Baseline Characteristics and Early Blood Pressure Control in the CONVINCE Trial

Dry Mouth Dilemma: A Comprehensive Review of Xerostomia in Complete Denture Wearers

Xerostomia, commonly known as dry mouth, presents a significant challenge for individuals wearing complete dentures, affecting their oral health and quality of life. This review explores the relationship between saliva and complete dentures, highlighting the varied management strategies for xerostomia. Saliva plays a critical role in denture retention, lubrication, and oral environment buffering. Complete denture wearers often experience reduced salivary flow, aggravating symptoms of xerostomia. Various management approaches are discussed, including general measures such as hydration and salivary stimulation techniques which aim to boost saliva production naturally. The use of salivary substitutes provides artificial lubrication and moisture to alleviate dry mouth discomfort. Oral lubricating devices, such as sprays, gels, and lozenges, offer relief by mimicking saliva's lubricating properties, thereby improving denture stability and comfort. This review addresses the etiology of xerostomia in complete denture wearers and explores preventive measures to reduce its impact. A comprehensive approach has been discussed for the management of xerostomia which will help to improve the oral health and well-being of complete denture wearers experiencing dry mouth.

Evening versus morning dosing regimen drug therapy for hypertension

BACKGROUND

Variation in blood pressure levels display circadian rhythms. Complete 24-hour blood pressure control is the primary goal of antihypertensive treatment and reducing adverse cardiovascular outcomes is the ultimate aim. This is an update of the review first published in 2011.

OBJECTIVES

To evaluate the effectiveness of administration-time-related effects of once-daily evening versus conventional morning dosing antihypertensive drug therapy regimens on all-cause mortality, cardiovascular mortality and morbidity, total adverse events, withdrawals from treatment due to adverse effects, and reduction of systolic and diastolic blood pressure in people with primary hypertension.

SEARCH METHODS

We searched the Cochrane Hypertension Specialised Register via Cochrane Register of Studies (17 June 2022), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2022); MEDLINE, MEDLINE In-Process and MEDLINE Epub Ahead of Print (1 June 2022); Embase (1 June 2022); ClinicalTrials.gov (2 June 2022); Chinese Biomedical Literature Database (CBLD) (1978 to 2009); Chinese VIP (2009 to 7 August 2022); Chinese WANFANG DATA (2009 to 4 August 2022); China Academic Journal Network Publishing Database (CAJD) (2009 to 6 August 2022); Epistemonikos (3 September 2022) and the reference lists of relevant articles. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing the administration-time-related effects of evening with morning dosing monotherapy regimens in people with primary hypertension. We excluded people with known secondary hypertension, shift workers or people with white coat hypertension.

DATA COLLECTION AND ANALYSIS

Two to four review authors independently extracted data and assessed trial quality. We resolved disagreements by discussion or with another review author. We performed data synthesis and analyses using Review Manager Web for all-cause mortality, cardiovascular mortality and morbidity, serious adverse events, overall adverse events, withdrawals due to adverse events, change in 24-hour blood pressure and change in morning blood pressure. We assessed the certainty of the evidence using GRADE. We conducted random-effects meta-analysis, fixed-effect meta-analysis, subgroup analysis and sensitivity analysis.

MAIN RESULTS

We included 27 RCTs in this updated review, of which two RCTs were excluded from the meta-analyses for lack of data and number of groups not reported. The quantitative analysis included 25 RCTs with 3016 participants with primary hypertension. RCTs used angiotensin-converting enzyme inhibitors (six trials), calcium channel blockers (nine trials), angiotensin II receptor blockers (seven trials), diuretics (two trials), α-blockers (one trial), and β-blockers (one trial). Fifteen trials were parallel designed, and 10 trials were cross-over designed. Most participants were white, and only two RCTs were conducted in Asia (China) and one in Africa (South Africa). All trials excluded people with risk factors of myocardial infarction and strokes. Most trials had high risk or unclear risk of bias in at least two of several key criteria, which was most prominent in allocation concealment (selection bias) and selective reporting (reporting bias). Meta-analysis showed significant heterogeneity across trials. No RCTs reported on cardiovascular mortality and cardiovascular morbidity. There may be little to no differences in all-cause mortality (after 26 weeks of active treatment: RR 0.49, 95% CI 0.04 to 5.42; RD 0, 95% CI -0.01 to 0.01; very low-certainty evidence), serious adverse events (after 8 to 26 weeks of active treatment: RR 1.17, 95% CI 0.53 to 2.57; RD 0, 95% CI -0.02 to 0.03; very low-certainty evidence), overall adverse events (after 6 to 26 weeks of active treatment: RR 0.89, 95% CI 0.67 to 1.20; I² = 37%; RD -0.02, 95% CI -0.07 to 0.02; I² = 38%; very low-certainty evidence) and withdrawals due to adverse events (after 6 to 26 weeks active treatment: RR 0.76, 95% CI 0.47 to 1.23; I² = 0%; RD -0.01, 95% CI -0.03 to 0; I² = 0%; very low-certainty evidence), but the evidence was very uncertain.

AUTHORS' CONCLUSIONS

Due to the very limited data and the defects of the trials' designs, this systematic review did not find adequate evidence to determine which time dosing drug therapy regimen has more beneficial effects on cardiovascular outcomes or adverse events. We have very little confidence in the evidence showing that evening dosing of antihypertensive drugs is no more or less effective than morning administration to lower 24-hour blood pressure. The conclusions should not be assumed to apply to people receiving multiple antihypertensive drug regimens.

First-line diuretics versus other classes of antihypertensive drugs for hypertension

BACKGROUND

Different first-line drug classes for patients with hypertension are often assumed to have similar effectiveness with respect to reducing mortality and morbidity outcomes, and lowering blood pressure. First-line low-dose thiazide diuretics have been previously shown to have the best mortality and morbidity evidence when compared with placebo or no treatment. Head-to-head comparisons of thiazides with other blood pressure-lowering drug classes would demonstrate whether there are important differences.

OBJECTIVES

To compare the effects of first-line diuretic drugs with other individual first-line classes of antihypertensive drugs on mortality, morbidity, and withdrawals due to adverse effects in patients with hypertension. Secondary objectives included assessments of the need for added drugs, drug switching, and blood pressure-lowering.

SEARCH METHODS

Cochrane Hypertension's Information Specialist searched the Cochrane Hypertension Specialized Register, CENTRAL, MEDLINE, Embase, and trials registers to March 2021. We also checked references and contacted study authors to identify additional studies. A top-up search of the Specialized Register was carried out in June 2022.

