[Algorithm of drug therapy for the treatment of arterial hypertension in elderly and old age patients]

Taking into consideration data of modern research and in conformity with the acting normative instruments and national recommendations we have developed the algorithm of drug therapy for the treatment of arterial hypertension in elderly patients. We give brief characteristic of main pharmacological groups of antihypertensive drugs with respect to their influence upon the elderly organism, systematize criteria for priority and limited prescription of drugs to the groups of old age patients. Given are the rational combinations of medical drugs to be used when single-drug therapy is not effective enough.

Evaluation of antihypertensive therapy among ischemic stroke survivors: impact of ischemic heart disease

BACKGROUND

Hypertension and ischemic heart disease (IHD) are among the most prevalent modifiable risk factors for stroke. Clinical trial evidence suggests that antihypertensive medications are recommended for prevention of recurrent ischemic stroke in hypertensive and normotensive patients.

OBJECTIVES

The objectives of this study were to analyze and evaluate the utilization of antihypertensive medication for acute ischemic stroke (AIS) or transient ischemic attack (TIA) survivors in relation to recent recommendations and guidelines and to compare their use among patients with or without IHD.

METHODS

This was a retrospective cohort study of all patients with AIS/TIA attending the hospital from July 1, 2008 to December 31, 2008. Demographic data, clinical characteristics, different classes of antihypertensive medications, and different antihypertensive combinations prescribed to AIS/TIA survivors were analyzed among patients with and without IHD. Statistical Package for Social Sciences (SPSS) program version 15 was used for data analysis.

RESULTS

In all, 383 AIS/TIA survivors were studied, of which 66 (19.5%) had a documented history of IHD. Three quarters (n = 260; 76.9%) of AIS or TIA survivors received antihypertensive medication, mostly as monotherapy, at discharge. The majority of patients (n = 201, 59.5%) were prescribed angiotensin-converting enzyme inhibitors (ACEIs). Patients with IHD were significantly prescribed more β-blockers than patients without IHD (P = .003). A history of hypertension, a history of diabetes mellitus, and age were significantly associated with prescription of antihypertensive medications at discharge (P < .001, P < .001, and P < .001, respectively).

CONCLUSION

Patterns of antihypertensive therapy were commonly but not adequately consistent with international guidelines. Screening stroke survivors for blood pressure control, initiating appropriate antihypertensive medications, and decreasing the number of untreated patients might help reduce the risk of recurrent strokes and increase survival.

Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis

INTRODUCTION

Unexplained differences between classes of antihypertensive drugs in their effectiveness in preventing stroke might be due to class effects on intraindividual variability in blood pressure. We did a systematic review to assess any such effects in randomised controlled trials.

METHODS

Baseline and follow-up data for mean (SD) of systolic blood pressure (SBP) were extracted from trial reports. Effect of treatment on interindividual variance (SD2) in blood pressure (a surrogate for within-individual variability), expressed as the ratio of the variances (VR), was related to effects on clinical outcomes. Pooled estimates were derived by use of random-effects meta-analysis.

FINDINGS

Mean (SD) SBP at follow-up was reported in 389 (28%) of 1372 eligible trials. There was substantial heterogeneity between trials in VR (p<1 x 10(-40)), 68% of which was attributable to allocated drug class. Compared with other drugs, interindividual variation in SBP was reduced by calcium-channel blockers (VR 0.81, 95% CI 0.76-0.86, p<0.0001) and non-loop diuretic drugs (0.87, 0.79-0.96, p=0.007), and increased by angiotensin-converting enzyme (ACE) inhibitors (1.08, 1.02-1.15, p=0.008), angiotensin-receptor blockers (1.16, 1.07-1.25, p=0.0002), and beta blockers (1.17, 1.07-1.28, p=0.0007). Compared with placebo only, interindividual variation in SBP was reduced the most by calcium-channel blockers (0.76, 0.67-0.85, p<0.0001). Effects were consistent in parallel group and crossover design trials, and in analyses of dose-response. Across all trials, effects of treatment on VR of SBP (r2=0.372, p=0.0006) and on mean SBP (r2=0.328, p=0.0015) accounted for effects on stroke risk (eg, odds ratio 0.79, 0.71-0.87, p<0.0001, for VR< or =0.80), and both remained significant in a combined model.

