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A CLOSER LOOK AT

Nearly one in four


Americans has high
blood pressure.

A JOINT PROJECT BETWEEN


T H E A M E R I C A N H E A R T A S S O C I AT I O N A N D
T H E N AT I O N A L P H A R M AC E U T I C A L C O U N C I L
H
igh blood pressure is a silent killer responsible for the blood pressure. Most Americans also consume far more salt
deaths of more than 44,000 Americans in 1998. Data than their bodies need. Heavy sodium consumption
indicate that the death rate associated with high blood increases blood pressure in some people, leading to high
pressure is rising. Two types of blood blood pressure. The American Heart Association Nutrition
pressure—systolic and diastolic—are Committee recommends a diet low in salt and fat, and rich in
measured. High blood pressure, or potassium, calcium, magnesium and protein.4
hypertension, is defined in an adult as a
systolic pressure of 140 millimeters of The Sixth Report of the Joint National Committee on
mercury (mm Hg) or higher and/or a Prevention, Detection, Evaluation, and Treatment of
diastolic pressure of 90 mm Hg or higher Hypertension (JNC), published in 1997, contains practice
(see box on next page).1 guidelines for treatment of high blood pressure.1 The
guidelines state that patients with mild or moderate high
High blood pressure can occur in blood pressure should begin treatment with long-acting, once-
children or adults, but is particularly daily drug therapy. Patients with severe high blood pressure
prevalent in African-Americans, may require a more aggressive medication regimen. If the
middle-aged and elderly people, obese initial therapy fails, a drug from a different therapeutic class or
people, heavy drinkers, and women combination therapy should be prescribed.
taking oral contraceptives. People with
diabetes, gout, or kidney disease have a There are several classes of medications used to treat high
higher frequency of high blood blood pressure and each reduces blood pressure through a
pressure.2 Roughly 50 million different mechanism. Diuretics rid the body of excess fluids
Americans age six and older have high and salt; beta blockers reduce heart rate and the heart’s
blood pressure.3 Left untreated, high output of blood; sympathetic nerve inhibitors prevent
blood pressure can lead to heart nerves from constricting blood vessels; vasodilators relax
disease, kidney disease, and stroke.3 In the muscles in the walls of blood vessels; ACE inhibitors and
2001, the estimated total direct costs of angiotensin II receptor blockers affect the body’s
treating high blood pressure are production and absorption of angiotensin, a chemical that
estimated at $29.6 billion, in addition to causes arteries to constrict; and calcium channel blockers
$10.8 billion in indirect costs from lost reduce heart rate and relax blood vessels.5 These drugs are
productivity.3 also used to treat people with heart problems, glaucoma,
kidney disease, and other conditions. Currently no class of
Many people have undiagnosed high blood pressure drugs is accepted to be most effective for treating high
because the symptoms are not always obvious. It is blood pressure. Combinations of existing drugs are often
estimated that only 68 percent of Americans with high more effective than single-drug therapy.6, 7 Studies have
blood pressure are aware of their condition. While four- shown that among patients with high blood pressure,
fifths of those diagnosed with high blood pressure take maintaining a healthy blood pressure requires the use of
medication for it, only half of those patients actually control multiple drugs in most cases.8, 9
their blood pressure adequately. This failure to control high
blood pressure may be due to improper treatment, A number of studies have highlighted the health benefits of
noncompliance with prescribed medications and lifestyle lowering high blood pressure even by small amounts.
changes, or other reasons.1 Analyses of recent clinical trials indicate a 38 percent decrease
in strokes among patients who lowered their blood pressure
High blood pressure is primarily treated through lifestyle only slightly.10 More recent studies point to a 16 percent
modification and drug therapy. Patients may be advised to reduction in heart disease-related deaths for individuals
stop smoking, lose weight, exercise regularly, and limit their undergoing long-term drug therapy for high blood pressure.10
intake of salt, fats, and alcohol.1 Studies have found that body Treating high blood pressure long-term has been shown to
weight, changes in body weight over time, and skinfold lower health care costs and to reduce rates of related diseases
thickness are related to changes in blood pressure levels. and death. According to one study, when the number of
These factors have been linked to the later rise and patients controlling high blood pressure increased from 44 to
development of high blood pressure. People who are 68 percent, annual health care costs dropped by 40 percent.11
overweight are more likely to have high-normal to mild-high
T
here is some concern that the prescription of drugs may not always follow the JNC
guidelines. This could, in some cases, be due to poor compliance and other
medical conditions. High blood pressure treatment compliance appears to be
closely tied to the side-effect profiles of drugs and cost concerns. In general, as the
side-effect profile of a medication worsens, so does treatment compliance.12 Physicians
may also deviate from standard guidelines to accommodate other medical conditions.
Certain drugs, for instance, can aid people with Type I diabetes by decreasing their
resistance to insulin.13

In the face of rising prevalence, meeting national treatment goals may require
coordinated efforts to raise awareness, encourage treatment, and achieve control of
high blood pressure. Education programs can alert the public to the need for blood
pressure testing and highlight the health benefits of controlling hypertension. New
medications can also play a role. Together, new therapies and better practice
patterns are the keys to improving high blood pressure control.

