Abstract
Objectives. This study was performed to clarify whether treatment of hypertension and concomitant risk factors in Finland has improved after the introduction of national evidence‐based guidelines for antihypertensive treatment in 2002. Changes in the other cardiovascular risk factors of the Finnish hypertensive patients were also assessed. Design. Nationwide questionnaire survey of consecutive hypertensive patients having met by general practitioners during a given week in autumn 2006. Setting. Finnish general practice offices in primary care. Subjects. Data from 715 hypertensive patients, 358 men and 357 women, from 72 general practice offices. Main outcome measures. Systolic and diastolic blood pressure, serum lipids, smoking status and information about other risk factors. Results. The mean blood pressure of the patients was 147/88 mmHg. Eighty‐one men (23%) and 85 women (24%) reached the treatment goal of 140/85 mmHg or less. Low‐density lipoprotein‐cholesterol level below 2.5 mmol/l was reached by 104 (29%) men and 104 (29%) women. Only 13% of the hypertensive patients (16.8% of the men and 9.2% of the women) were active smokers. Conclusions. Roughly three‐quarters of hypertensive patients still failed to reach the blood pressure target of 140/85 mmHg recommended by the current Finnish Hypertension Guidelines. Our results are disappointing, considering the homogenous Finnish population and thorough primary healthcare system. Although the mean serum cholesterol concentration of the hypertensive population exceeded target values set by the guidelines, a clear improvement compared with early 21st century is seen. Also smoking has diminished considerably.
Introduction
Half of the Finnish men aged 35–64 years and one third of women in the same age group are hypertensive Citation[1]. More than half a million Finns received special reimbursement for antihypertensive drug treatment in 2006 Citation[2]. Although blood pressure levels in the general population have decreased significantly since the year 1972 Citation[1], the blood pressure level of the Finnish population is still high compared with other nations Citation[3].
The current evidence‐based National Hypertension Guidelines were first introduced in the year 2002 and updated in 2005 Citation[4]. According to the update, the treatment goal for blood pressure is at least below 140/85 mmHg. For diabetics, the target is set to ≤ 140/80 mmHg and in diabetics with nephropathy or proteinuria to ≤ 130/80 mmHg Citation[4].
The majority of Finnish patients with mild to moderate hypertension have at least one additional cardiovascular risk factor Citation[5],Citation[6]. Hypertensive patients have higher mean serum cholesterol concentrations and higher body mass index (BMI) compared with the normotensive population Citation[5],Citation[7]. Because of this accumulation of risk factors leading to increased risk of developing atherothrombotic disease, poorly treated hypertension is likely to be especially harmful among Finnish hypertensive patients.
In addition to published national guidelines, a series of changes supporting more effective antihypertensive treatment have taken place during the early 21st century in Finland. Fixed‐dose drug combinations and new, better tolerated antihypertensive drugs have been introduced. The reimbursed prices of the older antihypertensive drugs have fallen and home blood pressure measurement has become increasingly available. This study sought to clarify whether antihypertensive treatment results from the Finnish general practice reflect these recent changes.
Material and methods
The study patients were recruited among hypertensive patients visiting general practitioners (GP) offices during autumn 2006. Altogether 72 physicians from all five Finnish university hospital districts took part into the study. They were asked to collect data from all drug‐treated hypertensive patients aged 18 years or more having visited their office on a given week. GPs informed patients about the study and received written consent from those who agreed to take part into the study.
The study was accepted by the common ethical committee of Turku University and Varsinais‐Suomi Hospital District.
GPs filled in the study questionnaire, which contained age, sex, height, weight, blood pressure measurement data, tobacco data and latest blood lipid and glucose values. A mercury sphygmomanometer was used to measure systolic and diastolic (Korotkoff sounds, phase V) blood pressure, according to the Finnish Hypertension Guidelines Citation[4]. Physicians were also asked to collect data of other cardiovascular diseases, medication and the method patient used to monitor blood pressure.
The questionnaires were delivered to the health centres and collected from them by the representatives of the medical company LeirasFinland Oy. The study was financed by a grant from Turku University Hospital.
Statistics
Student's t‐test was used in the statistical analysis. Results are given as mean ± standard deviation (SD).
Results
Patients
The study population consisted of 358 men and 357 women.
The mean age of the patients was 59.76 12.1 years with 57.26 11.0 years in men and 61.36 12.14 years in women. The mean BMI was 29.36 5.3 kg/m2. The majority of the patients (79% of the women and 83% of the men) were overweight (BMI ≥ 25 kg/m2). About one third of the study patients (41% of the women and 34% of the men) were obese (BMI ≥ 30 kg/m2).
