Americans not being effectively treated for high blood pressure and cholesterol

One out of every three adult Americans has high cholesterol levels and two-thirds of them do not have it under control, the Centers for Disease Control and Prevention said Tuesday. Similarly, one out of every three adults has high blood pressure and half of them do not have it under control. High blood pressure and high cholesterol are two of the major risk factors for heart attacks, strokes and other cardiovascular diseases, which are the leading cause of death in the United States, killing 800,000 people every year. Overall, 100 million Americans have high blood pressure, high cholesterol or both, and that has serious health and economic consequences for the country, according to the new CDC report released in an early version of the agency's Morbidity and Mortality Weekly Report. The conditions cost the country $300 billion per year in direct medical costs alone -- $1 out of every $6 spent for healthcare -- and that number is expected to triple in the next 20 years, said Dr. Thomas R. Frieden, the CDC director. "The bottom line is, high blood pressure and cholesterol are out of control."

The data for the study came from the National Health and Nutrition Examination Survey, which interviewed and examined 11,154 participants over the age of 18 between 2005 and 2008. The data may be somewhat conservative because it did not include the elderly residing in nursing homes and other institutions, who have a high incidence of age-related hypertension.  Blood pressure should be less than 120/80, and requires management if it is higher than 140/90. LDL cholesterol (also known as bad cholesterol) should be less than 160 for people without heart disease or diabetes; less than 130 for people without heart disease or diabetes but with two or more other risk factors for heart disease; and below 100 for people with heart disease or diabetes.

During the period of the study, 68 million adult Americans had high blood pressure, about the same number as a decade ago. Of those, 48 million were receiving drugs for their condition and 31 million had their condition under control. Surprisingly, 86% of those with uncontrolled blood pressure had insurance, suggesting that they simply did not take advantage of it -- most likely because hypertension generally does not exhibit any symptoms.

An estimated 71 million Americans had high cholesterol levels during the study period, but just 34 million were being treated and only 23 million had their cholesterol levels under control. The proportion being treated had grown from 28.4% a decade earlier, suggesting significant progress in the area, Frieden said, and the prevalence of control increased from 14.6% to 33.2%. Among those with uncontrolled cholesterol levels, 82.8% reported having some form of insurance.

In a Tuesday news conference, Frieden had a message for doctors: "Controlling blood pressure and cholesterol is one of, if not the, most important thing you can do for your patient." He also called for increased efforts to reduce sodium in food, both in processed foods and in restaurants. Reducing average daily sodium intake from 3,400 milligram to 2,300 milligrams could reduce hypertension by as many as 11 million cases, and reducing it to 1,500 milligrams per day could reduce hypertension by an additional 16.4 million cases.

Source: LA Times

Cash incentive made no difference to GP’s over high blood pressure management

A study was conducted on the impact of the new pay for performance scheme that was introduced as part of the new GP contract in 2004. GPs were awarded points for achieving targets aimed at improving care for patients across a range of diseases. A total of £1.8bn was available for GPs in England under the scheme, called the Quality and Outcomes Framework, and 20 per cent of that was awarded for achieving five targets related to blood pressure. The move was controversial as most GPs achieved near to maximum points, leading to critics saying the Labour government had negotiated a bad deal for the taxpayer. The research published in the British Medical Journal analysed the effect of the scheme on the care of patients with high blood pressure.

The team from Harvard University in Boston, America, and Nottingham Medical School in Britain found that there was no impact of the scheme, largely because doctors were already improving care and were acheiving the targets that had been set. Monitoring of blood pressure did not increase, prescribing of drugs for the condition did not change significantly and there was no change in the rates of strokes, heart attacks and other problems that are caused by high blood pressure, they found. Lead author Brian Serumaga, who works at both Nottingham University and Harvard in pharmaceutical policy research, wrote in the journal: "Our study has shown that explicit financial incentives did not improve the quality of care and clinical outcomes for patients with hypertension in primary care in the United Kingdom. "We found that the quality of care for hypertension was improving and already close to the threshold set for maximum payment in the pay for performance initiative. Some performance thresholds may have been set too low for the financial incentives to be effective. "It seems that doctors may be less responsive to performance based monetary incentives to improve the care of hypertension than most policy makers believe. "Furthermore, evidence from studies of educational interventions suggests that fewer, simpler messages are more likely to achieve behaviour change than more complex, diffuse messages. "Perhaps the resources devoted to pay for performance for hypertension would be better spent on implementing these interventions more widely."

