Effects of nonpersistence with medication on outcomes in high-risk patients with cardiovascular disease

Angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers for preventing the progression of diabetic kidney disease

BACKGROUND

Guidelines suggest that adults with diabetes and kidney disease receive treatment with angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). This is an update of a Cochrane review published in 2006.

OBJECTIVES

We compared the efficacy and safety of ACEi and ARB therapy (either as monotherapy or in combination) on cardiovascular and kidney outcomes in adults with diabetes and kidney disease.

SEARCH METHODS

We searched the Cochrane Kidney and Transplants Register of Studies to 17 March 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

We included studies evaluating ACEi or ARB alone or in combination, compared to each other, placebo or no treatment in people with diabetes and kidney disease.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

One hundred and nine studies (28,341 randomised participants) were eligible for inclusion. Overall, the risk of bias was high. Compared to placebo or no treatment, ACEi may make little or no difference to all-cause death (24 studies, 7413 participants: RR 0.91, 95% CI 0.73 to 1.15; I2 = 23%; low certainty) and with similar withdrawals from treatment (7 studies, 5306 participants: RR 1.03, 95% CI 0.90 to 1.19; I2 = 0%; low certainty). ACEi may prevent kidney failure (8 studies, 6643 participants: RR 0.61, 95% CI 0.39 to 0.94; I2 = 0%; low certainty). Compared to placebo or no treatment, ARB may make little or no difference to all-cause death (11 studies, 4260 participants: RR 0.99, 95% CI 0.85 to 1.16; I2 = 0%; low certainty). ARB have uncertain effects on withdrawal from treatment (3 studies, 721 participants: RR 0.85, 95% CI 0.58 to 1.26; I2 = 2%; low certainty) and cardiovascular death (6 studies, 878 participants: RR 3.36, 95% CI 0.93 to 12.07; low certainty). ARB may prevent kidney failure (3 studies, 3227 participants: RR 0.82, 95% CI 0.72 to 0.94; I2 = 0%; low certainty), doubling of serum creatinine (SCr) (4 studies, 3280 participants: RR 0.84, 95% CI 0.72 to 0.97; I2 = 32%; low certainty), and the progression from microalbuminuria to macroalbuminuria (5 studies, 815 participants: RR 0.44, 95% CI 0.23 to 0.85; I2 = 74%; low certainty). Compared to ACEi, ARB had uncertain effects on all-cause death (15 studies, 1739 participants: RR 1.13, 95% CI 0.68 to 1.88; I2 = 0%; low certainty), withdrawal from treatment (6 studies, 612 participants: RR 0.91, 95% CI 0.65 to 1.28; I2 = 0%; low certainty), cardiovascular death (13 studies, 1606 participants: RR 1.15, 95% CI 0.45 to 2.98; I2 = 0%; low certainty), kidney failure (3 studies, 837 participants: RR 0.56, 95% CI 0.29 to 1.07; I2 = 0%; low certainty), and doubling of SCr (2 studies, 767 participants: RR 0.88, 95% CI 0.52 to 1.48; I2 = 0%; low certainty). Compared to ACEi plus ARB, ACEi alone has uncertain effects on all-cause death (6 studies, 1166 participants: RR 1.08, 95% CI 0.49 to 2.40; I2 = 20%; low certainty), withdrawal from treatment (2 studies, 172 participants: RR 0.78, 95% CI 0.33 to 1.86; I2 = 0%; low certainty), cardiovascular death (4 studies, 994 participants: RR 3.02, 95% CI 0.61 to 14.85; low certainty), kidney failure (3 studies, 880 participants: RR 1.36, 95% CI 0.79 to 2.32; I2 = 0%; low certainty), and doubling of SCr (2 studies, 813 participants: RR 1.14, 95% CI 0.70 to 1.85; I2 = 0%; low certainty). Compared to ACEi plus ARB, ARB alone has uncertain effects on all-cause death (7 studies, 2607 participants: RR 1.02, 95% CI 0.76 to 1.37; I2 = 0%; low certainty), withdrawn from treatment (3 studies, 1615 participants: RR 0.81, 95% CI 0.53 to 1.24; I2 = 0%; low certainty), cardiovascular death (4 studies, 992 participants: RR 3.03, 95% CI 0.62 to 14.93; low certainty), kidney failure (4 studies, 2321 participants: RR 1.15, 95% CI 0.67 to 1.95; I2 = 29%; low certainty), and doubling of SCr (3 studies, 2252 participants: RR 1.18, 95% CI 0.85 to 1.64; I2 = 0%; low certainty). Comparative effects of different ACEi or ARB and low-dose versus high-dose ARB were rarely evaluated. No study compared different doses of ACEi. Adverse events of ACEi and ARB were rarely reported.

AUTHORS' CONCLUSIONS

ACEi or ARB may make little or no difference to all-cause and cardiovascular death compared to placebo or no treatment in people with diabetes and kidney disease but may prevent kidney failure. ARB may prevent the doubling of SCr and the progression from microalbuminuria to macroalbuminuria compared with a placebo or no treatment. Despite the international guidelines suggesting not combining ACEi and ARB treatment, the effects of ACEi or ARB monotherapy compared to dual therapy have not been adequately assessed. The limited data availability and the low quality of the included studies prevented the assessment of the benefits and harms of ACEi or ARB in people with diabetes and kidney disease. Low and very low certainty evidence indicates that it is possible that further studies might provide different results.

A randomized trial of genotype-guided perindopril use

OBJECTIVE

Cough caused by angiotensin-converting enzyme inhibitors (ACEIs) limits their clinical application and cardiovascular benefits. This randomized trial investigated whether genotype-guided perindopril use could reduce drug-related cough in 20 to 79-year-old individuals with hypertension.

METHODS

After screening 120 patients and randomization, 68 were assigned to genotyping ( n  = 41) and control ( n  = 27) groups. NELL1 p.Arg382Trp (rs8176786) and intron (rs10766756) genotype information was used to subdivide the genotyping group into high-risk and low-risk subgroups with at least one or no risk alleles for ACEI-related cough, respectively. The high-risk subgroup received candesartan (8 mg/day) for 6 weeks, whereas the low-risk subgroup received perindopril (4 mg/day). The control group, which was not genotyped, received perindopril (4 mg/day). The primary outcome variables were cough and moderate/severe cough; the secondary outcome variable was any adverse event.

RESULTS

During the 6-week period, the risk of cough was lower in the genotyping group than in the control group [five (12.2%) and nine (33.3%) participants, respectively; hazard ratio: 0.25; log-rank P  = 0.017]. The moderate/severe cough risk was also lower in the genotyping group [one (2.4%) and five (18.5%) participants, respectively; hazard ratio: 0.12; log-rank P  = 0.025]. Differences in cough (hazard ratio: 0.56; log-rank P  = 0.32) and moderate/severe cough risk (hazard ratio: 0.26; log-rank P  = 0.19) between the low-risk and control groups were not significant. The risk of total adverse events was similar between any two groups.

CONCLUSION

Cough risk was lower during genotype-guided treatment than during conventional treatment. These results support the utility of NELL1 variant data in clinical decision making to personalize renin-angiotensin system blocker therapy use.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT05535595 (retrospectively registered at September 7, 2022).

