Asian management of hypertension: Current status, home blood pressure, and specific concerns in Pakistan

Assessment of blood pressure variability: characteristics and comparison of blood pressure measurement methods

Previous studies have reported that blood pressure variability (BPV) is associated with the risk of cardiovascular events independent of blood pressure (BP) levels. While there is little evidence from intervention trials examining whether suppressing BPV is useful in preventing cardiovascular disease, it is suggested that detection of abnormally elevated BPV may be useful in reducing cardiovascular events adding by complementing management of appropriate BP levels. Cuffless BP devices can assess beat-to-beat BPV. Although cuffless BP monitoring devices have measurement accuracy issues that need to be resolved, this is an area of research where the evidence is accumulating rapidly, with many publications on beat-to-beat BPV over several decades. Ambulatory BP monitoring (ABPM) can assess 24-hour BPV and nocturnal dipping patterns. Day-to-day BPV and visit-to-visit BPV are assessed by self-measured BP monitoring at home and office BP measurement, respectively. 24 h, day-to-day, and visit-to-visit BPV have been reported to be associated with cardiovascular prognosis. Although there have been several studies comparing whether ABPM and self-measured BP monitoring at home is the superior measurement method of BPV, no strong evidence has been accumulated that indicates whether ABPM or self-measured home BP is superior. ABPM and self-measured BP monitoring have their own advantages and complement each other in the assessment of BPV.

Home Blood Pressure Monitoring and Its Association With Blood Pressure Control Among Hypertensive Patients With High Cardiovascular Risk in China

Objective

Home blood pressure monitoring (HBPM) is viewed as a facilitating factor in the initial diagnosis and long-term management of treated hypertension. However, evidence remains scarce about the effectiveness of HBPM use in the real world. This study aimed to examine the associations of HBPM use with blood pressure (BP) control and medication adherence.

Methods

This prospective cohort study included hypertensive patients with high cardiovascular risk who were aged ≥50 years. At baseline, information about types of BP monitor, frequency of HBPM, perception of anti-hypertensive treatment, and measured office BP were collected. During the 1-year follow-up (visits at 1, 2, 3, 6, and 12 months), information on medication adherence was collected at each visit. The 2 major outcomes were BP control at baseline and medication adherence during the 1-year follow-up. A log-binomial regression model was used to examine the association between frequency of HBPM and outcomes, stratified by the perceptions of anti-hypertensive treatment.

Results

A total of 5,363 hypertensive patients were included in the analysis. The age was (64.6 ± 7.2) years, and 41.2% (2,208) were female. Of the total patients, 85.9% (4,606) had a home BP monitor and 47.8% (2,564) had an incorrect perception of anti-hypertensive treatment. Overall, 24.2% (1,299) of patients monitored their BP daily, 37.6% (2,015) weekly, 17.3% (926) monthly, and 20.9% (1,123) less than monthly. At baseline, the systolic BP and diastolic BP were (146.6 ± 10.8) mmHg and (81.9 ± 10.6) mmHg, respectively, and 28.5% (1,527) of patients had their BP controlled. Regardless of whether the patients had correct or incorrect perceptions of anti-hypertensive treatment, there is no significant association between HBPM frequency and BP control at baseline. During the 1-year follow-up, 23.9% (1,280) of patients had non-adherence to medications at least once. In patients with an incorrect perception of anti-hypertensive treatment, those monitoring BP most frequently (daily) had the highest non-adherence rate (29.9%, 175/585). Compared with those monitoring their BP less than monthly, patients who monitored their BP daily were more likely not to adhere to anti-hypertensive medications (adjusted relative risk = 1.38, 95% confidence interval: 1.11-1.72, P = 0.004).

Conclusions

HBPM performance among hypertensive patients in China is, in general, sub-optimal. No association was observed between using HBPM alone and hypertension control, indicating that the effects of HBPM could be conditional. Patients' misconceptions about anti-hypertensive treatment may impair the role of BP monitoring in achieving medication adherence. Fully incorporating the correct perception of hypertension into the management of hypertensive patients is needed.

Association of Depression and Anxiety With Hypertensive Crisis: A Cross-Sectional Study From a Hospital Setting in Karachi, Pakistan

Introduction

Hypertension, a leading risk factor for cardiovascular death, has been closely linked with depression and anxiety. The aim of this study was to examine the association of depression or anxiety with hypertensive crisis in patients and also see if the association is affected by age group or gender. This was carried out in a hospital setting.

