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Mu H, Liu J, Huang C, Tang H, Li S, Dong C, Yang T, Liu L, Xu B. Application of five risk stratification tools for syncope in older adults. J Int Med Res 2024; 52:3000605231220894. [PMID: 38190847 PMCID: PMC10775749 DOI: 10.1177/03000605231220894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/24/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVE Treatment of syncope in older adults places a burden on healthcare systems. We used five risk stratification tools to predict short-term adverse outcomes in older patients with syncope. METHODS This was a retrospective analysis of patients with syncope (age ≥60 years) in the emergency department of an urban academic hospital. The data were evaluated using the Risk Stratification of Syncope in the Emergency Department (ROSE), San Francisco Syncope Rule (SFSR), FAINT, Canadian Syncope Risk Score (CSRS), and Boston Syncope Criteria (BSC) tools. Sensitivity, specificity, accuracy, positive and negative predictive value (NPV), and positive and negative likelihood ratios of each tool were calculated and compared for adverse events within 1 month. RESULTS In total, 221 patients (average age 75.6 years) were analyzed. Fifty-nine patients (26.7%) had experienced an adverse event within 1 month. For the ROSE, SFSR, FAINT, CSRS and BSC tools, sensitivities were 81.3%, 76.3%, 93.2%, 71.2%, and 94.9%, specificities were 88.3%, 87.7%, 56.8%, 71.6%, and 67.3%, and NPVs were 92.9%, 91.0%, 95.8%, 87.2%, and 97.3%, respectively. CONCLUSION The five assessed tools could be useful for physicians in screening older patients with syncope for the risk of short-term adverse events, according to the patient's actual situation.
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Affiliation(s)
- Hong Mu
- Department of Emergency, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiexin Liu
- Department of Neurocardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Cheng Huang
- Pingmo Health Center, Daozhen County, Zunyi, Guizhou, China
| | - Hefei Tang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Sisi Li
- The Fifth Medical College, Capital Medical University, Beijing, China
| | - Chang Dong
- The Fifth Medical College, Capital Medical University, Beijing, China
| | - Tiecheng Yang
- Department of Emergency, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Limin Liu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Xu
- Department of Emergency, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Martinez JD, Thomas IC, Montez-Rath ME, Pao AC, Fung E, Charu V, Sim JJ, An J, Odden MC, Tamura MK. Treatment and Control of Hypertension Among Adults With Chronic Kidney Disease, 2011 to 2019. Hypertension 2023; 80:2533-2543. [PMID: 37706307 PMCID: PMC10873114 DOI: 10.1161/hypertensionaha.123.21523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Hypertension frequently accompanies chronic kidney disease (CKD) as etiology and sequela. We examined contemporary trends in hypertension treatment and control in a national sample of adults with CKD. METHODS We evaluated 5% cross-sectional samples of adults with CKD between 2011 and 2019 in the Veterans Health Administration. We defined CKD as a sustained estimated glomerular filtration rate value <60 mL/min per 1.73 m2 or a urine albumin-to-creatinine ratio ≥30 mg/g. The main outcomes were blood pressure (BP) control, defined as a systolic BP <140 mm Hg and a diastolic BP <90 mm Hg based on the mean of monthly BP measurements, and prescriptions for antihypertensive medications. RESULTS The annual samples ranged between n=22 110 and n=33 039 individuals, with a mean age of 72 years, 96% of whom were men. Between 2011 and 2014, the age-adjusted proportion of adults with controlled BP declined from 78.0% to 72.2% (P value for linear trend, <0.001), reached a nadir of 71.0% in 2015, and then increased to 72.9% by 2019 (P value for linear trend, <0.001). Among adults with BP above goal, the age-adjusted proportion who did not receive antihypertensive treatment increased throughout the decade from 18.8% to 21.6%, and the age-adjusted proportion who received ≥3 antihypertensive medications decreased from 41.8% to 36.3%. Prescriptions for first-line antihypertensive agents also decreased. CONCLUSIONS Among adults with CKD treated in the Veterans Health Administration, the proportion with controlled BP declined between 2011 and 2015 followed by a modest increase, coinciding with fewer prescriptions for antihypertensive medications.
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Affiliation(s)
- Joshua D. Martinez
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, CA
| | - I-Chun Thomas
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Maria E. Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, CA
| | - Alan C. Pao
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, CA
| | - Enrica Fung
- Division of Nephrology, Department of Medicine, Loma Linda University School of Medicine and Loma Linda VA Health Care System, Loma Linda, CA
| | - Vivek Charu
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - John J. Sim
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Jaejin An
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Michelle C. Odden
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, CA
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
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Silva RP, Rodrigues H. New Diagnostic Criteria for Overmedication in Systemic Arterial Hypertension. Tex Heart Inst J 2022; 49:486881. [PMID: 36179107 DOI: 10.14503/thij-20-7350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Guidelines on managing arterial blood pressure have begun to include lower targets, despite the risk for overmedication-induced hypotension. Because there is no consensus as to what constitutes overmedication in the treatment of hypertension, we conducted a study to develop relevant diagnostic criteria. METHODS We used ambulatory monitoring during a 24-hour period to measure blood pressure in 567 patients with medication-controlled hypertension. We then divided this cohort into 3 groups. Group A (n = 413 [72.8%]) comprised patients in whom less than 10% of systolic blood pressure measurements were less than 100 mm Hg (no or mild hypotension). Group B (n = 154 [27.2%]) comprised patients in whom 10% or more of the measurements were less than 100 mm Hg, signifying overmedication. Group C comprised those patients in Group B in whom 20% or more of the measurements were less than 100 mm Hg (n = 74 [48.1%]; attributed to "accentuated" overmedication). Group C patients were prescribed significantly more antihypertensive drugs than were group A patients. RESULTS Our findings support a 2-part definition of overmedication in hypertension treatment: (1) mild overmedication, in which 10% or more but less than 20% of systolic blood pressure measurements are less than 100 mm Hg in the awake state and less than 90 mm Hg during sleep; and (2) accentuated overmedication, characterized by 20% or more of valid systolic blood pressure measurements less than 100 mm Hg in the awake state and less than 90 mm Hg during sleep, during a 24-hour period. CONCLUSION We think this guidance will help to avoid overmedicating and consequences such as fainting and falls when systolic blood pressure is too low.
