Relation between insufficient response to antihypertensive treatment and poor compliance with treatment: a prospective case-control study

Unveiling Novel Molecules and Therapeutic Targets in Hypertension - A Narrative Review

Hypertension is a prevalent non-communicable disease with serious cardiovascular complications, including heart failure, myocardial infarction, and stroke, often resulting from uncontrolled hypertension. While current treatments primarily target the renin-angiotensin-aldosterone pathway, the therapeutic response remains modest in many patients, with some developing resistant hypertension. Newer therapeutic approaches aim to address hypertension from various aspects beyond conventional drugs, including targeting central nervous system pathways, inflammatory pathways, vascular smooth muscle function, and baroreceptors. Despite these advancements, each therapy faces unique clinical and mechanistic challenges that influence its clinical translatability and long-term viability. This review explores the mechanisms of novel molecules in preclinical and clinical development, highlights potential therapeutic targets, and discusses the challenges and ethical considerations related to hypertension therapeutics and their development.

Impact of a motivational interviewing intervention targeting statins on adherence to concurrent hypertension or diabetes medications

OBJECTIVE

This study explored if a motivational interviewing intervention customized for statins impacted adherence to concomitantly used antidiabetic/antihypertensive medications.

METHODS

The intervention was conducted among patients with a history of suboptimal adherence to statins and included 152 patients in intervention and 304 controls. This retrospective study design identified patients with claims for statins and either antidiabetic/antihypertensive medications. The outcome variable was adherence, measured as proportion of days covered ≥ 0.80, to antidiabetic/antihypertensive medications. Multivariable linear and logistic regression evaluated the effect of intervention on adherence to antidiabetic/antihypertensive medications during the 6 months post-intervention.

RESULTS

The antidiabetic group had 53 intervention patients and 102 controls. The antihypertensive group had 80 intervention patients and 159 controls. There was no significant improvement in adherence for antidiabetic/antihypertensive medications following the intervention. Adherence at baseline was a significant predictor of adherence post-intervention in the antidiabetic (OR = 6.5;P < 0.0001) and antihypertensive (OR = 4.1; P = 0.0001 & β = 0.09; P = 0.008) users. Physician specialty (OR = 3.902; P = 0.01& β = 0.09; P = 0.015) among antidiabetic users and age >70 years (OR = 2.148; P = 0.025) among antihypertensive users were predictors of adherence.

CONCLUSION

The intervention targeting statin did not significantly improve antihypertensive/antidiabetic adherence.

PRACTICE IMPLICATIONS

Targeted interventions tailored to patient past adherence and specific medications should be explored.

Adverse effects and non-adherence to antihypertensive medications in University of Gondar Comprehensive Specialized Hospital

Background

A considerable proportion of cardiovascular events could be attributed to poor adherence to antihypertensive medications. Adverse effects can be severe enough to affect adherence to antihypertensive medications. This study aimed to measure the contribution of adverse effects on antihypertensive medications adherence.

Methods

The study was conducted from May 1 to June 30, 2017, at the ambulatory clinic of University of Gondar Comprehensive Specialized Hospital (UOGCSH) in Gondar town. A binary logistic regression was performed to determine the significance of the association between adverse effects and adherence to antihypertensive medications. An institution-based cross-sectional study was conducted by administering a questionnaire to hypertensive patients who came for follow-up at the ambulatory clinic of UOGCSH. Level of adherence to antihypertensive medications was used as outcome measure.

Results

A total of 249 patients were included in the final analysis with a mean age of 56.51 years and a female majority (53%). The following variables were identified as predictors of poor adherence: tiredness [AOR (95% CI): 3.802 (1.723-8.391), p = 0.001], muscle pain [AOR (95% CI): 5.199 (1.407-19.214), p = 0.013], poor sleep [AOR (95% CI): 4.891 (1.578-15.160), p = 0.006] and, believing that the symptoms were caused by antihypertensive medications [AOR (95% CI): 3.249 (1.248-8.456), p = 0.016].

Conclusion

Adverse effect significantly contributes to antihypertensive medication non-adherence among hypertensive patients.

Adherence of Patients with Diabetes to a Lifestyle Advice and Management Plan in Basra, Southern Iraq

<b><i>Background:</i></b> Poor adherence to treatment regimens is a complex problem, especially for those with chronic illnesses. Noncompliance is believed to be the most common reason for treatment failure in diabetic patients, leading to the absence of metabolic control and accelerating disease-related complications. Data on the adherence of people with diabetes in Iraq are lacking. <b><i>Objectives:</i></b> The purpose of this study was to measure the rate of adherence among Iraqi patients with diabetes. <b><i>Methods:</i></b> This was a cross-sectional study conducted in the Specialized Endocrine and Diabetes Center in Basra, southern Iraq, during the period from June to August 2018. Data were collected by completing an interviewing questionnaire consisting of 13 questions. <b><i>Results:</i></b> A total of 231 patients were included in the study (54.5% were female). Mean age was 51.85 ± 13.55 years. 65.4% of the participants were taking their medications at the right times. The most common reason for not taking their medication (48.8%) was difficulty in remembering the dosage times. 40.7% of the participants were sedentary. Only one-third of the patients followed their doctors’ instructions regarding diet. <b><i>Conclusions:</i></b> The rate of adherence to medication regimens and lifestyle advice was unsatisfactory in this study group. The awareness of diabetic patients and their caring physicians about the importance of adherence to therapy, exercise, and diet should be emphasized.

Assessing adherence to multiple medications and in daily life among patients with multimorbidity

OBJECTIVE

Chronic conditions often require multiple medication intake. However, past research has focused on assessing overall adherence or adherence to a single index medication only. This study explored adherence measures for multiple medication intake, and in daily life, among patients with multiple chronic conditions (i.e. multimorbidity).

DESIGN

Eighty-four patients with multimorbidity and multiple-medication regimens completed three monthly panel questionnaires. A randomly assigned subsample additionally completed a 30-day daily diary.

MAIN OUTCOME MEASURE

The Non-Adherence Report; a brief self-report measure of adherence to each prescribed medication (NAR-M), and in daily life. We further assessed the Medication Adherence Report Scale (MARS), and a subsample of participants were randomised to electronic adherence monitoring.

RESULTS

The NAR-M indicated M = 94.7% adherence at Time 1 (SD = 9.3%). The NAR-M was significantly correlated with the MARS (r_t1 = .52, r_t2 = .57, and r_t3 = .65; p < .001), and in tendency with electronically assessed adherence (r_t2 = .45, r_t3 = .46, p < .10). Variance components analysis indicated that between-person differences accounted for 10.2% of the variance in NAR-M adherence rates, whereas 22.9% were attributable to medication by person interactions.

