American Journal of Hypertension Advance Access published May 11, 2015
Original Article
Trends in Antihypertensive Medication Use and Blood Pressure Control Among Adults With Hypertension in Germany Giselle Sarganas,1,2 Hildtraud Knopf,1 Daniel Grams,1 and Hannelore K. Neuhauser1,2
METHODS Data from German Health Examination Surveys (GNHIES98 1998, n = 7,124 and DEGS1 2008–2011 n = 7,988, age 18–79 years) including standardized blood pressure (BP) measurements and Anatomical Therapeutic Chemical (ATC) medication codes were analyzed. RESULTS The use of antihypertensive medication among adults with hypertension in Germany increased from 54% to 72% in 1 decade. In 2008–2011, 67% of users were treated with polytherapy. The most commonly used antihypertensive class in 1998 was diuretics (43%) and in 2008–2011 beta-blockers (54%). Ramipril and metoprolol are currently the most
BACKGROUND
Blood pressure (BP) control reduces cardiovascular morbidity and mortality.1–4 The European Society of Hypertension and the European Society of Cardiology guidelines for the management of arterial hypertension published in 2007 and updated in 20135,6 reconfirm that the 5 main groups—diuretics, beta-blockers, calcium channel blockers (CCB), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARB)—can all be used for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in combination and that there is no general ranking of antihypertensive drugs. The guidelines mention that in order to control BP most patients require the combination of at least 2 drugs.6 Other studies have also shown that in order to lower BP it is more effective to use a combination of drugs than to increase the dose of a single drug.7 Based on 1998 data, Germany was reported to have higher BP and lower treatment and control than other western Correspondence: Giselle Sarganas ([email protected]). Initially submitted February 10, 2015; date of first revision March 5, 2015; accepted for publication April 14, 2015.
commonly used monotherapy agents, while ramipril in combination with hydrochlorothiazide is the most frequent polytherapy. Being a woman, older age, having statutory health insurance, diabetes, coronary heart disease (CHD), stroke, and obesity were positively associated with antihypertensive use. The control rate among treated increased from 42% to 72%. Young women (18–54 years) had better control compared to older women or to men. Having CHD or stroke was positively associated with BP control.
CONCLUSIONS Increased and improved antihypertensive use might be a main contributor to the decrease in BP observed in Germany in the last decade. However, there are still socio-demographic and health disparities in hypertension treatment and control. Keywords: blood pressure; antihypertensive; control; factors-associated; hypertension; treatment; trends; Germany. doi:10.1093/ajh/hpv067
countries.8,9 A decade later (2008–2011), although the overall hypertension prevalence was unchanged, mean BP in the population was markedly lower (both mean systolic BP (SBP) and diastolic BP (DBP) decreased by about 5 mm Hg) and the proportion of controlled hypertension more than doubled from 23% to 51%, suggesting increased and intensified antihypertensive medication.10 The aim of this study is to compare the antihypertensive use in adults (18–79 years) with hypertension in Germany in 1998 (GNHIES98, n = 2,037) and in 2008–2011 (DEGS1, n = 2,635), and to determine the factors associated with antihypertensive use and BP control in 2008–2011. METHODS Study population
Nationwide data on BP among the population in Germany based on standardized measurements is available only from national health examination surveys in 1998 (GNHIES98) 1Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany; 2DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany.
© American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: [email protected]
American Journal of Hypertension 1
Downloaded from http://ajh.oxfordjournals.org/ at Dalhousie University on May 17, 2015
BACKGROUND Hypertension is a major risk factor for morbidity and mortality, therefore its control is of great importance. In this study we compare the use of antihypertensive medication among adults with hypertension in Germany 1998 and 2008–2011 and determine factors associated with use and control.
Sarganas et al.
