Hypertension management initiative prospective cohort study: comparison between immediate and delayed intervention groups

Resistance to Antihypertensive Drugs: Is Gut Microbiota the Missing Link?

Microbiota colonization begins at birth and continuously reshapes throughout the course of our lives, resulting in tremendous interindividual heterogeneity. Given that the gut microbiome, similar to the liver, houses many categories of catalytic enzymes, there is significant value in understanding drug-bacteria interactions. The discovery of this link could enhance the therapeutic value of drugs that would otherwise have a limited or perhaps detrimental effect on patients. Resistant hypertension is one such subset of the hypertensive population that poorly responds to antihypertensive medications, resulting in an increased risk for chronic cardiovascular illnesses and its debilitating effects that ultimately have a detrimental impact on patient quality of life. We recently demonstrated that the gut microbiota is involved in the metabolism of antihypertensive drugs and thus contributes to the pathophysiology of resistant hypertension. Due to a lack of knowledge of the mechanisms, novel therapeutic approaches that account for the gut microbiota may allow for better therapeutic outcomes in resistant hypertension. Therefore, the purpose of this review is to summarize our current, albeit limited, understanding of how the gut microbiota may possess particular enzymatic activities that influence the efficacy of antihypertensive drugs.

Does education of primary care professionals promote patient self-management and improve outcomes in chronic disease? An updated systematic review

BACKGROUND

Primary care has a vital role in supporting patient autonomy to enable people with long-term conditions to manage their own health and wellness. Evidence is needed on whether education and training of health professionals helps support patient self-management and improves outcomes. The authors' first systematic review included only two articles showing patient outcomes following health professional training for promoting patient self-management.

AIM

To present an updated review undertaken from September 2013 to August 2018.

DESIGN & SETTING

A systematic review was undertaken using the PRISMA guidelines, following the methodology of the first review and is outlined in the PROSPERO registered protocol.

METHOD

Six databases were searched - Cochrane Library, PubMed, ERIC, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO - in addition to web searches, hand searches, and bibliographies for articles published from 1 September 2013 to 31 August 2018.

RESULTS

The updated systematic review showed more evidence is now available with 18 articles in the 5-year period from the 4284 abstracts located. Twelve of these articles showed a difference between intervention and control groups. Of the 18 articles identified, 11 were assessed as having a low risk of bias and five overall were rated of weak quality. The educational interventions with health professionals spanned a range of techniques and modalities, and many incorporated multiple interventions including patient components. There may be a lack of adoption owing to several challenges, including that complex interventions may not be delivered as planned and are difficult to assess, and owing to patient engagement and the need for ongoing follow-up.

CONCLUSION

More high-quality research is needed on what methods work best, for which patients, and for what clinical conditions in the primary care setting. The practical implications of training healthcare professionals require specific attention.

Assessment of Interprofessional Collaborative Practices and Outcomes in Adults With Diabetes and Hypertension in Primary Care: A Systematic Review and Meta-analysis

IMPORTANCE

Interprofessional collaborative practice (ICP), the collaboration of health workers from different professional backgrounds with patients, families, caregivers, and communities, is central to optimal primary care. However, limited evidence exists regarding its association with patient outcomes.

OBJECTIVE

To examine the association of ICP with hemoglobin A1C (HbA1c), systolic blood pressure (SBP), and diastolic blood pressure (DBP) levels among adults receiving primary care.

DATA SOURCES

A literature search of English language journals (January 2013-2018; updated through March 2020) was conducted using MEDLINE; Embase; Ovid IPA; Cochrane Central Register of Controlled Trials: Issue 2 of 12, February 2018; NHS Economic Evaluation Database: Issue 2 of 4, April 2015; Clarivate Analytics WOS Science Citation Index Expanded (1990-2018); EBSCOhost CINAHL Plus With Full Text (1937-2018); Elsevier Scopus; FirstSearch OAIster; AHRQ PCMH Citations Collection; ClinicalTrials.gov; and HSRProj.

STUDY SELECTION

Studies needed to evaluate the association of ICP (≥3 professions) with HbA1c, SBP, or DBP levels in adults with diabetes and/or hypertension receiving primary care. A dual review was performed for screening and selection.

DATA EXTRACTION AND SYNTHESIS

This systematic review and meta-analysis followed the PRISMA guideline for data abstractions and Cochrane Collaboration recommendations for bias assessment. Two dual review teams conducted independent data extraction with consensus. Data were pooled using a random-effects model for meta-analyses and forest plots constructed to report standardized mean differences (SMDs). For high heterogeneity (I2), data were stratified by baseline level and by study design.

MAIN OUTCOMES AND MEASURES

The primary outcomes included HbA1c, SBP, and DBP levels as determined before data collection.