CONCLUSION

This study highlights the importance and feasibility of studying adherence to multiple medications differentially, and in daily life. Future studies may use these measures to investigate within-person and between-medication differences in adherence.

The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial

BACKGROUND

Medication organisation devices (MODs) provide compartments for a patient's medication to be organised into the days of the week and the recommended times the medication should be taken.

AIM

To define the optimal trial design for testing the clinical effectiveness and cost-effectiveness of MODs.

DESIGN

The feasibility study comprised a systematic review and focus groups to inform a randomised controlled trial (RCT) design. The resulting features were tested on a small scale, using a 2 × 2 factorial design to compare MODs with usual packaging and to compare weekly with monthly supply. The study design was then evaluated.

SETTING

Potential participants were identified by medical practices.

PARTICIPANTS

Aged over 75 years, prescribed at least three solid oral dosage form medications, unintentionally non-adherent and self-medicating. Participants were excluded if deemed by their health-care team to be unsuitable.

INTERVENTIONS

One of three MODs widely used in routine clinical practice supplied either weekly or monthly.

OBJECTIVES

To identify the most effective method of participant recruitment, to estimate the prevalence of intentional and unintentional non-adherence in an older population, to provide a point estimate of the effect size of MODs relative to usual care and to determine the feasibility and acceptability of trial participation.

METHODS

The systematic review included MOD studies of any design reporting medication adherence, health and social outcomes, resource utilisation or dispensing or administration errors. Focus groups with patients, carers and health-care professionals supplemented the systematic review to inform the RCT design. The resulting design was implemented and then evaluated through questionnaires and group discussions with participants and health-care professionals involved in trial delivery.

RESULTS

Studies on MODs are largely of poor quality. The relationship between adherence and health outcomes is unclear. Of the limited studies reporting health outcomes, some reported a positive relationship while some reported increased hospitalisations associated with MODs. The pre-trial focus groups endorsed the planned study design, but suggested a minimum recruitment age of 50-60 years. A total of 35.4% of patients completing the baseline questionnaire were excluded because they already used a MOD. Active recruitment yielded a higher consent rate, but passive recruitment was more cost-effective. The prevalence of intentional non-adherence was 24.7% [n = 71, 95% confidence interval (CI) 19.7% to 29.6%] of participants. Of the remaining 76 participants, 46.1% (95% CI 34.8% to 57.3%) were unintentionally non-adherent. There was no indication of a difference in adherence between the study arms. Participants reported a high level of satisfaction with the design. Five adverse/serious adverse events were identified in the MOD study arms and none was identified in the control arms. There was no discernible difference in health economic outcomes between the four study arms; the mean intervention cost was £20 per month greater for MOD monthly relative to usual supply monthly.

CONCLUSIONS

MOD provision to unintentionally non-adherent older people may cause medication-related adverse events. The primary outcome for a definitive MOD trial should be health outcomes. Such a trial should recruit patients by postal invitation and recruit younger patients.

FUTURE WORK

A study examining the association between MOD initiation and adverse effects is necessary and a strategy to safely introduce MODs should be explored. A definitive study testing the clinical effectiveness and cost-effectiveness of MODs is also required.

STUDY REGISTRATION

Current Controlled Trials ISRCTN 30626972 and UKCRN 12739.

FUNDING

This project was funded by National Institute for Health Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 20, No. 50. See the NIHR Journals Library website for further project information.

[Determinants of controlled hypertension in patients treated with antihypertensive drugs in France: The French League Against Hypertension Survey (FLAHS 2015)]

OBJECTIVE

The FLASH 2015 survey sought the determinants of hypertension control in subjects treated with antihypertensive drugs in France.

METHOD

Sending self-administered questionnaire by mail to a representative sample of the population living in metropolitan France (MetaScope basis, TNS Sofres, France). Patients who declare taking antihypertensive drugs are considered treated hypertensives. A home blood pressure monitoring during 3 days was asked in subjects owing a blood pressure monitor and the average of 18 measurements was calculated.

RESULTS

A total of 6379 subjects aged 55 and older were included with 2814 (44.1%) treated with antihypertensive drugs. Home blood pressure was obtained from 1455 subjects including 882 (60.6%) treated. SBP/DBP are 129.3±13.5/75.5±9.0mmHg and are higher in treated subjects in each age category. BP<135/85 was observed in 55.4% and BP<140/90 in 71.7%. Determinants of BP control (<135/85) are the number of measurement for averaging (18 measures over 3 days vs 3 measurements on a morning; 55.4%/44.3%), age (55-64 years vs 80 years old; 57.6%/49.1%), gender (women vs men; 60.3%/50.1%), BMI (<25 vs >30; 63.1%/46.1%). In the 80 and older, a SBP<145 was observed in 74.7% of subjects. The control was 61% when considering an SBP/DBP<135/85 in 55-79 years and SBP<145 among 80 and older.

CONCLUSION

The control of hypertension evaluated by home blood pressure on a representative population living in metropolitan France is estimated at between 44.3% and 74.7% and several determinants influence the control of blood pressure like age, gender and BMI.

Sleep duration and treatment compliance: a population-based cross-sectional study of hypertensive patients in Bangladesh

BACKGROUND

Treatment with appropriate medication is a key factor to control hypertension and reduce the associated risk of complications. However, compliance with treatment is often sub-optimal, especially in developing countries. Our aim in this cross-sectional study is to investigate whether there is an association between sleep duration and treatment compliance among skilled professionals who are experiencing hypertension.

METHODS

A questionnaire was given to all skilled professionals who are found hypertensive in an organization of Bangladesh. To assess treatment compliance, questions on self-reported compliance test were used. We collected information on self-reported short sleep duration (6 h or less) along with socio-demographic factors and clinical conditions of the subjects.

RESULTS

Sleep duration is associated with compliance with treatment among hypertensive skilled professionals. We found overall associations of sleep duration (odds ratio (OR) 3.77, confidence interval 1.44-10.83) with treatment compliance among hypertensive patients. In addition, body mass index (OR 1.19), marital status (OR 0.16) and duration of having hypertension are found significant factors for non-compliance with treatment.

CONCLUSION

There is an association between sleep duration and treatment compliance among the hypertensive patients. However, the study is conducted with a small group of skilled professionals from an organization and it is important to include multi-centers to validate the conclusion.

