Abstract
We sought to investigate the psychosocial characteristics of patients with uncontrolled hypertension and examine factors that influence blood pressure (BP) control. A total of 1011 patients with uncontrolled hypertension were enrolled in 13 tertiary hospitals. Uncontrolled hypertension was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg despite on antihypertensive therapy. Socio‐demographics, anthropometrics, behavioral risk factors, medication pattern, adherence, and measures of health‐related quality of life (HRQoL; EuroQol 5D visual analog scale [EQ‐5D VAS]) were assessed at baseline and during follow‐up visits (3 and 6 months). Patients were divided into 2 groups based on BP control status at 6 months (controlled group [n = 532] vs uncontrolled group [n = 367]). There were no differences in clinical characteristics except the proportion of smokers and baseline BP between patients with controlled BP and uncontrolled BP. At 6 months, the adherence of antihypertensive medication did not differ between the groups but the proportion of combination therapy with ≥3 antihypertensives was significantly higher in patients with uncontrolled BP. EQ‐5D VAS at follow‐up was significantly lower in patients with uncontrolled BP despite similar baseline values. Multivariate logistic regression analysis revealed that EQ‐5D VAS at follow‐up significantly correlated with BP control. Patients with worse HRQoL had higher Charlson Comorbidity Index and higher proportion of taking ≥3 antihypertensives, but medication adherence was similar to those with better HRQoL. These findings suggest that along with pharmacologic intervention of hypertension, management of comorbid conditions or psychological support might be helpful for optimizing BP control in patients with uncontrolled hypertension.
Keywords: adherence, blood pressure, health‐related quality of life, hypertension
1. INTRODUCTION
Hypertension, a highly prevalent chronic disease, is a major risk factor of cardiovascular and cerebrovascular diseases. 1 The incidences of cardiovascular diseases and all‐cause death increase with elevation of blood pressure (BP), and antihypertensive therapy does reduce clinical events. Despite advances in antihypertensive drug therapy, BP control continues to be a challenge. 2 As clinical benefit of hypertension treatment only when the BP falls sufficiently below target levels, it is important to pay close attention to hypertension control rate. The worldwide prevalence of hypertension in adults is around 30%, and the rate of awareness and treatment is 60%‐80% and 50%‐70%, respectively. In addition, uncontrolled hypertension persists despite medical treatment in almost 50% of patients. 3 , 4 Even under the previous guidelines, only half of patients classified as having hypertension had their BP controlled. However, as a result of strict target BP levels proposed by 2017 American College of Cardiology/American Heart Association guidelines, 5 the rate of uncontrolled hypertension will inevitably rise. Causes for uncontrolled hypertension include therapeutic inertia on the part of the attending physician and suboptimal medication adherence, but various other factors are also at play such as education, marriage status, health insurance, and income level. 6
Health‐related quality of life (HRQoL) is a multi‐dimensional concept encompassing a patient's physical, mental, emotional, and social functioning. 7 HRQoL has been studied for its relationship with a variety of chronic diseases and was shown to be an important predictor of mortality. 8 HRQoL of patients with hypertension is lower than that of normotensive patients, and the measure of HRQoL is an independent predictor of new‐onset hypertension. 9 , 10 In addition, HRQoL is lower in hypertensive patients with comorbidities than those with hypertension alone, and the number of comorbidities is independent of HRQOL. 11 , 12 Poor quality of life can adversely affect the level of adherence to antihypertensive medication. 13 However, the impact of HRQoL on hypertension treatment and BP control has not yet been fully explored. With an increasingly aged population, the prevalence of accompanying comorbidities is rising in hypertensive patients. In this regard, HRQoL can be used as an important measure of health status and the effectiveness of therapy. 14 It is necessary, therefore, to establish epidemiological data of uncontrolled hypertension and to investigate the relationship between BP control and HRQoL.
