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Who fails to achieve blood pressure

and lipid targets patients or doctors?
Francesco P Cappuccio MBBS MD MSc FRCP FFPH FAHA
Professor of Cardiovascular Medicine & Epidemiology, Warwick Medical School
Consultant Cardiovascular Physician, UHCW NHS Trust, Coventry

CV Mortality Risk
Doubles with each 20/10 mm Hg BP increment

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CV mortality:
-fold increase

8
7
6
5
4
3
2
1
0
115/75

135/85
155/95
BP (SBP/DBP mm Hg)

175/105

Lewington S, et al. Lancet 2002; 60: 1903-1913

Long-term antihypertensive
treatment reduces CV risk
0

CV event

Stroke

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CHD

10
20
30

2021
2128

40

3039

50
Relative risk reduction (%)

Risk of CV event with ACEI or CCB relative to placebo

CV: cardiovascular
CHD: coronary heart disease

Neal B, et al. 2000

Uncontrolled BP results in major

CV events*

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DBP/SBP uncontrolled

Major CV events/year*
50 000

DBP uncontrolled
SBP uncontrolled

40 000
30 000
20 000
10 000
0

Medicated

Unmedicated

Total

Uncontrolled BP results in major CV events

(myocardial infarction [MI], stroke or CV-related death)
*Study of the US population

Flack JM, et al. 2002

Serum Total Cholesterol and Blood Pressure

strong determinants of cardiovascular risk

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Erhardt LR et al. Atherosclerosis 2008;196:532-41

Evolution of guidelines on lipid

management

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Erhardt LR et al. Atherosclerosis 2008;196:532-41

Large numbers of patients are still not

reaching cholesterol targets

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Erhardt LR et al. Atherosclerosis 2008;196:532-41

One conclusion from an expert panel

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Harmonise guidelines
Focus on common areas of consensus
Remove boundary between primary and
secondary prevention
Focus on level of risk
Help policy makers to understand the different
component of CVD
Include professional societies from different
specialties in guidelines development and
implementation to increase ownership and
decrease fragmentation
Erhardt LR et al. Atherosclerosis 2008;196:532-41

BHS NICE Guidelines

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Potential barriers to BP control in

patients with inadequately controlled
hypertension in primary care

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Jan-Mar 2004: 110/155 (71%; 27% A/C) patients (50-80 yrs)

with last recorded BP >150/90 mmHg (>140/85 mmHg if
diabetic) seen in a nurse-led clinic
Standardised measurements plus questionnaire (including lifestyle, compliance and awareness)
53% still had inadequate BP control
Of those on Rx, 94% reported taking tablets at least 6
days/week
Only 9% knew their target number
Only 39% knew the purpose of BP management and control
Patients with diabetes were more likely to have BP > audit
standard (79% vs 42%; p<0.001)

Dean SC et al. Fam Pract 2007; 24: 259-62

NSF for CHD progress report: new

drugs and policies of reform and
investment have helped to reduce CVD
deaths in the UK by more than 23%

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Erhardt LR et al. Atherosclerosis 2008;196:532-41

Q.O.F. Blood pressure (audit) targets

Hypertension

C.H.D.

Stroke & TIA

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Diabetes

Data on >8,000 General Practices in England (>97%)

Modified from Ashworth M et al. Br Med J 2008;337:on-line November

A more aggressive strategy for the

treatment of hypertension is needed

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Patients with hypertension control (%)

Hypertension control defined as:

systolic BP <140 mmHg and diastolic BP <90 mmHg
Wang, Y. R. et al. Arch Intern Med 2007;167:141-147.

Prevalence, awareness, treatment and

control of hypertension* in Europe
Prevalence** (%)

Awareness** (%)

Treatment** (%)

Control** (%)

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* ESH criteria **adjusted for age, sex and SES

Costanzo S et al. J Hypertens 2008; December (in press)

The incidence of hypertension is

predicted to increase dramatically
Population with hypertension (%)
30

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2000
2025

28
26
24

Overall

Men

Women

The global incidence of hypertension in the adult population

is predicted to exceed 29% by the year 2025
Kearney PM, et al. Lancet 2005

Discordance between increase in use of

medications and failure to control BP

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Hypertension: >140/90 mmHg or >130/80 mmHg in diabetics

Raised TC: >4.5 mmol/L
Raised LDL-C: >2.5 mmol/L

EUROASPIRE Surveys - E.S.C. Vienna 2007

Patients with hypertension have

additional co-morbidities, making
treatment difficult
Men

Women

1
19%

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Obesity

1
17%

Glucose intolerance

26%

27%

Hyperinsulinaemia

4+

8%

Reduced HDL-C

4+

12%

Elevated LDL-C
22%

Elevated
triglycerides

25%

Left Ventricular
Hypertrophy

20%

24%

>50% have two or more comorbidities

Kannel WB, 2000

Multiple antihypertensive agents

are needed to reach BP goal

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Trial (SBP achieved)