SELECTION CRITERIA

Randomized active comparator trials of at least one year's duration were included. Trials had a clearly defined intervention arm of a first-line diuretic (thiazide, thiazide-like, or loop diuretic) compared to another first-line drug class: beta-blockers, calcium channel blockers, alpha adrenergic blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, direct renin inhibitors, or other antihypertensive drug classes. Studies had to include clearly defined mortality and morbidity outcomes (serious adverse events, total cardiovascular events, stroke, coronary heart disease (CHD), congestive heart failure, and withdrawals due to adverse effects).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 20 trials with 26 comparator arms randomizing over 90,000 participants. The findings are relevant to first-line use of drug classes in older male and female hypertensive patients (aged 50 to 75) with multiple co-morbidities, including type 2 diabetes. First-line thiazide and thiazide-like diuretics were compared with beta-blockers (six trials), calcium channel blockers (eight trials), ACE inhibitors (five trials), and alpha-adrenergic blockers (three trials); other comparators included angiotensin II receptor blockers, aliskiren (a direct renin inhibitor), and clonidine (a centrally acting drug). Only three studies reported data for total serious adverse events: two studies compared diuretics with calcium channel blockers and one with a direct renin inhibitor. Compared to first-line beta-blockers, first-line thiazides probably result in little to no difference in total mortality (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.84 to 1.10; 5 trials, 18,241 participants; moderate-certainty), probably reduce total cardiovascular events (5.4% versus 4.8%; RR 0.88, 95% CI 0.78 to 1.00; 4 trials, 18,135 participants; absolute risk reduction (ARR) 0.6%, moderate-certainty), may result in little to no difference in stroke (RR 0.85, 95% CI 0.66 to 1.09; 4 trials, 18,135 participants; low-certainty), CHD (RR 0.91, 95% CI 0.78 to 1.07; 4 trials, 18,135 participants; low-certainty), or heart failure (RR 0.69, 95% CI 0.40 to 1.19; 1 trial, 6569 participants; low-certainty), and probably reduce withdrawals due to adverse effects (10.1% versus 7.9%; RR 0.78, 95% CI 0.71 to 0.85; 5 trials, 18,501 participants; ARR 2.2%; moderate-certainty). Compared to first-line calcium channel blockers, first-line thiazides probably result in little to no difference in total mortality (RR 1.02, 95% CI 0.96 to 1.08; 7 trials, 35,417 participants; moderate-certainty), may result in little to no difference in serious adverse events (RR 1.09, 95% CI 0.97 to 1.24; 2 trials, 7204 participants; low-certainty), probably reduce total cardiovascular events (14.3% versus 13.3%; RR 0.93, 95% CI 0.89 to 0.98; 6 trials, 35,217 participants; ARR 1.0%; moderate-certainty), probably result in little to no difference in stroke (RR 1.06, 95% CI 0.95 to 1.18; 6 trials, 35,217 participants; moderate-certainty) or CHD (RR 1.00, 95% CI 0.93 to 1.08; 6 trials, 35,217 participants; moderate-certainty), probably reduce heart failure (4.4% versus 3.2%; RR 0.74, 95% CI 0.66 to 0.82; 6 trials, 35,217 participants; ARR 1.2%; moderate-certainty), and may reduce withdrawals due to adverse effects (7.6% versus 6.2%; RR 0.81, 95% CI 0.75 to 0.88; 7 trials, 33,908 participants; ARR 1.4%; low-certainty). Compared to first-line ACE inhibitors, first-line thiazides probably result in little to no difference in total mortality (RR 1.00, 95% CI 0.95 to 1.07; 3 trials, 30,961 participants; moderate-certainty), may result in little to no difference in total cardiovascular events (RR 0.97, 95% CI 0.92 to 1.02; 3 trials, 30,900 participants; low-certainty), probably reduce stroke slightly (4.7% versus 4.1%; RR 0.89, 95% CI 0.80 to 0.99; 3 trials, 30,900 participants; ARR 0.6%; moderate-certainty), probably result in little to no difference in CHD (RR 1.03, 95% CI 0.96 to 1.12; 3 trials, 30,900 participants; moderate-certainty) or heart failure (RR 0.94, 95% CI 0.84 to 1.04; 2 trials, 30,392 participants; moderate-certainty), and probably reduce withdrawals due to adverse effects (3.9% versus 2.9%; RR 0.73, 95% CI 0.64 to 0.84; 3 trials, 25,254 participants; ARR 1.0%; moderate-certainty). Compared to first-line alpha-blockers, first-line thiazides probably result in little to no difference in total mortality (RR 0.98, 95% CI 0.88 to 1.09; 1 trial, 24,316 participants; moderate-certainty), probably reduce total cardiovascular events (12.1% versus 9.0%; RR 0.74, 95% CI 0.69 to 0.80; 2 trials, 24,396 participants; ARR 3.1%; moderate-certainty) and stroke (2.7% versus 2.3%; RR 0.86, 95% CI 0.73 to 1.01; 2 trials, 24,396 participants; ARR 0.4%; moderate-certainty), may result in little to no difference in CHD (RR 0.98, 95% CI 0.86 to 1.11; 2 trials, 24,396 participants; low-certainty), probably reduce heart failure (5.4% versus 2.8%; RR 0.51, 95% CI 0.45 to 0.58; 1 trial, 24,316 participants; ARR 2.6%; moderate-certainty), and may reduce withdrawals due to adverse effects (1.3% versus 0.9%; RR 0.70, 95% CI 0.54 to 0.89; 3 trials, 24,772 participants; ARR 0.4%; low-certainty). For the other drug classes, data were insufficient. No antihypertensive drug class demonstrated any clinically important advantages over first-line thiazides.

AUTHORS' CONCLUSIONS

When used as first-line agents for the treatment of hypertension, thiazides and thiazide-like drugs likely do not change total mortality and likely decrease some morbidity outcomes such as cardiovascular events and withdrawals due to adverse effects, when compared to beta-blockers, calcium channel blockers, ACE inhibitors, and alpha-blockers.

Clinical assessment of levamlodipine besylate combination therapy for essential hypertension: A protocol for systematic review and meta-analysis

BACKGROUND

Essential hypertension has been regarded a significant risk factor for cardiovascular disease across the globe, and a significant escapable causation of early death as well as morbidity in the U.S. When angiotensin II receptor blockers and calcium channel blockers are used to treat essential hypertension, most patients will have inadequate blood pressure management. As a result, including a diuretic in the regimen is necessary. The current study's aim is to investigate the effectiveness as well as safety of levamlodipine besylate combination therapy in treating essential hypertension at varying degrees of severity.

METHODS

In establishing the effectiveness and safety of the mix of levamlodipine besylate and dihydropyridine for essential hypertension, the authors will conduct a systematic review and, where applicable, a meta-analysis of randomized controlled clinical trials. A total of 8 electronic databases will be used in the search, including 4 English databases (PubMed, Web of Science, EMBASE, and Cochrane Library) and 4 Chinese databases (China National Knowledge Infrastructure, Chinese BioMedical Literature database, Chinese Scientific Journal database, and WanFang database). All articles published in the databases will be considered between their inception and January 18, 2022. Only articles published in English or Mandarin Chinese will be picked. A group of writers will independently evaluate each reference to see if it is eligible and whether there are any duplicates. The same authors will do data extraction for all eligible studies and use the Cochrane risk of bias tool to evaluate the risk of bias in the trials chosen for inclusion.

RESULTS

The analysis will evaluate the efficiency and level of safeness of levamlodipine besylate combined treatment for essential hypertension.

CONCLUSIONS

Our systematic review will offer evidence for judging whether levamlodipine besylate combination therapy can be considered an effective intercession for essential hypertension.

ETHICS AND DISSEMINATION

Ethical approval will not be required as no original data will be collected as part of this review.

REGISTRATION NUMBER

DOI 10.17605/OSF.IO/H8ZR2.

Fixed-dose Combination of Metoprolol, Telmisartan, and Chlorthalidone for Essential Hypertension in Adults with Stable Coronary Artery Disease: Phase III Study

INTRODUCTION

The aim of the study was to evaluate the efficacy and safety of fixed-dose combination (FDC) of metoprolol, telmisartan, and chlorthalidone in patients with essential hypertension and stable coronary artery disease (CAD) who showed inadequate response to dual therapy.

