To evaluate barriers to adherence to hypertension guidelines among publicly employed general practitioners (GPs).
Questionnaire-based survey distributed to GPs in 24 randomly selected primary care centres in the Region of Skåne in southern Sweden.
A total of 109 GPs received a self-administered questionnaire and 90 of them responded.
Main outcome measures
Use of risk assessment programmes. Reasons to postpone or abstain from pharmacological treatment for the management of hypertension.
Reported managing of high blood pressure (BP) varied. In all, 53% (95% CI 42–64%) of the GPs used risk assessment programmes and nine out of 10 acknowledged blood pressure target levels. Only one in 10 did not inform the patients about these levels. The range for immediate initiating pharmacological treatment was a systolic BP 140–220 (median 170) mmHg and diastolic BP 90–110 (median 100) mmHg. One-third (32%; 95% CI 22–42%) of the GPs postponed or abstained from pharmacological treatment of hypertension due to a patient's advanced age. No statistically significant associations were observed between GPs’ gender, professional experience (i.e. in terms of specialist family medicine and by number of years in practice), and specific reasons to postpone or abstain from pharmacological treatment of hypertension.
These data suggest that GPs accept higher blood pressure levels than recommended in clinical guidelines. Old age of the patient seems to be an important barrier among GPs when considering pharmacological treatment for the management of hypertension.
Barriers; family practice; guidelines; hypertension; primary care; survey
BACKGROUND: When managing hypertension, the assessment of the absolute risk of a cardiovascular' event is now advocated as the most accurate way in which the risks and benefits of anti-hypertensive therapy should be judged. Most studies that have examined control of hypertension have relied solely on the blood pressure level attained after treatment, with no measurement of the likely absolute risk in individual patients. AIM: To assess control of hypertension by quantifying the 10-year absolute risk of cardiovascular disease in patients treated by their general practitioners, and to assess which risk factors are associated with uncontrolled hypertension in this group of patients. METHOD: A cross-sectional study was made of patients on drug treatment for hypertension in 18 Oxfordshire general practices subscribing to the VAMP (value-added medical products) computer system. The absolute risk of suffering a cardiovascular event in the following 10 years was measured according to each individual's risk factor profile. Factors associated with uncontrolled hypertension were ascertained using multiple logistic regression analysis. RESULTS: Overall, 40.9% (37.6% to 44.1%) of the hypertensive population had an absolute risk exceeding 20% of having a cardiovascular event in the following 10 years. The distribution of risk factors varies throughout the population. A higher blood pressure reading was strongly associated with an increased likelihood of high absolute risk, but high blood pressure readings in individual patients did not necessarily equate to a high absolute risk. The factors independently associated with uncontrolled hypertension were age, sex, past history of stroke, ischaemic heart disease and transient ischaemic attack, a body mass index greater than 30, diabetes, and current smoking. CONCLUSIONS: Absolute risk assessment maximizes the risk-benefit ratio in treated hypertensive patients. Individual control and management requires multifactorial assessment and management. Treatment of hypertension according to blood pressure reading alone is not a reliable way of reducing the absolute risk of cardiovascular disease.
Background. Evidence-based guidelines should in most cases be followed also in the treatment of elderly. Older people are often suboptimally treated with the recommended drugs. Objectives. To describe how well general practitioners adhere to current guidelines in the treatment of elderly with cardiovascular disease and evaluate local education as a tool for improvement. Method. Data was collected from the medical records of patients aged ≥65, who visited a primary health care center in Sweden 2006 and had one or more of the following diagnoses: hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation, or prior stroke. Local education was organized and included feed-back to the patient's doctor and discussion about regional guidelines. Repeated measurements were performed in 2008. Results and Conclusion. The adherence to guidelines was low. Approximately one-third of the patients with hypertension reached target blood pressure, stroke patients more often. More patients with heart failure were treated with angiotensin converting enzyme inhibitor than in other European countries, but still only 60%. Half of the patients with chronic atrial fibrillation were treated with Warfarin, although more than two-thirds had a CHADS2 score indicating the need. Educational efforts appeared to increase the adherence and hence should be encouraged.
To assess the pharmacological treatment and the control of major modifiable cardiovascular risk factors in everyday practice according to the patients’ cardiovascular risk level.
