Journal of Hypertension:
Blood pressure control in the hypertensive population. What else the doctor can do?
de la Sierra, Alejandro
Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain
Correspondence to Alejandro de la Sierra, Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Plaza Dr Robert, 5, 08221-Terrassa, Spain Tel: +34 937365000 x1295; fax: +34 937365037; e-mail: firstname.lastname@example.org; email@example.com
Arterial hypertension (HTA) is the main factor responsible for premature mortality in the world and, therefore constitutes the main global burden of disease. Observational data attributed to blood pressure elevation (values above 115 mmHg systolic) a total of 7.6 million deaths (13.5% of total mortality) and 92 million (6% of total) of the sum of deaths and disability adjusted life years (DALYs). This burden affects not only developed but also developing countries and not just individuals with hypertension, but those with blood pressure values in categories above those considered optimal . Clinical trials conducted in the last five decades have demonstrated that antihypertensive treatment, mainly pharmacological , but also some lifestyle changes , are all associated with an improved prognosis of hypertensive patients and that this improvement is directly related to the amount of blood pressure reduction, with ancillary effects of antihypertensive drugs playing a secondary role. In this sense, it seems quite clear that the blood pressure values achieved during treatment are the main prognostic indicator and are much more important than the degree of initial blood pressure elevation. On the basis of this evidence obtained from clinical research, virtually all practice guidelines place a special emphasis on the need to control hypertensive patients, achieving therapeutic targets that allegedly prove to be beneficial towards the prognosis of patients. Values below 140/90 mmHg for most hypertensive patients, regardless of age, are common in most clinical guidelines [4,5].
In contrast to the soundness of these recommendations, the daily clinical practice is far away from what is proposed in the guidelines. Epidemiological surveys conducted in different parts of the world have demonstrated that in most situations less than one-third of patients reach treatment goals and manage to have their blood pressure values controlled . Noteworthy, it seems even more surprising, is the inability of physicians to improve substantially the proportion of patients who are controlled .
This situation invites a reflection regarding the reasons for this apparent difficulty in controlling high blood pressure. It is now clear that there is no simple solution; otherwise we would have expected a big improvement in the control figures over recent years. Nevertheless, some elements can help us to explain these low control rates. They include a limited value of the standard clinical measurement, some discrepancies between clinical research data and recommendations contained in the guidelines and, in some countries, contradictory messages received by the doctors, with simultaneous claims to improve blood pressure control, but without using new, better-tolerated, but also more expensive antihypertensive drugs. All of these can have influence on the motivation, and thus on the ability of physicians to achieve blood pressure goals.
The importance of physician motivation is addressed by Consoli et al.  in the current issue of the Journal of Hypertension. In a cross-sectional survey carried out by cardiologists and primary care physicians in France, they found that those with a high motivation regarding their perception of hypertension and associated risks, had better control rates in their patients, probably suggesting a lower degree of clinical inertia in this group of doctors. This observation is important and indicates that we must keep in mind those elements that can help the doctor to maintain himself/herself motivated in order to better control blood pressure and cardiovascular risk factors.
The first point that influences the lack of improvement in hypertension control is the limited value of a clinical measurement of blood pressure, even if it has been the standard guide to antihypertensive therapy in most trials. The use of more appropriate measurement techniques such as self measurement at home or ambulatory monitoring has been shown to improve the prognostic significance of blood pressure measurement, but, more importantly, has demonstrated that a considerable proportion of patients can be classified in a distinct group regarding office or ambulatory blood pressures. The analysis of the Spanish Registry of ambulatory blood pressure monitoring (ABPM) has shown that the percentage of patients with blood pressure controlled doubled with a systematic use of ABPM, from 25% when blood pressure was measured at the office to more than 50% when daytime BP was considered . This ‘white-coat’ effect was more pronounced in older individuals, and in those with resistant hypertension . The knowledge of these data can influence the doctor's behaviour, especially if ABPM is not available in their routine clinical practice.
A second aspect that probably influences a degree of inertia in trying to achieve therapeutic goals is the gap between recommendations and actual figures achieved in clinical trials. If we focus on studies carried out in the elderly, in both the Syst-Eur  and HYVET  studies, the blood pressure goal was 150 mmHg, whereas in the SHEP study , targets were dependent on baseline blood pressure, but in most cases they were set below 160 mmHg. This situation is even more evident in studies in diabetic patients, where the figures reached were also above the recommendation of 130/80 mmHg. These discrepancies have been recently reviewed  and were the basis for a reappraisal of the European Society of Hypertension guidelines . If these more achievable therapeutic goals would translate in a change of doctor's behaviour or motivation is something we will have to check in the future.
A third cause that may also influence the low level of blood pressure control and the small improvement that has occurred in recent years is the growing bureaucratization of medicine with the emergence of many elements of surveillance which, with the objective of containing global pharmaceutical expenditure, argues against freedom in prescription. It is clear that the treatment of hypertension has been improved with the emergence of new, better-tolerated drugs and therefore more likely to facilitate adherence and persistence , which theoretically will result in better control rates. Similarly, the presence of fixed combinations with complementary mechanisms of action and additive antihypertensive effects are advantageous, as they could have a positive impact on blood pressure control and adherence . These theoretical advantages contrast with the fact that the quality indicators by which the various healthcare providers evaluate medical practice many times criminalize the therapeutic use of such improvements, as they are included in the list of products that generate higher pharmaceutical costs. In this sense, we can only call on the responsibility of the physician in the rational use of resources, meaning that his/her most important mission is to provide to the patient the best treatment available.
In conclusion, some of the elements described earlier affects medical practice, and might be responsible for both the low level of blood pressure control, as for the relative stability of the figures in recent years. The strategies for improving this situation should necessarily cover some of the points raised here, and others that are equally important in doctor–patient relationship and doctor's motivation. Results reported by Consoli et al.  suggest that a motivated doctor is more able to control his/her patients. Anyway, the final objective would be the reduction in the impact of cardiovascular disease, the leading cause of death in Europe, by reducing the burden of disease provided by the high number of hypertensive patients who are still not controlled.
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