INTERPRETATION

Drug-class effects on interindividual variation in blood pressure can account for differences in effects of antihypertensive drugs on risk of stroke independently of effects on mean SBP.

FUNDING

None.

[Renal effects of combined anti-hypertensive treatments]

ACE inhibitors and angiotensin receptor blockers confer renal protection in proteinuric nephropaties, but recently worsening of renal outcomes has been reported in non-proteinuric patients treated with a combination of ramipril and telmisartan, compared to ramipril only. In view of these apparently contradictory data, the review wants to shed light on treatment modalities of patients with hypertension and chronic kidney disease.

[High prognostic significance of blood pressure variability in consecutive checks]

In a series of papers in the Lancet and Lancet Neurology, comprising 3 post-hoc studies and one meta-analysis of hypertension and TIA trials, Peter Rothwell and coworkers showed that the within-person visit-to-visit blood pressure variability - changes in office blood pressure between visits spaced 3 months apart - is a strong risk predictor for stroke and coronary events. There was also a strong association between the so defined blood pressure variability and the classes of antihypertensive drugs that were used: beta-blockers and then diuretics increased variability most and reduced stroke risk least, calcium-antagonists increased variability least and reduced stroke risk most, in spite of comparable effects on mean blood pressure. ACE- inhibitors and AII receptor-antagonists had intermediate positions. The 'Rothwell' variability seems to be driven by different mechanisms than the short-term variability in blood pressure: it is likely that individual pharmacokinetic and dynamic properties drive the former, and that vessel wall characteristics and autonomic function drive the latter. Rothwell et al. do not argue the importance of mean or usual blood pressure as the most important risk predictor, but make a strong case for looking at the visit-to-visit blood pressure as well. In practice these findings most easily translate in to choosing drugs that provide stable blood pressures over time, such as calcium-antagonists for the elderly patients that took part in the Rothwell analyses.

Calcium channel blockers: differences between subclasses

Calcium channel blockers (CCBs) share a common mechanism of action. However, the manner in which they exert their pharmacological effects is different between subclasses. Dihydropyridine (DHP) CCBs tend to be more potent vasodilators than non-dihydropyridine (non-DHP) agents, whereas the latter have more marked negative inotropic effects. Both subclasses have a similar capacity to lower BP; however, non-DHPs appear to offer potential advantages in the management of patients with chronic kidney disease and diabetic nephropathy. Representatives of both classes are now available in fixed-dose combinations containing an ACE inhibitor, the benefits of which include effective 24-hour BP control, a reduced incidence of adverse effects, and improved adherence.

Management of hypertension: evidence from the Blood Pressure Lowering Treatment Trialists' Collaboration and from major clinical trials

Deciding who to treat should be based on estimation of the total cardiovascular risk, not just the blood pressure (BP), so that patients with established cardiovascular disease or at high risk of cardiovascular disease should have their BP lowered even though it may be in the "normal range". Drug treatment should build upon effective lifestyle measures. Meta-analyses from the Blood Pressure Lowering Treatment Trialists' Collaboration have shown that differences between drug classes are quite small, even across different age groups, compared to the benefits of maximizing the reduction in BP, especially the systolic pressure. The major guidelines now recommend a focus on building effective drug combinations rather than arguing about which drug to use, and they approve initiation of treatment with combinations in high risk groups. While clinical trials have demonstrated some differences in the efficacy of individual drug classes in reducing cause specific outcomes such as coronary disease, stroke or heart failure, there are still very few comparisons between drug combinations. Our own preferred combinations include angiotensin converting enzyme inhibitors (ACEI) and diuretics, which comprise my first choice for Caucasians and Asians, and angiotensin receptor blockers (ARB) which are best used with diuretics when ACEI are not tolerated. ACEI and calcium channel blockers (CCB) are also very effective and CCB and diuretics are preferred for black subjects or those with isolated systolic hypertension. Combinations to avoid in patients with uncomplicated hypertension include ACEI and beta-blockers and ACEI and ARBs, since their beneficial effects are not additive.

