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Clinical Validation of a Dried Blood Spot Assay for 8 Antihypertensive Drugs and 4 Active Metabolites. Ther Drug Monit 2021; 42:460-467. [PMID: 31593031 DOI: 10.1097/ftd.0000000000000703] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Drug nonadherence is one of the major challenges faced by resistant hypertension patients, and identification of this problem is needed for optimizing pharmacotherapy. Dried blood spot (DBS) sampling is a minimally invasive method designed to detect and determine the degree of nonadherence. In this study, a DBS method for qualifying 8 antihypertensive drugs (AHDs) and 4 active metabolites was developed and validated using ultra high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). METHOD The DBS assay was validated analytically and clinically, in accordance with FDA requirements. Analytical validation was accomplished using UHPLC-MS/MS. For clinical validation, paired peak and trough levels of DBS and plasma samples were simultaneously collected and comparatively analyzed using Deming regression and Bland-Altman analyses. All concentrations below the set lower limit were excluded. Deming regression analysis was used to predict comparison bias between the collected plasma and DBS samples, with DBS concentrations corrected accordingly. RESULTS The UHPLC-MS/MS method for simultaneously measuring 8 AHDs and their metabolites in DBS, was successfully validated. With Deming regression no bias was observed in N = 1; constant bias was seen in N = 6 and proportional bias in N = 11 of the AHDs and metabolites. After correction for bias, only one metabolite (canrenone) met the 20% acceptance limit for quantification, after Bland-Altman analyses. In addition, amlodipine, valsartan, and [enalaprilate] met the 25% acceptance limit. CONCLUSIONS A novel DBS assay for simultaneously qualifying and quantifying 8 AHDs and their metabolites, has been successfully developed and validated. The DBS assay is therefore a suitable method to detect drug nonadherence. However, with the exception of canrenone, the interchangeable use of plasma and DBS sampling to interpret drug quantities should be avoided.
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52
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Maskell PD, Parks C, Button J, Liu H, McKeown DA. Clarification of the Correct Nomenclature of the Amino Metabolite of Clonazolam: 8-Aminoclonazolam. J Anal Toxicol 2021; 45:e1-e2. [PMID: 33150945 DOI: 10.1093/jat/bkaa169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/16/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- Peter D Maskell
- Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, UK
| | - Claire Parks
- Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, UK
| | - Jenny Button
- Chiron AS, Stiklestadveien 1, 7041 Trondheim, Norway
| | - Huiling Liu
- Chiron AS, Stiklestadveien 1, 7041 Trondheim, Norway
| | - Denise A McKeown
- Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, UK
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53
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Burns AD, Alghamadi R, Iqbal A, Davies T, Lane D, Patel P, Gupta P. Urine Concentration Does Not Affect Biochemical Testing for Non-adherence. J Anal Toxicol 2021; 45:e1-e5. [PMID: 33300570 PMCID: PMC7953415 DOI: 10.1093/jat/bkaa192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/07/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022] Open
Abstract
Hypertension is one of the most important modifiable risk factor causing cardiovascular disease. Unfortunately, non-adherence to antihypertensive medications is frequently observed in hypertensive patients and can lead to an increase in morbidity and mortality. Until recently, there was no robust clinical method to objectively diagnose non-adherence. Recently, the detection of medications in urine or blood by mass spectrometry techniques such as liquid chromatography-tandem mass spectrometry (LC–MS-MS) has been accepted as the diagnostic method of choice for the detection of non-adherence. Despite this, it is unclear whether the concentration of urine can affect the detection of medications in urine. Therefore, this study aimed to assess the effect of urine concentration on detection of antihypertensive medications by LC–MS-MS in which urine creatinine is used as an independent marker of urine concentration. Biochemical adherence results for 22 different medications (1,709 prescriptions) in 463 different subjects were converted to an adherence score. The adherence score was defined as the ratio of the total number of subjects in which the drug was detected to the total number of subjects to whom the drug was prescribed. The adherence scores for each medication were correlated with urine creatinine concentration for each medication. Non-adherence was observed in 47.1% of samples with a mean urine creatinine concentration of these samples of 9.4 ± 7.1 mmol/L. There was no significant difference between the urine creatinine concentrations in the detected vs non-detected groups for each of the 22 medications. Furthermore, there are no differences in adherence scores across the urine creatinine concentration. This is the first study to demonstrate that urine creatinine concentration does not affect the results of the adherence screening by LC–MS-MS.
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Affiliation(s)
- A D Burns
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - R Alghamadi
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - A Iqbal
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.,Sheffield Hallam University, Sheffield, UK
| | - T Davies
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - D Lane
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.,Department of Health Sciences, University of Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - P Patel
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - P Gupta
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
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54
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Madhur MS, Elijovich F, Alexander MR, Pitzer A, Ishimwe J, Van Beusecum JP, Patrick DM, Smart CD, Kleyman TR, Kingery J, Peck RN, Laffer CL, Kirabo A. Hypertension: Do Inflammation and Immunity Hold the Key to Solving this Epidemic? Circ Res 2021; 128:908-933. [PMID: 33793336 PMCID: PMC8023750 DOI: 10.1161/circresaha.121.318052] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Elevated cardiovascular risk including stroke, heart failure, and heart attack is present even after normalization of blood pressure in patients with hypertension. Underlying immune cell activation is a likely culprit. Although immune cells are important for protection against invading pathogens, their chronic overactivation may lead to tissue damage and high blood pressure. Triggers that may initiate immune activation include viral infections, autoimmunity, and lifestyle factors such as excess dietary salt. These conditions activate the immune system either directly or through their impact on the gut microbiome, which ultimately produces chronic inflammation and hypertension. T cells are central to the immune responses contributing to hypertension. They are activated in part by binding specific antigens that are presented in major histocompatibility complex molecules on professional antigen-presenting cells, and they generate repertoires of rearranged T-cell receptors. Activated T cells infiltrate tissues and produce cytokines including interleukin 17A, which promote renal and vascular dysfunction and end-organ damage leading to hypertension. In this comprehensive review, we highlight environmental, genetic, and microbial associated mechanisms contributing to both innate and adaptive immune cell activation leading to hypertension. Targeting the underlying chronic immune cell activation in hypertension has the potential to mitigate the excess cardiovascular risk associated with this common and deadly disease.
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Affiliation(s)
- Meena S. Madhur
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center
- Department of Molecular Physiology and Biophysics, Vanderbilt University
| | - Fernando Elijovich
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew R. Alexander
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center
| | - Ashley Pitzer
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeanne Ishimwe
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin P. Van Beusecum
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David M. Patrick
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center
| | - Charles D. Smart
- Department of Molecular Physiology and Biophysics, Vanderbilt University
| | - Thomas R. Kleyman
- Departments of Medicine, Cell Biology, Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Justin Kingery
- Center for Global Health, Weill Cornell Medical College, New York, NY, USA
- Department of Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Robert N. Peck
- Center for Global Health, Weill Cornell Medical College, New York, NY, USA
- Department of Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
- Mwanza Intervention Trials Unit (MITU), Mwanza, Tanzania
| | - Cheryl L. Laffer
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Annet Kirabo
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Molecular Physiology and Biophysics, Vanderbilt University
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Directly Measured Adherence to Treatment in Chronic Heart Failure: LEVEL-CHF Registry. Am J Med Sci 2021; 361:491-498. [PMID: 33781390 DOI: 10.1016/j.amjms.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 11/08/2020] [Accepted: 12/04/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Currently, most available data on the medication adherence of patients with chronic heart failure are based on indirect methods. We examined the level of adherence to medical therapy using a direct method - serum drug level testing. METHODS We carried out a prospective single-centre registry of patients with chronic heart failure (LEVEL-CHF registry), in whom we analysed serum levels of the medications prescribed for the treatment of heart failure: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists. We labelled a patient as non-adherent if at least one serum level of a prescribed drug was unmeasurable (below the detection limit). Patients with all tested drugs identifiable in serum were labelled as adherent. We enrolled 274 patients (208 men and 66 women) mean age 62 years. RESULTS 82.5% of patients were adherent and 17.5% non-adherent to prescribed medications. 3.6% were completely non-adherent without any detectable drugs in serum. Patients aged <60 years were more likely to be non-adherent than older patients (OR 2.15). No other clinical or laboratory parameters predicted non-adherence. CONCLUSIONS A significant proportion of outpatients with chronic heart failure were non-adherent to treatment when assessed by a direct method of serum drug level testing. Non-adherence was more likely in younger patients.
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56
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Lauder L, Ewen S, Glasmacher J, Lammert F, Reith W, Schreiber N, Kaddu-Mulindwa D, Ukena C, Böhm M, Meyer MR, Mahfoud F. Drug adherence and psychosocial characteristics of patients presenting with hypertensive urgency at the emergency department. J Hypertens 2021; 39:1697-1704. [PMID: 33734143 DOI: 10.1097/hjh.0000000000002842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify potentially targetable psychosocial factors associated with nonadherence to prescribed antihypertensive medications in patients presenting with hypertensive urgencies at an emergency department. METHODS This prospective study included patients treated with antihypertensive drugs who presented with hypertensive urgencies (SBP ≥180 mmHg and/or DBP ≥110 mmHg) at the emergency department of a tertiary referral clinic between April 2018 and April 2019. Health literacy was assessed using the Newest Vital Sign test. The Hospital Anxiety and Depression Scale (HADS) was used to quantify symptoms of anxiety and depression. Patients were classified nonadherent if less than 80% of the prescribed antihypertensive drugs were detectable in urine or plasma using liquid chromatography-high-resolution mass spectrometry. RESULTS A total of 104 patients (62% women) presenting with hypertensive urgencies with a median SBP of 200 mmHg (IQR 190-212) and DBP of 97.5 mmHg (IQR 87-104) were included. Twenty-five patients (24%) were nonadherent to their antihypertensive medication. Nonadherent patients were more often men (66 versus 23%, P = 0.039), prescribed higher numbers of antihypertensive drugs (median 3, IQR 3-4 versus 2, IQR 1-3; P < 0.001), and more often treated with calcium channel blockers (76 versus 25%; P < 0.001) and/or diuretics (64 versus 40%; P = 0.030). There was no difference in health literacy (P = 0.904) or the scores on the HADS subscales for depression (P = 0.319) and anxiety (P = 0.529) between adherent and nonadherent patients. CONCLUSION Male sex, higher numbers of antihypertensive drugs, and treatment with diuretics and/or calcium channel blockers were associated with nonadherence. We did not identify a specific psychosocial characteristic associated with nonadherence.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University.,Emergency Department, Universitätsklinikum des Saarlandes
| | - Julius Glasmacher
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University
| | | | | | - Naemi Schreiber
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University
| | - Dominic Kaddu-Mulindwa
- Department of Hematology, Oncology, Clinical Immunology, Rheumatology, Saarland University Medical Center
| | - Christian Ukena
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University
| | - Markus R Meyer
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University.,Institute for Medical Engineering and Science, MIT, Cambridge, Massachusetts, USA
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57
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Lauder L, Böhm M, Mahfoud F. The current status of renal denervation for the treatment of arterial hypertension. Prog Cardiovasc Dis 2021; 65:76-83. [PMID: 33587963 DOI: 10.1016/j.pcad.2021.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 02/08/2023]
Abstract
Despite the availability of safe and effective antihypertensive drugs, blood pressure (BP) control to guideline-recommended target values is poor. Several device-based therapies have been introduced to lower BP. The most extensively investigated approach is catheter-based renal sympathetic denervation (RDN), which aims to interrupt the activity of afferent and efferent renal sympathetic nerves by applying radiofrequency energy, ultrasound energy, or injection of alcohol in the perivascular space. The second generation of placebo-controlled trials have provided solid evidence for the BP-lowering efficacy of radiofrequency- and ultrasound-based RDN in patients with and without concomitant pharmacological therapy. In addition, the safety profile of RDN appears to be excellent in all registries and clinical trials. However, there remain unsolved issues to be addressed. This review summarizes the rationale as well as the current evidence and discusses open questions and possible future indications of catheter-based RDN.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany; Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA.
