Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004—BHS IV

Control of Blood Pressure and Risk Attenuation: Post Trial Follow-Up of Randomized Groups

Background

Evidence on long term effectiveness of public health strategies for lowering blood pressure (BP) is scarce. In the Control of Blood Pressure and Risk Attenuation (COBRA) Trial, a 2 x 2 factorial, cluster randomized controlled trial, the combined home health education (HHE) and trained general practitioner (GP) intervention delivered over 2 years was more effective than no intervention (usual care) in lowering systolic BP among adults with hypertension in urban Pakistan. However, it was not clear whether the effect would be sustained after the cessation of intervention. We conducted 7 years follow-up inclusive of 5 years of post intervention period of COBRA trial participants to assess the effectiveness of the interventions on BP during extended follow-up.

Methods

A total of 1341 individuals 40 years or older with hypertension (systolic BP 140 mm Hg or greater, diastolic BP 90 mm Hg or greater, or already receiving treatment) were followed by trained research staff masked to randomization status. BP was measured thrice with a calibrated automated device (Omron HEM-737 IntelliSense) in the sitting position after 5 minutes of rest. BP measurements were repeated after two weeks. Generalized estimating equations (GEE) were used to analyze the primary outcome of change in systolic BP from baseline to 7- year follow-up. The multivariable model was adjusted for clustering, age at baseline, sex, baseline systolic and diastolic BP, and presence of diabetes.

Findings

After 7 years of follow-up, systolic BP levels among those randomised to combined HHE plus trained GP intervention were significantly lower (2.1 [4.1–0.1] mm Hg) compared to those randomised to usual care, (P = 0.04). Participants receiving the combined intervention compared to usual care had a greater reduction in LDL-cholesterol (2.7 [4.8 to 0.6] mg/dl.

Conclusions

The benefit in systolic BP reduction observed in the original cohort assigned to the combined intervention was attenuated but still evident at 7- year follow-up. These findings highlight the potential for scaling-up simple strategies for cardiovascular risk reduction in low- and middle- income countries.

Trial Registration

ClinicalTrials.gov NCT00327574

Managing hypertension with ambulatory blood pressure monitoring

There has been a dramatic shift in the manner in which blood pressure (BP) is measured to provide far more comprehensive clinical information than that provided by a single set of office BP readings. Extensive clinical and epidemiological research shows an important role of ambulatory BP monitoring (ABPM) in the management of hypertensive patients. A 24-h BP profile helps to determine the absence of nocturnal dipping status and evaluate BP control in patients on antihypertensive therapy. The ability to detect white-coat or masked hypertension is enhanced by ambulatory BP monitoring. In 2001, the Center for Medicare and Medicaid Services approved ABPM for reimbursement for the identification of patients with white-coat hypertension. In 2011, the National Institute for Health and Clinical Excellence (NICE) in the UK published guidelines that recommended the routine use of ABPM in all patients suspected of having hypertension. The European Society of Hypertension (ESH) 2013 guidelines also support greater use of ABPM in clinical practice. While the advantages of ABPM are apparent from a clinical perspective, its use should be considered in relation to its cost, the complexity of data evaluation, as well as patient inconvenience. In this review, we evaluate the clinical importance of ABPM, highlighting its role in the current management of hypertension.

Antihypertensive Drugs and Male Sexual Dysfunction

Background:

Published clinical practice guidelines have addressed antihypertensive therapy and sexual dysfunction (SD) in many different ways.

Objective:

In this systematic review, we evaluated guidelines that address antihypertensive drug-associated SD, guideline recommendations, and recent guideline trends.

Methods:

Thirty sets of guidelines for hypertension management in adults that had been published in the English language since 2000 were reviewed. The primary outcome measure was antihypertensive-associated SD potential, which was independently evaluated using specific questions by 2 authors in a nonblinded standardized manner.

Results:

Sexual dysfunctions associated with thiazide-class diuretics, β-blockers, and centrally acting sympathoplegics were addressed by half of the guidelines reviewed. There is no clarity on β-blockers and thiazide-class diuretics because one-third of the guidelines are vague about individual β-blockers and diuretics, and there is no statement on third-generation β-blockers and thiazide-like diuretics that can improve erectile function. The revised guidelines never use terms such as loss of libido, ejaculatory dysfunction, lack of orgasm, and priapism. Summary versions of guidelines are inadequate to reflect the key interpretation of the primary guidelines on SD associated with antihypertensives, even in the major guidelines that were updated recently. Therapeutic issues such as exploring SD in clinical history, assessing SD prior to and during treatment with antihypertensives, substituting the offending agents with alternatives that possess a better safety profile, intervening with phosphodiesterase-5 inhibitors, and avoiding the concomitant use of nitrovasodilators are superficially addressed by most guidelines, with the exception of 2013 European Society of Hypertension/European Society of Cardiology and Seventh Joint National Committee recommendations.

Conclusion:

Future guideline revisions, including both full and summary reports, should provide a balanced perspective on antihypertensive-related SD issues to improve the impact of hypertension treatment guidelines on patient care and quality of life.

Prevalence and determinants of white coat effect in a large UK hypertension clinic population

White coat hypertension (WCH) is common and termed white coat effect (WCE) in those on treatment for hypertension. The UK guideline suggests that all patients in stage 1 and 2 hypertension, but not stage 3 hypertension, should have ambulatory blood pressure monitoring (ABPM) performed before commencing treatment. The relationship between office blood pressure (BP) and ABPM and the factors that influence the WCE were examined in a large British cohort (n=2056) from 2 hypertension clinics (1998-2011). Data were collected prospectively: the median age was 56 years: 53% were female, 76% Caucasian, 9% African Caribbean, 15% South Asian and 86% taking antihypertensives. Fifty-one percent had WCE and differences between clinic BP and ABPM measurements increased with the stage of hypertension varying from 2/4 (normotensive), 13/10 (stage 1 hypertension), 24/14 (stage 2) and 40/20 mm Hg (stage 3). The degree of difference is greater in this study than described in other populations. A positive correlation was found between clinic systolic and diastolic BP and the WCE (r=0.74 and r=0.56, respectively, P<0.0001). Significant (P<0.05) independent associations of systolic WCE were clinic systolic BP (β=0.707), Caucasian ethnicity (South Asian β=-0.06; African Caribbean β=-0.043), female gender (male β=-0.047), nonsmoking status (smoker β=-0.100) and reduced renal function (estimated glomerular filtration rate β=-0.036). Significant independent associations of diastolic WCH were clinic diastolic BP (β=0.624), age (β=0.207), female gender (male β=-0.104), Caucasian ethnicity (South Asian β=-0.052, African Caribbean β=-0.079) and being a nonsmoker (β=-0.082) or ex-smoker (β=0.046). The results support current UK guidelines but suggest those with stage 3 hypertension would also benefit from ABPM.