Adherence to prescribed medications of Iranian traditional medicine in a group of patients with chronic disease

OBJECTIVE

The extent to which a person's health-related behavior corresponds with medical instructions (adherence) is an important modifier of health system effectiveness. This study was designed to determine the patients' adherence to Iranian traditional medicine in a group of patients with chronic disease.

METHODS

Convenience sampling was used to enroll 320 patients with chronic diseases from January 2014 to January 2015 in clinics of traditional medicine affiliated with medical universities in Tehran. Morisky Medication Adherence Scale (MMAS) was used to measure the adherence. After describing the variables and the frequency of adherence, logistic regression analysis was used to determine the influencing factors.

FINDINGS

Mean age was 40.8 (standard deviation [SD] =13) years. The mean of the duration of disease was 54.6 (SD = 56.1) months and mean of the duration of referring to the clinics 6.5 (SD = 6.9) months. Total score of MMAS was zero in 33 (10.3%) of patients (high adherence), one or two in 128 (40%) of patients (moderate adherence), and more than two in 159 (49.7%) of patients (low adherence). Forgetfulness, bad taste, not availability, and the high cost of the drugs were the most commonly reported causes of non-adherence. Adherence was associated with age (odds ratio [OR] =1.05, 95% confidence interval [95% CI] 1-1.1), marriage (OR = 10.8, 95% CI 2.05-57.6), number of prescribed drugs (OR = 0.05, 95% CI 0.02-0.14), and duration of disease (OR = 1.01, 95% CI 1-1.02).

CONCLUSION

Considering the low adherence in users of medications of Iranian traditional medicine, health care practitioners need to be trained in adherence and the influencing factors and also to use some interventions to increase the adherence.

Results of a pilot multicenter genotype-based randomized placebo-controlled trial of propranolol to reduce pain after major thermal burn injury

BACKGROUND

Results of previous studies suggest that β-adrenoreceptor activation may augment pain, and that β-adrenoreceptor antagonists may be effective in reducing pain, particularly in individuals not homozygous for the catechol-O-methyltransferase (COMT) high-activity haplotype.

MATERIALS AND METHODS

Consenting patients admitted for thermal burn injury at participating burn centers were genotyped; those who were not high-activity COMT homozygotes were randomized to propranolol 240 mg/d or placebo. Primary outcomes were study feasibility (consent rate, protocol completion rate) and pain scores on study days 5 to 19. Secondary outcomes assessed pain and posttraumatic stress disorder symptoms 6 weeks postinjury.

RESULTS

Seventy-seven percent (61/79) of eligible patients were consented and genotyped, and 77% (47/61) were genotype eligible and randomized. Ninety-one percent (43/47) tolerated study drug and completed primary outcome assessments. In intention-to-treat and per-protocol analyses, patients randomized to propranolol had worse pain scores on study days 5 to 19.

CONCLUSIONS

Genotype-specific pain medication interventions are feasible in hospitalized burn patients. Propranolol is unlikely to be a useful analgesic during the first few weeks after burn injury.

Cross-Cultural Adaptation, Reliability, and Validity of the Turkish Version of the Compliance Questionnaire on Rheumatology in Patients With Behçet's Disease

PURPOSE

The aim of this study was to examine the psychometric properties of the Turkish versionof the Compliance Questionnaire on Rheumatology (CQR-T) for patients with Behçet's disease (BD).

METHOD

A sample of 105 Turkish patients with BD participated in this study. The scale was cross-culturally adapted through a process including translation, comparison with versions in other languages, back translation, and pretesting. Construct validity was evaluated by factor analysis, and criterion validity was evaluated using the Morisky Medication Adherence Scale.

RESULTS

The CQR-T demonstrated acceptable internal consistency (Cronbach's α = .832), adequate test-retest reliability (intraclass correlation coefficient = .630), and correlations with Morisky Medication Adherence Scale scores (r = -.389, p< .001), indicating convergent validity.

CONCLUSION

The CQR-T was found to be a valid and reliable instrument for evaluating the compliance of Turkish BD patients with prescribed medications.

IMPLICATIONS FOR PRACTICE

The CQR-T might be a helpful tool in two ways: for determining the level of compliance of patients with BD and for adjusting their management and follow-up based on the results.

Renal denervation

PURPOSE OF REVIEW

Renal denervation (RDN) has, within recent years, been suggested as a novel treatment option for patients with resistant hypertension. This review summarizes the current knowledge on this procedure as well as limitations and questions that remain to be answered.

RECENT FINDINGS

The Symplicity HTN-1 (2009) and HTN-2 (2010) studies re-introduced an old treatment approach for resistant hypertension and showed that catheter-based RDN was feasible and resulted in substantial blood pressure (BP) reductions. However, they also raised questions of durability of BP reduction, correct patient selection, anatomical and physiological effects of RDN as well as possible beneficial effects on other diseases with increased sympathetic activity. The long awaited Symplicity HTN-3 (2014) results illustrated that the RDN group and the sham-group had similar reductions in BP.

SUMMARY

Initial studies demonstrated that RDN in patients with resistant hypertension was both feasible and safe and indicated that RDN may lead to impressive reductions in BP. However, recent controlled studies question the BP lowering effect of RDN treatment. Large-scale registry data still supports the favorable BP reducing effect of RDN. We suggest that, in the near future, RDN should not be performed outside clinical studies. The degree of denervation between individual operators and between different catheters and techniques used should be clarified. The major challenge ahead is to identify which patients could benefit from RDN, to clarify the lack of an immediate procedural success parameter, and to establish further documentation of overall effect of treatment such as long-term cardiovascular morbidity and mortality.

Factors affecting compliance to management of diabetes in Urban Health Center of a tertiary care teaching hospital of south India

Aim:

To Study the Factors affecting compliance to diabetes management and study risk factors and complications of type II diabetes.

Settings and Design:

Primary health center, Descriptive study.

Materials and Methods:

A descriptive study of previously diagnosed diabetics (n = 135) attending the chronic disease clinic of Urban Health Center, Jawaharlal Institute of Postgraduate Medical Education and Research (JIUHC) was carried out during October 2011 to December 2011. Data were collected by personal interview on demographic parameters, duration of diabetes, number of doses missed in the last 15 days, co-morbidities, knowledge and practice of dietary modification, physical activity, self-care, family support, awareness about risk factors and complications of diabetes.

Statistical Analysis Used:

The findings were expressed in terms of proportions. Chi-square test was used to study the association between socio-demographic factors and compliance.