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58
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Rognstad S, Søraas CL, Bergland OU, Høieggen A, Strømmen M, Helland A, Opdal MS. Establishing Serum Reference Ranges for Antihypertensive Drugs. Ther Drug Monit 2021; 43:116-125. [PMID: 32881780 DOI: 10.1097/ftd.0000000000000806] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/05/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) involves the measurement of serum drug concentrations to optimize pharmacotherapy. Traditionally, blood pressure measurements alone, and not TDM, have been used to evaluate the antihypertensive drug response. However, approximately 50% of hypertensive patients treated with lifestyle changes and antihypertensive drugs fail to achieve blood pressure control. Serum drug concentration measurements could be useful to select the optimal drugs in adjusted doses and to identify nonadherence. Implementation of TDM in clinical routine for antihypertensive drugs depends on established serum reference ranges. METHODS Commonly used antihypertensive drugs were identified based on prescription data. The authors performed a review of authoritative literature on reported serum drug concentrations and calculated expected concentrations from previously reported pharmacokinetic parameters with commonly prescribed daily doses. Finally, serum drug concentrations in samples from patients undergoing antihypertensive treatment were measured. RESULTS Serum reference ranges for 24 frequently used antihypertensive drugs were established based on results from 3 approaches. CONCLUSIONS Serum drug concentration measurements, interpreted in light of the established reference ranges, together with blood pressure measurements and other clinical data, may help identify nonadherent patients and tailor individual antihypertensive treatment when deviant drug responses appear in line with the concept of personalized medicine.
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Affiliation(s)
- Stine Rognstad
- Department of Pharmacology, Oslo University Hospital
- Institute of Clinical Medicine, University of Oslo
- Section of Cardiovascular and Renal Research, Oslo University Hospital
| | - Camilla L Søraas
- Section of Cardiovascular and Renal Research, Oslo University Hospital
- Unit of Environmental and Occupational Medicine, Oslo University Hospital
| | - Ola U Bergland
- Institute of Clinical Medicine, University of Oslo
- Section of Cardiovascular and Renal Research, Oslo University Hospital
| | - Aud Høieggen
- Institute of Clinical Medicine, University of Oslo
- Section of Cardiovascular and Renal Research, Oslo University Hospital
- Department of Nephrology, Oslo University Hospital, Ullevål
| | - Magnus Strømmen
- Department of Surgery, Center for Obesity Research, St. Olavs University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology
| | - Arne Helland
- Department of Clinical Pharmacology, St. Olavs University Hospital; and
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Mimi S Opdal
- Department of Pharmacology, Oslo University Hospital
- Institute of Clinical Medicine, University of Oslo
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59
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Asirvatham-Jeyaraj N, Gauthier MM, Banek CT, Ramesh A, Garver H, Fink GD, Osborn JW. Renal Denervation and Celiac Ganglionectomy Decrease Mean Arterial Pressure Similarly in Genetically Hypertensive Schlager (BPH/2J) Mice. Hypertension 2021; 77:519-528. [PMID: 33390041 PMCID: PMC7803455 DOI: 10.1161/hypertensionaha.119.14069] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Supplemental Digital Content is available in the text. Renal denervation (RDNX) lowers mean arterial pressure (MAP) in patients with resistant hypertension. Less well studied is the effect of celiac ganglionectomy (CGX), a procedure which involves the removal of the nerves innervating the splanchnic vascular bed. We hypothesized that RDNX and CGX would both lower MAP in genetically hypertensive Schlager (BPH/2J) mice through a reduction in sympathetic tone. Telemeters were implanted into the femoral artery in mice to monitor MAP before and after RDNX (n=5), CGX (n=6), or SHAM (n=6). MAP, systolic blood pressure, diastolic blood pressure, and heart rate were recorded for 14 days postoperatively. The MAP response to hexamethonium (10 mg/kg, IP) was measured on control day 3 and postoperative day 10 as a measure of global neurogenic pressor activity. The efficacy of denervation was assessed by measurement of tissue norepinephrine. Control MAP was similar among the 3 groups before surgical treatments (≈130 mm Hg). On postoperative day 14, MAP was significantly lower in RDNX (−11±2 mm Hg) and CGX (−11±1 mm Hg) groups compared with their predenervation values. This was not the case in SHAM mice (−5±3 mm Hg). The depressor response to hexamethonium in the RDNX group was significantly smaller on postoperative day 10 (−10±5 mm Hg) compared with baseline control (−25±10 mm Hg). This was not the case in mice in the SHAM (day 10; −28±5 mm Hg) or CGX (day 10; −34±7 mm Hg) group. In conclusion, both renal and splanchnic nerves contribute to hypertension in BPH/2J mice, but likely through different mechanisms.
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Affiliation(s)
- Ninitha Asirvatham-Jeyaraj
- From the Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis (M.M.G., C.T.B., A.R., J.W.O.).,Department of Biotechnology, Indian Institute of Technology Madras, Chennai (N.A.-J.)
| | | | - Christopher T Banek
- From the Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis (M.M.G., C.T.B., A.R., J.W.O.).,Department of Physiology, University of Arizona, Tucson (M.M.G., C.T.B.)
| | - Abhismitha Ramesh
- From the Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis (M.M.G., C.T.B., A.R., J.W.O.)
| | - Hannah Garver
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing (H.G., G.D.F.)
| | - Gregory D Fink
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing (H.G., G.D.F.)
| | - John W Osborn
- From the Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis (M.M.G., C.T.B., A.R., J.W.O.)
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Abstract
PURPOSE OF REVIEW Of the roughly 1.4 billion people with hypertension worldwide, only about one in seven has their blood pressure (BP) successfully treated and adequately controlled. This review will focus on new therapeutic approaches of hypertension. RECENT FINDINGS Several recent clinical studies and guidelines have favoured the assessment of target organ damage and cardiovascular risk scores for the diagnosis and treatment approach of hypertension. Paradigm shifts recommended in the guidelines are the initiation of antihypertensive treatment with combination (not mono) therapy and the recommendation of single-pill combinations (SPC), which improve adherence and result in rapid and effective BP control. In clinical trials with optimized design and renal denervation (RDN) technology, the biological proof of concept has been established. Consistent, durable ambulatory and office BP reductions without procedure associated serious adverse events have been documented. The challenges are now to identify patients who respond best to interventional treatment. SUMMARY Major key points in the treatment strategy for hypertension are: individualization of the therapy according to total cardiovascular risk, combination therapy as initial step, recommendation of SPC and RDN as promising interventional therapy.
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Affiliation(s)
- Agnes Bosch
- Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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61
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Kably B, Billaud EM, Boutouyrie P, Azizi M. Is there any Hope for Monitoring Adherence in an Efficient and Feasible Way for Resistant Hypertension Diagnosis and Follow-Up? Curr Hypertens Rep 2020; 22:96. [PMID: 33052474 DOI: 10.1007/s11906-020-01105-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Non-adherence to antihypertensive treatment is highly prevalent and represents a major factor affecting their effectiveness in hypertensive patients, thus contributing to apparent treatment resistance. It is however often overlooked because the methods to assess non-adherence are mainly subjective, limiting their usefulness in clinical practice. Non-adherence to treatment affects daily patient management, resulting in inappropriate, costly, and potentially harmful treatments and loss of the expected benefits from antihypertensive drugs. RECENT FINDINGS Specialized centers now use a combination of objective screening tools. Firstly, snapshots of adherence levels can be provided by analytical drug detection in various biological matrixes using liquid chromatography-tandem mass spectrometry (LC-MS/MS) and secondly electronic monitoring systems of drug delivery which provide longitudinal data on adherence. Routine utilization of those tools allows the detection of non-adherence in patients with resistant hypertension, thus enabling implementation of appropriate interventions to improve drug adherence and avoid unnecessary treatment intensification. Other complementary techniques, such as digital health feedback system with ingestible sensors, are currently evaluated. In the context of an increasing burden of uncontrolled and apparent treatment-resistant hypertension, detecting non-adherence to antihypertensive therapy is, as acknowledged by the latest guidelines, a top priority to implement in clinical practice but still faces medical conservatism and disbelief.
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Affiliation(s)
- Benjamin Kably
- Université de Paris, F-75006, Paris, France
- Pharmacology Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Inserm U970, Paris Centre de Recherche Cardiovasculaire-PARCC, F-75015, Paris, France
| | - Eliane M Billaud
- Pharmacology Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Inserm U970, Paris Centre de Recherche Cardiovasculaire-PARCC, F-75015, Paris, France
| | - Pierre Boutouyrie
- Université de Paris, F-75006, Paris, France
- Pharmacology Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Inserm U970, Paris Centre de Recherche Cardiovasculaire-PARCC, F-75015, Paris, France
| | - Michel Azizi
- Université de Paris, F-75006, Paris, France.
- Hypertension Unit, DMU CARTE, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France.
- Inserm, CIC 1418, F-75015, Paris, France.
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Kandzari DE, Mahfoud F, Bhatt DL, Böhm M, Weber MA, Townsend RR, Hettrick DA, Schmieder RE, Tsioufis K, Kario K. Confounding Factors in Renal Denervation Trials: Revisiting Old and Identifying New Challenges in Trial Design of Device Therapies for Hypertension. Hypertension 2020; 76:1410-1417. [PMID: 32981360 DOI: 10.1161/hypertensionaha.120.15745] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent randomized sham-controlled trials have demonstrated significant blood pressure reductions following renal denervation (RDN) in patients with hypertension, both in the presence and absence of antihypertensive therapy. These new data encouraged us to revisit previously published insights into potential clinical trial confounding factors that informed the design and conduct of forthcoming trials. Initially identified confounders related to procedural technique, medication variability, and selected patient subgroups have been addressed in contemporary trial design. Regarding procedural method and technology, blood pressure reductions may be improved by ensuring circumferential lesion creation in the distal renal arteries and branch vessels. Safety of the RDN procedure has been demonstrated in multiple independent meta-analyses including thousands of treated patients with low reported rates of renal vessel complications and maintenance of renal function. However, a newer generation of RDN trials has also introduced insights related to medication adherence, patient selection, and the definition of treatment response. Evolving evidence indicates that RDN therapy may be considered in higher risk populations of uncontrolled hypertension regardless of ethnicity and in patients expressing a strong preference for a nondrug therapy option. Despite advances in procedural technique and clinical trial conduct, inconsistent antihypertensive-drug adherence behavior remains perhaps the most critical clinical trial design issue for device-based hypertension therapies. As the balance in clinical equipoise increasingly favors RDN, justification of sham-controlled trial designs will be revisited, and novel study designs may be required to evaluate the safety and efficacy of novel devices and procedures intended to address the escalating prevalence of poorly controlled hypertension.
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Affiliation(s)
- David E Kandzari
- From the Piedmont Heart Institute, Atlanta, GA (D.E.K.).,Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School (D.L.B.)
| | - Felix Mahfoud
- University Hospital of Saarland, Saarland University, Homburg, Germany (F.M., M.B.)
| | | | - Michael Böhm
- University Hospital of Saarland, Saarland University, Homburg, Germany (F.M., M.B.)
| | - Michael A Weber
- SUNY Downstate College of Medicine, Brooklyn, New York (M.A.W.)