Office blood pressure
The measured office blood pressure values among different patient subgroups are summarized in . The systolic office blood pressure of the patients ranged from 92 to 250 mmHg and diastolic from 57 to 133 mmHg with a mean pressure of 147 ± 22/88 ± 12. Twenty‐three per cent of men and 24% of women reached the blood pressure target below 140/85 mmHg. Thirty‐five per cent of the patients reached the systolic blood pressure target < 140 mmHg and 54% the diastolic blood pressure target < 90 mmHg. Only 17% of the diabetics reached the target below 140/80 mmHg . Fourteen per cent of the diabetics reached the systolic blood pressure target < 130 mmHg and 29% the diastolic blood pressure target < 80 mmHg.
Table I. Measured office blood pressure (mmHg).
Table II. The number (%) of patients reaching target blood pressure.
Besides hypertension, 558 patients had at least one additional cardiovascular risk factor (diabetes, hypercholesterolemia, left ventricular hypertrophy, smoking) or hypertensive complication (myocardial infarction, nephropathy, stroke). The mean blood pressure of the patients with hypertension as the only cardiovascular risk factor was 147 ± 21/91 ± 12 mmHg (n = 157). The systolic blood pressure of the patients with three or more additional risk factors was significantly lower compared with those with one or two additional risk factors. The diastolic blood pressure was lower the more additional risk factors the patients had ().
Table III. Measured office blood pressure (mmHg) in patients with and without other risk factors than hypertension.
The patients prescribed two antihypertensive drugs had significantly lower blood pressure than those on antihypertensive monotherapy (). The systolic blood pressure of the patients prescribed three or more antihypertensive drugs was significantly higher than in those on two drugs. However, the diastolic blood pressure in those prescribed three or more drugs was significantly lower than in those on monotherapy. The proportions of patients reaching the target below 140/85 mmHg were 27.7%, 32.3% and 26.5% in patients prescribed one, two and three or more antihypertensive drugs, accordingly.
Table IV. Measured office blood pressure (mmHg) in patients with one, two or at least three antihypertensive drugs.
Other cardiovascular risk factors
HMG‐CoA reductase inhibitors (statins) were prescribed to 297 patients (41.5%), 157 (43.9%) men and 140 (39.2%) women. The mean serum total cholesterol concentration of the patients prescribed statin treatment was 4.72 ± 1.04 mmol/l and low‐density lipoprotein (LDL)‐cholesterol 2.61 ± 0.92 mmol/l (). The mean HDL‐cholesterol of all patients was 1.47 ± 0.44 mmol/l and the mean plasma triglyceride concentration 1.50 ± 0.84 mmol/l. LDL‐cholesterol below 2.5 mmol/l was seen in 29% of the patients.
Table V. Mean ± standard deviation serum cholesterol and low‐density lipoprotein (LDL) concentrations along with the number (%) of patients reaching target cholesterol concentrations.
About one fourth (n = 191 (27%), 28% of the men and 25% of the women) of the patients had diabetes. Majority of the study patients (n = 546 (76.4%), 83.8% of the women and 69.0% of the men) had never smoked. Seventy‐six (10.6%) of the patients had quit smoking. Ninety‐three patients (13.0%) smoked regularly. Smoking was more common among men (16.8% in men vs 9.2% in women).
Antihypertensive medication
Nearly half of the drug‐treated patients were prescribed beta‐blockers (). The use of medication not belonging to the groups listed in was very marginal (12 patients with moxonidine and two with prazosine). Sixty‐three per cent of the patients with antihypertensive drugs used combination therapy. Fixed‐dose combinations were used by 186 patients (22.7% of those on antihypertensive drug therapy).
Table VI. Antihypertensive medications used.
Home blood pressure measurements
Four hundred thirty‐six (61%) patients used home blood pressure measurements regularly.
Discussion
Our data was obtained from general practitioners as a cross‐section of their normal, daily hypertensive patient flow. This mode of data collection may result in underestimation of the overall severity of hypertension as a national problem because patients who visit physicians regularly are most often those who are committed to their treatment. This approach is, however, straightforward, effective and easy to perform. Besides, all study designs that rely on voluntary patient recruitment or data collection are susceptible to overrepresentation of benign and less‐severe cases. Questionnaire based on data collection can lead to some underestimation of the occurrence of harming life habit factors, especially smoking. Nevertheless, GPs share the same problems in their everyday work. The present study looks at the problem of hypertension and its treatment from GP's perspective with all its pros and cons.
