Management of hypertension and stroke prevention: results of the Italian cardiologist survey

Triple Combination Therapies Based on Olmesartan: A Personalized Therapeutic Approach to Improve Blood Pressure Control

Recent epidemiological surveys have demonstrated that effective and sustained blood pressure (BP) control is achieved in a relatively small proportion of treated hypertensive patients. Indeed, treatment of hypertension represents a key strategy for preventing coronary artery disease, stroke, congestive heart failure and cardiovascular death. Several interventions have been proposed by international guidelines for ameliorating hypertension management and control, mostly including integrated and multi-dimensional pharmacological and non-pharmacological strategies. In particular, numerous evidence demonstrated that a more extensive use of combination therapy may represent a valid therapeutic option for treating hypertensive patients at different risk profile. This strategy has been definitely strengthened by the availability of single pill fixed-dose combinations. Among potential combination therapies, those based on the association of renin-angiotensin system antagonists, thiazide diuretics and calcium channel blockers are very effective in lowering BP levels and well tolerated. We will provide here an overview of clinical evidence supporting the use of triple combination therapy, with a focus on that based on olmesartan medoxomil, a thiazide diuretic (hydrochlorothiazide) and a calcium channel blocker (amlodipine besylate), which is available in multiple dosages. Finally, in view of the recognised importance of single-pill combination therapy for treating hypertension, we will examine the potential benefits of dual (fixed) combination therapy based on olmesartan medoxomil with either thiazide diuretic hydrochlorothiazide or calcium channel blocker amlodipine in terms of efficacy, safety and tolerability profile.

Attitudes and preferences for the clinical management of patients with hypertension and hypertension with chronic obstructive pulmonary disease in Italy: main results of a survey questionnaire

Hypertension treatment and control represent a clinical challenge, particularly in case of concomitant risk factors and comorbidities, including chronic obstructive pulmonary disease (COPD). To evaluate attitudes and preferences for the clinical management of hypertension and hypertension associated with COPD by a large community sample of physicians in Italy. A predefined 18-item survey questionnaire was anonymously administered to both specialised physicians (SPs) and general practitioners (GPs), who have been included in an educational programme, performed between January and June 2014. A total of 1181 physicians (767 males, mean age 55.8 ± 7.3 years, average age of medical activity 27.6 ± 8.3 years), among whom 64 (5.4 %) SPs and 1117 (94.6 %) GPs, provided 21,809 valid answers to the survey questionnaire. Concomitant presence of hypertension and COPD was frequently associated (21-40 %) with hypertension-related organ damage and comorbidities. Concomitant presence of hypertension and COPD was able to affect physicians' ability to achieve the recommended therapeutic targets. To achieve the recommended BP goals, ACE inhibitors or ARBs were considered the most effective antihypertensive strategies, both in monotherapies and in combination therapies with either diuretics or calcium-channel blockers. This observational, cross-sectional survey provides useful information on physicians' attitudes and preferences for the clinical management of patients with hypertension and hypertension associated with COPD.

Clinical management of patients with hypertension and high cardiovascular risk in specialised centers and in general practice. Analysis from an Italian Survey Questionnaire

BACKGROUND AND AIM

Hypertension control remains poorly achieved worldwide, despite the use of modern diagnostic tools and advanced therapeutic strategies. We aimed to evaluate the preferences expressed by either specialised physicians (SPs) or general practitioners (GPs) for the clinical management of hypertension and high cardiovascular risk in Italy.

METHODS AND RESULTS

A predefined questionnaire was anonymously administered to a large community sample of physicians, stratified according to clinical expertise. From a total of 64 questions, 557 physicians (478 male, mean age 54.2 ± 7.1 years, average age of medical activity 28.0 ± 8.1 years), including 261 (46.9%) SPs and 296 (53.1%) GPs, provided 9564 answers to the survey questionnaire. Involved clinicians spent the majority of their time and practice for hypertension management and control. SPs aimed to achieve the recommended BP targets (<140/90 mmHg), whereas GPs tended to achieve more rigorous BP goals (<130/80 mmHg); nonetheless, they both reported a very high rate of BP control (about 70%). Concomitant presence of diabetes, organ damage, as well as comorbidities, was reported to be relatively frequent (26-50%), mostly by SPs. ESH/ESC 2007 risk score stratification was preferred by SPs compared to GPs, who favored a comprehensive clinical evaluation. ACE inhibitors or ARBs were considered the best pharmacological option to start antihypertensive treatment, thus adding diuretics or calcium-channel blockers, if needed.

