Response to Target Blood Pressure Level Before Antihypertensive Class to Improve Outcomes More Quickly in Uncomplicated Hypertension
We appreciate Wexler’s1 comments about the need for improvement in hypertension treatment in primary care settings. We agree that initiating treatment and adequately controlling blood pressure should be key objectives of primary care physicians. Our focus on patterns of drug selection in hypertension treatment did not intend to diminish the important implications of suboptimal treatment and control of elevated blood pressure. At the same time, appropriate medication choice may not only further the goal of blood pressure control but also achieve the goal of lowering the global risk for heart attack and stroke by ensuring that patients receive cost-effective medications with the best evidence of clinical efficacy. Current practices continue to deviate substantially from national recommendations.
Our analysis used 2 federally collected US national ambulatory care surveys to examine 1993–2004 trends in the prescription of antihypertensive drugs for uncomplicated hypertension. Thiazide diuretic prescriptions increased significantly immediately after the 2002 publication of main results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial demonstrated clinical equivalence or, in some cases, superiority of thiazide diuretics compared with calcium channel blockers and angiotensin-converting enzyme inhibitors.2 Use of calcium channel blockers and angiotensin-converting enzyme inhibitors declined after the 1997 release of JNC-6 in which diuretics and β-blockers were the recommended first-line drug therapies for uncomplicated hypertension.3,4 These changes, however, seemed transitory, because prescribing patterns subsequently regressed toward their previous levels. This illustrates the difficulty involved in disseminating evidence-based practice, an issue not limited to hypertension.
With spending on prescription drugs in the United States projected to reach $219 billion for 2006,5 the provision of the most cost-effective and clinically appropriate medications should be a priority. Basing prescribing decisions on the best evidence available can ensure that the greatest number of people can be treated with existing resources. Thiazide diuretics are a cost-effective class of antihypertensives and a recommended component of blood pressure control in patients with uncomplicated hypertension.2–4,6,7 Approximately 70% of US hypertensive adults do not have comorbidities that compel the initial use of other drug classes.2 Although we agree that aggressive treatment of patients with unrecognized and recognized hypertension should be a priority, we are concerned that current practices are not adequately cost-effective or evidence based.
Sources of Funding
This research was funded by research awards from the National Institute on Aging (P30 AG017253-06) and the US Agency for Healthcare Research and Quality (R01-HS11313).
Wexler R. Target blood pressure level before antihypertensive class to improve outcomes more quickly in uncomplicated hypertension. Hypertension. 2007; 49: e16.
ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002; 288: 2981–2997.
Stafford R, Monti V, Furberg C, Ma J. Long-term and short-term changes in antihypertensive prescribing by office-based physicians in the United States, Hypertension,. 2006; 48: 213–218.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42: 1206–1252.
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