A retrospective cohort study of the potency of lipid-lowering therapy and race-gender differences in LDL cholesterol control.

BACKGROUND: Reasons for race and gender differences in controlling elevated low density lipoprotein (LDL) cholesterol may be related to variations in prescribed lipid-lowering therapy. We examined the effect of lipid-lowering drug treatment and potency on time until LDL control for black and white women and men with a baseline elevated LDL. METHODS: We studied 3,484 older hypertensive patients with dyslipidemia in 6 primary care practices over a 4-year timeframe. Potency of lipid-lowering drugs calculated for each treated day and summed to assess total potency for at least 6 and up to 24 months. Cox models of time to LDL control within two years and logistic regression models of control within 6 months by race-gender adjust for: demographics, clinical, health care delivery, primary/specialty care, LDL measurement, and drug potency. RESULTS: Time to LDL control decreased as lipid-lowering drug potency increased (P < 0.001). Black women (N = 1,440) received the highest potency therapy (P < 0.001) yet were less likely to achieve LDL control than white men (N = 717) (fully adjusted hazard ratio [HR] 0.66 [95% CI 0.56-0.78]). Black men (N = 666) and white women (N = 661) also had lower adjusted HRs of LDL control (0.82 [95% CI 0.69, 0.98] and 0.75 [95% CI 0.64-0.88], respectively) than white men. Logistic regression models of LDL control by 6 months and other sensitivity models affirmed these results. CONCLUSIONS: Black women and, to a lesser extent, black men and white women were less likely to achieve LDL control than white men after accounting for lipid-lowering drug potency as well as diverse patient and provider factors. Future work should focus on the contributions of medication adherence and response to treatment to these clinically important differences.

Does a single-pill antihypertensive/lipid-lowering regimen improve adherence in US managed care enrolees? A non-randomized, observational, retrospective study.

BACKGROUND: A previous study in 4703 patients suggested that a single-pill combination of amlodipine and atorvastatin is associated with greater adherence to therapy than a two-pill calcium channel antagonist (calcium channel blocker [CCB]) and HMG-CoA reductase inhibitor (statin) regimen. However, the impact of prior medication use on the potential adherence benefits of single-pill amlodipine/atorvastatin has not been studied. OBJECTIVE: To compare adherence to single-pill amlodipine/atorvastatin versus two-pill CCB + statin regimens in a large managed care population, stratified according to prior CCB and statin use. METHODS: This retrospective study was conducted among managed care enrolees in the US. Patients included in the analysis had to have a pharmacy claim for single-pill amlodipine/atorvastatin or claims for both a CCB and a statin within any 30-day window between April 2004 and April 2005. Adherence was measured over 6 months following the index date (the date of the first single-pill amlodipine/atorvastatin claim or of the claim for the second medication class for any two-pill CCB + statin regimen) as the proportion of days covered (PDC) by both CCB and statin therapy; patients were considered 'adherent' if PDC was > or =80%. Patients were divided into four cohorts based on pre-index CCB and statin use: (i) naive (CCB)/naive (statin); (ii) experienced (CCB)/naive (statin); (iii) naive (CCB)/experienced (statin); and (iv) experienced (CCB)/experienced (statin). Within each cohort, adherence was compared for patients receiving single-pill amlodipine/atorvastatin versus two-pill amlodipine + atorvastatin or other two-pill CCB + statin regimens (including amlodipine or atorvastatin but not both) at index. Multivariable logistic regression with propensity score weighting was used to adjust for covariates, including age, sex and co-morbidities. RESULTS: In total, 35,430 patients were included in the analysis. At month 6 (after adjusting for covariates), patients in the experienced (CCB)/naive (statin) cohort receiving single-pill amlodipine/atorvastatin were more than twice as likely to be adherent as those receiving two-pill amlodipine + atorvastatin (odds ratio [OR] 2.20; p < 0.0001) or other two-pill CCB + statin regimens (OR 2.75; p < 0.0001). Similarly, patients in the naive (CCB)/experienced (statin) cohort receiving single-pill amlodipine/atorvastatin were more likely to be adherent than those receiving two-pill amlodipine + atorvastatin (OR 1.72; p < 0.0001) or other two-pill CCB + statin regimens (OR 2.81; p < 0.0001). In contrast, in the naive (CCB)/naive (statin) cohort there was no significant difference in adherence between patients receiving single-pill amlodipine/atorvastatin versus two-pill amlodipine + atorvastatin (OR 1.00), although patients receiving single-pill amlodipine/atorvastatin were slightly more likely to be adherent than those receiving other two-pill CCB + statin regimens (OR 1.29; p < 0.01). In the experienced (CCB)/experienced (statin) cohort there was also no significant difference between patients receiving single-pill amlodipine/atorvastatin versus two-pill amlodipine + atorvastatin (OR 1.08), and only a slightly greater likelihood of achieving adherence to single-pill amlodipine/atorvastatin versus other two-pill CCB + statin regimens (OR 1.19; p < 0.01). CONCLUSIONS: This large retrospective study confirms previous observations that single-pill amlodipine/atorvastatin can help improve adherence versus two-pill CCB + statin regimens. However, greater improvements in adherence are likely to be observed in patients with prior experience of either CCB or statin therapy than in those either naive to, or experienced with, both therapies.