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Affiliation(s)
- Ricardo Pereira Silva
- School of Medicine, Federal University of Ceará, Fortaleza, Brazil.,Unicordis, Hospital São Mateus, Fortaleza, Brazil
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Telemonitoring and protocolized case management for hypertensive community dwelling older adults (TECHNOMED): a randomized controlled trial. J Hypertens 2022; 40:1702-1712. [PMID: 35943099 DOI: 10.1097/hjh.0000000000003202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Home blood pressure (BP) telemonitoring combined with case management leads to BP reductions in individuals with hypertension. However, its benefits are less clear in older (age ≥ 65 years) adults. METHODS Twelve-month, open-label, randomized trial of community-dwelling older adults comparing the combination of home BP telemonitoring (HBPM) and pharmacist-led case management, vs. enhanced usual care with HBPM alone. The primary outcome was the proportion achieving systolic BP targets on 24-h ambulatory BP monitoring (ABPM). Changes in HBPM were also examined. Logistic and linear regressions were used for analyses, adjusted for baseline BP. RESULTS Enrollment was stopped early due to coronavirus disease 2019. Participants randomized to intervention (n = 61) and control (n = 59) groups were mostly female (77%), with mean age 79.5 years. The adjusted odds ratio for ABPM BP target achievement was 1.48 (95% confidence interval 0.87-2.52, P = 0.15). At 12 months, the mean difference in BP changes between intervention and control groups was -1.6/-1.1 for ABPM (P-value 0.26 for systolic BP and 0.10 for diastolic BP), and -4.9/-3.1 for HBPM (P-value 0.04 for systolic BP and 0.01 for diastolic BP), favoring the intervention. Intervention group participants had hypotension (systolic BP < 110) more frequently (21% vs. 5%, P = 0.009), but no differences in orthostatic symptoms, syncope, non-mechanical falls, or emergency department visits. CONCLUSIONS Home BP telemonitoring and pharmacist case management did not improve achievement of target range ambulatory BP, but did reduce home BP. It did not result in major adverse consequences.
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O'Donoghue P, O'Halloran A, Kenny RA, Romero-Ortuno R. Older adults identified as frail by Frailty Index and FRAIL scale who were intensively treated for hypertension were at increased risk of 2-year adverse health outcomes in The Irish Longitudinal Study on Ageing (TILDA). HRB Open Res 2022. [DOI: 10.12688/hrbopenres.13522.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Frailty is associated with adverse health outcomes. In frail older adults, blood pressure (BP) treated intensively may result in adverse events. We hypothesised that frail older adults, with BP treated below the threshold of the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guideline (<130/70 mmHg), could be associated with adverse health outcomes. Methods: Data was gathered from participants in Wave 1 (W1) of The Irish Longitudinal Study on Ageing (TILDA) who were aged ≥65 years and on treatment for hypertension. Frail classifications as per a 32-item Frailty Index (FI) and FRAIL (Fatigue, Resistance, Ambulation, Illnesses & Loss of Weight) scale were compared in their ability to predict W2 (2-year) adverse outcomes associated with intensive BP control (‘below threshold (BT)’: <130/70 mmHg vs. ‘above threshold (AT)’: ≥130/70 mmHg). We created eight participant groups based on frailty-BP status. W2 outcomes were analysed using adjusted binary logistic regression models. Results: In W1, 1,920 participants were included. Of these 1,274 had complete FI-BP and 1,276 FRAIL-BP data. The frail by FI treated BT and frail by FRAIL treated BT had increased risk of hospitalisation, heart failure and falls/fracture by W2. The frail by FRAIL treated BT also had increased risk of mortality by W2. The frail by FI treated AT had increased risk of syncope and falls/fractures. The non-frail by FI or FRAIL did not have any increased risk of the adverse outcomes studied. Conclusions: FI and FRAIL captured increased risk of adverse health outcomes when BP was treated below the current ESC/ESH threshold. FI and FRAIL could be more useful than other frailty identification tools to signal risks associated with tighter BP control in frail older adults. Future hypertension management guidelines should consider incorporating specific frailty identification tools to help guide clinicians in making personalised BP medication treatment decisions.
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O'Donoghue P, O'Halloran A, Kenny RA, Romero-Ortuno R. Older adults identified as frail by Frailty Index and FRAIL scale who were intensively treated for hypertension were at increased risk of 2-year adverse health outcomes in The Irish Longitudinal Study on Ageing (TILDA). HRB Open Res 2022. [DOI: 10.12688/hrbopenres.13522.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Frailty is associated with adverse health outcomes. In frail older adults, blood pressure (BP) treated intensively may result in side effects including orthostatic hypotension, falls or fractures. We hypothesised that frail older adults, with BP treated below the threshold of the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guideline (<130/70 mmHg), could be associated with adverse health outcomes. Methods: Data was gathered from participants in Wave 1 (W1) of The Irish Longitudinal Study on Ageing (TILDA) who were aged ≥65 years and on treatment for hypertension. Frail classifications as per a 32-item Frailty Index (FI) and FRAIL (Fatigue, Resistance, Ambulation, Illnesses & Loss of Weight) scale were compared in their ability to predict W2 (2-year) adverse outcomes associated with intensive BP control (‘low’: <130/70 mmHg vs. ‘high’: ≥130/70 mmHg). We created eight participant groups based on frailty-BP status. W2 outcomes were analysed using adjusted binary logistic regression models. Results: In W1, 1,920 participants were included. Of these 1,274 had complete FI-BP and 1,276 FRAIL-BP data. The frail by FI treated low and frail by FRAIL treated low had increased risk of hospitalisation, heart failure and falls/fracture by W2. The frail by FRAIL treated low also had increased risk of mortality by W2. The frail by FI treated high had increased risk of syncope and falls/fractures. The non-frail by FI or FRAIL did not have increased risk of any of the adverse outcomes studied. Conclusions: FI and FRAIL captured increased risk of adverse health outcomes when BP was treated below the current ESC/ESH threshold. FI and FRAIL could be more useful than other frailty identification tools to signal risks associated with tighter BP control in frail older adults. Hypertension management guidelines should specify which frailty identification tools clinicians should use to help them make personalised treatment decisions.
