Drug adherence in hypertension: from methodological issues to cardiovascular outcomes

Sex-based disparities with cost-related medication adherence issues in patients with hypertension, ischemic heart disease, and heart failure

IMPORTANCE AND OBJECTIVE

Identifying sources of sex-based disparities is the first step in improving clinical outcomes for female patients. Using All of Us data, we examined the association of biological sex with cost-related medication adherence (CRMA) issues in patients with cardiovascular comorbidities.

MATERIALS AND METHODS

Retrospective data collection identified the following patients: 18 and older, completing personal medical history surveys, having hypertension (HTN), ischemic heart disease (IHD), or heart failure (HF) with medication use history consistent with these diagnoses. Implementing univariable and adjusted logistic regression, we assessed the influence of biological sex on 7 different patient-reported CRMA outcomes within HTN, IHD, and HF patients.

RESULTS

Our study created cohorts of HTN (n = 3891), IHD (n = 5373), and HF (n = 2151) patients having CRMA outcomes data. Within each cohort, females were significantly more likely to report various cost-related medication issues: being unable to afford medications (HTN hazards ratio [HR]: 1.68, confidence interval [CI]: 1.33-2.13; IHD HR: 2.33, CI: 1.72-3.16; HF HR: 1.82, CI: 1.22-2.71), skipping doses (HTN HR: 1.76, CI: 1.30-2.39; IHD HR: 2.37, CI: 1.69-3.64; HF HR: 3.15, CI: 1.87-5.31), taking less medication (HTN HR: 1.86, CI: 1.37-2.45; IHD HR: 2.22, CI: 1.53-3.22; HF HR: 2.99, CI: 1.78-5.02), delaying filling prescriptions (HTN HR: 1.83, CI: 1.43-2.39; IHD HR: 2.02, CI: 1.48-2.77; HF HR: 2.99, CI: 1.79-5.03), and asking for lower cost medications (HTN HR: 1.41, CI: 1.16-1.72; IHD HR: 1.75, CI: 1.37-2.22; HF HR: 1.61, CI: 1.14-2.27).

DISCUSSION AND CONCLUSION

Our results clearly demonstrate CRMA issues disproportionately affect female patients with cardiovascular comorbidities, which may contribute to the larger sex-based disparities in cardiovascular care. These findings call for targeted interventions and strategies to address these disparities and ensure equitable access to cardiovascular medications and care for all patients.

Non-adherence to cardiometabolic medication as assessed by LC-MS/MS in urine and its association with kidney and cardiovascular outcomes in type 2 diabetes mellitus

AIMS/HYPOTHESIS

Non-adherence to medication is a frequent barrier in the treatment of patients with type 2 diabetes mellitus, potentially limiting the effectiveness of evidence-based treatments. Previous studies have mostly relied on indirect adherence measures to analyse outcomes based on adherence. The aim of this study was to use LC-MS/MS in urine-a non-invasive, direct and objective measure-to assess non-adherence to cardiometabolic drugs and analyse its association with kidney and cardiovascular outcomes.

METHODS

This cohort study includes 1125 participants from the PROVALID study, which follows patients with type 2 diabetes mellitus at the primary care level. Baseline urine samples were tested for 79 cardiometabolic drugs and metabolites thereof via LC-MS/MS. An individual was classified as totally adherent if markers for all drugs were detected, partially non-adherent when at least one marker for one drug was detected, and totally non-adherent if no markers for any drugs were detected. Non-adherence was then analysed in the context of cardiovascular (composite of myocardial infarction, stroke and cardiovascular death) and kidney (composite of sustained 40% decline in eGFR, sustained progression of albuminuria, kidney replacement therapy and death from kidney failure) outcomes.

RESULTS

Of the participants, 56.3% were totally adherent, 42.0% were partially non-adherent, and 1.7% were totally non-adherent to screened cardiometabolic drugs. Adherence was highest to antiplatelet and glucose-lowering agents and lowest to lipid-lowering agents. Over a median (IQR) follow-up time of 5.10 (4.12-6.12) years, worse cardiovascular outcomes were observed with non-adherence to antiplatelet drugs (HR 10.13 [95% CI 3.06, 33.56]) and worse kidney outcomes were observed with non-adherence to antihypertensive drugs (HR 1.98 [95% CI 1.37, 2.86]).

CONCLUSIONS/INTERPRETATION

This analysis shows that non-adherence to cardiometabolic drug regimens is common in type 2 diabetes mellitus and negatively affects kidney and cardiovascular outcomes.

Patient Knowledge, Medication Adherence, and Influencing Factors: A Cross-Sectional Study among Hypertensive Patients in Greece

This study aimed to investigate the knowledge of patients with hypertension about their condition, adherence to antihypertensive medication, and the factors influencing it. A cross-sectional study was conducted in two cardiology outpatient clinics of two tertiary hospitals, in Greece. The study included 188 patients diagnosed with hypertension. The patients' knowledge about their disease and adherence to medication were assessed by using the HK-LS and A-14 scales, respectively. Patients had sufficient knowledge levels about their disease, but significantly low levels of adherence to medication. Patients with higher knowledge levels were more adherent to medications [r(188) = 0.885, p < 0.001]. By using multivariate analysis, higher age (p = 0.018), residence in a more populous area (p = 0.041), more years with the disease (p = 0.012), and a lower number of medications (p = 0.03) were associated with higher levels of knowledge. Conversely, younger age (p = 0.036), lower educational levels (p = 0.048), fewer years with the disease (p = 0.001), and a higher number of medications (p = 0.003) were associated with lower adherence to medication. The Greek patients' hypertension knowledge was sufficient; however, adherence to medication was significantly low. Healthcare managers could utilize our findings to design targeted interventions for improving adherence to medication for these patients.

Clinical event reductions in high-risk patients after renal denervation projected from the global SYMPLICITY registry

AIMS

Renal denervation has been shown to lower blood pressure in sham-controlled trials and represents a device-based treatment option for hypertension. We sought to project clinical event reductions after radiofrequency renal denervation using a novel modelling approach.

METHODS AND RESULTS

The Global SYMPLICITY Registry is a global, prospective all-comer registry to evaluate safety and efficacy after renal denervation. For this analysis, change in office systolic blood pressure from baseline was calculated from reported follow-up in the Global SYMPLICITY Registry. Relative risks for death and other cardiovascular events as well as numbers needed to treat for event avoidance were obtained for the respective blood pressure reductions based on previously reported meta-regression analyses for the full cohort and high-risk subgroups including type 2 diabetes, chronic kidney disease, resistant hypertension, and high basal cardiovascular risk. Average baseline office systolic blood pressure and reduction estimates for the full cohort (N = 2651) were 166±25 and -14.8 ± 0.4 mmHg, respectively. Mean reductions in blood pressure ranged from -11.0--21.8 mmHg for the studied high-risk subgroups. Projected relative risks ranged from 0.57 for stroke in the resistant hypertension cohort to 0.92 for death in the diabetes cohort. Significant absolute reductions in major adverse cardiovascular events over 3 years compared with the projected control (8.6 ± 0.7% observed vs. 11.7 ± 0.9% for projected control; P < 0.01) were primarily due to reduced stroke incidence. The robustness of findings was confirmed in sensitivity and scenario analyses.

CONCLUSION

Model-based projections suggest radiofrequency renal denervation for patients with uncontrolled hypertension adds considerable clinical benefit across a spectrum of different cohort characteristics.

Measurement Tools and Utility of Hair Analysis for Screening Adherence to Antihypertensive Medication

Poor adherence to the prescribed antihypertensive therapy is an understated public health problem and is one of the main causes of the high prevalence of uncontrolled hypertension in sub-Saharan Africa. Medication adherence is vital for the effectiveness of antihypertensive treatment and is key to ameliorating the clinical outcomes in hypertensive patients. However, it has often been ignored because the current methods used to assess medication adherence are not reliable, limiting their utilization in clinical practice. Therefore, the identification of the most accurate and clinically feasible method for measuring medication adherence is critical for tailoring effective strategies to improve medication adherence and consequently achieve blood pressure goals. This review not only explores various available methods for estimating medication adherence but also proposes therapeutic drug monitoring in hair for the measurement of medication adherence to the antihypertensive medication period.

