(Hypertension. 1998;31:771-779.)
© 1998 American Heart Association, Inc.
Antihypertensive Efficacy of Treatment Regimens Used in Veterans Administration Hypertension Clinics
H. Mitchell Perry, Jr;
Stephen Bingham;
Anne Horney;
Gale Rutan;
Mohinder Sambhi;
Sharon Carmody;
Joseph Collins;
; for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents
From the Cooperative Studies Program of the Medical Research Service,
Department of Veterans Affairs, St Louis, Mo.
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Abstract
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Abstract—There is continuing
uncertainty about whether morbidity and mortality of treated
hypertensive patients depends on the drug(s) used to treat or only on
the level of blood pressure achieved. This study was undertaken in a
sample of special Veterans Administration hypertension clinics to
determine which antihypertensive drugs were selected by the involved
healthcare providers and how effective they were in achieving
normotension. Hypertensive veterans (n=6100) were followed in six VA
Hypertension Screening and Treatment Program clinics for 46 months
beginning in May 1989. Their average age was 60.7 years; 53% lived in
the Stroke Belt; 46% had target organ damage, 36% were black, 23%
smoked, and 10% had diabetes mellitus. Antihypertensive regimens were
divided into 12 all-inclusive categories. Blood pressures were averaged
at the last study visit for all patients on a regimen. The regimens of
diuretic or diuretic plus ß-blocker gave the lowest
average pressures (140.6/82.3 mm Hg) and calcium
antagonist the highest (149.0/86.5 mm Hg). ANOVA
indicated that differences between seven common regimens and also
between the four single drug regimens were highly significant
(P<.0001). This pattern of low treated pressure with
the "old" agents and higher treated pressure with newer agents was
reflected in the percentage of patients controlled below 140/90
mm Hg and the percentage uncontrolled above 159/94 mm
Hg. Blacks and patients with target organ damage resembled the entire
cohort in average treated diastolic blood pressure, but the
former had lower and the latter had higher treated systolic
blood pressure than the entire cohort.
Key Words: drug efficacy • target organ damage • race • blood pressure
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Introduction
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This report examines
the overall results of treating hypertension in six Hypertension
Screening and Treatment Program (HSTP) clinics of the Department of
Veterans Affairs. The period covered was from May 1989 through February
1993. The choice of antihypertensive regimen and the extent of the
effort to achieve the HSTP diastolic blood pressure (DBP)
goal of 95 mm Hg were left to the discretion of the
physician-coordinator of the clinic and the clinic staff. For this
report, the various pharmacological treatments that were used have been
divided into 12 regimens.
In 1974, the Veterans Administration (VA) initiated a special HSTP
consisting of physician-supervised clinics in which primary care was
provided by nurses and physician assistants intensively trained in
hypertension.1 2 Initially they followed the
treatment guidelines, including step-care, as described by Task Force I
of the NHBPEP.3 These guidelines were
periodically revised in accordance with the Joint National Committee
(JNC) Reports, culminating in JNC-IV.4
For the first 3 years of its existence from 1974 through 1976, the
adequacy of the HSTP was monitored by having clinical data collected at
all patient visits and entered into a computerized database.
Approximately 10 000 previously untreated hypertensive veterans were
carefully followed during this period. Combination of their baseline
and early treatment data with 15- to 20-year mortality data has yielded
useful information on the natural history of treated
hypertension.5 6 7 8 9 10
The data collected here were obtained in a "real world" VA
outpatient setting rather than in a randomized double-blind research
setting. The cohort studied was unusual in being 50% minority,
economically deprived, and drawn from throughout the United States. In
addition, it was primarily male and largely limited to those with mild
and moderate hypertension because more severely hypertensive subjects
were referred to more intensive care. This data collection project
was designed to provide both quality control of antihypertensive
treatment for the individual and information about the efficacy of
treatment for individual clinics as well as for the entire HSTP.
This report examines the efficacy with which blood pressure was
controlled by 12 mutually exclusive but all-inclusive pharmacological
antihypertensive regimens as they were used at six clinics. A separate
report deals with adverse effects, including morbid and mortal
events.
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Methods
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A total of 6100 veterans were treated in six HSTP clinics
(Indianapolis, Ind; Iowa City; Jackson, Miss; Memphis, Tenn; St Louis,
Mo; and San Juan, PR) during the 46 months between May 1, 1989, and
February 28, 1993. The clinical information determined at each patient
visit was computerized with a program developed for the HSTP. A study
chairman's office at the St Louis, Mo, VA Medical Center supervised
and facilitated the data collection at the HSTP clinics and data
transmission to the VA Coordinating Center at Perry Point, Md.