RESULTS

A total of 3543 titles or abstracts were screened; 170 abstracts or full texts were reviewed. Of 50 articles in the systematic review, 39 (15 randomized clinical trials [RCTs], 24 non-RCTs) were included in the meta-analyses of HbA1c (n = 34), SBP (n = 25), and DBP (n = 24). The sample size ranged from 40 to 20 524, and mean age ranged from 51 to 70 years, with 0% to 100% participants being male. Varied ICP features were reported. The SMD varied by baseline HbA1c, although all SMDs significantly favored ICP (HbA1c <8, SMD = -0.13; P < .001; HbA1c ≥8  to < 9, SMD = -0.24; P = .007; and HbA1c ≥9, SMD = -0.60; P < .001). The SMD for SBP and DBP were -0.31 (95% CI, -0.46 to -0.17); P < .001 and -0.28 (95% CI, -0.42 to -0.14); P < .001, respectively, with effect sizes not associated with baseline levels. Overall I2 was greater than 80% for all outcomes.

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis found that ICP was associated with reductions in HbA1c regardless of baseline levels as well as with reduced SBP and DBP. However, the greatest reductions were found with HbA1c levels of 9 or higher. The implementation of ICP in primary care may be associated with improvements in patient outcomes in diabetes and hypertension.

[Analysis of three health education strategies for patients with arterial hypertension]

The scope of this article is to compare the effect of three health and nutrition education strategies on adherence to the non-pharmacological treatment of systemic arterial hypertension (SAH), using anthropometric, biochemical, clinical and dietetic parameters. It is a longitudinal intervention study of the comparative and quantitative approach community test. The sample was comprised of 212 individuals diagnosed with SAH, who met the inclusion/exclusion criteria. Participants were allocated into three groups, in order to evaluate different methods of intervention, carried out on a monthly basis, for twelve months. The Kolmogorov-Smirnov, ANOVA and Kruskal-Wallis tests were performed for the analyses. Educational interventions in Group 1 and 2 provided the best results on adherence to the non-pharmacological treatment of SAH. In the comparative analysis of different groups, the reduction of glucose showed statistical significant difference, with Group 2 showing the best evolution. Group 1 and 2 had better results on adherence to non-pharmacological treatment of SAH. It is important to stress that in health service practices there is a challenge to promote health education able to intervene on the issue of adherence to the treatment of SAH.

Obesity and Hypertension in Association with Diastolic Dysfunction Could Reduce Exercise Capacity

BACKGROUND AND OBJECTIVES

Empirical evidence is lacking on the cumulative disease burden of obesity and hypertension and its impact on cardiac function and exercise capacity. The purpose of this study was to determine whether the presence of obesity and hypertension together was associated with cardiac dysfunction and exercise capacity.

SUBJECTS AND METHODS

Using a retrospective study design, medical records were reviewed for echocardiographic and treadmill exercise stress test data. Subjects were grouped according to four categories: normal control, obese, hypertensive, or obese and hypertensive.

RESULTS

Obese, hypertensive persons showed significantly lower Ea and E/A ratio and greater E/Ea ratio, deceleration time, left ventricular (LV) mass, and LV mass index compared to their counter parts (normal control, obese and/or hypertensive) (all p<0.05), after controlling for age and sex. After controlling for age and sex, significant differences in exercise capacity indices were found, with the obese group having shorter exercise time, lower metabolic equivalents, and lower maximal oxygen uptake than the normal control, hypertensive, or both groups (all p<0.05). The hypertensive or obese and hypertensive group had greater maximal blood pressure compared with the normal control group (all p<0.001). Obese and hypertensive persons were approximately three times more likely to have diastolic dysfunction (odd ratio=2.96, p=0.001), when compared to the reference group (normotensive, non-obese, or hypertensive only persons).

CONCLUSION

Diastolic dysfunction was associated with obesity and/or hypertension. The cumulative risk of obesity and hypertension and their impact on diastolic dysfunction which could be modifiable could reduce exercise capacity.

Adherence to non-pharmacological treatment: Analysis of the impact of three health educational and nutritional strategies in hypertensive patients

ABSTRACT Objective: To evaluate adherence to non-pharmacological treatment of hypertension by comparing biochemical, clinical, anthropometric, and dietary parameters before and after three health educational and nutritional strategies. Methods: This longitudinal clinical trial included 212 hypertensive individuals who met the inclusion criteria. The participants were allocated to three groups to assess the impact of monthly intervention methods over twelve months. Results: Waist circumference decreased significantly in all groups. Weight and body mass index decreased significantly in Groups 2 and 3. Blood glucose, total cholesterol, and low-density lipoprotein cholesterol decreased significantly in Groups 1 and 2. The interventions also reduced the mean per capita intakes of oil, sugar, and salt in all groups. Conclusion: Educational interventions promoted adherence to non-pharmacological treatment of treatment of hypertension evidenced by anthropometric (weight, body mass index, and waist circumference), biochemical (blood glucose, total cholesterol, and low-density lipoprotein cholesterol), and dietary (meanper capita intake of oil, sugar, and salt) parameters.