Editorial Comment
Reducing therapeutic inertia to improve blood pressure control: the Spanish lesson Massimo Volpe a and Giuliano Tocci b
See original paper on page 1138
E
ffective clinical management and control of hypertension remains a major challenge for physicians operating in different clinical settings, worldwide. Despite the majority of physicians reporting relatively high rates of perceived blood pressure control [1], over the past decade, observational studies and epidemiological surveys still have consistently and systematically showed relatively low proportions of hypertensive patients who attained the recommended blood pressure targets [2–6]. Several factors have been claimed to explain this gap between perceived and attained blood pressure control, among which some are related to patients (e.g. lack of adherence and frequent discontinuations from prescribed antihypertensive therapy due to drug-related side effects or adverse reactions) and some others to physicians (e.g. use of inappropriate therapeutic regimens, extensive use of monotherapy, complex combination therapies, and association of nonsynergistic antihypertensive drugs) [7]. Mostly, therapeutic inertia – that is the lack of therapeutic intervention in the presence of treated uncontrolled blood pressure levels – has emerged as a frequent and potentially modifiable factor for improving blood pressure control in daily clinical practice. In this issue of the Journal, a study by Escobar et al. described the main findings of a systematic and comprehensive analysis performed on the PRESio´n arterial en la poblacio´n Espan˜ola en los Centros de Atencio´n Primaria [PRESCAP] databases, which collected data on temporal trends on blood pressure control rates achieved in Spain (three dataset of studies performed in 2002, 2006 and 2010), reporting that 36.1, 41.4 and 46.3% of the included patients
Journal of Hypertension 2014, 32:988–989 a Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine, University of Rome ‘Sapienza’, Sant’Andrea Hospital, Rome and bIRCCS Neuromed, Pozzilli, Italy
Correspondence to Professor Massimo Volpe, MD, FAHA, FESC, Chair and Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine, University of Rome ‘Sapienza’, Sant’Andrea Hospital, Via di Grottarossa 1035-9, 00189 Rome, Italy. Tel: +39 06 3377, 5654; fax: +39 06 3377 5061; e-mail: [email protected] Received 12 January 2014 Revised 20 January 2014 Accepted 20 January 2014 J Hypertens 32:988–989 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. DOI:10.1097/HJH.0000000000000144
988
www.jhypertension.com
achieved the recommended blood pressure targets [8]. This analysis focuses on therapeutic behaviours of physicians involved in the clinical management of hypertensive patients, with a particular emphasis on therapeutic inertia. The main findings of this analysis are, in our opinion, of particular relevance because they provide a clear example and useful information for improving blood pressure control rates in a setting of primary care practice in a Western country. In those patients with uncontrolled blood pressure levels, in fact, Spanish physicians modified the treatment in 18.3, 30.4 and 41.4% of the cases, respectively (P ¼ 0.0001). The most frequent action taken was the change to another drug in the first analysis of PRESCAP 2002 (47.0%), and the addition of other antihypertensive agents in subsequent analyses of PRESCAP 2006 and 2010 (46.3 and 55.6%, respectively). Predictors of therapeutic inertia were the physician’s perception of blood pressure control, being on treatment with combined therapy, and the absence of risk factors or cardiovascular disease. Similar findings have been also reported in other European countries, including Italy. For example, in the REassessment of Antihypertensive Chronic Therapy (REACT) study [9], which included about 1500 treated hypertensive adult patients, relatively small proportions of physicians modified antihypertensive medications in the presence of uncontrolled blood pressure levels. In particular, when investigators were asked how they would modify therapy, the dosages and the prescription of calcium antagonists, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (alone or in fixed-combination therapies) were only partially increased, whereas diuretics and beta-blockers remained almost the same. In a similar analysis from the Brisighella Heart Study database [10], which included 940 hypertensive patients from the original cohort of otherwise healthy adult volunteers, the increased use of combination therapy, the reduced use of diuretics and the increased use of calcium channel blockers and ACE inhibitors as first-line drugs were paralleled with an improved blood pressure control and lower rates of fatal and nonfatal cardiovascular events in a setting of primary care practice. Although therapeutic inertia has decreased in the past years in primary care setting in Spain, as well as in Italy or in Volume 32 Number 5 May 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Reducing therapeutic inertia to improve blood pressure control
other Western countries, nowadays, in nearly 60% of patients with uncontrolled blood pressure, no therapeutic action is actually taken. This clearly supports the need for improving educational and behavioural interventions for reducing physicians’ inertia and increasing patients’ adherence to prescribed medications at both national and local levels, as recently promoted by several national societies for hypertension management and control [11].
ACKNOWLEDGEMENTS
5. 6.
7. 8.
Conflicts of interest The authors have no conflict of interest to disclose.
