The challenge of blood pressure control in patients with ischaemic heart disease in Europe

Abstract

The goal of the paper is to summarize the current status of blood pressure management in patients with ischaemic heart disease. Recently published results from Europe and North America showed that about half of ischaemic heart disease patients have their blood pressure over 140/90 mmHg. Moreover, these data provide further evidence that poor hypertension management is common in a variety of healthcare settings. Although most ischaemic heart disease patients receive blood pressure‐lowering drugs, still a large proportion of them does not reach the recommended treatment goals. During recent years, several attempts were made to improve the control of risk factors (among them blood pressure) in patients with ischaemic heart disease; however, none of them was definitively successful.

• Hypertension
• ischaemic heart disease
• quality of medical care
• risk factors

The current status of hypertension management in general population is far from being satisfactory. Large studies have shown that the rate of controlled blood pressure (BP) among patients with hypertension does not exceed 30% worldwide [1–3], although safe and effective antihypertensive therapies are readily available and the importance of obtaining optimal BP control through the use of these therapies is being increasingly recognized. Several factors have been indicated as possibly responsible for poor hypertension management in general population [1], [3–5].

Recently published results from Europe and North America showed that about half of ischaemic heart disease (IHD) patients have their BP over 140/90 mmHg [6], [7]. EUROASPIRE I, a European Society of Cardiology survey conducted in nine European countries (published in 1997), showed that 53% of IHD patients had BP⩾140/90 mmHg [8]. Results from the Cracovian Program for Secondary Prevention of Ischaemic Heart Disease revealed that high BP was present in 46% of IHD patients in Cracow in 1997/1998 [9]. Surveys conducted in the following years did not show any significant improvement in BP control in Europe [6], [10], [11]. In addition, a cross‐sectional survey conducted in France showed that about 30% of patients admitted due to unstable angina or myocardial infarction leave hospital with uncontrolled hypertension [12]. Although hypertensive subjects with IHD are at a much higher risk when compared with their counterparts without IHD, little is known about factors influencing hypertension management in IHD patients. Analysis of the Cracovian Program for Secondary Prevention of Ischaemic Heart Disease data showed that men and non‐diabetics with IHD are at significantly higher risk of having unrecognized hypertension when compared with women and diabetics with IHD [13]. Age, gender, diabetes, body mass index, smoking and hypertension unawareness were indicated as predictors of uncontrolled hypertension in subjects with IHD [13], [14]. It seems that factors related to the quality of hypertension management in IHD patients may be somewhat different when compared with hypertensives without IHD.

It is known that quality of in‐hospital care is related to the quality of medical care in the post‐discharge period [15]. False‐negative diagnosis of hypertension during hospitalization due to IHD was found in up to 20% of cases [13]. One explanation of this finding could be that physicians may focus less on the history of hypertension treating IHD, which would be supported by the lack of information on previous hypertension in up to 20% of medical records [16].

The European and American guidelines recommend combination therapy when monotherapy fails to control hypertension [17], [18]. Low‐dose combination therapy may even be considered the first step in treating hypertensive patients, especially those with high BP values. Moreover, international guidelines stress the lack of diuretic treatment as a major cause of refractory hypertension. In light of these recommendations, underuse of combination therapy was observed in the studied populations [13], [14]. Among patients studied in the PRAKTIK and ESPOIR surveys, less then one‐third of uncontrolled hypertensives received at least a three‐drug combination including diuretics [14]. Even less frequent use of combined antihypertensive therapy was found in centres participating in the Cracovian Program for Secondary Prevention of IHD [13]. In the EUROASPIRE II survey, 51% of patients taking BP‐lowering medication had elevated BP [19]. Despite the liberal use of BP‐lowering drugs, BP was inadequately controlled in all participating regions, in both men and women, across different diagnostic categories and otherwise clinically important subgroups [19].

