Vol. 142 No. 4344 (2012)
Uncontrolled arterial hypertension in primary care – patient characteristics and associated factors
- Corinne Chmiel
- Mathyas Wang
- Oliver Senn
- Valerio Del Prete
- Marco Zoller
- Thomas Rosemann
- Claudia Steurer-Stey
PRINCIPLES: Most patients with arterial hypertension are treated in primary care. The objective is to assess characteristics of patients with uncontrolled arterial hypertension and its associated determinants in Swiss primary care.
METHOD: Data on 122 adult patients with uncontrolled hypertension (mm Hg >140 systolic and/or >90 diastolic) was collected from the baseline data of the on-going randomised controlled “CoCo” trial: Colour-coded Blood Pressure Control. Patient and general practitioner characteristics were analysed to investigate the relationship between BP and patient characteristics.
RESULTS: From October 2009 to March 2011 30 general practitioners recruited 122 patients; median age 64 years (IQR 54.8–72), 50% male, median BMI 28.3 kg/m2 (IQR 25.3–31.7), 21.5% smokers. 65.6% performed home blood pressure measurement, 88.5% received pharmacological treatment, 41.8% mono-therapy. Most frequent dual drug combinations: diuretics/angiotensin-receptor-blockers (33.3%), angiotensin-converting-enzyme-inhibitors/beta blockers (both 28.1%). BMI, smoking and age were independent predictors for elevated systolic blood pressure when controlled for gender, home blood pressure measurement, education, pulse rate and number of antihypertensive substances. We found a significant non-linear association between systolic blood pressure and number of antihypertensive substances. Age and any amount of antihypertensive substances were independently and inversely correlated with diastolic blood pressure. The findings did not change when additionally controlled for general practitioner clustering effect.
CONCLUSION: Smoking and high BMI are strong and independent factors associated with higher blood pressure levels in patients with uncontrolled arterial hypertension. A high rate of monotherapy and a decrease in the incremental gain on blood pressure control when more antihypertensive agents are used highlight the importance of adequate pharmacological treatment as well as risk factor control.
- Wolf-Maier K, Cooper RS, Kramer H, Banegas JR, Giampaoli S, Joffres MR, et al. Hypertension treatment and control in five European countries, Canada, and the United States. Hypertension. 2004;43(1):10–7.
- Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455):217–23.
- Chobanian AV. Isolated systolic hypertension in the elderly. N Engl J Med. 2007;357(8):789–96.
- Kannel WB. Risk stratification in hypertension: new insights from the Framingham study. Am J Hypertension. 2000;13(Supplement 1):S3–10.
- Jones DW, Hall JE. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and evidence from new hypertension trials. Hypertension. 2004;43(1):1–3.
- Danon-Hersch N, Marques-Vidal P, Bovet P, Chiolero A, Paccaud F, Pécoud A, et al. Prevalence, awareness, treatment and control of high blood pressure in a Swiss city general population: the CoLaus study. Eur J Cardiovasc Prev Rehabil. 2009;16(1):66–72.
- Paulsen MS, Sondergaard J, Reuther L, Larsen PS, Munck AP, Larsen PV, et al. Treatment of hypertension in general practice: a cross-sectional study of 5413 hypertensive patients. Family Practice. 2011.
- Van der Niepen P, Dupont AG. Improved blood pressure control in elderly hypertensive patients: results of the PAPY-65 Survey. Drugs Aging. 2010;27(7):573–88 510.2165/11537350-000000000-000000000.
- Steurer-Stey C, Zoller M, Chmiel Moshinsky C, Senn O, Rosemann T. Does a colour-coded blood pressure diary improve blood pressure control for patients in general practice: the CoCo trial. Trials. 2010;11:38.
- Mansia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al. 2007 ESH-ESC Guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Blood Press. 2007;16(3):135–232.
- Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007;25(6):1105–87.
- Kannel WB, D’Agostino RB, Sullivan L, Wilson PWF. Concept and usefulness of cardiovascular risk profiles. Am Heart J. 2004;148(1):16–26.
- Smulyan H, Safar ME. Blood pressure measurement: retrospective and prospective views. Am J Hypertens. 2011;24:628–34.
- Jankowski P K-JK, Czarnecka D, Brzozowska-Kiszka M, Styczkiewicz K, Loster M, Kloch-Badelek M, et al. Pulsatile but not steady component of blood pressure predicts cardiovascular events in coronary patients. Hypertension. 2008;51:848–55.
- Yoon C, Jung H, Kim Y. Evaluation of an incentive-based obesity management program in a workplace. Int J Occup Saf Ergon. 2011;17(2):147–54.