Results:

Majority of patients were in the age group of 50-59, of which 80% were females. Compliance (defined as not missing more than two doses in the last 15 days) to oral hypoglycemic agents was found in 103 (76%; 68.5-82.9). Dietary modifications was practiced by 110 (81.4%; 74.2-87.3) and 37% (29.2-45.4) practice physical activity. Annual eye check-up was carried out by 43.7%, renal function test by 46.6% and foot care by 54%. Knowledge regarding risk factors (66%; 42.7-59.4) and complications (79%; 71.8-85.4) was comparatively better than knowledge about self-care.

Conclusions:

Three-fourth of patients were compliant to medications and diet, but less than half follows modifications in physical activity and other self-care practices. Hence, it is essential to educate and motivate people in primary health-care level about self-care and life-style modifications.

High rates of non-adherence to antihypertensive treatment revealed by high-performance liquid chromatography-tandem mass spectrometry (HP LC-MS/MS) urine analysis

OBJECTIVES

Non-adherence to therapy is an important cause of suboptimal blood pressure control but few practical tools exist to accurately and routinely detect it. We used a simple urine-based assay to evaluate the prevalence of antihypertensive treatment non-adherence and its impact on blood pressure in a specialist hypertension centre.

METHODS

208 hypertensive patients (125 new referrals, 66 follow-up patients with inadequate blood pressure control and 17 renal denervation referrals) underwent assessment of antihypertensive drug intake using high-performance liquid chromatography-tandem mass spectrometry (HP LC-MS/MS) urine analysis at the time of clinical appointment. A total of 40 most commonly prescribed antihypertensive medications (or their metabolites) were screened for in spot urine samples.

RESULTS

Overall, 25% of patients were totally or partially non-adherent to antihypertensive treatment (total non-adherence 10.1%, partial non-adherence 14.9%). The highest prevalence of partial and total non-adherence was among follow-up patients with inadequate blood pressure control (28.8%) and those referred for consideration of renal denervation (23.5%), respectively. There was a linear relationship between blood pressure and the numerical difference in detected/prescribed antihypertensive medications-every unit increase in this difference was associated with 3.0 (1.1) mm Hg, 3.1 (0.7) mm Hg and 1.9 (0.7) mm Hg increase in adjusted clinic systolic blood pressure, clinic diastolic blood pressure (DBP) and 24 h mean daytime DBP (p=0.0051, p=8.62 × 10(-6), p=0.0057), respectively.

CONCLUSIONS

Non-adherence to blood pressure lowering therapy is common, particularly in patients with suboptimal blood pressure control and those referred for renal denervation. HP LC-MS/MS urine analysis could be used to exclude non-adherence and better stratify further investigations and intervention.

[Drug compliance and its factors in a group of hypertensive Congolese]

L'objectif de ce travail était d’évaluer le niveau d'observance des patients hypertendus et identifier les facteurs prédictifs de mauvaise observance. Il s'est agi d'une étude transversale à recueil de données prospectif sur une période de six mois. Elle s'est déroulée dans les services de consultations externes de cardiologie dans trois hôpitaux: le CHU de Brazzaville, l'hôpital central des armées de Brazzaville, et l'hôpital général de Loandjili (Pointe-Noire). Cette étude a concerné 212 patients dont 122 femmes (57.5%) et 90 hommes (42.5%), âgés de plus de 18ans, hypertendus traités depuis au moins six mois. Le questionnaire à six questions conçu par Girerd a été utilisé pour évaluer l'observance médicamenteuse. Une régression logistique a été utilisée pour rechercher les facteurs de mauvaise observance. L'observance était considérée comme bonne chez 45 patients soit 21.2%, et mauvaise chez 69 patients soit 32.5%. Dans 98 cas soit 46.2% il y avait un minime problème d'observance. Une HTA ancienne de plus de 5 ans, la présence des complications évolutives de l'HTA ainsi que les niveaux élevés de la PAS et de la PAD étaient liés à la mauvaise observance. Par contre aucune relation statistique n'a été retrouvée entre la mauvaise observance et l'existence d'une co-morbidité, la fréquence des prises médicamenteuses, le nombre de comprimés par jour et une pression artérielle non contrôlée. Les patients non observant étaient en moyenne plus âgés que les autres. Une mauvaise connaissance du traitement et des complications de l'HTA, le fait de ne pas acheter soi-même ses médicaments, l'ignorance de la gravité de l'HTA, et le coût élevé du traitement étaient prédictifs d'une mauvaise observance. La possession d'un tensiomètre électronique d'auto mesure tensionnelle ainsi que le rappel des prises médicamenteuses par les parents étaient liés à une bonne observance. Après ajustement par une régression logistique, seule la bonne connaissance du traitement et la perception de la gravité de l'HTA étaient liées à une bonne observance. L'observance médicamenteuse dans notre population d’étude s'est révélée faible. Il faut insister sur l’éducation thérapeutique des patients.

Predictors of resistant hypertension in an unselected sample of an adult male population in Italy

Prevalence, incidence and predictors of resistant hypertension (RH), (defined as blood pressure persistently above goal in spite of the concurrent use of three antihypertensive agents of different classes) in the general population remain largely unknown. A complete database including anthropometric and biochemical data was collected in 1994-1995 (baseline examination) in 1,019 participants (mean age 51.8, range: 25-79 years) and again in 2002-2004 in 794 male participants of the Olivetti Heart Study (OHS) in southern Italy. The incidence of RH over the average follow-up time of 7.9 years was 4.8% (38/794) in the whole study population and 10.1% (31/307) among hypertensive participants. Basal blood pressure (systolic, diastolic or pulse pressure), cholesterol and urinary albumin/creatinine ratio (ACR) significantly predicted the risk of developing RH using a logistic regression model that also included age as covariates. If in the same model we added basal pharmacological treatment, the fractional excretion of sodium (FENa) also became a statistically significant predictor, and this last model explained nearly 25% of the risk of developing RH. In this unselected sample of an adult male population, ACR (an early marker of organ damage), an elevated FENa (a proxy for dietary sodium intake), cholesterol and a higher basal blood pressure level were independent predictors of RH.

Capecitabine non-adherence: exploration of magnitude, nature and contributing factors

OBJECTIVES

The prescribing of oral chemotherapy agents previously available only in the intravenous formulation, such as capecitabine, has afforded many benefits including reduced administration costs and improved patient acceptability. However, it has introduced the new challenge of ensuring patient adherence to therapy. It is therefore necessary to quantify adherence, and with a view to improving services, explore factors that may impact on medication taking behavior.

