Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials

Is the plasma aldosterone-to-renin ratio associated with blood pressure response to treatment in general practice?

BACKGROUND

Individualized antihypertensive treatment based on specific biomarkers such as renin may lead to more effective blood pressure control in patients with newly diagnosed essential hypertension. Recent studies suggested that the plasma aldosterone-to-renin ratio (ARR) may also be a candidate predictor for this purpose.

OBJECTIVE

To assess whether the ARR is associated with the blood pressure response to antihypertensive treatment in patients with newly diagnosed hypertension.

METHODS

In this prospective cohort study in primary care, we determined the ARR in patients with newly diagnosed hypertension prior to starting treatment. Treatment was categorized in five groups: no medication, use of angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker, use of calcium channel blocker, use of diuretic, or use of beta blocker. We examined the relation between the ARR and blood pressure response within 1 year of treatment, taking into account the type of antihypertensive treatment and adjusting for gender, age, baseline blood pressure, and comorbidity.

RESULTS

Out of 304 patients, we used 947 measurements (727 no medication, 220 medication) for analysis. There was no association between the ARR and the response in blood pressure, and this applied to each treatment group. Target blood pressure, defined as systolic blood pressure <140 mmHg, was reached in 31% of patients. There was no association between the ARR and reaching target blood pressure (OR 1.002, 95% CI 0.983-1.022).

CONCLUSION

The ARR is not associated with the response in blood pressure within 1 year of antihypertensive treatment in primary care.

Association between gaps in antihypertensive medication adherence and injurious falls in older community-dwelling adults: a prospective cohort study

OBJECTIVE

Growing evidence suggests that older adults are at an increased risk of injurious falls when initiating antihypertensive medication, while the evidence regarding long-term use of antihypertensive medication and the risk of falling is mixed. However, long-term users who stop and start these medications may have a similar risk of falling to initial users of antihypertensive medication. Our aim was to evaluate the association between gaps in antihypertensive medication adherence and injurious falls in older (≥65 years) community-dwelling, long-term (≥≥1 year) antihypertensive users.

DESIGN

Prospective cohort study.

SETTING

Irish Community Pharmacy.

PARTICIPANTS

Consecutive participants presenting a prescription for antihypertensive medication to 106 community pharmacies nationwide, community-dwelling, ≥65 years, with no evidence of cognitive impairment, taking antihypertensive medication for ≥1 year (n=938).

MEASURES

Gaps in antihypertensive medication adherence were evaluated from linked dispensing records as the number of 5-day gaps between sequential supplies over the 12-month period prior to baseline. Injurious falls during follow-up were recorded via questionnaire during structured telephone interviews at 12 months.

RESULTS

At 12 months, 8.1% (n=76) of participants reported an injurious fall requiring medical attention. The mean number of 5-day gaps in medication refill behaviour was 1.47 (SD 1.58). In adjusted, modified Poisson models, 5-day medication refill gaps at baseline were associated with a higher risk of an injurious fall during follow-up (aRR 1.18, 95% CI 1.02 to 1.37, p=0.024).

CONCLUSION

Each 5-day gap in antihypertensive refill adherence increased the risk of self-reported injurious falls by 18%. Gaps in antihypertensive adherence may be a marker for increased risk of injurious falls. It is unknown whether adherence-interventions will reduce subsequent risk. This finding is hypothesis generating and should be replicated in similar populations.

Effect of geographic accessibility to primary care on treatment status of hypertension

Although primary care access is known to be an important factor when seeking care, its effect on individual health risk has not been evaluated by an appropriate spatial measure. This study examined whether geographic accessibility to primary care assessed by a sophisticated form of spatial measure is associated with a risk of hypertension and its treatment status among Japanese people in rural areas, where primary care is not yet established as specialization. We used an enhanced two-step floating catchment area method to calculate the neighborhood residential unit-level primary and secondary care accessibility for 52,029 subjects who participated in the 2015 annual health checkup held at 15 cities in Shimane Prefecture. Their hypertension level and treatment status were examined cross-sectionally with their neighborhood primary care and secondary care accessibility (computed with two separate distance-decay weight: slow and quick) by multivariable logistic regression controlling for demographics and neighborhood income level. The findings showed that greater geographic accessibility to primary care was associated with a decreased risk of hypertension in both slow and quick distance-decay weight, odds ratio (OR) = 0.989 (95% Confidence Interval (CI) = 0.984, 0.994), OR = 0.989 (95%CI = 0.984, 0.993), respectively. On the other hand, better secondary care accessibility was associated with an increased risk of hypertension and untreated hypertension; however, the effect of secondary care was mitigated by the effect of primary care accessibility in both slow and quick distance-decay model, hypertension: OR = 0.974 (95% CI = 0.957, 0.991), OR = 0.981 (95%CI = 0.970, 0.991), untreated hypertension: OR = 0.970 (95%CI = 0.944, 0.996), OR = 0.975 (95%CI = 0.959, 0.991), respectively. In addition, the results revealed that young and fit people were at a higher risk of untreated hypertension, which is a unique finding in the context of the Japanese healthcare system. Our findings indicate the importance of primary care even in Japan, where it is not yet established, and also emphasize the need for a culturally specific perspective in health equity.

Effect Modification by Age on the Benefit or Harm of Antihypertensive Treatment for Elderly Hypertensives: A Systematic Review and Meta-analysis

BACKGROUND

The influence of age on balance of benefit vs. potential harm of blood pressure (BP)-lowering therapy for elderly hypertensives is unclear. We evaluated the modifying effects of age on BP lowering for various adverse outcomes in hypertensive patients older than 60 years without specified comorbidities.

METHODS

All relevant randomized controlled trials (RCTs) were systematically identified. Coronary heart disease, stroke, heart failure (HF), cardiovascular death, major adverse cardiovascular events (MACE), renal failure (RF), and all-cause death were assessed. Meta-regression analysis was used to explore the relationship between achieved systolic BP (SBP) and the risk of adverse events. Random-effects meta-analysis was used to pool the estimates.

