Correspondence
Inadequate Management of Blood Pressure in a Hypertensive Population
N Engl J Med 1999; 340:1593-1595May 20, 1999
- Article
To the Editor:
Berlowitz et al. (Dec. 31 issue)1 reported inadequate control of blood pressure in a selected population of older men followed in outpatient clinics at five hospitals and concluded that physicians must accept some responsibility for the problem. We think that there are some flaws in the choice of the factors that are likely to influence decisions to change therapy and in the way the response to treatment was evaluated. In our experience, the most common reasons for requiring a change in antihypertensive treatment are side effects of the antihypertensive drugs prescribed and inadequate control of blood pressure. Unfortunately, Berlowitz et al. did not include side effects in their analysis, thus limiting the validity of their findings.
With regard to response to treatment, blood pressure was not measured at some of the visits and in 80.5 percent of the visits during which blood pressure was measured, it was measured only once. This limits considerably the reliability of the blood-pressure determinations, since, as indicated by all the internationally accepted guidelines,2-4 such measurements should be repeated at least twice after stable values have been reached. In addition, there is no mention of measurements of blood pressure performed outside the clinician's office. Patients' measuring their blood pressure at home has become a widely accepted method for assessing the response to antihypertensive medications and has the additional advantage of improving patients' adherence to treatment.5
There is no doubt that physicians share some responsibility for the poor control of hypertension when they do not measure blood pressure during all the visits, when they measure it only once at most visits, and when they do not use patients' own measurements of blood pressure to assess the response to antihypertensive medications.
5 ReferencesLeonardo A. Sechi, M.D.
Laura Zingaro, M.D.
Ettore Bartoli, M.D.
University of Udine, 33100 Udine, Italy1
Berlowitz DR ,Ash AS ,Hickey EC , et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998;339:1957-1963
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The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
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Petrie JC ,O'Brien ET ,Littler WA ,de Swiet M . Recommendations on blood pressure measurement. BMJ 1986;293:611-615
CrossRef | Web of Science | Medline4
The Guidelines Subcommittee of the WHO/ISH Mild Hypertension Liaison Committee
Web of Science | Medline5
Pickering T . Recommendations for the use of home (self) and ambulatory blood pressure monitoring. Am J Hypertens 1996;9:1-11
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To the Editor:
In their article on the inadequate management of hypertension, Berlowitz and colleagues attribute a substantial portion of the explanation for the poor control of blood pressure to a lack of aggressiveness on the part of physicians. Since the mean age of the subjects was about 65 years, a considerable number of men displayed isolated systolic hypertension during the early 1990s. The subjects with systolic blood pressure greater than 155 mm Hg had their medication increased only 25 percent of the time, which may indicate that many physicians were not yet aware of the results of the Systolic Hypertension in the Elderly Program (SHEP) study, published in 1991.1 Furthermore, before the publication of the guidelines of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure in 1993, systolic blood pressure under 160 mm Hg was still considered borderline.2 I would contend that a new analysis, after SHEP and after the promulgation of the Joint National Committee guidelines, might indicate more serious attitudes toward aggressively lowering blood pressure, especially in patients with diabetes and other high-risk populations.
2 ReferencesHarry J. Ward, M.D.
King–Drew Medical Center, Los Angeles, CA 900591
SHEP Cooperative Research Group
CrossRef | Web of Science2
National High Blood Pressure Education Program. The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, Md.: National Institutes of Health, 1993. (NIH publication no. 93-1088.)
To the Editor:
Berlowitz et al. report that about 40 percent of their male patients with hypertension have poorly controlled blood pressure of ≥160/90 mm Hg, whereas only 25 percent have well-controlled blood pressure of <140/90 mm Hg. They conclude that physicians are not aggressive enough in their approach to hypertension and suggest that their data are probably generalizable. However, we question whether their data can be generalized to all age groups and both sexes.
We analyzed the data of a recently conducted population-based study of the prevalence of microalbuminuria in the general population of the city of Groningen, the Netherlands. We analyzed consecutive data from 8268 subjects in whom we measured blood pressure with an automatic device (Dinamap). Blood pressure was measured while the subjects were in a supine position, after five minutes of rest, on two separate days. We found that only 24 percent had poorly controlled hypertension of ≥160/90 mm Hg and that 46 percent had well-controlled blood pressure of <140/90 mm Hg (Table 1Table 1
Blood-Pressure Control According to Sex and Age.). Furthermore, age and sex were associated with blood-pressure control. The blood pressure of women was better controlled than that of men (P=0.02), and the blood pressure of younger persons was better controlled than that of older persons (P<0.01). When we selected a population similar to that described by Berlowitz et al. (i.e., men with a mean age of 65 years), we still found better blood-pressure control (P=0.03). Therefore, we think that the data by Berlowitz et al. are not generalizable.Sara-Joan Pinto-Sietsma, M.D.
Hans L. Hillege, M.D.
Wilbert M.T. Janssen, M.D., Ph.D.
University Hospital Groningen, 9713 GZ Groningen, the NetherlandsAuthor/Editor Response
The authors reply:
To the Editor: We appreciate the interest in our recent article on managing hypertension. We share Dr. Ward's concern that the 1991 publication of the SHEP results may have changed the way physicians managed hypertension. However, blood-pressure control among the patients in our sample treated from 1993 to 1995 was no different than that among the patients treated earlier. We agree with Dr. Ward about the need to repeat our study with more recent data but also would not be surprised to find that a lack of aggressiveness on the part of physicians persists despite dissemination of the latest practice recommendations.
Pinto-Sietsma et al. raise questions regarding the generalizability of our study. Although the level of blood-pressure control in our sample was similar to that found in other American studies, our study was not intended to be a population-based examination of blood-pressure control, such as the National Health and Nutrition Examination Survey III1 or the study mentioned by Pinto-Sietsma et al. Rather, we examined how physicians' everyday decisions regarding the management of antihypertensive medications are associated with blood-pressure control. We emphasized this association in discussing generalizability. By understanding how physicians manage medications, we hope to improve both the process and the outcome of care of patients with hypertension. Despite the impressive level of blood-pressure control achieved in Groningen, considerable room for improvement remains.
Sechi et al. raise several additional issues of concern. We found that the side effects of medication were rarely mentioned in the medical records used for our study. We agree that the occurrence of side effects is likely to be an important predictor of changes in therapy. However, among visits with an “increase” in medication, as used in our model, the discontinuation of one medication at the same time another medication was started was infrequent. The association between the intensity of therapy and blood-pressure control would probably be even stronger if we considered only the increases that were in response to elevated blood pressure and not side effects. This would only strengthen our message with respect to the need for more aggressive treatment of hypertension. We also agree that many processes of hypertension care, such as the frequency of measuring blood pressure, could be improved. Past studies have evaluated such processes and have found no link to patients' outcomes.2 We believe, though, that in understanding poor blood-pressure control and improving outcomes among patients with hypertension, the greatest benefit will result from evaluating the critical process of how physicians decide to modify medication and not other processes of care.
2 ReferencesDan R. Berlowitz, M.D.
Bedford Veterans Affairs Hospital, Bedford, MA 01730Arlene S. Ash, Ph.D.
Mark A. Moskowitz, M.D.
Boston University School of Medicine, Boston, MA 021181
Burt VL ,Whelton P ,Roccella EJ , et al. Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension 1995;25:305-313
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Nobrega FT ,Morrow GW Jr ,Smoldt RK ,Offord KP . Quality assessment in hypertension: analysis of process and outcome methods. N Engl J Med 1977;296:145-148
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