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Practical solutions to the challenges of uncontrolled
hypertension: a white paper
Josep Redona, Hans R. Brunnerb, Claudio Ferric, Karl F. Hilgersd,
Rainer Kolloche and Gert van Montfransf
This white paper is an urgent call to action from an
international group of physicians. The continued failure to
control hypertension takes an unacceptable toll on patients,
families and society and it must be addressed. Any patient
with blood pressure of 140/90 mmHg or greater can be
characterized as a ‘challenging patient’, is at significant risk,
and requires persistent optimization of therapy until target
blood pressure is achieved. Six key challenges in reaching
this goal blood pressure are described: (1) inadequate
primary prevention; (2) faulty awareness of risk; (3) lack of
simplicity; (4) therapeutic inertia; (5) insufficient patient
empowerment; and (6) unsupportive healthcare systems.
This white paper identifies straightforward actions that will
produce rapid improvements in the management of
hypertension, with a simple aim: to treat all challenging
patients effectively to goal blood pressure, preventing
disability and saving lives. J Hypertens 26 (Suppl. 4):S1–S14
Q 2008 Wolters Kluwer Health | Lippincott Williams &
Wilkins.
Journal of Hypertension 2008, 26 (Suppl. 4):S1–S14
Introduction
Hypertension remains the leading cause of mortality and
the third largest cause of disability worldwide [1], despite
decades of concentrated effort. In many countries it also
remains uncontrolled in the majority of patients [2].
Different investigators report different absolute figures
[3–6] but the consistent message is that in Europe the
proportion of patients with acceptable blood pressure
control is too low – in the region of 30%, even among
those who are diagnosed and treated [2]. The majority of
patients are therefore not achieving acceptable blood
pressure control.
This situation confronts not only the physician but also
society with an abrupt choice: more resources can be
invested in treating patients to goal blood pressure, or
much higher costs can be paid when the consequences
of suboptimal control emerge in the form of fatal
or disabling cardiovascular events. These ‘challenging
patients’, that is, patients not reaching the agreed blood
pressure standard of less than 140/90 mmHg (office-based
measurement) represent a significant burden on healthcare services across Europe, with far reaching consequences. Unfortunately, physicians are insufficiently
aware of this problem and may not even recognize these
Keywords: antihypertensive agents, blood pressure/control, cardiovascular
diseases/prevention, challenging patient, health promotion,
hypertension/prevention/control
a
Hypertension Clinic, Internal Medicine, Hospital Clinico, University of Valencia,
Valencia, Spain, bLausanne University, Lausanne, Switzerland, cUniversita di
L’Aquila, Facolta di Medicina e Chirurgia, Dipartmento di Medicina Interna e
Sanita Pubblica, Coppito, L’Aquila, Italy, dDepartment of Nephrology and
Hypertension, University of Erlangen-Nuremberg, Erlangen, Germany,
e
Evangelisches Krankenhaus Bielefeld, Klinik fur Innere Medizin, Kardiologie,
Nephrologie und Pneumologie, Bielefeld, Germany and fDepartment of Vascular
Medicine, Academic Medical Centre, Amsterdam, the Netherlands
Correspondence and requests for reprints to Josep Redon, Hypertension Clinic,
Internal Medicine, Hospital Clinico, University of Valencia, Avda Blasco Ibañez 17,
46010 Valencia, Spain
Tel: +34 963862647; fax: +34 963862647; e-mail: [email protected]
Sponsored by DAIICHI SANKYO Europe GmbH, who had no content editorial
control.
DAIICHI SANKYO Europe GmbH provided financial support to the authors for
out of office expenses and to Huntsworth Health for writing support. A special
acknowledgement is made to Colleen Shannon for writing support and excellent
collation of author input.
Conflicts of interest: HB has received consultancy fees from Daiichi Sankyo and
SPEEEDEL/Novartis, and receives honoraria from Pfeizer and Bristol-Myers
Squibb. KFH has received grant support as well as advisory board and speakers
fees from several companies which market antihypertensive drugs, including
Daiichi Sankyo, Novartis, Sanofi Aventis and AstraZeneca.
challenging patients in clinical practice [7–9]. In the
absence of affirmative action to get challenging patients
to their blood pressure goal this situation will only
deteriorate, resulting in a deepening impasse driven by
uncontrolled hypertension.
On the positive side, the evidence provides a clear view
of the different reality that is possible. Blood pressure
values can be reduced with the appropriate drugs and
strategies. A target blood pressure of 140/90 mmHg was
achieved in 66% of patients over 5 years in the Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial (ALLHAT) study, which included
33 357 participants. This was an impressive improvement
over the 5-year study period. At baseline, just 27.4% of
patients were controlled to this level although 90% were
receiving antihypertensive treatment [10]. In the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) trial (n ¼ 9193), blood pressure fell from a
baseline of 160–200/95–115 mmHg by 30.2/16.6 and
29.1/16.8 mmHg in losartan and atenolol-based treatment
groups, respectively [11].
Looking at newer agents, in a recent meta-analysis of
36 studies Fabia et al. [12] demonstrated systolic blood
0263-6352 ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S2 Journal of Hypertension
2008, Vol 26 (suppl 4)
pressure (SBP) reductions of 20 mmHg, as measured in
the physician’s office, are achievable with angiotensin II
receptor antagonists.
Combining two agents with complementary mechanisms
of action can provide blood pressure control that is not
only effective but also rapid. In the Combination of
Olmesartan Medoxomil and Amlopidine Besylate in
Controlling High Blood Pressure (COACH) trial, 1940
patients were randomly assigned to placebo, olmesartan,
amlodipine or a combination of the two agents at one of
three dosages. At 8 weeks, 53.2% of patients receiving
the olmesartan and amlodipine fixed dose combination (20/10 mg) reached the target blood pressure of
140/90 mmHg (or 130/80 mmHg for those with diabetes).