METHODS

In this phase III, open-label, multicenter study, 254 adults with stable CAD having uncontrolled hypertension despite being treated with FDC of metoprolol (25/50 mg) and telmisartan (40 mg) were included. Patients received either of the following FDC for 24 weeks: metoprolol (25 mg), telmisartan (40 mg), and chlorthalidone (12.5 mg) (FDC1; n = 139) or metoprolol (50 mg), telmisartan (40 mg), and chlorthalidone (12.5 mg) (FDC2; n = 115) tablets once daily. The FDCs were developed using the novel Wrap Matrix™ platform technology. Primary endpoint assessed the mean change in seated diastolic blood pressure (SeDBP) and seated systolic blood pressure (SeSBP) from baseline to 24 weeks. Secondary efficacy endpoints included proportion of patients achieving < 90 mmHg SeDBP (SeDBP responder) and < 140 mmHg SeSBP (SeSBP responder) at weeks 12, 16, 20, and 24. Safety was assessed throughout the study.

RESULTS

A total of 243 (95.70%) patients completed study. The mean change in BP from baseline (FDC1, 155/96 mmHg; FDC2, 165/98 mmHg) to week 24 (FDC1, 128/82 mmHg; FDC2, 131/83 mmHg) was statistically significant (both groups p < 0.0001). Within FDC1 and FDC2, the mean change from baseline to week 24 in SeDBP (82.60 mmHg and 83.09 mmHg) and SeSBP (128.07 mmHg and 131.29 mmHg) was statistically significant (both groups p < 0.0001). At week 24, in FDC1, 80.15% and 84.73% were SeDBP and SeSBP responders, respectively; in FDC2, 79.46% and 74.11% were SeDBP and SeSBP responders, respectively. No serious adverse events or deaths were reported.

CONCLUSION

Triple FDCs of metoprolol, telmisartan, and chlorthalidone were considered effective and well tolerated in patients with hypertension who respond inadequately to dual therapy.

CLINICAL TRIAL REGISTRATION

CTRI/2016/11/007491.

Calcium channel blockers versus other classes of drugs for hypertension

BACKGROUND

This is the first update of a review published in 2010. While calcium channel blockers (CCBs) are often recommended as a first-line drug to treat hypertension, the effect of CCBs on the prevention of cardiovascular events, as compared with other antihypertensive drug classes, is still debated.

OBJECTIVES

To determine whether CCBs used as first-line therapy for hypertension are different from other classes of antihypertensive drugs in reducing the incidence of major adverse cardiovascular events.

SEARCH METHODS

For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials (RCTs) up to 1 September 2020: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 1), Ovid MEDLINE, Ovid Embase, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted the authors of relevant papers regarding further published and unpublished work and checked the references of published studies to identify additional trials. The searches had no language restrictions.

SELECTION CRITERIA

Randomised controlled trials comparing first-line CCBs with other antihypertensive classes, with at least 100 randomised hypertensive participants and a follow-up of at least two years.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected the included trials, evaluated the risk of bias, and entered the data for analysis. Any disagreements were resolved through discussion. We contacted study authors for additional information.

MAIN RESULTS

This update contains five new trials. We included a total of 23 RCTs (18 dihydropyridines, 4 non-dihydropyridines, 1 not specified) with 153,849 participants with hypertension. All-cause mortality was not different between first-line CCBs and any other antihypertensive classes. As compared to diuretics, CCBs probably increased  major cardiovascular events (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.00 to 1.09, P = 0.03) and increased congestive heart failure events (RR 1.37, 95% CI 1.25 to 1.51, moderate-certainty evidence). As compared to beta-blockers, CCBs reduced the following outcomes: major cardiovascular events (RR 0.84, 95% CI 0.77 to 0.92), stroke (RR 0.77, 95% CI 0.67 to 0.88, moderate-certainty evidence), and cardiovascular mortality (RR 0.90, 95% CI 0.81 to 0.99, low-certainty evidence). As compared to angiotensin-converting enzyme (ACE) inhibitors, CCBs reduced stroke (RR 0.90, 95% CI 0.81 to 0.99, low-certainty evidence) and increased congestive heart failure (RR 1.16, 95% CI 1.06 to 1.28, low-certainty evidence). As compared to angiotensin receptor blockers (ARBs), CCBs reduced myocardial infarction (RR 0.82, 95% CI 0.72 to 0.94, moderate-certainty evidence) and increased congestive heart failure (RR 1.20, 95% CI 1.06 to 1.36, low-certainty evidence).

AUTHORS' CONCLUSIONS

For the treatment of hypertension, there is moderate certainty evidence that diuretics reduce major cardiovascular events and congestive heart failure more than CCBs. There is low to moderate certainty evidence that CCBs probably reduce major cardiovascular events more than beta-blockers. There is low to moderate certainty evidence that CCBs reduced stroke when compared to angiotensin-converting enzyme (ACE) inhibitors and reduced myocardial infarction when compared to angiotensin receptor blockers (ARBs), but increased congestive heart failure when compared to ACE inhibitors and ARBs. Many of the differences found in the current review are not robust, and further trials might change the conclusions. More well-designed RCTs studying the mortality and morbidity of individuals taking CCBs as compared with other antihypertensive drug classes are needed for patients with different stages of hypertension, different ages, and with different comorbidities such as diabetes.

Calcium channel blockers versus other classes of drugs for hypertension

BACKGROUND

This is the first update of a review published in 2010. While calcium channel blockers (CCBs) are often recommended as a first-line drug to treat hypertension, the effect of CCBs on the prevention of cardiovascular events, as compared with other antihypertensive drug classes, is still debated.

OBJECTIVES

To determine whether CCBs used as first-line therapy for hypertension are different from other classes of antihypertensive drugs in reducing the incidence of major adverse cardiovascular events.

SEARCH METHODS

For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials (RCTs) up to 1 September 2020: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 1), Ovid MEDLINE, Ovid Embase, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted the authors of relevant papers regarding further published and unpublished work and checked the references of published studies to identify additional trials. The searches had no language restrictions.

SELECTION CRITERIA

Randomised controlled trials comparing first-line CCBs with other antihypertensive classes, with at least 100 randomised hypertensive participants and a follow-up of at least two years.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected the included trials, evaluated the risk of bias, and entered the data for analysis. Any disagreements were resolved through discussion. We contacted study authors for additional information.

MAIN RESULTS

This update contains five new trials. We included a total of 23 RCTs (18 dihydropyridines, 4 non-dihydropyridines, 1 not specified) with 153,849 participants with hypertension. All-cause mortality was not different between first-line CCBs and any other antihypertensive classes. As compared to diuretics, CCBs probably increased  major cardiovascular events (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.00 to 1.09, P = 0.03) and increased congestive heart failure events (RR 1.37, 95% CI 1.25 to 1.51, moderate-certainty evidence). As compared to beta-blockers, CCBs reduced the following outcomes: major cardiovascular events (RR 0.84, 95% CI 0.77 to 0.92), stroke (RR 0.77, 95% CI 0.67 to 0.88, moderate-certainty evidence), and cardiovascular mortality (RR 0.90, 95% CI 0.81 to 0.99, low-certainty evidence). As compared to angiotensin-converting enzyme (ACE) inhibitors, CCBs reduced stroke (RR 0.90, 95% CI 0.81 to 0.99, low-certainty evidence) and increased congestive heart failure (RR 1.16, 95% CI 1.06 to 1.28, low-certainty evidence). As compared to angiotensin receptor blockers (ARBs), CCBs reduced myocardial infarction (RR 0.82, 95% CI 0.72 to 0.94, moderate-certainty evidence) and increased congestive heart failure (RR 1.20, 95% CI 1.06 to 1.36, low-certainty evidence).