RESULTS

Our study included 18 RCTs (n = 53,993). Meta-regression analysis showed a lower achieved SBP related with a lower risk of stroke and cardiovascular death, but an increased risk of RF. The regression slopes were comparable between populations stratifying by age 75 years. In subgroup analysis, the relative risks of a more aggressive BP lowering strategy were similar between patients aged older or less than 75 years for all outcomes except for RF (P for interaction = 0.02). Compared to treatment with final achieved SBP 140-150 mm Hg, a lower achieved SBP (<140 mm Hg) was significantly associated with decreased risk of stroke (relative risk = 0.68; 95% confidence interval = 0.55-0.85), HF (0.77; 0.60-0.99), cardiovascular death (0.68; 0.52-0.89), and MACE (0.83; 0.69-0.99).

CONCLUSIONS

To treat hypertension in the elderly, age had trivial effect modification on most outcomes, except for renal failure. Close monitoring of renal function may be warranted in the management of elderly hypertension.

Factors associated with intensification of antihypertensive drug therapy in patients with poorly controlled hypertension

Objective

To assess antihypertensive management of older patients with poor blood pressure (BP) control.

Methods

Physicians, voluntary participating in the study, included six consecutive hypertensive patients during routine visits. Hypertension had to have been previously recognized and averaged office BP was ≥ 140 and/or ≥ 90 mmHg in spite of ≥ 6 weeks of antihypertensive therapy. The physicians completed a questionnaire on patients' history of cardiovascular (CV) risk factors, comorbidities, home BP monitoring, anthropometric data and the pharmacotherapy.

Results

Mean age of the 6462 patients was 61 years, 7% were ≥ 80 years, 51% were female. Mean ± SD office BP values were 158 ± 13/92 ± 10 mmHg. The most commonly prescribed antihypertensive drugs were: diuretics (67%), ACE inhibitors (64%), calcium channel blockers (58%) and β-blockers (54%), and their use increased with age. On monotherapy or dual therapy, 43% of the patients and 40% had their latest treatment modification within six months. Home BP monitoring was a factor that accelerated the modification of the therapy. Older patients had to have less chance on faster modification of antihypertensive therapy in spite of presence of diabetes and higher systolic BP.

Conclusions

Our study suggests that a large number of outpatients with poor BP control receive suboptimal antihypertensive therapy, especially in primary care. In older patients, higher BP values in the office settings are more frequently accepted by physicians even in case of higher CV risk. Regular home BP monitoring hastens the decision to intensify of antihypertensive treatment.

Descriptive analysis of pharmacy services provided after community pharmacy screening

Background Community pharmacies are promising locations for opportunistic screening due to pharmacist accessibility and ability to perform various health and medication management services. Little is known as to the provision of pharmacy services following screening initiatives. Objective To describe provision of pharmacy services for participants following a community pharmacy stroke screening initiative. Setting The Program for the Identification of "Actionable Atrial" Fibrillation Pharmacy initiative took place in 30 pharmacies in Alberta and Ontario, Canada. 1149 participants ≥ 65 were screened for atrial fibrillation, type 2 diabetes, and hypertension. Method Retrospective, secondary analysis of data using participant case-report forms, pharmacy data, and pharmacy claims to describe pharmacy services received by participants post-screening. Main Outcome Measure Number and types of remunerated pharmacy services received by participants post-screening. Results A total of 535/1149 (46.6%) participants screened at their regular pharmacy were included in this analysis. Of these, 165 (30.8%) participants received 229 pharmacy services within 3 months post-screening, including 146 medication reviews, 57 influenza vaccinations, and 21 pharmaceutical opinions. A median (interquartile range, IQR) of 6 (2-11) pharmacy services were delivered, and median (IQR) reimbursement was $187.50 ($67.50-$342.50). Conclusions Approximately one-third of participants received a pharmacy service within 3 months post-screening. Relatively large numbers of annual and follow-up medication reviews were delivered despite low eligibility for annual-only reviews and despite many missed opportunities for pharmacy service provision in at-risk patients. In-pharmacy screening may facilitate provision of some services, namely medication reviews, by providing opportunities to identify patients at-risk.

Metabolic syndrome as cardiovascular risk factor in childhood cancer survivors

Over the past decades, survival rates of childhood cancer have increased considerably from 5 to 30% in the early seventies to current rates exceeding 80%. This is due to the development of effective chemotherapy, surgery, radiotherapy and stem cell transplantation, combined with an optimized stratification of therapy and better supportive care regimens. As a consequence, active surveillance strategies of late sequelae have been developed to improve the quality of survival. Several epidemiological studies have reported an increased incidence of (components of) metabolic syndrome (MetS) and cardiovascular disease in childhood cancer survivors (CCS). Growth hormone deficiency (GHD) after cranial radiotherapy (CRT) has been previously described as an important cause of MetS. New insights suggest a role for abdominal radiotherapy as a determinant for MetS as well. The role of other risk factors, such as specific chemotherapeutic agents, steroids, gonadal impairment, thyroid morbidity and genetics, warrants further investigation. This knowledge is important to define subgroups of CCS that are at risk to develop (subclinical) MetS features. These survivors might benefit from standard surveillance and early interventions, for example lifestyle and diet advice and medical treatment, thereby preventing the development of cardiovascular disease.

Incidence and prevalence of cardiovascular disease in English primary care: a cross-sectional and follow-up study of the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC)

OBJECTIVES

To describe incidence and prevalence of cardiovascular disease (CVD), its risk factors, medication prescribed to treat CVD and predictors of CVD within a nationally representative dataset.

DESIGN

Cross-sectional study of adults with and without CVD.

SETTING

The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) is an English primary care sentinel network. RCGP RSC is over 50 years old and one of the oldest in Europe. Practices receive feedback about data quality. This database is primarily used to conduct surveillance and research into influenza, infections and vaccine effectiveness but is also a rich resource for the study of non-communicable disease (NCD). The RCGP RSC network comprised 164 practices at the time of study.