Hypertension

Raised blood pressure is the biggest single contributor to the global burden of disease and to global mortality. The numbers of people affected and the prevalence of high blood pressure worldwide are expected to increase over the next decade. Preventive strategies are therefore urgently needed, especially in less developed countries, and management of hypertension must be optimised. Genetic advances in some rare causes of hypertension have been made lately, but the aggregate effect on blood pressure of all the genetic loci identified to date is small. Hence, intervention on key environmental determinants and effective implementation of trial-based therapies are needed. Three-drug combinations can control hypertension in about 90% of patients but only if resources allow identification of patients and drug delivery is affordable. Furthermore, assessment of optimal drug therapy for each ethnic group is needed.

Do Obese Individuals With Hypertension Have More Difficult-to-Control Blood Pressure and End Organ Damage Than Their Nonobese Counterparts?

The authors assessed whether individuals with elevated body mass index (BMI) and hypertension had more difficult-to-control blood pressure (BP) and more evidence of end organ damage using data collected prospectively over 11 years from a secondary care hypertension clinic. A total of 1114 individuals were divided by BMI criteria into normal (n=207), overweight (n=440), and obese (n=467). Mean daytime, nighttime, and 24-hour systolic BP and diastolic BP were similar in all groups. There was less nocturnal dip in obese compared with overweight groups (P=.025). Individuals with a normal BMI were taking fewer antihypertensive medications than those in the obese group (P=.01). Individuals classified as obese had a higher left ventricular mass index than those with a normal BMI (female, P=.028; male, P<.001); this relationship remained after multivariate linear regression. Obese individuals with hypertension required more medication to achieve similar mean ambulatory BP values, had less nocturnal dip in BP, and had a higher prevalence of left ventricular hypertrophy. As such, obese patients are at potentially increased risk of cardiovascular events.

Assessment of potential cardiovascular risks of methylphenidate in comparison with sibutramine: do we need a SCOUT (trial)?

With the recent approval of methylphenidate (MPH) for treating attention-deficit/hyperactivity disorder (ADHD) in adults, the number of patients exposed will increase tremendously. The ongoing debate on the cardiovascular safety of MPH has triggered two large retrospective cohort studies in children and adolescents as well as in young to middle-aged adults. These studies looked into serious cardiovascular events (sudden cardiac death, acute myocardial infarction and stroke) as primary endpoints and concluded that MPH was safe after a mean duration of 2.1 years of follow-up in children and adolescents and mean duration of 0.33 years of current use in adults. The results are encouraging with respect to the short- and medium-term use of MPH. Without the inherent limitations of retrospective cohort studies, a prospective randomized, double-blind, placebo-controlled, multicenter trial in individuals stratified for cardiovascular risk factors would allow for an optimized risk assessment. With many millions of patients treated per year and drawing parallels to the lately discovered risks of sibutramine, another sympathomimetic with an overlapping mode of action and similar side effects on heart rate and blood pressure, we hypothesize that such a trial might be a dedicated risk mitigation strategy for public health. A critical assessment of cardiovascular side effects of MPH appears particularly warranted, because ADHD is associated with obesity, smoking and poor health in general. We summarize recent findings with the focus on cardiovascular risks of MPH in humans; we additionally analyze the limited number of rodent studies that have addressed cardiovascular risks of MPH.

Evaluating the angina plan in patients admitted to hospital with angina: a randomized controlled trial

The aim of this trial was to evaluate the Angina Plan (AP), a cognitive-behavioral nurse-facilitated self-help intervention against standard care (SC). A randomized controlled trial of 218 patients hospitalized with angina assessed participants predischarge and 6 months later. Data were collected during a structured interview using validated questionnaires, self-report, and physiological measurement to assess between group changes in mood, knowledge and misconceptions, cardiovascular risk, symptoms, quality of life, and health service utilization. The intention-to-treat (ITT) analysis found no reliable effects on anxiety and depression at 6 months. AP participants reported increased knowledge, less misconceptions, reduced body mass index (BMI), an increase in self-reported exercise, less functional limitation, and improvements in general health perceptions and social and leisure activities compared to those receiving SC. Sensitivity analysis excluding participants with high baseline depression revealed a statistical significant reduction in depression levels in AP compared to the SC participants. Analysis excluding participants receiving cardiac surgery or angioplasty removed the ITT effects on physical limitation, self-reported exercise and general health perceptions and the improvements seen in social and leisure activities, while adaptive effects on knowledge, misconceptions and BMI remained and between-group changes in depression approached significance. Initiating the AP in a secondary care setting for patients with new and existing angina produces similar benefits to those reported in newly diagnosed primary care patients. Further evaluation is required to examine the extent of observed effects in the longer term.