AUTHORS' CONCLUSIONS

For the treatment of hypertension, there is moderate certainty evidence that diuretics reduce major cardiovascular events and congestive heart failure more than CCBs. There is low to moderate certainty evidence that CCBs probably reduce major cardiovascular events more than beta-blockers. There is low to moderate certainty evidence that CCBs reduced stroke when compared to angiotensin-converting enzyme (ACE) inhibitors and reduced myocardial infarction when compared to angiotensin receptor blockers (ARBs), but increased congestive heart failure when compared to ACE inhibitors and ARBs. Many of the differences found in the current review are not robust, and further trials might change the conclusions. More well-designed RCTs studying the mortality and morbidity of individuals taking CCBs as compared with other antihypertensive drug classes are needed for patients with different stages of hypertension, different ages, and with different comorbidities such as diabetes.

Apparent treatment-resistant hypertension among ambulatory hypertensive patients: a cross-sectional study from 13 general hospitals

BACKGROUND/AIMS

To examine the prevalence and clinical characteristics of apparent treatment-resistant hypertension among ambulatory hypertensive patients.

METHODS

We enrolled adult ambulatory hypertensive patients at 13 well-qualified general hospitals in Korea from January to June 2012. Apparent resistant hypertension was defined as an elevated blood pressure > 140/90 mmHg with the use of three antihypertensive agents, including diuretics, or ≥ 4 antihypertensives, regardless of the blood pressure. Controlled hypertension was defined as a blood pressure within the target using three antihypertensives, including diuretics.

RESULTS

Among 16,915 hypertensive patients, 1,172 (6.9%) had controlled hypertension, and 1,514 (8.9%) had apparent treatment-resistant hypertension. Patients with apparent treatment-resistant hypertension had an earlier onset of hypertension (56.8 years vs. 58.8 years, p = 0.007) and higher body mass index (26.3 kg/m2 vs. 24.9 kg/m2, p < 0.001) than those with controlled hypertension. Drug compliance did not differ between groups. In the multivariable analysis, earlier onset of hypertension (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99; p < 0.001) and the presence of comorbidities (OR, 2.06; 95% CI, 1.27 to 3.35; p < 0.001), such as diabetes mellitus, ischemic heart disease, heart failure, and chronic kidney disease, were independent predictors. Among the patients with apparent treatment-resistant hypertension, only 5.2% were receiving ≥ 2 antihypertensives at maximally tolerated doses.

CONCLUSION

Apparent treatment-resistant hypertension prevalence is 8.9% among ambulatory hypertensive patients in Korea. An earlier onset of hypertension and the presence of comorbidities are independent predictors. Optimization of medical treatment may reduce the rate of apparent treatment-resistant hypertension.

Drug non-adherence in hypertensive patients in Morocco, and its associated risk factors

AIMS

Hypertension is a widespread public health problem; unfortunately, non-adherence to the treatment hinders the control of high blood pressure. Drug non-adherence is the degree to which a patient does not follow the prescription. We aimed to assess the extent of drug non-adherence among hypertensive patients treated in Meknes and identify risk factors associated with inobservance.

METHODS AND RESULTS

Between November and December 2017, we conducted a cross-sectional study enrolling 922 hypertensive patients managed at Meknes's primary healthcare facilities (PHCF) using the multistage sampling method. We interviewed patients face to face to collect their socio-demographic characteristics, lifestyle behaviours, clinical parameters, and the relationship between the care system, the patient, and the physician. A multivariate logistic regression analysis highlighted the risk factors associated with drug non-adherence. The prevalence of drug non-adherence was 91% with a mean age of 61 ± 11 years (mean ± standard deviation) and a male/female ratio of 1/3. Risk factors associated with drug non-adherence were: (i) male sex [adjusted odds ratio (AOR) = 2.5, 95% confidence interval (CI) (1.26-5.10)]; (ii) monthly income per household <150$ [AOR = 4.47, 95% CI (1.22-16.34)]; (iii) monthly income per household 150-200$ [AOR = 4.44, 95% CI (1.04-18.93)]; (iv) bad relationship with the healthcare system [AOR = 2.17, 95% CI (1.29-3.67)]; and (v) uncontrolled blood pressure [AOR = 1.87, 95% CI (1.15-3.02)].

CONCLUSION

The prevalence of drug non-adherence is general among hypertensive patients in Meknes. Prevention should: (i) ensure the availability of adequate stocks of the anti-hypertensive drug at the PHCF; (ii) secure sufficient drug stocks to treat the poorest patients first; and (iii) improve blood pressure control in patients.

Drug Compliance and Its Associated Factors Among Hypertensive Patients in Pakistan: A Cross-sectional Study

The drug compliance and its associated factors were investigated among hypertensive patients attending the outpatient department of National Institute of Cardiovascular Disease (NICVD), Karachi, from September 2014 to March 2015. Data were collected retrospectively from 300 hypertensive patients taken treatment for >1 year. Half of the patients (51%) were >55 years of age with the predominance of males (52.70%). Most respondents (47%) had had ischemic heart disease (IHD), 30% had diabetes, 47% had both IHD and diabetes, while only a small number of subjects (18%) reporting no comorbidity. Most respondents (82%) reported that they took medicine regularly. Drug compliance was found significantly higher in males (55.70%) as compared with females (44.30%) (P = .025). Similarly, drug compliance was found significantly higher in patients who monitored their blood pressure (BP) regularly (59.30%) as compared with the patients who did not monitor their BP regularly (40.70%) (P = .001). Most respondents (46.30%) with hypertension (HTN) duration ≤5 years had significantly higher drug compliance as compared with the patients with HTN duration of 6 to 10 years and ≥11 years, that is, 33.30% and 20.30%, respectively (P = .018). In conclusion, the rate of drug adherence is not up to the mark in hypertensive patients, with high compliance reported in only half of the respondents.

Sex Differences in Hypertension: Where We Have Been and Where We Are Going

While it has been known since the 1940s that men have greater increases in blood pressure (BP) compared with women, there have been intense efforts more recently to increase awareness that women are also at risk for developing hypertension and that cardiovascular diseases (CVDs) are the leading causes of death among both men and women in the United States. With the release of the 2017 Hypertension Clinical Guidelines, 46% of adults in the United States are now classified as hypertensive, and hypertension is the primary modifiable risk factor for the development of CVD. This increase in the prevalence of hypertension is reflected in an increase in prevalence among both men and women across all demographics, although there were greater increases in the prevalence of hypertension among men compared with women. As a result, the well-established gender difference in the prevalence of hypertension is even more pronounced and now extends into the sixth decade of life. The goals of this review are to (i) review the historical clinical trial data and hypertension guidelines from the perspective of both genders and then (ii) review the role of the renin-angiotensin system and T-cell activation in contributing to sex differences in BP control.

Effectiveness of fixed-dose combination therapy in hypertension: systematic review and meta-analysis

INTRODUCTION

Clinical studies have revealed that fixed-dose combinations (FDCs) of drugs can have a better effect on blood pressure than free-equivalent combinations (FECs). Our objectives were to perform an up-to-date assessment of the effectiveness of FDCs and FECs in antihypertensive therapy, to provide more accurate results by using a stratified meta-analysis.

MATERIAL AND METHODS

A systematic review was performed in PubMed, Web of Science, and Cochrane databases according to PRISMA guidelines. The outcomes were adherence (compliance), persistence to medication, reduction of blood pressure and the safety profile. We used the Newcastle Ottawa scale or the Delphi list for the assessment of the quality of cohort studies or clinical trials, respectively. Heterogeneity was assessed using the Cochrane Q test and I² statistic.