Obesity and hypertension: mechanisms, cardio-renal consequences, and therapeutic approaches

The increasing prevalence of obesity in the industrialized world is causing an alarming epidemic. Almost 70% of American adults are overweight or obese. The link between increasing body weight and hypertension is well established. Obesity hypertension through metabolic, endocrinic, and systemic hemodynamic alteration causes structural vascular and cardiac adaptations that trigger concentric, eccentric left ventricular hypertrophy and electrophysiological changes, which may increase the risk for congestive heart failure and sudden cardiac death as a result of arrhythmias. The increased renal blood flow in conjunction with a decreased renal vascular resistance causes renal hyperperfusion and hyperfiltration. Such changes lead to glomerulomegaly, focal segmental glomerulosclerosis, tubulointerstitial inflammation, and fibrosis that characterize the renal damage in obese hypertensive subjects. We propose that weight reduction, with the addition of other nonpharmacological approaches that included exercise and reduction in alcohol intake, should be the first choice to treat obesity hypertension. Salt restriction may be helpful only in salt-sensitive patients. The benefits of diet in obese patients include improvement of insulin sensitivity, reduction in sympathetic nervous and renin angiotensin system activities, and restoration of leptin sensitivity. As a consequence of these and other metabolic changes, the previously described systemic and renal hemodynamic alterations improved and the cardiovascular and renal morphological changes induced by obesity were lessened. After reviewing the medications available, we believe that owing to the cardiovascular and renal morbidity and mortality that characterized obesity hypertension, the ACEI or ARBs offer the best cardio-renal protection and should be the pharmacologic treatment of choice. If these alone do not control BP adequately, then a low-dose diuretic should be added as a second approach. Although we strongly believe in our proposal, more multicenter long-term clinical pharmacological trials are needed to evaluate the efficacy and safety of the antihypertensive approaches in the treatment of obesity hypertension.

The quality of arterial hypertension treatment in cardiology service in Kosovo--a single center study

OBJECTIVE

The epidemiological data have shown that the goal blood pressure (BP) control is achieved in only a small percentage of the hypertensive patients. The aim of this study was to assess the quality of the management of arterial hypertension (AH) in patients hospitalized in Service of Cardiology, University Clinical Centre of Kosovo, in Prishtina, and to determine the predictors of uncontrolled AH.

METHODS

This retrospective study included 938 consecutive hypertensive patients (63.1+/- 11.3 years, 55.1% females), admitted to our institution between January 2003 and June 2006. Systolic and diastolic blood pressure, blood analyses, drug prescription and echocardiographic findings were analyzed in all study patients. Multiple regression analysis was used to identify the independent associates of poor BP control.

RESULTS

Overall, 83%f of patients were discharged on angiotensin-converting enzyme inhibitors (A), 71% - on beta-blockers (B), 26% - on calcium channel blockers (C) and 60% - on diuretics (D). The most frequent drug combination used was ABD (30.5%), followed by AB (18%) and AD (8%). The goal systolic and diastolic BP was achieved in 50% of patients. Multivariate analysis identified diabetes, (OR=0.479, 95% confidence interval [CI] 0.339-0.677, <0.001), creatinine level (OR=0.997, 95% CI 0.996-0.999, p=0.001], and ABCD combination therapy (OR=0.445, 95% CI 0.253-0.774, p=0.046)], as independent correlates of in-hospital poor BP control.

CONCLUSIONS

Half of hypertensive patients hospitalized in the Service of Cardiology had achieved the goal blood pressure. The diabetes, level of creatinine and a combination of 4 antihypertensive drugs were independent predictors of poor hypertension control.

Taking aim at hypertensive crises

Your patient's BP is severely elevated. Here's how to respond appropriately to protect target organs.

Maternal use of antihypertensive drugs in early pregnancy and delivery outcome, notably the presence of congenital heart defects in the infants

PURPOSE

To investigate the association between maternal use of antihypertensives in early pregnancy and delivery outcome, notably infant congenital malformations.

METHODS

A cohort study of 1,418 women who had used antihypertensive drugs in early pregnancy but had no diabetes diagnosis were identified from the Swedish Medical Birth Register.

RESULTS

There was an excess risk for placental abruption, caesarean section, delivery induction, and post-delivery hemorrhage in women taking hypertensives. Infants were more often than expected born preterm, were small for gestational age, and had an excess of various neonatal symptoms. Cardiovascular defects occurred with an adjusted odds ratio of 2.59 (95% CI 1.92-3.51). The results were similar when the woman had used ACE inhibitors or other antihypertensives, notably beta blockers. Stillbirth rate was increased (risk ratio 1.87, 95% CI 1.02-3.02), again without any clear drug specificity.

