Marked Underdiagnosis and Undertreatment of Hypertension in Rheumatoid Arthritis: A large Gap to Close
Maria Usman Khan1,3,4, Fahd Adeeb1,3, Usman Azhar Khan2,3, Alwin Sebastian1, Azhar Abbas4, Hafiz Hamid Bajwa4, Mary Brady1, Siobhan Morrisey1, Mary Gillespie1, John Paul Doran1, Joseph Devlin1, Alexander Fraser1,3
1. Department of Rheumatology, University Hospital Limerick, Limerick, Ireland 2. Department of Cardiology, University Hospital Limerick, Limerick, Ireland 3. Graduate Entry Medical School, University of Limerick, Limerick, Ireland 4. Department of Rheumatology, Beaumont Hospital, Dublin, Ireland preprocess
In rheumatoid arthritis (RA), hypertension (HTN) doubles the risk of the composite cardiovascular outcome. Current guidelines  provide evidence-based indications for time to initiate therapeutic interventions & specific target blood pressure (BP) goals. preprocess
To determine the prevalence of HTN and to evaluate BP management in comparison to the EULAR recommendations  in our Midwest RA cohort after devising departmental guidelines and continuous education based on the results of first audit cycle (May-June 2016). preprocess
100 consecutive patients with definite RA were recruited in this multicenter quality improvement project involving 2 teaching hospitals (Croom hospital & University Hospital Limerick) between january-febuary2017. A proforma was completed for each patient based on medical notes & electronic data including BP record within the last 4 years and recent antihypertensive medications. HTN was defined as BP of ≥140/90 mmHg. Based on the EULAR guidelines, ACE inhibitors (ACE-I) & angiotensin II (AT-II) blockers are preferred agents when indicated due to favorable effect on inflammatory markers and the endothelial function in RA. Based upon the results of our first audit cycle, we encouraged the use of ACE-I and AT-II blockers in our RA cohort as the preferred antihypertensive agents when indicated at both departmental and community level. preprocess
1) There was an overall improvement in BP monitoring by 4%, and 70% of the patients had up-to-date BP recordings. 2) There was 5% increment in hypertensive patient cohort (element of white coat HTN not excluded) and at least 45% of patients were sub-optimally managed with mono or combination antihypertensive therapy in both cycles. Encouragingly ACE-I and AT-II blockers remained the main stay of treatment and constituted 50% of total drugs in the second audit compared to 54% in the first audit. 3) There were 6% reduction in the numbers of normotensive patients; 36% patients were adequately controlled with antihypertensive therapy in both audits. Interestingly the overall use of both ACE-I and AT-II blockers as primary antihypertensive was increased by 7% as compared to the first audit. preprocess
Management of HTN in our RA cohort remained low and will require a re-audit. Several major barriers exist, including lack of time and staff. Rheumatologists need to be more actively involved in managing HTN in RA patients with possible referral to the relevant specialty if in doubt regarding the diagnosis and/or management.
References available on demand.