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Fischer H, Hahn EE, Li BH, Munoz-Plaza CE, Luong TQ, Harrison TN, Slezak JM, Sim JJ, Mittman BS, Lee EA, Singh H, Kanter MH, Reynolds K, Danforth KN. Potentially Harmful Medication Dispenses After a Fall or Hip Fracture: A Mixed Methods Study of a Commonly Used Quality Measure. Jt Comm J Qual Patient Saf 2022; 48:222-232. [PMID: 35190249 DOI: 10.1016/j.jcjq.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 12/16/2021] [Accepted: 01/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND High-risk medication dispenses to patients with a prior fall or hip fracture represent a potentially dangerous disease-drug interaction among older adults. The research team quantified the prevalence, identified risk factors, and generated patient and provider insights into high-risk medication dispenses in a large, community-based integrated health system using a commonly used quality measure. METHODS This was a mixed methods study with a convergent design combining a retrospective cohort study using electronic health record (EHR) data, individual interviews of primary care physicians, and a focus group of patient advisors. RESULTS Of 113,809 patients ≥ 65 years with a fall/fracture in 2009-2015, 35.4% had a potentially harmful medication dispensed after their fall/fracture. Most medications were prescribed by primary care providers. Older age, male gender, and race/ethnicity other than non-Hispanic White were associated with a reduced risk of high-risk medication dispenses. Patients with a pre-fall/fracture medication dispense were substantially more likely to have a post-fall/fracture medication dispense (hazard ratio [HR] = 13.26, 95% confidence interval [CI] = 12.91-13.61). Both patients and providers noted that providers may be unaware of patient falls due to inconsistent assessments and patient reluctance to disclose falls. Providers also noted the lack of a standard location to document falls and limited decision support alerts within the EHR. CONCLUSION High-risk medication dispenses are common among older patients with a history of falls/fractures. Future interventions should explore improved assessment and documentation of falls, decision support, clinician training strategies, patient educational resources, building trusting patient-clinician relationships to facilitate long-term medication discontinuation among persistent medication users, and a focus on fall prevention.
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Blood pressure, antihypertensive drugs, and incident frailty: The Multidomain Alzheimer Preventive Trial (MAPT). Maturitas 2022; 162:8-14. [DOI: 10.1016/j.maturitas.2022.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 02/15/2022] [Accepted: 03/05/2022] [Indexed: 12/21/2022]
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Sánchez-Martínez M, López-García E, Guallar-Castillón P, Ortolá R, García-Esquinas E, Cruz J, Gijón-Conde T, Rodríguez-Artalejo F, Townsend RR, Banegas JR. Home and ambulatory blood pressure levels below target range and clinical effort to detect this condition: a population-based study in older treated hypertensives. Age Ageing 2022; 51:6454232. [PMID: 35150580 DOI: 10.1093/ageing/afab236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND With implementation of stricter blood pressure (BP) treatment targets, potential for excessive BP lowering becomes an important issue, especially in older patients. OBJECTIVES Assess the magnitude, indicators and detection effort of BP levels below-target-range (BTR-BP) recommended by the European hypertension guidelines in older treated hypertensive patients (130-139/70-79 mmHg). DESIGN Cross-sectional, retrospective study (Seniors-ENRICA-2 cohort). SETTING General population. SUBJECTS 1,329 treated hypertensive patients aged ≥65, assessed with three home casual BP measurements and 24-hour ambulatory BP monitoring (ABPM). METHODS Based on the European hypertension guidelines and the literature, BTR-BPs were defined as mean BP <130/70, <125/65, <130/70 and <110/55 mmHg, for casual BP, 24-hour BP, daytime BP and nighttime BP, respectively, and hypotension as <110/70, <105/65, <110/70 and <90/55 mmHg, respectively. RESULTS Participants' mean age was 72 ± 4.4 (50.3%, women). Based on casual BP, 7.2% of patients were in target range (130-139/70-79 mmHg), 44.3% in BTR-BP (<130/70) and 20.8% hypotensive (<110/70). Some 44.9, 54.9 and 22.0% of patients were in BTR-BP for 24-hour BP, daytime BP and nighttime BP, respectively, and 11.0, 21.1 and 5.6%, respectively, were hypotensive. The number of patients needed for ABPM to detect one case of 24-hour-, daytime-, and nighttime-BTR-BP was 3, 2 and 5, respectively, and 10, 5 and 18, respectively, for detecting one hypotensive case. Cardiovascular disease and female sex were associated with both BTR-BP and hypotension, and the number of antihypertensive drugs was only associated with hypotension. CONCLUSIONS BTR-BP levels were common in older treated patients at home and in everyday life, more frequent than many trials report, and daytime ABPM is highly size-efficient for detecting the low ambulatory BP conditions.
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Affiliation(s)
- Mercedes Sánchez-Martínez
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ and CIBERESP, Madrid, Spain
- Department of Health Science, Universidad Católica Santa Teresa de Jesús de Ávila, Ávila, Spain
| | - Esther López-García
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ and CIBERESP, Madrid, Spain
- IMDEA Food Institute, CEI UAM+CSIC, Madrid, Spain
| | - Pilar Guallar-Castillón
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ and CIBERESP, Madrid, Spain
- IMDEA Food Institute, CEI UAM+CSIC, Madrid, Spain
| | - Rosario Ortolá
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ and CIBERESP, Madrid, Spain
| | - Esther García-Esquinas
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ and CIBERESP, Madrid, Spain
- IMDEA Food Institute, CEI UAM+CSIC, Madrid, Spain
| | - Juan Cruz
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ and CIBERESP, Madrid, Spain
| | - Teresa Gijón-Conde
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ and CIBERESP, Madrid, Spain
- Centro de Salud Universitario Cerro del Aire, Madrid, Spain
| | - Fernando Rodríguez-Artalejo
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ and CIBERESP, Madrid, Spain
- IMDEA Food Institute, CEI UAM+CSIC, Madrid, Spain
| | - Raymond R Townsend
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ and CIBERESP, Madrid, Spain
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - José R Banegas
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ and CIBERESP, Madrid, Spain
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Chen YH, Hung CS, Huang CC, Lee JK, Yu JY, Ho YL. The Impact of Synchronous Telehealth Services With a Digital Platform on Day-by-Day Home Blood Pressure Variability in Patients with Cardiovascular Diseases: Retrospective Cohort Study. J Med Internet Res 2022; 24:e22957. [PMID: 35006089 PMCID: PMC8787660 DOI: 10.2196/22957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/20/2020] [Accepted: 11/05/2020] [Indexed: 11/16/2022] Open
Abstract
Background Hypertension is associated with a large global disease burden with variable control rates across different regions and races. Telehealth has recently emerged as a health care strategy for managing chronic diseases, but there are few reports regarding the effects of synchronous telehealth services on home blood pressure (BP) control and variability. Objective The objective of this study is to investigate the effect of synchronous telehealth services with a digital platform on home BP. Methods This retrospective study was conducted by the Taiwan ELEctroHEALTH study group at the Telehealth Center of the National Taiwan University Hospital. We analyzed home BP data taken from 2888 patients with cardiovascular disease (CVD) enrolled in our telehealth program between 2009 to 2017. Of the 2888 patients with CVD, 348 (12.05%) patients who received home BP surveillance for ≥56 days were selected for BP analysis. Patients were stratified into three groups: (1) poorly controlled hypertension, (2) well-controlled hypertension, and (3) nonhypertension. The mean, SD, coefficient of variation (CV), and average real variability were calculated. Results Telehealth interventions significantly and steadily reduced systolic blood pressure (SBP) in the poorly controlled hypertension group from 144.8.2±9.2 to 133.7±10.2 mmHg after 2 months (P<.001). BP variability reduced in all patients: SBP-SD decreased from 7.8±3.4 to 7.3±3.4 after 2 months (P=.004), and SBP-CV decreased from 6.3±2.5 to 5.9±2.6 after 2 months (P=.004). Event-free survival (admission) analysis stratified by SBP-SD showed longer time to first hospitalization for Q1 patients compared with Q4 patients (P=.02, odds ratio 2.15, 95% CI 1.18-3.89). Conclusions Synchronous telehealth intervention may improve home BP control and decrease day-by-day home BP variability in patients with CVD.
