Antihypertensive drug therapy and blood pressure control in men and women: an international perspective

Pharmacogenomics of hypertension and heart disease

Heart disease is a leading cause of death in the United States, and hypertension is a predominant risk factor. Thus, effective blood pressure control is important to prevent adverse sequelae of hypertension, including heart failure, coronary artery disease, atrial fibrillation, and ischemic stroke. Over half of Americans have uncontrolled blood pressure, which may in part be explained by interpatient variability in drug response secondary to genetic polymorphism. As such, pharmacogenetic testing may be a supplementary tool to guide treatment. This review highlights the pharmacogenetics of antihypertensive response and response to drugs that treat adverse hypertension-related sequelae, particularly coronary artery disease and atrial fibrillation. While pharmacogenetic evidence may be more robust for the latter with respect to clinical implementation, there is increasing evidence of genetic variants that may help predict antihypertensive response. However, additional research and validation are needed before clinical implementation guidelines for antihypertensive therapy can become a reality.

[Is blood pressure control different in women than in men?]

Blood pressure (BP) evolves with age; until the 50's it is higher in men than in women, equaling and even then increasing in women. The prevalence of controlled BP appears to be similar between the sexes, but the prevalence of cardiovascular disease is higher in women than in men. The possibility that BP influences the cardiovascular risk differently according to sex must therefore be considered. While some studies suggest no difference exists, others have shown evidence of an increased risk in women with respect to men despite equal BP. In this way, it seems that the measurement of ambulatory BP, but not office BP, would mark the differences in the association between BP-gender and cardiovascular risk. It should therefore be investigated the possibility of a different BP goal for women and men, especially by evaluating ambulatory BP.

Treatment of Hypertensive Patients With Diabetes and Microalbuminuria With Combination Indapamide SR/Amlodipine: Retrospective Analysis of NESTOR

BACKGROUND

Combination treatments for hypertension most often include a renin-angiotensin-aldosterone system (RAAS) inhibitor. However, systolic blood pressure (SBP) remains difficult to control. Non-RAAS-inhibiting strategies such as calcium channel blocker/thiazide-like diuretic combinations may offer effective alternatives.

METHODS

Hypertensive diabetic patients with microalbuminuria were included in this retrospective, post-hoc analysis of the Natrilix SR Versus Enalapril Study in Hypertensive Type 2 Diabetics With MicrOalbuminuRia (NESTOR) trial if they were uncontrolled on monotherapy (indapamide slow release (SR) 1.5 mg or enalapril 10mg) and had been given add-on amlodipine 5 mg. Patients uncontrolled with monotherapy/amlodipine 5mg were uptitrated to 10 mg.

RESULTS

After 52 weeks, supine SBP/diastolic BP (DBP) decreased from baseline by 26±13/14±9 mm Hg in the indapamide SR/amlodipine group (n = 135) and by 21±14/11±9 mm Hg in the enalapril/amlodipine group (n = 156) (P = 0.006 for ΔSBP). In the amlodipine 10mg subgroup, SBP/DBP decreased from baseline by 26±13/13±9 mm Hg in the indapamide SR/amlodipine group (n = 62) and by 20±13/12±8 mm Hg in the enalapril/amlodipine group (n = 77) (P = 0.02 for ΔSBP). Treatment with indapamide SR/amlodipine was well tolerated. Few patients experienced edema, with no between-group differences. As expected with diuretics, slight changes in kalemia and in uricemia were observed in the indapamide SR/amlodipine group. Changes in fasting glucose, lipids, natremia, and creatinine clearance were similar between groups.

CONCLUSIONS

Indapamide SR/amlodipine results in superior SBP reduction with a safety profile in line with that of its components and tolerability equivalent to that of an angiotensin-converting enzyme inhibitor/amlodipine strategy.

Pharmacogenetic effects of 'candidate gene complexes' on stroke in the GenHAT study

OBJECTIVE

The aim of this study was to investigate whether there is a genotype-by-treatment interaction in patients experiencing stroke and treated with one of three antihypertensive drugs, that is chlorthalidone, amlodipine, or lisinopril.

PARTICIPANTS AND METHODS

A population of 436 African Americans and 539 whites who had experienced stroke in the GenHAT study were genotyped for 768 single nucleotide polymorphisms (SNPs) in 280 candidate genes. To detect a genotype-by-treatment interaction, we used the Pearson's χ-test to assess whether the genotype frequencies differed at the single SNP level for the three drug treatment groups. From these single SNP analyses, we derived a summary statistic for the degree of association at the gene and gene complex levels. This was done by grouping SNPs using information on gene locations and defining gene complexes on the basis of protein-protein interactions. To assess the statistical significance of the observed test statistic, we derived an empirical P-value by simulating data under the null hypothesis.

RESULTS

We found that, in patients who have experienced stroke, there is a significant genetic difference between hypertension drug treatment groups. In African Americans, SNP rs12143842 showed a significant association (P<0.001) with drug treatment. At the gene level, HNRNPA1P4 and NOS1AP in African Americans and PRICKLE1 and NINJ2 in non-Hispanic whites were significantly associated (P<0.01) with drug treatment, whereas none of the gene complexes tested showed significance.

CONCLUSION

On the basis of the genetic differences between drug treatment groups, we conclude that there may be an interaction between certain genotypes and antihypertensive treatment in stroke patients. This needs to be replicated in other studies.

Triple combination therapy in hypertension: the antihypertensive efficacy of treatment with perindopril, amlodipine, and indapamide SR

BACKGROUND AND OBJECTIVE

The blood pressure (BP) of most patients on antihypertensive monotherapy or bitherapy remains uncontrolled. Our study evaluated the efficacy of triple therapy with perindopril, amlodipine, and indapamide sustained release (SR) in patients with uncontrolled hypertension on previous antihypertensive therapy.

METHODS

This 4-month, multicenter, prospective, observational, open-label study included patients switched from previous antihypertensive therapy to triple therapy with perindopril, amlodipine, and indapamide SR. The main outcome was change in office BP from baseline to 4 months, as well as changes in 24-h ambulatory BP monitoring (ABPM) parameters in a subgroup of patients.