RESULTS

Data were extracted from the records of 1 275 174 adults. Approximately a fifth (21.3%; 95% CI 21.2% to 21.4%) had CVD (myocardial infarction (MI), angina, atrial fibrillation (AF), peripheral arterial disease, stroke/transient ischaemic attack (TIA), congestive cardiac failure) or hypertension. Smoking, unsafe alcohol consumption and obesity were more common among people with CVD. Angiotensin system modulating drugs, 3-hydroxy-3-methylglutaryl-coenzyme (HMG-CoA) reductase inhibitors (statins) and calcium channel blockers were the most commonly prescribed CVD medications. Age-adjusted and gender-adjusted annual incidence for AF was 28.2/10 000 (95% CI 27.8 to 28.7); stroke/TIA 17.1/10 000 (95% CI 16.8 to 17.5) and MI 9.8/10 000 (95% CI 9.5 to 10.0). Logistic regression analyses confirmed established CVD risk factors were associated with CVD in the RCGP RSC network dataset.

CONCLUSIONS

The RCGP RSC database provides comprehensive information on risk factors, medical diagnosis, physiological measurements and prescription history that could be used in CVD research or pharmacoepidemiology. With the exception of MI, the prevalence of CVDs was higher than in other national data, possibly reflecting data quality. RCGP RSC is an underused resource for research into NCDs and their management and welcomes collaborative opportunities.

Impact of a Mediterranean Dietary Pattern and Its Components on Cardiovascular Risk Factors, Glucose Control, and Body Weight in People with Type 2 Diabetes: A Real-Life Study

This study evaluates the relation of a Mediterranean dietary pattern and its individual components with the cardiovascular risk factors profile, plasma glucose and body mass index (BMI) in people with type 2 diabetes. We studied 2568 participants at 57 diabetes clinics. Diet was assessed with the EPIC (European Prospective Investigation into Cancer and Nutrition) questionnaire, adherence to the Mediterranean diet was evaluated with the relative Mediterranean diet score (rMED). A high compared to a low score was associated with a better quality of diet and a greater adherence to the nutritional recommendations for diabetes. However, even in the group achieving a high score, only a small proportion of participants met the recommendations for fiber and saturated fat (respectively 17% and 30%). Nonetheless, a high score was associated with lower values of plasma lipids, blood pressure, glycated hemoglobin, and BMI. The relationship of the single food items components of the rMED score with the achievement of treatment targets for plasma lipids, blood pressure, glucose, and BMI were also explored. The study findings support the Mediterranean dietary model as a suitable model for type 2 diabetes and the concept that the beneficial health effects of the Mediterranean diet lie primarily in its synergy among various nutrients and foods rather than on any individual component.

High Inequalities Associated With Socioeconomic Deprivation in Cardiovascular Disease Burden and Antihypertensive Medication in Hungary

The wide life expectancy gap between the old and new member states of the European Union is most strongly related to the high rate of premature mortality caused by cardiovascular diseases (CVDs). To learn more about the background of this gap, the relationship of socioeconomic status (SES) with CVD mortality, morbidity and the utilization of antihypertensive drugs was studied in Hungary, a Central-Eastern European country with an extremely high relative risk of premature CVD mortality. Risk analysis capabilities were used to estimate the relationships between SES, which was characterized by tertiles of a multidimensional composite indicator (the deprivation index) and CVD burden (mortality and morbidity) as well as the antihypertensive medications at the district level in Hungary. The excess risks caused by premature mortality from CVDs showed a strong correlation with deprivation using the Rapid Inquiry Facility. The distribution of prevalence values related to these diseases was found to be similar, but in the areas of highest deprivation, where the prevalence of chronic ischaemic heart diseases and cerebrovascular diseases was found to be higher than the national average by 30 and 20%, the prevalence of hypertension exceeded the national average by only 4%. A linear association between the relative frequency of prescriptions/redemptions and deprivation for most antihypertensive drugs, except angiotensinogen receptor blockers, was shown. More intense screening for hypertension is proposed to improve the control of CVDs in countries affected by high disease burden.

Estimating the Association of the 2017 and 2014 Hypertension Guidelines With Cardiovascular Events and Deaths in US Adults: An Analysis of National Data

Importance

The 2017 American College of Cardiology/American Heart Association hypertension guideline recommends lower blood pressure (BP) thresholds for initiating antihypertensive medication and treatment goals than the 2014 evidence-based hypertension guideline.

Objective

To estimate the potential association of the 2017 and 2014 hypertension guidelines with the proportion of US adults defined as being hypertensive or recommended for antihypertensive treatment and with risk reduction of major cardiovascular disease (CVD) and all-cause mortality.

Design, Setting, and Participants

Using data from the National Health and Nutrition Examination Survey 2013 to 2016, we estimated the proportions of US adults with hypertension or recommended for antihypertensive treatment according to the 2017 and 2014 hypertension guidelines. Using data from the National Health and Nutrition Examination Survey, antihypertensive clinical trials, and population-based cohort studies, we estimated risk reductions of CVD and all-cause mortality assuming the entire US adult population achieved guideline-recommended systolic BP (SBP) treatment goals. Data were analyzed between October 2017 and March 2018.

Main Outcomes and Measures

Proportions and numbers of individuals with hypertension or recommended for antihypertensive treatment and numbers of CVD and all-cause mortality reduction.

Results

According to the 2017 hypertension guideline, the prevalence of hypertension (BP level ≥130/80 mm Hg) was 45.4% (95% CI, 43.9%-46.9%), representing 105.3 (95% CI, 101.9-108.8) million US adults, which was significantly higher than estimates per the 2014 hypertension guideline (BP level ≥140/90 mm Hg): 32.0% (95% CI, 30.3%-33.6%) or 74.1 (95% CI, 70.3-77.9) million individuals, respectively. Additionally, the proportion of individuals recommended for antihypertensive treatment was significantly higher according to the 2017 hypertension guideline (35.9%; 95% CI, 34.2%-37.5%) compared with the 2014 hypertension guideline (31.1%; 95% CI, 29.6%-32.7%). Achieving the 2017 hypertension guideline SBP treatment goals is estimated to reduce 610 000 (95% CI, 496 000-734 000) CVD events and 334 000 (95% CI, 245 000-434 000) total deaths in US adults 40 years and older. Corresponding estimates after achieving the 2014 hypertension guideline SBP treatment goals were 270 000 (95% CI, 202 000-349 000) and 177 000 (95% CI, 123 000-241 000), respectively. Implementing the 2017 hypertension guideline is estimated to increase 62 000 hypotension and 79 000 acute kidney injury or failure events.