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Affiliation(s)
- Ying-Hsien Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Sheng Hung
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Chang Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Kuang Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiun-Yu Yu
- Department of Business Administration, College of Management, National Taiwan University, Taipei, Taiwan
| | - Yi-Lwun Ho
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Ambrož M, de Vries ST, Hoogenberg K, Denig P. Older Age, Polypharmacy, and Low Systolic Blood Pressure Are Associated With More Hypotension-Related Adverse Events in Patients With Type 2 Diabetes Treated With Antihypertensives. Front Pharmacol 2021; 12:728911. [PMID: 34630105 PMCID: PMC8497792 DOI: 10.3389/fphar.2021.728911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/06/2021] [Indexed: 01/30/2023] Open
Abstract
Background and Aims: Low systolic blood pressure (SBP) levels while being treated with antihypertensives may cause hypotension-related adverse events (hrAEs), especially in the elderly, women, and frail patients. We aimed to assess the association between the occurrence of hrAEs and low SBP levels, age, sex, and polypharmacy among patients with type 2 diabetes (T2D) treated with antihypertensives. Methods: In this cohort study, we used the Groningen Initiative to ANalyse Type 2 diabetes Treatment (GIANTT) database which includes patients managed for T2D in primary care from the north of the Netherlands. Patients treated with ≥1 antihypertensive drug and ≥1 SBP measurement between 2012 and 2014 were included. The outcome was the presence of an hrAE, i.e. postural hypotension, dizziness, weakness/tiredness, and syncope in 90 days before or after the lowest recorded SBP level. Age (≥70 vs. <70 years), sex (women vs. men), polypharmacy (5–9 drugs or ≥10 drugs vs. <5 drugs), and SBP level (<130 or ≥130 mmHg) were included as determinants. Logistic regression analyses were conducted for age, sex and polypharmacy, including the SBP level and their interaction, adjusted for confounders. Odds ratios (OR) with 95% confidence intervals (CI) are presented. Results: We included 21,119 patients, 49% of which were ≥70 years old, 52% were women, 57% had polypharmacy, 61% had an SBP level <130 mmHg and 5.4% experienced an hrAE. Patients with an SBP level <130 mmHg had a significantly higher occurrence of hrAEs than patients with a higher SBP level (6.2 vs. 4.0%; ORs 1.41, 95%CI 1.14–1.75, 1.43, 95%CI 1.17–1.76 and 1.33, 95%CI 1.06–1.67 by age, sex, and polypharmacy, respectively). Older patients (OR 1.29, 95%CI 1.02–1.64) and patients with polypharmacy (OR 5–9 drugs 1.27, 95%CI 1.00–1.62; OR ≥10 drugs 2.37, 95% CI 1.67–3.37) were more likely to experience an hrAE. The association with sex and the interactions between the determinants and SBP level were not significant. Conclusion: Low SBP levels in patients with T2D treated with antihypertensives is associated with an increase in hrAEs. Older patients and those with polypharmacy are particularly at risk of hrAEs. Age, sex, and polypharmacy did not modify the risk of hrAEs associated with a low SBP level.
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Affiliation(s)
- Martina Ambrož
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Sieta T de Vries
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Klaas Hoogenberg
- Department of Internal Medicine, Martini Hospital, Groningen, Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Ren J, Li G, Zhang L, Zhang N, Ren J. Hypothetical Interventions for Falls Among Older Adults: An Application of the Parametric G-Formula. Front Med (Lausanne) 2021; 8:732136. [PMID: 34568390 PMCID: PMC8457044 DOI: 10.3389/fmed.2021.732136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/18/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction: Falls, which have a higher incidence and mortality due to accidental injuries, are a major global health challenge. The effects of lifestyle factor, health indicator, psychological condition, and functional status interventions on the risk of falls are unknown and the conventional regression model would not adjust for the confounders. This study aimed to evaluate the 4-year risk of falls on the basis of these hypothetical interventions among Chinese older adults. Methods: Data were obtained from 9,692 aged 65 years and over older adults in the China Health and Retirement Longitudinal Study wave, from 2011 to 2015. We used the parametric g-formula to evaluate the risk of falls on the basis of independent hypothetical interventions of sleep duration, social activities, smoking status, drinking status, body mass index (BMI), systolic blood pressure (SBP), vision, depression, activities of daily living (ADL), and their different joint intervention combinations. Results: During the follow-up of 4 years, we documented 1,569 falls. The observed risk of falls was 23.58%. The risk ratios (95% confidence intervals [CIs]) of falls under the intensive hypothetical interventions on increasing sleep duration, participating in more social activities, quit smoking and drinking, reducing BMI and SBP, better vision, alleviating depressive symptoms, and improving ADL capability were 0.93 (0.87–0.96), 0.88 (0.79–0.92), 0.98 (0.95–1.03), 0.97 (0.95–1.02), 0.92 (0.86–1.03), 0.93 (0.87–1.04), 0.86 (0.74–0.91), 0.91 (0.85–0.96), and 0.79 (0.74–0.85), respectively. The feasible and intensive joint hypothetical intervention reduced the 4-year fall risk by 22% (95% CI: 0.52–0.91) and 33% (95% CI: 0.56–0.72), respectively. Conclusions: Hypothetical interventions for increasing sleep duration, participating in more social activities, better vision, alleviating depressive symptoms, and improving ADL capability help protect older adults from falls. Our findings suggest that a combination of lifestyle factors, health indicators, psychological conditions, and functional status may prove to be an effective strategy for preventing falls among older adults.