REFERENCES 1. Volpe M, Tocci G. Managing hypertension in cardiology practice according to risk profile. Int J Clin Pract 2008; 62:1403–1412. 2. Tocci G, Rosei EA, Ambrosioni E, Borghi C, Ferri C, Ferrucci A, et al. Blood pressure control in Italy: analysis of clinical data from 2005–2011 surveys on hypertension. J Hypertens 2012; 30:1065–1074. 3. Volpe M, Tocci G, Trimarco B, Rosei EA, Borghi C, Ambrosioni E, et al. Blood pressure control in Italy: results of recent surveys on hypertension. J Hypertens 2007; 25:1491–1498. 4. Prugger C, Keil U, Wellmann J, de Bacquer D, de Backer G, Ambrosio GB, et al. Blood pressure control and knowledge of target blood
Journal of Hypertension
9.
10. 11.
pressure in coronary patients across Europe: results from the EUROASPIRE III survey. J Hypertens 2011; 29:1641–1648. Dallongeville J, Banegas JR, Tubach F, Guallar E, Borghi C, Backer GD, et al. Survey of physicians’ practices in the control of cardiovascular risk factors: the EURIKA study. Eur J Prev Cardiol 2012; 19:541–550. Bramlage P, Bohm M, Volpe M, Khan BV, Paar WD, Tebbe U, Thoenes M. A global perspective on blood pressure treatment and control in a referred cohort of hypertensive patients. J Clin Hypertens (Greenwich) 2010; 12:666–677. Volpe M, Tocci G. Challenging hypertension: how to diagnose and treat resistant hypertension in daily clinical practice. Expert Rev Cardiovasc Ther 2010; 8:811–820. Escobar C, Barrios V, Alonso-Moreno FJ, Prieto MA, Valls F, Calderon A, et al., on behalf of the Working Group of Arterial Hypertension of the Spanish Society of Primary Care Physicians (Group HTA/SEMERGEN) and the PRESCAP 2010 investigators. Evolution of therapy inertia in primary care setting in Spain during 2002–2010. J Hypertens 2014; 32:1138–1145. Volpe M, Notaro LA, Tocci G, Panina G, Veglia F, Agabiti Rosei E, et al. The REassessment of Antihypertensive Chronic Therapy (REACT) Study: an Italian observational study on hypertension management in patients with established therapy. High Blood Press Cardiovasc Prev 2004; 11:175–185. Borghi C, Dormi A, D’Addato S, Gaddi A, Ambrosioni E. Trends in blood pressure control and antihypertensive treatment in clinical practice: the Brisighella Heart Study. J Hypertens 2004; 22:1707–1716. Volpe M. The changing role of hypertension societies: shifting gears in Italy. High Blood Press Cardiovasc Prev 2012; 19:1–2.
www.jhypertension.com
989
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Reducing therapeutic inertia to improve blood pressure control: the Spanish lesson Massimo Volpe a and Giuliano Tocci b
See original paper on page 1138
E
ffective clinical management and control of hypertension remains a major challenge for physicians operating in different clinical settings, worldwide. Despite the majority of physicians reporting relatively high rates of perceived blood pressure control [1], over the past decade, observational studies and epidemiological surveys still have consistently and systematically showed relatively low proportions of hypertensive patients who attained the recommended blood pressure targets [2–6]. Several factors have been claimed to explain this gap between perceived and attained blood pressure control, among which some are related to patients (e.g. lack of adherence and frequent discontinuations from prescribed antihypertensive therapy due to drug-related side effects or adverse reactions) and some others to physicians (e.g. use of inappropriate therapeutic regimens, extensive use of monotherapy, complex combination therapies, and association of nonsynergistic antihypertensive drugs) [7]. Mostly, therapeutic inertia – that is the lack of therapeutic intervention in the presence of treated uncontrolled blood pressure levels – has emerged as a frequent and potentially modifiable factor for improving blood pressure control in daily clinical practice. In this issue of the Journal, a study by Escobar et al. described the main findings of a systematic and comprehensive analysis performed on the PRESio´n arterial en la poblacio´n Espan˜ola en los Centros de Atencio´n Primaria [PRESCAP] databases, which collected data on temporal trends on blood pressure control rates achieved in Spain (three dataset of studies performed in 2002, 2006 and 2010), reporting that 36.1, 41.4 and 46.3% of the included patients
Journal of Hypertension 2014, 32:988–989 a Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine, University of Rome ‘Sapienza’, Sant’Andrea Hospital, Rome and bIRCCS Neuromed, Pozzilli, Italy
Correspondence to Professor Massimo Volpe, MD, FAHA, FESC, Chair and Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine, University of Rome ‘Sapienza’, Sant’Andrea Hospital, Via di Grottarossa 1035-9, 00189 Rome, Italy. Tel: +39 06 3377, 5654; fax: +39 06 3377 5061; e-mail: [email protected] Received 12 January 2014 Revised 20 January 2014 Accepted 20 January 2014 J Hypertens 32:988–989 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. DOI:10.1097/HJH.0000000000000144
988
www.jhypertension.com
