British Hypertension Society guidelines for hypertension management 1999: summary

Inverse association of prepregnancy systolic blood pressure and live birth rate in normotensive women undergoing in vitro fertilization/intracytoplasmic sperm injection

OBJECTIVE

To explore whether maternal baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) affect pregnancy outcomes particularly in normotensive women (SBP, 90-139 mm Hg; DBP, 60-89 mm Hg) and hypertensive women undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

DESIGN

Retrospective cohort study.

SETTING

Maximum care hospital for reproductive medicine.

PATIENT(S)

This study included 73,462 patients who underwent IVF/ICSI at the Reproductive and Genetic Hospital of CITIC-Xiangya between January 1, 2016, and November 30, 2020, selected on the basis of pre-established criteria. Analysis was limited to the first transfer cycle of the first stimulation cycle.

INTERVENTION

Baseline SBP and DBP.

MAIN OUTCOME MEASURE(S)

The primary outcome focused on the live birth rate (LBR), with the secondary outcomes including clinical pregnancy rate, ectopic pregnancy rate, first-trimester miscarriage rate, second- or third-trimester fetal loss, and delivery/neonatal/maternal outcomes. Analytic methods included Poisson regression, linear regression, linear mixed-effect model, and restricted cubic spline analysis as appropriate.

RESULT(S)

For normotensive women, a 10-mm Hg increase in SBP was associated with an adjusted relative risk of 0.988 (95% confidence interval, 0.981-0.995) for live birth likelihood. However, DBP was not significantly associated with LBR after adjustments. The secondary outcomes indicated that increases in SBP and DBP were associated with higher risks of first-trimester miscarriage, gestational diabetes mellitus, and gestational hypertension in the normotensive subset. Sensitivity analyses confirmed these associations between SBP/DBP and LBR, consistent with the main findings even under stricter guidelines and after adjusting for multiple confounders. Subgroup analyses showed variation in the impact of blood pressure on LBR across different demographics and conditions. Consistent with earlier studies on blood pressure and birth outcomes, we found a 10-mm Hg increase in SBP was associated with a 5.4% (adjusted relative risk per 10 mm Hg, 0.946; 95% confidence interval, 0.907-0.986) reduction in LBR in the hypertensive subgroup.

CONCLUSION(S)

Systolic blood pressure impacted LBR outcomes in normotensive women who underwent IVF/ICSI, which suggests the need for reconsidering blood pressure management guidelines for reproductive-age women, focusing on reproductive health in addition to cardiovascular risk.

Twenty years on from the introduction of the high risk strategy for stroke and cardiovascular disease prevention: a systematic scoping review

BACKGROUND AND PURPOSE

Early this century, the high risk strategy of primary stroke and cardiovascular disease (CVD) prevention for individuals shifted away from identifying (and treating, as appropriate) all at-risk individuals towards identifying and treating individuals who exceed arbitrary thresholds of absolute CVD risk. The public health impact of this strategy is uncertain.

METHODS

In our systematic scoping review, the electronic databases (Scopus, MEDLINE, Embase, Google Scholar, Cochrane Library) were searched to identify and appraise publications related to primary CVD/stroke prevention strategies and their effectiveness published in any language from January 1990 to August 2023.

RESULTS

No published randomized controlled trial was found on the effectiveness of the high CVD risk strategy for primary stroke/CVD prevention. Targeting high CVD risk individuals excludes a large proportion of the population from effective blood-pressure-lowering and lipid-lowering treatment and effective CVD prevention. There is also evidence that blood pressure lowering and lipid lowering are beneficial irrespective of blood pressure and cholesterol levels and irrespective of absolute CVD risk and that risk-stratified pharmacological management of blood pressure and lipids to only high CVD risk individuals leads to significant underuse of blood-pressure-lowering and lipid-lowering medications in individuals otherwise eligible for such treatment.

CONCLUSIONS

Primary stroke and CVD prevention needs to be done in all individuals with increased risk of CVD/stroke. Pharmacological management of blood pressure and blood cholesterol should not be solely based on the high CVD risk treatment thresholds. International guidelines and global strategies for primary CVD/stroke prevention need to be revised.

Biomass using tribal women exhibited respiratory symptoms, hypertensive risks and abnormal pulmonary function

In rural areas of developing countries, solid fuels are still widely used for cooking, heating, and lighting purposes. This study investigates the effects of household air pollutants (HAPs) exposure on the occurrence of respiratory symptoms, blood pressure, and lung function. In this study, we randomly selected 123 (83 biomass and 40 clean fuel user) subjects to assess the impact of smoke generated from solid biomass fuel by assessing their health status along with the ventilation pattern of the kitchens and living rooms. HAPs (PM10, PM2.5, and CO) and different health parameters were measured along with monitoring of self-reported health symptoms for a consecutive period of eight months. Results revealed that the concentration of CO, PM2.5, and PM10 were found highest in biomass using households. Higher odds of the upper respiratory symptoms, runny nose (OR: 4.08, 95% CI: 1.22-22.14, p < 0.03), nasal congestion (OR: 9.07, 95% CI: 1.39-97.89, p < 0.01) and the odds of the lower respiratory symptoms like wheezing (OR: 1.62, 95% CI: 1.23-10.94, p < 0.01), breathlessness (OR: 4.44, 95% CI: 1.3-14.75, p < 0.01), chest tightness (OR: 4.89, 95% CI: 1.23-22.14, p < 0.03) and dry cough (OR: 3.661, 95% CI: 1.05-12.25, p < 0.04) were significantly higher in biomass fuel user. Similarly higher systolic (+11.41 mmHg), higher diastolic pressure (+3.3 mmHg), higher pulse pressure (+8.11 mmHg), and a 6 mmHg higher mean arterial pressure among biomass fuel using tribal women. The risk of hypertension was significantly (p < 0.03) higher (OR: 3.04; 95% CI: 1.18-7.89) among solid biomass fuel users. The lung abnormality was recorded 28.91% (OR: 5.02, 95% CI: 1.50 to 16.56, p < 0.01) among biomass fuel user. Finally, it is suggested that the use of efficient cookstoves, increase in cross ventilation, and cleaner fuel are urgently needed to curb the pollution load.

The relationship between hypertension and physical activity in middle-aged and older adults controlling for demographic, chronic disease, and mental health variables

To explore the relationship between hypertension and physical activity (PA) in the middle-aged and elderly after controlling demographic characteristics, chronic diseases and mental health variables. The 2018 China Health and Retirement Longitudinal Study (CHARLS) was used to collect the data. A baseline survey of middle-aged and older people was carried out nationally using the PPS sample method to look into their demographic, health state, and other information. The investigation included 4593 adults over 50 with complete data on PA level and hypertension prevalence. Z-test, logistic regression analysis, and linear hierarchical regression analysis were performed on the gathered data using the SPSS 27.0 program. The prevalence of hypertension among middle-aged and senior persons was 12.2%, and the percentage of those who did not have it was 87.8%. Males were more likely than females to have hypertension. Participants who reported high levels of PA made up 49.2% of the total, while those who reported low levels of PA made up 50.8% of the total. High levels of PA were significantly inversely correlated with hypertension (P < .05). There was still a statistically significant relationship between PA and hypertension (P < .05) after controlling demographic factors (gender, age, household registration type, education level, widowhood), chronic disease (arthritis, diabetes, disability, asthma, self-assessment of health, memory disease, stroke, hyperlipidemia) and mental health variables (bad mood and depression). High-level PA is significantly related to the low risk of hypertension. After controlling demographic characteristics, chronic diseases and mental health variables, this correlation is still significant.

