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Evaluation
of Patients with Hypertension in the light of the JNC
7 Report: Use of Combination and Individualized Therapy
is Unsatisfactory
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Authors:
Selcuk Mistik, M.D.
Assistant Professor, Erciyes University
Medical Faculty, Department of Family Medicine
Ramazan Topsakal, M.D.
Assistant Professor, Erciyes University Medical Faculty, Department
of Cardiology
Zekeriya Akturk, M.D.
Assistant Professor, Trakya University Medical Faculty, Department
of Family Medicine
Gursel Ates, M.D.
Assistant Professor, Maltepe University Medical Faculty, Department
of Cardiology
Cahit Ozer, M.D.
Lecturer, Trakya University Medical Faculty, Department of
Family Medicine
Correspondence:
Selcuk Mistik
Erciyes University Medical Faculty
Department of Family Medicine
38039 Kayseri
TURKEY
Hypertension is a disease
that affects a wide range of the population. The control rate
was <50% even among those patients known to have hypertension
and are considered to be receiving active treatment. The aim
of this study was to evaluate the patients with hypertension
according to the JNC 7 Report, and to assess their use of
combination therapy and the adherence to individualized therapy.
Patients were recruited from three different centers of Turkey.
A questionnaire that comprise 30 questions was administered
to each patient. A total of 153 patients (51 men, 102 women)
of hypertension were included in the study, 88 (57.5%) of
which were under the treatment of combined drug therapy. The
blood pressure control rate of the study group was 58.2% according
to blood pressure < 140/90. There was no difference in
the control rates among the patients using single-drug and
combined drug therapy (p>0.05). The patients who had regular
BP measurements had better control rate (p<0.05). The results
of this study showed that there are still measures to be taken
for achieving better individualized therapy, and physicians'
judgement on the patients' therapy should be made considering
the patient-centered care to achieve better results with individualized
therapy.
Keywords: hypertension; combined drug
therapy; individualized therapy
Introduction
Hypertension is a disease that affects a wide range of
the population, especially the elderly after the age of 55.
Individuals who are normotensive at 55 years of age have a
90% lifetime risk of developing hypertension. It affects approximately
a billion individuals worldwide (1). Although there are many
drugs of choice for the treatment of hypertension, the control
rate is <50% even among those patients known to have hypertension
and are considered to be receiving active treatment (2).
'The Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure' (JNC 7 Report) provides a new guideline for
hypertension prevention and management. There are seven key
messages in this report:
| 1. |
In persons older than 50 years,
systolic BP of more than 140 mm Hg is a much more cardiovascular
disease(CVD) risk factor than diastolic BP |
| 2. |
The risk of CVD begins at 115/75
mm Hg, doubles with each increment of 20/10 mm Hg |
| 3. |
Individuals with a systolic
BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm
Hg should be considered as pre-hypertensive and require
health promoting lifestyle modifications to prevent CVD
|
| 4. |
Thiazide-type diuretics should
be used in drug treatment for most patients with uncomplicated
hypertension, either alone or combined with drugs from
other classes |
| 5. |
Most patients
with hypertension will require 2 or more anti-hypertensive
medications to achieve goal BP, if BP is more than 20/10
mm Hg above goal BP |
| 6. |
Consideration should be given
initiating therapy with 2 agents, 1 of which usually should
be a thiazide-type diuretic |
| 7. |
The most effective
therapy prescribed by the most careful clinician will
control hypertension only if patients are motivated (1).
There are still obstacles in keeping the BP at the demanded
levels. Physicians should pay more attention to the individualized
therapy. |
This study aims to evaluate the patients with
hypertension according to the JNC 7 Report, and to assess
their use of combination therapy and the adherence to individualized
therapy.
Materials and Methods
Study population
This research was carried out in May - June 2003 in three
different centers of Turkey with different socio-economic
and cultural status. The research group was chosen from the
patients of hypertension who have been admitted to the three
centers during these two months. The inclusion criteria was
the presence of hypertension.
