Hypertension management progresses in England, but room for improvement remains
9 février 2009 :
London, UK - New survey results from England show that the management of high blood pressure there improved between 2003 and 2006. In their paper published online February 9, 2009 in Hypertension [1], Dr Emanuela Falaschetti (University College, London) and colleagues say important and significant increases in rates of awareness, treatment, and control of hypertension are apparent over the three years studied, particularly among women.
"This is good news, but there is still room for improvement, especially among those at highest risk," Falaschetti told heartwire.
In an accompanying editorial [2], Drs Sailesh Mohan and Norm R C Campbell (University of Calgary, Alberta) agree : "Although these findings indicate continued improvement in hypertension management, they are far from optimum."
Majority have BP controlled for the first time
Falaschetti and colleagues explain that data from the annual nationally representative Health Survey for England showed improving levels of blood-pressure control between 1994 and 1998, and subsequently in 2003 but, despite this progress, control rates were only 22% in 2003. They then compared the 2006 survey results with those from 2003, with the added bonus that the 2006 survey allowed them to assess the impact of the introduction, in April 2004, of payments to general practitioners in the UK for achieving various clinical targets, including lowering blood pressure.
Overall mean BP levels in 2006 were 130.8/74.2 mm Hg in men and 124.0/72.4 mm Hg in women. Awareness of hypertension increased significantly in the overall population-from 62% in 2003 to 66% in 2006 (p<0.001)-as did the proportion of those treated-from 48% to 54% (p<0.001). Control rates (to <140/90 mm Hg) were higher in 2006-up from 22% in 2003 to 28% (p<0.001). Among those on treatment, control rates also increased, from 46% to 52%, over the course of the three years (p<0.001).
For the first time, in 2006, the majority of those on treatment had their blood pressure controlled.
Falaschetti told heartwire : "These improvements continue a trend already shown in previous publications. You can see that for the first time, in 2006, the majority of those on treatment had their blood pressure controlled."
Much room for improvement in highest-risk patients
But Falaschetti says that despite these encouraging findings, there is room for further improvement in detection, treatment, and control of high blood pressure, "especially among those at highest risk."
Among patients with a cardiovascular disease risk of 20% or greater (based on Framingham), only 17% had their blood pressure controlled to <140/90 mm Hg in 2006. Similarly, only 42% of diabetics and 47% of those with a history of angina, heart attack, or stroke had their BP controlled to below 140/90 mm Hg.
Falaschetti and colleagues found that the most common agents used for monotherapy in 2006 were ACE inhibitors or ARBs, despite the fact that current guidance in the UK recommends calcium channel blockers (CCBs) or diuretics for those of African origin and for those 55 years or older (the majority of hypertensives).
When a single agent does not adequately control BP, the NICE/British Hypertension Society guidance currently recommends use of either A+C (ACE inhibitor or ARB plus CCB) or A+D (ACE inhibitor or ARB plus diuretic), they add. Overall in 2006, A+D was the most common combination used, but A+C was not used more commonly than C+D or A+B (where B stands for beta blockers).
They note that the use of beta blockers as monotherapy has fallen from 29% in 2003 to 21% in 2006, "in keeping with the latest guidance," although among those on two drugs, >35% used beta blockers, "conflicting with current guidelines." The most common combinations of three and four drugs used were in keeping with the British guidelines, they found.
Don’t forget dietary salt reduction
In their editorial [2], Mohan and Campbell say that despite the improving trends in England, "more intensive efforts are clearly warranted to prevent and control hypertension so that a meaningful impact can be achieved in reducing hypertension-associated CVD." Low-tech strategies, such as reducing dietary salt intake, should not be forgotten, they point out, although they note that England started a national campaign to reduce dietary salt in 2003.
Canadian doctors also question the supposition by Falaschetti et al that the new payments to English doctors for attaining blood pressure targets has an impact on hypertension management there. The reasons behind the improved management of hypertension prior to and following the introduction of the pay for performance require "more rigorous exploration," they assert.
But Falaschetti told heartwire that they appear to have miscalculated some figures, and that her numbers show that the better improvement among women support the hypothesis that the pay-per-performance policy is likely to have contributed, "as it is known that women are more likely to visit their GP than men."
Sources
1. Falaschetti E, Chaudury M, Mindell J, et al. Continued improvement in hypertension management in England. Results from the Health Survey for England 2006. Hypertension 2009 ; DOI:10.1161/HYPERTENSIONAHA.108.125617. Available at http://hyper.ahajournals.org/.
2. Mohan S, Campbell NRC. Hypertension management : time to shift gears and scale up national efforts. Hypertension2009 ; DOI:10.1161/HYPERTENSIONAHA.108.127076. Available at http://hyper.ahajournals.org/.
3. Solomon SD, Appelbaum E, Manning WJ, et al. Effect of the direct renin inhibitor aliskiren, the angiotensin receptor blocker, losartan, or both on left ventricular mass in patients with hypertension and left ventricular hypertrophy. Circulation 2009 ; 119 : 530-537. |
