The four forces that determine therapeutic success
The question
What is the impact of the patient, the doctor, the disease and the therapy?
Answer: Controlling high blood pressure does not depend solely on the choice of the right drug or the availability of effective treatment protocols. Instead, it is a complex, multifactorial process involving at least four key elements: the patient, the doctor, the disease itself and the therapy adopted. The interplay between these factors can determine success or failure in achieving pressure goals.
1. The role of the patient: The patient must be placed at the centre of the management of hypertension as his or her behaviour plays a key role in the effectiveness of the therapy. On the one hand, in terms of lifestyle, on the other hand, therapeutic adherence is crucial. Many patients, in fact, do not take their prescribed medication regularly, discontinue them without informing their doctor or take them incorrectly. There are various possible justifications for this: the paradox of prevention (i.e. the absence of perceived symptoms), the occurrence of side effects, the complexity of the treatment schedule and often poor disease compression.
2. The doctor's role: the doctor must make an early and accurate diagnosis. He or she must verify the cause of hypertension itself: approximately 90% of subjects have hypertension defined as essential, which does not identify an unknown cause and develops gradually over time; the remaining 10% suffer from hypertension due to secondary causes (renal diseases, adrenal diseases and sometimes congenital vascular alterations), which require a very different therapeutic approach. In addition, the physician has the task of educating the patient to provide awareness of the disease, medication effects and therapeutic goals. It must be emphasised that this is often difficult to apply when the time devoted to the examination is short, as is the case in most parts of the National Health System due to the limited availability of medical and healthcare personnel. All the various public health actors are important in this regard: for example, the pharmacist, who has a close relationship with the chronic patient, can play a key role in providing the patient with tools for consultation and awareness.
3. The impact of the disease Arterial hypertension, although very common, is a condition that is often underestimated because it is asymptomatic. However, its chronic nature, the variability of values and associated comorbidities (diabetes, dyslipidaemia, obesity, renal insufficiency) make clinical management particularly complex. It is essential to be able to recognise the disease at its onset: this prevents damage to various fundamental organs (heart, kidney, vessels, brain), which otherwise, once it has set in, is essentially non-reversible and makes pressure control even more difficult. In addition, there are certain types of patients with a very complex disease that worsens rapidly: this is the case with resistant hypertension or malignant hypertension.
4. The impact of therapy: finally, the therapy itself plays a key role. The heterogeneity of drugs means that, if a precise rationale is not followed in their choice, sub-optimal control of blood pressure values may be achieved. The type of patient, the presence of side effects, and the simplification of the treatment scheme with fixed combination therapies are all key points to be taken into account.