2. METHODS
2.1. Study design and participants
This study was a multi‐center, non‐interventional, prospective study with medical chart review and patient survey in patients with uncontrolled hypertension who were receiving medical treatment. A total of 1011 patients who met inclusion criteria were enrolled in 13 tertiary hospitals in the Republic of Korea from February 2014 to June 2016. Patients at least 20 years old with uncontrolled hypertension who were on antihypertensive medication at baseline were considered for inclusion. Uncontrolled hypertension was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg. Office BP was obtained from 2 measurements taken 5 minutes apart after sitting for 5 minutes. Pregnant women and those deemed unfit to participate in the study by investigators were excluded. Written informed consent was collected from all enrolled patients. Two follow‐up (FU) visits were performed once at 3 months (FU1) and at 6 months (FU2) from baseline visit (Figure 1). To accommodate each patient's schedule, patients were given a ±4 week visit window. The study protocol was approved by the Institutional Review Boards of participating centers.
FIGURE 1.
An outline of the study
2.2. Medication information
The variables from chart review consist of clinical characteristics, that is, anthropometric data, BP, comorbidity, and treatment pattern. Details of antihypertensive medication were also collected (eg, drug class and number of drugs). Treatment patterns were described as 4 categories: mono, single‐pill combination (SPC), free combination (FC), and ≥3 antihypertensive combination. Mono was defined as a single‐pill antihypertensive drug. SPC was defined as a single pill of two agents, at least one of which was an antihypertensive. SPC was thus divided into two categories: one with two antihypertensives (Anti HTN + Anti HTN), and one with an antihypertensive and non‐antihypertensive (anti‐HTN + non‐anti‐HTN). FC was defined as two separate pills of different agents. ≥3 antihypertensive medications were defined as at least 3 antihypertensive agents taken as either a single‐pill or multiple pill formulation.
2.3. Patient questionnaire on adherence and health‐related quality of life
Morisky Medication Adherence Scale (MMAS)‐4 was used to measure the adherence to antihypertensive medications at follow‐up visits. MMAS‐4 consists of four “yes” or “no” questions. 15 Each “yes” response counts as 1 point.
HRQoL was evaluated with the EQ‐5D‐3L which was developed by the EuroQol Group to assess self‐rated health status. 16 The EQ‐5D‐3L comprises of the following five dimensions measured in three levels of difficulty (no problem, some problems, and extreme problems): mobility, self‐care, usual activities, pain/discomfort, and anxiety/depression. It includes a visual analog scale (VAS) asking respondents to mark today's health status on a 0‐100 scale. A higher scale corresponds to higher HRQoL. 17
The surveys differed in the number of times they were conducted: MMAS‐4 at FU1 and FU2 as opposed to EQ‐5D‐3L at baseline, FU1, and FU2.
2.4. Statistical analysis
Patients were divided into 2 groups (uncontrolled and controlled) according to the BP control status at 6 months. Mean values and standard deviation (SD) were used for continuous variables, whereas percentage was used to describe categorical variables. Student's t test was used to compare means, and chi‐square test (χ 2) was used to compare proportions between groups. Logistic regression analysis was performed to identify relationship between hypertension control and HRQoL as measured on EQ‐5D VAS. Adjusted odds ratios (OR) and their 95% confidence intervals were presented. In addition, patients were divided into 2 groups according to HRQoL (≥mean EQ‐5D vas score and <mean EQ‐5D vas score) at 6 months to compare the patients' characteristics, pharmacologic treatment pattern, and medication adherence. Binary verification test was used for all verification statistics, and a P value of <.05 was regarded statistically significant.
3. RESULTS
Of the total 1011 patients who met inclusion criteria and enrolled at baseline, 899 were fully followed up on the basis of available BP data at 6 months. The mean age of enrolled patients was 64.6 ± 12.5 years, and 56.9% of patients were over 65 years. Based on body mass index (BMI), over half of the patients (54.6%) were obese (BMI ≥25.0 kg/m2), whereas only 1.05% were underweight. Smokers made up 15.4%, and one‐third of patients (31.5%) were alcohol drinkers. Mean duration of hypertension was 5.6 ± 4.8 years, and more than one‐third of patients had comorbid diabetes (39.3%). After 6 months of follow‐up, hypertension remained uncontrolled in almost 40% of patients. Between uncontrolled and controlled groups, there were no significant differences in terms of baseline clinical characteristics, except for proportion of smokers which was higher in the uncontrolled group (Table 1).
