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Is Treatment for Hypertension Aggressive Enough?

Am Fam Physician. 2004 Jul 15;70(2):387.

Hypertension is one of the most common diseases in the United States, accounting for a significant number of outpatient physician visits. Although hypertension usually is asymptomatic, it may be associated with serious adverse outcomes. Blood pressure control has been shown to reduce the risk for adverse outcomes. Recommendations for blood pressure control set a goal of less than 140/90 mm Hg in most patients. Recent studies have shown that even lower goals should be established for patients with diabetes or renal disease. Despite these recommended goals, most studies have shown that patients have not achieved adequate blood pressure control. In one study, results showed that poor blood pressure control was related to health care professionals failing to be aggressive with antihypertensive medications. These published studies improved awareness of this problem in the general public and medical profession. Borzecki and colleagues evaluated blood pressure control in hypertensive patients, determined the level of blood pressure control in subgroups with diabetes and renal disease, compared these results to prior studies, and determined if treatment practices have changed from previous studies.

The sample population included patients who received regular medical care at 10 Veterans Affairs (VA) outpatient clinics in 1999. The clinics selected had to be using the computerized patient record system and computerized physicians’ notes. Inclusion criteria were patients who were identified as hypertensive according to International Classification of Diseases, 9th ed., codes and were regular users of the VA health care system. Information abstracted from the records included medical visit types and dates, blood pressure measurements, diagnoses, and medications. In addition, medication records were abstracted from local pharmacy records. Up to four blood pressure measurements were retrieved from each clinic visit. Data from earlier medical records of a 1990 to 1995 study also were recorded.

There were 981 randomly selected veterans with hypertension in the 1999 sample and 800 in the 1990 to 1995 study. The mean systolic blood pressure was 3.1 mm Hg lower in the 1999 study compared with the earlier study. This was particularly evident in the diabetes and renal disease subgroups, where the mean systolic blood pressure was 13.7 mm Hg lower in the 1999 group than the earlier study group. Larger decreases were noted in mean diastolic blood pressures in the 1999 group. There were significantly fewer patients with blood pressures of 140/90 mm Hg or greater in the 1999 group compared with the earlier study group, but 57 percent still had not reached their blood pressure goal. Patients with diabetes and renal disease had significantly better blood pressure control in 1999 than in the earlier group. In addition, more antihypertensive medications were prescribed during office visits in 1999 than in the earlier group.

The authors conclude that blood pressure control was better in this study but still exceeded recommended levels in most patients. They also note that in patients with diabetes and renal disease, blood pressure control was improved but still not in agreement with current recommendations for tighter control. The authors comment that there is room for improvement in adherence to hypertension guidelines.

Borzecki AM, et al. Hypertension control. How well are we doing? Arch Intern Med. December 2003;163:2705–11.


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