Withdrawal of antihypertensive medication: a systematic review

Hemp seed protein and its hydrolysate compared with casein protein consumption in adults with hypertension: a double-blind crossover study

BACKGROUND

The effects of consuming hemp seed protein (HSP) as well as its hydrolysate-derived bioactive peptide (HSP+) on blood pressure (BP) has not, to our knowledge, been investigated in humans.

OBJECTIVES

We aimed to investigate how consumption of HSP and its hydrolysate modulates 24-h systolic (SBP) and diastolic BP (DBP) and plasma biomarkers of BP compared with casein.

METHODS

In a double-blind, randomized, crossover design trial, 35 adults who had mild hypertension with SBP between 130 and 160 mmHg and DBP ≤110 mmHg were recruited. Participants were randomly assigned to varying sequences of 3 6-wk treatments, 50 g casein/d, 50 g HSP/d, or 45 g HSP plus 5 g HSP-derived bioactive peptides/d (HSP+), separated by a 2-wk washout period. Treatment effects were assessed with a linear mixed model with repeated measures.

RESULTS

Compared with casein, after HSP+ consumption, 24-h SBP and 24-h DBP decreased from 135.1 and 80.0 mmHg to 128.1 ± 1.6 (P < 0.0001) and 76.0 ± 1.4 mmHg (P < 0.0001), respectively, whereas these values were 133.5 ± 1.6 and 78.9 ± 1.4 mmHg after HSP consumption (P < 0.0001). There were no differences between the HSP and HSP+ consumption in plasma angiotensin-converting enzyme (ACE) activity, renin, or nitric oxide (NO) concentrations. However, these 2 treatments were able to lower both ACE and renin activities and raise NO concentration in plasma compared with casein.

CONCLUSIONS

These results suggest that hemp protein consumption, as well as in combination with bioactive peptides, may have a role in the dietary management of hypertension. This trial was registered at clinicaltrials.gov as NCT03508895.

Targets for deprescribing in patients with hypertension and reflex syncope

BACKGROUND

We aimed to identify the target of deprescribing, i.e. the 24-hour SBP increase needed to achieve the greatest reduction of SBP drops.

METHOD

Forty hypertensive patients (mean age 73.6 ± 9.3 years, 26 females) with reflex syncope and SBP drops on a screening ABPM were advised to withdraw or to reduce their therapy. The study objective was the reduction of SBP drops <90 mmHg and <100 mmHg on a second ABPM performed within 3 months.

RESULTS

Out of a total of 98 drugs taken during ABPM 1, 44 were withdrawn, 16 had a dose reduction and 38 remained unchanged at the time of ABPM 2. 24-hour SBP increased from 119.7 ± 10.1 mmHg to 129.4 ± 13.2 mmHg during ABPM2. Total disappearance of daytime SBP drops <100 mmHg was achieved in 20 (50 %) patients who had 24-hour SBP of 134±13 mmHg and an increase from ABPM 1 of 12 (IQR 5-20) mmHg. Compared with the 20 patients who had persistence of drops, these patients had a greater reduction of the number of hypotensive drugs (67 % versus 19 %, p = 0.002) and a greater rate of withdrawals (62 % versus 29 %, p = 0.003).

CONCLUSION

In hypertensive patients with reflex syncope, an increase of 12 mmHg and an absolute value of 24-hour SBP of 134 mmHg appear to represent the optimal goals aimed to prevent SBP drops. Drugs withdrawal, rather than simply dose reduction, is mostly required to achieve the above target.

Blood pressure and variability responses to the down-titration of antihypertensive drugs

OBJECTIVES

Several recent guidelines have proposed the gradual reduction of antihypertensive drugs for patients with well controlled blood pressure (BP). However, no studies have examined alterations in BP variability (BPV) during the down-titration of antihypertensives. This study aims to investigate changes in home BPV during the down-titration of antihypertensives.

METHODS

We analyzed 83 hypertensive patients who underwent down-titration of antihypertensives and had available home BP data during the down-titration. Down-titration was performed when home SBP was less than 120 mmHg, regardless of the clinic SBP. Primary exposure variable was the standard deviation (SD) of home BP.

RESULTS

Among 83 patients (mean age 66.3 ± 11.9 years; 45.8% men), down-titration led to increase home SBP (from 110.5 to 118.7 mmHg; P  < 0.001), and home DBP (from 68.8 to 72.8 mmHg; P  = 0.001) significantly. There were no significant differences in SDs of SBP [from 6.02 ± 3.79 to 5.76 ± 3.09 in morning, P  = 0.570; from 6.13 ± 3.32 to 6.63 ± 3.70 in evening, P  = 0.077; and from 6.54 (4.80, 8.31) to 6.37 (4.65, 8.76) in home SBP, P  = 0.464] and SDs of DBP during the down-titration of antihypertensive drugs.

CONCLUSION

Down-titration of antihypertensive drugs did not have notable impact on clinic BP and home BPV, while significantly increasing home BP. These findings provide important insights indicating that the potential concern related to an increase in BPV in the planned strategy of reducing antihypertensive drugs is not substantial.

Mechanism-based therapy of non-cardiac syncope: a practical guide

The term non-cardiac syncope includes all forms of syncope, in which primary intrinsic cardiac mechanism and non-syncopal transient loss of consciousness can be ruled out. Reflex syncope and orthostatic hypotension are the most frequent aetiologies of non-cardiac syncope. As no specific therapy is effective for all types of non-cardiac syncope, identifying the underlying haemodynamic mechanism is the essential prerequisite for an effective personalized therapy and prevention of syncope recurrences. Indeed, choice of appropriate therapy and its efficacy are largely determined by the syncope mechanism rather than its aetiology and clinical presentation. The two main haemodynamic phenomena leading to non-cardiac syncope include either profound hypotension or extrinsic asystole/pronounced bradycardia, corresponding to two different haemodynamic syncope phenotypes, the hypotensive and bradycardic phenotypes. The choice of therapy-aimed at counteracting hypotension or bradycardia-depends on the given phenotype. Discontinuation of blood pressure-lowering drugs, elastic garments, and blood pressure-elevating agents such as fludrocortisone and midodrine are the most effective therapies in patients with hypotensive phenotype. Cardiac pacing, cardioneuroablation, and drugs preventing bradycardia such as theophylline are the most effective therapies in patients with bradycardic phenotype of extrinsic cause.

Strategies for subtyping primary aldosteronism

Adrenal venous sampling (AVS) is a crucial method for the lateralization of primary aldosteronism (PA). It is advised to halt the use of the patient's antihypertensive medications and correct hypokalemia prior to undergoing AVS. Hospitals equipped to conduct AVS should establish their own diagnostic criteria based on current guidelines. If the patient's antihypertensive medications cannot be discontinued, AVS can be performed as long as the serum renin level is suppressed. The Task Force of Taiwan PA recommends using a combination of adrenocorticotropic hormone stimulation, quick cortisol assay, and C-arm cone-beam computed tomography to maximize the success of AVS and minimize errors by using the simultaneous sampling technique. If AVS is not successful, an NP-59 (131 I-6-β-iodomethyl-19-norcholesterol) scan can be used as an alternative method to lateralize PA. We depicted the details of the lateralization procedures (mainly AVS, and alternatively NP-59) and their tips and tricks for confirmed PA patients who would consider to undergo surgical treatment (unilateral adrenalectomy) if the subtyping shows unilateral disease.

De-escalating treatment indications for patients who achieve metabolic goals

INTRODUCTION

Robust evidence exists regarding initiation, intensification or modification of treatments. Recommendations to de-escalate therapy are lacking, specifically in diabetes. A successful treatment de-intensification reduces overtreatment, polypharmacy, and risk of adverse effects.

OBJECTIVE

To encompass current recommendations for deprescribing common drugs and create a consensus among health professionals.

METHODS

We reviewed four databases for deprescribing approaches published between 2010 and 2022. Articles were divided into different groups of drugs (for uric-acid, hypoglycemic, lipid-lowering, and psychotropic drugs).

RESULTS

Hypoglycemic agents: strategies were limited to newer agents and insulin regimens for elderly individuals. Reducing insulin was associated with 1.1% reduction of A1c over time. SGLT2i and GLP-1RAs dose reduction depends on adverse events. Lipid-lowering agents: studies show that patients with very low cholesterol have fewer cardiovascular events without associated increased risk. Antihypertensive agents: Younger patients, lower systolic blood pressure, and few comorbidities are ideal characteristics for discontinuation. Uric acid therapy: we found no recommendation for dose de-escalation. Poor treatment adherence is associated with episodes of gout and deforming arthritis in the long term.