Questionnaire
A questionnaire comprising of 30 questions was administered
to all of the patients. The questionnaire was performed by
a face-to-face interview. The first five questions were about
the demographic data of the patients. The remaining questions
were regarding the diagnosis, and the evaluation at the time
of the diagnosis, adherence to diet and the prescribed drug
therapy, the duration of control by the physician, the change
in the firstly prescribed drugs, the measures taken when the
blood pressure (BP) is high, the use of combination therapy,
and the existence of comorbid diseases.
Statistical analysis
Statistical analysis was performed by using SPSS statistical
package (Version 11.0, SPSS Inc., Chicago, IL, USA) for Windows.
Chi-square tests were used to determine the differences between
the groups. The level of statistical significance was set
at p < 0.05.
Results
A total of 153 patients of hypertension were included in the
study. There were 51 men (33.3%) and 102 women (66.6%) with
a mean age of 57.2 ± 11.9 (range, 25-88). BP control
was better when age was <55 (Table 1).
| Table
1 BP Control According to Gender, Age, and Education |
| |
n
|
BP>140/90
|
x/2
|
(p-value)
|
| |
|
Number
|
%
|
|
|
Total
|
153
|
64
|
41.8
|
|
|
Gender
|
|
|
|
|
|
Male
|
51
|
21
|
41.1
|
|
|
Female
|
102
|
43
|
42.1
|
0.01
|
>0.05
|
Age
|
|
|
|
|
|
<55
|
71
|
23
|
32.3
|
|
|
³55
|
82
|
42
|
51.2
|
4.78
|
<0.05
|
Education
|
|
|
|
|
|
Primary school and less
|
87
|
42
|
48.2
|
|
|
High school and lycee
|
33
|
11
|
33.3
|
|
|
| University |
33
|
11
|
33.3
|
3.44
|
<0.05
|
|
The most common educational status was primary
school graduates (34.2%), followed by graduates of University
(%21.5). The mean BP measurements at the time of the diagnosis
were 5. Laboratory examinations were performed for 94 (62.7%)
patients after diagnosis. Eighty-six (56.2%) patients stated
that they could get enough information about the treatment
of the disease. Sixty-seven (44.4%) patients were on diets
after diagnosis. The mean of the duration of the diets was
36.5 ± 91.8 months. One hundred and nineteen (77.7%)
patients were currently on diets.
One hundred and forty-six (95.4%) patients were
regularly taking their drugs. One hundred and fifteen (75.1%)
patients were having regular BP measurements. There was a
statistically significant difference in the BP control among
the patients having regular and irregular BP measurements,
where the patients having regular BP measurements had better
control (p<0.05) (Table 2). The frequency of blood pressure
measurements was once in 9.0 ± 24.7 days. The mean
and SD of the Body Mass Index (BMI) was 30.2 ± 5.4.
| Table
2 BP Control According to Enough Knowledge, Diet,
Regular Intake of Drugs, Regular Measurement of
BP, Visiting Doctor when BP is High, and Body
Mass Index (BMI). |
| |
BP>140/90 |
x/2
|
(p-value)
|
| |
Number
|
%
|
|
|
Enough knowledge
|
|
|
|
|
Yes
|
36 |
41.8 |
|
|
No
|
21 |
62.4 |
1.36 |
>0.05 |
On diet
|
|
|
|
|
Yes
|
46 |
38.6 |
|
|
No
|
12 |
35.2 |
0.02 |
>0.05 |
Drug use
|
|
|
|
|
Regular
|
60 |
41.0 |
|
|
Irregular
|
1 |
14.3 |
1.04 |
>0.05 |
BP
measurement
|
|
|
|
|
Regular
|
39 |
34.0 |
|
|
Irregular
|
23 |
60.5 |
7.33 |
<0.05 |
Doctor visit
|
|
|
|
|
Yes
|
7 |
26.0 |
|
|
No
|
52 |
41.3 |
1.61 |
>0.05 |
BMI
|
|
|
|
|
Normal
|
13 |
50.0 |
|
|
| Overweight and
Obese |
47 |
37.1 |
1.03 |
>0.05 |
|
The mean duration of doctor visits was once
in 5.24±5.19 months. The percentage of patients with
systolic BP over than 140/90 mm Hg was 41.8. There were 24
(15.6%) patients visiting their doctors when their BPs were
high, 30 (19.6%) taking one more of their antihypertensive
drug, 54 (35.2%) eating garlic, and 65 (42.4%) eating lemon.