Dr Laurence Buckman, Chairman of the British Medical Association's GPs Committee, said: "There is a mistaken belief that the Quality and Outcomes Framework is simply an incentive scheme, but it's much more than that. "It was designed to fund work by GPs that previously wasn't being funded, to ensure that patients received uniform high-quality care no matter where they lived in the country, and, by doing that, to improve public health over the long term and help reduce health inequalities. "The QOF is still relatively new. Other studies have shown that it has improved care and treatment for people with diabetes and reduced the number of heart attacks and deaths, particularly in deprived areas. We expect the true gains will be seen in the long term as more evidence becomes available."

A spokesman for the Department of Health said: "The Health Bill sets out the Government's vision for a patient-centred NHS that achieves health outcomes that are among the best in the world. "The Quality and Outcomes Framework and other incentives for GPs are insufficiently focused on outcomes, including patient experience. "We therefore intend to reform the current payment system so that GPs are rewarded appropriately for improving patient outcomes."

Source: Daily Telegraph

Heart Benefits for Women Who Cut Hypertension

Researchers Say Study Points Out 'Missed Opportunities' to Prevent Heart Disease

Middle-aged women who take steps to lower their blood pressure could reduce their risk of having a stroke, heart attack, or developing heart failure, a new study shows. Researchers say they found that high systolic pressure -- the blood pressure when the heart contracts -- is a significant risk factor for cardiovascular disease and its complications in middle-aged and older women.

Doctors say 36% of serious cardiovascular events such as heart attacks and strokes are preventable by lowering blood pressure in women, compared to only 24% in men. For the study, investigators examined data on 9,357 adults in 11 countries in Europe, Asia, and South America for a median of 11 years. The researchers looked for absolute and relative risks of cardiovascular disease that were associated with systolic blood pressure.

They report that three major risk factors account for 85% of the modifiable risk for heart disease in men and women -- high systolic (the top number) blood pressure, high cholesterol, and smoking. And high systolic pressure is the most important risk factor, according to the researchers.

"I was surprised by the study findings that highlight the missed opportunities for prevention of heart disease in older women," researcher Jan A. Staessen, MD, PhD, of the University of Leuven in Belgium, says in a news release.

He says the research team found that a relatively small increase of 15 points in systolic blood pressure increased the risk of cardiovascular disease by 56% in women and 32% in men.

For the study, the researchers looked at ambulatory blood pressure, which involves measuring blood pressure at set intervals for 24 hours during a person's daily routine and when asleep, and conventional blood pressure readings taken in doctors' offices.

The researchers say ambulatory blood pressure readings have less potential for error and provide more accurate estimates of usual blood pressure and prognosis for cardiovascular disease.

The monitor used for ambulatory readings was a small, portable device programmed to take blood pressures at specific intervals. In the study, ambulatory readings were taken at intervals of 15 to 30 minutes during the daytime, and 30 to 45 minutes at night.

Nighttime readings are a better predictor of heart disease than daytime readings because the readings taken at night are more standardized, the researchers say. And blood pressure at night is less likely to be influenced by physical activity.

"It is recognized that women live longer than men, but that older women usually report lower quality of life than men," Staessen says. "By lowering systolic pressure by 15 [points] in hypertensive women, there would be an increased benefit in quality of life by prevention of cardiovascular disease."

 

The researchers say that women and their doctors ought to become more aggressive in diagnosing and treating high systolic blood pressure.

The study is published in Hypertension: Journal of the American Heart Association.

Source: WebMD Health News / Bill Hendrick

 

World's top blood pressure drug gets failing mark

The world's most popular blood pressure medicine is much less effective than comparable drugs and gives patients a false sense of security, researchers said Monday. In a review of earlier studies, they found the drug, a diuretic, or "water pill," called hydrochlorothiazide, lowered blood pressure by only about half as much as common alternatives such as beta blockers and ACE inhibitors.

