The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지

Analysis of Treatment Patterns and Blood Pressure Changes According to Risk Stratification in Hypertensive Subjects

고혈압 환자에서 위험도 층별화에 따른 진료 형태 및 혈압변화 분석

  • Published : 2011.03.01
⟨ Previous Next ⟩

Abstract

Background/Aims: The aims of this study were to identify real world treatment patterns of hypertension according to cardiovascular risk stratification and to evaluate blood pressure changes with anti-hypertensive treatment in each risk group. Methods: This study included patients who were newly-diagnosed with hypertension or known hypertensive patients with uncontrolled blood pressure (BP) at seven tertiary hospitals in Busan and Ulsan. World Health Organization/International Society of Hypertension (WHO/ISH) cardiovascular risk stratification was performed through retrospective chart review. Results: Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers were the most frequently prescribed drugs. The higher WHO/ISH risk group received a greater number of drugs at the initial treatment, and one year after treatment. Target BP was achieved less frequently in the higher risk group (68.2% vs. 85.2% vs. 89.0%, p & 0.001). The rate of attaining target BP was lower (50.7% vs. 81.6%, p & 0.001), and the time to attaining target BP was longer $(106.5\;{\pm}\;79.2\;days\;vs.\;82.1\;{\pm}\;75.3,\;p\;=\;0.001),$ in patients with renal disease or diabetes. Initial systolic BP above 160 mmHg (OR: 4.91, 95% CI: 2.27~10.65), renal disease (3.42, 1.60~7.32), medium or high risk group status (2.27, 1.23~4.20), initial diastolic BP above 100 mmHg (2.11, 1.11~4.04), and diabetes (2.06, 1.29~3.25) were independent factors that predicted failure of attaining the target BP. Conclusions: BP control was relatively unsatisfactory in patients with higher initial BP, renal disease, higher WHO/ISH risk group status, and diabetes. Individualized approaches for such patients are needed to improve BP control in routine clinical practice.

목적: 실제 진료 현장에서 심혈관 위험도 층별화에 따른 고혈압 치료 형태를 분석하고 각 위험도군 별 혈압 조절 양상에 대해 알아보고자 하였다. 방법: 부산 및 울산의 7개 3차 병원에서 처음 고혈압을 진단받고 외래진료를 받은 20세 이상의 성인을 대상으로 하였고, 기존에 고혈압 약제를 복용하고 있었던 환자는 최초 진료 당시 혈압이 조절되지 않아 기존 약제에서 치료내용이 변경된 경우 연구대상에 포함하였다. 2003년 개정된 세계 보건기구/국제 고혈압학회(World Health Organization/International Society of Hypertension, WHO/ISH) 기준에 따라 후향적 의무기록 분 석을 통해 위험도를 층별화 하였다. 결과: 총 643명이 분석 대상에 포함되었다. 전환효소 차단제 혹은 안지오텐신 II 수용체 차단제가 가장 빈번하게 처방되고 있었다. 최초 처방시점과 치료 1년째에 더 높은 위험도 군일수록 처방 받는 항고혈압 약제의 수가 더 많았다. 치료 1년째 목표혈압 도달률은 고위험도군에서 유의하게 낮았다 (고위험군 68.2%, 중등도위험군 85.2%, 저위험군 89.0%, p < 0.001). 당뇨병이나 신장 질환이 있는 환자들에서는 그렇지 않은 환자들에 비해 목표혈압 도달률이 더 낮았고(50.7% vs. 81.6%, p < 0.001) 목표혈압에 도달하기까지 걸린 시간도 더 길었다(106.5 ${\pm}$ 79.2일 vs. 82.1 ${\pm}$ 75.3일, p = 0.001). 다형회귀 분석에서 고혈압 치료목표 달성 실패의 가장 중요한 결정인자는 치료 전 160 mmHg 이상의 수축기 혈압(위험비 [OR]: 4.91, 95% 신뢰구간 [CI]: 2.27~10.65), 동반된 신장 질환(OR: 3.43, 95% CI: 1.60~7.32), 중등도 이상의 WHO/ISH 위험도군(OR: 2.27, 95% CI: 1.23~4.20), 치료 전 100 mmHg 이상의 확장기 혈압(OR: 2.11, 95% CI: 1.11~4.04), 그리고 동반된 당뇨병(OR: 2.06, 95% CI: 1.29~3.25)이었다. 결론: 치료 전 혈압이 높은 환자, 신장 질환이 있거나 WHO/ISH 고위험군인 환자, 또는 당뇨병이 있는 환자의 혈압조절이 상대적으로 취약하였다. 실제 진료현장에서 이러한 환자 들의 혈압조절을 위한 개별적으로 차별화 된 접근이 필요할 것으로 판단된다.