Concatenated convolutional neural network model for cuffless blood pressure estimation using fuzzy recurrence properties of photoplethysmogram signals

Due to the importance of continuous monitoring of blood pressure (BP) in controlling hypertension, the topic of cuffless BP estimation has been widely studied in recent years. A most important approach is to explore the nonlinear mapping between the recorded peripheral signals and the BP values which is usually conducted by deep neural networks. Because of the sequence-based pseudo periodic nature of peripheral signals such as photoplethysmogram (PPG), a proper estimation model needed to be equipped with the 1-dimensional (1-D) and recurrent layers. This, in turn, limits the usage of 2-dimensional (2-D) layers adopted in convolutional neural networks (CNN) for embedding spatial information in the model. In this study, considering the advantage of chaotic approaches, the recurrence characterization of peripheral signals was taken into account by a visual 2-D representation of PPG in phase space through fuzzy recurrence plot (FRP). FRP not only provides a beneficial framework for capturing the spatial properties of input signals but also creates a reliable approach for embedding the pseudo periodic properties to the neural models without using recurrent layers. Moreover, this study proposes a novel deep neural network architecture that combines the morphological features extracted simultaneously from two upgraded 1-D and 2-D CNNs capturing the temporal and spatial dependencies of PPGs in systolic and diastolic BP estimation. The model has been fed with the 1-D PPG sequences and the corresponding 2-D FRPs from two separate routes. The performance of the proposed framework was examined on the well-known public dataset, namely, multi-parameter intelligent in Intensive Care II. Our scheme is analyzed and compared with the literature in terms of the requirements of the standards set by the British Hypertension Society (BHS) and the Association for the Advancement of Medical Instrumentation (AAMI). The proposed model met the AAMI requirements, and it achieved a grade of A as stated by the BHS standard. In addition, its mean absolute errors and standard deviation for both systolic and diastolic blood pressure estimations were considerably low, 3.05 ± 5.26 mmHg and 1.58 ± 2.6 mmHg, in turn.

Assessment of household air pollution exposure of tribal women

There is a growing evidence that the burning of unprocessed biomass fuels is associated with adverse health impacts. This study estimated the gaseous pollutants (CO, CO₂, O_3, SO₂, and NO₂) and particulate matters (PM_2.5 and PM₁₀) during the burning of biomass and liquefied petroleum gas (LPG) fuels and their impacts on the health of tribal women. The results revealed that the tribal women mainly used six types of unprocessed biomass fuels (dry leaves, cow dung cake, dry woods, twigs, rice straw, and agricultural residues) along with five types of traditional earthen stoves. The concentration of gaseous and PM was recorded as in the order of CO₂ > SO₂ > CO > O₃ and total suspended particulate matter (TSPM) > PM₁₀ > PM_2.5, respectively. The pollutant concentration inside the kitchen room for biomass users was significantly (p < 0.001) higher than LPG users. The biomass using tribal women might be suffering from higher cardiovascular risk than LPG users. The lung function study results also indicated that the mean values of forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), and FEV₁/FVC were lower among biomass users than LPG users. The correlation study shows that tribal women who were exposed to biomass smoke were in a more vulnerable position than those who used LPG. Moreover, the toxicological risk among tribal biomass users was observed high (3.52) compared to LPG users (0.39). On the other hand, the Monte Carlo probabilistic simulation model for uncertainty analysis revealed that the mean value of Hazard Quotient (HQ) for PM_2.5 in kitchen room was observed as 4.31E-00 and 9.40E-01 for biomass and LPG users, respectively. Modelling study also revealed that exposure of duration and cooking time are extremely important for toxicological risk assessment. However, further long-term comprehensive studies are extremely important.

Epicardial fat thickness is associated with retinopathy in patients with newly diagnosed hypertension

OBJECTIVE

Hypertensive retinopathy develops based on endothelial dysfunction, inflammation, and atherosclerosis. Epicardial fat secretes various cytokines associated with endothelial dysfunction, oxidative stress, inflammation, and atherosclerosis. We aimed to evaluate whether epicardial adipose tissue (EAT) thickness is a marker for retinopathy in newly diagnosed hypertensive patients.

METHODS

A total of 73 newly diagnosed hypertension (HT) patients were included in the study. Transthoracic echocardiography (TTE) was used to measure EAT thickness. To evaluate the presence of retinopathy in HT patients, hypertensive retinopathy staging was performed by ophthalmologists, according to Scheie classification.

RESULTS

Retinopathy was detected in 27 (37.0%) of 73 patients. EAT thickness in HT patients with retinopathy was higher than the group without retinopathy (5.07±1.45 mm vs. 4.19±1.20 mm, p=0.007). Low-density lipoprotein cholesterol (LDL-C) levels in HT patients with retinopathy were higher than the group without retinopathy (162.4±41.2 mg/dl vs. 138.1±35.6 mg/dl, p=0.010). As a result of the regression analysis, LDL-C (OR=1.016, 95% CI 1.001-1.031, p=0.043) and EAT thickness (OR=1.674, 95% CI 1.069-2.626, p=0.043) were the independent predictors of retinopathy.

CONCLUSION

Increased EAT thickness is associated with the presence of retinopathy in hypertensive patients.

Evolution of Blood Pressure Clinical Practice Guidelines: A Personal Perspective

Before the second half of the 20th century, most clinical decision making was based on expert opinion. By the 1960s, experience in actuarial and research cohort studies had provided strong evidence that blood pressure was an important risk factor for cardiovascular disease. The landmark 1967 and 1970 Veterans Administration Cooperative Study trials confirmed the value of antihypertensive drug therapy in preventing stroke, myocardial infarction, and heart failure in adults with high levels of diastolic blood pressure. They also provided an impetus to develop the first blood-pressure-related clinical practice guideline in 1977. In subsequent years, more structured and comprehensive blood-pressure guidelines have evolved to become a major resource in clinical and public health practice. Despite some limitations, these guidelines provide useful evidence-based guidance for diagnosis and management of high blood pressure. The core advice in most of the current comprehensive blood pressure guidelines is more similar than different. Modelling studies suggest that better adherence to guideline recommendations would result in a lower average blood pressure and substantial improvement in public health.

Prevalence and clinical spectrum of hypertensive retinopathy among hypertension clinic patients at Queen Elizabeth Central Hospital in Malawi

Background

Prevalence and spectrum of hypertensive retinopathy in the population reflects the status of hypertension control and the associated risks for cardiovascular events. We investigated the prevalence and clinical spectrum of hypertensive retinopathy among patients attending hypertension clinic at a tertiary hospital in Malawi.

Methods

This was a cross-sectional study of systematically selected patients attending hypertension clinic at Queen Elizabeth Central Hospital. Patient interviews using a structured questionnaire and review of patients' medical records (health passports) were done to obtain the following information: demographics, duration since the diagnosis of hypertension, history of stroke and blood pressure measurements. The presence and severity of hypertensive retinopathy was determined by dilated fundoscopy through slit lamp biomicroscopy.

Results

We recruited 104 patients. Women outnumbered men by 3:1. Women tended to be younger compared to men (mean ages 54 and 61 years respectively). Of the surveyed patients, 80% had sub-optimal blood pressure control and 75% had evidence of hypertensive retinopathy. History of stroke was associated with hypertensive retinopathy.

Conclusions

Hypertensive retinopathy is very common in patients attending the hypertension clinic at Queen Elizabeth Central Hospital in Blantyre, Malawi. This may be a reflection of sub-optimal blood pressure control in this patient population. There is a need to identify the actual reasons, rectify them and intensify intervention in control of hypertension in this patient population.

Changes in thickness of central macula and retinal nerve fibre layer in severe hypertensive retinopathy: a 1-year longitudinal study

OBJECTIVE

To analyse the longitudinal changes in the thickness of the central macula and retinal nerve fibre layer (RNFL) in patients with hypertensive retinopathy (HTNR) using spectral-domain optical coherence tomography (SD-OCT).

METHODS

This was a prospective cohort study. We studied 18 eyes of patients with HTNR of grade IV who had been followed up for more than 1 year, and 36 normal eyes (without any relevant medical history; the control group). Antihypertensive treatment successfully normalized the blood pressure of HTNR patients. The RNFL thickness and that of the central macula of HTNR patients were measured using a Cirrus HD-OCT instrument, and compared with those of the control group.

RESULTS

At 12 months of follow-up, the mean thickness of the RNFL and central macula was significantly lower in the HTNR group than in the control group (the RNFL was measured first, and then the central macular thickness (CMT): 77.4 ± 9.1 and 233.8 ± 30.8 μm versus 94.1 ± 7.8 and 256.3 ± 28.1 μm, respectively; p < 0.05). With time, the RNFL thickness and CMT became significantly less than that at the initial diagnosis (p < 0.05).

CONCLUSION

Severe HTNR causes a decrease in the thickness of the RNFL and central macula over time. Therefore, the impact of retinal changes associated with systemic diseases such as hypertension should be considered in analysing the thicknesses of the RNFL and central macula in ocular disorders, including retina, glaucoma and neuro-ophthalmologic diseases.

