Barriers to hypertension control

Adherence to antihypertensives in the United States: A comparative meta-analysis of 23 million patients

Adherence to antihypertensives is crucial for control of blood pressure. This study analyzed factors and interventions that could affect adherence to antihypertensives in the US. PubMed, Scopus, Web of Science, and Embase were searched on January 21, 2022 and December 25, 2023 for studies on the adherence to antihypertensives in the US. Nineteen studies and 23 545 747 patients were included in the analysis, which showed that adherence to antihypertensives was the highest among Whites (OR: 1.47, 95% CI 1.34-1.61 compared to African Americans). Employment status and sex were associated with insignificant differences in adherence rates. In contrast, marital status yielded a significant difference where unmarried patients demonstrated low adherence rates compared to married ones (OR: 0.8, 95% CI 0.67-0.95). On analysis of comorbidities, diabetic patients reported lower adherence to antihypertensives (OR: 0.95, 95% CI 0.92-0.97); furthermore, patients who did not have Alzheimer showed higher adherence rates. Different BMIs did not significantly affect the adherence rates. Patients without insurance reported significantly lower adherence rates than insured patients (OR: 3.93, 95% CI 3.43-4.51). Polypill users had higher adherence rates compared with the free-dose combination (OR: 1.21, 95% CI 1.2-1.21), while telepharmacy did not prove to be as effective. Lower adherence rates were seen among African Americans, uninsured, or younger patients. Accordingly, interventions such as fixed-dose combinations should be targeted at susceptible groups. Obesity and overweight did not affect the adherence to antihypertensives.

Barriers and Facilitators in Access to Diabetes, Hypertension, and Dyslipidemia Medicines: A Scoping Review

Objective: Identify barriers and facilitators in access to medicines for diabetes, hypertension, and dyslipidemia, considering patient, health provider, and health system perspectives.

Methods: Scoping review based on Joanna Briggs methodology. The search considered PubMed, Cochrane Library, CINAHL, Academic Search Ultimate, Web of Science, SciELO Citation Index, and grey literature. Two researchers conducted screening and eligibility phases. Data were thematically analyzed.

Results: The review included 219 documents. Diabetes was the most studied condition; most of the evidence comes from patients and the United States. Affordability and availability of medicines were the most reported dimension and specific barrier respectively, both cross-cutting concerns. Among high- and middle-income countries, identified barriers were cost of medicines, accompaniment by professionals, long distances to facilities, and cultural aspects; cost of transportation emerges in low-income settings. Facilitators reported were financial accessibility, trained health workers, medicines closer to communities, and patients’ education.

Conclusion: Barriers and facilitators are determined by socioeconomic and cultural conditions, highlighting the role of health systems in regulatory and policy context (assuring financial coverage and free medicines); providers’ role bringing medicines closer; and patients’ health education and disease management.

Adverse Reaction of Acupuncture and Antihypertensive Drugs for Treatment of Essential hypertension: A Protocol for Bayesian Network Meta-Analysis

Background

Hypertension, as a high risk factor of cardiovascular disease, has led to a significant upward trend in the population and incidence of the disease. Hypertension patients need to take antihypertensive drugs for life, and therefore people gradually pay more attention to the adverse reactions of antihypertensive drugs. This study protocol outlines a plan to assess the adverse reaction of the different antihypertensive drugs and acupuncture in order for clinical application.

Objective

To compare the side effects of different antihypertensive drugs and acupuncture in the treatment of hypertension.

Methods

and analysis. We will search the databases containing CNKI, Wan-Fang database, Chinese Scientific Journal Database(VIP), PubMed, Cochrane, and Embase, and randomized controlled trials (RCTs) of commonly used antihypertensive drugs or acupuncture for primary hypertension will be obtained. Then, Stata14.0 and Gemtc will be used to assess the statistics. Ethics and dissemination. Since no personal patient consent will be required in the study, there is no ethical approval. The results of this reporting will be submitted to a peer-reviewed publication. PROSPERO registration number: CRD42020152703.

Barriers, Enablers and Strategies for the Treatment and Control of Hypertension in Nepal: A Systematic Review

Background: Understanding country-specific factors influencing hypertension care is critical to address the gaps in the management of hypertension. However, no systematic investigation of factors influencing hypertension treatment and control in Nepal is available. This study aimed to systematically review the published literature and synthesise the findings on barriers, enablers, and strategies for hypertension treatment and control in Nepal.

Methods: Embase, PubMed, Web of Science, CINAHL, ProQuest and WorldCat, and Nepali journals and government websites were searched for qualitative, quantitative, and mixed-methods studies on factors or strategies related to hypertension treatment and control in Nepal. Information from qualitative studies was analysed using template analysis, while results from quantitative studies were narratively synthesised. Summary findings were framed under “health system”, “provider”, and “patient” domains. The protocol was registered in PROSPERO (registration number: CRD42020145823).

Results: We identified 15 studies; ten related to barriers and enablers and five to strategies. The identified barriers associated with the health system were: lack of affordable services and lack of resources. The barriers at the provider's level were: communication gaps, inadequate counselling, long waiting hours for appointments, lack of national guidelines for hypertension treatment, and provider's unsupportive behaviours. Non-adherence to medication, irregular follow-up visits, lack of awareness on blood pressure target, poor help-seeking behaviours, reluctance to change behaviours, perceived side-effects of anti-hypertensive medication, self-medication, lack of family support, financial hardship, lack of awareness on blood pressure complications, and comorbidity were barriers identified at patient level. The following enablers were identified: free essential health care services, family support, positive illness perception, and drug reminders. Strategies implemented at the health system, provider and patient levels were: establishing digital health records at health centres, health worker's capacity development, and health education.

Conclusion: There is a range of barriers for hypertension treatment and control in Nepal pertaining to the health system, health providers, and patients. Comprehensive interventions are needed at all three levels to further improve management and control of hypertension in Nepal.

Barriers and facilitators for treatment and control of high blood pressure among hypertensive patients in Kathmandu, Nepal: a qualitative study informed by COM-B model of behavior change

Background

Nepal has a high prevalence of hypertension which is a major risk factor for cardiovascular diseases globally. It is inadequately controlled even after its diagnosis despite the availability of effective treatment of hypertension. There is a need for an in-depth understanding of the barriers and facilitators using theory to inform interventions to improve the control of hypertension. This formative study was conducted to address this gap by exploring the perceived facilitators and barriers to treatment and control of hypertension in Nepal.

Methods

We conducted in-depth interviews (IDIs) among hypertensive patients, their family members, healthcare providers and key informants at primary (health posts and primary health care center) and tertiary level (Kathmandu Medical College) facilities in Kathmandu, Nepal. Additionally, data were collected using focus group discussions (FGDs) with hypertensive patients. Recordings of IDIs and FGDs were transcribed, coded both inductively and deductively, and subthemes generated. The emerging subthemes were mapped to the Capability, Opportunity, and Motivation-Behaviour (COM-B) model using a deductive approach.

Results

Major uncovered themes as capability barriers were misconceptions about hypertension, its treatment and difficulties in modifying behaviour. Faith in alternative medicine and fear of the consequences of established treatment were identified as motivation barriers. A lack of communication between patients and providers, stigma related to hypertension and fear of its disclosure, and socio-cultural factors shaping health behaviour were identified as opportunity barriers in the COM-B model. The perceived threat of the disease, a reflective motivator, was a facilitator in adhering to treatment.

Conclusions

This formative study, using the COM-B model of behaviour change identified several known and unknown barriers and facilitators that influence poor control of blood pressure among people diagnosed with hypertension in Kathmandu, Nepal. These findings need to be considered when developing targeted interventions to improve treatment adherence and blood pressure control of hypertensive patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11548-4.

Phone-Based Intervention under Nurse Guidance after Stroke (PINGS II) Study: Protocol for a Phase III Randomized Clinical Trial

OBJECTIVES

The Sub-Saharan African (SSA) region now has the highest estimated effect size of hypertension for stroke causation worldwide. An urgent priority for countries in SSA is to develop and test self-management interventions to control hypertension among those at highest risk of adverse outcomes. Thus the overall objective of the Phone-based Intervention under Nurse Guidance after Stroke II study (PINGS-2) is to deploy a hybrid study design to assess the efficacy of a theoretical-model-based, mHealth technology-centered, nurse-led, multi-level integrated approach to improve longer term blood pressure (BP) control among stroke survivors.