In 2002, 22% of Finnish treated hypertensive men and 26% of women reached the treatment goal of 140/85 mmHg in general practice Citation[8]. The antihypertensive treatment efficacy at GP level still remains unsatisfactory because only 23% of men and 24% of women reached the same target in our study. According to the population survey in Finland by Kastarinen et al. Citation[1], the number of hypertensive patients reaching the target below 140/90 mmHg has increased from 13.7% to 33.3% in men and from 11.4% to 32.0% in women from the year 1982 to the year 2002 in Eastern and South‐Western parts of Finland. In our study, this less tight target was reached by 29% of the patients. The proportion of diabetics reaching target blood pressure of ≤ 130/80 in this study was even smaller (9%). The proportion of patients prescribed antihypertensive drug combinations (63%) remained at the same level as in 2002 Citation[8]. The poor blood pressure control observed in Finnish population parallels the recent reports from other European countries Citation[3],Citation[9]. However, according to the recent NHANES study, a slight majority of hypertensive patients reached the treatment goal of 140/90 mmHg in the USA, suggesting that better treatment results are achievable also in Europe Citation[10]. Our results also show that the diastolic target pressure is easier to reach than the systolic, which is one of the basic findings of the present study.
The more cardiovascular risk factors the patients had, the lower the diastolic blood pressure. This suggests that the general practitioners recognized these patients as high‐risk individuals and intensified their treatment accordingly. The lowest systolic and diastolic blood pressure in the group with three or more risk factors could at least partly be explained by a higher prevalence of cardiomyopathy and hence cardiac pump failure in this subgroup.
We find our results somewhat surprising given the recent improvements in antihypertensive drug therapy, improved blood pressure measurements capabilities and the thorough primary healthcare system in Finland. It is plausible that physicians and other healthcare professionals do not base and update their treatment routines according to the newest evidence‐based guidelines, highlighting the importance of continuous medical education to healthcare professionals.
The average blood pressure was about 5 mmHg lower in patients prescribed two antihypertensive drugs compared with those on monotherapy. Yet, patients prescribed three or more antihypertensive regimen did not have better blood pressure control than those prescribed two drugs. This suggests that patient non‐compliance may be an important barrier limiting the achievement of target blood pressure Citation[11]. Therefore, all efforts to improve treatment compliance, including developing a good doctor‐patient relationship, are needed Citation[12]. Alternatively but not exclusively, this may also reflect the higher prevalence of more severe, drug‐resistant hypertension in this subgroup.
In this study, the office blood pressure was measured by general practitioners according to the Finnish Hypertension Guidelines recommending a 5‐min rest with the cuff attached before the double measurement. However, lower values would probably have been registered and a greater proportion of patients would have reached the treatment target if blood pressure was measured by a nurse Citation[1],Citation[13]. According to a recent study, blood pressure of 146/88 mmHg measured by a physician matches 140/85 mmHg measured by a nurse Citation[14]. In this study, 35.2% of the study patients reached the blood pressure of 146/88 mmHg or less.
In this study, the office blood pressure was measured by general practitioners according to the Finnish Hypertension Guidelines recommending a 5‐min rest with the cuff attached before the double measurement. However, lower values would probably have been registered and a greater proportion of patients would have reached the treatment target if blood pressure was measured by a nurse Citation[1],Citation[13]. According to a recent study, blood pressure of 146/88 mmHg measured by a physician matches 140/85 mmHg measured by a nurse Citation[14]. In this study, 35.2% of the study patients reached the blood pressure of 146/88 mmHg or less.
Obesity is a major health problem in Finland. In the year 2005, 40% of Finnish women and 60% of men were overweight. The hypertensive patients in our study were even more obese than the general population in Finland. In our study, 80% of the patients exceeded the BMI of 25 kg/m2. Furthermore, every fourth patient in the present study was diabetic. The prevalence of diabetes was twice as high as in the general Finnish population Citation[15]. Compared with the study by Meriranta et al. from the year 2002 Citation[8], the prevalence of diabetes was higher, which reflects the increasing prevalence of obesity among Finns and underlines the importance of all procedures aiming to reduce the prevalence of obesity.
Smoking as a habit is decreasing among Finnish hypertensive patients. In the FINNRISK 2002 study, 36% of men and 24% of women in working age were smokers Citation[6]. According to the National Institute of Health, 27% of males and 18% of females in Finland smoked in the year 2005 Citation[16]. In the present study, only 13% of the patients admitted smoking and 10% had stopped smoking. Recent anti‐smoking campaigns and legislative actions banning smoking in public venues, including restaurants, have probably contributed to this positive development.