In a cross-sectional study general practitioners (GPs) had to identify a random sample of their patients with cardiovascular risk factors or diseases and collect essential data on the pharmacological treatment and control of hypertension, hyperlipidemia, and diabetes according to the patients’ cardiovascular risk level and history of cardiovascular disease. Participants were subjects of both sexes, aged 40–80 years, with at least one known cardiovascular risk factor or a history of cardiovascular diseases.
From June to December 2000, 162 Italian GPs enrolled 3120 of their patients (2470 hypertensives, 1373 hyperlipidemics, and 604 diabetics). Despite the positive association between the perceived level of global cardiovascular risk and lipid-lowering drug prescriptions in hyperlipidemic subjects (from 26% for lowest risk to 56% for highest risk p < 0.0001) or the prescription of combination therapy in hypertensives (from 41% to 70%, p < 0.0001) and diabetics (from 24% to 43%, p = 0.057), control was still inadequate in 48% of diabetics, 77% of hypertensives, and 85% of hyperlipidemics, with no increase in patients at highest risk. Trends for treatment and control were similar in patients with cardiovascular diseases.
Even in high-risk patients, despite a tendency towards more intensive treatment, pharmacological therapy is still under used and the degree of control of blood pressure, cholesterol level and diabetes is largely unsatisfactory.
global cardiovascular risk; hypertension; hyperlipideamia; diabetes; general practice
OBJECTIVES--To investigate and quantify the extent to which variations in guidelines influence assessment of control of hypertension. DESIGN--Cross sectional study. Selected patients had hypertension assessed as controlled or uncontrolled with guidelines from New Zealand, Canada, the United States, Britain, and the World Health Organisation. SETTING--18 general practices in Oxfordshire. SUBJECTS--876 patients with diagnosed hypertension and taking antihypertensive drugs. MAIN OUTCOME MEASURES--Proportion of patients with controlled hypertension according to each set of guidelines. RESULTS--The proportion of patients with controlled hypertension varied from 17.5% to 84.6% with the different guidelines after adjustment for the sampling method. All five sets of guidelines agreed on the classification for 31% (277) of the patients. The New Zealand guidelines calculate an absolute risk of a cardiovascular event. When this was taken as the standard half of the patients with uncontrolled hypertension by the United States criteria would be treated unnecessarily and 31% of those classified as having controlled hypertension by the Canadian guidelines would be denied beneficial treatment. CONCLUSIONS--Hypertension guidelines are inconsistent in their recommendations and need to make clear the absolute benefits and risks of treatment.
In order to prevent cardiovascular events, it is essential to effectively manage overall risk of cardiovascular disease. However, despite guideline recommendations to this effect, current management of the major, modifiable cardiovascular risk factors such as hypertension and dyslipidemia is disconnected and patient adherence to therapy is poor. This is particularly important for patients with multiple cardiovascular risk factors, who are often prescribed multiple medications. The JEWEL study program investigated the use of single-pill amlodipine/atorvastatin as a strategy to improve management of these patients. The JEWEL program consisted of two 16-week, international, open-label, multicenter, titration-to-goal studies in patients with hypertension and dyslipidemia. The two studies differed based on country of enrollment and certain tertiary endpoints, but the overall designs were very similar. Patients were enrolled from 255 centers across Canada and 13 European countries. The study was designed to assess the efficacy, safety, and utility of amlodipine/atorvastatin single-pill therapy in a real-world setting. Patients were initiated at a dose of amlodipine 5 mg/atorvastatin 10 mg, unless previously treated, and were uptitrated as necessary. The primary efficacy parameter was the percentage of patients, at different levels of cardiovascular risk, achieving country-specific guideline-recommended target levels for blood pressure and lipids. A secondary analysis of efficacy measured attainment of the same single goal for blood pressure across all study participants (JEWEL I and II) and the same single goal for LDL-C across all study participants (JEWEL I and II). The program utilized a newly developed questionnaire to gain better understanding of participants’ beliefs and behaviors towards medical treatment of their multiple risk factors. Approximately 2850 patients were enrolled in the program, which was completed in August 2005. The JEWEL program assessed the effectiveness of a single pill (amlodipine/atorvastatin) in targeting the two principal risk factors for cardiovascular disease simultaneously to achieve nationally applicable treatment targets in a routine clinical practice setting.