MATERIALS AND METHODS

A phase III randomized controlled trial involving 500 recent stroke survivors to be enrolled across 10 Ghanaian hospitals. Using a computer-generated sequence, patients will be randomly assigned 1:1 into the intervention or usual care arms. The intervention comprises of (i) home BP monitoring at least once weekly with nurse navigation for high domiciliary BP readings; (2) medication reminders using mobile phone alerts and (3) education on hypertension and stroke delivered once weekly via audio messages in preferred local dialects. The intervention will last for 12 months. The control group will receive usual care as determined by local guidelines. The primary outcome is the proportion of patients with systolic BP <140 mm Hg at 12 months. Secondary outcomes will include medication adherence, self-management of hypertension, major adverse cardiovascular events, health related quality of life and implementation outcomes.

CONCLUSION

An effective PINGS intervention can potentially be scaled up and disseminated across healthcare systems in low-and-middle income countries challenged with resource constraints to reduce poor outcomes among stroke survivors.

Trends in the Prevalence, Awareness, Treatment, and Control of Hypertension in Nepal between 2000 and 2025: A Systematic Review and Meta-Analysis

BACKGROUND

Understanding the burden and trend of hypertension and the associated care cascade can provide direction to the development of interventions preventing and controlling hypertension. This study aimed to assess prevalence and trends of hypertension and its awareness, treatment, and control in Nepal.

METHODS

We systematically searched CINAHL, Embase, ProQuest, PubMed, Web of Science, WorldCat, and government and health agency-owned websites to identify studies reporting prevalence of hypertension, awareness, treatment, and control in Nepal between 2000 and 2020. We applied the random-effects model to compute the pooled prevalence in the overall population and among subgroups in each 5-year interval period between 2000 and 2020. We used linear meta-regression analysis to predict hypertension from 2000 to 2025.

RESULTS

We identified 23 studies having a total of 84,006 participants. The pooled prevalence of hypertension, awareness, treatment, and control for 2016-2020 was 32% (95% CI: 23-40%), 50% (95% CI: 30-69%), 27% (95% CI: 19-34%), and 38% (95% CI: 28-48%), respectively. The prevalence of hypertension varied by age, gender, education, and geographical area. Hypertension increased by 6 percentage points (pp), awareness increased by 12 pp, treatment increased by 11 pp, and control increased by 3 pp over the 20 years studied. Since 2000, the rate of increment of hypertension has been 3.5 pp per decade, where 44.7% of men are expected to suffer from hypertension by 2025.

CONCLUSION

The markedly increased prevalence of hypertension and relatively poor progress in hypertension awareness, treatment, and control in Nepal suggest that there is a need for hypertension preventive approaches as well as strategies to optimize hypertension care cascade.

Effect of Different Blood-Pressure-Lowering Regimens on the Blood Pressure Control among Hypertensive Patients Treated in Hospital Conditions

BACKGROUND

Scientific references lack sufficient amount of data on analyses of the reasons for hospital admissions or assessment of efficacy of arterial hypertension treatment at hospitals.

OBJECTIVES

The aim of the study was to evaluate the efficacy of antihypertensive drug therapy on the blood pressure control among hospitalized hypertensive patients. Methodology. A cross-sectional retrospective study consisted of 204 patients aged 18-65 years admitted to the hospital due to hypertension between January 2018 and December 2018. The study was based on analysis of electronic records, obtained from the medical database of the selected healthcare facility.

RESULTS

As a result of the treatment applied at the hospital, 65.19% of the patients achieved the desired degree of blood pressure normalization (≤130/80 mmHg). Vast majority of the patients during their stay at the ward would receive three or more hypertensive drugs (63.73%). The most frequently prescribed antihypertensive drug combinations included bitherapies such as diuretics + ACEI and ACEI + β-blockers and tritherapy such as diuretics + β-blockers and calcium channel antagonists and diuretics + ACEI and ARBs. The highest blood-pressure lowering effects were observed among patients receiving combination therapy of a ACEI, a diuretic, and a ARBs. Tritherapy induced a significant mean reduction of inpatients`s SBP compared with bitherapy (p=0.0001).

CONCLUSION

During their hospital stay, vast majority of patients (65.19%) achieved normal values of blood pressure, mostly owing to combined treatment with several hypertensive drugs. Efficacy of the most frequently used combinations of hypertensive drugs in normalizing arterial pressure varies.

Racial Differences in the Effectiveness of a Multifactorial Telehealth Intervention to Slow Diabetic Kidney Disease

BACKGROUND

African Americans are significantly more likely than non-African Americans to have diabetes, chronic kidney disease, and uncontrolled hypertension, increasing their risk for kidney function decline.

OBJECTIVE

The objective of this study was to compare how African Americans and non-African Americans with diabetes responded to a multifactorial telehealth intervention designed to slow kidney function decline.

RESEARCH DESIGN

Secondary analysis of a randomized trial. Primary care patients (N=281, 56% African American) were allocated to either: (1) a multifactorial, pharmacist-delivered phone-based telehealth intervention focused on behavioral and medication management of diabetic kidney disease; or (2) an education control.

MEASURES

The primary study outcome was change in estimated glomerular filtration rate (eGFR). Linear mixed models were used to explore the moderating effect of race on the relationship between study arm and eGFR decline over time; the mean annual rate of eGFR decline was estimated by race and study arm.

RESULTS

Findings demonstrated a differential intervention effect on kidney function over time by race (Pinteraction=0.005). Among African Americans, the intervention arm had significantly greater preservation of eGFR over time than the control arm (difference in the annual rate of eGFR decline=1.5 mL/min/1.73 m; 95% confidence interval: 0.04, 3.02). For non-African Americans, the intervention arm had a faster decline in eGFR over time than the control arm (difference in the annual rate of eGFR decline=-1.7 mL/min/1.73 m; 95% confidence interval: -3.3, -0.02).

CONCLUSION

A multifactorial, pharmacist-delivered telehealth intervention for diabetic kidney disease may be more effective for slowing eGFR decline among African Americans than non-African Americans.

Patient adherence to antihypertensive medications in upper Egypt: a cross-sectional study

Background

Control of hypertension is a very difficult issue. Non-adherence to medications is a well-recognized factor contributing to uncontrolled hypertension. It is required to detect factors that affect adherence of patients to antihypertensive medications at different societies and good planning with the collaboration of governments, universities, media, pharmaceutical companies, and civil society to create intervention programs ensuring good adherence to medications. In our study, we aimed to determine different factors affecting adherence to antihypertensive medications in Upper Egypt societies.

Results

From September 2015 to September 2019, we conducted a large cross-sectional multi-center study among 2420 hypertensive patients attending the out-patient cardiac clinics at three different university hospitals. Data was collected through a personal interview with the patients using a questionnaire to cover a variety of items.

In the total of 2420 patients, we found that 1116 (46.12%) patients were adherent to medications and 1304 (53.88%) were non-adherent. From the final regression analysis of the results, we found that age > 65 years, illiterate patients, low income, associated comorbidities, using three or more antihypertensive pills, and living in rural areas were statistically significant socio-demographic factors associated with non-adherence to treatment. Also, missing doses of medication and lack of complying with dietary regimen were statistically significant behavioral causes associated with non-adherence.

Conclusion

Many factors are predictors of good adherence to antihypertensive drugs, including young age, urban residence, a smaller number of pills, absence of comorbid conditions, high income, and high education level. Also missed doses of drugs and absence of complies with dietary regimen were the significant causes of non-adherence. Health institutions and governmental efforts should be directed toward improving adherence by creating effective intervention programs targeting these factors. Therefore, it might be concluded that patients who are more health ware are more adherent to medications than non-health aware patients.

The global epidemiology of hypertension

Hypertension is the leading cause of cardiovascular disease and premature death worldwide. Owing to the widespread use of antihypertensive medications, global mean blood pressure (BP) has remained constant or has decreased slightly over the past four decades. By contrast, the prevalence of hypertension has increased, especially in low- and middle-income countries (LMICs). Estimates suggest that 31.1% of adults (1.39 billion) worldwide had hypertension in 2010. The prevalence of hypertension among adults was higher in LMICs (31.5%, 1.04 billion people) than in high-income countries (28.5%, 349 million people). Variations in the levels of risk factors for hypertension, such as high sodium intake, low potassium intake, obesity, alcohol consumption, physical inactivity and unhealthy diet, may explain some of the regional heterogeneity in hypertension prevalence. Despite the increasing prevalence, the proportions of hypertension awareness, treatment and BP control are low, particularly in LMICs, and few comprehensive assessments of the economic impact of hypertension exist. Future studies are warranted to test implementation strategies for hypertension prevention and control, especially in low-income populations, and to accurately assess the prevalence and financial burden of hypertension worldwide.

