At Issue

Inertia, adherence among critical topics in hypertension

The problem of hypertension is a multifaceted one. Many factors contribute to the increasing global burden of hypertension. Cardiology Today asked some of the nation’s leading experts on hypertension to glean their thoughts on the most critical issues facing patients and clinicians in that area.

Weighing in are Cardiology Today Editorial Board Member Rhonda Cooper-DeHoff, PharmD, MS, FAHA, FACC, FCCP, associate professor and Research Foundation Professor in the College of Pharmacy at the University of Florida; Suzanne Oparil, MD, FACC, FAHA, FASH, FAPS, distinguished professor of medicine, holder of the United Therapeutics Endowed Professorship in Pulmonary Vascular Disease, professor of cell, developmental and integrative biology, section chief of vascular biology and hypertension and director of the Vascular Biology and Hypertension Program at the University of Alabama at Birmingham; Raymond R. Townsend, MD, professor of medicine and director of the Hypertension Program at the Hospital of the University of Pennsylvania; and Randall M. Zusman, MD, director of the division of hypertension at Massachusetts General Hospital Heart Center, consultant in cardiology at the Massachusetts Institute of Technology and associate professor of medicine at Harvard Medical School. – by Erik Swain

What is the biggest issue in hypertension today?

Rhonda Cooper-DeHoff, PharmD, MS, FAHA, FACC, FCCP

Rhonda Cooper-DeHoff, PharmD, MS, FAHA, FACC, FCCP
Rhonda Cooper-DeHoff

The biggest problem is inertia on the part of the clinician to recognize when hypertension treatment adjustments are necessary to optimize BP reduction. For example, in a patient on a single BP-lowering drug with continued elevated BP readings, the addition of a second drug from a different drug class can result in an additional 10 mm Hg reduction. Prescribing of combination products, all of which are available in a generic format, can substantially improve BP control and patient adherence.

Suzanne Oparil, MD, FACC, FAHA, FASH, FAPS

The biggest issue in hypertension today is chronic hypertension in pregnancy, ie, what to do with the BP of hypertensive women who become pregnant.

Suzanne Oparil, MD, FACC, FAHA, FASH, FAPS
Suzanne Oparil

Hypertension is the most common major medical disorder during pregnancy, affecting 2% to 6%, or up to 260,000, of U.S. births annually. Given temporal increases in obesity, older maternal age and more aggressive diagnostic criteria for hypertension, the prevalence of chronic hypertension in pregnancy is rising. Chronic hypertension in pregnancy is associated with a marked two- to fivefold increase in adverse outcomes, including fetal growth restriction/small for gestational age infants, fetal or newborn death, placental abruption and preterm birth, as well as heart disease and death in the mother.

Despite these serious complications, treatment recommendations for chronic hypertension during pregnancy are very different from those for hypertension in the general population. Pharmacologic treatment of chronic hypertension is standard care for the general population because of major long-term benefits, including reductions in death, MI, HF, stroke and kidney failure. However, during pregnancy, current guidelines from the American College of Obstetricians and Gynecologists recommend that treatment be withheld or may be discontinued for most hypertensive women — those with chronic hypertension classified as mild. This recommendation results from the lack of data documenting maternal or perinatal benefits of antihypertensive treatment during pregnancy and concerns about the safety of a treatment that may increase placental insufficiency and, therefore, harm the fetus.

Available data from limited clinical trials and systematic reviews show that antihypertensive treatment did lower BP but did not reduce the risk for pregnancy outcomes such as small for gestational age infants, placental abruption and preterm birth. In fact, decreasing maternal BP with antihypertensive medication has been associated with increased risk for small for gestational age and low birth weight infants. For more than 2 decades, scientific and professional organizations have called for large clinical trials to evaluate the benefits and safety of antihypertensive therapy in pregnancy. The Chronic Hypertension and Pregnancy (CHAP) project is an ongoing NHLBI-funded pragmatic randomized trial designed to evaluate the benefits and harms of pharmacologic treatment of mild chronic hypertension in pregnancy. Results of CHAP should be available within 2 years and will provide valuable new information on the short-term outcomes of treating chronic hypertension in pregnancy that will inform future treatment guidelines.

