Many Rheumatologists Reluctant to Address Hypertension

Alice Goodman

October 28, 2013

SAN DIEGO — Fewer than 1 in 3 rheumatologists report discussing hypertension with patients who have uncontrolled blood pressure, despite the fact that those with rheumatoid arthritis are at increased risk for cardiovascular disease compared with the general population and that hypertension is a modifiable risk factor.

"Our study shows that uncontrolled high blood pressure was addressed in only 31% of encounters with rheumatologists at academic clinics," said lead investigator Christie Bartels, MD, from the University of Wisconsin at Madison. "Rheumatoid arthritis is an independent cardiovascular disease risk factor. Rheumatologists may not view managing blood pressure as part of their province, but their thinking needs to change," she said. "Patients with hypertension should be treated by the rheumatologist or referred to primary care for treatment."

The study, presented here at the American College of Rheumatology (ACR) 2013 Annual Meeting, is based on electronic health records of patients with primary and rheumatologic care, uncontrolled hypertension, and encounters at 1 of 3 academic rheumatology clinics.

Investigators examined the association between Joint National Committee 7 criteria for hypertension stage on the presence of any documented communication with the patient about hypertension.

Out of 1267 patients, 501 had uncontrolled hypertension. Rheumatologist visits numbered 2677. A total of 461 visits were with normotensive patients, 931 with prehypertensive patients, 952 visits with patients who had stage I hypertension, and 333 visits with patients who had stage II hypertension.

In an analysis controlled for confounding factors, only 23% of all visits included communication about hypertension.

Table. Adjusted Probability of Communication About Hypertension

Stage Adjusted (%) 95% Confidence Interval P-Value

Normotensive

18.7 15.1 - 22.2 <.001

Prehypertension

19.1 16.6 - 26.6 <.001
Hypertension (I) 24.7 22.0 - 27.5 <.001

Hypertension (II)

31.4 26.3 - 36.5 <.001

 

Dr. Bartels said that these findings are consistent with other reports about whether rheumatologists would actively manage blood pressure. It is possible that regional differences exist in rheumatologists' communication about blood pressure, but this study was not designed to show this.

Asked by Medscape Medical News to comment on the study, Gordon Starkebaum, MD, from the University of Washington in Seattle, said, "We target low disease activity in rheumatoid arthritis. We need to pay attention to other risk factors and work with primary care physicians to optimize other outcomes. If the primary care doctor is not accomplishing this, then rheumatologists have an obligation to help."

Dr. Starkebaum said that blood pressure should be measured at each office visit to a rheumatologist. "If the hypertension is abnormal, that means it is not being managed. I try to engage both the patient and the primary care physician, with one of the goals being empowerment of patients," he added.

Dr. Bartels receives funding from the National Institutes of Health. Dr. Starkebaum reports no relevant financial relationships.

ACR 2013 Annual Meeting. Abstract 207. Presented October 27, 2013.

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