Combined effect of glycemic and blood pressure control on diabetic retinopathy among Chinese with type-2 diabetes mellitus

BACKGROUND

To explore the associations of glycemic and blood pressure (BP) control with diabetic retinopathy (DR), with special focus on whether different combinations of categories of these two interventions are additive.

METHODS

A community-based survey including 913 patients with known type-2 diabetes mellitus (T2DM) was conducted in Suzhou, China. Retinal photographs were graded for the presence of DR using the Airlie House classification system. BP and blood hemoglobin A1c (HbA1C) levels were measured by standardized protocols. Binary logistic regression models were established to examine the associations of risk factors with DR.

RESULTS

The overall prevalence of any DR was 18.0% [95% confidence interval (95% CI) 15.5-20.6%] in this population. Stratified by conventional control thresholds, lower levels of either systolic blood pressure (SBP, < 140 mmHg) or HbA1C (< 7.0%) were not significantly associated with decreased susceptibility to DR, while patients simultaneously with lower HbA1C and SBP levels demonstrated 43% reduced likelihood of developing DR [adjusted odds ratio (OR) = 0.57, 95% CI 0.33-0.99, P = 0.045)], comparing with those with both higher levels of HbA1C (≥ 7.0%) and SBP (≥ 140 mmHg). Meanwhile, the group achieved intensive HbA1C (< 6.5%) and SBP (< 120 mmHg) control goals were found to have the smallest OR, but failed in yielding statistical significance (P = 0.10).

CONCLUSIONS

In this community-based DR screening study of Chinese adults with T2DM, combination but not individual of lower SBP (< 140 mmHg) and HbA1C (< 7.0%) levels, were suggested to be associated with a significantly reduced likelihood of having DR.

Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association

BACKGROUND AND PURPOSE

Population-wide reductions in cardiovascular disease incidence and mortality have not been shared equally by African Americans. The burden of cardiovascular disease in the African American community remains high and is a primary cause of disparities in life expectancy between African Americans and whites. The objectives of the present scientific statement are to describe cardiovascular health in African Americans and to highlight unique considerations for disease prevention and management.

METHOD

The primary sources of information were identified with PubMed/Medline and online sources from the Centers for Disease Control and Prevention.

RESULTS

The higher prevalence of traditional cardiovascular risk factors (eg, hypertension, diabetes mellitus, obesity, and atherosclerotic cardiovascular risk) underlies the relatively earlier age of onset of cardiovascular diseases among African Americans. Hypertension in particular is highly prevalent among African Americans and contributes directly to the notable disparities in stroke, heart failure, and peripheral artery disease among African Americans. Despite the availability of effective pharmacotherapies and indications for some tailored pharmacotherapies for African Americans (eg, heart failure medications), disease management is less effective among African Americans, yielding higher mortality. Explanations for these persistent disparities in cardiovascular disease are multifactorial and span from the individual level to the social environment.

CONCLUSIONS

The strategies needed to promote equity in the cardiovascular health of African Americans require input from a broad set of stakeholders, including clinicians and researchers from across multiple disciplines.

Trends for prevalence and incidence of resistant hypertension: population based cohort study in the UK 1995-2015

Objective To estimate the incidence and prevalence of resistant hypertension among a UK population treated for hypertension from 1995 to 2015.Design Cohort study.Setting Electronic health records from the UK Clinical Practice Research Datalink in primary care.Participants 1 317 290 users of antihypertensive drugs with a diagnosis of hypertension.Main outcome measures Resistant hypertension was defined as concurrent use of three antihypertensive drugs inclusive of a diuretic, uncontrolled hypertension (≥140/90 mm Hg), and adherence to the prescribed drug regimen, or concurrent use of four antihypertensive drugs inclusive of a diuretic and adherence to the prescribed drug regimen. To determine incidence, the numerator was new cases of resistant hypertension and the denominator was person years of those with treated hypertension and at risk of developing resistant hypertension. To determine prevalence, the numerator was total number of cases with resistant hypertension and the denominator was those with treated hypertension. Prevalence and incidence were age standardised to the 2015 hypertensive population.Results The age standardised incidence of resistant hypertension increased from 0.93 cases per 100 person years (95% confidence interval 0.87 to 1.00) in 1996 to a peak level of 2.07 cases per 100 person years (2.03 to 2.12) in 2004. Incidence then decreased to 0.42 cases per 100 person years (0.40 to 0.44) in 2015. Age standardised prevalence increased from 1.75% (95% confidence interval 1.66% to 1.83%) in 1995 to a peak of 7.76% (7.70% to 7.83%) in 2007. Prevalence then plateaued and subsequently declined to 6.46% (6.38% to 6.54%) in 2015. Compared with patients aged 65-69 years, those aged 80 or more years were more likely to have prevalent resistant hypertension throughout the study period.Conclusions Prevalent resistant hypertension has plateaued and decreased in recent years, consistent with a decrease in incidence from 2004 onwards. Despite this, resistant hypertension is common in the UK hypertensive population. Given the importance of hypertension as a modifiable risk factor for cardiovascular disease, reducing uncontrolled hypertension should remain a population health focus.

Beta-blockers for hypertension

BACKGROUND

Beta-blockers refer to a mixed group of drugs with diverse pharmacodynamic and pharmacokinetic properties. They have shown long-term beneficial effects on mortality and cardiovascular disease (CVD) when used in people with heart failure or acute myocardial infarction. Beta-blockers were thought to have similar beneficial effects when used as first-line therapy for hypertension. However, the benefit of beta-blockers as first-line therapy for hypertension without compelling indications is controversial. This review is an update of a Cochrane Review initially published in 2007 and updated in 2012.

OBJECTIVES

To assess the effects of beta-blockers on morbidity and mortality endpoints in adults with hypertension.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to June 2016: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 6), MEDLINE (from 1946), Embase (from 1974), and ClinicalTrials.gov. We checked reference lists of relevant reviews, and reference lists of studies potentially eligible for inclusion in this review, and also searched the the World Health Organization International Clinical Trials Registry Platform on 06 July 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of at least one year of duration, which assessed the effects of beta-blockers compared to placebo or other drugs, as first-line therapy for hypertension, on mortality and morbidity in adults.

DATA COLLECTION AND ANALYSIS

We selected studies and extracted data in duplicate, resolving discrepancies by consensus. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI) and conducted fixed-effect or random-effects meta-analyses, as appropriate. We also used GRADE to assess the certainty of the evidence. GRADE classifies the certainty of evidence as high (if we are confident that the true effect lies close to that of the estimate of effect), moderate (if the true effect is likely to be close to the estimate of effect), low (if the true effect may be substantially different from the estimate of effect), and very low (if we are very uncertain about the estimate of effect).

MAIN RESULTS

Thirteen RCTs met inclusion criteria. They compared beta-blockers to placebo (4 RCTs, 23,613 participants), diuretics (5 RCTs, 18,241 participants), calcium-channel blockers (CCBs: 4 RCTs, 44,825 participants), and renin-angiotensin system (RAS) inhibitors (3 RCTs, 10,828 participants). These RCTs were conducted between the 1970s and 2000s and most of them had a high risk of bias resulting from limitations in study design, conduct, and data analysis. There were 40,245 participants taking beta-blockers, three-quarters of them taking atenolol. We found no outcome trials involving the newer vasodilating beta-blockers (e.g. nebivolol).There was no difference in all-cause mortality between beta-blockers and placebo (RR 0.99, 95% CI 0.88 to 1.11), diuretics or RAS inhibitors, but it was higher for beta-blockers compared to CCBs (RR 1.07, 95% CI 1.00 to 1.14). The evidence on mortality was of moderate-certainty for all comparisons.Total CVD was lower for beta-blockers compared to placebo (RR 0.88, 95% CI 0.79 to 0.97; low-certainty evidence), a reflection of the decrease in stroke (RR 0.80, 95% CI 0.66 to 0.96; low-certainty evidence) since there was no difference in coronary heart disease (CHD: RR 0.93, 95% CI 0.81 to 1.07; moderate-certainty evidence). The effect of beta-blockers on CVD was worse than that of CCBs (RR 1.18, 95% CI 1.08 to 1.29; moderate-certainty evidence), but was not different from that of diuretics (moderate-certainty) or RAS inhibitors (low-certainty). In addition, there was an increase in stroke in beta-blockers compared to CCBs (RR 1.24, 95% CI 1.11 to 1.40; moderate-certainty evidence) and RAS inhibitors (RR 1.30, 95% CI 1.11 to 1.53; moderate-certainty evidence). However, there was little or no difference in CHD between beta-blockers and diuretics (low-certainty evidence), CCBs (moderate-certainty evidence) or RAS inhibitors (low-certainty evidence). In the single trial involving participants aged 65 years and older, atenolol was associated with an increased CHD incidence compared to diuretics (RR 1.63, 95% CI 1.15 to 2.32). Participants taking beta-blockers were more likely to discontinue treatment due to adverse events than participants taking RAS inhibitors (RR 1.41, 95% CI 1.29 to 1.54; moderate-certainty evidence), but there was little or no difference with placebo, diuretics or CCBs (low-certainty evidence).