RESULTS

Age was 62.8 ± 11.3 years in 6,088 patients (55 % were male). Office BP at baseline was 158.1 ± 13.0/92.6 ± 8.8 mmHg. By 4 months, office BP decreased by 26.7 ± 13.3/12.9 ± 9.4 mmHg (p < 0.001). ABPM was performed in 62 patients. In these patients, 24-h systolic BP decreased (from 138.7 ± 12.5 to 125.5 ± 12.8 mmHg), as did 24-h diastolic BP (from 77.5 ± 11.4 to 70.4 ± 8.7 mmHg) (both p < 0.0001). Heart rate remained unchanged. In patients previously on renin-angiotensin-aldosterone system (RAAS) inhibitor/amlodipine, 24-h ambulatory systolic and diastolic BP decreased from 136.9 ± 12.8 to 125.4 ± 13.3 mmHg (p = 0.0003) and from 76.3 ± 12.6 to 70.2 ± 9.5 mmHg (p = 0.0005). In those previously on RAAS inhibitor/hydrochlorothiazide, 24-h ambulatory systolic and diastolic BP decreased from 137.8 ± 12.7 to 122.7 ± 15.4 mmHg (p = 0.0039) and from 73.6 ± 9.4 to 65.7 ± 7.3 mmHg (p = 0.002). Most (74 and 80 %, respectively) patients reached target ABPM values (<130/80 mmHg).

CONCLUSION

A triple combination of perindopril, amlodipine, and indapamide SR controlled BP effectively in hypertensive patients uncontrolled by previous antihypertensive monotherapy or bitherapy, including RAAS inhibitor/amlodipine or RAAS inhibitor/hydrochlorothiazide combinations.

Younger females are at greater risk of vasodilation-related adverse symptoms caused by dihydropyridine calcium channel blockers: results of a study of 11,918 Japanese patients

BACKGROUND AND OBJECTIVE

Adequate control of blood pressure in younger females is of crucial importance, because they are at higher risk of hypertensive target organ damage compared with males of similar age. In addition, female sex is a risk factor for adverse effects of antihypertensive drugs, especially dihydropyridines. This study set out to assess the incidence of adverse reactions during dihydropyridine use in a real-life clinical setting, focusing on the influence of female sex and age.

METHODS

The incidence of adverse reactions to dihydropyridine calcium channel blockers were investigated in 11,918 Japanese patients who participated in the Drug Event Monitoring project of the Japan Pharmaceutical Association conducted in Kumamoto prefecture. A multiple logistic regression analysis was used to determine the association between the incidence of adverse symptoms and female sex, with adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Vasodilation-related adverse symptoms occurred significantly more often in females than in males (OR 1.87, 95% CI 1.28-2.71, p=0.001). Furthermore, among females only, the younger age group (<50 years) complained of vasodilation-related symptoms more frequently (OR 2.39, 95% CI 1.02-5.59, p=0.045) and the older age group (≥80 years) complained of vasodilation-related symptoms less frequently (OR 0.56, 95% CI 0.33-0.95, p=0.030) than the middle age group (50-79 years).

CONCLUSION

To the best of our knowledge, this is the first report showing that younger females are at high risk for vasodilation-related adverse symptoms during dihydropyridine use in a real-life clinical setting. These results should be verified in clinical studies using larger samples of young patients and more parameters.

Thiazide-like/calcium channel blocker agents: a major combination for hypertension management

In recent years, treatment strategies for hypertension have often focused on combination therapies that include diuretics and renin angiotensin aldosterone system blockers such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. However, in clinical practice, a significant number of patients do not respond completely to these combination treatments, and long-term reduction of cardiovascular risk remains insufficient. The particularly high residual cardiovascular risk of hypertensive patients, even when adequately treated with strategies based on renin angiotensin aldosterone system blockers, speaks in favor of new, innovative strategies. Thus, it has become relevant to consider whether it is always necessary to block plasma renin activation and whether other guideline-approved combinations should be considered routinely. Diuretic/calcium channel blocker combinations, which are supported by significant long-term evidence, are put forth as a preferred combination in the main guidelines, but are still underused by physicians who do not yet have easy access to such treatments. Fixed-dose indapamide sustained release/amlodipine is the first such single-pill combination to become available. Complementary mechanisms of action of these two molecules are expected to lead to greater and longer-term reductions in systolic blood pressure and pulse pressure and potentially to the reduction of cardiovascular risk.

An update on the pharmacogenetics of treating hypertension

Hypertension is a leading cause of cardiovascular mortality, but only one third of patients achieve blood pressure goals despite antihypertensive therapy. Genetic polymorphisms may partially account for the interindividual variability and abnormal response to antihypertensive drugs. Candidate gene and genome-wide approaches have identified common genetic variants associated with response to antihypertensive drugs. However, there is no currently available pharmacogenetic test to guide hypertension treatment in clinical practice. In this review, we aimed to summarize the recent findings on pharmacogenetics of the most commonly used antihypertensive drugs in clinical practice, including diuretics, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, beta-blockers and calcium channel blockers. Notably, only a small percentage of the genetic variability on response to antihypertensive drugs has been explained, and the vast majority of the genetic variants associated with antihypertensives efficacy and toxicity remains to be identified. Despite some genetic variants with evidence of association with the variable response related to these most commonly used antihypertensive drug classes, further replication is needed to confirm these associations in different populations. Further studies on epigenetics and regulatory pathways involved in the responsiveness to antihypertensive drugs might provide a deeper understanding of the physiology of hypertension, which may favor the identification of new targets for hypertension treatment and genetic predictors of antihypertensive response.

Antihypertensive efficacy of triple combination perindopril/indapamide plus amlodipine in high-risk hypertensives: results of the PIANIST study (Perindopril-Indapamide plus AmlodipiNe in high rISk hyperTensive patients)

OBJECTIVE

Our objective was to evaluate a triple-drug antihypertensive strategy for blood pressure control in patients with difficult-to-treat hypertension.

DESIGN

The Perindopril-Indapamide plus AmlodipiNe in high rISk hyperTensive patients (PIANIST) trial was an observational, 4-month, open-label study.

