blood pressure control in hypertensive patients in irish primary care practices

O r i g i n a l P a p e r

Blood Pressure Control in HypertensivePatients in Irish Primary Care Practices

Brendan Buckley, MD;1 Eamonn Shanahan, MD;2 Niall Colwell, MD;3

Eva Turgonyi, MD;4 Peter Bramlage, MD;5 Ivan J. Perry, MD6

In Ireland, cardiovascular disease is a majorcause of death. However, blood pressure (BP)goal achievement is unsatisfactory. The authorsaimed to document BP control and increaseawareness. A total of 1534 patients were enrolledin the study, with a mean age of 64.7�11.9 years(53.8% women). Duration of hypertension was8.7�7.7 years, and 14.6% had diabetes, 13.8%had coronary artery disease, and 40.5% weretaking antihypertensive monotherapy. b-Blockers(39.8%), angiotensin-converting enzyme inhibi-tors (32.2%), and angiotensin receptor blockers(22.0%) were prescribed most frequently. MeanBP was 136.0�6.1 mm Hg ⁄ 89.5�5.0 mm Hg innondiabetic patients (48.6% <140 ⁄ 90 mm Hg)and 131.0�7.4 mm Hg ⁄ 81.7�4.6 mm Hg in dia-betic patients (16.7% <130 ⁄ 80 mm Hg). Diet,exercise, and lifestyle modifications (63.5%) werefrequently recommended. Increased patientawareness and compliance together with the

adherence of physicians to current guidelines andgreater willingness to take action in patients withuncontrolled hypertension should help in improv-ing BP control and thus reduce cardiovascularrisk. J Clin Hypertens (Greenwich).2009;11:432–440. ª2009 Wiley Periodicals, Inc.

High blood pressure (BP) is a major risk fac-tor for cardiovascular (CV) disease and

affects about 30% of the adult population in theUnited States and Canada as well as up to 50%of adults in European countries.1 It is the leadingcause of death globally, with more than 7 milliondeaths attributed to CV disease each year.2

Although many different effective drugs anddrug classes are available,3 control rates are low.4

While between 40% and 50% of treated patientsare well controlled in North America, control ratesin Europe and Asian countries can be as low as20%. This control rate is only the tip of the ice-berg, however, as illustrated by a recent survey inprimary care in Germany in which many patientswith hypertension were previously undiagnosed.5

Many patients are underdiagnosed and undertreat-ed in a primary care setting. A recent global surveyhas shown that this relates to partial inertia towardtight BP control on both the patient and physicianside.6 As illustrated by a number of recent surveysin the United States, about one third of patientswhose BP values are consistently above goal levelsdo not have medication started, changed, orincreased.7–9 It can be overcome, however, as arecent article nicely summarized.10

By contrast with the situation in the UnitedStates, Europe, and the United Kingdom, there arelimited contemporary data on the distribution of

From the European Centre for Clinical Trials in RareDiseases, University College Cork, Cork, Ireland;1 theFarranfore Medical Centre, Farranfore, Co Kerry,Ireland;2 Consultant Cardiologist, Dublin, Ireland;3

Sanofi-Aventis Ireland Ltd, Dublin, Ireland;4 theInstitute for Cardiovascular Pharmacology,Epidemiology, Mahlow, Germany;5 and theDepartment of Epidemiology & Public Health,University College Cork, Cork, Ireland6

Address for correspondence:Brendan Buckley, European Centre for Clinical Trialsin Rare Diseases, University College Cork, LancasterHall, 6 Little Hanover Street, Cork, IrelandE-mail: [email protected] received March 2, 2009; revised June 2, 2009;accepted June 3, 2009