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.)
| | | | | | - Konstantinos Tsioufis
- National and Kapodistrian University of Athens, Hippocration Hospital, Athens Medical Center, Greece (K.T.)
| | - Kazuomi Kario
- Jichi Medical University School of Medicine, Tochigi, Japan (K.K.)
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res 2020; 42:1235-1481. [PMID: 31375757 DOI: 10.1038/s41440-019-0284-9] [Citation(s) in RCA: 1059] [Impact Index Per Article: 264.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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65
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McDonough CW, Babcock K, Chucri K, Crawford DC, Bian J, Modave F, Cooper-DeHoff RM, Hogan WR. Optimizing identification of resistant hypertension: Computable phenotype development and validation. Pharmacoepidemiol Drug Saf 2020; 29:1393-1401. [PMID: 32844549 DOI: 10.1002/pds.5095] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Computable phenotypes are constructed to utilize data within the electronic health record (EHR) to identify patients with specific characteristics; a necessary step for researching a complex disease state. We developed computable phenotypes for resistant hypertension (RHTN) and stable controlled hypertension (HTN) based on the National Patient-Centered Clinical Research Network (PCORnet) common data model (CDM). The computable phenotypes were validated through manual chart review. METHODS We adapted and refined existing computable phenotype algorithms for RHTN and stable controlled HTN to the PCORnet CDM in an adult HTN population from the OneFlorida Clinical Research Consortium (2015-2017). Two independent reviewers validated the computable phenotypes through manual chart review of 425 patient records. We assessed precision of our computable phenotypes through positive predictive value (PPV) and test validity through interrater reliability (IRR). RESULTS Among the 156 730 HTN patients in our final dataset, the final computable phenotype algorithms identified 24 926 patients with RHTN and 19 100 with stable controlled HTN. The PPV for RHTN in patients randomly selected for validation of the final algorithm was 99.1% (n = 113, CI: 95.2%-99.9%). The PPV for stable controlled HTN in patients randomly selected for validation of the final algorithm was 96.5% (n = 113, CI: 91.2%-99.0%). IRR analysis revealed a raw percent agreement of 91% (152/167) with Cohen's kappa statistic = 0.87. CONCLUSIONS We constructed and validated a RHTN computable phenotype algorithm and a stable controlled HTN computable phenotype algorithm. Both algorithms are based on the PCORnet CDM, allowing for future application to epidemiological and drug utilization based research.
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Affiliation(s)
- Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Kyle Babcock
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Kristen Chucri
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Dana C Crawford
- Department of Population and Quantitative Health Sciences, Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jiang Bian
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - François Modave
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - William R Hogan
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
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Special Article - The management of resistant hypertension: A 2020 update. Prog Cardiovasc Dis 2020; 63:662-670. [PMID: 32795462 DOI: 10.1016/j.pcad.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 11/21/2022]
Abstract
Resistant hypertension (RH) induces higher morbidity and mortality due to cardiovascular disease and stroke than hypertension without treatment resistance. New guidelines define RH as blood pressure (BP) ≥130/80 mmHg in a patient taking ≥3 antihypertensive agents of different classes or BP <130/80 mmHg in a patient taking ≥4 antihypertensive drugs. According to the new definition, pseudo-resistance due to error in BP measurement, white coat effect and medication nonadherence must be excluded to make the diagnosis of RH. This 2020 update focuses on the lifestyle and antihypertensive drug management of RH and includes recent proof-of-principle trials of renal nerve ablation in hypertension. Stepwise evidence-based pharmacologic treatment of RH includes optimization of the 3-drug regimen, substitution of a thiazide-like for a thiazide diuretic and addition of a mineralocorticoid receptor antagonist as the fourth drug. Non-evidence-based recommendations include addition of a β-blocker as the fifth drug and switching to a minoxidil-based regimen as the final step in achieving BP control.
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Benefit of serum drug monitoring complementing urine analysis to assess adherence to antihypertensive drugs in first-line therapy. PLoS One 2020; 15:e0237383. [PMID: 32776967 PMCID: PMC7416922 DOI: 10.1371/journal.pone.0237383] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/24/2020] [Indexed: 12/05/2022] Open
Abstract
With obesity having doubled in the last decade, hypertension is on the rise. In one-third of hypertensive patients the metabolic syndrome is present. This might be one factor for the increasing number of prescriptions for angiotensin receptor blockers and calcium-channel blockers besides a more favorable risk-to-benefit ratio. The aim of the present study was to evaluate a therapeutic drug monitoring (TDM) method for assessment of adherence based on cut-offs in inpatients and to compare it to an established urine drug screening in outpatients. A method for quantification of calcium-channel blockers and angiotensin receptor blockers using high-performance liquid chromatography-tandem mass spectrometric analysis (LC-MS/MS) was developed and validated. The method was applied to serum samples of 32 patients under supervised medication to establish cut-off values for adherence assessment based on dose-related concentrations (DRC, calculated from pharmacokinetic data). Furthermore, corresponding urine and blood samples of 42 outpatients without supervised medication were analysed and the results compared with regard to adherence assessment. All serum concentrations measured for amlodipine (n = 40), lercanidipine (n = 14), candesartan (n = 10), telmisartan (n = 4) and valsartan (n = 10) in inpatients were above the patient specific lower DRC confirming adherence. Of 42 outpatients the identification of analytes in urine as well as the quantification in serum exhibited differing results. According to urinalysis, adherence was demonstrated in only 87.0% of prescriptions, compared to 91.3% for serum analyses. Differences were observed for amlodipine, lercanidipine and candesartan which can be explained by a higher specificity of the serum analysis approach due to pharmacokinetics. The present study confirms that assessing adherence based on serum drug concentrations with individually calculated lower DRCs is more accurate than using qualitative urine analysis. In particular, drugs with low bioavailability, low renal excretion or high metabolism rate such as lercanidipine and candesartan may lead to underestimation of adherence via urine analysis.
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68
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Accuracy of a Symptom-Based Approach to Identify Hypertensive Emergencies in the Emergency Department. J Clin Med 2020; 9:jcm9072201. [PMID: 32664670 PMCID: PMC7408741 DOI: 10.3390/jcm9072201] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/08/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A hierarchical symptoms-based diagnostic strategy relying on the presence of five main symptoms (chest pain, acute dyspnea, neurological symptoms, headache, visual impairment) was recently proposed to diagnose patients with hypertensive emergency. However, poor scientific evidence is available about the role of symptoms in both diagnosis and management of acute hypertensive disorders. METHODS Data from 718 patients presenting to the emergency department of the "Città della Salute e della Scienza" Hospital of Turin with systolic blood pressure > 180 and/or diastolic blood pressure > 110 mm/Hg were retrospectively analyzed. The accuracy of the typical symptoms for identification of hypertensive emergencies was assessed. RESULTS A total of 79 (11%) out of 718 patients were diagnosed with hypertensive emergencies (51% had cardiovascular and 49% neurovascular acute organ damage). Patients with hypertensive emergencies were older and with higher prevalence of coronary artery disease and chronic heart failure than patients with uncontrolled hypertension. Typical symptoms could discriminate true hypertensive emergency from uncontrolled hypertension with 64% accuracy, 94% sensitivity, and 60% specificity. CONCLUSION Typical symptoms might be used as a simple screening test (99% negative predictive value) in the emergency department to select for further evaluations of patients with suspected hypertensive emergencies among those with acute hypertensive disorders.
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Bergo KK, Larstorp AC, Hoffmann P, Hjørnholm U, Cataliotti A, Høieggen A, Rostrup M, Fadl Elmula FEM. Renal sympathetic denervation lowers systemic vascular resistance in true treatment-resistant hypertension. Blood Press 2020; 30:31-40. [PMID: 32633141 DOI: 10.1080/08037051.2020.1789446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Renal sympathetic denervation (RDN) is again gaining interest as recent well-designed trials have demonstrated reduced ambulatory blood pressure (BP) after RDN. However, the hemodynamic mechanisms have not been elucidated. We aimed for the first time to investigate the effect of RDN on the "Hallmark of Hypertension" namely increased systemic vascular resistance index (SVRI). MATERIALS AND METHODS We investigated SVRI change in patients with true treatment-resistant hypertension randomised to RDN (n = 9) or drug adjusted control (n = 9). Treatment-resistant hypertension was defined as office systolic BP ≥ 140 mmHg despite ≥ 3 antihypertensive drugs including a diuretic. True treatment-resistant hypertension was confirmed prior to inclusion with ambulatory daytime systolic BP ≥ 135 mmHg immediately after witnessed intake of antihypertensive drugs. Hemodynamic variables were recorded with thoracic impedance cardiography at baseline and at three and six months follow-up after RDN. This non-invasive method also guided further tailoring of drug treatment in the control group aiming to normalise hemodynamic variables and BP. RESULTS From three to six months follow-up after RDN, SVRI decreased with a median of -611 dyn*s*m2/cm5 [IQR -949 to -267] (p < 0.01), while supine mean BP decreased with a median of -11 mmHg [IQR -21 to -3] (p = 0.02). In the same period, SVRI in the control group was reduced with -674 dyn*s*m2/cm5 [IQR -1,309 to -340] (p < 0.01), while supine mean BP decreased with -15 mmHg [IQR -29 to -6] (p = 0.01). Thus, hemodynamic variables and BP in the two groups normalised in parallel. CONCLUSION Our data suggest that in patients with true treatment-resistant hypertension, renal sympathetic denervation lowers BP by reducing systemic vascular resistance of similar size as in the control group with careful individual selection of antihypertensive drugs and dose titration.