TABLE 1.
Baseline patient characteristics according to hypertension control status at 6 mo of follow‐up
| Variables |
Total (n = 1011) |
Uncontrolled after 6 mo (n = 367) a |
Controlled after 6 mo (n = 532) a |
P value c |
|---|---|---|---|---|
| Age (y) | 64.6 ± 12.5 | 64.2 ± 13.1 | 64.6 ± 12.0 | .624 |
| Male, N (%) | 526 (52.0) | 200 (54.5) | 268 (50.4) | .224 |
| BMI (kg/m2) | 25.8 ± 3.7 | 25.9 ± 3.9 | 25.7 ± 3.5 | .322 |
| BMI ≥25 kg/m2, N (%) | 521 (54.6) | 207 (59.0) | 264 (52.8) | .746 |
| Current or ex‐smoker, N (%) | 155 (15.4) | 73 (20.0) | 68 (12.8) | .004 |
| Alcohol drinking, N (%) | 317 (31.5) | 129 (35.3) | 158 (29.8) | .087 |
| Charlson Comorbidity Index b | 1.69 ± 0.92 | 1.69 ± 0.95 | 1.72 ± 0.90 | .788 |
| Diabetes b , N (%) | 212 (47.0) | 92 (48.9) | 120 (47.4) | .913 |
| Congestive heart failure b , N (%) | 172 (33.1) | 75 (37.9) | 73 (28.9) | .076 |
| Cerebrovascular disease b , N (%) | 87 (16.8) | 27 (13.6) | 50 (19.8) | .081 |
| Myocardial infarction b , N (%) | 74 (14.6) | 34 (17.2) | 30 (11.9) | .135 |
Data are presented as mean ± SD or N (%).
Abbreviation: BMI, body mass index.
Number of patients is based on available blood pressure data at 6 mo.
Comorbidity data were available in 198 patients in the uncontrolled group and 253 in the controlled group.
P value from t test or chi‐square test between uncontrolled and controlled group.
Table 2 shows BP at baseline and follow‐up. Baseline mean (±SD) BP of the uncontrolled group (systolic BP: 153.0 ± 12.6 mm Hg, P < .001; diastolic BP: 87.5 ± 12.7 mm Hg, P = .003) was significantly higher than that of the controlled group (systolic BP: 148.9 ± 10.2 mm Hg; diastolic BP: 85.1 ± 11.2 mm Hg). The difference in BP between two groups was evident at FU1 (systolic BP: 144.1 ± 14.3 vs 132.7 ± 14.1 mm Hg, P < .001; diastolic BP: 83.5 ± 11.1 vs 79.0 ± 10.6 mm Hg, P < .001), and the difference widened at FU2 (systolic BP: 147.4 ± 10.4 vs 125.2 ± 9.4 mm Hg, P < .001; diastolic BP: 86.2 ± 11.1 vs 75.1 ± 8.6 mm Hg, P < .001).
TABLE 2.
Blood pressure at baseline and follow‐up according to hypertension control status at 6 mo of follow‐up
| Visit | Total | Uncontrolled after 6 mo | Controlled after 6 mo | a P value | |
|---|---|---|---|---|---|
| Baseline | N | 1011 | 367 | 532 | |
| SBP (mm Hg) | 150.8 ± 11.4 | 153.0 ± 12.6 | 148.9 ± 10.2 | <.001 | |
| DBP (mm Hg) | 85.7 ± 12.2 | 87.5 ± 12.7 | 85.1 ± 11.2 | .003 | |
| Follow‐up 1 | N | 877 | 335 | 474 | |
| SBP (mm Hg) | 137.1 ± 15.1 | 144.1 ± 14.3 | 132.7 ± 14.1 | <.001 | |
| DBP (mm Hg) | 80.5 ± 11.0 | 83.5 ± 11.1 | 79.0 ± 10.6 | <.001 | |
| Follow‐up 2 | N | 899 | 367 | 532 | |
| SBP (mm Hg) | 134.3 ± 14.7 | 147.4 ± 10.4 | 125.2 ± 9.4 | <.001 | |
| DBP (mm Hg) | 79.2 ± 10.9 | 85.2 ± 11.1 | 75.1 ± 8.6 | <.001 | |
Data are presented as mean ± SD.
Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure.
P value from t test between uncontrolled and controlled group.
Similar treatment patterns were shown between the two groups during follow‐up (Table 3). The majority of patients took at least 3 different antihypertensive drugs (≥3 antihypertensive medications) at baseline, FU1, and FU2 (37.0%, 37.7% and 40.6%, respectively). On the other hand, about 20% of patients took only one antihypertensive at baseline and during follow‐up (20.9%, 19.8%, and 18.3%, respectively). Between the uncontrolled and controlled groups, there were no significant differences in treatment pattern except for the proportion of patients on combination therapy of at least 3 antihypertensives (42.1% vs 34.7% at FU1, P = .031; 46.4% vs 36.7% at FU2, P = .004).
TABLE 3.
Pharmacological treatment pattern according to hypertension control status at 6 mo of follow‐up
| Uncontrolled after 6 mo | Controlled after 6 mo | P value a | |
|---|---|---|---|
| Follow‐up 1 | N = 342 | N = 481 | |
| Monotherapy, N (%) | 63 (18.4) | 95 (19.8) | .633 |
| Single‐pill combination, N (%) | 56 (16.4) | 100 (20.8) | .111 |
| Antihypertensive + antihypertensive | 52 (15.2) | 95 (19.8) | |
| Antihypertensive + non‐antihypertensive | 4 (1.2) | 5 (1.0) | |
| Free combination, N (%) | 79 (23.1) | 119 (24.7) | .587 |
| ≥3 antihypertensive medications, N (%) | 144 (42.1) | 167 (34.7) | .031 |
| Follow‐up 2 | N = 358 | N = 512 | |
| Monotherapy, N (%) | 59 (16.5) | 100 (19.5) | .252 |
| Single‐pill combination, N (%) | 55 (15.4) | 94 (18.4) | .248 |
| Antihypertensive + antihypertensive | 52 (14.5) | 87 (17.0) | |
| Antihypertensive + non‐antihypertensive | 3 (0.8) | 7 (1.4) | |
| Free combination, N (%) | 78 (21.8) | 130 (25.4) | .220 |
| ≥3 antihypertensive medications, N (%) | 166 (46.4) | 188 (36.7) | .004 |
Data are presented as N (%).
P value from chi‐square test between uncontrolled and controlled group.
During follow‐up, the MMAS‐4 score was 0.5 ± 0.8 and 0.5 ± 0.8 at FU1 and FU2, respectively. No significant difference in questionnaire responses was found between the groups at FU1 and FU2 (Table 4). In addition, the adherence score did not differ between the groups at FU1 and FU2. Non‐adherent patients (score from 1 to 4) made up 35.4% and 32.2% of the total patients, respectively. Among non‐adherent patients, forgetting to take medication was the most common reason (24.4% at FU1; 22.8% at FU2).
TABLE 4.