RESULTS

Of 301 abstracts screened, 26 primary studies and 2 other meta-analyses were identified, of which 12 studies were included in the meta-analyses and 3 studies were included in the narrative review. The FDC treatment is associated with a significant improvement in adherence and persistence in comparison with FEC treatment, e.g., the average medicine possession ratio increased with FDC by 13.1% (p < 0.001). For endpoints correlated with higher adherence (e.g., a reduction in blood pressure), a nonsignificant benefit was observed for FDCs. Moreover, it was demonstrated that higher adherence can lead to a lower risk of cardiovascular events.

CONCLUSIONS

In comparison with FECs, the FDC treatment is associated with a significant improvement in the cooperation between a doctor and a patient and with increased patients' adherence to the treatment schedule.

Utilization Study of Antihypertensives in a South Indian Tertiary Care Teaching Hospital and Adherence to Standard Treatment Guidelines

AIM

Hypertension represents a major health problem primarily because of its role in contributing to the initiation and progression of major cardiovascular diseases. Concerns pertaining to hypertension and its sequelae can be substantially addressed and consequent burden of disease reduced by early detection and appropriate therapy of elevated blood pressure. This cross-sectional observational study aims at analyzing the utilization pattern of antihypertensives used for the treatment of hypertension at a tertiary care hospital in perspective of standard treatment guidelines.

MATERIALS AND METHODS

Prescriptions were screened for antihypertensives at the medicine outpatient department of a tertiary care teaching hospital. Medical records of the patients were scrutinized after which 286 prescriptions of patients suffering from hypertension were included. The collected data were sorted and analyzed on the basis of demographic characteristics and comorbidities.

RESULTS

The calcium channel blockers were the most frequently used antihypertensive class of drugs (72.3%). Amlodipine (55.6%) was the single most frequently prescribed antihypertensive agent. The utilization of thiazide diuretics was 9%. Adherence to the National List of Essential Medicines (NLEMs) was 65%. The combination therapy was used more frequently (51.5%) than monotherapy (48.8%). The use of angiotensin-converting enzyme inhibitors/angiotensin 2 receptor blockers (ACE-I/ARB) was 41.4% in diabetes.

CONCLUSIONS

The treatment pattern, in general, conformed to standard treatment guidelines. Few areas, however, need to be addressed such as the underutilization of thiazide diuretics, need for more awareness of drugs from the NLEMs and enhanced use of ACE-I/ARB in diabetic hypertensives.

Obesity: A Perspective from Hypertension

The prevalence of obesity-related hypertension is high worldwide and has become a major health issue. The mechanisms by which obesity relates to hypertensive disease are still under intense research scrutiny, and include altered hemodynamics, impaired sodium homeostasis, renal dysfunction, autonomic nervous system imbalance, endocrine alterations, oxidative stress and inflammation, and vascular injury. Most of these contributing factors interact with each other at multiple levels. Thus, as a multifactorial and complex disease, obesity-related hypertension should be recognized as a distinctive form of hypertension, and specific considerations should apply in planning therapeutic approaches to treat obese individuals with high blood pressure.

Health Insurance Coverage and Hypertension Control in China: Results from the China Health and Nutrition Survey

BACKGROUND

China has rapidly expanded health insurance coverage over the past decade but its impact on hypertension control is not well known. We analyzed factors associated with hypertension and the impact of health insurance on the management of hypertension in China from 1991 to 2009.

METHODS AND FINDINGS

We used individual-level data from the China Health and Nutrition Survey (CHNS) for blood pressure, BMI, and other socio-economic variables. We employed multi-level logistic regression models to estimate the factors associated with prevalence and management of hypertension. We also estimated the effects of health insurance on management of hypertension using propensity score matching. We found that prevalence of hypertension increased from 23.8% (95% CI: 22.5-25.1%) in 1991 to 31.5% (28.5-34.7%) in 2009. The proportion of hypertensive patients aware of their condition increased from 31.7% (28.7-34.9%) to 51.1% (45.1-57.0%). The proportion of diagnosed hypertensive patients in treatment increased by 35.5% in the 19 years, while the proportion of those in treatment with controlled blood pressure remained low. Among diagnosed hypertensives, health insurance increased the probability of receiving treatment by 28.7% (95% CI: 10.6-46.7%) compared to propensity-matched individuals not covered by health insurance.

CONCLUSIONS

Hypertension continues to be a major health threat in China and effective control has not improved over time despite large improvements in awareness and treatment access. This suggests problems in treatment quality, medication adherence and patient understanding of the condition. Improvements in hypertension management, quality of medical care for those at high risk, and better health insurance packages are needed.

Attainment of multifactorial treatment targets among the elderly in a lipid clinic

OBJECTIVE

To examine target attainment of lipid-lowering, antihypertensive and antidiabetic treatment in the elderly in a specialist setting of a University Hospital in Greece.

METHODS

This was a retrospective study including consecutive subjects ≥ 65 years old (n = 465) with a follow-up ≥ 3 years. Low-density lipoprotein cholesterol (LDL-C), blood pressure (BP) and glycated hemoglobin (HbA1c) goal achievement were recorded according to European Society of Cardiology/European Atherosclerosis Society (ESC/EAS), European Society of Hypertension (ESH)/ESC and European Association for the Study of Diabetes (EASD) guidelines.

RESULTS

The LDL-C targets were attained by 27%, 48% and 62% of very high, high and moderate risk patients, respectively. Those receiving statin + ezetimibe achieved higher rates of LDL-C goal achievement compared with those receiving statin monotherapy (48% vs. 33%, P < 0.05). Of the diabetic subjects, 71% had BP < 140/85 mmHg, while 78% of those without diabetes had BP < 140/90 mmHg. A higher proportion of the non-diabetic individuals (86%) had BP < 150/90 mmHg. Also, a higher proportion of those with diabetes had HbA1c < 8% rather than < 7% (88% and 47%, respectively). Of note, almost one out of three non-diabetic individuals and one out of ten diabetic individuals had achieved all three treatment targets.

CONCLUSIONS

Even in a specialist setting of a University Hospital, a high proportion of the elderly remain at suboptimal LDL-C, BP and HbA1c levels. The use of drug combinations could improve multifactorial treatment target attainment, while less strict targets could be more easily achieved in this population.

Identification and evaluation of risk factors in patients with continuously uncontrolled hypertension

An aggressive strategy to manage hypertension in a large integrated healthcare organization achieved blood pressure control in 82% of hypertensive patients, as compared with 52% nationwide. It is unknown why the remaining 18% is uncontrolled. The objective of this study was to identify characteristics associated with patients whose blood pressure remains continuously uncontrolled. This nested case-control study included 1583 continuously uncontrolled cases and 7901 matched controls. Univariate analysis revealed patients who visited their primary care provider frequently (odds ratio, 0.42; 95% confidence interval, 0.39-0.46) were adherent to antihypertensive medications (odds ratio, 0.12; 95% confidence interval, 0.10-0.14), and dispensed more medications (odds ratio, 0.86; 95% confidence interval, 0.85-0.87) were less likely to be continuously uncontrolled. Patient characteristics that were associated with continuously uncontrolled hypertension were the Patient Health Questionnaire-9 score and higher body mass index. Since patients with controlled hypertension visited their provider more often, patients with continuously uncontrolled hypertension may benefit from more interaction with their healthcare system.