amlodipine; atorvastatin; risk factors; hypertension; dyslipidemia; cardiovascular disease
The views of 542 general practitioners (GPs) and 64 consultant physicians about the management of patients with hypertension in general practice were sought by postal questionnaire. 325 (60%) of the GPs and 45 (70%) of the consultant physicians completed the questionnaire. For a 40-year-old man with no other cardiovascular risk factors most general practitioners would intervene with drugs at blood pressure levels specified in published guidelines, whereas many local consultants and older GPs would consider drug treatment at lower levels. About 75% of GPs, compared with 87% of consultants, would suggest drug treatment in a woman of 70 years with a BP of 180/100 mmHg. Although consultants tended to expect GPs to order more tests when investigating a patient with hypertension than the GPs actually did, both GPs and consultants would order similar types of investigations apart from imaging. Consultants had different expectations about the frequency with which general practitioners should record patients' blood pressure and the GPs' ability to prevent cardiovascular events in hypertensive patients. Many older GPs and consultants seem to have unrealistic expectations of the value of treating patients with hypertension.
Treatment goals for cardiovascular risk management are generally not achieved. Specialized practice nurses are increasingly facilitating the work of general practitioners and self-monitoring devices have been developed as counseling aid. The aim of this study was to compare standard treatment supported by self-monitoring with standard treatment without self-monitoring, both conducted by practice nurses, on cardiovascular risk and separate risk factors.
Men aged 50–75 years and women aged 55–75 years without a history of cardiovascular disease or diabetes, but with a SCORE 10-year risk of cardiovascular mortality ≥5% and at least one treatable risk factor (smoking, hypertension, lack of physical activity or overweight), were randomized into two groups. The control group received standard treatment according to guidelines, the intervention group additionally received pro-active counseling and self-monitoring (pedometer, weighing scale and/ or blood pressure device). After one year treatment effect on 179 participants was analyzed.
SCORE risk assessment decreased 1.6% (95% CI 1.0–2.2) for the control group and 1.8% (1.2–2.4) for the intervention group, difference between groups was .2% (−.6–1.1). Most risk factors tended to improve in both groups. The number of visits was higher and visits took more time in the intervention group (4.9 (SD2.2) vs. 2.6 (SD1.5) visits p < .001 and 27 (P25 –P75:20–33) vs. 23 (P25 –P75:19–30) minutes/visit p = .048).
In both groups cardiovascular risk decreased significantly after one year of treatment by practice nurses. No additional effect of basing the pro-active counseling on self-monitoring was found, despite the extra time investment.
Primary health care; Arteriosclerosis; Cardiovascular diseases; Prevention and control; Self-management; Risk factors
Hypertension is a progressive cardiovascular syndrome that arises from many differing, but interrelated, etiologies. Hypertension is the most prevalent cardiovascular disorder, affecting 20% to 50% of the adult population in developed countries. Arterial hypertension is a major risk factor for cardiovascular diseases and death. Epidemiologic data have shown that control of hypertension is achieved in only a small percentage of hypertensive patients. Findings from the World Health Organization project Monitoring Trends and Determinants in Cardiovascular Diseases (MONICA) showed a remarkably high prevalence (about 65%) of hypertension in Eastern Europeans. There is virtually no difference however, between the success rate in controlling hypertension when comparing Eastern and Western European populations. Diagnosing hypertension depends on both population awareness of the dangers of hypertension and medical interventions aimed at the detecting elevated blood pressure, even in asymptomatic patients. Medical compliance with guidelines for the treatment of hypertension is variable throughout Eastern Europe. Prevalence of hypertension increases with age, and the management of hypertension in elderly is a significant problem. The treatment of hypertension demands a comprehensive approach to the patient with regard to cardiovascular risk and individualization of hypertensive therapy.
Eastern Europe; Epidemiology; Hypertension
In most developed countries, risk factors for cardiovascular diseases (CVD) are more prevalent in low socio-economic classes. However, the pattern in developing countries appears to be different. This study sought to evaluate and compare risk factors for CVD as well as absolute CVD risk in hypertensive subjects grouped by income in Kano, Nigeria.
The study was cross-sectional in design and carried out in Aminu Kano Teaching Hospital, Kano, Nigeria. Seventy treatment-naïve hypertensives and an equal number of hypertensives on treatment were recruited by balloting from the outpatient clinics, and then regrouped into low- and high-income earners. These two groups were then compared in terms of their profile of CVD risk factors and absolute CVD risk. All the assessed CVD risk factors are recognised in standard guidelines for the management of persons with systemic hypertension.
