The importance of blood pressure control in the patient with diabetes

Digital Health in Diabetes and Cardiovascular Disease

BACKGROUND

Digital health technologies are rapidly evolving and transforming the care of diabetes and cardiovascular disease (CVD).

PURPOSE OF THE REVIEW

In this review, we discuss emerging approaches incorporating digital health technologies to improve patient outcomes through a more continuous, accessible, proactive, and patient-centered approach. We discuss various mechanisms of potential benefit ranging from early detection to enhanced physiologic monitoring over time to helping shape important management decisions and engaging patients in their care. Furthermore, we discuss the potential for better individualization of management, which is particularly important in diseases with heterogeneous and complex manifestations, such as diabetes and cardiovascular disease. This narrative review explores ways to leverage digital health technology to better extend the reach of clinicians beyond the physical hospital and clinic spaces to address disparities in the diagnosis, treatment, and prevention of diabetes and cardiovascular disease.

CONCLUSION

We are at the early stages of the shift to digital medicine, which holds substantial promise not only to improve patient outcomes but also to lower the costs of care. The review concludes by recognizing the challenges and limitations that need to be addressed for optimal implementation and impact. We present recommendations on how to navigate these challenges as well as goals and opportunities in utilizing digital health technology in the management of diabetes and prevention of adverse cardiovascular outcomes.

Monitoring peripheral hemodynamic response to changes in blood pressure via photoacoustic imaging

Chronic wounds and amputations are common in chronic kidney disease patients needing hemodialysis (HD). HD is often complicated by drops in blood pressure (BP) called intra-dialytic hypotension. Whether intra-dialytic hypotension is associated with detectable changes in foot perfusion, a risk factor for wound formation and impaired healing remains unknown. Photoacoustic (PA) imaging is ideally suited to study perfusion changes. We scanned the feet of 20 HD and 11 healthy subjects. HD patients were scanned before and after a dialysis session whereas healthy subjects were scanned twice at rest and once after a 10 min exercise period while BP was elevated. Healthy (r = 0.70, p < 0.0001) and HD subjects (r = 0.43, p < 0.01) showed a significant correlation between PA intensity and systolic BP. Furthermore, HD cohort showed a significantly reduced PA response to changes in BP compared to the healthy controls (p < 0.0001), showing that PA can monitor hemodynamic changes due to changes in BP.

Comprehensive Management of Cardiovascular Risk Factors for Adults With Type 2 Diabetes: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death in patients with diabetes. Cardiovascular disease in diabetes is multifactorial, and control of the cardiovascular risk factors leads to substantial reductions in cardiovascular events. The 2015 American Heart Association and American Diabetes Association scientific statement, "Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence," highlighted the importance of modifying various risk factors responsible for cardiovascular disease in diabetes. At the time, there was limited evidence to suggest that glucose-lowering medications reduce the risk of cardiovascular events. At present, several large randomized controlled trials with newer antihyperglycemic agents have been completed, demonstrating cardiovascular safety and reduction in cardiovascular outcomes, including cardiovascular death, myocardial infarction, stroke, and heart failure. This AHA scientific statement update focuses on (1) the evidence and clinical utility of newer antihyperglycemic agents in improving glycemic control and reducing cardiovascular events in diabetes; (2) the impact of blood pressure control on cardiovascular events in diabetes; and (3) the role of newer lipid-lowering therapies in comprehensive cardiovascular risk management in adults with diabetes. This scientific statement addresses the continued importance of lifestyle interventions, pharmacological therapy, and surgical interventions to curb the epidemic of obesity and metabolic syndrome, important precursors of prediabetes, diabetes, and comorbid cardiovascular disease. Last, this scientific statement explores the critical importance of the social determinants of health and health equity in the continuum of care in diabetes and cardiovascular disease.

Antihypertensive Efficacy of a Triple Fixed-Dose Combination of Perindopril, Indapamide, and Amlodipine: Clinical Effectiveness in Ambulatory Practice (Results of the PETRA Study)

Most patients with arterial hypertension (AH) for successful long-term blood pressure (BP) control require combination of antihypertensive drugs acting on various target organs. Accumulated experience shows that about 30 % of patients require combination therapy with 3 drugs from different pharmacological classes. Efficacy of BP control in real clinical practice with the use of various doses of perindopril, indapamide, and amlodipine as components of taken once-daily triple fixed combination was assessed in the 3-months prospective observational open-label PETRA study. In this study data of office BP measurements and 24-hour ambulatory BP monitoring (ABPM) were obtained from 11209 ambulatory patients (47.6 % women) with AH. Initial mean office BP (BPmoff) was 156.58±16.10 / 91.56±9.33 mm Hg, AH duration - 9.48±7.19 years. After switching to triple fixed dose combination of perindopril, indapamide, and amlodipine BPmoff decreased by 24.81±15.47 / 11.41±9.90 mm Hg (p&lt;0.0001). Doses of perindopril, indapamide, and amlodipine in combination at the final visit were 5 / 1.25 / 5, 10 / 2.5 / 5, and 10 / 2.5 / 10 mg. 24-hour ambulatory BP monitoring (ABPM) was carried out in 76 patients. Mean 24-hour BP lowed from mean 155.51±17.43 / 85.28±11.48 down to 134.63±12.51 / 77.83±8.99 mm Hg (p&lt;0.0001). Clinically relevant improvement of a number of parameters of metabolism occurred after 3 months of the study (in particular, lowering of levels of total and low-density lipoprotein cholesterol [-8.6 and - 11.4 %, respectively], triglycerides [-12,1 %], fasting blood glucose [-6.6 %]). Thus, results of the PETRA study confirmed 24-hour long antihypertensive efficacy of triple fixed dose combination of perindopril, indapamide, and amlodipine. This drug combination can present novel possibility in treatment of patients with AH who have not achieved target BP values on preceding dual combination therapy and fully corresponds with the single pill concept for formation of adherence to therapy.