CONCLUSION

Deprescribing hypoglycemic, statins, antihypertensives, and urate-lowering agents may be feasible in selected patients, but periodic surveillance is important. More evidence is necessary to support this decision entirely.

Interventions aimed to increase average 24-h systolic blood pressure reduce blood pressure drops in patients with reflex syncope and orthostatic intolerance

AIMS

Systolic blood pressure (SBP) drops recorded by 24-h ambulatory blood pressure (BP) monitoring (ABPM) identify patients with susceptibility to reflex syncope and orthostatic intolerance. We tested the hypothesis that treatments aimed to increase BP (reassurance, education, and lifestyle measures plus pharmacological strategies) can reduce SBP drops.

METHODS AND RESULTS

This was a multicentre, observational proof-of-concept study performed in patients with reflex syncope and/or orthostatic intolerance and with SBP drops on a screening ABPM. Among 144 eligible patients, 111 underwent a second ABPM on average 2.5 months after start of treatment. Overall, mean 24-h SBP increased from 114.1 ± 12.1 to 121.4 ± 14.5 mmHg (P < 0.0001). The number of SBP drops <90 and <100 mmHg decreased by 61%, 46% during daytime, and by 48% and 37% during 24-h period, respectively (P < 0.0001 for all). The dose-response relationship between difference in 24-h average SBP increase and reduction in number of SBP drops reached a plateau around ∼15 mmHg increase of 24-h SBP. The reduction in SBP drop rate was consistent and significant in patients who underwent deprescription of hypotensive medications (n = 44) and in patients who received BP-rising drugs (n = 67).

CONCLUSION

In patients with reflex syncope and/or orthostatic intolerance, an increase in average 24-h SBP, regardless of the implemented strategy, significantly reduced the number of SBP drops and symptom burden. A 13 mmHg increase in 24-h SBP appears to represent the optimal goal for aborting the maximal number of SBP drops, representing a possible target for future interventions. ClincalTrials.gov identifier: NCT05729724.

Generative Artificial Intelligence in Patient Education: ChatGPT Takes on Hypertension Questions

Introduction Uncontrolled hypertension significantly contributes to the development and deterioration of various medical conditions, such as myocardial infarction, chronic kidney disease, and cerebrovascular events. Despite being the most common preventable risk factor for all-cause mortality, only a fraction of affected individuals maintain their blood pressure in the desired range. In recent times, there has been a growing reliance on online platforms for medical information. While providing a convenient source of information, differentiating reliable from unreliable information can be daunting for the layperson, and false information can potentially hinder timely diagnosis and management of medical conditions. The surge in accessibility of generative artificial intelligence (GeAI) technology has led to increased use in obtaining health-related information. This has sparked debates among healthcare providers about the potential for misuse and misinformation while recognizing the role of GeAI in improving health literacy. This study aims to investigate the accuracy of AI-generated information specifically related to hypertension. Additionally, it seeks to explore the reproducibility of information provided by GeAI. Method A nonhuman-subject qualitative study was devised to evaluate the accuracy of information provided by ChatGPT regarding hypertension and its secondary complications. Frequently asked questions on hypertension were compiled by three study staff, internal medicine residents at an ACGME-accredited program, and then reviewed by a physician experienced in treating hypertension, resulting in a final set of 100 questions. Each question was posed to ChatGPT three times, once by each study staff, and the majority response was then assessed against the recommended guidelines. A board-certified internal medicine physician with over eight years of experience further reviewed the responses and categorized them into two classes based on their clinical appropriateness: appropriate (in line with clinical recommendations) and inappropriate (containing errors). Descriptive statistical analysis was employed to assess ChatGPT responses for accuracy and reproducibility. Result Initially, a pool of 130 questions was gathered, of which a final set of 100 questions was selected for the purpose of this study. When assessed against acceptable standard responses, ChatGPT responses were found to be appropriate in 92.5% of cases and inappropriate in 7.5%. Furthermore, ChatGPT had a reproducibility score of 93%, meaning that it could consistently reproduce answers that conveyed similar meanings across multiple runs. Conclusion ChatGPT showcased commendable accuracy in addressing commonly asked questions about hypertension. These results underscore the potential of GeAI in providing valuable information to patients. However, continued research and refinement are essential to evaluate further the reliability and broader applicability of ChatGPT within the medical field.

Posterior reversible encephalopathy syndrome due to nonadherence to antihypertensive treatment: A case report from Nepal

Key Clinical Message

Posterior reversible encephalopathy syndrome may occur secondary to abrupt cessation of antihypertensive therapy. A gradual reduction in blood pressure and counseling regarding medication adherence are crucial to prevent adverse consequences.

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a reversible clinical radiographic syndrome with headache, hypertensive encephalopathy, seizures, and visual disturbances as common modes of presentation. PRES can be attributed to several risk factors. We reported the case of a 66-year-old Asian female with PRES following nonadherence to antihypertensive treatment. Initially, her computed tomography scan of the head was normal. After 48 h, we again ordered a head CT scan, which showed lesions suggestive of hypertensive encephalopathy. We immediately reduced 20%-25% of mean arterial pressure, followed by a gradual blood pressure lowering to avoid adverse consequences. We did a follow-up CT scan of the head at 2 weeks, showing the resolution of early lesions. Hence, we made a diagnosis of PRES. In these patients, it is crucial to ensure medication adherence to avoid complications.

Patient-Reported Reasons for Antihypertensive Medication Change: A Quantitative Study Using Social Media

INTRODUCTION

Hypertension is the leading cause of heart disease in the world, and discontinuation or nonadherence of antihypertensive medication constitutes a significant global health concern. Patients with hypertension have high rates of medication nonadherence. Studies of reasons for nonadherence using traditional surveys are limited, can be expensive, and suffer from response, white-coat, and recall biases. Mining relevant posts by patients on social media is inexpensive and less impacted by the pressures and biases of formal surveys, which may provide direct insights into factors that lead to non-compliance with antihypertensive medication.

METHODS

This study examined medication ratings posted to WebMD, an online health forum that allows patients to post medication reviews. We used a previously developed natural language processing classifier to extract indications and reasons for changes in angiotensin receptor II blocker (ARB) and angiotensin-converting enzyme inhibitor (ACEI) treatments. After extraction, ratings were manually annotated and compared with data from the US Food and Drug administration (FDA) Adverse Events Reporting System (FAERS) public database.

RESULTS

From a collection of 343,459 WebMD reviews, we automatically extracted 1867 posts mentioning changes in ACEIs or ARBs, and manually reviewed the 300 most recent posts regarding ACEI treatments and the 300 most recent posts regarding ARB treatments. After excluding posts that only mentioned a dose change or were a false-positive mention, 142 posts in the ARBs dataset and 187 posts in the ACEIs dataset remained. The majority of posts (97% ARBs, 91% ACEIs) indicated experiencing an adverse event as the reason for medication change. The most common adverse events reported mapped to the Medical Dictionary for Regulatory Activities were "musculoskeletal and connective tissue disorders" like muscle and joint pain for ARBs, and "respiratory, thoracic, and mediastinal disorders" like cough and shortness of breath for ACEIs. These categories also had the largest differences in percentage points, appearing more frequently on WebMD data than FDA data (p < 0.001).

CONCLUSION

Musculoskeletal and respiratory symptoms were the most commonly reported adverse effects in social media postings associated with drug discontinuation. Managing such symptoms is a potential target of interventions seeking to improve medication persistence.

Life Course Patterns of Prescription Drug Use in the United States

Prescription drug use has reached historic highs in the United States-a trend linked to increases in medicalization, institutional factors relating to the health care and pharmaceutical industries, and population aging and growing burdens of chronic disease. Despite the high and rising prevalence of use, no estimates exist of the total number of years Americans can expect to spend taking prescription drugs over their lifetimes. This study provides the first estimates of life course patterns of prescription drug use using data from the 1996-2019 Medical Expenditure Panel Surveys, the Human Mortality Database, and the National Center for Health Statistics. Newborns in 2019 could be expected to take prescription drugs for roughly half their lives: 47.54 years for women and 36.84 years for men. The number of years individuals can expect to take five or more drugs increased substantially. Americans also experienced particularly dramatic increases in years spent taking statins, antihypertensives, and antidepressants. There are also important differences in prescription drug use by race and ethnicity: non-Hispanic Whites take the most, Hispanics take the least, and non-Hispanic Blacks fall in between these extremes. Americans are taking drugs over a wide and expanding swathe of the life course, a testament to the centrality of prescription drugs in Americans' lives today.

Centrally acting antihypertensives and alpha-blockers in people at risk of falls: therapeutic dilemmas-a clinical review

PURPOSE

The aim of this clinical review was to summarise the existing knowledge on the adverse effects of alpha-blockers and centrally acting antihypertensives, the effect these may have on falls risk, and guide deprescribing of these medications.