T
OTAL DIRECT COSTS OF TREATING HYPERTENSION ARE
ESTIMATED TO BE $29.6 BILLION IN 2001.

BLOOD PRESSURE DEFINED


Blood pressure Optimal Normal High Normal Hypertension
(mm Hg)

Systolic Less than 120 Less than 130 130-139 140 or higher
(top number)

Diastolic Less than 80 Less than 85 85-89 90 or higher


(bottom number)

FACTORS THAT INCREASE YOUR RISK OF DEVELOPING


HIGH BLOOD PRESSURE:
• Family history of high blood pressure
• Race (African-Americans are more likely to have high blood pressure than Caucasians.)
• Male gender (Men have a greater risk of high blood pressure than women until age 55, when their respective risks are
similar. At age 75 and older, women are more likely to develop high blood pressure than men.)
• Age (Blood pressure tends to increase with age.)
• Sensitivity to salt
• Obesity and excess weight
• Heavy alcohol consumption
• Use of oral contraceptives and some other medications
• Sedentary or inactive lifestyle

Source: American Heart Association. (2001) Heart and Stroke A-Z Guide: High Blood Pressure, Factors that Contribute to.
[Online]. Available: http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/hbpf.html [10/18/01].
FACTORS INFLUENCING DRUG SPENDING FOR
HIGH BLOOD PRESSURE 1994-1997
METHODOLOGY Spending on pharmaceuticals was analyzed for individuals who received health benefit
coverage from large employers in 1994 and 1997. The sample included individuals who
This study separately
received drug treatment for high blood pressure and those who were diagnosed with a
analyzed prescription drug
condition other than high blood pressure for which these drugs are often prescribed.
spending growth for two
large national claims
databases, one representing 20
managed care plan enrollees Volume Factors
and the other representing
15
those covered by large
employer-provided health
benefit plans. The study 10
defined and assessed
several factors affecting the 5
price per day of therapy and
the volume of therapy — 0
the number of days of
therapy received and the -5
number of patients receiving
drug therapy. The analysis -10 Price Factors
also examined the effects of
price and volume changes
for established drugs on the Spending for high blood pressure drugs rose 10 percent from 1994 to 1997. Volume factors
market during the entire (increased numbers of people with high cholesterol receiving cholesterol lowering
period of analysis and for prescriptions, and increased intensity and duration of drug therapy) far outweighed price
new drugs that were first factors, which had a negative impact on spending growth.
marketed during this period.

Factors Influencing Growth in Rx Expenditures: % Positive Impact % Negative Impact


Total Growth in Expenditures +10
Growth Due to Volume Factors +18
Changes in the Number of Prescriptions per Person for Established Drugs -5
Changes in the Number of Prescriptions per Person for New Entrants +18
Changes in Days of Therapy for Established Drugs +9
Changes in Days of Therapy for New Entrants 0
Patients per 1000 Health Care Enrollees -3
Growth Due to Price Factors -8
Inflation +1
Changes in Mix of Established Drugs -7
Price of New Entrants -2
Source: MEDSTAT’s Marketscan database
SPENDING PER CAPITA FOR HIGH BLOOD PRESSURE MEDICATIONS
1994
250
1997
Avg. $ Per Capita

200
150
100
50
0
All ACE Inhibitors Alpha-Beta Beta Blockers Calcium Hypotensive Vasodilating
Blockers Channel Agents Agents
Blockers

Drug spending per capita decreased from 1994 to 1997 across most classes of high blood pressure drugs. Per capita spending on ACE
inhibitors, calcium channel blockers, alpha-beta blockers and beta blockers each fell roughly 20 percent from 1994 to 1997, while
spending on vasodilating agents dropped 6 percent. The only increase in per capita spending was for hypotensive agents. Spending
for these drugs grew 7 percent in three years.

Source: MEDSTAT’s Marketscan database

INDIVIDUALIZED CARE FOR


AFRICAN-AMERICANS
High blood pressure can occur in people of all ages, genders and races, but it is particularly
common in African-Americans. In fact, the prevalence of high blood pressure in African-
Americans is among the highest in the world. Compared with Caucasians, African-Americans
develop high blood pressure at an earlier age and their average blood pressures are much
higher. African-Americans have moderate high blood pressure twice as often as Caucasians and
severe high blood pressure three times as often. As a result, African-Americans have a 2- to 3-
fold greater risk of stroke and are more likely to die of stroke than Caucasians.