TRIPLE ANTIHYPERTENSIVE THERAPY: FOCUS ON EFFICACY AND PROGNOSIS

In the article, with regard to current clinical recommendations, the place of combined antihypertensive therapy, especially triple drugs regimens, is considered in the treatment of patients with arterial hypertension. Special focus is given to the body of evidence for the efficacy of valsartan and amlodipine, as the reference drug of angiotensin II receptor blockers and calcium channel blockers, respectively. Not only their high antihypertensive properties are demonstrated, but also a favorable effect on target-organ protection and prognosis is described. In particular, the possibilities of valsartan in reducing the severity of left ventricular hypertrophy and microalbuminuria are described, and its unique properties in the class of sartans that allow the use of this drug in patients with ischemic heart disease and chronic heart failure are emphasized. Data on the antiatherosclerotic effects of amlodipine and its proven ability to reduce cardiovascular risk are presented. Current data are presented about their use in a fixed-dose combination with hydrochlorothiazide, including real clinical practice settings. The evidence base of high clinical efficacy, safety and metabolic neutrality of the triple combination of antihypertensive drugs valsartan, amlodipine and hydrochorothiazide is presented. The issues of increasing adherence of patients to treatment when prescribing fixed-dose combinations are considered. An algorithm for the selection of antihypertensive drugs in the form of monotherapy and combination therapy of two or three drugs depending on the clinical situation (the presence of certain target-organs damages and associated clinical conditions, primarily ischemic heart disease, atherosclerosis of carotid arteries and chronic heart failure) and the severity of the additional risk of cardiovascular complications.

Hypertension and blood pressure variability management practices among physicians in Singapore

Purpose

There are limited data on blood pressure variability (BPV) in Singapore. The absence of updated local guidelines might contribute to variations in diagnosis, treatment and control of hypertension and BPV between physicians. This study evaluated BPV awareness, hypertension management and associated training needs in physicians from Singapore.

Materials and methods

Physicians from Singapore were surveyed between September 8, 2016, and October 5, 2016. Those included were in public or private practice for ≥3 years, cared directly for patients ≥70% of the time and treated ≥30 patients for hypertension each month. The questionnaire covered 6 main categories: general blood pressure (BP) management, BPV awareness/diagnosis, home BP monitoring (HBPM), ambulatory BP monitoring (ABPM), BPV management and associated training needs.

Results

Responses from 60 physicians (30 general practitioners [GPs], 20 cardiologists, 10 nephrologists) were analyzed (77% male, 85% aged 31–60 years, mean 22 years of practice). Approximately 63% of physicians considered white-coat hypertension as part of BPV. The most common diagnostic tool was HBPM (overall 77%, GPs 63%, cardiologists 65%, nephrologists 70%), but ABPM was rated as the tool most valued by physicians (80% overall), especially specialists (97%). Withdrawn Singapore guidelines were still being used by 73% of GPs. Approximately 48% of physicians surveyed did not adhere to the BP cutoff recommended by most guidelines for diagnosing hypertension using HBPM (>135/85 mmHg). Hypertension treatment practices also varied from available guideline recommendations, although physicians did tend to use a lower BP target for patients with diabetes or kidney disease. There were a number of challenges to estimating BPV, the most common of which was patient refusal of ABPM/HBPM. The majority of physicians (82%) had no training on BPV, but stated that this would be useful.

Conclusion

There appear to be gaps in knowledge and guideline adherence relating to the assessment and management of BPV among physicians in Singapore.

The Antihypertensive Efficacy of the Triple Fixed Combination of Perindopril, Indapamide, and Amlodipine: The Results of the PETRA Study

INTRODUCTION

The etiology of essential hypertension is multifactorial. Therefore, treatment with combinations of antihypertensive agents acting on multiple targets is necessary for successful therapy in the majority of patients. According to the experience and clinical data accumulated so far, combination therapy with three agents from different pharmacological classes is required in approx. 30% of patients in order to achieve long-term blood pressure control. The primary objective of the PETRA study was to evaluate the efficacy of blood pressure (BP) control with once daily administration of the different dosage strengths of the once-daily, triple fixed combination of perindopril, indapamide, and amlodipine. The evaluation was based on office BP readings and ambulatory blood pressure monitoring (ABPM) data gathered in routine clinical practice.

METHODS

Data from 11,209 hypertensive patients (the proportion of female subjects was 47.6%) were processed and interpreted in a 3-month-long prospective, observational, non-interventional, open-label study conducted in 997 centers in Hungary.

RESULTS

Mean baseline office BP was 156.58 ± 16.10/91.56 ± 9.33 mmHg (mean ± SD), whereas the mean duration of hypertension was 9.48 ± 7.19 years. Mean office BP decreased by 24.81 ± 15.47/11.41 ± 9.90 mmHg after switching to the triple fixed combination of perindopril, indapamide, and amlodipine (p < 0.0001). At the final visit 45.1% of patients took the 5/1.25/5 mg, 33.5% of them 10/2.5/5 mg, and 21.4% of them 10/2.5/10 mg strength of the perindopril/indapamide/amlodipine triple fixed combination. The 24-h blood pressure was obtained in 76 subjects. The mean 24-h BP decreased from 155.51 ± 17.43/85.28 ± 11.48 to 134.63 ± 12.51/77.83 ± 8.99 mmHg (p < 0.0001). Statistically significant (p < 0.0001) and clinically relevant improvement of a number of metabolic parameters-including total cholesterol (-8.6%), LDL-cholesterol (-11.4%), triglyceride (-12.1%), and fasting blood glucose (-6.6%) levels-was observed over the 3-month study period.

CONCLUSIONS

During the 3 months of the PETRA study, the outstanding 24-h antihypertensive efficacy of the triple fixed combination of perindopril, indapamide, and amlodipine was confirmed both by office BP readings and by ABPM recordings. This combination may offer a new therapeutic option for hypertensive patients who have failed to achieve the desired BP target on their previous dual combination therapy.

FUNDING

EGIS Pharmaceuticals PLC.