doi: 10.1111/j.1751-7176.2009.00151.x

THE JOURNAL OF CLINICAL HYPERTENSION VOL. 11 NO. 8 AUGUST 2009432

BP, the prevalence of hypertension, and the prob-lem of treatment inertia in the ethnically and cul-turally more homogenous Irish population. This ismore surprising since CV disease remains the pri-mary cause of death in Ireland, although there is apositive trend for improvement.11 On the basis ofdata from England,12 it can be estimated that atleast 50% of the population aged 50 years andolder are hypertensive in Ireland. This estimate isfurther supported by data from the Cork and KerryHeart Disease study, which documented a hyper-tension prevalence of 47% (480 of 1018 patients)for both men and women in primary care in1997,13 with an age-dependent increase from anage of 50 until 69 years. Of these hypertensivepatients, 38% (182 of 480) were known to behypertensive and treated accordingly and less thanhalf of these patients (41%) (74 of 182) had theirBP controlled when being treated. The most recentdata have been obtained in the 2007 Survey ofLifestyle, Attitudes, and Nutrition in Ireland(SLAN) project in which 6 of 10 respondents hadhigh BP, of which 6 of 10 were not taking medica-tion and of which 7 of 10 were not controlled toBP levels <140 ⁄90 mm Hg (http://www.dohc.ie/publications/slan07_report.html).

Therefore, hypertension is one of the most com-mon problems that Irish general practitioners haveto manage and they are faced with considerablechallenges when trying to adequately control BP.14

This was the rationale to set up the ‘‘i-targetIreland’’ Blood Pressure Goal Program, which wasdesigned to collect data on the rate of BP controlin patients with essential hypertension currentlyreceiving antihypertensive treatment. The primaryobjective of the survey was to determine the pro-portion of hypertensive patients not achieving theirBP goals on current treatment. Further objectiveswere to increase the awareness of the importanceof BP goals set by international guidelines.

PATIENTS AND METHODSThis was a cross-sectional survey conducted in pri-mary care practices throughout Ireland. To recruitgeneral practices, a conditioned random sample of300 centers was drawn from a nationwide database.Physicians were asked to provide data of 20 conse-cutive patients in their care who were diagnosedwith essential hypertension and had been receivingtreatment with antihypertensive monotherapy orcombination agents. The protocol and survey mate-rial was reviewed by the research ethics committeeof the Cork Teaching Hospitals. Informed consentwas obtained from each patient prior to enrollment.

Data CollectionPhysicians completed a questionnaire duringpatients’ single routine visit to the practices. Thefollowing data were collected: (1) demographics:age, sex, duration of hypertension (years ⁄months),smoking status, current office BP readings, andthe date of visit. (2) Comorbidities: diabetesmellitus, metabolic syndrome, peripheral arterialdisease, diabetic nephropathy, history of atrialfibrillation, history of myocardial infarction, obes-ity, coronary artery disease, congestive heart fail-ure, history of stroke, other, or none of these. Toensure consistency across practices, comorbiditydefinitions and diagnostic criteria were providedalong with the questionnaire. (3) Information onlifestyle modifications recommended in the past:weight loss, stop smoking, exercise, diet, other,or none. (4) Current antihypertensive medication.(5) BP targets with reference to use of specific BPguidelines and whether BP goals had beenachieved in that patient. (6) The action that phy-sicians deemed necessary to take in case BP goalwas not achieved: increase dose, add anotherdrug, prescribe combination therapy, prescribenew agent in monotherapy, lifestyle modification,or none.

DefinitionsBP control was defined as having the current BPmeasurement <140 ⁄90 mm Hg in nondiabeticpatients and <130 ⁄80 mm Hg in diabetic patientsin accordance with the guidance of the EuropeanSociety of Hypertension ⁄European Society of Cardi-ology (ESH ⁄ESC) 2007. For each patient, physi-cian-defined targets were compared with the valuesobtained during the BP measurement on the surveyday. BP measurements were performed in accor-dance with recent recommendations.15 Readings,however, were only obtained once.

Statistical AnalysisStatistical analysis was performed descriptively andwas interpreted in an explorative way.

RESULTSOf the initially contacted 300 primary care physi-cians, 76 agreed to participate (response rate,25.3%). A total of 1542 patients were recruited inthe study; 8 patients were excluded from theanalysis due to nonadherence to the protocol (eg,nonhypertensive ⁄no antihypertensive treatment).Therefore the final total sample size was 1534(99.5%). These patients were the basis for the fol-lowing analyses.

VOL. 11 NO. 8 AUGUST 2009 THE JOURNAL OF CLINICAL HYPERTENSION 433

Demographic DataParticipating patients had a mean age of 64.7�11.9 years, with 53.8% being women. All patientswere hypertensive (inclusion criterion), with a meanduration of hypertension of 8.7�7.7 years. Meancurrent BP readings were 139.4�17.5 mm Hg sys-tolic and 81.1�10.0 mm Hg diastolic.