Marked changes have occurred in the general practitioners' prescription habits of different antihypertensive drugs during the early 21st century in Finland. In 2002, 18% of patients on antihypertensive drug treatment were prescribed angiotensin II type 1 receptor blockers (ARBs) Citation[8]. In our present study, the use of antagonists had more than doubled to 43%. Simultaneously fewer patients were taking angiotensin‐converting enzyme (ACE) inhibitors Citation[8]. There are only minor pharmacodynamical differences between ARBs and ACE inhibitors, and practically no differences in their efficacy to prevent major cardiovascular events Citation[17]. ARBs induce somewhat less adverse effects, especially cough Citation[17]. In randomized studies, however, the incidence of ACE inhibitor‐induced cough has been less than 10% Citation[17]. Thus, these rapid changes in the GP's prescription habits cannot be fully explained by scientific evidence and may at least partly reflect the active marketing of these drugs by the pharmaceutical industry.
In the present study, 47% of the drug‐treated hypertensive patients were prescribed beta‐blockers, which still remain as the most used antihypertensive drug class in Finland. This contrasts the national evidence‐based guidelines, which recommend beta‐blockers as first‐line alternatives only to hypertensive patients with coronary artery disease or heart failure, or during pregnancy Citation[4]. The risk of developing new‐onset diabetes is also higher on beta‐blocker therapy compared with newer antihypertensive drugs Citation[18].
Our results differ slightly from Finnish Statistics on Medicines 2006 Citation[19], which states according to the sales registry of Social Insurance Institution that ACE inhibitors were used by 37% (31%) of the Finnish hypertensive patients, ARBs 35% (43%), beta‐blockers 57% (47%) and calcium antagonists 38% (32%) (percentages in parenthesis from our study). The number of the patients using ARBs as their antihypertensive medication has increased steeply since the year 2000 (39% using ARBs in the year 2007). The higher number of ARBs and lower number of beta‐blockers in our study is possibly explained by a younger hypertensive population than in the statistics.
Only about half of the patients in our study had serum total cholesterol concentration below the target level of 5 mmol/l Citation[20]. The mean serum total cholesterol concentration in the present study was, however, clearly lower than in the FINRISK 2002 study Citation[5]. Besides sole cholesterol level changes, a broader cardiovascular risk reduction has also happened. Using the SCORE formula, 10‐year cardiovascular risk estimate for an average male patient in the present study is 6.7% and for female 3.0%. Corresponding estimates for untreated mildly hypertensive (160/95 or less) and non‐smoking Finns were calculated applying data from Kastarinen et al. Citation[5]. Risk estimates were 8.7% for men and 3.4% for women in 1982 and 7.9% vs 3.2% in 1997. If we compared our estimates to those of treated hypertensive patients in 1982 and 1997, the change was more obvious.
More extensive prescription of statins has at least partly contributed to this decline. Mean serum total cholesterol concentration of patients not taking any cholesterol lowering agent was also below that observed in the FINRISK 2002 study Citation[5]. Therefore, changes in lifestyle and nutritional habits have also contributed to this favourable development. However, only a half of our patients on statin therapy reached the recommended serum LDL‐level of 2.5 mmol/l, a target derived from the ASCOT study Citation[21].
Conclusion
Despite the introduction of national evidence‐based hypertension guidelines in 2002, the blood pressure control of Finnish hypertensive patients treated by general practitioners has not improved during the last 5 years and remains unsatisfactory. The prevalence of obesity and diabetes is increasing. Although mean serum cholesterol concentration exceeded the recommended targets, the proportion of patients reaching target total and LDL‐cholesterol levels has increased. Delightfully, the proportion of smokers has decreased. An extensive healthcare strategy including continuous medical education targeted to general practitioners and other healthcare professionals, as well as implementation of factors promoting patient compliance, such as home blood pressure measurements and fixed‐dose combination drugs (22,23), is needed in order to translate hypertension guidelines to real‐world treatment benefits in the near future.
Acknowledgements
We thank LeirasFinland Oy for the organization of delivering and collecting the study questionnaires and Turku University Hospital for a grant enabling the study.
