The results presented in this study describe the demographic and clinical characteristics of hypertensive patients attending the medical consultation of hypertension/dyslipidemia in a university teaching hospital located in the Eastern Central Region of Portugal for routine follow-up, focusing on the level of hypertension control and antihypertensive therapy.
According to a survey conducted in 2003 , of the total number of hypertensives in the Central Region of Portugal who reported taking their medication regularly, only 26.1% had their BP measurements <140/90 mmHg, which is significantly smaller than the 44.4% obtained in our study (Table 3). This difference possibly points to an improved current care of the hypertensives included in our study when compared to those included in the above mentioned survey. Increased awareness of hypertension and the importance of lower BP may have prompted Portuguese providers and patients to more aggressively treat high BP, especially after the publication of the JNC 7 report in 2003. Till now there has been no data about the percentage of treated hypertensives in clinical practice, in this Portuguese region, with their BP controlled according to the JNC 7 guidelines. Our study revealed that 37.1% of hypertensive patients had their BP controlled according to those guidelines, with the percentage of patients without diabetes or CKD attaining BP control (45.5%) significantly higher (P < 0.001) than the percentage of hypertensive patients with diabetes or CKD (10.2%). It should be noted that the reported levels of BP control can vary greatly depending on the study population, methods and time frame [4, 5]. For example, in one study based on data from the US National Health and Nutrition Examination Survey 2003-2004, the BP control rate (to <140/90 mmHg) was 56.6% in treated hypertensives, and 37.5% in treated hypertensive persons with diabetes mellitus (for whom the goal BP is <130/80 mmHg) . In a regional survey performed in the middle-West of France and involving 1050 treated hypertensives, Ragot et al. reported that 39% of patients had BP figures <140/90 mmHg and only 13% of the diabetic population were normalized according to the international recommendations (<130/80 mmHg) . In a more recent retrospective observational study conducted in the United States, Jackson et al.  reported a BP control of 49.3% in an after-JNC 7 cohort. In this cohort, a significantly higher percentage of nondiabetic patients achieved BP control compared with those with comorbid diabetes (60.9% versus 29.4%). Similarly, Andros et al.  conducted a retrospective observational study of BP control in an insured diabetic population, obtaining a BP control rate (defined by JNC 7) of 28%, similar to the 29.4% obtained by Jackson et al. . The results obtained in our study are less optimistic, especially when considering the percentage of BP control attained by hypertensives with diabetes or CKD (10.2%) and seem to be similar to those obtained by Ragot et al. in a French population . The percentage of patients taking a higher number of antihypertensive drugs were higher in patients with a lower target BP (<130/80 mmHg) (Figure 1), suggesting that an effort is being made to further lower BP in this hypertensive subgroup. However, our results insinuate that prescribers may not be fully following the JNC 7 recommended BP targets, especially those related to hypertensives with diabetes or CKD, because the above mentioned studies demonstrated that it is possible to obtain a higher BP control in this hypertensive subpopulation. In fact, there was no significantly difference in the percentage of hypertensives in each cohort that achieved a BP of <140/90 mmHg (45.5% versus 40.8%; P = 0.564). Thus, our findings indicate that patients who would benefit most from tighter control of BP, especially those with compelling indications, appeared to do worse than those with uncomplicated hypertension. Furthermore, it seems to us that stage 1 hypertension is not seen as a major problem because a rather significant percentage of hypertensive patients is maintained in this hypertension stage (Table 3). Other possible underlying causes of poor BP control are guidelines unawareness and therapeutic inertia on the part of providers and poor adherence and persistence with prescribed medications and lifestyle modifications by patients. Results of studies suggest that antihypertensive medications are frequently not intensified when BP remains uncontrolled, termed clinical inertia [9–11]. In the recent Harris Survey , more than 30% of hypertensive patients reported that their medication was not changed or increased despite the fact that their BP was still >140/90 mmHg. Antihypertensive medication nonadherence is another major factor that must be thought about when considering the possible reasons for the inadequate BP control. Indeed, there is a large proportion of patients in our study (65%) who had hypertension for over five years. It is known that patient persistence with prescribed therapy for any chronic disease typically declines over time, and hypertension is no exception [13–15].
Of particular note is that the BP control rate in patients with target values of <140/90 mmHg was significantly lower in older hypertensive individuals (25%; Table 2), which is in accordance with rates mentioned in the literature and are largely due to poor control of systolic BP [3, 16]. Obesity is identified as one cause of resistant hypertension  and there was a trend, albeit not significant, toward higher BP control between nonobese hypertensive patients (40% vs 28%, 0.127). The nonsignificant difference in BP control rate between obese and nonobese in our analysis could be because of the limited sample size, because >75% of the patients with diagnosed arterial hypertension were nonobese (body mass index <30).
The differences in rates of BP control between males and females were not significant in the <140/90 mmHg and in the <130/80 mmHg BP targeted population. Our results are in accordance with a recent study assessing gender difference in BP control that used the same cut points of uncontrolled BP defined by the JNC 7 .
Our results also indicate that there is a significantly higher percentage of patients with stage 2 hypertension in the first medical appointment at the hypertension/dyslipidemia clinic, when compared to the same patients and to the total study population at the last medical appointment. The decrease in stage 2 hypertension in patients attending the hypertension/dyslipidemia clinic for the first time was paralleled by a significant decrease in the systolic BP from the first to the last appointment (from 149.4 ± 17.1 to 138.1 ± 11.0, P < 0.001). These facts suggest that clinically important BP decreases can be achieved soon after hypertension medical appointment initiation.
Results from this study indicate that prescribers are following the JNC 7 drug therapy recommendations, including the use of thiazide-type diuretics as preferred initial agent in patients without compelling indications and those related to compelling indications. In fact, the use of ACEIs and ARBs in patients with diabetes and/or congestive heart failure coincides with JNC 7 recommendations. Data reported here do not, however, suggest that postmyocardial infarction patients are being mostly treated with beta-blockers.
The observed relationship between increased number of antihypertensive drugs and poorer BP control (Figure 2) could be explained by the fact that patients whose BP is more difficult to control are likely to be treated with multiple drugs. Thus, this measurement may be a consequence of poor BP control.
Several features of our study deserve further comment. First, the objective of this study was to describe levels of BP control in subgroups of hypertensive patients defined on the basis of important characteristics, and not to directly compare such levels across subgroups. For this motive, analyses adjusted for other characteristics were not conducted. Second, apart from patients initiating hypertension appointments within the study period, in which the BP measurements in the first appointment was also considered, BP control was determined based on the last available readings during the retrospective study period. These measurements may or may not be representative of the adequacy of control over the entire corresponding period. Third, drug information in the study database is confined to prescriptions written and not necessarily to those dispensed or used. Whether written prescriptions were filled by the patients and the level of medication adherence among patients who did fill the prescriptions is unknown. Finally, because of the retrospective design of the study, some data were not available or not able to be validated during the data collection process (Table 1). Although the missing data were quite reduced, the possibility exists that certain patient characteristics, conditions and risk factors were over- or under-represented.