Raymond R. Townsend, MD

There are a number of candidates for addressing which issue is the biggest one in hypertension, including proper measurement, using validated devices to measure BP, patient adherence to medications and nondrug approaches to BP lowering.

Raymond R. Townsend, MD
Raymond R. Townsend

It may not be obvious, but my pick is patient adherence to medications. I am amazed by data from the SPYRAL HTN-ON MED study, in which we told patients we were going to specifically check — using both urine and blood samples — for the presence of prescribed medicines required for participation in the study. In patients with hypertension taking one to three prescription medicines, we checked for the presence of the medication at three separate time points. We found about 60% of the patients were taking the medications. Amazingly, it was not the same 60%; people switched categories. Some had only one medication at one visit, and all three at the second visit, and only one again at the third visit. Ultimately, we found ourselves confronted with data that had virtually never been done before in a clinical trial. Moreover, when others have looked in clinic populations who are seeing hypertension doctors for “resistant hypertension,” they found that one time in six, the patients are taking no medication, and about one time in four the patients are taking fewer BP medicines than what they were prescribed based on their medical history.

Like former U.S. Surgeon General C. Everett Koop, MD, said, “Drugs don’t work in patients who don’t take them.” In a time where hypertension practitioners are witnessing even more stringent definitions of what constitutes controlled BP, and where our performance as health care practitioners on a metric like BP control can be ascertained by a few keystrokes in an electronic health record, it is increasingly important that we both acknowledge this issue with medication adherence, and figure out ways to promote adherence to treatments we administer to manage this crucial vital sign: BP.

Randall M. Zusman, MD

The number of hypertensive patients continues to grow as newer and more aggressive guidelines are adopted and applied to a progressively aging population. Fortunately, we now have dozens, if not hundreds, of choices to make for the treatment of high BP. Using an appropriately crafted medical regimen in the setting of lifestyle modification — dietary salt restriction, weight loss and exercise — it is almost always possible, if the patient is compliant with a multidrug regimen, to control their BP.

Randall M. Zusman, MD
Randall M. Zusman

So, what is the challenge or biggest issue in hypertension today? My answer is the need to identify those many patients who are indeed hypertensive and to initiate appropriate treatment when the elevated BP values are first identified. So often, I find that my new referrals are patients who have been known to be hypertensive for years, but were either untreated or undertreated for most of that time. Embedded within this patient population, of course, are a subset of those with secondary causes of their hypertension — most commonly, hyperaldosteronism — and identifying those with a disorder other than essential hypertension for which there is a targeted therapeutic regimen remains crucially important.

An additional challenge is then to integrate the therapies we use for the treatment of the patient’s hypertension, with the concomitant need to treat their hyperlipidemia (hypercholesterolemia and/or hypertriglyceridemia), diabetes, atrial fibrillation or other cardiac dysrhythmia, as well as their gastrointestinal, pulmonary, renal, cardiac (CAD/angina) or other comorbidities. The resultant multidrug regimens, which raise the question of adverse drug-drug interactions, place both a financial burden and a marked pill burden on many of our patients and prevent full adherence to their complex treatment needs. Only by treating all of the comorbidities that increase the patient’s CV risk profile can we hope to maximally reduce their morbidity/mortality while improving their quality of life.

Disclosures: Cooper-DeHoff and Zusman report no relevant financial disclosures. Oparil reports she has received personal fees from 98point6 and CinCor Pharma; grants and personal fees from ROX Medical; grants from Bayer and Idorsia Pharmaceutical; and personal fees and other/nonfinancial support from Preventric Diagnostics; and that she receives a stipend from Springer Science Business Media LLC. Townsend reports he consults for Medtronic.