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Affiliation(s)
- Kaja K Bergo
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway.,KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway and Center for Heart Failure Research, Oslo University Hospital, Oslo, Norway
| | - Anne C Larstorp
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Section of Cardiovascular and Renal Research, Oslo University Hospital, Oslo, Norway
| | - Pavel Hoffmann
- Section for Interventional Cardiology, Department of Cardiology, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway
| | - Ulla Hjørnholm
- Section of Cardiovascular and Renal Research, Oslo University Hospital, Oslo, Norway
| | - Alessandro Cataliotti
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway.,KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway and Center for Heart Failure Research, Oslo University Hospital, Oslo, Norway
| | - Aud Høieggen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Section of Cardiovascular and Renal Research, Oslo University Hospital, Oslo, Norway.,Department of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Morten Rostrup
- Section of Cardiovascular and Renal Research, Oslo University Hospital, Oslo, Norway.,Department of Acute Medicine, Oslo University Hospital, Oslo, Norway.,Department of Behavioural Sciences in Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Fadl Elmula M Fadl Elmula
- Section of Cardiovascular and Renal Research, Oslo University Hospital, Oslo, Norway.,Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
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Lauder L, Ewen S, Kunz M, Richter LHJ, Jacobs CM, Kindermann I, Böhm M, Meyer MR, Mahfoud F. Adherence to Antihypertensive Drugs Assessed by Hyphenated High-Resolution Mass Spectrometry Analysis of Oral Fluids. J Am Heart Assoc 2020; 9:e014180. [PMID: 32633188 PMCID: PMC7660713 DOI: 10.1161/jaha.119.014180] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background It is currently unknown if antihypertensive drugs can be monitored in oral fluid (OF) using liquid chromatography coupled to high‐resolution mass spectrometry. Methods and Results We assessed adherence using liquid chromatography coupled to high‐resolution mass spectrometry in OF, plasma, and urine of 56 consecutive patients with hypertension referred to a tertiary hypertension unit. Of these patients, 59% were completely adherent (all drugs detectable in urine), whereas 29% and 13% were partially adherent (1 drug not detectable in urine) or nonadherent (>1 drug not detectable in urine), respectively. Adherent patients were on fewer antihypertensive drugs (P=0.001), had fewer daily drug doses (P=0.012), and had lower 24‐hour ambulatory systolic (P=0.012) and diastolic (P=0.009) blood pressures than nonadherent or partially adherent patients. Most drugs were detected in urine compared with plasma and OF (181 versus 119 versus 88; P=0.001). Compared with urine and plasma, detection rates of angiotensin‐converting enzyme inhibitors, angiotensin II receptor blockers, and diuretics were lower in OF. There was no difference in the frequency of detecting β blockers (P=1.0) and calcium channel blockers (P=0.063) when comparing OF with urine. There was no difference in the number of calcium channel blockers (P=0.727), β blockers (P=1.000), thiazide diuretics (P=0.125), and α‐2 agonists (P=0.125) identified between OF and plasma. Conclusions This study shows the feasibility of drug adherence testing for several antihypertensive drugs, especially those without acidic components, in OF, with a similar recovery compared with plasma. Therefore, drug adherence testing in OF should be further explored as a noninvasive approach, which can easily be performed in an “out‐of‐office” setting.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III Kardiologie, Angiologie und Internistische Intensivmedizin Universitätsklinikum des Saarlandes and Saarland University Homburg/Saar Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III Kardiologie, Angiologie und Internistische Intensivmedizin Universitätsklinikum des Saarlandes and Saarland University Homburg/Saar Germany
| | - Michael Kunz
- Klinik für Innere Medizin III Kardiologie, Angiologie und Internistische Intensivmedizin Universitätsklinikum des Saarlandes and Saarland University Homburg/Saar Germany
| | - Lilian H J Richter
- Department of Experimental and Clinical Toxicology Institute of Experimental and Clinical Pharmacology and Toxicology Center for Molecular Signaling Saarland University Homburg/Saar Germany
| | - Cathy M Jacobs
- Department of Experimental and Clinical Toxicology Institute of Experimental and Clinical Pharmacology and Toxicology Center for Molecular Signaling Saarland University Homburg/Saar Germany
| | - Ingrid Kindermann
- Klinik für Innere Medizin III Kardiologie, Angiologie und Internistische Intensivmedizin Universitätsklinikum des Saarlandes and Saarland University Homburg/Saar Germany
| | - Michael Böhm
- Klinik für Innere Medizin III Kardiologie, Angiologie und Internistische Intensivmedizin Universitätsklinikum des Saarlandes and Saarland University Homburg/Saar Germany
| | - Markus R Meyer
- Department of Experimental and Clinical Toxicology Institute of Experimental and Clinical Pharmacology and Toxicology Center for Molecular Signaling Saarland University Homburg/Saar Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III Kardiologie, Angiologie und Internistische Intensivmedizin Universitätsklinikum des Saarlandes and Saarland University Homburg/Saar Germany.,Institute for Medical Engineering and Science MIT Cambridge MA
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Williams B, Masi S, Wolf J, Schmieder RE. Facing the Challenge of Lowering Blood Pressure and Cholesterol in the Same Patient: Report of a Symposium at the European Society of Hypertension. Cardiol Ther 2020; 9:19-34. [PMID: 31933276 PMCID: PMC7237547 DOI: 10.1007/s40119-019-00159-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Indexed: 11/24/2022] Open
Abstract
A symposium held at the 29th European Meeting on Hypertension and Cardiovascular Protection in Milan, Italy, discussed the potential impact and long-term benefits of early active management of cardiovascular disease (CVD) risk in patients with hypertension, and potential barriers to this strategy. Hypertension often aggregates with other cardiovascular risk factors, exponentially increasing morbidity and mortality. While effective therapies to treat hypertension exist, a substantial number of patients still experience major cardiovascular events. Two major issues account for these disappointing results: interventions initiated too late in the disease trajectory and lack of effective translation of the research findings into daily clinical practice. Results from genetic studies suggest that lifetime exposure to lower blood pressure (BP) and cholesterol levels due to protective gene mutations, can provide greater cardiovascular benefits than middle-/late-age interventions. Clinical guidelines suggest adding statins to BP-lowering therapies for further cardiovascular benefits in most hypertensive patients; however, real-world data show that physicians' compliance with these recommendations and patients' adherence to BP- and lipid-lowering treatments remain poor, resulting in poor risk factor control and an increased risk of adverse outcomes. The use of single-pill combinations (SPC) can partially mitigate these issues, as they are associated with increased patient adherence and improved BP control. Treatment with SPC has been recommended in the European Hypertension Guidelines, but optimization of the total CVD risk may need adoption of more ambitious treatment strategies aimed to deliver single pills that control multiple CVD risk factors. Amlodipine, perindopril and atorvastatin have been shown to improve BP and lipid levels to a great extent when given separately, and this combination has also been shown to improve cardiovascular outcomes. Overall, early intervention in patients with hypertension with use of an effective, high-intensity cardiovascular risk reduction regimen and attention to medication adherence through reducing pill burden are likely to result in optimal outcomes.
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Affiliation(s)
- Bryan Williams
- Institute of Cardiovascular Sciences, University College London, London, UK.
| | - Stefano Masi
- Institute of Cardiovascular Sciences, University College London, London, UK
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Jacek Wolf
- Department of Hypertension and Diabetology, Medical University of Gdańsk, Gdańsk, Poland
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University Erlangen Nuremberg, Erlangen, Germany
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Peeters LEJ, Feyz L, Boersma E, Daemen J, van Gelder T, Koch BCP, Versmissen J. Clinical Applicability of Monitoring Antihypertensive Drug Levels in Blood. Hypertension 2020; 76:80-86. [PMID: 32418497 DOI: 10.1161/hypertensionaha.120.15038] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Dried blood spot (DBS) analysis is a novel analytical method for therapeutic drug monitoring to identify nonadherence to antihypertensive drugs. This study was conducted to evaluate the clinical applicability of measuring drug concentrations of 8 antihypertensive drugs, using DBS and venipuncture. Furthermore, this study aimed to provide more insight into the between-patient variability in drug concentrations. False-negative values from DBS compared with a venipuncture were determined to assess drug adherence. A generalized estimating equation was used to estimate the model parameters, including sex, dose, age, weight, and the time interval, between drug intake and sampling, on the Cplasma (drug concentration in plasma). No false-negative values were found when measuring nonadherence using DBS compared with venipuncture. A high variability in Cplasma between patients was observed, especially at peak concentrations with a fold change reaching from 2.3 to 35.2. The time of intake was significantly related to the height of the Cplasma in 7 of the 8 measured drugs with a P<0.05, but the influence of dose, weight, age, and sex on drug levels differed largely between the measured drugs. DBS is a reliable and convenient method to assess nonadherence to antihypertensive drugs in clinical practice. The Cplasma of the 8 antihypertensive drugs in this study show a large interindividual difference, and therefore, low plasma concentrations do not necessarily mean nonadherence. Nonadherence can only be confirmed if drug levels are undetectable, that is, values below the lower limit of detection.
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Affiliation(s)
- Laura E J Peeters
- From the Department of Hospital Pharmacy (L.E.J.P., T.v.G., B.C.P.K.), Erasmus MC, University Medical Center Rotterdam, the Netherlands.,Department of Internal Medicine (L.E.J.P., T.v.G., J.V.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Lida Feyz
- Department of Cardiology (L.F., E.B., J.D.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology (L.F., E.B., J.D.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology (L.F., E.B., J.D.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Teun van Gelder
- From the Department of Hospital Pharmacy (L.E.J.P., T.v.G., B.C.P.K.), Erasmus MC, University Medical Center Rotterdam, the Netherlands.,Department of Internal Medicine (L.E.J.P., T.v.G., J.V.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Birgit C P Koch
- From the Department of Hospital Pharmacy (L.E.J.P., T.v.G., B.C.P.K.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Jorie Versmissen
- Department of Internal Medicine (L.E.J.P., T.v.G., J.V.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
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Italian Society of Arterial Hypertension (SIIA) Position Paper on the Role of Renal Denervation in the Management of the Difficult-to-Treat Hypertensive Patient. High Blood Press Cardiovasc Prev 2020; 27:109-117. [DOI: 10.1007/s40292-020-00367-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/02/2020] [Indexed: 12/17/2022] Open
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Rodionov AV. High Blood Pressure Variability is an Additional Cardiovascular Risk Factor. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-02-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Blood pressure (BP) is a highly variable physiological indicator. Most people have BP changes within 40-50 mmHg during the day. Various external factors (from the patient’s position during BP measurement to poor adherence to therapy and abuse of short-acting antihypertensive drugs) affect the assessed indicators. Evaluation of the average daily, intra-visit, as well as long-term ("from visit to visit") BP variability is used in clinical practice. In the past twenty years a number of major studies demonstrated that increased BP variability is an independent prognostic factor that increases the risk of cardiovascular complications. The largest meta-analysis of 41 studies showed that an increase in long-term BP variability was associated with 15% and 18% increase in total and cardiovascular mortality, respectively. According to the IDHOCO project, the threshold coefficient of variation for day-today variability is >11.0/12.8. Different groups of antihypertensive drugs have an uneven effect on BP variability. Consistent data from ASCOT-BPLA, X-CELLENT and ACCOMPLISH studies indicate that among the main groups of antihypertensive drugs, calcium antagonists, mainly amlodipine, have the greatest potential for the variability reduction. A decrease in BP variability, as shown in a post-hoc analysis of CAMELOT and PREVENT studies, has a positive effect on the incidence of major adverse cardiac events (MACE). Thus, the BP variability is an important indicator that reflects the prognosis in hypertensive patients. BP variability reduction can be considered as one of the independent goals of therapy. Calcium antagonists can be considered as first-line drugs for patients with high BP variability.
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Affiliation(s)
- A. V. Rodionov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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75
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Mahfoud F, Renkin J, Sievert H, Bertog S, Ewen S, Böhm M, Lengelé JP, Wojakowski W, Schmieder R, van der Giet M, Parise H, Haratani N, Pathak A, Persu A. Alcohol-Mediated Renal Denervation Using the Peregrine System Infusion Catheter for Treatment of Hypertension. JACC Cardiovasc Interv 2020; 13:471-484. [DOI: 10.1016/j.jcin.2019.10.048] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/15/2019] [Accepted: 10/22/2019] [Indexed: 12/20/2022]
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76
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Townsend RR. Is There Any Role for Device Therapies in Resistant Hypertension? PRO. KIDNEY360 2020; 1:6-8. [PMID: 35372856 PMCID: PMC8808483 DOI: 10.34067/kid.0000582019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.
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Affiliation(s)
- Michel Burnier
- From the Service of Nephrology and Hypertension, Department of Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.B.)
| | - Brent M Egan
- Department of Medicine, Care Coordination Institute, University of South Carolina School of Medicine, Greenville, SC (B.M.E.)