There were 76 (49.6%) patients still using the
initial drugs. The patients who have changed using their initial
drugs have used them for 30.6 ± 31.5 months. The main
reason for changing the drug was the insufficiency of maintaining
the desired control level (45.6%). There were 88 (57.5%) patients
using combined drug therapy, and 32 (20.9%) patients have
started using combination therapy at diagnosis. The most commonly
used combination was angiotensin converting enzyme (ACE) inhibitors
and diuretics, with 38 (24.8%) patients. There was no difference
between the BP controls of the patients using monotherapy
or combination therapy (Table 3).
| Table
3 Drug Groups and BP Control |
| |
BP>140/90 |
x/2 |
(p-value) |
| |
Number |
% |
|
|
| Monotherapy* |
23 |
35.3 |
|
|
| Combination therapy
|
35 |
39.7 |
0.15 |
>0.05 |
| *Monotherapy drugs: ACE
inhibitors, ARBs, BBs, CCBs, Diuretics, and a-1
Blockers |
|
There were 63 (41.1%) patients who had stage
2 hypertension at diagnosis, and 29 (46%) of these were started
on combination anti-hypertensive therapy. Of the 42 patients
using single-drug therapy and with initial diagnosis of stage
2 hypertension, 26 (61.9%) had BPs at goal. The mean duration
before starting the second drug was 22.9 ± 33.1 months.
The BP control rate of the study group according to <140/90
was 58.2%.
The most common comorbid disease was angina
pectoris, and the use of drugs was generally compliant with
the recommended drugs for compelling conditions. Of the 21
diabetes mellitus patients, 12 (57.1%) were using ACE inhibitors,
9 (42.8%) were using calcium channel blockers (CCBs), 4 (19%)
were using angiotensin receptor blockers (ARBs), and 1 (4.7%)
was using b-blockers (BBs). There were 11 (39.2%) patients
using BBs, and 11 (39.2%) patients using long-acting CCBs
among the patients who had angina pectoris. Of the 7 patients
who had myocardial infarction, 5 (71.4%) were using BBs, and
5 (71.4%) were using ACE inhibitors.
Discussion
The results of this study that the BP control rate of 58.2%
shows us the necessity of taking measures for increasing this
rate.
The present study has some limitations; we have not questioned
the exercise conditions of the patients, and the dietary intake
of salt and saturated fats. Alcohol consumption is not questioned
as well. However, the data obtained from the percentage of
high body mass index (BMI) strongly suggests that there are
yet a lot measures to take in order to achieve optimal lifestyles,
though the patients think that they are on diet. The small
number of patients in disease subgroups was another limitation.
It has been stated in some studies that BP control
can be achieved in most patients with hypertension, but the
majority will require 2 or more anti-hypertensive drugs (3,4).
The presence of the use of combined drug treatment by 88 of
the patients in this study shows that this is true for our
patients as well. However, the low percentage of BP control
in this group (60.2%) tells us that they still need either
an increase of dosage or addition of another drug in the treatment
regimen.
The reasons for inadequate BP control are stated
as failure of prescribing lifestyle modifications, adequate
anti-hypertensive drug doses, or appropriate drug combinations
(1). In this study, 79.2% of the patients stated that they
were still on diet, 50.4% of the patients changed the initial
anti-hypertensive drugs, 20.9% of the patients started the
treatment as combination treatment, reaching 57.5%. In spite
of these, there was still lack of achievement of desired BP
control levels in more than half of the patients. This may
indicate that it is still necessary to evaluate the use of
appropriate drug or drug combinations. Although the patients
stated that they were on diet, the calorie intakes should
be calculated to figure out whether they were performing a
sufficient diet or not.
Treating systolic BP and diastolic BP to targets
that are less than 140/90 mm Hg is associated with a decrease
in CVD complications (1). In patients with hypertension with
diabetes and renal disease, the target BP is less than 130/80
mm Hg (5,6). The control rate of 58.2% in this study was low
and the control rate was even lower (19%) for the patients
with diabetes mellitus.
