Effects of antihypertensive treatment in Asian populations: a meta-analysis of prospective randomized controlled studies (CARdiovascular protectioN group in Asia: CARNA)

Clinical studies on pharmacological treatment of hypertension in Japan

Differences in the epidemiology and phenotypes of hypertension in Japan compared with Western countries mean that optimal approaches to the pharmacological management of hypertension should be based on local data. Fortunately, there is a large body of evidence from studies conducted in Japanese populations to inform guidelines and treatment decisions. This article highlights treatment recommendations and BP targets for Japanese patients with hypertension, and summarizes key literature supporting these recommendations. The latest version of the Japanese Society of Hypertension (JSH) guidelines is consistent with US and European guidelines in recommending that the general BP target should be <130/80 mmHg for office blood pressure (BP) and <125/75 mmHg for home BP. There is good local evidence to support these targets. The JSH guidelines also strongly recommend that antihypertensive therapy is managed and monitored based on home BP, due to the closer association of this parameter with cardiovascular risk compared with office BP. Japan is a leader in out-of-office BP research, meaning that there is good evidence for the Japanese recommendations. Key features of antihypertensive agents for use in Japanese patients with hypertension include the ability to reduce stroke risk provide antihypertensive efficacy throughout the 24-h dosing period. Calcium channel blockers appear to be particularly effective in Asian populations, and are the most commonly prescribed agents in Japan. Again consistent with international recommendations, antihypertensive therapy should be started with a combination of agents to maximize the chances of achieving target BP.

Blood Pressure and Stroke: A Review of Sex- and Ethnic/Racial-Specific Attributes to the Epidemiology, Pathophysiology, and Management of Raised Blood Pressure

Raised blood pressure (BP) is the leading cause of death and disability worldwide, and its particular strong association with stroke is well established. Although systolic BP increases with age in both sexes, raised BP is more prevalent in males in early adulthood, overtaken by females at middle age, consistently across all ethnicities/races. However, there are clear regional differences on when females overtake males. Higher BP among males is observed until the seventh decade of life in high-income countries, compared with almost 3 decades earlier in low- and middle-income countries. Females and males tend to have different cardiovascular disease risk profiles, and many lifestyles also influence BP and cardiovascular disease in a sex-specific manner. Although no hypertension guidelines distinguish between sexes in BP thresholds to define or treat hypertension, observational evidence suggests that in terms of stroke risk, females would benefit from lower BP thresholds to the magnitude of 10 to 20 mm Hg. More randomized evidence is needed to determine if females have greater cardiovascular benefits from lowering BP and whether optimal BP is lower in females. Since 1990, the number of people with hypertension worldwide has doubled, with most of the increase occurring in low- and-middle-income countries where the greatest population growth was also seen. Sub-Saharan Africa, Oceania, and South Asia have the lowest detection, treatment, and control rates. High BP has a more significant effect on the burden of stroke among Black and Asian individuals than Whites, possibly attributable to differences in lifestyle, socioeconomic status, and health system resources. Although pharmacological therapy is recommended differently in local guidelines, recommendations on lifestyle modification are often very similar (salt restriction, increased potassium intake, reducing weight and alcohol, smoking cessation). This overall enhanced understanding of the sex- and ethnic/racial-specific attributes to BP motivates further scientific discovery to develop more effective prevention and treatment strategies to prevent stroke in high-risk populations.

The implications of blood pressure targets from the 2018 European Society of Cardiology hypertension guidelines in Asian patients: a systematic review and meta-analysis

BACKGROUND

The evidence for optimal blood pressure (BP) targets in Asian patients with hypertension is insufficient and controversial. Western guidelines should be used with caution in clinical practice until there is supporting evidence.

OBJECTIVE

Systematically synthesize the evidence on the efficacy of achieving the strict 2018 European Society of Cardiology (ESC) guideline BP targets versus standard BP targets in Asian patients.

DATA SOURCES

We searched PubMed, Web of Science, Scopus, the Cochrane Central Register of controlled trials, and additional databases to retrieve relevant Asian studies.