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78
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Burrello J, Buffolo F, Domenig O, Tetti M, Pecori A, Monticone S, Poglitsch M, Mulatero P. Renin-Angiotensin-Aldosterone System Triple-A Analysis for the Screening of Primary Aldosteronism. Hypertension 2020; 75:163-172. [DOI: 10.1161/hypertensionaha.119.13772] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Primary aldosteronism is recognized as the most frequent cause of secondary hypertension, and its screening is expected to become a routine evaluation in most patients with hypertension. The interference of antihypertensive therapies with the aldosterone-to-renin ratio during screening process is a major confounder. Renin-angiotensin-aldosterone system Triple-A analysis is a novel liquid chromatography/tandem mass spectrometry diagnostic assay that allows simultaneous quantification of aldosterone, equilibrium Ang I (angiotensin I), and Equilibrium Ang II in a single sample of serum. We performed a comparative evaluation of the diagnostic performance of the aldosterone-to-Ang II ratio and 5 renin-based diagnostic ratios, differing in methods to determine aldosterone levels and renin activity in a cohort of 110 patients with hypertension (33 patients with confirmed primary aldosteronism and 77 with essential hypertension). All ratios showed comparable areas under the curves ranging between 0.924 and 0.970 without significant differences between each other. The evaluation of the Ang II-to-Ang I ratio revealed persistent drug intake in some patients as cause for suppressed renin-based diagnostic ratios, while aldosterone-to-Ang II ratio remained unaffected. The Youden index optimal cutoff value for the aldosterone-to-Ang II ratio was 6.6 ([pmol/L]/[pmol/L]) with a sensitivity of 90% and a specificity of 93%, proving noninferiority compared with the aldosterone-to-renin ratio while pointing to the potential for an interference-free application in patients under ACE (angiotensin-converting enzyme) inhibitor therapy. This study shows for the first time the accuracy and reliability of renin-angiotensin-aldosterone system triple-A analysis for the screening of primary aldosteronism that can be applied in clinical routine.
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Affiliation(s)
- Jacopo Burrello
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (J.B., F.B., M.T., A.P., S.M., P.M.)
| | - Fabrizio Buffolo
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (J.B., F.B., M.T., A.P., S.M., P.M.)
| | | | - Martina Tetti
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (J.B., F.B., M.T., A.P., S.M., P.M.)
| | - Alessio Pecori
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (J.B., F.B., M.T., A.P., S.M., P.M.)
| | - Silvia Monticone
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (J.B., F.B., M.T., A.P., S.M., P.M.)
| | | | - Paolo Mulatero
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (J.B., F.B., M.T., A.P., S.M., P.M.)
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79
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Chen H, Ji M, Zhang Y, Xu Y, Qiao L, Shen L, Ge J. ReferencesEfficiency and safety of renal denervation via cryoablation (Cryo-RDN) in Chinese patients with uncontrolled hypertension: study protocol for a randomized controlled trial. Trials 2019; 20:653. [PMID: 31779672 PMCID: PMC6883652 DOI: 10.1186/s13063-019-3693-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 08/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical data show that due to the limited effects of lifestyle regulation and unsatisfactory drug adherence, only half of the hypertensive population have their blood pressure (BP) under control. In recent years, catheter-based renal denervation (RDN) has been used as a novel approach for treating uncontrolled hypertension. The safety and efficacy of catheter-based RDN have been confirmed by a number of studies and trials in which the participants were all non-Chinese and RDN was conducted via radiofrequency or ultrasound. METHODS/DESIGN This study is a prospective multicenter randomized sham-controlled trial that aims to investigate the safety and efficacy of cryoablation RDN (cryo-RDN) using a novel dedicated cryoablation balloon catheter (Cryofocus, China). A total of 200 Chinese patients who have uncontrolled hypertension despite standard medical treatment will be enrolled. With drug standardization, eligible participants will be randomized in a 1:1 ratio to undergo cryo-RDN treatment or renal angiography alone as a sham treatment. The primary endpoint is defined as the change in 24-h ambulatory systolic blood pressure from baseline to 6 months. Office BP and other 24-h ambulatory BP are included as secondary endpoints. Safety endpoints primarily include any adverse effects. DISCUSSION This study was designed to verify the safety and efficacy of cryo-RDN with Cryofocus balloon catheters in uncontrolled hypertensive patients on polypharmacy. The aim is to provide a new way to improve the control of hypertension in China as a complement to drug therapy. TRIAL REGISTRATION ChiCTR, ChiCTR1800017707. Registered on 10 August 2018.
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Affiliation(s)
- Han Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Meng Ji
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Institute of Biomedical Sciences, Fudan University, Shanghai, China
| | - Yi Zhang
- Department of Cardiology, Shanghai Tenth People’s Hospital, Shanghai, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Shanghai, China
| | - Lingjuan Qiao
- CryoFocus MedTech (Shanghai) Co., Ltd., Shanghai, China
| | - Li Shen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
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Hamdidouche I, Gosse P, Cremer A, Lorthioir A, Delsart P, Courand PY, Denolle T, Halimi JM, Girerd X, Ormezzano O, Rossignol P, Pereira H, Azizi M, Amar L, Bobrie G, Monge M, Pagny JY, Sapoval M, Claisse G, Midulla M, Mounier-Vehier C, Dauphin R, Fauvel JP, Lantelme P, Rouvière O, Grenier N, Lebras Y, Trillaud H, Dourmap C, Heautot JF, Larralde A, Paillard F, Cluzel P, Rosenbaum D, Alison D, Popovic B, Zannad F, Baguet JP, Thony F, Bartoli JM, Vaïsse B, Drouineau J, Herpin D, Sosner P, Tasu JP, Velasco S, Ribstein J, Kovacsik H, Bouhanick B, Chamontin B, Rousseau H, Le Jeune S, Lopez-Sublet M, Mourad JJ, Bellmann L, Esnault V, Ferrari E, Chatellier G. Clinic Versus Ambulatory Blood Pressure in Resistant Hypertension: Impact of Antihypertensive Medication Nonadherence. Hypertension 2019; 74:1096-1103. [DOI: 10.1161/hypertensionaha.119.13520] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinic-ambulatory blood pressure (BP) difference is influenced by patients- and device-related factors and inadequate clinic-BP measurement. We investigated whether nonadherence to antihypertensive medications may also influence this difference in a post hoc analysis of the DENERHTN trial (Renal Denervation for Hypertension). We pooled the data of 77 out of 106 evaluable patients with apparent resistant hypertension who received a standardized antihypertensive treatment and had both ambulatory BP and drug-screening results available at baseline after 1 month of standardized triple therapy and at 6 months on a median of 5 antihypertensive drugs. After drug assay samplings on study visits, patients took their antihypertensive treatment under supervision immediately after the start of the ambulatory BP recording, and supine clinic BP was measured 24 hours post-dosing; both allowed to calculate the clinic minus daytime ambulatory systolic BP (SBP) difference (clinic-SBP–day-SBP). A total of 29 (37.7%) were found nonadherent to medications at baseline and 38 (49.4%) at 6 months. At baseline, the mean clinic-SBP–day-SBP difference in the nonadherent group was 12.7 mm Hg (95% CI, 7.8–17.7 mm Hg,
P
<0.001). In contrast, clinic SBP was almost identical to day-SBP in the adherent group (clinic-SBP–day-SBP difference, 0.1 mm Hg; 95% CI, −3.3 to 3.5 mm Hg;
P
=0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mm Hg cutoff of clinic-SBP–day-SBP difference had 67% sensitivity and 69% specificity to predict nonadherence to the triple therapy at baseline. In conclusion, a large clinic-SBP–day-SBP difference may help discriminating between adherence and nonadherence to treatment in patients with resistant hypertension.
Clinical Trial Registration—
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01570777.
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Affiliation(s)
- Idir Hamdidouche
- From the INSERM, Centre d’Investigations Cliniques- Plurithématique 1418, Paris, France (I.H., H.P., M.A.)
| | - Philippe Gosse
- ESH Hypertension excellence center, Hopital Saint André, University hospital of Bordeaux, France (P.G., A.C.)
| | | | - Aurelien Lorthioir
- AP-HP, Hypertension unit and DMU CARTE, Hôpital Européen Georges-Pompidou, Paris, France (A.L., H.P., M.A.)
| | - Pascal Delsart
- CHU Lille, Institut Cœur Poumon, Bd Pr Leclercq, France (P.D.)
| | - Pierre-Yves Courand
- Cardiology department, European Society of Hypertension Excellence Center, Hôpital de la Croix-Rousse et Hôpital Lyon Sud, Hospices Civils de Lyon, France (P.-Y.C.)
- Université de Lyon, CREATIS; CNRS UMR5220; INSERM U1044; INSA-Lyon; Université Claude Bernard Lyon 1, France (P.-Y.C.)
| | - Thierry Denolle
- Hĉpital Arthur Gardiner, Centre d’Excellence en HTA Rennes- Dinard, France (T.D.)
| | - Jean-Michel Halimi
- Service de nephrologie-immunologie clinique, Hopital universitaire de Tours, et EA4245 Université Francois Rabelais, France (J.-M.H.)
| | - Xavier Girerd
- Unité de Prévention Cardio Vasculaire, Groupe Hospitalier Universitaire Pitié-Salpêtrière–Institut IE3M, Paris, France (X.G)
| | - Olivier Ormezzano
- Department of Cardiology, University Hospital and INSERM U1039, Bioclinic Radiopharmaceutics Laboratory, Grenoble, France (O.O.)
| | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France (P.R.)
| | - Helena Pereira
- From the INSERM, Centre d’Investigations Cliniques- Plurithématique 1418, Paris, France (I.H., H.P., M.A.)
- AP-HP, Hypertension unit and DMU CARTE, Hôpital Européen Georges-Pompidou, Paris, France (A.L., H.P., M.A.)
- AP-HP Clinical and Epidemiological Unit, Hopital Europeen Georges Pompidou, Paris, France (H.P.)
| | - Michel Azizi
- From the INSERM, Centre d’Investigations Cliniques- Plurithématique 1418, Paris, France (I.H., H.P., M.A.)
- AP-HP, Hypertension unit and DMU CARTE, Hôpital Européen Georges-Pompidou, Paris, France (A.L., H.P., M.A.)
- Université de Paris, Paris, France (M.A.)
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Kjeldsen SE, Os I. Poor reproducibility of masked and white coat uncontrolled hypertension: important new information on MUCH and WUCH. Eur Heart J 2019; 41:1572-1574. [DOI: 10.1093/eurheartj/ehz703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Sverre E Kjeldsen
- Department of Cardiology, Oslo University Hospital, Ullevål, and University of Oslo, Institute for Clinical Medicine, Oslo, Norway
| | - Ingrid Os
- Department of Nephrology, Oslo University Hospital, Ullevål, and University of Oslo, Institute for Clinical Medicine, Oslo, Norway
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82
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Kalman JM, Lavandero S, Mahfoud F, Nahrendorf M, Yacoub MH, Zhao D. Looking back and thinking forwards - 15 years of cardiology and cardiovascular research. Nat Rev Cardiol 2019; 16:651-660. [PMID: 31570832 DOI: 10.1038/s41569-019-0261-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2019] [Indexed: 12/24/2022]
Abstract
The first issue of Nature Reviews Cardiology was published in November 2004 under the name Nature Clinical Practice Cardiovascular Medicine. To celebrate our 15th anniversary in 2019, we invited six of our Advisory Board members to discuss what they considered the most important advances in their field of cardiovascular research or clinical practice in the past 15 years and what changes they envision for cardiovascular medicine in the next 15 years. Several practice-changing breakthroughs are described, including advances in procedural techniques to treat arrhythmias and hypertension and the development of novel therapeutic strategies to treat heart failure and pulmonary arterial hypertension, as well as those that target risk factors such as inflammation and elevated LDL-cholesterol levels. Furthermore, these key opinion leaders predict that machine learning technology and data derived from wearable devices will pave the way towards the coveted goal of personalized medicine.
