Therapeutic Nihilism in Older Hypertensives: A Resounding Call to Action.

HomeHypertensionVol. 80, No. 3Therapeutic Nihilism in Older Hypertensives: A Resounding Call to Action Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessEditorialPDF/EPUBTherapeutic Nihilism in Older Hypertensives: A Resounding Call to Action John M. Flack and Asad Cheema John M. FlackJohn M. Flack Correspondence to: John M. Flack, Sergio Rabinovich Endowed Chair of Internal Medicine, Department of Medicine, Southern Illinois University, 701 N. First St – Room D442, P.O. Box 19636, Springfield, IL 62794-9636. Email E-mail Address: [email protected] https://orcid.org/0000-0003-2584-5598 Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University. Search for more papers by this author and Asad CheemaAsad Cheema Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University. Search for more papers by this author Originally published15 Feb 2023https://doi.org/10.1161/HYPERTENSIONAHA.122.20091Hypertension. 2023;80:563–565This article is a commentary on the followingTrends in Blood Pressure Treatment Intensification in Older Adults With Hypertension in the United States, 2008 to 2018Hypertension control is a complex interaction between the patient, practitioner, healthcare system as well as the social determinants of health. In recent years, overall hypertension control (<140/90 mm Hg) has declined.1 Therapeutic inertia is an important factor2 contributing to poor hypertension control defined as encountering blood pressure (BP) elevations during a clinic visit without intensification/initiation of antihypertensive drug therapy and, unfortunately, is the norm rather than the exception in clinical practice.2–4 And although therapeutic inertia reflects clinical decision-making, patient preference to not intensify antihypertensive drug therapy also impacts it.4See related article, pp 553–562Therapeutic inertia in older (>60 years) hypertensives is a very important problem. First, hypertension prevalence rises with age as does the prevalence of risk-enhancing comorbidities. Second, the clinical benefit of hypertension treatment is directly related to the absolute level of pretreatment cardiovascular disease risk.5 Third, a substantial body of evidence shows cardiovascular disease and mortality risk reduction, inclusive of patients manifesting frailty,6,7 as well as a reduction in cognitive decline,8 with effective hypertension treatment but without substantive offset of this benefit from adverse treatment effects.6,9 Fourth, the clinical benefits of pharmacological treatment extend to hypertensive patients aged ≥75 years.6,7In this issue of the journal, Chiu et al10 describe therapeutic inertia in older established hypertensives with BP above guideline-specific thresholds in the nationally representative National Ambulatory Medical Care Survey over the 2008 to 2018 timeframe. Three cohorts meeting guideline-specific criteria for escalation of antihypertensive drug therapy were created: (1) ≥65 with systolic BP >130 mm Hg (American College of Physicians/American College of Cardiology), (2) 65- to 80-year-old with systolic BP (SBP) >140 mm Hg (European Society of Cardiology/European Society of Hypertension), and (3) ≥60 with SBP >150 mm Hg (American College of Physicians/American Academy of Family Physicians). Therapeutic inertia was defined as BP at or above the guideline-specific BP levels at a clinic visit without prescription of another antihypertensive agent. Over the time period of observation, the prescription of new antihypertensive drugs averaged 11%, 14.2%, and 18.9%, respectively, for these three cohorts; among those not prescribed antihypertensive medications, the prescription of new antihypertensive drugs was 16.5%, 20.1%, and 26.4%. This report extends previous reports3,4 of therapeutic inertia in older hypertensives by documenting escalating therapeutic inertia over time.A study of therapeutic inertia and its correlates from a primary care setting offers some important insight.4 In this study of established hypertensive patients with BP >140/90 mm Hg, predictors of therapeutic inertia were older age, systolic and diastolic BP being near goal, office BP was not considered representative of the patients true BP, waiting for