METHODS

Literature searches were conducted using PubMed and Embase. Additional articles were identified by searching reference lists and reference to personal libraries. We discuss the place of alpha-blockers and centrally acting antihypertensives in the treatment of hypertension and methods for deprescribing.

RESULTS

Alpha-blockers and centrally acting antihypertensives are no longer recommended for the treatment of hypertension unless all other agents are contraindicated or not tolerated. These medications carry a significant falls risk and non-falls risk-associated side effects. Tools to aid and guide de-prescribing and monitoring of the withdrawal of these medication classes are available to assist the clinician including information on reducing the risk of withdrawal syndromes.

CONCLUSIONS

Centrally acting antihypertensives and alpha-blockers increase the risk of falls through a variety of mechanisms-principally by increasing the risk of hypotension, orthostatic hypotension, arrhythmias and sedation. These agents should be prioritised for de-prescribing in older frailer individuals. We identify a number of tools and a withdrawal protocol to aid the clinician in identifying and de-prescribing these medications.

Rational Prescribing and Deprescribing of Antihypertensive Medications in Older People, a Three-Part Narrative Review, Part 3

What happens when you stop? This is the third of a three-part series on antihypertensive medication use in older people. In the first, we reviewed the importance of better blood pressure (BP) control, even in older people with hypertension. In the second, we discussed the limitations of the evidence favoring intensive therapy for some older people. For older people with advanced frailty or those with a limited life expectancy, medications taken for BP can actually be a source of morbidity. Guidelines encourage clinical judgment and rational prescribing. Sometimes the best action is to stop prescribing. De-prescribing of medical therapy is now considered good practice for a range of medications for suitable patients; should this include antihypertensives? In part three of this three-part series, we will review some of the evidence available thus far, demonstrating de-intensification of antihypertensive medications is not a new idea. We will offer a guide to identifying the most suitable patients for de-prescribing: cognitive impairment, frailty, when circumstances change, or when BP is (too) well-controlled. This is an area of equipoise and needs more research. There is a path forward that we hope to illuminate.

Withdrawal of antihypertensive medication in young to middle-aged adults: a prospective, single-group, intervention study

BACKGROUND

Although antihypertensive drug therapy is commonly believed to be a life-long therapy, several recent guidelines have suggested that antihypertensive medications can be gradually reduced or discontinued for some patients whose blood pressure (BP) is well-controlled for an extended period. Thus, this pilot study aimed to describe the success rate of antihypertensive drug discontinuation over 6 months among young and middle-aged patients with hypertension.

METHODS

This was a prospective, single-group, intervention study. Patients were eligible for inclusion if their cardiologist judged them to be appropriate candidates for this study, their BP had been controlled both in the office (< 140/90 mmHg) and 24-h ambulatory BP monitoring (< 135/85 mmHg) for at least 6 months with a single tablet dose of antihypertensive medication. A total of 16 patients withdrew their antihypertensive medications at baseline after they received the education, and were followed up over 6 months. After the follow-ups, six patients participated in the in-depth interview.

RESULTS

The likelihood of remaining normotensive at 30, 90, 180, and 195 days was 1.00, 0.85, 0.51, and 0.28, respectively. There were also no significant differences in baseline characteristics and self-care activities over time between normotensive (n = 8) and hypertensive groups (n = 8). In the interview, most patients expressed ambivalent feelings toward stopping medications. Psychological distress (e.g., anxiety) was the primary reason for withdrawal from this study although the patients' BP was under control.

CONCLUSIONS

We found that only a limited portion of antihypertensive patients could stop their medication successively over 6 months. Although we could not identify factors associated with success in maintaining BP over 6 months, we believe that careful selection of eligible patients may increase success in stopping antihypertensive medications. Also, continuous emotional support might be essential in maintaining patients' off-medication.

Headache in Workers: A Matched Case-Control Study

A case−control study including 446 workers reporting headaches (cases; 136 males and 310 females, mean age 46.71 ± 10.84 years) and 446 age- and sex-matched colleagues without headaches (controls; mean age 45.44 ± 10.13) was conducted in the second half of 2020 in a sample drawn from socio health and commercial services companies to investigate the association of headache with lifestyle, metabolic, and work-related factors. Workers suffering from headache reported higher body weight (OR: 1.92, 95% CI: 1.46−2.53, p < 0.001), higher blood cholesterol (OR: 2.01, 95% CI: 1.46−2.77, p < 0.001), triglyceride (OR: 2.01, 95% CI: 1.20−3.35, p < 0.01), blood glucose (OR: 1.91, 95% CI: 1.16−3.24, p < 0.01), and blood pressure levels (OR: 1.76, 95% CI: 1.23−2.52, p < 0.01). In the year preceding the survey, cases had experienced a higher frequency of workplace violence (OR: 2.29, 95% CI: 1.25−4.20, p < 0.01 for physical aggression, OR: 2.22, 95% CI: 1.45−3.41, p < 0.001 for threat, OR: 2.74, 95% CI: 1.72−4.38, p < 0.001 for harassment) and were more frequently distressed (effort/reward ratio > 1) (OR: 1.82, 95% CI: 1.39−2.40, p < 0.001) than the controls. Compared to the controls, cases also had higher scores on anxiety and depression scales, lower scores on happiness, and lower levels of sleep quality (p < 0.001). The association of headaches with metabolic and mental health problems suggests that monitoring headaches in the workplace could help to identify workers at risk of impairment.

Feasibility of a protocol for deprescribing antihypertensive medication in older patients in Dutch general practices

BACKGROUND

Older patients using antihypertensive medication may experience Adverse Drug Events (ADEs), and thus benefit from deprescribing. The lack of a practical protocol may hamper deprescribing. Therefore, we aimed to develop a deprescribing protocol, based on a review of literature, combined with a feasibility test in a small number of patients.

METHODS

A deprescribing protocol for general practitioners was drafted and tested in older patients using multiple antihypertensive medication in a single arm intervention. Patients were included if they were 75 years or older, were using two or more antihypertensives, had at least one ADE linked to antihypertensive medication and deprescribing was considered to be safe by their general practitioner. The primary outcome was the percentage of patients for whom one or more antihypertensive drugs were stopped or reduced in dose after 12 months of follow up while maintaining safe blood pressures. Secondary outcomes were the proportion of patients reporting no ADEs after 12 months and the number of deprescribed antihypertensives. Patient's opinions on deprescribing and enablers and barriers for study participation were also collected.

RESULTS

Nine general practitioners included 14 patients to deprescribe antihypertensive medication using the deprescribing protocol. After 12 months antihypertensive drug use was lowered in 11 patients (79%). These patients had a mean systolic blood pressure increase of 16 mmHg and a mean diastolic blood pressure increase of 8 mmHg. Nine patients (64%) reported experiencing no ADEs anymore after twelve months. The mean number of deprescribed antihypertensives was 1.1 in all patients and 1.4 (range: 0.5 to 3.5) in patients who successfully lowered their medication. At baseline, being able to use less medication was the most frequently mentioned enabler to participate in this study. The most frequently mentioned positive experience at the end of the study was using less medication, which was in line with the most mentioned enabler to participate in this study.

CONCLUSION

A protocol for deprescribing antihypertensives in older patients was considered feasible, as it resulted in a substantial degree of safe deprescribing in this pilot study. Larger studies are needed to demonstrate the effect and safety of deprescribing antihypertensives in older patients.

Hypertension Control and Medication Titration Associated With Lifestyle Medicine Virtual Group Visits and Home Blood Pressure Monitoring

Less than a quarter of the 116 million adults with hypertension in the United States have blood pressure (BP) lower than the guideline-recommended goal of 130/80 mmHg. There is a critical need for novel interventions that integrate evidence-based recommendations—such as lifestyle medicine and home BP monitoring (HBPM)—into clinical care. In this study, we tested the hypothesis that a four-part, primary care physician-led Virtual Group Visit (VGV) series combining lifestyle medicine, Health and Wellness Coaching (HWC), and HBPM could lead to a reduction in BP and antihypertensive medications. There was a decrease in systolic (β = −.108 mmHg per day; P = .046) and diastolic (β = −.058 mmHg per day; P = .026) BP. Thirteen of the 22 patients (59%) who started the VGV series on medications had at least one medication dosage reduced or discontinued during the VGV series, and 8 of the 18 patients (44%) who finished the VGV series on medications had at least one medication dosage reduced or discontinued in the 180 days after the VGV series. This pilot study demonstrates for the first time that lifestyle medicine VGVs, coupled with HWC and HBPM, are associated with improved BP control and medication deprescribing.