Advances in stroke prevention

Stroke remains to be a leading cause of disability. However, optimal strategies can prevent up to 80% of strokes. A large body of evidence supports many strategies for primary and secondary prevention of stroke. The purpose of this paper is to highlight recent major advances for management of modifiable medical and behavioral risk factors of stroke. Specific studies are highlighted, including those related to atrial fibrillation (AF), hypertension, revascularization, hyperlipidemia, antiplatelets, smoking, diet, and physical activity. Effective strategies include the use of novel oral anticoagulants for AF, antiplatelet therapy, and intensive lowering of atherosclerosis risk factors.

Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Clinical utility of fixed-dose combinations in hypertension: evidence for the potential of nebivolol/valsartan

Despite significant advances in pharmacologic approaches to treat hypertension during the last decades, hypertension- and hypertension-related organ damage are still a high health and economic burden because a large proportion of patients with hypertension do not achieve optimal blood pressure control. There is now general agreement that combination therapy with two or more antihypertensive drugs is required for targeted blood pressure accomplishment and reduction of global cardiovascular risk. The goals of combination therapies are to reduce long-term cardiovascular events by targeting different mechanism underlying hypertension and target organ disease, to block the counterregulatory pathways activated by monotherapies, to improve tolerability and decrease the adverse effects of up-titrated single agents, and to increase persistence and adherence with antihypertensive therapy. Multiple clinical trials provide evidence that fixed-dose combinations in a single pill offer several advantages when compared with loose-dose combinations. This review discusses the advances in hypertension control and associated cardiovascular disease as they relate to the prospect of combination therapy targeting a third-generation beta (β) 1-adrenergic receptor (nebivolol) and an angiotensin II receptor blocker (valsartan) in fixed-dose single-pill formulations.

A large cohort study evaluating risk factors associated with uncontrolled hypertension

Hypertension is the most common primary diagnosis in the United States. Risks for long-term consequences such as myocardial infarction, heart failure, stroke, and kidney disease continue to significantly increase as long as hypertension remains uncontrolled. This retrospective cohort study of 661,075 patients identified with uncontrolled hypertension, defined as systolic blood pressure (SBP) ≥ 140 mm Hg and/or diastolic blood pressure (DBP) ≥ 90 mm Hg, from a large integrated healthcare organization was conducted to examine multiple patient characteristics to determine their association with uncontrolled hypertension. Multivariate analysis revealed that compared with Caucasians, African Americans (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.16-1.20) were significantly associated with uncontrolled hypertension, as were unpartnered populations (OR, 1.15; 95% CI, 1.14-1.17), number of antihypertensive medications prescribed (OR, 1.37; 95% CI, 1.33-1.41), and adherence to most antihypertensive medications. A secondary analysis found an association between uncontrolled blood pressure and Patient Health Questionnaire-9 (PHQ-9) score (OR, 1.21; 95% CI, 1.16-1.26). Our findings suggest that the presence of these identified risk factors recommends a commitment to a more aggressive hypertension management program to prevent cardiovascular disease caused by uncontrolled hypertension.

Predicted impact of various clinical practice strategies on cardiovascular risk for the treatment of hypertension: a clinical trial simulation study

Hypertension control rate in the US is low with the current clinical practice (JNC 7) and cardiovascular disease (CVD) remain is the leading cause of morbidity and mortality. A 6-month clinical trial simulation case study testing different virtual clinical practice strategies was performed in an attempt to increase the control rate. The CVD risk was calculated using the Framingham CVD risk model at baseline and 6 months post-treatment. The estimated CVD events for the baseline patient sample without any treatment was 998 (95% CI: 967-1,026) over 6 months in 100,000 patients. Treating these patients for 6 months with current clinical practice, high dose strategy, high dose with low target BP strategy resulted in a reduction in CVD events of 191(95% CI: 169-205), 284 (95% CI: 261-305), and 353 (95% CI: 331-375), respectively. Hence the two alternative strategies resulted in an increase in treatment effect by 49% (95%CI: 44-59%) and 85% (95%CI: 79-99%), respectively. The increased safety with the current low dose strategy may potentially be offset by increased CVD risk in the time necessary to control hypertension.

Blood pressure control amongst patients living with hypertension presenting to an urban district hospital outpatient clinic in Kwazulu-Natal

BACKGROUND

The prevalence of hypertension in South Africa has been estimated to be 20% of the adult population with over six million people being affected. Poor adherence to treatment plans lead to inadequate blood pressure control and high morbidity. Many studies have looked at factors contributing to poor blood pressure control in South Africa but few studies actually focus on district hospitals in Kwazulu-Natal in particular, despite the fact that the province has the most heterogeneous population in South Africa.

METHOD

The study was a descriptive cross-sectional study conducted at the chronic out patient clinic of an urban district hospital involving 370 participants aged 18-90 years.

RESULT

The study showed poorly controlled blood pressure in 58% of the participants. Only 35% knew their blood pressure results on the day of interview and 19.2% were aware of their target blood pressure. Good adherence was self-reported by 95% of the participants, whist 51.4% reported significant side-effects to medication.

CONCLUSION

The majority of patients had poor knowledge about blood pressure and little awareness of their blood pressure reading. These may be precursors to poor blood pressure control and this needs further investigation. A high level of self-reported adherence to medication did not translate into effective blood pressure control. A significant number reported medication side-effects which may have contributed to the poor blood pressure control. The high adherence rate may therefore have been over reported. An objective way tomeasure adherence will be necessary for future research.

Prevalence and predictors of resistant hypertension in a primary care setting: a cross-sectional study

Background

Patients with resistant hypertension are subjected to a higher risk of getting stroke, myocardial infarction, congestive heart failure and renal failure. However, the exact prevalence of resistant hypertension in treated hypertensive patients in Malaysia is not known. This paper examines the prevalence and determinants of resistant hypertension in a sample of hypertensive patients.

Methods

We examined the control of blood pressure in a randomly selected sample of patients with hypertension in a primary care clinic. Demographic data, blood pressure and anti-hypertensive drug use were captured from patient records at the end of 2007. Resistant hypertension is defined as failure to achieve target blood pressure of < 140/90 mmHg while on full doses of an appropriate three-drug regimen that includes a diuretic. Multivariate logistic regression was used for the analysis.

Results

A total of 1217 patients with hypertension were entered into the analysis. Mean age of the patients was 66.8 ± 9.7 years and 64.4% were female. More than half of the subjects (56.9%) had diabetes mellitus. Median BP was 130/80 mmHg. Overall prevalence of resistant hypertension was 8.8% (N = 107/1217). In multivariate logistic regression analysis, presence of chronic kidney disease is more likely to be associated with resistant hypertension (odds ratio [OR] 2.89, 95% confidence interval [CI] 1.56-5.35). On the other hand, increase per year of age is associated with lower odds of resistant hypertension in this population (OR 0.96, 95% CI 0.93-0.99).

Conclusions

Resistant hypertension is present in nearly one in ten hypertensive patients on treatment. Hypertensive patients who have underlying chronic kidney disease are associated with higher odds of having resistant hypertension. Hence, in managing patients with hypertension, primary care physicians should be more alert and identify patients with chronic kidney disease as such patients are more likely to develop resistant hypertension. By doing that, these patients can be treated more aggressively earlier in order to achieve blood pressure target and thus reduce cardiovascular events.

Effects of low-dose combination therapy with an angiotensin-converting enzyme inhibitor and a diuretic on flow-mediated vasodilation in hypertensive patients: a 6-month, single-center study

BACKGROUND

Combination therapy with an angiotensin-converting enzyme (ACE) inhibitor and a diuretic has been shown to be highly effective in hypertension. Clinical trials have demonstrated that ACE inhibitors may improve endothelial cell dysfunction in hypertension. However, the effectiveness of the combination treatment in endothelial cell dysfunction is unknown.

