Non-Adherence to Antihypertensive Guidelines in Patients with Asymptomatic Carotid Stenosis
William Haley1, Fayaz Shawl2, W Charles Sternbergh3
1Department of Hypertension and Nephrology (retired), Mayo Clinic, Jacksonville, FL, United States.
Insights
Many patients with carotid stenosis and hypertension do not adhere to treatment guidelines, with preferred medications often under-prescribed. This study highlights opportunities to improve hypertension pharmacotherapy in this high-risk group.
Area of Science:
- Cardiovascular Medicine
- Neurology
- Clinical Pharmacology
Background:
- Hypertension and carotid stenosis are significant stroke risk factors.
- Tight hypertension control can be concerning in patients with carotid stenosis due to hypoperfusion risks.
Purpose of the Study:
- To assess opportunities for improving hypertension pharmacotherapy in patients with asymptomatic high-grade carotid stenosis.
- To evaluate adherence to evidence-based hypertension treatment guidelines in this population.
Main Methods:
- Cross-sectional analysis of baseline data from the CREST-2 clinical trial.
- Examined anti-hypertensive medication prescription patterns and adherence.
- Included 1479 participants with asymptomatic high-grade carotid stenosis and hypertension.
Main Results:
- Only 34% of participants were on guideline-adherent hypertension regimens.
- A majority (43%) were on three or more antihypertensive medications.
- Preferred antihypertensive drug classes were frequently under-prescribed.
Conclusions:
- Non-adherence to hypertension guidelines is prevalent in patients with severe carotid disease.
- Opportunities exist to optimize pharmacotherapy for hypertension in this cohort.
- The CREST-2 trial will further investigate outcomes with guideline-based care.
Importance:
Hypertension and carotid stenosis are both risk factors for stroke, but the presence of carotid stenosis might dampen enthusiasm for tight control of hypertension because of concerns for hypoperfusion.
Objective:
To determine the extent to which there are opportunities to potentially improve pharmacotherapy for hypertension in patients known to have asymptomatic high-grade carotid stenosis.
Design:
We examined anti-hypertensive medication prescription and adherence to evidence-based hypertension treatment guidelines in a cross-sectional analysis of baseline data of patients enrolled in a clinical trial.
Setting:
The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) is a multicenter prospective randomized open blinded end-point clinical trial of intensive medical management with or without revascularization by endarterectomy or stenting for asymptomatic high-grade carotid stenosis.
Participants:
1479 participants (38.6% female; mean age 69.8 years) from 132 clinical centers enrolled in the CREST-2 trial as of April 6, 2020 who were taking ≥1 antihypertensive drug at baseline.
Exposures:
Pharmacotherapy for hypertension.
Main Outcome:
Adherence to evidence-based guidelines for treating hypertension.
Results:
Of 1458 participants with complete data, 26% were on one, 31% on 2, and 43% on ≥3 antihypertensive medications at trial entry. Thirty-two percent of participants were prescribed thiazide; 74%, angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB); 38%, calcium channel blocker (CCB); 56%, a beta blocker; 11%, loop diuretic; and 27%, other. Of those prescribed a single antihypertensive medication, the proportion prescribed thiazide was 5%; ACEI or ARB, 55%, and CCB, 11%. The prevalence of guideline-adherent regimens was 34% (95% CI, 31-36%).
Conclusions And Relevance:
In a diverse cohort with severe carotid disease and hypertension, non-adherence to hypertension guidelines was common. All preferred classes of antihypertensive drug were under-prescribed. Using staged iterative guideline-based care for hypertension, CREST-2 will characterize drug tolerance and stroke rates under these conditions.
Trial Registration:
ClinicalTrials.gov Number NCT02089217.
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