Comorbidities in Treated Hypertensive PatientsFigure 1 displays the comorbidity burden of hyper-tensive patients included in the study. Diabetesmellitus was the most frequent comorbidity(14.6%), followed by coronary artery disease(13.8%) and a history of atrial fibrillation (8.0%).A total of 66.4% of patients had at least 1 comor-bidity and 26.3% had �2 comorbidities. Further-more, 13.1% were current smokers, and 7.4% hadthe metabolic syndrome.

BP Goal AchievementOf this cohort, 48.6% of nondiabetic patientsachieved BP target of <140 ⁄90 mm Hg and only16.7% of patients with diabetes were controlledusing the goal of <130 ⁄80 mm Hg recommendedin the ESH ⁄ESC guidelines (Figure 2). Given thatmore than 2 of 3 (83.3%) patients with hyperten-sion and diabetes had uncontrolled BP underlinesthat BP goal achievement was highly dependent onwhether a patient was diabetic or not.

BP goal achievement was also assessed based onindividual (not as per guideline) targets set byphysicians: 40.1% of nondiabetic and 54.7% ofdiabetic patients were perceived to be adequatelycontrolled despite a proportion of these patientsmissing the guideline-recommended BP goals.Therefore BP goal achievement was underestimatedin nondiabetic (40.6% vs 48.6%; D=)8.0%) andgrossly overestimated in diabetic patients (54.7%vs 16.7%; D=)38.0%).

Antihypertensive Drug UtilizationA total of 40.5% of patients were taking mono-therapy and 59.5% received either free or fixedcombinations of antihypertensive drugs (Figure 3).Renin-angiotensin system (RAS)–blocking agentswere most frequently used (32.2% angiotensin-converting enzyme [ACE] inhibitors and 22.0%angiotensin receptor blockers [ARBs]). A total of39.8% of patients received b-blockers. Combina-tions of diuretics with ACE inhibitors or ARBswere chosen in 6.6% and 8.0% of patients, respec-tively. ACE inhibitors together with calcium chan-nel blockers (CCBs) were used in 1.2% of patients.

Use of GuidelinesIn the present survey, most Irish physicians indi-cated use of the British Hypertension SocietyGuidelines to a large extent (54%), followed by the

Figure 1. Comorbidities in patients with treated hypertension. Left side: proportion of patients with the respectivecomorbidities. Right side: number of comorbidities in these patients. CAD indicates coronary artery disease; AF, atrialfibrillation; MI, myocardial infarction; PAD, peripheral arterial disease; CHF, congestive heart failure; Diab.Nephropathy, diabetic nephropathy; 4+, 4 or more drugs.


guidance of the ESH ⁄ESC (38%). Six percentreferred to even more localized guidance (includingno guidance), and only 2% to those of the Seventh

Report of the Joint National Committee on Preven-tion, Detection, Evaluation, and Treatment of HighBlood Pressure (JNC 7).

Nondiabetic

Nondiabetic

Figure 2. Left panel: Goal achievement in patients with and without diabetes based on the 2007 guidelines of theEuropean Society of Hypertension ⁄ European Society of Cardiology (ESH ⁄ ESC). Right panel: Physician-indicatedblood pressure (BP) goals (median and mean) and proportion of patients indicated by the physician to have reachedtheir BP goal. SBP indicates systolic blood pressure; DBP, diastolic blood pressure; DM, diabetes mellitus.

Figure 3. Antihypertensive drugs used in primary care in Ireland. Numbers reflect the proportion of patients with therespective antihypertensive medications. Straight and dashed lines indicate possible and preferred combinations as tothe European Society of Hypertension ⁄ European Society of Cardiology (ESH ⁄ ESC) guidelines. Right upper corner:proportion of patients taking monotherpay or combination therapy. Mono indicates monotherapy; combo,combination therapy; ARB, angiotensin receptor blocker; ACEi, angiotensin-converting enzyme inhibitor.