Conclusions and Relevance

Compared with the 2014 hypertension guideline, the 2017 hypertension guideline was associated with an increase in the proportion of adults recommended for antihypertensive treatment and a further reduction in major CVD events and all-cause mortality, but a possible increase in the number of adverse events in the United States.

ACE insertion/deletion polymorphism is positively associated with resistant hypertension in Morocco

OBJECTIVE

The aim of the present study was to investigate the association of I/D polymorphisms of ACE gene is associated with resistant hypertension and essential controlled hypertension.

RESULTS

Our results show that the homozygous mutant genotype DD was more represented among resistant than controlled (58.1% vs 41.9% respectively), however the homozygote wild was more represented among controlled than resistant (70.6% vs 29.4% respectively). But more heterozygous ID among controlled than resistant patients (63.6% vs 36.4% respectively). The difference was statistically significant (p = 0.04). Analysis of clinical parameters indicated that physical activity contributes to resistant hypertension (P < 0.05). Based on our findings, the homozygous mutant for DD of ACE gene is associated with resistant hypertension in our population. Further studies with larger sample sizes are needed to confirm the results of this study.

[Try to achieve quickly the blood pressure target in newly diagnosed hypertensive patients is safe and effective]

OBJECTIVES

To compare a so-called an "accelerated" antihypertensive strategy to a "standard" strategy, in terms of blood pressure control rates and adverse events.

METHODS

Prospective open-label randomized controlled trial, which included consecutive hypertensive patients, newly diagnosed, 40 to 70 years old, with no prior antihypertensive treatment. Hypertension was diagnosed if office blood pressure was≥140/90mmHg, confirmed by an increase of Home or a daytime ambulatory blood pressure. The patients were randomly assigned according to 1:1 ratio to an "accelerated" strategy or to a "standard" strategy. The primary end-point was the rate of blood pressure control at 12weeks. The secondary end-point was the rate of adverse events (a safety end-point).

RESULTS

We recruited 268 patients (132 in the "accelerated" strategy group), with a mean age of 55 years and 62% of men. The mean office blood pressure at baseline was 168/95mmHg. The clinical characteristics were on average similar between the 2 treatment groups. At 12 weeks, the rates of blood pressure control were 63.6% in the "accelerated" strategy and 38.2% in the "standard" strategy (P<0.001). There was no significantly difference between the rates of adverse events in the 2 strategies (6.06% versus 5.14%; P=0.8).

CONCLUSION

The "accelerated" antihypertensive strategy was more effective than a standard one, in terms of blood pressure control, without an increase in adverse events rate. This could translate into a future cardiovascular events reduction.

Blood Pressure Measurement in SPRINT (Systolic Blood Pressure Intervention Trial)

Recent publications have stated that the blood pressure (BP) measurement technique used in SPRINT (Systolic Blood Pressure Intervention Trial) was unattended. However, the SPRINT protocol does not address the issue of attendance. A survey was conducted immediately after SPRINT closeout visits were completed to inquire whether BP measurements were usually attended or unattended by staff. There were 4082 participants at 38 sites that measured BP after leaving the participant alone the entire time (always alone), 2247 at 25 sites that had personnel in the room the entire time (never alone), 1746 at 19 sites that left the participant alone only during the rest period (alone for rest), and 570 at 6 sites that left the participant alone only during the BP readings (alone for BP measurement). Similar systolic and diastolic BPs within randomized groups were noted during follow-up at the majority of visits in all 4 measurement categories. In the always alone and never alone categories, the intensive group had a similarly reduced risk for the primary outcome compared with the standard group (hazard ratio, 0.62; 95% confidence interval, 0.51-0.76 and hazard ratio, 0.64; 95% confidence interval, 0.46-0.91, respectively; pairwise interaction P value, 0.88); risk was not significantly reduced for the intensive group in the smaller alone-for-rest and the alone-for-BP-measurement categories. Similar BP levels and cardiovascular disease risk reduction were observed in the intensive group in SPRINT participants whether the measurement technique used was primarily attended or unattended.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01206062.

Cost-effectiveness of interventions to control cardiovascular diseases and diabetes mellitus in South Asia: a systematic review

OBJECTIVES

More than 80% of cardiovascular diseases (CVD) and diabetes mellitus (DM) burden now lies in low and middle-income countries. Hence, there is an urgent need to identify and implement the most cost-effective interventions, particularly in the resource-constraint South Asian settings. Thus, we aimed to systematically review the cost-effectiveness of individual-level, group-level and population-level interventions to control CVD and DM in South Asia.

METHODS

We searched 14 electronic databases up to August 2016. The search strategy consisted of terms related to 'economic evaluation', 'CVD', 'DM' and 'South Asia'. Per protocol two reviewers assessed the eligibility and methodological quality of studies using standard checklists, and extracted incremental cost-effectiveness ratios of interventions.

RESULTS

Of the 2949 identified studies, 42 met full inclusion criteria. Critical appraisal of studies revealed 15 excellent, 18 good and 9 poor quality studies. Most studies were from India (n=37), followed by Bangladesh (n=3), Pakistan (n=2) and Bhutan (n=1). The economic evaluations were based on observational studies (n=9), randomised trials (n=12) and decision models (n=21). Together, these studies evaluated 301 policy or clinical interventions or combination of both. We found a large number of interventions were cost-effective aimed at primordial prevention (tobacco taxation, salt reduction legislation, food labelling and food advertising regulation), and primary and secondary prevention (multidrug therapy for CVD in high-risk group, lifestyle modification and metformin treatment for diabetes prevention, and screening for diabetes complications every 2-5 years). Significant heterogeneity in analytical framework and outcome measures used in these studies restricted meta-analysis and direct ranking of the interventions by their degree of cost-effectiveness.