The low-income group comprised 45 patients (32.1%) while the remaining 95 (67.9%) had a high income. The most prevalent CVD risk factor was dyslipidaemia, found in 77.8 and 71.6% of low- and high-income earners, respectively (p = 0.437). The prevalence of proteinuria was significantly higher among low-income earners (42.2%) compared with highincome earners (15.8%) (p = 0.001). Mean serum creatinine was also higher among low-income earners but the difference did not reach statistical significance (p = 0.154). Very high CVD risk was found in 75.6 and 70.5% of low- and high-income earners, respectively (p = 0.535).
Dyslipidaemia and very high CVD risk were found in over 71% of the patients regardless of their level of income. Low-income earners had a higher prevalence of indices of renal damage. These findings pose a great challenge to the present and future management of all subjects, particularly those in the low-income group, given that in Nigeria, healthcare is largely paid for directly out of their pockets.
Cardiovascular disease represents the leading cause of morbidity and mortality in Western countries, and hypertension-related cardiovascular events affect about 37 million people per year, worldwide. In this perspective, hypertensive patients are at increased risk to experience cardiovascular events during life-long period, and treatment of high blood pressure represents one of the most effective strategies to reduce global cardiovascular risk. However, due to its multifactorial pathophysiology and its frequent association with other relevant risk factors and clinical conditions, treatment of hypertension requires an integrated approach, including lifestyle measures, antihypertensive drugs and other therapies. Yet, worldwide general practitioners continue to focus their attention on the management of a single risk factor, eg, blood pressure, rather than to global cardiovascular risk profile. In this view, modern strategies of cardiovascular prevention in hypertensive patients should move from a single risk factor based approach toward a more comprehensive risk evaluation in the individual patient. In other words, it is important to define the global cardiovascular risk to manage hypertensive patients at high-risk, rather than to focus on the high level of a single risk factor, for reducing cardiovascular morbidity and mortality in the general population, as well as in hypertensive population.
hypertension; hypercholesterolemia; cardiovascular prevention; global cardiovascular risk
Assessment of absolute cardiovascular risk is a rational method of managing hypertension. General practitioners and practice nurses were asked to estimate absolute risk in a group of elderly hypertensive patients during clinical practice. Risk was correctly estimated in 21% of patients, underestimated in 63% of patients, and overestimated in 16% of patients. Unless primary health care professionals use cardiovascular risk charts or tables, treatment decisions in primary care may not be made against realistic estimates of patients' susceptibility to cardiovascular disease.
Blood pressure (BP) control in people of African descent is poor, largely because of a lack of treatment. Although the requirements for immediate initiation of antihypertensive drug therapy are defined by global cardiovascular risk, the global cardiovascular risk profiles of untreated hypertensives at a community level are uncertain.
To identify the distribution of global cardiovascular risk profiles of untreated hypertensives in an urban, developing community of African descent in South Africa.
As part of the African Programme on Genes in Hypertension, we assessed nurse-derived clinic BP (the mean of five standardised BP values obtained according to guidelines), current antihypertensive therapy, and total cardiovascular risk in 1 029 participants older than 16 years of age from randomly selected nuclear families from the South West Township of Gauteng (SOWETO).
Approximately 46% of participants had systolic/diastolic BP values ≥ 140/90 mmHg and ~23% of participants were hypertensives not receiving antihypertensive medication. Approximately 12% of untreated hypertensives had a high added risk and ~18% a very high added risk (6.7% of the total sample). In untreated hypertensives, in contrast to the absence of severe hypertension and diabetes mellitus in those with lower risk profiles, a high cardiovascular risk profile in this group was characterised by severe hypertension in ~52% and diabetes mellitus in ~33%. Based on a high added risk carrying at least a 20% chance and a very high added risk at least a 30% chance of a cardiovascular event in 10 years, this translates into 1 740 events per 100 000 of the population within 10 years, events that could be prevented through antihypertensive drug therapy.
In an urban, developing community of African ancestry, a significant proportion (6.7%) of people may have untreated hypertension and a global cardiovascular risk profile that suggests a need for antihypertensive drug therapy. Cardiovascular risk in this group is driven largely by the presence of severe hypertension or diabetes mellitus.
blood pressure control; antihypertensive treatment; detection of hypertension
Although hypertension constitutes a major risk factor for cardiovascular morbidity and mortality, research on adherence to antihypertensive treatment has shown that at least 75% of patients are not adherent because of the combined demographic, organizational, psychological, and disease- and medication-related factors. This study aimed to elicit hypertensive patients’ beliefs on hypertension and antihypertensive treatment, and their role to adherence.