AUTHORS' CONCLUSIONS

Most outcome RCTs on beta-blockers as initial therapy for hypertension have high risk of bias. Atenolol was the beta-blocker most used. Current evidence suggests that initiating treatment of hypertension with beta-blockers leads to modest CVD reductions and little or no effects on mortality. These beta-blocker effects are inferior to those of other antihypertensive drugs. Further research should be of high quality and should explore whether there are differences between different subtypes of beta-blockers or whether beta-blockers have differential effects on younger and older people.

A Survey of Coronary Risk Factors in a Cohort of Cardiac Nurses from Europe: Do Nurses Practise What They Preach?

BACKGROUND

Cardiac nurses play a key role in coronary heart disease (CHD) prevention, health promotion and education. Thus, one would expect that nurses would have a heightened awareness of the need to modify lifestyle in order to prevent or reduce the risk of CHD.

AIMS

The aim of this study was to determine the prevalence of the major CHD risk factors in a cohort of cardiac nurses from a range of European countries.

METHODS

Data on CHD risk factors were collected at a health-screening interview. The sample consisted of 130 cardiac nurses from 11 countries attending a European cardiac nursing conference held in the UK. Demographic data, lipid profile, blood pressure and exercise, alcohol and smoking habits were recorded.

RESULTS

Of the 130 nurses who took part in this survey, 81% were from the UK. The mean (S.D.) age of the sample was 40 (7.5) years and 91% were female. The means (S.D.) of the risk factors were: systolic blood pressure 132 (16) mmHg; diastolic blood pressure 83 (11) mmHg; body mass index (BMI) 24.6 (3.8) kg/m(2); total cholesterol 5.1 (0.9) mmol/l; and blood glucose 5.5 (1.2) mmol/l. Ten nurses admitted to smoking and the mean weekly alcohol consumption was 10 units. Over half (53%) of the sample reported a family history of CHD and 49% reported exercising regularly.

CONCLUSIONS

Results indicate that in general, cardiac nurses have adopted a healthier lifestyle than the general population. Self-reported exercise was higher than the UK national norms and BMI was lower than UK national norms.

A reversible posterior leucoencephalopathy syndrome including blindness caused by preeclampsia

Complications of (pre)eclampsia may involve multiple systems and organs. Neurological symptoms may occur. Visual symptoms concern up to 25% the of patients with severe preeclampsia and 50% of the patients with eclampsia. An uncommon effect of severe preeclampsia is sudden blindness. Blindness may be part of a clinical and radiological presentation named Posterior Reversible Encephalopathy Syndrome (PRES). PRES may lead to permanent neurological deficit, recurrences or death. We report the case of a 24-year-old Caucasian patient, gravida 5 para 2 who developed preeclampsia and PRES complicated with blindness at 32 weeks of gestation. Optimal care allowed visual symptoms to resolve within 24 hours and a favourable maternal outcome and no long- term sequelae. We describe different causes and manifestations of PRES and highlight the need for immediate care in order to optimize the chance of symptoms reversibility.

Review: Implications from hypertension outcome trials for the management of patients with hypertension and diabetes

The UKPDS highlighted the importance of blood pressure control in patients with type 2 diabetes. In this review I draw on data from the INSIGHT and other recent outcome trials in hypertension which provide clear evidence that it is the achievement of good control of blood pressure, irrespective of the initial choice of drug, that is the major determinant of outcome. The INSIGHT trial provides hard evidence of how resistant to treatment patients with diabetes really are. In this review I offer a theoretical and practical solution in the form of a stepwise algorithm using multiple therapies.

Contribution of Nursing to Risk Factor Management as Perceived by Patients with Established Coronary Heart Disease

Background: Guidelines stress the importance of risk factor management in patients with coronary heart disease (CHD). Aims: To evaluate whether guidelines on patient education in risk factor management are followed in clinical practice and to assess the contribution of nursing to risk factor management as perceived by patients with established CHD. Methods: Within three Dutch hospitals consecutive patients were identified after a first coronary–artery bypass graft, a first percutaneous transluminal coronary angioplasty or hospital admission for acute myocardial infarction or ischaemia ( n=357). Data were collected through patient interviews at least 6 months after hospital admission. Results: Among smokers, overweight patients, patients with hypertension, high cholesterol, and sedentary lifestyle, respectively 75, 36, 67, 61 and 49% reported that information on presence or management of these risk factors was provided. The proportion of patients informed by nurses ranged from 14% (lowering cholesterol) to 23% (increasing physical activity), while 55% (lowering cholesterol) to 71% (stop smoking) were informed by physicians. Conclusion: Many patients with established CHD and cardiovascular risk factors do not remember ever having received information about management of their risk factors. Clearly, there is a substantial potential to improve professionals’ compliance to guidelines on risk factor management, including those on patient education. The perceived contribution of nurses to risk factor management is small compared to that of physicians and other caregivers. If risk factor management is felt to be a main responsibility of nurses, current nursing activities in this area should be reconsidered within an improved organisational structure.

Investigating Six-Month Health Outcomes of Patients with Angina Discharged from a Chest Pain Service

Hospital admissions for patients with suspected cardiac chest pain are increasing. The development of a chest pain service allows rapid diagnosis, investigation and treatment. Since the in-patient stay is often short, there is limited time for education and risk factor management. Little is known about the patients' recovery post discharge. This study was completed to investigate the 6-month health outcomes of 57 patients discharged from the chest pain service by measuring cardiovascular symptoms and risk profiles, mood and quality of life, adherence to secondary prevention, morbidity and mortality. The results of this study showed that 58% of the sample still suffered angina, 72% reported breathlessness, and 79% reported lethargy. Assessment of mood showed that 76% suffered from anxiety and 78% depression. Quality of life was impaired. A reduction of cholesterol level was the only significant change in risk factors. Secondary prevention measures showed that there was still room for improvement. Twenty-five percent of the sample was readmitted to hospital due to their cardiac condition. Patients had an average of eight contacts with their general practitioner, four of which were cardiac related. The ongoing symptoms, anxiety and depression and uncorrected risk factors can impact on their recovery. Currently, however, no programme of rehabilitation is available for angina patients, despite the potential for up to 30% of patients suffering a subsequent cardiac event (Ghandi et al., British Heart Journal 73 (1995) 193–198). This study suggests the need to develop, implement and evaluate a CR programme in this client group.

To Examine the Effectiveness of a Hospital-Based Nurse-Led Secondary Prevention Clinic

Modification of cardiovascular risk factors can reduce the incidence of myocardial infarction (MI), effectively extend survival, decrease the need for interventional procedures, and improve quality of life in persons with known cardiovascular disease. Pharmacological treatments and important lifestyle changes reduce people's risks substantially (by 1/3 to 2/3) and can slow and perhaps reverse progression of established coronary disease. When used appropriately, these interventions are more cost-effective than many other treatments, currently provided by the National Health Service [Department of Health National Service Frameworks: coronary heart disease. Preventing coronary heart disease in high risk patients. 2000. HMSO.] Secondary prevention clinics are effective means by which to ensure targets are achieved and assist primary care in long-term maintenance of lifestyle change and drug optimisation.

A 2-year hospital-based pilot project was established at the Royal Hospitals, April 2001–April 2003. The aim of the project was to target patients with coronary heart disease, post-MI and/or coronary artery bypass grafting and/or percutaneous coronary intervention, 6 months following their cardiac event. The plan was to assess patient risk factors and medication a minimum of 6 months following their cardiac event to ascertain if government targets were being achieved; secondly, to examine the effectiveness of a hospital-based nurse-led secondary prevention clinic on modifying risk factors and optimising drug therapies.

