The Prevalence of Hypertension and Utilization of Antihypertensive Therapy in a District Diabetes Population

Hypertension and antihypertensive treatment (AHT) impact on diabetes vascular outcomes and systolic blood pressure (SBP) probably confers a greater risk than diastolic blood pressure (1,2). Recent guidelines promote low intervention thresholds and target blood pressures (<130–140/80–85 mmHg) without considering the impact on clinical service provision (3,4). Using SBP targets, we describe hypertension prevalence, AHT utilization, and efficacy in a large district diabetes population.

We studied 6,485 of 7,123 registered adults (≥18 years) who had complete SBP and AHT data. Only 4,987 (76%) had complete data within 18 months. The subject (n = 6,485) characteristics were age 60 ± 15 years (mean ± SD); BMI 29 ± 8 kg/m²; 3,584 (55%) males; 5,115 (79%) type 2 diabetic subjects; 4,242 (65%) Caucasians; 1,259 (20%) Asians; and 546 (8%) Afro-Caribbean subjects. Blood pressure was measured by trained nurses (DinamapXL automated monitor; Johnson and Johnson Medical, Arlington, TX) with readings taken while the patient was sitting, from the right arm, and after a 5-min rest.

The mean SBP was 149 ± 24 mmHg. Hypertension prevalence (SBP ≥140 mmHg and/or AHT use) was 74% (4,788). Overall (Table 1), 2,252 subjects (35%) were untreated, 1,949 (30%) were suboptimally treated, 587 (9%) were treated to target SBP <140 mmHg, and only 285 (4%) attained a target of <130 mmHg. Using 160 mmHg as the definition and treatment target, 54% were hypertensive (3,493 of 6,485), of whom 957 were untreated and 1,069 were suboptimally treated (i.e., overall, 31% had SBP >160 mmHg).

Our hypertension prevalence (74%), low treatment rates (2,536 of 4,788, 53%), and poor control rates (587 of 4,788, 12%) at SBP of 140 mmHg compare directly with another U.K. study (5). These data clearly imply a huge workload for resource-constrained services. The obligation to improve access, equity, and systematic health care will increase this workload. Priority setting may deprive some people of potential but small benefits. However, concepts of rationing and prioritization to maximize gains and improve the efficiency of delivery of health care overall (6) must consider the curvilinear relationship between SBP and vascular risk. High-risk groups may be defined by understanding event rates for all vascular/diabetes complications at different SBP thresholds (1) (40.4, 51.3, and 76.2 per 1,000 person-years at <130, <140, and >160 mmHg, respectively). Our data strongly suggest that service providers must embrace these questions, and a necessary debate should ensue regarding the need for pragmatic intervention targets and how best to achieve them.