High blood pressure affects about a third of U.S. adults, according to the National Heart, Lung, and Blood Institute (NHLBI), and ups the risk of heart attack and stroke when left unchecked. "By giving hydrochlorothiazide we give patients and physicians a false sense of security," said study researcher Dr. Franz Messerli, who heads the hypertension program at St. Luke's-Roosevelt Hospital in New York.

"Hydrochlorothiazide should no longer be used alone," he urged, adding that he has been prescribing it to patients himself for the past 25 years. The drug belongs to an older group of water pills called thiazides, which are sold as generics for a few dollars per month. It is also sold as Aquazide H and HydroDIURIL, among other brand names.

The NHLBI currently recommends thiazides as first-line treatment to rein in high blood pressure, after a large government-funded study failed to find additional benefits from newer, more expensive medicines. The problem is that hydrochlorothiazide, which wasn't tested in that study, remains the go-to water pill, said Messerli.

According to his report, published in the Journal of the American College of Cardiology, American doctors wrote 134 million prescriptions for the drug in 2008 alone, landing it far ahead of the beta-blocker atenolol, the second-most commonly used blood pressure medicine. "You cannot just recommend a thiazide as the NHLBI does, knowing that for physicians that translates into hydrochlorothiazide," Messerli told Reuters Health.

Neither the NHLBI nor the American Heart Association could be reached for comments.

For the new study, Messerli and colleagues reviewed 19 studies that compared hydrochlorothiazide to other drugs in randomized trials.

Measured over 24 hours, the low doses of hydrochlorothiazide commonly used reduced systolic or "top" blood pressure by 6.5 points. A top reading of more than 140 is considered high blood pressure. In contrast, angiotensin-converting enzyme, or ACE, inhibitors cut the top number by 12.9 points, beta blockers by 11.2 points, and calcium-channel blockers by 11 points.

While higher doses of hydrochlorothiazide were more effective, Messerli said they were rarely used because of an increase in side effects such as blood sugar and insulin problems.

He added that office-based blood pressure measurements could be deceiving, because hydrochlorothiazide appears to be particularly weak during the night.

"We know that nighttime blood pressure and early-morning blood pressure are very important risk factors for strokes and heart attacks," Messerli said, although he added that how hydrochlorothiazide affects those risks has never been studied.

The new findings don't concern other thiazides such as chlorthalidone or indapamide.

Apart from drug treatment, lifestyle modifications also help rein in blood pressure. Doctors often recommend eating a healthy diet with a low sodium content as well as exercising more and not smoking.

Source: Reuters Health / Frederik Joelving



Below is the recommended medication regime in the UK which is recommended by NICE and the British Hypertension Society

Now listen carefully - "Storytelling" found to aid blood pressure control

People who have trouble keeping their blood pressure in check might benefit from hearing about other patients' struggles with the same problem, a preliminary study suggests. The study, of 299 African-American patients with high blood pressure, looked at the effects of so-called "storytelling" on participants' blood pressure control. About three-quarters of the people in the study were women. Researchers randomly assigned half of the patients to watch a series of three DVDs featuring other patients -- not actors -- recounting their own struggles with learning to rein in their blood pressure numbers. The rest of the patients - who didn't get any DVDs -- served as a comparison group.

DVDs were distributed at the start of the study, three months after the start, and again six months after the start. Periodically, the researchers would ask participants how much time they'd spent watching the DVDs. On average, participants said they watched for a total of nearly 90 minutes over the entire length of the study. In general, the DVDs didn't make a difference to people whose high blood pressure was under control.

But the DVDs did seem to help those who had high blood pressure at the start of the study, the research team says. In those men and women, systolic blood pressure -- the first number in a blood-pressure reading -- dropped by 17 points, on average, after three months. Their diastolic pressure (the second number in a reading) dipped by about 7 points. That compared with declines of 6 points and 1 point, respectively, among patients with uncontrolled blood pressure who were in the comparison group.

In contrast, patients whose high blood pressure was under control at the outset did not seem to benefit from the DVDs. The findings, reported in the Annals of Internal Medicine, suggest that at least some people with high blood pressure may respond to hearing from people similar to themselves -- rather than just their doctors. The theory, said lead researcher Dr. Thomas K. Houston, is that "the more you relate to the person in the story, the more engaged you become."

