INERTIA OR INACTION? BLOOD PRESSURE MANAGEMENT AND CARDIOVASCULAR RISK IN DIABETES^‡

Abstract

1. Diabetes is a significant risk factor for cardiovascular disease (CVD), but the presence of comorbidities, such as hypertension, markedly increases CVD risk. The aim of the present study was to determine the effectiveness of hypertension management in patients with diabetes. 2. The cvTRAC Study was a cross-sectional study of CVD risk factors in primary care practices across Australia. General medical practitioners enrolled patients they considered to be at increased risk of CVD and reported on cardiovascular disease history, CVD risk factor levels and current therapy. 3. In all, 9857 men and 8332 women with diabetes participated in the study, with > 85% having at least two CVD risk factors in addition to diabetes and 68% having a history of hypertension. Lost therapeutic benefit in diabetes patients with hypertension was seen in those who were failing to meet targets on antihypertensive drug therapy (therapeutic inertia: > 73% of the hypertensive cohort), with a smaller proportion accounted for by those who met prescribing guidelines but were not being treated pharmacologically (treatment gap: 5.4% of the hypertensive cohort). Lack of compliance with lifestyle guidelines was estimated to account for over 8% of those not meeting blood pressure targets. Age (odds ratio (OR) 0.983, 95% confidence interval (CI) 0.980-0.986; P < 0.001), compliance with physical activity guidelines (OR 1.219, 95% CI 1.088-1.366; P = 0.001) and compliance with dietary guidelines (OR 1.298, 95% CI 1.188-1.420; P < 0.001) were independent predictors of target blood pressure attainment in the diabetic population. 4. Deficiencies in pharmacological and lifestyle-related therapeutic strategies contribute to suboptimal hypertension management in diabetes. Therapeutic inertia is a greater contributor to lost therapeutic benefit than treatment gap in this population.

Optimal type 2 diabetes mellitus management: the randomised controlled OPTIMISE benchmarking study: baseline results from six European countries

“…61 Therapeutic inertia, whereby therapy is initiated but not subsequently modified when the patient remains uncontrolled, was identified as a major contributing factor for failure of patients with hypertension to meet BP targets in a cross-sectional study of 6603 men and 5896 women with diabetes in primary care in Australia. 62 In this study, therapeutic inertia was identified in > 73% of uncontrolled patients receiving treatment, compared with just 5.4% of uncontrolled patients identified as requiring treatment according to treatment guidelines but not receiving therapy -a significant therapeutic inertia gap. The authors surmised that current guidelines for controlling BP in patients with T2D have not been very effective in ensuring therapy is intensified or modified when treatment goals are unmet 62 i.e.…”

Treatment Intensification in a Hypertension Telemanagement Trial

“…1 Studies have suggested that clinical inertia, or provider failure to initiate or intensify hypertension therapy when indicated based on clinical guidelines, is a prime contributor to inadequate BP control. 2,3 One study examined Ϸ46 000 clinic visits and found that, in 87% of visits where patients had BP Ͼ140/90 mm Hg, providers did not intensify therapy. 4 Others have attempted to evaluate underlying causes for clinical inertia.…”

Fatores Associados a Tensão Arterial Não Controlada em Pessoas com Diabetes Tipo 2 Seguidas nos Cuidados de Saúde Primários em Portugal

“…Após análise de regressão logística, verificou-se que os fatores independentemente associados Tabela 3 -Fatores associados a não controlo tensional após análise de regressão logística, com risco relativo (odds ratio e intervalo de confiança (IC)) 35,36 Isto pode-se explicar pela menor utilização pelos homens dos cuidados de saúde e sua menor valorização destes cuidados e de estilos de vida saudáveis. 37,38 A formação académica esteve associada a maior controlo da TA, tal como noutros estudos 19,20 realizados em locais com níveis globais de baixo nível de formação e socio-económica.…”

“…22,[55][56][57] Ainda assim, há diversos estudos que reportam uma terapêutica não farmacológica insuficiente no que se refere a exercício físico em pessoas com diabetes, mostrando muito potencial de melhoria no seu controlo tensional. 36 Seria então esperada uma relação direta com o controlo tensional em pessoas com diabetes. Uma possível explicação para este resultado poderá estar relacionada com o facto da escala utilizada medir além do nível de atividade física também a motivação para o aumentar o que poderá levar a alguma inércia terapêutica, específica em doentes com maior motivação, esperando-se mais tempo até intensificação da terapêutica farmacológica.…”