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Affiliation(s)
- Jiaojiao Ren
- Department of Preventive Medicine, Zhuhai Campus of Zunyi Medical University, Zhuhai, China
| | - Guangyou Li
- Department of Preventive Medicine, Zhuhai Campus of Zunyi Medical University, Zhuhai, China
| | - Liju Zhang
- Department of Preventive Medicine, Zhuhai Campus of Zunyi Medical University, Zhuhai, China
| | - Na Zhang
- Department of Preventive Medicine, Zhuhai Campus of Zunyi Medical University, Zhuhai, China
| | - Juan Ren
- Department of Preventive Medicine, Zhuhai Campus of Zunyi Medical University, Zhuhai, China
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13
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Rivasi G, Torabi P, Secco G, Ungar A, Sutton R, Brignole M, Fedorowski A. Age-related tilt test responses in patients with suspected reflex syncope. Europace 2021; 23:1100-1105. [PMID: 33564843 DOI: 10.1093/europace/euab024] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/19/2021] [Indexed: 12/17/2022] Open
Abstract
AIMS Tilt testing (TT) is recognized to be a valuable contribution to the diagnosis and the pathophysiology of vasovagal syncope (VVS). This study aimed to assess the influence of age on TT responses by examination of a large patient cohort. METHODS AND RESULTS Retrospective data from three experienced European Syncope Units were merged to include 5236 patients investigated for suspected VVS by the Italian TT protocol. Tilt testing-positivity rates and haemodynamics were analysed across age-decade subgroups. Of 5236 investigated patients, 3129 (60%) had a positive TT. Cardioinhibitory responses accounted for 16.5% of positive tests and were more common in younger patients, decreasing from the age of 50-59 years. Vasodepressor (VD) responses accounted for 24.4% of positive tests and prevailed in older patients, starting from the age of 50-59. Mixed responses (59.1% of cases) declined slightly with increasing age. Overall, TT positivity showed a similar age-related trend (P = 0.0001) and was significantly related to baseline systolic blood pressure (P < 0.001). Tilt testing was positive during passive phase in 18% and during nitroglycerine (TNG)-potentiated phase in 82% of cases. Positivity rate of passive phase declined with age (P = 0.001), whereas positivity rate during TNG remained quite stable. The prevalence of cardioinhibitory and VD responses was similar during passive and TNG-potentiated TT, when age-adjusted. CONCLUSIONS Age significantly impacts the haemodynamic pattern of TT responses, starting from the age of 50. Conversely, TT phase-passive or TNG-potentiated-does not significantly influence the type of response, when age-adjusted. Vagal hyperactivity dominates in younger patients, older patients show tendency to vasodepression.
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Affiliation(s)
- Giulia Rivasi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Parisa Torabi
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Gianmarco Secco
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milano, Italy.,Emergency Medicine Unit, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Andrea Ungar
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital, London, UK.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milano, Italy.,Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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14
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Crutzen S, Abou J, Smits SE, Baas G, Hugtenburg JG, Heringa M, Denig P, Taxis K. Older people's attitudes towards deprescribing cardiometabolic medication. BMC Geriatr 2021; 21:366. [PMID: 34134649 PMCID: PMC8207766 DOI: 10.1186/s12877-021-02249-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Overtreatment with cardiometabolic medication in older patients can lead to major adverse events. Timely deprescribing of these medications is therefore essential. Self-reported willingness to stop medication is usually high among older people, still overtreatment with cardiometabolic medication is common and deprescribing is rarely initiated. An important barrier for deprescribing reported by general practitioners is the patients' unwillingness to stop the medication. More insights are needed into the influence of patients' characteristics on their attitudes towards deprescribing and differences in these attitudes between cardiometabolic medication groups. METHODS A survey in older people using cardiometabolic medication using the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire was performed. Participants completed the general rPATD and an adapted version for four medication groups. Linear and ordinal logistic regression were used to assess the influence of age, sex, therapeutic area and number of medications used on the patients' general attitudes towards deprescribing. Univariate analysis was used to compare differences in deprescribing attitudes towards sulfonylureas, insulins, antihypertensive medication and statins. RESULTS Overall, 314 out of 1143 invited participants completed the survey (median age 76 years, 54% female). Most participants (80%) were satisfied with their medication and willing to stop medications if their doctor said it was possible (88%). Age, sex and therapeutic area had no influence on the general attitudes towards deprescribing. Taking more than ten medicines was significantly associated with a higher perceived medication burden. Antihypertensive medication and insulin were considered more appropriate than statins, and insulin was considered more appropriate than sulfonylureas not favouring deprescribing. CONCLUSIONS The majority of older people using cardiometabolic medication are willing to stop one of their medicines if their doctor said it was possible. Health care providers should take into account that patients perceive some of their medication as more appropriate than other medication when discussing deprescribing.
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Affiliation(s)
- Stijn Crutzen
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
- Universitair Medisch Centrum Groningen, Petra Denig Clinical Pharmacy and Pharmacology, EB70, Postbus 30.001, Hanzeplein1, 9700 RB, Groningen, The Netherlands.