CONCLUSIONS

The cost-effectiveness evidence for CVD and DM interventions in South Asia is growing, but most evidence is from India and limited to decision modelled outcomes. There is an urgent need for formal health technology assessment and policy evaluations in South Asia using local research data.

PROSPERO REGISTRATION NUMBER

CRD42013006479.

Correlation among lipid parameters, pulse wave velocity and central blood pressure in young Korean population

BACKGROUND

Central blood pressure is closely related to the important cardiovascular intermediate end points, such as vascular hypertrophy and extent of carotid atherosclerosis. Therefore it is prudent to study correlation among central aortic blood pressure, body composition, lipid profiles, and pulse wave velocity in population-based study. Consequently, we investigate the correlation between central aortic blood pressure and other risk parameters of hypertension such as body composition and lipid profile.

METHODS

We recruited 20 young participants diagnosed with hypertension as well as 30 without hypertension. The study used an X-SCAN PLUS 950 machine for measurement of overall body composition. Measurements of central blood pressure and carotid-femoral pulse wave velocity were carried out using SphygmoCor XCEL.

RESULTS

The hypertensive participants had significantly higher total weight without fat, body moisture mass, muscle mass, body mass index, basal metabolic rate, intracellular and extracellular water contents, protein and mineral contents along with brachial and central aortic blood pressures. In both hypertensive and non-hypertensive participants, central aortic diastolic blood pressure were significantly related to the lipid parameters.

CONCLUSION

Overall, the correlations between central blood pressure, pulse wave velocity, and lipid profile in hypertensive and non-hypertensive participants were substantial.

Racial/ethnic heterogeneity in associations of blood pressure and incident cardiovascular disease by functional status in a prospective cohort: the Multi-Ethnic Study of Atherosclerosis

OBJECTIVES

Research has demonstrated that the association between high blood pressure and outcomes is attenuated among older adults with functional limitations, compared with healthier elders. However, it is not known whether these patterns vary by racial/ethnic group. We evaluated race/ethnicity-specific patterns of effect modification in the association between blood pressure and incident cardiovascular disease (CVD) by functional status.

SETTING

We used data from the Multi-Ethnic Study of Atherosclerosis (2002-2004, with an average of 8.8 years of follow-up for incident CVD). We assessed effect modification of systolic blood pressure and cardiovascular outcomes by self-reported physical limitations and by age.

PARTICIPANTS

The study included 6117 participants (aged 46 to 87; 40% white, 27% black, 22% Hispanic and 12% Chinese) who did not have CVD at the second study examination (when self-reported physical limitations were assessed).

OUTCOME MEASURES

Incident CVD was defined as an incident myocardial infarction, coronary revascularisation, resuscitated cardiac arrest, angina, stroke (fatal or non-fatal) or death from CVD.

RESULTS

We observed weaker associations between systolic blood pressure (SBP) and CVD among white adults with physical limitations (incident rate ratio (IRR) per 10 mm Hg higher SBP: 1.09 (95% CI 0.99 to 1.20)) than those without physical limitations (IRR 1.29 (1.19, 1.40); P value for interaction <0.01). We found a similar pattern among black adults. Poor precision among the estimates for Hispanic or Chinese participants limited the findings in these groups. The attenuated associations were consistent across both multiplicative and additive scales, though physical limitations showed clearer patterns than age on an additive scale.

CONCLUSION

Attenuated associations between high blood pressure and incident CVD were observed for blacks and whites with poor function, though small sample sizes remain a limitation for identifying differences among Hispanic or Chinese participants. Identifying the characteristics that distinguish those in whom higher SBP is associated with less risk of morbidity or mortality may inform our understanding of the consequences of hypertension among older adults.

Echocardiographic Left Ventricular Reverse Remodeling After 18 Months of Antihypertensive Treatment in Stage I Hypertension. Results From the Prever-Treatment Study

BACKGROUND

Antihypertensive treatment improves echocardiographic parameters of hypertensive target organ damage in stage II hypertension, but less is known about the effects in stage I hypertension.

METHODS

In a cohort study nested in the randomized double-blind trial PREVER-treatment, 2-dimensional echocardiograms were performed in 110 individuals, aged 54.8 ± 7.9 years-old, with stage I hypertension at baseline and after 18 months of treatment with chlorthalidone/amiloride or losartan.

RESULTS

At baseline, 66 (60%) participants had concentric remodeling. After antihypertensive treatment, systolic (SBP) and diastolic blood pressure (BP) were reduced from 141/90 to 130/83 mm Hg (P = 0.009). There was a significant reduction in left ventricular (LV) mass (LVM) index (82.7 ± 17.1 to 79.2 ± 17.5 g/m2; P = 0.005) and relative wall thickness (0.45 ± 0.06 to 0.42 ± 0.05; P < 0.001), increasing the proportion of participants with normal LV geometry (31% to 49%, P = 0.006). Left atrial (LA) volume index reduced (26.8 ± 7.3 to 24.9 ± 6.5 ml/m2; P = 0.001), and mitral E-wave deceleration time increased (230 ± 46 to 247 ± 67 ms; P = 0.005), but there was no change in other parameters of diastolic function. LVM reduction was significantly higher in the 2 higher tertiles of SBP reduction compared to the lower tertile.

CONCLUSIONS

Treatment of patients with stage I hypertension for 18 months promotes favorable effects in the LA and LV remodeling. This improvement in cardiac end-organ damage might be associated with reduction of long term clinical consequences of hypertensive cardiomyopathy, particularly heart failure with preserved ejection fraction.

