Lawrence R. Krakoff

Cost-Effectiveness of Ambulatory Blood Pressure: A Reanalysis

Accurate diagnosis of hypertension and prognosis for future cardiovascular events can be enhanced through the use of 24-hour ambulatory blood pressure monitoring. It has been suggested that the use of ambulatory monitoring as a secondary screening for hypertension might be cost-effective. Many needed studies that are related to the calculation of cost-effectiveness for ambulatory monitoring have become available in recent years. More accurate estimates for cost of care, costs for testing, prevalence of white-coat hypertension, and incidence of the transition from normal pressures to hypertension have been reported. This study presents calculations of the cost savings likely to take place when ambulatory blood pressure monitoring is implemented for newly detected hypertensive subjects. These calculations are based on current estimates for cost of testing, cost of treatment, prevalence of white-coat hypertension at baseline, and varying the incidence of new hypertension after the initial screening. The results indicate a potential savings of 3% to 14% for cost of care for hypertension and 10% to 23% reduction in treatment days when ambulatory blood pressure monitoring is incorporated into the diagnostic process. At current reimbursement rates, the cost of ambulatory blood pressure monitoring for secondary screening on an annual basis would be <10% of treatment costs. Calculated savings for use of ambulatory blood pressure monitoring can take place when annual treatment costs are as little as

Diuretics for Hypertension

300. These estimates should be considered for the management of recently detected hypertension, especially when the risk of future cardiovascular is disease is low.

Systems for Care of Hypertension in the United States

A 67-year-old African-American woman was referred to a hypertension specialty clinic for refractory hypertension and intermittent hypokalemia. Evaluations for primary aldosteronism and renal artery stenosis were negative; plasma renin was low. She had been hypertensive for 15 years. Most recently, she had taken chlorthalidone 25 mg, amlodipine 5 mg, and metoprolol 50 mg twice daily. She was not diabetic and had never smoked. Her blood pressures were in the range of 160 to 170/95 to 100 mm Hg. Except for her being mildly overweight (body mass index, 28), the physical examination was unremarkable, with no sign of target organ damage. Voltage criteria for left ventricular enlargement were present on the ECG. She was considered to be adherent to medication. Spironolactone 50 mg/d was prescribed, and her dose of chlorthalidone was reduced to 12.5 mg/d. Over the next year, her blood pressure fell to the range of 135 to 145/85 mm Hg, and serum potassium was consistently normal. This patient was taking three antihypertensive drugs, including a diuretic, which is considered by many as a necessary component for her management, yet remained uncontrolled, with an especially high risk of stroke. The addition of another diuretic was successful in bringing her pressure into an acceptable range and reversed the tendency toward hypokalemia that was caused by the thiazide-type diuretic. What is the lesson here? First, diuretic combinations from different subclasses play an important role in the management of hypertension. Second, salt-sensitive refractory hypertension in the African-American population, reflected clinically by low renin levels, can provide a clue to optimal management.1,2 Treatment of hypertension that uses a diuretic-based strategy has been effective in preventing stroke and cardiac disease in the earliest randomized clinical trials in the 1960s, with a consistently successful “track record” extending to contemporary trials, as emphasized …

Comments on ALLHAT and doxazosin

Control of hypertension in recent clinical trials varies from 48% to 65%. However, in community care of hypertension in the United States, estimates of control of hypertension are far lower. The United States has no single system of care; however, several care systems can be identified for comparison, such as the Department of Veterans Affairs, managed care organizations, and the Indian Health Service. This review compares control of hypertension in certain centers in these systems with that achieved in clinical trials and in the community at large. Certain components of care systems are assessed for their contribution to the control of hypertension. The author concludes that for community control of hypertension to approach that achieved in clinical trials, the use of physician extenders, together with reduced or minimal cost of medication, improved education of providers with feedback, and computerization of management systems will be needed. In addition, specific interventions targeted to medically underserved groups will be required.

Ambulatory blood pressure monitoring can improve cost-effective management of hypertension.

This commentary has two purposes: to summarize the rationale, design and initial results of the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) trial; and to provide a history of the response to ALLHAT that led to a civil action and a Citizens Petition that was the basis for a public hearing by the US Food and Drug Administration, in May 2001. The author concludes that the results of ALLHAT should be widely disseminated. All clinicians must be warned that initial therapy with doxazosin (and possibly other alpha1 blockers) is definitely inferior to low dose diuretic treatment for patients at high risk for cardiovascular disease, such as those enrolled in ALLHAT.