Perceptions and practices related to diabetes reported by persons with diabetes attending diabetic care clinics: The India 11-city 9-state study

BACKGROUND

India has the second largest population of persons with diabetes and a significant proportion has poor glycemic control and inadequate awareness of management of diabetes.

OBJECTIVES

Determine the level of awareness regarding management of diabetes and its complications and diabetic care practices in India.

METHODS

The cross-sectional, hospital-based survey was conducted in 11 cities where public and private providers of diabetic care were identified. At each diabetic care facility, 4-6 persons with diabetes were administered a structured questionnaire in the local language.

RESULTS

Two hundred and eighty-five persons with diabetes were interviewed. The mean duration since diagnosis of diabetes was 8.1 years (standard deviation ± 7.3). Half of the participants reported a family history of diabetes and 41.7% were hypertensive. Almost 62.1% stated that they received information on diabetes and its management through interpersonal channels. Family history (36.1%), increasing age (25.3%), and stress (22.8%) were the commonest causes of diabetes reported. Only 29.1% stated that they monitored their blood sugar levels at home using a glucometer. The commonest challenges reported in managing diabetes were dietary modifications (67.4%), compliance with medicines (20.5%), and cost of medicines (17.9%). Around 76.5% were aware of complications of diabetes. Kidney failure (79.8%), blindness/vision loss (79.3%), and heart attack (56.4%) were the commonest complications mentioned. Almost 67.7% of the respondents stated that they had had an eye examination earlier.

CONCLUSIONS

The findings have significant implications for the organization of diabetes services in India for early detection and management of complications, including eye complications.

BP and Renal Outcomes in Diabetic Kidney Disease: The Veterans Affairs Nephropathy in Diabetes Trial

BACKGROUND AND OBJECTIVES

Proteinuric diabetic kidney disease frequently progresses to ESRD. Control of BP delays progression, but the optimal BP to improve outcomes remains unclear. The objective of this analysis was to evaluate the relationship between BP and renal outcomes in proteinuric diabetic kidney disease.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

BP data from all 1448 randomized participants in the Veterans Affairs Nephropathy in Diabetes Trial were included in a post hoc analysis. The associations of mean on-treatment BP with the primary end point (decline in eGFR, ESRD, or death), renal end point (decline in eGFR or ESRD), rate of eGFR decline, and mortality were measured.

RESULTS

The median (25th, 75th percentile) follow-up time was 2.2 (1.2, 3.0) years. There were 284 primary end points. In univariate analyses, both mean systolic and mean diastolic BPs were strongly associated (P<0.001) with the primary end point. After multivariate adjustment, the hazard of developing the primary end point became progressively higher as mean systolic BP rose from <120 to ≥ 150 mmHg (P=0.02), with a significantly higher hazard ratio for 140-149 versus 120-129 mmHg (1.51 [1.06, 2.15]; P=0.02). There was also a significant association of mean diastolic BP with the hazard of developing the primary end point (P<0.01), with a significantly higher hazard ratio when mean diastolic BP was 80-89 versus 70-79 mmHg (1.54 [1.05, 2.25]; P=0.03); there was also a strong trend when mean diastolic BP was <60 mmHg. Associations between BP and both renal end point and rate of eGFR decline were similar to those with the primary end point. No association of BP with mortality was observed, possibly because of the limited number of mortality events.

CONCLUSIONS

In patients with proteinuric diabetic kidney disease, mean systolic BP ≥ 140 mmHg and mean diastolic BP ≥ 80 mmHg were associated with worse renal outcomes.

Motivational interviewing to explore culturally and linguistically diverse people's comorbidity medication self-efficacy

AIMS AND OBJECTIVES

To examine the perceptions of a group of culturally and linguistically diverse participants with the comorbidities of diabetes, chronic kidney disease and cardiovascular disease to determine factors that influence their medication self-efficacy through the use of motivational interviewing.

BACKGROUND

These comorbidities are a global public health problem and their self-management is more difficult for culturally and linguistically diverse populations living in English-speaking communities. Few interventions have been tested in culturally and linguistically diverse people to improve their medication self-efficacy.

DESIGN

A series of motivational interviewing telephone calls were conducted in the intervention arm of a randomised controlled trial using interpreter services.

METHODS

Patients with these comorbidities aged ≥18 years of age whose preference it was to speak Greek, Italian or Vietnamese were recruited from nephrology outpatient clinics of two Australian metropolitan hospitals in 2009.

RESULTS

The average age of the 26 participants was 73·5 years. The fortnightly calls averaged 9·5 minutes. Thematic analysis revealed three core themes which were attitudes towards medication, having to take medication and impediments to chronic illness medication self-efficacy. A lack of knowledge about medications impeded confidence necessary for optimal disease self-management. Participants had limited access to resources to help them understand their medications.

CONCLUSION

This work has highlighted communication gaps and barriers affecting medication self-efficacy in this group. Culturally sensitive interventions are required to ensure people of culturally and linguistically diverse backgrounds have the appropriate skills to self-manage their complex medical conditions.

RELEVANCE TO CLINICAL PRACTICE

Helping people to take their medications as prescribed is a key role for nurses to serve and protect the well-being of our increasingly multicultural communities. The use of interpreters in motivational interviewing requires careful planning and adequate resources for optimal outcomes.

Are there any new pharmacologic therapies on the horizon to better treat hypertension? A state-of-the-art paper

Hypertension is the most important cardiovascular risk factor. We have witnessed a significant improvement in hypertension treatment and control and an impressive growth in the pharmacologic options available to clinicians and hypertension specialists. With up to a third of patients with hypertension not at the recommended goal blood pressures, it is critically important to develop novel therapeutic approaches to better treat hypertension. This review will explore the ever-expanding horizon of antihypertensive treatment and will focus on 2 major areas of drug development. First, we will review novel targets for pharmacologic treatment and novel molecules and classes of drugs in various phases of development and recognize the limitations we face in their transition from research and development to clinical practice. Then, we will discuss an expanding array of combination strategies to better treat hypertension with the goal of minimizing the burden of cardiovascular and renal complications of hypertension.