STUDY SELECTION

Randomized controlled trials (RCTs) and observational studies that reported clinical endpoints, had a minimal follow-up period of one year and included Asian patients older than 18 years with essential hypertension.

DATA EXTRACTION

Two investigators independently conducted the study selection with any discrepancies resolved between team members.

DATA SYNTHESIS

We selected 15 studies for analysis (4 RCTs, 7 observational studies, and 4 post-hoc analyses). The evidence for the strict BP targets in elderly patients was insufficient. In middle-aged patients, the meta-analysis of observational studies revealed a significant reduction in major adverse cardiac events (MACCE) (hazard ratio (HR)=0.78; 95% confidence interval (CI: 0.74-0.81). For studies that reported results for patients of any age, the tight systolic BP-lowering therapy was associated with a decrease in MACCE (HR=0.80; 95% CI: 0.69-0.92), stroke (HR=0.82; 95% CI: 0.71-0.94), but not in cardiac events (HR=0.91; 95% CI: 0.72-1.14, P=.41), all-cause (HR=0.80; 95% CI: 0.57-1.13) and cardiovascular mortality (HR=0.73; 95% CI: 0.40-1.33, P=.30). Similar findings were obtained for the strict diastolic BP targets.

CONCLUSION

Our findings provide evidence for Asian patients that support the efficacy of the strict antihypertensive treatment with BP targets proposed by the 2018 ESC hypertension guidelines for the prevention of cardiovascular events. However, these data were obtained from only observational studies and the results were not confirmed by RCTs, probably due to insufficient power. Therefore, further high-quality RCTs are crucial.

LIMITATIONS

Use of aggregated data, the subgroup and meta-regression analyses are inconclusive, limited to English language, unable to estimate summary measures for some outcomes, publication bias difficult to assess, and unclear that results could be extrapolated.

REGISTRATION

The protocol registered in PROSPERO (CRD42018115570).

CONFLICT OF INTEREST

None.

The HOPE Asia Network activity for "zero" cardiovascular events in Asia: Overview 2020

The impact of hypertension-related cardiovascular disease and target organ damage, and therefore the benefits of blood pressure (BP) control, is greater in Asian than in Western countries. Asia-specific features of hypertension and its effective management are important and active areas of research. The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was formed in 2016 and is now a member of the World Hypertension League. The main goal of the HOPE Asia Network is to improve the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia. Considerable work has already been done on the journey to achieving this goal. We have shown that BP control status in Asia differs between countries, and even between regions within the same country. Several expert panel consensus recommendations and clinical guidance papers are available to support the use of home and ambulatory BP monitoring in the region. In addition, the AsiaBP@Home study prospectively investigated home BP control status across 15 specialist centers using the same validated device and measurement schedule. We have also proposed the concept of systemic hemodynamic atherothrombotic syndrome (SHATS), a vicious cycle of BP variability and vascular disease on cardiovascular events and organ damage, and suggested a SHATS score for risk stratification for clinical practice. This special issue of the journal collates Asia-specific resources and data, contributing to advances in hypertension management and cardiovascular disease prevention in the region.

Managing hypertension in 2018: which guideline to follow?

Hypertension is a global public health issue and a major cause of morbidity and mortality. Its prevalence is increasing in many Asian countries, with a number of countries with blood pressure above the global average. Although the average systolic blood pressure is decreasing worldwide since the 1980s at the rate of about 1 mm Hg systolic blood pressure per decade, it is increasing in low-income and middle-income countries, especially in the East and South Asian population. Of note, the much larger base Asian population results in a considerably larger absolute number of individuals affected. When compared with Western countries, hypertension among Asian populations has unique features in terms of its onset, clustering of associated cardiovascular risk factors, complications and outcomes. Moreover, only a minority of hypertensive individuals are receiving treatment and achieving control. Projected number of deaths related to hypertension dramatically increased in the last 25 years in some Asian regions with a disproportionately high mortality and morbidity from stroke compared with Western countries. The relation between blood pressure and the risk of stroke is stronger in Asia than in Western regions. Although new Guidelines for hypertension diagnosis and management have been recently released from Europe and North America, the unique features of Asian hypertensive patients raise concerns on the clinical applicability of Western Guidelines to Asian populations. To this purpose, we critically reviewed key elements from the most updated Guidelines. We also discussed their core concepts to verify the impact on hypertension prevention and management in Asian countries.