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Affiliation(s)
- Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia. .,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
| | - Sergio Lavandero
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical and Pharmaceutical Sciences & Faculty of Medicine, University of Chile, Santiago, Chile. .,Department of Internal Medicine (Cardiology Division), University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Felix Mahfoud
- Department of Internal Medicine III, Saarland University Hospital, Homburg (Saar), Germany. .,Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA.
| | - Matthias Nahrendorf
- Center for Systems Biology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA. .,Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Magdi H Yacoub
- National Heart and Lung Institute, Heart Science Centre, Harefield Hospital, London, UK. .,The Magdi Yacoub Foundation, Aswan Heart Centre, Aswan, Egypt.
| | - Dong Zhao
- Capital Medical University, Beijing Anzhen Hospital, Beijing, China.
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Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 138:e484-e594. [PMID: 30354654 DOI: 10.1161/cir.0000000000000596] [Citation(s) in RCA: 220] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul K Whelton
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Robert M Carey
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Wilbert S Aronow
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Donald E Casey
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Karen J Collins
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Cheryl Dennison Himmelfarb
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sondra M DePalma
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Samuel Gidding
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Kenneth A Jamerson
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Daniel W Jones
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Eric J MacLaughlin
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Paul Muntner
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Bruce Ovbiagele
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sidney C Smith
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Crystal C Spencer
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Randall S Stafford
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sandra J Taler
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Randal J Thomas
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Kim A Williams
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Jeff D Williamson
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Jackson T Wright
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
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Wallbach M, Koziolek MJ. Baroreceptors in the carotid and hypertension-systematic review and meta-analysis of the effects of baroreflex activation therapy on blood pressure. Nephrol Dial Transplant 2019; 33:1485-1493. [PMID: 29136223 DOI: 10.1093/ndt/gfx279] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 08/08/2017] [Indexed: 02/06/2023] Open
Abstract
Activation of baroreceptors in the carotid modulates the autonomic nervous system. Baroreflex activation therapy (BAT), which activates baroreceptors in the carotid, has become available in the treatment of resistant hypertension. Besides this, a carotid implant modulating baroreceptors as well as pharmacological modulation of carotid bodies were quite recently presented. This review will underscore currently available and promising approaches that activate baroreceptors in the carotid, and thereby contribute to beneficial effects in patients with arterial hypertension, and discusses potential organoprotective BAT effects beyond blood pressure (BP) reduction. A systematic review and meta-analysis was conducted including observational studies or randomized controlled trials that investigated the effect of BAT on BP in resistant hypertension. Nine studies, seven observational and two randomized, with a total of 444 patients, were included in the evaluation. Analysing the longest follow-up visit from the different studies, there was a significant reduction of systolic BP after BAT of -36 mmHg [95% confidence interval (CI) -42 to -30 mmHg]. Separate meta-analysis of the short-term (1-6 months) and long-term effects (≥12 months) revealed a reduction of -21 mmHg (95% CI -26 to -17 mmHg) and -38 mmHg (95% CI -46 to -30 mmHg), respectively. There are promising data both in the experimental and the clinical application for BAT. Though the present meta-analysis suggests beneficial effects of BAT on BP, the results must be interpreted extremely carefully. Considering that evidence from controlled trials is very limited, it is evident that there is a strong need for further investigation.
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Affiliation(s)
- Manuel Wallbach
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael J Koziolek
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
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85
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Sun J, Ashley J, Kellawan JM. Can Acupuncture Treatment of Hypertension Improve Brain Health? A Mini Review. Front Aging Neurosci 2019; 11:240. [PMID: 31572163 PMCID: PMC6753179 DOI: 10.3389/fnagi.2019.00240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/19/2019] [Indexed: 12/29/2022] Open
Abstract
With age, cerebrovascular and neurodegenerative diseases (e.g., dementia and Alzheimer’s) are some of the leading causes of death in the United States. Related to these outcomes is the increased prevalence of hypertension, which independently increases the development of cerebrovascular and neurodegenerative diseases. While a direct mechanistic link between hypertension and poor brain health is unknown, many hypothesize that the etiology stems from poor blood pressure (BP) and cerebrovascular regulation. This dysfunction fosters hypoperfusion of the brain, causing stress to the tissue through a nutrient mismatch, subtly damaging the brain over many years. Current Western medical treatment relies on pharmacological treatment (mainly beta-blockers, angiotensin-converting enzyme inhibitors, or a combination of the two). However, Western treatments have not been successful in mitigating brain health outcomes and are burdened with unwanted side effects and non-adherence issues. Alternatively, traditional East Asia medicine has used acupuncture as a treatment for hypertension and may offer a promising approach in response to the limitations of conventional therapy. While detailed clinical and mechanistic experimental evidence is lacking, acupuncture has been observed to reduce BP and improve endothelial function in hypertensive adults. Further, acupuncture has been shown to have specific cerebrovascular effects, increasing cerebrovascular reactivity in healthy adults, highlighting possible neuroprotective properties. Therefore, our review is aimed at evaluating acupuncture as a treatment for hypertension and the potential impact on brain health. We will interrogate the current literature as well as discuss the proposed neural and vascular mechanisms by which acupuncture acts.
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Affiliation(s)
- Jongjoo Sun
- Human Circulation Research Laboratory, Department of Health and Exercise Science, University of Oklahoma, Norman, OK, United States
| | - John Ashley
- Human Circulation Research Laboratory, Department of Health and Exercise Science, University of Oklahoma, Norman, OK, United States
| | - J Mikhail Kellawan
- Human Circulation Research Laboratory, Department of Health and Exercise Science, University of Oklahoma, Norman, OK, United States
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86
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Lorthioir A, Belmihoub I, Fouassier D, Azizi M, Amar L. [Spironolactone in resistant essential hypertension]. Presse Med 2019; 48:1431-1438. [PMID: 31473027 DOI: 10.1016/j.lpm.2019.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/23/2019] [Indexed: 11/26/2022] Open
Abstract
Resistant hypertension is defined as uncontrolled blood pressure (BP) despite three antihypertensive agents including a diuretic (thiazide diuretic if renal function is normal or loop diuretic in case of chronic kidney disease with eGFR<30mL/min), a renin-angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, at optimal doses. Resistance must be confirmed by out-of-office measurements (ambulatory blood pressure monitoring or home blood pressure monitoring) and patients should be asked about treatment compliance and excessive salt or alcohol intake. If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for secondary causes of hypertension as they are frequent in this context. If essential resistant hypertension is confirmed, the mineralocorticoid receptor antagonist, spironolactone, should be added (25 to 50mg daily). In the event of a contraindication to spironolactone, or if adverse effects occur, a beta-blocker, an alpha-blocker, or a centrally acting antihypertensive drug should be prescribed.
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Affiliation(s)
- Aurélien Lorthioir
- AP-HP, hôpital européen Georges-Pompidou, hypertension unit, 20, rue Leblanc, 75015 Paris, France.
| | - Inès Belmihoub
- AP-HP, hôpital européen Georges-Pompidou, hypertension unit, 20, rue Leblanc, 75015 Paris, France; Paris-Descartes university, faculty of medicine, 75006 Paris, France
| | - David Fouassier
- Paris-Descartes university, faculty of medicine, 75006 Paris, France; AP-HP, hôpital Européen Georges Pompidou, Centre d'Investigation Clinique, 20, rue Leblanc, 75015 Paris, France
| | - Michel Azizi
- AP-HP, hôpital européen Georges-Pompidou, hypertension unit, 20, rue Leblanc, 75015 Paris, France; Paris-Descartes university, faculty of medicine, 75006 Paris, France; AP-HP, hôpital Européen Georges Pompidou, Centre d'Investigation Clinique, 20, rue Leblanc, 75015 Paris, France
| | - Laurence Amar
- AP-HP, hôpital européen Georges-Pompidou, hypertension unit, 20, rue Leblanc, 75015 Paris, France; Paris-Descartes university, faculty of medicine, 75006 Paris, France
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87
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Kichou B, Henine N, Himeur Y, Kichou L, Ait Said M, Mazeghrane A, Hammouche A. [Assessment of adherence to antihypertensive drugs in patients with resistant hypertension receiving optimal treatment]. Ann Cardiol Angeiol (Paris) 2019; 68:264-268. [PMID: 31471039 DOI: 10.1016/j.ancard.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/19/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The primary objective was to estimate the proportion of non-adherence to antihypertensive drugs in patients with an apparently resistant hypertension despite optimal medical treatment. The secondary objective was to identify related factors to poor adherence. METHODS Monocentric, prospective and observational study, including consecutive patients, managed for an apparently resistant hypertension between January 2014 and December 2017, with an ambulatory blood pressure measurement (ABP) in the past year and a thorough etiological work up in the 2 past years. Hypertension was considered resistant if the daytime ABP was ≥ 135/85mmHg and/or the 24hours ABP≥to 130/80mmHg, despite 4 antihypertensive medications at optimal doses. Adherence to treatment was assessed by the eight-item Morisky Scale (MMAS-8). RESULTS We enrolled 386 patients, with a mean age of 64.6 years, and 48.2% of men. The mean office blood pressure, 24hours and daytime APB were 178.6/101.3mmHg, 164.4/97.2mmHg and 170.5/99.7mmHg respectively. The proportions of low, medium and high adherence were 24.5%, 47.6% and 27.9% respectively. Associated-factors with poor adherence were female sex, low education level, celibacy, polypharmacy and lack of home self-blood pressure monitoring. CONCLUSION Over two out of three patients with an apparently resistant hypertension under optimal treatment were partially or fully nonadherent to treatment in our study. Assessment of adherence would be systematic in these patients before implementing complex investigations or non-pharmacologic invasive procedures.
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Affiliation(s)
- B Kichou
- Service de cardiologie, centre hospitalier universitaire de Tizi-Ouzou, 15000, Tizi-Ouzou, Algérie.
| | - N Henine
- Service de cardiologie, centre hospitalier universitaire de Tizi-Ouzou, 15000, Tizi-Ouzou, Algérie
| | - Y Himeur
- Service de cardiologie, centre hospitalier universitaire de Tizi-Ouzou, 15000, Tizi-Ouzou, Algérie
| | - L Kichou
- Service de cardiologie, centre hospitalier universitaire de Tizi-Ouzou, 15000, Tizi-Ouzou, Algérie
| | - M Ait Said
- Service de cardiologie, centre hospitalier universitaire de Tizi-Ouzou, 15000, Tizi-Ouzou, Algérie
| | - A Mazeghrane
- Service de cardiologie, centre hospitalier universitaire de Tizi-Ouzou, 15000, Tizi-Ouzou, Algérie
| | - A Hammouche
- Service de cardiologie, centre hospitalier universitaire de Tizi-Ouzou, 15000, Tizi-Ouzou, Algérie
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88
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Kjeldsen SE, Os I. Are People With Masked Hypertension Adherent to Their Antihypertensive Medication? Hypertension 2019; 74:497-498. [DOI: 10.1161/hypertensionaha.119.13350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sverre E. Kjeldsen
- From the Institute for Clinical Medicine, University of Oslo, Norway (S.E.K., I.O.)
- Departments of Cardiology (S.E.K.), Oslo University Hospital, Norway
| | - Ingrid Os
- From the Institute for Clinical Medicine, University of Oslo, Norway (S.E.K., I.O.)