Role of ambulatory blood pressure monitoring in hypertension and diabetes

The prevalence of hypertension and diabetes are both rising in the USA and around the globe. The treatment of hypertension in the ambulatory setting begins with proper blood pressure measurement, and often the involvement of home blood pressure monitoring. If the diagnosis of hypertension is confirmed, then education on lifestyle modifications is the foundation to reaching blood pressure goals. If it is unclear, then ambulatory blood pressure monitoring should be performed to properly evaluate daily trends in blood pressure. The National Institute for Health and Clinical excellence (NICE) recommends 24-hour ambulatory blood pressure evaluation in all newly diagnosed patients with hypertension. The much-anticipated JNC 2013, while not likely to endorse this approach, will likely recommend an office goal systolic blood pressure of less than 140 mmHg in patients with diabetes as do the most recent American Diabetes Association clinical practice guidelines. All new guidelines are derived from a critical evidence based evaluation of the available data.

Titration of telmisartan, but not addition of amlodipine, reduces urine albumin in diabetic patients treated with telmisartan-diuretic

OBJECTIVES

Microalbuminuria is closely associated with an increased risk of renal and cardiovascular adverse outcomes. The present study tested the hypothesis that titration of telmisartan reduces urinary excretion of albumin more than does addition of amlodipine in patients treated with a standard dose of telmisartan combined with a low-dose diuretic for the same degree of blood pressure (BP) reduction.

METHODS

Hypertensive patients with type 2 diabetes mellitus and microalbuminuria under treatment with a combination of a standard dose of telmisartan (40 mg/day) and trichlormethiazide (1 mg/day) were randomly assigned to receive either an increased dose of telmisartan (80 mg/day) combined with trichlormethiazide [increased dose angiotensin receptor blocker (ARB) group, n = 20] or a combination consisting of telmisartan (40 mg/day), trichlormethiazide, and amlodipine (5 mg/day) (triple combination group, n = 20) for 6 months. The primary endpoint was a reduction in urinary albumin levels.

RESULTS

Although BP was reduced to a similar extent by the two regimens, patients receiving the increased dose ARB showed a higher reduction in urinary albumin (-37.4 ± 16.9%) than those on the triple combination regimen (-8.9 ± 23.7%; P < 0.0001). The reduction in urinary albumin was correlated with the drop in BP in the latter group, but not in the increased dose ARB group.

CONCLUSION

Uptitration of telmisartan more effectively reduces urinary albumin than addition of amlodipine in hypertensive patients with diabetes treated with a combination of telmisartan and diuretic for the same degree of BP reduction.

From bad behaviour to bad biology: pitfalls and promises in the management of resistant hypertension

Control rates for hypertension have dramatically improved during the past 2 decades-especially in Canada. However, hypertension remains one of the top risk factors for premature death globally. Furthermore, one-third of Canadians with hypertension have not obtained adequate blood pressure control. Most of these patients have resistant hypertension with uncontrolled blood pressure despite therapy. The etiology of resistant hypertension is multifactorial but includes both behavioural and biological factors. Among behavioural factors, nonadherence on the part of patients and especially clinical inertia on the part of health care professionals are contributing causes. An understanding of the root causes underlying the failure to control an individual's blood pressure is central to optimal subsequent management. Further advances in blood pressure control rates in this group of patients will depend on improvements in health care delivery systems and the further development of innovative therapies. Drugs combining multiple antihypertensive agents in a single pill and the development of new technologies to lower blood pressure, primarily by disruption of the sympathetic nervous system, have the potential to be useful strategies in this effort.

Rate of decline of kidney function in patients with type 2 diabetes mellitus and the associated factors: a 10-year retrospective cohort study

This study examines the rate of decline of estimated glomerular filtration rate (eGFR) over a 10-year period and the associated risk factors in type 2 diabetes mellitus (T2DM) patients. Medical records of T2DM patients were randomly selected. The rate of fall in eGFR (simplified modification of diet in renal disease formula) was used as a measure of decline. Univariate and multivariate analysis were performed to determine the factors associated with decline of kidney function. A total of 504 patients were selected. Mean age was 57.8 ± 9 years; 65.3% were females. The mean decline rate of eGFR was 0.89 ± 2.16 mL/min/1.73 m(2)/y. Baseline proteinuria, glycosylated hemoglobin level, duration of T2DM, and Malay race were associated with faster decline in eGFR. The expected greater deterioration in kidney function in this cohort was not seen. Treatment of proteinuria and glycemia should be optimized early to retard the decline in kidney function in patients with T2DM.

Pill burden in hypertensive patients treated with single-pill combination therapy--an observational study

INTRODUCTION

Hypertension is a condition which in many cases is treated with more than one drug. Additionally, patients with hypertension often suffer from other concomitant diseases, such as diabetes mellitus or dyslipidemia, which adds to the number of pills that patients need to take (pill burden). The aim of this study was to investigate the impact of this pill burden on patients with hypertension in clinical practice in Germany.

METHODS

This prospective, open-label, observational study enrolled adult patients for whom their physician considered treatment with a single-pill combination of amlodipine, valsartan, and hydrochlorothiazide as indicated. At the start of the observation period, physicians and patients filled in a respective questionnaire.

RESULTS

The questionnaires of 7,101 patients and 905 physicians were analyzed. The survey among the patients showed that the majority of patients felt burdened by the high number of pills to be taken. This was also seen as a potential reason for medication errors. Approximately half of the patients would be willing to make an out-of-pocket payment for reducing the number of pills to half. The results of the physician questionnaire indicate that the physicians were well aware of the set of problems that is generally associated with the high pill burden and that there is a clear willingness to use combination products in order to reduce the pill burden.

CONCLUSION

A high number of pills is considered a burden by the patients. This burden increases with the number of pills taken per day.