The problem of hypertension is a multifaceted one. Many factors contribute to the increasing global burden of hypertension. Cardiology Today asked some of the nation’s leading experts on hypertension to glean their thoughts on the most critical issues facing patients and clinicians in that area.

Weighing in are Cardiology Today Editorial Board Member Rhonda Cooper-DeHoff, PharmD, MS, FAHA, FACC, FCCP, associate professor and Research Foundation Professor in the College of Pharmacy at the University of Florida; Suzanne Oparil, MD, FACC, FAHA, FASH, FAPS, distinguished professor of medicine, holder of the United Therapeutics Endowed Professorship in Pulmonary Vascular Disease, professor of cell, developmental and integrative biology, section chief of vascular biology and hypertension and director of the Vascular Biology and Hypertension Program at the University of Alabama at Birmingham; Raymond R. Townsend, MD, professor of medicine and director of the Hypertension Program at the Hospital of the University of Pennsylvania; and Randall M. Zusman, MD, director of the division of hypertension at Massachusetts General Hospital Heart Center, consultant in cardiology at the Massachusetts Institute of Technology and associate professor of medicine at Harvard Medical School. – by Erik Swain

What is the biggest issue in hypertension today?

Rhonda Cooper-DeHoff, PharmD, MS, FAHA, FACC, FCCP

Rhonda Cooper-DeHoff, PharmD, MS, FAHA, FACC, FCCP
Rhonda Cooper-DeHoff

The biggest problem is inertia on the part of the clinician to recognize when hypertension treatment adjustments are necessary to optimize BP reduction. For example, in a patient on a single BP-lowering drug with continued elevated BP readings, the addition of a second drug from a different drug class can result in an additional 10 mm Hg reduction. Prescribing of combination products, all of which are available in a generic format, can substantially improve BP control and patient adherence.

Suzanne Oparil, MD, FACC, FAHA, FASH, FAPS

The biggest issue in hypertension today is chronic hypertension in pregnancy, ie, what to do with the BP of hypertensive women who become pregnant.

Suzanne Oparil, MD, FACC, FAHA, FASH, FAPS
Suzanne Oparil

Hypertension is the most common major medical disorder during pregnancy, affecting 2% to 6%, or up to 260,000, of U.S. births annually. Given temporal increases in obesity, older maternal age and more aggressive diagnostic criteria for hypertension, the prevalence of chronic hypertension in pregnancy is rising. Chronic hypertension in pregnancy is associated with a marked two- to fivefold increase in adverse outcomes, including fetal growth restriction/small for gestational age infants, fetal or newborn death, placental abruption and preterm birth, as well as heart disease and death in the mother.

Despite these serious complications, treatment recommendations for chronic hypertension during pregnancy are very different from those for hypertension in the general population. Pharmacologic treatment of chronic hypertension is standard care for the general population because of major long-term benefits, including reductions in death, MI, HF, stroke and kidney failure. However, during pregnancy, current guidelines from the American College of Obstetricians and Gynecologists recommend that treatment be withheld or may be discontinued for most hypertensive women — those with chronic hypertension classified as mild. This recommendation results from the lack of data documenting maternal or perinatal benefits of antihypertensive treatment during pregnancy and concerns about the safety of a treatment that may increase placental insufficiency and, therefore, harm the fetus.

Available data from limited clinical trials and systematic reviews show that antihypertensive treatment did lower BP but did not reduce the risk for pregnancy outcomes such as small for gestational age infants, placental abruption and preterm birth. In fact, decreasing maternal BP with antihypertensive medication has been associated with increased risk for small for gestational age and low birth weight infants. For more than 2 decades, scientific and professional organizations have called for large clinical trials to evaluate the benefits and safety of antihypertensive therapy in pregnancy. The Chronic Hypertension and Pregnancy (CHAP) project is an ongoing NHLBI-funded pragmatic randomized trial designed to evaluate the benefits and harms of pharmacologic treatment of mild chronic hypertension in pregnancy. Results of CHAP should be available within 2 years and will provide valuable new information on the short-term outcomes of treating chronic hypertension in pregnancy that will inform future treatment guidelines.