Financial incentives for hypertension control: rationale and study design

Background

Even though the effectiveness of lifestyle modifications and antihypertensive pharmaceutical treatment for the prevention of hypertension and its complications have been demonstrated in randomized controlled trials, the benefits of adhering to these treatments have not been popularized among the general public. Studies suggest that incentive approaches based on behavioral economic concepts can improve patients’ adherence to treatment. Therefore, we aimed to test whether financial incentives will reduce the blood pressure (BP) of hypertensive patients in China.

Methods/Design

This is a multicenter, randomized controlled trial with two parallel arms. A total of 400 participants from six cities in the Liaoning and Shanxi provinces of China are block-randomized into intervention and control group with a 1:1 ratio. Patients in the control group will receive interactive management of mobile devices, including patient education and communication. Patients in the intervention group will receive financial incentives in addition to interactive management of mobile devices, conditional on them achieving their antihypertensive goals or hypertension control. Masking the arm allocation will be precluded by the behavioral nature of the intervention and investigators of BP measurement and statistics are masked to clinic assignment. The primary outcome is net change in systolic BP (SBP) from baseline to month 12 between the intervention and control groups. The secondary outcomes are net change in diastolic BP (DBP), BP control, change in medication adherence and lifestyle, and cost-effectiveness.

Discussion

This trial will determine whether financial incentives will improve hypertension control and generate necessary data for controlling hypertension and concomitant cardiovascular diseases among hypertensive patients in China.

Trial registration

ISRCTN13467677. Registered on 16 May 2019.

Uncontrolled Blood Pressure in Hypertensive Patients with High Medication Adherence: A Korean Nationwide Population-Based Study

Background

Uncontrolled blood pressure (BP) is relatively common despite treatment with antihypertensive medication. This study aimed to investigate factors associated with uncontrolled systolic BP (SBP) and diastolic BP (DBP) separately in hypertensive patients with high medication adherence in Korea.

Methods

This population-based cross-sectional study included 3,236 participants in the Korea National Health and Nutrition Examination Survey from 2013 to 2015. Hypertensive patients with high medication adherence were defined when they stated that they were taking antihypertensive medication daily. “Uncontrolled SBP and DBP” were defined as SBP ≥140 mm Hg and DBP ≥90 mm Hg, respectively. Data were analyzed using logistic regression to determine the association between uncontrolled SBP or DBP and various factors.

Results

The prevalence of uncontrolled SBP and uncontrolled DBP was 23.3%, and 9.0%, respectively. In multivariate analysis, uncontrolled SBP was positively associated with older age, female sex, blue-collar occupation or no work (vs. white-collar), presence of a spouse, short sleep duration, frequent heavy alcohol drinking, longer hypertension duration, diabetes, stroke, and missing antihypertensive medication on the examination day, but negatively associated with high stress. Uncontrolled DBP was positively associated with frequent heavy alcohol drinking, but negatively associated with older age, blue-collar occupation or no work (vs. white-collar), and diabetes.

Conclusion

After excluding low medication adherence, we identified various factors associated with uncontrolled SBP or DBP in Korean adults with treated hypertension. There were differences between factors associated with uncontrolled SBP or DBP. Separate analysis of SBP and DBP may help understand the factors involved in BP control.

Differential pricing of medicines to improve access to medicines for hypertension and diabetes control in Ghana: The Ghana Access and Affordability Program, a multi-center prospective trial

Background: Access to medicines for hypertension and diabetes mellitus (DM) management is challenging in resource-limited countries. We sought to assess whether differential pricing of medicines based on socio-economic status would improve affordability of antihypertensive and anti-diabetic medications. A quasi-experimental, prospective cohort study was implemented at five Ghanaian health facilities, using medicines differentially priced by three pharmaceutical companies. Methods: Adult patients ≥18 years with hypertension or DM were enrolled and assigned to a lower tiered differential price (DP arm) or market price (MP arm) based on minimum wage earning or a score >6/18 on a multi-dimensional poverty index scale. Study medicines were purchased at either the DP or MP when prescribed. Participants were followed for 18 months to assess blood pressure (BP) and glycemic control. Predictors of ability to purchase study medicines were assessed using parsimonious logistic regression models. Results: 3,296 participants were enrolled with mean age of 57±12.7 years, 76.6% females. 1,869 (56.7%) had hypertension, 422 (12.8%) had DM, and 1,005 (30.5%) with both hypertension and DM. Average follow-up was 14 months. There were prescriptions of study medications for 526 participants of which 238 (45.2%) were able to make purchases at DP 60.9% versus MP 39.1%. Independent predictors of purchasing ability were higher income, MP arm, willingness to purchase additional medicines, and being at tertiary level institution. Conclusions: Approximately 45% of Ghanaians could afford prescribed study medicines provided at a differential pricing mechanism albeit at an unsustainable basis. Further price reductions are expected to enhance access to medicines for hypertension and DM control.

The Sub-Saharan Africa Conference on Stroke (SSACS): An idea whose time has come

Stroke is a leading cause of global morbidity and mortality. Sub-Saharan Africa (SSA), where an unprecedented rise in stroke burden is currently raging, has the highest age-standardized stroke incidence, stroke prevalence, and stroke mortality rates. This is in sharp contrast to the relative decline in stroke incidence in high-income countries over the past four decades through better awareness and control of vascular risk factors. Compared to other groups, Africans tend to have a higher risk of stroke, higher percentage of the hemorrhagic type and much poorer outcomes. Indeed, stroke levies a heavy toll on the developing SSA economy by affecting a relatively younger age group. In this commentary, we examine the disproportionately high burden of stroke in the setting of grossly inadequate resources and evidence-based interventions. We propose an annual pan-regional stroke conference (starting in 2020) to harness global resources and local talent with the goal of galvanizing action to tackle this escalating burden. We anticipate that a successful conference series could become a rallying point for the eventual establishment of an African Stroke Organization.

Physician Trust and Home Remedy Use Among Low-Income Blacks and Whites with Hypertension: Findings from the TRUST Study

INTRODUCTION

Home remedies are used for the treatment of hypertension despite unsubstantiated claims of their effectiveness. Home remedy use is often attributed to mistrust towards healthcare providers. Few studies examine the relationship between home remedy use and physician trust. The objective of this study was to examine and compare the association between home remedy use and trust in physicians in a cohort of low-income Blacks and Whites with hypertension living in an inner city in Alabama.

METHODS

A cross-sectional examination was conducted among 925 Black and White patients receiving care at an urban hospital. Data was collected from in-person surveys. Trust in physicians was self-reported using the Hall General Trust Scale which included questions about honesty, confidentiality, and trust. Home remedy use was self-reported using the Brown and Segal scale which included questions about home remedy use and types of home remedies used. Covariates included demographic factors such as age, race, gender, and health outcomes. Data were analyzed using linear regression.

RESULTS

Twenty-eight percent of Black and 15% of White participants reported home remedy use (p = 0.001). Black home remedy users (38.9) and non-users (39.3) had similar trust scores (p = 0.582). Whites home remedy users (32.9) reported lower trust in physicians than White non-users (37.7) (p = 0.026).

CONCLUSIONS

Black home remedy users, non-users, and White non-users reported similar trust scores; the lowest trust scores were found among White home remedy users. Home remedy use was higher among Black participants. Future studies should examine the context of mistrust and home remedy use among Whites.

Achieving control of resistant hypertension: Not just the number of blood pressure medications

Resistant hypertension (RH) has a prevalence of around 12% and is associated with an increased risk of cardiovascular disease, progression to end-stage renal disease, and even mortality. In 2017, the American College of Cardiology and American Heart Association released updated guidelines that detail steps to ensure proper diagnosis of RH, including the exclusion of pseudoresistance. Lifestyle modifications, such as low salt diet and physical exercise, remain at the forefront of optimizing blood pressure control. Secondary causes of RH also need to be investigated, including screening for obstructive sleep apnea. Notably, the guidelines demonstrate a major change in medication management recommendations to include mineralocorticoid receptor antagonists. In addition to advances in medication optimization, there are several device-based therapies that have been showing efficacy in the treatment of RH. Renal denervation therapy has struggled to show efficacy for blood pressure control, but with a re-designed catheter device, it is once again being tested in clinical trials. Carotid baroreceptor activation therapy (BAT) via an implantable pulse generator has been shown to be effective in lowering blood pressure both acutely and in long-term follow up data, but there is some concern about the safety profile. Both a second-generation pulse generator and an endovascular implant are being tested in new clinical trials with hopes for improved safety profiles while maintaining therapeutic efficacy. Both renal denervation and carotid BAT need continued study before widespread clinical implementation. Central arteriovenous anastomosis has emerged as another possible therapy and is being actively explored. The ongoing pursuit of blood pressure control is a vital part of minimizing adverse patient outcomes. The future landscape appears hopeful for helping patients achieve blood pressure goals not only through the optimization of antihypertensive medications but also through device-based therapies in select individuals.