Methods

This cross-sectional study was conducted between July 2019 and March 2022 on 290 patients admitted to the Aga Khan University Hospital (AKUH), Karachi, Pakistan. All adult patients more than 18 years of age admitted with uncontrolled hypertension with a systolic blood pressure of >140 and a diastolic blood pressure of >90 admitted through emergency were included. A hypertensive crisis was defined as a systolic blood pressure greater than 180 mm Hg or a diastolic blood pressure greater than or equal to 120 mm Hg, with or without accompanying end organ damage. Symptoms of depression and anxiety were evaluated using the Hospital Anxiety and Depression Scale (HADS), with a cut-off score ≥8.

Results

Of the patients identified with uncontrolled hypertension, a total of 140 (48.3%) of the patients presented with a hypertensive crisis, while 150 (51.3%) did not have a hypertensive crisis at presentation. In the hypertensive crisis group, 60 (49.3%) had HADS scores consistent with depression, while 83 (59.3%) had HADS scores consistent with anxiety. In patients with hypertensive crisis, HADS depression and anxiety were most prevalent in the 61-75 age group (39.7%). In the comparison of gender, it was found that males and females with hypertensive crisis had an almost equal prevalence of anxiety (49.4% in males versus 50.6% in females). A slightly higher prevalence of depression was seen in females with hypertensive crises when compared to males.

Conclusion

We found no association between depression or anxiety with hypertensive crisis, and the association is not affected by age group or gender. However, do note that half of the patients with hypertensive crises had depression or anxiety. Future large multicentered studies are required to study the link in greater detail.

Ziziphus Oxyphylla hydro-methanolic extract ameliorates hypertension in L-NAME induced hypertensive rats through NO/cGMP pathway and suppression of oxidative stress related inflammatory biomarkers

ETHNOPHARMACOLOGICAL RELEVANCE

Ziziphus Oxyphylla belongs to family Ziziphus and has been used traditionally in hypertension. It is enriched with quercetin and kaempferol derivatives, catechin and cyclopeptide alkaloids.

AIM

The current research evaluates the antihypertensive potential of aqueous methanolic extract of Z. oxyphylla (AMEZO) in NG-nitro-L-arginine methyl ester (LNAME) induced hypertension in rats.

MATERIAL AND METHODOLOGY

Phytochemical analysis of AMEZO was carried out using high performance liquid chromatography (HPLC) and electrospray ionization mass spectrometry (ESI-MS/MS). Antihypertensive activities of AMEZO (200 and 400 mg/kg) and Kaempferol were assessed in L-NAME (185 μmol/kg, intraperitoneal) injected hypertensive rats. In normotensive rats, blood pressure was assessed using Power Lab data system. Serum and tissue samples were preserved for estimation of nitric oxide (NO), Cyclic guanosine monophosphate (cGMP), interleukin-6 (IL-6), tumor necrosis factor (TNF- α) and oxidative stress markers respectively. mRNA levels of eNOS, ACE, COX-2 and NF-kB genes were assessed through qPCR.

RESULTS

The HPLC and ESI-MS/MS identified kaempferol, quercetin, catechin, ceanothic acid, zizybernalic acid and oxyphylline F. Chronic administration of AMEZO and kaempferol in L-NAME induced hypertensive rats significantly (p < 0.001) reduced systolic, diastolic and mean blood pressure. AMEZO and kaempferol caused meaningfully improved (p < 0.001) serum NO and cGMP levels. AMEZO administration also noticeably decrease the elevated IL-6 and TNF- α concentration in hypertensive animals. Administration of AMEZO and kaempferol also improved oxidative stress markers (MDA, CAT, SOD, GSH). The antihypertensive activity of AMEZO also resulted in upregulation of eNOS and downregulation of ACE.

CONCLUSION

These data depict that AMEZO and kaempferol showed antihypertensive activity in LNAME induced hypertensive rats possibly mediated through improvement in NO and cGMP levels, modulation of mRNA expression of eNOS, ACE, COX-2 and NF-kB and suppression of oxidative stress related inflammatory markers, proposing a defensive role in cardiovascular diseases.

Three Hours Ambulatory Blood Pressure: A Surrogate for Daytime Ambulatory Blood Pressure Assessment in the Pakistani Population