Clinical Trial Design Principles and Outcomes Definitions for Device-Based Therapies for Hypertension: A Consensus Document From the Hypertension Academic Research Consortium

The clinical implications of hypertension in addition to a high prevalence of both uncontrolled blood pressure and medication nonadherence promote interest in developing device-based approaches to hypertension treatment. The expansion of device-based therapies and ongoing clinical trials underscores the need for consistency in trial design, conduct, and definitions of clinical study elements to permit trial comparability and data poolability. Standardizing methods of blood pressure assessment, effectiveness measures beyond blood pressure alone, and safety outcomes are paramount. The Hypertension Academic Research Consortium (HARC) document represents an integration of evolving evidence and consensus opinion among leading experts in cardiovascular medicine and hypertension research with regulatory perspectives on clinical trial design and methodology. The HARC document integrates the collective information among device-based therapies for hypertension to better address existing challenges and identify unmet needs for technologies proposed to treat the world’s leading cause of death and disability. Consistent with the Academic Research Consortium charter, this document proposes pragmatic consensus clinical design principles and outcomes definitions for studies aimed at evaluating device-based hypertension therapies.

Risk stratification of syncope: Current syncope guidelines and beyond

Syncope is an alarming event carrying the possibility of serious outcomes, including sudden cardiac death (SCD). Therefore, immediate risk stratification should be applied whenever syncope occurs, especially in the Emergency Department, where most dramatic presentations occur. It has long been known that short- and long-term syncope prognosis is affected not only by its mechanism but also by presence of concomitant conditions, especially cardiovascular disease. Over the last two decades, several syncope prediction tools have been developed to refine patient stratification and triage patients who need expert in-hospital care from those who may receive nonurgent expert care in the community. However, despite promising results, prognostic tools for syncope remain challenging and often poorly effective. Current European Society of Cardiology syncope guidelines recommend an initial syncope workup based on detailed patient's history, physical examination supine and standing blood pressure, resting ECG, and laboratory tests, including cardiac biomarkers, where appropriate. Subsequent risk stratification based on screening of features aims to identify three groups: high-, intermediate- and low-risk. The first should immediately be hospitalized and appropriately investigated; intermediate group, with recurrent or medium-risk events, requires systematic evaluation by syncope experts; low-risk group, sporadic reflex syncope, merits education about its benign nature, and discharge. Thus, initial syncope risk stratification is crucial as it determines how and by whom syncope patients are managed. This review summarizes the crucial elements of syncope risk stratification, pros and cons of proposed risk evaluation scores, major challenges in initial syncope management, and how risk stratification impacts management of high-risk/recurrent syncope.

A predictive model for identifying low medication adherence among older adults with hypertension: A classification and regression tree model

Various individual characteristics may affect medication adherence; however, few studies have investigated the effect of interrelationships among these various individual characteristics on medication adherence. This cross-sectional study explored the interrelationships among risk factors for medication adherence and established a predictive model of low medication adherence among older adults with hypertension. Convenience sampling was used to recruit 300 older adults with hypertension. The following parameters were recorded: demographic and disease characteristics, health beliefs, self-efficacy, social support, and medication adherence of antihypertensive drugs. Classification and regression tree (CART) analysis was performed to develop a predictive model of low medication adherence. The CART model revealed that health belief, disease duration, self-efficacy, and social support interacted to contribute to various pathways of low medication adherence. The predicted accuracy of the model was validated with a low misclassification rate of 26%. The proposed classification model can help identify risk cases with low medication adherence. Suitable health education programs based on these risk factors to manage and improve medication adherence for older adults with hypertension could be considered.

Antihypertensive medication needs and blood pressure control with weight loss in the Diabetes Remission Clinical Trial (DiRECT)

AIMS/HYPOTHESIS

Our aim was to evaluate the safety and efficacy of a planned therapeutic withdrawal of all antihypertensive and diuretic medications, on commencing a formula low-energy diet replacement, targeting remission of type 2 diabetes.

METHODS

Post hoc analysis of changes in BP, antihypertensive medication prescriptions and symptoms during the initial total diet replacement phase was performed in the intervention arm of the Diabetes Remission Clinical Trial (n = 143) and in the subset (n = 69) who discontinued antihypertensive medications at the start of total diet replacement. The Counterweight-Plus total diet replacement provided about 3470 kJ/day (830 kcal) with automatic reductions in all nutrients, including sodium, to achieve marked negative energy balance and rapid weight loss over 12-20 weeks, with regular BP monitoring and an antihypertensive reintroduction protocol based on current clinical guidelines.

RESULTS

Of 143 intervention group participants who commenced total diet replacement, 78 (55%) were on treatment for hypertension at baseline. The overall mean BP fell significantly from the start of total diet replacement (week 1) and was significantly lower at week 20, after total diet replacement finished, and also at 12 and 24 months. Of the 78 participants previously on treatment for hypertension, 65 (83%) stopped all antihypertensive and diuretic medications as per protocol, and four (5%) stopped some drugs. These 69 participants experienced no immediate (within the first week) change in BP, but their mean BP fell significantly from 9 weeks. No excessive rises in BP were recorded in individuals, but antihypertensive medications were reintroduced during total diet replacement to manage raised BP for 19/69 (27.5%) participants, mostly within the first 3-7 weeks, despite some weight loss. Reintroduction of antihypertensive medications was necessary for 5/19 participants previously on one drug, and for 14/19 previously on two or more drugs. Of the 69 who stopped antihypertensives, 19 (28%) remained off medications at 24 months. Among the 53 participants who achieved sustained remissions of diabetes at 24 months (with a mean weight loss of 11.4 kg), 31 had been previously treated for hypertension. Twenty-seven stopped medication at baseline, and 15/27 required reintroduction of antihypertensive medications. Mild to moderate dizziness, suggesting some postural hypotension, was reported during total diet replacement by 51 participants, 15 of whom had recorded dizziness at baseline prior to starting total diet replacement, with nine of these on antihypertensive or diuretic medications.

CONCLUSIONS/INTERPRETATION

Replacing antihypertensive medications with a 3470 kJ/day (830 kcal) diet to induce weight loss reduces BP substantially and may increase mild dizziness. It is safe to stop antihypertensives, but BP should be monitored regularly, particularly for those taking two or more antihypertensives, as over two-thirds will require reintroduction of some medications. Long-term support to maintain weight loss is vital.

TRIAL REGISTRATION

ISRCTN registry, number 03267836.

Arterial hypertension

Arterial hypertension is the most important contributor to the global burden of disease; however, disease control remains poor. Although the diagnosis of hypertension is still based on office blood pressure, confirmation with out-of-office blood pressure measurements (ie, ambulatory or home monitoring) is strongly recommended. The definition of hypertension differs throughout various guidelines, but the indications for antihypertensive therapy are relatively similar. Lifestyle adaptation is absolutely key in non-pharmacological treatment. Pharmacologically, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, calcium channel blockers, and diuretics are the first-line agents, with advice for the use of single-pill combination therapy by most guidelines. As a fourth-line agent, spironolactone should be considered. The rapidly evolving field of device-based therapy, especially renal denervation, will further broaden therapeutic options. Despite being a largely controllable condition, the actual rates of awareness, treatment, and control of hypertension are disappointingly low. Further improvements throughout the process of patient screening, diagnosis, treatment, and follow-up need to be urgently addressed.

Time-Efficient Inspiratory Muscle Strength Training Lowers Blood Pressure and Improves Endothelial Function, NO Bioavailability, and Oxidative Stress in Midlife/Older Adults With Above-Normal Blood Pressure

Background High-resistance inspiratory muscle strength training (IMST) is a novel, time-efficient physical training modality. Methods and Results We performed a double-blind, randomized, sham-controlled trial to investigate whether 6 weeks of IMST (30 breaths/day, 6 days/week) improves blood pressure, endothelial function, and arterial stiffness in midlife/older adults (aged 50-79 years) with systolic blood pressure ≥120 mm Hg, while also investigating potential mechanisms and long-lasting effects. Thirty-six participants completed high-resistance IMST (75% maximal inspiratory pressure, n=18) or low-resistance sham training (15% maximal inspiratory pressure, n=18). IMST was safe, well tolerated, and had excellent adherence (≈95% of training sessions completed). Casual systolic blood pressure decreased from 135±2 mm Hg to 126±3 mm Hg (P<0.01) with IMST, which was ≈75% sustained 6 weeks after IMST (P<0.01), whereas IMST modestly decreased casual diastolic blood pressure (79±2 mm Hg to 77±2 mm Hg, P=0.03); blood pressure was unaffected by sham training (all P>0.05). Twenty-four hour systolic blood pressure was lower after IMST versus sham training (P=0.01). Brachial artery flow-mediated dilation improved ≈45% with IMST (P<0.01) but was unchanged with sham training (P=0.73). Human umbilical vein endothelial cells cultured with subject serum sampled after versus before IMST exhibited increased NO bioavailability, greater endothelial NO synthase activation, and lower reactive oxygen species bioactivity (P<0.05). IMST decreased C-reactive protein (P=0.05) and altered select circulating metabolites (targeted plasma metabolomics) associated with cardiovascular function. Neither IMST nor sham training influenced arterial stiffness (P>0.05). Conclusions High-resistance IMST is a safe, highly adherable lifestyle intervention for improving blood pressure and endothelial function in midlife/older adults with above-normal initial systolic blood pressure. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03266510.