Questionnaire results on medication adherence according to hypertension control status at 6 mo of follow‐up
| Uncontrolled after 6 mo | Controlled after 6 mo | a P value | |
|---|---|---|---|
| Follow‐up 1 | N = 343 | N = 490 | |
| MMAS‐4 Questions, N (%) | |||
| Do you ever forget to take your medicine? | 83 (24.2) | 114 (23.3) | .755 |
| Are you careless at times about taking your medicine? | 78 (22.7) | 109 (22.2) | .866 |
| When you feel better do you sometimes stop taking your medicine? | 13 (3.8) | 24 (4.9) | .445 |
| If you feel worse when taking the medicine, do you sometimes stop taking it? | 1 (0.3) | 8 (1.6) | .090 |
| Score of 1‐4, N (%) | 120 (35.0) | 171 (34.9) | .979 |
| Adherence score | 0.5 ± 0.8 | 0.5 ± 0.8 | .858 |
| Follow‐up 2 | N = 363 | N = 531 | |
| MMAS‐4 Questions, N (%) | |||
| Do you ever forget to take your medicine? | 86 (23.7) | 109 (20.5) | .261 |
| Are you careless at times about taking your medicine? | 75 (20.1) | 94 (17.7) | .267 |
| When you feel better do you sometimes stop taking your medicine? | 12 (3.3) | 14 b (2.6) | .999 |
| If you feel worse when taking the medicine, do you sometimes stop taking it? | 3 (0.8) | 5 b (0.9) | .562 |
| Score of 1‐4, N (%) | 124 (34.2) | 158 (29.8) | .170 |
| Adherence score | 0.5 ± 0.8 | 0.4 ± 0.7 | .180 |
Data are presented as mean ± SD or N (%).
P value from Chi‐square test between uncontrolled and controlled group.
One patient only answered for Q1 and Q2, and missed Q3 and Q4.
In both groups, the EQ‐5D VAS score increased during follow‐up, suggesting improved HRQoL during the treatment and follow‐up. Interestingly, during follow‐up, the EQ‐5D VAS score of the controlled group was significantly higher than that of the uncontrolled group despite similar values at baseline. (Figure 2, Table 5) After adjusting for sex, age, and smoking, logistic regression analysis revealed that EQ‐5D VAS during follow‐up was significantly associated with BP control (Table 5).
FIGURE 2.
EQ‐5D VAS score at baseline and follow‐up
TABLE 5.
Difference of health‐related quality of life measured on EQ‐5D vas according to hypertension control status and logistic regression models for their relationship
| Visit | Uncontrolled after 6 months | Controlled after 6 months | P value a | Odd ratio (95% CI) | P b value | |
|---|---|---|---|---|---|---|
| Baseline | N | 367 | 532 | |||
| EQ‐5D VAS score | 70.3 ± 16.9 | 72.2 ± 16.2 | .092 | 1.008 (0.999‐1.016) | .069 | |
| Follow‐up 1 | N | 344 | 490 | |||
| EQ‐5D VAS score | 72.9 ± 14.3 | 75.3 ± 14.4 | .014 | 1.014 (1.004‐1.024) | .007 | |
| Follow‐up 2 | N | 364 | 530 | |||
| EQ‐5D VAS score | 72.3 ± 14.4 | 74.6 ± 14.9 | .017 | 1.013 (1.003‐1.022) | .010 |
Data are presented as mean ± SD.
P value from t test between uncontrolled and controlled group.
Logistic regression was performed with hypertension control status as dependent variable and EQ‐5D vas score as independent variable after adjusting for sex, age, and smoking.
There were significant differences in several clinical characteristics according to the HRQoL (Table 6). Patients with worse HRQoL (<mean EQ‐5D vas score) were older, more likely to be women, and less likely to be smokers and drinkers than patients with better HRQoL (≥mean EQ‐5D vas score). They had higher Charlson Comorbidity Index.
TABLE 6.