Measurements and definitions. Three BP measurements were taken in both surveys at the right arm at 3-minute intervals after a non-strenuous part of the examination and an additional 5-minute rest. Participants sat on a heightadjustable chair, back supported, arm lying on a table at heart level, feet on the floor and legs uncrossed. A standard mercury sphygmomanometer (Erkameter 3000; Erka, Bad Tölz, Germany) was used in GNHIES98 and an automated oscillometric device (Datascope Accutorr Plus, Mahwah, NJ) in DEGS1. Three different cuff sizes were used in each study.13 GNHIES98 BP data were calibrated for comparison with DEGS1 data based on a validation study in order to account for cuff and device differences.13 The second and third measurements were averaged. Antihypertensive medication intake was recorded during computer-assisted personal interviews; 7,099 adults have participated in the medication interview from GNHIES98 and 7,091 from DEGS1. Participants were requested to bring all original medication packages they had used in the previous 7 days and all Anatomical Therapeutic Chemical (ATC) codes were documented.14 Hypertension was defined as mean SBP ≥140 mm Hg, or mean DBP ≥90 mm Hg, or the use of antihypertensives (ATC codes: C02 antihypertensives, C03 diuretics, C07 beta-blockers, C08 CCB or C09 ACE inhibitors, and ARB). However, as the indication for taking these drugs may be other than hypertension, antihypertensive medication was only used for defining prevalent and treated hypertension if the participants reported having hypertension. For the analysis of hypertension treatment and control 7 classes of antihypertensives (diuretics, thiazide-diuretics, beta-blockers, CCB, ACE inhibitors, ARB, and antihypertensive) based on detailed ATC codes were examined (Supplementary Data online). Monotherapy was defined as the use of only one antihypertensive agent, and polytherapy (combination therapy) was defined as the use of >1 antihypertensive agent. Single-pill antihypertensive combination users were considered to be receiving polytherapy. If a person used antihypertensive medication containing more than 1 active ingredient the person was counted once within each of the antihypertensive classes. 2 American Journal of Hypertension
In contrast to previous analyses,10 10 participants with imprecise self-reported medication (as compared to those who brought medication packages) were not counted as treated. Therefore, estimates of treatment and control may differ by less than 1% compared to previous reports. Control was defined as: SBP < 140 mm Hg and DBP < 90 mm Hg in treated adults with hypertension. We investigated a range of self-reported participants’ characteristics for associations with antihypertensive use and BP control. Socio-demographic characteristics included age, gender, socioeconomic status based on income, education, and occupation15; municipality size classified into the categories rural (
Original Article
Trends in Antihypertensive Medication Use and Blood Pressure Control Among Adults With Hypertension in Germany Giselle Sarganas,1,2 Hildtraud Knopf,1 Daniel Grams,1 and Hannelore K. Neuhauser1,2
METHODS Data from German Health Examination Surveys (GNHIES98 1998, n = 7,124 and DEGS1 2008–2011 n = 7,988, age 18–79 years) including standardized blood pressure (BP) measurements and Anatomical Therapeutic Chemical (ATC) medication codes were analyzed. RESULTS The use of antihypertensive medication among adults with hypertension in Germany increased from 54% to 72% in 1 decade. In 2008–2011, 67% of users were treated with polytherapy. The most commonly used antihypertensive class in 1998 was diuretics (43%) and in 2008–2011 beta-blockers (54%). Ramipril and metoprolol are currently the most
BACKGROUND
Blood pressure (BP) control reduces cardiovascular morbidity and mortality.1–4 The European Society of Hypertension and the European Society of Cardiology guidelines for the management of arterial hypertension published in 2007 and updated in 20135,6 reconfirm that the 5 main groups—diuretics, beta-blockers, calcium channel blockers (CCB), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARB)—can all be used for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in combination and that there is no general ranking of antihypertensive drugs. The guidelines mention that in order to control BP most patients require the combination of at least 2 drugs.6 Other studies have also shown that in order to lower BP it is more effective to use a combination of drugs than to increase the dose of a single drug.7 Based on 1998 data, Germany was reported to have higher BP and lower treatment and control than other western Correspondence: Giselle Sarganas ([email protected]). Initially submitted February 10, 2015; date of first revision March 5, 2015; accepted for publication April 14, 2015.
commonly used monotherapy agents, while ramipril in combination with hydrochlorothiazide is the most frequent polytherapy. Being a woman, older age, having statutory health insurance, diabetes, coronary heart disease (CHD), stroke, and obesity were positively associated with antihypertensive use. The control rate among treated increased from 42% to 72%. Young women (18–54 years) had better control compared to older women or to men. Having CHD or stroke was positively associated with BP control.
