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Helping hypertensives: Revised guidelines call on physicians to assist patients with treatment compliance

April 25, 2006

By Andrew Skelly
The Medical Post

Prescribing antihypertensive medication is one thing—whether the patient will actually take it as prescribed is quite another. But updated Canadian hypertension treatment guidelines are addressing that problem by putting a new emphasize on improving patient adherence to therapy.

The 2006 Canadian Hypertension Education Program (CHEP) recommendations also alert physicians to a recently recognized group of patients who have normal blood pressure in the clinic, but not at home.

"In most Westernized countries, only 20% to 30% of patients who are on treatment will have reached their target blood pressure," and non-adherence to therapy is a major reason for that poor control of hypertension, said Dr. Rhian Touyz, a guideline co-author and Canada Research Chair in Hypertension at the University of Ottawa.

In an interview, she outlined CHEP's recommendations for improving patient adherence, which are available in full on the Canadian Hypertension Society's Web site at www. hypertension.ca.

The recommendations include:

• Teach patients to take their pills on a regular schedule associated with a routine daily activity such as brushing teeth.

• Simplify regimens using long-acting, once-daily medications.

• Use fixed-dose combination pills, which Dr. Touyz said are becoming more readily available in Canada. (For example, an ACE inhibitor or AT1 receptor blocker combined with a thiazide diuretic.)

• Encourage greater patient responsibility and autonomy in regular monitoring of their blood pressure.

• Assess adherence to drug and non-drug treatment at every visit.

• Provide health-care practitioner-based telephone support, particularly over the first three months of therapy. (Dr. Touyz said one study showed compliance rates were improved by 24% with weekly phone calls from office personnel.)

• Co-ordinate with workplace health-care givers to improve monitoring of hypertension management.

Dr. Touyz said referral to a hypertension clinic may be appropriate for patients who have compliance problems despite these measures.

Masked hypertension

The 2006 CHEP guidelines also identify an emerging issue in hypertension diagnosis and treatment: the phenomenon of "masked" hypertension.

"It's the opposite of white coat hypertension," Dr. Touyz said. "Masked hypertension is defined as hypertension at home but not in the clinic.

"The evidence that is coming out is that patients who have masked hypertension have just as high risks as patients who have been diagnosed as having (sustained) hypertension."

She said the exact definition of masked hypertension is still a matter of debate, but one study described it as a clinic blood pressure of less than 140/90 mm Hg at two office visits and a home blood pressure measurement of more than 135/85 mm Hg based on three measurements taken in the morning and the evening over two days.

Dr. Touyz said the existence of masked hypertension strengthens the need for home blood pressure monitoring.

Several machines validated for home use are listed at www.hypertension.ca.

Reproduced with permission from The Medical Post.