In comparison, 20% and 32.5% of patients achieved their
blood pressure goal in the olmesartan (20 mg) and amlodipine (10 mg) arms, respectively [13].
The Hypertension Optimal Treatment (HOT) study
(n ¼ 18 790) demonstrated the cardiovascular mortality
benefits of intensively lowering diastolic blood pressure
(DBP). Felodipine was given as baseline therapy with the
addition of other agents, according to a five-step regimen.
Patients started with a mean DBP of 105 mmHg and were
set targets of 90 mmHg or less, 85 mmHg or less, and
80 mmHg or less. DBP was reduced by 20.3 mmHg,
22.3 mmHg, and 24.3 mmHg, respectively [14].
A summary of the relationship between blood pressure
and cardiovascular outcomes is described by Staessen
et al. [15] (Fig. 1), with changes in risk explained through
differences in SBP observed between the arms of the
large number of trials examining different interventional
therapies.
Therefore, simple follow-up algorithms for treatment, if
applied with persistence, can achieve an impressive rate
of hypertension control. Unfortunately, such success is
seldom replicated outside a research setting.
If anything, progress in the management of hypertension
is slowing down because of the daily challenges that
physicians face. In its seventh report, the Joint National
Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure notes ‘the decline
rates in coronary heart disease and stroke-associated
deaths have slowed in the past decade. . . Undiagnosed,
untreated, and uncontrolled hypertension clearly places
a substantial strain on the healthcare delivery system’
[16].
The truth is that healthcare professionals have frequent
opportunities to diagnose and treat hypertension in dayto-day practice. In a study examining national cardiovascular prescribing data in Canada for an 11-year period,
hypertension was the leading diagnosis for patient visits
to a physician’s office [17]. Physicians have not only the
occasion but also the means to intervene effectively.
They may choose from numerous risk assessment
tools, widely accepted management guidelines, and
well-researched treatment options.
What actions can healthcare professionals implement
to alter the current critical situation in hypertension
control?
Fig. 1
Numerous trials have demonstrated the clear mortality reduction benefits of effective blood pressure lowering. ACEIs, Angiotensin-converting
enzyme inhibitors; CCBs, calcium antagonists. Reproduced with permission of Elsevier from Staessen et al. [15].
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Solutions to the challenges of uncontrolled hypertension Redon et al.
This working party gathered to answer that question,
engaging in a discussion of the evidence, drawing on vast
clinical experience gained in a number of nations
throughout Europe and formulating practical solutions.
This white paper is the result.
A call to action
White papers have long been used in parliamentary
politics. They propose a solution to a well-defined problem, providing useful information and expert opinion to
support the logic of their conclusions [18]. Above all, a
white paper is a spur to action, which is why this format
has been adopted. Action is the aim, swift action to see
that every patient with hypertension (the ‘challenging
patient’) is treated effectively to at least a blood pressure
level of less than 140/90 mmHg, preventing disability and
saving lives.
The working group identified six challenges that stand in
the way of achieving goal blood pressure for all patients:
inadequate primary prevention; faulty awareness of risk;
an urgent need for simplicity; therapeutic inertia; lack of
patient empowerment and responsibility; and unsupportive healthcare structures and policy.
Among these challenges primary prevention must be the
first priority. Vigorous efforts must be directed towards
the ‘left of the curve’, to decrease blood pressure across
the population by promoting dietary changes, exercise
and improved prenatal care.
Healthcare professionals can begin to meet these
challenges by concentrating on just a few uncomplicated
steps: effectively communicate the real dangers of
hypertension to individual patients and across all sectors
of society; concentrated and consolidated effort into
patient education; optimize use of the multidisciplinary
team; encourage patients to become more accountable for
ensuring their own cardiovascular health; simplify treatment; and take a leadership role.
Some of these actions will involve persuading others
and winning the cooperation of many different people:
colleagues, patients, healthcare managers and funders,
schools and local officials, and perhaps even the media
and national government. There is, however, one action
that physicians can take independently and immediately:
simplifying treatment.
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agents such as angiotensin-converting enzyme inhibitors
and angiotensin II receptor blockers [12,15,19]. There are
also numerous guidelines to read and interpret, from
authoritative sources including the World Health Organization, the International Society of Hypertension, the
European Society of Hypertension and Cardiology and
the US Joint National Committee on the Prevention,
Detection, Evaluation and Treatment of High Blood
Pressure [16,20,21]. In addition, many physicians must
also familiarize themselves with national guidelines and
local prescribing policies. The profession may be paralyzed by the bewildering amount of information and
therapeutic inertia is setting in [7,8].
When the information is distilled down, however, the
numerous guidelines and the studies that have informed
them come to the same conclusion. Effective treatment of hypertension significantly reduces morbidity
and mortality.
In everyday clinical practice, physicians are in danger of
spending too much time considering the details and
missing the larger picture: hypertension is inadequately
controlled in the majority of their patients. There is also a
failure to take the simplest, most important actions:
treating all patients with hypertension, following them
up and persisting until the treatment brings blood pressure down to a safe level of less than 140/90 mmHg as a
minimum target. The net result is that the population of
challenging patients at increased risk of cardiovascular
disease progression continues to expand.
In the middle of a busy clinic, the patient with hypertension sitting in the chair is an opportunity not to be missed.
Physicians need a simple rule that will quickly lead to
effective action, then and there in the consulting room.