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Raymond R. Townsend, MD

There are a number of candidates for addressing which issue is the biggest one in hypertension, including proper measurement, using validated devices to measure BP, patient adherence to medications and nondrug approaches to BP lowering.

Raymond R. Townsend, MD
Raymond R. Townsend

It may not be obvious, but my pick is patient adherence to medications. I am amazed by data from the SPYRAL HTN-ON MED study, in which we told patients we were going to specifically check — using both urine and blood samples — for the presence of prescribed medicines required for participation in the study. In patients with hypertension taking one to three prescription medicines, we checked for the presence of the medication at three separate time points. We found about 60% of the patients were taking the medications. Amazingly, it was not the same 60%; people switched categories. Some had only one medication at one visit, and all three at the second visit, and only one again at the third visit. Ultimately, we found ourselves confronted with data that had virtually never been done before in a clinical trial. Moreover, when others have looked in clinic populations who are seeing hypertension doctors for “resistant hypertension,” they found that one time in six, the patients are taking no medication, and about one time in four the patients are taking fewer BP medicines than what they were prescribed based on their medical history.

Like former U.S. Surgeon General C. Everett Koop, MD, said, “Drugs don’t work in patients who don’t take them.” In a time where hypertension practitioners are witnessing even more stringent definitions of what constitutes controlled BP, and where our performance as health care practitioners on a metric like BP control can be ascertained by a few keystrokes in an electronic health record, it is increasingly important that we both acknowledge this issue with medication adherence, and figure out ways to promote adherence to treatments we administer to manage this crucial vital sign: BP.

Randall M. Zusman, MD

The number of hypertensive patients continues to grow as newer and more aggressive guidelines are adopted and applied to a progressively aging population. Fortunately, we now have dozens, if not hundreds, of choices to make for the treatment of high BP. Using an appropriately crafted medical regimen in the setting of lifestyle modification — dietary salt restriction, weight loss and exercise — it is almost always possible, if the patient is compliant with a multidrug regimen, to control their BP.

Randall M. Zusman, MD
Randall M. Zusman

So, what is the challenge or biggest issue in hypertension today? My answer is the need to identify those many patients who are indeed hypertensive and to initiate appropriate treatment when the elevated BP values are first identified. So often, I find that my new referrals are patients who have been known to be hypertensive for years, but were either untreated or undertreated for most of that time. Embedded within this patient population, of course, are a subset of those with secondary causes of their hypertension — most commonly, hyperaldosteronism — and identifying those with a disorder other than essential hypertension for which there is a targeted therapeutic regimen remains crucially important.

An additional challenge is then to integrate the therapies we use for the treatment of the patient’s hypertension, with the concomitant need to treat their hyperlipidemia (hypercholesterolemia and/or hypertriglyceridemia), diabetes, atrial fibrillation or other cardiac dysrhythmia, as well as their gastrointestinal, pulmonary, renal, cardiac (CAD/angina) or other comorbidities. The resultant multidrug regimens, which raise the question of adverse drug-drug interactions, place both a financial burden and a marked pill burden on many of our patients and prevent full adherence to their complex treatment needs. Only by treating all of the comorbidities that increase the patient’s CV risk profile can we hope to maximally reduce their morbidity/mortality while improving their quality of life.

Disclosures: Cooper-DeHoff and Zusman report no relevant financial disclosures. Oparil reports she has received personal fees from 98point6 and CinCor Pharma; grants and personal fees from ROX Medical; grants from Bayer and Idorsia Pharmaceutical; and personal fees and other/nonfinancial support from Preventric Diagnostics; and that she receives a stipend from Springer Science Business Media LLC. Townsend reports he consults for Medtronic.