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for adults with early (stage 1 to 3) non-diabetic chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is a long-term condition that occurs as a result of damage to the kidneys. Early recognition of CKD is becoming increasingly common due to widespread laboratory estimated glomerular filtration rate (eGFR) reporting, raised clinical awareness, and international adoption of the Kidney Disease Improving Global Outcomes (KDIGO) classifications. Early recognition and management of CKD affords the opportunity to prepare for progressive kidney impairment and impending kidney replacement therapy and for intervention to reduce the risk of progression and cardiovascular disease. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are two classes of antihypertensive drugs that act on the renin-angiotensin-aldosterone system. Beneficial effects of ACEi and ARB on kidney outcomes and survival in people with a wide range of severity of kidney impairment have been reported; however, their effectiveness in the subgroup of people with early CKD (stage 1 to 3) is less certain. This is an update of a review that was last published in 2011.

OBJECTIVES

To evaluate the benefits and harms of ACEi and ARB or both in the management of people with early (stage 1 to 3) CKD who do not have diabetes mellitus (DM).

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 6 July 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and Embase, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) reporting the effect of ACEi or ARB in people with early (stage 1 to 3) CKD who did not have DM were selected for inclusion. Only studies of at least four weeks duration were selected. Authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria.

DATA COLLECTION AND ANALYSIS

Data extraction was carried out by two authors independently, using a standard data extraction form. The methodological quality of included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another. When more than one study reported similar outcomes, data were pooled using the random-effects model. Heterogeneity was analysed using a Chi² test and the I² test. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach MAIN RESULTS: Six studies randomising 9379 participants with CKD stages 1 to 3 (without DM) met our inclusion criteria. Participants were adults with hypertension; 79% were male from China, Europe, Japan, and the USA. Treatment periods ranged from 12 weeks to three years. Overall, studies were judged to be at unclear or high risk of bias across all domains, and the quality of the evidence was poor, with GRADE rated as low or very low certainty. In low certainty evidence, ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo may make little or no difference to death (any cause) (2 studies, 8873 participants): RR 2.00, 95% CI 0.26 to 15.37; I² = 76%), total cardiovascular events (2 studies, 8873 participants): RR 0.97, 95% CI 0.90 to 1.05; I² = 0%), cardiovascular-related death (2 studies, 8873 participants): RR 1.73, 95% CI 0.26 to 11.66; I² = 54%), stroke (2 studies, 8873 participants): RR 0.76, 95% CI 0.56 to 1.03; I² = 0%), myocardial infarction (2 studies, 8873 participants): RR 1.00, 95% CI 0.84 to 1.20; I² = 0%), and adverse events (2 studies, 8873 participants): RR 1.33, 95% CI 1.26 to 1.41; I² = 0%). It is uncertain whether ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo reduces congestive heart failure (1 study, 8290 participants): RR 0.75, 95% CI 0.59 to 0.95) or transient ischaemic attack (1 study, 583 participants): RR 0.94, 95% CI 0.06 to 15.01; I² = 0%) because the certainty of the evidence is very low. It is uncertain whether ARB (losartan 50 mg) compared to placebo (1 study, 226 participants) reduces: death (any-cause) (no events), adverse events (RR 19.34, 95% CI 1.14 to 328.30), eGFR rate of decline (MD 5.00 mL/min/1.73 m2, 95% CI 3.03 to 6.97), presence of proteinuria (MD -0.65 g/24 hours, 95% CI -0.78 to -0.52), systolic blood pressure (MD -0.80 mm Hg, 95% CI -3.89 to 2.29), or diastolic blood pressure (MD -1.10 mm Hg, 95% CI -3.29 to 1.09) because the certainty of the evidence is very low. It is uncertain whether ACEi (enalapril 20 mg, perindopril 2 mg or trandolapril 1 mg) compared to ARB (olmesartan 20 mg, losartan 25 mg or candesartan 4 mg) (1 study, 26 participants) reduces: proteinuria (MD -0.40, 95% CI -0.60 to -0.20), systolic blood pressure (MD -3.00 mm Hg, 95% CI -6.08 to 0.08) or diastolic blood pressure (MD -1.00 mm Hg, 95% CI -3.31 to 1.31) because the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to determine the effectiveness of ACEi or ARB in patients with stage 1 to 3 CKD who do not have DM. The available evidence is overall of very low certainty and high risk of bias. We have identified an area of large uncertainty for a group of patients who account for most of those diagnosed as having CKD.

Medication Adherence and Blood Pressure Control Among Hypertensive Outpatients Attending a Tertiary Cardiovascular Hospital in Tanzania: A Cross-Sectional Study

Background

Notwithstanding the availability of effective treatments, asymptomatic nature and the interminable treatment length, adherence to medication remains a substantial challenge among patients with hypertension. Suboptimal adherence to BP-lowering agents is a growing global concern that is associated with the substantial worsening of disease, increased service utilization and health-care cost escalation. This study aimed to explore medication adherence and its associated factors among hypertension outpatients attending a tertiary-level cardiovascular hospital in Tanzania.

Methods

The pill count adherence ratio (PCAR) was used to compute adherence rate. In descriptive analyses, adherence was dichotomized and consumption of less than 80% of the prescribed medications was used to denote poor adherence. Logistic regression analyses was used to determine factors associated with adherence.

Results

A total of 849 outpatients taking antihypertensive drugs for ≥1 month prior to recruitment were randomly enrolled in this study. The mean age was 59.9 years and about two-thirds were females. Overall, a total of 653 (76.9%) participants had good adherence and 367 (43.2%) had their blood pressure controlled. Multivariate logistic regression analysis showed; lack of a health insurance (OR 0.5, 95% CI 0.3-0.7, p<0.01), last BP measurement >1 week (OR 0.6, 95% CI 0.4-0.8, p<0.01), last clinic attendance >1 month (OR 0.4, 95% CI 0.3-0.6, p<0.001), frequent unavailability of drugs (OR 0.6, 95% CI 0.3-0.9, p = 0.03), running out of medication before the next appointment (OR 0.6, 95% CI 0.4-0.9, p = 0.01) and stopping medications when asymptomatic (OR 0.6, 95% CI 0.4-0.8, p<0.001) to be independent associated factors for poor adherence.

Conclusion

A substantial proportion of hypertensive outpatients in this tertiary-level setting had good medication adherence. Nonetheless, observed suboptimal blood pressure control regardless of a fairly satisfactory adherence rate suggests that lifestyle modification plays a central role in hypertension management.

Genetic Variants Associated with Adverse Events after Angiotensin-Converting Enzyme Inhibitor Use: Replication after GWAS-Based Discovery

PURPOSE

Angiotensin-converting enzyme inhibitors (ACEIs) are medications generally prescribed for patients with high cardiovascular risk; however, they are suboptimally used due to frequent adverse events (AEs). The present study aimed to identify and replicate the genetic variants associated with ACEI-related AEs in the Korean population.