Ambulatory Blood Pressure Variability Increases Over a 10-Year Follow-Up in Community-Dwelling Older People

BACKGROUND

Greater ambulatory blood pressure variability (ABPV) is associated with end-organ damage and increased mortality. Age-related changes in the cardiovascular and autonomic nervous systems make age-associated increases in ABPV likely. Cross-sectional studies support this hypothesis, showing greater ABPV among older compared to younger adults. The only longitudinal study to examine changes in ABPV, however, found ABPV decreased over 5 years follow-up. This unexpected observation probably reflected the highly selected nature of the study participants.

METHODS

In this longitudinal study, we assessed changes in ABPV over 10 years in a community-cohort of older people. In addition, we examined the extent to which ABPV was predicted by demographics, cardiovascular risk factors, and medication. Clinical examination and 24-hour ambulatory blood pressure monitoring were carried out at baseline and at 10 years follow-up in 83 people, median age 70 years. ABPV was calculated using SD and coefficient of variation (Cv). Three time periods were examined: daytime, nighttime, and 24 hours.

RESULTS

Daytime and 24-hour, systolic and diastolic, SD, and Cv were significantly greater at follow-up than at baseline (P < 0.001 in all cases). Mean BP did not change.

CONCLUSIONS

Multilevel modeling showed follow-up interval had a significant, positive effect on SD and Cv (P < 0.004), independent of age, sex, and medication.ABPV increased over a 10-year follow-up despite stable mean BP. ABPV may therefore be an additional target for treatment in older people. Future studies should examine what degree of ABPV is harmful and if control of ABPV reduces adverse outcome.

Understanding and treating hypertension in diabetic populations

Hypertension and diabetes frequently occurs in the same individuals in clinical practice. Moreover, the presence of hypertension does increase the risk of new-onset diabetes, as well as diabetes does promote development of hypertension. Whatever the case, the concomitant presence of these conditions confers a high risk of major cardiovascular complications and promotes the use integrated pharmacological interventions, aimed at achieving the recommended therapeutic targets. While the benefits of lowering abnormal fasting glucose levels in patients with hypertension and diabetes have been consistently demonstrated, the blood pressure (BP) targets to be achieved to get a benefit in patients with diabetes have been recently reconsidered. In the past, randomized clinical trials have, indeed, demonstrated that lowering BP levels to less than 140/90 mmHg was associated to a substantial reduction of the risk of developing macrovascular and microvascular complications in hypertensive patients with diabetes. In addition, epidemiological and clinical reports suggested that "the lower, the better" for BP in diabetes, so that levels of BP even lower than 130/80 mmHg have been recommended. Recent randomized clinical trials, however, designed to evaluate the potential benefits obtained with an intensive antihypertensive therapy, aimed at achieving a target systolic BP level below 120 mmHg as compared to those obtained with less stringent therapy, have challenged the previous recommendations from international guidelines. In fact, detailed analyses of these trials showed a paradoxically increased risk of coronary events, mostly myocardial infarction, in those patients who achieved the lowest BP levels, particularly in the high-risk subsets of hypertensive populations with diabetes. In the light of these considerations, the present article will briefly review the common pathophysiological mechanisms, the potential sites of therapeutic interactions and the currently recommended BP targets to be achieved under pharmacological treatment in hypertension and diabetes.

Modification of solid lipid nanoparticles loaded with nebivolol hydrochloride for improvement of oral bioavailability in treatment of hypertension: polyethylene glycol versus chitosan oligosaccharide lactate

Nebivolol (NB)-loaded solid lipid nanoparticles (SLNs) were prepared and modified with chitosan oligosaccharide lactate (COL) and polyethylene glycol (PEG) stearate for improvement of its oral bioavailability. Compritol, poloxamer and lecithin were used for the preparation of SLNs by homogenisation method. After in vitro characterisation effect of lipase, pepsin, or pancreatin on degradation and release rate were investigated. Cytotoxicity and permeation were studied on Caco-2 cells. As COL concentration increased in SLNs, size and zeta potential increased. PEG concentration was reversely proportional to particle size with no change in zeta potential. Encapsulation efficiencies (EEs) were determined as 84-98%. DSC confirmed solubilisation of NB in lipid matrix. A sustained release with no burst effect was determined. The presence of enzymes affected the release. SLNs did not reveal cytotoxicity and highest permeability was obtained with PEG modification. PEG-modified SLNs could be offered as a promising strategy for oral delivery of NB.

Exercise is associated with metabolism regulation and complications in Korean patients with type 2 diabetes

[Purpose] The aim of the present study was to investigate the current evidence for the effect of exercise on glycemic control, the lipid profile, body composition, vascular health, and complications in Korean patients with type 2 diabetes. [Subjects and Methods] The subjects were 1,263 patients receiving outpatient care at 13 general hospitals located in Seoul and Gyeonggido who were subjected to examinations in the areas of blood glucose management, complications management, and diabetes education between March 19 and May 29, 2013. The relations between exercise and various regulatory factors including patient's general and clinical characteristics, metabolic regulation, achievement of goals for metabolic regulation, and complication incidence in patients with type 2 diabetes were investigated. [Results] Exercise management was associated with a decrease in systolic blood pressure, fasting glucose, postprandial glucose, hemoglobin A1c, total cholesterol, triglyceride, and low-density lipoprotein Regarding achievement of goals for metabolic regulation, significant odds ratios were observed for the effect of exercise treatment on blood pressure, fasting glucose, postprandial glucose, hemoglobin A1c, triglyceride, HDL in men, and BMI in patients with type 2 diabetes. Moreover, exercise management was associated with decreased occurrence of cerebrovasculopathy. [Conclusion] In conclusion, exercise induced metabolic regulation of glycemic control, the lipid profile, and body composition, as well as vascular health and complications, in Korean patients with type 2 diabetes.

Incremental Blood Pressure-Lowering Effect of Titrating Amlodipine for the Treatment of Hypertension in Patients Including Those Aged ≥55 Years

Small reductions in blood pressure reduce the risk of cardiovascular events. Here, we report 2 post hoc pooled analyses assessing the antihypertensive effect of amlodipine in patients who had not responded to 5 mg and were uptitrated to 10 mg. The first analysis assessed subgroups of patients aged either younger than 55 years or 55 years or older and the second analysis pooled all patients irrespective of age. Of 706 patients in the age-related analysis, a statistically significant decrease in blood pressure from baseline was observed {for younger than 55 years [N = 253]: systolic blood pressure = −12.8 [standard error (SE) = 0.90] mm Hg, diastolic blood pressure = −8.0 [SE = 0.55] mm Hg; for 55 years or older [N = 453]: systolic blood pressure = −12.1 [SE = 0.66] mm Hg, diastolic blood pressure = −6.7 [SE = 0.39] mm Hg; all P < 0.0001}. In total, 45.8% and 39.3% of patients aged younger than 55 and 55 years or older, respectively, achieved their blood pressure goals. Adverse events were experienced by 62 (24.5%) patients aged younger than 55 years and 136 (30.0%) patients aged 55 years or older. Similar efficacy and safety results were seen in the all patient pooled analysis. Titration of amlodipine from 5 mg to 10 mg significantly decreased blood pressure in older hypertensive patients, which is clinically relevant because increased age is associated with hypertension and cardiovascular events.

Blood pressure after recent stroke: baseline findings from the secondary prevention of small subcortical strokes trial

BACKGROUND

Hypertension is the most powerful risk factor for stroke. The aim of this study was to characterize baseline blood pressure in participants in the Secondary Prevention of Small Subcortical Strokes trial.

METHODS

For this cross-sectional analysis, participants were categorized by baseline systolic blood pressure (SBP) < 120, 120-139, 140-159, 160-179, and ≥ 180 mm Hg and compared on demographic and clinical characteristics. Predictors of SBP < 140 mm Hg were examined.

RESULTS

Mean SBP was 143±19 mm Hg while receiving an average of 1.7 antihypertensive medications; SBP ≥ 140 mm Hg for 53% and ≥ 160 mm Hg for 18% of the 3,020 participants. Higher SBP was associated with a history of hypertension and hypertension for longer duration (both P < 0.0001). Higher SBPs were associated with more extensive white matter disease on magnetic resonance imaging (P < 0.0001). There were significant differences in entry-level SBP when participants were categorized by race and region (both P < 0.0001). Black participants were more likely to have SBP ≥ 140 mm Hg. Multivariable logistic regression showed an independent effect for region with those from Canada more likely (odds ratio = 1.7; 95% confidence interval, 1.29, 2.32) to have SBP < 140 mm Hg compared with participants from United States.

