Should blood pressure goal be individualized in hypertensive patients?

The Patient-Provider Gap: A Cross-sectional Survey to Understand Barriers and Motivating Factors for Home Blood Pressure Monitoring in a CKD Cohort

Background

Blood pressure (BP) management can decrease morbidity and mortality in chronic kidney disease (CKD) patients. Evidence-based hypertension guidelines endorse home BP monitoring (HBPM), and the growing use of virtual health has highlighted the need for HBPM. A comprehensive understanding of HBPM adoption in our province is lacking.

Objective

To identify the baseline practices, perspectives, barriers, and enablers in both providers and patients in our kidney care clinics regarding HBPM. Ultimately, this will inform the development of a provincial intervention that empowers providers to both increase patient understanding and equip them for accurate and reliable home BP measurement.

Design

Cross-sectional, descriptive study using online survey methodology.

Setting

Kidney care clinic network in the province of British Columbia, Canada.

Patients or Sample or Participants

Kidney care clinic staff and patients who perform HBPM.

Methods

Data were collected using semi-structured online surveys, one for staff and one for patients and/or caregivers. These surveys were developed by an interdisciplinary working group that included patient partners and addressed some key components of the implementation of an HBPM program (including perceived barriers to uptake, education, and adoption of best practices).

Results

In all, 46 patients and 43 staff responded to the survey from 16 kidney care clinics. Of the patients 53% were women, and the most common age range was 60 to 69 years (25%); 93% of the staff respondents were women and 63% were nurses. We identified numerous areas of discordance between providers and patients and the need for improvement from the perspective of implementing best practices from hypertension guidelines, both in staff teaching and patient usage of HBPM. Blood pressure targets were not known to 18% of patients and 39% of patients had received a BP target from their kidney care clinic team; 89% of patients had not had their upper arm circumference measured for cuff size. Furthermore, 54% of patients knew what to do when their BP is off-target. All recognized the benefits of HBPM, providers were more likely to perceive anxiety as a barrier relative to patients, and patients were more likely to report expense as a barrier than providers.

Limitations

This study includes only a single provincial health care system limiting generalizability to other jurisdictions and sampled a small subset of patients and providers.

Conclusions

The systematic evaluation of education, understanding, implementation of best practices, and barriers and motivating factors for HBPM from both patient and clinician perspectives is an important step in designing strategies to improve the use of HBPM. Given differences in staff and patient perspectives, targeted interventions based on these responses may lead to improved use of HBPM, and ultimately enhance hypertension self-management and BP control in our CKD patients.

Short-chain fatty acids combined with intronic DNA methylation of HIF3A: Potential predictors for diabetic cardiomyopathy

BACKGROUND

Hyperglycemia can induce the heart to enter an oxygen-restricted environment, which results in diabetic cardiomyopathy (DCM). Microbiota-derived short-chain fatty acids (SCFAs) affect O₂ consumption and play crucial roles in modulating metabolic and cardiovascular health. The epigenetic regulation of the hypoxia-inducible factor 3A (HIF3A) gene is implicated in oxidative metabolism in the pathogenesis of diabetes. Identifying the associations between plasma SCFA levels and intronic DNA methylation of HIF3A may reveal useful predictors or provide insights into the disease processes of DCM.

METHODS

In this cross-sectional study, we analyzed plasma SCFA levels, HIF3A expression, and CpG methylation of HIF3A intron 1 in peripheral blood from patients with type 2 diabetes presenting with (n = 92) and without (n = 105) cardiomyopathy.

RESULTS

Plasma butyric acid levels and HIF3A mRNA expression in peripheral blood were decreased in DCM patients, whereas 3 CpGs in HIF3A intron 1 (CpG 6, CpG 7 and CpG 11) were highly methylated in DCM patients. Interestingly, butyric acid levels positively correlated with HIF3A levels, while a negative association was identified between butyric acid levels and the methylation rates of HIF3A intron 1 at CpG 6. Butyric acid levels also correlated with several clinical/echocardiographic factors in DCM patients. Additionally, the combination of plasma butyric acid levels and HIF3A intron 1 methylation at CpG 6 discriminated DCM patients from type2 diabetes mellitus (T2DM) patients.

CONCLUSIONS

The novel associations between plasma butyric acid levels and HIF3A intron 1 methylation at CpG 6 may highlight an underlying mechanism by which the "microbial-myocardial" axis and host-microbe interactions may participate in the pathogenesis of DCM.

Low admission blood pressure as a marker of poor 1-year survival in patients with revascularized critical limb ischemia

OBJECTIVE

To contrast the association between blood pressure (BP) level and antihypertensive medications at hospital admission with 1-year mortality in patients undergoing revascularization for critical limb ischemia (CLI).

METHODS

From November 2013 to May 2019, 315 consecutive patients were retrospectively included. A median of seven (IQR 3-13) separate readings were recorded for each patient before revascularization procedure and the average represented patient's mean BP. BP-lowering medications, clinical and biological parameters were recorded at baseline. The main outcome was total 1-year mortality.

