Download Improving Blood Pressure Treatment in the Community: A Joint

Improving Blood Pressure Treatment in the
Community: A Joint Project of the National High
Blood Pressure Education Program and
Antihypertensive and Lipid-Lowering Treatment to
Prevent Heart Attack Trial
Collaborative Research Group
This dissemination project is
jointly sponsored by the NHLBI
Office of Prevention, Education
and Control and the Clinical
Applications and Prevention
Program of the Division of
Epidemiology
and
Clinical
Applications.
ALLHAT Steering Committee:
Paul Whelton, MD, MSC (Chair)
Michael Alderman, MD
Henry R. Black, MD
William C. Cushman, MD
Jeffrey A. Cutler, MD, MPH
Barry R. Davis, MD, PhD
Curt Furberg, MD, PhD
Richard Grimm, MD, PhD
L. Julian Haywood, MD
Frans Leenen, MD, PhD
Karen Margolis, MD
Chuke Nwachuku, MA, MPH, DrPH
Suzanne Oparil, MD
Jeffrey Probstfield, MD
Mahboob Rahman, MD
Jeffrey Williamson, MD, MHS
Jackson T. Wright, Jr., MD, PhD
Thank you for giving us the opportunity to update you and your colleagues
regarding the Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). These
guidelines, based on the results from the Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack Trial (ALLHAT) and many other clinical trials,
provide an evidence-based approach to hypertension prevention and management.
As with all treatment guidelines, potential exists for a disconnect between strategy
and implementation. In order to address this issue, an ALLHAT Dissemination
Committee was formed to consult with experts in dissemination theory and help craft
a carefully conceived approach to initial and long-term dissemination.
Traditionally, clinical trial results and new treatment guidelines have been
presented at scientific meetings, published in peer-reviewed journals, and
summarized in press briefings. Such efforts have been accomplished and wellreceived and they will continue, but broader and more vigorous efforts must continue
to communicate the recommendations and challenge the misinformation that is being
generated. With active participation and financial support from the National Heart,
Lung, and Blood Institute, such an initiative to increase awareness of and
commitment to the ALLHAT results and JNC7 guidelines is underway. Several
strategies have been selected for dissemination of the messages:
 ALLHAT Investigator Educators will disseminate the ALLHAT/JNC7 messages
to 29,000 practitioner colleagues. The presentation to you and your group was a
very important part of this effort.
 About 100,000 patients will be informed regarding the ALLHAT/JNC7
messages and encouraged to discuss the messages in their encounters with their
health care providers.
 Formulary Medical Directors and others who influence use of prescription
medications in formulary systems will be contacted in order to increase
awareness of the ALLHAT results and JNC7 recommendations, potentially
impacting the prescribing habits of 100,000 health care providers.
 Twenty-two professional associations will be encouraged to facilitate the
provision of our ALLHAT/JNC7 messages to 135,000 association members who
are health care providers.
Implications for Your Practice and Your Patients
The JNC7 report states that the most effective ways to better control blood pressure
and reduce CVD risk is for physicians to:
 Help most patients achieve a blood pressure goal of <140/90 mm Hg.
 Encourage and influence patients to make lifestyle changes.
 To prescribe thiazide-type diuretics for most patients diagnosed with Stage 1
hypertension.
 To prescribe thiazide-type diuretics as part of a multi-drug regimen for most
patients with Stage 2 hypertension.
 To add a thiazide-type diuretic to the treatment regimens of most patients with
uncontrolled hypertension.
Physicians report the positive effects of prescribing thiazide-type diuretics
Joshua Barzilay, M.D.
Michael A Farber, M.D.
Kaiser Permanente of
Georgia
Tucker, Georgia
Pitman Internal Medicine
Associates
Pitman, New Jersey &
Mullica Hill, New Jersey
My best experiences with
diuretics are with diabetic
patients. I am an endocrinologist
in a referral practice, so I rarely
see an untreated hypertensive
patient. I do see numerous
diabetic patients with
hypertension and diabetes. Unfortunately, many have
inadequately controlled blood pressure despite being on 2 or 3
medications. When I add a diuretic to their treatment
protocol, their blood pressure goes down. This is especially so
with African American patients. Diuretics work and should be
part of the armamentarium of all blood pressure treatment. I
am a practicing physician who sees a lot of problems and their
complications. In many people, more than one type of
medication is needed for blood pressure control. Diuretics are
efficacious.
Previous to learning the
ALLHAT results, I was not
using diuretics as first line
therapy, perhaps influenced by
other sources. Since the results
of ALLHAT, I have certainly
increased the use of diuretics as
first-line therapy. I believe that the results of the ALLHAT
trial are compelling. I have been happy with my patients’
responses to the use of thiazide diuretics. Certainly, my use of
diuretics has increased, and my partners have increased their
use to a degree. I have presented the results to several
different groups at a local hospital and had a favorable
response, especially from family care practitioners.
Gabriel Habib, M.D.
Richard Dart, MD
Marshfield Clinic
Department of Nephrology &
Hypertension
Marshfield, Wisconsin
My practice is referralbased, so I see patients whose
blood pressures are difficult to
treat. Many patients have
already been treated with
several drugs, but the blood
pressure is still not under
control. Most physicians who refer to me are resistant to the
use of diuretics due to practice habits and patterns. But I
regularly use diuretics with great success. For example, a
young physician in his 40’s with essential hypertension and
significant medical problems was referred to me for treatment
because his BP was not controlled. Although he was hesitant
to start a diuretic, I added one. Within three weeks his blood
pressure was improved, and it is now under control.
The JNC7 is a very large collection of literature with a
complexity of information and studies put together by experts
in the field of hypertension. These experts review and collate
all the information which brings a new level of awareness to
what we know about how to treat patients. To bring together
all the best literature is useful to the practice. This
information is not opinion, but has relevance in today’s busy
practices.
For more information, please see these web sites:
NHLBI.NIH.ORG & ALLHAT.ORG
VAMC Houston
Cardiology Section
Houston, Texas
My patients are usually
older African-Americans who
suffer from CVD and isolated
systolic hypertension. The
results of ALLHAT and the
JNC7 recommendations
convinced me that, compared to
other drug classes, thiazide
diuretics help control blood pressure better and decrease CVD
risks and I now use them regularly. I am more convinced of
the critical role of optimal BP reduction in reducing the risk of
heart attacks and strokes in higher risk older patients. I strive
to optimize BP control in my patients, particularly those with
diabetes and metabolic syndrome, and I am more aggressive in
maximizing antihypertensive drugs, using drugs in
combination, and using diuretics. I rarely use a thiazide
diuretic as monotherapy, but they are an important part of my
armamentarium of medications that I commonly use in
carefully targeted combinations to minimize CHD and stroke
risk in patients with different co-morbid conditions such as
heart failure, diabetes mellitus, nephropathy and others. I
have three recommendations for my colleagues:(1) do not
underestimate the SBP lowering ability of an inexpensive
thiazide diuretic or its proven efficacy to decrease CVD
events; (2) optimize blood pressure reduction, especially
systolic pressure in older patients, and (3) target your higher
risk patients with a comprehensive CVD prevention strategy
including multiple antihypertensive drugs, as well as
aggressive lipid reduction, smoking cessation, exercise and
dietary counseling.