PATIENTS AND INTERVENTIONS

A total of 4,731 patients at high or very high cardiovascular risk with hypertension that was not properly controlled [ , and for [corrected] whom study treatment (fixed-dose perindopril 10 mg/indapamide 2.5 mg + amlodipine 5 or 10 mg) was consistent with their existing therapeutic plan, were included.

OUTCOMES

One-sample t tests and Chi-squared tests were performed to evaluate changes in blood pressure.

RESULTS

Mean baseline office blood pressure (OBP) was 160.5 ± 13.3/93.8 ± 8.7 mmHg. After 4 months of therapy, OBP decreased by 28.3 ± 13.5/13.8 ± 9.4 to 132.2 ± 8.6/80.0 ± 6.6 mmHg (p < 0.0001). Blood pressure targets were reached by 72.0% of patients and by 81 and 91% of patients previously treated with an angiotensin-converting enzyme inhibitor/hydrochlorothiazide or an angiotensin receptor blocker/hydrochlorothiazide, respectively. Changes in OBP were 18.7 ± 8.3/9.7 ± 7.2 mmHg for grade 1 (n = 1,679), 30.4 ± 10.1/14.7 ± 8.6 mmHg for grade 2 (n = 2,397), and 45.4 ± 15.1/20.7 ± 12.1 mmHg for grade 3 patients (n = 655; all p < 0.0001). In patients who underwent ambulatory blood pressure monitoring (n = 104), 24-h mean blood pressure decreased from 147.4 ± 13.8/82.1 ± 11.9 to 122.6 ± 9.1/72.8 ± 7.4 mmHg (p < 0.0001). Ankle edema was infrequent (0.2% of patients).

CONCLUSION

Triple combination perindopril/indapamide/amlodipine was effectively and safely administered to a large population of high- and very high-risk hypertensive patients who had not reached target OBP values with previous treatment.

Tubulointerstitial disease in diabetic nephropathy

Diabetes mellitus is the major cause of end stage renal disease (ESRD). We cannot predict which patient will be affected. ESRD patients suffer an extremely high mortality rate, due to a very high incidence of cardiovascular disease. Several randomized, prospective studies have been conducted to quantify the impact of strict glycemic control on morbidity and mortality, and have consistently demonstrated an association between strict glycemic control and a reduction in ESRD. Within the past 20 years, despite the implementation of treatments that were presumed to be renoprotective, diabetes mellitus has continued to rank as the leading cause of ESRD, which clearly indicates that we are still far from understanding the mechanisms involved in the initiation of ESRD. Progressive albuminuria has been considered as the sine qua non of diabetic nephropathy, but we know now that progression to diabetic nephropathy may well happen in the absence of initial microalbuminuria. The search for new biomarkers of early kidney damage has received increasing interest, since early identification of the pathways leading to kidney damage may allow us to adopt measures to prevent the development of ESRD. Most of these biomarkers are deeply influenced by environment, genetics, sex differences, and so on, making it extremely difficult to identify the ideal biomarker to target. At present, there are no new drugs that come close to providing the solutions we desire for our patients (ie, reducing complications). Even when used in combination with standard care, renal complications are, at best, only modestly reduced, at the considerable expense of additional pill burden and exposure to serious off-target effects. In this review, some of the hypothesized mechanisms of this heterogeneous disease will be considered, with particular attention to the tubule–interstitial compartment.

Efficacy and tolerability of fixed-dose combination of perindopril/indapamide in type 2 diabetes mellitus: PICASSO trial

Background

Hypertension and type 2 diabetes mellitus (T2DM) synergistically deteriorate the vascular environment, making blood pressure reduction challenging, and substantially increasing cardiovascular risk.

Methods

In the real-life, open-label, observational, PICASSO study, 9,257 hypertensive patients unsuccessfully treated with antihypertensives were switched to fixed-dose combination of perindopril 10 mg/indapamide 2.5 mg. In this subgroup analysis, we analyzed changes in blood pressure and laboratory parameters of 2,762 hypertensive patients with T2DM or pre-diabetes.

Results

After 3 months of treatment, significant decreases in office blood pressure were noted in the whole cohort (−27.0 ± 14.8/−12.7 ± 9.8 mmHg; p < 0.001). Significant decreases were also recorded in patients with grade 1 hypertension (19.2 ± 10.0/−9.4 ± 7.9 mmHg), grade 2 (29.2 ± 10.9/−13.3 ± 8.7 mmHg) and grade 3 (−45.1 ± 15.4/−21.5 ± 11.2 mmHg). Significant decreases in ambulatory blood pressure were also noted (n = 93). In patients previously treated with angiotensin-converting enzyme inhibitor ± hydrochlorothiazide or angiotensin receptor blocker ± hydrochlorothiazide, mean 24-h blood pressure decreased by 23.4 ± 13.9/11.5 ± 9.7 and 22.3 ± 8.7/10.4 ± 13.2 mmHg, respectively (p < 0.001). Treatment was well tolerated and the switch to treatment with perindopril/indapamide was associated with improvements in laboratory parameters.

Conclusions

Data from this diabetes subgroup analysis suggest that fixed combination of perindopril 10 mg/indapamide 2.5 mg should be routinely considered for the treatment of hypertension in diabetic patients who are unsuccessfully managed with other antihypertensive medications.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-014-0107-y) contains supplementary material, which is available to authorized users.

Effects of combination of perindopril, indapamide, and calcium channel blockers in patients with type 2 diabetes mellitus: results from the Action In Diabetes and Vascular Disease: Preterax and Diamicron Controlled Evaluation (ADVANCE) trial

The objective of the present analysis was to determine the effects of a fixed combination of perindopril and indapamide in combination with calcium channel blockers (CCBs) in patients with type 2 diabetes mellitus. The Action in Diabetes and Vascular Disease: Preterax and Diamicron Controlled Evaluation (ADVANCE) trial was a factorial randomized controlled trial. A total of 11 140 patients with type 2 diabetes mellitus were randomly assigned to fixed combination of perindopril-indapamide (4/1.25 mg) or placebo. Effects of randomized treatment on mortality and major cardiovascular outcomes were examined in subgroups defined by baseline use of CCBs. Patients on CCB at baseline (n=3427) constituted a higher risk group compared with those not on CCB (n=7713), with more extensive use of antihypertensive and other protective therapies. Active treatment reduced the relative risk of death by 28% (95% confidence interval, 10%-43%) among patients with CCB at baseline compared with 5% (-12% to 20%) among those without CCB (P homogeneity=0.02) and 14% (2%-25%) for the whole population. Similarly, the relative risk reduction for major cardiovascular events was 12% (-8% to 28%) versus 6% (-10% to 19%) for those with and without CCB at baseline although the difference was not statistically significant (P homogeneity=0.38). There was no detectable increase in adverse effects in those receiving CCB. The combination of perindopril and indapamide with CCBs seems to provide further protection against mortality in patients with type 2 diabetes mellitus.