It is not surprising then that the treatment for high blood pressure affects African-Americans
and Caucasians differently. In general, ACE inhibitors are less effective for African-American
patients than they are for Caucasian patients – although they are often the first choice
treatment. Beta-blockers also exhibit different levels of effectiveness among ethnic groups.
While all medications used to treat high blood pressure can be effective for African-Americans,
different dosages are often necessary. Drug therapy should be tailored to the individual patient
in order to achieve optimal results.

Source: American Heart Association. (2001) Biostatistical Fact Sheet-Populations,


African-Americans and Cardiovascular Diseases. [Online].
Available: http://www.americanheart.org/statistics/biostats/bioafr.htm [10/18/01].
FOR MORE INFORMATION ABOUT
ABOUT THIS
PUBLICATION:
HIGH BLOOD PRESSURE, PLEASE CONTACT:
The American Heart Association (AHA)
“A Closer Look at High Blood Pressure” is www.americanheart.org
a joint publication of the American Heart 1-800-AHA-USA1
Association and the National
Pharmaceutical Council. The National Institutes of Health (NIH)
www.nih.gov
The American Heart Association spent 301-496-4000
about $337 million during fiscal year
1999-2000 on research support, public The National Heart, Lung and Blood Institute (NHLBI)
and professional education, and www.nhlbi.nih.gov
community programs. Nationwide, our 1-800-575-9355
organization has grown to include more
than 22.5 million volunteers and The National Institute of Neurological Disorders and Stroke (NINDS)
supporters who carry out our mission in www.ninds.nih.gov
communities across the country. The 1-800-352-9424
association is the largest voluntary
health organization fighting heart American College of Cardiology (ACC)
disease, stroke and other cardiovascular www.acc.org
diseases, which annually kill about
1-800-253-4636
950,000 Americans.

Since 1953, the National Pharmaceutical


Council (NPC) has sponsored and
conducted scientific, evidence-based
analyses of the appropriate use of
pharmaceuticals and the clinical and
economic value of pharmaceutical 1
Joint National Committee. The Sixth Report of The 8
Hansson L, Zanchetti A, Carruthers SG et al. Effects
innovation. NPC provides educational Joint National Committee on Detection, Evaluation of intensive blood-pressure lowering and low-dose
resources to a variety of health care and Treatment of High Blood Pressure (JNC-VI). NIH aspirin in patients with hypertension: principal
stakeholders, including patients, Pub. No. 98-4080. Rockville, MD: National Heart, results of the Hypertension Optimal Treatment (HOT)
Lung, and Blood Institute, National Institutes of randomised trial. Lancet 1998;351:1755-1762.
clinicians, payers and policy makers. Health, 1997.
More than 20 research-based 9
Moser M. National recommendations for the
pharmaceutical companies are members 2
American Heart Association. (2001) Heart and Stroke pharmacological treatment of hypertension: Should
of the NPC. A-Z Guide: High Blood Pressure. [Online]. Available: they be revised? Arch Intern Med 1999;159:1403-1406.
http://www.americanheart.org/Heart_and_Stroke_
A_Z_Guide/hbp.html [10/18/01]. 10
Moser M. Hypertension can be treated effectively
without increasing the cost of care. Journal of Human
3
American Heart Association. (2001) Heart and Stroke Hypertension 1996;10(Suppl. 2):S33-S38.
Statistical Update. Dallas, TX: AHA, 2000.
11
Moser M. The cost of treating hypertension: can we
4
American Heart Association. (2001) Heart and Stroke keep it under control without compromising the level
A-Z Guide: High Blood Pressure, Factors that of care? Am J Hypertens 1998;11(8, pt. 2):120S-127S.
Contribute to. [Online]. Available: http://www.
americanheart.org/Heart_and_Stroke_A_Z_Guide/ 12
Hansson L. Medical and cost-economy aspects of
hbpf.html [10/18/01]. modern antihypertensive therapy—with special
reference to 2 years of clinical experience with
5
American Heart Association. (2001) Heart and Stroke losartan. Blood Pressure 1997;6(Suppl 1):52-55.
A-Z Guide: High Blood Pressure, What Can Be Done.
[Online]. Available: http://www.americanheart.org/ Barrie W. Cost-effective therapy for hypertension.
13

Heart_and_Stroke_A_Z_Guide/hbpwhat.html West J Med 1996;164:303-309.


[10/18/01].
For more information about NPC or for 6
Moser M, Black H. The role of combination therapy
additional resources, please contact: in the treatment of hypertension. Am J Hypertens
1998;11(6, pt. 2):73S-78S.
The National Pharmaceutical Council
1894 Preston White Drive 7
Gradman AH, Cutler NR, Davis PD, et al. Combined
Reston, VA 20191-5433 enalapril and felodipine extended release (ER) for
systemic hypertension. Am J Cardiol 1997;79:431-435.
Phone: 703-620-6390 Cited in Moser and Black, 1998.
Fax: 703-476-0904
www.npcnow.org