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Goal-oriented hypertension management: translating clinical trials to practice
Gregory M Singer1, Munavvar Izhar, Henry R Black
1Rush University Hypertension Service, Rush-Presbyterian St. Luke's Medical Center, Chicago, Ill 60612, USA.
Insights
Goal-oriented management in specialist clinics significantly improved blood pressure (BP) control rates, achieving Sixth Joint National Committee (JNC VI) goals in most patients. Systolic BP control remained challenging, but this approach effectively translates trial results to outpatient practice.
Area of Science:
- Cardiology
- Hypertension Management
- Clinical Practice Research
Background:
- Clinical trials using BP treatment algorithms show superior control rates compared to national data.
- The Sixth Joint National Committee (JNC VI) established specific blood pressure goals for hypertension management.
- Previous studies indicate challenges in achieving target blood pressure levels in routine practice.
Purpose of the Study:
- To evaluate the effectiveness of "goal-oriented management" in achieving JNC VI blood pressure goals in a specialist clinic setting.
- To assess blood pressure control rates after at least one year of follow-up using a non-algorithmic, goal-focused approach.
- To compare achieved control rates with those reported in clinical trials and national surveys.
Main Methods:
- Retrospective analysis of 437 consecutive patients in a specialist clinic.
- Implementation of "goal-oriented management" focusing on specific blood pressure targets without a formal algorithm.
- Assessment of adherence to JNC VI diastolic blood pressure (<90 mm Hg) and systolic blood pressure (<140 mm Hg) goals.
Main Results:
- 63% of patients achieved systolic BP goal, 86% achieved diastolic BP goal, and 59% achieved both.
- Monotherapy was used in 23% of patients; 34% required two drugs, and 37% required three or more.
- Diabetic patients showed lower achievement rates for both JNC VI and stricter ADA/NKF goals.
Conclusions:
- Goal-oriented management significantly improves blood pressure control in outpatient specialist settings.
- Achieving diastolic blood pressure goals is feasible, but systolic blood pressure control remains a challenge.
- This management strategy effectively bridges the gap between clinical trial outcomes and real-world patient care.
Abstract:
Several clinical trials using a blood pressure (BP) treatment algorithm focused on a predetermined goal have achieved better control rates than those of national survey data. These trials reached the Sixth Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI) diastolic blood pressure (DBP) goal of <90 mm Hg in >90% of volunteers and systolic blood pressure (SBP) goal of <140 mm Hg in >60% of volunteers. We evaluated BP control of 437 consecutive patients after at least one year of follow up in a specialist clinic which employed "goal-oriented management," ie, treating to a specific BP goal without a formal drug treatment algorithm, to determine whether JNC VI goals could be achieved. Overall, 276 (63%) patients achieved SBP goal, with 376 (86%) at DBP goal and 358 (59%) at both goals. Only 23% of patients were on monotherapy, with 34% requiring 2 drugs and 37% requiring 3 or more medications. There was no substantial difference in BP control rates among age, gender, and ethnicity subgroups. However, in the 20% of patients who were diabetic, only 52% had a BP of <140 mm Hg and <90 mm Hg, whereas fewer (22% and 15%, respectively) achieved the more stringent goals of JNC VI and the American Diabetic Association (ADA)/National Kidney Foundation (NKF). Goal-oriented management achieved dramatically better control rates than what is reported. Although DBP control was easy to achieve, achieving SBP goal still remained difficult. Employing goal-oriented management can translate BP control results achieved in clinical trials into outpatient practice.