Hemodynamic and hormonal patterns of untreated essential hypertension in men and women

BACKGROUND

Knowledge of hemodynamic factors accounting for the development of hypertension should help to tailor therapeutic approaches and improve blood pressure control. Few data exist regarding sex differences of hemodynamic factors contributing to hypertension progression among patients with untreated nondiabetic stage I and II prehypertension (PreHyp) as defined by the Joint National Committee-7 guidelines (JNC-7).

METHODS

We utilized noninvasive impedance cardiography, applanation tonometry and plasma measures of angiotensin II, angiotensin (1-7), serum aldosterone, high-sensitivity C-reactive protein (hs-CRP) and cytokine biomarkers of inflammation to characterize the hemodynamic and hormonal profile of 100 patients with untreated hypertension (39 women).

RESULTS

Despite there being no differences between women and men in terms of office blood pressure, heart rate and body mass index, men demonstrated lower values of pulse pressure, systemic vascular resistance, brachial artery pulse wave velocity and augmentation index. In each of the three hypertension categories, the increased blood pressure in men was associated with significant augmentations in stroke volume and cardiac output compared with women. Sex-related hemodynamic differences were associated in women with higher plasma levels of leptin, hs-CRP, plasma angiotensin II and serum aldosterone, and no differences in the serum concentrations of cytokinins. In women but not men, hs-CRP correlated with plasma concentrations of transforming growth factor β1 (TGFβ1) and body weight; in addition, plasma TGFβ1 correlated with levels of serum vascular cell adhesion molecule 1.

CONCLUSION

The impact of sex differences in the hemodynamic factors accounting for the elevation in arterial pressure in subjects with essential hypertension has been poorly characterized or this information is not available. We suggest that this gap in knowledge may adversely influence choices of drug treatment since our study shows for the first time significant differences in the hemodynamic and hormonal mechanisms accounting for the increased blood pressure in women compared to men.

Predicting changes in hypertension control using electronic health records from a chronic disease management program

OBJECTIVE

Common chronic diseases such as hypertension are costly and difficult to manage. Our ultimate goal is to use data from electronic health records to predict the risk and timing of deterioration in hypertension control. Towards this goal, this work predicts the transition points at which hypertension is brought into, as well as pushed out of, control.

METHOD

In a cohort of 1294 patients with hypertension enrolled in a chronic disease management program at the Vanderbilt University Medical Center, patients are modeled as an array of features derived from the clinical domain over time, which are distilled into a core set using an information gain criteria regarding their predictive performance. A model for transition point prediction was then computed using a random forest classifier.

RESULTS

The most predictive features for transitions in hypertension control status included hypertension assessment patterns, comorbid diagnoses, procedures and medication history. The final random forest model achieved a c-statistic of 0.836 (95% CI 0.830 to 0.842) and an accuracy of 0.773 (95% CI 0.766 to 0.780).

CONCLUSIONS

This study achieved accurate prediction of transition points of hypertension control status, an important first step in the long-term goal of developing personalized hypertension management plans.

Sex differences in the biomechanics and contractility of intramural coronary arteries in angiotensin II-induced hypertension

BACKGROUND

It is well known that sex differences occur in both the pathogenesis and therapy of hypertension. A deeper understanding of the underlying processes may be helpful when planning a personalized therapeutic strategy.

OBJECTIVE

In laboratory animal experiments, we studied the early mechanisms of vascular adaptation of the intramural small coronary arteries that play a fundamental role in the blood supply of the heart.

METHODS

In our study, an osmotic minipump was implanted into 10 male and 10 female Sprague-Dawley rats. The pump remained in situ for 4 weeks, infusing a dose of 100 ng/kg/min angiotensin II acetate. Four weeks later, the animals were killed, and the intramural coronary arteries from the left coronary branch, which are fundamentally responsible for the blood supply of the heart, were prepared. The pharmacologic reactivity and biomechanical properties of the prepared segments were studied in a tissue bath.

RESULTS

The relative heart mass and vessel wall thickness were greater in females than males (0.387 [0.009] g/100 g vs 0.306 [0.006] g/100 g body weight; 41.9 [4.09] μm vs 33.45 [3.37] μm on 50 mm Hg). The vessel tone and vasoconstriction in response to thromboxane agonists were, however, significantly more pronounced in males. The extent of relaxation in response to bradykinin was also greater in females. Although we observed inward eutrophic remodeling in females, an increase in wall stress and elastic modulus dominated in males.

CONCLUSION

The early steps of angiotensin II-dependent hypertension evoked very different adaptation mechanisms in males and females.

Sex differences in cardiovascular drug-induced adverse reactions causing hospital admissions

AIMS

Cardiovascular disease in women is often underestimated. The effects of cardiovascular drugs differ between the sexes because of pharmacokinetic and pharmacodynamic differences. Adverse drug reactions (ADRs) within these drug classes may have serious consequences, leading to hospital admission. We aimed to study differences between men and women in hospital admissions for ADRs due to cardiovascular drugs.

METHODS

We conducted a nationwide study of all hospital admissions between 2000 and 2005 with data from the Dutch National Medical Register. Relative risks were calculated of hospital admissions due to ADRs to the different cardiovascular drug groups for women compared with men. By an ecological design, risks were adjusted for the total number of Dutch inhabitants and the total number of prescriptions.

