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Wang N, Harris K, Woodward M, Harrap S, Mancia G, Poulter N, Chalmers J, Rodgers A. Clinical Utility of Short-Term Blood Pressure Measures to Inform Long-Term Blood Pressure Management. Hypertension 2023; 80:608-617. [PMID: 36468403 DOI: 10.1161/hypertensionaha.122.20458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Decisions about hypertension management are substantially influenced by blood pressure (BP) levels measured before and soon after starting BP lowering drugs. We aimed to assess the utility of short-term BP changes in individuals in terms of long-term treatment response. METHODS Post hoc analyses of 2 randomized trials with 4-to-6 weeks active run-in for all participants, followed by randomization to active BP lowering treatment (combination perindopril±indapamide) or placebo. We categorized individuals by degree of systolic BP (SBP) change during active run-in treatment and assessed associations with subsequent postrandomization placebo-corrected BP reduction, cardiovascular events, and tolerability. We included individuals with baseline BP ≥140/90 mm Hg from the PROGRESS trial (Perindopril Protection Against Recurrent Stroke Study; 4275 individuals with cerebrovascular disease) and ADVANCE trial (The Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation; 6610 individuals with diabetes). RESULTS During the active run-in period, the proportion of participants with initial SBP changes in 4 categories (SBP increase, 0-9.9 mm Hg decrease, 10-19.9 mm Hg decrease, and ≥20 mm Hg decrease) were 17%, 27%, 28%, and 28% in PROGRESS and 21%, 22%, 24%, and 33% in ADVANCE. Randomization to active therapy achieved similar placebo-corrected long-term BP reductions across the 4 initial SBP change groups in both trials (P-values for heterogeneity >0.1). There was no significant difference in achieving BP <140/90 mm Hg at follow-up, major cardiovascular events, nor treatment tolerability according to the SBP change during active run-in period (all P-values >0.1). CONCLUSIONS An individual's apparent BP change immediately after commencing therapy has limited clinical utility. Therefore, more emphasis should be given to use of evidence-based regimens and measures over the long-term to ensure sustained BP control. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT00145925.
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Affiliation(s)
- Nelson Wang
- The George Institute for Global Health UNSW, Sydney, Australia (N.W., K.H., M.W., J.C., A.R.).,Royal Prince Alfred Hospital, Sydney, Australia (N.W.).,Sydney Medical School, University of Sydney, Australia (N.W.)
| | - Katie Harris
- The George Institute for Global Health UNSW, Sydney, Australia (N.W., K.H., M.W., J.C., A.R.)
| | - Mark Woodward
- The George Institute for Global Health UNSW, Sydney, Australia (N.W., K.H., M.W., J.C., A.R.)
| | - Stephen Harrap
- Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (S.H.)
| | | | - Neil Poulter
- School of Public Health, Imperial College London, United Kingdom (N.P.)
| | - John Chalmers
- The George Institute for Global Health UNSW, Sydney, Australia (N.W., K.H., M.W., J.C., A.R.)
| | - Anthony Rodgers
- The George Institute for Global Health UNSW, Sydney, Australia (N.W., K.H., M.W., J.C., A.R.)
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Wang N, Salam A, Webster R, de Silva A, Guggilla R, Stepien S, Mysore J, Billot L, Jan S, Maulik PK, Naik N, Selak V, Thom S, Prabhakaran D, Patel A, Rodgers A. Association of Low-Dose Triple Combination Therapy With Therapeutic Inertia and Prescribing Patterns in Patients With Hypertension: A Secondary Analysis of the TRIUMPH Trial. JAMA Cardiol 2021; 5:1219-1226. [PMID: 32717045 DOI: 10.1001/jamacardio.2020.2739] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Fixed-dose combination (FDC) therapies are being increasingly recommended for initial or early management of patients with hypertension, as they reduce treatment complexity and potentially reduce therapeutic inertia. Objective To investigate the association of antihypertensive triple drug FDC therapy with therapeutic inertia and prescribing patterns compared with usual care. Design, Setting, and Participants A post hoc analysis of the Triple Pill vs Usual Care Management for Patients With Mild-to-Moderate Hypertension (TRIUMPH) study, a randomized clinical trial of 700 patients with hypertension, was conducted. Patients were enrolled from 11 urban hospital clinics in Sri Lanka from February 2016 to May 2017; follow-up ended in October 2017. Data were analyzed from September to November 2019. Interventions Once-daily FDC antihypertensive pill (telmisartan, 20 mg; amlodipine, 2.5 mg; and chlorthalidone, 12.5 mg) or usual care. Main Outcomes and Measures Therapeutic inertia, defined as not intensifying therapy