Efficacy of Calcium Channel Blockers on Major Cardiovascular Outcomes for the Treatment of Hypertension in Asian Populations: A Meta-analysis

BACKGROUND

Whether calcium channel blockers exert a greater effect on cardiovascular risk reduction in Asian populations than other antihypertensive agents is unclear. We conducted a meta-analysis of hypertension trials of dihydropyridine calcium channel blockers in Asian populations to clarify this association.

METHODS

EMBASE, MEDLINE, and Cochrane databases were searched (from inception to August 2016) for randomized controlled trials on cardiovascular death, major adverse cardiovascular events, stroke, congestive heart failure, and coronary revascularization in Asian persons with hypertension. We identified 9 trials that reported data specific to Asian populations (N = 29,643). These trials included 1 placebo-controlled trial and 8 active comparator trials; of these, 5 had angiotensin receptor blockers as the active comparator.

RESULTS

One placebo-controlled trial (n = 9711) showed significantly reduced cardiovascular mortality, major adverse cardiovascular events, and stroke with calcium channel blockers. Among 8 active comparator trials (n = 19,932), there were no significant differences in mortality (relative risk [RR], 1.10; 95% confidence interval [CI], 0.72-1.67; I² = 0.0%), major adverse cardiovascular events (RR, 1.02; 95% CI, 0.90-1.15; I² = 0.0%), stroke (RR, 0.97; 95% CI, 0.80-1.17; I² = 0.0%), congestive heart failure (RR, 1.01; 95% CI, 0.51-2.00; I² = 53.7), or coronary revascularization rates (RR, 0.98; 95% CI, 0.76-1.25; I² = 0.0%) in the calcium channel blocker group compared with other antihypertensive agents. When restricting the meta-analysis to angiotensin receptor blocker comparators (n = 10,384), there were no significant differences in cardiovascular outcomes.

CONCLUSIONS

There is no evidence that dihydropyridine calcium channel blockers are superior to other antihypertensive agents in Asian populations for the treatment of hypertension.

Cost-Effectiveness Analysis of Screening for and Managing Identified Hypertension for Cardiovascular Disease Prevention in Vietnam

OBJECTIVE

To inform development of guidelines for hypertension management in Vietnam, we evaluated the cost-effectiveness of different strategies on screening for hypertension in preventing cardiovascular disease (CVD).

METHODS

A decision tree was combined with a Markov model to measure incremental cost-effectiveness of different approaches to hypertension screening. Values used as input parameters for the model were taken from different sources. Various screening intervals (one-off, annually, biannually) and starting ages to screen (35, 45 or 55 years) and coverage of treatment were analysed. We ran both a ten-year and a lifetime horizon. Input parameters for the models were extracted from local and regional data. Probabilistic sensitivity analysis was used to evaluate parameter uncertainty. A threshold of three times GDP per capita was applied.

RESULTS

Cost per quality adjusted life year (QALY) gained varied in different screening scenarios. In a ten-year horizon, the cost-effectiveness of screening for hypertension ranged from cost saving to Int$ 758,695 per QALY gained. For screening of men starting at 55 years, all screening scenarios gave a high probability of being cost-effective. For screening of females starting at 55 years, the probability of favourable cost-effectiveness was 90% with one-off screening. In a lifetime horizon, cost per QALY gained was lower than the threshold of Int$ 15,883 in all screening scenarios among males. Similar results were found in females when starting screening at 55 years. Starting screening in females at 45 years had a high probability of being cost-effective if screening biannually was combined with increasing coverage of treatment by 20% or even if sole biannual screening was considered.

CONCLUSION

From a health economic perspective, integrating screening for hypertension into routine medical examination and related coverage by health insurance could be recommended. Screening for hypertension has a high probability of being cost-effective in preventing CVD. An adequate screening strategy can best be selected based on age, sex and screening interval.