Background Office blood pressure (BP) measurement is affected by the white-coat phenomenon and shows a weaker correlation with the gold standard ambulatory blood pressure monitoring (ABPM). To overcome this limitation, 24-hour ABPM is recommended by the guidelines for the diagnosis of hypertension. However, 24-hour ABPM is expensive and cumbersome, which limits its use in low to middle-income countries like Pakistan. We aimed to assess if an abbreviated ABPM interval can be utilized to diagnose hypertension effectively in our population. Methods A cross-sectional study, involving 150 participants as part of the Post Clinic Ambulatory Blood Pressure (PC-ABP) study, was conducted in the cardiology clinics. Participants ≥18 years of age, who were either hypertensive or referred for assessment of hypertension, were included. Blood pressure (BP) readings were taken with an ambulatory BP monitor over a 24-hour period. After excluding the first hour called the 'white-coat window,' the mean of the first six systolic readings taken every half hour during the daytime was calculated and was called systolic three-hour ABPM. Pearson correlation coefficients were calculated and Bland-Altman plots were constructed to determine the correlation and limits of agreement between mean systolic three-hour ABPM and daytime-ABPM. Receiver operating characteristic (ROC) curve for systolic and diastolic three-hour daytime ABPM and area under the curve (AUC) were analyzed for the level of accuracy in predicting hypertension. Results Of the 150 participants, 49% were male, and 76% of all were hypertensive. The mean age of participants was 60.3 ± 11.9 years. The mean systolic three-hour ABPM was 135.0 ± 16 mmHg. The mean systolic daytime ABPM was 134.7 ± 15 mmHg. Pearson correlation coefficient between mean systolic three-hour ABPM and mean systolic daytime ABPM was 0.85 (p-value <0.001). The limits of agreement were 18 mmHg to -17 mmHg between the two readings on Bland-Altman plots and the area under the curve of the receiver operating characteristic (ROC) was 0.96, suggesting that three-hour systolic ABPM is a good predictor of hypertension. Conclusion Three-hour ABPM correlates well with 24-hour ABPM in the Pakistani population. We recommend considering the use of this abbreviated ABPM to screen hypertension where a full-length ABPM cannot be used. Further studies can be conducted on a larger sample size to determine the prognostic implications of this shortened ABPM.

Epidemiological Features of Cardiovascular Disease in Asia

Cardiovascular disease (CVD) is the leading cause of death in Asia. To combat the harmful impacts of CVD on public health in Asian countries with more effective strategies and actions, it is crucial to understand the current epidemiologic features of CVD in Asia. Through a systematic study and analysis of various timely data on CVD epidemiology in Asian countries from multiple sources, this state-of-the-art review provides an overview of the important epidemiologic features of CVD in Asia. Current and future challenges in CVD prevention implied by the epidemiologic features in Asian countries are highlighted and discussed in this review.

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Comprehensive data for the current features of CVD epidemics in Asia are lacking.

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This review provides an overview of the epidemiologic features of CVD in Asia.

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Current and future challenges and requirements for CVD prevention in Asian countries are addressed.

Hypertension and stroke in Asia: A comprehensive review from HOPE Asia

Stroke is the primary cause of disability and vascular death worldwide, including Asia. Asian characteristics that differ from the West lead to higher stroke incidence. Stroke epidemiology studies in Asia have shown varying levels of mortality, incidence, prevalence, and burden of disease. Hypertension is the most prevalent risk factor found in Asia. Besides ethnicity that is associated with stroke incidence, both systolic blood pressure, diastolic blood pressure, and blood pressure variability are positively correlated with stroke incidence. Post-stroke cognitive impairment is one of the sequelae that affect one-third of stroke survivors and has become a significant public health concern that is often neglected despite its increasing prevalence. Therefore, it is very important to prevent recurrence by treating stroke optimally and effectively. Increasing awareness and treatment adherence to hypertension, the leading risk factor for stroke, became the main goal in several countries in Asia.

Current status of adherence interventions in hypertension management in Asian countries: A report from the HOPE Asia Network

Adherence continues to be the major hurdle in hypertension management. Since the early 2000s, systematic approaches have been emphasized to tackle multi-dimensional issues specific for each regional setting. However, there is little data regarding implementation of adherence interventions in Asian countries. Eleven hypertension experts from eight Asian countries answered questionnaires regarding the use of adherence interventions according to 11 theoretical domain frameworks by Allemann et al. A four-point Likert scale: Often, Sometimes, Seldom, and Never used was administered. Responses to 97 items from 11 domains excluding three irrelevant items were collected. "Often-used" interventions accounted for 5/9 for education, 1/8 for skills, 1/2 for social/professional role and identity, 1/1 for belief about capabilities, 0/3 for belief about consequences, 2/4 for intentions, 2/9 for memory, attention, and decision process, 11/20 for environmental context and resources, 0/2 for social influences, 0/2 for emotion, and 2/2 for behavioral regulation. Most of them are dependent on conventional resources. Most of "Never used" intervention were the adherence interventions related to multidisciplinary subspecialties or formal training for behavioral therapy. For adherence interventions recommended by 2018 ESC/ESH hypertension guidelines, only 1 in 7 patient level interventions was "Often used." In conclusion, conventional or physician level interventions such as education, counseling, and prescription have been well implemented but multidisciplinary interventions and patient or health system level interventions are in need of better implementation in Asian countries.