Factors influencing adherence to treatment in older adults with hypertension

PURPOSE

Hypertension (HT) is considered to be the most common disorder in the general population. Demographic data indicate that older adults commonly suffer from HT. Older age is one of the key factors affecting the adherence of patients with HT. The main purpose was to identify demographic, socioeconomic, and clinical factors that affect adherence in older adults with HT.

MATERIALS AND METHODS

This cross-sectional study included 150 patients (84 women and 66 men) with mean age of 72.1 years. The Hill-Bone Compliance to High Blood Pressure Therapy Scale (Hill-Bone CHBPTS) was used to evaluate the adherence to therapeutic recommendations for HT.

RESULTS

The mean score obtained by the patients in the Hill-Bone CHBPTS was 20.19 (SD±4.05). The linear regression model showed the independent predictors of the total score (P<0.05): 1) age, each subsequent year of life raises the total score by an average of 0.2 points; 2) gender, males raise it by an average of 1.34 points compared to females; 3) education, a secondary, higher, or higher professional education lowers it by an average of 1.75 points compared to a primary education or no education; and 4) living with the family, having familial support lowers it by an average of 1.91 points compared to living alone or in an organized institution.

CONCLUSION

Our study has shown that the variables of age, education level, and living with the family were statistically significant in explaining the adherence rates. Health care professionals should pay more attention to older HT patients who have a low level of education and who experience the lack of social support. There is a need for a tailored education among this group of patients to better understand and adhere to medication treatment.

Factors Affecting Adherence to Antihypertensive Medication

BACKGROUND

Hypertension is a major contributor to the global disease burden of cardiovascular and cerebrovascular disease. The aim of this study was to determine demographic and clinical factors associated with adherence to antihypertensive medication.

METHODS

From August 2012 to February 2015, we recruited 1,523 Korean patients with hypertension who visited family physicians. The study was conducted in 24 facilities located in urban and metropolitan areas. Of these facilities, two were primary care clinics and 22 were level 2 or 3 hospitals. Adherence was assessed using the pill count method; a cut-off value of 80% was used as the criterion for good adherence. Sociodemographic and lifestyle factors were compared between the adherent and nonadherent groups using the chi-square test for categorical variables and t-test for continuous variables. Binary logistic regression analysis was performed with medication adherence as the outcome variable.

RESULTS

Of the 1,523 patients, 1,245 (81.7%) showed good adherence to antihypertensive medication. In the multivariate logistic analysis, age ≥65 years, exercise, treatment in a metropolitan-located hospital, being on ≥2 classes of antihypertensive medication and concomitant medication for diabetes, and a family history of hypertension or cardiovascular diseases were associated with good adherence. Patients who had a habit of high salt intake were less adherent to medication.

CONCLUSION

Multiple classes of antihypertensive medications, concomitant medication, and exercise were associated with good adherence to antihypertensive medication, and high salt intake was associated with poor adherence to antihypertensive medication. These factors should be considered to improve hypertension control.

Prescription of physical activity in the management of high blood pressure in Australian general practices

This study investigated the prevalence of physical activity prescriptions in the management of high blood pressure (BP), the characteristics of people given these, and whether prescriptions were associated with the physical activity beliefs and practices of patients. A retrospective cohort study was undertaken, involving 365 general practitioners (GPs) from across Australia. The records of up to 20 patients per GP with high BP (N = 6512) were audited to identify physical activity and pharmacological prescriptions over four consecutive consultations. A sub-sample (n = 535) of patients completed a physical activity questionnaire. Physical activity prescriptions were recorded for 42.6% of patients with controlled BP, 39.5% for those with mild hypertension and 35.7% of those with moderate to severe hypertension. These were more likely in patients with cardiovascular disease (OR 1.41, 95% CI 1.23-1.62) and diabetes (OR 1.21, 95% CI 1.04-1.42), and less likely in those with moderate to severe hypertension (OR 0.80, 95% CI 0.69-0.94), aged 75 years and over (OR 0.62, 95% CI 0.51-0.74) and with high cholesterol (OR 0.73, 95% CI 0.57-0.94). Patients receiving a physical activity prescription were more likely to report this behaviour as important for their health and that they had increased their levels of participation. Most patients with high BP are not receiving physical activity prescriptions, and GPs show greater readiness to address this behaviour in patients with existing chronic disease. There is a need for efficacious and practical strategies for promoting physical activity that can be adopted in the routine management of high BP in general practice.

Adherence to Antihypertensive Medication in Older Adults With Hypertension

Background/Objectives:

Effective prevention of cardiovascular events in people with hypertension requires optimal control of blood pressure. Despite advances in management, poor adherence to antihypertensive medications is often reported as the major reason attenuating treatment efficacy. Research has provided limited evidence of associations between illness perceptions, satisfaction with consultations, and medication adherence. The aim of this study is to identify factors significantly associated with medication adherence in a group of Chinese older adults with essential hypertension.

Design/Setting/Participants:

A cross-sectional correlational study was conducted. Data were collected from 195 older adults (mean [SD] age, 76 [6.6] years) recruited from 12 community centers.

Measurements:

The Illness Perception Questionnaire–Revised was used to measure illness perceptions, and the Medical Interview Satisfaction Scale was used to measure satisfaction with individual consultations. The Morisky Medication Adherence Scale was used to measure the extent of adherence to antihypertensive medications. Multivariate logistic regression analysis was performed to examine factors, including illness perceptions, consultation satisfaction, and demographic and clinical characteristics, that were significantly associated with medication adherence.

Results:

More than half of the respondents (55.9%) acknowledged some degree of medication nonadherence. Older age, living alone, and perception related to treatment control were independently associated with increased odds of medication adherence, with odds ratios ranging from 1.14 to 1.92 (P < .05).

Conclusion:

The results highlight the importance of cultivating positive beliefs that hypertension is amenable to control by treatment. Furthermore, the adherence behavior of those of younger individuals and living with family should be closely monitored.

Assessing Mobile Health Capacity and Task Shifting Strategies to Improve Hypertension Among Ghanaian Stroke Survivors

BACKGROUND

There has been a tremendous surge in stroke prevalence in sub-Saharan Africa. Hypertension (HTN), the most potent, modifiable risk factor for stroke, is a particular challenge in sub-Saharan Africa. Culturally sensitive, efficacious HTN control programs that are timely and sustainable are needed, especially among stroke survivors. Mobile health (mHealth) technology and task-shifting offer promising approaches to address this need.

METHODS

Using a concurrent triangulation design, we collected data from stroke survivors, caregivers, community leaders, clinicians and hospital personnel to explore the barriers, facilitators and perceptions toward mHealth related to HTN management among poststroke survivors in Ghana. Exploration included perceptions of a nurse-led navigational model to facilitate care delivery and willingness of stroke survivors and caregivers to use mHealth technology.

RESULTS

Two hundred stroke survivors completed study surveys while focus groups (n = 4) were conducted with stroke survivors, caregivers and community leaders (n = 28). Key informant interviews were completed with clinicians and hospital personnel (n = 10). A total of 93% of survey respondents had HTN (60% uncontrolled). Findings support mHealth strategies for poststroke care delivery and HTN management and for task-shifting through a nurse-led model. Of survey and focus group participants, 76% and 78.6%, respectively, have access to mobile phones and 90% express comfort in using mobile phones and conveyed assurance that task-shifting through a nurse-led model could facilitate management of HTN. Findings also identified barriers to care delivery and medication adherence across all levels of the social ecological model.

CONCLUSIONS

Participants strongly supported enhanced care delivery through mobile health and were receptive toward a nurse-led navigational model.

Neighborhood conditions, religious coping, and uncontrolled hypertension

The purpose of this study is to see whether God-mediated control beliefs moderate the relationship between living in rundown neighborhoods and uncontrolled hypertension. God-mediated control refers to the belief that God will help people handle the stressors that arise in life. Data are provided by a nationwide survey of adults (N = 1919). Three ways of assessing uncontrolled hypertension are examined: a binary format contrasting people with and without uncontrolled hypertension, systolic and diastolic blood pressure scored continuously, and a four ordinal category scheme recommended by the American Heart Association. The data suggest that stronger God-mediated control beliefs moderate the relationship between neighborhood conditions and uncontrolled blood pressure when blood pressure is scored continuously and when the American Heart Association scheme are used as outcomes.