Safety and efficacy of LCZ696, a first-in-class angiotensin receptor neprilysin inhibitor, in Japanese patients with hypertension and renal dysfunction

This 8-week, multi-center, open-label study assessed the safety and efficacy of LCZ696, a first-in-class angiotensin receptor neprilysin inhibitor, in Japanese patients with hypertension and renal dysfunction. Patients (n=32) with mean sitting systolic blood pressure (msSBP) ⩾140 mm Hg (after a 2–5-week washout of previous antihypertensive medications) and estimated glomerular filtration rate (eGFR) ⩾15 and <60 ml min⁻¹ 1.73 m⁻² received LCZ696 100 mg with an optional titration to 200 and 400 mg in a sequential manner starting from Week 2 in patients with inadequate BP control (msSBP ⩾130 mm Hg and mean sitting diastolic blood pressure (msDBP) ⩾80 mm Hg) and without safety concerns. Safety was assessed by monitoring and recording all adverse events (AEs) and change in potassium and creatinine. Efficacy was assessed as change from baseline in msSBP/msDBP. The mean baseline BP was 151.6/86.9 mm Hg, urinary albumin/creatinine ratio (UACR) geometric mean was 7.3 mg mmol⁻¹ and eGFR was ⩾30 and <60 in 25 (78.1%) patients and was ⩾15 and <30 in 7 (21.9%) patients. Fourteen (43.8%) patients reported at least one AE, which were mild in severity. No severe AEs or deaths were reported. There were no clinically meaningful changes in creatinine, potassium, blood urea nitrogen and eGFR. The geometric mean reduction in UACR was 15.1%, and the mean reduction in msSBP and msDBP was 20.5±11.3 and 8.3±6.3 mm Hg, respectively, from baseline to Week 8 end point. LCZ696 was generally safe and well tolerated and showed effective BP reduction in Japanese patients with hypertension and renal dysfunction without a decline in renal function.

Body composition indices and predicted cardiovascular disease risk profile among urban dwellers in Malaysia

Objectives. This study aims to compare various body composition indices and their association with a predicted cardiovascular disease (CVD) risk profile in an urban population in Kuala Lumpur, Malaysia. Methods. A cross-sectional survey was conducted in metropolitan Kuala Lumpur, Malaysia, in 2012. Households were selected using a simple random-sampling method, and adult members were invited for medical screening. The Framingham Risk Scoring algorithm was used to predict CVD risk, which was then analyzed in association with body composition measurements, including waist circumference, waist-hip ratio, waist-height ratio, body fat percentage, and body mass index. Results. Altogether, 882 individuals were included in our analyses. Indices that included waist-related measurements had the strongest association with CVD risk in both genders. After adjusting for demographic and socioeconomic variables, waist-related measurements retained the strongest correlations with predicted CVD risk in males. However, body mass index, waist-height ratio, and waist circumference had the strongest correlation with CVD risk in females. Conclusions. The waist-related indicators of abdominal obesity are important components of CVD risk profiles. As waist-related parameters can quickly and easily be measured, they should be routinely obtained in primary care settings and population health screens in order to assess future CVD risk profiles and design appropriate interventions.

Molecular targets of antihypertensive peptides: understanding the mechanisms of action based on the pathophysiology of hypertension

There is growing interest in using functional foods or nutraceuticals for the prevention and treatment of hypertension or high blood pressure. Although numerous preventive and therapeutic pharmacological interventions are available on the market, unfortunately, many patients still suffer from poorly controlled hypertension. Furthermore, most pharmacological drugs, such as inhibitors of angiotensin-I converting enzyme (ACE), are often associated with significant adverse effects. Many bioactive food compounds have been characterized over the past decades that may contribute to the management of hypertension; for example, bioactive peptides derived from various food proteins with antihypertensive properties have gained a great deal of attention. Some of these peptides have exhibited potent in vivo antihypertensive activity in both animal models and human clinical trials. This review provides an overview about the complex pathophysiology of hypertension and demonstrates the potential roles of food derived bioactive peptides as viable interventions targeting specific pathways involved in this disease process. This review offers a comprehensive guide for understanding and utilizing the molecular mechanisms of antihypertensive actions of food protein derived peptides.

Pharmacology in peripheral arterial disease: what the interventional radiologist needs to know

Peripheral arterial disease (PAD) is a progressive disease with significant morbidity and mortality. Risk factor control, using diet and lifestyle modification, exercise, and pharmacological methods, improves symptoms and reduces associated cardiovascular events in these patients. Antiplatelet agents and anticoagulants may be used to reduce the incidence of acute events related to thrombosis. The armamentarium available for symptom relief and disease modification is discussed. Novel treatments such as therapeutic angiogenesis are in their evolutionary phase with promising preclinical data.

Does the position or contact pressure of the stethoscope make any difference to clinical blood pressure measurements: an observational study

This study aimed to investigate the effect of stethoscope position and contact pressure on auscultatory blood pressure (BP) measurement. Thirty healthy subjects were studied. Two identical stethoscopes (one under the cuff, the other outside the cuff) were used to simultaneously and digitally record 2 channels of Korotkoff sounds during linear cuff pressure deflation. For each subject, 3 measurements with different contact pressures (0, 50, and 100 mm Hg) on the stethoscope outside the cuff were each recorded at 3 repeat sessions. The Korotkoff sounds were replayed twice on separate days to each of 2 experienced listeners to determine systolic and diastolic BPs (SBP and DBP). Variance analysis was performed to study the measurement repeatability and the effect of stethoscope position and contact pressure on BPs. There was no significant BP difference between the 3 repeat sessions, between the 2 determinations from each listener, between the 2 listeners and between the 3 stethoscope contact pressures (all P > 0.06). There was no significant SBP difference between the 2 stethoscope positions at the 2 lower stethoscope pressures (P = 0.23 and 0.45), but there was a small (0.4 mm Hg, clinically unimportant) significant difference (P = 0.005) at the highest stethoscope pressure. The key result was that, DBP from the stethoscope under the cuff was significantly lower than that from outside the cuff by 2.8 mm Hg (P < 0.001, 95% confidence interval -3.5 to -2.1 mm Hg). Since it is known that the traditional Korotkoff sound method, with the stethoscope outside the cuff, tends to give a higher DBP than the true intra-arterial pressure, this study could suggest that the stethoscope position under the cuff, and closer to the arterial occlusion, might yield measurements closer to the actual invasive DBP.

The prevalence of dementia subtypes in rural Tanzania

OBJECTIVES

The prevalence of dementia is predicted to increase rapidly in developing countries. Vascular risk factors may contribute to this rise. Our aim was to estimate the proportions of Alzheimer's disease (ADD) and vascular dementia (VAD) in a prevalent cohort of dementia cases in rural Tanzania.

