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Impact of socio-economic factors on the long-term effectiveness of antihypertensive treatment with an angiotensin II receptor blocker: an observational study

OBJECTIVE

To investigate the role of socio-economic factors on the therapeutic effectiveness of and therapeutic adherence to the angiotensin II receptor blocker (ARB) olmesartan (OM) alone or in combination with hydrochlorothiazide in the treatment of arterial hypertension.

RESEARCH DESIGN AND METHODS

In a multi-center, open-label, prospective and long-term observational study, data from hypertensive patients treated with OM were analyzed at baseline, month 3 and month 12 within the context of patients' socio-economic status (SES), determined using pre-defined criteria by physicians in outpatient practices and including multivariate analysis.

RESULTS

Overall, 7724 patients were assigned to three subgroups representing low, medium and high socio-economic status. Baseline conditions differed significantly between the subgroups. Patients of low SES had worse nutritional habits, less physical activity and more concomitant medication compared to patients of high SES. Cardiovascular risk factors were more common in the low SES group as were concomitant diseases such as heart failure, coronary heart disease, atherosclerosis and renal failure. OM therapy led to a significant decrease in blood pressure (23.0/11.6 mmHg) in all patients. The blood pressure target of <140/90 mmHg was achieved in about 70% of the documented population. Effectiveness was comparable between patients with low, medium or high SES. Treatment adherence was high in the overall population with only minor differences between the subgroups. In total the incidence of adverse events (AEs) was 1.6% documented in 98 patents (1.3%) during the course of the study. Of this total number only 1.0% was related to the drug, matching the percentage expressed in the Summary of Product Characteristics (SmPC).

CONCLUSIONS

The ARB OM is effective and well tolerated in all patients, irrespective of their socio-economic status. The risk status and the established cardiovascular disease of hypertensive patients are strongly influenced by the SES. To validate these interesting data a randomized controlled trial is needed.

[Prevalence of chronic pain in Germany. A representative survey of the general population]

BACKGROUND

There are no up to date data from representative samples of the general German population on the prevalence of debilitating pain and of pain diseases available.

METHODS

A cross-sectional survey of a representative sample of the German general population including persons ≥ 14 years of age was conducted in 2012 based on face-to-face interviews using standardized questionnaires. Chronic pain was assessed by the widespread pain index (WPI), disability by the subscales physical functioning and role function of the European Organisation for Research and Treatment of Cancer (EORTC QLQ-C30) and psychological distress by the patient health questionnaire (PHQ-4). Chronic pain with associated physical and social impairments was defined by at least one pain site over 3 months in the WPI and at least one response of a moderate or severe impairment in both subscales of the EORTC 30 QLQ-C30. Chronic pain with associated physical, mental and social impairment (pain disease) required in addition a probable depressive and/or anxiety disorder in the PHQ-4.

RESULTS

A total of 2,515 out of 4,480 (56.1 %) of contacted persons finished the study of which 32.9 % reported chronic pain, 5.4 % reported chronic pain with associated physical and social impairments and 2.3 % associated physical, mental and social impairments. No participants with local pain (only one pain site) but 24.0 % of participants with widespread pain (6-19 pain sites) met the criteria of a pain disease.

CONCLUSIONS

The reports of chronic pain in epidemiological studies do not necessarily imply a suffering (physical, psychological and social impairment) from pain.

Hypersensitivity to acute ANG II in female growth-restricted offspring is exacerbated by ovariectomy

Female growth-restricted offspring are normotensive in adulthood. However, ovariectomy induces a marked increase in mean arterial pressure (MAP) that is abolished by renin angiotensin system (RAS) blockade, suggesting RAS involvement in the etiology of hypertension induced by ovariectomy in adult female growth-restricted offspring. Blockade of the RAS also abolishes hypertension in adult male growth-restricted offspring. Moreover, sensitivity to acute ANG II is enhanced in male growth-restricted offspring. Thus, we hypothesized that an enhanced sensitivity to acute ANG II may contribute to hypertension induced by ovariectomy in female growth-restricted offspring. Female offspring were subjected to ovariectomy (OVX) or sham ovariectomy (intact) at 10 wk of age. Cardio-renal hemodynamic parameters were determined before and after an acute infusion of ANG II (100 ng·kg(-1)·min(-1) for 30 min) at 16 wk of age in female offspring pretreated with enalapril (40 mg·kg(-1)·day(-1) for 7 days). Acute ANG II induced a significant increase in MAP in intact growth-restricted offspring (155 ± 2 mmHg, P < 0.05) relative to intact control (145 ± 4 mmHg). Ovariectomy augmented the pressor response to ANG II in growth-restricted offspring (163 ± 2 mmHg, P < 0.05), with no effect in control (142 ± 2 mmHg). Acute pressor responses to phenylephrine did not differ in growth-restricted offspring relative to control, intact, or ovariectomized. Furthermore, renal hemodynamic responses to acute ANG II were significantly enhanced only in ovariectomized female growth-restricted offspring. Thus, these data suggest that enhanced responsiveness to acute ANG II is programmed by intrauterine growth restriction and that sensitivity to acute ANG II is modulated by ovarian hormones in female growth-restricted offspring.

Individual socioeconomic factors conditioning cardiovascular disease risk

BACKGROUND

Our objective is to ascertain whether the socioeconomic situation of individuals has an influence on the cardiovascular disease (CVD) risk estimation.

METHODS

The subjects were part of VAMPAHICA study and had been recently diagnosed as hypertensive. The study subjects were seen in primary care centers, were aged between 15 and 75 years and have never been treated for hypertension (HT). Normotensive individuals were also included in the study sample. All individuals answered a questionnaire that included questions related to sociodemographic and socioeconomic variables as well as habit and lifestyle variables. Of a total of 424 individuals initially invited to answer the questionnaire, 388 finally did so. Due to missing data in the dependent variables, 304 individuals were included in the European Society of Hypertension (ESH) risk tables and 287 in the Systematic Coronary Risk Evaluation (SCORE) tables. The response variable CVD risk, which is a polytomic variable, was estimated using an ordered probit model.

RESULTS

We found that individual's socioeconomic status, expressed mainly as their level of education, was an independent variable that had repercussions on the estimated CVD risk. This finding was more evident in the SCORE tables, and when risk was stratified according to the ESH tables the repercussions were only marginal. In particular, we found that individuals with only primary education had a 27% higher probability of CVD risk (> or =5%) in the SCORE tables, whereas individuals with a higher level of education had 50% less probability of high risk.

CONCLUSIONS

The CVD risk estimation tables for the general population (SCORE) reflect the socioeconomic factor better than the CVD risk stratification tables for HT (ESH tables). Target organ damage (TOD) is an important factor for stratifying risk in the ESH tables; however, the SCORE tables do not take this into account. Therefore, socioeconomic factors may already be incorporated in the ESH tables through an intermediate variable, such as TOD.

Review: Hypertension, a health economics perspective

The economic aspects of hypertension are critical to modern medicine. The medical, economic, and human costs of untreated and inadequately controlled hypertension are enormous. Hypertension is distributed unequally and with iniquity in different countries and regions of the world. Treatment of hypertension requires an investment over many years to prolong disease-free quality years of life. The high prevalence and high cost of the disease impacts on the microeconomics and macroeconomics of countries and regions. The criteria used for inclusion in clinical guidelines for hypertension impact on the cost and cost/utility of diagnosis or treatment.