Impact of Ambulatory Blood Pressure Monitoring on Control of Untreated, Undertreated, and Resistant Hypertension in Older People in Spain

Numerical values and impact of hypertension in Spain

In Spain, 33% of adults aged 30 to 79 years (10 million) were hypertensive in 2019. Among them, 68% were diagnosed, 57% received drug therapy, and effective therapeutic coverage (control) reached 33%. Both diagnosis and control show geographical and social disparities. Approximately 46 000 cardiovascular deaths per year are attributable to hypertension. In recent decades, the control of hypertension has increased, due to improvements in lifestyle measures and increased use of polytherapy, coinciding with a reduction in stroke mortality. There are several modifiable determinants of the lack of hypertension control: a) white-coat phenomenon affects 22% to 33% of treated individuals, partly due to the limited availability of ambulatory blood pressure monitoring (ABPM) (49%) and self-measured BP (SMBP) (78%); b) inadequate patient adherence to medication and healthy lifestyles (weight loss, the most effective measure, is the least used, ≈40%); and c) insufficient use of polytherapy (≈55%). The remaining challenges include: a) technological aspects, such as measuring BP with more accurate techniques (ABPM, SMBP) and using cardiovascular-risk estimation tools (eg, SCORE); b) clinical challenges, such as reducing therapeutic inertia (≈59%), involving patients in their own management (medication adherence, ≈62%) and effectively implementing clinical guidelines); and c) public health challenges, such as reducing the burden of obesity (≈24%), monitoring progress with updated surveys, and setting national BP control targets.

Risk of heart failure in ambulatory resistant hypertension: a meta-analysis of observational studies

The impact of ambulatory resistant hypertension (ARH) on the occurrence of heart failure (HF) is not yet completely known. We performed for the first time a meta-analysis, by using published data or available data from published databases, on the risk of HF in ARH. Patients with ARH (24-h BP ≥ 130/80 mmHg during treatment with ≥3 drugs) were compared with those with controlled hypertension (CH, clinic BP < 140/90 mmHg and 24-h BP < 130/80 mmHg regardless of the number of drugs used), white coat uncontrolled resistant hypertension (WCURH, clinic BP ≥ 140/90 mmHg and 24-h BP < 130/80 mmHg in treated patients) and ambulatory nonresistant hypertension (ANRH, 24-h BP ≥ 130/80 mmHg during therapy with ≤2 drugs). We identified six studies/databases including 21,365 patients who experienced 692 HF events. When ARH was compared with CH, WCURH, or ANRH, the overall adjusted hazard ratio for HF was 2.32 (95% confidence interval (CI) 1.45-3.72), 1.72 (95% CI 1.36-2.17), and 2.11 (95% CI 1.40-3.17), respectively, (all P < 0.001). For some comparisons a moderate heterogeneity was found. Though we did not find variables that could explain the heterogeneity, sensitivity analyses demonstrated that none of the studies had a significant influential effect on the overall estimate. When we evaluated the potential presence of publication bias and small-study effect and adjusted for missing studies identified by Duval and Tweedie's method the estimates were slightly lower but remained significant. This meta-analysis shows that treated hypertensive patients with ARH are at approximately twice the risk of developing HF than other ambulatory BP phenotypes.

Characterization of Individuals With Apparent Resistant Hypertension Using Contemporary Guidelines: Insights From CV-QUIC

BACKGROUND

Apparent resistant hypertension (aRH) carries excess cardiovascular risk beyond nonresistant forms of hypertension; however, our understanding of this at-risk population, as defined by current US practice guidelines, is limited. Accordingly, we sought to evaluate the prevalence, clinical characteristics, and pharmacotherapeutic patterns of patients with aRH using contemporary blood pressure guidance.

METHODS

We classified patients at 3 large healthcare systems by hypertensive status using contemporary hypertension guidelines. We subsequently described the demographic and clinical characteristics of patients with aRH and compared these factors among hypertensive patients without aRH and between those with controlled and uncontrolled aRH.

RESULTS

A total of 2 420 468 patients were analyzed, of whom 1 343 489 (55.6%) were hypertensive according to contemporary guidelines. Among hypertensive patients, 11 992 (8.5%) met criteria for aRH, with nearly all assessed comorbid conditions, particularly diabetes and heart failure, being more common in those with aRH. When compared with patients with uncontrolled aRH, those with controlled aRH were more frequently prescribed a beta-blocker, diuretic, and nitrate, with the largest standardized difference observed for a mineralocorticoid receptor antagonist (35.4% versus 10.4%, Cohen D 0.62). Consistent findings were noted in sensitivity analyses using the blood pressure threshold of 140/90 mm Hg.