- Departments of Cardiology (S.E.K.), Oslo University Hospital, Norway
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89
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Abstract
PURPOSE OF REVIEW To discuss the current definition as well as recommendations for diagnosis and treatment of resistant hypertension (RH) based on the 2018 American Heart Association (AHA) guidelines and recent literature. RECENT FINDINGS RH is defined as uncontrolled blood pressure (BP) on ≥ 3 anti-hypertensives, one of which should be a diuretic, prescribed at maximally tolerated doses and appropriate dosing frequency. The diagnosis of RH requires exclusion of white coat effect and medication non-adherence, underscoring the importance of out-of-office BP measurements. Secondary causes of hypertension must be excluded in all patients with RH. A step-wise approach to treatment focusing on lifestyle modifications and medication optimization can be effective in > 50% of the patients with RH. Device-based interventional therapies for RH are currently investigational. Out-of-office BP measurements are central to the diagnosis of RH. Medication optimization is successful in most patients. Further studies are needed to define the role of device-based interventions.
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Affiliation(s)
- Irene Chernova
- Yale School of Medicine/Section of Nephrology, New Haven, CT, USA
| | - Namrata Krishnan
- Yale School of Medicine/Section of Nephrology, New Haven, CT, USA. .,Veterans Affairs Medical Center, 950 Campbell Ave., West Haven, CT, 06516, USA.
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90
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Dell'Oro R, Quarti-Trevano F, Seravalle G, Zanchettin F, Bertoli S, Airoldi F, Mancia G, Grassi G. Sympathetic Nerve Traffic and Arterial Baroreflex Function in Apparent Drug-Resistant Hypertension. Hypertension 2019; 74:903-909. [PMID: 31378103 DOI: 10.1161/hypertensionaha.119.13009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
True drug-resistant hypertension (RHT) is characterized by a marked neuroadrenergic activation and reflex alterations compared with the nonresistant hypertensive state. It is unknown however, whether this behavior is specific for the RHT state or is also shared by apparent RHT (ARHT). In 38 middle-age patients with RHT, 44 treated essential controlled hypertensives (HT) and 32 ARHT; we evaluated sphygmomanometric, beat-to-beat (Finapres) and 24-hour (Spacelabs) blood pressure, heart rate and muscle sympathetic nerve traffic (microneurography). Measurements included plasma aldosterone, plasma norepinephrine, homeostasis model assessment index, and spontaneous baroreflex-muscle sympathetic nerve traffic sensitivity. All the various above-mentioned blood pressure values were significantly greater in both RHT and ARHT as compared with HT, while 24-hour blood pressure was significantly lower in ARHT as compared with RHT. In ARHT, muscle sympathetic nerve traffic was significantly lower than RHT (74.8±5.2 versus 89.2±4.8 bursts/100 hb, P<0.01) and similar to HT (69.7±4.8 bursts/100 hb, P=NS). RHT showed, at variance from the other 2 groups, greater plasma aldosterone and homeostasis model assessment index values and an impaired baroreflex function. In RHT, but not in ARHT and HT, muscle sympathetic nerve traffic was significantly and inversely related to baroreflex function (r=-0.40, P<0.02) and directly to plasma aldosterone and homeostasis model assessment index values (r=0.34-0.36, P<0.05). Plasma norepinephrine and heart rate values were not significantly different in the 3 groups. These data provide evidence that the marked sympathetic activation and baroreflex dysfunction detected in RHT is not present in ARHT, which displays a sympathetic and baroreflex profile superimposable to that seen in HT. These differences in the neurogenic function may have important clinical and therapeutic implications.
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Affiliation(s)
- Raffaella Dell'Oro
- From the Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca (R.D., F.Q.-T., G.S., F.Z., G.G.)
| | - Fosca Quarti-Trevano
- From the Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca (R.D., F.Q.-T., G.S., F.Z., G.G.)
| | - Gino Seravalle
- From the Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca (R.D., F.Q.-T., G.S., F.Z., G.G.)
| | - Francesca Zanchettin
- From the Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca (R.D., F.Q.-T., G.S., F.Z., G.G.)
| | - Silvio Bertoli
- Istituto di Ricerca a Carattere Scientifico Multimedica, Sesto San Giovanni, Milan (S.B., F.A.)
| | - Flavio Airoldi
- Istituto di Ricerca a Carattere Scientifico Multimedica, Sesto San Giovanni, Milan (S.B., F.A.)
| | | | - Guido Grassi
- From the Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca (R.D., F.Q.-T., G.S., F.Z., G.G.)
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91
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Abstract
PURPOSE OF REVIEW Interventional cardiology and in particular the field of renal denervation is subject to constant change. This review provides an up to date overview of renal denervation trials and an outlook on what to expect in the future. RECENT FINDINGS After the sham-controlled SYMPLICITY HTN-3 trial dampened the euphoria following early renal denervation trials, the recently published results of the sham-controlled SPYRAL HTN and RADIANCE HTN trials provided proof-of-principle for the blood pressure-lowering efficacy of renal denervation. However, these studies underline the major issue of patients' non-adherence to antihypertensive medication as well as the need for reliable patient- and procedure-related predictors of response. The second generation of sham-controlled renal denervation trials provided proof of principle for the blood pressure-lowering efficacy of RDN. However, larger trials have to assess long-term safety and efficacy.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Medical Center and Saarland University, 66421, Homburg, Saar, Germany.
| | - Milan A Wolf
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Medical Center and Saarland University, 66421, Homburg, Saar, Germany
| | - Sean S Scholz
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Medical Center and Saarland University, 66421, Homburg, Saar, Germany
| | - Mathias Hohl
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Medical Center and Saarland University, 66421, Homburg, Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Medical Center and Saarland University, 66421, Homburg, Saar, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Medical Center and Saarland University, 66421, Homburg, Saar, Germany
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92
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Pappaccogli M, Di Monaco S, Georges CM, Petit G, Eula E, Ritscher S, Lengelé JP, Fanelli E, Severino F, Renkin J, Avataneo V, Wallemacq P, Toennes SW, de Timary P, Rabbia F, Persu A. Predictors of blood pressure control in patients with resistant hypertension after intensive management in two expert centres: the Brussels-Torino experience. Blood Press 2019; 28:336-344. [DOI: 10.1080/08037051.2019.1633908] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Marco Pappaccogli
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Silvia Di Monaco
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Coralie M.G. Georges
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Géraldine Petit
- Adult Psychiatry Department and Institute of Neuroscience, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Elisabetta Eula
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Sabrina Ritscher
- Institute of Legal Medicine, Department of Forensic Toxicology, University Hospital Frankfurt, Goethe-University, Frankfurt, Frankfurt/Main, Germany
| | - Jean-Philippe Lengelé
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Department of Nephrology, Grand Hôpital de Charleroi, Gilly, Belgium
| | - Elvira Fanelli
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesca Severino
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jean Renkin
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Valeria Avataneo
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Pierre Wallemacq
- Clinical Chemistry Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Centre for Toxicology and Applied Pharmacology, Université Catholique de Louvain, Brussels, Belgium
| | - Stefan W. Toennes
- Institute of Legal Medicine, Department of Forensic Toxicology, University Hospital Frankfurt, Goethe-University, Frankfurt, Frankfurt/Main, Germany
| | - Philippe de Timary
- Adult Psychiatry Department and Institute of Neuroscience, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Franco Rabbia
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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Li Q, Li L, Wang F, Zhang W, Guo Y, Wang F, Liu Y, Jia J, Lin S. Effect and safety of LCZ696 in the treatment of hypertension: A meta-analysis of 9 RCT studies. Medicine (Baltimore) 2019; 98:e16093. [PMID: 31305392 PMCID: PMC6641826 DOI: 10.1097/md.0000000000016093] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND LCZ696 has been introduced in patients with hypertension in several trials. Here, we performed a meta-analysis to evaluate the effect and safety of LCZ696 in hypertensive patients. METHODS PubMed, Embase, the Cochrane Library and ClinicalTrials.gov databases were searched to identify the available randomized controlled trials (RCTs) investigating the effect and safety of LCZ696 in hypertension patients. The last search date was October 31, 2018. RESULTS Nine RCTs with 6765 subjects were finally included, in which 8 trials compared the effect and safety between LCZ696 and angiotensin receptor antagonists (ARBs). Evidences showed LCZ696, compared with ARBs, achieved a better blood pressure control rate (OR 1.24, 95% CI: 1.14-1.35), specifically, LCZ696 were better at reducing systolic blood pressure [WMD -4.11 mmHg, 95% CI: (-5.13, -3.08) mmHg], diastolic blood pressure [WMD -1.79 mmHg, 95% CI: (-2.22, -1.37) mmHg], mean 24-hour ambulatory systolic blood pressure [WMD -3.24 mmHg, 95% CI: (-4.48, -1.99) mmHg] and mean 24-hour ambulatory diastolic blood pressure [WMD -1.25 mmHg, 95% CI: (-1.81, -0.69) mmHg]. There was no difference in the events of adverse events (risk ratio [RR] 1.01, 95% CI: 0.39-1.09), serious adverse events (RR 0.80, 95% CI: 0.52-1.22) and discontinuation of treatment for any adverse events (RR 0.79, 95% CI: 0.56-1.11) between LCZ696 group and ARB/placebo group, except LCZ696 reduced the rate of headaches (RR 0.69, 95% CI: 0.48-0.99) while increased cough (RR 2.12, 95% CI: 1.11-4.04; P = .02; I = 25%). CONCLUSION Our finding provides evidence that LCZ 696 was more effective than ARB on blood pressure control and was safe enough in patients with hypertension.
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Affiliation(s)
- Qiongqiong Li
- Department of Nephrology, General Hospital of Tianjin Medical University
| | - Lina Li
- Department of Nephrology, General Hospital of Tianjin Medical University
| | - Fanghao Wang
- Department of Nephrology, General Hospital of Tianjin Medical University
| | - Wei Zhang
- Department of Cardiac Surgery, Tianjin Chest Hospital
| | - Yipeng Guo
- Department of Epidemiology, Tianjin Public Health Bureau, Tianjin
| | - Fuzhen Wang
- Department of Statistics, Fenyang Hospital of Shanxi Province, Fenyang, China
| | - Youxia Liu
- Department of Nephrology, General Hospital of Tianjin Medical University
| | - Junya Jia
- Department of Nephrology, General Hospital of Tianjin Medical University
| | - Shan Lin
- Department of Nephrology, General Hospital of Tianjin Medical University
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94
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Antihypertensive drug use in resistant and nonresistant hypertension and in controlled and uncontrolled resistant hypertension. J Hypertens 2019; 36:1563-1570. [PMID: 29601411 DOI: 10.1097/hjh.0000000000001729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIM Treatment-resistant hypertension (TRH) is associated with particular clinical features, nonadherence, and suboptimal treatment. We assessed possible associations of antihypertensive drug classes, specific agents inside each class, and types of combinations, with the presence of non-TRH vs. TRH, and with controlled vs. uncontrolled TRH. METHODS Comparisons were done in 14 264 patients treated with three drugs (non-TRH: 2988; TRH: 11 276) and in 6974 treated with at least four drugs (controlled TRH: 1383; uncontrolled TRH: 5591). Associations were adjusted for age, sex, and previous cardiovascular event. RESULTS In both groups of patients treated with three or with at least four drugs, aldosterone antagonists among drug classes [adjusted odds ratio (OR): 1.82 and 1.41, respectively], and ramipril (OR: 1.28 and 1.30), olmesartan (OR: 1.31 and 1.37), and amlodipine (OR: 1.11 and 1.41) inside each class were significantly associated with blood pressure control (non-TRH or controlled TRH). In patients treated with three drugs, non-TRH was also associated with the use of chlorthalidone (OR: 1.50) and bisoprolol (OR: 1.19), whereas in patients treated with at least four drugs, controlled TRH was significantly associated with the triple combination of a renin-angiotensin system blocker, a calcium channel blocker, and a diuretic (OR: 1.17). CONCLUSION The use of aldosterone antagonists is associated with blood pressure control in patients treated with three or more drugs. Similar results are observed with specific agents inside each class, being ramipril, olmesartan, chlorthalidone, amlodipine, and bisoprolol those exhibiting significant results. An increased use of these drugs might probably reduce the burden of TRH.
