Standardization and individualization in the treatment of hypertension
To meet the needs of hypertension prevention and treatment, the Department of Disease Control of the Ministry of Health, the Cardiovascular Disease Prevention and Control Research Center of the Ministry of Health, and the Chinese Hypertension Consortium organized experts from relevant disciplines to develop the Guidelines for the Prevention and Treatment of Hypertension in China (the Guidelines), which have been revised several times and recently a grassroots version of the Guidelines (to be released at the end of 2009) that is more understandable to community health workers has been developed. The development of the Guidelines has undoubtedly had the following effects on the prevention and treatment of hypertension: increased medication adherence and control rates while reducing acute events of cardiovascular and cerebrovascular disease. However, if the principles of individualized management of hypertensive patients are neglected in the implementation of intensive standardized management of hypertension prevention and control, many problems that should be avoided can occur and may even increase the cardiovascular risk of patients. How to organically combine standardization and individualization in the process of hypertension prevention and treatment, and implement them in medical practice so that they are both opposing and complementary, thus better converting the Guidelines into effective clinical practice, is an important issue in the process of hypertension prevention and treatment, and is the focus of this paper. Tian Bo, Department of Rheumatology, Ningxia Institute of Traditional Chinese Medicine
I. The prevention and control of hypertension must be standardized
1. The situation of hypertension prevention and control is not optimistic
At present, the prevalence of hypertension in China is very high, the incidence of acute cardiovascular events caused by it, the incidence of disability and death rate is also always high, hypertension and its related adverse events have become a major public health problem endangering the health of our people. 2002 national nutrition survey results show that the prevalence of hypertension in people over 18 years of age in China is 18.8%, the number of patients reached 160 million According to the 2005 China Cardiovascular Disease Report, the prevalence of cardiovascular and cerebrovascular diseases closely related to hypertension is as follows: 2 million new cases of stroke per year and 7 million existing cases of stroke; 500,000 new cases of myocardial infarction per year and 2 million existing cases of myocardial infarction. With the development of social and economic development, the incidence and mortality rate of these diseases will continue to climb! The World Health Organization (WHO) predicts that “by 2020, non-communicable diseases will account for 79% of the causes of death in China, with cardiovascular disease taking the lead”. Some experts also predict that the prevalence of hypertension in China will reach 27.4% by 2025, and the number of patients will be as many as 300 million. However, the current prevention and treatment of hypertension in China still shows the awareness rate, treatment rate and control rate “three low” situation, the situation is worrying.
In the face of such a large number of hundreds of millions of people with the disease and thousands of health workers at all levels (especially primary health workers) involved in the prevention and treatment of hypertension, China must establish standardized techniques and procedures for the prevention and treatment of hypertension and the evaluation of the effectiveness of prevention and treatment. This is because only by implementing the prevention and treatment measures under the guidance of standardization can the prevention and treatment effects be maximized, and the occurrence and death of hypertension and related diseases be prevented and controlled to the greatest extent possible.
2. Urgent need for standardized management of hypertension prevention and treatment
China’s Guidelines for the Prevention and Treatment of Hypertension, formulated under the direct guidance of the Ministry of Health, is the most authoritative standardized guidance document for hypertension prevention and treatment techniques. It is a consensus reached after summarizing relevant research results, referring to other countries’ guidelines, combining with China’s national conditions, and repeated discussions and arguments by renowned experts nationwide. The Guide standardizes blood pressure measurement, criteria for graded diagnosis and risk assessment of hypertension, risk factors and control criteria for cardiovascular disease, strong indications for the application of antihypertensive drugs and criteria for blood pressure attainment, principles and criteria for the management of hypertension in special populations, as well as content and criteria for two-way referral, health education and patient follow-up guidance. The Guidelines provide a detailed description of the prevention and treatment techniques for hypertension and are clinically operable in a good way. Therefore, from this perspective, our hypertension prevention and treatment techniques are quite mature. The community should implement hypertension prevention and control according to the criteria and indicators required in the Guidelines as much as possible.
Depending on the specific implementation and the progress of evidence-based medicine, the Guidelines will be continuously revised by relevant institutions and experts. Any physician must follow the Guidelines when developing treatment measures for patients. As the Guidelines state, “The goal of treatment is to bring hypertensive patients up to blood pressure standards through antihypertensive therapy with the aim of minimizing the overall risk of cardiovascular morbidity and mortality.” To pay attention to prescribing an antihypertensive prescription without focusing on achieving blood pressure targets, or to lower blood pressure without focusing on reducing the overall risk of cardiovascular disease, are non-standardized management categories. Some primary care physicians do not even know the blood pressure control goals for hypertensive patients in general, let alone for those with diabetes and kidney disease, to the extent that some communities still have a 20% prevalence of grade 3 hypertension after 4 years of hypertension prevention and treatment, indicating that the standards in the Guidelines are not well grasped and implemented in prevention and treatment. For example, the Guidelines state that “most patients with hypertension require 2 or more antihypertensive medications to achieve their target blood pressure” and propose “low-dose monotherapy or a low-dose combination of two medications, depending on baseline blood pressure levels and the presence or absence of comorbidities. “The guidelines also set out a standard procedure for the diagnosis and treatment of hypertension. These are the standards and principles of hypertension treatment. However, the 2002 National Nutrition Survey showed that the rate of single antihypertensive drug treatment for hypertension in China still reached more than 80%, and the rate of combined drug use was less than 20%. Physicians still have many problems in treating hypertension without paying attention to the patient’s blood pressure level, without paying attention to the presence of other risk factors and related diseases, without considering the need for combination drugs, and without prescribing antihypertensive drugs without a comprehensive assessment of the patient, all of which are clearly against the principles of standardized management.
