Underuse of antihypertensive therapies in at-risk populations
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Corresponding author John M. Flack, MD, MPH Wayne State University, 4201 St. Antoine, Suite 2E, Detroit, MI 48201, USA. E-mail: jfl[email protected] Current Cardiovascular Risk Reports 2008, 2:192 –197 Current Medicine Group LLC ISSN 1932-9520 Copyright © 2008 by Current Medicine Group LLC
Effective control of elevated blood pressure (BP) levels over the long term substantially lowers the likelihood of premature mortality, microvascular and macrovascular diseases, and pressure-sensitive organ failure (eg, heart failure). High-risk hypertensive patients, such as those with concomitant cardiovascular-renal conditions (eg, diabetes, dyslipidemia), vascular disease, depressed heart/kidney function, or even just severe BP elevations, are at high risk for pressure-sensitive complications. African Americans are another high-risk demographic group but, arguably, because diet and lifestyle attributes lead to high levels of cardiovascular-renal conditions. Although high-risk hypertensive patients accrue the largest absolute risk reductions when treated effectively, they are least likely to attain goal BP levels below recommended targets. This is significantly attributable to resistance to antihypertensive treatment. Undertreatment of high-risk hypertensive patients occurs because of factors related to the patient, physician, the patient–physician interface, and the system (or typically lack thereof) of care delivery.
Introduction The relationship between blood pressure (BP) and premature mortality, cardiovascular-renal diseases, and organ failure is continuous, graded, and evident at incrementally higher BP levels within the so-called normal range [1, 2]. Although systolic and diastolic BP have been linked to these pressure-related complications, systolic BP confers more risk than diastolic BP, at least in middle-aged or older persons [3,4]. When other cardiovascular-renal conditions are present, the absolute risk of pressurerelated complications is considerably augmented at any given level of BP [5–10].
There have been many large, long-term, clinical endpoint trials in hypertensive patients with and without other cardiovascular-renal comorbidities. These trials have not yielded unconfounded evidence of harm in these populations during treatment; arguably, however, clinical benefit has not been proven in all subgroups known to be at risk from elevated BP. Even when clinical benefit has been proven, the optimal target BP level is not always known. Nevertheless, there is good reason to believe that current target levels of below 140/90 mm Hg or even below 130/80 mm Hg in persons with diabetes and/or chronic kidney disease are not low enough to maximally lower pressure-related risk [11], because the risk of pressure-related complications begins to escalate at BP levels greater than 115/75 mm Hg, doubling every 20/10 mm Hg. Despite a few uncertainties, there is a compelling case for aggressive hypertension treatment at least to, and probably lower than, currently recommended BP targets, even in groups in which benefit has not bee
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