At the Coordinating Center, the data were entered into a master file
and analyzed. All clinics began entering clinic visit data in
May of 1989 except for Indianapolis, which began in September of 1989;
all continued to enter data through February of 1993. Every patient
with a visit at one of the six HSTP clinics during this period was
included in this report.
Data Collected
Two one-page forms were used to record data. Form 1 was
completed once when a veteran entered the HSTP; it included demographic
and pre-HSTP data including age, race, sex, height, past and family
histories, years of education, and marital status. Form 2 (except for
the "annual visit section") was completed at each visit; it
included the average of three blood pressures, antihypertensive
medication prescribed at that visit (drug and dose), self-reported
compliance with the medication prescribed at the prior visit (>80% of
pills taken, 50% to 80%, 20% to 50%, or <20%), individually
volunteered symptoms and their severity (easily tolerated, tolerated
with difficulty, or intolerable), interval history (including any
morbid cardiovascular event since last visit),
ancillary medication, and weight.
The "annual visit section" of Form 2 was designed to be completed
every 12 to 18 months. It included alcohol intake (none, <3 drinks/d,
or 
3 drinks/d), cigarette usage (number/d), abnormal physical
findings (with emphasis on the cardiovascular system),
and evidences of target organ damage (in retina, heart, kidney, nervous
system, and vasculature). It also included ECG abnormalities, as
defined by the Minnesota Code11 ; its specifically
listed diagnoses were left ventricular
hypertrophy, old myocardial infarction, premature
ventricular contractions, ST-T changes,
arrhythmias, and conduction defects. The annual visit section
also included laboratory data, specifically serum glucose (with
notation if nonfasting), serum cholesterol (HDL
cholesterol optional), serum creatinine,
potassium, uric acid, SGOT, and finally urinary protein and sugar by
dipstick. Entries in the "annual visit section" of Form 2 were
accepted into the master file whether or not all items were
completed.
HSTP Cohort
The characteristics of the cohort are tabulated in Table 1
. There were 6025 men and 75 women.
Fifty-nine percent of the entire cohort was older than 60 years of age,
with the percentage of patients over 60 varying among the six clinics
from 56% to 64%. The racial distribution for the entire 6100 patients
was 36% black, 50% white, and 14% Hispanic; however, it varied
markedly among the six clinics: 98% of the Iowa City cohort was white,
72% of the St Louis cohort was black, and 99% of the San Juan cohort
was Hispanic.
Target organ damage had been recognized in 46% of patients before
their last visit during the observation period. On this basis, these
patients were designated as having "complicated hypertension" or as
being "complicated." The incidence of damage to individual target
organs was retina, 27%; heart, 14%; peripheral
vasculature, 6%; kidney, 4%; and central nervous system, 4%. Some
ECG abnormality was recorded for 46% of patients, with 12% having
left ventricular hypertrophy. The cohort with
target organ damage differed from the entire cohort in age and racial
composition. Only 41% of blacks but 48% of nonblacks had target organ
damage. Likewise, only 37% of patients 60 years of age or younger but
51% of those older than 60 had target organ damage.
As of February 28, 1993, the 6100 patients had been followed in
the HSTP for an average of 6.4±5.7 years. Eleven percent of all
patients had been followed for >15 years; 17% for 11 to 15 years;
20% for 6 to 10 years; and 52% for 0 to 5 years. The percentage
followed for >15 years differed markedly among clinics, with a range
of 1.5% to 40%.
On entering the HSTP, the average blood pressure for the entire 6100
patient cohort was 148/92 mm Hg; for 19% (1092 patients) who
denied taking antihypertensive drugs at that time, the average was
158/100 mm Hg. The first blood pressure recorded in this
46-month study period averaged 144/86 mm Hg for the entire
cohort; the last one recorded averaged 144/85 mm Hg.
Patient Visits
A master file was compiled for all 6100 patients consisting of
(1) the demographic and baseline data obtained at the first HSTP visit
after April of 1989, (2) blood pressure and medication data obtained at
all of the 41 498 visits made by these 6100 patients during the 46
months of study follow-up, and (3) physical findings, laboratory work,
alcohol intake, and cigarette usage for the 3421 of these patients who
had annual visit data collected during the last year of follow-up. The
number of visits averaged 6.8 per patient. Eleven percent of patients
had only 1 visit, 19% had 2 or 3 visits, 25% had 4 to 6 visits, 25%
had 7 to 10 visits, and 20% had >10 visits. The interval between
visits averaged 118 days (median, 96 days). The total follow-up time
equaled 11 444 patient-years.