Baseline characteristics of the study patients according to health‐related quality of life (HRQoL) at 6 mo of follow‐up
|
Better HRQoL (≥mean EQ‐5D vas score) |
Worse HRQoL (<mean EQ‐5D vas score) |
P value a | |
|---|---|---|---|
| N = 664 b | N = 289 b | ||
| Age (y) | 61.6 ± 12.4 | 71.6 ± 9.5 | <.001 |
| Male, N (%) | 388 (58.4) | 107 (37.0) | <.001 |
| BMI (kg/m2) | 25.8 ± 3.6 | 25.8 ± 3.7 | .881 |
| Current or ex‐smoker, N (%) | 118 (17.9) | 21 (10.7) | .006 |
| Alcohol drinking, N (%) | 252 (38.1) | 48 (16.6) | <.001 |
| Charlson Comorbidity Index c | 1.58 ± 0.81 | 1.85 ± 1.03 | .002 |
| Diabetes mellitus c , N (%) | 132 (45.1) | 97 (49.5) | .929 |
| Congestive heart failure c , N (%) | 90 (30.1) | 74 (37.8) | .106 |
| Cerebrovascular disease c , N (%) | 40 (13.7) | 42 (21.4) | .024 |
| Myocardial infarction c , N (%) | 42 (14.3) | 29 (14.8) | .887 |
Data are presented as N (%).
P value from t test or chi‐square test.
Number of patients is based on HRQoL data at 6 mo.
Comorbidity data were available in 293 patients in the better HRQoL group and 196 in the worse HRQoL group.
The pharmacologic treatment pattern differed according to HRQoL (Table 7). The proportion of patients on monotherapy was lower in patients with worse HRQoL than those with better HRQoL. On the other hand, the proportion of patients taking ≥3 antihypertensive medications was higher in patients with worse HRQoL.
TABLE 7.
Pharmacological treatment pattern at baseline and follow‐up according to health‐related quality of life (HRQoL) at 6 mo of follow‐up
|
Better HRQoL (≥mean EQ‐5D vas score) |
Worse HRQoL (<mean EQ‐5D vas score) |
P value a | |
|---|---|---|---|
| Baseline | N = 664 | N = 289 | |
| Monotherapy, N (%) | 150 (22.6) | 40 (13.8) | .002 |
| Single‐pill combination, N (%) | 126 (19.0) | 40 (13.8) | .055 |
| Antihypertensive + antihypertensive | 117 (17.6) | 39 (13.5) | |
| Antihypertensive + non‐antihypertensive | 9 (1.4) | 1 (0.4) | |
| Free combination, N (%) | 162 (24.4) | 77 (26.6) | .462 |
| ≥3 antihypertensive medications, N (%) | 226 (34.0) | 132 (45.7) | <.001 |
| Follow‐up 1 | N = 602 | N = 274 | |
| Monotherapy, N (%) | 130 (21.6) | 38 (13.9) | .007 |
| Single‐pill combination, N (%) | 130 (21.6) | 27 (9.9) | <.001 |
| Antihypertensive + antihypertensive | 121 (20.1) | 27 (9.9) | |
| Antihypertensive + non‐antihypertensive | 9 (1.5) | 0 (0.0) | |
| Free combination, N (%) | 145 (24.1) | 75 (48.9) | .300 |
| ≥3 antihypertensive medications, N (%) | 197 (32.7) | 134 (48.9) | <.001 |
| Follow‐up 2 | N = 646 | N = 275 | |
| Monotherapy, N (%) | 130 (20.1) | 38 (13.8) | .023 |
| Single‐pill combination, N (%) | 126 (19.5) | 24 (8.7) | <.001 |
| Antihypertensive + antihypertensive | 116 (18.0) | 24 (8.7) | |
| Antihypertensive + non‐antihypertensive | 10 (1.6) | 0 (0.0) | |
| Free combination, N (%) | 155 (24.0) | 72 (26.2) | .481 |
| ≥3 antihypertensive medications, N (%) | 235 (36.4) | 141 (51.3) | <.001 |
Data are presented as N (%).
P value from chi‐square test between uncontrolled and controlled group.
The MMAS‐4 score did not differ according to the quality of life (Table 8). However, the percentage of people who answered "yes" to the question, "When you feel better do you sometimes stop taking your medicine?", was higher in the patients with worse HRQoL.
TABLE 8.