References
- Kastarinen MJAntikainen RLLaatikainen TKSalomaa VVTuomilehto JONissinen AM, et al. Trends in hypertension care in eastern and south-western Finland during 1982–2002. J Hypertens 2006; 24: 829–836
- Finnish Statistics on Medicines 2006. Lääkelaitos ja Kansaneläkelaitos. Edita OyHelsinki2007
- Antikainen RLMoltchanov VA, Chukwuma C, Sr, Kuulasmaa KA, Marques‐Vidal PM, Sans S, et al. WHO MONICA Projectl. Trends in the prevalence, awareness, treatment and control of hypertension: the WHO MONICA Project. Eur J Cardiovasc Prev Rehabil 2006; 13: 13–29
- The Finnish Current Care Guidelines: hypertension. Duodecim. 2002;118:110–26. First update. 2005;121:1–22.
- Kastarinen MTuomilehto JVartiainen EJousilahti PSundvall JPuska P, Nisinen A. Trends in lipid levels and hypercholesterolemia in hypertensive and normotensive Finnish adults from 1982 to 1997. J Intern Med 2000; 247: 53–62
- Kastarinen MTuomilehto JVartiainen EJousilahti PNissinen A, Puska P. Smoking trends in hypertensive and normotensive Finns during 1982–1997. J Hum Hypertens 2002; 16: 299–303
- Kastarinen MJNissinen AMVartiainen EAJousilahti PJKorhonen HJPuska PM, et al. Blood pressure levels and obesity trends in hypertensive and normotensive Finnish population from 1982 to 1997. J Hypertens 2000; 18: 255–262
- Meriranta PTikkanen I, Kumpusalo E. Verenpainepotilas terveyskeskuksessa: Hoitotulokset paranemassa. Suom Lääkäril 2004; 36: 3253–3258
- Control of hypertension – An important national priority. New Eng J Med 2001; 345: 534–535
- Giles T, Aranda J, Jr, Suh DChoi IPreblick RRocha R, Frech‐Tamas F. Ethnic/racial variations in blood pressure awareness, treatment, and control. J Clin Hypertens (Greenwich) 2007; 9: 345–354
- Kyngäs H, Lahdenperä T. Compliance of patients with hypertension and associated factors. J Adv Nursing 1999; 29: 832–839
- Campbell N. Treating hypertension with guidelines in general practice. BMJ 2004; 329: 523–524
- Fung V, Huang J, Brand R, Newhouse JP, Hsu J. Hypertension treatment in a medicare population: Adherence and systolic blood pressure control. Clin Ther 2007; 29: 972–984
- Kumpusalo E, Teho A, Laitila R, Takala J. Janus faces of the white coat effect: blood pressure not only rises, it may also fall. J Hum Hypertens 2002; 16: 725–728
- Ylihärsilä H, Lindström J, Eriksson JGJousilahti PValle TTSundvall J, et al. Prevalence of diabetes and impaired glucose regulation in 45‐ to 64‐year‐old individuals in three areas of Finland. Diabet Med 2005; 22: 88–91
- Tolonen H, Helakorpi S, Talala KHelasoja V, Martelin T, Prättälä R. 25-year trends and socio-demographic differences in response rates: Finnish adult health behaviour survey. Eur J Epidemiol 2006; 21: 409–415
- Matchar D, McCrory D, Orlando L, Patel MPatel U, Patwardhan M, et al. Systematic review: comparative effectiveness of angiotensin‐converting enzyme inhibitors and angiotensin II receptor blockers for treating essential hypertension. Ann Intern Med 2008; 148: 16–29
- Bangalore S, Parkar S, Grossman E, Messerli FH. A meta‐analysis of 94,492 patients with hypertension treated with beta blockers to determine the risk of new‐onset diabetes mellitus. Am J Cardiol 2007; 100(8)1254–1262
- Finnish Statistics on Medicines 2006. National Agency for Medicines and Social Insurance Institution. Edita Prima OyHelsinki2007
- The Finnish Current Care Guidelines: Dyslipaemia. Duodecim 2004; 120: 1794–1816
- Sever P, Dahlöf B, Poulter NWedel HBeevers GCaulfield M, et al. ASCOT investigators. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower‐than‐average cholesterol concentrations, in the Anglo‐Scandinavian Cardiac Outcomes Trial – Lipid Lowering Arm (ASCOT‐LLA): a multicentre randomized controlled trial. Lancet 2003; 361: 1149–1158
- Neutel JM. Prescribing patterns in hypertension: the emerging role of fixed‐dose combinations for attaining BP goals in hypertensive patients. Curr Med Res Opin July 9, 2008, [Epub ahead of print].
- Edmonds D, Foerster EGroth HGreminger PSiegenthaler W, Vetter W. Does self‐measurement of blood pressure improve patient compliance in hypertension. J Hypertens Suppl 1985; 3: S31–S34