Major lifestyle modifications with BP lowering
effects cause weight reduction in those individuals who are
overweight or obese (7,8). There were 127 patients with overweight
or obese status in the study group, indicating the necessity
of dealing with this inconvenient condition individually for
each patient. Patients must be motivated to loose weight and
to perform exercise regularly. Physicians must be able to
motivate patients for achieving lifestyle modifications. It
is a high possibility to start drugs to the patients without
giving any chance for lifestyle modifications.
Excellent clinical trial outcome data prove
that lowering of BP with several classes of drugs such as
angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor
blockers (ARBs), calcium channel blockers (CCBs), and thiazide-type
diuretics will all reduce the complications of hypertension
(9-11). Thiazide type-diuretics have been the basis of antihypertensive
therapy in most outcome trials (11). When BP is more than
20/10 mm Hg above the target, consideration should be given
to initiating therapy with 2 drugs, either as separate prescriptions
or fixed-dose combinations (1). The use of antihypertensive
drugs in our study is suitable for both patients with and
without compelling indications. The lack of a higher control
rate has a wide range of possible reasons, which cannot be
attributed only to the use of appropriate or inappropriate
use of both monotherapy and combination therapy.
Once antihypertensive drug therapy is initiated,
most patients will return for follow-up and adjustment of
medications at approximately monthly intervals until the BP
target is reached. After BP is at a target and stable, follow-up
visits can usually be at 3 to 6 month intervals (1). The patients
in the study group visited their doctors in intervals less
than 6 months, but the effectiveness of these doctor visits
were questionable considering the high rate of uncontrolled
patients. Only 24 (15.6%) patients declared that they visited
their doctors when their BPs were high. Most of the patients
with chronic diseases probably visited doctors for prescription
of drugs without being evaluated for the current control status
of the disease, which must be differentiated from the visits
made with the demand of disease evaluation.
In patients with hypertension and stable angina
pectoris, the first drug of choice is usually a b-blocker.
Alternatively, long acting CCBs can be used (1). The use of
these drugs was 39.2% in the study group, which could be increased.
In patients with acute coronary syndromes (unstable angina
or myocardial infarction), hypertension should be treated
initially with b-blockers and ACE inhibitors, with addition
of other drugs as indicated for the control of BP (12). In
patients with postmyocardial infarction, ACE inhibitors, b-blockers,
and aldosterone antagonists have proven to be most beneficial
(13-16). The use of ACE inhibitors and b-blockers in patients
who had myocardial infarction in the study group was 71.4%,
which could be evaluated as a satisfactory use of the recommended
drugs.
Thiazide diuretics, b-blockers, ACE inhibitors,
ARBs, and CCBs are beneficial in reducing CVD and stroke incidence
in patients with diabetes (17-19). The ACE inhibitors and
ARBs have demonstrated favourable effects on the progression
of diabetic and nondiabetic renal disease (20-25). The diabetes
mellitus patients in the study group were using drug groups,
which are recommended in the JNC 7 Report. The low control
rates of BP for the patients with diabetes mellitus suggests
that this is independent of the type of the used drug or combination
therapy, and is likely due to the lack of increasing the dosage
of the drug or drugs, or addition of another drug to either
monotherapy or combination therapy.
Conclusion
In conclusion, the control rate is
at desired level when Healthy People 2010 goal of 50% control
is considered, but the control rates for the compelling condition
diabetes mellitus is still far from the target level (1).
The aim of controlling the hypertension of 50% of the patients
is not satisfactory when the patients are considered individually,
because the remaining 50% will still be susceptible to all
of the complications of the disease. There are still many
measures to take from the point of individualized therapy
The physicians' judgement on the patients' therapy should
be made considering the patient-centered care in order to
achieve better results with individualized therapy. In addition,
more attention should be paid on the patients by spending
appropriate time to eliminate the barrier factors in achieving
the goal BP.
ACKNOWLEDGEMENTS
The authors would like to thank Professor Fevziye
Cetinkaya from Public Health Department of Erciyes University
Medical Faculty for her comments on the manuscript, and Mr.
Ahmet Ozturk from Kayseri Health Training Institute for his
assistance in statistical analyses.
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