Published online before print February 23, 2009, doi: 10.1161/HYPERTENSIONAHA.108.123455
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(Hypertension. 2009;53:646.)
© 2009 American Heart Association, Inc.
Original Articles |
A Simplified Approach to the Treatment of Uncomplicated Hypertension
A Cluster Randomized, Controlled Trial
From the Robarts Clinical Trials (R.D.F., G.Y.Z., M.K.V., C.J.W., S.A.E.N., B.G.F.), Robarts Research Institute, London, Ontario, Canada; Schulich School of Medicine and Dentistry, Department of Medicine (R.D.F., B.G.F.), Department of Physiology and Pharmacology (R.D.F.), and Department of Epidemiology and Biostatistics (G.Y.Z., B.G.F.), University of Western Ontario, London, Ontario, Canada.
Correspondence to Ross D. Feldman, Robarts Research Institute, 100 Perth Dr, London, Ontario N6A 5K8, Canada. E-mail Ross.Feldman{at}lhsc.on.ca
Notwithstanding the availability of antihypertensive drugs and practice guidelines, blood pressure control remains suboptimal. The complexity of current treatment guidelines may contribute to this problem. To determine whether a simplified treatment algorithm is more effective than guideline-based management, we studied 45 family practices in southwestern Ontario, Canada, using a cluster randomization trial comparing the simplified treatment algorithm with the Canadian Hypertension Education Program guidelines. The simplified treatment algorithm consisted of the following: (1) initial therapy with a low-dose angiotensin-converting enzyme inhibitor/diuretic or angiotensin receptor blocker/diuretic combination; (2) up-titration of combination therapy to the highest dose; (3) addition of a calcium channel blocker and up-titration; and (4) addition of a non—first-line antihypertensive agent. The proportion of patients treated to target blood pressure (systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg for patients without diabetes mellitus or systolic blood pressure <130 mm Hg and diastolic blood pressure <80 mm Hg for diabetic patients) at 6 months was analyzed at the practice level. The proportion of patients achieving target was significantly higher in the intervention group (64.7% versus 52.7%; absolute difference: 12.0%; 95% CI: 1.5% to 22.4%; P=0.026). Multivariate analysis of patient-level data showed that assignment to the intervention arm increased the chance of reaching the target by 20% (P=0.028), when adjusted for other covariates. In conclusion, the Simplified Treatment Intervention to Control Hypertension Study indicates that a simplified antihypertensive algorithm using initial low-dose fixed-dose combination therapy is superior to guideline-based practice for the management of hypertension.
Key Words: hypertension management • randomized, controlled trial • fixed-dose combination therapy • cluster randomization • hypertension
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