Transcripts from semistructured interviews and focus groups were content analyzed to extract participants’ beliefs about hypertension and antihypertensive treatment, and attitudes toward patient–physician and patient–pharmacist relationships.
Hypertension was considered a very serious disease, responsible for stroke and myocardial infarction. Participants expressed concerns regarding the use of medicines and the adverse drug reactions. Previous experience with hypertension, fear of complications, systematic disease management, acceptance of hypertension as a chronic disease, incorporation of the role of the patient and a more personal relationship with the doctor facilitated adherence to the treatment. On the other hand, some patients discontinued treatment when they believed that they had controlled their blood pressure.
Cognitive and communication factors affect medication adherence. Results could be used to develop intervention techniques to improve medication adherence.
hypertension; medication adherence; patient compliance; doctor–patient communication; antihypertensive medicine
Recent guidelines recommend assessment and treatment of the overall risk for cardiovascular disease (CVD) through management of multiple risk factors in patients at high absolute risk. The aim of our study was to assess the level of cardiovascular risk in patients with known risk factors for CVD by applying the SCORE risk function and to study the implications of European guidelines on the use of treatment and goal attainment for blood pressure (BP) and lipids in the primary care of Cyprus.
Retrospective chart review of 1101 randomly selected patients with type 2 diabetes mellitus (DM2), or hypertension or hyperlipidemia in four primary care health centres. The SCORE risk function for high-risk regions was used to calculate 10-year risk of cardiovascular fatal event. Most recent values of BP and lipids were used to assess goal attainment to international standards. Most updated medications lists were used to compare proportions of current with recommended antihypertensive and lipid-lowering drug (LLD) users according to European guidelines.
Implementation of the SCORE risk model labelled overall 39.7% (53.6% of men, 31.3% of women) of the study population as high risk individuals (CVD, DM2 or SCORE ≥5%). The SCORE risk chart was not applicable in 563 patients (51.1%) due to missing data in the patient records, mostly on smoking habits. The LDL-C goal was achieved in 28.6%, 19.5% and 20.9% of patients with established CVD, DM2 (no CVD) and SCORE ≥5%, respectively. BP targets were achieved in 55.4%, 5.6% and 41.9% respectively for the above groups. There was under prescription of antihypertensive drugs, LLD and aspirin for all three high risk groups.
This study demonstrated suboptimal control and under-treatment of patients with cardiovascular risk factors in the primary care in Cyprus. Improvement of documentation of clinical information in the medical records as well as GPs training for implementation and adherence to clinical practice guidelines are potential areas for further discussion and research.
The optimization of preventive strategies in patients at high risk of cardiovascular events and the evaluation of bottlenecks and limitations of transferring current guidelines to the real world of clinical practice are important limiting steps to cardiovascular prevention. Treatment with n-3 polyunsaturated fatty acids improves prognosis after myocardial infarction, but evidence of this benefit is lacking in patients at high cardiovascular risk, but without a history of myocardial infarction.
Patients were eligible if their general practitioner (GP) considered them at high cardiovascular risk because of a cardiovascular disease other than myocardial infarction, or multiple risk factors (at least four major risk factors in non-diabetic patients and one in diabetics).
Patients were randomly allocated to treatment with n-3 polyunsaturated fatty acids (1 g daily) or placebo in a double-blind study and followed up for five years by their GPs to assess the efficacy of the treatment in preventing cardiovascular mortality (including sudden death) and hospitalization for cardiovascular reasons. The secondary, epidemiological, aim of the study is to assess whether it is feasible to adopt current guidelines in everyday clinical practice, with a view to optimizing all the available preventive strategies in people at high cardiovascular risk.
A nation-wide network of 860 GPs admitted 12,513 patients to the study between February 2004 and March 2007. The mean age was 64 years and 62% were males. Diabetes mellitus plus one or more cardiovascular risk factors was the main inclusion criterion (47%). About 30% of patients were included because of a history of atherosclerotic cardiovascular disease, 21% for four or more risk factors, and less than 1% for other reasons.
The Rischio and Prevenzione (R&P) project provides a feasible model to test the efficacy of n-3 polyunsaturated fatty acid therapy in patients at high cardiovascular risk with no history of myocardial infarction, and to assess how to implement recommended preventive strategies in general practice.
Purpose. Guidelines of the Dutch Association of General Practitioners (NHG) dictate the evaluation, treatment, and referral process of patients with stable chest pain syndromes (CPS). Adherence to this guideline was assessed in a consecutive group of patients referred to our hospital.
