Robarts Research Institute, PO Box 5015, 100 Perth Drive, London, ON N6A 5K8, Canada.
J Hypertens. 2013 Aug;31(8):1702-13. doi: 10.1097/HJH.0b013e3283619d6a.
Notwithstanding improving rates of hypertension control in North America, management of patients with both hypertension and dyslipidemia remains problematic. Based on evidence of improved control utilizing a simplified algorithm for management of hypertension (STITCH), we questioned whether a simplified comprehensive treatment algorithm featuring initial use of single-pill combinations (SPCs) would improve management of participants with both hypertension and dyslipidemia.
We randomized 35 primary care practices in Ontario to either Guidelines-care (following current Canadian guidelines) or STITCH2-care (following a treatment algorithm featuring SPCs). Practices each enrolled up to 50 participants with at least one risk factor above target at entry based on Canadian guidelines for BP and LDL-cholesterol control. The primary endpoint was achieving targets for both hypertension and dyslipidemia control after 6 months, assessed at the practice level.
The primary endpoint was achieved in 31.3% of participants in STITCH2-care practices, compared with 28.1% in Guidelines-care practices, yielding a difference of 3.2% (P = 0.63). Notably, STITCH2-care practices had a significantly greater reduction in SBP while LDL-cholesterol reduction was only marginally greater in STITCH2 practices.
The STITCH2 algorithm resulted in significantly greater use of any SPC compared with Guidelines-care and greater use of the SPC of calcium channel blocker/statin. Unwillingness of the prescribing physician to advance treatment beyond a monotherapy threshold was found to be an important determinant for failing to achieve blood pressure control. In contrast, the more important determinant for failing to achieve LDL control appeared to be the unwillingness of the prescribing physician to initiate therapy with a statin.
尽管北美的高血压控制率有所提高，但高血压和血脂异常患者的管理仍然存在问题。基于利用简化的高血压管理算法（STITCH）改善控制率的证据，我们质疑是否使用初始使用单一药物复方（SPC）的简化综合治疗算法会改善高血压和血脂异常患者的管理。
我们在安大略省随机选择了 35 家初级保健诊所，分别进行指南护理（遵循当前加拿大指南）或 STITCH2 护理（遵循以 SPC 为特色的治疗算法）。每个诊所根据加拿大的血压和 LDL 胆固醇控制指南，招募了多达 50 名至少有一个风险因素高于目标的参与者。主要终点是在 6 个月后评估，在诊所水平上实现高血压和血脂异常控制的目标。
在 STITCH2 护理实践中，主要终点在 31.3%的参与者中达到，而在指南护理实践中为 28.1%，差异为 3.2%（P=0.63）。值得注意的是，与指南护理相比，STITCH2 护理实践中 SBP 的降低幅度显著更大，而 LDL 胆固醇的降低幅度仅略有增加。
与指南护理相比，STITCH2 算法显著增加了任何 SPC 的使用，并增加了钙通道阻滞剂/他汀类药物的 SPC 使用。发现未能实现血压控制的一个重要决定因素是处方医生不愿意将治疗推进到单一疗法阈值以上。相比之下，未能实现 LDL 控制的更重要决定因素似乎是处方医生不愿意开始使用他汀类药物进行治疗。