Dried Urine Spot Analysis for assessing cardiovascular drugs exposure applicable in spaceflight conditions

Cardiovascular pharmacological countermeasures will be required as a preventive measure of cardiovascular deconditioning and early vascular ageing for long term space travelers. Physiological changes during spaceflight could have severe implications on drug pharmacokinetics and pharmacodynamics (PK/PD). However, limitations exist for the implementation of drug studies due to the requirements and constraints of this extreme environment. Therefore, we developed an easy sampling method on dried urine spot (DUS), for the simultaneous quantification of 5 antihypertensive drugs in human urine: irbesartan, valsartan, olmesartan, metoprolol and furosemide analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), considering spaceflight parameters. This assay was validated in terms of linearity, accuracy, and precision with satisfactory results. There were no relevant carry-over, matrix interferences. The targeted drugs were stable in urine collected by DUS until 6 months at +21 °C, +4°C, -20 °C (with or without desiccants) and at 30 °C during 48 h. Irbesartan, valsartan and olmesartan were not stable at 50 °C during 48 h. This method was found to be eligible for space pharmacology studies in terms of practicality, safety, robustness and energy costs. It has been successfully implemented in space tests programs led in 2022.

SPUR-27 - Psychometric Properties of a Patient-Reported Outcome Measure of Medication Adherence in Chronic Obstructive Pulmonary Disease

PURPOSE

People living with COPD who struggle to take their medicines often experience poorer health outcomes such as exacerbations of symptoms, more frequent and lengthy hospital admissions, and worsening mortality rates. This study aimed to evaluate the psychometric properties of the previously validated SPUR-27 model, a multi-factorial model of medication adherence.

PATIENTS AND METHODS

This cross-sectional study was conducted with 100 adult patients living with COPD in a hospital setting in Southwest London. Medication adherence was assessed using a shortened SPUR model (SPUR-27) against the validated Inhaler Adherence Scale (IAS) as a comparator. In addition, objective medication adherence data, presented as the Medication Possession Ratio (MPR), were derived from patient medical and pharmacy records. The COPD Assessment Tool (CAT) score was used to examine the relationship between medication adherence and COPD symptom severity. Reliability of SPUR-27 was assessed using internal consistency estimates. Exploratory factor analysis, partial confirmatory factor analysis, and maximum likelihood analysis were conducted in conjunction with construct, concurrent, and known-group validity testing to explore the psychometric properties of the SPUR model in this population.

RESULTS

A 7-factor model for SPUR-27 was derived with adequate factor loadings. SPUR (α=0.893) observed strong internal consistency (>0.8). The model was significantly positively correlated with IAS score (p<0.001) as well as MPR (p<0.01). A significant (p<0.01) relationship between poor medication adherence and worsening symptom severity, as defined by the CAT score, was identified for SPUR (χ ² = 8.570) using Chi-Square analysis. Furthermore, SPUR-27 demonstrated early evidence of validity with good incremental fit indices: NFI (0.96), TFI (0.97), and CFI (0.93) were all reported as >0.9 in addition to the RMSEA, which was <0.08 (0.059).

CONCLUSION

SPUR demonstrated strong psychometric properties in patients living with COPD. Further work should look to examine the test-retest reliability of the model and its application in broader sample populations.

On the issue of low adherence of patients to antihypertensive therapy: the use of therapeutic drug monitoring of drugs: A review

Low adherence of patients to antihypertensive therapy remains an urgent problem and is recognized as the main cause of insufficient BP control at the population level. In this regard, to increase the motivation of patients in clinical practice, methods for assessing adherence (compliance) to drugs. Along with indirect assessment methods (questionnaires, self-reports, pill counts, etc.), which, however, do not always reflect the real patients adherence, more objective is the measurement of antihypertensive drug concentrations in physiological fluids therapeutic drug monitoring (TDM). For these purposes, methods of high-performance liquid chromatography with mass spectrometry were recently adapted, reference ranges of antihypertensive drug concentrations in blood serum and urine for standard doses of drugs were determined, as well as criteria for assessing complete or partial non-compliance. There have been a number of studies using TDM to assess adherence, which show a high rate of non-compliance (low compliance) of more than 50% of cases with a variability from 25 to 86.1%, with complete non-compliance 10.134.5% in patients with uncontrolled and/or resistant hypertension (3 antihypertensive drug). In a population of patients with a normal course of hypertension, taking 12 antihypertensive drug, the level of non-compliance according to the results of TDM did not exceed 10%. Comparison of the TDM method with indirect methods of assessing adherence did not reveal consistency; at the same time, the detection of antihypertensive drug better characterized the clinical problems of patients with arterial hypertension. In clinical practice, direct assessment methods (TDM) can be used to measure adherence in problem patients with uncontrolled hypertension and high cardiovascular risk despite optimal therapy.

Measuring adherence to antihypertensive medication using an objective test in older adults attending primary care: cross-sectional study

Analysis of urine samples using liquid chromatography-tandem mass spectrometry (LC-MS/MS) has previously revealed high rates of non-adherence to antihypertensive medication. It is unclear whether these rates represent those in the general population. This study aimed to investigate whether it is feasible to collect urine samples in a primary care setting and analyse them using LC-MS/MS to detect non-adherence to antihypertensive medication. This study used a prospective, observational cohort design. Consecutive patients were recruited opportunistically from five general practices in UK primary care. They were aged ≥65 years with hypertension and had at least one antihypertensive prescription. Participants were asked to provide a urine sample for analysis of medication adherence. Samples were sent to a laboratory via post and analysed using LC-MS/MS. Predictors of adherence to medication were explored with multivariable logistic regression. Of 349 consecutive patients approached for the study, 214 (61.3%) gave informed consent and 191 (54.7%) provided a valid urine sample for analysis. Participants were aged 76.2 ± 6.6 years and taking a median of 2 antihypertensive medications (IQR 1-3). A total of 27/191 participants (14.2%) reported not taking all of their medications on the day of urine sample collection. However, LC-MS/MS analysis of samples revealed only 4/27 (9/191 in total; 4.7%) were non-adherent to some of their medications. Patients prescribed more antihypertensive medications were less likely to be adherent (OR 0.24, 95%CI 0.09-0.65). Biochemical testing for antihypertensive medication adherence is feasible in routine primary care, although non-adherence to medication is generally low, and therefore widespread testing is not indicated.

Clinical characteristics do not reliably identify non-adherence in patients with uncontrolled hypertension

PURPOSE

Chemical adherence testing is a reliable method to assess adherence to antihypertensive drugs. However, it is expensive and has limited availability in clinical practice. To reduce the number and costs of chemical adherence tests, we aimed to develop and validate a clinical screening tool to identify patients with a low probability of non-adherence in patients with uncontrolled hypertension.

MATERIALS AND METHODS

In 495 patients with uncontrolled hypertension referred to the University Medical Centre Utrecht (UMCU), the Netherlands, a penalised logistic regression model including seven pre-specified easy-to-measure clinical variables was derived to estimate the probability of non-adherence. Non-adherence was defined as not detecting at least one of the prescribed antihypertensive drugs in plasma or urine. Model performance and test characteristics were evaluated in 240 patients with uncontrolled hypertension referred to the Heartlands Hospital, United Kingdom.

RESULTS

Prevalence of non-adherence to antihypertensive drugs was 19% in the UMCU and 44% in the Heartlands Hospital population. After recalibration of the model's intercept, predicted probabilities agreed well with observed frequencies. The c-statistic of the model was 0.63 (95%CI 0.53-0.72). Predicted probability cut-off values of 15%-22.5% prevented testing in 5%-15% of the patients, carrying sensitivities between 97% (64-100) and 90% (80-95), and negative predictive values between 74% (10-99) and 70% (50-85).

CONCLUSION

The combination of seven clinical variables is not sufficient to reliably discriminate adherent from non-adherent individuals to safely reduce the number of chemical adherence tests. This emphasises the complex nature of non-adherence behaviour and thus the need for objective chemical adherence tests in patients with uncontrolled hypertension.

SPUR: psychometric properties of a patient-reported outcome measure of medication adherence in type 2 diabetes

INTRODUCTION

Poor medication adherence is associated with worsening patient health outcomes and increasing healthcare costs. A holistic tool to assess both medication adherence and drivers of adherence behaviour has yet to be developed. This study aimed to examine SPUR, a multifactorial patient-reported outcome measure of medication adherence in patients living with type 2 diabetes, with a view to develop a suitable model for psychometric analysis.Furthermore, the study aimed to explore the relationship between the SPUR model and socio-clinical factors of medication adherence.

RESEARCH DESIGN AND METHODS

The study recruited 378 adult patients living with type 2 diabetes from a mix of community and secondary-care settings to participate in this non-interventional cross-sectional study. The original SPUR-45 tool was completed by participants with other patient-reported outcome measures for comparison, in addition to the collection of two objective adherence measures; HbA1c and the medication possession ratio (MPR).

RESULTS

Factor and reliability analysis conducted on SPUR-45 produced a revised and more concise version (27-items) of the tool, SPUR-27, which was psychometrically assessed. SPUR-27 observed strong internal consistency with significant correlations to the other psychometric measures (Beliefs about Medication Questionnaire, Diabetes Treatment Satisfaction Questionnaire, Medicine Adherence Rating Scale) completed by participants. Higher SPUR-27 scores were associated with lower HbA1c values and a higher MPR, as well as other predicted socio-clinical factors such as higher income, increased age and lower body mass index.