subsequent confirmatory BP readings, optimizing lifestyle first, and the presence of diabetes.One perceived source of treatment-induced harm has been that lowering diastolic BP could compromise coronary blood flow and thus precipitate coronary ischemia; nevertheless, the linkage of low diastolic BP with coronary risk is unlikely to be a causal association. In the SHEP pilot study (Systolic Hypertension in the Elderly Program),11 the strongest correlate of carotid stenosis was SBP >160 mm Hg; when diastolic BP was <65 mm Hg, the prevalence of carotid stenosis was an astounding 62.5%. In the SHEP study,12 5-year average BP was 155/72 and 143/68 mm Hg, respectively, in the placebo and active treatment arms; stroke, nonfatal myocardial infarction+coronary death, myocardial infarction, and heart failure were lowered by 36%, 27%, 33%, and 54%. Mean on-treatment BP levels were even lower in participants ≥75 years in the SPRINT trial (Systolic Blood Pressure Intervention Trial; 123.4/62 [intensive treatment group]) versus 134.8/67.2 mm Hg [standard treatment group]), a study where intensive treatment significantly lowered the primary cardiovascular disease composite outcome and total mortality.6 A recent trial9 of intensive hypertension treatment (SBP target 110–129 versus 130–149 mm Hg) in participants aged 60 to 80 years showed a significant 26% reduction in a composite cardiovascular outcome with similar benefit in those with diastolic BP <60 mm Hg at baseline or pulse pressure >60 mm Hg within 3 months of randomization.Despite our strong advocacy for treatment, we implement and monitor drug therapy in older hypertensives a bit differently than in younger hypertensives. Our general approach, a local tailoring of recommendations in the American College of Cardiology/American Heart Association hypertension guideline, is depicted in the Figure. We first establish an SBP target of <130 mm Hg13 for noninstitutionalized older adults, even for those with frailty. We fully embrace shared decision-making though we typically recommend concurrent implementation of lifestyle modifications and drug therapy. When BP remains above goal, we uptitrate drugs every 4 to 6 weeks until BP is less than target. Our clinic staff and patients are trained to measure BP with validated and calibrated devices using this protocol (https://www.heart.org./en/news/2018/05/01aha-ama-launch-high-blood-initiation); this minimizes in-office white coat effect and produces both clinic and home BP readings that can be confidently used for therapeutic decision-making. Obtaining self-measured home BP readings engages the patient which can, in turn, also help mitigate therapeutic inertia. Orthostatic hypotension prevalence is directly related to age and most patients with an orthostatic drop in BP (after one-minute standing) do not have orthostatic hypotension. Most patients with orthostatic dizziness do not actually have orthostatic hypotension. Orthostatic hypotension incidence amongst SPRINT participants aged >75 years was similar in the intensive and standard treatment groups.6 When the standing SBP falls >10 mm Hg, we use this BP not seated BP to guide treatment as long as this condition persists. Antihypertensive drug therapy starts with prescription of comorbidity-indicated drugs (eg, beta-blockers in thoracic aortic disease). If BP remains above goal, then incrementally add angiotensin receptor blockers or angiotensin-converting enzyme inhibitors (A), calcium antagonists (C), and thiazide-like >thiazide diuretics (D). The ultimate target regimen is comorbidity-indicated drugs+[A+C+D] drugs as needed to control BP.Download figureDownload PowerPointFigure. Accurate measurement of blood pressure in any setting requires purposeful actions but is never as time efficient as obtaining blood pressure readings without a standard protocol. Although infrequently done in clinical settings assessing orthostatic blood pressure change is essential to prevent treatment-induced harm. Comorbidity-indicated drugs are the first priority for inclusion when assembling an antihypertensive drug regimen. These drugs can be added in any order; however, we favor thiazide-like (chlorthalidone, indapamide)>thiazide (hydrochlorothiazide) diuretics if one of the initial 2 