A primary care database from 2015 to 2017 was analyzed to report the management effectiveness among hypertensive patients in this study. The results indicated that the effective management rates significantly rose from 83.6–95.1% within 3 years in urban community of Shanghai; Increase in drug treatment rates and BP control rates were observed among the effectively managed patients, whereas the two-year cumulative incidence of comorbidities indicated unpleasant results.
The current general status of hypertension management in China is poor because of the high prevalence and poor treatment and control effect. Through the PEACE MPP study, only 33.8% of the 3362 basic medical institutions nationwide stocks all four conventional classes of antihypertensive drugs , which indicates the alarming insufficient of medical resources. However, in the largest city of China like Shanghai, the treatment rate and BP control rate of hypertensive patients reached at 94.1% and 80.7% in 2017, respectively. This is mainly attributed to the effective management of GP, since it has great advantages in terms of health education, continuous supervision, follow-up, and timely adjustment of treatment prescription for hypertensive patients . Another reason is that the community is located in urban region of Shanghai, the most developed cities in China. The superior medical conditions and the generally highly educated residents make it possible that the situation of hypertension management is better than the average level in other parts of the country.
These advantages of our results still exist when compared with recent survey data from other countries [16, 17]. A retrospective analysis showed that the BP control rate of hypertension was 60.6% in the general practice in Italy in 2013 . In the most recent surveys on high-income countries, their treatment rates were at most 80% and control rates were less than 70% . Among them, Canada, the United States, South Korea and Germany have the highest control coverage, and they all have national hypertension education and health check-up, which is definitely important for management effect . Overall, the treatment and control effects of hypertensive patients in this study were considerable.
At present, there are many types of antihypertensive agents available for patients, mainly including CCB, ARB, angiotensin converting enzyme inhibitor (ACEI), diuretics and beta blockers [5, 19]. The guidelines for prevention and treatment of hypertension in China recommended that all five major classes of antihypertensive drugs could be used as initial treatment drugs, and appropriate drugs for individual patient should be chose according to the specific population and comorbidities . Many studies pointed out that CCB drugs significantly decreased the incidence of stroke and mortality in patients with hypertension especially in eastern Asian population [20–22]. In the Avoiding Cardiovascular events through Combination therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) study, CCB/ACEI combination reduced approximately 20% hazard ratio for cardiovascular events compared to diuretic/ACEI regardless of the presence of cardiovascular disease [23, 24]. In addition, ARB and ACEI are particularly suitable for patients with diabetes [7, 8, 12]. These evidences partly explain that CCB and ARB categories became the most favored antihypertensive agents since the prevalence of stroke and diabetes were relatively high in this population.
Although the treatment rate and control rate of hypertensive patients in this community seemed to be gratifying, the incidence rate of comorbidities was still unoptimistic. Up to 46.9% hypertensive patients had at least one comorbidity in 2017 and 31% of them experienced new comorbidities within two years. Through the Chinese National Surveillance System, the most common comorbidity of hypertension was coronary heart disease, with detection rates of 21.71%, while 7.53% had cerebral infarction which ranked fifth . In contrast, the incidence of stroke (22.3%) was particularly high, while coronary heart disease (6.4%) was relatively lower in our study. Of note, the population was generally old with an average age of 70 years old, one of independent risk factors for the comorbidities, especially for stroke. On the other hand, recent study indicated that different comorbidities of hypertension influenced the patients’ choices of hospital class to visit in China, that the patients with coronary heart disease were more likely to visit higher-classed hospitals instead of community hospitals . Anyway, the high prevalence of comorbidities reminds general practitioners that it should not only aim to lower BP in the management of hypertension, but also focus on the prevention and treatment of other cardiovascular risk factors, such as using the lipid-lowering drugs and antithrombotic drugs.
BP control is associated with many factors such as age, lifestyle, BP level, choice of antihypertensive drugs, and compliance. And the resistant hypertension greatly increases cardiovascular risk. This study also indicated that uncontrolled hypertensive patients possessed higher cardiovascular risk than patients with target BP, since the history of stroke and kidney damage were more common after multivariate logistic regression analysis.
This study assessed the current status of patients with hypertension in general practice administration in Shanghai, China, including antihypertensive drug intervention rate, BP control rate, medication prescriptions and comorbidities. The research findings might provide useful insights into how to effectively improve management strategies and what might be the current burden of cardiovascular comorbidities associated with hypertension.
There are also some limitations in this study. Only one community was selected as a single-center study, which means selection bias existed, and we excluded hypertensive patients who were not effectively managed (less than 4 visits per year) in the analysis. Moreover, a retrospective study does not adequately analyze the causal relationship between BP control and comorbidities. In addition, we were unable to assess other risk factors such as smoke status and blood lipid level for comorbidities, therefore could not infer how many parts of these increased risks of comorbidities were related to hypertension.