Physician Underutilization of Effective Medications for Resistant Hypertension at Office Visits in the United States: NAMCS 2006–2010

Abstract

BACKGROUND:The American Heart Association (AHA) published guidelines for treatment of resistant hypertension in 2008 recommending use of thiazide diuretics (particularly chlorthalidone), aldosterone antagonists, and fixed-dose combination medications, but it is unclear the extent to which these guidelines are being followed. OBJECTIVE: To describe trends in physician use of recommended medications for resistant hypertension and assess variations in medication use based on geography, physician specialty and patient characteristics. DESIGN: Cross-sectional analysis using the National Ambulatory Medical Care Survey from 2006 to 2010. STUDY SAMPLE: We analyzed visits of hypertension patients to family physicians, general internists, and cardiologists. Resistant hypertension was defined as concurrent use of ≥ 4 classes of blood pressure (BP) medications or elevated BP despite the use of ≥ 3 medications. Pregnant patients and visits with diagnosed heart failure or end-stage renal disease were excluded. MAIN OUTC OME: U se of A HA-r ec ommen d ed medications for management of resistant hypertension. RESULTS: Of 19,500 patient visits with hypertension, 1,567 or 7.1 % CI (6.6-7.7 %) met criteria for resistant hypertension. Thiazide diuretic use was reported in 58.9 % of visits pre-guidelines vs. 54.8 % postguidelines (p=0.37). Use of aldosterone antagonists was low and also did not change significantly after guideline publication (3.1 % vs. 4.5 %, p=0.27). Fixeddose combinations use was 42.0 % before and 37 % after guideline publication (p = 0.29). Each 10-year increase in patient age was associated with lower thiazide use (OR 0.87,, as was presence of comorbid ischemic heart disease (OR 0.62, CI 0.41-0.94). Medication use did not vary by geography or physician specialty. CONCLUSION: Use of AHA-recommended medications for resistant hypertension remains low after publication of guidelines. Healthcare systems should encourage more frequent prescribing of these medications to improve care in this high-risk population.

Trends in Antihypertensive Medication Use Among US Patients With Resistant Hypertension, 2008 to 2014

“…These results are consistent with previous cross-sectional studies in the TRH population. 17,18 Using data from the National Ambulatory Medical Care Surveys, Fontil et al 19 observed nonsignificant increases between 2006 and 2010 in the use of β-blockers, CCBs, and aldosterone receptor antagonists, similar to the trends found in our study. In contrast, the authors saw thiazide diuretic use decrease slightly during the study period, whereas we observed no substantial change in the prevalence of thiazide diuretics among TRH regimens.…”

“…Interestingly, we observed an unexpected decrease in the proportion of regimens containing an ACE-I during the study period. Although of a lower magnitude, Fontil et al 19 Our finding that hydrochlorothiazide remains the most commonly used thiazide diuretic is not surprising given its overwhelming use in the general hypertensive population. However, chlorthalidone use remains remarkably low in patients with TRH, despite evidence suggesting its superior BP-lowering ability and possible greater reductions in major adverse cardiovascular outcomes in most, [21][22][23][24] but not all, hypertensive populations.…”

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

“…However, real-world evaluation of practice patterns suggests frequent missed opportunities for appropriate treatment intensification in management of hypertension. 17,[34][35][36][37] The large impact of treatment intensification on population BP control seen in our model argues for large-scale adoption of interventions that have been shown to increase treatment intensification rates. 36,[38][39][40][41] Our results suggest that visit frequency is an important parameter in the management of hypertension.…”

Is 60 the New 80 in Hypertension?

“…A recent publication in this journal suggests that patients with resistant hypertension are elderly (mean age 68 years), with a high prevalence of comorbid conditions. 14 The authors noted that, overall, the use of AHArecommended medications for resistant hypertension remains low, despite publication of guidelines targeting this demographic. Given that these patients represent a population at very high risk of cardiovascular events, we are concerned that relaxed blood pressure standards would increase clinical inertia regarding necessary multi-drug therapy for hypertension.…”