Keywords

References

  1. Guilbert JJ. The world health report 2002-reducing risks, promoting healthy life. Educ Health 2003;16:230. https://doi.org/10.1080/1357628031000116808
  2. 통계청편집부. 2007년 사망원인통계연보-전국편. 통계청 2008.
  3. 국민건강보험공단, 건강보험심사평가원. 2006 건강보험통계 연보 2007.
  4. Mancia G, De Backer G, Dominiczak A, et al. 2007 guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European society of hypertension (ESH) and of the European society of cardiology (ESC). J Hypertens 2007;25:1105-1187. https://doi.org/10.1097/HJH.0b013e3281fc975a
  5. Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American heart association council for high blood pressure research and the councils on clinical cardiology and epidemiology and prevention. Circulation 2007;115:2761-2788. https://doi.org/10.1161/CIRCULATIONAHA.107.183885
  6. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA 2003;289:2560-2572. https://doi.org/10.1001/jama.289.19.2560
  7. Whitworth JA. 2003 world health organization (WHO)/international society of hypertension (ISH) statement on management of hypertension. J Hypertens 2003;21:1983-1992. https://doi.org/10.1097/00004872-200311000-00002
  8. Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000;355:253-259. https://doi.org/10.1016/S0140-6736(99)12323-7
  9. Ruggenenti P, Fassi A, Ilieva AP, et al. Preventing microalbuminuria in type 2 diabetes. N Engl J Med 2004;351:1941-1951. https://doi.org/10.1056/NEJMoa042167
  10. Dahlof B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the losartan intervention for endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002;359:995-1003. https://doi.org/10.1016/S0140-6736(02)08089-3
  11. Lindholm LH, Ibsen H, Dahlof B, et al. Cardiovascular morbidity and mortality in patients with diabetes in the losartan intervention for end-point reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002;359:1004-1010. https://doi.org/10.1016/S0140-6736(02)08090-X
  12. Kim KI, Kim Y, Kim HJ, et al. Current status and characteristics of hypertension treatment by primary physicians in Korea: data from Korean epidemiology study on hypertension (KEY study). Am J Hypertens 2008;21:884-889. https://doi.org/10.1038/ajh.2008.191
  13. Sung J, Choi JH, On YK, et al. Study of compliance to antihypertensive medication in Korean hypertensive patients using medication event monitoring system. Korean Circ J 2005;35:821-826.
  14. Banegas JR, Segura J, Ruilope LM, et al. Blood pressure control and physician management of hypertension in hospital hypertension units in Spain. Hypertension 2004;43:1338-1344. https://doi.org/10.1161/01.HYP.0000127424.59774.84
  15. Lloyd-Jones DM, Evans JC, Larson MG, O'Donnell CJ, Roccella EJ, Levy D. Differential control of systolic and diastolic blood pressure : factors associated with lack of blood pressure control in the community. Hypertension 2000;36:594-599. https://doi.org/10.1161/01.HYP.36.4.594
  16. Degli Esposti E, Di Martino M, Sturani A, et al. Risk factors for uncontrolled hypertension in Italy. J Hum Hypertens 2004;18: 207-213. https://doi.org/10.1038/sj.jhh.1001656
  17. 박길섭, 라현진, 조희경 등. 일차의료에서 고혈압의 치료 행태와 진료지침의 유용성. 가정의학회지 2006;27:789-797.
  18. Borzecki AM, Oliveria SA, Berlowitz DR. Barriers to hypertension control. Am Heart J 2005;149:785-794. https://doi.org/10.1016/j.ahj.2005.01.047
  19. Pittrow D, Kirch W, Bramlage P, et al. Patterns of antihypertensive drug utilization in primary care. Eur J Clin Pharmacol 2004;60: 135-142. https://doi.org/10.1007/s00228-004-0731-6
  20. Oliveria SA, Lapuerta P, McCarthy BD, L'ltalien GJ, Berlowitz DR, Asch SM. Physician-related barriers to the effective management of uncontrolled hypertension. Arch Intern Med 2002;162: 413-420. https://doi.org/10.1001/archinte.162.4.413
  21. Blumenfeld JD. JNC-7 versus renin-based strategies for optimal antihypertensive drug treatment: another look at the evidence. Am J Hypertens 2004;17:1002-1004.
  22. 조명찬. 고혈압의 새로운 치료방법. 대한내과학회지 2009;76: 409-415.
  23. 하용찬, 천현주, 황혜경, 김병성, 김장락. 농촌 지역의 고혈압 유병률, 관리 양상 및 그 관련요인. 예방의학회지 2000;33:513-520.
  24. 이고은, 김영식. 서울 시민의 고혈압 관리 행태. 대한임상건강증진학회지 2004;4:216-222.