The efficacy and safety of triple vs dual combination of angiotensin II receptor blocker and calcium channel blocker and diuretic: a systematic review and meta-analysis

Many hypertensive patients require ≥2 drugs to achieve blood pressure targets. This study aims to review and analyze the clinical studies conducted with dual or triple combination of angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), and diuretics. Medical literature between January 1990 and April 2012 was reviewed systematically and data from eligible studies were abstracted. Data were analyzed using random-effects models. Of the 224 studies screened, 7563 eligible patients from 11 studies were included. Triple combinations of ARBs (olmesartan or valsartan), CCBs (amlodipine), and diuretics (hydrochlorothiazide) at any dose provided more blood pressure reduction in office and 24-hour ambulatory measurements than any dual combination of these molecules (P<.0001 for both). Significantly more patients achieved blood pressure targets with triple combinations (odds ratio, 2.16; P<.0001). Triple combinations did not increase adverse event risk (odds ratio, 0.96; P=.426). Triple combinations at any dose seem to decrease blood pressure more effectively than dual combination of the same molecules without any remarkable risk elevation for adverse events. Further prospective studies evaluating the efficacy and safety of triple combinations, especially in the form of single pills, are required.

Single-pill combination of telmisartan/amlodipine in patients with severe hypertension: results from the TEAMSTA severe HTN study

This 8-week, randomized, double-blind, controlled study compared efficacy and tolerability of telmisartan/amlodipine (T/A) single-pill combination (SPC) vs the respective monotherapies in 858 patients with severe hypertension (systolic/diastolic blood pressure [SBP/DBP] ≥180/95 mm Hg). At 8 weeks, T/A provided significantly greater reductions from baseline in seated trough cuff SBP/DBP (-47.5 mm Hg/-18.7 mm Hg) vs T (P<.0001) or A (P=.0002) monotherapy; superior reductions were also evident at 1, 2, 4, and 6 weeks. Blood pressure (BP) goal and response rates were consistently higher with T/A vs T or A. T/A was well tolerated, with less frequent treatment-related adverse events vs A (12.6% vs 16.4%) and a numerically lower incidence of peripheral edema and treatment discontinuation. In conclusion, treatment of patients with substantially elevated BP with T/A SPCs resulted in high and significantly greater BP reductions and higher BP goal and response rates than the respective monotherapies. T/A SPCs were well tolerated.

A multifactorial intervention to improve blood pressure control in co-existing diabetes and kidney disease: a feasibility randomized controlled trial

AIMS

The aim of this study was to test the feasibility and impact of an intervention consisting of self-monitored blood pressure, medicine review, a Digital Versatile Disc, and motivational interviewing telephone calls to help people with diabetes and kidney disease improve their blood pressure control and adherence to prescribed medications.

BACKGROUND

People with co-existing diabetes, kidney disease and hypertension require multiple medications to manage their health. About 50% of people are non-adherent to their prescribed medications with non-adherence increasing in the presence of chronic conditions.

DESIGN

Randomized controlled trial.

METHODS

Patients aged ≥18 years with diabetes, chronic kidney disease and systolic hypertension were recruited from nephrology and diabetes outpatients' clinics of an Australian metropolitan hospital between 2008-2009. Participants were randomly allocated on a 1:1 basis to one of two groups in a randomized controlled trial: the intervention delivered over 3 months (n = 39) and usual care (n = 41), with follow-up at 3, 6 and 9 months postintervention. People collecting data and assessing outcomes were blinded to group assignment.

RESULTS

  Seventy-five participants completed the study. The intervention was acceptable and feasible for this cohort. There were no statistically significant differences between groups, although the mean systolic blood pressure reduction in the intervention group (n = 36) was -6·9 mmHg 95% CI (-13·8, -0·02) at 9 months postintervention.

CONCLUSION

The study was feasible and statistically significant differences may be determinable in a larger sample to overcome the variability between groups, paying attention to recommendations for further research.

TRIAL REGISTRATION

  The trial was prospectively registered with the Australian and New Zealand Clinical Trials Register (ACTRN12607000044426).

Valsartan/amlodipine single pill combination for the treatment of hypertension

Data from numerous hypertension intervention studies show that the majority of hypertensive patients, approximately two-thirds, need at least two antihypertensive agents to reach and to stay at their blood pressure goal. Furthermore, any chronic therapy has to be kept as simple as possible in order to improve long-term adherence to the prescribed therapy. Therefore, guidelines generally recommend providing combination therapy as single pill combinations. The single pill combination of valsartan and amlodipine is the first such combination available containing an angiotensin receptor blocker and a calcium channel blocker (CCB). It combines two agents that have been studied extensively in large morbidity and mortality end point trials. Available evidence demonstrates that the combination of valsartan plus amlodipine lowers blood pressure more effectively than the respective monotherapies. The combination of valsartan and amlodipine has to be viewed on the background of recent data from a large end point trial suggesting that blockade of the renin-angiotensin system plus a CCB may be more beneficial than the combination of a renin-angiotensin system blocker plus a thiazide diuretic. Finally, while angiotensin receptor blockers have been shown to exhibit placebo-like tolerability, dihydropyridine CCBs, such as amlodipine, are capable of exerting a dose-dependent swelling predominantly in the ankle regions of the lower extremities, known as vasodilatory edema. This side effect of amlodipine is reduced markedly with the coadministration of valsartan. In conclusion, the single pill combination of valsartan plus amlodipine represents an effective and tolerable treatment option for patients with the need for combination treatment.

Management of diabetic hypertensives

Hypertension occurs twice as commonly in diabetics than in comparable nondiabetics. Patients with both disorders have a markedly higher risk for premature microvascular and macrovascular complications. Aggressive control of blood pressure (BP) reduces both micro- and macrovascular complications. In diabetic hypertensives, angiotensin converting enzyme inhibitors (ACEIs) are the first line in management of hypertension, and can be replaced by angiotensin II receptor blockers (ARBs) if patients are intolerant of them. Recent studies suggest ARBs to be on par with ACEI in reducing both macro- and microvascular risks. Adding both these agents may have a beneficial effect on proteinuria, but no extra macrovascular risk reduction. Thiazides can also be used as first line drugs, but are better used along with ACEI/ARBs. Beta-blockers [especially if the patient has coronary artery disease] and calcium channel blockers are used as second line add-on drugs. Multidrug regimens are commonly needed in diabetic hypertensives. Achieving the target BP of <130/80 is the priority rather than the drug combination used in order to arrest and prevent the progression of macro- and microvascular complications in diabetic hypertensives.