CONCLUSIONS

There seems to be little drug specificity in the association between maternal use of antihypertensives and an increased risk for infant cardiovascular defects.

The management of hypertensive crises: a clinical review

Hypertension is an exceedingly common disorder in Western societies; but, thanks to improved management of chronic hypertension, the number of patients who present with hypertensive crisis (HC) is less than 1%. However, critical elevation of blood pressure (BP) obliges to a proper and immediate management in order to prevent serious injury to organ target of hypertension (brain, heart, kidney and vessels). Moreover, the so called hypertensive emergencies (HE) and the hypertensive urgencies (HU) expect a several therapeutic approach. The HE warrant both prompt admission to an intensive care unit, where it is available a continuous monitoring of BP, and a prompt starting of a therapy with parenteral anti-hypertensive drugs. The treatment of HU can be managed choosing oral anti-hypertensive agents followed by a tight observation of the patient also in ambulatory system, lowering the BP more gradually over 12 to 24-48 hours. The present clinical review is aimed at reporting the current opinions on the management of HC, examining as well the drugs of largest use. Any drug that lowers BP precipitously should be avoided. Choice of the appropriate agent should be based on the underlying pathophysiological and clinical findings, on the mechanism of action, and on its potential side effects.

Utilising practice management system data for quality improvement in use of blood pressure lowering medications in general practice

AIM

To assess use of Electronic Medical Records (EMRs) to identify patient cases for potential quality improvement in use of blood pressure-lowering medications in general practice.

SETTING

One metropolitan general practice in Auckland with a high proportion of Pacific patients.

PARTICIPANTS

Patients registered as regular patients with the practice; classified within the previous 5 years as having hypertension; with at least one prescription for antihypertensive medication in the year prior to the evaluation period of 9 May to 8 November 2007.

INTERVENTION

Iterative discussion of quality improvement opportunities and review of EMRs with a panel of practice clinicians to identify agreed quality indicators based on EMR data. This resulted in a set of eight evidence-based criteria for patients classified with hypertension, implemented as database queries, which identify cases for potential quality improvement. The panel conducted blind assessment of antihypertensive therapy on a sample of 20 cases matching at least one criterion and 20 cases that met no criterion; the case classifications based on the database queries were then revealed for direct comment and consideration by the panel.

RESULTS

Of 517 eligible patients, 209 (40.4%) met one or more of the eight criteria. Of these 209, 110 (21.3%) met only criteria related to persistence of medication possession and/or blood pressure recording. After assessment of the 40-patient sample by the practice GPs, the eight criteria taken as a whole had a Positive Predictive Value of 70% (95% CI 46-88%) and Negative Predictive Value of 70% for clinician assessment of suboptimal therapy and/or process.

CONCLUSION

EMRs can provide moderately reliable identification of patients with suboptimal management of blood pressure in general practice. It should be noted, however, that the complexity of required query formulation is substantial with current tools. Identification of patients with poor persistence of antihypertensive therapy is the most promising outcome for follow-up investigation. The study needs to be replicated in a range of different practice settings.

Establishment of a Difficult Hypertension Clinic in Whangarei, New Zealand: the first 18 months

A Difficult Hypertension Clinic was established at Whangarei Hospital (Whangarei, Northland, New Zealand) in March 2006 in response to a perceived need amongst general practitioners. The experience with the first 150 patients is reviewed. Mean BP at referral was 162/89 mmHg, and mean number of antihypertensive drugs was 2.49. Mean BP at discharge from the Difficult Hypertension Clinic was 138/78 mmHg and mean number of antihypertensive drugs 3.16. The commonest cause of hypertension resistance was underprescription of diuretics. Secondary or contributory causes of hypertension were identified in 28 (19%) of patients, and white coat hypertension in three (2%). The Difficult Hypertension Clinic established in our hospital is an effective model for achieving clinical targets and care recommended in evidence-based guidelines.

Cardiovascular disease risk factor assessment and management in gout: an analysis using guideline-based electronic clinical decision support

AIM

To assess the need for cardiovascular disease (CVD) risk management in patients with gout.

METHODS

We studied 100 consecutive patients referred to the rheumatology service for management of gout. CVD risk factor and management data were collected. PREDICT CVD decision support software was used to calculate Framingham 5-year CVD risk, and to analyse therapeutic targets.