MATERIALS AND METHODS

A two-stage approach employing genome-wide association study (GWAS)-based discovery and replication through target sequencing was used. In total, 1300 individuals received ACEIs from 2001 to 2007; among these, 228 were selected for GWAS. An additional 336 patients were selected for replication after screening 1186 subjects treated from 2008 to 2018. Candidate genes for target sequencing were selected based on the present GWAS, previous GWASs, and data from the PharmGKB database. Furthermore, association analyses were performed between no AE and AE or cough groups after target sequencing.

RESULTS

Five genes, namely CRIM1, NELL1, CACNA1D, VOPP1, and MYBPC1, were identified near variants associated with ACEI-related AEs. During target sequencing of 34 candidate genes, six single-nucleotide polymorphisms (SNPs; rs5224, rs8176786, rs10766756, rs561868018, rs4974539, and rs10946364) were replicated for association with all ACEI-related AEs. Four of these SNPs and rs147912715 exhibited associations with ACEI-related cough, whereas four SNPs (rs5224, rs81767786, rs10766756, and rs4974539 near BDKRB2, NELL1, NELL1 intron, and CPN2, respectively) were significantly associated with both categories of AEs.

CONCLUSION

Several variants, including novel and known variants, were successfully replicated and found to have associations with ACEI-related AEs. These results provide rare and clinically relevant information for safer use of ACEIs.

Cardiovascular Outcomes According to Polypharmacy and Drug Adherence in Patients with Atrial Fibrillation on Long-Term Anticoagulation (from the RE-LY Trial)

Prevalence of atrial fibrillation (AF) increases with age, along with comorbidities and, thus, polypharmacy. Non-adherence is associated with polypharmacy. This study aimed to identify patients at risk for cardiovascular events according to their pharmacological treatment intensity and adherence. Patients (n = 18,113) with a mean age of 71.5 ± 8.7 years, at high cardiovascular risk were followed between December 2005 until December 2007 for a median time of 2 years. The association between polypharmacy and adherence and their impact on cardiovascular and bleeding events were explored. Adherence was defined as a study drug intake of ≥80%. Patients with more co-medications had a higher body mass index, higher prevalence of hypertension, coronary heart disease, heart failure, and diabetes mellitus (all p < 0.0001) compared to ≤4 or 5-8 co-medications, but no differences in history of stroke (p = 0.68) or transient ischemic attack (p = 0.065). Across all treatments, the adjusted hazard ratios (HRs) increased in patients with more co-medications (≥9 vs ≤4) for all-cause death (HR 1.30; 1.06-1.59), major bleeding (HR 1.65; 1.33-2.05), and all bleeding events (HR 1.44; 1.31-1.59). Yearly event rates were higher in non-adherent than adherent patients for stroke and systemic embolism (SSE) (3.14 vs 1.00), all-cause death (7.76 vs 2.66), major bleeding (6.21 vs 2.65), and all bleeding (28.71 vs 19.05; all p < 0.0001). After an event the patients were more likely to become non-adherent (adherence after SSE 30.3%, after major bleeding 33.4%, after all bleeding 66.7%; all p < 0.0001). The treatment effects were consistent to the overall group in the different polypharmacy groups. In conclusion, polypharmacy and non-adherence are risk indicators for increased adverse cardiovascular and bleeding events. Dabigatran is safe to use across the full spectrum of AF patients, independent of the number of co-medications and adherence. Patients with co-medications and comorbidities require special attention and encouragement to adhere to oral anticoagulation.

A Cross-Sectional Survey on Medication Management Practices for Noncommunicable Diseases in Europe During the Second Wave of the COVID-19 Pandemic

Maintaining healthcare for noncommunicable diseases (NCDs) is particularly important during the COVID-19 pandemic; however, diversion of resources to acute care, and physical distancing restrictions markedly affected management of NCDs. We aimed to assess the medication management practices in place for NCDs during the second wave of the COVID-19 pandemic across European countries. In December 2020, the European Network to Advance Best practices & technoLogy on medication adherencE (ENABLE) conducted a cross-sectional, web-based survey in 38 European and one non-European countries. Besides descriptive statistics of responses, nonparametric tests and generalized linear models were used to evaluate the impact on available NCD services of the number of COVID-19 cases and deaths per 100,000 inhabitants, and gross domestic product (GDP) per capita. Fifty-three collaborators from 39 countries completed the survey. In 35 (90%) countries face-to-face primary-care, and out-patient consultations were reduced during the COVID-19 pandemic. The mean ± SD number of available forms of teleconsultation services in the public healthcare system was 3 ± 1.3. Electronic prescriptions were available in 36 (92%) countries. Online ordering and home delivery of prescription medication (avoiding pharmacy visits) were available in 18 (46%) and 26 (67%) countries, respectively. In 20 (51%) countries our respondents were unaware of any national guidelines regarding maintaining medication availability for NCDs, nor advice for patients on how to ensure access to medication and adherence during the pandemic. Our results point to an urgent need for a paradigm shift in NCD-related healthcare services to assure the maintenance of chronic pharmacological treatments during COVID-19 outbreaks, as well as possible future disasters.

Drug adherence and psychosocial characteristics of patients presenting with hypertensive urgency at the emergency department

OBJECTIVE

To identify potentially targetable psychosocial factors associated with nonadherence to prescribed antihypertensive medications in patients presenting with hypertensive urgencies at an emergency department.

METHODS

This prospective study included patients treated with antihypertensive drugs who presented with hypertensive urgencies (SBP ≥180 mmHg and/or DBP ≥110 mmHg) at the emergency department of a tertiary referral clinic between April 2018 and April 2019. Health literacy was assessed using the Newest Vital Sign test. The Hospital Anxiety and Depression Scale (HADS) was used to quantify symptoms of anxiety and depression. Patients were classified nonadherent if less than 80% of the prescribed antihypertensive drugs were detectable in urine or plasma using liquid chromatography-high-resolution mass spectrometry.

RESULTS

A total of 104 patients (62% women) presenting with hypertensive urgencies with a median SBP of 200 mmHg (IQR 190-212) and DBP of 97.5 mmHg (IQR 87-104) were included. Twenty-five patients (24%) were nonadherent to their antihypertensive medication. Nonadherent patients were more often men (66 versus 23%, P = 0.039), prescribed higher numbers of antihypertensive drugs (median 3, IQR 3-4 versus 2, IQR 1-3; P < 0.001), and more often treated with calcium channel blockers (76 versus 25%; P < 0.001) and/or diuretics (64 versus 40%; P = 0.030). There was no difference in health literacy (P = 0.904) or the scores on the HADS subscales for depression (P = 0.319) and anxiety (P = 0.529) between adherent and nonadherent patients.

CONCLUSION

Male sex, higher numbers of antihypertensive drugs, and treatment with diuretics and/or calcium channel blockers were associated with nonadherence. We did not identify a specific psychosocial characteristic associated with nonadherence.

The current status of renal denervation for the treatment of arterial hypertension

Despite the availability of safe and effective antihypertensive drugs, blood pressure (BP) control to guideline-recommended target values is poor. Several device-based therapies have been introduced to lower BP. The most extensively investigated approach is catheter-based renal sympathetic denervation (RDN), which aims to interrupt the activity of afferent and efferent renal sympathetic nerves by applying radiofrequency energy, ultrasound energy, or injection of alcohol in the perivascular space. The second generation of placebo-controlled trials have provided solid evidence for the BP-lowering efficacy of radiofrequency- and ultrasound-based RDN in patients with and without concomitant pharmacological therapy. In addition, the safety profile of RDN appears to be excellent in all registries and clinical trials. However, there remain unsolved issues to be addressed. This review summarizes the rationale as well as the current evidence and discusses open questions and possible future indications of catheter-based RDN.

