Treatment of Hypertension in Patients 80 Years of Age or Older

Beckett, Nigel; Peters, Ruth; Fletcher, Astrid; Staessen, Jan A.; Liu, Lisheng; Dumitraşcu, Dan L.; Stoyanovsky, Vassil; Antikaínen, Riitta; Nikitin, Yu. P.; Anderson, Craig S.; Belhani, Alli; Forette, Françoise; Rajkumar, Chakravarthi; Thijs, Lutgarde; Banya, Winston; Bulpitt, Christopher J.

doi:10.1056/nejmoa0801369

Cited by 2,755 publications

(1,912 citation statements)

References 32 publications

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“…The age-related arterial hardening and aortic stiffness seen in many elderly hypertensive patients makes it more difficult to control the SBP component [1][2][3]23]. In this situation, physicians need to be educated that achieving BP goals is likely to require combination therapy with three or more antihypertensive drugs, given the likely multifactorial origin of the hypertension [1,24,25].…”

Section: Discussionmentioning

confidence: 99%

Clinical Inertia in Poorly Controlled Elderly Hypertensive Patients: A Cross-Sectional Study in Spanish Physicians to Ascertain Reasons for Not Intensifying Treatment

Gil-Guillén

Orozco‐Beltrán

Carratalá‐Munuera

et al. 2013

Am J Cardiovasc Drugs

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Background Clinical inertia, the failure of physicians to initiate or intensify therapy when indicated, is a major problem in the management of hypertension and may be more prevalent in elderly patients. Overcoming clinical inertia requires understanding its causes and evaluating certain factors, particularly those related to physicians. Objective The objective of our study was to determine the rate of clinical inertia and the physician-reported reasons for it. Methods An observational, cross-sectional, multi-center study was carried out in a primary care setting. We included 512 physicians, with a consecutive sampling of 1,499 hypertensive patients with clinical inertia. Main Outcome Measure Clinical inertia was defined when physicians did not modify treatment despite knowing that the therapeutic target had not been reached. Clinical inertia was considered to be justified (JCI) when physicians provided an explanation for not intensifying treatment and as not justified (nJCI) when no reasons were given. Results JCI was observed in 30.1 % (95 % CI 27.8-32.4) of patients (n = 451) and nJCI in 69.9 % (95 % CI 67.6-72.2) (n = 1,058). JCI was associated with higher blood pressure (BP) values (both systolic and diastolic) and diabetes (p = 0.012) than nJCI. nJCI was associated with patients having an isolated increase of systolic or diastolic or high borderline BP values or cardiovascular disease. Conclusion Physicians provided reasons for not intensifying treatment in poorly controlled patients in only 30 % of instances. Main reasons for not intensifying treatment were borderline BP values, co-morbidity, suspected white coat effect, or perceived difficulty achieving target. nJCI was associated with high borderline BP values and cardiovascular disease.

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Section: Discussionmentioning

confidence: 99%

Clinical Inertia in Poorly Controlled Elderly Hypertensive Patients: A Cross-Sectional Study in Spanish Physicians to Ascertain Reasons for Not Intensifying Treatment

Gil-Guillén

Orozco‐Beltrán

Carratalá‐Munuera

et al. 2013

Am J Cardiovasc Drugs

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“…25 In addition, the HYVET (Hypertension in the Very Elderly Trial) study has also shown that treating hypertension reduces the risk of death from stroke, and from any cause in very elderly patients (aged 480 years). 26 Of further relevance here is a recent analysis that looked at patients in this study who received olmesartan/ amlodipine 40/5 mg or 40/10 mg during the final open-label phase. This found that baseline SeSBP was related to the change in SeSBP achieved at the end of the study, so that patients with higher baseline levels of SeSBP showed larger reductions.…”

Section: Discussionmentioning

confidence: 99%

Efficacy and safety of olmesartan medoxomil plus amlodipine in age, gender and hypertension severity defined subgroups of hypertensive patients