CONCLUSIONS

In this cohort with symptomatic lacunar stroke, more than half had uncontrolled hypertension at approximately 2.5 months after stroke. Regional, racial, and clinical differences should be considered to improve control and prevent recurrent stroke.

Validated spectrophotometric methods for the simultaneous determination of telmisartan and atorvastatin in bulk and tablets

Aim:

Three simple, accurate, and reproducible spectrophotometric methods have been developed and validated for simultaneous estimation of telmisartan (TELM) atorvastatin (ATV) in combined tablet dosage form.

Materials and Methods:

The first method is based on first-order derivative spectroscopy. The sampling wavelengths were 223 nm (zero crossing of TELM) where ATV showed considerable absorbance and 272 nm (zero crossing of ATV) where TELM showed considerable absorbance. The second method Q-analysis (absorbance ratio), involves formation of Q-absorbance equation using respective absorptivity values at 280.9 nm (isobestic point) and 296.0 nm (λmax of TELM). The third method involves determination using multicomponent mode method; sampling wavelengths selected were 296.0 and 246.9 nm.

Results:

TELM and ATV followed linearity in the concentration range of 5–40 and 4–32 μg/ml for method I, 5–30 μg/ml and 2–24 μg/ml for method II and III, respectively. Mean recoveries for all three methods were found satisfactory. All methods were validated according to International Conference on Harmonization Q2B guidelines.

Conclusion:

The developed methods are simple, precise, rugged, and economical. The utility of methods has been demonstrated by analysis of commercially available tablet dosage form.

[Hypertension in pregnancy: the current state of the art]

Hypertension complicates 6-8% of pregnancies and includes the following four conditions: hypertension preceding pregnancy or documented before the 20th week of gestation; pre-eclampsia (PE)/eclampsia; chronic hypertension with superimposed pre-eclampsia; and gestational hypertension. The latter is defined as a significant rise in blood pressure after the 20th week of pregnancy in previously normotensive women, to over 140/90 mmHg. When blood pressure remains above 160/110 mmHg, it is considered severe. PE is defined as the presence of proteinuria (> or = 300 mg/24 h) in pregnant women with hypertension. The hypertensive syndromes of pregnancy are among the leading causes of maternal and fetal morbidity and mortality and anti-hypertensive treatment is part of the therapeutic arsenal used to prevent serious complications. Although the role of utero-placental insufficiency due to deficient migration of trophoblasts to the spiral arteries is universally accepted, the pathophysiology of PE remains largely unknown and is the subject of debate. No effective ways of predicting or preventing PE have been found, which highlights the need for further research in this field. This review aims primarily to evaluate recent advances in our understanding of the pathophysiology of gestational hypertension and especially PE, and new ways of predicting PE. Additionally, we present a brief review on the diagnosis, prevention and treatment of PE.

Beta-blockers for hypertension

BACKGROUND

This review is an update of the Cochrane Review published in 2007, which assessed the role of beta-blockade as first-line therapy for hypertension.

OBJECTIVES

To quantify the effectiveness and safety of beta-blockers on morbidity and mortality endpoints in adults with hypertension.

SEARCH METHODS

In December 2011 we searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and reference lists of previous reviews; for eligible studies published since the previous search we conducted in May 2006.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of at least one year duration, which assessed the effects of beta-blockers compared to placebo or other drugs, as first-line therapy for hypertension, on mortality and morbidity in adults.

DATA COLLECTION AND ANALYSIS

We selected studies and extracted data in duplicate. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI) and combined them using the fixed-effects or random-effects method, as appropriate.

MAIN RESULTS

We included 13 RCTs which compared beta-blockers to placebo (4 trials, N=23,613), diuretics (5 trials, N=18,241), calcium-channel blockers (CCBs: 4 trials, N=44,825), and renin-angiotensin system (RAS) inhibitors (3 trials, N=10,828). Three-quarters of the 40,245 participants on beta-blockers used atenolol. Most studies had a high risk of bias; resulting from various limitations in study design, conduct, and data analysis.Total mortality was not significantly different between beta-blockers and placebo (RR 0.99, 95%CI 0.88 to 1.11; I(2)=0%), diuretics or RAS inhibitors, but was higher for beta-blockers compared to CCBs (RR 1.07, 95%CI 1.00 to 1.14; I(2)=2%). Total cardiovascular disease (CVD) was lower for beta-blockers compared to placebo (RR 0.88, 95%CI 0.79 to 0.97; I(2)=21%). This is primarily a reflection of the significant decrease in stroke (RR 0.80, 95%CI 0.66 to 0.96; I(2)=0%), since there was no significant difference in coronary heart disease (CHD) between beta-blockers and placebo. There was no significant difference in withdrawals from assigned treatment due to adverse events between beta-blockers and placebo (RR 1.12, 95%CI 0.82 to 1.54; I(2)=66%).The effect of beta-blockers on CVD was significantly worse than that of CCBs (RR 1.18, 95%CI 1.08-1.29; I(2)=0%), but was not different from that of diuretics or RAS inhibitors. In addition, there was an increase in stroke in beta-blockers compared to CCBs (RR 1.24, 95%CI 1.11-1.40; I(2)=0%) and RAS inhibitors (RR 1.30, 95%CI 1.11 to 1.53; I(2)=29%). However, CHD was not significantly different between beta-blockers and diuretics, CCBs or RAS inhibitors. Participants on beta-blockers were more likely to discontinue treatment due to adverse events than those on RAS inhibitors (RR 1.41, 95% CI 1.29 to 1.54; I(2)=12%), but there was no significant difference with diuretics or CCBs.

AUTHORS' CONCLUSIONS

Initiating treatment of hypertension with beta-blockers leads to modest reductions in cardiovascular disease and no significant effects on mortality. These effects of beta-blockers are inferior to those of other antihypertensive drugs. The GRADE quality of this evidence is low, implying that the true effect of beta-blockers may be substantially different from the estimate of effects found in this review. Further research should be of high quality and should explore whether there are differences between different sub-types of beta-blockers or whether beta-blockers have differential effects on younger and elderly patients.

Effectiveness and Safety of Amlodipine in Newly Diagnosed Hypertensive Patients and in Previously Diagnosed Hypertensive Patients not Controlled with their Usual Treatment (NOTA Study)

OBJECTIVE

To evaluate the effectiveness and safety of amlodipine in two cohorts of hypertensive patients, one newly diagnosed and the other previously diagnosed but not controlled with drug therapy, and to assess the risk factors for the entire sample at the outset of the study.

PATIENTS AND DESIGN

We designed a postmarketing, multicentre, open-label, prospective, observational surveillance study with a 6-month follow-up, which included hypertensive patients (systolic blood pressure [SBP] >/=140mm Hg and/or diastolic blood pressure [DBP] >/=90mm Hg) who attended specialised units and had either newly diagnosed or previously diagnosed pharmacologically uncontrolled arterial hypertension.

RESULTS

Of the total of 1797 patients eligible for evaluation, 760 (42.3%) were newly and 1037 (57.7%) were previously diagnosed. Of these, 22.9% were classified as being in the high-risk and 43.2% in the very high-risk groups at the outset of the study (WHO-ISH [International Society of Hypertension]). On conclusion of the 6-month follow-up, 54.3% of newly diagnosed and 44.4% of previously treated patients had attained the BP therapy targets defined as SBP <140mm Hg and DBP <90mm Hg, representing a statistically significant difference (p < 0.0001). A total of 8% of patients experienced some adverse event during the course of the study, with this percentage being somewhat higher in the previously treated than in the newly diagnosed group (10.8% vs 5.1%, p < 0.0001). Only 0.3% experienced some severe adverse event, although in no case was this linked to the drug under evaluation.

CONCLUSIONS

We conclude that amlodipine has shown itself to be an effective and safe drug for the control of hypertension, whether isolated or associated with other cardiovascular risk factors, both in patients without a previous diagnosis of arterial hypertension and in those previously diagnosed although not controlled under a prior treatment regimen.

Beta-blockers for hypertension

BACKGROUND

This review is an update of the Cochrane Review published in 2007, which assessed the role of beta-blockade as first-line therapy for hypertension.