Renal outcomes and blood pressure patterns in diabetic and nondiabetic individuals at high cardiovascular risk

BACKGROUND

Diabetes and hypertension are risk factors for renal and cardiovascular outcomes. Data on the association of achieved blood pressure (BP) with renal outcomes in patients with and without diabetes are sparse. We investigated the association of achieved SBP, DBP with renal outcomes and urinary albumin excretion (UAE) in people with vascular disease.

METHODS

In this pooled analysis, we assessed renal outcome data from high-risk patients aged 55 years or older with a history of cardiovascular disease, 70% of whom had hypertension, randomized to The Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial and to Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease trials investigating telmisartan, ramipril and their combination with a median follow-up of 56 months. Standardized office BP was measured every 6 months, estimated glomerular filtration rate (eGFR) and UAE at baseline, 2 years and study end. Associations of mean achieved BP on treatment were investigated on major renal outcomes including end-stage renal disease (ESRD), decline of eGFR by at least 40%, doubling of creatinine and the composites thereof and on UAE. Analyses were by Cox regression analysis, analysis of variance and Chi2-test. Of 30 937 patients with complete data, 19 450 patients without and 11 487 with diabetes were enrolled between 1 December 2001 and 31 July 2003 and followed until 31 July 2008. Data were pooled as the outcomes for telmisartan 80 mg/day (n = 2903) or placebo (n = 2907) for Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease and ramipril 10 mg/day (n = 8407), telmisartan 80 mg/day (n = 8386) or the combination of both (n = 8334) were similar.

RESULTS

For both those with and without diabetes, the hazard ratios for the composites ESRD or doubling of serum creatinine (707 events overall) and ESRD or 40% eGFR loss (2371 events overall) reached a nadir at achieved SBP of 120 to less than 140 mmHg, and increased with higher and lower SBP with similar relative risk with or without diabetes. For example, risk for the former composite reached a hazard ratios 3.06 (confidence interval 1.90-4.92) with a mean achieved SBP more than 160 mmHg compared with 120 to less than 130 mmHg with diabetes and hazard ratios 2.14 (1.09-4.26) without diabetes. In contrast, the development of new microalbuminuria and macroalbuminuria (3002 and 846 events overall) associated linearly over the whole range of achieved SBP (apart from a slight increase in risk at SBP less than 120 mmHg only in those without diabetes). Absolute risks for the composite and albuminuria outcomes were consistently greater in those with diabetes as compared with without diabetes with high event rates over the whole SBP spectrum. The increased renal risk at low SBP was not related to a meaningful reduction of mandated study drugs or open label renin-angiotensin-aldosterone system inhibition.

CONCLUSION

In patients at high cardiovascular risk, SBP levels more than 140 mmHg and less than 120 are associated with increased risk for renal outcomes. Renal risk was greater in diabetes across the whole range of achieved SBP and DBP. These data suggest similar target BP range in patients with and without diabetes to prevent renal outcomes, a frequent complication in high-risk vascular patients.

CLINICAL TRIAL REGISTRATION

Clinical Trial registration: http://clinicaltrials.gov.Unique identifier: NCT00153101.

Patterns of Use and Discontinuation of Secondary Prevention Medications After Stroke

OBJECTIVE

To investigate whether certain patient, acute care, or primary care factors are associated with medication initiation and discontinuation in the community after stroke or TIA.

METHODS

This is a retrospective cohort study using prospective data on adult patients with first-ever acute stroke/TIA from the Australian Stroke Clinical Registry (April 2010 to June 2014), linked with nationwide medication dispensing and Medicare claims data. Medication users were those with ≥1 dispensing in the year postdischarge. Discontinuation was assessed among medication users and defined as having no medication supply for ≥90 days in the year postdischarge. Multivariable competing risks regression, accounting for death during the observation period, was conducted to investigate factors associated with time to medication discontinuation.

RESULTS

Among 17,980 registry patients with stroke/TIA, 91.4% were linked to administrative datasets. Of these, 9,817 adults with first-ever stroke/TIA were included (45.4% female, 47.6% aged ≥75 years, and 11.4% intracerebral hemorrhage). While most patients received secondary prevention medications (79.3% antihypertensive, 81.8% antithrombotic, and 82.7% lipid-lowering medication), between one-fifth and one-third discontinued treatment over the subsequent year postdischarge (20.9% antihypertensive, 34.1% antithrombotic, and 28.5% lipid-lowering medications). Prescription at hospital discharge (sub-hazard ratio [SHR] 0.70; 95% confidence interval [CI] 0.62-0.79), quarterly contact with a primary care physician (SHR 0.62; 95% CI 0.57-0.67), and prescription by a specialist physician (SHR 0.87; 95% CI 0.77-0.98) were all inversely associated with antihypertensive discontinuation.

CONCLUSIONS

Patterns of use of secondary prevention medications after stroke/TIA are not optimal, with many survivors discontinuing treatment within 1 year postdischarge. Improving postdischarge care for patients with stroke/TIA is needed to minimize unwarranted discontinuation.

Effects of glucose-lowering on outcome incidence in diabetes mellitus and the modulating role of blood pressure and other clinical variables: overview, meta-analysis of randomized trials

BACKGROUND

Randomized controlled trials (RCTs) of antidiabetic agents started in the 1960s. Updated meta-analyses of RCTs investigating glucose-lowering in patients with type 2 diabetes mellitus are lacking. Also, no previous attempt was made to evaluate the role of blood pressure (BP) reduction and LDL cholesterol (LDL-C) change on outcome incidence following glucose-lowering.

OBJECTIVES

Three main clinical questions were investigated: the extent of different outcome reductions by glucose-lowering in patients with diabetes, the proportionality of outcome reductions to glycated hemoglobin (HBA1c) reductions and whether ongoing BP and LDL-C difference in RCTs can change glucose-lowering outcome effects.

METHODS

PubMed between 1960 and January 2019 (any language), Cochrane Collaboration Library and previous overviews were used as data sources to identify and select all RCTs comparing the glucose-lowering drugs with placebo or less intense treatment (intentional glucose-lowering RCTs); comparing glucose-lowering drugs with placebo without glucose-lowering intention, but HBA1c difference (nonintentional glucose-lowering RCTs); enrolling type 2 diabetes mellitus patients; and reporting ongoing SBP and DBP difference. We excluded RCTs of acute care, glucose intolerance, type 1 diabetes, multiple interventions applied and glucose-lowering by lifestyle or other interventions. Risk ratios and 95% confidence intervals, of seven fatal and nonfatal outcomes and of treatment-related discontinuations were calculated (random-effects model) before and after adjustment for the ongoing BP difference, while LDL-C difference was also considered. The relationships of different outcome reductions to HBA1c reductions were investigated by meta-regressions.

