Background:
Arterial Hypertension (HTN) affects approximately 32% of the adult population in Germany, yet more than half of patients fail to achieve guideline-recommended target blood pressure levels. Effective hypertension control substantially improves cardiovascular outcomes and life expectancy. While primary care is central to HTN management, the role of office-based cardiologists in treatment escalation of complex patients remains poorly characterized.
Objectives:
To evaluate the role of cardiologists in the diagnosis, management, and treatment escalation of patients with incident HTN in Germany.
Methods:
A retrospective claims data analysis was conducted using German statutory health insurance data. Patients with incident HTN were identified by ICD codes I10-I13 and followed over a 3-year observation period. In parallel, structured qualitative interviews were performed with 18 primary care physicians and 9 cardiologists to assess clinical practice patterns, referral reasons, and treatment decision-making.
Results:
The cohort had a mean age of approximately 53.1 years (derived from age-band midpoints), 50.2% were male. The most prevalent comorbidities included lipid disorders (26.3%), obesity (15.6%), and type 2 diabetes (8.9%).
Initial HTN diagnosis was predominantly established in primary care (73.8%), followed by the hospital setting (19.3%) and cardiologists (11.5%). Patients receiving more intensive pharmacotherapy were more likely to consult cardiologists: 42.8% of patients prescribed ≥4 antihypertensive agents had at least one cardiology visit. These patients exhibited a substantially higher cardiovascular disease burden compared with the overall cohort (e.g., heart failure: 27.3% vs. <5.8%).
Interview findings revealed that referrals to cardiologists were primarily driven by suspected or confirmed cardiovascular comorbidities, need for echocardiography or uncontrolled blood pressure despite treatment with ≥3 antihypertensive agents.
Despite this involvement in more complex cases, cardiologists accounted for only 6.8% and 9.4% of initial prescriptions of the fourth and fifth antihypertensive agent, respectively, and were responsible for just 1.9% of all follow-up prescriptions. Regarding drug class selection, cardiologists showed a preference for mineralocorticoid receptor antagonists (MRAs) and angiotensin receptor blockers (ARBs).
Conclusions:
Primary care physicians remain central to HTN diagnosis and long-term management, whereas office-based cardiologists are mainly involved in patients with advanced or treatment-resistant disease and cardiovascular comorbidities. Despite frequent specialist involvement in complex cases, cardiologists contribute only marginally to antihypertensive treatment escalation. Improved coordination between primary care and cardiology may help optimize blood pressure control in Germany.
