Sunday, November 4, 2007

AHA - 2007: The Simplified Treatment Intervention to Control Hypertension (STITCH)

Step-care more effective than Canadian guidelines in treating hypertension

American Heart Association Scientific Sessions Late-Breaking News:

ORLANDO, Nov.4 – A simplified, step-care protocol for treating high blood pressure was more effective than guidelines-based practice in helping people reduce their blood pressure, according to late- breaking clinical trial results presented at the American Heart Association’s Scientific Sessions 2007.

The Simplified Treatment Intervention to Control Hypertension (STITCH) trial included 2,104 patients with high blood pressure (hypertension) at 45 family practices in southwestern Ontario, Canada. In order to increase the percentage of hypertensive people who reduce their blood pressure to “goal” levels, researchers wanted to see if there was a simpler way to direct treatment for hypertension than by following national guidelines for optimal management of blood pressure.

“The complexity of existing guidelines for managing hypertension could be a barrier to effective therapy,” said Ross D. Feldman, M.D., R.W. Gunton Professor of Therapeutics at the University of Western Ontario in London, Canada. “To examine this question, we conducted a cluster randomization trial. Family practices were randomly assigned to implement a simplified step-care algorithm (STITCH-care) or guidelines-based care for managing hypertension.”

The STITCH algorithm consisted of four steps: 1) Initiate therapy with ACE-inhibitor/diuretic or angiotensin receptor blocker/diuretic combination; 2) Increase the dosage of this combination therapy to the highest tolerated dose; 3) Add a calcium channel blocker and increase to the highest tolerated dose; 4) Add one of the non-first line antihypertensive agents.

In the guidelines-care physicians learned about the national guidelines of the Canadian Hypertension Education Program, which has 12 options for initial therapy that physicians can choose from depending on the type of hypertension and the patient’s co-existing medical conditions (very similar to options in the U.S. Joint National Committee guidelines).

The proportion of patients who reduced blood pressure to the target level was significantly higher in the STITCH-care group (65 percent) compared with the guidelines-care group (53 percent). Average systolic blood pressure (the top number in a blood pressure measurement) was reduced by 23 mmHg in the STITCH-care arm, significantly more than the 18 mmHg in the guidelines-care arm. In addition, diastolic blood pressure (the bottom number) was reduced by 10 mmHg in the STITCH-care patients and 8 mmHg in the guidelines-care group, a difference that was also statistically significant.

“Assignment to the STITCH-care arm increased the chance of reaching the optimal blood pressure target by over 20 percent,” Feldman said. “We believe that use of a simplified algorithm to treat hypertension is implementable, accepted by family physicians and results in improved blood pressure control rates. This return to ‘step-care’ may be an important way forward for the treatment of hypertension and may be a paradigm for managing a range of chronic diseases.”

While these guidelines would seem to offer a more patient-centric approach, tailoring care to each individual, it’s possible the number of options is confusing to busy physicians with limited time to spend with each patient.

Support for this study was provided by Pfizer.

Statements and conclusions of study authors that are presented at American Heart Association scientific meetings are solely those of the study authors and do not necessarily reflect association policy or position. The American Heart Association makes no representation or warranty as to their accuracy or reliability.

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