achieved the recommended blood pressure targets [8]. This analysis focuses on therapeutic behaviours of physicians involved in the clinical management of hypertensive patients, with a particular emphasis on therapeutic inertia. The main findings of this analysis are, in our opinion, of particular relevance because they provide a clear example and useful information for improving blood pressure control rates in a setting of primary care practice in a Western country. In those patients with uncontrolled blood pressure levels, in fact, Spanish physicians modified the treatment in 18.3, 30.4 and 41.4% of the cases, respectively (P ¼ 0.0001). The most frequent action taken was the change to another drug in the first analysis of PRESCAP 2002 (47.0%), and the addition of other antihypertensive agents in subsequent analyses of PRESCAP 2006 and 2010 (46.3 and 55.6%, respectively). Predictors of therapeutic inertia were the physician’s perception of blood pressure control, being on treatment with combined therapy, and the absence of risk factors or cardiovascular disease. Similar findings have been also reported in other European countries, including Italy. For example, in the REassessment of Antihypertensive Chronic Therapy (REACT) study [9], which included about 1500 treated hypertensive adult patients, relatively small proportions of physicians modified antihypertensive medications in the presence of uncontrolled blood pressure levels. In particular, when investigators were asked how they would modify therapy, the dosages and the prescription of calcium antagonists, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (alone or in fixed-combination therapies) were only partially increased, whereas diuretics and beta-blockers remained almost the same. In a similar analysis from the Brisighella Heart Study database [10], which included 940 hypertensive patients from the original cohort of otherwise healthy adult volunteers, the increased use of combination therapy, the reduced use of diuretics and the increased use of calcium channel blockers and ACE inhibitors as first-line drugs were paralleled with an improved blood pressure control and lower rates of fatal and nonfatal cardiovascular events in a setting of primary care practice. Although therapeutic inertia has decreased in the past years in primary care setting in Spain, as well as in Italy or in Volume 32 Number 5 May 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Reducing therapeutic inertia to improve blood pressure control
other Western countries, nowadays, in nearly 60% of patients with uncontrolled blood pressure, no therapeutic action is actually taken. This clearly supports the need for improving educational and behavioural interventions for reducing physicians’ inertia and increasing patients’ adherence to prescribed medications at both national and local levels, as recently promoted by several national societies for hypertension management and control [11].
ACKNOWLEDGEMENTS
5. 6.
7. 8.
Conflicts of interest The authors have no conflict of interest to disclose.
REFERENCES 1. Volpe M, Tocci G. Managing hypertension in cardiology practice according to risk profile. Int J Clin Pract 2008; 62:1403–1412. 2. Tocci G, Rosei EA, Ambrosioni E, Borghi C, Ferri C, Ferrucci A, et al. Blood pressure control in Italy: analysis of clinical data from 2005–2011 surveys on hypertension. J Hypertens 2012; 30:1065–1074. 3. Volpe M, Tocci G, Trimarco B, Rosei EA, Borghi C, Ambrosioni E, et al. Blood pressure control in Italy: results of recent surveys on hypertension. J Hypertens 2007; 25:1491–1498. 4. Prugger C, Keil U, Wellmann J, de Bacquer D, de Backer G, Ambrosio GB, et al. Blood pressure control and knowledge of target blood
Journal of Hypertension
9.
10. 11.
pressure in coronary patients across Europe: results from the EUROASPIRE III survey. J Hypertens 2011; 29:1641–1648. Dallongeville J, Banegas JR, Tubach F, Guallar E, Borghi C, Backer GD, et al. Survey of physicians’ practices in the control of cardiovascular risk factors: the EURIKA study. Eur J Prev Cardiol 2012; 19:541–550. Bramlage P, Bohm M, Volpe M, Khan BV, Paar WD, Tebbe U, Thoenes M. A global perspective on blood pressure treatment and control in a referred cohort of hypertensive patients. J Clin Hypertens (Greenwich) 2010; 12:666–677. Volpe M, Tocci G. Challenging hypertension: how to diagnose and treat resistant hypertension in daily clinical practice. Expert Rev Cardiovasc Ther 2010; 8:811–820. Escobar C, Barrios V, Alonso-Moreno FJ, Prieto MA, Valls F, Calderon A, et al., on behalf of the Working Group of Arterial Hypertension of the Spanish Society of Primary Care Physicians (Group HTA/SEMERGEN) and the PRESCAP 2010 investigators. Evolution of therapy inertia in primary care setting in Spain during 2002–2010. J Hypertens 2014; 32:1138–1145. Volpe M, Notaro LA, Tocci G, Panina G, Veglia F, Agabiti Rosei E, et al. The REassessment of Antihypertensive Chronic Therapy (REACT) Study: an Italian observational study on hypertension management in patients with established therapy. High Blood Press Cardiovasc Prev 2004; 11:175–185. Borghi C, Dormi A, D’Addato S, Gaddi A, Ambrosioni E. Trends in blood pressure control and antihypertensive treatment in clinical practice: the Brisighella Heart Study. J Hypertens 2004; 22:1707–1716. Volpe M. The changing role of hypertension societies: shifting gears in Italy. High Blood Press Cardiovasc Prev 2012; 19:1–2.
www.jhypertension.com
989
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