Methods. We retrospectively studied the records of 296 subjects referred to our outpatient department in 2007 for evaluation of stable CPS. Referral letters were checked for completeness (past and present history, mentioning of risk factors for cardiovascular disease, physical examination, listing of medication) and used to judge adherence to the guideline. In a subset of patients, additional information regarding the referral process was gathered by telephone interview.
Results. The referral letter was complete in only 67 patients (23%); items most often not reported were physical examination (63%) and cardiovascular risk factors (62%). Judging from the referral letter, 23 patients (8%) were evaluated in accordance with the NHG guideline prior to their referral. In patients in whom the final diagnosis of angina pectoris was made by the cardiologist, this was 20%. Seventy-nine patients were contacted by telephone after their work-up by the cardiologist; 36 of them (44%) reported being referred at their first visit to their primary physician, while 14 (18%) were referred at their own request.
Conclusion: Prior to referral, only a minority of patients with stable CPS were evaluated and treated in accordance with NHG guidelines. Furthermore, their referral letter was often incomplete. (Neth Heart J 2010;18:178–82.20428415)
Chest Pain; Practice Guidelines as Topic; Netherlands; Research; Guideline Adherence
Purpose. To examine the usefulness of cardiovascular risk estimation models in people with diabetes. Methods. Review of published studies that compare the discriminative power of major cardiovascular risk factors single or in combination in individuals with and without diabetes, for major cardiovascular outcomes. Results. In individuals with and without diabetes, major risk factors affect cardiovascular risk similarly, with no evidence of any significant interaction. Accounting for diabetes-specific parameters, cardiopreventative therapies can significantly improve risk estimation in diabetes. General and diabetes-specific cardiovascular risk models have a useful discriminative power, but tend to overestimate risk in individuals with diabetes. Their impact on care delivery, adherence to therapies, and patients' outcome remain poorly understood. Conclusions. The high-risk status conferred by diabetes does not preclude the estimation of absolute cardiovascular risk estimation using global risk tools in individuals with diabetes, as this is useful for the initiation and intensification of preventive measures.
In many forms of erectile dysfunction (ED), cardiovascular risk factors, in particular arterial hypertension, seem to be extremely common. While causes for ED are related to a broad spectrum of diseases, a generalized vascular process seems to be the underlying mechanism in many patients, which in a large portion of clinical cases involves endothelial dysfunction, ie, inadequate vasodilation in response to endothelium-dependent stimuli, both in the systemic vasculature and the penile arteries. Due to this close association of cardiovascular disease and ED, patients with ED should be evaluated as to whether they may suffer from cardiovascular risk factors including hypertension, cardiovascular disease or silent myocardial ischemia. On the other hand, cardiovascular patients, seeking treatment of ED, must be evaluated in order to decide whether treatment of ED or sexual activity can be recommended without significantly increased cardiac risk. The guideline from the first and second Princeton Consensus Conference may be applied in this context. While consequent treatment of cardiovascular risk factors should be accomplished in these patients, many antihypertensive drugs may worsen sexual function as a drug specific side-effect. Importantly, effective treatment for arterial hypertension should not be discontinued as hypertension itself may contribute to altered sexual functioning; to the contrary, alternative antihypertensive regimes should be administered with individually tailored drug regimes with minimal side-effects on sexual function. When phosphodiesterase-5 inhibitors, such as sildenafil, tadalafil and vardenafil, are prescribed to hypertensive patients on antihypertensive drugs, these combinations of antihypertensive drugs and phosphodiesterase 5 are usually well tolerated, provided there is a baseline blood pressure of at least 90/60 mmHg. However, there are two exceptions: nitric oxide donors and α-adrenoceptor blockers. Any drug serving as a nitric oxide donor (nitrates) is absolutely contraindicated in combination with phosphodiesterase 5 inhibitors, due to significant, potentially life threatening hypotension. Also, α-adrenoceptor blockers, such as doxazosin, terazosin and tamsulosin, should only be combined with phosphodiesterase 5 inhibitors with special caution and close monitoring of blood pressure.
Sexual function; erectile dysfunction; hypertension; antihypertensive therapy; phosphodiesterase 5 inhibitors
Guidelines recommend antihypertensive, lipid-lowering and/or antiplatelet therapy for prevention of cardiovascular disease (CVD). This study examined the utilisation of cardiovascular therapies among individuals at CVD risk to assess adherence to guidelines.