CONCLUSIONS

In an analysis of over 2.4 million individuals, a lower prevalence of aRH was observed than previously reported (12%-15%), but with a high burden of comorbidities. Identification of differences in pharmacotherapy between patients with controlled and uncontrolled aRH, particularly lower rates of mineralocorticoid receptor antagonist use, help define potential opportunities to improve care and lower cardiovascular risk.

The value of ABPM and subclinical target organ damage parameters in diagnosis of resistant hypertension

INTRODUCTION

We aimed to assess the effectiveness of ambulatory blood pressure monitoring (ABPM) and subclinical target organ damage parameters for diagnosis of resistant hypertension (RH).

METHODS

We assessed demographic and anthropometric variables, the incidence of cardiovascular events and subclinical target organ damage (n=112). We also studied the relationship between these variables and the ABPM results.

RESULTS

Of the 112 patients referred from primary care with a diagnosis of RH, 69 (61.6%) were confirmed by ABPM. We found statistically significant differences (P<.001) between patients with RH and pseudo-resistant hypertension in the appearance of subclinical target organ damage. A percentage of 84 of the patients had microalbuminuria: 66.25±30.7mg/dl); 44.9% had stage 3 chronic kidney disease: the average glomerular filtration was 59ml/min/1.73m²; and 56.5% had left ventricular hypertrophy on echocardiography. Fundoscopy revealed that 64% of the patients had hypertensive retinopathy. Three variables were associated with an increased HR risk: microalbuminuria, hypertensive retinopathy and left ventricular hypertrophy (OR 5.7, 6.2 and 11.2, respectively).

CONCLUSIONS

This study shows that the systematic testing for target organ damage, particularly in terms of albuminuria, is a simple and inexpensive tool, with a high predictive value for RH (85%), which could be useful for prioritising patients who need ABPM.

Hypertension Prevalence, Awareness, Treatment, and Control: Should 24-Hour Ambulatory Blood Pressure Monitoring be the Tool of Choice?

We aimed to examine hypertension prevalence, awareness, treatment and control in a community sample and investigate the impact of using 24 hour ABPM. Office blood pressure (BP) was taken from the electronic health record. Study BP was measured by standardised methods. Participants were invited to undergo ABPM. Hypertension was defined by accepted thresholds or anti-hypertensive use. Standardised questions assessed awareness and treatment. Control was defined as anti-hypertensive use with BP below normal threshold. There were 931 (45%) participants with office BP, study BP and ABPM. By study BP, hypertension prevalence was 60%, awareness 59%, 60% were treated and 46% controlled. By daytime ABPM threshold, prevalence was 61%, awareness 59%, 59% were treated and 54% controlled. ABPM reclassified 13.5% from normotensive to hypertensive and 14.5% from hypertensive to normotensive. ABPM may not hugely impact population hypertension prevalence but at an individual level it reduces misclassification and facilitates more appropriate management.

Relationship Between Hyperuricemia and Cardiovascular Disease Risk Factors in a Chinese Population: A Cross-Sectional Study

BACKGROUND

To study the relationship between hyperuricemia and cardiovascular diseases (CVDs) risk factors in a Chinese population.

MATERIAL AND METHODS

Data analyzed in this study were from the Chinese Hyperuricemia and Gout Database. Indicators of serum uric acid (SUA) level, height, weight, systolic blood pressure (SBP), diastolic blood pressure (DBP), smoking status, alcohol consumption, blood glucose, cholesterol, and triglycerides were measured. T test, one-way analysis of variance, Pearson's correlation, multivariate linear regression, and multivariate logistic regression were used.

RESULTS

Compared with normouricemic men, hyperuricemic men had greater height (P<0.01), weight (P<0.001), body mass index (BMI) (P<0.001), SBP (P<0.01), DBP (P<0.001), cholesterol (P<0.01), and triglyceride (P<0.001). Compared with normouricemic women, hyperuricemic women were older (P<0.01) and had greater weight (P<0.05), BMI (P<0.01), SBP (P<0.01), DBP (P<0.05), glucose (P<0.05), and triglyceride (P<0.001). In men, an increase of 1 mg/dL in SUA was associated with a 0.279 kg/m2 increase in BMI (P<0.001), a 2.438 mg/dL increase in cholesterol (P<0.05), a 10.358 mg/dL increase in triglyceride (P<0.001), and a 3.1 mg/dL decrease in glucose (P<0.01). In women, an increase of 1 mg/dL SUA was associated with a 0.168 kg/m2 increase in BMI (P<0.01) and a 3.708 mg/dL increase in triglyceride (P<0.01). After adjustment, SUA was strongly associated with obesity and hyperlipidemia in both sexes.

CONCLUSIONS

Elevated serum uric acid concentration was strongly associated with obesity and hyperlipidemia in both men and women. These results indicated that, among hyperuricemia patients, we should pay more attention to the possibility of cardiovascular complications. These results might provide a novel target or a possible new treatment for cardiovascular diseases by lowering the level of serum uric acid.