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Prof. Denis Clement ,
Studies in the early seventies turned the world’s attention to hypertension. What came out were the message to change our lifestyles, and drugs with fewer side effects. By the late 80’s, satisfactory BP control went from 10 to 29%. Newer drugs and measuring techniques were developed since but adequate pressure control reaches no more than 50% of cases, worldwide.Taking time with our patients and their families to explain hypertension, asking for self-recordings, are the most important points of the 2007 guidelines. Working closely together with GPs would help. We need better reimbursement methods to be able to spend the time required.
The challenge of controlling blood pressure in the population has been with us for many years. After the landmark studies of the early seventies on prevalence and efficacy of treatment, several hypertension Societies and Leagues worldwide have devoted all of their efforts to promoting their message on the risks hypertensive patients run and what can be done to prevent and eventually treat high blood pressure.
For prevention, life style adaptation was given as main message to the population; decreasing the amount of salt in food, for example in bread, was advised as a cheap way of preventing blood pressure to increase with age, and thereby decreasing the need for antihypertensive drugs. As for treatment, the benefits of giving the existing (old) drugs were explained even with the knowledge of their many quite unpleasant side effects. This message also stimulated research to develop newer drugs with fewer side effects; quality of life and long term prognosis were significantly improved as a result.
This opened a new era for hypertensive patients. Also in terms of the public at large, the message spread out quickly; people became interested in the problem of hypertension and consequently, control largely improved. The frequently used adagio when referring to hypertension could be adapted: initially it was said that from the total hypertensive population only 50% was known to the medical world, in these 50% only half were receiving antihypertensive drugs and in the remaining 50% only half were reaching target blood pressure. Such that in only 10 to 12.5% of all hypertensives, blood pressure was successfully reduced to target. With the worldwide campaigns on high blood pressure, this poor figure could largely be upgraded; data published by the national health and nutrition survey (see JNC 7, ref.2) (table 1) showed that satisfactory blood pressure control in the late eighties was increased from 10 to 29 %!
However, cardiovascular medicine has many life threatening problems to cope with; interest was diverted to other important issues like coronary artery disease, heart failure; clinicians felt the process of hypertension control was under way and not many new efforts were carried out except for excellent research in blood pressure measuring techniques and development of new drugs. Attention was no longer focused on the results obtained and stagnation of blood pressure control became evident (table 1). Unfortunately, up to very recently, fewer efforts were done to control blood pressure in the population and the consequences are self explanatory. Today, satisfactory blood pressure control is achieved in no more than 50% of cases, worldwide.
Table 1. Results of the national health and nutrition surveys on satisfactory blood pressure control in the population (see JNC7, ref.2)
In 1976-80 : 10%In 1988-91 : 29%In 1991-94 : 27%In 1999-2000 : 34%
The spontaneous reaction to such findings is that they do not reflect the situation in our immediate surroundings. However, that is not so. Data are there, indicating that such statistics are valid for almost all parts of the world. Even more disturbing is the finding that even patients who have gone through a coronary accident and who logically, should be stimulated to do better, do not achieve the goals (EuroAspire studies) (ref 3). Comparing the EuroAspire I and II results not only indicated that also in this specific population with a coronary accident in their past history, blood control was no better but also that it did not improve when comparing EuroAspire I and II; results of EuroAspire III seem to confirm this negative trend…
There is a remarkable similarity in this respect between hypertension and peripheral artery disease (PAD), another severe risk factor. Indeed, PAD patients also seem not to receive the necessary prevention means they deserve even though we know that they are at frightefully elevated risks of developing coronary or cerebral vascular accidents. Recent data from the REACH registry (ref.4 ) have shown that fewer than 25% of all PAD patients get any treatment; less than 46% get any risk factor control and less than 25% get full risk factor control! Evidently, talking about prevention and effectively applying it in practice are two very different issues, at far distance from each other…
Fortunately, there is again a return of interest toward these important aspects of cardiovascular medicine. Results of the above mentioned EuroAspire studies have stimulated physicians to re-look at was has been achieved in reality. After all, there is an almost unbelievable contrast between our capacity of controlling blood pressure and the results obtained. Yes: we have all the possibilities to do it well: prevention with life style adaptation, diagnosis with simple and sophisticated means, old and new antihypertensive drugs are all very effective tools to decrease blood to the targets as set in the guidelines. But we have not gotten that far. Still, in some countries, the situation is improving. In the USA, data get a trend of better control; in Europe and in France in particular, data point toward a significantly better control of blood pressure in the population ( ref 5).
What can be done? The 2007 guidelines give a number of excellent suggestions to improve control; the essential advice is given in table 2. The most important is to talk to the patient and his or her family. It is essential to explain what hypertension is and what the risks are; what the essential goals of the treatment are as well as potential side effects of treatment. Definition of blood pressure is often improved by asking to make self recordings in order to let the patient realise that his pressure indeed is too high.
Each of these steps are time consuming and make the consultation longer than planned; reimbursement often is not adapted to this type of activity; governmental and insurance systems should understand this approach and help in solving the problem. Again, as said above, we have everything in our hands to get blood pressure controlled: all physicians and in particular, cardiologists in private practice, just need to apply the rules in reality and continuously check the figures obtained. It also is very helpful to closely collaborate in this issue with the general practitioner. Insurance systems should give physicians the practical and financial tools to reach these important goals.
Table 2. Suggestions for improvement of blood pressure control (Adapted from the 2007 Guidelines)
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.
1. ESC-ESH 2007 Guidelines for the management of hypertension: J.Hypertension: 2007:25:1105-1187
2. JNC 7: JAMA:2003:289
3. EuroAspire II: Eur. Heart J. 2001: 22:554-72
4. One-year cardiovascular event rates in outpatients with atherothrombosis (REACH registry): JAMA: 2007:297: 1197-1206
5. Points de Repère (l’Assurance maladie): octobre 2007:numéro 10: Pp. 1-8
Vol 6 N°34
Prof. D. L. Clement Ghent, Belgium Past-President of the Working Group for hypertension and the heart
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