Numerous publications in the past few years have discussed and agonized over statistics that indicate that only about 30% of patients with hypertension in the United States are being effectively treated to goal levels of <140/90 mm Hg, levels set by national committees. In addition, these publications have highlighted that the occurrence of congestive heart failure (CHF) and end‐stage renal disease (ESRD) are increasing. Should we be as concerned about these numbers as some of our colleagues have suggested?
THE HOSPITAL EXPERIENCE
It is clear to any clinician that the pattern of hypertensive diseases has changed dramatically in the past 30–40 years. When many of us were house staff officers in the 1940s and 1950s, it was a given that every third or fourth bed in the hospital was occupied by a middle‐aged patient (40–60 years of age) with hypertension—malignant or accelerated hypertension, CHF as a result of hypertension, stroke as a result of hypertension, or rapidly failing kidneys as a result of hypertension. These were all extremely sick individuals. Today the picture is completely different. It is difficult to find a patient in the hospital with elevated blood pressure—except for the rare case being studied for secondary causes. Something has happened to change the pattern. Patients are being treated earlier and complications are being prevented. Yes, there are cases of CHF and ESRD but these are in older individuals who often have several comorbid conditions in addition to a history of long‐standing hypertension.
PRACTICE AND CLINICAL TRIAL EXPERIENCE
It is also a fact that fewer cases of hypertension‐related strokes, heart, and kidney failure are seen by practicing physicians in their office practices. Epidemiologic data report that the occurrence of stroke has decreased dramatically (by more than 60%) since the 1970s, when a national effort to control hypertension was launched; this, despite the fact that the numbers of hypertensive patients achieving goal pressures are not ideal, even in well‐controlled office or clinic‐based long‐term trials. In many clinical trials where physicians are encouraged to increase or change medication and to actively pursue lifestyle interventions, diastolic blood pressures (DBPs) are reduced to goal levels in only about 60%–80% of patients, but morbidity/mortality has been reduced significantly in treated compared to control patients. In a practice experience that was oriented toward the treatment of hypertension, DBP control was achieved in almost 80% of patients but systolic blood pressure (SBP) reductions to <140 mm Hg were only noted in about 60% of subjects. Controlling SBP is considerably more difficult, especially in the elderly. In a few “goal related” trials DBP has been controlled in about 90% of cases. In the real world of clinical practice, the numbers are less; national surveys appear to confirm this. Preliminary data from a recent large clinical trial (the Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack [ALLHAT]) where aggressive treatment was encouraged, reported almost 90% of DBPs and about 60% of SBPs were reduced to goal levels. This should probably serve as a model of what can be achieved.
RESULTS OF NATIONAL SURVEYS—ARE THERE REASONS FOR THE NUMBERS?
National surveys still report that fewer than one third of hypertensive patients are treated effectively. Are these poor rates of control due to physicians' lack of interest, lack of time, or lack of appreciation of the importance of SBP and risk? Or are they the result of lack of knowledge regarding the benefits of lowering blood pressure? On the other hand, are these results accounted for by a lack of patient adherence to therapy, lack of knowledge of the seriousness of hypertension, the fear of side effects from medication, lack of symptoms, and an attitude “if it doesn't hurt, why bother,” or is the cost of care an important factor in the less than ideal outcome? These questions have been pondered by experts for many years.
Some of the poor statistics on control may, however, relate to the fact that definitions of hypertension have changed in the past 5–10 years. For example, the definition of isolated systolic hypertension was, until recent years, a blood pressure of >160/<90 mm Hg. This has changed. The new definition is >140/<90 mm Hg. Many physicians have still not caught up with the new definitions and are not treating patients if SBPs are >140 but <160 mm Hg. The numbers of patients with a diagnosis of isolated systolic hypertension has increased dramatically and the percentages controlled have decreased because of the change in definition.
FACTORS THAT MAY EXPLAIN THE CHF AND ESRD NUMBERS
In view of the fact that many more hypertensive patients are being treated today than 20–30 years ago (even if not to specific goal levels), can we blame the trend in the occurrence of CHF and ESRD on poorly‐controlled hypertension or are there other factors that may be responsible? Is there an explanation for the increase in these serious disabilities other than just inadequate control of elevated blood pressure?
CHF is on the rise for many reasons, not necessarily because hypertension is poorly treated. Fewer people are dying of strokes; fewer people are dying of renal disease at an early age; fewer people are dying of myocardial infarctions or diabetes in their 50s and 60s. They are living longer. Certainly a percentage of the increase in CHF can be explained by the fact that people are not dying of cardiovascular diseases at younger ages. The management of hypertension has undoubtedly moved the age of developing CHF to an older group of patients. Antihypertensive therapy reverses left ventricular hypertrophy (LVH), a major predictor of CHF and a factor in early cardiac death. Data indicate a longer survival in patients who have experienced LVH regression. This has enabled the patient to survive many more years. The rise in the incidence of CHF cannot therefore just be attributed to poor control of hypertension.
