Physicians Fall Short Prescribing Optimal BP Meds per Guidelines

This study was published as a preprint and has not yet been peer reviewed.

Key Takeaways

Only half of patients treated for markedly elevated blood pressure (BP) received guideline-recommended combination antihypertensive drug therapy in a study from a major healthcare system.
Clinician shortfalls in adhering to guidelines on the initiation or intensification of antihypertensive drug therapy represent a major barrier to hypertension control in such patients.

Why This Matters

Almost half of adults in the United States have hypertension, which is associated with an increased risk for adverse cardiovascular and renal events.
Although current practice guidelines recommend two or more antihypertensive agents initially for patients with markedly elevated BP, physician adherence to such recommendations appears suboptimal.
A better understanding of guideline adherence surrounding antihypertensive drug prescription could inform efforts to improve effective management of patients with markedly elevated BP.

Study Design

The population-based, retrospective study covered adult patients in a single healthcare delivery system with markedly elevated BP, which was defined as two sequential outpatient appointments with systolic BP ≥160 mm Hg or diastolic BP ≥100 mm Hg occurring between October 2015 and December 2018.
Previously and newly prescribed antihypertensive medications within 90 days of patients’ second outpatient visit with elevated BP were documented.
Antihypertensive medications for patients prescribed drugs from two classes were assessed for whether the classes adhered to the 2017 American College of Cardiology/American Heart Association hypertension guidelines. Results were stratified by whether patients had prior myocardial infraction (MI), diabetes, chronic kidney disease (CKD), or uncomplicated hypertension.

Key Results

Of 16,377 patients (mean age 66) found to have had markedly elevated BP, assessed for drug prescriptions within 90 days after their second visit:
- 29.8% showed no active antihypertensive drug prescriptions
- 20% had been prescribed a drug from one class
- 50.2% were prescribed drugs from at least two classes of antihypertensive
Angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) were the most commonly prescribed drug classes among patients prescribed one such agent, and calcium channel blockers (CCB) were the second most common drug class.
ACEI or ARB with thiazide diuretic (21%) was the most common combination in patients prescribed two drug classes, followed by ACEI or ARB plus a CCB (20.6%).
Only 54.3% of the population receiving initial antihypertensive therapy received a guideline-recommended two-drug class combination regimen.
Appropriate drug therapy was prescribed in 67% of patients with prior MI, 51.4% of those with diabetes, 48.2% of patients with CKD, and 49.2% of patients with uncomplicated hypertension.
Prescription of guideline-recommended combination therapy was generally lower in patients who were older, had a lower body mass index, and lower BP.

Limitations

The data may not be representative of other health systems.
The electronic health record system was used by only one federally qualified health center. Although the health center is the largest system in the state, some patients with markedly elevated BP being treated in the community were likely overlooked in this study.
Patients treated only as inpatients or in the emergency department setting were excluded.
There was no available data on patient adherence to medication.

Disclosures

The study received no commercial funding.
Yuan Lu, ScD, reports funding from the National Heart, Lung, and Blood Institute and the Yale Center for Implementation Science.
Harlan M. Krumholz, MD, reports receipt of expenses and/or personal fees from UnitedHealth, Element Science, Aetna, Reality Labs, Johnson & Johnson, the Siegfried and Jensen Law Firm, Arnold and Porter Law Firm, Martin/Baughman Law Firm, and F-Prime; and being a co-founder of Refactor Health and HugoHealth, and associated with contracts, through Yale New Haven Hospital, from the Centers for Medicare & Medicaid Services.
Wade L. Schulz, MD, PhD, reports collaboration with the National Center for Cardiovascular Diseases in Beijing, being a technical consultant to HugoHealth, a co-founder of Refactor Health, and a consultant for Interpace Diagnostics Group.
Joseph S. Ross, MD, reports research support through Yale University from Johnson and Johnson, the Medical Device Innovation Consortium, the US Food and Drug Administration, the Agency for Healthcare Research and Quality, the National Heart, Lung and Blood Institute, and the Laura and the John Arnold Foundation.

This is a summary of a preprint research study, “Medication Guideline Adherence Among Patients with Markedly Elevated Blood Pressure in A Real-World Setting” written by Yuan Lu From Yale New Haven Hospital and the Yale School of Medicine and colleagues on MedRxiv, provided to you by Medscape. This study has not yet been peer reviewed. The full text of the study can be found on medRxiv.org.

For more news, follow Medscape on Facebook, Twitter, Instagram, YouTube, and LinkedIn

Source: Read Full Article