in those with blood pressure (BP) above target, was assessed at baseline and during follow-up visits. Prescribing patterns were characterized by BP-lowering drug class and treatment regimen potency. Predictors of therapeutic inertia were assessed with binomial logistic regression. Results Of the 700 included patients, 403 (57.6%) were female, and the mean (SD) age was 56 (11) years. Among patients who did not reach the BP target, therapeutic inertia was more common in the triple pill group compared with the usual care group at the week 6 visit (92 of 106 [86.8%] vs 124 of 194 [63.9%]; P < .001) and week 12 visit (81 of 90 [90%] vs 116 of 179 [64.8%]; P < .001). At the end of the study, 221 of 318 patients in the triple pill group (69.5%) and 182 of 329 patients in the usual care group (55.3%) reached BP targets. Among those who received treatment intensification, the increase in estimated regimen potency was greater in the triple pill group compared with the usual care group at baseline (predicted mean [SD] increase in regimen potency: triple pill, 15 [6] mm Hg; usual care, 10 [5] mm Hg; P < .001), whereas there were no significant differences at the week 6 or at week 12 visit. Clinic systolic BP level was the only consistent predictor of treatment intensification during follow-up. During follow-up, there were 23 vs 54 unique treatment regimens per 100 treated patients in the triple pill vs usual care groups, respectively (P < .001). Conclusions and Relevance Triple pill FDC therapy was associated with greater rates of therapeutic inertia compared with usual care. Despite this, triple pill FDC therapy substantially simplified prescribing patterns and improved 6-month BP control rates compared with usual care. Further improvements in hypertension control could be achieved by addressing therapeutic inertia among the minority of patients who do not achieve BP control after initial FDC therapy. Trial Registration ANZCTR Identifier: ACTRN12612001120864.
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Affiliation(s)
- Nelson Wang
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Abdul Salam
- The George Institute for Global Health, New Delhi, India
| | - Ruth Webster
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Rama Guggilla
- Division of Dentistry, Division of Medical Education in English, Department of Population Medicine and Civilization Diseases Prevention, Faculty of Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Sandrine Stepien
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Jayanthi Mysore
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | | | - Nitish Naik
- All India Institute of Medical Sciences, New Delhi, India
| | - Vanessa Selak
- Department of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Simon Thom
- Department of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control and Public Health Foundation, New Delhi, India
| | - Anushka Patel
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
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Yuguero O, Marsal JR, Esquerda M, Soler-González J. Occupational burnout and empathy influence blood pressure control in primary care physicians. BMC FAMILY PRACTICE 2017; 18:63. [PMID: 28499346 PMCID: PMC5429573 DOI: 10.1186/s12875-017-0634-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 05/01/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Good physician-patient communication can favor the adoption of healthy lifestyle habits, which is essential in high blood pressure (BP) management. More empathic physicians tend to have lower burnout and better communication skills. We analyzed the association between burnout and empathy among primary care physicians and nurses and investigated the influence on BP control performance. METHODS Descriptive study conducted in 2014 investigating burnout and empathy levels in 267 primary care physicians and nurses and BP control data for 301,657 patients under their care. We administered the Maslach Burnout Inventory and the Jefferson Scale of Physician Empathy and defined good BP control as a systolic BP <130 mmHg. RESULTS Low burnout and high empathy were observed in 58.8% and 33.7% of practitioners, respectively. Burnout and empathy were significantly negatively associated (p < 0.009). Practitioners with high empathy and low burnout had significantly better BP control and performance than those with low empathy and high burnout (p < 0.05). CONCLUSIONS Low burnout and high empathy were significantly associated with improved BP control and performance, possibly in relation to better physician/nurse-patient communication.
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Affiliation(s)
- Oriol Yuguero
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain. .,Regió Sanitària de Lleida. Institut Català de la Salut, Lleida, Spain.