RESULTS

In total, 14 207 of the hospital admissions (34% of all ADR-related admissions) were attributed to cardiovascular drugs [7690 in women (54%; 95% confidence interval 53-55%)]. 'Anticoagulants and salicylates' (n= 8988), 'high- and low-ceiling diuretics' (n= 2242) and 'cardiotonic glycosides' (n= 932) were responsible for the majority of the ADR-related hospital admissions. The most pronounced sex differences were seen in users of low-ceiling diuretics (relative risk 4.02; 95% confidence interval 3.12-5.19), cardiotonic glycosides (relative risk 2.38; 95% confidence interval 2.06-2.74), high-ceiling diuretics (relative risk 2.10; 95% confidence interval 1.91-2.32) and coronary vasodilators (relative risk 0.77; 95% confidence interval 0.65-0.91).

CONCLUSIONS

Clear sex differences exist in ADRs requiring hospital admission for different cardiovascular drug groups. Sex differences should be taken into account in the prescription and evaluation of drugs.

Pharmacometabolomics reveals racial differences in response to atenolol treatment

Antihypertensive drugs are among the most commonly prescribed drugs for chronic disease worldwide. The response to antihypertensive drugs varies substantially between individuals and important factors such as race that contribute to this heterogeneity are poorly understood. In this study we use metabolomics, a global biochemical approach to investigate biochemical changes induced by the beta-adrenergic receptor blocker atenolol in Caucasians and African Americans. Plasma from individuals treated with atenolol was collected at baseline (untreated) and after a 9 week treatment period and analyzed using a GC-TOF metabolomics platform. The metabolomic signature of atenolol exposure included saturated (palmitic), monounsaturated (oleic, palmitoleic) and polyunsaturated (arachidonic, linoleic) free fatty acids, which decreased in Caucasians after treatment but were not different in African Americans (p<0.0005, q<0.03). Similarly, the ketone body 3-hydroxybutyrate was significantly decreased in Caucasians by 33% (p<0.0001, q<0.0001) but was unchanged in African Americans. The contribution of genetic variation in genes that encode lipases to the racial differences in atenolol-induced changes in fatty acids was examined. SNP rs9652472 in LIPC was found to be associated with the change in oleic acid in Caucasians (p<0.0005) but not African Americans, whereas the PLA2G4C SNP rs7250148 associated with oleic acid change in African Americans (p<0.0001) but not Caucasians. Together, these data indicate that atenolol-induced changes in the metabolome are dependent on race and genotype. This study represents a first step of a pharmacometabolomic approach to phenotype patients with hypertension and gain mechanistic insights into racial variability in changes that occur with atenolol treatment, which may influence response to the drug.

The impact of cardiovascular risk-factor profiles on blood pressure control rates in adults from Canada and the United States

BACKGROUND

It is unclear whether blood pressure control varies across the spectrum of atherosclerotic risk.

METHODS

We used data from nonpregnant adults who had fasted laboratory samples drawn for the 2007-2009 cycle of the Canadian Health Measures Survey (CHMS) or the 2005-2008 US National Health and Nutrition Examination Survey (NHANES).

RESULTS

The 1692 CHMS subjects and 3541 NHANES participants were demographically similar (aged a mean of 45 years), although NHANES participants exhibited higher obesity rates (33.8% vs. 22.2%, P < 0.001). Over 80% of CHMS and NHANES subjects with hypertension had at least 1 other cardiovascular risk factor. As the number of atherosclerotic risk factors increased, hypertension prevalence increased, but blood pressure control rates improved (from 48% among hypertensives with no other risk factors in CHMS to 77% among those with 3 or more risk factors, and from 35% to 53% in NHANES). However, the converse was not true: The distribution of Framingham risk scores for those subjects with "controlled hypertension" was nearly identical to the distribution among those adults with uncontrolled hypertension in both CHMS and NHANES and substantially higher than scores in normotensive subjects.

CONCLUSIONS

Although control of blood pressure was better in patients with multiple atherosclerotic risk factors, hypertensives with controlled blood pressures exhibited risk-factor profiles similar to those of participants with uncontrolled blood pressures. This suggests the need, in educational messaging and therapy decision making, for an increased focus on total atherosclerotic risk rather than just blood pressure control.

[Patterns in the prescription of antihypertensive drugs in Norway, 1975-2010]

BACKGROUND

A complete overview of drugs used for hypertension is not available from official data sources. The aim of this study was to investigate the use of blood pressure medication over the years to identify trends in consumption patterns.

MATERIAL AND METHOD

Data were collected from the Norwegian drug wholesaler statistics for the years 1975-2010 and from the Norwegian prescription database 2004-2010. Defined daily doses (DDD) per 1000 inhabitants per day, number of users and prevalence by gender and age were analysed.

RESULTS

In the period 1975 to 2010 the use of antihypertensives increased from 55 to 248 DDD/1000 inhabitants/day (Norwegian drug wholesaler statistics). Data from the Norwegian prescription database show that in 2010 there were a total of 754 909 users of antihypertensives, of whom 638 830 had received the diagnosis hypertension. Thiazides and angiotensin II antagonists had the greatest increase in number of users from 2004 to 2010. In all ages up to 73 years, a higher proportion of men were prescribed drugs for hypertension in 2010, whereas in the over-73 s these drugs were most widely used by women.

INTERPRETATION

The use of antihypertensives is steadily increasing. Angiotensin II antagonists and thiazides are the most commonly used drugs. The authorities'' decision in 2004 that thiazides should be regarded as first-line therapy for hypertension probably contributed to increased use of thiazides.

Pharmacogenetic implications for eight common blood pressure-associated single-nucleotide polymorphisms

OBJECTIVE

We aimed to test whether eight common recently identified single-nucleotide polymorphisms (SNPs), strongly associated with blood pressure (BP) in the population, also have impact on the degree of BP reduction by antihypertensive agents with different mechanisms.

METHODS

In 3863 Swedish hypertensive patients, we related number of unfavorable alleles of each SNP (i.e. alleles associated with higher baseline BP) to the magnitude of BP reduction during 6 months of monotherapy with either a beta-blocker, a thiazide diuretic or diltiazem.

