Guessous, Idris

RERO DOC Digital Library

Capsule Commentary on Fontil, et al. Physician Underutilizationof Effective Medications for Resistant Hypertension at Office Visitsin the United States: NAMCS 2006-2010Idris Guessous, MDUnit of Population Epidemiology, Division of Primary Care Medicine, Department of Community Medicine, Primary Care and EmergencyMedicine, Geneva University Hospitals, Geneva 14, Switzerland.J Gen Intern Med 29(3):516DOI: 10.1007/s11606-013-2711-y© Society of General Internal Medicine 2013R esistant hypertension is defined as elevated bloodpressure despite optimal or best-tolerated treatmentwith at least three antihypertensive agents (one of which isusually a diuretic). Compared to patients with controlledblood pressure, patients with resistant hypertension are50 % more likely to experience adverse cardiovascularevents over a 4-year period.1 The first managementguideline for management of resistant hypertension waspublished by the American Heart Association (AHA) in2008.2 Currently, there are several guidelines on treatingresistant hypertension.Using data from the National Ambulatory Medical CareSurvey, Fontil et al. described trends in physician (general/family practitioners, internists, cardiologists) use of recom-mended medications for resistant hypertension before andafter the 2008 AHA guidelines.3 The authors found that useof recommended medications for resistant hypertension waslow and remained low 2 years after guideline publication.Assuming that the contribution of pseudo-resistant hyper-tension to these results is limited (e.g., minimal white coathypertension), these findings are unfortunately in line withprevious studies that highlighted the limited impact ofguideline publications.4 Fontil et al. discussed the use oftreatment algorithms to encourage prescription of recom-mended medications including the importance of feedbackto physicians regarding patterns of medication use. It is notclear whether it will be sufficient to swiftly improve thecare of patients with resistant hypertension. Indeed, theclinical inertia of physicians not specialized in hypertension(an inertia due to several factors including misguidedacceptance of elevated blood pressure and underestimationof cardiovascular disease risk)5 might remain a meaningfulbarrier to changing treatment of resistant hypertension evenafter the implementation of a treatment algorithm.An alternative would be to consider a “detect andredirect” approach. Non-specialist practitioners could betrained and helped (including by algorithms) to detectpatients with resistant hypertension and then be guided toredirect them to physicians (including general internists) orto units/clinics specialized in the management of hyperten-sion. In addition to improving the recommended medicationuse, this approach could also contribute to improving theinvestigation of resistant hypertension in general (e.g.,diagnosis, secondary causes, target organ damage). Whetherthis would improve outcomes is worthy of future research.Conflict of Interest: The author has no conflict with any of thematerial in this manuscript.Corresponding Author: Idris Guessous, MD; Unit of PopulationEpidemiology, Division of Primary Care Medicine, Department ofCommunity Medicine, Primary Care and Emergency Medicine,Geneva University Hospitals, 4, Rue Gabrielle-Perret-Gentil 1211,Geneva 14, Switzerland (e-mail: idris.guessous@hcuge.ch).REFERENCES1. Pimenta E, Calhoun DA. Resistant hypertension: incidence, prevalence,and prognosis. Circulation. 2012;125(13):1594–6.2. Calhoun DA, Jones D, Textor S, Goff DC, Murphy TP, Toto RD, WhiteA, Cushman WC, White W, Sica D, Ferdinand K, Giles TD, Falkner B,Carey RM. Resistant hypertension: diagnosis, evaluation, and treatment.A scientific statement from the American Heart Association ProfessionalEducation Committee of the Council for High Blood Pressure Research.Hypertension. 2008;51(6):1403–19.3. Fontil et al. Physician Underutilization of Effective Medications forResistant Hypertension at Office Visits in the United States : NAMCS2006-2010. J Gen Intern Med, 2013; doi:10.1007/s11606-013-2683-y.4. Davis DA, Taylor-Vaisey A. Translating guidelines into practice. Asystematic review of theoretic concepts, practical experience and researchevidence in the adoption of clinical practice guidelines. CMAJ.1997;157(4):408–16.5. Myat A, Redwood SR, Qureshi AC, Spertus JA, Williams B. Resistanthypertension. BMJ. 2012;345:e7473.Published online December 6, 2013516

Capsule Commentary on Fontil, et al. Physician Underutilization of Effective Medications for Resistant Hypertension at Office Visits in the United States: NAMCS 2006-2010

http://doc.rero.ch/record/324740/files/11606_2013_Article_2711.pdf

Capsule Commentary on Fontil, et al. Physician Underutilization of Effective Medications for Resistant Hypertension at Office Visits in the United States: NAMCS 2006-2010

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library