CONCLUSIONS

This predefined analysis of a survey questionnaire showed relatively different opinions with respect to recommended BP targets and distributions of cardiovascular risk profile, and similar diagnostic and therapeutic choices between GPs and SPs.

Attitudes and preferences for the clinical management of hypertension and hypertension-related cardiac disease in general practice: results of the Italian Hypertension and Heart Survey

The aim of this study was to evaluate attitudes and preferences for the clinical management of hypertensive patients with cardiac organ disease, including left ventricular hypertrophy (LVH) and coronary artery disease (CAD), in Italy. A predefined 15-item questionnaire was anonymously administered to a large community sample of general practitioners (GPs) and specialised physicians between November 2012 and June 2013. Estimated prevalence of hypertension-related clinical conditions was stratified into four groups (10-20%, 20-40%, 40-50%, >50%); preferences were reported as percentage among valid answers to the survey questionnaire. A total of 1319 physicians (672 males, age 55.0 ± 7.1 years, age of medical activity 27.1 ± 7.6 years), among whom 1264 GPs and 55 specialised physicians, was included. LVH was reported to be the most frequent marker of organ damage by the majority of physicians (73.5%). LV diastolic dysfunction was reported to be relatively frequent (>40%) by more than half of the specialised physicians (58.2%) and less frequent (10-20%) by GPs (49.8%); LV systolic dysfunction, atrial fibrillation and CAD were considered to be less frequent (10-20%) by the majority of physicians (61.3, 71.6 and 53.3%, respectively). Echocardiography was the preferred diagnostic tool used to estimate LVH (76.6%). Tight blood pressure control (130/80 mm Hg) was considered to be the most appropriate by the majority of physicians, both in hypertensive patients with LVH and in those with CAD. With the well-known limitations of a cross-sectional survey, this study provides information on attitudes and preferences for the clinical management of outpatients with hypertension and high CV risk profile in general practice in Italy.

Triple combination therapy to improve blood pressure control: experience with olmesartan-amlodipine-hydrochlorothiazide therapy

INTRODUCTION

Effective treatment of hypertension is a key strategy for preventing and reducing the burden of hypertension-related cardiovascular diseases. In spite of these well-established concepts, hypertension remains poorly controlled, worldwide. Among the different pharmacological strategies required to improve blood pressure (BP) control, a more extensive use of combination therapy is progressively emerging as a cornerstone of a more effective treatment of hypertension. Among different drug combinations currently available for the clinical management of hypertension, those based on the association of drugs inhibiting the renin-angiotensin system, thiazide diuretics and calcium channel blockers have demonstrated to be very effective in lowering both systolic and diastolic, clinic and 24-h ambulatory BP levels with a good tolerability and safety profile.

AREAS COVERED

In the present manuscript the authors provide an overview of the evidence supporting the use of triple combination therapy with different classes of antihypertensive drugs, with a particular focus on those based on olmesartan medoxomil, a thiazide diuretic (hydrochlorothiazide) and a calcium channel blocker (amlodipine besylate).

EXPERT OPINION

Available data indicate that triple combination therapy based on olmesartan provides effective and sustained clinical and 24-h BP control in a high proportion of individuals among a broad range of hypertensive patients.

Global cardiovascular risk management in different Italian regions: an analysis of the Evaluation of Final Feasible Effect of Control Training and Ultra Sensitisation (EFFECTUS) educational program

BACKGROUND AND AIM

The Final Evaluation Feasible Effect of Ultra Control Training and Sensitization (EFFECTUS) is an educational program, aimed at improving global CV risk stratification and management in Italy. The present study evaluates differences on clinical approach to global CV risk among physicians involved in the EFFECTUS program and stratified in three geographical macro-areas (North, Center, South) of our Country.