RESULTS

The cohort included 172 men (55%) and 143 women (45%), with a mean age of 77.9 ± 11.9 years. Treated hypertension was present in 245 (78%) patients; 288 (91%) patients had BP-lowering drug prescriptions (2.1 ± 1.3 medications at baseline). Mean SBP, DBP, mean BP (MBP) and pulse pressure (PP) were 132 ± 18, 70 ± 8, 90 ± 10 and 62 ± 16mmHg. During 1-year follow-up, 80 (25.4%) patients died. In single-pressure multivariate analysis, SBP (hazard ratio 0.97; 95% CI 0.96-0.99; P = 0.005), MBP (hazard ratio 0.96; 95% CI 0.92-0.99; P = 0.01), PP (hazard ratio 0.97; 95% CI 0.95-0.99; P = 0.009), but not DBP, were inversely correlated with 1-year mortality, independently of age, coronary heart disease, left ventricular ejection fraction, brain natriuretic peptide, serum albumin, institutionalized status and antihypertensive drugs. Association between SBP, MBP and PP with 1-year mortality had a quite linear reverse pattern.

CONCLUSION

Among patients undergoing revascularization for CLI, there is an inverse correlation between admission SBP, MBP and PP with 1-year mortality. BP may represent a modifiable therapeutic target to prevent poor outcome in CLI patients.

The new US and European guidelines in hypertension: A multi-dimensional analysis

The Systolic Blood Pressure Intervention Trial (SPRINT) compared the clinical outcomes between target systolic blood pressure (SBP) levels between 140 and 120 mmHg or lower. Both,the 2017 ACC/AHA and the 2018 ESC/ESH guidelines in hypertension are derived from the SPRINT trial and advise initiation and/or intensification of treatment at lower blood pressure thresholds. The ACC/AHA guidance supersedes the 2014 Eight Joint National Committee guideline (JNC-8) which advised initiation of treatment when the BP was 140/90 mmHg or higher; in adults 60 years or over, the target was 150/90 mmHg. Compared to JNC-8, the new guidelines lower the SBP target by 10 mmHg in patients under age of 60 years, and by 20 mmHg in the elderly. We performed a qualitative multi-dimensional analysis in order to answer two key questions: will the new guidelines deliver the stated benefits? and, will translation to the clinic be simple, risk-free, and affordable? A major investment by national healthcare administrations will be necessary for the initiation and support of this program but this decision can only be justified by a valid expectation of clinical benefit. At this time, a definitive answer is not available and a "wait and see" attitude appears appropriate and reasonable. In the interim, efforts are best directed to the immediate problem of untreated hypertension worldwide.

Blood pressure targets for hypertension in patients with type 2 diabetes

BACKGROUND

Clinical guidelines vary in determining optimal blood pressure targets in adults with diabetes mellitus.

METHODS

We systematically searched PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov in March 2018; conducted random effects frequentist meta-analyses of direct aggregate data; and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

From eligible 14 meta-analyses and 95 publications of randomized controlled trials (RCT), only 6 RCTs directly compared lower versus higher blood pressure targets; remaining RCTs aimed at comparative effectiveness of hypotensive drugs. In adults with diabetes mellitus and elevated systolic blood pressure (SBP), direct evidence (2 RCTs) suggests that intensive target SBP <120-140 mmHg decreases the risk of diabetes-related mortality [relative risk (RR) =0.68; 95% confidence interval (CI), 0.50-0.92], fatal (RR =0.41; 95% CI, 0.20-0.84) or nonfatal stroke (RR =0.60; 95% CI, 0.43-0.83), prevalence of left ventricular hypertrophy and electrocardiogram (ECG) abnormalities, macroalbuminuria, and non-spine bone fractures, with no differences in all-cause or cardiovascular mortality or falls. In adults with diabetes mellitus and elevated diastolic blood pressure (DBP) ≥90 mmHg, direct evidence (2 RCTs) suggests that intensive DBP target ≤80 versus 80-90 mmHg decreases the risk of major cardiovascular events. Published meta-analyses of aggregate data suggested a significant association between lower baseline and attained blood pressure and increased cardiovascular mortality.

CONCLUSIONS

We concluded that in adults with diabetes mellitus and arterial hypertension, in order to reduce the risk of stroke, clinicians should target blood pressure at 120-130/80 mmHg, with close monitoring for all drug-related harms.

[Blood pressure targets : The lower the better does not suit all]

BACKGROUND

The systolic blood pressure intervention trial (SPRINT) published in 2015 has opened up new discussions on whether a lower blood pressure target as recommended by the current guidelines would be better for some patient groups.

OBJECTIVES

To review patient groups in which lower blood pressure targets would not be better.

MATERIALS AND METHODS

The results of SPRINT, its post-hoc and subgroup analyses, other studies and newer studies, as well as metaanalyses on the topic of blood pressure targets are reviewed and discussed. Studies with patients excluded from the SPRINT study were also analysed. The current international guidelines and recommendations of the Deutsche Hochdruckliga e. V. DHL® are included.

RESULTS

Blood pressure monitoring methods differed considerably in the previously published studies. The low blood pressure value in SPRINT was mainly achieved due to the unusual method of blood pressure monitoring used and, as such, cannot be compared with blood pressure values in other studies. Based on current evidence, "the lower the better" should not be recommended in the following patient groups: older patients, in particular infirm older patients, patients with diabetes, patients without coronary heart disease or with low cardiovascular risk.

CONCLUSIONS

When determining a blood pressure target, the method of blood pressure monitoring should be defined. A lower blood pressure target has been shown to be better in some well defined patient groups. However, adverse events due to antihypertensive medications should always be taken into account. Given the multiple exclusion criteria in trials and the results of many studies, "new" lower blood pressure targets could not be recommended in a large population of patients.