Hypertension phenotypes and incident cardiovascular disease and mortality events in a decade follow-up of a Middle East cohort

OBJECTIVE

To investigate the association of hypertension phenotypes, with the risk of cardiovascular disease (CVD) and mortality.

METHODS

We examined the risk of hypertension phenotypes, that is, isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), systolic-diastolic hypertension (SDH), controlled blood pressure (CBP), and uncontrolled blood pressure (UBP) among 6974 middle-aged and 882 elderly participants. Cox regression analysis was used to estimate the hazard ratio for hypertension phenotypes, considering those with normotension as the reference.

RESULTS

During more than 10 years of follow-up, in the middle-aged group, 490 CVD events and 152 deaths occurred; corresponding rates for the elderly group were 194 and 183, respectively. In middle-aged patients, ISH, SDH, and UBP increased the risk of CVD, whereas UBP increased the risk of mortality due to CVD and any cause (hazard ratio 5.67 and 2.95, respectively) and IDH increased only the risk of total mortality in the middle-aged group (hazard ratio 2.01; all P values <0.05). In elderly patients, ISH, SDH, and UBP significantly increased the risks of CVD. IDH (hazard ratio 3.20 and 2.01), SDH (hazard ratio 3.80 and 3.23) and CBP (hazard ratio 2.86 and 1.87) increased the risks of CVD and all-cause mortality in this group, respectively (all P values <0.05).

CONCLUSION

In both middle-aged and elderly population, ISH, SDH, and UBP increase the risk of CVD. Controlling of BP to less than 140/90 mmHg decreases the risk of mortality events among the middle-aged population; however, it is not suitable for the elderly as it was associated with higher risk of mortality.

LCZ696, a First-in-Class Angiotensin Receptor-Neprilysin Inhibitor: The First Clinical Experience in Patients With Severe Hypertension

The safety of LCZ696, a novel angiotensin receptor-neprilysin inhibitor, was evaluated for the first time in patients with severe hypertension in this 8-week, multicenter, open-label study. Thirty-five Japanese patients with either office systolic blood pressure (SBP) ≥180 mm Hg or diastolic blood pressure (DBP) ≥110 mm Hg received LCZ696 200 mg. If blood pressure was uncontrolled, the LCZ696 dose was increased to 400 mg after 2 weeks (if there were no safety concerns; n=32), followed by an optional addition of another antihypertensive drug (except angiotensin receptor blocker and angiotensin-converting enzyme inhibitor) after 4 weeks (n=21). Reductions in office SBP/DBP (baseline, 173.4 mm Hg/112.4 mm Hg) and pulse pressure (baseline, 61.0 mm Hg) at week 8 were 35.3/22.1 mm Hg and 13.2 mm Hg, respectively. The overall incidence of adverse events was 48.6% with no reports of dizziness, hypotension, or angioedema. The LCZ696-based regimen was generally well-tolerated and could present a treatment option for severe hypertension in Asian patients especially in reducing SBP and pulse pressure.

Prevention, management, and rehabilitation of stroke in low- and middle-income countries

Although stroke incidence in high-income countries (HICs) decreased over the past four decades, it increased dramatically in low- and middle-income countries (LMICs). In this review, we describe the current status of primary prevention, treatment, and management of acute stroke and secondary prevention of and rehabilitation after stroke in LMICs. Although surveillance, screening, and accurate diagnosis are important for stroke prevention, LMICs face challenges in these areas due to lack of resources, awareness, and technical capacity. Maintaining a healthy lifestyle, such as no tobacco use, healthful diet, and physical activity are important strategies for both primary and secondary prevention of stroke. Controlling high blood pressure is also critically important in the general population and in the acute stage of hemorrhagic stroke. Additional primary prevention strategies include community-based education programs, polypill, prevention and management of atrial fibrillation, and digital health technology. For treatment of stroke during the acute stage, specific surgical procedures and medications are recommended, and inpatient stroke care units have been proven to provide high quality care. Patients with a chronic condition like stroke may require lifelong pharmaceutical treatment, lifestyle maintenance and self-management skills, and caregiver and family support, in order to achieve optimal health outcomes. Rehabilitation improves physical, speech, and cognitive functioning of disabled stroke patients. It is expected that home- or community-based services and tele-rehabilitation may hold special promise for stroke patients in LMICs.