DESIGN

A two-stage door-to-door dementia prevalence study.

SETTING

Hai district, Tanzania

PARTICIPANTS

In Phase I, the Community Screening Instrument for Dementia (CSI-D) was used to screen 1198 community-dwelling people for dementia. In Phase II, 168/184 (91.3%) of those with poor performance, 56/104 (53.8%) of those with intermediate performance and 72/910 (7.9%) of those with good performance on CSI-D were interviewed and diagnoses were made using the DSM-IV criteria.

MEASUREMENTS

For subtype diagnosis, DSM-IV dementia criteria plus NINCDS-ADRDA criteria were used for ADD and NINDS-AIREN criteria for VAD. Other dementias were diagnosed by international consensus criteria. Diagnoses were confirmed or excluded by computerised tomography where clinically appropriate.

RESULTS

Of 78 dementia cases, 38 (48.7%) were ADD and 32 (41.0%) were VAD. The crude prevalence of ADD was 3.7% (95% CI 2.5 to 4.9) and of VAD was 2.9% (95% CI 1.9 to 3.9). The age-adjusted prevalence was 3.0% (95% CI 1.8 to 4.2) for ADD and 2.6% (95% CI 1.6 to 3.6) for VAD. A previous diagnosis of diabetes mellitus was independently associated with greater odds of having VAD than ADD.

CONCLUSIONS

VAD accounted for a greater proportion of dementia cases than expected. Further investigation and treatment of risk factors is required in this setting.

CPAP treatment supported by telemedicine does not improve blood pressure in high cardiovascular risk OSA patients: a randomized, controlled trial

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) has been associated with hypertension, which is one of the intermediary mechanisms leading to increased cardiovascular morbidity. This study aimed at evaluating the effects of a combination of continuous positive airway pressure (CPAP) and telemedicine support on blood pressure (BP) reduction in high cardiovascular risk OSA patients.

DESIGN

A multi-center randomized controlled trial that compared standard CPAP care and CPAP care and a telemedicine intervention.

SETTING

Sleep clinics in France.

PATIENTS OR PARTICIPANTS

107 adult (18-65 years old) OSA patients (AHI > 15 events/h) with a high cardiovascular risk (cardiovascular SCORE > 5% or secondary prevention).

INTERVENTIONS

Patients were randomized to either standard care CPAP (n = 53) or CPAP and telemedicine (n = 54). Patients assigned to telemedicine were equipped with a smartphone for uploading BP measurements, CPAP adherence, sleepiness, and quality of life data; in return, they received pictograms containing health-related messages.

MEASUREMENTS

The main outcome was home self-measured BP and secondary outcomes were cardiovascular risk evolution, objective physical activity, CPAP adherence, sleepiness and quality of life.

RESULTS

Self-measured BP did not improve in either group (telemedicine or standard care). Patients in primary prevention showed greater BP reduction with CPAP treatment than those in secondary prevention.

CONCLUSIONS

CPAP treatment supported by telemedicine alone did not improve blood pressure and cardiovascular risk in high cardiovascular risk OSA patients. This study emphasizes the need for diet and physical activity training programs in addition to CPAP when aiming at decreasing cardiometabolic risk factors in these patients.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT01226641.

Drug treatment of hypertension in pregnancy: a critical review of adult guideline recommendations

This review evaluates the guideline recommendations for the management of hypertension in pregnancy as presented by 25 national/international guidelines developed for the management of arterial hypertension in adults. There is a general consensus that oral α-methyldopa and parenteral labetalol are the drugs of choice for nonsevere and severe hypertension in pregnancy, respectively. Long-acting nifedipine is recommended by various guidelines as an alternative for first-line and second-line therapy in nonsevere and severe hypertension. The safety of β-blockers, atenolol in particular, in early and late stages of pregnancy is unresolved; their use is contraindicated according to several guidelines. Diuretic-associated harmful effects on maternal and fetal outcomes are controversial: their use is discouraged in pregnancy. It is important to develop specific guidelines for treating hypertension in special groups such as adult females of childbearing age and sexually active female adolescents to minimize the risk of adverse effects of drugs on the fetus. In several guidelines, the antihypertensive classes, recommended drug(s), intended drug formulation, and route of administration are not explicit. These omissions should be addressed in future guideline revisions in order to enhance the guidelines' utility and credibility in clinical practice.

Prediction of BP reactivity to talking using hybrid soft computing approaches

High blood pressure (BP) is associated with an increased risk of cardiovascular diseases. Therefore, optimal precision in measurement of BP is appropriate in clinical and research studies. In this work, anthropometric characteristics including age, height, weight, body mass index (BMI), and arm circumference (AC) were used as independent predictor variables for the prediction of BP reactivity to talking. Principal component analysis (PCA) was fused with artificial neural network (ANN), adaptive neurofuzzy inference system (ANFIS), and least square-support vector machine (LS-SVM) model to remove the multicollinearity effect among anthropometric predictor variables. The statistical tests in terms of coefficient of determination (R (2)), root mean square error (RMSE), and mean absolute percentage error (MAPE) revealed that PCA based LS-SVM (PCA-LS-SVM) model produced a more efficient prediction of BP reactivity as compared to other models. This assessment presents the importance and advantages posed by PCA fused prediction models for prediction of biological variables.

A cluster-randomized controlled trial to evaluate the effects of a simplified cardiovascular management program in Tibet, China and Haryana, India: study design and rationale

Background

In resource-poor areas of China and India, the cardiovascular disease burden is high, but availability of and access to quality healthcare is limited. Establishing a management scheme that utilizes the local infrastructure and builds healthcare capacity is essential for cardiovascular disease prevention and management. The study aims to develop, implement, and evaluate the feasibility and effectiveness of a simplified, evidence-based cardiovascular management program delivered by community healthcare workers in resource-constrained areas in Tibet, China and Haryana, India.