RESULTS

For six SNPs (rs16998073, rs1378942, rs3184504, rs1530440, rs16948048, rs17367504) no pharmacogenetic interactions were suggested, whereas two SNPs showed nominal evidence of association with treatment response: PLCD3-rs12946454 associated with more SBP (beta = 1.53 mmHg per unfavorable allele; P = 0.010) and DBP (beta = 0.73 mmHg per unfavorable allele; P = 0.014) reduction in patients treated with diltiazem, in contrast to those treated with beta-blockers or diuretics wherein no treatment response association was found. CYP17A1-rs11191548 associated with less DBP reduction (beta = -1.26 mmHg per unfavorable allele; P = 0.018) in patients treated with beta-blockers or diuretics, whereas there was no treatment response association in diltiazem-treated patients. However, if accounting for multiple testing, the significant associations for rs12946454 and rs11191548 were attenuated.

CONCLUSION

For a majority of these, eight recently identified BP-associated SNPs, there are probably no important pharmacogenetic interactions for BP reduction with use of beta-blockers, diuretics or diltiazem. Whether the nominally significant associations for rs12946454 and rs11191548 are true signals and could be of possible clinical relevance for deciding treatment of polygenic essential hypertension should be further tested.

A GENS-based approach to cardiovascular pharmacology: impact on metabolism, pharmacokinetics and pharmacodynamics

Pharmacological outcomes depend on many factors, with many of them being sexually dimorphic. Thus, physiological gender/sex (GENS) differences can influence pharmacokinetics, pharmacodynamics and, thus, bioavailability and resulting in efficacy of treatment, meaning GENS differences should be an important consideration in therapeutics. In particular, drug response can change according to different hormonal environments. Therefore, GENS-specific differences have a particular clinical relevance in terms of drug delivery, especially for those substances with a narrow therapeutic margin. Since adverse effects are more frequent among women, safety is a key issue. Overall, the status of women, from a pharmacological point of view, is often different and less studied than that of men and deserves particular attention. Further studies focused on women's responses to drugs are necessary in order to make optimal pharmacotherapeutic decisions.

Advancing management of hypertension through pharmacogenomics

Hypertension is the most common, chronic disease in the world, and there are many effective pharmacological agents available for its treatment. Despite the plethora of treatment options, data across the globe suggest that blood pressure control rates are < 50%, a fact likely influenced in part by the inability to predict the antihypertensive drug likely to be most effective for an individual patient. Pharmacogenomics in hypertension holds the promise of identifying genetic biomarkers for antihypertensive drug response, which might be used in the future in treatment selection. Research in the field is also likely to enhance our understanding of hypertension and the mechanisms by which the various drugs produce efficacy. There are several examples in the literature of genes with relatively strong data on associations of genetic polymorphisms with antihypertensive response; the data on ADRB1, CACNB2, and NEDD4L are detailed as examples. Substantial additional data in hypertension pharmacogenomics are expected to be forthcoming from recently completed genome-wide association studies. Increased collaboration among research groups will help insure successful discoveries from these large-scale studies. The next decade should clearly define the potential clinical implications of the research in hypertension pharmacogenomics that is currently in progress.

Evaluation of the correlation between self-report and electronic monitoring of adherence to hypertension therapy

Blood pressure (BP) control remains sub-optimal all over the world. Medication adherence is an important determinant of BP control. None of the available methods for measuring medication adherence is currently regarded as a universal consensus gold standard. In this study, we evaluated the correlation between self-report (Morisky's Medication Adherence Self-assessment Scale) and electronic (eCap) methods of medication adherence assessment. The self-report measure was administered at study entry while electronic compliance data was collected prospectively. Almost all (97.4%) of enrolled patients completed the study. Medication adherence scores ranged from 0 to 100% (69.33, ± 27.57) and 6.6-100% (66.92 ± 22.59) for Morisky's scale and eCap, respectively (Wilcoxon rank sum test, p = 0.253). Modal class interval for adherence scores were 61-80% (n = 28, 37.3%) and 81-100% (n = 23, 30.7%) for the eCap and Morisky's scale respectively. Overall, a weak correlation was found between the two methods (r = 0.056). The weak correlation was also maintained in subgroup analysis defined by attainment of BP control (r = 0.109 vs 0.0009), age (range r = -0.53 to 0.067), sex (0.009 to 0.151), level of education (-0.217 to 0.276), and Mini Mental State Examination score (-0.107 to 0.258). Our findings suggest that these methods are not equivalent in the evaluation of medication adherence.

Perceptions of hypertension treatment among patients with and without diabetes

BACKGROUND

Despite the availability of a wide selection of effective antihypertensive treatments and the existence of clear treatment guidelines, many patients with hypertension do not have controlled blood pressure. We conducted a qualitative study to explore beliefs and perceptions regarding hypertension and gain an understanding of barriers to treatment among patients with and without diabetes.

METHODS

Ten focus groups were held for patients with hypertension in three age ranges, with and without diabetes. The topic guides for the groups were: What will determine your future health status? What do you understand by "raised blood pressure"? How should one go about treating raised blood pressure?

RESULTS

People with hypertension tend to see hypertension not as a disease but as a risk factor for myocardial infarction or stroke. They do not view it as a continuous, degenerative process of damage to the vascular system, but rather as a binary risk process, within which you can either be a winner (not become ill) or a loser. This makes non-adherence to treatment a gamble with a potential positive outcome. Patients with diabetes are more likely to accept hypertension as a chronic illness with minor impact on their routine, and less important than their diabetes. Most participants overestimated the effect of stress as a causative factor believing that a reduction in levels of stress is the most important treatment modality. Many believe they "know their bodies" and are able to control their blood pressure. Patients without diabetes were most likely to adopt a treatment which is a compromise between their physician's suggestions and their own understanding of hypertension.

CONCLUSION

Patient denial and non-adherence to hypertension treatment is a prevalent phenomenon reflecting a conscious choice made by the patient, based on his knowledge and perceptions regarding the medical condition and its treatment. There is a need to change perception of hypertension from a gamble to a disease process. Changing the message from the existing one of "silent killer" to one that depicts hypertension as a manageable disease process may have the potential to significantly increase adherence rates.