An overview of candesartan in clinical practice

Hypertension is a major risk factor for coronary heart disease, stroke, heart failure and renal disease. The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure 7 defined hypertension as a blood pressure of more than 140/90 mmHg and recommended to initiate treatment with a two-drug combination for stage 2 hypertension (blood pressure of 160-179/100-109 mmHg). The need for drug combinations is clear from a patient and physician perspective as they provide more effective blood pressure lowering, reduce pill burden, improve compliance and decrease hypertension-related morbidity and mortality. Angiotensin II receptor blocker therapy has been proven to be well tolerated and effective in the management of hypertension, chronic heart failure with left ventricular dysfunction and the prevention and progression of diabetic renal disease. Blockers of the renin-angiotensin system are an important component of antihypertensive combination therapy. Thiazide-type diuretics are usually added to increase the blood pressure lowering efficacy. Fixed drug-drug combinations of both principles, such as candesartan/hydrochlorothiazide, are highly effective in lowering blood pressure while providing improved compliance, a good tolerability and largely neutral metabolic profile. In this article, we review the literature for the role of candesartan-based therapy for hypertension, stroke, diabetes mellitus and heart failure.

Aliskiren-based stepped-care treatment algorithm provides effective blood pressure control

AIMS

Recent guidelines for the management of hypertension recommend an individualised stepped-care treatment approach in mild-to-moderate hypertensive patients, to achieve blood pressure (BP) goals. This study evaluated the probability of patients achieving BP targets with an aliskiren-based stepped-care treatment regimen.

METHODS

This was a 24-week, open-label, non-comparator study design that included six sequential 4-week treatment periods in patients with mild-to-moderate hypertension. Over the potential 24 weeks of active treatment, incremental therapy included the following add-on therapies at 4-week intervals: aliskiren 150-300 mg once daily, hydrochlorothiazide (HCTZ) 12.5-25 mg once daily, and finally amlodipine 5-10 mg once daily, as needed to achieve target BP. Subjects achieving BP targets following any given 4 weeks of therapy were considered study completers, while subjects not achieving their clinical BP target entered into the next step of incremental therapy. The primary efficacy end-point was the estimated cumulative probability of patients achieving BP target.

RESULTS

Of 256 patients treated, 232 (90.6%) completed the study. Baseline mean sitting BP was 155.7/91.7 mmHg. At study end-point, the estimated cumulative probability of reaching BP target was 86.12%. The stepped-care treatment regimen was well tolerated at the maximal recommended doses of all the individual complimentary therapies.

CONCLUSION

An aliskiren-based stepped-care treatment regimen that subsequently included both HCTZ and amlodipine is effective in achieving BP goals in approximately 90% of patients with mild-to-moderate hypertension.

Optimal use of beta-blockers in high-risk hypertension: a guide to dosing equivalence

Hypertension is the number one diagnosis made by primary care physicians, placing them in a unique position to prescribe the antihypertensive agent best suited to the individual patient. In individuals with diabetes mellitus, blood pressure (BP) levels >130/80 mmHg confer an even higher risk for cardiovascular and renal disease, and these patients will benefit from aggressive antihypertensive treatment using a combination of agents. β-blockers are playing an increasingly important role in the management of hypertension in high-risk patients. β-blockers are a heterogeneous class of agents, and this review presents the differences between β-blockers and provides evidence-based protocols to assist in understanding dose equivalence in the selection of an optimal regimen in patients with complex needs. The clinical benefits provided by β-blockers are only effective if patients adhere to medication treatment long term. β-blockers with proven efficacy, once-daily dosing, and lower side effect profiles may become instrumental in the treatment of hypertensive diabetic and nondiabetic patients.

Optimizing blood pressure control through the use of fixed combinations

The majority of hypertensive patients need ≥2 antihypertensive agents to reach goal blood pressure. As an estimate, one-third of unselected hypertensive patients may be successfully treated with monotherapy, one-third may require 2 and the remaining one-third of patients will need ≥3 antihypertensive agents for effective blood pressure control. However, doctors are often hesitant to expand therapy in treated patients whose blood pressure is not lowered to goal (therapeutic inertia). Multiple-drug therapy in the majority of hypertensive patients may also represent one of several factors responsible for the low rates of adherence with chronic antihypertensive treatment. As a consequence, both US and European guidelines recommend single pill combinations to lower the number of pills needed in order to increase medication adherence and, possibly, reduce therapeutic inertia. For 2 drug combinations, the recently revised European (ESC/ESH) guidelines recommend the following options: diuretic plus either calcium channel blocker (CCB) or renin–angiotensin system (RAS) blocker (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker) or CCB plus RAS-blocker. In the absence of substantial evidence, neither JNC-7 (from 2003) nor the European guidelines from 2007 give any meaningful advice on triple combination treatment. It is therefore of interest that the 2009 reappraisal of the European guidelines gives preference to the combination of a RAS blocker and a CCB plus a diuretic. On the background of the substantial number of patients requiring ≥3 drugs for blood pressure control, the recent approval of a single-pill 3-drug combination composed in accordance with the above mentioned ESC/ESH recommendations should be appreciated.