Determination of Blood Pressure
At all visits, three blood pressures were measured on seated
subjects under minimally stressful conditions, with standardized
mercury sphygmomanometers. The three pressures were averaged to obtain
a "visit pressure." In compiling Table 3, the blood pressure at the
last visit is coupled with the antihypertensive regimen prescribed at
the next-to-last visit because that medication was considered to be
primarily responsible for blood pressure at the following
visit.*
Antihypertensive Treatment Regimens
In Table 2 and subsequent tables,
the patients are divided into 12 groups on the basis of the
antihypertensive regimen prescribed at their next-to-last visit. These
12 regimens are defined as ND, no antihypertensive drug; D,
diuretic; B, ß-blocker; A, ACE inhibitor; C,
calcium antagonist; OD, other single antihypertensive drug;
D+B, diuretic+ß-blocker; D+S,
diuretic+non–ß-blocker sympatholytic agent; D+A,
diuretic+ACE inhibitor; D+C,
diuretic+calcium antagonist; D+OD,
diuretic+single antihypertensive agent not listed above; and
Other, any regimen not listed above. All two-drug regimens without a
diuretic and all regimens with three or more drugs are included
under "Other."
Sixty-one percent of the patients were receiving one of the seven most
frequently prescribed, that is, common regimens. These included four
one-drug regimens (D, B, A, and C) and three two-drug regimens
consisting of diuretic plus a second drug (D+B, D+A, and D+C).
These seven regimens are emphasized in the presentation of
"Results" and in the "Discussion."
Statistical Methodology
ANOVA and 
2 techniques were used to
assess the significance of differences between treatment regimens.
Confidence intervals were calculated in two different ways. Standard
95% confidence intervals for average systolic blood pressure
(SBP) and DBP were calculated independently for each treatment regimen.
Confidence intervals for the differences between regimens were
determined from Tukey's studentized range test. Two-way ANOVA with
medical center as a blocking factor was also used to assess the
significance of differences between treatment regimens with regard to
SBP and DBP.
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Results
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Prescribed Antihypertensive Agents
Sixty-one percent of the 6100 patients studied used one of the
seven common regimens, that is, four single drug regimens and three
regimens involving diuretic plus a second drug. Two of the
seven, the two single-drug regimens consisting of either
diuretic (D) or calcium antagonist (C), were used
much more frequently than any of the other five (Table 2
). The 39% of
patients not following any of these seven common regimens were
following a variety of regimens (Table 2). Two-drug regimens without
diuretic (7.6%, n=463), three-drug regimens (11.9%, n=724),
and four- or five-drug regimens (0.12%, n=62) have been combined into
"Other Treatment Regimens" in Table 2. The six clinics differed
widely in their patterns of regimen usage (Table 2).
Total Usage of `Early' Drugs
An examination of the overall usage of antihypertensive agents
revealed that 3265 patients across all treatment regimens (54% of the
cohort) took diuretics. Of those taking diuretics, 55%
used hydrochlorothiazide (exclusive of combination
pills), 25% used the combination of hydrochlorothiazide and
triamterene, 8% used furosemide, and 5% used chlorthalidone.
Twenty-one percent of patients took a ß-blocker, with atenolol being
responsible for 44%, metoprolol for 22%, propranolol for
15%, and nadolol for 13% of their usage. A total of 11.8% of
patients took one of the older sympatholytic agents, with clonidine
accounting for 63% and reserpine for 29% of their usage.
Total Usage of `Newer' Drugs
Of the "newer" antihypertensive agents, calcium
antagonists were taken by 33% of the patients, ACE
inhibitors by 25%, and 
-blockers by 4.9%. For calcium
antagonists, the percentage used in individual clinics
varied substantially, ranging from 19% to 49%. Nifedipine
was responsible for 33% of the calcium antagonist usage,
verapamil for 53%, and diltiazam for 13%. For ACE
inhibitors, the percentage used in individual clinics
ranged from 15% to 58%. Enalapril was responsible for 60% of the ACE
inhibitor usage, lisinopril for 26%, and
captopril for 14%.
