Post on 19-Dec-2015
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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 SchoolConsultant Cardiovascular Physician, UHCW NHS Trust, Coventry
CSRICV Mortality Risk
Doubles with each 20/10 mm Hg BP incrementC
V m
ort
alit
y:
-fo
ld i
ncr
ease
BP (SBP/DBP mm Hg)
0
1
2
3
4
5
6
7
8
115/75 135/85 155/95 175/105
Lewington S, et al. Lancet 2002; 60: 1903-1913
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Relative risk reduction (%)
−50
−40
−30
−20
−10
0CHDStrokeCV event
20–21
21–28
30–39
Risk of CV event with ACEI or CCB relative to placeboCV: cardiovascularCHD: coronary heart disease
Long-term antihypertensive treatment reduces CV risk
Neal B, et al. 2000
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Flack JM, et al. 2002*Study of the US population
Major CV events/year*
10 000
20 000
30 000
40 000
50 000
Medicated Unmedicated Total0
DBP/SBP uncontrolled
DBP uncontrolled
SBP uncontrolled
Uncontrolled BP results in major CV events (myocardial infarction [MI], stroke or CV-related death)
Uncontrolled BP results in major CV events*
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Erhardt LR et al. Atherosclerosis 2008;196:532-41
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
CSRIOne 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
CSRIBHS NICE Guidelines
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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
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Erhardt LR et al. Atherosclerosis 2008;196:532-41
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%”
CSRIQ.O.F. Blood pressure (audit) targets
Modified from Ashworth M et al. Br Med J 2008;337:on-line November
60
65
70
75
80
85
90
2005
2006
2007
2005
2006
2007
2005
2006
2007
2005
2006
2007
%
Most deprived Least deprived
Hypertension C.H.D. Stroke & TIA Diabetes
Data on >8,000 General Practices in England (>97%)
CSRIA more aggressive strategy for the treatment of hypertension is needed
4640
31
4036
63
0
10
20
30
40
50
60
70
France Germany Italy Spain UK USA
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.
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Prevalence, awareness, treatment and control of hypertension* in Europe
0
5
10
15
20
25
30
35
40
All Men Women
0
10
20
30
40
50
60
70
All Men Women
Costanzo S et al. J Hypertens 2008; December (in press)
0
10
20
30
40
50
60
All Men Women
0
10
20
30
40
50
60
70
All Men Women
Prevalence** (%) Awareness** (%)
Treatment** (%) Control** (%)
* ESH criteria **adjusted for age, sex and SES
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Kearney PM, et al. Lancet 2005
The incidence of hypertension is predicted to increase dramatically
Population with hypertension (%)
30
Overall
26
28
Men Women
20002025
24
The global incidence of hypertension in the adult population is predicted to exceed 29% by the year 2025
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0
10
20
30
40
50
60
70
80
90
100
Hypertension Raised TC Raised LDL-C Diabetes
(%)
I (1995-1996) II (1999-2000) III (2005-2007)
EUROASPIRE Surveys - E.S.C. Vienna 2007
Hypertension: >140/90 mmHg or >130/80 mmHg in diabeticsRaised TC: >4.5 mmol/LRaised LDL-C: >2.5 mmol/L
Discordance between increase in use of medications and failure to control BP
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Patients with hypertension have additional co-morbidities, making
treatment difficult
Obesity
Glucose intolerance
Hyperinsulinaemia
Reduced HDL-C
Elevated LDL-C
Elevatedtriglycerides
Left Ventricular Hypertrophy
3
4+
0 1
2
26%
25%
8%
22%
19%
3
4+
0 1
2
27%
24%
12%
20%
17%
>50% have two or more comorbidities
Men Women
Kannel WB, 2000
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Average no. of antihypertensive medications
1 2 3 4
Multiple antihypertensive agents are needed to reach BP goal
Trial (SBP achieved)
Adapted from Bakris et al. Am J Med 2004;116(5A):30S–8 Dahlöf et al. Lancet 2005;366:895–906
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)
CSRIAchieved BP in trials in hypertensive diabetics and number of drugs needed
G Mancia J Hypertens 2002;20:1461-4
CSRI Predictors of target failure
Nilsson PM, J Hypertension 2005
CSRI24-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;21:1011–10532. Elliott WJ. Am J Hypertens 2001;14:291S–295S
3. Burnier M, et al. J Hypertens 2003;21(Suppl 2):S37–S42
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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
24-hour ambulatory SBP ≥135 mmHg24-hour ambulatory SBP <135 mmHg
Incidence of CV events per 1000 person-years
Clinic systolic BP
<140 mmHg 140–159 mmHg ≥160 mmHg
25
20
15
10
5
0
30
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Wang, Y. R. et al. Arch Intern Med 2007;167:141-147.
Still significant variations in the use of drug classes and combination therapy
Cross-national differences in the use of 7 antihypertensive drug classes and combination drug therapy among treated hypertensive patients
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Erhardt LR et al. Atherosclerosis 2008;196:532-41
Physicians often underestimate their patients’ CV risk
Comparison of actual vs perceived 10-year risk among 80 Swedish GPs
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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.
‘Clinical Inertia’
CSRI10 steps before you refer for hypertension1. 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. Stop drugs that raise blood pressure [NSAIDs; OC; ciclosporin]5. Maximise medication using ACD [BHS-NICE algorithm]6. Spironolactone [low-dose (12.5mg) to start; watch U+E’s and for postural
hypotension]7. Establish that better control is required [clear, written plan]8. Ensure that other preventive measures are in place [multi-factorial
approach]9. Are there any investigations that might be useful for the
specialist? [TFTs; ECG; Echo-cardio; U/S kidneys; Ur Na, K, Albumin, VMA;]
10. 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
CSRIWhat 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
• 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 elsePatient - Wouldn’t it be better if you gave me that something else right now?