Numerous articles have addressed the lack of adherence to therapy on the part of patients with hypertension. Most of these papers have described methods to improve adherence to treatment—suggestions to remind patients when to take their pills (when they brush their teeth, when they have breakfast, when they get into bed, and so forth). These methods have been evaluated in numerous trials, in some of which the incentives for improved compliance included such rewards as extra time with a doctor or nurse on return visits, or theater or baseball game tickets. In many of the trials, some improvement in adherence occurred, at least while the study was underway, but in most cases the methods used were not applicable to the real world of medical practice.
Poor patient adherence has been cited to explain the low response rate in the management of hypertension. Yes, the problem can be partly solved by continued focus on this issue, but there are other reasons why fewer than 30% of hypertensive patients in the United States are controlled at goal levels of <140/90 mm Hg—reasons other than poor patient adherence to therapy.
PROBLEMS WITH DEFINITIONS, ESPECIALLY IN THE ELDERLY
There are many problems with a discussion of therapy adherance. One is the definition—adherence should not merely mean that a patient takes a predetermined percentage of the pills prescribed, or comes back for visits at the scheduled time to achieve adherence. A goal should be defined and reached if at all possible. Perhaps blood pressure is lowered to a goal of 130/85 mm Hg and the patient has taken only 50% of the prescribed medication—clearly too much has been prescribed. If we define adherence as a goal reached, we involve and place responsibility on both the patient and the person giving care.
Another problem has to do with changing definitions of a disease. For many years, isolated systolic hypertension (ISH), which is present in a significant number of hypertensives in the U.S. above the age of 55, was defined as blood pressures of >160/90 mm Hg. If physicians had followed treatment guidelines carefully and had treated patients according to these guidelines, many patients with systolic blood pressure levels of 140–160 mm Hg would not have been treated. Consequently, they would be listed in any survey in which 140 mm Hg is the systolic blood pressure goal as “not controlled.” This may account for at least some of the data indicating that there are more patients with uncontrolled systolic blood pressure than with uncontrolled diastolic blood pressure (<90 mm Hg).
Treating the elderly has been widely neglected. Some of the reasons for this neglect are the prevailing myths that 1) elevated blood pressure may not be an important cardiovascular risk factor in the elderly; 2) the elderly do not tolerate medication well; and 3) the benefit of treating patients over the age of 60 or 65 has not been proved. All of these myths have been proved false by carefully controlled studies.
THE QUESTION OF SYMPTOMS
Because of the asymptomatic nature of hypertension in most, but not all, patients, physicians were and still are under little pressure to treat them. A patient with a chronic cough or bursitis wants relief. Few people with hypertension complain or insist on therapy. If there is little or no pressure for treatment from the patient and a physician is led to believe that less severe degrees of blood pressure elevation (stage I hypertension: 140–160/90–100 mm Hg; ISH: > 140/90 mm Hg) do not pose an important risk, there is little incentive to treat.
CONFUSION ABOUT RESULTS OF THERAPY: THEORETIC ADVERSE EFFECTS OF MEDICATIONS
For years, physicians were advised that the antihypertensive drugs used in all of the major clinical trials—specifically, β blockers and diuretics—had deleterious metabolic effects and that the benefits of treatment were limited to reduction of strokes and heart failure, while coronary heart disease events were not reduced by treatment. Treatment programs were often complicated and expensive. Certainly, these factors did not encourage physicians to treat. However, the clinical trials demonstrated a reduction in both cerebrovascular and cardiovascular events, and the “deleterious metabolic effects” proved to be illusory or of little clinical significance. Although many of the drugs used prior to the availability of diuretics and β blockers—specifically, reserpine, a methyldopa, the ganglion blocking agents, and others—did produce symptoms that often deterred both the physician and the patient from continuing treatment, medications in use since the late 1950s–1960s are generally well tolerated.
THE CONCEPT OF “NEWER IS BETTER”: ITS EFFECT ON OUTCOME
There will always be incentives to use newer drugs as they are approved. Patients and physicians alike want to be up‐to‐date and avail themselves of the “best,” but often a newer medication is substituted for a highly effective older one when there is no reason to do so. If a patient is doing well, with good blood pressure control and few symptoms, there must be a compelling reason to change medications. A change should not necessarily be based on a paper delivered at a medical meeting, information in an industry‐sponsored monograph, or receipt of drug samples. Newer drugs may present advantages, but often they are used because they are new, and controlled patients often become less well controlled after a change in therapy. This is especially true of diuretic use: frequently, when patients are taken off a diuretic and given another drug, blood pressure control is more difficult. “Adherence” to a goal blood pressure is compromised.