"They're younger… it's harder." Primary providers' perspectives on hypertension management in young adults: a multicenter qualitative study

BACKGROUND

Young adults (18-39 year-olds) have the lowest hypertension control rates among adults with hypertension in the United States. Unique barriers to hypertension management in young adults with primary care access compared to older adults have not been evaluated. Understanding these differences will inform the development of hypertension interventions tailored to young adults. The goals of this multicenter study were to explore primary care providers' perspectives on barriers to diagnosing, treating, and controlling hypertension among young adults with regular primary care.

METHODS

Primary care providers (physicians and advanced practice providers) actively managing young adults with uncontrolled hypertension were recruited by the Wisconsin Research & Education Network (WREN), a statewide practice-based research network. Semi-structured qualitative interviews were conducted in three diverse Midwestern clinical practices (academic, rural, and urban clinics) using a semi-structured interview guide, and content analysis was performed.

RESULTS

Primary care providers identified unique barriers across standard hypertension healthcare delivery practices for young adults. Altered self-identity, greater blood pressure variability, and unintended consequences of medication initiation were critical hypertension control barriers among young adults. Gender differences among young adults were also noted as barriers to hypertension follow-up and antihypertensive medication initiation.

CONCLUSIONS

Tailored interventions addressing the unique barriers of young adults are needed to improve population hypertension control. Augmenting traditional clinic structure to support the "health identity" of young adults and self-management skills are promising next steps to improve hypertension healthcare delivery.

One-Year Rates and Determinants of Poststroke Systolic Blood Pressure Control among Ghanaians

BACKGROUND AND OBJECTIVE

Elevated systolic blood pressure (SBP) is potently associated with risk of recurrent strokes. In resource-limited settings, there is a dearth of data on the rates and determinants of uncontrolled SBP among stroke survivors at high risk of recurrent events. The objective of this study is to assess the rates and determinants of uncontrolled SBP over the first year post stroke.

METHODS

This is a retrospective observational study involving stroke survivors who enrolled into an outpatient neurology clinic in Kumasi, Ghana, between January 2012 and June 2014. Baseline demographic features, clinical characteristics, antihypertensive medications prescribed at each clinic visit, treatment modifications, and clinic blood pressure measurements were recorded. Predictors of uncontrolled SBP during follow-up were assessed using a multivariable logistic regression model.

RESULTS

A total of 602 stroke survivors enrolled for follow-up within the study period of which 89.8% had hypertension. Up to 35% of subjects had an SBP above 140 mmHg during follow-up clinic visits. Among those with uncontrolled SBP, 17% had antihypertensive treatment modifications during follow-up. Predictors of uncontrolled SBP were SBP at enrollment into clinic, with an adjusted odds ratio (OR [95% confidence interval {CI}]) of 1.31 (1.17-1.47)/10 mmHg increase, and average number of antihypertensive medications prescribed, with an adjusted OR (95% CI) of 1.30 (1.06-1.60) for an increase in the number of antihypertensives prescribed.

CONCLUSION

A third of stroke survivors had SBP not on target during follow-up possibly due to a combination of therapeutic inertia, apparent treatment resistance, and poor adherence to therapy. Longer-term prospective interventional studies on hypertension control among stroke survivors are warranted in sub-Saharan Africa.

Phone-based Intervention under Nurse Guidance after Stroke (PINGS): study protocol for a randomized controlled trial

BACKGROUND

Hypertension is the premier modifiable risk factor for recurrent stroke. In sub-Saharan Africa (SSA) where the stroke burden is escalating, little is known about the role of behavioral interventions in enhancing blood pressure (BP) control after stroke. Our objective is to test whether an m-Health technology-enabled, nurse-led, multilevel integrated approach is effective in improving BP control among Ghanaian stroke patients within 1 month of symptom onset compared with standard of care.

METHODS

This two-arm cluster randomized controlled feasibility pilot trial will involve 60 recent-stroke survivors. Using a computer-generated sequence, patients will be randomly allocated into four clusters of 15 patients each per physician: two clusters in the intervention arm and two in the control arm. Patients in the intervention arm will receive a simple pillbox, a Blue-toothed UA-767Plus BT BP device and smartphone for monitoring and reporting BP measurements and medication intake under nurse guidance for 3 months. Tailored motivational text messages will be delivered based upon levels of adherence to the medication intake. Both groups will be followed up for 6 months to compare BP control at months 3, 6 and 9 as primary outcome measure. Physicians assessing BP control will be blinded to arms into which patients are allocated. Secondary outcome measures will include medication adherence scores and Competence and Autonomous Self-regulation Scale scores. A qualitative study is planned after follow-up to explore the lived experiences of participants in the intervention arm.

DISCUSSION

A feasible and preliminarily effective intervention would lead to a larger more definitive efficacy/effectiveness randomized controlled trial powered to look at clinical events, with the potential to reduce stroke-related morbidity and mortality in a low- to middle-income country.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02568137 , registered on 13 July 2015.

Association of Controlled and Uncontrolled Hypertension With Workplace Productivity

The authors estimated the lost productive time (LPT) due to absenteeism and presenteeism among employees at the Group Health Cooperative with controlled and uncontrolled hypertension compared with normotensive patients. The patients responded to a survey inquiring about health behaviors with links to their medical record to identify diagnoses, blood pressure measurement, and prescription drug dispenses. Individuals with controlled hypertension were more likely to report any LPT relative to individuals with uncontrolled hypertension (40.6% vs 32.6%, P<.05). There were no significant differences in the average hours of LPT due to presenteeism among individuals regardless of their hypertension status but individuals with hypertension were more likely to report hours of LPT due to absenteeism compared with normotensive individuals (1.04 vs 0.59 hours; P=.001). Individuals with uncontrolled hypertension were more likely to report LPT due to absenteeism compared with individuals with controlled hypertension (1.35 vs 0.72 hours; P=.001). There were no significant differences between individuals with hypertension whose blood pressure was controlled and normotensive individuals with respect to the likelihood of reporting any LPT or in the amounts of absenteeism and presenteeism.

Culturally adaptive storytelling method to improve hypertension control in Vietnam - "We talk about our hypertension": study protocol for a feasibility cluster-randomized controlled trial

Background

Vietnam is experiencing an epidemiologic transition with an increased prevalence of non-communicable diseases. At present, the major risk factors for cardiovascular disease (CVD) are either on the rise or at alarming levels in Vietnam; inasmuch, the burden of CVD will continue to increase in this country unless effective prevention and control measures are put in place. A national survey in 2008 found that the prevalence of hypertension (HTN) was approximately 25 % among Vietnamese adults and it increased with advancing age. Therefore, novel, large-scale, and sustainable interventions for public health education to promote engagement in the process of detecting and treating HTN in Vietnam are urgently needed.

Methods

A feasibility randomized trial will be conducted in Hung Yen province, Vietnam to evaluate the feasibility and acceptability of a novel community-based intervention using the “storytelling” method to enhance the control of HTN in adults residing in four rural communities. The intervention will center on stories about living with HTN, with patients speaking in their own words. The stories will be obtained from particularly eloquent patients, or “video stars,” identified during Story Development Groups. The study will involve two phases: (i) developing a HTN intervention using the storytelling method, which is designed to empower patients to facilitate changes in their lifestyle practices, and (ii) conducting a feasibility cluster-randomized trial to investigate the feasibility, acceptability, and potential efficacy of the intervention compared with usual care in HTN control among rural residents. The trial will be conducted at four communes, and within each commune, 25 individuals 50 years or older with HTN will be enrolled in the trial resulting in a total sample size of 100 patients.

Discussion

This feasibility trial will provide the necessary groundwork for a subsequent large-scale, fully powered, cluster-randomized controlled trial to test the efficacy of our novel community-based intervention. Results from the full-scale trial will provide health policy makers with practical evidence on how to combat a key risk factor for CVD using a feasible, sustainable, and cost-effective intervention that could be used as a national program for controlling HTN in Vietnam and other developing countries.

Trial registration

ClinicalTrials.gov. Registration number: https://clinicaltrials.gov/ct2/show/NCT02483780(registration date June 22, 2015).

Ethnopharmacological investigation of the diuretic and hemodynamic properties of native species of the Brazilian biodiversity

ETHNOPHARMACOLOGICAL RELEVANCE

Although Echinodorus grandiflorus, Cuphea carthagenensis, and Phyllanthus tenellus infusions are used in Brazilian folk medicine due to their possible diuretic effect, none of these species was critically investigated as a diuretic drug. So, the aim of this study was to evaluate the possible acute diuretic activity of ethanol soluble fractions (ES) obtained from these species and assess the relationship between renal cortical blood flow and their antioxidant and hypotensive activity using normotensive Wistar rats.