RESULTS

Fifty-nine (59%) patients had a high (>15%) or very high (> or = 20%) 5-year CVD risk. For those at high risk of CVD, target systolic blood pressure was achieved in 34%; target LDL-cholesterol in 49%, target HDL-cholesterol in 56%; and 81% did not smoke. For patients with diabetes, target HbA1c was reached in 40%. For high-risk individuals only 50% of eligible patients were on aspirin, 64% on beta-blockers, 53% statins, and 65% ACE inhibitors. There were no significant differences in duration of gout, presence of tophaceous disease, use of urate-lowering therapy or C-reactive protein between patients at high risk of CVD, and those with lower risk.

CONCLUSIONS

Patients with gout referred to secondary care are at high risk for CVD, and have a large burden of modifiable risk factors. Implementation of CVD screening and management programs in these patients should have high therapeutic yield.

Pulmonary arterial hypertension: an overview of current pharmacologic treatment

Various pharmacologic options exist for patients with PAH. Their overall effect on the disease is modest; however, with proper selection and monitoring they can improve symptoms and improve the quality and duration of life. Patient education is vital to ensure the proper use of these medications. Initial and continued responses vary greatly between patients necessitating trials of several different medications for some patients to achieve optimal outcomes. While newer agents may be better tolerated than older ones, improved efficacy has not yet been observed. In the future, improved outcomes may rely on determining optimal combination strategies.

[Blood pressure goal and choice of antihypertensive treatment in patients with mild hypertensive cardiovascular disease]

Guidelines for the management of hypertension are established to reduce hypertension-related morbidity and mortality. Fundamental aims of interventions are designed to prevent and/or slow the development of cardiovascular diseases such as myocardial ischemia, heart failure and left ventricular hypertrophy by effecting favorably the natural history. In clinical trials, antihypertensive therapy has been associated with reductions in cardiovascular events even in patients with mild hypertension. Several classes of medications are recommended to achieve target blood pressure in patients with mild hypertensive cardiovascular diseases.

[Arterial hypertension and cardiovascular risk: need for a combined strategy of intervention]

Arterial hypertension represents one of the most common conditions associated with an increased cardiovascular risk. New evidences support the need to adopt a global approach to the treatment of cardiovascular risk in hypertensive subjects by using drugs with proven benefits, not only for blood pressure control, but also for their pleiotropic effects. A greater understanding of the pathogenetic mechanisms of hypertension would provide a better strategy for preventing and treating this condition. Angiotensin II seems to be responsible for triggering vascular inflammation by inducing oxidative stress, resulting in up-regulation of pro-inflammatory mediators that lead to endothelial dysfunction and vascular injury. The interaction of angiotensin II, oxidative stress and endothelial dysfunction might be a target of a new integrated approach with important clinical implications.

Adults with diabetes - pharmacological management of hypertension

Cardiovascular and renal disease are leading causes of morbidity and mortality in patients with diabetes. Hypertension is an independent risk factor for both macrovascular (stroke, myocardial infarct, peripheral vascular disease) and microvascular (nephropathy, neuropathy, retinopathy) complications, and is a common co-existing condition in diabetes.

[Potential of using pattern diagnosis of traditional Chinese medicine to improve the clinical use of antihypertensive agents]

Despite the availability of six classes of antihypertensive agents, control of blood pressure and improving patients' quality of life remain far from ideal. There is a wide variability in terms of the hypotensive effect and side effect profile for the same antihypertensive agent used in different patients. How to select the right agent to provide the most beneficial results in terms of efficacy and improvement of quality of life as well as to decrease clinical symptoms and minimize adverse reactions is an important therapeutic challenge. It has been suggested that clinical usage of pattern (Zheng) diagnosis of traditional Chinese medicine may improve the accuracy in selecting the right antihypertensive agents with improved efficacy and deceased adverse effects. Limited research in this area suggested the calcium channel blocker may work better in treating phlegmatic damp excess pattern and blood stasis pattern while beta-blockers may be more beneficial in the liver yang rising pattern. On the other hand, angiotensin converting enzyme inhibitors may be more suitable in a yin deficiency and yang hyperactivity pattern as well as combined liver and kidney yin deficiency pattern. More research studies using this innovative approach in improving the selection of antihypertensive agents including mechanistic studies are urgently needed.