Many Older Adults Not Receiving Adequate Hypertensive Therapy, with Deepak Bhatt, MD, MPH

An analysis of data from a 10-year period spanning 2008-2018 suggests that, despite a renewed emphasis on blood pressure control in recent years, appropriate treatment intensification for older adults in the US was suboptimal, with most recent data suggesting guideline-directed treatment intensification occurred in fewer than 20% of patients.

Presented at the American Heart Association 63rd Scientific Sessions (AHA 2022) in Chicago, Il, the analysis of data from the National Ambulatory Medical Care Survey (NAMCS), which assessed appropriate intensification to target goals set within various international guidelines, found that treatment intensification was subpar and rates of appropriate intensification have been declining since 2008.

"Strategies to mitigate therapeutic inertia are needed, and clinical practices should make concerted efforts to improve appropriate treatment intensification in older adults," wrote investigators.

The progress made against cardiovascular disease since the turn of the century has been hailed as one of the greatest public health accomplishments in history. Despite this marked progress, hypertension management remains a key issue for the more than 100 million US adults with hypertension. As a result, the most recent iterations of hypertension management guidelines from major organizations, including the ACC/AHA, the ESC, and the ACP/AAFP guidelines, have lowered the threshold for ideal blood pressure control.

The current study was conducted by Nicholas Chiu, MD, a resident physician at Beth Israel Deaconess Medical Center, and a team of colleagues with an interest in developing a greater understanding of contemporary trends in hypertension management among older patient populations in the US. With this in mind, investigators designed their study to leverage data from adults aged 60 years or older from within the NAMCS database, which is a based on a national sample of visits to emergency department, outpatient departments, and ambulatory surgery locations.

The primary outcome of interest for the analysis was the proportion of individuals receiving appropriate treatment intensification based on targets set forth in guidelines from the ACC/AHA, the ESC, and the ACP/AAFP. For the purpose of analysis, appropriate intensification was defined last the addition of an antihypertensive for a blood pressure above target goal.

Results of the investigators' analyses indicated that from 2008-2018 appropriate treatment intensification, as defined by the ACC/AHA guidelines occurred at 11.1% (95% CI, 9.8-12.5%) of visits, which is a decrease 13.6% (95% CI, 15.6-28.7%) of visits in 2008-2009 to 10.4% (95% CI, 10.9-26.4%) in 2015-2018. For ESC guidelines, appropriate intensification occurred at 14.2% (95% CI, 12.1-16.6%) of visits during the study period, with the overall rate decreasing from 16.9% (95% CI, 13.5-21.0%) in 2008-2009 to 12.5% (95% CI, 7.4-20.3%) from 2015-2018. Using AAFP/ACP guideline thresholds, appropriate treatment intensification occurring at 18.9% (16.2-22.0%) of visits during the study period, with the rate decreasing from 24.7% (95% CI, 20.2-29.0%) in 2008-2009 to 14.9% (95% CI, 9.0-23.7%) from 2015-2018. Investigators noted, when an all-inclusive criterion was used, intensification trended towards worsening with time (OR, 0.93 [95% CI, 0.87-1.00]; P=.07).

With an interest in the implications for public health systems, our editorial team reached out to senior investigator Deepak Bhatt, MD, MPH, executive director of interventional cardiovascular programs at Brigham and Women’s Hospital, to learn more.

This study, “Trends in Blood Pressure Treatment Intensification in Older Adults With Hypertension in the United States, 2008-2018,” was presented at AHA 2022.