METHODS

Patients with a diagnosis of breast or colorectal cancer and prescribed capecitabine were recruited from a UK teaching hospital. Data regarding self-reported adherence, beliefs about medicines, side effects, and satisfaction with information received about capecitabine were recorded.

RESULTS

Non-adherence was reported by 23.3% of the 43 participants. Capecitabine therapy was perceived necessary by 97.6%, but almost one-third of participants had strong concerns. Side effects were reported by 80% of participants, with Palmar-Plantar erythrodysesthesia and fatigue most troubling participants. Complete satisfaction with information received was reported by 65% of participants; however, dissatisfaction about how to tell if capecitabine is working and the proposed duration of therapy was expressed by 42.9% and 37.3% of participants, respectively.

CONCLUSIONS

Adherence to capecitabine is high with a strong conviction that the therapy is necessary. However, concerns were expressed regarding the experience of side effects. Patients have unmet information needs regarding the processes involved with monitoring capecitabine efficacy and determination of therapy duration. Healthcare professionals may therefore wish to consider a greater focus on involving patients in the monitoring of their care with respect to efficacy and planned treatment schedules.

Cultural adaptation of a compliance questionnaire for patients with rheumatoid arthritis to a Korean version

BACKGROUND/AIMS

The Compliance Questionnaire-Rheumatology (CQR) is a validated scale to evaluate patient compliance for anti-rheumatic medications. We developed a Korean version of the CQR (KCQR) and confirmed its reliability and validity.

METHODS

We prepared the KCQR by translating and back-translating the original CQR with modifications to adapt it to Korean culture. Fifty Korean patients with rheumatoid arthritis (RA) were enrolled in this study. The test-retest reliability of the KCQR was evaluated at a 2-week interval using the intraclass correlation coefficient (ICC). The validity of the KCQR was assessed by identifying associations between KCQR scores and patient compliance, measured using pharmacy refill data.

RESULTS

The reliability of the KCQR was adequate, with an ICC of 0.71 for test-retest reliability. With respect to validity, the summed score of the weighted KCQR showed a significant correlation with pharmacy refill data (r² = 0.57) on multiple regression analysis.

CONCLUSIONS

Our results indicate that the KCQR is a reliable, valid instrument to evaluate compliance of Korean patients for RA medications.

Different aspects of adherence to antihypertensive treatments

This review collects together data concerning the measurement of patient behavior towards antihypertensives, considering all its aspects - adherence, persistence and switching. The wide heterogeneity of terms, outcome definitions and methods of assessment (the multiplicity of approaches did not allow a full meta-analysis, but a qualitative description of the results) are demonstrated. The percentages of adherence/compliance from the studies discussed in this review range from 15 to 99% across different study designs, populations and methods. Large, observational studies are suggested as a reliable method to measure patient behavior. An emerging issue is the relevance of patient motivation and education, which could provide a higher level of compliance to treatment, thus allowing achievement of better clinical outcomes and improved use of resources for the healthcare system.

[Medication adherence of a sample of hypertensive patients in the region of Sfax (Tunisia)]

THE AIM OF THE STUDY

Medication noncompliance is one of the daily problems of the physician. Improving the medication adherence allows better management of hypertension. The aim of this work was to determine the level of compliance for patients with hypertension and to identify factors that determine compliance.

METHODS

A cross-sectional study was carried out among a sample of hypertensive patients attending general and specialist practitioners in public or private clinics of Sfax. Two hundred and seventy-three participants had accepted to be interviewed. Patients were identified as noncompliants using a questionnaire developed by the Comité de lutte contre l'hypertension artérielle (CFLHTA).

RESULTS

Non-compliance rate was 63.4%. The low level of education was associated with a lower adherence. The monotherapy, the once-daily regimen with fewer number of tablets were associated with a better adherence (p<10(-6)). The welcome and the availability of drugs in the public clinic affect positively the adherence of patients (p<0.0002). A patient very satisfied with his consultation and the explanation given by the doctor about his illness and its treatment had a better adherence (p<0.00003).

CONCLUSION

Our study had demonstrated a low compliance with antihypertensive drug therapy. Tunisian health care system should elaborate a management plan which takes into account our particular predictors of compliance to improve adherence to antihypertensive medication.

[Drug therapy and hypertension in the newspapers]

OBJECTIVE

The most recent country-wide Canadian data have revealed that only 33% of people with hypertension take medication and fewer than half of them have their blood pressure under control. One of the most important reasons for difficulty in controlling blood pressure is lack of drug treatment compliance. In addition, media coverage of health facts has an impact on beliefs, attitudes and behaviours related to health. Our goal was to analyze newspaper coverage of drugs related to hypertension.

METHOD

We conducted a thematic content analysis of newspapers covering medications related to hypertension. The study comprised 104 articles drawn from three of the most important francophone daily newspapers in Canada--a reference one, a general broadsheet and a tabloid.

RESULTS

We identified three major themes: 1) drugs as an effective treatment, 2) specific problematic cases, and 3) problems with the pharmacological approach in general. We noted a gradual change from positive to negative as we moved from the most serious newspaper to the most popular. We discuss the Fiske hypothesis which suggests that tabloid-format newspapers are a repository of popular opposition to the discourse of groups who hold power in society.

CONCLUSION

In the tabloid, the most widely-read newspaper in Quebec, medications are often presented in negative fashion in articles on hypertension. However, further studies are required to determine if there is a causal association between media discourse and the phenomenon of lack of drug treatment compliance.

Effect of reminder cards on compliance with antihypertensive medication

Objective

Poor compliance to antihypertensive medications has been identified as a primary cause of uncontrolled blood pressure (BP), with consequent increases in hypertension-related morbidity and mortality. Therefore, any measure known to improve compliance should be encouraged. This study assessed the impact of reminder cards on compliance to antihypertensive therapy.

Method

A field trial was undertaken in pharmacies located in the districts of Lisbon and Porto. Eligible participants comprised those aged 30–74 years, prescribed an angiotensin-converting enzyme inhibitor (ACEI) in monotherapy, and taken on a once-daily regimen. Patients were allocated to control group (CG) or intervention group (IG), the latter being provided with a reminder card, an alarm-type device due to remind the patient of the time to take his medication. Patients were monitored monthly during 3 months for compliance and blood pressure control.