CONCLUSIONS

SPUR-27 demonstrated strong psychometric properties. Further work should look to examine the test-retest reliability of the model as well as examine transferability to other chronic conditions and broader population samples. Overall, the initial findings suggest that SPUR-27 is a reliable model for the multifactorial assessment of medication adherence among patients living with type 2 diabetes.

Global Burden, Regional Differences, Trends, and Health Consequences of Medication Nonadherence for Hypertension During 2010 to 2020: A Meta-Analysis Involving 27 Million Patients

Background

Nonadherence to antihypertensive medications is the leading cause of poor blood pressure control and thereby cardiovascular diseases and mortality worldwide.

Methods and Results

We investigated the global epidemiology, regional differences, and trend of antihypertensive medication nonadherence via a systematic review and meta‐analyses of data from 2010 to 2020. Multiple medical databases and clinicaltrials.gov were searched for articles. Observational studies reporting the proportion of patients with anti‐hypertensive medication nonadherence were included. The proportion of nonadherence, publication year, year of first recruitment, country, and health outcomes attributable to antihypertensive medication nonadherence were extracted. Two reviewers screened abstracts and full texts, classified countries according to levels of income and locations, and extracted data. The Joanna Briggs Institute prevalence critical appraisal tool was used to rate the included studies. Prevalence meta‐analyses were conducted using a fixed‐effects model, and trends in prevalence were analyzed using meta‐regression. The certainty of evidence concerning the effect of health consequences of nonadherence was rated according to Grading of Recommendations, Assessment, Development and Evaluations. A total of 161 studies were included. Subject to different detection methods, the global prevalence of anti‐hypertensive medication nonadherence was 27% to 40%. Nonadherence was more prevalent in low‐ to middle‐income countries than in high‐income countries, and in non‐Western countries than in Western countries. No significant trend in prevalence was detected between 2010 and 2020. Patients with antihypertensive medication nonadherence had suboptimal blood pressure control, complications from hypertension, all‐cause hospitalization, and all‐cause mortality.

Conclusions

While high prevalence of anti‐hypertensive medication nonadherence was detected worldwide, higher prevalence was detected in low‐ to middle‐income and non‐Western countries. Interventions are urgently required, especially in these regions. Current evidence is limited by high heterogeneity.

Registration

URL: www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021259860.

Reproducibility of blood pressure phenotypes identified by office and ambulatory blood pressure in treated hypertensive patients. Data from the PHYLLIS study

Previous studies have shown that white-coat and masked uncontrolled hypertension (WUCH and MUCH, respectively) are clinical conditions with very poor reproducibility over time. This is also the case for the different nighttime blood pressure (BP) patterns (dipping, nondipping, reverse dipping or extreme dipping). Whether and to what extent the phenomenon might depend on the type of antihypertensive treatment is unknown. In the present study, we addressed this issue by analyzing the data collected in the Plaque Hypertension Lipid-Lowering Italian Study (PHYLLIS), in which office and ambulatory BP were measured three times during an almost 3-year treatment period. The results showed that a limited number of WUCH or MUCH patients at an initial office measurement and 24-h systolic (S) BP measurement maintained the same status at a second set of measurements one or more years later. This was also the case for all dipping patterns, and only a minimal number of patients exhibited the same phenotype throughout all on-treatment SBP measurements. The results were similar for treatment with a thiazide diuretic or an ACE inhibitor and are in line with those of the European Lacidipine Study on Atherosclerosis (ELSA) trial, i.e., the only other available trial with multiple on-treatment office and ambulatory BP measurements, in which patients were treated with a calcium channel blocker or a beta-blocker. All the BP patterns identified in hypertensive patients treated by joint office and ambulatory BP measurements display poor reproducibility, and this is unrelated to the type of antihypertensive treatment used.

Impact of medication adherence on the efficacy of Baroreflex activation therapy

Therapy adherence significantly determines the success of antihypertensive therapy, especially in patients with resistant hypertension. Our study investigates the impact of drug adherence on the efficacy of Baroreflex‐activation‐therapy (BAT). In this retrospective analysis, the authors measured blood pressure (BP) and antihypertensive medication adherence (by gas chromatography‐mass spectrometry [GC‐MS] urine analysis) before and 6 months after BAT initiation. Adherence was defined as detection of ≥80% intake of prescribed medication at the time of follow‐up. Response to BAT was defined as BP drop ≥5 mmHg in systolic 24 h‐ambulatory BP (ABP) after 6 months. Overall patients (n = 38) median medication adherence was low, but rose from 60% (IQR 25%–100%) to 75% (IQR 38%–100%; p = .0194). After 6 months of BAT, mean systolic and diastolic office BP (‐21 ± 25 mmHg and ‐9 ± 15 mmHg; p < .0001 and .0004) as well as 24 h‐ABP dropped significantly (‐9 ± 17 mmHg and ‐5 ± 12 mmHg; p = .0049 and .0280). After 6 months of BAT, 21 patients (60%) could be classified as responders. There was neither significant difference in mean office systolic (‐21 ± 23 mmHg vs. ‐21 ± 28 mmHg; p = .9581) nor in 24 h‐systolic ABP decrease (‐11 ± 19 mmHg vs. ‐7 ± 15 mmHg; p = .4450) comparing adherent and non‐adherent patients. Whereas Antihypertensive Therapeutic Index (ATI) was unchanged in non‐responders, it significantly decreased in responders (from 50 ± 16 to 46 ± 16; p = .0477). These data are the first to show that BAT‐initiation leads to a clear BP reduction independently of patients´ medication adherence. Response to BAT is associated with a significant lowering of ATI, which might contribute to an underestimation of BAT efficacy.

Effectiveness of a Pharmacist-Led Web-Based Medication Adherence Tool With Patient-Centered Communication: Results of a Clustered Randomized Controlled Trial

Background

Growing numbers of people use medication for chronic conditions; nonadherence is common, leading to poor disease control. A web-based tool to identify an increased risk for nonadherence with related potential individual barriers might facilitate tailored interventions and improve adherence.

Objective

This study aims to assess the effectiveness of a newly developed tool aimed at improving medication adherence.

Methods

We performed a cluster randomized controlled trial in patients initiating cardiovascular or oral blood glucose–lowering medication. Participants were recruited from community pharmacies. They completed an online questionnaire comprising assessments of their risk for medication nonadherence and subsequently of barriers to adherence. In pharmacies belonging to the intervention group, individual barriers displayed in a graphical profile on a tablet were discussed by pharmacists and patients with high nonadherence risk in face-to-face meetings and shared with their general practitioners and practice nurses. Tailored interventions were initiated by pharmacists. Barriers of control patients were not presented nor discussed and these patients received usual care. The primary outcome was the effectiveness of the intervention on medication adherence at 8 months’ follow-up between patients with an increased nonadherence risk from the intervention and control groups, calculated from dispensing data.

Results

Data from 492 participants in 15 community pharmacies were available for analyses (intervention 253, 7 pharmacies; control 239, 8 pharmacies). The intervention had no effect on medication adherence (B=–0.01; 95% CI –0.59 to 0.57; P=.96), nor in the post hoc per-protocol analysis (B=0.19; 95% CI –0.50 to 0.89; P=.58).

Conclusions

This study showed no effectiveness of a risk stratification and tailored intervention addressing personal barriers for medication adherence. Various potential explanations for lack of effectiveness were identified. These explanations relate, for instance, to high medication adherence in the control group, study power, and fidelity. Process evaluation should elicit possible improvements and inform the redesign of intervention and implementation.

Trial Registration

The Netherlands National Trial Register NTR5186; https://tinyurl.com/5d8w99hk

A Cross-Sectional Study on Hypertension Medication Adherence in a High-Burden Region in Namibia: Exploring Hypertension Interventions and Validation of the Namibia Hill-Bone Compliance Scale

In Namibia, the prevalence of hypertension among women and men aged 35−64 years is high, ranging from 44% to 57%. In this study, we aimed to determine adherence and predictors to antihypertensive therapy in Khomas region, Namibia. A cross-sectional study was performed to consecutively sample 400 patients from urban and peri-urban settings in Namibia. Results were validated using the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Crude associations between predictors of adherence and compliance were tested using the Pearson chi-square test. A multivariable logistic regression analysis was then performed on adherence variables found to be significant to adjust for confounders, and the results are presented as adjusted odds ratios (aOR) with 95% confidence intervals. A total of 400 patients participated in this study. The participants’ mean age and standard deviation were Mean ± SD = 48.9 ± 12.5. In this study, 351 (87.7%) patients were estimated to have good adherence. Education, employment, and the presence of other chronic diseases were associated with adherence. Following multivariate adjustment, the following factors were significantly associated and are therefore predictors of adherence (95%CI, p < 0.005): receiving enough medication at last check-up until next one (OR = 5.44, CI 1.76−16.85), lack of encouragement from family and friends (OR = 0.11 (0.03−0.42)), and attendance of follow-ups on schedule (OR = 8.49, CI = 3.82−18.85). The success of hypertension therapy is dependent on the healthcare systems and healthcare professionals in supplying enough medication, support of friends/family, and maintaining scheduled follow-ups. A combination of interventions using low-cost mobile technology led by healthcare professionals could be endorsed. To fully practice universal access to medication, public and private hospitals in Namibia should collaborate.