The effect of labetalol and nifedipine MR on blood pressure in women with chronic hypertension in pregnancy

AIM

To compare the blood pressure (BP) lowering effects of labetalol and nifedipine modified release (MR) in hypertensive pregnant women. We also investigated the effect on the heart rate (HR) and determined the proportion of time spent in target.

METHODS

This was an exploratory study. Women with chronic hypertension taking either labetalol or nifedipine were offered 24-h ambulatory blood pressure monitoring (ABPM). Sleep, wake and drug ingestion times were self-reported. An indirect response model was used to analyse the systolic BP (SBP), diastolic BP (DBP) and HR time-series; the effect of gestation and type of drug was evaluated.

RESULTS

Forty-eight women were recruited: 24 in each group. There was no difference in clinical characteristics. In women taking nifedipine there was a positive association between the dose of nifedipine and pre-dose BP p = .002, this was not present in the labetalol group. There was a difference between the drug effects on both the SBP and DBP time-series (p = .014). In comparison to labetalol, there was less variation in day time BP in those women prescribed nifedipine. Women on labetalol spent a larger proportion of time with their DBP below target (<80 mmHg). The HR dynamics were qualitatively different, a stimulatory effect was found with nifedipine compared to an inhibitory effect with labetalol.

CONCLUSION

There are significant and important differences between the BP lowering effects of nifedipine and labetalol. A large randomised control trial is required to investigate the relationship between BP variability and time in target on pregnancy outcomes.

Renin angiotensin aldosterone inhibition in the treatment of cardiovascular disease

A collective century of discoveries establishes the importance of the renin angiotensin aldosterone system in maintaining blood pressure, fluid volume and electrolyte homeostasis via autocrine, paracrine and endocrine signaling. While research continues to yield new functions of angiotensin II and angiotensin-(1-7), the gap between basic research and clinical application of these new findings is widening. As data accumulates on the efficacy of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers as drugs of fundamental importance in the treatment of cardiovascular and renal disorders, it is becoming apparent that the achieved clinical benefits is suboptimal and surprisingly no different than what can be achieved with other therapeutic interventions. We discuss this issue and summarize new pathways and mechanisms effecting the synthesis and actions of angiotensin II. The presence of renin-independent non-canonical pathways for angiotensin II production are largely unaffected by agents inhibiting renin angiotensin system activity. Hence, new efforts should be directed to develop drugs that can effectively block the synthesis and/or action of intracellular angiotensin II. Improved drug penetration into cardiac or renal sites of disease, inhibiting chymase the primary angiotensin II forming enzyme in the human heart, and/or inhibiting angiotensinogen synthesis would all be more effective strategies to inhibit the system. Additionally, given the role of angiotensin II in the maintenance of renal homeostatic mechanisms, any new inhibitor should possess greater selectivity of targeting pathogenic angiotensin II signaling processes and thereby limit inappropriate inhibition.

Effectiveness and safety of beta blockers in the management of hypertension in older adults: a systematic review to help reduce inappropriate prescribing

BACKGROUND

The benefit from a blood pressure lowering therapy with beta blockers may not outweigh its risks, especially in older populations. The aim of this study was to look for evidence on risks and benefits of beta blockers in older adults and to use this evidence to develop recommendations for the electronic decision support tool of the PRIMA-eDS project.

METHODS

Systematic review of the literature using a stage approach with searches for systematic reviews and meta-analyses first, and individual studies only if the previous searches are inconclusive. The target population were older adults (≥65 years old) with hypertension. We included studies reporting on the effectiveness and/or safety of beta blockers on clinically relevant endpoints (e.g. mortality, cardiovascular events, and stroke) in the management of hypertension. The recommendations were developed according to the GRADE methodology.

RESULTS

Fifteen studies were included, comprising one meta-analysis, four randomized controlled trials, six secondary analyses of randomized controlled trials and four observational studies. Seven studies involved only older adults and eight studies reported subgroup analyses by age. With regard to a composite endpoint (death, stroke or myocardial infarction) beta blockers were associated with a higher risk of events then were other antihypertensive agents. Further, beta blockers showed no benefit compared to other antihypertensive agents or placebo regarding mortality. They appear to be less effective than other antihypertensive agents in reducing cardiovascular events. Contradictory results were found regarding the effect of beta blockers on stroke. None of the studies explored the effect on quality of life, hospitalisation, functional impairment/status, safety endpoints or renal failure.

CONCLUSION

The quality of current evidence to interpret the benefits of beta blockers in hypertension is rather weak. It cannot be recommended to use beta blockers in older adults as first line agent for hypertension.

Quantifying sociodemographic and income disparities in medical therapy and lifestyle among symptomatic patients with suspected coronary artery disease: a cross-sectional study in North America

OBJECTIVES

To evaluate potential gaps in preventive medical therapy and healthy lifestyle practices among symptomatic patients with suspected coronary artery disease (CAD) seeing primary care physicians and cardiologists and how gaps vary by sociodemographic characteristics and baseline cardiovascular risk.

DESIGN

Cross-sectional study assessing potential preventive gaps.

PARTICIPANTS

10 003 symptomatic outpatients evaluated by primary care physicians, cardiologists or other specialists for suspected CAD.

SETTING

PROspective Multicenter Imaging Study for Evaluation of Chest Painfrom 2010 to 2014.

MEASURES

Primary measures were absence of an antihypertensive, statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker for renal protection in patients with hypertension, dyslipidaemia or diabetes, respectively, and being sedentary, smoking or being obese.

RESULTS

Preventive treatment gaps affected 14% of patients with hypertension, 36% of patients with dyslipidaemia and 32% of patients with diabetes. Overall, 49% of patients were sedentary, 18% currently smoked and 48% were obese. Women were significantly more likely to not take a statin for dyslipidaemia and to be sedentary. Patients with lower socioeconomic status were also significantly more likely to not take a statin. Compared with Whites, Blacks were significantly more likely to be obese, while Asians were less likely to smoke or be obese. High-risk patients sometimes experienced larger preventive care gaps than low-risk patients. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event (HR 1.35, 95% CI 1.02 to 1.82).