Schmieder

Böhm

2010

J Hum Hypertens

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Effective antihypertensive therapy is crucial for preventing cardiovascular events; however, blood pressure (BP) control rates remain poor. The objective of this analysis was to determine the efficacy of olmesartan/ amlodipine in age, severity and gender-based subgroups of patients with moderate-to-severe hypertension uncontrolled by amlodipine monotherapy. Patients with uncontrolled BP after 8 weeks' amlodipine 5 mg monotherapy (n ¼ 755) were randomized to continue amlodipine 5 mg or receive olmesartan (10-40 mg) plus amlodipine 5 mg for 8 weeks. Patients whose BP remained suboptimal were uptitrated to olmesartan/ amlodipine 20/5, 40/5 or 40/10 mg. Changes in BP and numbers of controlled patients were calculated separately to assess efficacy in patients aged o65 or X65 years, in those with moderate or severe hypertension, and in males and females. The antihypertensive effects of olmesartan/amlodipine were similar in patients aged o65 and X65 years of age. Compared with patients with moderate hypertension at baseline, those with severe hypertension tended to show higher decreases in BP, but achieved lower goal rates despite this. Females showed larger mean reductions in diastolic (1.61 mm Hg; P ¼ 0.003) and systolic BP (1.72 mm Hg; P ¼ 0.053) than males, independent of age and dose. This gender difference appeared to be higher and more consistent across dose groups for patients o50 years of age, but the difference in the pattern between both age groups was not statistically significant (P ¼ 0.1526). These results suggest that olmesartan/amlodipine is effective and safe in a wide range of patients, regardless of age or hypertension severity. Small differences in responsiveness between females and males may exist, which require further investigation.

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“…1 Achieving blood pressure control (BP) in patients with hypertension reduces the risk of stroke and ischemic heart disease. [2][3][4] Despite everincreasing public health resources dedicated to improving BP control, [5][6][7] only half of the 78 million Americans with hypertension have their BP treated and controlled to the recommended value of below 140/90 mmHg. 8 Under new BP targets recommended by the Panel Members Appointed to the Eighth Joint National Committee (JNC 8), 9 BP is controlled in less than 60 % of hypertensive patients overall, and in less than 50 % of patients younger than 60 years of age.…”

Section: Introductionmentioning

confidence: 99%

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

et al. 2015

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BACKGROUND: Only half of hypertensive adults achieve blood pressure (BP) control in the United States, and it is unclear how BP control rates may be improved most effectively and efficiently at the population level. OBJECTIVE: We sought to compare the potential effects of system-wide isolated improvements in medication adherence, visit frequency, and higher physician prescription rate on achieving BP control at 52 weeks. DESIGN: We developed a Markov microsimulation model of patient-level, physician-level, and system-level processes involved in controlling hypertension with medications. The model is informed by data from national surveys, cohort studies and trials, and was validated against two multicenter clinical trials (ALLHAT and VALUE). SUBJECTS: We studied a simulated, nationally representative cohort of patients with diagnosed but uncontrolled hypertension with a usual source of care. INTERVENTIONS:We simulated a base case and improvements of 10 and 50 %, and an ideal scenario for three modifiable parameters: visit frequency, treatment intensification, and medication adherence. Ideal scenarios were defined as 100 % for treatment intensification and adherence, and return visits occurring within 4 weeks of an elevated office systolic BP. MAIN OUTCOME: BP control at 52 weeks of follow-up was examined. RESULTS: Among 25,000 hypothetical adult patients with uncontrolled hypertension (systolic BP ≥ 140 mmHg), only 18 % achieved BP control after 52 weeks using base-case assumptions. With 10/50 %/idealized enhancements in each isolated parameter, enhanced treatment intensification achieved the greatest BP control (19/23/71 %), compared with enhanced visit frequency (19/21/35 %) and medication adherence (19/23/26 %). When all three processes were idealized, the model predicted a BP control rate of 95 % at 52 weeks.CONCLUSION: Substantial improvements in BP control can only be achieved through major improvements in processes of care. Healthcare systems may achieve greater success by increasing the frequency of clinical encounters and improving physicians' prescribing behavior than by attempting to improve patient adherence to medications.

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Treatment of Hypertension in Patients 80 Years of Age or Older

Cited by 2,755 publications

References 32 publications

Clinical Inertia in Poorly Controlled Elderly Hypertensive Patients: A Cross-Sectional Study in Spanish Physicians to Ascertain Reasons for Not Intensifying Treatment

Clinical Inertia in Poorly Controlled Elderly Hypertensive Patients: A Cross-Sectional Study in Spanish Physicians to Ascertain Reasons for Not Intensifying Treatment

Efficacy and safety of olmesartan medoxomil plus amlodipine in age, gender and hypertension severity defined subgroups of hypertensive patients

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

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