Questionnaire results on medication adherence according to health‐related quality of life (HRQoL) at 6 months of follow‐up
|
Better HRQoL (≥mean EQ‐5D vas score) |
Worse HRQoL (<mean EQ‐5D vas score) |
a P value | |
|---|---|---|---|
| Follow‐up 1 | N = 615 | N = 274 | |
| MMAS‐4 Questions, N (%) | |||
| Do you ever forget to take your medicine? | 148 (24.1) | 69 (25.2) | .720 |
| Are you careless at times about taking your medicine? | 136 (22.1) | 57 (20.8) | .662 |
| When you feel better do you sometimes stop taking your medicine? | 22 (3.6) | 19 (6.9) | .028 |
| If you feel worse when taking the medicine, do you sometimes stop taking it? | 7 (1.1) | 4 (1.5) | .745 |
| Score of 1‐4, N (%) | 397 (64.6) | 218 (65.0) | .906 |
| Adherence score | 0.5 ± 0.8 | 0.5 ± 0.9 | .556 |
| Follow‐up 2 | N = 661 | N = 289 | |
| MMAS‐4 Questions, N (%) | |||
| Do you ever forget to take your medicine? | 149 (22.5) | 69 (23.9) | .653 |
| Are you careless at times about taking your medicine? | 128 (19.4) | 51 (17.4) | .533 |
| When you feel better do you sometimes stop taking your medicine? | 22 (3.3) | 5 (1.7) | .175 |
| If you feel worse when taking the medicine, do you sometimes stop taking it? | 8 (1.2) | 1 (0.3) | .291 |
| Score of 1‐4, N (%) | 449 (67.9) | 194 (67.4) | .864 |
| Adherence score | 0.5 ± 0.8 | 0.4 ± 0.7 | .549 |
Data are presented as mean ± SD or N (%).
P value from chi‐square test
4. DISCUSSION
The principal findings of this study are that self‐rated HRQoL of patients with controlled BP was significantly better than that in those with uncontrolled BP. There was a close relationship between the HRQoL and BP control even during follow‐up. These findings suggest that along with pharmacological intervention of hypertension, management of comorbid conditions or psychological support might be helpful to optimizing BP control in patients with uncontrolled hypertension.
During the 6‐month follow‐up period in this study, only 60% of patients reached the target BP. In the VALsartan Longterm Use Evaluation Trial (VALUE), the systolic BP control rate was 59.5%. 18 Among participants of the Anglo‐Scandinavian Cardiac Outcomes Trials (ASCOT), 56%, 60%, 70%, and 72% had reached the target BP at 6 months, and 1, 3, and 4 years, respectively. 19 Although this study had the non‐interventional observational design, it showed a fairly similar BP control rate at 6 months after enrollment compared to previous studies. Primary reasons for insufficient BP control in previous large randomized clinical trials were physician inertia, and lack of drug dose titration or combination. 20 In the VALUE Trial, 23.9% of patients who did not reach target systolic BP remained on the lowest dose of antihypertensive medication. As many as 19% of ASCOT participants who did not reach target diastolic BP at 6 months still remained on the first dose at titration step during 4 years of study period. 19 However, in this study, the use of at least 3 antihypertensive agents increased during follow‐up and did so at a significantly higher rate in the uncontrolled group compared to the controlled group. This means that a significant number of patients still remained uncontrolled, even though the physician made effort to add or adjust drugs to lower patients' BP. Another important cause of failure to reach target BP is poor medication adherence. 21 However, in our study, the proportion of non‐adherent patients did not differ between the uncontrolled and controlled groups, suggesting that other factors besides medication adherence may be associated with inadequate BP control.
