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• A more accurate definition of clinical inertia
  oscar,m jolobe
  Published on: 26 October 2023

• Published on: 26 October 2023

  A more accurate definition of clinical inertia

  • oscar,m jolobe, retired geriatrician British Medical Association

  It is, indeed, a truism that poor rates blood pressure(BP) control are, in part, attributable to clinical inertia, whereby therapy is not escalated when BP is uncontrolled[1]. However, the criterion for escalation of antihypertensive therapy utilised by the authors, namely, a BP amounting to 140/90 mm Hg or more[1], is inappropriate, given the fact that the goal BP most likely to mitigate the risk of incident hypertension-related atrial fibrillation(AF) and hypertension-related congestive heart failure(CHF), respectively, is a goal BP amounting to < 120/80 mm Hg[2],[3]. In principle, that goal BP can be achieved by ultralow-dose quadruple combination therapy either on its own or in combination with lifestyle antihypertensive strategies such as regular exercise[4] and low-salt diet with or without abstinence from alcohol[5]. The younger the patient the more compelling the requirement to attain a BP amounting to < 120/80 mm Hg because it is theoretically possible that the longer the duration of suboptimal blood pressure the greater the long term risk of AF, CHF, and, arguably, hypertension-related vascular dementia[6].
  Attainment of optimum goal BP crucially depends on accurate measurement of both "office" and home blood pressures[7],[8], and both those goals are predicated on the use of well-validated blood pressure monitors[8]. However, the minimum requirement for ultimate success in the control of BP is an honest conversation between doctor...

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  It is, indeed, a truism that poor rates blood pressure(BP) control are, in part, attributable to clinical inertia, whereby therapy is not escalated when BP is uncontrolled[1]. However, the criterion for escalation of antihypertensive therapy utilised by the authors, namely, a BP amounting to 140/90 mm Hg or more[1], is inappropriate, given the fact that the goal BP most likely to mitigate the risk of incident hypertension-related atrial fibrillation(AF) and hypertension-related congestive heart failure(CHF), respectively, is a goal BP amounting to < 120/80 mm Hg[2],[3]. In principle, that goal BP can be achieved by ultralow-dose quadruple combination therapy either on its own or in combination with lifestyle antihypertensive strategies such as regular exercise[4] and low-salt diet with or without abstinence from alcohol[5]. The younger the patient the more compelling the requirement to attain a BP amounting to < 120/80 mm Hg because it is theoretically possible that the longer the duration of suboptimal blood pressure the greater the long term risk of AF, CHF, and, arguably, hypertension-related vascular dementia[6].
  Attainment of optimum goal BP crucially depends on accurate measurement of both "office" and home blood pressures[7],[8], and both those goals are predicated on the use of well-validated blood pressure monitors[8]. However, the minimum requirement for ultimate success in the control of BP is an honest conversation between doctor and patient about the goals of treatment. The patient should be told that achievable treatment goals include mitigation of risk of hypertension-related AF and, hence, AF-related stroke, and mitigation of risk of hypertension-related CHF. The doctor can then proceed to spell out their role, which consists of checking the "office" BP and instigating regular ambulatory blood pressure measurements, as well as titrating antihypertensive medication on the basis of all the available blood pressure readings, including home blood pressure readings. The role of the patient is to do home blood pressure checks, to comply with medication and to adhere to a lifestyle which is compliant with good BP control.
  That might well be the most cost-effective strategy for hypertension control.
  I have no funding and no conflict of interest
  References
  [1] Bellows BK., Kazi DS
  Ultralow-dose quadruple combination therapy. A cost effective solution for hypertension control
  HEART doi.org/10.1136/heartjnl-2023-323007
  [2]Soliman EZ., Rahman AKMF., Zhang Z-m et al
  Effect of intensive blood pressure lowering on the risk of atrial fibrillation
  HYPERTENSION 2020;75:1491-1496
  [3]Upadhya B., Rocco M., Lewis CE et al
  Effect of intensive blood pressure treatment on heart failure events in the systolic blood pressure reduction intervention trial
  Circ Heart Faul 2017 doi.:10.1161/CIRCHEARTFAILURE.116.003613
  [4] Jolobe OMP
  Regular exercise as an adjunct to antihypertensive therapy
  American Journal of Emergency Medicine 2019;37:530-531
  [5] Tse Y-H., Tuet C-Y., Lau K-K., Tse H-F
  Dietary modification for prevention and control of high blood pressure
  Postgrad Med J 2023 doi.org/10.1093postmjqgad021
  [6] Li C., Zhu Y., Ma Y et al
  Association of cumulative blood pressure with cognitive decline, dementia, and mortality
  JACC 2022;79:1321-1335
  [7] Johnson KC., Whelton PK., Cushman WC et al
  Blood pressure measurement in SPRINT(systolic blood pressure intervention trial)
  HYPERTENSION 2018;71:848-857
  [8] Cheung AK., Whelton PK., Muntner P et al
  International consensus on standardized cliic blood pressure measurement-a call to action
  Am J Med drg/10/1016/j.amje,d.2022.12.015

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  Conflict of Interest:
  None declared.

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