Although patient adherence was not assessed in the above‐mentioned studies, it is unlikely that patient non‐adherence alone could explain the failure of physicians to diagnose and initiate or advance therapy appropriately. Rather, the results suggest that patients are not receiving adequate BP‐lowering treatment. Indeed, in 50% of hospitalized patients studied by de Macedo et al. [20] extemporaneously prescription of antihypertensive medication was not associated with maintained antihypertensive treatment. In the study of Berlowitz et al. [21], physicians did not increase medications during about three‐quarters of visits in which elevated BP values were recorded. Indeed, recent evidence suggests that even in hospitalized high‐risk patients, hypertension is not always correctly recognized [13]. The above data suggest that in a majority of cases practitioners do not perceive tight BP control as a suitable or realistic goal. This “treatment gap” has been attributed to factors including physician focus on acute problems, time constraints, lack of incentives, lack of resources and facilities, and inadequate specialist–generalist communication [22]. It was shown that an important reason why physicians do not treat hypertension more aggressively is that they are willing to accept an elevated BP (especially systolic) in their patients [23], [24]. Importantly, most physicians typically believe they are quite aggressive in treating hypertension, especially in patients with established IHD.

During recent years, several attempts were made to improve the control of risk factors (among them BP) in patients with IHD. In the Southampton Heart Integrated Care Project (SHIP), the intervention led by specialist nurses who coordinated and supported follow‐up care in general practice of patients who had a hospital diagnosis of myocardial infarction or angina failed to show any improvement in the BP control at 1 year follow‐up [25]. On the other hand, nurse‐led secondary prevention clinics in a study of Murchie et al. were shown to improve BP control (96.5% vs. 88.0%; p<0.05), although this improvement did not persist during next 3 years after finishing of the intervention [26]. In the Extensive Lifestyle Management Intervention programme, a 3‐mmHg increase in the mean systolic BP was found in the usual care group, whereas no significant change could be seen in the intervention arm (the intervention consisted of exercise sessions, telephone follow‐ups and risk factor and lifestyle counselling; [27]). It should be underlined, that this prevention of BP increase, although modest, can have a real impact on the patient's prognosis. Although the intervention (audit and feedback, interactive workshops for physicians, printed materials) conducted in the Cracovian Program for Secondary Prevention of Ischaemic Heart Disease improved the quality of BP management during hospitalization due to IHD [16], no improvement in BP control was found in the post‐discharge period [11]. Tuniz et al. studied the effectiveness of secondary prevention programme (including exercise training, education, risk factors modification, psychosocial counselling) in patients who had undergone percutaneous coronary intervention [28]. The rate of patients with BP within normal range at the end of the study (47%) did not vary significantly from the rates found in EUROASPIRE surveys [6], [8]. Another approach was tested in the study of Fox et al. [29]: a multi‐professional, family‐based programme of lifestyle and risk factor modification was offered to patients with IHD. Although the programme was related to better BP control after 8 weeks of intervention (24% patients with high BP), this improvement could not be seen during 1 year follow‐up (47% patients with high BP). As it is underlined by the authors, BP control was the least well maintained aspect of secondary prevention in that study [29].

All the above‐mentioned studies have shown that the problem of BP control in IHD patients is far from being solved. Therefore, the European Society of Cardiology made a new effort and has established the EuroAction trial [30]. The EuroAction project is a randomized controlled trial aiming at reaching the goals recommended in the European guidelines [31] and is being conducted in eight European countries (Denmark, France, Italy, Poland, Spain, Sweden, the Netherlands and the UK). If this new effort gives a new promise of BP control, we should see an improvement in IHD patients in the near future.

Recently published studies indicate that hypertension treatment in the secondary prevention of IHD is not satisfactory in Europe. Moreover, these data provide further evidence that poor hypertension management is common in a variety of healthcare settings. Although most patients receive BP‐lowering drugs, a large proportion of them has elevated BP values. An improvement in the efficacy of implementation of secondary prevention of IHD is thus mandatory.

Conclusions

Hypertension management in the secondary prevention of IHD still is not satisfactory in Europe, despite attempts made to improve BP control. A new effort should be made to raise the quality of medical care in the field of hypertension management in IHD patients.