Key findings

Seventy-one patients participated in the study (intervention: 35; control group: 36). Compliance was similar between the groups in the first 2 months of follow-up (97.1% IG vs 94.9% CG at first follow-up and 97.5% IG vs 94.2% CG at second follow-up) and higher in the intervention group at the end of the study (97.3% IG vs 87.3% CG; P = 0.011). There were no mean blood pressure differences between compliant and non-compliant subjects at the end of the study (P value for differences in systolic BP (Psyst) = 0.580; and P value for differences in diastolic BP (Pdlast) = 0.175).

Conclusion

This small-scale study indicates a possible positive impact on patients' compliance resulting from the use of reminder cards. However, this needs confirming in larger scale studies with longer monitoring periods.

A randomised controlled trial of the effects of note-based medication review by community pharmacists on prescribing of cardiovascular drugs in general practice

Objective Recent trends in primary care have seen closer working relationships between community pharmacists and general practitioners (GPs) in an attempt to improve the effectiveness and efficiency of prescribing. Community pharmacists are appropriate for a role in the management of prescribed medicines because of their detailed training in pharmacology, therapeutics and pharmaceutics. The aim of this project was to quantify the benefit of a general practice-based, community pharmacist-led, note-based medication review of patients with hypertension or angina.

Method Trained community pharmacists (20), attached to Grampian general practices (43), reviewed repeat prescriptions of a random sample of patients taking cardiovascular drugs for the treatment of angina or hypertension, and made recommendations to the GP for changes, where appropriate. The effect of the pharmaceutical intervention was measured in terms of prescribing indicators, patient outcomes (quality of life, symptom control), and physiological and biochemical markers at baseline, 6 and 12 months. A control group was treated following standard practice. An economic evaluation of the interventions was also conducted.

Key findings The baseline standard of treatment as measured against guidelines was good. At 12 months, there was a small improvement in prescribing of antiplatelet drugs, but overall changes were minimal. Average overall cost per patient was higher in the intervention group. The quality of life measures showed no change between the groups.

Conclusions Improvements in the intervention group were small and less than in other reported studies of pharmacist interventions. The National Health Service (NHS) costs of the intervention group were higher than those of the controls. Note-based medication review by community pharmacists was found to be associated with minimal changes in prescribing.

Assessing medication adherence simultaneously by electronic monitoring and pill count in patients with mild-to-moderate hypertension

BACKGROUND

Poor adherence to antihypertensive medication is one of the major problems in the treatment of hypertension. Electronic monitoring is currently considered to be the gold standard for assessing adherence, but it may trigger patients to open the pill bottle without taking medication or to take out more than prescribed. In adjunct to electronic monitoring, pill count could be a valuable tool for exploring adherence patterns, and their effects on blood pressure reduction.

METHODS

Among a total of 228 patients with mild-to-moderate hypertension, adherence to treatment was measured by means of both the Medication Event Monitoring System (MEMS) and pill count. Patients were followed-up for seven visits over a period of 1 year. At each visit to the physician's office, patient's adherence was assessed by both methods.

RESULTS

Adherence is defined as the percentage of days with correct dosing; median adherence according to MEMS was lower than median adherence according to pill count (91.6 vs. 96.1; P < 0.001). Both methods agreed in defining patients as adherent in 107 (47%) and nonadherent in 33 (14%) patients. Thirty-one (14%) patients were adherent only by MEMS and 59 (25%) patients only by pill count. At the end of the study, patients in the four categories reached comparable blood pressure values and reductions.

CONCLUSIONS

Pill count could be a useful adjunct to electronic monitoring in assessing adherence patterns. Although deviant intake behavior occurred frequently, the effect on achieved blood pressure and blood pressure reduction was not remarkable.

Implantable carotid sinus stimulator for the treatment of resistant hypertension: local effects on carotid artery morphology

BACKGROUND

The Rheos System is a chronically implanted carotid sinus baroreflex activating system with a pulse generator and bilateral perivascular carotid sinus leads (CSLs) that is being evaluated in prospective clinical trials for the treatment of drug-resistant hypertension. We evaluated carotid artery structural integrity after implantation of the CSLs.

METHODS

To assess the effect of chronic CSL attachment, 29 CSLs were implanted on the common carotid arteries of eight sheep. The studies were terminated at 3 and 6 months postimplantation to assess anatomic and histologic changes. Additionally, 10 patients with resistant hypertension were enrolled in the Rheos Multicenter Feasibility Trial. Duplex ultrasound (DUS) was performed before device implantation and at 1 and 4 months postimplantation in this patient cohort. An independent core laboratory assessed all DUSs.

RESULTS

Ovine carotid angiography revealed no significant stenoses, while anatomic and histologic evaluations demonstrated electrode encapsulation in a thin layer of connective tissue with no evidence of stenosis, erosion, or inflammation. DUS evaluation revealed no significant increase in peak systolic velocities of the common and internal carotid arteries 1 and 4 months after initial implantation, indicating a lack of injury, remodeling, or stenosis.

CONCLUSION

The current data suggest that the CSLs used with the Rheos System are not associated with the development of carotid stenosis or injury. These short-term data support the concept of CSL placement and merit long-term investigation in a larger multicenter prospective trial.

Patient adherence and the choice of antihypertensive drugs: focus on lercanidipine

Despite the development of many effective antihypertensive drugs, target blood pressures are reached in only a minority of patients in clinical practice. Poor adherence to drug therapy and the occurrence of side effects are among the main reasons commonly reported by patients and physicians to explain the poor results of actual antihypertensive therapies. The development of new effective antihypertensive agents with an improved tolerability profile might help to partly overcome these problems. Lercanidipine is an effective dihydropyridine calcium channel blocker of the third generation characterized by a long half-life and its lipophylicity. In contrast to first-generation dihydropyridines, lercanidipine does not induce reflex tachycardia and induces peripheral edema with a lower incidence. Recent data suggest that in addition to lowering blood pressure, lercanidipine might have some renal protective properties. In this review we shall discuss the problems of drug adherence in the management of hypertension with a special emphasis on lercanidipine.

Differential risks of stroke in pharmacotherapy on uncomplicated hypertensive patients?

OBJECTIVE

To determine the risk of stroke associated with various antihypertensive drugs among previously uncomplicated hypertensive patients.

METHODS

A retrospective cohort study was undertaken, covering the period from 1997 to 2004, of a 1,000,000-person random sample obtained from Taiwan's National Health Insurance reimbursement database. Between January 1999 and December 2004, 29 759 patients aged 30 years or older were identified as newly diagnosed uncomplicated hypertensive cases. They were followed up until the end of 2004. A time-dependent Cox's proportional hazards model was specified to analyze the risk of stroke development.