The Contribution of Gut Microbiota and Endothelial Dysfunction in the Development of Arterial Hypertension in Animal Models and in Humans

The maintenance of the physiological values of blood pressure is closely related to unchangeable factors (genetic predisposition or pathological alterations) but also to modifiable factors (dietary fat and salt, sedentary lifestyle, overweight, inappropriate combinations of drugs, alcohol abuse, smoking and use of psychogenic substances). Hypertension is usually characterized by the presence of a chronic increase in systemic blood pressure above the threshold value and is an important risk factor for cardiovascular disease, including myocardial infarction, stroke, micro- and macro-vascular diseases. Hypertension is closely related to functional changes in the endothelium, such as an altered production of vasoconstrictive and vasodilator substances, which lead to an increase in vascular resistance. These alterations make the endothelial tissue unresponsive to autocrine and paracrine stimuli, initially determining an adaptive response, which over time lead to an increase in risk or disease. The gut microbiota is composed of a highly diverse bacterial population of approximately 10¹⁴ bacteria. A balanced intestinal microbiota preserves the digestive and absorbent functions of the intestine, protecting from pathogens and toxic metabolites in the circulation and reducing the onset of various diseases. The gut microbiota has been shown to produce unique metabolites potentially important in the generation of hypertension and endothelial dysfunction. This review highlights the close connection between hypertension, endothelial dysfunction and gut microbiota.

A Critical Review of Medication Adherence in Hypertension: Barriers and Facilitators Clinicians Should Consider

Hypertension is a global public health problem, and its prevalence is increasing worldwide. Impacting all human societies and socioeconomic strata, it remains the major modifiable risk factor for global burden of cardiovascular disease all-cause mortality and the leading cause of loss of disability-adjusted life years. Despite increased awareness, the rate of blood pressure control remains unsatisfactory, particularly in low- to middle-income countries. Apparent treatment-resistant hypertension is associated with worse adverse health outcomes. It includes both true resistant and pseudo-resistant hypertension, which requires out-of-office blood pressure monitoring to exclude white-coat effect and confirmation of adherence to the agreed recommended antihypertensive therapy. The depth of medication non-adherence remains poorly recognized among medical practitioners, thus presenting an underestimated modifiable risk factor. Medication non-adherence is a complex and multidimensional variable with three quantifiable phases: initiation, implementation, and discontinuation, collectively called persistence. Non-adherence can be both intentional and non-intentional and usually involves several interconnected factors. Persistence declines over time in the treatment of chronic diseases like hypertension. The risk is higher in patients with new diagnosis, poor insurance status, polypharmacy, and multiple comorbidities, particularly psychiatric disorders. The World Health Organization divides the contributing factors impacting adherence into five categories. Screening and detection for medication non-adherence are challenging due to its dynamic nature and potential white-coat effect. Easy-to-conduct screening methods have low reliability and validity, whereas more reliable and valid methods are costly and difficult to perform. Medication non-adherence is associated with poor clinical outcome and potential negative impact on health-care costs. Evaluation of adherence should become an integral part of assessment of patients treated for hypertension. Medication adherence can significantly improve with a patient-centered approach, non-judgmental communication skills, and collaborative multidisciplinary management, including engagement of the patients in their care by self-blood pressure monitoring.

Catheter-Based Renal Denervation Therapy: Evolution of Evidence and Future Directions

Motivated by the persistence of uncontrolled blood pressure and its public health impact, the development and evaluation of device-based therapies for hypertension has advanced at an accelerated pace to complement pharmaceutical and lifestyle intervention strategies. Countering widespread interest from early studies, the lack of demonstrable efficacy for renal denervation (RDN) in a large, sham-controlled randomized trial motivated revision of trial design and conduct to account for confounding variables of procedural technique, medication variability, and selection of both patients and end points. Now amidst varied trial design and methods, several sham-controlled, randomized trials have demonstrated clinically meaningful reductions in blood pressure with RDN. With this momentum, additional studies are underway to position RDN as a potential part of standard therapy for the world's leading cause of death and disability. In parallel, further studies will address unresolved issues including durability of blood pressure lowering and reduction in antihypertensive medications, late-term safety, and impact on clinical outcomes. Identifying predictors of treatment effect and surveys of patient-reported outcomes and treatment preferences are also evolving areas of investigation. Aside from confirmatory studies of safety and effectiveness, these additional studies will further inform patient selection, expand experience with RDN in broader populations with hypertension, and provide guidance to how RDN may be incorporated into treatment pathways.

Clinical characteristics, practice patterns, and outcomes of patients with acute severe hypertension visiting the emergency department

OBJECTIVES

Data regarding acute severe hypertension, a life-threatening condition encountered in the emergency department, are limited. We aimed to identify the characteristics, practice patterns, and outcomes of patients with acute severe hypertension in the emergency department.

METHODS

This cross-sectional study at a tertiary referral centre included patients aged at least 18 years who were admitted to the emergency department between January 2016 and December 2019 for acute severe hypertension, which was defined as SBP at least 180 mmHg and/or DBP at least 100 mmHg.

RESULTS

Of 172 105 patients who visited the emergency department, 10 219 (5.9%) had acute severe hypertension. Of them, 2506 (24.5%) patients had acute hypertension-mediated organ damage (HMOD), and these patients had more cardiovascular risk factors than did patients without HMOD. Additionally, 4137 (40.5%) patients were admitted, and nine (0.1%) died in the emergency department. The overall 3-month, 1-year, and 3-year mortality rates were 4.8, 8.8, and 13.9%, respectively. In patients with HMOD, the 1-year mortality rate was 26.9%, and patients lost to follow-up had a significantly higher 1-year mortality rate than those who were followed up (21.3 vs. 10.5%, respectively, P < 0.001).

CONCLUSION

The mortality rate in patients with acute severe hypertension in the emergency department is high, especially in patients with HMOD. Evaluation of HMOD, investigating the underlying causes, and adequate follow-up are mandatory to improve the outcomes in these patients. This study emphasizes the need for disease-specific guidelines that include detailed acute treatment strategies and follow-up management for acute severe hypertension.

Clinical Impact of the Maximum Mean Value of Home Blood Pressure on Cardiovascular Outcomes: A Novel Indicator of Home Blood Pressure Variability

[Figure: see text].

Assessment of a strategy combining ambulatory blood pressure, adherence monitoring and a standardised triple therapy in resistant hypertension

PURPOSE

Poor adherence to drug therapy and inadequate drug regimens are two frequent factors responsible for the poor blood pressure (BP) control observed in patients with apparent resistant hypertension. We evaluated the efficacy of an antihypertensive management strategy combining a standardised therapy with three long acting drugs and electronic monitoring of drug adherence in patients with apparent resistant hypertension.

MATERIALS AND METHODS

In this multicentric observational study, adult patients with residual hypertension on 24 h ambulatory BP monitoring (ABMP) despite the use of three or more antihypertensive drugs could be included. Olmesartan/amlodipine (40/10 mg, single pill fixed-dose combination) and chlorthalidone (25 mg) were prescribed for 3 months in two separated electronic pills boxes (EPB). The primary outcome was 24 h ambulatory systolic BP (SBP) control at 3 months, defined as mean SBP <130 mmHg.

RESULTS

We enrolled 48 patients (36.0% women) of whom 35 had complete EPB data. After 3 months, 52.1% of patients had 24 h SBP <130 mmHg. 24 h SBP decreased by respectively -9.1 ± 15.5 mmHg, -22.8 ± 30.6 mmHg and -27.7 ± 16.6 mmHg from the tertile with the lowest adherence to the tertile with the highest adherence to the single pill combination (p = 0.024). A similar trend was observed with tertiles of adherence to chlorthalidone. Adherence superior to 90% was associated with 24 h systolic and diastolic blood pressure control in multiple logistic regression analysis (odds ratio = 14.1 (95% confidence interval 1.1-173.3, p = 0.039).