Management of hypertension: Current state of the art and challenges

Hypertension is a major modifiable cardiovascular risk factor. Hypertension is also recognized as the most important risk factor for global disease burden. It is well established that a sustained reduction in blood pressure by drugs reduces the incidence of cardiovascular morbidity and mortality. In recent years, studies and new guidelines published for the management of hypertension. Awareness, treatment and control of hypertension are very poor, despite the new guidelines. We highlighted the management of hypertension in the light of current literature.

The 2014 hypertension guidelines: implications for patients and practitioners in Asia

Hypertension is a global public health issue and a major cause of morbidity and mortality. Because of population growth and ageing, the number of people with uncontrolled hypertension rose from 600 million in 1980 to nearly 1 billion in 2008. Furthermore, the number of adults with hypertension in 2025 has also been predicted to increase by about 60% to a total of 1.56 billion. The prevalence of hypertension in most Asian countries has increased over the last 30 years and more dramatically in the last 10 years. Several factors contributed to such changes in Asia, but acculturation to Western lifestyle, modernisation and urbanisation are considered key contributing factors. There are some unique features in regards to cardiovascular risk in Asia. Specifically, Asian regions have disproportionately higher mortality and morbidity from stroke compared with Western countries. Furthermore, the relationship between blood pressure level and risk of stroke is stronger in Asia than in Western regions. Although evidence-based and qualified guidelines for hypertension diagnosis and management have been released recently from Europe and North America, the unique features of Asian patients with hypertension raise concerns in regards to the real clinical applicability of Western guidelines in Asian populations. Specifically, it is not yet clear to what extent the new blood pressure target proposed by Western guidelines for high risk and elderly hypertensive individuals apply to Asian populations.

Rapid emergence of atherosclerosis in Asia: a systematic review of coronary atherosclerotic heart disease epidemiology and implications for prevention and control strategies

PURPOSE OF REVIEW

There is a global epidemic of coronary heart disease (CHD) caused by atherosclerosis. We discussed its emergence, underlying reasons, and implications for prevention and control strategies in Asia.

RECENT FINDINGS

Most countries in Asia are experiencing the challenges from CHD, with the mortality rate varying from 103 to 366 per 100 000 adult populations, reported by recently published studies. Raised population cholesterol levels played a pivotal role. Men, older adults, and those with dyslipidemia, hypertension, and diabetes were high-risk individuals. During the past decade, there was a marked rising trend of atherosclerosis-related burden particularly in Eastern Asia where an alarming increase of 117.2 and 115.3% of total deaths and disability adjusted life-years, respectively, were observed. The rise of CHD could be attributed to unhealthy lifestyles, clinical-risk factors, psychosocial factors, and public health transitions. Ageing, urbanization, and increase in prosperity may serve as underlying key drivers.

SUMMARY

The burden of CHD is substantial, whereas contributors are multifactorial. This grand challenge should be a top priority for injecting healthcare resources. The formulation of public health measures will need to adopt an integrated and life-course approach, based on the need and risks of different population subgroups in Asia.

Cardiovascular mortality among a cohort of hypertensive and normotensives in Rio de Janeiro - Brazil - 1991-2009

Background

Although there is strong evidence of the benefits of antihypertensive treatment, the high prevalence of this important cardiovascular risk factor and its complications, as well as the low control rates of hypertension observed in many studies justify the investigation of these relationships in population studies. The objective was to investigate the ratio of cardiovascular disease mortality between hypertensives (non-treated, controlled and uncontrolled) and non-hypertensives in a cohort of a population sample of adults living in Ilha do Governador, Rio de Janeiro state, Brazil, who were classified in a survey conducted in 1991 and 1992 and whose death certificates were sought 19 years later.