RESULTS

From the 29,759 uncomplicated hypertensive patients, 1078 new cases of stroke were identified and followed up for at least 1 month during the study period, including 654 ischemic stroke cases. After adjustment for various risk factors, the hazard ratio of developing stroke was significantly higher for poor medication compliance (hazard ratio 1.5-1.9), old age, male sex, and comorbid diabetes mellitus and/or other heart diseases. Different categories of antihypertensive medications were not associated with differential effects on stroke development. In the subsequent analysis, we found that patients receiving pharmacotherapy with beta-blockers were 1.3 (95% confidence interval 1.0-1.6) times more likely to develop ischemic stroke than those who had been treated with other types of antihypertensive medication.

CONCLUSION

Poor medication compliance is a key determinant of developing stroke among hypertensive patients. This study suggests that there has been no differential effect of antihypertensive medication on overall risk of stroke, whereas beta-blockers might be associated with more ischemic stroke. Further studies are needed to corroborate this hypothesis.

The significance of compliance and persistence in the treatment of diabetes, hypertension and dyslipidaemia: a review

OBJECTIVES

To review studies of patient compliance/persistence with cardiovascular or antidiabetic medication published since the year 2000; to compare the methods used to measure compliance/persistence across studies; to compare reported compliance/persistence rates across therapeutic classes and to assess whether compliance/persistence correlates with clinical outcomes.

METHODS

English language papers published between January 2000 and November 2005 investigating patient compliance/persistence with cardiovascular or antidiabetic medication were identified through searches of the MEDLINE and EMBASE databases. Definitions and measurements of compliance/persistence were compared across therapeutic areas using contingency tables.

RESULTS

Of the 139 studies analysed, 32% focused on hypertension, 27% on diabetes and 13% on dyslipidaemia. The remainder covered coronary heart disease and cardiovascular disease (CVD) in general. The most frequently reported measure of compliance was the 12-month medication possession ratio (MPR). The overall mean MPR was 72%, and the MPR did not differ significantly between treatment classes (range: 67-76%). The average proportion of patients with an MPR of >80% was 59% overall, 64% for antihypertensives, 58% for oral antidiabetics, 51% for lipid-lowering agents and 69% in studies of multiple treatments, again with no significant difference between treatment classes. The average 12-month persistence rate was 63% and was similar across therapeutic classes. Good compliance had a positive effect on outcome in 73% of the studies examining clinical outcomes.

CONCLUSIONS

Non-compliance with cardiovascular and antidiabetic medication is a significant problem, with around 30% of days 'on therapy' not covered by medication and only 59% of patients taking medication for more than 80% of their days 'on therapy' in a year. Good compliance has a positive effect on clinical outcome, suggesting that the management of CVD may be improved by improving patient compliance.

Electronic pillboxes (MEMS) to assess the relationship between medication adherence and blood pressure control in primary care

OBJECTIVE

To investigate the relationship between blood pressure and medication adherence using electronic pillboxes (MEMS).

SETTING

Five general practices in Bristol, UK.

SUBJECTS

A total of 239 individuals with a clinical diagnosis of hypertension and being prescribed at least one blood pressure-lowering medication. Participants were asked to use the electronic pillbox as their drug bottle for at least one month.

MAIN OUTCOME MEASURES

"Timing adherence" (correct inter-dose intervals) as measured through MEMS and systolic (SBP) and diastolic (DBP) office blood pressure.

RESULTS

Mean (+/-SD) timing adherence was 88% (+/-17),>80% in 175 (73%), and less than 50% in 11 (5%) participants. Adherence was monitored for a mean of 33 (+/-6) days. Mean (+/-SD) SBP was 147.9+/-19.1 mmHg and DBP 82.3+/-10.1 mmHg. There was no evidence to suggest that timing adherence was associated with SBP or DBP (overall correlation coefficients -0.01 and -0.02 respectively). According to current guidelines, about one in four of all participants had controlled SBP (only 6% of diabetic patients). DBP was under control in 66% of the individuals.

CONCLUSIONS

No relationship between adherence and blood pressure in patients with hypertension recruited from primary care was found. Average timing adherence measured by electronic monitors was high (88%) and blood pressure was controlled in a minority of patients. Our findings suggest that in terms of poor blood pressure control pharmacological non-response to or insufficient intensity of blood pressure-lowering medication might be more important than poor adherence to antihypertensive drug therapy.

The efficacy of the combination of sertraline with buspirone for smoking cessation. A randomized clinical trial in nondepressed smokers

In a double-blind placebo-controlled trial, we evaluated the efficacy of the combination of sertraline and buspirone plus cognitive-behavioral treatment to promote tobacco abstinence in individuals referred to a chemical dependency clinic. Ninety eight individuals 18-65 years of age were randomized to placebo or sertraline 25 mg/day for 2 days, followed by 50 mg from day 3 to 90, and buspirone 5 mg three times a day for 7 days, and 10 mg from day 8 to 90. The rate of continuous abstinence at the 26th week of follow-up, informed by the patient, was 43.5% in the active treatment group and 17.3% in the control group (p = 0.01). The odds ratio for continuous abstinence for the intervention group was 4.74 (95% CI 1.50-14.55) (adjusted for smoker households and number of cognitive sessions). Nicotine withdrawal symptoms were common in both groups (98.7% vs. 95.5% p = 0.37). The combination of sertraline and buspirone with cognitive-behavioral therapy was more effective than placebo and cognitive-behavioral therapy to promote smoking cessation.

An Implantable Carotid Sinus Baroreflex Activating System: Surgical Technique and Short-Term Outcome from a Multi-Center Feasibility Trial for the Treatment of Resistant Hypertension

OBJECTIVES

To assess perioperative outcomes and blood pressure (BP) responses to an implantable carotid sinus baroreflex activating system being investigated for the treatment of resistant hypertension.

METHODS

We report on the first seventeen patients enrolled in a multicenter study. Bilateral perivascular carotid sinus electrodes (CSL) and a pulse generator (IPG) are permanently implanted. Optimal placement of the CSL is determined by intraoperative BP responses to test activations. Acute BP responses were tested postoperatively and during the first four months of follow-up.

RESULTS

Prior to implant, BP was 189.6+/-27.5/110.7+/-15.3 mmHg despite stable therapy (5.2+/-1.8 antihypertensive drugs). The mean procedure time was 202+/-43 minutes. No perioperative strokes or deaths occurred. System tests performed 1 or up to 3 days postoperatively resulted in significant (all p < or = 0.0001) mean maximum reduction, with standard deviations and 95% confidence limits for systolic BP, diastolic BP and heart rate of 28+/-22 (17, 39) mmHg, 16+/-11 (10, 22) mmHg and 8+/-4 (6, 11) BPM, respectively. Repeated testing during 3 months of therapeutic electrical activation demonstrated a durable response.