Of course, to achieve standardization of hypertension prevention and treatment, everything must be done according to the requirements of the Guidelines. Although it is a very difficult task to promote and practice the Guidelines, in order to raise the national level of hypertension prevention and treatment to a new level, it is necessary to fully implement the Guidelines, so that the principles of the Guidelines become standardized practical action, to achieve the conversion from the Guidelines to practice.
Second, the community prevention and treatment of hypertension must be individualized
From the general requirement, hypertension prevention and treatment strategies must be standardized, which refers to the uniformity in principle. However, for each specific patient, hypertension prevention and treatment must be individualized. The principles of prevention and treatment set forth in the Guidelines are the consensus of experts, which encompass common issues in the prevention and treatment of hypertension and are of general guidance. The individualized treatment plan for a specific patient depends on each physician’s specific judgment and understanding of the Guidelines for each case.
Because hypertension is caused by a variety of complex and as yet unknown etiologies, the pathophysiological mechanisms that arise under the action of different etiologies vary, which determines that each hypertensive patient has a different efficacy response to different antihypertensive drug treatments. Moreover, different hypertensive patients have different risk factors, target organ damage and coexisting diseases, and it is obviously unscientific to treat all hypertensive patients with the same drug or the same class of drugs.
Individualized diagnosis and treatment of hypertension has the following three levels.
1. a comprehensive assessment of the patient
A thorough assessment of the patient should be performed at the time of diagnosis. In addition to different overall blood pressure levels and risk stratification, it is more important to consider whether each patient is associated with different risk factors, target organ damage and coexisting cardiac, renal and vascular diseases, and whether secondary hypertension or white coat hypertension is possible. The need for treatment or continued observation is judged based on the assessment results, and if treatment is needed an appropriate time to start treatment should be selected.
2. Develop an individualized treatment plan
When deciding on patient treatment, individual differences in the therapeutic response (effectiveness, adverse effects and tolerability) to various types of antihypertensive drugs should be taken into account in different patients, which may be accompanied by diseases that are antagonistic to the action of a certain antihypertensive drug (e.g. asthma, arrhythmia, metabolic abnormalities, etc.), so clinicians should develop a treatment plan that is appropriate for the patient according to the different antihypertensive goals of each case. For example, the Guidelines state that “all five classes of antihypertensive drugs can be used as starting and maintenance medications for antihypertensive therapy,” and several evidence-based medical studies have confirmed that calcium channel blockers (CCBs) are effective in reducing total peripheral vascular resistance and are the most commonly used antihypertensive drugs for hypertensive patients, with their use accounting for 41% of antihypertensive drugs in China. However, CCB may aggravate the condition of patients with tachyarrhythmia or congestive heart failure, especially short-acting CCB may also increase the risk of myocardial infarction in patients with coronary artery disease, so it should be used with caution.
Clinicians should give individualized treatment according to the specific conditions of hypertensive patients.
[Combination of different stages of coronary artery disease].
The choice of antihypertensive drugs should be different, and individualized treatment principles should be applied. For example, angiotensin-converting enzyme inhibitors (ACEI) are mainly used in patients with myocardial infarction and ischemic heart disease and heart failure who are at high risk of combined coronary artery disease, stable angina, and ST-segment elevation. Because meta-analyses of large studies such as EUROPA, HOPE, and PEACE have shown that ACEIs significantly reduce the risk of cardiovascular death and nonfatal myocardial infarction in patients with coronary artery disease, ACEIs should be used as the renin angiotensin system (RAS) blockers of choice for secondary prevention of coronary artery disease for initial and ongoing therapy, and angiotensin receptor blockers (ARBs) are only used as an alternative when ACEI is not tolerated. β-blockers are more often used in patients with myocardial infarction with combined unstable angina and non-ST-segment elevation.
[Combined stroke].