| | - Josep Ramon Marsal
- Unitat de Suport a la Recerca Lleida. Institut Universitari d'Investigació en Atenció Primària Jordi Gol, Barcelona, Spain
| | | | - Jorge Soler-González
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Regió Sanitària de Lleida. Institut Català de la Salut, Lleida, Spain
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Práctica clínica en el manejo de la hipertensión y la diabetes en Atención Primaria: estudio ATENCION. Semergen 2017; 43:196-206. [DOI: 10.1016/j.semerg.2016.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/09/2016] [Accepted: 04/20/2016] [Indexed: 11/22/2022]
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Estudio PATHWAY-2. La visión del médico de familia en el abordaje de la hipertensión arterial resistente. HIPERTENSION Y RIESGO VASCULAR 2016; 33:145-149. [DOI: 10.1016/j.hipert.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/02/2016] [Accepted: 06/06/2016] [Indexed: 11/23/2022]
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[Therapeutic inertia in the management of type 2 diabetic patients in Primary Health Care]. Semergen 2015; 42:152-7. [PMID: 25910605 DOI: 10.1016/j.semerg.2015.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 02/16/2015] [Accepted: 02/21/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess therapeutic inertia (TI) in the management of type 2 diabetic patients (DM2), as regards glycemic and lipid control. MATERIALS AND METHODS Two groups of patients were studied. Group 1: All the patients were older than 14 years, diagnosed with DM2 up to 28th February 2013, and their last determination of HbA1c was ≥ 8.5%. Group 2: All patients, under 60 years old, diagnosed with DM2 between the 1st January 2011 and the 31st December 2012, with no chronic complications and their last determination of HbA1c was ≥ 6.5%. RESULTS Group 1: 253 patients were included (13% of DM2 diagnosed). TI was 43% for DM2, 83% for LDL cholesterol, and 80% for triglycerides. TI was lower (P=.037) in patients with HbA1c ≥ 10%. There was no difference in TI as regards the management of lipid profile depending on the HbA1c levels. Group 2: All DM2 patients (n=53) who met inclusion criteria were assessed (2.7% of DM2 diagnosed). Percentage of visits of those patients that had TI: 55% for DM2, 63% for LDL cholesterol and 64% for triglycerides. A more intense therapy was observed in patients with HbA1c>7.5% in 3 of the 5 visits made. CONCLUSIONS TI in both groups was high and there is a lack of recording the reasons for this. It is important to improve the attitude of the professionals who care for the diabetic population.
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Díaz Rodríguez A, Murga N, Camafort-Babkowski M, López Peral JC, Ruiz E, Ruiz-Baena J, Valdivielso P. Therapeutic inertia in hypercholesterolaemia is associated with ischaemic events in primary care patients. A case-control study. Int J Clin Pract 2014; 68:1001-9. [PMID: 24667004 DOI: 10.1111/ijcp.12419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The frequency of therapeutic inertia (TI) is very high in the management of vascular risk factors, although its impact on the incidence of ischaemic events is not well-established. Our aim was to investigate the relationship between TI in the treatment of hypercholesterolaemia and the appearance of ischaemic events. METHODS An observational, multicentre, case-control study was conducted in 70 primary care centres in Spain. Case subjects (n = 235) were high-risk hypercholesterolaemic patients (both genders, ≥ 18 years) who had had a first event in the 12 months prior to recruitment. They were matched with 235 controls (by vascular risk, age and gender). The observation period was 18 months prior to the onset of a first event (cases) or to date of recruitment (control subjects). RESULTS The TI in the basal visit (an average of 7.8 months before the event) was slightly higher in cases than in controls (39.7% vs. 34.8%, NS). However, the accumulated TI was similar in both groups (70.7% for cases and 73.95% for controls, NS). The multivariate analysis, taking ischaemic events as the dependent variable, showed that the TI at baseline visit was significantly associated with the development of the event [OR 2.18 (95% CI 1.04-4.51), p < 0.05]. Other variables also associated with the ischaemic event were a family history of premature vascular disease [OR 3.38 (95% CI 1.35-8.49), p < 0.05] and uncontrolled hypertension [OR 2.35 (95% CI 1.02-5.43), p < 0.05]. CONCLUSION The TI in high-risk hypercholesterolaemic patients in primary prevention in Spanish primary care centres doubled the risk of an ischaemic event in the short term.