OBJECTIVE

This study investigated the effects of a new low-dose combination, perindopril 2 mg plus indapamide 0.625 mg, on brachial artery flow-mediated vasodilation (FMD) and left ventricular diastolic function in hypertension.

METHODS

Patients aged 18 to 75 with newly diagnosed stage I or II hypertension were eligible. Endothelium-dependent brachial artery FMD and endothelium-independent vasodilation were assessed at baseline. Patients were treated with oral perindopril 2 mg plus indapamide 0.625-mg tablets once daily for 6 months. FMD measurements were then repeated. Percentage changes in FMD from baseline to 6 months, as well as left ventricular diastolic function parameters (isovolumic relaxation time [IVRT] and mitral diastolic E-wave deceleration time [EDT]), indicated the effectiveness of the intervention.

RESULTS

Twenty-nine Turkish patients were enrolled (17 women, 12 men; mean [SD] age, 54.5 [9.5] years [range, 38-75 years]). The mean (SD) baseline FMD was 7.00% (2.39%) (endothelial cell dysfunction) and increased significantly to 8.68% (2.78%) at 6 months (P = 0.02); FMD improved in 15 patients (51.7%). At baseline and 6 months of therapy, mean (SD) IVRT was 101.7 (12.4) ms and 95.5 (7.7) ms, respectively (P<0.001), and EDT was 234.7 (33.9) ms and 217.9 (25.6) ms, respectively (P<0.001).

CONCLUSIONS

In this small sample of hypertensive patients, a low-dose combination ACE inhibitor and diuretic significantly improved brachial artery FMD and left ventricular diastolic function. The improvement in FMD values was independent of the stage of hypertension. These findings suggest a relationship between improvement in endothelial cell function and diastolic function.

Medication adherence and its associated factors among Chinese community-dwelling older adults with hypertension

OBJECTIVE

To investigate the factors that influence medication adherence in Chinese community-dwelling older adults with hypertension.

METHODS

A cross-sectional study was conducted with a convenience sample of 382 older adults with hypertension recruited from six health centers in Macao, China. Chinese versions of the Morisky 4-Item Self-Report Measure of Medication-Taking Behavior, Fear of Intimacy with Helping Professionals scale and Exercise of Self-care Agency scale were administered to participants.

RESULTS

Participants older than 65 years (β = .118, p = .017), with a low level of education (β = .128, p = .01), who had more than one other common disease (β = .120, p = .015), were on long-term medication (β = .221, p < .001) and who reported higher self-care (β = .188, p = .001), had better medication adherence.

CONCLUSIONS

Health care professionals should consider these factors when planning medication regimens for Chinese older adults with hypertension, to enhance medication adherence and improve patient outcomes.

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

METHODS

Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.

CONCLUSIONS

The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Barriers to achieving blood pressure treatment targets in elderly hypertensive individuals

High blood pressure (BP) is highly prevalent among the elderly, and even with pharmacological therapy BP is difficult to control to guideline recommended levels. Although poor compliance to therapy is associated with less BP control, little is known regarding other barriers to attaining on-treatment target BP. This study examined factors associated with achieving on-treatment target BP in 6010 hypertensive participants aged 65-84 years from the Second Australian National Blood Pressure study. Participants were followed for a median of 4.1 years, with BP monitored every 6 months. 'Target BP' was defined as a reduction of systolic/diastolic BP of at least 20/10 mm Hg and BP <160/90 mm Hg from randomization in two consecutive follow-up visits. Cox regression was used to identify factors associated with achieving target BP from a number of baseline and in-study factors. Mean BP at randomization was 168/91 mm Hg and patients had a median of 9 (range: 2-20) study visits. Target BP was achieved in 50% of patients. Demographic factors associated with achieving target BP were male gender, living in a regional area; and clinical factors included history of antihypertensive therapy, increased plasma creatinine, lower pretreatment pulse pressure and in-study use of multiple BP-lowering drugs. Those aged >80 years and seeking care from multiple doctors (hazard ratio 0.40, 95% confidence interval 0.36-0.45, P<0.001) were less likely to achieve target BP. These findings identify clinical markers that can be targeted for intervention, but also demographic factors related to service delivery, which may provide further opportunity for achieving better BP control in hypertensive elderly.

The TRINITY Study: distribution of systolic blood pressure reductions

Background

Elevated systolic blood pressure is more difficult to control than elevated diastolic blood pressure. The objective of this prespecified analysis of the Triple Therapy with Olmesartan Medoxomil, Amlodipine, and Hydrochlorothiazide in Hypertensive Patients Study (TRINITY) was to compare the efficacy of olmesartan medoxomil (OM) 40 mg, amlodipine besylate (AML) 10 mg, and hydrochlorothiazide (HCTZ) 25 mg triple-combination treatment with the component dual-combination treatments in reducing elevated seated systolic blood pressure (SeSBP).

Methods

The 12-week TRINITY study randomized participants to either one of the three component dual-combination treatments (OM 40 mg/AML 10 mg, OM 40 mg/HCTZ 25 mg, or AML 10 mg/HCTZ 25 mg) or the triple-combination treatment. The primary outcome of this analysis was the categorical distribution of SeSBP reductions at week 12 from baseline with OM 40 mg/AML 10 mg/HCTZ 25 mg versus the dual-combination treatments.

Results

SeSBP reductions >50 mmHg were seen in 24.4% of participants receiving triple-combination treatment versus 8.1%–15.8% receiving dual-combination treatment. More participants receiving triple-combination treatment achieved the SeSBP target of <140 mmHg (73.6% versus 51.3%–58.8%; P < 0.001) and the seated blood pressure target of <140/90 mmHg (69.9% versus 41.1%–53.4%; P < 0.001). Prevalence and severity of adverse events were similar in all treatment groups.

Conclusion

Treatment with OM 40 mg/AML 10 mg/HCTZ 25 mg was well tolerated and more effective in reducing SeSBP than the dual-combination treatments.

Determinants of medication adherence to antihypertensive medications among a Chinese population using Morisky Medication Adherence Scale

BACKGROUND AND OBJECTIVES

Poor adherence to medications is one of the major public health challenges. Only one-third of the population reported successful control of blood pressure, mostly caused by poor drug adherence. However, there are relatively few reports studying the adherence levels and their associated factors among Chinese patients. This study aimed to study the adherence profiles and the factors associated with antihypertensive drug adherence among Chinese patients.

METHODS

A cross-sectional study was conducted in an outpatient clinic located in the New Territories Region of Hong Kong. Adult patients who were currently taking at least one antihypertensive drug were invited to complete a self-administered questionnaire, consisting of basic socio-demographic profile, self-perceived health status, and self-reported medication adherence. The outcome measure was the Morisky Medication Adherence Scale (MMAS-8). Good adherence was defined as MMAS scores greater than 6 points (out of a total score of 8 points).

RESULTS

From 1114 patients, 725 (65.1%) had good adherence to antihypertensive agents. Binary logistic regression analysis was conducted. Younger age, shorter duration of antihypertensive agents used, job status being employed, and poor or very poor self-perceived health status were negatively associated with drug adherence.

CONCLUSION

This study reported a high proportion of poor medication adherence among hypertensive subjects. Patients with factors associated with poor adherence should be more closely monitored to optimize their drug taking behavior.