drugs is not a diuretic.A indicates Angiotensin receptor blocker or angiotensin-converting enzyme inhibitor; C, calcium antagonist; and D, thiazide-like>thiazide diuretic.The report in this issue of the journal confirms that the level of therapeutic inertia in high-risk older hypertensives has escalated over time. Given the proven benefits of treatment without off-setting treatment-related adverse effects, we conclude that these data are a resounding call to action.Article InformationDisclosures Research Grants for J.M. Flack from Glaxo Smith Kline, Indorsia, ReCor Medical, Quantam Genomics, Vascular Dynamics. Expert Witness for Teva. Consultant for ReCor Medical, Sanofi, Janssen, Amgen, Ardylex, FibroGen.FootnotesThe opinions expressed in this article are not necessarily those of the editors nor the American Heart Association.Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/HYPERTENSIONAHA.122.20091.For Disclosures, see page 565.Correspondence to: John M. Flack, Sergio Rabinovich Endowed Chair of Internal Medicine, Department of Medicine, Southern Illinois University, 701 N. First St – Room D442, P.O. Box 19636, Springfield, IL 62794-9636. Email jflack47@siumed.eduReferences1. Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, Colantonio LD. Trends in blood pressure control among US adults with hypertension, 1999 – 2000 to 2017 – 2018.JAMA. 2020; 324:1190–1200. doi: 10.1001/jama.2020.14545CrossrefMedlineGoogle Scholar2. Okonofua EC, Simpson KN, Jesri A, Rehman SU, Durkalski V, Egan BM. Therapeutic inertia is an impediment to achieving the healthy people 2010 blood pressure control goals.Hypertension. 2006; 47:345–351. doi: 10.1161/01.HYP.0000200702.76436.4bLinkGoogle Scholar3. Redon J, Coca A, Lazaro P, Aguilar D, Cabanas M, Gil N, Sanchez-Zamorano MA, Aranda P. Factors associated with therapeutic inertia in hypertension: validation of a predictive model.J Hypertens. 2010; 28:1770–1777. doi: 10.1097/HJH.0b013e32833b4953CrossrefMedlineGoogle Scholar4. Ali DH, Kilic B, Hart HE, Bots ML, Biermans MCJ, Spiering W, Rutten FH, Hollander M. Therapeutic inertia in the management of hypertension in primary care.J Hypertens. 2021; 39:1238–1245. doi: 10.1097/HJH.0000000000002783CrossrefMedlineGoogle Scholar5. 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No evidence that frailty modifies the positive impact of antihypertensive treatment in very elderly people: an investigation of the impact of frailty upon treatment effect in the HYpeertension in the Very Elderly Trial (HYVET) study, a double-blind, placebo-controlled study of antihypertensives in people with hypertension aged 80 and over.BMC Med. 2015; 13:78. doi: 10.1186/s12916-015-0328-1CrossrefMedlineGoogle Scholar8. Gupta A, Perdomo S, Billinger S, Beddhu S, Burns J, Gronseth G. Treatment of hypertension reduces cognitive decline in older adults: a systematic review and meta-analysis.BMJ Open. 2020; 10:e038971. doi: 10.1136/bmjopen-2020-038971CrossrefMedlineGoogle Scholar9. Zhang W, Zhang S, Deng Y, Wu S, Ren J, Sun G, Yang J, Jiang Y, Xu X, Wang T-D., et al; Cai J for the STEP Study Group. Trial of intensive blood-pressure control in older patients with hypertension.N Engl J Med. 2021; 385:1268–1279. doi: 10.1056/NEJMoa2111437CrossrefMedlineGoogle Scholar10. Chiu N, Chiu L, Aggarwal R, Raber I, Bhatt DL, Mukamal KJ. Trends in blood pressure treatment intensification in older adults with hypertension in the United States, 2008-2018.Hypertension. 2023; 80:553–562. doi: 10.1161/HYPERTENSIONAHA.122.19882LinkGoogle Scholar11. Sutton-Tyrell K, Alcorn HG, Wolfson SK, Kelsey SF, Kuller LH. Predictors of carotid stenosis in older adults with and without isolated systolic hypertension.Stroke. 1993; 24:355–361. doi: 10.1161/01.str.24.3.355LinkGoogle Scholar12. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension.JAMA. 1991; 265:3255–3264. doi: 101001/jama.1991.03460240051027CrossrefMedlineGoogle Scholar13. Whelton PK, Carey RM, Aronow WS, CaseyCollins DEKJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, et al. 2017 ACC/AHA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.Hypertension. 2018; 71:e13–e115. doi: 10.1161/0000000000000065LinkGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. 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