Around the world hypertension management guidelines
agree on target blood pressure [16,20,21]. This is a very
simple message that has been lost. Therefore, the working group proposes an uncomplicated rule of thumb,
which for practical purposes aligns with all of the major
guidelines: if blood pressure is 140/90 mmHg or more,
treat the challenging patient with the most effective
regimen possible. Many guidelines recommend a lower
target level (<130/80 mmHg) for patients with diabetes,
existing cardiovascular disease or renal complications
[16,20,21]. In view of the dismal state of blood pressure
control in Europe, we feel that achieving blood pressure
levels below 140/90 mmHg is the more urgent need.
A simple step
Perhaps part of the problem is that physicians have so
much data and so many treatment options to consider. A
simple search of the database for the Cochrane reviews
illustrates this point. Entering the term ‘hypertension’
returns more than 470 results. Dozens of robust, placebocontrolled trials have examined and often compared
diuretics, beta-blockers, calcium antagonists and newer
The challenging patient
Who are challenging patients? It is simple: any patient not
achieving their blood pressure goal poses a challenge
to the physician and can therefore be described as
a ‘challenging patient’. Overcomplicated professional
thinking may have distracted from this core issue. Physicians might be stuck on the perception that high-risk
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S4 Journal of Hypertension
2008, Vol 26 (suppl 4)
individuals with multiple comorbidities are the only
challenging patients. These patients require significant
resources to help them achieve the goal and blood pressure control as blood pressure is also an important prognosis of risk. The working group would argue that any
patient with blood pressure above the recommended
upper limits of 140/90 mmHg or greater is a ‘challenging
patient’. All individuals not achieving goal blood pressure
have a significantly increased risk of cardiovascular death
[22] and are likely to become non-adherent to treatment
in less than a year [23] unless physicians intervene
effectively to address their needs.
A challenging patient is any patient not reaching goal blood pressure.
(Minimum target <140/90 mmHg)
Whatever the circumstances, it is essential to continue
monitoring the patient and if the target blood pressure is
not achieved, treatment must be optimized until the goal
is reached. In order to reduce the risk of cardiovascular
events all challenging patients must be treated to
goal blood pressure and not only ‘close to blood pressure
goal’.
Even then the task is not complete. Patients with hypertension must be kept in sight continually with regular
review, treatment updates (when necessary), and steady
encouragement. This is where the multidisciplinary team
comes into its own, with the ability to sustain a high level
of effectiveness over time [24].
Small changes, big difference
Such efforts will prove worthwhile and there is no shortage of evidence to support this determined approach.
Effective treatment saves lives, as a number of robust
trials have demonstrated and the tighter the control, the
better [14,15,22]. Why is getting the challenging patient
to goal blood pressure important? In the HOT study,
Hansson et al. [14] demonstrated that tight blood pressure
control, as opposed to treating patients close to goal
(i.e. 5–10 mmHg above target blood pressure goal) can
significantly reduce the incidence of stroke by 44% and
mortality by 22%.
In a meta-analysis of 61 prospective observational studies
involving one million adults [22], usual blood pressure
was directly related to cardiovascular mortality and to allcause mortality throughout middle and old age. In this
analysis, the Prospective Studies Collaboration also confirmed the benefits of treatment. At ages 40–69 years,
each difference of 20 mmHg usual SBP, or 10 mmHg
usual DBP, was associated with twofold differences in
the death rates from ischaemic heart disease. The impact
on stroke mortality was even greater.
In another meta-regression analysis of 27 hypertension
treatment trials involving 136 124 patients, Staessen et al.
[15] highlighted the relationship between optimal blood
pressure control and cardiovascular risk reduction. In its
simplest form; the lower the blood pressure (to normal
blood pressure) the greater the reduction in cardiovascular complications (Fig. 1).
These examples clearly demonstrate that treating to at
least the universally accepted blood pressure threshold
(<140/90 mmHg) should be the target for all patients
with hypertension. Achieving this goal results in a
marked reduction in cardiovascular risk.
Reduction of mortality is a commonly accepted endpoint.
The fact that the effective treatment of hypertension can
prevent significant disability, for example from stroke, is
just as important to note. In clinical practice, patients
often say they dread losing their independence and
quality of life even more than they fear death. Discussing
the possibility of a disabling stroke or heart attack is one
way the clinician can encourage patients to show focused
attention and make a commitment to treatment and
lifestyle changes. Linking the clinical outcome of hypertension to the devastating effects of disability on family
life is a mechanism that resonates strongly with the
patient and can be used successfully to focus them on
achieving their blood pressure goal.
Yet, for so many patients, these fears may be adverted.
Cardiovascular disease is now widely understood as a
continuum (Fig. 2) driven by many risk factors, with
hypertension spanning the entire arc. Dzau and Braunwald [25] illustrated this concept. Over time it has been
adapted to reflect accumulating evidence about various
risk factors, with hypertension emerging as one of the
significant influences on cardiovascular risk [26,27].
Organ damage begins long before overt clinical disease
is detectable. In the later stages, multiple pathophysiological routes end in heart disease, stroke, and renal
damage. It is not inevitable that patients should decline
along this continuum, and treatment for hypertension has benefits at each and every point along the
way [25–27].
In light of all the information available, physicians are
still undertreating patients across this continuum. In the
Reduction of Atherothrombosis for Continued Health
(REACH) study of patients with established arterial
disease (n ¼ 67 888), 81.8% had hypertension and 50%
were undertreated, with elevated blood pressure at baseline [28]. With effort, such as recently described at
the American College of Cardiology meeting in 2008,
the Avoiding Cardiovascular Events in Combination
Therapy in Patients Living with Systolic Hypertension
(ACCOMPLISH) study demonstrated that approximately 80% of the patients achieved their blood pressure
goal at 30 months [29]. Impressive as these results are, it
still means that 20% were not controlled.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Solutions to the challenges of uncontrolled hypertension Redon et al.