Racial disparities in hypertension control, but not treatment intensification.

BACKGROUND: Racial disparities in hypertension control are well documented, yet the contribution of providers to these disparities remains unclear. The objective of this study was to examine whether provider management of uncontrolled hypertension differed by patient race. METHODS: In a retrospective cohort of 16,881 hypertensive adults in six academic primary care practices from 1/2004 to 12/2006, we evaluated hypertension control in black vs. white patients according to expert guidelines and, among those with uncontrolled hypertension, whether antihypertensive drugs were intensified by providers. Generalized estimating equations accounted for clustering and adjusted sequentially and additively for patient, provider, and practice characteristics, as well as health-care utilization and antihypertensive medication potency. RESULTS: Black patients' visits (55.5% of 132,730 visits) had a higher unadjusted odds (1.63, 95% confidence interval (CI) 1.57-1.69) of uncontrolled hypertension than white patients' visits; the fully adjusted odds ratio remained significant (1.40, CI 1.33-1.48, P < 0.001). Among 66,327 visits with uncontrolled hypertension, no intensification of antihypertensive drugs was less likely for blacks' visits before adjustment (0.80, CI 0.76-0.83, P < 0.001) but moderated in the fully adjusted model (adjusted odds ratio 0.93, CI 0.87-0.99, P < 0.05) compared with whites' visits. Accounting for provider race, intensification was more likely at black patients' visits compared with white patients' visits. CONCLUSIONS: In our study, black patients had poorer hypertension control, and providers were more likely to intensify antihypertensive drugs at visits of black compared with white patients as appropriate. These data suggest that more research is needed to understand racial disparities in hypertension control.

Are high-risk hypertensive patients being prescribed concomitant statin therapy?: a retrospective cohort study.