Methods/design

This yearlong cluster-randomized controlled trial will be conducted in 20 villages in Tibet and 20 villages in Haryana. Randomization of villages to usual care or intervention will be stratified by country. High cardiovascular disease risk individuals (aged 40 years or older, history of heart disease, stroke, diabetes, or measured systolic blood pressure of 160 mmHg or higher) will be screened at baseline. Community health workers in the intervention villages will be trained to manage and follow up high-risk patients on a monthly basis following a simplified ‘2 + 2’ intervention model involving two lifestyle recommendations and the appropriate prescription of two medications. A customized electronic decision support system based on the intervention strategy will be developed to assist the community health workers with patient management. Baseline and follow-up surveys will be conducted in a standardized fashion in all villages. The primary outcome will be the net difference between-group in the proportion of high-risk patients taking antihypertensive medication pre- and post-intervention. Secondary outcomes will include the proportion of patients taking aspirin and changes in blood pressure. Process and economic evaluations will also be conducted.

Discussion

To our knowledge, this will be the first study to evaluate the effect of a simplified management program delivered by community health workers with the help of electronic decision support system on improving the health of high cardiovascular disease risk patients. If effective, this intervention strategy can serve as a model that can be implemented, where applicable, in rural China, India, and other resource-constrained areas.

Trial registration

The trial was registered in the clinicaltrials.gov database on 30 December, 2011 and the registration number is NCT01503814.

Type of β-blocker use among patients with versus without diabetes after myocardial infarction

BACKGROUND

Discharge β-blocker prescription after myocardial infarction (MI) is recommended for all eligible patients. Numerous β-blocker choices are presently available with variable glycometabolic effects, which could be an important consideration in patients with diabetes mellitus (DM). Whether patients with DM preferentially receive β-blockers with favorable metabolic effects after MI and if this choice is associated with better glycemic control postdischarge is unknown.

METHODS

Among patients from 24 US hospitals enrolled in an MI registry (2005-2008), we investigated the frequency of "DM-friendly" β-blocker prescription at discharge by DM status. β-Blockers were classified as DM-friendly (eg, carvedilol and labetalol) or non-DM-friendly (eg, metoprolol and atenolol), based on their effects on glycemic control. Hierarchical, multivariable logistic regression examined the association of DM with DM-friendly β-blocker use. Among DM patients, we examined the association of DM-friendly β-blockers with worsened glycemic control at 6 months after MI.

RESULTS

Of 4,031 MI patients, 1,382 (34%) had DM. β-Blockers were prescribed at discharge in 93% of patients. Diabetes mellitus-friendly β-blocker use was low regardless of DM status, although patients with DM were more likely to be discharged on a DM-friendly β-blocker compared with patients without DM (13.5% vs 10.3%, P = .003), an association that remained after multivariable adjustment (odds ratio 1.41, 95% CI 1.13-1.77). There was a trend toward a lower risk of worsened glucose control at 6 months in DM patients prescribed DM-friendly versus non-DM-friendly β-blockers (Relative Risk 0.80, 95% CI 0.60-1.08).

CONCLUSION

Most DM patients were prescribed non-DM-friendly β-blockers-a practice that was associated with a trend toward worse glycemic control postdischarge. Although in need of further confirmation in larger studies, our findings highlight an opportunity to improve current practices of β-blockers use in patients with DM.

Molecular insights from dysregulation of the thiazide-sensitive WNK/SPAK/NCC pathway in the kidney: Gordon syndrome and thiazide-induced hyponatraemia

Human blood pressure is dependent on balancing dietary salt intake with its excretion by the kidney. Mendelian syndromes of altered blood pressure demonstrate the importance of the distal nephron in this process and of the thiazide-sensitive pathway in particular. Gordon syndrome (GS), the phenotypic inverse of the salt-wasting Gitelman syndrome, is a condition of hyperkalaemic hypertension that is reversed by low-dose thiazide diuretics or a low-salt diet. Variants within at least four genes [i.e. with-no-lysine(K) kinase 1 (WNK1), WNK4, kelch-like family member 3 (KLHL3) and cullin 3 (CUL3)] can cause the phenotype of GS. Details are still emerging for some of these genes, but it is likely that they all cause a gain-of-function in the thiazide-sensitive Na(+) -Cl(-) cotransporter (NCC) and hence salt retention. Herein, we discuss the key role of STE20/sporulation-specific protein 1 (SPS1)-related proline/alanine-rich kinase (SPAK), which functions as an intermediary between the WNKs and NCC and for which a loss-of-function mutation produces a Gitelman-type phenotype in a mouse model. In addition to Mendelian blood pressure syndromes, the study of patients who develop thiazide-induced-hyponatraemia (TIH) may give further molecular insights into the role of the thiazide-sensitive pathway for salt reabsorption. In the present paper we discuss the key features of TIH, including its high degree of reproducibility on rechallenge, possible genetic predisposition and mechanisms involving excessive saliuresis and water retention. Together, studies of Gordon syndrome and TIH may increase our understanding of the molecular regulation of sodium trafficking via the thiazide-sensitive pathway and have important implications for hypertensive patients, both in the identification of new antihypertensive drug targets and avoidance of hyponatraemic side-effects.

Home and ambulatory blood pressure monitoring: when? who?

Blood pressure measurement in the diagnosis and management of hypertension, including the technique required for ambulatory blood pressure monitoring and home blood pressure monitoring, will be reviewed in this article. Home and ambulatory measurements are widely used, both to confirm the diagnosis and to improve adherence to therapy. The major advantage of out-of-office blood pressure monitoring is that it provides a large number of blood pressure measurements away from the medical environment, which represents a more reliable assessment of actual blood pressure than office blood pressure. The advantage of ambulatory blood pressure monitoring is its unique ability to measure nocturnal blood pressure. Although not fully validated in large-scale clinical trials, ambulatory blood pressure monitoring appears to correlate best with prognosis. Ambulatory blood pressure monitoring and home blood pressure monitoring provide somewhat different information on the subject's blood pressure status, and the two methods should thus be regarded as complementary, rather than competitive or alternative.

Hypertension management in England: a serial cross-sectional study from 1994 to 2011

BACKGROUND

Hypertension is the leading risk factor contributing to the global burden of disease. We aimed to assess the change in blood pressure management between 1994 and 2011 in England with a series of annual surveys.

