This may be due to the lack of awareness and promotion of new concepts and technologies, insufficient attention to target organ protection, and misconceptions about basic blood pressure measurement methods. As the main battlefield of hypertension prevention and control, primary care physicians should try to master blood pressure measurement methods and pay more attention to the two “weapons” of ambulatory blood pressure monitoring and home blood pressure self-measurement.
The concept and method of diagnosis and treatment of hypertension are inadequate
At present, the blood pressure rate of nearly 200 million hypertensive patients in China is <10% (in 2002, the survey on the nutrition and health status of Chinese residents was only 6.1%), while in the United States, Japan and other developed countries, the control rate of hypertension has gradually increased to 30% to 50% in recent years. This makes people ponder: Why is the control rate of hypertension in China so low? Although the reasons are many, but from the doctor's point of view, the concept and method of diagnosis and treatment of hypertension is still inadequate?
The author conducted a questionnaire study on 3,125 physicians in selected tertiary, secondary and primary hospitals across China, aiming to understand the perceptions and approaches of domestic physicians in the clinical diagnosis and management of hypertension, such as whether they judge hypertension correctly or not, whether they pay in-depth attention to the blood pressure profile and the overall cardiovascular disease risk of hypertensive patients. The results showed that
①The vast majority of physicians (80%) relied only on office blood pressure to diagnose hypertension, and only a small proportion used ambulatory blood pressure (ABPM) or home self-measured blood pressure (HBPM) to diagnose (20%) or evaluate the efficacy (9%) of hypertensive patients;
(ii) Only 13% of physicians closely monitored their patients’ blood pressure around the clock (morning, afternoon, night, and early morning), as well as the characteristics of their blood pressure profile (spoon or non-spoon);
③Only 15% of physicians performed a comprehensive assessment and risk stratification based on various risk factors before treating patients with hypertension.
This shows that many clinicians are still far from being aware of hypertension, and there are many misconceptions in the process of clinical diagnosis and treatment, and the prevention and treatment of hypertension are very ineffective, which is an important reason for the low control rate of hypertension and the high incidence of cardiovascular and cerebrovascular events in the country.
Judging blood pressure levels by office blood pressure alone
What clinicians measure in the office is the patient’s immediate blood pressure, but immediate blood pressure often does not reflect the patient’s true blood pressure status. There is a “blind spot” in the understanding of blood pressure because the physician does not know the patient’s blood pressure at other important times (especially at night and in the early morning). It has been observed that many patients who take medication early in the morning have normal blood pressure in the morning, but their blood pressure is still significantly higher than normal in the afternoon, evening, night, and early morning, so their hypertension is not really under full and stable control. Obviously, the diagnosis and evaluation of the efficacy of hypertension based on morning office blood pressure alone is extremely arbitrary and one-sided.
24-hour ambulatory blood pressure monitoring is an effective means of detecting white coat hypertension There are often patients with higher than normal office blood pressure who return home with normal blood pressure, the so-called “white coat hypertension”. Some doctors therefore diagnose hypertension and even require patients to take medication for a long time, which is extremely wrong and also puts a heavy mental and financial burden on the patient.
At present, it is believed that after a period of rest or the elimination of mental and emotional stimuli, blood pressure in patients with white coat hypertension can generally return to normal levels very quickly. Ambulatory blood pressure monitoring can identify hypertension from such transient blood pressure elevation and avoid overmedication.
Hidden hypertension is easily missed by in-office blood pressure measurement
Occult hypertension, also known as “anti-white coat hypertension,” is a clinical phenomenon in which the blood pressure is normal on occasional office tests but higher than normal on 24-hour ambulatory blood pressure or home self-measurement, which is one of the reasons why hypertension is often underdiagnosed. Studies have shown that occult hypertension and persistent hypertension have similar degrees of damage to important target organs such as the heart, brain, and kidneys. If clinicians do not recognize the importance of this clinical condition, there is a risk of missed diagnosis and treatment, with unnecessary and serious consequences.
Response strategy: Physicians must have a comprehensive grasp of the patient’s 24/7 blood pressure and change patterns. At present, ambulatory blood pressure or home self-measurement of blood pressure has become an important adjunct to the diagnosis and treatment of hypertension, especially ambulatory blood pressure monitoring can more accurately and comprehensively assess the patient’s true blood pressure level and circadian rhythm characteristics, which can effectively identify white coat hypertension and detect occult hypertension.
Using this as a basis to guide antihypertensive treatment helps to further improve the 24/7 blood pressure compliance rate, thus minimizing cardiovascular and cerebrovascular events, and has important clinical application value. Therefore, only by fully grasping this “weapon” can clinicians turn “blind areas” into “clear areas” and give patients accurate diagnosis and appropriate treatment.
Insufficient attention to nocturnal hypertension and morning peak blood pressure
Abnormal blood pressure rhythm
Many doctors do not pay attention to the “spoon” and “non-spoon” curves of blood pressure. Normal blood pressure is spoon shaped, with a 10% to 20% decrease in blood pressure at night compared to daytime; non-spoon shaped blood pressure (<10% decrease in blood pressure at night), deep spoon shaped blood pressure (>20% decrease in blood pressure at night) and anti-spoon shaped blood pressure (increase in blood pressure at night instead of decrease) are abnormal blood pressure rhythm patterns.