MATERIAL AND METHODS

The preparation obtained from E. grandiflorus (ES-EG), C. carthagenensis (ES-CC), and P. tenellus (ES-PT) infusions was orally administered in a single dose to rats. Urine excretion rate, pH, density, conductivity and Na(+), K(+), Cl(-) and HCO3(-) contents were measured in the urine of saline-loaded animals. Concentration of electrolytes, total protein, urea, creatinine, and angiotensin converting enzyme (ACE) activity were evaluated in collected serum. The involvement of the renal cortical blood flow and antioxidative activity in the hypotensive and diuretic effects was also determined.

RESULTS

Water and Na(+), Cl(-) and Na(+) excretion rates were significantly increased by ES-EG, while urinary bicarbonate excretion was reduced. Moreover, ES obtained from E. grandiflorus was able to significantly increase renal blood flow and reduce mean arterial pressure and oxidative stress in "in vitro" and "in vivo" models. All other parameters evaluated were not affected by any treatment.

CONCLUSION

The results presented here shown that the ES-EG obtained from E. grandiflorus leaves shown a significant diuretic and hypotensive activity and suggest that these effects could be related with an important renal and systemic vasodilator effect. In addition, it was shown for the first time that the pharmacological effects of ES obtained from P. tenellus and C. carthagenensis do not support its popular use as a diuretic agent.

A systematic review and metaanalysis on the effects of garlic preparations on blood pressure in individuals with hypertension

BACKGROUND

Many patients prefer herbal medications to conventional drugs. Limited trial evidence suggests that garlic preparations reduce high blood pressure (BP).

METHODS

We searched electronic databases through March 2014 to identify all randomized controlled trials that compared a garlic preparation to placebo in hypertensive patients. Trials were required to report BP values at baseline and after a follow-up of at least 4 weeks.

RESULTS

Nine double-blind trials with 482 individuals fulfilled our inclusion criteria. Included trials were rather small, and the quality of the majority of included trials was moderate. Follow-up ranged from 8 to 26 weeks. All trials reported office BP measurements. Systolic BP and diastolic BP (SBP and DBP) were more effectively reduced in individuals treated with garlic preparations than in individuals treated with placebo. However, heterogeneity was high (weighted mean difference (WMD) for SBP was -9.1 mm Hg; 95% confidence interval (CI), -12.7 to -5.4; P for heterogeneity = 0.0006; and I2 = 71%; WMD for BP was -3.8 mm Hg; 95% CI, -6.7 to -1.0; P for heterogeneity = 0.00001; I2 = 80%). When analyses were restricted to higher-quality trials using intention-to-treat analysis or to trials with concealed treatment allocation and standardized and blinded BP measurement, effect sizes for SBP but not for DBP were lower and heterogeneity disappeared.

CONCLUSIONS

Although evidence from this review suggests that garlic preparations may lower BP in hypertensive individuals, the evidence is not strong. A well-conducted and powered trial of longer duration is needed to confirm these findings.

Phone-based intervention under nurse guidance after stroke: concept for lowering blood pressure after stroke in Sub-Saharan Africa

Over the last 4 decades, rates of stroke occurrence in low- and middle-income countries (LMIC) have roughly doubled, whereas they have substantively decreased in high-income countries. Most of these LMIC are in Sub-Saharan Africa (SSA) where the burden of stroke will probably continue to rise over the next few decades because of an ongoing epidemiologic transition. Moreover, SSA is circumstantially distinct: socioeconomic obstacles, cultural barriers, underdiagnosis, uncoordinated care, and shortage of physicians impede the ability of SSA countries to implement cardiovascular disease prevention among people with diabetes mellitus in a timely and sustainable manner. Reducing the burden of stroke in SSA may necessitate an initial emphasis on high-risk individuals motivated to improve their health, multidisciplinary care coordination initiatives with clinical decision support, evidence-based interventions tailored for cultural relevance, task shifting from physicians to nurses and other health providers, use of novel patient-accessible tools, and a multilevel approach that incorporates individual- and system-level components. This article proposes a theory-based integrated blood pressure (BP) self-management intervention called Phone-based Intervention under Nurse Guidance after Stroke (PINGS) that could be tested among hospitalized stroke patients with poorly controlled hypertension encountered in SSA. PINGS would comprise the implementation of nurse-run BP control clinics and administration of health technology (personalized phone text messaging and home telemonitoring), aimed at boosting patient self-efficacy and intrinsic motivation for sustained adherence to antihypertensive medications.

Medication non-adherence after myocardial infarction: an exploration of modifying factors

BACKGROUND

Medication non-adherence is a major impediment to the management of cardiovascular disease risk factors. A better understanding of the modifying factors underlying medication non-adherence among individuals with known cardiovascular disease may inform approaches for addressing non-adherence.

OBJECTIVE

The purpose of this study was to identify demographic and patient characteristics, medical comorbidities, psychosocial factors, and health belief-related factors associated with medication non-adherence among patients with known cardiovascular disease.

DESIGN

We performed secondary analysis of baseline data from a randomized trial.

PATIENTS

The study included 405 patients with a diagnosis of hypertension and history of acute myocardial infarction that was diagnosed within a three-year period prior to enrollment.

MAIN MEASURES

Baseline demographics and patient characteristics, medical comorbidities, psychosocial factors, health belief-related factors, and patient-reported medication non-adherence were analyzed.

KEY RESULTS

Of 405 patients, 173 (42.7 %) reported medication non-adherence. Factors associated with non-adherence in bivariate analysis included younger age, non-white race, having less than 12 years of education, smoking, financial insecurity, identifying as nervous or tense, higher life chaos score, greater worry about having a myocardial infarction, and greater worry about having a stroke. Using multivariable modeling, we determined that age (OR 0.97 per additional year, 95 % CI, 0.95-0.99), life chaos (OR 1.06 per additional point, 95 % CI, 1.00-1.11), and worry about stroke (OR 1.12 per additional point, 95 % CI, 1.01-1.25) remained significantly associated with self-reported medication non-adherence.

CONCLUSIONS

We found that worry about having a stroke, higher life chaos, and younger age were all significantly associated with self-reported medication non-adherence in patients with cardiovascular disease and a history of myocardial infarction. Further research exploring these factors as targets for intervention is needed, as is additional research examining modifiable causes of medication non-adherence among patients with cardiovascular disease.

Comprehensive approach for hypertension control in low-income populations: rationale and study design for the hypertension control program in Argentina

Although the efficacy and effectiveness of lifestyle modifications and antihypertensive pharmaceutical treatment for the prevention and control of hypertension and concomitant cardiovascular disease have been demonstrated in randomized controlled trials, this scientific knowledge has not been fully applied in the general population, especially in low-income communities. This article summarizes interventions to improve hypertension management and describes the rationale and study design for a cluster randomized trial testing whether a comprehensive intervention program within a national public primary care system will improve hypertension control among uninsured hypertensive men and women and their families. We will recruit 1,890 adults from 18 clinics within a public primary care network in Argentina. Clinic patients with uncontrolled hypertension, their spouses and hypertensive family members will be enrolled. The comprehensive intervention program targets the primary care system through health care provider education, a home-based intervention among patients and their families (home delivery of antihypertensive medication, self-monitoring of blood pressure [BP], health education for medication adherence and lifestyle modification) conducted by community health workers and a mobile health intervention. The primary outcome is net change in systolic BP from baseline to month 18 between intervention and control groups among hypertensive study participants. The secondary outcomes are net change in diastolic BP, BP control and cost-effectiveness of the intervention. This study will generate urgently needed data on effective, practical and sustainable intervention programs aimed at controlling hypertension and concomitant cardiovascular disease in underserved populations in low- and middle-income countries.

The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review

BACKGROUND

Therapeutic inertia has been defined as the failure of health-care provider to initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major cause of uncontrolled hypertension. The exploration of its causes and the interventions to reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We therefore systematically searched the literature for definitions and discussions on the concept of therapeutic inertia in hypertension in primary care, to try and form an operational definition.

METHODS

A systematic review of all types of publications related to clinical inertia in hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and databases, BDSP, CRD and NGC were searched from the start of their databases to June 2013. Articles were selected independently by two authors on the basis of their conceptual content, without other eligibility criteria or formal quality appraisal. Qualitative data were extracted independently by two teams of authors. Data were analyzed using a constant comparative qualitative method.

RESULTS

The final selection included 89 articles. 112 codes were grouped in 4 categories: terms and definitions (semantics), "who" (physician, patient or system), "how and why" (mechanisms and reasons), and "appropriateness". Regarding each of these categories, a number of contradictory assertions were found, most of them relying on little or no empirical data. Overall, the limits of what should be considered as inertia were not clear. A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care, depending on the situation.