BACKGROUND: Treatment guidelines for dyslipidemic patients have focused on lipid levels and risk assessments. However, normolipidemic patients who have multiple risk factors for cardiovascular disease may also benefit from HMG-CoA reductase inhibitor (statin) therapy. OBJECTIVE: We examined the frequency of statin prescriptions in patients initiating antihypertensive drug treatment in a US managed-care setting. STUDY DESIGN AND PATIENT: This retrospective cohort study used the PharMetrics' Patient-Centric Database to identify enrollees initiating antihypertensive treatment (September 2001 to February 2004). Patients newly treated with antihypertensives and with various levels of coronary heart disease (CHD) risk (including dyslipidemia, established CHD, type 2 diabetes mellitus, and no CHD but three or more cardiovascular risk factors) were included in the study. MAIN OUTCOME MEASURE: Cumulative probability of receiving statin therapy each month after antihypertensive initiation. Multivariable logistic regression was used to identify factors associated with receiving concomitant statin therapy. RESULTS: Of 142 389 patients (mean age 51.7 years) newly treated with antihypertensives, 32 056 (22.5%) were prescribed statins within 1 year. The cumulative probability of being prescribed a statin increased with increasing numbers of CHD risk factors, irrespective of dyslipidemia status. After adjusting for age, sex, and other potential predictors, patients were more likely to receive statin therapy if they had a history of dyslipidemia (adjusted odds ratio [AOR] 5.68 [95% CI 5.52, 5.85]), established CHD/congestive heart failure (AOR 3.39 [95% CI 3.16, 3.63]), or three or more additional cardiovascular risk factors but no CHD (AOR 3.01 [95% CI 2.74, 3.30]). CONCLUSION: Among patients beginning antihypertensive treatment, those with established CHD or CHD risk factors were more likely to receive statins, but a substantial fraction did not fill any statin prescription. The increased use of statin therapy could benefit many hypertensive patients with additional CHD risk factors.

Association between prescription burden and medication adherence in patients initiating antihypertensive and lipid-lowering therapy.

PURPOSE: The association between prescription burden and medication adherence in patients initiating antihypertensive and lipid-lowering therapy was studied. METHODS: Patients enrolled in managed care organizations who initiated antihypertensive therapy coincident with lipid-lowering therapy (no more than 90 days apart) between January 1, 1997, and April 30, 2000, were eligible for inclusion. Analysis was limited to new users of antihypertensive and lipid-lowering therapy. The proportion of days covered (PDC) by antihypertensive and lipid-lowering therapy was calculated for the first year after therapy initiation; patients with a PDC of > or =80% for both drug classes were considered adherent. Prescription burden was defined as the number of prescription medications taken in the year prior to starting antihypertensive and lipid-lowering therapy. Demographic, clinical, and health-service-use variables associated with both prescription burden and medication adherence were measured using medical and pharmacy claims data from the year before initiation of antihypertensive and lipid-lowering therapy. RESULTS: Among 5759 patients, the mean +/- S.D. prescription burden was 3.6 +/- 3.7 (median, 3) medications, and the mean +/- S.D. PDC with antihypertensive and lipid-lowering therapy was 53.9% +/- 31.9% (median, 58.5%). Among patients with 0, 1, and 2 prior medications, 41%, 35%, and 30% of patients were adherent, respectively, to antihypertensive and lipid-lowering therapy. Among patients with 10 or more prior medications, 20% were adherent. CONCLUSION: Among patients in a managed care database taking antihypertensive and lipid-lowering medications, adherence to those regimens became less likely as the number of prescription medications increased. The reduction in adherence with additional prescription medications was greatest in patients with the fewest preexisting prescriptions.

Transition probabilities and predictors of adherence in a California Medicaid population using antihypertensive and lipid-lowering medications.

OBJECTIVES: To determine adherence rates, transition probabilities, and factors associated with transition from higher to lower adherence in antihypertensive (AH) and lipid-lowering (LL) medications. METHODS: California Medicaid data (1995-2003) were used to identify hypertensive patients with prescriptions for both AH and LL medications. Proportion of days covered (PDC) was used to define three adherence classifications: fully adherent (FA, PDC >or= 0.8), partially adherent (PA, 0.2

Effect of patient comorbidities on filling of antihypertensive prescriptions.