Action Taken to Control BPFigure 4 displays the actions that physicians tookwhen faced with uncontrolled BP. In the top panel,the total number of patients is displayed. For57.5% of these patients, no action was takenbecause the physician considered the BP to be ontarget (which did not mean guideline goals weremet). In the bottom panel, only patients withuncontrolled BP (using the physicians’ perspective)are displayed. The most frequent recommendationswere diet, exercise, and lifestyle modifications(63.5%). In 20.2% of patients, the dose of anti-hypertensive drug was increased and 17.4% ofpatients were reviewed, referred, encouraged tocomply, or had ambulatory BP measurementperformed.

DISCUSSIONA recent global survey of 1259 primary care physi-cians in 17 countries worldwide reported a gap

between clinical practice and recent recommenda-tions in hypertension management.6 The surveyshowed that physicians believed that 62% of theirpatients had their BP controlled and 86% said theyagreed with the guideline-recommended BP goals,but 41% still aimed to reduce BP to unspecified‘‘acceptable’’ levels only. The present survey essen-tially confirms these observations for Ireland, acountry that did not take part in the global survey.BP goals enforced by recent guidelines16–18 werewell-known, but patients were allowed to havehigher BP readings in many cases. This is the morealarming finding, as data from the recent EuropeanUnion Heart Index have shown that Ireland ranks16 out of 29 countries, owing to not meeting therequirements for quick access to heart treatment.19

The authors suggested that there should be astronger emphasis on cardiac prevention, such as anational screening program, BP monitoring, andcompulsory exercise in schools.

Figure 4. Actions to be taken when uncontrolled hypertension is recognized. Upper panel: total number of patientsand the proportion of action to be taken. Lower panel: subset of patients with uncontrolled hypertension and theproportion of actions to be taken. ABPM indicates ambulatory blood pressure measurement.


BP Goal AchievementThe Kilkenny Health Project carried out a baselinepopulation health examination study in CountyKilkenny from 1985 to 1992.20 Risk factors werecompatible with the high mortality rates in Irelandat that time. BP levels were also high. Averagelevels were 146 ⁄79 mm Hg in men and 142 ⁄78mm Hg in women. The prevalence of hypertension(at that time defined as either �160 mm Hgsystolic and ⁄or �95 mm Hg diastolic, or takingantihypertensive treatment) ranged from 8% inmen aged 35 to 44 years to 40% in men aged 55to 64 years and from 4% to 52% in women. Previ-ous data from primary care are available from theCork and Kerry Heart Disease study (1997)13 inwhich prevalence of hypertension was 47%. A totalof 38% were taking antihypertensive medicationand only 41% of these patients were actually con-trolled <140 ⁄90 mm Hg. Studies in different coun-tries, however, have shown that BP control ratesmay be as low as 18.0% (Taiwan), 19.8%(Turkey), or 21.8% (Mexico), but may even reach53.1% (United States) or 55.7% (Japan) in othercountries.4

Although the numbers are not directly compa-rable, the data from the present study documentan improvement in BP control, with 48.6% ofnondiabetic patients reaching BP values<140 ⁄90 mm Hg. Diabetic patients, however, arecontrolled to a much lesser extent, with 83.3%having a BP reading >130 ⁄80 mm Hg on the dayof the survey. While these measurements wereusually carried out once and actual values mayhave been influenced by the study setting, the situ-ation is clearly not acceptable given that everyfurther reduction can reduce morbidity and mor-tality to a considerable extent.21 Indeed, even a2-mm Hg lower usual systolic BP would involveabout 10% lower stroke mortality and about 7%lower mortality from ischemic heart disease orother vascular causes in middle age on a popula-tion level.21

Given that multiple risk factors merge into theabsolute CV risk of a given patient, the controlrates mentioned above are certainly optimistic esti-mates of appropriate BP control in the Irish popula-tion. Guidelines such as those from the ESH ⁄ESC200716 highlight the need for a risk-adaptedapproach to BP control. Multiple risks includingorgan damage, diabetes, and established cardiovas-cular and renovascular disease lower the targets forBP control and will thus increase the number ofpatients who currently have uncontrolled BP.Therefore, a vital role of physicians in primary care

is the assessment of CV risk together with anadapted–BP-lowering strategy.