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Fig. 2
Effective intervention is possible at any stage of the cardiovascular disease continuum. CKD, Chronic kidney disease; ESRD, end-stage renal
disease. Adapted with permission of Elsevier from Dzau and Braunwald [25].
Statin and antiplatelet agents were also underused in the
REACH study [28]. This second point is a reminder that
hypertension is of course intertwined with other risk
factors and is not treated in isolation. The ineffective
treatment of hypertension may, however, negate the
work that physicians achieve with other risk factors, as
demonstrated by Lewington et al. [30]. In a 2007 analysis
[30] of their bank of 61 trials, the Prospective Studies
Collaboration found that the absolute effects of cholesterol and blood pressure were additive in determining the
risk of morbidity and mortality. Furthermore, the benefit
of treatment with statins was effectively cancelled out in
patients with uncontrolled hypertension.
Even when managing just one risk factor, hypertension,
treatment with a single agent is often insufficient and the
Fig. 3
Cumulative probability of
treatment persistence
1.0
ARB
0.8
Thiazide
ACEI
α-antagonist
CCB
Potassium-sparing diuretic
β-blocker
Miscellaneous
majority of patients require combination therapy with
two or more antihypertensive agents from different
classes [16,20,21]. The requirement for multiple agents
makes the task of ensuring patient compliance with
therapy even more challenging. Persistence with antihypertensive therapy declines substantially within the
first year of treatment [23] (Fig. 3) and this situation
creates a downward spiral. Physicians question how long
the patient will persist with lifestyle changes and medication adherence, and this scepticism contributes to
therapeutic inertia (Fig. 4).
One simple solution is to consider a fixed dose combination, to improve adherence and obtain more rapid
control of blood pressure [16,17,20,21]. Fixed-dose combinations are effective and allow simple treatment strategies, helping the physician escape from the cycle of
therapeutic inertia. There is no shortage of agents to
choose from and physicians can refer to robust data and
well-designed guidelines to support those choices.
A call to action
This white paper is a call to action. It defines the scale of
the current ‘critical situation’, examines ‘the human
impact’ created by uncontrolled hypertension, defines
‘the challenges’ faced every day in the clinic, and
suggests straightforward, practical steps that can save
lives and prevent disability.
0.6
0.4
0.2
0
0
1
2
Follow-up time (years)
3
4
Persistence with antihypertensive therapy declines substantially within
the first year of treatment. ACEI, Angiotensin-converting enzyme
inhibitor; ARB, angiotensin receptor blocker; CCB, calcium antagonist.
Reproduced with permission from Burke et al. [23].
The scale of current critical situation: Unmet
clinical need
Worldwide, 26.4% of the adult population, 972 million
people, presented with hypertension in 2002. This figure
is predicted to rise by 60% between now and 2025, to a
total of 1.56 billion people, or 29% of the population [31].
Considering current clinical practice and outcomes, the
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S6 Journal of Hypertension
2008, Vol 26 (suppl 4)
Fig. 4
patients with hypertension manifested with a blood pressure of less than 140/90 mmHg [6].
Other good quality reviews have produced varying figures
for undetected and untreated hypertension, but all estimates point to one conclusion: the number of challenging
patients in Europe is too high [2–6]. It is important to
have reliable and detailed statistics. This level of detail
must, however, not detract from the vital message. Too
many patients are not achieving target blood pressure and
are at increased risk of disability or avoidable premature
death.
Link between therapeutic inertia, awareness and compliance.
healthcare professions are ill-prepared to meet this coming tidal wave of challenging patients.
Too often hypertension remains undetected. According
to one of the global analyses by Kearney et al. [2], the
diagnosis is least likely to be missed in the United States,
where 68.9% of patients with hypertension are aware of
their blood pressure (Fig. 5). In the European countries
studied in this review, patients were aware of their
hypertension in the following proportions: Greece:
60.8%; Germany: 59.5%; England: 46.2%; Spain: 44.5%.
Studies in other European countries have been no more
encouraging. In a survey assessing blood pressure control
among patients living in central Italy, less than 30% of
One question that must be asked is why clinicians in the
United States consistently achieve better blood pressure
control than their peers in Europe [2,5,6]. Guideline
targets are similar worldwide, but are the guidelines
themselves regarded as more prescriptive in the United
States, whereas in other countries they are perceived in
an educational light? Another difference may be that
professional and public awareness of hypertension and
the risks to health are greater in the United States.
Perhaps US patients are more willing to question their
physicians, press for the best treatment and take charge
of their own health. In addition, an overly optimistic
perception of the success of therapy results in a pool
of patients who the physician incorrectly regards as
‘controlled’ when, in fact, goal blood pressure has not
been reached [7–9]. Such patients must be acknowledged as challenging patients, who are actually being
undertreated.
Uncontrolled hypertension: The human
impact
Worldwide, 13.5% of premature deaths in 2001 were
attributed to hypertension in an analysis by Lawes
et al. [32]. Faced with the sheer magnitude of the
Fig. 5
Canada
England
41.0
29.2
Germany
Japan
33.6
55.7
Turkey
19.8
USA
Greece
53.1
China
49.5
28.8
Taiwan
Spain
Mexico
18.0
38.8
21.8
Egypt
33.5
South Africa
47.6
Italy
37.5
Patients reaching blood pressure goals, worldwide. Based on data from Kearney et al. [2].
