States. The surveys were part of Cardiomonitor, an ongoing survey of physician visits by ambulatory adult patients with cardiovascular diseases in selected countries carried out since 1980 by an international market research company (Taylor Nelson Sofres Healthcare, London). In 2004, the physicians in the survey were randomly selected, and those who agreed to participate completed 2-page diaries for 15 cardiovascular patients. Information collected included patient characteristics, initial blood pressure level before treatment, any co-occurring diseases, and the use of 7 types of antihypertensive drugs.

Investigators led by Y. Richard Wang, MD, PhD, of Temple University Hospital and University of Pennsylvania, Philadelphia, identified a total of 21,053 patients with a primary or secondary diagnosis of hypertension in all 6 countries. These patients had visited a total of 291 cardiologists and 1284 primary care physicians. The patients were 53% male, mean age was 65 years, and 23% had diabetes mellitus. At least 92% of patients with hypertension in each country were receiving antihypertensive drug therapy. Use of thiazide-type diuretics was similar across all countries (29% to 13%), but use of other antihypertensive drug classes -- beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) -- varied considerably. Use of combination therapy (≥ 2 drugs) was highest in the United States (64% vs 44% to 59% in European countries).

Initial blood pressure measurements before treatment were available for 61% to 80% of patients per country and were lowest in the United States (average of 161/94 mm Hg, vs an average of 167-173/96-99 mm Hg in Europe). The most recent blood pressure reading was also lower in the United States than in any other country (average of 134/79 mm Hg, vs an average of 139-144/80-84 mm Hg in Europe). Only 65% of US patients had an initial pretreatment blood pressure level ≥ 160/100 mm Hg, compared with 81% to 90% of patients in the European countries.

The rate of hypertension control was found to be highest among the US patients, whether control was defined as < 140/90 mm Hg for all patients or as < 130/80 mm Hg in patients with diabetes and < 140/90 mm Hg in all others. By the later definition, 53% of US patients achieved hypertension control compared with 27% to 40% of European patients.

Multivariate analyses controlling for age, sex, current smoking, and physician specialty showed that, compared with US patients, European patients had higher latest systolic blood pressure (SBP) levels (by 5.3-10.2 mm Hg across countries examined) and diastolic blood pressure (DBP) levels (by 1.9-5.3 mm Hg; all P < .001). These differences remained significant (P < .01) after controlling for comorbidities and concurrent drug treatment. European patients were less likely than US patients to have hypertension control or a medication increase for inadequately controlled hypertension (P < .001). The researchers found that initial pretreatment blood pressure levels accounted for most of the cross-national differences in latest SBP and DBP levels and the likelihood of hypertension control.

Dr. Yang and his colleagues suggest that aggressive treatment in the United States means that some patients may be receiving drug treatment they do not need, involving extra cost. However, these costs are small compared with those that would result from a future cardiovascular event that occurred due to inadequate blood pressure control.

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