- Pede S, Lombardo M. Cardiovascular risk stratification. Systolic, diastolic or pulse pressure? Ital Heart J Suppl. 2001;2(4):356–8.
- Nichols WW. Clinical measurement of arterial stiffness obtained from noninvasive pressure waveforms. Am J Hypertens. 2005;18(1 Pt 2):3S–10S.
- Franklin SS, Gustin Wt, Wong ND, Larson MG, Weber MA, Kannel WB, Levy D. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation. 1997;96(1):308–15.
- Primatesta P, Falaschetti E, Gupta S, Marmot MG, Poulter NR. Association between smoking and blood pressure: evidence from the Health Survey for England. Hypertension. 2001;37(2):187–93.
- Li H, Tong W, Wang A, Lin Z, Zhang Y. Effects of cigarette smoking on blood pressure stratified by BMI in Mongolian population, China. Blood Pressure. 2010;19(2):92–7.
- Brenner R, Waeber B, Allemann Y. Medical treatment of hypertension in Switzerland. The 2009 Swiss Hypertension Survey (SWISSHYPE). Swiss Med Wkly. 2011;141:w13169.
- Ferrari P, Hess L, Pechere-Bertschi A, Muggli F, Burnier M. Reasons for not intensifying antihypertensive treatment (RIAT): a primary care antihypertensive intervention study. J Hypertens. 2004;22(6):1221–9.
- Schroeder K, Fahey T, Ebrahim S. How can we improve adherence to blood pressure-lowering medication in ambulatory care? Systematic review of randomized controlled trials. Arch Intern Med. 2004;164(7):722–32.
- De Geest S, Sabate E. Adherence to long-term therapies: evidence for action. Eur J Cardiovasc Nurs. 2003;2(4):323.
- Burnier M. Medication adherence and persistence as the cornerstone of effective antihypertensive therapy. Am J Hypertens. 2006;19(11):1190–6.
- Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database of Systematic Reviews 2004(2):CD004804.
- Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487–97.
- Heisler M, Hogan MM, Hofer TP, Schmittdiel JA, Pladevall M, Kerr EA. When more is not better: treatment intensification among hypertensive patients with poor medication adherence. Circulation. 2008;117(22):2884–92.
- Materson BJ, Reda DJ, Cushman WC, Massie BM, Freis ED, Kochar MS, et al. Single-drug therapy for hypertension in men – a comparison of six antihypertensive agents with placebo. N Engl J Med. 1993;328(13):914–21.
- Timbie JW, Hayward RA, Vijan S. Diminishing efficacy of combination therapy, response-heterogeneity, and treatment intolerance limit the attainability of tight risk factor control in patients with diabetes. Health Services Research. 2010;45(2):437–56.
- Cushman WC, Evans GW, Byington RP, Goff DC, Jr., Grimm RH, Jr., Cutler JA, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575–85.
- Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care. 2001;24(10):1821–33.
- Houston Miller N, Hill M, Kottke T, Ockene IS. The multilevel compliance challenge: eecommendations for a call to action: a statement for healthcare professionals. Circulation. 1997;95(4):1085–90.
- Qureshi NN, Hatcher J, Chaturvedi N, Jafar TH. Effect of general practitioner education on adherence to antihypertensive drugs: cluster randomised controlled trial. BMJ. 2007;335(7628):1030.
- Verberk WJ, Kroon AA, Kessels AGH, de Leeuw PW. Home blood pressure measurement: a systematic review. J Am Coll Cardiol. 2005;46(5):743–51.
- Weiner JP, Parente ST, Garnick DW, Fowles J, Lawthers AG, Palmer RH. Variation in office-based quality. JAMA: The Journal of the American Medical Association 1995;273(19):1503–8.
- Krein SL, Hofer TP, Kerr EA, Hayward RA. Whom should we profile? Examining diabetes care practice variation among primary care providers, provider groups, and health care facilities. Health Services Research. 2002;37(5):1159–80.
- Greenfield S, Kaplan SH, Kahn R, Ninomiya J, Griffith JL. Profiling care provided by different groups of physicians: effects of patient case-mix (bias) and physician-level clustering on quality assessment results. Ann Intern Med. 2002;136(2):111–21.
- Rosemann T, Marty F, Bhend H, Wagner J, Brunner L, Zoller M. Utilisation of information technologies in ambulatory care in Switzerland. Swiss Med Wkly. 2010;140:w13088.
- Chmiel C, Bhend H, Senn O, Zoller M, Rosemann T. The FIRE project: a milestone for research in primary care in Switzerland. Swiss Med Wkly. 2011;140:w13142.