Respondents to the SHIELD study were classified based on National Cholesterol Education Program Adult Treatment Panel III risk categories. High coronary heart disease (CHD) risk (n = 7510) was defined as self-reported diagnosis of heart disease/heart attack, narrow or blocked arteries, stroke or diabetes; moderate risk (n = 4823) included respondents with ≥ 2 risk factors (i.e., men > 45 years, women > 55 years, hypertension, low high-density lipoprotein cholesterol, smoking and family history of CHD); and low risk (n = 5307) was 0–1 risk factor. Respondents reporting a myocardial infarction, stroke or revascularisation at baseline (prior CVD event) (n = 3777), those reporting a new CVD event during 2 years of follow up (n = 953), and those with type 2 diabetes mellitus (n = 3937) were evaluated. The proportion of respondents reporting treatment with lipid-lowering, antiplatelet or antihypertensive agents was calculated.
Utilisation of lipid-lowering therapy was low (≤ 25%) in each group. Prescription antithrombotic therapy was minimal among respondents with prior CVD events, but 47% received antihypertensive medication. No use before or after a new CVD event was reported by 36% of respondents for lipid-lowering, 32% for antithrombotic and > 50% for antihypertensive medications.
More than 50% of at-risk respondents and > 33% of respondents with new CVD events were not taking CVD therapy as recommended by guidelines.
Aims. To explore general practitioners' (GPs') descriptions of their thoughts and action when prescribing cardiovascular preventive drugs. Methods. Qualitative content analysis of transcribed group interviews with 14 participants from two primary health care centres in the southeast of Sweden. Results. GPs' prescribing of cardiovascular preventive drugs, from their own descriptions, involved “the patient as calculated” and “the inclination to prescribe,” which were negotiated in the interaction with “the patient in front of me.” In situations with high cardiovascular risk, the GPs reported a tendency to adopt a directive consultation style. In situations with low cardiovascular risk and great uncertainty about the net benefit of preventive drugs, the GPs described a preference for an informed patient choice. Conclusions. Our findings suggest that GPs mainly involve patients at low and uncertain risk of cardiovascular disease in treatment decisions, whereas patient involvement tends to decrease when GPs judge the cardiovascular risk as high. Our findings may serve as a memento for clinicians, and we suggest them to be considered in training in communication skills.
Inadequate blood pressure control and poor adherence to treatment remain among the major limitations in the management of hypertensive patients, particularly of those at high risk of cardiovascular events. Preliminary evidence suggests that home blood pressure telemonitoring (HBPT) might help increasing the chance of achieving blood pressure targets and improve patient’s therapeutic adherence. However, all these potential advantages of HBPT have not yet been fully investigated.
The purpose of this open label, parallel group, randomized, controlled study is to assess whether, in patients with high cardiovascular risk (treated or untreated essential arterial hypertension - both in the office and in ambulatory conditions over 24 h - and metabolic syndrome), long-term (48 weeks) blood pressure control is more effective when based on HBPT and on the feedback to patients by their doctor between visits, or when based exclusively on blood pressure determination during quarterly office visits (conventional management (CM)). A total of 252 patients will be enrolled and randomized to usual care (n=84) or HBPT (n=168). The primary study endpoint will be the rate of subjects achieving normal daytime ambulatory blood pressure targets (<135/85 mmHg) 24 weeks and 48 weeks after randomization. In addition, the study will assess the psychological determinants of adherence and persistence to drug therapy, through specific psychological tests administered during the course of the study. Other secondary study endpoints will be related to the impact of HBPT on additional clinical and economic outcomes (number of additional medical visits, direct costs of patient management, number of antihypertensive drugs prescribed, level of cardiovascular risk, degree of target organ damage and rate of cardiovascular events, regression of the metabolic syndrome).
The TELEBPMET Study will show whether HBPT is effective in improving blood pressure control and related medical and economic outcomes in hypertensive patients with metabolic syndrome. It will also provide a comprehensive understanding of the psychological determinants of medication adherence and blood pressure control of these patients.