METHODS

We did a serial cross-sectional study of five Health Survey for England surveys based on nationally representative samples of non-institutionalised adults (aged ≥16 years). Mean blood pressure levels and rates of awareness, treatment, and control of hypertension were assessed. Hypertension was defined as systolic blood pressure 140 mm Hg or higher, diastolic blood pressure 90 mm Hg or higher, or receiving treatment for high blood pressure.

FINDINGS

The mean blood pressure levels of men and women in the general population and among patients with treated hypertension progressively improved between 1994 and 2011. In patients with treated hypertension, blood pressure improved from 150·0 (SE 0·59)/80·2 (0·27) mm Hg to 135·4 (0·58)/73·5 (0·41) mm Hg. Awareness, treatment, and control rates among men and women combined also improved significantly across each stage of this 17-year period, with the prevalence of control among treated patients almost doubling from 33% (SE 1·4) in 1994 to 63% (1·7) in 2011. Nevertheless, of all adults with survey-defined hypertension in 2011, hypertension was controlled in only 37%.

INTERPRETATION

If the same systematic improvement in all aspects of hypertension management continues until 2022, 80% of patients with treated hypertension will have controlled blood pressure levels with a potential annual saving of about 50,000 major cardiovascular events.

FUNDING

None.

European Society of Hypertension position paper on ambulatory blood pressure monitoring

Ambulatory blood pressure monitoring (ABPM) is being used increasingly in both clinical practice and hypertension research. Although there are many guidelines that emphasize the indications for ABPM, there is no comprehensive guideline dealing with all aspects of the technique. It was agreed at a consensus meeting on ABPM in Milan in 2011 that the 34 attendees should prepare a comprehensive position paper on the scientific evidence for ABPM.This position paper considers the historical background, the advantages and limitations of ABPM, the threshold levels for practice, and the cost-effectiveness of the technique. It examines the need for selecting an appropriate device, the accuracy of devices, the additional information and indices that ABPM devices may provide, and the software requirements.At a practical level, the paper details the requirements for using ABPM in clinical practice, editing considerations, the number of measurements required, and the circumstances, such as obesity and arrhythmias, when particular care needs to be taken when using ABPM.The clinical indications for ABPM, among which white-coat phenomena, masked hypertension, and nocturnal hypertension appear to be prominent, are outlined in detail along with special considerations that apply in certain clinical circumstances, such as childhood, the elderly and pregnancy, and in cardiovascular illness, examples being stroke and chronic renal disease, and the place of home measurement of blood pressure in relation to ABPM is appraised.The role of ABPM in research circumstances, such as pharmacological trials and in the prediction of outcome in epidemiological studies is examined and finally the implementation of ABPM in practice is considered in relation to the issue of reimbursement in different countries, the provision of the technique by primary care practices, hospital clinics and pharmacies, and the growing role of registries of ABPM in many countries.

Models to Predict the Burden of Cardiovascular Disease Risk in a Rural Mountainous Region of Vietnam

OBJECTIVE

To compare and identify the most appropriate model to predict cardiovascular disease (CVD) in a rural area in Northern Vietnam, using data on hypertension from the communities.

METHODS

A cross-sectional survey was conducted including all residents in selected communities, aged 34 to 65 years, during April to August 2012 in Thai Nguyen province. Data on age, sex, smoking status, blood pressure, and blood tests (glucose, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol) were collected to identify the prevalence of high blood pressure and to use as input variables for the models. We compared three models, Asian, Chinese Multiple-provincial Cohort Study (CMCS), and Framingham, to estimate cardiovascular risk in the coming years in this context and compare these models and outcomes.

RESULTS

The prevalence of high blood pressure in these communities was lower than reported nationally (12.3%). CVD risk differed greatly depending on the model applied: approximately 21% of the subjects according to the CMCS and Asian models, but 37% using the Framingham model, had more than 10% risk for CVD. In the group without current CVD, these numbers decreased to 9% using the CMCS and Asian models but increased to 28% according to the Framingham model. There were no significant differences between the Asian and CMCS models, but differences were highly significant when comparing Asian versus Framingham or CMCS versus Framingham model.

CONCLUSIONS

The Asian and CMCS models provided similar results in predicting CVD risk in the Vietnamese population in Thai Nguyen. The Framingham model provided vastly different results. The suggestion may be that for the specific Vietnamese setting, the Asian and CMCS models provide most valid and reliable results; however, this has to be investigated in further analyses using real-life data for potential confirmation.

Urinary angiotensinogen excretion is associated with blood pressure independent of the circulating renin-angiotensin system in a group of african ancestry

Although the circulating renin-angiotensin system (RAS) is suppressed in salt-sensitive populations, the role of the intrarenal RAS in blood pressure (BP) control in these groups independent of the circulating RAS is uncertain. We evaluated the relationship between 24-hour urinary angiotensinogen excretion and either office (mean of 5 measurements; n=425) or 24-hour ambulatory (n=340) BP independent of the circulating RAS in a community-based sample of African descent that had never received antihypertensive drug therapy. Circulating RAS activity was determined from plasma renin and angiotensinogen and serum aldosterone concentrations. Urinary angiotensinogen to creatinine ratio (angiotensinogen/creat) was correlated with plasma angiotensinogen concentrations (P<0.0005) but not with indexes of salt intake. However, urinary angiotensinogen/creat was independently associated with office systolic BP (partial r=0.16; P<0.001), whereas plasma angiotensinogen (partial r=0.07; P=0.14) was not independently associated with office systolic BP. Urinary angiotensinogen/creat was also associated with 24-hour systolic BP (partial r=0.11; P<0.05). The relationships between urinary angiotensinogen/creat and BP survived further adjustments for plasma angiotensinogen and serum aldosterone concentrations, plasma renin concentrations, estimated glomerular filtration rate, urinary Na(+)/K(+), or 24-hour urinary Na(+) excretion rates (P<0.005 for all). Participants with the highest compared with the lowest quartile of urinary angiotensinogen/creat showed an 8.2-mm Hg higher office (P<0.005) and 4.6-mm Hg higher 24-hour (P=0.01) systolic BP. In conclusion, independent of the systemic RAS, including plasma angiotensinogen concentrations, urinary angiotensinogen excretion is associated with BP in a salt-sensitive, low-renin group of African descent. These data lend further support for a role of the RAS in BP control in salt-sensitive groups of African ancestry.