Methods

A cohort study was performed on probabilistic linkage between data from an epidemiological study of hypertension performed in Ilha do Governador, in Rio de Janeiro, Brazil (1991 to 1992) and data from the Mortality Information System of Rio de Janeiro (1991 to 2009). The survey aimed to estimate the prevalence of hypertension and other cardiovascular risk factors in 1,270 adults aged 20 years or older selected through a probabilistic sampling of households at three economic levels (low, middle and high income). We performed a probabilistic record linkage of these databases and estimated the risk of cardiovascular death using Kaplan-Meier method to plot survival curves and Cox proportional hazards models comparing hypertensive subjects all together, and by hypertension subgroups: untreated, controlled, and uncontrolled hypertensives with non-hypertensive ones.

Results

A total of 170 deaths occurred, of which 31.2 % attributed to cardiovascular causes. The hazard ratio for cardiovascular death was 6.1 times higher (95 % CI 2.7 – 13.7) in uncontrolled hypertensive patients relative to non-hypertensive patients. The hazard ratios for untreated hypertensive and controlled hypertensive patients were 2.7 times (95 % CI 1.1 – 6.3) and 2.1 times (95 % CI 0.38 – 11.5) higher than for normotensive patients, respectively.

Conclusion

The present study demonstrated a higher cardiovascular death risk among hypertensive than among non-hypertensive ones that is not associated uniquely to treatment, because uncontrolled hypertensives demonstrated a greater risk than untreated ones. Although the subgroups of hypertensive individuals were susceptible to changes in their classification over the 19 years of the study, the baseline classification was consistent with a worse prognosis in these individuals.

Key Points of the Japanese Society of Hypertension Guidelines for the Management of Hypertension in 2014

The Japanese Society of Hypertension (JSH) published the new JSH guidelines for the management of hypertension in 2014, which is the revision of the JSH guidelines of 2009. The primary objective of the guideline is to provide physicians the standard treatment strategy of hypertension to prevent the hypertension-related target organ damage and cardiovascular events. The management of hypertension should be performed in hypertensive patients with a blood pressure of ≥140/90 mm Hg. As Asians have a higher prevalence of stroke than of coronary artery disease and stroke is more steeply associated with the level of blood pressure, the target blood pressure should be lower than 130/80 mm Hg for high-risk patients such as those with diabetes or chronic kidney disease. Because of the increasing prevalence of obesity and the related metabolic syndrome, more salt intake and higher salt sensitivity in the population, lifestyle modifications are necessary in hypertensive patients and subjects with high normal blood pressure. This guideline provides evidence-based recommendations for the management of patients with hypertension with the characteristics of our society.

Practical clinical trials in psychopharmacology: a systematic review

Practical clinical trials (PCTs) are randomized experiments under typical practice conditions with the aim of testing the "real-life" benefits and risks of therapeutic interventions. Influential PCTs have been conducted in cardiology, oncology, and internal medicine. Psychotropic medications are widely and increasingly used in medical practice. This review examines recent progress in conducting PCTs in psychopharmacology. The January 2000 to October 2014 MEDLINE, Scopus, and ClinicalTrials.gov databases were searched for peer-reviewed publications of PCTs with at least 100 subjects per treatment arm. Most PCTs in psychiatry evaluated mental health services or psychosocial interventions rather than specific pharmacotherapies. Of 157 PCTs in psychiatry, 30 (19%) were in psychopharmacology, with a median of 2 publications per year and no increase during the period of observation. Sample size ranged from 200 to 18,154; only 11 studies randomized 500 patients or more. Psychopharmacology PCTs were equally likely to be funded by industry as by public agencies. There were 10 PCTs of antidepressants, for a total of 4206 patients (in comparison with at least 46 PCTs of antihypertensive medications, for a total of 208,014 patients). Some psychopharmacology PCTs used suicidal behavior, treatment discontinuation, or mortality as primary outcome and produced effectiveness and safety data that have influenced both practice guidelines and regulatory decisions. Practical clinical trials can constitute an important source of information for clinicians, patients, regulators, and policy makers but have been relatively underused in psychopharmacology. Electronic medical records and integrated practice research networks offer promising platforms for a more efficient conduct of PCTs.