| | - Jamila Abou
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands
| | - Sanne E Smits
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Gert Baas
- SIR Institute for Pharmacy Practice and Policy, Theda Mansholtstraat 5B, 2331 JE, Leiden, The Netherlands
| | - Jacqueline G Hugtenburg
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, Theda Mansholtstraat 5B, 2331 JE, Leiden, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Katja Taxis
- Unit of PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
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15
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Bhandari SK, Adams AL, Li BH, Rhee CM, Sundar S, Krasa H, Danforth KN, Kanter MH, Kalantar-Zadeh K, Jacobsen SJ, Sim JJ. Sub-acute hyponatraemia more than chronic hyponatraemia is associated with serious falls and hip fractures. Intern Med J 2021; 50:1100-1108. [PMID: 31707754 DOI: 10.1111/imj.14684] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/01/2019] [Accepted: 11/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Falls and hip fractures among older people are associated with high morbidity and mortality. Hyponatraemia may be a risk for falls/hip fractures, but the effect of hyponatraemia duration is not well understood. AIMS To evaluate individuals with periods of sub-acute and chronic hyponatraemia on subsequent risk for serious falls and/or hip fractures. METHODS Retrospective cohort study in the period 1 January 1998 to 14 June 2016 within an integrated health system of individuals aged ≥55 years with ≥2 outpatient serum sodium measurements. Hyponatraemia was defined as sodium <135 mEq/L with sub-acute (<30 days) and chronic (≥30 days) analysed as a time-dependent exposure. Multivariable Cox proportional-hazards modelling was used to estimate hazard ratios (HR) for serious falls/hip fractures based on sodium category. RESULTS Among 1 062 647 individuals totalling 9 762 305 sodium measurements, 96 096 serious falls/hip fracture events occurred. Incidence (per-1000-person-years) of serious falls/hip fractures were 11.5, 27.9 and 19.8 for normonatraemia, sub-acute and chronic hyponatraemia. Any hyponatraemia duration compared to normonatraemia had a serious falls/hip fractures HR (95%CI) of 1.18 (1.15, 1.22), with sub-acute and chronic hyponatraemia having HR of 1.38 (1.33, 1.42) and 0.91 (0.87, 0.95), respectively. Examined separately, the serious falls HR was 1.37 (1.32, 1.42) and 0.92 (0.88, 0.96) in sub-acute and chronic hyponatraemia, respectively. Hip fracture HR were 1.52 (1.42, 1.62) and 1.00 (0.92, 1.08) for sub-acute and chronic hyponatraemia, respectively, compared to normonatraemia. CONCLUSIONS Our findings suggest that early/sub-acute hyponatraemia appears more vulnerable and associated with serious falls/hip fractures. Whether hyponatraemia is a marker of frailty or a modifiable risk factor for falls remains to be determined.
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Affiliation(s)
- Simran K Bhandari
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Annette L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Bonnie H Li
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Connie M Rhee
- Otsuka Pharmaceuticals Development & Commercialization, Inc., San Francisco, California, USA
| | - Shirin Sundar
- Division of Nephrology and Hypertension, UC Irvine Medical Center, Irvine, California, USA
| | - Holly Krasa
- Division of Nephrology and Hypertension, UC Irvine Medical Center, Irvine, California, USA
| | - Kim N Danforth
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Michael H Kanter
- Department of Clinical Science, Kaiser Permanente School of Medicine, Pasadena, California, USA
| | - Kamyar Kalantar-Zadeh
- Otsuka Pharmaceuticals Development & Commercialization, Inc., San Francisco, California, USA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
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16
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Abstract
Hypertension and hypotension are strictly related phenomena, that frequently coexist within the spectrum of cardiovascular autonomic dysfunction, especially at advanced age. Indeed, antihypertensive treatment may predispose to orthostatic and post-prandial hypotension, while intensive blood pressure lowering may be responsible for systemic hypotension. Over recent years, systemic and orthostatic hypotension have emerged as important although often neglected risk factors for adverse outcomes, paralleling the widely recognized arterial hypertension. Both hypertension and hypotension are associated with detrimental effects on target organs and survival, thus significantly impacting patients' prognosis, functional autonomy and quality of life. Balancing low and high blood pressure requires accurate diagnostic assessment of blood pressure values and patients' hypotensive susceptibility, which allow for the development of customized treatment strategies based on individual hypo/hypertensive risk profile. The present review illustrates the complex interrelationship between hypotension and hypertension and discusses the relevant prognostic role of these conditions. Additionally, it provides an overview on hypotension detection and treatment in patients with hypertension, focusing on customized diagnostic and therapeutic strategies.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy -
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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17
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An J, Luong T, Qian L, Wei R, Liu R, Muntner P, Brettler J, Jaffe MG, Moran AE, Reynolds K. Treatment Patterns and Blood Pressure Control With Initiation of Combination Versus Monotherapy Antihypertensive Regimens. Hypertension 2020; 77:103-113. [PMID: 33190560 DOI: 10.1161/hypertensionaha.120.15462] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many patients with hypertension require 2 or more drug classes to achieve their blood pressure (BP) goal. We compared antihypertensive medication treatment patterns and BP control between patients who initiated combination therapy versus monotherapy. We identified adults with hypertension enrolled in a US integrated healthcare system who initiated antihypertensive medication between 2008 and 2014. Patient demographics, clinical characteristics, antihypertensive medication, and BP were extracted from electronic health records. Antihypertensive medication patterns and multivariable adjusted prevalence ratios (PRs) of achieving the 2017 American College of Cardiology/American Heart Association guideline-recommended BP <130/80 mm Hg were evaluated for 2 years following treatment initiation. Of 135 971 patients, 43% initiated antihypertensive combination therapy (35% ACE [angiotensin converting enzyme] inhibitor (ACEI)-thiazide diuretics; 8% with other combinations) and 57% initiated monotherapy (22% ACEIs; 16% thiazide diuretics; 11% β blockers; 8% calcium channel blockers). After multivariable adjustment including premedication BP levels, patients who initiated ACEI-thiazide diuretic combination therapy were more likely to achieve BP <130/80 mm Hg compared with their counterparts who initiated monotherapy with ACEI (PR, 1.10 [95% CI, 1.08-1.12]), thiazide diuretic (PR, 1.21 [95% CI, 1.18-1.24]), β blocker (PR, 1.17 [95% CI, 1.14-1.20]), or calcium channel blocker (PR, 1.25 [95% CI, 1.22-1.29]). Compared with initiating monotherapy, patients initiating ACEI-thiazide diuretic combination therapy were more likely to achieve BP goals.
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Affiliation(s)
- Jaejin An
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.)
| | - Tiffany Luong
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.)
| | - Lei Qian
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.)
| | - Rong Wei
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.)
| | - Ran Liu
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.)
| | | | - Jeffrey Brettler
- Southern California Permanente Medical Group, Los Angeles (J.B.)
| | - Marc G Jaffe
- The Permanente Medical Group, San Francisco, CA (M.G.J.)
| | - Andrew E Moran
- Resolve to Save Lives, an Initiative of Vital Strategies, New York City (A.E.M.).,Division of General Medicine, Columbia University Irving Medical Center, New York City (A.E.M.)
| | - Kristi Reynolds
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.).,Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (K.R.)