Statistics indicate that ESRD is on the increase over the past decade based on the number of patients on dialysis. But who were the people on dialysis 10–15 years ago?—certainly not 75 and 80+‐year‐old diabetics or former hypertensive patients. These are people considerably older than were previously accepted for this procedure. With the increase in dialysis of older people who are not dying of other diseases and people with diabetes who are living longer, it is natural to record an increase in the numbers of ESRD; this is not necessarily the result of failure to treat hypertension.
CAN WE DO BETTER?
Can we reduce the occurrence of CHF or ESRD despite the factors enumerated above if we are more aggressive in treating hypertension? Possibly, but perhaps not to the degree that has been predicted, because inadequate treatment of elevated blood pressure is only a partial explanation for the problem.
So are we running in place or are we making progress? The doomsday sayers are convinced that we are not making progress. How can they explain the fact that hypertensive patients are living longer, are not experiencing strokes or CHF at an early age, or progressing to severe hypertension and progressive renal disease in their 40s and 50s and even 60s? How can they explain that hypertensive diabetics are living longer without inexorable progression of their disease?
But can we do better and how do we do it? Can further education of both patients and physicians change the numbers? What kind of effort is necessary? Some experts remain discouraged about the numbers of patients who still will not follow directions and physicians who are still not treating adequately. Obviously, as more and more physicians pay more attention to lowering SBP, especially in the elderly, results will improve and some cases of CHF and ESRD (even when they occur at older ages) will be prevented or delayed. However, we must remind ourselves that we will not achieve goal SBP in as high a percentage of patients as we do with DBP. For example, a certain number of elderly patients who have blood pressures reduced from 180 to 160 or 150 mm Hg will experience some symptoms. They will resist further lowering of pressure or the use of more medication. In these patients, it is probably prudent to back off, maintain the first‐stage blood pressure lowering for several months, and then try again after baroreceptors may have been reset. More people with systolic hypertension can be controlled, but expectations should not be set at unrealistic numbers. A 60% goal is reasonable; this can be achieved and is far better than noted at present. Better outcome can be expected as the percentage of responders' increases. An important point to remember—benefit is noted in the elderly, with a decrease of only about 12–15 mm Hg SBP. A dramatic decrease in morbidity/mortality has been noted even in patients above the age of 80.
Blood pressures below 140/90 mm Hg or even lower in patients with diabetes or renal disease should continue to be the goal; in fact, a treatment blood pressure goal should be as close to 120/80 mm Hg as possible. But we must also remember that this may not be achievable in a certain percentage of patients regardless of how effectively we handle medication and regardless of how enthusiastically we approach other aspects of treatment.
WHAT CAN BE DONE—ARE PRESENT EFFORTS A WASTE OF TIME?
Educational efforts do help to improve results. Symposia, lectures, and written material in journals do influence treatment practices but results may not always be immediately visible. It takes time for treatment messages to be adopted. It may frustrate the leaders of the hypertension community when statistics on outcome do not show steady improvement, but progress is being made.
In symposia that have been held throughout the country over the past five years frequent comments from the attendees include “I will now pay more attention to systolic hypertension,” or “I will now be more aggressive in treating my diabetic patients, especially those with proteinuria.” These are positive steps in improving outcome. Telephone and web site programs also help. Patient education can also be effective, but it must be repetitive and reinforced by both educational material and health care providers. Far too little patient education material is available in physicians' offices or clinics; yet, it can be obtained at little cost.*
Many physicians may consider the management of hypertension dull and not very exciting, certainly not as exciting as an angioplasty or treatment of CHF or diabetic coma. Physicians are not under pressure to treat hypertensive patients because of the relative lack of symptoms. Despite the fact that hypertension results in more death and disability than most other illnesses, there are no “walks for hypertension” or telethons. A vocal constituency for the treatment of hypertension is not in place. Repetitive messages are necessary; yet, the media often respond to requests for an update about hypertension with a “We did that story last year.”
FINAL COMMENTS
No, we are not running in place; yes, we are making progress; and yes, we should look behind the statistics to see what they mean. When one community reports that stroke rates are stable or may be rising slightly, we should not overreact. Look and see what has happened to hypertensive patients over the past 20–30 years. Benefits of the treatment of hypertension have been dramatic. The Hypertension Treatment Story represents a model for preventive medicine activities. The story can have an even happier ending if further efforts are made to improve blood pressure control. There are reasons to be encouraged but also reasons to continue to strive for even better results.
*An up‐to‐date Patient Eduction Booklet can be downloaded from the HypertensionFoundation.org web site. Other excellent material is available from the National Heart, Lung, and Blood Institute, Bethesda, MD.