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Solutions to the challenges of uncontrolled hypertension Redon et al.
S7
numbers, it is all too easy to forget that this is not merely
an abstract, intellectual argument. It is a human tragedy
on a huge scale. In 2001 alone, 7.6 million individuals did
not live out their years and their families lost them too
soon [32].
Post-stroke, many patients in that study suffered from
mental ill health (57%), from the physical after-effects of
stroke (79%) and the burden on carers in the study was
heavy, with one in three also receiving treatment for
depression after the event.
Hypertension also causes hidden harm, in that survivors
of stroke and myocardial infarction can be left with
profound disability. Worldwide in this study, hypertension accounted for 6% of disability-adjusted life
years worldwide. The figure for Europe was 92 million
disability-adjusted life years, or 19.6% of the total
[32].
Lawes et al. [32] determined that 54% of strokes and 47%
of ischaemic heart disease cases are attributable to high
blood pressure. It is not a great leap to perceive the
connection between these statistics and the impact of
uncontrolled hypertension for millions of individuals,
both patients and care givers.
Cost to society: economic burden of disease
The human cost
The statistics speak volumes but physicians do not treat
populations, they treat patients. Thinking about the
consequences of uncontrolled hypertension in terms of
concrete outcomes for individual patients might therefore help to focus professional minds.
Duran et al. [33] described the effects of stroke on the
daily lives of survivors and their carers. In that study from
Spain, 137 patient and carer interviews were conducted
during 2004. The interviews were carried out a minimum
of 6 months post-stroke, when the period between the
stroke and the interview was longer than 3 years and in
50% of patients. A minority of patients (8.5%) reported
no disability and nearly half (45%) experienced both
physical and mental disabilities.
The survey revealed that among stroke patients some
level of care was required: 80% could not be left alone for
more than 2 hours; 40% could not be left alone at all; 93%
were dependent for use of the bathroom, 87% for getting
dressed, 65% for basic mobility and 29% for eating
(Fig. 6).
In addition to the personal cost to the individual patient,
uncontrolled hypertension creates huge, avoidable, economic burdens when viewed in terms of the general
population. The data below demonstrate the impact of
uncontrolled hypertension on direct costs such as medical
care and rehabilitation for patients suffering avoidable
strokes, myocardial infarction and renal disease. In
addition, the effects of hypertension contribute to significant indirect economic stresses, including increased
welfare benefits, demands on social care, lost income
and productivity.
In a burden of disease modelling study, Lloyd et al. [34]
determined that 33% of adults in England have uncontrolled hypertension (>140/90 mmHg). If these patients
were controlled to target, an estimated 58 000 major
cardiovascular events could be avoided every year and
the cost of managing these events in the National Health
Service (NHS) would fall by £97.2 million per year
(at 2000/2001 prices).
Building on data relating blood pressure and cardiovascular events in the HOT study, Hansson et al. [35]
Fig. 6
The human cost of uncontrolled hypertension. Based on data from Duran et al. [33].
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
2008, Vol 26 (suppl 4)
applied a cost of illness model to estimate the impact of
uncontrolled hypertension on national healthcare systems in France, Germany, Italy, Sweden and the United
Kingdom. As in the Lloyd analysis, 33% of adults in these
countries were estimated to have a blood pressure level
greater than 140/90 mmHg. Annual healthcare system
costs of s1.26 billion could be avoided with successful
hypertension management to achieve blood pressure
targets.
In Italy, Gerzeli et al. [36] determined that after a stroke,
social costs in the first 6 months after the attack were
s11 600 per patient; 53% of this total was healthcare
costs, 39% was non-healthcare costs and the remaining
8% was accounted for by productivity losses.
The UK government estimated that in 2005, the overall
cost of stroke to the nation was £7 billion. Of this
total, informal costs such as care giving accounted for
£2.4 billion and indirect costs such as welfare benefits,
lost income and morbidity accounted for £1.8 billion
[37].
Across the European Union, Leal et al. [38] estimated
the annual cost of cardiovascular disease to be s169
billion annually, with healthcare accounting for 62%
of this amount. Productivity losses and informal care
represented 21% and 17% of costs, respectively. Coronary
heart disease represented 27% and cerebrovascular diseases 20% of overall cardiovascular disease costs.
It is clear that uncontrolled hypertension in challenging
patients, and the resultant increase in cardiovascular
events, creates huge financial burdens for individuals
and nations throughout Europe.
Fig. 7
Population
strategy
High-risk
strategy
Optimal distribution
Percent of population
S8 Journal of Hypertension
Present distribution
High risk
0
5
10
15
20
25
30
35
40
10-year cardiovascular disease risk
Inadequate primary prevention is the priority challenge. Efforts must
also be directed towards the ‘left of the curve’ with the aim of
decreasing blood pressure levels across the population. Reproduced
with permission of Dove Medical Press Ltd. from Mendis [40].
ally reduction in salt, must be encouraged. The WHO
prevention guidelines cite a Cochrane review by He and
MacGregor [41], which concluded that across the population, even a modest reduction in salt intake would
reduce stroke deaths by 14% and coronary deaths by
9% in people with hypertension. Even in people with
normal blood pressure, deaths would fall by 6% and 4%,
respectively. There is also an urgent need to address the
epidemic of obesity with exercise as well as improved
diet. In the longer term, improved prenatal care to
address low birth weight in developing countries should
provide additional benefits [42–44].
Challenge 2: Faulty awareness of risk
The challenges
Given the size of the current critical situation, and all of
the therapies available, why are physicians failing with
the majority of their patients with hypertension? This
working group identified six key challenges faced by
health professionals.