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18
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Zhou H, Sim JJ, Shi J, Shaw SF, Lee MS, Neyer JR, Kovesdy CP, Kalantar-Zadeh K, Jacobsen SJ. β-Blocker Use and Risk of Mortality in Heart Failure Patients Initiating Maintenance Dialysis. Am J Kidney Dis 2020; 77:704-712. [PMID: 33010357 DOI: 10.1053/j.ajkd.2020.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/12/2020] [Indexed: 11/11/2022]
Abstract
RATIONAL & OBJECTIVE Beta-blockers are recommended for patients with heart failure (HF) but their benefit in the dialysis population is uncertain. Beta-blockers are heterogeneous, including with respect to their removal by hemodialysis. We sought to evaluate whether β-blocker use and their dialyzability characteristics were associated with early mortality among patients with chronic kidney disease with HF who transitioned to dialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adults patients with chronic kidney disease (aged≥18 years) and HF who initiated either hemodialysis or peritoneal dialysis during January 1, 2007, to June 30, 2016, within an integrated health system were included. EXPOSURES Patients were considered treated with β-blockers if they had a quantity of drug dispensed covering the dialysis transition date. OUTCOMES All-cause mortality within 6 months and 1 year or hospitalization within 6 months after transition to maintenance dialysis. ANALYTICAL APPROACH Inverse probability of treatment weights using propensity scores was used to balance covariates between treatment groups. Cox proportional hazard analysis and logistic regression were used to investigate the association between β-blocker use and study outcomes. RESULTS 3,503 patients were included in the study. There were 2,115 (60.4%) patients using β-blockers at transition. Compared with nonusers, the HR for all-cause mortality within 6 months was 0.79 (95% CI, 0.65-0.94) among users of any β-blocker and 0.68 (95% CI, 0.53-0.88) among users of metoprolol at transition. There were no observed differences in all-cause or cardiovascular-related hospitalization. LIMITATIONS The observational nature of our study could not fully account for residual confounding. CONCLUSIONS Beta-blockers were associated with a lower rate of mortality among incident hemodialysis patients with HF. Similar associations were not observed for hospitalizations within the first 6 months following transition to dialysis.
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Affiliation(s)
- Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center. Los Angeles, CA.
| | - Jiaxiao Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Sally F Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center. Los Angeles, CA
| | - Jonathan R Neyer
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center. Los Angeles, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, CA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
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19
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Yeung A, Kiss A, Gallagher D. Intensive control of hypertension and risk of Alzheimer's dementia in older adults with depression. Int J Geriatr Psychiatry 2020; 35:888-896. [PMID: 32281159 PMCID: PMC7375011 DOI: 10.1002/gps.5309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/30/2020] [Accepted: 04/03/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Intensive control of hypertension has been reported to decrease risk of cognitive decline. However, the effect of this in older adults with hypertension and comorbid depression is not well understood. We aim to identify whether intensive control of systolic blood pressure (BP) is associated with reduced risk of Alzheimer's dementia (AD) in a clinical population. METHODS Using data from the National Alzheimer's Coordinating Center, we conducted survival analyses in older adults with normal cognition at baseline and treated hypertension. We also examined those with comorbid depression, to determine if intensive control of systolic BP (≤120 mmHg) was associated with reduced risk of AD. RESULTS In all older adults with treated hypertension (n = 4505), 298 (6.6%) developed AD during a median follow-up duration of 4.2 years. In the comorbid depression subgroup (n = 1327), 152 (11.5%) developed AD. Intensive control of systolic BP was not significantly associated with reduced risk of AD in the overall sample (HR 1.13, 95%, 0.79-1.64). However, in the comorbid depression subgroup, intensive control of systolic BP (≤120 mmHg) was associated with increased risk of AD (HR 1.49, 95%, 1.03-2.15) compared to standard control (121-139 mmHg). CONCLUSIONS In a clinical population of older adults with hypertension and comorbid depression, we found that an intensive systolic BP target of ≤120 mmHg was associated with increased risk of AD. While these findings are preliminary, they suggest that a more cautious approach to hypertension treatment may be warranted in this vulnerable subgroup.
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Affiliation(s)
- Anthony Yeung
- Department of Psychiatry, University of Toronto, Ontario
| | - Alex Kiss
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Program, Sunnybrook Research Institute
| | - Damien Gallagher
- Department of Psychiatry, University of Toronto, Ontario
- Division of Geriatric Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario
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20
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Blood pressure management in hypertensive patients with syncope: how to balance hypotensive and cardiovascular risk. J Hypertens 2020; 38:2356-2362. [DOI: 10.1097/hjh.0000000000002555] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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21
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Apparent treatment-resistant hypertension: characteristics and prevalence in a real-world environment of an integrated health system. J Hypertens 2020; 38:1603-1611. [PMID: 32251197 DOI: 10.1097/hjh.0000000000002419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We compared the prevalence of apparent treatment-resistant hypertension (aTRH) according to the seventh report of the Joint National Committee (JNC 7) and the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline in an integrated healthcare delivery system. METHODS We identified individuals aged at least 18 years with hypertension from Kaiser Permanente Southern California between 1 July 2014 and 30 June 2015. aTRH was defined as either blood pressure (BP) above goal (≥140/90 mmHg per JNC7, and ≥130/80 mmHg per 2017 ACC/AHA for most adults with hypertension) while taking at least 3 classes of antihypertensive medication or taking at least four classes regardless of BP level. A secondary analysis was conducted requiring use of a diuretic for the definition of aTRH. Patient clinical characteristics and antihypertensive medication use were described using electronic health records. RESULTS We included 469 509 patients with treated hypertension [mean (SD) age 65 years (12), 46% white, 26% Hispanic, 13% black, and 12% Asian]. The prevalence of aTRH was 16.9 and 21.8% according to the JNC 7 and the 2017 ACC/AHA guidelines, respectively [Δ = 4.9% (95% CI: 4.7--5.1%)]. By requiring a diuretic to be considered as aTRH, the prevalence of aTRH decreased to 13.4 and 17.2% according to the JNC 7 and the 2017 ACC/AHA guidelines, respectively. Among patients with aTRH, 1.9% received a long-acting thiazide-like diuretic, and 5.6% received a mineralocorticoid receptor blocker. CONCLUSION The prevalence of aTRH increased using the more stringent BP goals of the 2017 ACC/AHA guideline. The use of recommended therapy for aTRH was suboptimal suggesting a potential area for improvement.