OBJECTIVES: To evaluate the extent of patient failure to fill antihypertensive prescriptions and to test the hypothesis that the presence of noncardiovascular disease is negatively associated with filling an antihypertensive prescription, and, conversely, that the presence of cardiovascular disease is positively associated with filling an antihypertensive prescription. STUDY DESIGN: Cross-sectional. METHODS: We sampled prescriptions written for 327 African Americans aged >or=18 years. Patients were enrolled in a Medicaid managed care plan and treated in 6 primary care practices between January 1, 2003, and February 8, 2005. Prescription filling was defined as a match between a new or renewed electronic prescription and an insurance claim within the next 30 days. We assessed the association of comorbidity type with filling an antihypertensive prescription by using an adjusted logistic regression model that accounted for clustering of prescriptions within patients. RESULTS: Of 1742 antihypertensive prescriptions, 1309 (75.1%) were filled. Prescriptions written for persons with 5 or more noncardiovascular comorbidities were significantly more likely to be filled (adjusted odds ratio [OR], 1.59; 95% confidence interval [CI], 1.07 +/- 2.36) versus those for persons with fewer noncardiovascular comorbidities. The presence of cardiovascular comorbidities was not associated with filling of an antihypertensive prescription (adjusted OR, 0.72; 95% CI, 0.45-1.14). CONCLUSION: Many antihypertensive prescriptions were not filled. Different types of patient comorbidity may differentially impact prescription filling. Further studies should examine whether these results generalize to other populations.

The clinical and economic burden of nonadherence with antihypertensive and lipid-lowering therapy in hypertensive patients.

OBJECTIVE: We sought to determine lifetime costs, morbidity, and mortality associated with varying adherence to antihypertensive and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statin) therapy in a hypertensive population. METHODS: A model was constructed to compare costs and outcomes under three adherence scenarios: no treatment, ideal adherence, and real-world adherence. Simulated patients' characteristics matched those of participants in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm and event probabilities were calculated with Framingham Heart Study risk equations. The real-world adherence scenario employed adherence data from an observational study of a US population; risk reductions at each level of adherence were based on linear extrapolations from clinical trials. Outputs included life expectancy, frequencies of primary and secondary coronary heart disease and stroke, and direct medical costs in 2006 US$. The incremental cost per life-year gained and incremental cost per event avoided were calculated comparing the three adherence scenarios. RESULTS: Mean life expectancy was 14.73 years (no-treatment scenario), 15.07 (real-world adherence), and 15.49 (ideal adherence). The average number of cardiovascular events per patients was 0.738 (no treatment), 0.610 (real-world adherence), and 0.441 (ideal adherence). The incremental cost of real-world adherence versus no treatment is $30,585 per life-year gained, and ideal adherence versus real-world adherence is $22,121 per life-year gained. CONCLUSIONS: Hypertensive patients taking antihypertensive and statin therapy at real-world adherence levels can be expected to receive approximately 50% of the potential benefit seen in clinical trials. Depending on its cost, the incremental benefits of an effective adherence intervention program could make it an attractive value.

Does synchronizing initiation of therapy affect adherence to concomitant use of antihypertensive and lipid-lowering therapy?

Although efficacious medications are available to treat hypertension and dyslipidemia, treatment adherence is often poor. This retrospective study evaluated adherence in patients newly initiating antihypertensive (AH) and lipid-lowering (LL) therapies simultaneously versus within 180 days of one another. Data were analyzed for US managed care plan enrollees initiating AH before LL (cohort 1;n = 7099), LL before AH (cohort 2; n = 3229), or AH/LL simultaneously (cohort 3; n = 5072). A multivariate model evaluated potential predictors of adherence (medication possession ratio >or= 0.80 over a bimonthly period). Percentages of patients adherent to AH/LL at 2, 6, and 12 months were as follows: 59.4%, 32.7%, and 31.3% in cohort 1; 45.0%, 30.8%, and 31.0% in cohort 2; and 75.2%, 34.4%, and 34.0% in cohort 3, respectively. After adjustment for potential confounders, patients initiating AH before LL therapy, or LL before AH therapy, were less likely to be adherent than patients prescribed both agents simultaneously (odds ratios = 0.838 and 0.691, respectively; P , 0.0001). Synchronous initiation of AH and LL therapies is an important predictor of adherence.

