Blood Pressure Control in Hispanics in the Antihypertensive and Lipidlowering Treatment to Prevent H

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Blood Pressure Control in Hispanics in the
Antihypertensive and Lipid-lowering Treatment to
Prevent Heart Attack Trial (ALLHAT)

• Karen L. Margolis, Linda B. Piller, Charles E.
  Ford, Mario Henriquez, William C. Cushman, Paula
  T. Einhorn, Pedro J. Colon, Sr., Donald G. Vidt,
  Rudell Christian, Nathan D. Wong, Jackson T.
  Wright, Jr., David C. Goff, Jr., for the
• ALLHAT Collaborative Research Group
• Hypertension. 200750854-861

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Prevalence of Hypertension in U.S.
byRace/Ethnicity 1988-2004
Population With Hypertension ()
From Bernard Cheung Ong, et al, Hypertension 2007
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Hypertension Awareness,Treatment and Control
 
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Changes in Hypertension Awareness, Treatment, and
Control

• NHANES 2003-2004 some improvement among
  Mexican-Americans, but disparities remain

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Reasons for Racial and Ethnic Differences in BP
Control?

• Lack of access to health care
• Inability to afford medication
• Other socioeconomic factors
• Beliefs about hypertension
• Language barriers
• Poor MD-patient communication
• Family influences
• Diet
• Metabolic risk factors
• Other biological factors ? insufficient treatment
  or resistance to treatment

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AntihypertensiveTrial Design

• Randomized, double-blind, concurrently controlled
  practice-based clinical trial in 42,418
  participants with hypertension comparing 4
  commonly-used antihypertensive drugs.
• ALLHAT investigated whether there was a
  difference in fatal CHD nonfatal MI (primary
  endpoint) among patients randomized to CCB, ACEI,
  or alpha-blocker compared to a thiazide-type
  diuretic.
• Step-up medications as needed for BP control.

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Secondary Outcomes

• All-cause mortality
• Stroke
• Combined CHD nonfatal MI, CHD death, coronary
  revascularization, hospitalized angina
• Combined CVD combined CHD, stroke, lower
  extremity revascularization, other treated
  angina, treated HF
• Other renal (reciprocal serum creatinine, ESRD,
  estimated GFR), diabetes, and cancer

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Inclusion Criteria

• Men and women aged gt 55 years
• Seated blood pressure (2 categories)
• 1) Treated for _at_ least 2 months (1-2 drugs).
• 2) Not on drugs or on drugs lt2 months.
• Additional risk factor or target organ damage.

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BP Eligibility Criteria
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Doxazosin Arm Terminated Early

• Statistically significant 25 higher rate of
  major secondary endpoint, combined CVD outcomes
  (2-fold higher rate of heart failure and 20
  higher risk of stroke)
• Futility of finding a significant difference for
  primary CHD outcome

JAMA. 20001967-1975 Hypertension.
200342239-246.
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Randomized Design of ALLHAT BP Trial
42,418 High-risk hypertensive patients
Consent / Randomize
Amlodipine Chlorthalidone Doxazosin Lisinopril
Follow until death or end of study (4-8 years,
mean 4.9 years)
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Study Population

• 42,418 participants randomized (Feb. 1994 through
  Jan. 1998)
• After excluding doxazosin arm 33,357
• 3 Black Hispanic (BH)
• 16 White Hispanic (WH)
• 33 Black nonHispanic (BNH)
• 48 White nonHispanic (WNH)
• 73 of Hispanics were from Puerto Rico

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Treatment

• Access to high-quality hypertension care
• Study medications at no cost
• Required dosage titration and additional
  medications if SBP ?140 or DBP ?90 mmHg.

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Antihypertensive Treatment Regimen
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Baseline Characteristics-1
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Baseline Characteristics-2
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Mean Systolic Blood Pressureby Race and Ethnicity
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Mean Diastolic Blood Pressureby Race and
Ethnicity
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Blood Pressure Control
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Number of Antihypertensive Medications
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Participants with Uncontrolled BP on 1 Medication
Percentage Stepped Up
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Participants with Uncontrolled BP on 2
Medications Percentage Stepped Up
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Relative Odds ofBP Control at Year 2
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Summary - 1

• U.S. population 14.1 Hispanic/Latino in 2004
• Hispanic ALLHAT participants had equivalent or
  superior BP control compared with non-Hispanics
• Equal access to care
• No-cost medications
• Also reported in INVEST
• Hispanic Blacks had slightly lower levels of BP
  control compared with Hispanic whites, similar BP
  control to non-Hispanic whites, and better BP
  control than non-Hispanic Blacks.

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Summary - 2

• Compared with non-Hispanic whites, Hispanics less
  likely to have health insurance or regular source
  of care, less likely to receive preventive
  services
• Linked to lower rates of BP screening and
  treatment in Hispanics
• Primary care clinics in Boston Hispanic
  participants less likely to have meds
  intensified, but if intensified, equally likely
  to achieve BP control
• THUS
• Hispanic patients likely to face barriers to
  hypertension screening, initiation of therapy,
  and appropriate intensification of therapy.

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Conclusions

• Low rate of BP control in US Hispanics not due to
  biological factors.
• Controlled in ? 2/3 of Hispanic ALLHAT
  participants
• Commonly-available medications, including
  thiazide-type diuretics
• Focus on improving
• Hypertension knowledge and awareness
• Doctor-patient communication
• Access to medical care
• Affordable medications
• BP control in Hispanic patients is an achievable
  goal and should therefore be declared a public
  health priority

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Reserve Slide
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Summary - 3

• Other explanations for better BP control among
  Hispanic participants?
• Adherence to med may have been lower among
  Hispanics prior to randomization (slightly higher
  BP levels) more Hispanics essentially
  untreated?
• Systematic bias in BP measurements
• 0 terminal digit preference associated with
  underestimates of BP, undertreatment of
  hypertension
• Relatively high frequency (24 for SBP at 1 year)
  42 in Hispanics vs 21 in non-Hispanics)
  especially high in PR and USVI
• No evidence for systematic effort to inflate BP
  control rates

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Clinical Inertia

• Failure to advance therapy despite suboptimal BP
  control
• Reinforces need for effective methods to improve
  BP control through comprehensive programs
• Patients
• Providers
• Health care systems