CONCLUSIONS

Among contemporary, symptomatic patients with suspected CAD, significant gaps exist in preventive care and lifestyle practices, and high-risk patients sometimes had larger gaps. Differences by sex, age, race/ethnicity, socioeconomic status and geography are modest but contribute to disparities and have implications for improving opulation health. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event.

CLINICAL TRIAL REGISTRATION

Clinical Trials.gov identifier NCT01174550.

Cardiovascular Biomarkers in Hypertensive Patients with Medical Treatment-Results from the Randomized TEAMSTA Protect I Trial

BACKGROUND

High blood pressure (BP) is associated with an increased rate of cardiovascular events and mortality. Cardiovascular biomarkers are able to predict long-term risk in the general population, particularly in diseased cohorts. We undertook an investigation of the effect of 2 different antihypertensive treatments on cardiovascular biomarkers in a randomized trial.

METHODS

The TEAMSTA study included 481 hypertensive patients. They were randomized to either 80-mg telmisartan + 5-mg amlodipine (TA) or 40-mg olmesartan + 12.5-mg hydrochlorothiazide (OH). The trial was performed as a prospective, randomized, double-blinded, controlled, single-center study. We measured BP, high-sensitivity cardiac troponin I (hs-cTnI), high-sensitivity cardiac troponin T (hs-cTnT), B-type natriuretic peptide (BNP), and N-terminal-pro-BNP (NT-proBNP) before randomization and after 6 months.

RESULTS

Individuals were randomized into 2 groups: 230 individuals to the OH-group and 251 to the TA-group. After 6 months of treatment, a reduction in BP (systolic/diastolic) was seen, from 135.2/85.2 mmHg to 122.5/75.7 mmHg with similar effects in both groups. hs-cTnT concentrations were measureable in 26.2% of the study population, while hs-cTnI was detected in 98.3%. hs-cTnI concentrations were significantly reduced from 4.6 to 4.2 ng/L in the overall population, from 4.7 to 4.4 ng/L in the OH-group, and from 4.6 to 4.0 ng/L in the TA-group (all P < 0.001). No significant changes of hs-cTnT were observed. BNP and NT-proBNP concentrations decreased from 15.0 to 12.4 ng/L (P < 0.001) and from 64.8 to 53.3 ng/L (P < 0.001), respectively, after 6 months.

CONCLUSIONS

The reduction in BP was associated with a decrease of high-sensitivity troponin I, BNP, and NT-proBNP concentrations, which might represent a cardiovascular risk reduction.

CLINICAL TRIAL REGISTRATION

EudraCT 2009-017010-68.

Replacement of Amlodipine and Lercanidipine by Barnidipine: Tolerability and Effectiveness in a Real-Life Study

INTRODUCTION

Hypertension is the leading cause of cardiovascular disease worldwide. Calcium channel blockers are an effective antihypertensive treatment, but frequently hypertension remains uncontrolled for many patients, partly due to tolerability issues.

AIM

To assess the tolerability and effectiveness of barnidipine in mild to moderate hypertension patients switching treatment from other calcium channel blockers in daily practice.

METHODS

BASIC-HT, a prospective real life study, enrolled 20,479 hypertensive patients initiating barnidipine treatment. The present paper focuses on a subgroup of patients in BASIC-HT for whom the previous treatment with amlodipine or lercanidipine was replaced by barnidipine. Tolerability and effectiveness of barnidipine in these patients were assessed at two visits during a 3-month follow up.

RESULTS

In 1710 mild to moderate hypertension patients switching treatment from amlodipine or lercanidipine to barnidipine monotherapy or in combination with other antihypertensive drug classes, mean blood pressure decreased during 3-month follow-up. The mean systolic blood pressure decreased from 153.15 mmHg [95% CI 152.35-153.95] at baseline to 139.20 mmHg [95% CI 138.58-139.82] at visit 3, after 3 months. The mean diastolic blood pressure decreased from 88.85 mmHg at baseline [95% CI 88.36-89.34], to 81.56 mmHg [95% CI 81.20-81.91] at visit 3. Among these patients, 65.4% replaced their initial calcium channel blocker treatment to barnidipine for tolerability reasons. During the follow-up, the main adverse event reported was edema (4.8%). The nature and frequency of events reported in this subgroup of switcher patients were in line with those reported by the total population in BASIC-HT.

CONCLUSION

This real-life study suggests that replacement of other calcium channel blockers with barnidipine is a valuable therapeutic option, especially when tolerability is an issue.

Pharmacotherapy for hypertension in adults aged 18 to 59 years

BACKGROUND

Hypertension is an important risk factor for adverse cardiovascular events including stroke, myocardial infarction, heart failure and renal failure. The main goal of treatment is to reduce these events. Systematic reviews have shown proven benefit of antihypertensive drug therapy in reducing cardiovascular morbidity and mortality but most of the evidence is in people 60 years of age and older. We wanted to know what the effects of therapy are in people 18 to 59 years of age.

OBJECTIVES

To quantify antihypertensive drug effects on all-cause mortality in adults aged 18 to 59 years with mild to moderate primary hypertension. To quantify effects on cardiovascular mortality plus morbidity (including cerebrovascular and coronary heart disease mortality plus morbidity), withdrawal due adverse events and estimate magnitude of systolic blood pressure (SBP) and diastolic blood pressure (DBP) lowering at one year.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to January 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We contacted authors of relevant papers regarding further published and unpublished work.

SELECTION CRITERIA

Randomized trials of at least one year' duration comparing antihypertensive pharmacotherapy with a placebo or no treatment in adults aged 18 to 59 years with mild to moderate primary hypertension defined as SBP 140 mmHg or greater or DBP 90 mmHg or greater at baseline, or both.

DATA COLLECTION AND ANALYSIS

The outcomes assessed were all-cause mortality, total cardiovascular (CVS) mortality plus morbidity, withdrawals due to adverse events, and decrease in SBP and DBP. For dichotomous outcomes, we used risk ratio (RR) with 95% confidence interval (CI) and a fixed-effect model to combine outcomes across trials. For continuous outcomes, we used mean difference (MD) with 95% CI and a random-effects model as there was significant heterogeneity.