Adherence with single-pill amlodipine/atorvastatin vs a two-pill regimen.

While clinical trials demonstrate the benefits of blood pressure and cholesterol reduction, medication adherence in clinical practice is problematic. We hypothesized that a single-pill would be superior to a 2-pill regimen for achieving adherence. In this retrospective, cohort study based on pharmacy claims data, patients newly initiated on a calcium channel blocker (CCB) or statin simultaneously or within 30 days, regardless of sequence, were followed (N=4703). Adherence was measured over 6 months as proportion of days covered (PDC). At baseline, mean age was 63.0 years, 51.6% were female, and mean number of other medications was 7.8. Overall, 16.9% of patients were on single-pill amlodipine/atorvastatin, 15.6% amlodipine + atorvastatin, 24.7% amlodipine + other statin, 13.9% other CCB + atorvastatin, 28.9% other CCB + other statin. Percentages of patients achieving adherence (PDC >or= 80%) were: 67.7% amlodipine/atorvastatin; 49.9% amlodipine + atorvastatin; 40.4% amlodipine + other statin; 46.9% other CCB + atorvastatin; 37.4% other CCB +other statin. After adjusting for treatment selection and cohort differences, odds ratios for adherence with amlodipine/atorvastatin were 1.95 (95% confidence interval [CI], 1.80-2.13) vs amlodipine + atorvastatin, 3.10 (95% CI, 2.85-3.38) vs amlodipine + other statin, 2.06 (95% CI, 1.89-2.24) vs other CCB + atorvastatin, 2.85 (95% CI, 2.61-3.10) vs other CCB + other statin (all p<0.0001). Single-pill amlodipine/atorvastatin may provide clinical benefits through improving adherence, offering clinicians a practical solution for cardiovascular risk management.

Predictors of adherence to concomitant antihypertensive and lipid-lowering medications in older adults: a retrospective, cohort study.

BACKGROUND: Many older individuals have concomitant hypertension and dyslipidaemia--two conditions that, together with age, increase the risk of adverse cardiovascular events. Adherence to antihypertensive (AH) and lipid-lowering (LL) therapy is therefore particularly important in older patients with concomitant hypertension and dyslipidaemia. OBJECTIVE: To determine patterns and predictors of adherence to concomitant AH and LL therapy among an older Medicare-eligible population. METHODS: Enrolees (n=4052) aged>or=65 years who initiated treatment with both AH and LL therapy within a 90-day period were studied in this retrospective cohort study conducted in a US managed care organization. Adherence to AH and LL medications was measured as the proportion of days covered by any AH and/or LL medication in each 3-month interval, from the start of concomitant therapy for up to 36 months (mean follow-up 19.5 months). In each interval, patients were considered 'adherent' to AH and LL therapy if they had filled prescriptions sufficient to cover>or=80% of days with both medication classes. A multivariable regression model evaluated potential predictors of adherence to concomitant therapy, including patient demographics, clinical characteristics and health services use patterns at baseline. RESULTS: The percentage of patients adherent to both AH and LL therapy declined rapidly, before stabilizing, with 40.5%, 32.7% and 32.9% adherent at 3, 6 and 12 months, respectively. At each timepoint, an additional 27.8-35.0% of patients were adherent to either AH or LL therapy, but not both. Adherence was on average greater to AH than LL therapy. After adjusting for age, sex and other potential predictors, patients were more likely to be adherent if AH/LL therapies were initiated closer together in time (adjusted odds ratio [AOR] 1.13 for 0-30 days vs 61-90 days, p=0.0563), had a history of cardiovascular disease (AOR 1.27, p=0.0004), took fewer additional medications (AOR 0.43 for six or more medications vs zero or one medication, p<0.0001) or had more outpatient physician visits in the prior year (AOR 1.26 for four to six visits vs zero to one visit, p<0.0027). CONCLUSION: Adherence to concomitant AH and LL therapy among older adults is poor. Modifiable factors that may improve adherence in Medicare-eligible patients include initiating therapy concurrently and reducing patients' overall pill burden.

