I enjoyed reading the article by Wexler and Feldman1 concerning which antihypertensive drugs to choose for patients with cardiovascular disease. I thought their recommendations for treatment of heart failure, coronary artery disease, and stroke were rational and well supported by the literature. However, they did not fully address the major issues that face clinicians regarding the persistent gaps between the identification, awareness, treatment, and control rates for hypertension in our country.2
I was cited as a proponent of an individualized approach to treatment, as opposed to using the more formulaic approach advocated by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7).3 Not mentioned in their article is my rationale behind this position: the continuous, graded relationship between blood pressure and cardiovascular events.4 Unfortunately, threshold-based considerations for treatment do not provide a broad enough perspective; many patients require earlier and more intensive strategies to control blood pressure sufficiently to prevent cardiovascular events.
Healthcare providers need to recognize that choice of appropriate blood pressure goals for individual patients should be predicated on cardiovascular risk rather than on hitting a given threshold. An individualized approach should be thoughtfully considered in each patient based on global cardiovascular risk, which encompasses an understanding of family history; comorbid conditions such as dyslipidemia, diabetes, and obesity; and lifestyle factors such as smoking, dietary, and exercise habits.
Better strategies needed for compliance
As I consider what has changed in the past 10 years in blood pressure-lowering therapeutics, I am struck by 3 key factors that increase the gap between treatment and control rates:
- Greater focus on controlling systolic blood pressure, in large part driven by the Framingham Heart Study indicating that after age 60 years cardiovascular events are better predicted by systolic than diastolic blood pressure5
- Recognition that in many patients—particularly those with cardiovascular disease, kidney disease, or diabetes—lower systolic blood pressure goals may be preferable6-8
- The fact that increasing numbers of our patients are overweight, sedentary, and have unhealthy eating patterns that limit the efficacy of antihypertensive medications.9,10
As a result, patients are less likely to get to goal with 1 medication. More often than not, patients require anywhere from 2 to 4 medications to control systolic blood pressure. Of added concern is that patients often require multiple medications for other medical problems. Thus, healthcare providers and patients may be less willing to accept more than 1 medication to treat only high blood pressure. This creates substantial “therapeutic inertia” on both the provider and patient sides of treatment planning.11
Consequently, improved strategies for overcoming therapeutic inertia are needed, in particular renewed educational efforts as to the importance of achieving lower blood pressure goals, which does make a difference in decreasing the likelihood of cardiovascular events. Moreover, there needs to be greater awareness among providers of strategies to simplify the therapeutic approach.
One option is to consider using more robust fixed-dose combinations to provide better blood pressure control without increasing the number of pills patients must take. I often illustrate to patients the overall effectiveness rate of antihypertensive medications: we generally need at least 1 drug for each 10-mm Hg systolic blood pressure reduction. Consequently, a patient with systolic blood pressure 30 mm Hg above goal will often require 3 medications. Optimally, a fixed-dose combination containing 2 medications that lower blood pressure by different and complementary mechanisms should close at least 20 mm Hg of that gap, in addition to critical dietary changes such as limiting salt intake. The advantage of well-tolerated medicines in simple fixed-dose formulations to facilitate blood pressure control is evident in several clinical trials.12
Options for targeting renin-angiotensin blockade
Another important point brought out in the Wexler and Feldman review is that patients at risk for cardiovascular disease often benefit from the use of drugs that block the renin-angiotensin system or the sympathetic nervous system as part of an effective blood pressure-lowering regimen.13 This is true for patients with a history of heart failure, coronary artery disease, or stroke. Personally, I feel that each patient needs careful and cautious individualization in this regard. I am struck by the consistency of data showing that targeting the renin-angiotensin system as part of a successful blood pressure-lowering regimen provides incremental benefit for reducing the risk of cardiovascular events. These agents should be dosed in the top range approved for controlling blood pressure, as most clinical trials indicate that the higher dosing range is often associated with the greatest cardiovascular risk reduction.14