Challenge 1: Inadequate primary prevention
Considering the scale of the unmet medical needs (i.e.
the current critical situation), effective treatment of highrisk individuals will not be enough to stop the gathering
tide from overwhelming healthcare systems in the coming years. Efforts must be directed towards the ‘left of the
curve’ with the aim of decreasing blood pressure levels
across the population in order to reduce cardiovascular
risk. The need for such an approach has been affirmed
recently by the World Health Organization (WHO) in
its 2007 guidelines on the prevention of cardiovascular
disease [39,40] (Fig. 7). The population’s addiction to
junk food can leave physicians in despair but this issue is
too important to surrender on. Dietary changes, especi-
There is a large gap between physicians’ perceptions and
clinical reality when it comes to assessing the degree of
risk (which is underestimated) and the success of therapy
(which is overestimated). In a survey investigating
hypertension management in the United States [8], most
physicians were satisfied with SBP of 150 mmHg, well
above the target of 140 mmHg recommended in national
guidelines [16]. In Germany, a similar survey assessed the
quality of drug treatment in 7302 patients with hypertension seen by 286 cardiologists on three consecutive
days [9]. Physician predictions about their patients’
degree of blood pressure control were overly optimistic
when compared with the actual readings. Although physicians estimated that blood pressure would be less than
140/90 mmHg in approximately 60% of their patients, in
fact this figure was less than 40%.
Data demonstrate that physicians consistently and significantly underestimate the sheer number of ‘challenging patients’ requiring treatment (Fig. 8) [5,45]. As
stated, every patient not reaching target blood pressure
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Solutions to the challenges of uncontrolled hypertension Redon et al.
S9
Fig. 8
Physicians consistently and significantly underestimate the sheer number of ‘challenging patients’ requiring treatment. Based on data from Wang
et al. [5] and from Datamonitor [45].
is a ‘challenging patient’ because they are at increased
risk of cardiovascular events. All patients with hypertension must be treated to goal blood pressure and not only
‘close to blood pressure goal’ in order to prevent cardiovascular events [14].
In the general population, blood pressure must be lowered to
<140/90 mmHg, the universally agreed minimum blood pressure target
to reduce the risk of mortality or significant morbidity.
Challenge 4: Therapeutic inertia
Challenge 3: An urgent need for simplicity
There is a dangerous gap between guidelines and clinical
reality. Whereas physicians are fortunate to have comprehensive, evidence-based guidelines, overanalysis can
cause them to lose sight of the most important concept at
that moment when the patient sits before them. In the
general population, blood pressure must be lowered to
less than 140/90 mmHg, the universally agreed minimum
blood pressure target to reduce the risk of mortality or
significant morbidity. The target should be more aggressive (130/80 mmHg) when there is also existing cardiovascular disease, diabetes or renal damage. The simple
message must not be lost, however, by discussing different target blood pressure levels. Whatever the patient’s
age, sex, race or comorbidities, lowering blood pressure is
going to be beneficial at every stage of the cardiovascular
disease continuum. Risk charts are based on substantial
datasets but essentially ‘the challenging patient’ is any
individual not meeting the minimum blood pressure goal.
Simpler treatment regimens might also improve adherence and at the population level ultimately shift blood
pressure to the ‘left of the curve’ thereby reducing
cardiovascular risk.
The terms ‘clinical inertia’ or ‘therapeutic inertia’ have
become popular in recent times and there is increasing
evidence that these buzzwords are based on a real
phenomenon. Okonofua et al. [7] conducted a retrospective cohort study on 7253 patients with hypertension with
four or more visits and one or more elevated blood
pressure readings in a year. Antihypertensive therapy
was increased on just 13.1% of visits when patients
presented with uncontrolled blood pressure. A therapeutic inertia score was determined by calculating the
difference between expected and observed medication
rates. If this therapeutic inertia score could be reduced by
50%, blood pressure control would increase from 45.1% to
65.9% in just one year.
Why are such opportunities missed? Part of the reason is
lack of time. Physicians have heavy workloads and the
demands on their time are intense. Following up, counselling patients, adjusting treatment, following up again –
all of this takes time. Repeat prescriptions may continue
for years, leading to the under-identification of challenging patients who are not reaching their blood pressure
goals. There are failings at every stage of the therapeutic
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S10 Journal of Hypertension
2008, Vol 26 (suppl 4)
process: false awareness of risk feeds therapeutic inertia,
which in turn feeds poor adherence (Fig. 4). If physicians
cannot see the full benefits of treatment and are not
enthusiastic, it is no surprise that patients do not follow
their advice.
Physicians are fully aware that compliance in hypertension patients often tails off substantially within the first
year of treatment [23] and this knowledge must contribute to therapeutic inertia. Patients struggle to see the
point of lifestyle changes or daily tablets when they have
no noticeable symptoms and are unaware of the risks.
This reaction (or more accurately lack of reaction) has a
hugely demoralizing effect on the physician. The net
result is a loop that is difficult to escape (Fig. 4).
Challenge 5: Lack of patient empowerment or
acceptance of responsibility for own health
Clinicians are concerned that the majority of their
patients do not implement recommended lifestyle
changes or even know what their blood pressure is. In
a recent investigation conducted in central Italy, only
35% of treated patients with hypertension significantly
changed their dietary habits or increased physical activity
(C. Ferri, 2008, personal communication). Often, the
attitude is that ‘the drugs will cure me’, although paradoxically persistence with treatment is suboptimal. Initiating drug treatment is useless if the tablets are unused.