Evaluation of a specialist nurse-led hypertension clinic with consultant backup in two inner city general practices: randomized controlled trial

BACKGROUND

Although practice nurses are increasingly involved in hypertension management, there is little robust evidence of effectiveness.

OBJECTIVE

To evaluate the effect of a specialist nurse-led hypertension clinic with consultant backup on change in systolic blood pressure.

DESIGN

Randomized trial.

SETTING

Two inner city general practices. Participants. Three hundred and fifty-three patients, mean age 62 years (range 18-99), with last recorded blood pressure ≥ British Hypertension Society audit standard were randomly allocated to the nurse-led clinic or usual care. Intervention. Patients received a letter informing them that their last blood pressure was over target and inviting them to the clinic. After assessment at the clinic, the nurse discussed any changes in anti-hypertensive treatment with a visiting consultant and the patient's GP, and followed up the patient over 6 months until blood pressure targets were achieved.

MAIN OUTCOME MEASURE

Reduction in systolic blood pressure, assessed using two audits of the practices' computerized records where blood pressure was measured independently by practice staff before and after the intervention period.

RESULTS

Follow-up was 89% (313/353). There was greater reduction in systolic blood pressure in the clinic group (n = 144) than usual care group (n = 169, adjusted difference 4.4 mmHg; 95% CI 0.7 to 8.2). Of 167 patients randomly selected for the clinic, 91 (55%) attended, 49 had blood pressure above target when measured according to protocol and 26 had their anti-hypertensive treatment intensified by their GP.

CONCLUSION

Invitation to a specialist nurse-led hypertension clinic with consultant back up was associated with reduced systolic blood pressure.

Serum potassium levels predict blood pressure response to aldosterone antagonists in resistant hypertension

The objective of this study was to identify factors associated with the blood pressure (BP) response to spironolactone--aldosterone receptor antagonist as an add-on therapy in patients with resistant hypertension (HTN). We retrospectively reviewed the data of subjects with resistant HTN who were treated with add-on spironolactone in a large HTN clinic. A paired Student's t-test was used to assess the differences between the BP values before and during spironolactone administration, and multivariate analysis was used to assess the predictors of a satisfactory BP response (a decrease in systolic BP >10%). We analyzed the data of 48 hypertensive participants. The add-on spironolactone therapy had a significant BP-lowering effect in both systolic and diastolic BP values (P < 0.01 for both). Baseline serum potassium levels of <4.5 mEq l(-1) were associated with a satisfactory BP response (P < 0.01). Furthermore, every decrement of 1 mEq l(-1) of serum potassium was independently associated with a fivefold higher rate of achieving a satisfactory BP response to spironolactone therapy (P = 0.024). Additional factors independently associated with an improved systolic BP response were old age (P = 0.033), body mass index (P = 0.033) and high baseline systolic BP (P=0.004). Our results support the use of add-on spironolactone therapy in patients with resistant HTN who are elderly and obese and have high systolic BP and serum potassium levels <4.5 mEq l(-1).

Impact of ethnic-specific guidelines for anti-hypertensive prescribing in primary care in England: a longitudinal study

Background

In England, the National Institute for Health and Care Excellence (NICE) produces guidelines for the management of hypertension. In 2006, the NICE guidelines introduced an ethnic-age group algorithm based on the 2004 British Hypertension Society guidelines to guide antihypertensive drug prescription.

Methods

A longitudinal retrospective study with 15933 hypertensive patients aged 18 years or over and registered with 28 general practices in Wandsworth, London in 2007 was conducted to assess variations in antihypertensive prescribing. Logistic models were used to measure variations in the odds of being prescribed the 2006 NICE first line recommended monotherapy among NICE patient groups over the period.

Results

From 2000 to 2007, the percentage of patients prescribed the recommended monotherapy increased from 54.2% to 61.4% (p < 0.0001 for annual trend). Over the study period, black patients were more likely to be prescribed the recommended monotherapy than younger non-black patients (OR 0.16, 95% CI 0.12 – 0.21) and older non-black patients (OR 0.49, 95% CI 0.37 – 0.65). After the introduction of the NICE guidelines there was an increase in the NICE recommended monotherapy (OR 1.44, 95% CI 1.19 – 1.75) compared with the underlying trend. Compared to black patients, an increase in the use of recommended monotherapy was observed in younger non-black patients (OR 1.49, 95% CI 1.17 – 1.91) but not in older non-black patients (OR 0.58, 95% CI 0.46 – 0.74).

Conclusion

The introduction of the 2006 NICE guideline had the greatest impact on prescribing for younger non-black patients. Lower associated increases among black patients may be due to their higher levels of recommended prescribing at baseline. The analysis suggests that guidelines did not impact equally on all patient groups.

Interarm difference in blood pressure: reproducibility and association with peripheral vascular disease

The present study aimed at examining the interarm difference in blood pressure and its use as an indicator of peripheral arterial disease (PAD). Data were included from consecutive patients referred from their general practitioner to our vascular laboratory for possible PAD aged 50 years or older without known cardiac disease, renal disease, or diabetes mellitus. 824 patients (453 women) with mean age of 72 years (range: 50-101) were included. 491 patients had a diagnosis of hypertension and peripheral arterial disease (PAD) was present in 386 patients. Systolic blood pressure was 143 ± 24 mmHg and 142 ± 24 mmHg on the right and left arm, respectively (P = 0.015). The interarm difference was greater in patients with hypertension (P = 0.002) and PAD (P < 0.0005). 443 patients were measured on two separate occasions and the interarm difference for systolic blood pressure was reproducible for differences >20 mmHg. This study confirmed the presence of a systematic but clinically insignificant difference in systolic blood pressure between arms. The interarm difference was larger in hypertension and PAD. Consistent lateralisation is present for differences ≥20 mmHg and an interarm difference >25 mmHg is a reliable indicator of PAD in the legs.