Effect of unrelated comorbid conditions on hypertension management.

BACKGROUND: Quality-of-care assessment at a single visit can be affected by whether a patient's comorbid conditions are related or unrelated to a specific measure. OBJECTIVE: To examine the association of unrelated comorbid conditions with treatment of uncontrolled hypertension in primary care visits. DESIGN: Examination of a database derived from electronic medical records collected during routine care of a cohort of primary care patients. SETTING: 6 primary care practices in Philadelphia, Pennsylvania. PATIENTS: 15,459 patients with uncontrolled hypertension who made 70,557 visits to 200 clinicians from January 2004 through December 2006. MEASUREMENTS: Intensification of any antihypertensive treatment before the next visit was assessed. Patient and clinician information were obtained from electronic medical records and administrative data. Unrelated comorbid conditions included 28 conditions, such as arthritis and emphysema, whereas related comorbid conditions included vascular diseases. Generalized estimating equation logistic regression models were used to adjust for patient, health care, and provider characteristics and for clustering. Variation in the effect of unrelated comorbid conditions was examined at the visit, patient, and provider level. RESULTS: At study visits, patients had a mean of 2.2 (SD, 1.8) unrelated comorbid conditions. The adjusted odds of treatment intensification decreased with the number of unrelated comorbid conditions, from 0.85 (95% CI, 0.80 to 0.90) for 1 to 0.59 (CI, 0.51 to 0.69) for 7 or more versus none. The relationship between treatment intensification and unrelated comorbid conditions persisted at the visit, patient, and provider levels (P < 0.001). LIMITATIONS: The reasons for not intensifying treatments are unknown. The recorded blood pressure may be inaccurate. Physicians may vary in their recording of comorbid conditions. CONCLUSION: Patients with more unrelated comorbid conditions were less likely to have uncontrolled hypertension addressed at a visit. The effect of different types of comorbid conditions on meeting quality-of-care measures merits further investigation.

Impact of systemic hypertension on the cardiovascular benefits of statin therapy--a meta-analysis.

The ASCOT-LLA and ALLHAT-LLT trials provide conflicting evidence of the efficacy of statins in decreasing cardiovascular (CV) morbidity and mortality in hypertensive patients. We performed a meta-analysis to compare the overall efficacy of statins in hypertensive and nonhypertensive patients enrolled in major randomized clinical trials. We systematically reviewed PubMed publications from 1985 onward for placebo-controlled randomized trials that examined the effect of statins on cardiac morbidity and mortality. Only trials that followed >or=1,000 patients for >or=2 years were included in the meta-analysis. Outcomes included cardiac or CV death, major coronary events, or major CV events. Pooled estimates of relative risk (RR) were calculated separately for hypertensive and nonhypertensive patients. The moderating effect of the percentage of hypertensive patients at baseline was tested using meta-regression. Besides the ASCOT-LLA and ALLHAT-LLT, 12 trials enrolling 69,984 patients met inclusion criteria. Overall, in these 12 trials, statin therapy decreased cardiac death by 24% (RR 0.76, 95% confidence interval [CI] 0.71 to 0.82). There was no evidence of difference in RR estimates for hypertensive (RR 0.78, 95% CI 0.72 to 0.84) and nonhypertensive (RR 0.76, 95% CI 0.72 to 0.80) patients. Similarly, meta-regression showed that the efficacy of statins was not moderated by the percentage of hypertensive patients at baseline (Q estimate 1.51, p=0.22). In conclusion, statin therapy effectively decreases CV morbidity and mortality to the same extent in hypertensive and nonhypertensive patients.

Regional differences in the prevalence, treatment and control of hypertension and dyslipidemia in US urban Hispanic populations participating in health screening events.

