CSRI Who fails to achieve blood pressure and lipid targets – patients or doctors? Francesco P Cappuccio MBBS MD MSc FRCP FFPH FAHA Professor of Cardiovascular

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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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Evolution of guidelines on lipid management

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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


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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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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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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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)


‘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

CSRI

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?

Documents

CSRI Who fails to achieve blood pressure and lipid targets – patients or doctors? Francesco P Cappuccio MBBS MD MSc FRCP FFPH FAHA Professor of Cardiovascular