Several studies have shown that HRQoL accurately reflects health status and can be used as a predictor of mortality. 22 , 23 , 24 HRQoL is different between healthy individuals and those with chronic diseases. HRQoL is also a measure of the severity of the disease. 25 , 26 , 27 In the field of cardiovascular diseases, the validity and reliability of self‐rated HRQoL as an outcome measure have been demonstrated, and the HRQoL may vary depending on BP or the presence of accompanying complications of hypertension. 28 , 29 , 30 In this study, EQ‐5D VAS increased during treatment and follow‐up period in both controlled and uncontrolled groups. However, EQ‐5D VAS during follow‐up was significantly higher in the controlled group compared with that of uncontrolled group. Moreover, it was closely related to BP control even after adjusting for sex, age, and smoking. These findings imply that BP control and HRQoL were closely interrelated particularly in patients with uncontrolled hypertension. This result is similar to that of studies examining the relationship between diabetes and HRQoL. Diabetes, like hypertension, needs steady management toward a therapeutic goal. HRQoL and glycemic control have a bidirectional relationship in diabetic patients. Better glycemic control improves the HRQoL, and higher HRQoL enhances glycemic control. 31 , 32 , 33 Our finding suggests that patients with high HRQoL may have better BP control and vice versa.
In the present study, patients with worse HRQoL had a high Charlson Comorbidity Index. Therefore, it can be inferred that more patients with relatively poor medical health conditions are included. Hypertensive patients are aware of the decline in their HRQoL due to accompanying comorbidities or complications. 12 And the number of comorbid illness is an independent factor that determines the HRQoL. 34 Patients with resistant hypertension have more comorbidities than those with non‐resistant hypertension. 35 The presence of comorbidities is one of the most important patient‐related factors related to poor control of BP. 36 It also has been shown that HRQoL is significantly associated with treatment satisfaction, adherence to medication, and low HRQOL may be an important barrier to achieve high medication adherence among hypertensive patients. 13 , 37 However, our study showed that medication adherence did not differ according to the HRQoL but there was a higher proportion of ≥3 antihypertensive medications among patients with worse HRQoL. It indicates that poor BP control in these patients was independent of medication adherence. Therefore, there is a possibility that comorbidity plays a vital role between HRQoL and BP control.
The limitations of this study are as follows. First, the baseline BP of the uncontrolled group was significantly higher than that of the controlled group. The initial BP has important influence on the response to antihypertensive medication. However, HRQoL at follow‐up was associated with success of BP control after adjusting for differences in baseline BP. Second, because our study population had only 2 follow‐up visits 3 months apart, the percentage of patients with unsuccessful BP control may be higher. The 2017 Hypertension Clinical Practice Guideline recommends 1‐month interval of follow‐up to achieve target BP. 5 More frequent follow‐up would have increased the success rate of BP control. Third, a detailed analysis of the five dimensions of the EQ‐5D was not conducted. Further research would be needed to determine which components of HRQoL relate to BP control.
Despite the availability of many antihypertensive medications, the BP control rate remains low. To cope with this, various strategies have been tried including pharmacologic intervention. Recent meta‐analysis showed that a team‐based strategy involving non‐physicians can control BP effectively because it allows tailored, frequent patient‐centered care. 38 In this respect, improving HRQoL through management of comorbid conditions or psychological support may be helpful in controlling BP.
In conclusion, BP control significantly correlated with HRQoL. In addition to pharmacologic intervention of hypertension, management of comorbid conditions or psychological support might be helpful to optimizing BP control in patients with uncontrolled hypertension. The results of our study underscore the need to implement both medical and non‐medical measures to optimize BP control in patients with uncontrolled hypertension.
CONFLICT OF INTEREST
The authors have nothing to declare.
AUTHOR CONTRIBUTIONS
Jong‐Won Ha contributed to the study design and interpretation of results; Chan Joo Lee contributed to data analysis, interpretation of results, and drafting the manuscript; Woo Jung Park, Eue‐Keun Choi, Tae‐Soo Kang, and Dong Woon Jeon contributed to interpretation of results and editing the manuscript; Sang‐Wook Lim, Dae‐Hyeok Kim, Kwang Soo Cha, and Nam‐Ho Kim contributed to the study design, statistical design, and editing the manuscript.
ACKNOWLEDGMENT
None.
Lee CJ, Park WJ, Suh J‐W, et al. Relationship between health‐related quality of life and blood pressure control in patients with uncontrolled hypertension. J Clin Hypertens. 2020;22:1415–1424. 10.1111/jch.13941
Funding information
This study was funded by Novartis Korea, Ltd.
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