OBJECTIVES

To quantify the effectiveness and safety of beta-blockers on morbidity and mortality endpoints in adults with hypertension.

SEARCH METHODS

In December 2011 we searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and reference lists of previous reviews; for eligible studies published since the previous search we conducted in May 2006.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of at least one year duration, which assessed the effects of beta-blockers compared to placebo or other drugs, as first-line therapy for hypertension, on mortality and morbidity in adults.

DATA COLLECTION AND ANALYSIS

We selected studies and extracted data in duplicate. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI) and combined them using the fixed-effects or random-effects method, as appropriate.

MAIN RESULTS

We included 13 RCTs which compared beta-blockers to placebo (4 trials, N=23,613), diuretics (5 trials, N=18,241), calcium-channel blockers (CCBs: 4 trials, N=44,825), and renin-angiotensin system (RAS) inhibitors (3 trials, N=10,828). Three-quarters of the 40,245 participants on beta-blockers used atenolol. Most studies had a high risk of bias; resulting from various limitations in study design, conduct, and data analysis.Total mortality was not significantly different between beta-blockers and placebo (RR 0.99, 95%CI 0.88 to 1.11; I(2)=0%), diuretics or RAS inhibitors, but was higher for beta-blockers compared to CCBs (RR 1.07, 95%CI 1.00 to 1.14; I(2)=2%). Total cardiovascular disease (CVD) was lower for beta-blockers compared to placebo (RR 0.88, 95%CI 0.79 to 0.97; I(2)=21%). This is primarily a reflection of the significant decrease in stroke (RR 0.80, 95%CI 0.66 to 0.96; I(2)=0%), since there was no significant difference in coronary heart disease (CHD) between beta-blockers and placebo. There was no significant difference in withdrawals from assigned treatment due to adverse events between beta-blockers and placebo (RR 1.12, 95%CI 0.82 to 1.54; I(2)=66%).The effect of beta-blockers on CVD was significantly worse than that of CCBs (RR 1.18, 95%CI 1.08-1.29; I(2)=0%), but was not different from that of diuretics or RAS inhibitors. In addition, there was an increase in stroke in beta-blockers compared to CCBs (RR 1.24, 95%CI 1.11-1.40; I(2)=0%) and RAS inhibitors (RR 1.30, 95%CI 1.11 to 1.53; I(2)=29%). However, CHD was not significantly different between beta-blockers and diuretics, CCBs or RAS inhibitors. Participants on beta-blockers were more likely to discontinue treatment due to adverse events than those on RAS inhibitors (RR 1.41, 95% CI 1.29 to 1.54; I(2)=12%), but there was no significant difference with diuretics or CCBs.

AUTHORS' CONCLUSIONS

Initiating treatment of hypertension with beta-blockers leads to modest reductions in cardiovascular disease and no significant effects on mortality. These effects of beta-blockers are inferior to those of other antihypertensive drugs. The GRADE quality of this evidence is low, implying that the true effect of beta-blockers may be substantially different from the estimate of effects found in this review. Further research should be of high quality and should explore whether there are differences between different sub-types of beta-blockers or whether beta-blockers have differential effects on younger and elderly patients.

Trends in antihypertensives use among Moroccan patients

PURPOSE

In this study, we analyzed the consumption trends of antihypertensives in Morocco during the 1991-2010 period and the impacts after the institution of Mandatory Health Insurance and the marketing of generic drugs.

METHODS

We used sales data from the Moroccan subsidiary of IMS Health "Intercontinental Marketing Service". The consumption volumes were converted into defined daily doses (DDDs).

RESULTS

Between 1991 and 2010, outpatient consumption of antihypertensives went from 4.37 to 23.14 DDD/1000 inhabitants/day, a 5.30-fold increase. In 2010, calcium channel blockers (CCBs) and angiotensin converting enzyme inhibitors (ACEI) were the most consumed (4.97 DDD/1000 inhabitants/day) for each one, followed by diuretics (4.20 DDD/1000 inhabitants/day). The most consumed products were amlodipine (4.27 DDD/1000 inhabitants/day) followed by ramipril (3.18 DDD/1000 inhabitants /day) and indapamide (1.72 DDD/1000inhabitants/day). Between 1991 and 2010, the consumption of generic antihypertensives went from 2% to 46%.

CONCLUSION

Antihypertensive consumption increased between 1991 and 2010. However, despite the increase of generic drugs consumption, the levels of antihypertensive consumption remain lower than the needs of hypertensive patients.

The α(2C)-Del322-325 adrenoceptor polymorphism and the occurrence of left ventricular hypertrophy in hypertensives

OBJECTIVES

Sympathetic activation has a role in the development of left ventricular hypertrophy (LVH). The presynaptic α(2C)-adrenoceptor inhibits the release of norepinephrine from sympathetic nerve terminals in the heart. A deletion polymorphism in the α(2C)-adrenoceptor (α(2C)Del322-325) generates a hypofunctional α(2C)-adrenoceptor, which may result in chronic adrenergic signalling. This study aimed to investigate whether the α(2C)Del322-325 polymorphism was associated with an increased prevalence of LVH in patients with systemic hypertension.

METHODS

Left ventricular mass was measured in 205 patients with systemic hypertension and 60 normal volunteers using a 1.5-T Philips MRI system. Genotyping was performed using a restriction fragment length polymorphism assay.

RESULTS

No significant difference was observed between the distribution of the α(2C)Del322-325 genotypes in hypertensive patients with LVH compared with those without LVH. Adjusting for confounding variables the odds ratio (OR) of being ins/del for the α(2C)Del322-325 and having LVH was 0.49 (95% CI 0.14-1.69, p = 0.256).

CONCLUSIONS

These observations suggest that there is little evidence for an association between α(2C)Del322-325 polymorphism and an increased prevalence of LVH in patients with systemic hypertension.

An economic evaluation based on a randomized placebo-controlled trial of varenicline in smokers with cardiovascular disease: results for Belgium, Spain, Portugal, and Italy

BACKGROUND

An estimated 17.2% of patients continue to smoke following diagnosis of cardiovascular disease (CVD). To reduce the risk of further morbidity or mortality in cardiovascular patients, smoking cessation has been shown to reduce the risk of mortality by 36% and myocardial infarction by 32%. The objective of this study was to evaluate the long-term health and economic consequences of smoking cessation in patients with CVD.

DESIGN AND METHODS

Results of a randomized clinical trial comparing varenicline plus counselling vs. placebo plus counselling were extrapolated using a Markov model to simulate the lifetime costs and health consequences of smoking cessation in patients with stable CVD. For the base case, we considered a payer's perspective including direct costs attributed to the healthcare provider, measuring cumulative life years (LY) and quality adjusted life (QALY) years as outcome measures. Secondary analyses were conducted from a societal perspective, evaluating lost productivity due to premature mortality. Sensitivity and subgroup analyses were also undertaken. Results were analysed for Belgium, Spain, Portugal, and Italy.

RESULTS

Varenicline plus counselling was associated with a gain in LY and QALY across all countries; relative to placebo plus counselling. From a payer's perspective, incremental cost effectiveness ratios were € 6120 (Belgium), € 5151 (Spain), € 5357 (Portugal), and € 5433 (Italy) per QALY gained. From a societal perspective, varenicline in addition to counselling was less costly than placebo and counselling in all cases. Sensitivity analyses showed little sensitivity in outcomes to model assumptions or uncertainty in model parameters.

CONCLUSIONS

Varenicline in addition to counselling is cost-effective compared to placebo and counselling in smokers with CVD.

Assessment of hypertension control in a district of Mombasa, Kenya

As populations move to urban centres across East Africa, lifestyle habits that affect cardiovascular disease have changed, affecting non-communicable disease risk. In particular, the prevalence of hypertension, and associated awareness of this life-threatening condition, has not been studied in Mombasa, Kenya. This paper assesses the rates of prevalence, awareness, treatment and control of hypertension in Old Town, an urban district of the coastal city. We surveyed 469 subjects, gathered via a clustered sampling technique. Age-adjusted prevalence of hypertension was measured at 32.6% (± 2.2) for adults over 18 and was linearly related to age. Results indicate that hypertension awareness was associated with age and sex, as women were substantially more likely to be aware of and to control their hypertension. Only 23.2% (± 2.0) of subjects had knowledge of both the causes of and practical solutions to hypertension, and practical hypertension knowledge was associated with hypertension awareness and gender (women had higher rates of knowledge than men). These results indicate that hypertension is a real public health concern in Old Town, and that younger individuals, particularly males, are least likely to be aware of the dangers of hypertension. Public health measures should focus on this population.

