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Clinical Corner

This Editorial has been written by the specialist opinion leader, Lee A Green, MD, MPH, Associate Professor, Department of Family Medicine, University of Michigan, Michigan and published in the latest issue of the serial publication, Drugs in Context.

For more information, you can download a free-of-charge Quick Reference Guide to the Losartan in Hypertension and Cardiovascular Disease issue of Drugs in Context which is designed to give you an insight into the numerous key points of information and practical guidance contained in each issue, via carefully selected quotations taken directly from each part of the publication.

CSF Medical Communications publishes Drugs in Context which aims to provide clinicians around the world with a comprehensive, authoritative and independent review of all the significant data on a specific drug, placed in the context of the disease area and today's clinical practice. Each issue comprises four parts - an opening Editorial, a Disease Overview, a Drug Review and finally an Improving Practice section. Each drug is placed within the context of its indications and the clinical practice situation concerned.

Hypertension is the most common chronic disease encountered in primary care, affecting approximately 50 million Americans. More than half of the population above 65 years of age are affected, while the lifetime risk of developing hypertension approaches 90%. The World Health Organization (WHO) recently identified hypertension as one of the most important preventable causes of death worldwide. The evidence base supporting the effectiveness of antihypertensive treatment is the largest in clinical medicine. The number needed to treat to prevent one death over 10 years among patients with one or more cardiovascular risk factors (i.e. those patients typically seen in primary care) is only 11, making the control of hypertension one of the most beneficial treatments medicine has to offer.

Over the past 30 years, we have progressed from having only a handful of antihypertensives that were unpleasant to take and had to be dosed several times a day to having a wide range of options that are tolerable to patients and can be taken just once or twice daily. Concomitantly, we have progressed from studies that demonstrated only reductions in blood pressure to real outcome data proving that lowering blood pressure reduces cardiovascular morbidity and mortality. We now have data refined enough to focus on different populations and subgroups with varying cardiovascular risk, particularly individuals with diabetes, left ventricular hypertrophy, hyperlipidemia, renal disease, elderly patients with isolated systolic hypertension, and different ethnic groups. This sound base of data has allowed the formulation of evidence-based guidelines focused on improving outcomes that matter to patients.

Unfortunately, implementation of these patient-oriented, evidence-based guidelines has been patchy. Failure to use what we know, rather than not knowing enough, is why we are currently failing to achieve blood pressure targets in practice. Not many more than half of patients with hypertension are treated at all, and only half of those treated are treated to goal. In actuality, substantial progress has been made, but blood pressure goals (especially for those with diabetes or renal disease) have also been lowered as evidence of benefit has accumulated, leaving the gap only modestly narrowed compared with a generation ago.

We have abundant evidence that lowering blood pressure with appropriate lifestyle and medication choices will reduce the risk of congestive heart failure, stroke and myocardial infarction. How do we improve the translation of this evidence into clinical practice? For all our improved knowledge of treatment efficacy, this last step remains woefully under-researched. Yet, it is there that the greatest potential exists to improve outcomes for people with hypertension.

Some additional knowledge about hypertension is still needed. Front-line clinicians must understand that for the majority of patients, adequate control will require more than one drug. Researchers must move beyond single-agent comparison studies towards defining the optimum combinations that deliver the greatest outcome improvements for various kinds of patients.

Most importantly, front-line primary-care practitioners and academic researchers must join together to study hypertension treatment in the context in which it actually occurs - actual practice in the community. Practice-based research networks (PBRNs) provide the ideal setting for studying what really works for patients more representative of community practice, and how to translate what we know into what we do in ways that are generalizable and sustainable in primary care. In PBRNs, hypertension treatment can be studied in the context of competing health priorities, and also in the context of other interventions (e.g. statins) aimed at preventing the same outcomes. That research is the crucial next step in improving hypertension care.