Linda Brookes, MSc
Medscape Cardiology 7(2), 2003. © 2003 Medscape Posted 07/16/2003
Introduction
The month of June saw publication of the first hypertension guidelines specifically aimed at the European populations. The new European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guidelines take a noticeably different approach from the recently published US guidelines, "JNC 7 Express" (the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure); specifically, they have not included a "prehypertension" category, they recommend no specific drug class as initial treatment, and they support the possibility of starting with combination therapy. On the other hand, bad news for all guidelines, including those for hypertension, came from a survey that found that patients in the United States are still receiving only a suboptimal percentage of the recommended care, and reservations about taking any antihypertensive drugs were recorded in a group of UK patients. Also from the United Kingdom came a proposal for a revolutionary approach to all cardiovascular disease, the "Polypill," a daily formulation of 6 drugs, including 3 antihypertensive agents, proposed for the prevention of heart disease and stroke. Just at press time, newly released NHANES data revealed that, reversing a decade of improvement, the incidence of hypertension has actually begun to increase in the United States, an "unacceptable" development. And finally, while waiting for implementation of all these new developments and discoveries, hypertension might be prevented by avoiding bullying bosses at work or argumentative spouses at home, according to researchers in the United Kingdom and United States, respectively.
New European Hypertension Guidelines Published
The 2003 European guidelines for the management of arterial hypertension were disclosed during the 13th European Meeting on Hypertension, held June 13-17 in Milan, Italy, and the full version was published simultaneously in the Journal of Hypertension.[1] They were prepared by a committee established by ESH and the ESC and are endorsed by the International Society of Hypertension (ISH). The guidelines update the 1999 World Health Organization (WHO)/ISH guidelines,[2] but are specifically aimed at the European continent.
According to the authors, the European guidelines were prepared on the principle that guidelines should be educational rather than merely prescriptive. The recommendations are based on all available scientific evidence, including, but not exclusively, large, randomized, controlled clinical trials and meta-analyses. They are noticeably different from the recently released US guidelines, JNC 7 Express,[3] particularly with regard to the classification of blood pressure and the treatment recommendations.
The European guidelines retain the 1999 WHO/ISH classification of blood pressure, with the reservation that the real threshold for hypertension must be considered flexible, being higher or lower based on the total (global) cardiovascular risk profile of each individual. The guidelines for initiating antihypertensive treatment are based on 2 criteria: the total level of cardiovascular risk and the levels of both SBP and DBP. The primary goal of treatment is to achieve the maximum reduction in the long-term total risk of cardiovascular morbidity and mortality. The guidelines recommend that on the basis of current evidence from trials, blood pressure should be lowered to below at least 140/90 mm Hg and to lower levels, if tolerated, in all patients, and to below 130/80 mm Hg in diabetic patients.
Lifestyle modifications are recommended in all patients. Following that, the major classes of antihypertensive agents listed as suitable for the initiation and maintenance of therapy are diuretics, beta-blockers, calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs). The guidelines do not recommend specific classes of drugs as initial treatment, but note the evidence for the use of specific classes of drugs in special groups of patients. They recommend initiating therapy either with a low dose of a single agent or with a low-dose combination of 2 agents.
As well as treatment of special populations, other areas in the management of hypertension covered in the guidelines include genetic analysis, use of ambulatory/home blood pressure, follow-up strategies, the importance of long-acting agents, evaluation of adverse effects, and treatments for associated risk factors. The importance of implementation of these experts' recommendations in medical practice is emphasized. A shorter, summarized version of the guidelines is scheduled to be published in a few months' time, and translations into other European languages are planned.
Adherence to US Guidelines Found to be Poor
Adherence to guidelines for care in all areas of medicine, including hypertension, is still lacking in the United States, to the point of posing serious threats to health, according to a recently published survey in The New England Journal of Medicine.[4] An analysis of questionnaire answers and medical records of 6712 individuals in 12 US metropolitan areas showed that overall, participants received only 54.9% of recommended care, based on calculated aggregate scores of 439 indicators of care. People with hypertension (based on 3 indicators, including lifestyle modification for patients with mild hypertension, pharmacotherapy for uncontrolled mild hypertension, and changes in treatment for persistently uncontrolled blood pressure) received 64.7% of the recommended care. Care requiring a medical encounter or other interventions, such as the annual visit recommended for patients with hypertension, had the highest rate of adherence (73.4%), while processes involving counseling and education, such as lifestyle modification, had the lowest (18.3%). To improve this situation, the investigators suggest a major overhaul of current health information systems and establishment of a national baseline for performance.
Most UK Patients Have Reservations About Taking Antihypertensives
In a survey of patients prescribed antihypertensive medications in one UK general practice,[5] 80% (363 out of 452) said they had reservations about their medicines in at least 1 of 4 areas of concern in the questionnaire, listed as:
1. I'd prefer to lower my blood pressure without taking blood pressure tablets.
2. I wonder whether I still need to take blood pressure tablets.
3. I'm concerned my blood pressure tablets might be having bad effects I can't feel.
4. I'm concerned my blood pressure tablets might have bad effects on me in the long run.
A substantial 36% of the patients said they had unwelcome side effects at some time, and 17% continued to experience them. The most popular reasons for taking antihypertensive medications were "because of what happens at the doctor's" and "to achieve some good results." Most patients were aware that they balanced reservations they had about the medications against reasons for taking them. The investigators call for further debate about how best to achieve open discussion about taking antihypertensives between physicians and patients.