CONCLUSIONS Increased and improved antihypertensive use might be a main contributor to the decrease in BP observed in Germany in the last decade. However, there are still socio-demographic and health disparities in hypertension treatment and control. Keywords: blood pressure; antihypertensive; control; factors-associated; hypertension; treatment; trends; Germany. doi:10.1093/ajh/hpv067
countries.8,9 A decade later (2008–2011), although the overall hypertension prevalence was unchanged, mean BP in the population was markedly lower (both mean systolic BP (SBP) and diastolic BP (DBP) decreased by about 5 mm Hg) and the proportion of controlled hypertension more than doubled from 23% to 51%, suggesting increased and intensified antihypertensive medication.10 The aim of this study is to compare the antihypertensive use in adults (18–79 years) with hypertension in Germany in 1998 (GNHIES98, n = 2,037) and in 2008–2011 (DEGS1, n = 2,635), and to determine the factors associated with antihypertensive use and BP control in 2008–2011. METHODS Study population
Nationwide data on BP among the population in Germany based on standardized measurements is available only from national health examination surveys in 1998 (GNHIES98) 1Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany; 2DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany.
© American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: [email protected]
American Journal of Hypertension 1
Downloaded from http://ajh.oxfordjournals.org/ at Dalhousie University on May 17, 2015
BACKGROUND Hypertension is a major risk factor for morbidity and mortality, therefore its control is of great importance. In this study we compare the use of antihypertensive medication among adults with hypertension in Germany 1998 and 2008–2011 and determine factors associated with use and control.
Sarganas et al.
Measurements and definitions. Three BP measurements were taken in both surveys at the right arm at 3-minute intervals after a non-strenuous part of the examination and an additional 5-minute rest. Participants sat on a heightadjustable chair, back supported, arm lying on a table at heart level, feet on the floor and legs uncrossed. A standard mercury sphygmomanometer (Erkameter 3000; Erka, Bad Tölz, Germany) was used in GNHIES98 and an automated oscillometric device (Datascope Accutorr Plus, Mahwah, NJ) in DEGS1. Three different cuff sizes were used in each study.13 GNHIES98 BP data were calibrated for comparison with DEGS1 data based on a validation study in order to account for cuff and device differences.13 The second and third measurements were averaged. Antihypertensive medication intake was recorded during computer-assisted personal interviews; 7,099 adults have participated in the medication interview from GNHIES98 and 7,091 from DEGS1. Participants were requested to bring all original medication packages they had used in the previous 7 days and all Anatomical Therapeutic Chemical (ATC) codes were documented.14 Hypertension was defined as mean SBP ≥140 mm Hg, or mean DBP ≥90 mm Hg, or the use of antihypertensives (ATC codes: C02 antihypertensives, C03 diuretics, C07 beta-blockers, C08 CCB or C09 ACE inhibitors, and ARB). However, as the indication for taking these drugs may be other than hypertension, antihypertensive medication was only used for defining prevalent and treated hypertension if the participants reported having hypertension. For the analysis of hypertension treatment and control 7 classes of antihypertensives (diuretics, thiazide-diuretics, beta-blockers, CCB, ACE inhibitors, ARB, and antihypertensive) based on detailed ATC codes were examined (Supplementary Data online). Monotherapy was defined as the use of only one antihypertensive agent, and polytherapy (combination therapy) was defined as the use of >1 antihypertensive agent. Single-pill antihypertensive combination users were considered to be receiving polytherapy. If a person used antihypertensive medication containing more than 1 active ingredient the person was counted once within each of the antihypertensive classes. 2 American Journal of Hypertension
In contrast to previous analyses,10 10 participants with imprecise self-reported medication (as compared to those who brought medication packages) were not counted as treated. Therefore, estimates of treatment and control may differ by less than 1% compared to previous reports. Control was defined as: SBP < 140 mm Hg and DBP < 90 mm Hg in treated adults with hypertension. We investigated a range of self-reported participants’ characteristics for associations with antihypertensive use and BP control. Socio-demographic characteristics included age, gender, socioeconomic status based on income, education, and occupation15; municipality size classified into the categories rural (