MAIN RESULTS

The population in the seven included studies (17,327 participants) were predominantly healthy adults with mild to moderate primary hypertension. The Medical Research Council Trial of Mild Hypertension contributed 14,541 (84%) of total randomized participants, with mean age of 50 years and mean baseline blood pressure of 160/98 mmHg and a mean duration of follow-up of five years. Treatments used in this study were bendrofluazide 10 mg daily or propranolol 80 mg to 240 mg daily with addition of methyldopa if required. The risk of bias in the studies was high or unclear for a number of domains and led us to downgrade the quality of evidence for all outcomes.Based on five studies, antihypertensive drug therapy as compared to placebo or untreated control may have little or no effect on all-cause mortality (2.4% with control vs 2.3% with treatment; low quality evidence; RR 0.94, 95% CI 0.77 to 1.13). Based on 4 studies, the effects on coronary heart disease were uncertain due to low quality evidence (RR 0.99, 95% CI 0.82 to 1.19). Low quality evidence from six studies showed that drug therapy may reduce total cardiovascular mortality and morbidity from 4.1% to 3.2% over five years (RR 0.78, 95% CI 0.67 to 0.91) due to reduction in cerebrovascular mortality and morbidity (1.3% with control vs 0.6% with treatment; RR 0.46, 95% CI 0.34 to 0.64). Very low quality evidence from three studies showed that withdrawals due to adverse events were higher with drug therapy from 0.7% to 3.0% (RR 4.82, 95% CI 1.67 to 13.92). The effects on blood pressure varied between the studies and we are uncertain as to how much of a difference treatment makes on average.

AUTHORS' CONCLUSIONS

Antihypertensive drugs used to treat predominantly healthy adults aged 18 to 59 years with mild to moderate primary hypertension have a small absolute effect to reduce cardiovascular mortality and morbidity primarily due to reduction in cerebrovascular mortality and morbidity. All-cause mortality and coronary heart disease were not reduced. There is lack of good evidence on withdrawal due to adverse events. Future trials in this age group should be at least 10 years in duration and should compare different first-line drug classes and strategies.

Novel Cardiac Intracrine Mechanisms Based on Ang-(1-12)/Chymase Axis Require a Revision of Therapeutic Approaches in Human Heart Disease

PURPOSE OF THE REVIEW

Drugs targeting the renin-angiotensin system (RAS), namely angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers, are the most commonly prescribed drugs for patients with or at risk for cardiovascular events. However, new treatment strategies aimed at mitigating the rise of the heart failure pandemic are warranted because clinical trials show that RAS blockers have limited benefits in halting disease progression. The main goal of this review is to put forward the concept of an intracrine RAS signaling through the novel angiotensin-(1-12)/chymase axis as the main source of deleterious angiotensin II (Ang II) in cardiac maladaptive remodeling leading to heart failure (HF).

RECENT FINDINGS

Expanding traditional knowledge, Ang II can be produced in tissues independently from the circulatory renin-angiotensin system. In the heart, angiotensin-(1-12) [Ang-(1-12)], a recently discovered derivative of angiotensinogen, is a precursor of Ang II, and chymase rather than ACE is the main enzyme contributing to the direct production of Ang II from Ang-(1-12). The Ang-(1-12)/chymase axis is an independent intracrine pathway accounting for the trophic, contractile, and pro-arrhythmic Ang II actions in the human heart. Ang-(1-12) expression and chymase activity have been found elevated in the left atrial appendage of heart disease subjects, suggesting a pivotal role of this axis in the progression of HF. Recent meta-analysis of large clinical trials on the use of ACE inhibitors and angiotensin receptor blockers in cardiovascular disease has demonstrated an imbalance between patients that significantly benefit from these therapeutic agents and those that remain at risk for heart disease progression. Looking to find an explanation, detailed investigation on the RAS has unveiled a previously unrecognized complexity of substrates and enzymes in tissues ultimately associated with the production of Ang II that may explain the shortcomings of ACE inhibition and angiotensin receptor blockade. Discovery of the Ang-(1-12)/chymase axis in human hearts, capable of producing Ang II independently from the circulatory RAS, has led to the notion that a tissue-delimited RAS signaling in an intracrine fashion may account for the deleterious effects of Ang II in the heart, contributing to the transition from maladaptive cardiac remodeling to heart failure. Targeting intracellular RAS signaling may improve current therapies aimed at reducing the burden of heart failure.

Triple Combination Therapies Based on Olmesartan: A Personalized Therapeutic Approach to Improve Blood Pressure Control

Recent epidemiological surveys have demonstrated that effective and sustained blood pressure (BP) control is achieved in a relatively small proportion of treated hypertensive patients. Indeed, treatment of hypertension represents a key strategy for preventing coronary artery disease, stroke, congestive heart failure and cardiovascular death. Several interventions have been proposed by international guidelines for ameliorating hypertension management and control, mostly including integrated and multi-dimensional pharmacological and non-pharmacological strategies. In particular, numerous evidence demonstrated that a more extensive use of combination therapy may represent a valid therapeutic option for treating hypertensive patients at different risk profile. This strategy has been definitely strengthened by the availability of single pill fixed-dose combinations. Among potential combination therapies, those based on the association of renin-angiotensin system antagonists, thiazide diuretics and calcium channel blockers are very effective in lowering BP levels and well tolerated. We will provide here an overview of clinical evidence supporting the use of triple combination therapy, with a focus on that based on olmesartan medoxomil, a thiazide diuretic (hydrochlorothiazide) and a calcium channel blocker (amlodipine besylate), which is available in multiple dosages. Finally, in view of the recognised importance of single-pill combination therapy for treating hypertension, we will examine the potential benefits of dual (fixed) combination therapy based on olmesartan medoxomil with either thiazide diuretic hydrochlorothiazide or calcium channel blocker amlodipine in terms of efficacy, safety and tolerability profile.