Is Peri-Operative Isolated Systolic Hypertension (ISH) a Cardiac Risk Factor?

We are presenting a review of Isolated Systolic Hypertension (ISH) as a cardiovascular risk factor with emphasis on the perioperative period.

Isolated systolic hypertension is associated with aging and is the most frequent subtype (65%) among patients with uncontrolled hypertension. ISH is strongly associated with increased risks of cardiac and cerebrovascular events exceeding those in comparably aged individuals with diastolic hypertension. Patients with ISH show an increase in left ventricular (LV) mass and an increase in the prevalence of left ventricular hypertrophy (LVH). These LV changes increase cardiovascular events and frequently lead to diastolic dysfunction (DD). Treatment to reduce elevated systolic blood pressure has been shown to reduce the risk of cardiovascular events.

In the perioperative setting, essential hypertension has not been found to be a significant risk factor for cardiac complications. Most of the studies were based on the definition of essential hypertension and underpowered in sample size. The significance of perioperative ISH, however, is not well studied, partly due to its recognition only fairly recently as a cardiovascular risk factor in the non-surgical setting, and partly due to the evolving definition of ISH.

Perioperative cardiac complications remain a significant problem to the healthcare system and to the patient. Although the incidence of perioperative cardiac complications is prominent in high-risk patients as defined by the Revised Cardiac Risk Index (RCRI), the bulk of the cardiac complications actually occur in low-risk group. Currently, little understanding exists on the occurrence of perioperative cardiac complications in low- risk patients. A factor such as ISH, with its known pathophysiological changes, is a potential perioperative risk factor.

We believe ISH is an under-recognized perioperative risk factor and deserves further studying. Our research group has recently been funded by the Heart Stroke Foundation (HSF) to examine ISH as a perioperative risk factor (PROMISE Study).

Management of hypertension in patients with diabetes mellitus

OBJECTIVE

To investigate the management of hypertension in patients with diabetes mellitus, living in a rural setting.

METHOD

A community health screening clinic was conducted at Charles Sturt University, Albury-Wodonga, in rural southeastern Australia. Patients with either diagnosed hypertension or high blood pressure who attended the clinic were eligible for inclusion in the present study. The awareness and control of hypertension was compared between patients with and without diabetes mellitus.

RESULTS

A total of 449 patients with hypertension were analyzed. One hundred twenty-one (26.9%) had hypertension and diabetes mellitus, and 328 (73.1%) had hypertension without diabetes mellitus. Hypertension awareness (61.2% versus 36.9%, P=0.014) and control (17.4% versus 7.0%, P=0.040) were significantly better in the hypertensive patients with diabetes mellitus than in the hypertensive patients without diabetes mellitus. Antihypertensive medication use was also significantly higher in patients with diabetes mellitus than in patients without diabetes mellitus (one antihypertensive medication, 41.3% versus 25.0%, P=0.045).

CONCLUSION

Awareness and control of hypertension were suboptimal in the patients in the present study. Diabetes mellitus, however, was associated with both higher awareness and better control of hypertension than having hypertension alone. This may be partially due to a higher use of antihypertensive medications by patients with diabetes mellitus.

The Secondary Prevention of Small Subcortical Strokes (SPS3) study

BACKGROUND

Small subcortical strokes, also known as lacunar strokes, comprise more than 25% of brain infarcts, and the underlying vasculopathy is the most common cause of vascular cognitive impairment. How to optimally prevent stroke recurrence and cognitive decline in S3 patients is unclear. The aim of the Secondary Prevention of Small Subcortical Strokes study (Trial registration: NCT00059306) is to define strategies for reducing stroke recurrence, cognitive decline, and major vascular events.

METHODS

Secondary Prevention of Small Subcortical Strokes is a randomised, multicentre clinical trial (n = 3000) being conducted in seven countries, and sponsored by the US NINDS/NIH. Patients with symptomatic small subcortical strokes in the six-months before and an eligible lesion on magnetic resonance imaging are simultaneously randomised, in a 2 × 2 factorial design, to antiplatelet therapy--325 mg aspirin daily plus 75 mg clopidogrel daily, vs. 325 mg aspirin daily plus placebo, double-blind--and to one of two levels of systolic blood pressure targets--'intensive' (<130 mmHg) vs. 'usual' (130-149 mmHg). Participants are followed for an average of four-years. Time to recurrent stroke (ischaemic or haemorrhagic) is the primary outcome and will be analysed separately for each intervention. The secondary outcomes are the rate of cognitive decline and major vascular events. The primary and most secondary outcomes are adjudicated centrally by those unaware of treatment assignment.

CONCLUSIONS

Secondary Prevention of Small Subcortical Strokes will address several important clinical and scientific questions by testing two interventions in patients with recent magnetic resonance imaging-defined lacunar infarcts, which are likely due to small vessel disease. The results will inform the management of millions of patients with this common vascular disorder.

Perioperative myocardial ischemia and isolated systolic hypertension in non-cardiac surgery

PURPOSE

To determine whether patients with isolated systolic hypertension (ISH) undergoing non-cardiac surgery have a higher incidence of perioperative myocardial ischemia than normotensive patients and hence a greater risk for perioperative adverse events.

METHODS

After obtaining Research Ethics Board approval, patients were recruited to either an ISH group (systolic blood pressure [SBP] > 140 mmHg with diastolic blood pressure [DBP] < 90 mmHg) or a normotensive group (SBP < 140 mmHg and DBP < 90 mmHg), according to their resting preoperative blood pressure. The primary outcome was the overall incidence of perioperative myocardial ischemia (PMI) as determined by 48-hr ambulatory Holter monitoring. P values ≤ 0.05 were considered to be statistically significant.

RESULTS

A total of 312 (150 ISH and 162 normotensive) patients completed the study. Orthopedic surgery was the most frequent surgical procedure in both groups. The overall incidence of PMI was 19.7% in the ISH group compared with 18.8% in the normotensive group (difference 0.9%; 95% confidence interval [CI], -7.9% to 9.8%). The overall incidence of adverse events was 4.0% in the ISH group compared with 1.9% in the normotensive group (difference 2.2%; 95% CI, -1.6% to 5.9%).

CONCLUSION

In this study, we chose to examine ISH as potential cardiac risk factor for patients undergoing non-cardiac surgery. The incidence of myocardial ischemia, a surrogate outcome, was similar in the two groups. The relatively high incidence of myocardial ischemia (19.2%) was of particular interest in this relatively low cardiac risk surgical population. (ClinicalTrials.gov number, NCT01237652).

Pharmacist-led hypertension drug use review

Focal points

Red meat from animals offered a grass diet increases plasma and plateletn-3 PUFA in healthy consumers

Red meat from grass-fed animals, compared with concentrate-fed animals, contains increased concentrations of long-chain (LC)n-3 PUFA. However, the effects of red meat consumption from grass-fed animals on consumer blood concentrations of LCn-3 PUFA are unknown. The aim of the present study was to compare the effects on plasma and platelet LCn-3 PUFA status of consuming red meat produced from either grass-fed animals or concentrate-fed animals. A randomised, double-blinded, dietary intervention study was carried out for 4 weeks on healthy subjects who replaced their habitual red meat intake with three portions per week of red meat (beef and lamb) from animals offered a finishing diet of either grass or concentrate (n20 consumers). Plasma and platelet fatty acid composition, dietary intake, blood pressure, and serum lipids and lipoproteins were analysed at baseline and post-intervention. Dietary intakes of totaln-3 PUFA, as well as plasma and platelet concentrations of LCn-3 PUFA, were significantly higher in those subjects who consumed red meat from grass-fed animals compared with those who consumed red meat from concentrate-fed animals (P < 0·05). No significant differences in concentrations of serum cholesterol, TAG or blood pressure were observed between groups. Consuming red meat from grass-fed animals compared with concentrate-fed animals as part of the habitual diet can significantly increase consumer plasma and platelet LCn-3 PUFA status. As a result, red meat from grass-fed animals may contribute to dietary intakes of LCn-3 PUFA in populations where red meat is habitually consumed.