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95
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Therapeutic Drug Monitoring to Assess Drug Adherence in Assumed Resistant Hypertension: A Comparison With Directly Observed Therapy in 3 Nonadherent Patients. J Cardiovasc Pharmacol 2019; 72:117-120. [PMID: 29878936 DOI: 10.1097/fjc.0000000000000602] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Resistant hypertension is a common health problem leading to suboptimal cardiovascular prevention. A large number of patients with resistant hypertension have poor medication adherence explaining their assumed resistance to therapy. We combined directly observed therapy (DOT) with therapeutic drug monitoring (TDM) in 3 patients at several time points to enable an extensive feedback on blood pressure (BP) and drug levels. BP was measured with an automatic oscillatory device at regular intervals of 5 minutes (directly before and after drug intake) and at 30-minute intervals (at night) during admission. Blood samples were obtained at different time points (t = in hours; t = 0, 2, 4, 6, 12, and 24 hours after drug intake). DOT was performed under supervision of the physician. In 2 of the 3 patients, automated BP decreased directly after DOT, -10/0 and -5/-5 mm Hg, respectively. Plasma drug levels for several drugs or active metabolites were 0 at t = 0, whereas plasma levels were positive at t = 24 hours after observed intake. We recommend a more frequent use of TDM combined with repeated BP measurements in clinical practice because this is a convenient, objective method of measurement and to ensure that actual drug levels reflect the BP at the time of measurement.
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Weber MA, Mahfoud F, Schmieder RE, Kandzari DE, Tsioufis KP, Townsend RR, Kario K, Böhm M, Sharp AS, Davies JE, Osborn JW, Fink GD, Euler DE, Cohen DL, Schlaich MP, Esler MD. Renal Denervation for Treating Hypertension. JACC Cardiovasc Interv 2019; 12:1095-1105. [DOI: 10.1016/j.jcin.2019.02.050] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/22/2019] [Accepted: 02/26/2019] [Indexed: 12/14/2022]
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Carey RM, Calhoun DA, Bakris GL, Brook RD, Daugherty SL, Dennison-Himmelfarb CR, Egan BM, Flack JM, Gidding SS, Judd E, Lackland DT, Laffer CL, Newton-Cheh C, Smith SM, Taler SJ, Textor SC, Turan TN, White WB. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension 2019; 72:e53-e90. [PMID: 30354828 DOI: 10.1161/hyp.0000000000000084] [Citation(s) in RCA: 589] [Impact Index Per Article: 117.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.
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Wunder C, Persu A, Lengelé JP, Mg Georges C, Renkin J, Pasquet A, Carlier M, Zhang ZY, Staessen JA. Adherence to antihypertensive drug treatment in patients with apparently treatment-resistant hypertension in the INSPiRED pilot study. Blood Press 2019; 28:168-172. [PMID: 30942111 DOI: 10.1080/08037051.2019.1599814] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Drug adherence may be a major problem in the therapy of hypertension and in the diagnosis of therapy resistance. Adherence can be assessed by indirect methods or by direct methods like drug detection in urine with liquid chromatography-mass spectrometric methods. MATERIALS AND METHODS The current analysis included patients with apparently treatment- resistant hypertension (TRH) referred for renal denervation (RDN) and included in the the INSPiRED pilot trial (NCT01505010). Adherence was repeatedly assessed by toxicological urine analysis over a time range of up to 17 months in a total of 18 patients. RESULTS In the first urine samples of 18 patients the adherence rate (percentage of number of detected vs. prescribed medical drugs) ranged from 0 to 100% with a median of 73.2%. In further urine samples collected during the following up to 17 months every individual patient exhibited considerable changes in the adherence rate, neither a constancy nor a tendency could be deduced. CONCLUSIONS Urine analysis results exhibit variation over time and an assessment at a certain time point cannot be regarded as representative or predictor for future behavior. Therefore, it appears necessary to perform drug adherence testing repeatedly over time.
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Affiliation(s)
- Cora Wunder
- a Institute of Legal Medicine, Goethe-University Frankfurt , Frankfurt , Germany
| | - Alexandre Persu
- b Division of Cardiology , Cliniques Universitaires Saint-Luc, Université Catholique de Louvain , Brussels , Belgium.,c Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique , Université Catholique de Louvain , Brussels , Belgium
| | - Jean-Philippe Lengelé
- b Division of Cardiology , Cliniques Universitaires Saint-Luc, Université Catholique de Louvain , Brussels , Belgium.,d Department of Nephrology , Grand Hôpital de Charleroi , Gilly , Belgium
| | - Coralie Mg Georges
- b Division of Cardiology , Cliniques Universitaires Saint-Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Jean Renkin
- b Division of Cardiology , Cliniques Universitaires Saint-Luc, Université Catholique de Louvain , Brussels , Belgium.,c Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique , Université Catholique de Louvain , Brussels , Belgium
| | - Agnès Pasquet
- b Division of Cardiology , Cliniques Universitaires Saint-Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Marc Carlier
- e Department of Cardiology , Grand Hôpital de Charleroi , Gilly , Belgium
| | - Zhen-Yu Zhang
- f Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences , University of Leuven , Leuven , Belgium
| | - Jan A Staessen
- f Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences , University of Leuven , Leuven , Belgium.,g Cardiovascular Research Institute Maastricht (CARIM), Maastricht University , Maastricht , The Netherlands
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- a Institute of Legal Medicine, Goethe-University Frankfurt , Frankfurt , Germany
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99
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Schmidt K, Kelley W, Tringali S, Huang J. Achieving control of resistant hypertension: Not just the number of blood pressure medications. World J Hypertens 2019; 9:1-16. [DOI: 10.5494/wjh.v9.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/11/2019] [Accepted: 01/22/2019] [Indexed: 02/06/2023] Open
Abstract
Resistant hypertension (RH) has a prevalence of around 12% and is associated with an increased risk of cardiovascular disease, progression to end-stage renal disease, and even mortality. In 2017, the American College of Cardiology and American Heart Association released updated guidelines that detail steps to ensure proper diagnosis of RH, including the exclusion of pseudoresistance. Lifestyle modifications, such as low salt diet and physical exercise, remain at the forefront of optimizing blood pressure control. Secondary causes of RH also need to be investigated, including screening for obstructive sleep apnea. Notably, the guidelines demonstrate a major change in medication management recommendations to include mineralocorticoid receptor antagonists. In addition to advances in medication optimization, there are several device-based therapies that have been showing efficacy in the treatment of RH. Renal denervation therapy has struggled to show efficacy for blood pressure control, but with a re-designed catheter device, it is once again being tested in clinical trials. Carotid baroreceptor activation therapy (BAT) via an implantable pulse generator has been shown to be effective in lowering blood pressure both acutely and in long-term follow up data, but there is some concern about the safety profile. Both a second-generation pulse generator and an endovascular implant are being tested in new clinical trials with hopes for improved safety profiles while maintaining therapeutic efficacy. Both renal denervation and carotid BAT need continued study before widespread clinical implementation. Central arteriovenous anastomosis has emerged as another possible therapy and is being actively explored. The ongoing pursuit of blood pressure control is a vital part of minimizing adverse patient outcomes. The future landscape appears hopeful for helping patients achieve blood pressure goals not only through the optimization of antihypertensive medications but also through device-based therapies in select individuals.
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Affiliation(s)
- Kara Schmidt
- Department of Internal Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA 93701, United States
| | - William Kelley
- Department of Internal Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA 93701, United States
| | - Steven Tringali
- Department of Internal Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA 93701, United States
| | - Jian Huang
- Department of Internal Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA 93701, United States
- Medicine Service, VA Central California Health Care System, Fresno, CA 93703, United States
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100
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Chen S, Kiuchi MG, Yin Y, Liu S, Schratter A, Acou WJ, Meyer C, Pürerfellner H, Chun KRJ, Schmidt B. Synergy of pulmonary vein isolation and catheter renal denervation in atrial fibrillation complicated with uncontrolled hypertension: Mapping the renal sympathetic nerve and pulmonary vein (the pulmonary vein isolation plus renal denervation strategy)? J Cardiovasc Electrophysiol 2019; 30:658-667. [PMID: 30680830 DOI: 10.1111/jce.13858] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/14/2019] [Accepted: 01/19/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Disturbance of sympathetic and vagal nervous system participates in the pathogenesis of hypertension and atrial fibrillation (AF). Renal denervation (RDN) can modulate autonomic nervous activity and reduce blood pressure (BP) in hypertensive patients. We aimed to evaluate the effect of RDN combined with pulmonary vein isolation (PVI) in patients with AF and hypertension. METHODS Clinical trials including randomized data comparing PVI plus RDN vs PVI alone were enrolled. Primary outcome was incidence of AF recurrence after procedure. RESULTS A total of 387 patients, of them 252 were randomized and were enrolled. Mean age was 57 ± 10 years, 71% were male, and mean left ventricular ejection fraction was 57.4% ± 6.9%. Follow-up for randomized data was 12 months. Overall comparison for primary outcome showed that PVI + RDN was associated with significantly lower AF recurrence as compared with PVI alone (35.8% vs 55.4%, P < 0.0001). This advantageous effect was consistently maintained among randomized patients (37.3% vs 61.9%, odds ratio = 0.37, P = 0.0001), and among patients with implanted devices for detection of AF recurrence (38.9% vs 61.6%, P = 0.007). Post-hoc sensitivity and regression analysis demonstrated very good stability of this primary result. Pooled Kaplan-Meier analysis further showed that PVI + RDN was associated with significantly higher freedom from AF recurrence as compared with PVI alone (log-rank test, P = 0.001). Besides, RDN resulted in significant BP reduction without additionally increasing the risk of adverse events. CONCLUSIONS RDN may provide synergetic effects with PVI to reduce the burden of AF and improve BP control in patients with AF and uncontrolled hypertension.
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Affiliation(s)
- Shaojie Chen
- Cardioangiologisches Centrum Bethanien (CCB) Frankfurt am Main, Frankfurt Academy For Arrhythmias (FAFA), Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Marcio G Kiuchi
- School of Medicine-Royal Perth Hospital Unit, University of Western Australia, Perth, Western Australia, Australia
| | - Yuehui Yin
- Department of Cardiology, Chongqing Cardiac Arrhythmia Service Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shaowen Liu
- Department of Cardiology, Shanghai First People's Hospital/Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Alexandra Schratter
- Medizinische Abteilung mit Kardiologie, Krankenhaus Hietzing Wien, Vienna, Austria
| | | | - Christian Meyer
- Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie, Universitäres Herzzentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Helmut Pürerfellner
- Abteilung der kardialen Elektrophysiologie/Kardiologie, Akademisches Lehrkrankenhaus der Elisabethinen, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - K R Julian Chun
- Cardioangiologisches Centrum Bethanien (CCB) Frankfurt am Main, Frankfurt Academy For Arrhythmias (FAFA), Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien (CCB) Frankfurt am Main, Frankfurt Academy For Arrhythmias (FAFA), Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt, Germany
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