How big a role should JNC 7 play in the care of hypertensive patients?
Another question is how best to facilitate blood pressure lowering in patients taking a renin-angiotensin system blocker. As I examine the literature, it is evident that thiazide diuretics or calcium channel blockers provide the most robust means for enhancing blood pressure reduction in conjunction with a renin-angiotensin system blocker, because of their complementary mechanisms of action. For example, thiazide diuretics lower blood pressure by reducing volume, which may activate the reninangiotensin system as a compensatory mechanism and in turn raise blood pressure; a renin-angiotensin system blocker counteracts this effect and provides additive blood pressure control.14 Which combinations are associated with the greatest opportunity to reduce cardiovascular events is unknown, but fortunately the subject of current clinical trials. In the meantime, it is fair to say that these 2 classes of drugs should be considered as important adjuncts to renin-angiotensin system blockade as part of an overall blood pressure-lowering strategy. The efficacy and tolerability of such combinations are well established.
In perspective, the thorough article by Wexler and Feldman starts the process of understanding why certain therapeutic approaches are appropriate in patients with cardiovascular disease. These findings are supported by evidence from large-scale clinical trials. However, also important to note is that in almost all of these trials, the majority of patients required 2, 3, or more drugs to control their blood pressure. The real focus for the future, therefore, may be identifying the optimal regimen-based pharmacotherapy for reducing the likelihood of cardiovascular events.
Based on examination of the clinical literature, and my own experience, I advocate an individualized approach to choosing not only appropriate blood pressure goals for individual patients, but also making careful and well-planned decisions about an optimal medical regimen. This takes into account how much blood pressure reduction is required and, of course, concomitant cardiovascular conditions. The majority of patients who have or are at risk for cardiovascular disease will need therapy that targets the renin-angiotensin system as part of a successful blood pressure-lowering regimen. Optimally, a robust fixed-dose combination therapy approach should be considered. The more effective and simpler the regimen, the more likely the patient is to stay on treatment.
Future clinical efforts should be dedicated to improving education and overcoming therapeutic inertia among both healthcare providers and patients alike. Improving adherence to any hypertensive regimen is crucial over the long term in order to achieve the lower blood pressure goals that are consistently associated with lessened risk for cardiovascular events.
Matthew R. Weir, MD
Professor and Director, Division of Nephrology, University
of Maryland School of Medicine, Baltimore
The authors respond:
We are in agreement with Dr Weir that it is incumbent upon physicians to overcome the “therapeutic inertia” so prevalent in the treatment of hypertension.15 We further agree that in the ideal setting, individualization of patient treatment would be preferred. Guidelines (such as the JNC-72) should be utilized as a mechanism to support the clinician’s thought process when attempting to determine the correct medical therapy for each patient, not supplant it.
Our primary objective of this review was risk attenuation. In our opinion a clinician should take into account the specifics of each patient in developing a health care plan that best suites that patient. As such, there should be only a limited number of discrepancies between an individualized care-plan and “the guidelines.” As Dr Weir pointed out, risk reduction is graduated and we seek to maximize medical therapy for each patient. However, given the poor state of blood pressure control in the US, we have previously opined that clinicians must first recognize the importance of blood pressure control and that it may require aggressive medical therapy with multiple medications, before it is possible to implement treatment on an individual basis.
In 2002, 89.7% of all patients screened or treated for hypertension were evaluated in a primary care office.16 In a national survey of primary care physicians 41% were not familiar with, or had not heard of, the JNC recommendations.17 Before we can expect patient individualization, we must first improve physician understanding of the disease itself. Once clinicians have begun to close the gap on the number of untreated/under-treated patients, we can move to the next level of an individualized care plan.
Therefore in the year 2006, although less than perfect, we support the recommendations promulgated by JNC-7). Although not individualized, sometimes artificial “goals” may not be a bad surrogate of the future ideal. The theory that there is a gradation of risk attenuation supports the notion that some medical therapy may be better than none at all. These guidelines (JNC-7) are unlikely to be deleterious to any patient, and may help with drug selection, provide gross generalities for blood pressure management, or prompt a clinician to refer a patient to a specialist if they are uncomfortable reaching “the goal.” Best individualized therapy or a “guideline” is the difference between health care policy versus the best patient care. Phrased in colloquial terms, what is best for the nation versus what is be best for your specific patient? Neither is incorrect but two different perspectives of the same issue that should complement one another.