That's in contrast to hearing "just the facts" from your doctor, according to Houston, of the University of Massachusetts Medical School in Worcester. The researchers are not sure why patients who saw the DVDs tended to fare better. (In fact, they had to take the patient's word that he or she had actually watched the DVDs at all.) It's possible that people in the DVD group were more likely to stick with their medication, or make diet and exercise changes, according to Houston. But the study did not measure those behavior changes.

So, many questions remain for future studies.

One is how widely effective any set of collection of stories might be. In this study, the participants and the patients in the DVDs were all from the same inner-city Alabama medical clinic. "The question is, would these DVDs made in Alabama be useful if you gave them to patients in Chicago, or in LA?" Houston said in an interview. Or would individual medical centers have to create their own videos? Another question is how long any benefits of storytelling might last. Houston's team found that six to nine months after the study's start, patients' average blood pressure had started to move upward, though to a lesser degree in the DVD group. "We would anticipate that the benefit would be likely to wane," Houston said. He added, though, that any storytelling tactic would only be part of overall care for people with high blood pressure. "It might help," Houston said, "by opening the door to people talking more with their doctors."

In the study DVDs, one of the topics patients discussed was how they had learned to best communicate with their doctors. An editorial published with the study calls the findings "provocative," but also says storytelling is not yet ready for the medical mainstream. "Stories are unlikely to become a routine part of treatment until additional evidence shows that their effect is both sustainable and generalizable," write Drs. Kimberly R. Myers and Michael J. Green, of Penn State College of Medicine in Hershey, Pennsylvania. They add that an "intriguing" question is whether online social networks, like YouTube and Facebook, could be used for medical storytelling.

Houston pointed out that such videos need not be Hollywood production value. To create their DVDs, he and his colleagues took a low-cost approach -- complete with "bad lighting" and editing by the researchers themselves.

The study was funded by a national program of the Robert Wood Johnson Foundation called Finding Answers: Disparities Research for Change.

Source: Reuters Health/Amy Norton

Deep Brain Stimulation for Stubborn Hypertension

Case Study Suggests Stimulating Brain With Electrical Impulses May Treat High Blood Pressure

 Using electrical pulses to stimulate nerve centers deep within the brain may reduce high blood pressure that can't be controlled with medication, a case report shows. Doctors in the U.K. made the discovery after implanting a device that works as an electric stimulator of a region of the brain in a 55-year-old man who had developed chronic pain on the left side of his body following a stroke. Though his pain eventually returned after four months, his doctors report that their patient's previously uncontrolled blood pressure has remained normal for nearly three years.

That was a surprise because experts had long thought that pain had to be reduced to see a reduction in blood pressure. "Pain creates stress and that can have an effect on one's blood pressure," says Nikunj J. Patel, MD, a neurosurgeon at Frenchay Hospital in Bristol, U.K., and an author of the case study.

Patel says that makes the impact of the case study "startling and exciting" because if studies bear the findings out, deep brain stimulation may one day help people with hypertension whose blood pressure remains uncontrolled on multiple medications. The case study is published in the Jan. 25 issue of Neurology.

While the case study is only an example of the phenomenon occurring in a single person, previous reports have observed the same kinds of reductions in blood pressure in people getting deep brain stimulation for pain, though researchers had believed that the blood pressure benefit was directly tied to the degree of pain relief the person experienced.

"What their case report shows is that blood pressure can be reduced in a sustained fashion in a patient with unsuccessful deep brain stimulation for pain," says Erlick Pereira, MD, a neurosurgeon at the University of Oxford. Pereira wrote about blood pressure reductions in a patient getting deep brain stimulation in the January 2010 issue of the Journal of Clinical Neuroscience.

"I think that's important because it paves the way for potentially studying patients without chronic pain and offering the treatment sometime in the future to reduce blood pressure," he says.

The doctors report that their patient, immediately following his stroke, had spiking blood pressure that ranged from 153/89 to 265/96. Normal blood pressure is 120/80 or lower. Even after taking a combination of four different hypertension medications, the man was unable to get his blood pressure down, and eventually, though he regained movement after being partially paralyzed by his stroke, he developed a chronic pain.

