title: Physician underutilization of effective medications for resistant hypertension at office visits in the United States: NAMCS 2006-2010.
abstract: BACKGROUND
  The American Heart Association (AHA) published guidelines for treatment of resistant hypertension in 2008 recommending use of thiazide diuretics (particularly chlorthalidone), aldosterone antagonists, and fixed-dose combination medications, but it is unclear the extent to which these guidelines are being followed.
  
  
  OBJECTIVE
  To describe trends in physician use of recommended medications for resistant hypertension and assess variations in medication use based on geography, physician specialty and patient characteristics.
  
  
  METHODS
  Cross-sectional analysis using the National Ambulatory Medical Care Survey from 2006 to 2010.
  
  
  METHODS
  We analyzed visits of hypertension patients to family physicians, general internists, and cardiologists. Resistant hypertension was defined as concurrent use of ≥ 4 classes of blood pressure (BP) medications or elevated BP despite the use of ≥ 3 medications. Pregnant patients and visits with diagnosed heart failure or end-stage renal disease were excluded.
  
  
  RESULTS
  Use of AHA-recommended medications for management of resistant hypertension.
  
  
  RESULTS
  Of 19,500 patient visits with hypertension, 1,567 or 7.1 % CI (6.6-7.7 %) met criteria for resistant hypertension. Thiazide diuretic use was reported in 58.9 % of visits pre-guidelines vs. 54.8 % post-guidelines (p = 0.37). Use of aldosterone antagonists was low and also did not change significantly after guideline publication (3.1 % vs. 4.5 %, p = 0.27). Fixed-dose combinations use was 42.0 % before and 37 % after guideline publication (p = 0.29). Each 10-year increase in patient age was associated with lower thiazide use (OR 0.87, CI 0.77-0.97), as was presence of comorbid ischemic heart disease (OR 0.62, CI 0.41-0.94). Medication use did not vary by geography or physician specialty.
  
  
  CONCLUSIONS
  Use of AHA-recommended medications for resistant hypertension remains low after publication of guidelines. Healthcare systems should encourage more frequent prescribing of these medications to improve care in this high-risk population.
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
authors.forename: Valy
authors.initials: V
authors.lastname: Fontil
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Pletcher
authors.forename: Raman
authors.initials: R
authors.lastname: Khanna
authors.forename: David
authors.initials: D
authors.lastname: Guzman
authors.forename: Ronald
authors.initials: R
authors.lastname: Victor
authors.forename: Kirsten
authors.initials: K
authors.lastname: Bibbins-Domingo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D004363:Drug Utilization / Q000639:trends*; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D009819:Office Visits / Q000639:trends*; D010819:Physician's Role; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D000959:Antihypertensive Agents