RESULTS

A total of 25 RCTs (174 235 individuals, follow-up 3.5 years) were eligible, and the resulted ongoing SBP/DBP difference was -1.4/-0.4 mmHg. Both before and after adjustment for BP difference, glucose-lowering reduced CHD (coronary heart disease) and both composites of major cardiovascular events were reduced by a mean of 8 and 5%, respectively, while before BP-adjustment the risk of treatment-related discontinuations was increased by 26% and the risk of stroke and all-cause death was reduced by 7 and 6%, respectively. Logarithmic risk ratios were related to HBA1c reductions for the composite of CHD and stroke and for treatment-related discontinuations. Glucose-lowering had no differential outcome effects, before and after estimate adjustment for the ongoing BP difference, at different HBA1c thresholds and targets, as well as when both baseline BP and achieved BP, overall cardiovascular risk and diabetes mellitus duration were considered as dichotomous effect modifiers. Although heart failure incidence was found increased by 15% in the early glucose-lowering RCTs, this effect faded away in contemporary RCTs. LDL-C change was overall trivial and did not change glucose-lowering outcome effects.

CONCLUSION

Meta-analyses of all glucose-lowering RCTs involving patients with diabetes provide precise estimates of benefits for CHD and major cardiovascular events after consideration of the resulting ongoing BP difference. No benefit or harm on mortality, heart failure and stroke were noticed, while discontinuations related to adverse events because of treatment were increased following glucose-lowering. The extent of glucose-lowering is proportionally related to changes of CHD and stroke composite, and treatment-related discontinuations.

On the Road to Accurate Biomarkers for Cardiometabolic Diseases by Integrating Precision and Gender Medicine Approaches

The need to facilitate the complex management of cardiometabolic diseases (CMD) has led to the detection of many biomarkers, however, there are no clear explanations of their role in the prevention, diagnosis or prognosis of these diseases. Molecules associated with disease pathways represent valid disease surrogates and well-fitted CMD biomarkers. To address this challenge, data from multi-omics types (genomics, epigenomics, transcriptomics, proteomics, metabolomics, microbiomics, and nutrigenomics), from human and animal models, have become available. However, individual omics types only provide data on a small part of molecules involved in the complex CMD mechanisms, whereas, here, we propose that their integration leads to multidimensional data. Such data provide a better understanding of molecules related to CMD mechanisms and, consequently, increase the possibility of identifying well-fitted biomarkers. In addition, the application of gender medicine also helps to identify accurate biomarkers according to gender, facilitating a differential CMD management. Accordingly, the impact of gender differences in CMD pathophysiology has been widely demonstrated, where gender is referred to the complex interrelation and integration of sex (as a biological and functional marker of the human body) and psychological and cultural behavior (due to ethnical, social, and religious background). In this review, all these aspects are described and discussed, as well as potential limitations and future directions in this incipient field.

New Insights in the Control of Low-Density Lipoprotein Cholesterol to Prevent Cardiovascular Disease

PURPOSE OF REVIEW

Low-density lipoprotein cholesterol (LDL-C) is one major cause of cardiovascular disease (CVD). In this review, we discuss current developments in the understanding of LDL-C as lifelong risk factor, treatment targets, and emerging approaches to reduce cardiovascular risk by lowering LDL-C.

RECENT FINDINGS

Recent evidence underscores the importance of LDL-C lowering in CVD prevention by mechanisms that increase the hepatic clearance of apolipoprotein B-containing lipoproteins from the plasma. Mendelian randomization studies provided evidence on both safety and efficacy of lower LDL-C in the long term. For young individuals, metrics other than 10-year CVD risk are required. Despite this evidence, LDL-C treatment target attainment is poor. Novel approaches are therefore needed. These include individualized strategies and new LDL-C-lowering pharmaceuticals. Early, long-term treatment with LDL-C-lowering therapies has the potential to markedly reduce CVD incidence and progression. Future research should aim to identify patient characteristics that enable physicians to tailor therapy to each individual patient.

Association of Diabetes Mellitus Status and Glycemic Control With Secondary Prevention Medication Adherence After Acute Myocardial Infarction

Background

Cardioprotective medication adherence can mitigate the risk of recurrent cardiovascular events and mortality after acute myocardial infarction (AMI). We examined the associations of diabetes mellitus status and glycemic control with cardioprotective medication adherence after AMI.

Methods and Results

We performed a retrospective observational cohort study of 14 517 US veterans who were hospitalized for their first AMI between 2011 and 2014 and prescribed a beta‐blocker, 3‐hydroxy‐3‐methyl‐glutaryl‐CoA‐reductase inhibitor, and angiotensin‐converting enzyme inhibitor or angiotensin receptor blocker. The primary exposure was a diagnosis of type 2 diabetes mellitus; in diabetes mellitus patients, hemoglobin A1c (HbA1c) was a secondary exposure. The primary outcome was 1‐year adherence to all 3 medication classes, defined as proportion of days covered ≥0.8, assessed using adjusted risk differences and multivariable Poisson regression. Of 14 517 patients (mean age, 66.3 years; 98% male), 52% had diabetes mellitus; 9%, 31%, 24%, 15%, and 21% had HbA1c <6%, 6% to 6.9%, 7% to 7.9%, 8% to 8.9%, and ≥9%, respectively. Diabetes mellitus patients were more likely to be adherent to all 3 drug classes than those without diabetes mellitus (adjusted difference in adherence, 2.1% [0.5, 3.7]). Relative to those with HbA1c 6% to 6.9%, medication adherence declined with increasing HbA1c (risk ratio of achieving proportion of days covered ≥0.8, 0.99 [0.94, 1.04], 0.93 [0.87, 0.99], 0.82 [0.77, 0.88] for HbA1c 7–7.9%, 8–8.9%, and ≥9%, respectively).

Conclusions

Although diabetes mellitus status had a minor positive impact on cardioprotective medication adherence after AMI, glycemic control at the time of AMI may help identify diabetes mellitus patients at risk of medication nonadherence who may benefit from adherence interventions after AMI.

Association of medication adherence and depression with the control of low-density lipoprotein cholesterol and blood pressure in patients at high cardiovascular risk

BACKGROUND

Many patients at high cardiovascular risk do not reach targets for low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP). Depression is a frequent comorbidity in these patients and contributes to poor medication adherence.

OBJECTIVE

The aim of this study was to elucidate the associations between adherence to lipid-and BP-lowering drugs, the diagnosis of depression, and the control of LDL-C and BP.

PATIENTS AND METHODS

This study was conducted as multicenter, single-visit cross-sectional study in Germany. Adherence was assessed by the Morisky Medication Adherence Scale-8 (MMAS-8), and depression was assessed as documented in the patient chart.

RESULTS

A total of 3,188 ambulatory patients with hypercholesterolemia (39.8%), stable coronary artery disease (CAD; 7.4%), or both (52.9%) were included. Patients had a history of myocardial infarction (30.8%), diabetes (42.0%), were smokers (19.7%), and 16.1% had the investigator-reported diagnosis of depression. High or moderate adherence to lipid-lowering medication compared to low adherence was associated with lower LDL-C levels (105.5±38.3 vs 120.8±42.4 mg/dL) and lower BP (systolic BP 133.4±14.5 vs 137.9±13.9 mmHg, diastolic BP 78.3±9.6 vs 81.8±9.6 mmHg) and with a higher proportion of patients achieving the guideline-recommended LDL-C (16.9% vs 10.1%) and BP target (52.2% vs 40.8%, all comparisons P<0.0001). Adherence was worse in patients with depression. Correspondingly, patients with depression showed higher LDL-C levels, higher BP, and a lower probability of achieving the LDL-C and BP goal. Medication adherence correlated between BP- and lipid-lowering medications.