Average SBP
In Fig 1, the treatment regimens for
the entire 6100 patients are arranged in ascending order of average SBP
at last visit, and the 95% confidence intervals are indicated. The
two-drug regimen consisting of diuretic+ß-blocker had the
lowest average SBP (140.1 mm Hg), whereas diuretic
alone and ß-blocker alone had the next two lowest average SBPs. In
contrast, calcium antagonist had the highest average SBP
(149.0 mm Hg). The 95% simultaneous confidence
interval for the difference between SBP associated with
diuretic and the SBP associated with calcium
antagonist was 5.1 to 11.3 mm Hg.
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Figure 1. Bars indicate the average systolic blood
pressure (SBP) (top) and diastolic blood pressure (DBP)
(bottom) at the last computerized visit for patients on the 12
treatment regimens in ascending order of SBP or DBP. Numbers at the top
of the bars give the average values; vertical lines in the bars
indicate 95% confidence intervals of these averages. The treatment
regimens were those prescribed at the next-to-last visit and hence
considered to be responsible for the SBP at the last visit. (For the
249 patients with only last-visit regimen available, the last-visit
regimen was used instead of the next-to-last visit regimen.) The seven
dark bars indicate the seven common regimens. ND indicates no
antihypertensive drug; D, diuretic; B, ß-blocker; A, ACE
inhibitor; C, calcium antagonist; OD, other
single antihypertensive drug; D+B, diuretic+ß-blocker; D+S,
diuretic+non–ß-blocker sympatholytic agent; D+A,
diuretic+ACE inhibitor; D+C,
diuretic+calcium antagonist; D+OD,
diuretic+single antihypertensive agent not listed above; and
Other, any other regimen not listed above. All two-drug regimens
without a diuretic and all regimens with three or more drugs
are included under "Other." The complete designation for all 12
regimens are given in Tables 2 to 6 and in the text.
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Average DBP
Fig 1 gives the pattern for DBP;
this was similar to but not identical with that for SBP. Here the
treatment regimens are arranged in ascending order of average DBP, with
the extreme contrast being between diuretic (81.9 mm
Hg) and calcium antagonist (86.5 mm Hg). Again
the 95% simultaneous confidence interval for the
difference between the DBPs associated with diuretic and
calcium antagonist was 3.0 to 6.3 mm Hg.
Interclinic Differences
The average blood pressure was lower for the entire cohort in the
three clinics with high diuretic usage (
21%) and low
calcium antagonist usage (9%) than it was for the
entire cohort in the other three clinics, which had an almost reverse
usage pattern of "early" versus "newer" drugs*
(141.8/82.0 versus 147.0/87.7 mm Hg) (Table 3). Thus the average difference in blood
pressure between these two groups of clinics was 5.2/5.7 mm
Hg. However, for each of the six clinics individually, the averages of
both SBP and DBP for the patients on diuretic alone were lower
than the averages for patients receiving calcium antagonist
alone (Table 3). The average difference in blood pressure between these
two single-drug regimens was 5.3/2.2 mm Hg (Table 3).
A two-factor ANOVA model was used with clinic as a blocking factor to
evaluate the differences between the seven common regimens as well as
the differences between the four single-drug regimens of Table 3. The
results were similar for both the seven common and the four single-drug
regimens and indicated that the differences between regimens were
significant (P<.0001) and did not depend on interclinic
differences, although remaining interactions indicated that regimen
efficacy did differ among clinics.
SBP 160 mm Hg
SBP at last visit is given by treatment regimen in Table 4. The treated SBP was <140 mm
Hg for 43% of the entire population and <160 mm Hg for
79%. At the other extreme, 5% of the cohort had treated SBP of
180 mm Hg (Table 4). At the time these data were collected,
the HSTP had no stated SBP goal. Diuretic plus ß-blocker had
the smallest percentage of patients whose treated SBP was >159
mm Hg (14.3%), whereas calcium antagonist had the
largest percentage (28.0%) (Fig 2).
DBP 95 mm Hg
For the six individual clinics, the fraction of patients with DBP
<95 mm Hg ranged from 75% to 93%. Reflecting the average
DBP pattern, diuretic was associated with the smallest
percentage of patients with treated DBP of >94 mm Hg (8.6%),
whereas calcium antagonist was associated with the largest
percentage (20.4%) (Table 5).
Blacks
Overall, the 2175 black patients had better SBP control than the
entire cohort (Table 4). For each of the 12 regimens, blacks had lower
average treated SBP than the entire cohort. Moreover, for 11 of the 12
regimens, the percentage of black patients with SBP >159 mm
Hg was less than the percentage for the entire cohort (Fig 2). In
contrast, blacks did not differ from the total cohort in average
treated DBP or in percentage of patients with treated DBP >94
mm Hg (Table 5).