Doctors tried for three years to control their patient's pain, without success. So they agreed that he might be a candidate for deep brain stimulation, which can sometimes be helpful for people who can't find relief any other way.

At first, the neurostimulator seemed to help the pain, and when doctor's measured their patient's blood pressure, they were surprised to find that it had dropped significantly -- to as low as 80/53. They took the patient off all his hypertension medications, and his blood pressure normalized to an average of110/65 in the first eight weeks after surgery. Within 12 weeks, his blood pressure had inched back up only slightly to 124/76.

After four months, the pain relief from the electrical stimulation wore off, but his blood pressure stayed down. After more than two years, with blood pressure still near normal, his doctors tested his response by switching the neurostimulator on and off.

When the device was off, his blood pressure increased by about 18/5 points. When it was turned back on, his blood pressure dropped by 33/13 points.

Drug-Resistant High Blood Pressure

According to the National Center for Health Statistics, about one in three Americans has high blood pressure. Studies suggest that about one in eight people being treated for hypertension can't get their blood pressure under control, even on three or more medications. Uncontrolled high blood pressure can lead to myriad health problems including heart and kidney failure, eye damage and blindness, strokes and heart attacks, dementia, and erectile dysfunction.

When medication fails, newer surgical interventions -- including renal nerve ablation, where nerves in the major arteries of the kidneys are zapped and deactivated with radiofrequency energy, and carotid baroreceptor stimulation, where electrodes stimulate nerves near major arteries that supply blood to the brain -- may be options that can help reduce the risks of major complications from very high blood pressure.

"These treatments are not a panacea," Patel says. "One-third of the people who get these interventions are still not helped."

With further testing, experts think deep brain stimulation could become a third interventional option for patients. "It's a procedure with tiny, but important risks" says Pereira. Those risks include bleeding in the brain, infection, and reactions to the surgical anesthesia. "But if we can follow a group of patients over three years or more and show that the blood pressure reductions are sustained, this could become an important third option.

Deep Brain Stimulation and Blood Pressure

The region of the brain being stimulated in these procedures, which is called the periaqueductal gray (PAG)/periventricular gray (PVG) region, acts like a switchboard for pain signals throughout the body. It also controls the body's response to stress, the fight-or-flight response.

In response to a perceived threat, the body prepares for action by increasing the heart rate and blood pressure.

Some researchers think that stimulating the PAG/PVG region can help shut down an overactive stress response, letting blood pressure and heart rate return to normal levels. In deep brain stimulation, electrodes are implanted into areas of the brain. Wires attach the electrodes to small, metal electrical impulse generators that are implanted under the skin on the chest.

Deep brain stimulation is FDA approved to treat movement disorders, including Parkinson's disease and essential tremor. It is also has an FDA humanitarian device exemption for treatment of dystonia and severe cases of obsessive-compulsive disorder.

Source: Brenda Goodman / WebMD Health News


 

What you need to know about ACE inhibitors and high blood pressure.

ACE inhibitors are a popular "first choice" medicine for many GP's beginning a person with high blood pressure on medication. If you are under 55 and not from an African-Caribbean background then it is common for you to be given an ACE Inhibitor. If you have been given an ACE inhibitor your medicine's name will end in "-pril" – such as Ramapril or Lisinopril. Remember though that this is just the generic name – the brand name of your medicine may well be different. For Ramapril for instance, the brand name of your medicine might be Lopace or Triapin. If you have any doubt, ask your pharmacist.

ACE inhibitors work by stopping your body from producing a chemical called angiotensin II. Angiotensin II does a number of things to your body. First it has the effect of narrowing your blood vessels when it enters the blood stream which raises your blood pressure as blood is forced to travel through these narrower vessels. Secondly, it triggers a hormone that encourages your body to retain water which can also cause your blood pressure to rise.

ACE inhibitors can help lower your blood pressure by reducing the amount of angiotensin II in your body. This helps your blood vessels to relax and widen and lowers the amount of fluid your body retains, both of which help lower your blood pressure.

The most common side-effect of ACE inhibitors is a persistent dry cough. If this happens to you speak to your Doctor as there are a range of medicines available to lower blood pressure.