The health impacts of preventive cardiovascular medication reduction on older populations: protocol for a systematic review and meta-analysis

BACKGROUND

Polypharmacy is inevitable and appropriate for many conditions, but in some cases, it can be problematic resulting in an increased risk of harm and reduced quality of life. There has been an increasing interest to reduce cardioprotective medications in older adults to potentially reduce the risk of harm due to treatment; however, there is no evidence on safety and efficacy to support this practice currently. This paper describes a protocol for a systematic review on the safety and efficacy of reducing cardioprotective medication in older populations.

METHODS

MEDLINE (PubMed), Embase (Ovid), and CENTRAL (Cochrane Central Register of Controlled Trials) will be searched from their inception onwards for relevant studies. Randomised controlled trials and non-randomised studies on interventions (prospective, retrospective cohort, case-control) conducted in older adults (75 years or older) examining reduction of cardioprotective medications will be included. The primary outcome of this study will be all-cause hospitalisation. Secondary outcome variables of interest are all-cause hospitalisation, mortality, quality of life, serious adverse events, major adverse cardiovascular events, falls, fractures, cognitive functioning, bleeding events, renal functioning, medication burden, drug reinstatement, time-in-hospital, and frailty status. Two reviewers will independently screen all citations, full-text articles, and extract data. Confidence in cumulative evidence will be assessed using the GRADE approach; the risk of bias will be assessed by the RoB-II tool for randomised controlled studies and ROBINS-I for non-randomised studies. Where sufficient data are available, we will conduct a random effects meta-analysis by combining the outcomes of the included studies. Sub-group analysis and meta-regression are planned to assess the potential harms and risks of different drug classes and the impacts in different patient populations (e.g. sex, cognitive status, renal status, and age).

DISCUSSION

The study will be a comprehensive review on all published articles identified using our search strategy on the safety and efficacy of cardioprotective medication reduction in the older population. The findings will be crucial to inform clinicians on potential health outcomes of reducing cardiovascular medication in the elderly.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020208223.

Evaluation of Patients with Syncope in the Emergency Department: How to Adjust Pharmacological Therapy

The rate of syncope in the Emergency Department ranges between 0.9 and 1.7%. Syncope is mostly related to a underlying reflex or orthostatic mechanism. A bradycardic or a hypotensive phenotype, may be identified. The latter is the most common and could be constitutional or drug induced. Consequently, obtaining an accurate drug history is an important step of the initial assessment of syncope. As anti-hypertensive medication might be responsible for orthostatic hypotension, managing hypertension in patients with syncope requires finding an ideal balance between hypotensive and cardiovascular risks. The choice of anti-hypertensive molecule as well as the therapeutic regimen and dosage, influences the risk of syncope. Not only could anti-hypertensive drugs have a hypotensive effect but opioids and psychoactive medications may also be involved in the mechanism of syncope. Proper drug management could reduce syncope recurrences and their consequences.

Hypertension, hypotension and syncope

Hypertension and hypotension are strictly related phenomena, that frequently coexist within the spectrum of cardiovascular autonomic dysfunction, especially at advanced age. Indeed, antihypertensive treatment may predispose to orthostatic and post-prandial hypotension, while intensive blood pressure lowering may be responsible for systemic hypotension. Over recent years, systemic and orthostatic hypotension have emerged as important although often neglected risk factors for adverse outcomes, paralleling the widely recognized arterial hypertension. Both hypertension and hypotension are associated with detrimental effects on target organs and survival, thus significantly impacting patients' prognosis, functional autonomy and quality of life. Balancing low and high blood pressure requires accurate diagnostic assessment of blood pressure values and patients' hypotensive susceptibility, which allow for the development of customized treatment strategies based on individual hypo/hypertensive risk profile. The present review illustrates the complex interrelationship between hypotension and hypertension and discusses the relevant prognostic role of these conditions. Additionally, it provides an overview on hypotension detection and treatment in patients with hypertension, focusing on customized diagnostic and therapeutic strategies.

Effects of antihypertensive medication and high-intensity interval training in hypertensive metabolic syndrome individuals

Pharmacological and non-pharmacological therapies are simultaneously prescribed when treating hypertensive individuals with elevated cardiovascular risk (ie, metabolic syndrome individuals). However, it is unknown if the interactions between antihypertensive medication (AHM) and lifestyle interventions (ie, exercise training) may result in a better ambulatory blood pressure (ABP) control. To test this hypothesis, 36 hypertensive individuals with metabolic syndrome (MetS) under long-term prescription with AHM targeting the renin-angiotensin-aldosterone system (RAAS) were recruited. Before and after 4 months of high-intensity interval training (HIIT), participants completed two trials in a double-blind, randomized order: (a) placebo trial consisting of AHM withdrawal for 3 days and (b) AHM trial where individuals held their habitual dose of AHM. In each trial, 24-h mean arterial pressure (MAP) was monitored and considered the primary study outcome. Secondary outcomes included plasma renin activity (PRA) and aldosterone concentration to confirm withdrawal effects on RAAS, along with the analysis of urine albumin-to-creatinine ratio (UACR) to assess kidney function. The results showed main effects from AHM and HIIT reducing 24-h MAP (-5.7 mmHg, p < 0.001 and -2.3 mmHg, p = 0.007, respectively). However, there was not interaction between AHM and HIIT on 24-h MAP (p = 0.240). There was a main effect of AHM increasing PRA (p < 0.001) but no effect on plasma aldosterone concentration (p = 0.368). HIIT did not significantly improve RAAS hormones or the UACR. In conclusion, AHM and HIIT have independent and additive effects in lowering ABP. These findings support the combination of habitual AHM with exercise training with the goal to reduce ABP in hypertensive MetS individuals.

New insights in diagnostics and therapies in syncope: a novel approach to non-cardiac syncope

This article aims to give advice on how to identify and manage patients with syncope who are at risk of severe outcomes, that is, at risk of trauma, potentially life-threatening episodes or frequent recurrences reducing quality of life. The first step of syncope diagnostic assessment is to identify patients with cardiac syncope, and once established, these patients must receive the adequate mechanism-specific treatment. If cardiac syncope is unlikely, reflex (neurally mediated) syncope and orthostatic hypotension are the most frequent causes of transient loss of consciousness. For these presentations, efficacy of therapy is largely determined by the mechanism of syncope rather than its aetiology or clinical features. The identified mechanism of syncope should be carefully assessed and assigned either to hypotensive or bradycardic phenotype, which will determine the choice of therapy (counteracting hypotension or counteracting bradycardia). The results of recent trials indicate that 'mechanism-specific therapy' is highly effective in preventing recurrences. Established mechanism-specific treatment strategies include withdrawal of hypotensive drugs, applying fludrocortisone and midodrine for the hypotensive phenotype and cardiac pacing in the bradycardic phenotype.

Hypertension Prevalence Based on Blood Pressure Measurements on Two vs. One Visits: A Community-Based Screening Programme and a Narrative Review

We assessed the difference in the prevalence of hypertension in community surveys when blood pressure (BP) was measured on two vs. one visits and its impact on hypertension awareness, treatment and control proportions. A community-based BP screening programme was conducted in public places in the Seychelles (619 adults) and BP was rechecked a few days later among untreated participants with high BP (≥140/90 mmHg). A narrative review of the literature on this question was also conducted. Only 64% of untreated participants with high BP still had high BP at the second visit. The prevalence of hypertension in the whole sample decreased by 13% (from 33.8% to 29.5%) when BP was measured on two vs. one visits. These results concurred with our findings in our narrative review based on 10 surveys. In conclusion, the prevalence of hypertension can be markedly overestimated in community surveys when BP is measured on two vs. one visits. The overestimation could be addressed by measuring BP on a second visit among untreated individuals with high BP or, possibly, by taking more readings at the first visit. These findings have relevance for clinical practice, policy and surveillance.