Considering only the seven common regimens, blacks who took a
diuretic plus ß-blocker had the lowest average SBP
(135.4 mm Hg), and those who took a calcium
antagonist had the highest (144.5 mm Hg). These
two regimens also produced the lowest and highest percentages of
patients with SBP> 159 mm Hg (10.6% and 19.2%) (Fig 2).
Patients With Target Organ Damage (Complicated
Hypertension)
The 2776 patients with target organ damage (both black and
nonblack) had higher average treated SBP (2.6 mm Hg) and a
higher percentage of patients with SBP >159 mm Hg (3.9%)
than the entire cohort (Table 4). However, like the blacks, the
complicated hypertension subjects had treated DBP similar to the
treated DBP of the entire cohort (Table 5).
Considering only the seven common regimens, complicated hypertension
subjects who took diuretics had the lowest average SBP
(141.8 mm Hg), and those who took calcium
antagonists had the highest (151.1 mm Hg).
Diuretics and ACE inhibitors produced the lowest
and highest average DBPs, respectively (81.0 and 86.4 mm
Hg).
Change in Treatment Regimen
Changes in treatment regimen (drug and/or dose) during the
follow-up are summarized in Table 6. For
23.6% of the 5440 patients with more than one visit, treatment was not
changed at all during the 44-month period of observation; for 26.6% it
was changed only once; for 19.7% it was changed twice; for 12.3% it
was changed thrice; and for 17.7% it was changed more than three
times. One third of the changes (34%) were because of unsatisfactory
blood pressure control; 15% were to reduce dosage; 12% were because
of symptoms; and 15% were made outside of the HSTP clinic and hence
for uncertain reasons. The remaining one fourth of the changes were
made for miscellaneous or unspecified reasons.
Forty-six percent of patients who were receiving a diuretic at
the next-to-last visit had not changed medication during the
observation period. In contrast, only 18% of patients receiving a
calcium antagonist or an ACE inhibitor and only
13% receiving diuretic+ACE inhibitor had no change
(Table 6).
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Discussion
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The data reported here indicate significant differences in the
blood pressure control associated with various antihypertensive
regimens at six HSTP clinics. Diuretics and ß-blockers were
associated with both lower average blood pressures (both SBP and DBP)
and lower percentages of uncontrolled blood pressures than calcium
antagonists (Tables 4 and 5). For DBP, the ACE
inhibitor pattern resembled the calcium
antagonist pattern. In contrast, for SBP, patients
receiving an ACE inhibitor did better and their values
resembled those of patients receiving a diuretic more closely
than those of patients receiving a calcium antagonist.
Finally, the difference in blood pressure response to the various
regimens was reflected in how often the regimen was changed, with half
of those receiving a diuretic having no change during follow-up
versus one fourth of those receiving a calcium antagonist
or ACE inhibitor (Table 6).
A simple explanation is that for the elderly cohort and the clinical
conditions described here, the diuretic was a more potent
antihypertensive agent than was the calcium antagonist.
However, other possible explanations for this apparent difference in
efficacy cannot be excluded. One is that clinics prescribing a calcium
antagonist for large numbers of patients (St Louis, 23.0%;
Iowa City, 22.8%) did not set their goal pressures as low as clinics
prescribing a diuretic for large numbers of patients (San Juan,
23.6%; Jackson, 20.1%; and Memphis, 18.5%). A second explanation is
that patients who were begun on diuretic and who were
uncontrolled by that regimen were then switched to a calcium
antagonist or had a second drug added to the regimen. A
third explanation is that patients originally selected for
diuretics differed from those selected for calcium
antagonists, that is, that the latter group had higher
pretreatment blood pressures, had more complicated hypertension, or
differed in other ways that might affect treated blood pressure.
In blacks, the average treated SBP differed from that achieved by the
entire cohort (141.2 versus 144.2 mm Hg); however, there was
no difference in DBP. A partial explanation for this dissociation of
SBP and DBP may well be the absence of an SBP goal and the presence of
a DBP goal that was attained by both blacks and nonblacks. The
dissociation in blacks might be associated with their younger age (1.4
years) and therefore a less predominantly systolic
hypertension. In support of this, the 16% of blacks for whom
pretreatment blood pressures were available had lower pretreatment SBP
(1.8 mm Hg) and higher pretreatment DBP (1.5 mm Hg)
than the rest of the cohort (Table 1).