CONCLUSIONS

A simplified standardised antihypertensive therapy combined with electronic monitoring of adherence normalises SBP in about half of patients with apparent resistant hypertension. Such combined management strategy enables identifying patients who need complementary investigations and those who rather need a long-term support of their adherence.

Non-adherence to antidiabetic and cardiovascular drugs in type 2 diabetes mellitus and its association with renal and cardiovascular outcomes: A narrative review

Cardiovascular and renal complications are a major burden for individuals with type 2 diabetes mellitus (T2DM). Besides lifestyle interventions, current guidelines recommend combination drug therapy to prevent or delay the incidence and progression of comorbidities. However, non-adherence to pharmacotherapy is common in chronic conditions such as T2DM and a barrier to successful disease management. Numerous studies have associated medication non-adherence with worse outcome as well as higher health care costs. This narrative review provides (i) an overview on adherence measures used within and outside research settings, (ii) an estimate on the prevalence of non-adherence to antidiabetic and cardiovascular drugs in T2DM, and (iii) specifically focuses on the association of non-adherence to these drugs with renal and cardiovascular outcomes.

The effect of the mobile "blood pressure management application" on hypertension self-management enhancement: a randomized controlled trial

BACKGROUND

Self-management of hypertension is of great significance given its increasing incidence and its associated disabilities. In view of the increased use of mobile health in medicine, the present study evaluated the effect of a self-management application on patient adherence to hypertension treatment.

METHODS

This clinical trial was performed on 120 hypertensive patients who were provided with a mobile intervention for 8 weeks and followed up until the 24th week. Data on the primary outcome (adherence to treatment) and secondary outcomes (adherence to the DASH diet, regular monitoring of blood pressure, and physical activity) were collected using a questionnaire and a mobile application, respectively. The inter-group change difference over time was analyzed using repeated measures ANOVA (general linear model).

RESULTS

The treatment adherence score increased by an average of 5.9 (95% CI 5.0-6.7) in the intervention group compared to the control group. The scores of "adherence to the low-fat and low-salt diet plans" were 1.7 (95% CI 1.3-2.1) and 1.5 (95% CI 1.2-1.9), respectively. Moreover, moderate physical activity increased to 100.0 min (95% CI 61.7-138.3) per week in the intervention group.

CONCLUSION

The treatment and control of blood pressure require a multifaceted approach given its complexity and multifactorial nature. Considering the widespread use of smartphones, mHealth interventions can be effective in self-management and better patient adherence to treatments. Our results showed that this application can be used as a successful tool for hypertension self-management in patients attending public hospitals in developing countries.

TRIAL REGISTRATION

Iran Randomized Clinical Trial Center IRCT2015111712211N2 . Registered on 1 January 2016.

Apparent treatment resistant hypertension and the risk of recurrent cardiovascular events and mortality in patients with established vascular disease

AIM

To quantify the relation between apparent treatment resistant hypertension (aTRH) and the risk of recurrent major adverse cardiovascular events (MACE including stroke, myocardial infarction and vascular death) and mortality in patients with stable vascular disease.

METHODS

7455 hypertensive patients with symptomatic vascular disease were included from the ongoing UCC-SMART cohort between 1996 and 2019. aTRH was defined as an office blood pressure ≥140/90 mmHg despite treatment with ≥3 antihypertensive drugs including a diuretic. Cox proportional hazard models were used to quantify the relation between aTRH and the risk of recurrent MACE and all-cause mortality. In addition, survival for patients with aTRH was assessed, taking competing risk of non-vascular mortality into account.

RESULTS

A total of 1557 MACE and 1882 deaths occurred during a median follow-up of 9.0 years (interquartile range 4.8-13.1 years). Compared to patients with non-aTRH, the 614 patients (8%) with aTRH were at increased risk of cardiovascular mortality (HR 1.27; 95% CI 1.03-1.56) and death from any cause (HR 1.25; 95% CI 1.07-1.45) but not recurrent MACE (HR 1.13; 95% CI 0.95-1.34). At the age of 50 years, patients with aTRH after a first cardiovascular event on average had a 6.4 year shorter median life expectancy free of recurrent MACE than patients with non-aTRH.

CONCLUSION

In hypertensive patients with clinically manifest vascular disease, aTRH is related to a higher risk of vascular death and death from any cause. Moreover, patients with aTRH after a first cardiovascular event have a 6.4 year shorter median life expectancy free of recurrent cardiovascular disease.

Hypertension: Current trends and future perspectives

Hypertension is a significant and increasing global health issue. It is a leading cause of cardiovascular disease and premature death worldwide due to its effects on end organs, and through its associations with chronic kidney disease, diabetes mellitus and obesity. Despite current management strategies, many patients do not achieve adequate blood pressure (BP) control. Hypertension-related cardiovascular mortality rates are rising in tandem with the increasing global prevalence of chronic kidney disease, diabetes mellitus and obesity. Improving BP control must therefore be urgently prioritised. Strategies include utilising existing antihypertensive agents more effectively, and using treatments developed for co-existing conditions (such as sodium-glucose cotransporter 2 inhibitors for diabetes mellitus) that offer additional BP-lowering and cardiovascular benefits. Additionally, novel therapeutic agents that target alternative prohypertensive pathways and that offer broader cardiovascular protection are under development, including dual angiotensin receptor-neprilysin inhibitors. Nonpharmacological strategies such as immunotherapy are also being explored. Finally, advancing knowledge of the human genome and molecular modification technology may usher in an exciting new era of personalised medicine, with the potential to revolutionise the management of hypertension.

Adherence to antihypertensive medication after referral to secondary healthcare: A prospective cohort study

BACKGROUND

Nonadherence (NAd) to antihypertensive medication is associated with lack of blood pressure control and worsened long-term outcomes. Increased access to a programme for high-risk cardiovascular patients has the potential to reduce NAd and improve clinical outcomes. We evaluated implementation NAd prevalence and risk factors among severely hypertensive patients after 12-month-long access to secondary healthcare centres.

METHODS

The Morisky Green Levine Scale (MGLS) was used to analyse antihypertensive medication NAd in a prospective cohort of 485 patients. Logistic regression models evaluated the influence of ecological model factors on NAd.

RESULTS

The majority of patients were female, had low health literacy, a low family income and a mean age of 61.8 ± 12.5 years. Prevalence of NAd fell from 57.1% at programme entry to 28.3% (P < .001) at the end of the study. After access to a secondary healthcare centre, we observed better blood pressure control, an increase in the number of pills/day and a higher number of antihypertensive medications. Predictive variables of NAd were age (OR 1.027; CI 1.003-1.051; P = .023), low health literacy (OR 1.987; CI 1.009-3.913; P = .047), systolic blood pressure (OR 1.010; CI 1.003-1.021; P = .049), dosages ≥ 2 times/day (OR 1.941; CI 1.091-3.451; P = .024) and patient satisfaction with the healthcare team (OR 0.711; IC 0.516-0.980; P = .037).

CONCLUSIONS

Greater access to health services is associated with a reduction in NAd to antihypertensive medication and better blood pressure control. NAd was correlated with modifiable variables such as treatment complexity and, for the first time, team satisfaction, suggesting that implementation of similar programmes may limit NAd in similar patient groups.

The prevalence and associated factors of nonadherence to antihypertensive medication in secondary healthcare

PURPOSE

Non-adherence (NA) to medication is a major contributor to treatment failure in hypertensive patients. Factors of the ecological model, at family/healthcare professional, service, and system levels, are rarely evaluated as correlates of NA in hypertensive patients.

METHODS

This crossectional study assessed the prevalence of and associated factors of NA to antihypertensive medication among 485 hypertensive patients upon receiving secondary healthcare. The Morisky Green Levine Scale (MGLS) measured the implementation phase of adherence, and the Short Assessment of Health Literacy for Portuguese-speaking Adults (SAHLPA) instrument, health literacy. Multivariate analysis to NA included variables according to the levels of the ecological model.

RESULTS

Most patients were female (56.3%), white (53.2%), mean age of 62.0 ± 12.6 years, illiterate (61.6%), with low health literacy (70.9%), and low income (65.4%). Uncontrolled BP was frequent (75.2%); 57.1% of patients were nonadherent. In multivariate analysis based on the ecological model, adjusted for micro, meso- and macro-level correlates, NA was associated only with variables of patient-level: low health literacy (OR 1.62, CI 1.07-2.44, p = 0.020), income ≥ two reference wages (OR 0.46, CI 0.22-0.93, p = 0.031), lack of homeownership (OR 1.99, CI 1.13-3.51, p = 0.017), sedentarism (OR 1.78, CI 1.12-2.83, p = 0.014), and complexity of treatment (number of medications taken ≥ two times/day) (OR 1.56, CI 1.01-2.41, p = 0.042).

