Landmark Hypertension Treatment Study
Launches Extensive Physician and Patient Education Program to Improve
Public Health
Researchers in the largest high blood pressure clinical trial ever
conducted are launching a comprehensive outreach program to improve
high blood pressure control nationwide. About 150 physicians in
34 states and Washington, DC, have completed training to educate
other physicians in their communities. Their goal: to help doctors
and patients prevent and better treat high blood pressure.
The new $3.7 million, three-year educational effort is a follow-up
to the landmark Antihypertensive and Lipid-Lowering Treatment to
Prevent Heart Attack Trial (ALLHAT) and is being implemented in
collaboration with the National High Blood Pressure Education Program
(NHBPEP). Funded by the National Heart, Lung, and Blood Institute
(NHLBI), part of the National Institutes of Health, the ALLHAT blood
pressure study compared the effects of four major classes of medications
to treat high blood pressure. More than 42,000 patients ages 55
and older participated. The main results were published in the Journal
of the American Medical Association in December 2002 and played
a central role in NHBPEP's revision of the clinical practice guidelines
on high blood pressure released in May 2003 (Seventh Report
of the Joint National Committee on the Prevention, Detection, Evaluation
and Treatment of High Blood Pressure).
"It often takes years for the results of major studies to
become part of standard health care," notes NHLBI director
Elizabeth G. Nabel, MD. "The results of ALLHAT and the clinical
guidelines could have an enormous impact on the health of millions
of Americans. We are confident that by playing a more active role
in sharing the information, we will be able to put the results into
action more quickly and more effectively."
An estimated 65 million American adults – nearly one in three
-- have high blood pressure. But, for more than two-thirds of them,
blood pressure remains out of control. High blood pressure leads
to more than half of all heart attacks, strokes, and heart failure
cases in the United States each year, and it increases the risk
of kidney failure and blindness. Clinical guidelines recommend that
physicians work with patients to keep blood pressures below 140/90
mmHg, even lower for people with diabetes or kidney disease, and
encourage all their patients to make healthy lifestyle changes,
such as losing excess weight, becoming physically active, limiting
alcoholic beverages, and following a heart-healthy eating plan,
including cutting back on salt and other forms of sodium, and not
smoking.
ALLHAT researchers reported in 2002 that, overall, diuretics are
more beneficial than calcium channel blockers, angiotensin converting
enzyme (ACE) inhibitors, or alpha blockers as initial treatment
to lower blood pressure and to protect against adverse effects of
high blood pressure. For patients with diabetes or with mildly elevated
fasting glucose—a sign of pre-diabetes—diuretics are
at least as effective, and in some cases more beneficial, than the
other two classes of medications, according to ALLHAT findings published
in June 2005.
In general, diuretics are well tolerated by patients, with few
side effects. Sometimes called "water pills," diuretics
reduce the amount of fluid in the body by helping the kidneys flush
excess water and salt from the body.
The other medications lower blood pressure differently. Calcium
channel blockers keep calcium from entering the muscle cells of
the heart and blood vessels, causing the blood vessels to relax.
ACE inhibitors prevent the formation of a hormone called angiotensin
II, which normally causes blood vessels to narrow. Alpha blockers
allow blood to pass more easily by reducing nerve impulses to blood
vessels. However, ALLHAT found that participants taking alpha blockers
had 25 percent more cardiovascular events and were twice as likely
to be hospitalized for heart failure as those taking the diuretic.
Because of these findings, the alpha blocker arm of the study was
stopped early.
“Based on the results, the ALLHAT investigators recommend
that in addition to lifestyle changes, diuretics should be the drug
of choice for first line blood pressure treatment,” says William
C. Cushman, MD, chair of the ALLHAT Dissemination Committee and
chief of Preventive Medicine at the Veterans Affairs Medical Center
in Memphis. “Because most patients require more than one drug,
diuretics should generally be part of any antihypertensive regimen.”
Cushman cites another advantage for using diuretics. “They
are much less expensive than the other two drug classes. For those
stretching their budgets, taking a medicine which costs less than
$100 a year is a very good thing.”
In the past 20 years, however, prescriptions for newer, more costly
medications began replacing diuretics. The newer drugs were shown
to lower blood pressure and heart disease risk compared to placebo,
but how the drugs compared to each other was unknown until ALLHAT.
Analyses of prescribing trends suggest that prescriptions for diuretics
have slowly begun to rise since the study ended and clinical guidelines
have encouraged the use of diuretics either alone or in combination
with other blood-pressure lowering medications.
"The guidelines were simplified and strengthened to emphasize
the most effective ways to control blood pressure – starting
with lifestyle changes and including diuretics when medication is
needed," notes Jeffrey Cutler, MD, NHLBI senior advisor and
ALLHAT project director.
The ALLHAT Dissemination Plan includes materials for investigator
educators to lead small, interactive educational sessions with physician
peers. Educators are asked to make at least one presentation per
month. The sessions include discussions of the study results, current
hypertension treatment guidelines, and common concerns in clinical
practice. Each educator receives training, presentation slides and
handouts, and materials such as posters and brochures for clinicians
to use in their offices. The educators expect to reach nearly 30,000
physicians by September 2006.
The dissemination plan also provides materials to encourage patients
to ask their health care providers about their blood pressure control
and the medicines they take. Brochures, recipe books, and other
tools to help patients adapt healthier lifestyles are also available.
Resources:
To schedule an interview:
- Jeffrey Cutler, MD, NHLBI senior advisor and ALLHAT project
officer – contact the NHLBI Communications Office at (301)
496-4236.
- Edward Roccella, PhD, MPH, coordinator of the National High
Blood Pressure Education Program – contact NHLBI as above.
- William C. Cushman, MD, chair of the ALLHAT Dissemination Committee
and chief of Preventive Medicine at the Veterans Affairs Medical
Center in Memphis – contact Willie Logan, communications
and public affairs officer, 901 577-7224.
- Barry Davis, MD, PhD, director of the ALLHAT Clinical Trials
Center, University of Texas Health Science Center at Houston –
contact Scott Merville, senior media relations specialist, 713-500-3030,
or Scott.Merville@uth.tmc.edu.
NHLBI is part of the National Institutes of Health (NIH), the Federal
Government’s primary agency for biomedical and behavioral
research. NIH is a component of the U.S. Department of Health and
Human Services. NHLBI press releases and other materials including
information about high blood pressure are available online at www.nhlbi.nih.gov.
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