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Huang CW, Li BH, Reynolds K, Jacobsen SJ, Rhee CM, Sim JJ. Association between hypothyroidism and chronic kidney disease observed among an adult population 55 years and older. Medicine (Baltimore) 2020; 99:e19569. [PMID: 32332605 PMCID: PMC7220776 DOI: 10.1097/md.0000000000019569] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Hypothyroidism and chronic kidney disease (CKD) are highly prevalent conditions with a potential mechanistic link. We sought to determine whether hypothyroidism is associated with CKD among a large diverse community-based cohort.A cross-sectional study was performed (January 1, 1990-December 31, 2017) within a large integrated health system. Individuals age ≥55 years of age with outpatient measurements of thyroid stimulating hormone (TSH) and ≥2 serum creatinine values were included. Hypothyroidism was defined as TSH >4 mIU/L and/or receipt of thyroid hormone replacement and further categorized as hypothyroid status: TSH >4 mcIU/mL and attenuated-hypothyroid status: TSH <4 mcIU/mL with receipt of thyroid hormone replacement. Euthyroidism was defined as TSH <4 mIU/L and no thyroid hormone replacement. Our primary measure was CKD defined as an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m. Multivariable logistic regression adjusting for age, sex, race, and comorbidities was used to estimate odds ratios (OR) for CKD by thyroid status.Among 378,101 individuals, 114,872 (30.4%) had hypothyroidism among whom 31,242 and 83,630 had hypothyroid and attenuated-hypothyroid statuses, respectively. Individuals with hypothyroidism had a CKD OR (95%CI) of 1.25 (1.21-1.29) compared with those with euthyroidism. Granular examination of thyroid statuses showed that hypothyroid and attenuated-hypothyroid statuses had CKD ORs (95% CI) of 1.59 (1.52-1.66) and 1.12 (1.08-1.16), respectively. A similar relationship was observed in analyses that defined CKD as an eGFR <60 L/min/1.73 m.Among individuals 55 years and older, we observed that those with hypothyroidism were more likely to have CKD. A stronger association was found among patients of hypothyroid status compared with attenuated-hypothyroid status suggesting a dose dependent relationship.
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Affiliation(s)
- Cheng-Wei Huang
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center
| | - Bonnie H. Li
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Steven J. Jacobsen
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Connie M. Rhee
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California, Irvine Medical Center, Irvine
| | - John J. Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
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23
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Sun AZ, Shu YH, Harrison TN, Hever A, Jacobsen SJ, O'Shaughnessy MM, Sim JJ. Identifying Patients with Rare Disease Using Electronic Health Record Data: The Kaiser Permanente Southern California Membranous Nephropathy Cohort. Perm J 2020; 24:19.126. [PMID: 32069207 DOI: 10.7812/tpp/19.126] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Developing a reliable means to identify and study real-world populations of patients with membranous nephropathy (MN) using electronic health records (EHRs) would help advance glomerular disease research. Identifying MN cases using EHRs is limited by the need for manual reviews of biopsy reports. OBJECTIVE To evaluate the accuracy of identifying patients with biopsy-proven MN using the EHR in a large, diverse population of an integrated health system. METHODS A retrospective cohort study was performed between June 28, 1999, and June 25, 2015, among patients with kidney biopsy results (N = 4723), which were manually reviewed and designated as MN or non-MN. The sensitivity, specificity, and positive predictive value (PPV) of International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes were determined using 2 approaches: 1) clinical (MN-specific codes 581.1, 582.1, or 583.1) and 2) agnostic/data-derived (codes selected from supervised learning at the highest predictive performance). RESULTS One year after biopsy, the sensitivity and specificity of an MN diagnosis were 86% and 76%, respectively, but the PPV was 26%. The data-driven approach detected that using only 2 codes (581.1 or 583.1) improved specificity to 94% and PPV to 58%, with a small decrease in sensitivity to 83%. When any code was reported at least 3 times, specificity was 98%; PPV, 78%; and sensitivity, 64%. DISCUSSION Our findings suggest that ICD-9 diagnosis codes might be a convenient tool to identify patients with MN using EHR and/or administrative claims information. Codes selected from supervised learning achieved better overall performance, suggesting the potential of developing data-driven methods.
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Affiliation(s)
- Amy Z Sun
- Division of Nephrology and Hypertension, Los Angeles Medical Center, CA
| | - Yu-Hsiang Shu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Aviv Hever
- Department of Renal Pathology, Los Angeles Medical Center, CA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - John J Sim
- Division of Nephrology and Hypertension, Los Angeles Medical Center, CA
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24
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Lee EA, Brettler JW, Kanter MH, Steinberg SG, Khang P, Distasio CC, Martin J, Dreskin M, Thompson NH, Cotter TM, Thai K, Yasumura L, Gibbs NE. Refining the Definition of Polypharmacy and Its Link to Disability in Older Adults: Conceptualizing Necessary Polypharmacy, Unnecessary Polypharmacy, and Polypharmacy of Unclear Benefit. Perm J 2019; 24:18.212. [PMID: 31905333 DOI: 10.7812/tpp/18.212] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The term polypharmacy in older adults is generally used in a pejorative context in the medical literature. Because of its link to geriatric syndromes and disability, the avoidance of polypharmacy is usually recommended in older adults as a strategy to optimize functional status. However, there are many polypharmacy regimens based on high-quality trials that clearly reduce the risk of disability in older adults. Other guidelines for older adults recommend the use of additional medications that may or may not be evidence based and that may or may not reduce disability. Therefore, we propose that, in the geriatric literature, polypharmacy now be categorized as "necessary polypharmacy," "unnecessary polypharmacy," or "polypharmacy of unclear benefit." In this article, we discuss the 3 categories of polypharmacy and give examples on each polypharmacy regimen and its potential relationship to disability in older adults.
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Affiliation(s)
- Eric A Lee
- Department of Internal Medicine, West Los Angeles Medical Center, CA
| | | | - Michael H Kanter
- Department of Clinical Science, Kaiser Permanente School of Medicine, Pasadena, CA
| | | | - Peter Khang
- Department of Geriatrics, Palliative Medicine, and Continuing Care, Los Angeles Medical Center, CA
| | | | - John Martin
- Department of Internal Medicine, Los Angeles Medical Center, CA
| | - Mark Dreskin
- Department of Integrated Behavioral Health, Los Angeles Medical Center, CA.,Urgent Care Division, Los Angeles Medical Center, CA
| | | | | | - Kim Thai
- Department of Physical Medicine and Rehabilitation, Baldwin Park Medical Center, CA
| | - Lyn Yasumura
- Department of Obstetrics and Gynecology, Baldwin Park Medical Center, CA
| | - Nancy E Gibbs
- Department of Geriatrics, Kaiser Permanente Southern California, Pasadena, CA
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