CONCLUSION

Self-reported medication adherence can be easily obtained in daily practice. A low adherence and the diagnosis of depression identify patients at risk for uncontrolled LDL-C and BP who likely benefit from intensified care.

Impact of medication adherence on risk of ischemic stroke, major bleeding and deep vein thrombosis in atrial fibrillation patients using novel oral anticoagulants

OBJECTIVES

Our study examined the impact of adherence to novel oral anticoagulants [NOACs - dabigatran and rivaroxaban] on ischemic-stroke (IS), major-bleeding (MB), deep-vein-thrombosis and pulmonary-embolism (DVTPE) risk in a large, nationwide, propensity-matched sample.

METHODS

A retrospective cohort study utilized data from a US commercial managed-care database (2010-2012). Adult patients with ≥1 diagnosis of atrial fibrillation/flutter (ICD-9 427.31/32), >1 prescription of NOACs and CHA₂DS₂-VASc score ≥1 were included. Patients were categorized as adherent versus nonadherent (using proportion of days covered [PDC ≥80%]) based on their NOAC use up to 6 months and those continued its use up to 12 months. The patients were matched using propensity score (based on inverse probability treatment weighting) and the risk of IS, MB, DVTPE outcomes was evaluated for the matched cohorts' post-adherence (exposure) assessment using multivariable Cox regression.

RESULTS

A total of 3,629 and 1,946 patients with at least 6 and 12 months of NOAC use were included. Based on a PDC threshold of ≥80%, adherence rates at 6 and 12 month usage were 77% and 76%, respectively. Patients with lowest adherence were from the South, had low stroke risk and EPO/HMO insurance. Using Cox models with matched cohorts, nonadherence within the first 6 months' use was significantly associated with higher risk of IS and DVTPE (IS: hazard ratio [HR] = 1.82, p = .002; DVTPE: HR = 2.12, p = .010) and the risk increased with nonadherence for the prolonged period of 12 months' use (IS: HR = 2.08, p = .022; DVTPE: HR = 5.39, p = .003). The risk of MB was not different (p > .05) between adherent and nonadherent groups for both 6 month and 12 month cohorts.

CONCLUSION

Adherence to NOACs for both 6 months and prolonged use (up to 12 months) was associated with a reduction in IS and DVTPE risk, but did not substantially increase risk of MB. Further studies on newer, individual NOACs and older populations are warranted.

Non-persistence in ischaemic stroke: Risk of recurrent vascular events

OBJECTIVES

Ischaemic stroke is one of the leading causes of death and disability worldwide. Although the secondary preventive medication should be continued for life, its use commonly declines in time. This may lead to recurrent vascular events. In this study, we investigated if during a long follow-up period discontinuation of medication (non-persistence) in real life ischaemic stroke patients increased the risk of recurrent vascular events.

MATERIALS AND METHODS

This was a retrospective cohort study with the data retrieved from a database and the original patient records. The occurrence of new vascular events was determined from the electronic medical record. Medication use at time of follow-up was ascertained using the pharmacy-link in the electronic medical file and through a telephone interview. Primary endpoint was recurrent vascular events. Patients with two or more vascular risk factors were considered as having a high-risk profile.

RESULTS

A total of 286 patients (persistent n = 182 and non-persistent n = 104) were included. After median follow-up period of 5½ years in the persistent group 14.8% had a recurrent vascular event, vs 23.1% in the non-persistent group (P = .801). In the patients with a high-risk profile, the persistent group had significantly less recurrent vascular events than the non-persistent group (23.5% against 46.4% P = .021).

CONCLUSION

After a long follow-up period, ischaemic stroke patients with a high vascular risk profile who stopped taking their secondary preventive medication had an increased risk of a recurrent vascular events.

Financial strain is associated with medication nonadherence and worse self-rated health among cardiovascular patients

Non-traditional indicators of socioeconomic status (SES; e.g., home ownership) may be just as or even more predictive of health outcomes as traditional indicators of SES (e.g., income). This study tested whether financial strain (i.e., difficulty paying monthly bills) predicted medication non-adherence and worse self-rated health. Research assistants administered surveys to 1,527 patients with acute coronary syndromes or acute decom-pensated heart failure. In adjusted models, having a higher income was associated with being more adherent (p &lt; .001), but was non-significant when adjusted for financial strain. Education, income, less financial strain, and being employed were each associated with better self-rated health (p &lt; .001). Financial strain was associated with less adherence (β =-.17, p &lt; .001) and worse self-rated health (β = -.23, p &lt; .001), and mediated the effect of income on adherence (coeff = .078 [BCa 95% CI: .051 to .108]). Future research should further explore the nuanced link between SES and health behaviors and outcomes.

Effects of blood pressure lowering treatment in hypertension: 8. Outcome reductions vs. discontinuations because of adverse drug events - meta-analyses of randomized trials

BACKGROUND

Previous meta-analyses of randomized controlled trials (RCTs) of blood pressure (BP)-lowering treatment provided overwhelming evidence that treatment markedly reduces risk of cardiovascular outcomes in hypertensive patients. However, adverse events associated with BP-lowering treatment have never been surveyed systematically.

OBJECTIVES

Identifying among BP-lowering RCTs those reporting a common and meaningful index of treatment-attributed adverse events, and describing the burden of these adverse events accompanying the benefits of mortality and morbidity reduction induced by treatment.

METHODS

The database consisted of the BP-lowering RCTs (active vs. placebo or less active treatment) we have described (70 RCTs, 255 970 participants, 1 091 964 patient-years). A common index of relevant adverse events was identified as permanent treatment discontinuation attributed to treatment adverse events. Risk ratios and 95% confidence intervals, standardized to a SBP/DBP reduction of 10/5 mmHg, of seven fatal and nonfatal outcomes and of treatment discontinuations for adverse events were calculated (random-effects model). The relationships of outcome reductions and discontinuation excess to SBP and DBP reductions were investigated by meta-regressions.

RESULTS

Forty-four RCTs provided data on treatment discontinuations for adverse events and six more on serious adverse events because of treatment (179 949 patients, 719 796 patient-years). In these 50 RCTs, a significant 24% reduction of major cardiovascular event risk was associated with a significant 89% increase in the risk of discontinuations (33 major cardiovascular effects prevented and 84 excess discontinuations/1000 patients for 5 years). Metaregression analysis indicated that both outcome reductions and treatment discontinuation excess were significantly related to the extent of SBP and DBP reduction, but absolute treatment discontinuation excess disproportionally increased with larger BP reductions than increase in outcome risk reduction. Furthermore, a standard SBP reduction was found associated with a constant relative reduction, but a smaller absolute reduction of cardiovascular events, and a greater relative excess of treatment discontinuations when the achieved SBP was below 130 mmHg rather than in higher ranges.

