Myths Accompanying Therapy of Arterial Hypertension

Hypertensive Patient – A Reality for Every Physician

CV diseases account for about 17 million deaths annually. Arterial hypertension is responsible for the development of heart failure, stroke, atrial fibrillation, and kidney failure. The three main reasons for unsatisfactory control of hypertension are considered to be insufficient attention from the physician, patient non-compliance, and the need for a larger number of medications to achieve target BP.

The uncertainty in therapy could also be fueled by the large number of various expert recommendations, which differed both in the definition of the disease and in therapeutic guidelines and patient stratification. Unified recommended procedures were achieved only in 2018. Medicinal treatment was extended to additional groups of patients, target BP values were reduced, and combination therapy was identified as the most effective for the majority of patients.

The Need to Debunk Persistent Myths

Early diagnosis and lifelong therapy can reduce morbidity and mortality in patients. Despite the many pieces of evidence available regarding the treatment of arterial hypertension, various myths persist in popular consciousness.

Myth 1: There's No Rush in Initiating Hypertension Treatment

Currently, there are two treatment strategies available that demonstrably lead to BP reduction. These are lifestyle modifications and medicinal therapy. Meta-analyses of randomized studies have also confirmed that reducing systolic BP by 10 mmHg and diastolic by 5 mmHg can lead to a reduction in the incidence of CV events by up to 20% and overall mortality by 10–15%. Conversely, every increase in BP by 20/10 mmHg approximately doubles CV mortality. Blood pressure threshold values depend on the patient's age and risk profile, and their implementation should ease the physician’s decision-making process regarding the initiation of therapy. Another helpful tool is establishing target values that, in addition to age, also reflect the presence of comorbidities.

One of the new concepts in hypertension therapy is the use of fixed-dose combinations at the start of therapy. Studies have confirmed that even low doses of medication in fixed-dose combinations are more effective than maximum doses administered in monotherapy.  

Myth 2: Dual Therapy Is Sufficient and Doesn't Need to Be Changed

Appropriate BP control is not always achieved on the first try; often the treatment regimen needs to be adjusted. The SHARE study monitored the therapeutic procedures of 2,629 physicians from 35 countries. It showed that 95% of them resorted to changing therapy only at BP values of 169/100 mmHg. This delay demonstrably leads to the development of complications and the subsequent cost of patient therapy rises sharply.

A large retrospective study evaluating the therapy of 88,756 hypertensive patients from 1986–2010 with an average follow-up period of 37.4 months demonstrated that delaying the initiation or intensification of therapy by more than 6 weeks significantly increases CV risk. Further research has shown that patient compliance after the first year of treatment is less than 50%. There is an inverse relationship between the number of antihypertensives used and patient adherence to treatment.

Once again, the advantage of fixed-dose combinations should be emphasized, as their use is associated with higher treatment efficacy, better patient compliance, and fewer adverse effects. If a patient does not achieve satisfactory control with dual therapy (e.g., perindopril erbumine/amlodipine), it is recommended to use a fixed triple combination (e.g., perindopril erbumine/amlodipine/indapamide).

Conclusion

In everyday practice, we encounter unfounded myths about the therapy of arterial hypertension. These need to be replaced with facts based on evidence-based medicine (EBM), which provide clear arguments in favor of early therapy tailored to the individual needs of the patient.

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Source: Vachulová A. Myths and Facts about the Treatment of Arterial Hypertension: Do We Really Know Everything About Arterial Hypertension? Vnitřní lékařství 2019; 65 (11): 728–733.