METHODS AND RESULTS

Physicians were asked to submit data already available in their medical records, covering the first 10 adult outpatients, consecutively seen in the month of May 2006. Overall, 1.078 physicians (27% females, aged 50 ± 7 years) collected data of 9.904 outpatients (46.5% females, aged 67 ± 9 years), among which 3.219 (32.5%) were residents in Northern, 3.652 (36.9%) in Central and 3.033 (30.6%) in Southern Italy. A significantly higher prevalence of major CV risk factors, including obesity, physical inactivity, hypertension and diabetes, was recorded in Southern than in other areas. Accordingly, Southern physicians more frequently prescribed antihypertensive, glucose and lipid lowering agents than other physicians, who paid significantly more attention to life-style changes in their clinical practice.

CONCLUSIONS

This analysis of the EFFECTUS study demonstrates a high prevalence of CV risk factors in Italy, particularly in Southern areas, and indicates some important discrepancies in the clinical management of global CV risk among physcians working in different Italian regions.

Modern clinical management of arterial hypertension: fixed or free combination therapies?

Blood pressure control is a key element in any cardiovascular prevention strategy. However, it is also one of the least frequently achieved goals in modern strategies for the clinical management of cardiovascular diseases, resulting in high impact in terms of cardiovascular morbidity and mortality. Among different factors that can be identified as the causes of poor blood pressure (BP) control in the general population of patients with hypertension, the excessive use of monotherapy, as opposed to combination therapy, is arguably one of the most significant. In this perspective, the use of combination therapies having synergic and complementary actions has been shown to reduce BP levels to increase the percentage of patients who respond to antihypertensive treatment and achieve the recommended BP targets. Moreover, recent studies have demonstrated that these strategies provide effective protection against hypertension-related organ damage, as well as a significant reduction of major cardiovascular events. While currently available evidence supports an increasingly important role of combination therapies compared with monotherapies, several other issues remain to be clarified. Among these, it has not yet been clearly established which classes of drugs should be considered for combination strategies, at what doses each component should be used, and whether combination strategies may be definitively considered as a first choice for the treatment of hypertensive patients at cardiovascular risk. Another relevant aspect concerns the choice between fixed and free combination therapies. This article discusses and analyses the different factors that may contribute to achieve effective BP control. In particular, the potential benefits and drawbacks associated with the use of fixed versus free combination therapies for hypertension treatment will be examined and discussed. The benefits of using combination strategies based on drugs that antagonize the renin-angiotensin system and dihydropyridine calcium antagonists will also be discussed, with a particular focus on amlodipine besylate combination therapies.

The management of hypertension for primary stroke prevention: a proposed approach

The prevalence of hypertension in society is high and increasing. Untreated hypertension results in stroke, dementia, and damage to major organs. This article reviews the risks that hypertension causes and the issues now generally accepted as playing a role in the low level of hypertension control. These include lack of public awareness of the significance of elevated blood pressure, lack of impetus to measure blood pressure, lack of sites to perform the measurements, occasional therapeutic inertia on the part of the medical community, and poor compliance with treatment on the part of affected individuals. Innovative measures that may result in improved management of this risk factor are discussed. These include ubiquitous blood pressure measurement sites, expanding therapeutic potential by involving allied health professionals, and offering rewards for treatment and for compliance. The article also emphasises that the ideal blood pressure target for the primary prevention of stroke remains unclear.

The role of fixed-dose combinations in the management of hypertension: focus on lercanidipine-enalapril

Achieving optimal blood pressure (BP) control is the most important single issue in the management of hypertension, and in most patients, it is difficult or impossible to achieve target levels with one drug. Blocking two or more regulatory systems provides a more effective and more physiologic reduction in BP, and current guidelines have recommended the use of combination therapy as first-line treatment, or early in the management of hypertension. Fixed-dose combination therapy is an efficacious, relatively safe and cost-effective treatment option in most patients with essential hypertension. Of note, the once-daily administration of a fixed-dose enalapril/lercanidipine, by bringing together two distinct and complementary mechanisms of action, reduces BP effectively and has the potential for improved target organ protection relative to either class agent alone.