CONCLUSION

The burden of adverse events associated with BP-lowering treatment should be considered not to deny patients the overwhelming benefits of BP lowering, but whenever the extent of the BP lowering or the BP target to be achieved are discussed.

Risks associated with permanent discontinuation of blood pressure-lowering medications in patients with type 2 diabetes

OBJECTIVE

The associations of discontinuation of the study medication on major outcomes were assessed in the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation Trial.

METHODS

ADVANCE was a factorial randomized controlled trial of blood pressure lowering (a fixed combination of perindopril and indapamide vs. placebo) and intensive glucose control (vs. standard glucose control) in patients with type 2 diabetes. Patients who permanently discontinued the randomized blood pressure-lowering medication during the study period (n = 1557) were compared with others (n = 9583). Cox's proportional hazards models were used to estimate the effects of the discontinuation on the risks of macrovascular events, microvascular events together and separately and all-cause mortality, using discontinuation as a time-dependent covariate.

RESULTS

In multivariable analyses, discontinuation was associated with increased risks of combined macro and microvascular events (hazard ratio 2.24, 95% CI 1.96-2.57), macrovascular events (3.23, 2.75-3.79), microvascular events (1.38, 1.11-1.71), and all-cause mortality (7.99, 6.92-9.21) compared to continuing administration of randomized medications during the trial period, which were highest in the first year after discontinuation. These associations were similar in active and placebo groups, except in the first year after discontinuation during which event rates were lower in the active group than in the placebo group (P ≤ 0.01).

CONCLUSION

Discontinuation of study medication is a potent risk marker for identifying high-risk patients. Thus it is important that clinicians seek to identify such patients early after discontinuation of treatment. Although some short-term residual effects of previous active treatment can be expected, patients who discontinue require further urgent investigation and management.

The Intensity of Primary Care for Heart Failure Patients: A Determinant of Readmissions? The CarPaths Study: A French Region-Wide Analysis

Background

We aimed to classify patients with heart failure (HF) by the style of primary care they receive.

Methods and Results

We used the claim data (SNIIRAM: Système National d’Information Inter-Régime de l’Assurance Maladie) of patients living in a French region. We evaluated three concepts. First, baseline clinical status with age and Charlson index. Second, primary care practice style with mean delay between consultations, quantity of nursing care, and variability of diuretic dose. Third, clinical outcomes with death during follow-up, readmission for HF, and rate of unforeseen consultations. The baseline clinical status and the clinical outcomes were included to give an insight in the reasons for, and performance of, primary care practice style. Patients were classified using a hierarchical ascending classification based on principal components. A total of 2,751 patients were included in this study and were followed for a median of 22 months. The mean age was 78 y (SD: 12); 484 (18%) died, and 818 (30%) were readmitted for HF. We found three different significant groups characterized by their need for care and the intensity of practice style: group 1 (N = 734) was “low need-low intensity”; group 2 (N = 1,060) was “high need-low intensity”; and group 3 (N = 957) was “high need-high intensity”. Their readmission rates were 17%, 41% and 28%, respectively.

Conclusions

This study evaluated the link between primary care, clinical status and main clinical outcomes in HF patients. In higher need patients, a low-intensity practice style was associated with poorer clinical outcomes.

Potential New Agents for the Management of Hyperkalemia

Hyperkalemia is a common electrolyte disturbance with multiple potential etiologies. It is usually observed in the setting of reduced renal function. Mild to moderate hyperkalemia is usually asymptomatic, but is associated with poor prognosis. When severe, hyperkalemia may cause serious acute cardiac arrhythmias and conduction abnormalities, and may result in sudden death. The rising prevalence of conditions associated with hyperkalemia (heart failure, chronic kidney disease, and diabetes) and broad use of renin-angiotensin-aldosterone system (RAAS) inhibitors and mineralocorticoid receptor antagonists (MRAs), which improve patient outcomes but increase the risk of hyperkalemia, have led to a significant rise in hyperkalemia-related hospitalizations and deaths. Current non-invasive therapies for hyperkalemia either do not remove excess potassium or have poor efficacy and tolerability. There is a clear need for safer, more effective potassium-lowering therapies suitable for both acute and chronic settings. Patiromer sorbitex calcium and sodium zirconium cyclosilicate (ZS-9) are two new potassium-lowering compounds currently in development. Although they have not yet been approved by the US FDA, both have demonstrated efficacy and safety in recent trials. Patiromer sorbitex calcium is a polymer resin and sorbitol complex that binds potassium in exchange for calcium; ZS-9, a non-absorbed, highly selective inorganic cation exchanger, traps potassium in exchange for sodium and hydrogen. This review discusses the merits of both novel drugs and how they may help optimize the future management of patients with hyperkalemia.

Medication Underuse in Aging Outpatients with Cardiovascular Disease: Prevalence, Determinants, and Outcomes in a Prospective Cohort Study

BACKGROUND

Cardiovascular disease is a leading cause of death in older people, and the impact of being exposed or not exposed to preventive cardiovascular medicines is accordingly high. Underutilization of beneficial drugs is common, but prevalence estimates differ across settings, knowledge on predictors is limited, and clinical consequences are rarely investigated.

METHODS

Using data from a prospective population-based cohort study, we assessed the prevalence, determinants, and outcomes of medication underuse based on cardiovascular criteria from Screening Tool To Alert to Right Treatment (START).

RESULTS

Medication underuse was present in 69.1% of 1454 included participants (mean age 71.1 ± 6.1 years) and was significantly associated with frailty (odds ratio: 2.11 [95% confidence interval: 1.24-3.63]), body mass index (1.03 [1.01-1.07] per kg/m2), and inversely with the number of prescribed drugs (0.84 [0.79-0.88] per drug). Using this information for adjustment in a follow-up evaluation (mean follow-up time 2.24 years) on cardiovascular and competing outcomes, we found no association of medication underuse with cardiovascular events (fatal and non-fatal) (hazard ratio: 1.00 [0.65-1.56]), but observed a significant association of medication underuse with competing deaths from non-cardiovascular causes (2.52 [1.01-6.30]).

CONCLUSION

Medication underuse was associated with frailty and adverse non-cardiovascular clinical outcomes. This may suggest that cardiovascular drugs were withheld because of serious co-morbidity or that concurrent illness can preclude benefit from cardiovascular prevention. In the latter case, adapted prescribing criteria should be developed and evaluated in those patients.