CONCLUSIONS

Our data analysis revealed a major lack of conceptualization of therapeutic inertia in hypertension and important discrepancies regarding its possible causes, mechanisms and outcomes. The concept should be split in two parts: appropriate inaction and inappropriate inertia. The development of consensual and operational definitions relying on empirical data and the exploration of the intimate mechanisms that underlie these behaviors are now needed.

Acculturation, Medication Adherence, Lifestyle Behaviors, and Blood Pressure Control Among Arab Americans

PURPOSE

The aim of this study was to examine the relationship between acculturation, medication adherence, lifestyle behaviors (e.g., physical activity, nutrition, weight control), and blood pressure control among hypertensive Arab Americans.

DESIGN

The study utilized a cross-sectional descriptive design. A convenience sample of 126 participants completed questionnaires and had measures of blood pressure, weight, and height. Forty-six participants were hypertensive and were included in the analysis.

RESULTS

Only 29.2% of participants reported high medication adherence. High medication adherence was associated with lower diastolic blood pressure, eating a healthy diet, and following lifestyle modifications. Acculturation was significantly associated with physical activity and body mass index.

CONCLUSION

Our study found that acculturated participants were more adherent to medications and physical activity and had better blood pressure control. Further studies are needed to explore how acculturation improves adherence and what factors contribute to better adherence in order to design culturally sensitive interventions.

Increasing complexity: which drug class to choose for treatment of hypertension in the elderly?

Treatment of hypertension in the elderly is expected to become more complex in the coming decades. Based on the current landscape of clinical trials, guideline recommendations remain inconclusive. The present review discusses the latest evidence derived from studies available in 2013 and investigates optimal blood pressure (BP) and preferred treatment substances. Three common archetypes are discussed that hamper the treatment of hypertension in the very elderly. In addition, this paper presents the current recommendations of the NICE 2011, JNC7 2013-update, ESH/ESC 2013, CHEP 2013, JNC8 and ASH/ISH guidelines for elderly patients. Advantages of the six main substance classes, namely diuretics, beta-blockers (BBs), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and direct renin inhibitors (DRIs) are discussed. Medical and economic implications of drug administration in the very elderly are presented. Avoidance of treatment-related adverse effects has become increasingly relevant. Current substance classes are equally effective, with similar effects on cardiovascular outcomes. Selection of substances should therefore also be based on collateral advantages of drugs that extend beyond BP reduction. The combination of ACEIs and diuretics appears to be favorable in managing systolic/diastolic hypertension. Diuretics are a preferred and cheap combination drug, and the combination with CCBs is recommended for patients with isolated systolic hypertension. ACEIs and CCBs are favorable for patients with dementia, while CCBs and ARBs imply substantial cost savings due to high adherence.

How are physicians prescribing the direct renin inhibitor aliskiren in the management of essential hypertension? A French observational study

OBJECTIVES

The aim of this French observational study was to evaluate how the direct renin inhibitor aliskiren is being prescribed to treat hypertension by primary care providers (PCPs) and office-based cardiologists.

METHODS

Each participating physician included the first three consecutive hypertensive patients who had been prescribed aliskiren at least 4 weeks beforehand and noted whether aliskiren was prescribed: alone or as part of a combination; as first-line therapy, to replace another drug or as an add-on therapy.

RESULTS

Five thousand, four hundred and eleven patients were analyzed [mean age, 63; 58% men; 24% diabetic; mean blood pressure (BP) 148/85 mmHg]. A total of 23.6% of patients had a controlled BP. Aliskiren was prescribed alone in 49.4% patients and as part of a combination in 50.6% (bitherapy 28.3%, tritherapy 14.7%, and quadri+therapy 7.6%), at the higher recommended dosage (300 mg daily) to two-thirds of cases. Aliskiren replaced another drug in 71.9% [mainly an angiotensin receptor blocker (ARB) or an angiotensin-converting enzyme inhibitor (ACEi)] and was added to an existing regimen in 22.5%. For bitherapy, aliskiren was combined with a diuretic (D; 39%) or a calcium channel blocker (CCB; 32%). For tritherapy, it was prescribed with CCB and D in 28% and β-blocker and D in 26%. In 8.9% of patients, aliskiren was prescribed with an ACEi or an ARB.

CONCLUSION

French physicians are generally following the current prescribing recommendations for aliskiren, but the place of this new class of antihypertensive in the management of essential hypertension will become clearer with longer experience, especially concerning effective doses and combinations.

Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies

Background

Although the importance of detecting, treating, and controlling hypertension has been recognized for decades, the majority of patients with hypertension remain uncontrolled. The path from evidence to practice contains many potential barriers, but their role has not been reviewed systematically. This review aimed to synthesize and identify important barriers to hypertension control as reported by patients and healthcare providers.

Methods

Electronic databases MEDLINE, EMBASE and Global Health were searched systematically up to February 2013. Two reviewers independently selected eligible studies. Two reviewers categorized barriers based on a theoretical framework of behavior change. The theoretical framework suggests that a change in behavior requires a strong commitment to change [intention], the necessary skills and abilities to adopt the behavior [capability], and an absence of health system and support constraints.

Findings

Twenty-five qualitative studies and 44 quantitative studies met the inclusion criteria. In qualitative studies, health system barriers were most commonly discussed in studies of patients and health care providers. Quantitative studies identified disagreement with clinical recommendations as the most common barrier among health care providers. Quantitative studies of patients yielded different results: lack of knowledge was the most common barrier to hypertension awareness. Stress, anxiety and depression were most commonly reported as barriers that hindered or delayed adoption of a healthier lifestyle. In terms of hypertension treatment adherence, patients mostly reported forgetting to take their medication. Finally, priority setting barriers were most commonly reported by patients in terms of following up with their health care providers.

Conclusions

This review identified a wide range of barriers facing patients and health care providers pursuing hypertension control, indicating the need for targeted multi-faceted interventions. More methodologically rigorous studies that encompass the range of barriers and that include low- and middle-income countries are required in order to inform policies to improve hypertension control.

Prevalence, awareness, treatment, and control of hypertension among Arab Americans

BACKGROUND

Hypertension (HTN) is a major risk factor for heart disease, which is the leading cause of death in the United States. Hypertension detection and blood pressure (BP) control are critically important for reducing the risk of myocardial infarction and strokes. Although there are more than 3.5 million Arab Americans in the United States, there are no national or regional data on HTN prevalence among Arab Americans.

OBJECTIVE

This study aims to estimate the prevalence of HTN in a community sample of Arab Americans; assess levels of awareness, treatment, and control in hypertensive patients; and describe and compare lifestyle behaviors (eg, physical activity, nutrition, and weight control).

METHODS

In this cross-sectional, descriptive study, 126 participants completed a self-administered questionnaire to measure physical activity, nutrition, and medical history. Height and weight were measured. Three BP measurements were obtained at 60-second intervals after resting for 5 minutes. Hypertension was defined as a mean systolic BP of 140 mm Hg or higher, or a diastolic BP 90 mm Hg or higher, and/or taking antihypertensive medications.

RESULTS

Overall, 36.5% of participants had HTN and 39.7% had pre-HTN. Among hypertensive participants, only 67.4% were aware of their high BP, and 52.2% were taking antihypertensive medication. Among those taking medication, 46% had controlled BP. The prevalence of HTN was higher in men than in women (45.9% and 23.2%, respectively; P = .029) and increased with age (P = .01). Hypertensive participants also had higher body mass index (mean, 31.55 kg/m) compared with normotensive participants (mean, 28.37 kg/m; P = .01).

CONCLUSION

Our results indicate that HTN and pre-HTN are highly prevalent in Arab Americans. Hypertension awareness and control rates were inadequate and low compared with national data. These results emphasize the urgent need to develop public health strategies to improve the prevention, detection, and treatment of HTN among Arab Americans.

Medication adherence to first-line antihypertensive drug class in a large Chinese population

PURPOSE

Suboptimal adherence to antihypertensive agents leads to adverse clinical outcomes. This study aims to evaluate the association between first-line antihypertensive drug class and medication adherence in a large Chinese population.

METHODS

All patients prescribed ≥ one antihypertensive drug in 2001-2003 and 2005 who have paid at least two consecutive clinic visits in the public healthcare system of Hong Kong were included. We excluded patients who have followed-up in the clinics for ≤ 30 days. Interval-based Proportion of Days Covered (PDC) was used to assess medication adherence. All patients were followed-up for up to 5 years. Binary logistic regression analysis was used to evaluate the factors associated with optimal adherence, defined as PDC ≥ 80%.