Factors associated with lack of awareness and uncontrolled high blood pressure among Canadian adults with hypertension

BACKGROUND

Approximately 17% of Canadians with high blood pressure were unaware of their condition, and of Canadians aware of having the condition, approximately 1 in 5 have uncontrolled high blood pressure despite high rates of pharmacotherapy. The objectives of the current study are to estimate the prevalence of resistant hypertension and examine factors associated with (1) lack of awareness and (2) uncontrolled hypertension despite pharmacotherapy.

METHODS

Using the 2007-2009 Canadian Health Measures Survey (N = 3473, aged 20-79 years) and logistic regression, we quantified relationships between characteristics and (1) presence of hypertension, (2) lack of awareness (among those with hypertension), and (3) uncontrolled high blood pressure (among those treated for hypertension).

RESULTS

Older age, lowest income, and less than high school education were associated with presence of hypertension. Men (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.2) and adults < 60 years (OR, 1.7; 95% CI, 1.1-2.6) were more likely than others to be unaware. Among those aged 60+ years, women were more likely than men to have uncontrolled high blood pressure (OR, 2.4; 95% CI, 1.1-5.2) despite treatment. Elevated systolic blood pressure was the issue in over 90% of women and 80% of men with uncontrolled hypertension. Depending on the definition employed, 4.4% (95% CI, 2.4-6.4) to 7.8% (95% CI, 6.0-9.6) of the population with hypertension had resistant hypertension.

CONCLUSIONS

Messaging or interventions encouraging screening may be helpful for all younger Canadian adults and men; programs encouraging blood pressure control may help older women.

Acute β-adrenergic blockade increases aortic wave reflection in young men and women: differing mechanisms between sexes

Acute β-adrenergic blockade increases aortic wave reflection; however, the mechanisms remain unclear. Evidence suggests that β-adrenergic receptor sensitivity in the peripheral vasculature differs between sexes. Therefore, the goal of this study was to examine whether β-adrenergic blockade alters aortic wave reflection to a similar extent in young men and women. In 31 subjects (16 men and 15 women; 26±1 years) noninvasive aortic pressure waveforms were synthesized from high-fidelity radial pressure waveforms via applanation tonometry before and during systemic β-blockade (0.25 mg/kg bolus, followed by 0.004 mg/kg per minute of continuous infusion of propranolol). β-Blockade increased aortic augmentation index and wave reflection amplitude (aortic augmented pressure) in both sexes (P<0.01). Although the increase in augmentation index was not significantly different between sexes (7.5±1.1% versus 4.6±1.5%; P=0.07), the increase in aortic augmented pressure was greater in women compared with men (2.8±0.5 versus 1.4±0.5 mm Hg; P<0.05). Aortic augmentation index adjusted for a heart rate of 75 bp increased in women (4.1±1.1%; P<0.05) after β-blockade, whereas it was unchanged in men (0.6±1.3%; P=0.33). Moreover, the change in aortic augmentation index was inversely associated with the change in heart rate only in men (r=-0.54; P<0.05). Our data suggest that aortic wave reflection is increased to a greater extent in women after systemic β-blockade, and enhanced aortic wave reflection appears to be mediated by a reduced heart rate in men, whereas the mechanism is unclear in women.

Efficacy and safety of triple-combination therapy with olmesartan, amlodipine, and hydrochlorothiazide in study participants with hypertension and diabetes: a subpopulation analysis of the TRINITY study

BACKGROUND

Most patients with hypertension and diabetes require two or more antihypertensive agents to achieve the recommended blood pressure (BP) goal of <130/80 mm Hg. This prespecified subgroup analysis from the TRIple Therapy with Olmesartan Medoxomil, Amlodipine, and Hydrochlorothiazide in HyperteNsIve PatienTs StudY assessed the efficacy and safety of triple-combination treatment (olmesartan medoxomil 40/amlodipine besylate 10/hydrochlorothiazide 25 mg) versus the component dual-combination treatments according to diabetes status (diabetes; non-diabetes).

METHODS

Participants received dual-combination treatment for 4 weeks or placebo for 2 weeks. Participants receiving placebo switched to dual-combination treatment from week 2 to week 4. At week 4, participants switched to triple-combination treatment or continued on dual-combination treatment until week 12.

RESULTS

The prespecified changes in BP from baseline for the diabetes subgroup receiving triple-combination treatment were greater than the respective dual-combination treatments (P ≤ .0013). Also, more participants with diabetes receiving triple-combination treatment reached BP goal (<130/80 mm Hg) versus those receiving dual-combination treatments (P ≤ .0092). In a post hoc analysis, significantly greater proportions of study participants with diabetes achieved BP targets with triple-combination treatment compared with each dual-combination treatment. Most treatment-emergent adverse events were mild to moderate in severity.

CONCLUSIONS

In participants with hypertension and diabetes, triple-combination treatment led to greater BP reductions and enabled greater proportions of participants to reach BP goal versus the dual-combination treatments. Triple-combination treatment was well tolerated in both diabetes and non-diabetes subgroups.

Changes in the rates of awareness, treatment and control of hypertension in Canada over the past two decades

BACKGROUND

Analyses of medication databases indicate marked increases in prescribing of antihypertensive drugs in Canada over the past decade. This study was done to examine the trends in the prevalence of hypertension and in control rates in Canada between 1992 and 2009.

METHODS

Three population-based surveys, the 1986-1992 Canadian Heart Health Surveys, the 2006 Ontario Survey on the Prevalence and Control of Hypertension and the 2007-2009 Canadian Health Measures Survey, collected self-reported health information from, and measured blood pressure among, community-dwelling adults.

RESULTS

The population prevalence of hypertension was stable between 1992 and 2009 at 19.7%-21.6%. Hypertension control improved from 13.2% (95% confidence interval [CI] 10.7%-15.7%) in 1992 to 64.6% (95% CI 60.0%-69.2%) in 2009, reflecting improvements in awareness (from 56.9% [95% CI 53.1%-60.5%] in 1992 to 82.5% [95% CI 78.5%-86.0%] in 2009) and treatment (from 34.6% [95% CI 29.2%-40.0%] in 1992 to 79.0% [95% CI 71.3%-86.7%] in 2009) among people with hypertension. The size of improvements in awareness, treatment and control were similar among people who had or did not have cardiovascular comorbidities Although systolic blood pressures among patients with untreated hypertension were similar between 1992 and 2009 (ranging from 146 [95% CI 145-147] mm Hg to 148 [95% CI 144-151] mm Hg), people who did not have hypertension and patients with hypertension that was being treated showed substantially lower systolic pressures in 2009 than in 1992 (113 [95% CI 112-114] v. 117 [95% CI 117-117] mm Hg and 128 [95% CI 126-130] v. 145 [95% CI 143-147] mm Hg).