Hypertension management in frail older adults: a gap in evidence

Hypertension management is challenging in frail older adults. The balance between treatment risks and benefits may be difficult to achieve due to an increased vulnerability to treatment-related adverse events, and limited evidence is available to support clinical decisions. The effects of frailty on blood pressure are unclear, as well as its impact on antihypertensive treatment benefits. Appropriate blood pressure targets in frail patients are debated and the frailty measure which best inform clinical decisions in hypertensive patients has yet to be identified. Therefore, hypertension management in frail older adults still represents a 'gap in evidence'. Knowledge of currently available literature is a fundamental prerequisite to develop future research and may help to implement frailty assessment and improve hypertension management in this vulnerable population. Given these premises, we present a narrative review illustrating the most relevant issues that are a matter of debate and that should be addressed in future studies.

Deprescribing: a challenge for clinical cardiologists

Deprescribing is a holistic process to identify medications that can be ceased, substituted or reduced. This process can improve the health of older patients and also enhance their compliance to the prescribed medications which are actually beneficial. Recommendations and guidelines have been elaborated for extensively prescribed drugs. In clinical cardiology the process of deprescribing is a challenge for doctors because of withdrawal-related adverse effects, but it may be applied in certain clinical conditions such as the discontinuation of statin prescription in patients with advanced senile dementia and those with limited life expectancy. Deprescribing is also focussed on the scarcely known effects of prolonged therapy after the acute phase of a disease is over, especially when continuation may signify potential life-long treatment. There needs to be collaboration between the consultant cardiologist who first prescribes medications and family doctors who are responsible for the long-term care of the patient and reviewing prescribed medications may be necessary.

COVID-19 pandemic and therapy with ibuprofen or renin-angiotensin system blockers: no need for interruptions or changes in ongoing chronic treatments

Scientists hypothesized that drugs such as ibuprofen or renin-angiotensin system (RAS) blockers could exacerbate the novel coronavirus disease COVID-19 by upregulating the angiotensin-converting enzyme 2 (ACE2), which serves as an entry receptor for the coronavirus SARS-CoV-2. This hypothesis was taken up by the lay press and led to concerns among doctors and patients whether the use of these drugs was still safe and justified against the background of the pandemic spread of SARS-CoV-2 with an increasing number of cases and deaths. In this article, we summarize what is known about the effect of RAS blockers or non-steroidal anti-inflammatory drugs (NSAIDs) on the course of COVID-19 disease. In the case of RAS inhibition, we also find evidence for the opposite hypothesis, namely, that RAS inhibition in COVID-19 could be protective. In view of the inconsistent and limited evidence and after weighing up the benefits and risks, we would not currently recommend discontinuing or switching an effective treatment with RAS blockers. NSAIDs should be used at the lowest effective dose for the shortest possible period. The choice of drug to treat COVID-19-associated fever or pain should be based on a benefit-risk assessment for known side effects (e.g., kidney damage, gastrointestinal ulceration).

Withdrawal of antihypertensive drugs in older people

BACKGROUND

Hypertension is an important risk factor for subsequent cardiovascular events, including ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Overall, the use of antihypertensive medications has led to reduction in cardiovascular disease, morbidity rates and mortality rates. However, the use of antihypertensive medications is also associated with harms, especially in older people, including the development of adverse drug reactions, drug-drug interactions and can contribute to increasing medication-related burden. As such, discontinuation of antihypertensives may be considered and appropriate in some older people.

OBJECTIVES

To investigate whether withdrawal of antihypertensive medications is feasible, and evaluate the effects of withdrawal of antihypertensive medications on mortality, cardiovascular outcomes, hypertension and quality of life in older people.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to April 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 3), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also conducted reference checking, citation searches and, when appropriate, contacted study authors to identify any additional studies. The searches had no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of withdrawal versus continuation of antihypertensive medications used for hypertension or primary prevention of cardiovascular disease in older adults (defined as 50 years and over). Participants were eligible if they lived in the community, residential aged care facilities, or were based in hospital settings. We sought to include trials looking at the complete withdrawal of the antihypertensive medication, and those focusing on a dose reduction of the antihypertensive medicine.

DATA COLLECTION AND ANALYSIS

We compared the intervention of discontinuing or reducing antihypertensive medication to usual treatment using mean differences (MD) and 95% confidence intervals (95% CIs) for continuous variables and we used Peto odds ratios (ORs) and 95% CI for binary variables. Our primary outcomes included: mortality, myocardial infarction, development of adverse drug reactions or adverse drug withdrawal reactions. Secondary outcomes included: blood pressure, hospitalisation, stroke, success of withdrawing from antihypertensives, quality of life, and falls. Two authors independently, and in duplicate, conducted all stages of study selection, data extraction and quality assessment.

MAIN RESULTS

Six RCTs met the inclusion criteria and were included in the review (1073 participants). Study duration and follow-up ranged from 4 weeks to 56 weeks. Meta-analysis of studies showed that, in the discontinuation group compared to continuation, the odds for all-cause mortality were 2.08 (95% CI 0.79 to 5.46; low certainty of evidence), for myocardial infarction 1.86 (95% CI 0.19 to 17.98; very low certainty of evidence) and for stroke 1.44 (95% CI 0.25 to 8.35; low certainty of evidence). Blood pressure was higher in the discontinuation group than the continuation group (systolic blood pressure: MD = 9.75 mmHg, 95% CI 7.33 to 12.18; and diastolic blood pressure: MD = 3.5 mmHg, 95% CI 1.82 to 5.18; low certainty of evidence). For the development of adverse events, meta-analysis was not possible; antihypertensive discontinuation did not appear to increase the risk of adverse events and may lead to resolution of adverse drug reactions, although eligible studies had limited reporting of adverse effects of drug withdrawal (very low certainty of evidence). One study reported hospitalisation with an odds ratio of 0.83 for discontinuation compared to continuation (95% CI 0.33 to 2.10; low certainty of evidence). No studies were identified which reported falls. Between 10.5% and 33.3% of participants in the discontinuation group compared to 9% to 15% in the continuation group experienced raised blood pressure or other clinical criteria (as pre-defined by the studies) that would require restarting of therapy/removal from the study. The sources of bias included selective reporting (reporting bias), lack of blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), and lack of blinding of participants and personnel (performance bias).

AUTHORS' CONCLUSIONS

There is no evidence of an effect of discontinuing compared with continuing antihypertensives used for hypertension or primary prevention of cardiovascular disease in older adults on all-cause mortality and myocardial infarction. The evidence was low to very low certainty mainly due to small studies and low event rates. These limitations mean that we cannot make any firm conclusions about the effect of deprescribing antihypertensives on these outcomes. Future research should focus on populations with the greatest uncertainty of the benefit:risk ratio for use of antihypertensive medications, such as those with frailty, older age groups and those taking polypharmacy, and measure clinically important outcomes such as falls, quality of life and adverse drug events.

Effect of Antihypertensive Medication Reduction vs Usual Care on Short-term Blood Pressure Control in Patients With Hypertension Aged 80 Years and Older: The OPTIMISE Randomized Clinical Trial

IMPORTANCE

Deprescribing of antihypertensive medications is recommended for some older patients with polypharmacy and multimorbidity when the benefits of continued treatment may not outweigh the harms.

OBJECTIVE

This study aimed to establish whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events during 12-week follow-up.

DESIGN, SETTING, AND PARTICIPANTS

The Optimising Treatment for Mild Systolic Hypertension in the Elderly (OPTIMISE) study was a randomized, unblinded, noninferiority trial conducted in 69 primary care sites in England. Participants, whose primary care physician considered them appropriate for medication reduction, were aged 80 years and older, had systolic blood pressure lower than 150 mm Hg, and were receiving at least 2 antihypertensive medications were included. Participants enrolled between April 2017 and September 2018 and underwent follow-up until January 2019.

INTERVENTIONS

Participants were randomized (1:1 ratio) to a strategy of antihypertensive medication reduction (removal of 1 drug [intervention], n = 282) or usual care (control, n = 287), in which no medication changes were mandated.

MAIN OUTCOMES AND MEASURES

The primary outcome was systolic blood pressure lower than 150 mm Hg at 12-week follow-up. The prespecified noninferiority margin was a relative risk (RR) of 0.90. Secondary outcomes included the proportion of participants maintaining medication reduction and differences in blood pressure, frailty, quality of life, adverse effects, and serious adverse events.