The level of achieved average SBP in hypertensive subjects with target
organ damage also differed from that of the entire cohort; for them it
was higher, again possibly reflecting the absence of an SBP goal and an
age difference, the average age of the complicated hypertension
subjects being 2.1 years older than that of the entire cohort.
Whether this better control of blood pressure with early drugs than
with newer agents that was observed in an unblinded "real-world"
study of elderly veterans will be reflected in the morbidity and
mortality results of a randomized, blinded study like the
Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Disease
Trial (ALLHAT), which is currently under way,12
remains to be seen. Certainly the relative antihypertensive efficacy of
the various classes of drugs observed in the VA Cooperative Study of
Single Drug Therapy13 was different and
apparently below what was observed here. The conditions, however, were
very different, and any comparison would be comparing two completely
different types of trials.
The importance of including a diuretic in antihypertensive drug
regimens when more than one agent is needed was demonstrated in a
recent report from the VA Cooperative Study Group on Antihypertensive
Agents. Patients who failed to be controlled with either of two
randomly selected antihypertensive drugs as monotherapy (from six study
drugs) were then treated with a combination of the two drugs. Two-drug
regimens containing the diuretic
hydrochlorothiazide as one of the drugs controlled 69%
of these "monotherapy-resistant" patients; regimens not
containing a diuretic only controlled 51% of
patients.14
The above data from six VA HSTP clinics do not represent the
results of a randomized clinical study. Rather, choice of drug is
subject to physician preference, formulary restrictions, and regional
differences in patient cohort. However, the data reflect overall
prescribing patterns in a sample of VA clinics and in the resulting
blood pressure response. These results support the efficacy of a
diuretic-based or ß-blocker–based regimen in treating
hypertension. The regimens with diuretic or ß-blocker or with
the two combined resulted in the lowest SBP and DBP (Tables 4 and 5),
although these three regimens represent only 43% of the seven
commonly used one- or two-drug regimens (Table 2). Both
diuretics and ß-blockers are the only antihypertensive agents
shown to reduce cardiovascular morbidity and mortality
in hypertensive patients in randomized clinical studies. Whether the
newer agents that are now widely prescribed will be just as effective
in reducing cardiovascular disease is currently being
tested in ongoing randomized clinical studies such as
ALLHAT.12 In the interim, surveillance of
prescribing patterns within the VA system emphasizes wide regional
variation but confirms the effectiveness of diuretics and
ß-blockers as first-line agents in treating hypertension.
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Acknowledgments
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This study was supported by the Cooperative Studies Program of
the Department of Veterans Affairs Medical Research Service
(Chairman's Office, St Louis, Mo: H. Mitchell Perry, Jr, Chairman;
Sharon E. Carmody, Administrator; Mohinder P. Sambhi
Consultant; Coordinating Center, Perry Point, Md: Joseph
Collins, Director; Stephen Bingham, Biostatistician; Anne Horney,
Statistician). Clinician members of the Department of Veterans Affairs
Cooperative Study Group for the Hypertension Screening and Treatment
Program were as follows: Indianapolis, Ind: J. Howard Pratt, Mary Jane
Spencer; Iowa City: Sharlene Hartman, George Uhl, Mary Wall; Jackson,
Miss: Richard Horne, Kent Kirchner, Martha Hilliburton, Betty Townsend;
Memphis, Tenn: William Cushman, John J. Davis, Gale Rutan, Marion
Taylor; St Louis, Mo: Karen Bobo, Greta H. Camel, Eleanor Janson,
Cecilia Pectol, Kathleen Wenzel; San Juan, PR: Jose Ciancini, Jean
DaMore, Eli Ramirez; Washington, DC: Grace Meyer.
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Footnotes
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Reprint requests to Dr Perry, Veterans Affairs Medical Center (111DJC), 915 N Grand Blvd, St Louis, MO 63106.
1 Eleven percent of the cohort (n=660) had only one visit during study follow-up. For 411 of them, the regimen was not changed at that visit and hence was the same as the regimen at the next-to-last visit. Because there is some uncertainty about the regimen at the next-to-last visit for the remaining 249, the regimen at the last visit was used for them. 
2 For Iowa City and St Louis, the heavily used "newer" drug was a calcium antagonist; for Indianapolis it was an ACE inhibitor.
Received January 9, 1997;
first decision February 14, 1997;
accepted October 9, 1997.
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Abstract
Introduction