Efficacy and safety of LCZ696, a first-in-class angiotensin receptor neprilysin inhibitor, in Asian patients with hypertension: a randomized, double-blind, placebo-controlled study

LCZ696 (Japanese adopted name: sucabitril valsartan sodium hydrate), a first-in-class angiotensin receptor neprilysin inhibitor, concomitantly inhibits neprilysin and blocks angiotensin type 1 receptor. This randomized, double-blind, placebo-controlled study, the first in Asia for this drug, evaluated the dose-related efficacy and safety of LCZ696 in patients with hypertension using 24-hour ambulatory blood pressure (BP) monitoring. Asian patients aged ≥18 years (n=389) with hypertension were randomized to receive LCZ696 100 mg (n=100), 200 mg (n=101), 400 mg (n=96), or placebo (n=92) for 8 weeks. The primary end point was mean difference across the 3 single-dose pairwise comparisons of LCZ696 versus placebo in clinic diastolic BP after 8-week treatment. Key secondary efficacy variables included changes in clinic systolic BP and pulse pressure and changes in 24-hour, daytime, and nighttime ambulatory BPs and pulse pressure. Safety assessments included recording all adverse events and serious adverse events. A total of 362 patients completed the study. Reductions in clinic systolic BP, diastolic BP (P<0.0001), and pulse pressure (P<0.001) were significantly greater with all doses of LCZ696 than with placebo. There were also significant reductions in 24-hour, daytime, and nighttime ambulatory systolic BP, diastolic BP, and pulse pressure for all doses of LCZ696 compared with placebo (P<0.0001). LCZ696 was well tolerated, and no cases of angioedema were reported. In conclusion, LCZ696 is effective for the treatment of hypertension in Asian population and, in general, is safe and well tolerated. Clinical Trial Information- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01193101.

Recent advances in the identification of genes for human hypertension

It is a well-established fact that genes are involved in the etiology of hypertension. However, identification of the gene variants still remains a challenge. Over the years, different approaches and technologies, including genome-wide scans, case-control association studies, experiments on inbred rodent models and expression profiling, have been utilized to elucidate hypertension susceptibility genes, but so far the results have been equivocal. During the last year, further chromosomal regions harboring blood pressure loci have been identified, and transcriptomics has been applied to aid the identification of disease genes. There are great expectations for the future with regards to further advancements in transcriptomics and proteomics. This review reports primarily on work that has been carried out in the last 12 months in the field, and considers its contribution towards a better understanding of the genetic mechanisms involved in blood pressure regulation and hypertension.

Impact of universal health insurance coverage on hypertension management: a cross-national study in the United States and England

Background

The Patient Protection and Affordable Care Act (ACA) galvanised debate in the United States (US) over universal health coverage. Comparison with countries providing universal coverage may illustrate whether the ACA can improve health outcomes and reduce disparities. We aimed to compare quality and disparities in hypertension management by socio-economic position in the US and England, the latter of which has universal health care.

Method

We used data from the Health and Retirement Survey in the US, and the English Longitudinal Study for Aging from England, including non-Hispanic White respondents aged 50–64 years (US market-based v NHS) and >65 years (US-Medicare v NHS) with diagnosed hypertension. We compared blood pressure control to clinical guideline (140/90 mmHg) and audit (150/90 mmHg) targets; mean systolic and diastolic blood pressure and antihypertensive prescribing, and disparities in each by educational attainment, income and wealth, using regression models.

Results

There were no significant differences in aggregate achievement of clinical targets aged 50 to 65 years (US market-based vs. NHS- 62.3% vs. 61.3% [p = 0.835]). There was, however, greater control in the US in patients aged 65 years and over (US Medicare vs. NHS- 53.5% vs. 58.2% [p = 0.043]). England had no significant socioeconomic disparity in blood pressure control (60.9% vs. 63.5% [p = 0.588], high and low wealth aged ≥65 years). The US had socioeconomic differences in the 50–64 years group (71.7% vs. 55.2% [p = 0.003], high and low wealth); these were attenuated but not abolished in Medicare beneficiaries.

Conclusion

Moves towards universal health coverage in the US may reduce disparities in hypertension management. The current situation, providing universal coverage for residents aged 65 years and over, may not be sufficient for equality in care.

Inter-arm blood pressure differences compared with ambulatory monitoring: a manifestation of the 'white-coat' effect?

BACKGROUND

Inter-arm difference in blood pressure of >10 mmHg is associated with peripheral vascular disease, but it is unclear how much of the difference in sequential right and left arm blood pressure measurements might be due to a 'white-coat' effect.

AIM

To use ambulatory blood pressure monitoring (ABPM) to better understand the clinical significance of inter-arm differences in blood pressure.

DESIGN AND SETTING

Retrospective study in a teaching hospital in Birmingham.

METHOD

Anonymised clinical data collected from 784 patients attending a single hospital-based hypertension clinic were retrospectively analysed. Each participant had blood pressure measured sequentially in both arms, followed by ABPM over the subsequent 24 hours.

RESULT

Data were available for 710 (91%) patients, of whom 39.3% (279) had a blood pressure difference of 10 mmHg or more between each arm. Compared to daytime systolic ABPM, the difference was 25.1 mmHg using the arm with the highest reading, but only 15.5 mmHg if the lower reading was taken (mean difference 9.6 mmHg (95% confidence interval [CI] = 9.0 mmHg to 10.3 mmHg)). However, differences between mean right (20.7 mmHg) or left (19.9 mmHg) arm blood pressure and daytime systolic ABPM were very similar.

CONCLUSION

Compared with ABPM, use of the higher of the left and right arm readings measured sequentially appears to overestimate true mean blood pressure. As there is no significant difference in the extent of disparity with ABPM by left or right arm, this is unlikely to be due to arm dominance and may be due to the 'white-coat' effect reducing blood pressure on repeated measurement. Where a large inter-arm blood pressure difference is detected with sequential measurement, healthcare professionals should re-measure the blood pressure in the original arm.