Elusive Hypertension Target: Prevent the Preventable

First the good news:

The American Medical Association and the World Health Organization are intensifying efforts to prevent and control hypertension, the number one risk factor for disability and death in the United States and worldwide.

And now the bad:

Only about half of the 78 million Americans with hypertension-a preventable disease-have it under control. In the rest of the world, the number of persons with uncontrolled hypertension reached close to 1 billion in 2008, up from 600 million in 1980.

Scientific statements and guidelines issued in earlier years were designed to provide a sound evidence-based approach to preventing and managing hypertension. However, the prevalence of self-reported hypertension continues to grow-it increased from 25.8% to 28.3% of adults in 2005-2009. By 2030, the prevalence of hypertension is projected to increase an additional 7.2%.

Progress has been made in preventing a preventable disease, but to date it has been minimal. Why?

Several factors come into play:

• Poor adherence to antihypertensive therapy is a major cause of lack of blood pressure control. About 40% of patients with newly diagnosed hypertension discontinue their antihypertensive medications during the first year of treatment. Poor adherence is common at the primary care level.

• Obesity is strongly associated with hypertension, and the current epidemic is expected to worsen. In an ongoing study of hypertension in public school students, hypertension was present in 1.6% of normal-weight youths, 2.6% of overweight youths, and 6.6% of obese youths.

• Along with obesity, older age is one of the strongest risk factors for uncontrolled hypertension. The incidence of resistant hypertension probably will increase as the population continues to get older.

• Diabetes is a common comorbidity. About 8% of the U S population-25.8 million children and adults-have diabetes. As many as 2 of 3 adults with diabetes have high blood pressure.

• The effectiveness of beta-blockers in reducing cardiovascular events has been called into question.

So the associations have very good reason to mount the attack.

The AMA is launching the first phase of its improving health outcomes initiative with a focus on the population of patients who have hypertension and a source of care but whose blood pressure is not at goal. The initial work, conducted in partnership with the Armstrong Institute for Patient Safety and Quality at the Johns Hopkins University, will help physicians, care teams, patients, and communities better understand the reasons for uncontrolled blood pressure and find clinically meaningful solutions.

The WHO’s hypertension effort focuses attention on reducing heart attacks and strokes. Specific objectives include raising awareness of the causes and consequences of high blood pressure, providing information on how to prevent it, and encouraging adults to check their blood pressure and to follow the advice of health care professionals.

Besides embracing these programs, what else can primary care physicians do?

• Encourage patients to become well-informed about hypertension.

• Promote patient-physician decision making.

• Use feedback from patient surveys to personalize care.

• Use a limited annual screening strategy to improve specificity without sacrificing sensitivity compared with routine screening at every visit.

The new initiatives are not going to make a major health problem that has resisted all previous initiatives go away all at once. But they are a welcome step in the right direction.

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