Antihypertensive Drug UtilizationAlthough there was a large variation in the use ofdifferent drug classes among physicians participat-ing in this survey, b-blockers and RAS-blockingagents were heavily used in general, although cur-rent evidence assigns a class 2 recommendation forb-blockers only. The recent 2006 National Institutefor Health and Clinical Excellence (NICE) guidanceon hypertension states that calcium channel block-ers and diuretics are first-line drugs in hypertensivepatients 55 years and older while ACE inhibitorsshould be used in patients younger than 55 years.The British Hypertension Society (BHS) considersb-blockers to be indicated in myocardial infarctionand stable heart failure (compelling indication). Inpatients with diabetes or the metabolic syndrome,b-blockers have been documented to either promotethe development of diabetes or a worsening ofblood sugar control. An excellent overview hassummarized the evidence for or against the use ofb-blockers.22

The more surprising is the frequent use of b-blockers in Ireland. A recent drug utilization studyinvestigated the use of antihypertensive drugs in 6countries throughout Europe.3 Finnish and Swedishpatients received b-blockers in 25% of cases, witha substantially lower use in Denmark (10%). Com-pelling indications16 may account in part for thefrequent use of b-blockers in Ireland such as previ-ous myocardial infarction (7.2%), angina pectoris(coronary artery disease 13.8%), history of atrialfibrillation (8.0%), and congestive heart failure(3.2%). The use of RAS-blocking agents wasbetween 42% and 60%, which is well compatiblewith the data obtained in Ireland (54.3%).

A total of 40.5% of patients received antihyper-tensive monotherapy, although the majority ofpatients had uncontrolled BP despite being on treat-ment. Guidelines like the ones of the ESH ⁄ESH200716 recommend to escalate to combination ther-apy after full-dose monotherapy has failed or asfirst-line therapy in patients with marked BPelevation (systolic >160 mm Hg or diastolic> 100 mm Hg) and ⁄or high or very high CV risk.In patients with uncontrolled hypertension, how-ever, only 19% either received an additional drugor combination was prescribed in the presentsurvey.

Overall treatment rates with monotherapy orcombination therapy are comparable for Irelandand the United States, for example, where 42% of


patients receive only 1 drug while the rest receiveany drug combination.23 The necessary escalationof drug therapy into drug-drug combinations is,however, not well appreciated by physicians in thisIrish survey. Bramlage and colleagues6 reportedthat physicians from a variety of countries in Eur-ope indicated a switch to combination therapy in74% of patients where monotherapy failed (51%would receive additional treatment, 23% wouldreceive fixed-dose combinations).

Use of GuidelinesGuidance for the treatment of hypertension can beobtained from various sources.16–18 Internationalguidelines, however, are not able to consider locallaws and regulations and the reimbursement situa-tion in a certain country. Guidance is also fre-quently tailored for specialists in hypertensiontreatment and not so much directed toward gen-eral practitioners who may need more straight rec-ommendations to consider in their daily complextask of screening and treating patients for all sortsof diseases. There are initiatives in certain Euro-pean countries to adapt guidelines for generalpractitioners aiming at simplifying treatmentschemes and improving control rates. In the Uni-ted States, where guidelines such as JNC 7, whichare recently directed toward primary care provid-ers, give clear instructions on which drug class isto be used as initial therapy and the selection ofdrugs for the compelling indications, control ratesin treated hypertensive patients are particularlygood.

Physicians in Ireland tended to adhere to BritishHypertension Guidelines in the past because Irelanddoesn’t have its own national hypertension guide-line. Indeed, in the present survey, most Irish physi-cians indicated use of the British HypertensionSociety Guidelines (54%). These numbers are com-patible with data from a global survey,6 which indi-cated that local guidelines are most commonly used(32% for the subset of European countries). Giventhat these guidelines generally recommend BP goalsof <140 ⁄90 mm Hg and <130 ⁄80 mm Hg in dia-betic patients, while most patients do not achievethis goal, it can be questioned whether these actu-ally meet the needs for most physicians. This, inturn, raises the question of whether control rateswould improve if Ireland had its national guideline.Based on the aforementioned lack of quick accessto heart treatment and the need for a strongeremphasis on cardiac prevention,19 together with thefact that CV disease remains the primary cause ofdeath in Ireland,11 there is an apparent need for a

guideline that considers the specific morbidity bur-den and access to health care in Ireland.