RESULTS

From 147,914 eligible patients, 69.2% were adherent to the antihypertensive prescriptions. When compared with angiotensin converting enzyme inhibitors (ACEIs), patients initially prescribed α-blockers (adjusted odds ratio [AOR]=0.234, 95% C.I. 0.215-0.256), β-blockers (AOR=0.447, 95% C.I. 0.420, 0.477), thiazide diuretics (AOR=0.431 95% C.I. 0.399, 0.466) and calcium channel blockers (AOR=0.451, 95% C.I. 0.423, 0.481) were significantly less likely to be drug adherers. Angiotensin receptor blockers (ARBs) and fixed-dose combination therapies were similarly likely to be medication adherent. Older age, male gender, visits in general out-patient clinics, residence in urbanized regions, and the presence of comorbidity were positively associated with optimal drug adherence.

CONCLUSION

Patients receiving initial prescriptions of ACEIs, ARB and combination therapy had more favorable adherence profiles than the other major antihypertensive classes in real-life clinical practice.

Prevalence and determinants of controlled hypertension in a German population cohort

Background

Data of the German population-based cohort SHIP (Study of Health in Pomerania) were analysed to examine treatment rates, antihypertensive substances prescribed, and the proportion of hypertensive study participants reaching target values for blood pressure as well as determinants.

Methods

The study population was defined using baseline data of the cohort (collected between 1997 and 2001). Participants with blood pressure values ≥140/90 mmHg and/or antihypertensive medication with known hypertension and participants with risk-comorbidity (diabetes, stroke, angina pectoris, and/or myocardial infarction) and blood pressure values ≥130/80 mmHg were included. The analysis of treatment and target values was based on the 5-year follow-up of the cohort (collected between 2002 and 2006). Logistic regression was used to identify determinants for a normotensive blood pressure.

Results

3278 SHIP-participants with hypertensive blood pressure values were included (mean age: 55.5 years; SD 13.6, range 21–80 years). The raw hypertension prevalence was 50.9% (N = 1761). 58.7% (N = 1074) of all hypertensive patients reported some form of antihypertensive treatment. Thereof 65.1% (N = 728) received combination therapy. Of the patients without risk-comorbidity, 42.1% (N = 489) reached their target blood pressure values at the time of the 5-year follow-up of the cohort. Of the patients with any risk-comorbidity this proportion was only 21.7% (N = 131). Significant determinants for reaching the target values were being female and having antihypertensive combination therapy. Increasing age, having risk-comorbidities, and obesity were negatively associated with reaching the target values.

Conclusions

Both the proportion of participants receiving therapy and the number of participants reaching their target blood pressure values are very low. Combination therapy is associated with better blood pressure control as compared to mono therapy. However, even in the subgroup of hypertensive patients under combination therapy only 36% (both patients with and without comorbidity) reach target values.

Factors associated with non-adherence to three hypertension self-management behaviors: preliminary data for a new instrument

BACKGROUND

Clinicians have difficulty in identifying patients that are unlikely to adhere to hypertension self-management. Identifying non-adherence is essential to addressing suboptimal blood pressure control and high costs.

OBJECTIVES

1) To identify risk factors associated with non-adherence to three key self-management behaviors in patients with hypertension: proper medication use, diet, and exercise; 2) To evaluate the extent to which an instrument designed to identify the number of risk factors present for non-adherence to each of the three hypertension self-management behaviors would be associated with self-management non-adherence and blood pressure.

DESIGN

Cross-sectional analysis of randomized trial data.

PATIENTS

Six hundred and thirty-six primary care patients with hypertension.

MEASUREMENTS

1) Demographic, socioeconomic, psychosocial, and health belief-related factors; 2) measures of self-reported adherence to recommended medication use, diet recommendations, and exercise recommendations, all collected at baseline assessment; 3) systolic blood pressure (SBP) and diastolic blood pressure (DBP).

RESULTS

We identified patient factors associated with measures of non-adherence to medications, diet, and exercise in hypertension. We then combined risk factors associated with ≥1 adherence measure into an instrument that generated three composite variables (medication, diet, and exercise composites), reflecting the number of risk factors present for non-adherence to the corresponding self-management behavior. These composite variables identified subgroups with higher likelihood of medication non-adherence, difficulty following diet recommendations, and difficulty following exercise recommendations. Composite variable levels representing the highest number of self-management non-adherence risk factors were associated with higher SBP and DBP.

CONCLUSIONS

We identified factors associated with measures of non-adherence to recommended medication use, diet, and exercise in hypertension. We then developed an instrument that was associated with non-adherence to these self-management behaviors, as well as with blood pressure. With further study, this instrument has potential to improve identification of non-adherent patients with hypertension.

Racial differences in the effect of a telephone-delivered hypertension disease management program

BACKGROUND

African Americans are significantly more likely than whites to have uncontrolled hypertension, contributing to significant disparities in cardiovascular disease and events.

OBJECTIVE

The goal of this study was to examine whether there were differences in change in blood pressure (BP) for African American and non-Hispanic white patients in response to a medication management and tailored nurse-delivered telephone behavioral program.

PARTICIPANTS

Five hundred and seventy-three patients (284 African American and 289 non-Hispanic white) primary care patients who participated in the Hypertension Intervention Nurse Telemedicine Study (HINTS) clinical trial.

INTERVENTIONS

Study arms included: 1) nurse-administered, physician-directed medication management intervention, utilizing a validated clinical decision support system; 2) nurse-administered, behavioral management intervention; 3) combined behavioral management and medication management intervention; and 4) usual care. All interventions were activated based on poorly controlled home BP values.

MAIN MEASURES

Post-hoc analysis of change in systolic and diastolic blood pressure. General linear models (PROC MIXED in SAS, version 9.2) were used to estimate predicted means at 6-month, 12-month, and 18-month time points, by intervention arm and race subgroups (separate models for systolic and diastolic blood pressure).

KEY RESULTS

Improvement in mean systolic blood pressure post-baseline was greater for African American patients in the combined intervention, compared to African American patients in usual care, at 12 months (6.6 mmHg; 95 % CI: -12.5, -0.7; p=0.03) and at 18 months (9.7 mmHg; -16.0, -3.4; p=0.003). At 18 months, mean diastolic BP was 4.8 mmHg lower (95 % CI: -8.5, -1.0; p=0.01) among African American patients in the combined intervention arm, compared to African American patients in usual care. There were no analogous differences for non-Hispanic white patients.

CONCLUSIONS

The combination of home BP monitoring, remote medication management, and telephone tailored behavioral self-management appears to be particularly effective for improving BP among African Americans. The effect was not seen among non-Hispanic white patients.

[Barriers to hypertension treatment]

The objective was to describe the barriers faced by people with hypertension for non compliance to treatment and control the levels of blood pressure. This is a transversal and descriptive study which was carried out in 6 basic health units in Fortaleza-Ceará, Brazil. The population consisted of 246 people enrolled in the program to Control Hypertension for at least a year. Data were collected using a structured interview and electronic chart. Of them, 69 showed normal blood pressure levels. The main barriers discovered were: poor financial condition, continuous treatment with many medicines and practice physical activity. It was concluded that barriers to the anti-hypertensive treatment include the sick people, their environment and their access to health care.

Relationship of blood pressure self-monitoring, medication adherence, self-efficacy, stage of change, and blood pressure control among municipal workers with hypertension

Uncontrolled blood pressure remains a major public health issue. Medication adherence is a key factor in blood pressure management; however, adherence behavior is not clearly understood and the most significant factors contributing to poor medication adherence and blood pressure control are unknown. The purpose of this study was to determine the relationship of self-monitoring of blood pressure, medication adherence, self-efficacy, stage of change, and blood pressure control among municipal workers with access to health insurance. Stage of change was a significant independent predictor of self-monitoring of blood pressure, but not blood pressure control. A strong relationship was found between medication adherence and medication adherence self-efficacy (r = .549, p < .05).

Adherence behavior in the prevention and treatment of cardiovascular disease

Adherence is critical to the overall management of individuals at risk for and with cardiovascular disease. It forms an interplay between the patient, provider, and health care system and includes barriers that have been encountered within all 3 domains. Improving adherence to exercise, diet, and medication as well as focusing on addictive disorders such as smoking cessation requires patient, provider, and health care system approaches. The use of the cognitive/behavioral elements of health behavior change and communication strategies such as motivational interviewing and coaching serve to enhance overall adherence. Continuous quality improvement initiatives at the system level of change also increase the likelihood that teams will succeed in helping individuals change their behavior. Cardiac rehabilitation programs offer a unique opportunity for health care professionals to play a key role in supporting individuals through the health behavior change process.