Non-spoon type hypertension and nocturnal hypertension are associated with a variety of clinical events, such as chronic renal insufficiency, intractable hypertension, diabetes mellitus, autonomic dysfunction, sleep apnea syndrome, and metabolic syndrome. Compared to spoon type hypertension, patients with non-spoon type hypertension have more severe cardiovascular events, renal and vascular target organ damage, and a worse prognosis. Some studies have confirmed that non-spoon and anti-spoon blood pressure have a higher incidence of cardiovascular and cerebrovascular events than other types of blood pressure.
Therefore, hypertension treatment needs to focus not only on daytime blood pressure drop, but also on smooth control of nighttime blood pressure to ensure blood pressure compliance with normal rhythm patterns throughout the day and minimize the harm caused by hypertension.
”Early morning danger”
Early morning 6:00-10:00 am is a critical time for the sympathetic nervous system, renin-angiotensin-aldosterone system and catecholamine secretion to be active. The increased activity of the sympathetic nervous system increases the heart rate and blood pressure; the activation of the renin-angiotensin-aldosterone system increases plasma catecholamine and angiotensin II levels, causing vasoconstriction and blood pressure to rise. The rapid increase in blood pressure in the early morning is prone to cardiovascular and cerebrovascular events, which is known as “early morning risk”.
Both the ACAMPA study (using ABPM evaluation) and the J-MORE study (using HBPM evaluation) confirmed that about 60% of patients with controlled in-office hypertension did not have their blood pressure effectively controlled in the early morning, and the incidence of stroke and myocardial infarction (especially stroke) was significantly higher in the early morning hours than in other hours, i.e., early morning hypertension significantly increased the risk of cardiovascular events. The early morning risk occurs not only in patients with spoon type hypertension but also at a higher rate in patients with non-spoon type hypertension.
Response strategy: Clinicians must pay attention to the early morning blood pressure situation of patients. Early morning hypertension can be detected by 24-hour ambulatory blood pressure monitoring, and physicians can adjust the application of antihypertensive drugs based on the chronotherapeutic principle of hypertension to control the 24-hour blood pressure in the normal range and restore the normal spoon pattern, so that patients can live peacefully with the early morning danger and further reduce the occurrence of cardiovascular and cerebrovascular events.
Insufficient attention to overall cardiovascular disease risk
The Chinese Guidelines for the Prevention and Treatment of Hypertension 2010 clearly state that hypertension is a clinical “cardiovascular syndrome”, and in 2007, the European Society of Hypertension identified multiple risk factors other than blood pressure as important indicators for the treatment of hypertension, including advanced age, obesity, physical inactivity, hyperlipidemia, diabetes, early-onset cardiovascular disease, and family history of cardiovascular disease. family history of early-onset cardiovascular disease, etc.
All of these recommendations suggest to clinicians that the treatment of hypertension should not only target blood pressure itself, but also assess the overall cardiovascular disease risk of the patient. Unfortunately, only 15% of the clinicians in our survey did so.
Response Strategies
Clear risk stratification: Before a hypertension consultation, clinicians must assess patients for high, intermediate, and low risk by stratifying their risk according to various risk factors, target organ damage, and comorbidities. Low- and intermediate-risk patients (grade 1 or 2 hypertension combined with less than 2 risk factors) whose blood pressure does not normalize after several weeks of lifestyle changes should initiate drug therapy; high-risk patients (grade 1 or 2 hypertension combined with >2 risk factors, grade 3 hypertension or combined with target organ damage) should be initially treated with drugs.
Domestic and international guidelines for the prevention and treatment of hypertension consistently recommend that high-risk and very high-risk patients should receive stricter blood pressure control, and that blood pressure in hypertensive patients with combined diabetes, renal insufficiency, stroke, and myocardial infarction should be strictly controlled at 130/80 mm Hg.
Correction of other risk factors: It is worth noting that the benefit of all antihypertensive drugs in reducing the risk of cardiovascular events is basically similar, and the main benefit of antihypertensive therapy actually comes from lowering blood pressure itself, i.e., “blood pressure is the hard target”. However, in addition to lowering blood pressure, it is also important to correct other risk factors. When these risk factors co-exist in hypertensive patients, blood pressure abnormalities and metabolic risk factors often contribute to each other, creating a superimposed effect on cardiovascular disease risk, meaning that the overall cardiovascular disease risk is greater than the sum of the individual risk factors. Therefore, the ultimate goal of protecting target organs and reducing cardiovascular and cerebrovascular events can only be achieved if all risk factors are controlled in an integrated manner and blood pressure standards are strictly met.
Expert Conclusion
The results of a survey conducted by the author on clinicians’ awareness of hypertension suggest that there are currently some misconceptions about the diagnosis and treatment of hypertension among some physicians, which has become one of the important reasons for the low rate of hypertension control in the country. Clinicians should have a comprehensive understanding of their patients’ 24-hour blood pressure changes, and should fully grasp and apply the two important “weapons” of ambulatory blood pressure monitoring and home self-measurement of blood pressure.
The two most important goals in the treatment of hypertension are to control 24-hour blood pressure and to maintain a normal circadian blood pressure rhythm. Therefore, clinicians should adjust the medication according to the patient’s blood pressure characteristics during the treatment process, and choose the appropriate drug combination according to other risk factors and target organ damage when the two most important goals of treating hypertension are controlling 24-hour blood pressure and maintaining normal circadian blood pressure rhythm, so as to achieve individualized comprehensive treatment to reduce the overall cardiovascular disease risk of patients and achieve the purpose of high-quality blood pressure reduction!