Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02246, USA.
Harvard Medical School, Boston, MA, USA.
J Gen Intern Med. 2022 Dec;37(16):4223-4232. doi: 10.1007/s11606-022-07612-3. Epub 2022 Apr 26.
In 2014, hypertension guidelines for older adults endorsed increased use of fixed-dose combinations, prioritized thiazide diuretics and calcium channel blockers (CCBs) for Black patients, and no longer recommend beta-blockers as first-line therapy.
To evaluate older adults' antihypertensive use following guideline changes.
Time series analysis.
Twenty percent national sample of Medicare Part D beneficiaries aged 66 years and older with hypertension.
Eighth Joint National Committee (JNC8) guidelines MAIN MEASURES: Quarterly trends in prevalent and initial antihypertensive use were examined before (2008 to 2013) and after (2014 to 2017) JNC8. Analyses were conducted among all beneficiaries with hypertension, beneficiaries without chronic conditions that might influence antihypertensive selection (hypertension-only cohort), and among Black patients, given race-based guideline recommendations.
The number of beneficiaries with hypertension increased from 1,978,494 in 2008 to 2,809,680 in 2017, the proportions using antihypertensives increased from 80.3 to 81.2%, and the proportion using multiple classes and fixed-dose combinations declined (60.8 to 58.1% and 20.7 to 15.1%, respectively, all P<.01). Prior to JNC8, the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and CCBs was increasing. Use of CCBs as initial therapy increased more rapidly following JNC8 (relative change in quarterly trend 0.15% [95% CI, 0.13-0.18%), especially among Black beneficiaries (relative change 0.44% [95% CI, 0.21-0.68%]). Contrary to guidelines, the use of thiazides and combinations as initial therapy consistently decreased in the hypertension-only cohort (13.8 to 8.3% and 25.1 to 15.7% respectively). By 2017, 65.9% of Black patients in the hypertension-only cohort were initiated on recommended first-line or combination therapy compared to 80.3% of non-Black patients.
Many older adults, particularly Black patients, continue to be initiated on antihypertensive classes not recommended as first-line, indicating opportunities to improve the effectiveness and equity of hypertension care and potentially reduce antihypertensive regimen complexity.
2014 年，老年人高血压指南支持更多地使用固定剂量联合用药，优先为黑人患者选择噻嗪类利尿剂和钙通道阻滞剂（CCB），不再推荐将β受体阻滞剂作为一线治疗药物。
评估指南更新后老年人的降压药物使用情况。
时间序列分析。
20%的 Medicare Part D 受益人的全国样本，年龄在 66 岁及以上，患有高血压。
第八版联合国家委员会（JNC8）指南
在 JNC8 之前（2008 年至 2013 年）和之后（2014 年至 2017 年），对高血压患者的现有和初始降压药物使用的季度趋势进行了评估。在所有高血压患者、可能影响降压药物选择的慢性病患者（高血压患者队列）以及黑人患者中进行了分析，因为有基于种族的指南推荐。
高血压患者人数从 2008 年的 1978494 人增加到 2017 年的 2809680 人，使用降压药物的比例从 80.3%增加到 81.2%，而使用多种药物和固定剂量联合用药的比例下降（分别从 60.8%降至 58.1%和从 20.7%降至 15.1%，均 P<.01）。在 JNC8 之前，血管紧张素转换酶抑制剂、血管紧张素受体阻滞剂和 CCB 的使用呈上升趋势。JNC8 后，CCB 作为初始治疗的使用增加得更快（季度趋势的相对变化为 0.15%[95%置信区间，0.13-0.18%]），尤其是黑人患者（相对变化为 0.44%[95%置信区间，0.21-0.68%]）。与指南相反，噻嗪类药物和联合用药作为初始治疗的使用在高血压患者队列中持续下降（分别从 13.8%降至 8.3%和从 25.1%降至 15.7%）。到 2017 年，高血压患者队列中 65.9%的黑人患者接受了推荐的一线或联合治疗，而非黑人患者为 80.3%。
许多老年人，特别是黑人患者，继续接受不推荐作为一线治疗的降压药物治疗，这表明有机会提高高血压治疗的有效性和公平性，并可能降低降压药物治疗方案的复杂性。