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Evolution of therapy inertia in primary care setting in Spain during 2002–2010. J Hypertens 2014; 32:1138-45; discussion 1145. [DOI: 10.1097/hjh.0000000000000118] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Cinza-Sanjurjo S, Alonso-Moreno FJ, Prieto-Díaz MÁ, Divisón-Garrote JA, Rodríguez-Roca GC, Llisterri-Caro JL. [Resistant arterial hypertension in Primary Care patients in Spain. PRESCAP Study 2010]. Semergen 2014; 41:123-30. [PMID: 24768029 DOI: 10.1016/j.semerg.2014.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 02/15/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the prevalence and clinical and epidemiological characteristics of Primary Care patients with resistant hypertension (RHT) in Spain. PATIENTS AND METHODS A cross-sectional multicenter study was conducted on hypertensive patients aged 18 or over and seen in a Primary Care clinic. RHT was considered as the presence of uncontrolled blood pressure in patients treated with at least 3 drugs, one of which is a diuretic. RESULTS Of the 12,961 hypertensive patients in the PRESCAP 2010 study, 962 (7.4%) fulfilled criteria for RHT, of whom 51% were women, and with a mean age (SD) 68.8 [11.4] years. Patients with RHT were older (68.80 [10.69] years vs. 66.06 [11.44] years, P<.001), had a higher prevalence of obesity (55.2 vs. 38.6%, P<.001), a higher waist circumference (103.90 [13.89] vs. 99.32 [13.69] cm, P<.001), and a higher prevalence of DM (48.3 vs. 29.5%, P<.001). The prevalence of target organ damage (73.0 vs. 61.4%, P<.001) and cardiovascular disease (46.7 vs. 26.8%, P<.001) were higher in patients with resistant hypertension. The multivariate analysis showed that the variables associated with resistant hypertension were the presence of cardiovascular disease, diabetes mellitus, sedentary life style, microalbuminuria, body mass index, duration of AHT, and triglycerides. CONCLUSIONS The prevalence of RHT in Primary Care patients is related to inappropriate lifestyles, the presence of target organ damage, and cardiovascular disease.
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Affiliation(s)
- S Cinza-Sanjurjo
- Centro de Salud de Porto do Son, Porto do Son, A Coruña, España.
| | | | | | | | - G C Rodríguez-Roca
- Centro de Salud Puebla de Montalbán, La Puebla de Montalbán, Toledo, España
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Barquilla García A, Llisterri Caro JL, Prieto Díaz MA, Alonso Moreno FJ, García Matarín L, Galgo Nafría A, Mediavilla Bravo JJ. [Blood pressure control in a population of hypertensive diabetic patients treated in primary care: PRESCAP-Diabetes Study 2010]. Semergen 2014; 41:13-23. [PMID: 24703582 DOI: 10.1016/j.semerg.2014.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/12/2014] [Accepted: 02/12/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To determine the level of blood pressure (BP) control in hypertensive diabetic patients treated in primary care and to determine the factors associated with poor control. MATERIAL AND METHODS A cross-sectional, multicentre study that enrolled hypertensive diabetics recruited by consecutive sampling by family doctors in Spain in June 2010. A mean BP of less than 140/90mmHg was considered as good control of arterial hypertension. The percentages of patients with<130/80mmHg PA, 140/80mmHg, and 140/85mmHg, respectively, were also determined. Sociodemographic, clinical, cardiovascular risk factors, and pharmacological treatments were recorded. RESULTS A total of 3,993 patients were enrolled (50.1% female) with a mean age (standard deviation) of 68.2 (10.2) years, of whom 73.9% received combination therapy. The figures showed good control of both blood pressure values (<140/90mmHg) in 56.4% (95% CI: 54.3 to 58.4) of the cases, with 58.5% (95% CI: 57.0-60.0) only in systolic BP, and 84.6% (95% CI, 83.2 to 85.8) only in diastolic BP. The variables with strongest association with poor control were the presence of albuminuria, elevated total cholesterol, physical inactivity, and not taking the medication on the day of the interview. CONCLUSIONS The PRESCAP-Diabetes 2010 study results indicate that 43.6% of diabetics with hypertension seen in primary care have a poorly controlled BP, in particular, systolic BP.
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Affiliation(s)
- A Barquilla García
- Medicina de Familia y Comunitaria, Centro de Salud de Trujillo, Cáceres, España.
| | - J L Llisterri Caro
- Medicina de Familia y Comunitaria, Centro de Salud Ingeniero Joaquín Benlloch, Valencia, España
| | - M A Prieto Díaz
- Medicina de Familia y Comunitaria, Centro de Salud de Vallobín-La Florida, Oviedo, España
| | - F J Alonso Moreno
- Medicina de Familia y Comunitaria, Centro de Salud Sillería, Toledo, España
| | - L García Matarín
- Medicina de Familia y Comunitaria, Unidad de Gestión Clínica de Vicar, Almería, España
| | - A Galgo Nafría
- Medicina de Familia y Comunitaria, Centro de Salud Espronceda, Madrid, España
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Initial single-pill combination therapy for cardiovascular risk factor management: it is not just convenience. J Hypertens 2014; 31:1537-8. [PMID: 23822927 DOI: 10.1097/hjh.0b013e328361d016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alonso Moreno F. Nuevas indicaciones y recomendaciones en el tratamiento antihipertensivo. Semergen 2013; 39:61-2. [DOI: 10.1016/j.semerg.2012.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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