ASCOT-BPLA (136.9 mmHg)
ALLHAT (138 mmHg)
IDNT (138 mmHg)
RENAAL (141 mmHg)
UKPDS (144 mmHg)
ABCD (132 mmHg)
MDRD (132 mmHg)
HOT (138 mmHg)
AASK (128 mmHg)
1

Average no. of antihypertensive medications

Adapted from Bakris et al. Am J Med 2004;116(5A):30S8
Dahlf et al. Lancet 2005;366:895906

Achieved BP in trials in hypertensive

diabetics and number of drugs needed

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G Mancia J Hypertens 2002;20:1461-4

Predictors of target failure

Nilsson PM, J Hypertension 2005

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24-hour control of BP is a vital consideration for

treatment of hypertension patients

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Treatment guidelines recommend use of antihypertensive agents that

provide 24-hour efficacy with once-daily dosing 1

Sustained, 24-hour BP control is important in prevention of CV events 1

the risk of MI and stroke is greater in the morning than at other times
of day2

Control of BP beyond 24-hours is useful in preventing the

consequences of an occasional missed dose 3
occasional missing of doses is the most common form of
non-compliance in patients with hypertension 3

1. ESH/ESC guidelines. J Hypertens 2003;21:10111053

2. Elliott WJ. Am J Hypertens 2001;14:291S295S
3. Burnier M, et al. J Hypertens 2003;21(Suppl 2):S37S42

Greater 24-hour ambulatory BP control is

associated with fewer CV events

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Incidence of CV events per 1000 person-years

30
25
20
15
10
5
0

<140 mmHg

140159 mmHg
Clinic systolic BP

160 mmHg

24-hour ambulatory SBP <135 mmHg

24-hour ambulatory SBP 135 mmHg
Adapted from Clement DL, et al. N Engl J Med 2003;348:24072415

Still significant variations in the use of

drug classes and combination therapy

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Cross-national differences in the use of 7 antihypertensive drug classes and

combination drug therapy among treated hypertensive patients

Wang, Y. R. et al. Arch Intern Med 2007;167:141-147.

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Physicians often underestimate

their patients CV risk

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Comparison of actual vs perceived 10-year risk among 80 Swedish GPs

Erhardt LR et al. Atherosclerosis 2008;196:532-41

Clinical Inertia

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Multivariate-Adjusted, Cross-National Differences in the

Likelihood of Hypertension Control and Medication Increase
for Inadequately Controlled Hypertension* (Cardio-Monitor)

Wang, Y. R. et al. Arch Intern Med 2007;167:141-147.

10 steps before you refer for hypertension

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1.

Check that the measurement is correct [standardised procedure;

2.

Check compliance, establish concordance [agree with patient and

3.

Encourage weight loss and salt reduction [inform patients

4.
5.
6.

Stop drugs that raise blood pressure [NSAIDs; OC; ciclosporin]

Maximise medication using ACD [BHS-NICE algorithm]
Spironolactone [low-dose (12.5mg) to start; watch U+Es and for postural

7.
8.

Establish that better control is required [clear, written plan]

Ensure that other preventive measures are in place [multi-factorial

9.

Are there any investigations that might be useful for the

specialist? [TFTs; ECG; Echo-cardio; U/S kidneys; Ur Na, K, Albumin, VMA;]
Are you referring to the correct consultant? [Hypertension clinic in

10.

validated electronic device]

warn of side effects]

(www.bhsoc.org & www.salt.gov.uk)]

hypotension]
approach]

local hospital; European Hypertension specialists; ESH Centres of Excellence

for Hypertension (BHS website)]

McCormack T & Cappuccio FP. Br J Cardiol 2008;15:254-7

What are the barriers to an effective

management of hypertension?
Patient
Life-style
Poor compliance (and
concordance)
Ineffective drugs
Missed doses
Side effects or Adverse drug
reactions
White coat
Need for additional agents
Resistance to treatment
Loss to follow-up
Lack of awareness of targets

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Physician and health-professional

Attitudes
Training
Knowledge and awareness of guidelines
Measurement issues
Clinical inertia
Reluctance to change treatment despite
failure to achieve targets
Lack of regular review
Co-morbidity

Organisation
Lack of follow-up
Migration
Failure to refer to specialist centres

CSRI

Doctor - Try this. If it doesnt work, come back and I will give you something else
Patient - Wouldnt it be better if you gave me that something else right now?