A Simplified Approach to the Treatment of Uncomplicated Hypertension

Abstract

Abstract-Notwithstanding the availability of antihypertensive drugs and practice guidelines, blood pressure control remains suboptimal. The complexity of current treatment guidelines may contribute to this problem. To determine whether a simplified treatment algorithm is more effective than guideline-based management, we studied 45 family practices in southwestern Ontario, Canada, using a cluster randomization trial comparing the simplified treatment algorithm with the Canadian Hypertension Education Program guidelines. The simplified treatment algorithm consisted of the following: (1) initial therapy with a low-dose angiotensin-converting enzyme inhibitor/diuretic or angiotensin receptor blocker/diuretic combination; (2) up-titration of combination therapy to the highest dose; (3) addition of a calcium channel blocker and up-titration; and (4) addition of a non-first-line antihypertensive agent. The proportion of patients treated to target blood pressure (systolic blood pressure Ͻ140 mm Hg and diastolic blood pressure Ͻ90 mm Hg for patients without diabetes mellitus or systolic blood pressure Ͻ130 mm Hg and diastolic blood pressure Ͻ80 mm Hg for diabetic patients) at 6 months was analyzed at the practice level. Key Words: hypertension management Ⅲ randomized, controlled trial Ⅲ fixed-dose combination therapy Ⅲ cluster randomization Ⅲ hypertension T reatment of hypertension remains suboptimal despite the development of novel therapies and the widespread implementation of education programs. Although multiple barriers exist to achieving better control of blood pressure, these mainly consist of patient-and practitioner-centered factors.From the patient perspective, poor adherence to antihypertensive regimens is a significant component of the "treatment gap." 1-3 An important part of this problem is current prescribing practices. Unfortunately, most patients require Ն2 medications to achieve optimal control, 4 and these multidrug regimens are associated with lower adherence. 5,6 This has been suggested to be the most important contribution to inadequate blood pressure control. 7 Furthermore, switching medications, a strategy featured prominently in most national treatment guidelines, has also been linked to poor adherence. 8 Thus, the use of simpler, more effective drug regimens might improve blood pressure control.From a practitioner perspective, a number of behavioral factors have been associated with poor blood pressure control. One of the most important factors is "therapeutic inertia," whereby practitioners fail to appropriately escalate the intensity of therapy despite the presence of poorly controlled hypertension. 9 We speculate that the increasingly complex treatment regimens currently advocated by experts, national guidelines, and the pharmaceutical industry might contribute to this undesirable behavior.Given these issues, a simple, step-care-based algorithm for the pharmacological management of hypertension (Simplified Treatment Intervention to Control Hypertension [STITCH]) was developed. This algorithm...

Quarter-dose quadruple combination therapy for initial treatment of hypertension: placebo-controlled, crossover, randomised trial and systematic review

“…4,23 Initiating treatment with dual combination therapy has 272 been advocated 24 as a more effective means to achieve BP control rapidly and with fewer clinical visits. 25 …”

How Well Do Guidelines Incorporate Evidence on Patient Preferences?

“…Certainly, there is much to be said for simplicity. In one study, a simplification of hypertension treatment into an abridged algorithm allowed more uncomplicated patients to reach blood pressure targets than using CPG-based practice 32 . It must be acknowledged, however, that to ignore preference studies would result in the systematic exclusion of one class of relevant evidence.…”

Educational Interventions May Promote Better Blood Pressure Control in Russia

“…Information obtained from these analyses are of potential clinical relevance, since they can be effectively implemented by recommendations derived from international guidelines, in order to improve the clinical management and achieve the recommended blood pressure targets. In particular, recent studies have demonstrated that the implementation of rational and effective therapeutic regimes, mostly based on combination therapies, may promote higher rates of blood pressure control also in the setting of real practice [5][6][7].In this issue of High Blood Pressure and Cardiovascular Prevention, Kiselev and co-authors reported a detailed and comprehensive analysis of clinical factors that may have potential impact on the achievement of the blood pressure goals in a large sample of adult individuals with hypertension in the Ivanovo, Russia [8]. This study is part of the larger Russian Registry of Hypertension, Coronary Artery Disease and Chronic Heart Failure, which is a retrospective, continuous, nation-wide, web-based registry.…”

“…Information obtained from these analyses are of potential clinical relevance, since they can be effectively implemented by recommendations derived from international guidelines, in order to improve the clinical management and achieve the recommended blood pressure targets. In particular, recent studies have demonstrated that the implementation of rational and effective therapeutic regimes, mostly based on combination therapies, may promote higher rates of blood pressure control also in the setting of real practice [5][6][7].…”