OBJECTIVE: We examine the prevalence, treatment, and control of hypertension, dyslipidemia, and concomitant hypertension and dyslipidemia among Hispanics in four US communities. METHODS: This was a cross-sectional study of Hispanics who participated in health screening programs from 2004 to 2006. We enrolled 5288 Hispanics in Miami (n=372), New York (n=254), Los Angeles (n=4037), and Houston (n=625). The main outcome measures were prevalence, treatment and control rates of hypertension, dyslipidemia, and concomitant hypertension and dyslipidemia. RESULTS: Overall prevalence rates of hypertension, dyslipidemia, and concomitant hypertension and dyslipidemia were 37.5%, 26.6%, and 15.3%, respectively. Hypertension treatment rates ranged from 30.9% (Houston) to 68.2% (Miami) (P<.05); control was achieved in 34.7% (Los Angeles) to 47.8% (New York, P<.05). Dyslipidemia treatment rates were lowest in Houston (36.5%) and highest in New York (75.3%, P<.05); control rates were 62.3% (Houston) to 75.1% (Los Angeles P<.05). Dual treatment of hypertension/dyslipidemia ranged from 24.4% (Houston) to 69.4% (New York, P<.05), dual control was achieved in 4.5% (Houston) to 35.3% (New York, P<.05). Multivariable logistic regression analyses showed the odds of having each condition did not to differ by region, but regional differences existed for treatment and control. CONCLUSIONS: A high prevalence of hypertension, dyslipidemia, and combined hypertension and dyslipidemia and low control rates for hypertension and concomitant hypertension and dyslipidemia exist among US Hispanic adults in different communities.

Estimated prevalence of uncontrolled hypertension and multiple cardiovascular risk factors and their associated risk of coronary heart disease in the United States.

This study determined the prevalence of primary prevention patients aged 40 to 79 years with uncontrolled hypertension (HTN) and low/moderate cholesterol levels, and the clinical and economic consequences of their cardiovascular risk levels stratified by additional cardiovascular risk factors. Prevalence was estimated from the 1999 to 2002 National Health and Nutrition Examination Survey (NHANES) datasets. Framingham risk equations were used to calculate the 4-year risk of coronary heart disease (CHD). HTN and cholesterol levels were then statistically "controlled" to ideal levels and risks were recalculated. Prevalence of uncontrolled hypertension was 15.2 million cases (13.7%). Of those, 12.9 million (84.8%) had low/moderate cholesterol levels, and 2.2 million (16.7%) had >/=3 additional risk factors with no history of CHD. Nearly 200,000 coronary events are expected to occur within 4 years, incurring over $2.5 billion in direct medical costs. Statistical estimation suggests that 64% of 4-year risk was attributable to uncontrolled blood pressure and lipids. The large number and high cost of CHD events expected to occur within the next 4 years in primary prevention patients with uncontrolled hypertension and >/=3 additional risk factors justifies aggressive screening to ensure that these patients are identified and properly managed.

Calcium channel blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors: effectiveness in combination with diuretics or beta-blockers for treating hypertension.

This retrospective database analysis compared the effectiveness of dihydropyridine calcium channel blockers (DHPs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) added to diuretics or beta-blockers. Adults with hypertension treated with diuretic or beta-blocker monotherapy between 1998 and 2001 were identified from a large US electronic medical records database of primary care practices. Patients were required to have a baseline blood pressure (BP) > or =140/90 mmHg (> or =130/80 mmHg for diabetes mellitus) and recorded BP measurements within 6 months before and 1-12 months following index date. Patients were matched 1:1:1 by propensity score to correct for differences in baseline characteristics. 1875 patients met study criteria and 660 (220 in each cohort) were matched based on propensity scores. Matched cohorts had no significant differences in baseline characteristics. Mean changes in systolic/diastolic BP were -17.5/-8.8, -15.7/-6.3, and -13.0/-8.0 mmHg with DHPs, ACE inhibitors, and ARBs, respectively. Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High BP 6/7 goal attainment for each regimen was 47.3%, 40.0%, and 32.2%, respectively. DHPs, ACE inhibitors, and ARBs improved BP when added to patients' beta-blocker or diuretic therapy. The greatest benefits were observed with DHPs, followed by ACE inhibitors, then ARBs.