In primary prevention of stroke, all types of antihypertensive drugs can significantly reduce the occurrence of stroke, but there are differences in the secondary prevention of stroke between different classes of antihypertensive drugs. The effectiveness of diuretics and ARB antihypertensive drugs and ACEI combined with diuretics in secondary prevention of stroke has been confirmed in large clinical trials (PATS, MOSES, PROGRESS). Coronary artery disease is often an insidious coexisting disease in stroke patients and requires attention because atherosclerosis is a systemic disease. the use of ACEI not only reduces stroke recurrence, but also reduces the risk of cardiovascular events. Short-acting CCB should not be used for antihypertensive treatment in either the acute or stable phase of stroke because it increases the risk of rebleeding and infarction.
[Combined glucose metabolism disorders].
In 2009, the American Diabetes Association recommended ACEI and ARB as the preferred antihypertensive agents to counteract excessive activation of the RAS system, relieve insulin resistance, and delay kidney damage. Diabetes is an equivocal risk for coronary heart disease, and ACEI, aspirin, and statin should be chosen to reduce the risk of cardiovascular events in patients with concomitant cardiovascular disease.
[Combined microproteinuria or renal insufficiency].
In the absence of contraindications, ACEI or ARB should be preferred to reduce proteinuria and delay the progression of nephropathy. Since patients with renal impairment are at high risk of cardiovascular disease, comprehensive interventions are usually considered, and AECI analogues should be preferred because of their precise cardiovascular protection and non-blood pressure-dependent renal protection mechanisms.
[Elderly patients with hypertension over 65 years of age].
CCB and thiazide diuretics are usually preferred. Previous studies have shown that more than 60% of hypertensive patients need a combination of more than 2 antihypertensive drugs to achieve the target blood pressure, and if combined with abnormal lipid metabolism or glucose tolerance, the combination of lipid-regulating and glucose-lowering therapy should be used at the same time. Therefore, it is more important to take into account the above-mentioned conditions when combining drugs, and adopt a reasonable combination plan with additive antihypertensive effects and offsetting side effects, so that patients can obtain more benefits in addition to antihypertensive.
3. Setting individualized antihypertensive targets
When setting patients’ antihypertensive targets, more attention should be paid to individualized results. The Guidelines call for a goal of <140/90 mmHg for the general population, <130/80 mmHg for those with diabetes and renal disease, <125/75 mmHg for those with proteinuria >1 g/d, and <150 mmHg for systolic blood pressure in those over 65 years of age. In some special cases, individual patient factors must be taken into account.
For example, if an elderly patient has a diastolic blood pressure <60 mmHg at the time of antihypertensive therapy, but a systolic blood pressure >160 mmHg (which does not meet the guideline’s target), further lowering of blood pressure may pose a greater cardiovascular risk.
For example, in patients with hypertensive emergencies and acute ischemic stroke, the blood pressure should not be lowered to the target in a short period of time, and the magnitude of the lowering should be limited to 20% of the pre-drug basal blood pressure. Rapid lowering of blood pressure may abruptly reduce cerebral perfusion, leading to ischemic stroke, myocardial infarction, or aggravate ischemia in the infarcted area, thus causing reperfusion injury. For such patients, the acute risk period should be passed first, and then the blood pressure should be lowered slowly to gradually reach the target after the condition is stabilized.
In order to maximize the effect of antihypertensive therapy in preventing acute cardiovascular and cerebrovascular events, careful selection of antihypertensive drugs and control of the rate and magnitude of blood pressure lowering are needed while differentiating patients.
For those hypertensive patients without complications, comorbidities and target organ damage, and with relatively few risk factors, especially young and middle-aged patients, the risk of serious complications is low. However, those patients who have developed serious complications, target organ damage such as diabetes, nephropathy, stroke, etc., have a significantly increased cardiovascular risk, especially in older patients, and must develop an individualized rate and magnitude of blood pressure lowering, while more attention should be paid to the selection of antihypertensive drugs with cardioprotective effects so that greater benefit can be obtained from antihypertensive therapy. large studies such as ONTARGET and TRANSCEND The results show that ACEI is still the RAS blocker of choice to prevent vascular events in patients with cardiovascular disease or those at high risk of cardiovascular disease.
Third, standardization and individualization must be organically combined
The standards for the prevention and treatment of hypertension and related diseases set by the Guidelines are based on evidence-based medicine and the clinical practice experience of domestic and foreign experts, and are formed by referring to relevant foreign guidelines, capturing the essence and combining it with China’s national conditions, which contain macroscopic prevention and treatment strategies and have universal guiding significance. In the process of hypertension prevention and treatment, the principles of the current Guidelines must be followed to guide clinical practice.
Any clinician facing a case of hypertension must develop reasonable treatment measures and individualized treatment plans based on the principles of the Guidelines combined with his or her own clinical experience, and there is no basis for individualized treatment plans if they are not in accordance with the Guidelines. To truly implement the principles of individualized treatment, it requires in-depth study and thorough understanding of the Guidelines, as well as dedication and a high degree of responsibility on the part of physicians.
The prevention and treatment of hypertension should be both standardized and individualized, and the general principles of the Guidelines should be implemented while paying attention to the specificity of the patients, both of which are indispensable and should be organically combined to maximize the benefits of antihypertensive treatment.