CONCLUSION

In this group of severely hypertensive patients with high cardiovascular risk, only patient-related characteristics were associated with NA. Our findings highlight the need for effective actions to optimize clinical outcomes in similar healthcare programs.

Ambulatory Blood Pressure Monitoring to Predict Response to Renal Denervation: A Post Hoc Analysis of the RADIANCE-HTN SOLO Study

Renal denervation (RDN) is effective in lowering blood pressure (BP) in patients with hypertension. The issue remains how to best identify potential responders. Ambulatory BP monitoring may be useful. Baseline nighttime systolic BP (SBP) ≥136 mm Hg and its variability (SD) ≥12 mm Hg in DENER-HTN trial or 24-hour heart rate ≥73.5 bpm in SPYRAL HTN-OFF MED Trial were shown to predict the BP response to RDN. We applied these criteria to the patients with hypertension in the sham-controlled RADIANCE-HTN SOLO trial to predict the BP response to ultrasound RDN at 2 months while patients were maintained off medications. BP responders were defined as: clinical with 24-hour SBP <130 mm Hg (RDN: 22/64 versus sham: 7/58); meaningful with 24-hour SBP reduction ≥10 mm Hg (RDN: 24/64, sham: 7/58); and extreme with 24-hour SBP reduction above mean+2 SD of the SBP decrease in the sham group, that is, ≥16.5 mm Hg (RDN: 10/64 versus sham: 2/58). The predictive criteria reported above were tested for sensitivity, specificity, and positive and negative predictive values. The predictive value varied according to the definition of response, with the clinical definition being strongly influenced by regression to the mean. Baseline nighttime SBP and its variability, especially when combined, offered good specificity (>90% irrespective of definition) but low sensitivity (from 9.1% to 30% depending on the definition) to predict responders; the heart rate criterion had insufficient predictive value. This analysis suggests the potential role of nighttime SBP and its variability to predict BP response to RDN in patients with hypertension. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02649426.

Arterial Stiffness, Cognitive Dysfunction and Adherence to Antihypertensive Agents. Is there a Link to Hypertensive Patients?

The incidence of hypertension (HTN) and its cardiovascular (CV) complications are increasing throughout the world. Blood pressure (BP) control remains unsatisfactory worldwide. Medical inertia and poor adherence to treatment are among the factors that can partially explain, why BP control rate remains low. The introduction of a method for measuring the degree of adherence to a given medication is now a prerequisite. Complex treatment regimes, inadequate tolerance and frequent replacements of pharmaceutical formulations are the most common causes of poor adherence. In contrast, the use of stable combinations of antihypertensive drugs leads to improved patient adherence. We aim to review the relationships between arterial stiffness, cognitive function and adherence to medication in patients with HTN. Large artery stiffening can lead to HTN. In turn, arterial stiffness induced by HTN is associated with an increased CV and stroke risk. In addition, HTN can induce disorders of brain microcirculation resulting in cognitive dysfunction. Interestingly, memory cognitive dysfunction leads to a reduced adherence to drug treatment. Compliance with antihypertensive treatment improves BP control and arterial stiffness indices. Early treatment of arterial stiffness is strongly recommended for enhanced cognitive function and increased adherence.

Mediating Effect of Self-Efficacy on the Relationship Between Medication Literacy and Medication Adherence Among Patients With Hypertension

Background: Studies have reported that medication literacy had a positive effect on medication adherence in patients with hypertension. However, little is known about the mechanism underlying this relationship in patients with hypertension. Objective: The purpose of this study was to investigate the mediating effect of self-efficacy between medication literacy and medication adherence. Methods: A total of 790 patients with hypertension were investigated using the Chinese Medication Literacy Scale for Hypertensive Patients (C-MLSHP), the Morisky Medication Adherence Scale-8 (MMAS-8) and the Medication Adherence Self-efficacy Scale-Revision (MASES-R). Hierarchical regression and the bootstrap approach were used to analyze the mediating effect of self-efficacy on the relationship between medication literacy and medication adherence. Results: A total of 60.9% of hypertensive patients were low adherent to their antihypertensive drug regimens. Self-efficacy had a significant positive correlation with medication literacy (r= 0.408, p < 0.001) and medication adherence (r = 0.591, p < 0.001). Self-efficacy accounts for 28.7% of the total mediating effect on the relationship between medication literacy and adherence to antihypertensive regimens for hypertensive patients. Conclusion: More than half of the hypertensive patients in the study were low adherent to antihypertensive regimens. Self-efficacy had a partial significant mediating effect on the relationship between medication literacy and medication adherence. Therefore, it was suggested that hypertensive patients' medication adherence might be improved and driven by increasing self-efficacy. Targeted interventions to improve patients' self-efficacy should be developed and implemented. In addition, health care providers should also be aware of the importance of medication literacy assessment and promotion in patients with hypertension.

Plasma Trough Concentrations of Antihypertensive Drugs for the Assessment of Treatment Adherence: A Meta-Analysis

Supplemental Digital Content is available in the text.

Biochemical drug screening by liquid chromatography-tandem mass spectrometry in plasma is an accurate method for the quantification of plasma concentrations of antihypertensive medications in patients with hypertension. Trough concentrations could possibly be used as drug-specific cutoff values in the biochemical assessment of (non-)adherence. We performed a literature review and meta-analysis of pharmacokinetic studies to determine plasma trough concentrations of amlodipine, hydrochlorothiazide, and valsartan. PubMed was searched for pharmacokinetic studies up to September 2020. Eligible studies reported steady-state mean trough concentration and their variance. Pooled trough concentrations were estimated using a three-level random effects meta-analytic model. Moderator analyses were performed to explore sources of heterogeneity. One thousand three hundred eighteen potentially relevant articles were identified of which 45 were eligible for inclusion. The pooled mean trough concentration was 9.2 ng/mL (95% CI, 7.5–10.8) for amlodipine, 41.0 ng/mL (95% CI, 17.4–64.7) for hydrochlorothiazide, and 352.9 ng/mL (95% CI, 243.5–462.3) for valsartan. Substantial heterogeneity was present for all 3 pooled estimates. Moderator analyses identified dosage as a significant moderator for the pooled trough concentration of amlodipine (β₁=0.9; P<0.05), mean age, and mean body weight for the mean trough concentration of hydrochlorothiazide (β₁=2.2, P<0.05, respectively, β₁=−4.0, P<0.05) and no significant moderators for valsartan. Plasma trough concentrations of amlodipine, hydrochlorothiazide, and valsartan, measured with liquid chromatography-tandem mass spectrometry, are highly heterogeneous over the different studies. Use of the pooled trough concentration as a cutoff in the biochemical assessment of adherence can result in inaccurate diagnosis of (non-)adherence, which may seriously harm the patient-physician relationship, and is therefore not recommended.

Is there any Hope for Monitoring Adherence in an Efficient and Feasible Way for Resistant Hypertension Diagnosis and Follow-Up?

PURPOSE OF REVIEW

Non-adherence to antihypertensive treatment is highly prevalent and represents a major factor affecting their effectiveness in hypertensive patients, thus contributing to apparent treatment resistance. It is however often overlooked because the methods to assess non-adherence are mainly subjective, limiting their usefulness in clinical practice. Non-adherence to treatment affects daily patient management, resulting in inappropriate, costly, and potentially harmful treatments and loss of the expected benefits from antihypertensive drugs.

RECENT FINDINGS

Specialized centers now use a combination of objective screening tools. Firstly, snapshots of adherence levels can be provided by analytical drug detection in various biological matrixes using liquid chromatography-tandem mass spectrometry (LC-MS/MS) and secondly electronic monitoring systems of drug delivery which provide longitudinal data on adherence. Routine utilization of those tools allows the detection of non-adherence in patients with resistant hypertension, thus enabling implementation of appropriate interventions to improve drug adherence and avoid unnecessary treatment intensification. Other complementary techniques, such as digital health feedback system with ingestible sensors, are currently evaluated. In the context of an increasing burden of uncontrolled and apparent treatment-resistant hypertension, detecting non-adherence to antihypertensive therapy is, as acknowledged by the latest guidelines, a top priority to implement in clinical practice but still faces medical conservatism and disbelief.

State and Regional Variation in Prescription- and Payment-Related Promoters of Adherence to Blood Pressure Medication

INTRODUCTION

Medication adherence can improve hypertension management. How blood pressure medications are prescribed and purchased can promote or impede adherence.

METHODS

We used comprehensive dispensing data on prescription blood pressure medication from Symphony Health's 2017 Integrated Dataverse to assess how prescription- and payment-related factors that promote medication adherence (ie, fixed-dose combinations, generic formulations, mail order, low-cost or no-copay medications) vary across US states and census regions and across the market segments (grouped by patient age, prescriber type, and payer type) responsible for the greatest number of blood pressure medication fills.