Treatment and control of BP and lipids in patients with hypertension and additional risk factors.

BACKGROUND: NCEP ATP III (National Cholesterol Education Program Adult Treatment Panel III) guidelines recommend that for patients at high risk for cardiovascular disease (CVD), lipid-lowering therapy should be considered even at relatively low cholesterol levels (low-density lipoprotein-cholesterol>or=100 mg/dL). Furthermore, the ASCOT-LLA (Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm) has demonstrated the importance of statin therapy in the primary prevention of major cardiovascular events in people with hypertension and>or=3 cardiovascular risk factors with total cholesterol levels ofor=3 cardiovascular risk factors in addition to hypertension. MAIN OUTCOME MEASURES: The frequency of utilizing antihypertensive and lipid-lowering medications, and attainment of BP targets were assessed based on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines (<140/90 mm Hg, or<130/80 mm Hg for patients with diabetes mellitus or chronic kidney disease) and a ratio of total cholesterol/high-density lipoprotein-cholesterol (HDL-C)<6. RESULTS: A total of 7839 veterans were included. Mean age was 58.7+/-13.2 years, and 93.8% were men. Among patients with>or=3 cardiovascular risk factors, 81.9% received any antihypertensive medication and 60.4% were prescribed multiple antihypertensive agents compared with 69.7% and 44.3% of patients, respectively, in the group with<3 cardiovascular risk factors. Lipid-lowering medications were prescribed to 55.3% of patients with>or=3 cardiovascular risk factors, and to 33.8% of those with<3 cardiovascular risk factors. Overall, 14.3% of patients met both BP and lipid targets (8.1% and 17.4% of patients with>or=3 and<3 cardiovascular risk factors, respectively [p<0.0001]). JNC 7 goals were attained in 27.9% of patients with>or=3 cardiovascular risk factors and 41.7% of those with<3 cardiovascular risk factors (p<0.001). Total cholesterol/HDL-C ratio<6 was achieved by 32.3% of patients with>or=3 cardiovascular risk factors and 52.1% of those with<3 cardiovascular risk factors (p<0.001). CONCLUSION: Veterans with>or=3 risk factors for CVD were treated more intensively, but levels of goal attainment were lower compared with patients with<3 cardiovascular risk factors. Our results suggest that the therapeutic strategies used by physicians in the Atlanta VAMC need to be adapted in order to improve lipid goal attainment among patients with hypertension, and thereby further reduce the risk of cardiovascular events.

Treatment of hypertension and dyslipidemia or their combination among US managed-care patients.

The authors examined treatment rates in managed-care patients with hypertension (HTN) only or dyslipidemia (DYS) only compared with patients who had both (HTN+DYS). A retrospective, cross-sectional claims analysis was performed in a 2002 US national managed-care database of 1.23 million continuously eligible members aged 18 years or older. Median age was 44.0 years, 8.8% were aged 65 years or older, and 53.2% were women. Study criteria identified 354,324 patients, 32.9% with HTN only, 34.7% with DYS only, and 32.4% with HTN+DYS. Overall, 49.7% of HTN patients had DYS and 48.3% of DYS patients had HTN. Patients with HTN+DYS were significantly older, more likely to have cardiovascular comorbidities, and more likely to use medications and hospital facilities than were patients with HTN only or DYS only (P<.01). About two-thirds of patients with HTN only received 1 or more prescription for an antihypertensive medication, compared with three-quarters of those with HTN+DYS. Fewer than half of patients with DYS only and approximately two-thirds with HTN+DYS received a cholesterol-lowering agent.