Education alone will never be enough to solve this
problem [46]. Patients have many reasons for skipping
their medication but they do not always share their
thoughts with the physician. This is another intervention
that takes time, but someone must explore the patient’s
beliefs about antihypertensive medication and persuade
them that the benefits outweigh any worries they may
have [46].
Challenge 6: Unsupportive healthcare structures and
policy
Unfortunately, under most healthcare systems, physicians are not given sufficient incentives or resources to
control blood pressure effectively. As noted earlier, this is
a time-intensive intervention. Access to healthcare is an
issue for many patients - if they are unable to pay for care
or they live in an area with poor provision. When healthcare policies, funding and organization have made blood
pressure a priority, improvements have resulted. In the
United Kingdom, for example, the NHS contract guarantees financial rewards for general practitioners when
they systematically monitor and treat hypertension and
other cardiovascular risk factors. A study by Cupples et al.
[47] compared patients in Northern Ireland (part of the
United Kingdom covered by the contract), with the
Republic of Ireland, which has a similar population but
a different system of remuneration for physicians. Blood
pressure and cholesterol were both controlled more effectively under the NHS contract in Northern Ireland.
There was no difference, however, in terms of lifestyle
or quality of life, a finding that affirms just how stubbornly
these two issues resist concerted efforts.
Underlying each and every one of these challenges
is a fundamental necessity for clear communication:
between specialists and physicians on the front line;
between physicians and the rest of the healthcare
team; and between healthcare professionals and their
patients. There is also a critical need for dialogue
between governments, healthcare purchasers, professionals and the public.
Recommendations
This white paper has painted an alarming picture of the
current critical situation but in fact simple steps can make
significant differences. These steps can be taken by
individual clinicians in their everyday working lives
and by uniting with colleagues. Based on a discussion
of the evidence and clinical experience, the working
group urges the following measures to address the challenges defined in the white paper.
Action 1: Drive awareness of the dangers of
hypertension across all sectors of society
The most effective way to reduce the number of challenging patients within society is to inform people about
risks and lifestyle to avoid presentation of hypertension.
Only in this way will a shift to the ‘left of the curve’
become an achievable goal. Reducing, or at least controlling the number of patients entering the system will
also relieve the strain on healthcare resources.
Physicians are respected members of the community.
When they talk about health, people listen. Publicity
opportunities are everywhere and taking advantage of
them does not have to be complicated. Physicians must
get the message across to government, the public, professionals, carers and maybe the most important group,
schoolchildren who will be the next generation of
patients with hypertension if no action is taken.
Professionals can spread the message throughout the
healthcare community with peer-to-peer discussion, by
sharing best practice and by disseminating the latest
research evidence. Organizing a simple meeting about
how to manage the challenging patient with hypertension
and asking colleagues to share their experiences may be
a revelation.
Action 2: Get serious about patient education
Office visits provide an important opportunity to reinforce hypertension-related educational messages. Physicians could do more to underscore the importance
of medication adherence and healthy living to their
patients with hypertension [48]. New scientific findings
should rapidly be shared across the profession. The latest
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Solutions to the challenges of uncontrolled hypertension Redon et al. S11
knowledge should be shared with patients, especially in
the current world of the Internet, where the patient may
well be encouraged to investigate their condition further.
This engagement with treatment will aid with challenges
such as adherence and lifestyle changes.
As one example, recent data from the Framingham study
demonstrated that in middle-aged adults, soft drink
consumption is associated with a higher prevalence
and incidence of multiple metabolic risk factors [49].
In a cross-sectional analysis, individuals consuming more
than one soft drink per day had a higher prevalence of the
metabolic syndrome [odds ratio (OR) 1.48; 95% confidence interval (CI) 1.30–1.69] than those consuming less
than one drink per day. Hypertension was one of many
risk factors studied and individuals drinking more than
one soft drink per day had higher blood pressure (OR
1.18; 95% CI 0.96–1.44). Therefore, the simple advice to
the patient is to stop consuming high sugar soft drinks to
reduce the risks of death or disability from a cardiovascular event. This example demonstrates a useful
approach in counselling patients because - the goal is
simple. Therefore the patient can relate actions to
outcome, for example reducing sodium intake for a
better prognosis; The action is small enough to be
achievable. The physician is not asking the patient to
overhaul his or her entire lifestyle at once; Explicit advice
on how to achieve the goal is given (reduce soft drink
consumption).
Physicians will succeed if they communicate risks to their
patients in this manner, giving advice that is based on the
evidence and backed with simple actions that patients
view as achievable.
Action 3: Make better use of the multidisciplinary team
This article has mainly referred to physicians. It is a flaw
in the writing, which reflects a flaw in healthcare. How
many healthcare teams really make full use of the skills
offered by all of their members? Different members of
the team will form different relationships with the patient
and can deliver the same message to the same patient on
many levels. Patients may respond more positively to
various aspects of the message depending on the messenger. For example, nurses can spend more time with
patients, work very well to protocols, and can effectively
promote lifestyle changes to the entire family. Pharmacists can undertake regular medication reviews, provide
blood pressure monitoring in the community, and alert
physicians when repeat prescriptions appear ineffective.
They could even be encouraged to adjust the dose or
medication choice after treatment is initiated by a physician. The physician remains at the heart of the patient’s
treatment pathway and the way forward is to work as a
multidisciplinary team (MDT), under well-defined local
systems and protocols. As always, when health professionals work as a team, it is imperative that everyone
speaks to the patient with one voice and a consistent
message.