Issues in blood pressure control and the potential role of single-pill combination therapies

Hypertension (HTN) is a major risk factor for cardiovascular mortality, yet only a small proportion of hypertensive individuals receive appropriate therapy and achieve target blood pressure (BP) values. Factors influencing the success of antihypertensive therapy include physicians' acceptance of guideline BP targets, the efficacy and tolerability of the drug regimen, and patient compliance and persistence with therapy. It is now well recognised that most hypertensive patients require at least two antihypertensive agents to achieve their target BP. However, complicated treatment regimens are a major contributory factor to poor patient compliance. The use of combination therapy for HTN offers a number of advantages over the use of monotherapy, including improved efficacy, as drug combinations with a synergistic mechanism of action can be used. This additive effect means that lower doses of the individual components can be used, which may translate into a decreased likelihood of adverse events. The use of single-pill combination therapy, in which two or more agents are combined in a single dosage form, offers all the benefits of free combination therapy (improved efficacy and tolerability over monotherapy) together with the added benefit of improved patient compliance because of the simplified treatment regimen. The use of single-pill combination therapy may also be associated with cost savings compared with the use of free combinations for reasons of cheaper drug costs, fewer physician visits and fewer hospitalisations for uncontrolled HTN and cardiovascular events. Thus, the use of single-pill combination therapy for HTN should help improve BP goal attainment through improved patient compliance, leading to reduced costs for cardiovascular-related care.

ASH position paper: treatment of hypertension in patients with diabetes-an update

This report updates concepts on hypertension management in patients with diabetes. It focuses on clinical outcomes literature published within the last 3 years and incorporates these observations into modifications of established guidelines. While the fundamentals of treatment and goal blood pressures remain unchanged, approaches to specific patient-related issues has changed. This update focuses on questions such as what to do when a patient has an elevated potassium level when therapy is initiated and whether combinations of agents that block the renin-angiotensin system still be used. In addition, there are updates from trials, just published and in press, that focus on related management issues influencing cardiovascular outcomes in persons with diabetes. Last, an updated algorithm is provided that incorporates many of the new findings and is suggested as a starting point to achieve blood pressure goals.

Antihypertensive medication use and blood pressure control: a community-based cross-sectional survey (ON-BP)

BACKGROUND

The Ontario Blood Pressure (ON-BP) survey reported high treatment and control rates for hypertension in the province of Ontario, Canada, in a survey performed in 2006. This study examined patterns of utilization of antihypertensive drug classes and their impact on blood pressure (BP) control.

METHODS

Cross-sectional, population-based survey of adults, 20-79 years of age (population 7,996,653). Responses are weighted to the Ontario hypertensive population of 1,498,045.

RESULTS

Of all hypertensives, 51 and 49% were on monotherapy vs. 2+ drug therapy with similar control rates (86 vs. 80%, respectively). In those on monotherapy a renin-angiotensin system (RAS) blocker was the most commonly used drug class (62%) and use of other drug classes was only approximately 10%. In those on 2+ therapy, a RAS blocker was also the most common class (80%), followed by a diuretic (67%). In diabetics with hypertension 46 and 54% were on monotherapy vs. 2+ drug therapy with significantly higher control rates on monotherapy (90 vs. 46%). RAS blocker was also the most common drug class (85 and 80%, respectively), but in those on 2+ drugs only 45% were on a diuretic. Control rates did not differ by type of drug treatment in the overall hypertensive population and those with a comorbidity, but were low in diabetics on 2+ therapy and particularly in those on a calcium channel blocker (CCB) or diuretic.

CONCLUSIONS

High treatment and control rates of hypertension in Ontario are associated with high utilization of RAS blockers. Diabetics on 2+ therapy are the least effectively controlled, possibly reflecting the limited use of diuretics.

Clinical Use and Pathogenetic Basis of Laboratory Tests for the Evaluation of Primary Arterial Hypertension

This review focuses on the laboratory biochemical tests that are useful in the diagnostic approach to the hypertensive patient. A "minimal" diagnostic laboratory work-up, including a small number of tests that are simple and relatively inexpensive, is first described. Because these tests provide basic information on the presence of major cardiovascular (CV) risk factors and target organ damage, and might give some clues to the presence of a secondary form of hypertension (HT), they should be performed on all patients presenting with HT. Other tests that are aimed at assessing the overall CV risk, a major determinant of prognosis that dictates the therapeutic strategy in the individual HT patient, are then discussed. They allow identification of major CV risk factors and associated clinical conditions which, if present, lead to a substantial change of therapeutic strategy. The role of C-reactive protein as a marker of atherosclerosis and its predictive value for CV events are also discussed. Finally, a section is devoted to tests that are currently confined to research purposes, such as markers of endothelial function including endothelin-1, homocysteine and genetic analysis.

Combination therapy with valsartan/hydrochlorothiazide at doses up to 320/25 mg improves blood pressure levels in patients with hypertension inadequately controlled by valsartan 320 mg monotherapy

OBJECTIVES

To investigate the efficacy and tolerability of valsartan (Val) 320 mg once daily (o.d.), Val/hydrochlorothiazide (HCTZ) 320/12.5 mg o.d. and Val/HCTZ 320/25 mg o.d. in patients with hypertension not adequately controlled by Val monotherapy.

METHODS

This double-blind, active-controlled, parallel-group, randomized trial recruited patients > or =18 years with mild-to-moderate essential hypertension, defined as mean sitting diastolic blood pressure (MSDBP) of > or =95 mmHg and <110 mmHg without treatment. After washout, 3805 eligible patients received Val 320 mg o.d. single-blind for 4 weeks. Subsequently, patients with MSDBP > or =90 and <110 mmHg (n=2702) were randomized to double-blind treatment with Val 320 mg, Val/HCTZ 320/12.5 mg or Val/HCTZ 320/25 mg for 8 weeks. Mean changes in MSDBP and mean sitting systolic BP (MSSBP) from the start of the single-blind period were analysed, as well as the proportion of responders (MSDBP <90 mmHg or > or =10 mmHg decrease from the start of the double-blind period). Tolerability and safety were also assessed.

RESULTS

Reductions in MSDBP and MSSBP were observed in all groups. Both combinations were associated with significantly greater reductions than monotherapy for MSDBP and MSSBP at Weeks 8 and 12 (all p<0.0001). Both combinations also resulted in significantly greater proportion of responders at study end (74.9% and 68.8% for Val/HCTZ 320/25 mg and Val/HCTZ 320/12.5 mg, respectively) than monotherapy (52.7%; both p < 0.0001). In addition, a dose-response was observed with increasing dose of HCTZ with respect to MSSBP. All treatments were well tolerated.