SYMPLICITY HTN-Japan - First Randomized Controlled Trial of Catheter-Based Renal Denervation in Asian Patients -

BACKGROUND

SYMPLICITY HTN-Japan is a prospective, randomized, controlled trial comparing renal artery denervation (RDN) with standard pharmacotherapy for treatment of resistant hypertension (systolic blood pressure [SBP] ≥160 mmHg on ≥3 anti-hypertensive drugs including a diuretic for ≥6 weeks). When SYMPLICITY HTN-3 failed to meet the primary efficacy endpoint, the HTN-Japan enrollment was discontinued before completion. METHODS AND RESULTS: The 6-month change in office and 24-h ambulatory SBP were compared between RDN (n=22) and control (n=19) subjects. Mean baseline office SBP was 181.0±18.0 mmHg and 178.7±17.8 mmHg for the RDN and control groups, respectively. The 6-month office SBP change was -16.6±18.5 mmHg for RDN subjects (P<0.001) and -7.9±21.0 mmHg for control subjects (P=0.117); the difference between the 6-month change in RDN and control subjects was -8.64 (95% CI: -21.12 to 3.84, P=0.169). Mean 24-h SBP was 164.7±18.3 (RDN group) and 163.3±17.2 mmHg (control group). The 24-h 6-month SBP change for the RDN group was -7.52±11.98 mmHg (P=0.008) and -1.38±10.2 mmHg (P=0.563) for control subjects; the between-group difference in SBP change was -6.15 (95% CI: -13.23 to 0.94, P=0.087). No major adverse events were reported.

CONCLUSIONS

SYMPLICITY HTN-Japan, the first randomized controlled trial of RDN in an Asian population, was underpowered for the primary endpoint analysis and did not demonstrate a significant difference in 6-month BP change between RDN and control subjects.

Drug therapy for the patient with resistant hypertension

ABSTRACT 

Resistant hypertension is associated with high morbidity and mortality. Resistant hypertension is defined as blood pressure above targets despite treatment with at least three antihypertensive drugs in adequate dose and combination. Nonadherence is a frequent cause of uncontrolled hypertension and can be improved by providing fixed dose (of two or three agents) single pill combination. Triple combination of the most widely used antihypertensive agents (renin–angiotensin–aldosterone system antagonists, calcium channel blockers and diuretics) is a safe and effective therapy. Fourth line therapy is the use of an aldosterone antagonist. Renal denervation and baroreceptor stimulation can be considered in patients who remained uncontrolled despite optimal medical therapy.

Engineering practice variation through provider agreement: a cluster-randomized feasibility trial

Purpose

Minimal-risk randomized trials that can be embedded in practice could facilitate learning health-care systems. A cluster-randomized design was proposed to compare treatment strategies by assigning clusters (eg, providers) to “favor” a particular drug, with providers retaining autonomy for specific patients. Patient informed consent might be waived, broadening inclusion. However, it is not known if providers will adhere to the assignment or whether institutional review boards will waive consent. We evaluated the feasibility of this trial design.

Subjects and methods

Agreeable providers were randomized to “favor” either hydrochlorothiazide or chlorthalidone when starting patients on thiazide-type therapy for hypertension. The assignment applied when the provider had already decided to start a thiazide, and providers could deviate from the strategy as needed. Prescriptions were aggregated to produce a provider strategy-adherence rate.

Results

All four institutional review boards waived documentation of patient consent. Providers (n=18) followed their assigned strategy for most of their new thiazide prescriptions (n=138 patients). In the “favor hydrochlorothiazide” group, there was 99% adherence to that strategy. In the “favor chlorthalidone” group, chlorthalidone comprised 77% of new thiazide starts, up from 1% in the pre-study period. When the assigned strategy was followed, dosing in the recommended range was 48% for hydrochlorothiazide (25–50 mg/day) and 100% for chlorthalidone (12.5–25.0 mg/day). Providers were motivated to participate by a desire to contribute to a comparative effectiveness study. A study promotional mug, provider information letter, and interactions with the site investigator were identified as most helpful in reminding providers of their study drug strategy.

Conclusion

Providers prescribed according to an assigned drug-choice strategy most of the time for the purpose of a comparative effectiveness study. This simple design could facilitate research participation and behavior change in non-research clinicians. Waiver of patient consent can broaden the representation of patients, providers, and settings.

Impact of socio-economic factors on the long-term effectiveness of antihypertensive treatment with an angiotensin II receptor blocker: an observational study

OBJECTIVE

To investigate the role of socio-economic factors on the therapeutic effectiveness of and therapeutic adherence to the angiotensin II receptor blocker (ARB) olmesartan (OM) alone or in combination with hydrochlorothiazide in the treatment of arterial hypertension.

RESEARCH DESIGN AND METHODS

In a multi-center, open-label, prospective and long-term observational study, data from hypertensive patients treated with OM were analyzed at baseline, month 3 and month 12 within the context of patients' socio-economic status (SES), determined using pre-defined criteria by physicians in outpatient practices and including multivariate analysis.

RESULTS

Overall, 7724 patients were assigned to three subgroups representing low, medium and high socio-economic status. Baseline conditions differed significantly between the subgroups. Patients of low SES had worse nutritional habits, less physical activity and more concomitant medication compared to patients of high SES. Cardiovascular risk factors were more common in the low SES group as were concomitant diseases such as heart failure, coronary heart disease, atherosclerosis and renal failure. OM therapy led to a significant decrease in blood pressure (23.0/11.6 mmHg) in all patients. The blood pressure target of <140/90 mmHg was achieved in about 70% of the documented population. Effectiveness was comparable between patients with low, medium or high SES. Treatment adherence was high in the overall population with only minor differences between the subgroups. In total the incidence of adverse events (AEs) was 1.6% documented in 98 patents (1.3%) during the course of the study. Of this total number only 1.0% was related to the drug, matching the percentage expressed in the Summary of Product Characteristics (SmPC).

CONCLUSIONS

The ARB OM is effective and well tolerated in all patients, irrespective of their socio-economic status. The risk status and the established cardiovascular disease of hypertensive patients are strongly influenced by the SES. To validate these interesting data a randomized controlled trial is needed.

The effect of placebo adherence on reducing cardiovascular mortality: a meta-analysis

OBJECTIVE

We aim to demonstrate the effect of placebo adherence on reducing CV mortality.

BACKGROUNDS

Good adherence, whether to drug or placebo treatment, is associated with lower CV mortality. However, current evidence for the positive effect of placebo adherence on reducing CV mortality is relatively weak.

METHODS

We conducted a fixed-effect meta-analysis of eight randomized clinical trials to evaluate the effect of placebo adherence on reducing CV mortality. We made a comparison between good placebo adherence and poor drug adherence.

RESULTS

Compared with poor adherence to drug treatment, good adherence to placebo treatment was associated with lower CV mortality (OR = 0.68, 95% CI 0.60-0.77).

CONCLUSION

Good adherence to placebo has a positive effect on reducing CV mortality. The effect of adherence on reducing CV mortality may be independent of the drug effect.

Drug adherence in patients taking oral anticoagulation therapy

Oral anticoagulation has proven to reduce mortality and morbidity of thromboembolic events. One of the most important determinants of the effectiveness and safety of anticoagulation therapy is the adherence to the prescribed therapy. Vitamin K antagonists are characterized by under-utilization, a narrow therapeutic window and multiple food and drug interactions which contribute to a variable dose-response relationship with the risk of insufficient protection and/or increased bleeding risk. The "new" direct oral anticoagulants have demonstrated equal or superior protection and reduced bleeding risks compared to warfarin and are easier to use because of fixed dosing without monitoring of anticoagulation. Controlling of adherence to the direct oral anticoagulants is difficult. Therefore, continuous and regular medication intake represents a pre-requisite for achieving optimal protection. The present review aims to give an overview about the factors that affect drug adherence in patients taking oral anticoagulation drugs and discusses strategies to improve drug adherence.