Action Taken to Control BPThe action to be taken if BP control is not sufficientis obvious and steps to take should be illustrated inall guidelines.16–18 BP control rates in clinical trialsapproach 80%,24,25 and from this perspective it isnot clear why BP control is as low as 20% to 30%in several primary care studies,5 including the pres-ent one. The setting of a clinical trial, however, ischaracterized by a pre-selection phase that enforcescompliance on the patient side, where patients andphysicians are tightly monitored, physicians followrigorous protocols, and treatment duration is inmany cases shortened. The situation in primarycare is characterized by much lesser control. Inap-propriate patient education leads to lack of under-standing the consequences of uncontrolled BP, thuspatients either forget to pick up their prescriptionor to take their medication. Physicians on the otherhand are satisfied by near-normal BP control, usu-ally treating multimorbid patients with a number ofdifferent drugs and indications. To up-titrate medi-cation is obviously not enough to get a patient’s BPto goal.

Physicians in the present survey largely refer todiet, exercise, and lifestyle modification if BP is notcontrolled (63.5%) on monotherapy or combina-tion therapy. While these are principally beneficialand important measures to support the adjustmentof BP, they have proven to be largely ineffective inclinical practice. On the other hand, dose isincreased in 20.2% of cases, another drug added in11.1%, a combination prescribed in 7.3%, and anew agent installed in 5.2% (total 43.8%). Giventhat BP goals are not achieved to a large extent,diet, exercise, and lifestyle changes alone are clearlynot the optimal therapeutic choices for patients tak-ing failing antihypertensive monotherapy.

These facts have been well recognized in Ireland,and ‘‘Heartwatch’’ is a currently running secondaryprevention program in Ireland involving almost13,000 patients in general practice with the aim ofreducing morbidity and mortality due to CV dis-ease. After 1-year progress of the program, a statis-tically significant improvement in the control of(identifiable) risk factors (systolic BP, diastolic BP,total cholesterol, low-density lipoprotein choles-terol, and smoking) was reported, indicating bene-fits for patients directly involved. An improvementin systolic BP was reported in 22.8% of patients,and an improvement in diastolic BP was reportedin 47.8% of patients.26


Another step forward in the prevention of CVdisease and in improving BP control in Ireland, par-ticularly in diabetic patients, would be a closecooperation of general practitioners in primary carewith specialists. To improve the cooperation, trig-gers have to be defined that result in a referral ifcertain BP goals are not achieved in a given period.

LimitationsThe interpretation of the current survey is limitedby the fact that the BP readings have only beenobtained once (in-office). This may have resulted inan on-average slightly higher BP reading but wouldnot qualitatively change the low control rates. Fur-ther, there is no information regarding the dose ofthe drugs prescribed, which may interfere with thedegree of BP control. Although adherence and per-sistence are key issues in antihypertensive manage-ment, these parameters have likewise not beenobtained due to the cross-sectional design. Astrength of the study is the cross-sectional designwith a considerable number of general practicesthroughout Ireland, which should provide a realisticestimate of BP control in Ireland. The response rateof 25.3% is higher as in similar surveys27 but maystill overestimate the proportion of patients treatedto target.

CONCLUSIONSBP control while taking antihypertensive treatmentin primary care in Ireland is not optimal or in linewith guideline-provided goals since less than half(48%) of nondiabetic patients and less than onethird (18%) of diabetics achieved BP goal. The rea-sons for this discrepancy are multidimensional. Oneaspect is the type and dose of antihypertensivetreatment prescribed. There is room for improve-ment using fixed combinations of well-tolerateddrugs with a high persistence on treatment. Anotheraspect is to embed the effort to reduce BP into amore comprehensive approach to prevent the inci-dence of CV disease. An increase in patients’awareness and compliance together with anincreased adherence of physicians to current guide-lines should help in reducing the long-term CV con-sequences of hypertension.

Disclosures: This study was funded by an unrestrictededucational grant provided by Sanofi-Aventis Ireland. Thepreparation of the manuscript was supported by a grant fromSanofi-Aventis Ireland to PB. All authors take fullresponsibility for the content of the article, the interpretationof the data, preparation, review, and approval of themanuscript. BB, ES, NC, TF, PB, and IJP have beenparticipants at advisory board meetings at Sanofi-Aventis. ETis a former employee of Sanofi-Aventis Ireland.

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