Clinical Trials.gov: NCT01541566
Hypertension; Blood pressure; Home blood pressure telemonitoring; Adherence; Anxiety; Depression; Personality traits
Guidelines for the management of either hypertension or hyperlipidaemia have been widely published. However, recent data have shown the high frequency of an abnormal lipid profile in hypertensive subjects. We have therefore surveyed 195 general practitioners throughout Britain to determine current community-based attitudes and management approaches to hypertension with coexistent hypercholesterolaemia. Routine screening for lipids in hypertensive subjects was recommended by 40% of respondents. First-line antihypertensive drug choices were influenced by the knowledge of a hypercholesterolaemia, with preference for drugs known to have no adverse effects on the lipid profile. When first-choice drug failed to effectively lower blood pressure, the additional drug or the substitute choices were not influenced by the metabolic profiles of the alternative selected. The current wide choice of antihypertensive drugs and the complexity of metabolic complications of treatment plus the relationship of risk factor clustering has made the formulation of management strategies very difficult. This was supported by the finding that 88% of respondents in our survey felt that there was a clear need for consensus management guidelines for the treatment of hypertension with coexistent hypercholesterolaemia.
Hypertension has a major associated risk for organ damage and mortality, which is further heightened in patients with prior cardiovascular (CV) events, comorbid diabetes mellitus, microalbuminuria and renal impairment. Given that most patients with hypertension require at least two antihypertensives to achieve blood pressure (BP) goals, identifying the most appropriate combination regimen based on individual risk factors and comorbidities is important for risk management. Single-pill combinations (SPCs) containing two or more antihypertensive agents with complementary mechanisms of action offer potential advantages over free-drug combinations, including simplification of treatment regimens, convenience and reduced costs. The improved adherence and convenience resulting from SPC use is recognised in updated hypertension guidelines. Despite a wide choice of SPCs for hypertension treatment, clinical evidence from direct head-to-head comparisons to guide selection for individual patients is lacking. However, in patients with evidence of renal disease or at greater risk of developing renal disease, such as those with diabetes mellitus, microalbuminura and high-normal BP or overt hypertension, guidelines recommend renin-angiotensin system (RAS) blocker-based combination therapy due to superior renoprotective effects compared with other antihypertensive classes. Furthermore, RAS inhibitors attenuate the oedema and renal hyperfiltration associated with calcium channel blocker (CCB) monotherapy, making them a good choice for combination therapy. The occurrence of angiotensin-converting enzyme (ACE) inhibitor-induced cough supports the use of angiotensin II receptor blockers (ARBs) for RAS blockade rather than ACE inhibitors. In this regard, ARB-based SPCs are available in combination with the diuretic, hydrochlorothiazide (HCTZ) or the calcium CCB, amlodipine. Telmisartan, a long-acting ARB with preferential pharmacodynamic profile compared with several other ARBs, and the only ARB with an indication for the prevention of CV disease progression, is available in two SPC formulations, telmisartan/HCTZ and telmisartan/amlodipine. Clinical studies suggest that in CV high-risk patients and those with evidence of renal disease, the use of an ARB/CCB combination may be preferred to ARB/HCTZ combinations due to superior renoprotective and CV benefits and reduced metabolic side effects in patients with concomitant metabolic disorders. However, selection of the most appropriate antihypertensive combination should be dependent on careful review of the individual patient and appropriate consideration of drug pharmacology.
Amlodipine; Angiotensin receptor II blocker; Diabetes mellitus; Hydrochlorothiazide; Hypertension; Renal impairment; Single-pill combination; Telmisartan
Guidelines for the management of blood pressure (BP) in primary care generally suggest that decisions be made on the basis of specific threshold values (e.g. BP 140/90 mmHg); but this fails to adequately accommodate a common cause of variation – the play of chance.
To determine the impact of chance variability in BP readings on the clinical decision making of general practitioners (GPs) regarding anti-hypertensive treatment and cardiovascular risk management.
We used an internet based study design, where 109 GPs were assigned to manage one of eight case vignettes (guidelines would recommend treatment for only one of the eight) and presented with blood pressure readings that were randomly selected from an underlying population.
Seventeen (15.6%, 17/109) GPs consulted the vignette for whom treatment was recommended, but only 7/17 (41.2%) GPs prescribed treatment, whereas 14/92 (15.2%) GPs prescribed medication to the other vignettes. When deciding to follow-up a vignette GPs were influenced by threshold values for systolic and diastolic BP, but not by the overall cardiovascular risk. If the first reading was a low BP (systolic <140, diastolic <90) GPs were highly likely to discharge the vignette and follow-up a high BP reading (diastolic >90 or systolic BP≥140). Similar factors predicted the decision to prescribe a drug, although the vignette’s cardiovascular risk (>20%) was now statistically significant (p = 0.03).
GP decision making, whilst generally consistent with guidelines, appears to be compromised by chance variation leading to under and over treatment. Interventions to adequately accommodate chance variability into clinical decision making are required.