RESULTS

In 2017, 706.5 million prescriptions for blood pressure medication were filled, accounting for $29.0 billion in total spending (17.0% incurred by patients). As a proportion of all fills, factors that promoted adherence varied by state: fixed-dose combinations (from 5.8% in Maine to 17.9% in Mississippi); generic formulations (from 95.2% in New Jersey to 98.4% in Minnesota); mail order (from 4.7% in Rhode Island to 14.5% in Delaware); and lower or no copayment (from 56.6% in Utah to 72.8% in California). Furthermore, mean days' supply per fill (from 43.1 in Arkansas to 63.8 in Maine) and patient spending per therapy year (from $38 in Hawaii to $76 in Georgia) varied. Concentration of adherence factors differed by market segment. Patients aged 18 to 64 with a primary care physician prescriber and Medicaid coverage had the lowest concentration of fixed-dose combination fills, mean days' supply per fill, and patient spending per therapy year. Patients aged 65 years or older with a primary care physician prescriber and commercial insurance had the highest concentration of fixed-dose combinations fills and mail order fills.

CONCLUSION

Addressing regional and market segment variation in factors promoting blood pressure medication adherence may increase adherence and improve hypertension management.

Renin Angiotensin System Inhibitors Reduce Aortic Stiffness and Flow Reversal After a Cryptogenic Stroke

BACKGROUND

Blood flow reversal is a possible mechanism for retrograde embolism in the setting of high-risk atherosclerotic plaques in the descending aorta (DAo). Evidence suggests that pulse wave velocity (PWV) is a determinant of blood flow reversal and can be reduced by the destiffening effect of renin-angiotensin system inhibitors (RASI).

PURPOSE

To evaluate the impact of antihypertensive therapy on in vivo changes in PWV and flow reversal in patients with cryptogenic stroke.

STUDY TYPE

Prospective.

POPULATION

Sixteen patients (69 ± 9 years; 10 males) included after cryptogenic stroke.

FIELD STRENGTH/SEQUENCE

3T. 4D flow sequence (temporal resolution = 19.6 msec) ASSESSMENT: Patients underwent aortic MRI at baseline and at 6-month follow-up. Patients received standard-of-care antihypertensive therapy that were classified as RASI vs. non-RASI medications (ie, destiffening vs. nondestiffening).We compared aortic PWV, flow reversal fraction (FRF), aortic measurements, cardiac function, and other aortic and cardiac measurements in the antihypertensive therapy groups.

STATISTICAL TESTS

Two-tailed paired or unpaired Student's t-tests (normal distributions) or Wilcoxon tests (nonnormal distribution). Univariate correlations using Pearson correlation coefficients.

RESULTS

There was a significant decrease in PWV in the RASI (n = 10) group (9.4 ± 1.6 m/s vs. 8.3 ± 1.9 m/s; P < 0.05), as well as FRF (18.6% ± 4.1% vs. 16.3% ± 4.0%; P < 0.05) between baseline and the 6-month MRI studies. There were no changes in PWV or FRF in the non-RASI (n = 6) group (P = 0.146 and P = 0.32). A decrease in FRF was significantly correlated with a decrease in PWV (r = 0.53; P < 0.05).

DATA CONCLUSION

The findings of our study suggest that RASI therapy after cryptogenic stroke resulted in a decrease of blood flow reversal and aortic stiffness.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY STAGE: 4.

Effectiveness of a Multidisciplinary Approach Intervention to Improve Blood Pressure Control Among Elderly Hypertensive Patients in Rural Thailand: A Quasi-Experimental Study

Purpose

Uncontrolled blood pressure among Thai elderly hypertensive patients is a significant public health issue in primary health care facilities under the Universal Health Coverage Scheme in Thailand. This study examines the effectiveness of a multidisciplinary approach intervention to improve blood pressure control among elderly persons in rural Thailand.

Patients and Methods

This was quasi-experimental study conducted on 200 elderly persons who receive care for hypertension at primary health care facility in rural areas of Thailand. Participants were assigned to either the intervention or control groups. The intervention group was subjected to a multidisciplinary approach intervention program. This program included community-based care for hypertension, family-supportive care for hypertension, antihypertension medication adherence education program, the use of a reminder electronic pill box, and monthly pill counts and blood pressure measurements. The intervention continued for three months. The control group received care for hypertension at the hypertension clinic of the health center. Three measurements were taken at baseline, one month, and three months after the intervention. Data analysis included descriptive statistics and independent sample t-tests. Repeated-measure analysis of variance (ANOVA) and analysis of covariance (ANCOVA) were used to compare the differences between the two groups.

Results

At one month and three months after the intervention, the multidisciplinary approach intervention controlled blood pressure more effectively compared with the control group. Furthermore, the intervention group had lower systolic and diastolic blood pressure compared with the control group (P-value < 0.001).

Conclusion

These results suggest that the multidisciplinary approach intervention can be effective in controlling blood pressure in elderly hypertensive patients. Future studies should investigate a cost-effective means of integrating multidisciplinary approach interventions in routine hypertension care for elderly hypertensive patients.

What hypertensive patients want to know [and from whom] about their disease: a two-year longitudinal study

Background

This study explored both the evolution of the information needs and the perceived relevance of different health information sources in patients with essential hypertension. It also investigated the relationships between information needs and the perceived relevance of information sources with socio-demographic and clinical variables.

Methods

Two hundred and two patients with essential arterial hypertension were enrolled in the study and evaluated at baseline and during three follow-ups at 6, 12 and 24 months after baseline. Patients had a mean age of 54.3 years [range 21–78; SD = 10.4], and 43% were women. Repeated measures ANOVA, Bonferroni post hoc tests, and Cochran’s Q Test were performed to test differences in variables of interest over time.

Results

It was observed a significant reduction in all the domains of information needs related to disease management except for pharmacological treatment and risks and complications. At baseline, patients reported receiving health information primarily from specialists, general practitioners, relatives, and television, but the use of these sources decreased over time, even if the decrease was significant only for relatives. Multiple patterns of relationships were found between information needs and the perceived relevance of sources of information and socio-demographics and clinical variables, both at baseline and over time.

Conclusions

The findings showed a general decrease in both the desire for information and the perceived relevance of different information sources. Hypertensive patients appeared to show little interest in health communication topics as their disease progressed. Understanding patients’ information needs and the perceived relevance of different information sources is the first step in implementing tailored communication strategies that can promote patients’ self-management skills and optimal clinical outcomes.

Assessment of the clinical efficacy of telemonitoring and distant counseling in patients with uncontrolled hypertension

The aim of the study was to investigate the mathematical correlation of the clinical efficacy of blood pressure telemonitoring and distant counseling (BPTM) in patients in uncontrolled hypertension (HTN). Telehealth tools are widely used in HTN management. However clinical efficacy of such interventions assessed mainly in groups investigated without its populational and attributable impact. Materials and methods. The total of 240 patients were included, then randomized in 2:1 manner to BPTM group (n=160, median age 47 y.o.) and control group (n=80, median age 49 y.o). The user - friendly and secure telehealth software was provided with mobile application (patients) and desktop (doctors) platforms which allowed storage and analysis of self-BP monitoring data and remote consultations. A three - month surveillance was designed with mandatory baseline and final face - to - face visits with the assessment of office systolic BP (oSBP). Mathematical evaluation was based on target SBP rates achieved in comparator groups and included the absolute efficacies (AE), the attributable efficacy (AtE), the relative efficacy (RE) and the population attributable efficacy (PAtE). Results. BPTM group characterized by larger decrease in SBP level compared with controls (-16.8±2.9 mm Hg versus -7.9±3.9 mm Hg; p

Adherence in Hypertension

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Telemonitoring and remote counseling in hypertensive patients. Looking for new ways to do old jobs

XXI century emphasized humanity to embrace the digital era after a reality of Third and Fourth Industrial Revolutions, nowadays dictating new terms of social networking. It is expected that information and communication technologies integrated with value-based medicine will significantly impact healthcare delivery to tremendous number of patients with socially important noncommunicable diseases. Cardiovascular illnesses comprise the greatest part of such pathologies. Hypertension (HTN) being the most prevalent cardiovascular disease is also the key modifiable cardiovascular risk factor yet seems to be an attractive target for both value-based concept and telehealth interventions. Present review addresses up-to-date science on telehealth, sets out the main well-known, but yet unsolved challenges in management of HTN along with the new approaches involving telemedicine programs, digital health outlooks. The main barriers of telehealth implementation are also considered along with the possible solutions.