SPECIFIC REASONS FOR POOR CONTROL RATES
We are now able to pinpoint several specific reasons why hypertension control rates in the U.S. are so poor. Some of these are enumerated above and may account for recently reported evidence that even when patients return to physicians' offices with blood pressures above goal levels, and even if they are tolerating their medication, therapy is not changed or increased. This phenomenon probably applies to at least one half of patients who are not controlled at goal levels, especially in the elderly population, and is at least partially a function of lack of attention, on the part of the physician, to achievement of goal blood pressure levels.
Thus, it may not be patient non‐adherence that is the major problem; it may be physician non‐adherence to recent recommended treatment practices that accounts for much of the shortfall in the results of hypertension management. It is not that we lack the tools to lower blood pressure; in the majority of cases, the fact is that we are not using these tools appropriately.
HOW CAN WE INCREASE THE RATE OF ADEQUATE BLOOD PRESSURE CONTROL?
It is important to convince physicians of the benefits of treatment even for patients above 80 years of age. Almost everyone agrees that hypertension is a major risk factor for cardiovascular disease, heart failure, strokes, and kidney failure, but many are still unconvinced that lowering blood pressure reduces these risks significantly, even in people with stage I hypertension. “Treatment” must be redefined to stress the importance of reaching goal blood pressures and not just dispensing medication. Review of physicians' records often discloses that while the patient is receiving medication and returning for visits, blood pressures are not consistently controlled at goal levels of <140/90 mm Hg (or even lower in diabetics or patients with renal disease, to levels of <130–135/80–85 mm Hg).
HOW ELSE CAN WE ATTACK THE PROBLEM OF POOR BLOOD PRESSURE CONTROL?
There are several ways. 1) More must be done to educate patients about the significance of elevated blood pressure and the complications that might occur if blood pressure is not controlled.* We have not done a good job in this area, especially for patients with diabetes, lipid abnormalities, or a strong family history of hypertension. Patients should be encouraged to take an active role in their treatment. If their blood pressures are not reduced to <140/90 mm Hg, they should ask their doctors why. In more than 80% of patients, blood pressures can be controlled at goal levels with currently available medications.
Advice about adherence helps, home blood pressure monitoring may help, and keeping the cost of therapy as reasonable as possible may help, but the achievement of goal blood pressures of <140/90 mm Hg will not occur without help from the “quarterback.” Physicians and other health care providers are the quarterbacks in management efforts. They determine who needs treatment, how and when to treat, and what are the goals of therapy. Without ongoing and increasing efforts to improve the performance of the quarterbacks, we are not going to win the battle of attaining better blood pressure control in more patients.
2) Physicians must recognize that treatment is not merely prescribing a pill. Treatment should be defined as treating to goal levels if at all possible. This most frequently involves the use of multiple medications as well as such lifestyle interventions as exercise, weight loss, and sodium restriction, among others. None of the available medications will, as monotherapy, reduce blood pressure to goal levels in more than 50%–60% of patients. Recent guidelines strongly suggest the use of multiple medications, whether given separately or as a fixed combination. Most of the available medications that are recommended as initial therapy, i.e., diuretics, β blockers, angiotensin‐converting enzyme inhibitors, or in some cases angiotensin receptor blockers and calcium channel blockers, are tolerated well by the majority of patients. The potential for side effects always exists, but in most cases a combination of low doses of two different medications can be found that will lower blood pressure without adverse effects. This is true whether the patients are young or older.
We will increase the number of patients under adequate control only by emphasizing the role of physicians and other health care providers in managing the patient and lowering blood pressures to levels that are compatible with a decrease in morbidity and mortality. The emphasis on patient compliance should be continued, but more emphasis should be placed on physician practices.
*Copies of a booklet for patients entitled “High Blood Pressure—What You Should Know About It and What You Can Do To Help Your Doctor Treat It,” can be obtained from representatives of Reliant Pharmaceutics LLC, Bridgewater, NJ.