Six-drug Pill Proposed to Prevent Heart Disease and Stroke
The June 28 issue of the British Medical Journal (BMJ) contained a proposal for a new intervention for the prevention of cardiovascular disease that the authors claim "would have a greater impact on the prevention of disease in the Western world than any other known intervention."[6] This is the "Polypill," a single daily pill containing a statin (eg, atorvastatin 10 mg or simvastatin 40 mg); 3 antihypertensive drugs (eg, a thiazide diuretic, a beta-blocker, and an ACE inhibitor), each at half standard dose; folic acid 0.8 mg; and aspirin 75 mg. These components are intended to reduce 4 cardiovascular risk factors (low-density lipoprotein, blood pressure, serum homocysteine, and platelet function) simultaneously. Professors Nicholas Wald, DSc(Med), and Malcolm Law, MB BS (University of London, UK), estimate that the Polypill would reduce ischemic heart disease (IHD) events by 88% and stroke by 80% and that one third of people taking the Polypill from age 55 years would benefit and gain 11 years of life free from an IHD event. They calculate from randomized trials that adverse events of the Polypill would affect 8% to 15% of people, depending on the precise formulation, and that this rate would be acceptable. Professors Wald and Law arrived at their formulation after analyzing the results of meta-analyses of randomized trials and cohort studies and a meta-analysis of 15 trials of low-dose aspirin. Studies of safety and efficacy of the Polypill are planned, and a patent application has been filed for the formulation.
The Polypill proposal was supported in large part in an accompanying BMJ editorial by Anthony Rodgers, MD (University of Auckland, New Zealand),[7] who stressed its potential importance for developing countries, where people at high risk receive little or no preventive care. He noted that the Polypill need not be expensive if off-patent components are used. Other reactions have been less enthusiastic. ESC spokespersons Professor Lars Ryden, MD, PhD (Karolinska Hospital, Stockholm, Sweden), and Professor John GF Cleland, MD (University of Hull, UK)[8] each described the approach as "interesting," but stressed the need for further research. Robert Bonow, MD (Northwestern University Feinberg School of Medicine, Chicago),[9] president of the American Heart Association, was even more cautious, saying, "There are massive caveats. We are quite concerned about this." He is particularly concerned that giving aspirin to a general population would not save lives, because the number saved by preventing heart disease and stroke would be offset by the number killed by the bleedings caused. He also believes that the Polypill approach sends the wrong message to people who should be exercising, losing weight, and giving up smoking.
Latest NHANES Data Show Hypertension Prevalence Increasing, Control "Unacceptable"
Analysis of the most recent National Health and Nutrition Examination Survey (NHANES) data, published in the July 9 issue of JAMA,[10] indicates that hypertension prevalence is increasing in the United States. This reverses a decline reported by an earlier NHANES conducted between 1960 and 1991. In 1999-2000, 28.7% of the 5448 survey participants were hypertensive (defined as blood pressure >/= 140/90 mm Hg or use of antihypertensive medications). This represents a 3.7% increase over the prevalence in the previous NHANES report for 1988-1991.[11] Hypertension rates were highest in non-Hispanic blacks (33.5%) and lowest in Mexican Americans (20.7%), increased with age (65.4% among those aged >/= 60 years), and tended to be higher in women (30.1%). Because the recommended goal for hypertensive patients with diabetes was lowered in 1997 to 130/85 mm Hg,[12] the data were re-analyzed excluding patients with diabetes. This analysis still showed an increase in hypertension prevalence, although it was no longer significant.
In 1999-2000, 68.9% of NHANES participants were aware of their hypertension, unchanged since the previous survey. Increases were seen in treatment, by 6.0% to 58.4%, and in overall control, by 6.4% to 31.0%. Rates of control were significantly lower in women, Mexican Americans, and those aged >/= 60 years compared with men, younger individuals, and non-Hispanic whites. Despite the increased control rates, however, report authors Ihab Hajjar, MD (University of South Carolina, Columbia) and Theodore A Kotchen, MD (Medical College of Wisconsin, Milwaukee) call them "unacceptably low." They point out that if hypertension control rates continue to increase at this pace, the NHANES goal of blood pressure control in 50% of Americans with hypertension by 2010 will not be met.
Bosses and Spouses Can Raise Blood Pressure
Working for a supervisor who is perceived to be unfair can have a significant impact on cardiovascular functioning, UK researchers have found.[13] Among a group of 28 female healthcare assistants, those working under a supervisor they perceived unfavorably had higher SBP (15 mm Hg) and DBP (7 mm Hg) than when they were working under a favored supervisor. The researchers expect to find similar results among men and workers in other fields. They urge work supervisors to be aware of the effects that even "trivial incivilities and acts of unfairness" have on the health of those they supervise.
Increases in blood pressure during marital conflict were reported in a US study.[14] The largest increases in DBP was seen in husbands and wives who were seeking to change their spouses in some way. Women were more likely to want to change their husbands and the most often sought changes revolved around the in-laws, housework or childcare, money, or sex.
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