Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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.