The MDT approach maximizes the resources available
and drives the treatment paradigm that is most effective
both in medical and financial terms [24,50]. In a systematic review of 44 publications, Walsh et al. [50] demonstrated that patients treated by the MDT had significantly greater improvements in blood pressure control
compared with those in control groups. Median reductions in SBP and DBP were 4.5 mmHg and 2.1 mmHg
greater than observed for control patients. This additional
level of intervention may allow a patient to achieve their
blood pressure goal instead of remaining ‘close to goal’.
Median increases in the percentage of individuals achieving target goals for SBP and DBP were 16.2% and 6.0%,
respectively. Interventions that included team change as
a quality improvement strategy were associated with the
largest reductions in blood pressure.
Action 4: Encourage patients to become more
accountable for ensuring their own cardiovascular
health
Hypertension deserves to be viewed as seriously as other
chronic conditions such as diabetes and asthma. In these
diseases patients are routinely taught to monitor and take
responsibility for their own condition, for example,
checking peak flow rate or blood glucose. In the same
way, patients should regularly monitor and record their
own blood pressure at home to engage them with their
treatment and give them ownership of the goal they are
aiming to achieve. Self-monitoring would encourage
patients to take responsibility and could motivate them
to adhere to lifestyle changes and medication. It would
also begin to address the ‘inertia loop’ if patients become
more vocal in defining the goal as their own.
In a study of 441 patients who had failed to reach a target
of less than 140/85 mmHg, half were assigned to selfmonitoring, and SBP control was achieved in a significantly greater percentage after 6 months compared with
usual care. After one year the difference in blood pressure
control between the self-monitoring and the usual care
groups was no longer significant. The self-monitoring
patients, however, lost more weight, required fewer visits
to the physician’s office, and reported greater satisfaction
with their care. Self-monitoring did not increase costs
appreciably [51].
In addition a multifactorial study (n ¼ 778) compared
monitoring options of: (1) usual care; (2) home blood
pressure monitoring and Internet support; (3) or home
monitoring, Internet support plus pharmacist care management. Patients in the third group were significantly
more likely to achieve blood pressure control, compared
with those in home blood pressure monitoring plus webtraining only and usual care groups, at (3) 56% versus
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S12 Journal of Hypertension
2008, Vol 26 (suppl 4)
Fig. 9
Thiazide diuretic
β-blockers
ARB
α-blockers
CCB
ACEi
Treatment guidelines now excel in recommending optimal drug
combinations. ACEi, Angiotensin-converting enzyme inhibitor; ARB,
angiotensin receptor blocker; CCB, calcium antagonist. Reproduced
with permission from Mancia et al. [21].
(2) 36% and (1) 31%, respectively [52]. These findings
suggest that innovative combinations of self-management,
the use of new technology and multidisciplinary working
offer exciting possibilities.
Action 5: Simplify treatment
Monotherapy is usually insufficient to control blood
pressure and increasingly, physicians are using two or
more antihypertensive agents concurrently. Treatment
guidelines now excel in helping the physician select the
best combination in any given situation [16,20,21]
(Fig. 9). The next step is to identify and use the most
effective treatment combinations matched to the needs
of the challenging patient.
Fixed-dose combinations deliver agents from different
therapeutic classes to provide powerful blood pressure
reduction. They are packaged in a convenient format for
use in simple treatment regimens. Fixed-dose combinations can help to overcome adherence issues [53] and
are recommended in treatment guidelines [16,20,21].
They are also likely to give a rapid response [13,21]. It
is also worth remembering that when combining medications, the whole is greater than the sum of the parts.
That is, the benefits of combination therapy are not
merely additive. Combinations can be synergistic,
improving the efficacy of a treatment and reducing side
effects, both of which contribute to a more effective
treatment [13,29,54–56].
Action 6: Take a leadership role
Physicians and their colleagues in other health professions must take the lead on this issue. On an individual
level this means setting a good example for their patients
by following a healthy lifestyle. Clinicians need to campaign for improved healthcare policies and structures in
their own communities and even at the level of national
government. They are also in a position to make the case
for effective public education initiatives. Finally, it is
vital to improve professional education and ensure
that the message is getting through to younger colleagues, otherwise, there will be decades more with
no progress.
Conclusion
In the current critical situation, less than a third of
patients in Europe achieve acceptable blood pressure
control [2]. This is inexcusable and cannot continue.
The cost of inaction, or ineffective action, is too high
for patients, their families and society. Uncontrolled
hypertension means that patients are dying prematurely
or living with avoidable disability.
The human impact is that physicians have all of the
necessary tools to bring blood pressure under control: an
array of treatments, a robust evidence base and comprehensive guidelines. In fact, they almost have too many
options and therapeutic inertia is setting in. This working
group proposes a simple rule that aligns with accepted
guidelines; to be applied in clinical practice: regard any
patient with blood pressure of 140/90 mmHg or greater as
a ‘challenging patient’, the goal being to get this patient
below this universally agreed minimum blood pressure
target as quickly as possible (and the lower the better in
relation to normal blood pressure).
These patients are at significant risk and require persistent optimization of therapy until target blood pressure
is achieved.
To meet ‘the challenges’ identified in the white paper,
clinicians can take six effective actions:
Drive awareness about the dangers of uncontrolled
hypertension among patients, professionals and policy
makers;
Put serious effort into patient education;
Make effective use of the multidisciplinary team
(MDT);
Encourage patients to take responsibility for their own
cardiovascular health;
Simplify treatment;
Take a leadership role in their communities, professions and society.
These straightforward actions should produce rapid
improvements in the management of hypertension,
allowing physicians and their colleagues to treat all challenging patients effectively to goal blood pressure, preventing disability and saving the lives of millions.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Solutions to the challenges of uncontrolled hypertension Redon et al. S13
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