CONCLUSIONS

The combination ofVal and HCTZ at doses of 320/12.5 mg and 320/25 mg increases antihypertensive efficacy in patients with mild-to-moderate hypertension inadequately controlled with Val 320 mg monotherapy, without compromising tolerability.

High-risk patients with hypertension: Are we doing enough?

Despite the increasing risk of cardiovascular disease, especially in patients with multiple risk factors, blood pressure (BP) control remains suboptimal. This study investigated real-world BP goal attainment and prescribing patterns for high-risk patients. A retrospective chart review study was conducted in patients treated by eight large primary care physician group practices between December 2003 and May 2006. A total of 1,917 hypertensive patients were identified with >/=1 risk factors: African-American ethnicity (634); diabetes (851); advanced age (1,123); body mass index (BMI) 25 kg/m(2) (1,614). BP control rate was 46% overall, and similar in the advanced age and overweight/obese subpopulations, but substantially lower (28%) in the diabetic subpopulation. Systolic blood pressure >/=20 mm Hg above the Joint National Committee on Prevention, Detection, Evaluation, and Treatment Report recommendation was found in 13% of the overall, advanced age and overweight/obese subpopulations, and in 20% of diabetics and 18% of African-Americans. Overall, 62% of patients received >/=2 antihypertensive while 36% of diabetics, 31% of African-Americans, 28% of advanced age, and 26% of overweight/obese patients received >/=3 antihypertensive classes. Despite availability of multiple antihypertensive classes, BP control rates were still suboptimal in this study's high-risk patients. There is a need for awareness and more aggressive treatment in high-risk patients given their increased risk of poor outcomes.

Thiazolidinediones and diabetic nephropathy: need for a closer examination?

Diabetic nephropathy is an important public health issue and a major challenge for modern nephrology, as it is the primary cause of end-stage renal disease. In addition to established risk factors for diabetic nephropathy progression (ie, hyperglycemia and hypertension), current knowledge suggests that other factors can be involved. Population studies show that insulin resistance and hyperinsulinemia are also associated with chronic kidney disease, and several background mechanisms could explain this relationship. The hypoglycemic class of thiazolidinediones that act through reduction of insulin resistance were found to protect against renal injury in diabetic animals and to reduce urinary albumin excretion in patients with type 2 diabetes and microalbuminuria. This renoprotective action is supported by relevant studies showing that thiazolidinediones act beneficially on most of the players involved in diabetic nephropathy progression. Recent studies have raised uncertainty about the cardiovascular safety of thiazolidinediones. After the latter issue is resolved, however, it would appear very interesting to conduct specific studies in patients with overt diabetic nephropathy to determine the effect of these agents on proteinuria and kidney disease progression.

Lowering blood pressure with beta-blockers in combination with other renin-angiotensin system blockers in patients with hypertension and type 2 diabetes: results from the GEMINI Trial

The effects of beta-blockade in addition to more specific renin-angiotensin system (RAS) blockers on blood pressure (BP) in patients with diabetes are described. After washout of medications other than angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, patients were titrated to a BP level <130/80 mm Hg using therapy with carvedilol 6.25 to 25 mg bid (n=498) or metoprolol tartrate 50 to 200 mg bid (n=737). At the end of the beta-blocker titration period, a BP level <130/80 mm Hg was achieved in 37% of carvedilol-treated and 36% of metoprolol-treated participants who continued to receive a renin-angiotensin system blocker. In the approximately 60% of participants in whom a BP level <130/80 mm Hg was not attained with renin-angiotensin system blockade plus beta-blockade, hydrochlorothiazide was added in 43% and 44% of carvedilol and metoprolol groups, respectively; 25% (both arms) also required a calcium channel blocker. Among those in whom goal BP was not achieved, 42% of carvedilol- and 40% of metoprolol-treated participants were not titrated to the highest dose of beta-blocker. The use of carvedilol compared with metoprolol did not effect glycemic control.

Prevalence of hypertension in type 2 diabetes mellitus: impact of the tightening definition of high blood pressure and association with confounding risk factors

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) has recommended a downward shift in target blood pressure to <130/80 mm Hg in diabetic patients, thus operatively setting a new threshold level for the definition of hypertension at 130/80 mm Hg. The authors performed a retrospective chart analysis of 2227 type 2 diabetes patients treated in one hospital-based and two community-based clinics in central Israel to determine the prevalence of hypertension as a function of three diagnostic threshold levels. The prevalence of hypertension in this cohort was 60.2%, 76.5%, and 85.8% at blood pressure thresholds of 140/90, 130/85, and 130/80 mm Hg respectively. Hypertension prevalence increased with age, reaching a rate of 94.4% in patients aged 80 years or more when the cutoff value of 130/80 mm Hg was used. At this cutoff, 93.3% and 86.6% of patients with a body mass index over or under 30 kg/m(2), respectively, were diagnosed with hypertension. As hypertension appears to eventually afflict the vast majority of diabetic patients, the minority of subjects not developing hypertension emerges as a unique group, which potentially deserves further in-depth study.

Antihypertensive agents, insulin sensitivity, and new-onset diabetes

The effects of the antihypertensive drugs on carbohydrate metabolism and the development of diabetes have been a major research field for more than two decades. Many clinical studies have investigated the effects of the antihypertensive classes on insulin sensitivity and glycemic control, whereas several observational studies and large outcome trials have examined associations of antihypertensive agents with diabetes incidence. In general, thiazide diuretics and conventional beta blockers decrease insulin sensitivity and increase new-onset diabetes, whereas angiotensin-converting enzyme inhibitors, calcium channel blockers, and angiotensin II receptor blockers have neutral or beneficial effects on these parameters. However, several issues in this field, such as the specific properties of newer agents and the relationship of adverse metabolic outcomes and cardiovascular risk, remain to be fully elucidated. This article presents and evaluates the current knowledge in this important area.