RESULTS

Among 569 patients randomized (mean age, 84.8 years; 276 [48.5%] women; median of 2 antihypertensive medications prescribed at baseline), 534 (93.8%) completed the trial. Overall, 229 (86.4%) patients in the intervention group and 236 (87.7%) patients in the control group had a systolic blood pressure lower than 150 mm Hg at 12 weeks (adjusted RR, 0.98 [97.5% 1-sided CI, 0.92 to ∞]). Of 7 prespecified secondary end points, 5 showed no significant difference. Medication reduction was sustained in 187 (66.3%) participants at 12 weeks. Mean change in systolic blood pressure was 3.4 mm Hg (95% CI, 1.1 to 5.8 mm Hg) higher in the intervention group compared with the control group. Twelve (4.3%) participants in the intervention group and 7 (2.4%) in the control group reported at least 1 serious adverse event (adjusted RR, 1.72 [95% CI, 0.7 to 4.3]).

CONCLUSIONS AND RELEVANCE

Among older patients treated with multiple antihypertensive medications, a strategy of medication reduction, compared with usual care, was noninferior with regard to systolic blood pressure control at 12 weeks. The findings suggest antihypertensive medication reduction in some older patients with hypertension is not associated with substantial change in blood pressure control, although further research is needed to understand long-term clinical outcomes.

TRIAL REGISTRATION

EudraCT Identifier: 2016-004236-38; ISRCTN identifier: 97503221.

Deprescribing Antihypertensive Drugs in Patients of Older Age Groups

Arterial hypertension (AH) is one of the most common diseases in the elderly. It has been proven that lowering blood pressure (BP) is effective in preventing stroke and cardiovascular complications in patients even at the age of ≥80 years. On the other hand, there is evidence that a significant decrease in BP can be harmful to older people and may lead to a higher risk of overall mortality. Therefore, existing guidelines for the treatment of AH determine specific approaches for managing patients of older age groups, where the target BP levels are determined not only by age and concomitant diseases, but also by the presence of frailty. Moreover, there is a need to monitor the dynamics of frailty indicators (social, functional, cognitive and mental status of the patient), since their deterioration may require changes in the tactics of antihypertensive therapy (dose reduction, drug withdrawal or replacement) and changes in target BP levels. In this regard, in recent years, the possibility/necessity of a planned and controlled process of dose reduction, drug withdrawal or replacement, if this drug can be harmful and/or does not bring benefits (deprescribing), has attracted attention. This article is a review of current literature, which presents the design and main characteristics of randomized clinical trials (RCTs) and systematic reviews on the deprescribing of antihypertensive drugs in elderly patients with AH and frailty. An analysis of these studies showed the benefits of deprescribing of antihypertensive drugs for elderly patients with frailty, which avoids potential harm to their health, improves the quality of life and reduces the economic cost of treatment. Therefore, deprescribing of antihypertensive drugs can be used as an additional tool to achieve the necessary target BP values in patients of an older age group. However, for the development of deprescribing of antihypertensive drugs schemes and its introduction into clinical practice, the results of large specially planned RCTs are needed to study this issue.

Adrenal Venous Sampling: Where Do We Stand?

Adrenal venous sampling is the gold standard test to identify surgically curable primary aldosteronism, but it is markedly underused in clinical practice being perceived as a technically challenging and invasive procedure and, moreover, as difficult to interpret. This review provides updated information on current indications to adrenal venous sampling and how to perform and interpret adrenal venous sampling.

Going Beyond the Guidelines in Individualising the Use of Antihypertensive Drugs in Older Patients

Hypertension is commonly diagnosed in older patients, with increasing cardiovascular (CV) risk as systolic blood pressure (BP) increases. Maximising CV risk reduction must be reconciled with minimising the risk of treatment-related harms and burden, especially among frail, multi-morbid and older old patients who have been excluded from most randomised trials. Contemporary clinical guidelines, based on such trials, differ in their recommendations as to threshold levels warranting treatment with antihypertensive drugs (AHDs) and target levels that should be achieved. In optimising AHD prescribing in older patients, we propose the following decision framework: decide therapeutic goals in accordance with patient characteristics and preferences; estimate absolute CV risk; measure and profile BP accurately in ways that account for lability in BP levels and minimise error in BP measurement; determine threshold and target BP levels likely to confer net benefit, taking into account age, co-morbidities, frailty and cognitive function; and consider situations that warrant AHD deprescribing on the basis of potential current or future harm. In applying this framework to older persons, and based on a review of relevant randomised trials and observational studies, individuals most likely to benefit from treating systolic BP to no less than 130 mmHg are those of any age who are fit and have high baseline systolic BP (≥ 160 mmHg); high CV risk, i.e. established CV disease or risk of CV events exceeding 20% at 10 years; previous stroke or transient ischaemic attack; heart failure; and stage 3-4 chronic kidney disease with proteinuria. Individuals most likely to be harmed from treating BP to target systolic < 140 mmHg are those who have no CV disease and aged over 80 years; moderate to severe frailty, cognitive impairment or functional limitations; labile BP and/or history of orthostatic hypotension, syncope and falls; or life expectancy < 12 months. Treatment should never be so intense as to reduce diastolic BP to < 60 mmHg in any older person. At a time when guidelines are calling for less conservative management of hypertension in all age groups, we contend that a more temperate approach, such as that offered here and based on the totality of available evidence, may assist in maximising net benefit in older patients.

Hypertension management: experiences, wishes and concerns among older people-a qualitative study

OBJECTIVES

Sixty-five per cent of older people have hypertension, but little is known about their preferences and concerns regarding hypertension management. Guidelines on hypertension lack consensus on how to treat older people without previous cardiovascular disease (CVD). This asks for explicit consideration of patient preferences in decision making. Therefore, the aim of this study was to explore older peoples' experiences, preferences, concerns and perceived involvement regarding hypertension management.

DESIGN

Qualitative interview study.

SETTING

Participants were selected from 11 general practitioner (GP) practices in the Netherlands and purposively sampled until data saturation was achieved. Semistructured interviews were conducted, audio recorded and analysed by two researchers using thematic analysis.

PARTICIPANTS

Fifteen community dwelling older people aged 74-93 years with hypertension and without previous CVD participated.

RESULTS

Interviewees rarely started the conversation about hypertension management with their GP, although they did have concerns. Reasons for not discussing the subject included low priority of hypertension concerns, reliance on GPs or trust in GPs to make the right decision on their behalf. Also, interviewees anticipated regret of reducing medication, fearing vascular incidents. Interviewees would like to discuss tailoring treatment to their needs, deprescription of medication and ways to reduce side effects. They expected GPs to be more transparent on treatment effects.

CONCLUSION

Older people describe having little involvement in hypertension management, although they have several concerns. Since GPs are also known to be hesitant to bring up this subject, we signal a conspiracy of silence about antihypertensive medication. Through breaking this silence, GPs can facilitate shared decision-making on hypertension management and better tailored care.

Estimated Cardiovascular Risk and Guideline-Concordant Primary Prevention With Statins: Retrospective Cross-Sectional Analyses of US Ambulatory Visits Using Competing Algorithms

INTRODUCTION

The 2013 pooled cohort equations (PCE) may misestimate cardiovascular event (CVE) risk, particularly for black patients. Alternatives to the original PCE (O-PCE) to assess potential statin benefit for primary prevention-a revised PCE (R-PCE) and US Preventive Services Task Force (USPSTF) algorithms-have not been compared in contemporary US patients in routine office-based practice.

METHODS

We performed retrospective, cross-sectional analysis of a nationally representative, US sample of office visits made from 2011 to 2014. Sampling criteria matched those used for PCE development: aged 40 to 79 years, black or white race, no cardiovascular disease. Original PCE, R-PCE, and USPSTF algorithms were applied to biometric and demographic data. Outcomes included estimated 10-year CVE risk, percentage exceeding each algorithm's statin-treatment threshold (>7.5% risk for O-PCE and R-PCE, and >10% O-PCE plus >1 risk factor for USPSTF), and percentage prescribed statin therapy.

RESULTS

In 12 556 visits (representing 285 330 123 nationwide), 10.8% of patients were black, 27.1% had diabetes, and 15.7% were current smokers. Replacing O-PCE with R-PCE decreased mean (95% confidence interval [CI]) estimated CVE risk from 12.4% (12.0%-12.7%) to 8.5% (8.2%-8.8%). Significant (P < 0.05) racial disparity in the rate of CVE risk >7.5% was identified using O-PCE (black and white patients [95% CI], respectively: 58.8% [54.6%-62.9%] vs 52.8% [51.1%-54.4%], P = .006) but not R-PCE (41.6% [37.6%-45.7%] vs 39.9% [38.3%-41.5%], P = .448). Revised PCE and USPSTF recommendations were concordant for 90% of patients. Significant racial disparity in guideline-concordant statin prescribing was found using O-PCE (black and white patients, respectively, 35.0% [30.5%-39.9%] vs 41.8% [39.9%-44.4%], P = .013), but not R-PCE (40.6% [35.0%-46.6%] vs 43.0% [40.0%-45.9%], P = .482) or USPSTF recommendations (39.0% [33.8%-44.5%] vs 44.4% [41.5%-47.5%], P = .073).