[Assessment for antihypertensive drug intake in France in 2019 and adherence]

Non-adherence to antihypertensive treatment is one of the critical contributors to sub-optimal blood pressure control. The French Society of Hypertension remembered that urine and serum biochemical detection of antihypertensive drugs could be useful in a patient with resistant hypertension. Talking to a patient with biochemically confirmed non-adherence to blood pressure-lowering therapy and repeating them improved adherence to drugs. Despite its usefulness, biochemical detection of antihypertensive drugs is not routinely effective in France as they are not reimbursed by French Medical Care, except in patients attending hospitals. The list of blood pressure-lowering drugs able to be biochemically detected in France and their modalities are recorded here.

Emerging Drug Classes and Their Potential Use in Hypertension

Despite the availability of multiple antihypertensive drugs targeting the different pathways implicated in its pathophysiology, hypertension remains poorly controlled worldwide, and its prevalence is increasing because of the aging of the population and the obesity epidemic. Although nonadherence to treatment contributes to uncontrolled hypertension, it is likely that not all the pathophysiological mechanisms are neutralized by the various classes of antihypertensive treatment currently available, and, the counter-regulatory mechanisms triggered by these treatments may decrease their blood pressure–lowering effect. The development of new antihypertensive drugs acting on new targets, with different modes of action, therefore, remains essential, to improve blood pressure control and reduce the residual burden of cardiovascular risks further. However, the difficulties encountered in the conception, development, costs, and delivery to the market of new classes of antihypertensive agents highlights the hurdles that must be overcome to release and to evaluate their long-term safety and efficacy for hypertension only, especially because of the market pressure of cheap generic drugs. New chemical entities with blood pressure–lowering efficacy are thus being developed more for heart failure or diabetic kidney disease, 2 diseases pathophysiologically associated with hypertension. These include dual angiotensin II receptor-neprilysin inhibitors, soluble guanylate cyclase stimulators, nonsteroidal dihydropyridine-based mineralocorticoid receptor antagonists, as well as sodium-glucose cotransporter 2 inhibitors. However, centrally acting aminopeptidase A inhibitors and endothelin receptor antagonists have a dedicated program of development for hypertension. All these emergent drug classes and their potential use in hypertension are reviewed here.

Clinic Versus Ambulatory Blood Pressure in Resistant Hypertension: Impact of Antihypertensive Medication Nonadherence

Clinic-ambulatory blood pressure (BP) difference is influenced by patients- and device-related factors and inadequate clinic-BP measurement. We investigated whether nonadherence to antihypertensive medications may also influence this difference in a post hoc analysis of the DENERHTN trial (Renal Denervation for Hypertension). We pooled the data of 77 out of 106 evaluable patients with apparent resistant hypertension who received a standardized antihypertensive treatment and had both ambulatory BP and drug-screening results available at baseline after 1 month of standardized triple therapy and at 6 months on a median of 5 antihypertensive drugs. After drug assay samplings on study visits, patients took their antihypertensive treatment under supervision immediately after the start of the ambulatory BP recording, and supine clinic BP was measured 24 hours post-dosing; both allowed to calculate the clinic minus daytime ambulatory systolic BP (SBP) difference (clinic-SBP–day-SBP). A total of 29 (37.7%) were found nonadherent to medications at baseline and 38 (49.4%) at 6 months. At baseline, the mean clinic-SBP–day-SBP difference in the nonadherent group was 12.7 mm Hg (95% CI, 7.8–17.7 mm Hg, P <0.001). In contrast, clinic SBP was almost identical to day-SBP in the adherent group (clinic-SBP–day-SBP difference, 0.1 mm Hg; 95% CI, −3.3 to 3.5 mm Hg; P =0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mm Hg cutoff of clinic-SBP–day-SBP difference had 67% sensitivity and 69% specificity to predict nonadherence to the triple therapy at baseline. In conclusion, a large clinic-SBP–day-SBP difference may help discriminating between adherence and nonadherence to treatment in patients with resistant hypertension.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01570777.

Electronic Pill Bottles or Bidirectional Text Messaging to Improve Hypertension Medication Adherence (Way 2 Text): a Randomized Clinical Trial

BACKGROUND

Poor medication adherence contributes to inadequate control of hypertension. However, the value of adherence monitoring is unknown.

OBJECTIVE

To evaluate the impact of monitoring adherence with electronic pill bottles or bidirectional text messaging on improving hypertension control.

DESIGN

Three-arm pragmatic randomized controlled trial.

PATIENTS

One hundred forty-nine primary care patients aged 18-75 with hypertension and text messaging capabilities who were seen at least twice in the prior 12 months with at least two out-of-range blood pressure (BP) measurements, including the most recent visit.

INTERVENTIONS

Patients were randomized in a 1:2:2 ratio to receive (1) usual care, (2) electronic pill bottles for medication adherence monitoring (pill bottle), and (3) bidirectional text messaging for medication adherence monitoring (bidirectional text).

MAIN MEASURES

Change in systolic BP during the final 4-month visit compared with baseline.

KEY RESULTS

At the 4-month follow-up visit, mean (SD) change values in systolic blood pressure were - 4.7 (23.4) mmHg in usual care, - 4.3 (21.5) mmHg in the pill bottle arm, and - 4.6 (19.8) mmHg in the text arm. There was no significant change in systolic blood pressure between control and the pill bottle arm (p = 0.94) or the text messaging arm (p = 1.00), and the two intervention arms did not differ from each other (p = 0.93).

CONCLUSIONS

Despite good measured adherence, neither feedback with electronic pill bottles nor bidirectional text messaging about medication adherence improved blood pressure control. Adherence to prescribed medications was not improved enough to affect BP control or it was not the primary driver of poor control.

TRIAL REGISTRATION

clinicaltrials.gov (NCT02778542).

A Pilot Study to Evaluate the Acceptability of Using a Smart Pillbox to Enhance Medication Adherence Among Primary Care Patients

Smart pillboxes that remind patients to take medication may help avoid unintended non-adherence to medication regimens. To better understand the implementation potential of smart pillboxes among patients with chronic diseases, this study aimed to explore patients’ acceptability to use such devices and its associated factors. Five-hundred primary care patients aged 40 years or older were randomly recruited from a government-funded primary care clinic in Hong Kong. Patients were asked (i) if they needed to take medication daily, (ii) how many daily oral medications they needed to take on average, (iii) if they had ever missed a dose by accident, and (iv) if they were willing to use a smart pillbox for free to remind them to take medication. Out of the 344 participants included in the analysis who needed to take daily oral medication, 49.1% reported having previously missed a dose by accident, and 70.6% were willing to use a smart pillbox for free. A multiple logistic regression model found that male patients (adjusted odds ratio (aOR): 0.59) and patients with hypertension (aOR: 0.56) were less likely to have previously missed a dose by accident. Patients who needed to take a greater number of daily medications (aOR: 1.16), who had previously missed a dose by accident (aOR: 2.44), with heart disease (aOR: 3.67) and with a high monthly income (aOR: 2.30) were more willing to use a smart pillbox, while older patients (aOR: 0.95) were less willing to do so. Primary care patients who reported missing a dose by accident were 2.4 times as likely to want to use a smart pillbox while those with heart disease were almost 4 times as likely to want to use a smart pillbox. Further studies such as those evaluating the willingness to pay for smart pillboxes and randomised control trials to evaluate the effectiveness of smart pillboxes in enhancing medication adherence should be conducted to provide more evidence about the implementation potential of such devices.

Medication Adherence In Patients With Arterial Hypertension: The Relationship With Healthcare Systems' Organizational Factors

PURPOSE

Arterial hypertension is one of the most common diseases in the world, presenting a great impact on global mortality. Despite having good medication, the best control depends on patient's adherence. Our aim is to characterize the relationship of adherence to medication in hypertensive patients with consultation length and other organizational factors of healthcare systems.

PATIENTS AND METHODS

We performed a comprehensive review of literature using the MeSH terms "hypertension" and "medication adherence". 61 articles were selected for inclusion and adherence parameters were extracted, allowing us to estimate the mean adherence for each country. The adherence was then correlated with organizational aspects of healthcare systems: consultation length, number of health providers (doctors, nurses and pharmacists), number of hospital beds, health expenditure and general government expenditure.

RESULTS

Adherence to medication ranged between 11.8% in Indonesia and 85.0% in Australia. There is much heterogeneity in methodology, but the Morisky Medication Adherence Scale was the preferred method, used in 63.6% of the cases. We found no relation with consultation length, but a significant one with the greater number of health professionals available. Some differences were observed when considering European countries or Morisky Medication Adherence Scale alone.

CONCLUSION

The better the drugs, the better the control of blood pressure, if patients take them. Rather than investing in the prescription of more drugs, it is important to address non-adherence and reduce it to promote better blood pressure control. Organizational factors are relevant constraints and depend on administrative and political decisions. Although they are not always considered, they greatly impact the adherence to medication.