CONCLUSIONS

These preliminary data suggest an acceptable safety of the procedure with a low rate of adverse events and support further clinical development of baroreflex activation as a new concept to treat resistant hypertension.

An implantable carotid sinus stimulator for drug-resistant hypertension: surgical technique and short-term outcome from the multicenter phase II Rheos feasibility trial

BACKGROUND

A large number of patients have hypertension that is resistant to currently available pharmacologic therapy. Electrical stimulation of the carotid sinus baroreflex system has been shown to produce significant chronic blood pressure decreases in animals. The phase II Rheos Feasibility Trial was performed to assess the response of patients with multidrug-resistant hypertension to such stimulation.

METHODS

The system consists of an implantable pulse generator with bilateral perivascular carotid sinus leads. Implantation is performed bilaterally with patients under narcotic anesthesia (to preserve the reflex for assessment of optimal lead placement). Dose-response testing at 0 to 6 V is assessed before discharge and at monthly intervals thereafter; the device is activated after 1 month's recovery time. This was a Food and Drug Administration-monitored phase II trial performed at five centers in the United States.

RESULTS

Ten patients with resistant hypertension (taking a median of six antihypertensive medications) underwent implantation. All 10 were successful, with no significant morbidity. The mean procedure time was 198 minutes. There were no adverse events attributable to the device. Predischarge dose-response testing revealed consistent (r = .88) reductions in systolic blood pressure of 41 mm Hg (mean fall is from 180-139 mm Hg), with a peak response at 4.8 V (P < .001) and without significant bradycardia or bothersome symptoms.

CONCLUSIONS

A surgically implantable device for electrical stimulation of the carotid baroreflex system can be placed safely and produces a significant acute decrease in blood pressure without significant side effects.

[Determinants of the adherence to therapeutic plan in elderly Spaniards, over 60 years of age]

OBJECTIVE

To identify factors associated with the adherence to a therapeutic plan of awareness of hypertension.

MATERIAL AND METHODS

The data of the study "Arterial hypertension and other factors of risk in the elderly (> or = 60 years) Spanish population". This was a population-based survey of 4.009 older Spaniards. Information for this survey was obtained thorough household personal interviews to evaluate if these determining factors are independent of socio-demographic variables, the use of health system, lifestyles and the quality of life related to health.

RESULTS

In men, the adherence to a therapeutic plan according to the regions studied (OR Rural = 3.9; OR Cantabrian = 1.9). Beside general health (OR = 1.01). With respect to the women, the ones that complied with the therapeutic plan more frequently had a low scholastic level (OR = 1.8), physical condition (OR = 1.02), and had more frequent home medical visits monthly (OR = 3.0). The women with poor adherence had two chronic illnesses (OR = 0.6)

CONCLUSIONS

There are regional differences, gender, educational and to measure health-related quality of life. This demonstrates poor adherence, so the strategy should be directed toward in this variables mentioned.

Determinants of poor adherence in hypertensive patients: development and validation of the "Maastricht Utrecht Adherence in Hypertension (MUAH)-questionnaire"

OBJECTIVES

(1) To help identify patients with poor adherence and (2) to identify potential reasons that impede or facilitate adherence.

METHODS

Seventeen patients who used antihypertensive drugs participated in semi-standardized interviews. Interviews were recorded and reviewed by two investigators. Forty-four items were selected. An exploratory factor analysis was performed. Convergent validity was assessed by evaluating the association between sum scores on the identified subscales and three other adherence measures: (1) the Brief Medication Questionnaire (BMQ), (2) pharmacy refill records and (3) electronic monitoring. Regression analysis was used to evaluate the magnitude of associations.

RESULTS

Two hundred and fifty-five (90%) patients completed the questionnaire. Factor analysis resulted in a four-factor solution, explaining 30% of cumulative variance among respondents. The factors (scales) were labeled: positive attitude towards health care and medication (I), lack of discipline (II), aversion towards medication (III) and active coping with health problems (IV). Chronbach's alpha coefficient was 0.75, 0.80, 0.63 and 0.76 for scales I, II, III and IV, respectively. Convergent validity was partly supported by statistically significant associations that were found between sum scores of subscales 1 and II and the BMQ and electronic monitoring, respectively.

CONCLUSION

The MUAH-questionnaire has excellent psychometric properties and may be useful to identify factors that impede or facilitate adherence. However, it is not clear to what extent the questionnaire measures actual adherence.

PRACTICE IMPLICATIONS

Validation of the MUAH-questionnaire in other studies is needed.

Review of resistant hypertension

Despite the prevalence of hypertension, blood pressure (BP) can be controlled with effective therapy in most patients. However, in a small percentage of the hypertensive population, BP remains refractory to therapeutic measures. In such patients who have so-called "resistant" hypertension, proper evaluation and assessment have to be undertaken to improve the BP control. There are some situations or factors that may make hypertension control difficult in some patients. Therefore, it is necessary to identify possible reasons for the loss of BP control and rectify them to achieve normotension. In addition to indicated work-up for secondary causes, aggressive treatment (nonpharmacologic and pharmacologic) of hypertension is required to prevent excessive morbidity and mortality in this special population.

Relationship between medication adherence and blood pressure in primary care: prospective study

There is good evidence from randomised trials (RCTs) that treating high blood pressure is effective in reducing cardiovascular risk, but people with high blood pressure can find it difficult to take antihypertensive medication regularly. The relationship between adherence and achieved blood pressure is far from clear.

Bias in clinical intervention research

Research on bias in clinical trials may help identify some of the reasons why investigators sometimes reach the wrong conclusions about intervention effects. Several quality components for the assessment of bias control have been suggested, but although they seem intrinsically valid, empirical evidence is needed to evaluate their effects on the extent and direction of bias. This narrative review summarizes the findings of methodological studies on the influence of bias in clinical trials. A number of methodological studies suggest that lack of adequate randomization in published trial reports may be associated with more positive estimates of intervention effects. The influence of double-blinding and follow-up is less clear. Several studies have found a significant association between funding sources and pro-industry conclusions. However, the methodological studies also show that bias is difficult to detect and appraise. The extent of bias in individual trials is unpredictable. A-priori exclusion of trials with certain characteristics is not recommended. Appraising bias control in individual trials is necessary to avoid making incorrect conclusions about intervention effects.