CONCLUSIONS

Use of an alternative to O-PCE may reduce racial disparity in estimated CVE risk and may facilitate shared decision-making about primary prevention.

Deprescribing: Fashion Accessory or Fig Leaf?

Deprescribing is the general practice fashion accessory that no prescriber can be seen without. However, it is in danger of becoming a “fig leaf” substitute for the entire medication review suite.

Endoplasmic reticulum stress inhibition blunts the development of essential hypertension in the spontaneously hypertensive rat

Essential hypertension is the leading cause of premature death worldwide. However, hypertension’s cause remains uncertain. endoplasmic reticulum (ER) stress has recently been associated with hypertension, but it is unclear whether ER stress causes hypertension. To clarify this question, we examined if ER stress occurs in blood vessels before the development of hypertension and if ER stress inhibition would prevent hypertension development. We used the spontaneously hypertensive rat (SHR) as a model of human essential hypertension and the Wistar-Kyoto (WKY) rat as its normotensive control. Resistance arteries collected from young rats determined that ER stress was present in SHR vessels before the onset of hypertension. To assess the effect of ER stress inhibition on hypertension development, another subset of rats were treated with 4-phenylbutyric acid (4-PBA; 1 g·kg−1·day−1) for 8 wk from 5 wk of age. Blood pressure was measured via radiotelemetry and compared with untreated SHR and WKY rats. Mesenteric resistance arteries were collected and assessed for structural and functional changes associated with hypertension. Systolic and diastolic blood pressures were significantly lower in the 4-PBA-treated SHR groups than in untreated SHRs. Additionally, 4-PBA significantly decreased the media-to-lumen ratio and ER stress marker expression, improved vasodilatory response, and reduced contractile responses in resistance arteries from SHRs. Overall, ER stress inhibition blunted the development of hypertension in the SHR. These data add evidence to the hypothesis that a component of hypertension in the SHR is caused by ER stress.

NEW & NOTEWORTHY In this study, 4-phenylbutyric acid’s (4-PBA’s) molecular chaperone capability was used to inhibit endoplasmic reticulum (ER) stress in the small arteries of young spontaneously hypertensive rats (SHRs) and reduce their hypertension. These effects are likely mediated through 4-PBA's effects to reduce resistant artery contractility and increase nitric oxide-mediated endothelial vasodilation through a process preventing endothelial dysfunction. Overall, ER stress inhibition blunted the development of hypertension in this young SHR model. This suggests that a component of the increase in blood pressure found in SHRs is due to ER stress. However, it is important to note that inhibition of ER stress was not able to fully restore the blood pressure to normal, suggesting that a component of hypertension may not be due to ER stress. This study points to the inhibition of ER stress as an important new physiological pathway to lower blood pressure, where other known approaches may not achieve blood pressure-lowering targets.

Discontinuation of Antihypertensive Medication, Cognitive Complaints, and Incident Dementia

OBJECTIVES

To evaluate whether discontinuation of antihypertensive medication in community-dwelling older people is associated with a reduction in memory complaints and/or incident dementia.

DESIGN

Prospective observational cohort study within the Prevention of Dementia by Intensive Vascular Care (preDIVA) trial.

SETTING AND PARTICIPANTS

Community-dwelling participants (aged 70-78 years at baseline) who underwent 2-yearly assessments during 6-8 years of follow-up.

MEASURES

Cox regression analyses of the relation between discontinuation of antihypertensive medication during the study and change in subjective memory complaints, incident dementia, and mortality.

RESULTS

Dementia occurred more often in participants discontinuing antihypertensive treatment (13.4% vs 6.2%, P = .02); mortality was similar (16.5% vs 13.9%, P = .52). Discontinuation of antihypertensive medication was associated with a double dementia hazard [hazard ratio (HR) (95% confidence interval) = 2.15 (1.15-4.03)], which somewhat attenuated after adjustment for sex, blood pressure, number of antihypertensives and other medications [HR = 1.92 (1.01-3.65)], and additionally for stroke, cardiovascular disease, diabetes, smoking, memory complaints, and MMSE score [HR = 1.79 (0.93-3.44)]. Antihypertensive discontinuation was associated with an approximately 50% higher hazard of dementia and/or mortality combined [HR = 1.58 (1.04-2.40); model 2: HR = 1.64 (1.07-2.51); model 3: HR = 1.49 (0.96-2.30)]. Antihypertensive discontinuation was not associated with change in memory complaints [odds ratio (95% confidence interval) = 0.96 (0.55-1.67)]. Subgroup and sensitivity analyses addressing possible sources of bias and confounding gave similar results.

CONCLUSIONS/IMPLICATIONS

Our results suggest that antihypertensive withdrawal in community-dwelling older people does not preserve cognition and may in fact increase dementia risk. This is not due to reduced mortality as competing risk. Additional analyses suggest results are unlikely to be explainable by confounding, reverse causality, or observational biases. Studies with person-specific reasons for antihypertensive discontinuation may be able to exclude reverse causality completely. Given the beneficial effects of antihypertensive medication on cardiovascular risk, observational data may be the best currently obtainable on the pressing issue of when withdrawal of antihypertensives in older people is acceptable and what consequences need to be weighed.

OPtimising Treatment for MIld Systolic hypertension in the Elderly (OPTiMISE): protocol for a randomised controlled non-inferiority trial

INTRODUCTION

Recent evidence suggests that larger blood pressure reductions and multiple antihypertensive drugs may be harmful in older people, particularly frail individuals with polypharmacy and multimorbidity. However, there is a lack of evidence to support deprescribing of antihypertensives, which limits the practice of medication reduction in routine clinical care. The aim of this trial is to examine whether antihypertensive medication reduction is possible in older patients without significant changes in blood pressure control at follow-up.

METHODS AND ANALYSIS

This trial will use a primary care-based, open-label, randomised controlled trial design. A total of 540 participants will be recruited, aged ≥80 years, with systolic blood pressure <150 mm Hg and receiving ≥2 antihypertensive medications. Participants will have no compelling indication for medication continuation and will be considered to potentially benefit from medication reduction due to existing polypharmacy, comorbidity and frailty. Following a baseline appointment, individuals will be randomised to a strategy of medication reduction (intervention) with optional self-monitoring or usual care (control). Those in the intervention group will have one antihypertensive medication stopped. The primary outcome will be to determine if a reduction in medication can achieve a proportion of participants with clinically safe blood pressure levels at 12-week follow-up (defined as a systolic blood pressure <150 mm Hg), which is non-inferior (within 10%) to that achieved by the usual care group. Qualitative interviews will be used to understand the barriers and facilitators to medication reduction. The study will use economic modelling to predict the long-term effects of any observed changes in blood pressure and quality of life.

ETHICS AND DISSEMINATION

The protocol, informed consent form, participant information sheet and all other participant facing material have been approved by the Research Ethics Committee (South Central-Oxford A; ref 16/SC/0628), Medicines and Healthcare products Regulatory Agency (ref 21584/0371/001-0001), host institution(s) and Health Research Authority. All research outputs will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

EudraCT 2016-004236-38; ISRCTN97503221; Pre-results.

Screening and treatment of hypertension in older adults: less is more?

Screening and treatment of hypertension is a cornerstone of cardiovascular disease (CVD) prevention. Hypertension causes a large proportion of cases of stroke, coronary heart disease, heart failure, and associated disability and is highly prevalent especially among older adults. On the one hand, there is robust evidence that screening and treatment of hypertension prevents CVD and decreases mortality in the middle-aged population. On the other hand, among older adults, observational studies have shown either positive, negative, or no correlation between blood pressure (BP) and cardiovascular outcomes. Furthermore, there is a lack of high quality evidence for a favorable harm-benefit balance of antihypertensive treatment among older adults, especially among the oldest-old (i.e., above the age of 80 years), because very few trials have been conducted in this population. The optimal target BP may be higher among older treated hypertensive patients than among middle-aged. In addition, among frail or multimorbid older individuals, a relatively low BP may be associated with worse outcomes, and antihypertensive treatment may cause more harm than benefit. To guide hypertension screening and treatment recommendations among older patients, additional studies are needed to determine the most efficient screening strategies, to evaluate the effect of lowering BP on CVD risk and on mortality, to determine the optimal target BP, and to better understand the relationship between BP, frailty, multimorbidity, and health outcomes.