INTERPRETATION

The prevalence of hypertension has remained stable among community-dwelling adults in Canada over the past two decades, but the rates for treatment and control of hypertension have improved markedly during this time.

The therapeutic importance of home blood pressure assessment and combination antihypertensive therapy for achieving target blood pressure control: Ibaraki hypertension assessment trial

Tight blood pressure (BP) control is important for the prevention of cardiovascular disease in hypertensive patients. A cross-sectional study of 2339 patients from 101 clinics and hospitals in Ibaraki Prefecture was performed to evaluate BP control with the patients' current antihypertensive medication. Group A (n=892) included high-risk hypertensive patients with at least one of the following risk factors: diabetes mellitus, chronic kidney disease or a history of myocardial infarction. Group B (n=586) included patients <65 years old and Group C (n=859) included patients ≥65 years old. Both groups B and C included hypertensive patients without the above risk factors. A mean of 1.8±1.0 antihypertensive drugs per patient were prescribed. A total of 35.8% of all patients received monotherapy, 40% received a combination of three therapies and 20.3% received more than three kinds of drugs. The percentage of patients achieving the target BP at the office and at home was significantly higher in Group C than in the other groups (P<0.001). A combination of more than two antihypertensive drugs, including a high dose of either an angiotensin receptor blocker or a calcium channel blocker, was frequently prescribed to Group A to achieve the target office BP. Although the target BP should be lower in Group A (given their comorbidities), the absolute BP value and the number of medications were similar to the other groups. In conclusion, we demonstrated that physicians should treat hypertension more intensively with a combination of more than two antihypertensive drugs, using a high dose to achieve the target BP. In addition, it is important to teach hypertensive patients the clinical importance of monitoring their BP at home and the need to achieve home BP targets.

Urapidil, a dual-acting antihypertensive agent: Current usage considerations

Despite the availability of a wide range of effective blood pressure (BP)-lowering agents, a substantial proportion of patients with hypertension fail to achieve target BP levels. The majority of patients with hypertension need a combination of two or more drugs to achieve BP targets and choice of second-line or subsequent-line therapy is an important consideration in hypertension management. Alpha-1-adrenoreceptor antagonists (alpha-blockers) have a BP-lowering effect broadly similar to the other antihypertensive drug classes and are effective as add-on therapy in patients with inadequately controlled hypertension. Alpha-blockers may also have therapeutic benefits that go beyond BP control, including improvements in lipid profile and glucose metabolism, as well as reducing the symptoms of benign prostatic hyperplasia. Urapidil has an alpha-blocking effect but, unlike other alpha-blockers, also has a central sympatholytic effect mediated via stimulation of serotonin 5HT(1A) receptors in the central nervous system. Several studies have suggested that oral urapidil is effective and well tolerated when used as second-line therapy in patients with BP inadequately controlled with other agents. Urapidil has also been shown to improve glucose and lipid metabolism in hypertensive patients with concomitant diabetes and/or hyperlipidemia. Intravenous urapidil is effective in the treatment of hypertensive crises, perioperative hypertension, and pre-eclampsia and may have a potential role in the management of acute stroke. In this review, the use of alpha-blockers in hypertension is discussed, with particular focus on urapidil for the lowering of BP in a variety of clinical settings.

Stroke in women

AIMS

The aim of this article is to provide an overview of stroke in women and describe modifiable and non-modifiable risk factors for stroke.

DATA SYNTHESIS

Data supporting this article come from the National Center for Health Statistics, from American Heart Association publications, and from some of the large, multicenter trials and observational studies that inform guidelines for prevention of stroke. These data indicate that stroke is the third leading cause of death in women, that risk for stroke rises rapidly with age, and that the strongest risk factors for stroke are high blood pressure and atrial fibrillation, as well as diabetes and smoking. Risk rises rapidly when two or more risk factors are present. Hormone therapy in postmenopausal women increases risk of ischemic, but not hemorrhagic stroke, by 40-50%. Biomarkers of inflammation are associated with stroke risk. Other risk factors include certain lipids, physical inactivity, and low potassium diets. Although there has been improvement in the past decade, control of hypertension is inadequate in older women and many strokes could be prevented by better treatment of hypertension.

CONCLUSION

Death and disability from stroke can be reduced with modification, treatment, and better control of risk factors like hypertension, diabetes and atrial fibrillation.

Pharmacogenomics of antihypertensive drugs: past, present and future

Hypertension pharmacogenomics holds the promise of leading to individualized drug treatment approaches for the approximately 1 billion individuals worldwide with hypertension. Prior to 2000, the literature on hypertension pharmacogenomics was quite limited. The last decade has seen a substantial growth in the literature, with several examples of genes that appear to play an important role in antihypertensive response. The last decade has also made apparent the numerous challenges in hypertension pharmacogenomics, and addressing those challenges will be important. Moving forward, it seems clear that collaboration among researchers to allow replication or joint analyses will be essential in advancing the field, as will the use of genome-wide association approaches. The next decade should clearly define the clinical potential for hypertension pharmacogenomics.

The Pharmacogenomics of Anti-Hypertensive Therapy

Hypertension is a major public health problem, but measures to reduce blood pressure and thus cardiovascular risk are complicated by the high prevalence of treatment resistance, despite the availability of multiple drugs. Drug side-effects contribute considerably to suboptimal blood pressure control. Clinicians must often rely on empirical methods to match patients with effective drug treatment. Hypertension pharmacogenomics seeks to find genetic predictors of response to drugs that lower blood pressure and to translate this knowledge into clinical practice. In this review we summarise the current status of hypertension pharmacogenetics from monogenic hypertension to essential hypertension and discuss the issues that need to be considered in a hypertension pharmacogenomic study.