Lawrence J. Fine|Jeffrey A. Cutler
Hypertension and the Treating Physician
National Heart Lung and Blood Institute|National Institutes of Health|National Heart Lung and Blood Institute|National Institutes of Health
homehypertensionvol 47 3hypertension treating physician free accesseditorialpdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accesseditorialpdfepubhypertension treating physicianunderstanding reducing therapeutic inertia lawrence j fine jeffrey cutler lawrence j finelawrence j fine division epidemiology clinical applications national heart lung blood institute national institutes health bethesda md jeffrey cutlerjeffrey cutler division epidemiology clinical applications national heart lung blood institute national institutes health bethesda md originally published23 jan 2006httpsdoiorg10116101hyp000020069223410c9hypertension 200647319320other versions articleyou viewing recent version article previous versions january 23 2006 previous version 1 tide hypertension rising across globe including united states1 among 65 million americans hypertension inadequately treated patients contribute substantially overall magnitude problem based data national health nutrition examination survey 68 total remains therapeutic guideline blood pressure bp goals goal divide 3 groups unaware high bp 31 aware treated 11 treated remain goal 14090 mm hg 27 hypertensive persons 47 treated medication2in innovative article using data diverse set medical practices southeastern part united states dr okonofua colleagues provide insights latter groups inadequate treatment focus research therapeutic inertia ti defined providers failure increase therapy treatment goals unmet3 although sample based regional national probability sample findings southeast may wide applicability given level bp control study 45 end 2003 study period different national rate control 53 among persons treated hypertension reported 1999 2000 principal manifestation ti clinical inertia common term documented study failure increase dose antihypertensive medications add additional medication clinical encounters bp goal level patients whose providers showed high level ti number medications actually declined 1year study period average 16 14 whose providers showed lowest level ti medications increased 14 18 whereas rate bp control declined patients providers highest level ti control improved substantially patients providers lowest level ti illustrating importance changes medication dose number control hypertensionanother important observation study lack appropriate action frequent highrisk patients defined presence diabetes heart failure manifestations cardiovascular disease absolute benefit adequate treatment would greatest results emphasize need increase willingness clinicians add additional medication antihypertensive regimen 1 2 drugs provide inadequate control despite scientific limitations current study use nonstandardized single bp measurements definition ti consider degree elevation bp therapeutic goal lack use statistical approach define whether true bp goal little doubt overall conclusion study truethat ti explains large part failure adequately control pressure medical practicethe article okonofua et al provides little information reasons ti phillips proposed 3 primary reasons clinicians fail intensify treatment chronic conditions hypertension 1 overestimating many patients therapeutic goal 2 use soft reasoning avoid intensification therapy physician perception without patient input patient accept medications 3 lack education training organizational practices aimed achieving therapeutic goals4 addition suggest consistent phillips third explanation ti beliefs physicians regarding low risk adverse cardiovascular outcomes associated modest elevation systolic blood pressure sbp may shape behavior without effective education may fully appreciate magnitude increased risk seemingly modest sbp elevations 5 10 mm 140 mm hg evidence supports hypothesis comes 1996 1997 national survey primary care physicians 76 said would initiate drug therapy patients age 70 older sbp 140 159 mm hg 33 said would intensify treatment patient sbp 158 mm hg5 reluctance intensify treatment actually consistent lack strongly conclusive evidence randomized trials hypertensive patients treating sbp levels 140 mm hg would beneficial particularly older patients recent review concluded treatment systolic hypertension older patients sbp least 160 mm hg supported strong evidence based especially two large randomized treatment trials isolated systolic hypertension older patients evidence available support treatment patients level 140 mm hg baseline sbp 140 159 mm hg less strong6 behavior clinicians study may reflect conclusion baseline risk factor associated less ti stage 2 hypertension defined part sbp 160 mm hg higherthis lack appreciation true risk may illustrate anew long takes scientific knowledge diffuse clinical practice current focus systolic hypertension range 140 159 mm hg arose clinical trials 1980s early 1990s78 1993 fifth report joint national committee prevention detection evaluation treatment high blood pressure lowered criterion systolic hypertension 140 mm hg 160 mm hg situation regarding control range better united states many countries improving men among treated men united states bp control improved 45 60 19881991 19992000 stayed among women 482the need reduce ti clear dr okonofua colleagues estimate 50 reduction ti would reduce average sbp 5 mm hg lead attaining control rates similar seen many clinical trials 65 709 5 mm reduction sbp maintained several years reduces risk major cardiovascular events ie stroke coronary artery disease heart failure cardiovascular death approximately 15 20910several approaches studied eliminate clinical inertia treatment hypertension conditions include feedback physicians patients progress toward therapeutic goals decision support intensification treatment continuing training academic detailing organizational changes11 body evidence incomplete positive impact interventions modest variable studies often involve simultaneous use one intervention12 result need develop powerful practical interventions reduce clinical inertia learn better adapt effective interventions different practice settings future research use stronger research designs feasible describe fully characteristics interventions organizational settings12 scientific practical challenges also remain definition clinical inertia develop refinements definition inertia incorporate cause lack change therapy reflect magnitude risk patient effectively separate true deviation goal deviation caused random variation11as great problem ti today management hypertension may get worse increasing scientific evidence sbp goal lower 140 mm hg higher risk patients13 additional highquality clinical trials confirm strong epidemiological evidence limited clinical trial data therapeutic goal 120 mm hg rather current consensus goal 130 mm hg patients renal disease diabetes 140 mm hg goal patients effective strategies reduce ti become even important strategies important hypertension could applied common risk factors diseases ldl cholesterol levels hemoglobin a1c levels patients diabetes chronic diseases depression addition bp lowering must continue use current knowledge effective lifestyle strategies population clinical levels millimeter reduction sbp reduces cardiovascular riskthe opinions expressed editorial necessarily editors american heart associationthe views authors necessarily represent positions us department health human servicesfootnotescorrespondence lawrence j fine 6701 rockledge dr rm 8138 msc7936 bethesda md 20892 email email protected references 1 fields le burt vl cutler ja hughes j roccella ej sorlie p burden adult hypertension united states 19992000 tide rising hypertension 2004 44 398404linkgoogle scholar2 hajjar kotchen ta trends prevalence awareness treatment control hypertension united states 19882000 jama 2003 290 199206crossrefmedlinegoogle scholar3 okonofua ec simpson kn jesri rehman su 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