Clinical and economic outcomes associated with amlodipine/renin–angiotensin system blocker combinations

Objectives:

Since treatment regimen type can influence adherence and other outcomes, this study examined adherence, cardiovascular events, and economic outcomes in patients with hypertension treated with fixed-dose combination (FDC) amlodipine/olmesartan (AML/OM), FDC AML/benazepril (AML/BEN), and loose-dose combination AML plus angiotensin II receptor blockers (LDC AML/ARBs).

Methods:

Commercial health plan enrolees aged at least 18 years with index claim(s) for AML/OM, AML/BEN, or LDC AML/ARB were identified. Absence of study drug 6 months pre index, and continuous enrolment for at least 12 months post index were required. Descriptive analyses were executed to make comparisons between treatments, as well as multivariate models adjusting for baseline demographic and clinical characteristics, including propensity for assignment to study drug.

Results:

Descriptive results suggested mean follow-up adherence was higher in the AML/OM cohort [proportion of days covered (PDC) = 0.63] compared with the AML/BEN (PDC = 0.55; p < 0.001) and LDC AML/ARB cohorts (PDC = 0.34; p < 0.001). The proportion of individuals with an incident follow-up cardiovascular event composite was lower in the AML/OM cohort versus the AML/BEN and LDC AML/ARB cohorts (5.94% versus 7.85% and 16.89% respectively). Adjusted Cox models suggested that patients initiated on LDC AML/ARB (hazard ratio 1.35; p < 0.001), but not on AML/BEN, were at greater risk of a follow-up cardiovascular event (composite) compared with AML/OM. Adjusted generalized linear models suggested that mean follow-up per-member-per-month overall costs were higher in the AML/BEN (cost ratio = 1.169; p < 0.001; unadjusted mean cost US$780) and LDC AML/ARB cohorts (cost ratio = 1.286; p < 0.001; unadjusted mean cost US$1394) compared with the AML/OM cohort (unadjusted mean cost US$740).

Conclusion:

The results suggested that treatment with FDC AML/OM was associated with greater likelihood of adherence and lower overall costs than with FDC AML/BEN and LDC AML/ARB, and lower risk of cardiovascular event composite versus LDC AML/ARB.

Combination therapy as first-line treatment for hypertension

Systemic hypertension is a long-term risk factor for the development of atherosclerotic vascular disease and when uncontrolled is a short-term trigger of acute vascular events such as acute coronary syndromes and stroke. Thus, rapid reduction in BP is desirable. Patients at high risk for vascular disease, such as those with diabetes mellitus, have aggressive goal BP targets because studies have shown that achieving these targets reduces events. Given the dual goals in high-risk patients of reducing BP quickly and to aggressively low targets, the classic 'step therapy' of one drug titrated at a time to reduce BP is inadequate. Combination therapy with at least two potent medications makes more sense, and manufacturers are now increasing their offerings of single-pill combinations for hypertension. Combination pills are popular with patients and increase compliance with therapy. Many believe that renin-angiotensin aldosterone system (RAAS) blockers are the cornerstone of hypertension treatment in patients at high risk for vascular disease. The newer combination pills include a RAAS blocker and diuretics or a long-acting calcium channel antagonist (CCA). Recent studies have shown that a RAAS blocker plus a dihydropyridine CCA is superior to older diuretic-based combinations for preventing cardiovascular events. These considerations support a new approach to the higher risk hypertensive patient: effective doses of RAAS blocker/CCA combination pills to rapidly lower BP to <130/80 mmHg.

Baseline medication adherence and blood pressure in a 24-month longitudinal hypertension study

AIM AND OBJECTIVES

We sought to identify the feasibility and predictive validity of an easy and quick self-reported measure of medication adherence and to identify characteristics of people with hypertension that may warrant increase attentiveness by nurses to address hypertensive self-management needs.

BACKGROUND

Current control rates of hypertension are approximately 50%. Effective blood pressure control can be achieved in most people with hypertension through antihypertensive medication. However, hypertension control can only be achieved if the patient is adherent with their medication regimen. Patients who are non-adherent may be in need of additional intervention.

DESIGN

This secondary analysis evaluated the systolic blood pressure of patients who received usual hypertension management across 24 months at six-month intervals.

METHODS

A longitudinal study of 159 hypertensive patients in two primary care clinics.

RESULTS

In a sample of 159 patients receiving care in a primary care facility, baseline medication non-adherence was associated with a 6·3 mmHg increase in systolic blood pressure (p < 0·05) at baseline, a 8·4 mmHg increase in systolic blood pressure (p < 0·05) at 12 months and a 7·5 increase in systolic blood pressure at 24 months (p < 0·05) compared with adherent patients, respectively. Results also indicate a significant increase in systolic blood pressure across 24 months among people who identified as minority and of low financial status.

CONCLUSIONS

Non-adherence with antihypertensive medication at baseline was predictive of increased systolic blood pressure up to 24 months postbaseline.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrates the use of an easy-to-use questionnaire to identify patients who are non-adherent. We recommend assessing medication adherence to identify patients who are non-adherent with their anti-hypertensive medication and to be especially vigilant with patients who are minority or are considered low income.

Single-pill combination of telmisartan/amlodipine in patients with severe hypertension: results from the TEAMSTA severe HTN study

This 8-week, randomized, double-blind, controlled study compared efficacy and tolerability of telmisartan/amlodipine (T/A) single-pill combination (SPC) vs the respective monotherapies in 858 patients with severe hypertension (systolic/diastolic blood pressure [SBP/DBP] ≥180/95 mm Hg). At 8 weeks, T/A provided significantly greater reductions from baseline in seated trough cuff SBP/DBP (-47.5 mm Hg/-18.7 mm Hg) vs T (P<.0001) or A (P=.0002) monotherapy; superior reductions were also evident at 1, 2, 4, and 6 weeks. Blood pressure (BP) goal and response rates were consistently higher with T/A vs T or A. T/A was well tolerated, with less frequent treatment-related adverse events vs A (12.6% vs 16.4%) and a numerically lower incidence of peripheral edema and treatment discontinuation. In conclusion, treatment of patients with substantially elevated BP with T/A SPCs resulted in high and significantly greater BP reductions and higher BP goal and response rates than the respective monotherapies. T/A SPCs were well tolerated.

Disparities in Blood Pressure Control Within a Community-Based Provider Network: An Exploratory Analysis

Background:

Despite treatment for hypertension, blood pressure (BP) remains uncontrolled in many individuals. Identification of patterns in BP control may inform strategies to improve treatment and optimize health outcomes.

Objective:

To examine patterns in BP control among individuals receiving antihypertensive treatment in a diverse, community-based provider network.

Methods:

In this retrospective exploratory analysis, a total of 51.772 hypertensive subjects were identified in the electronic medical record between January 1, 2007, and June 30, 2010, who were aged 18 years or older, with 2 or more claims for antihypertensive medication, documented race/ethnicity, and 1 or more documented BP readings.

Results:

On the basis of Joint National Committee VII guidelines, 76.4% of nondiabetic patients had their BP controlled with treatment (<140/90 mm Hg) and 52.3% of those with diabetes had their BP controlled with treatment (<130/80 mm Hg). The overall rate of BP control was 71.4%. Factors associated with controlled BP included younger age, lower disease burden, better medication adherence, fewer concurrent prescriptions, lower prescription copayments, and living in a region with a higher median household income. Furthermore, when adjusting for age, sex, and disease burden, black (OR 0.68; 95% Cl 0.62 to 0.75; p < 0.001), Hispanic (OR 0.80; 95% Cl 0.74 to 0.86; p < 0.001), and other race/ethnic group (OR 0.81; 95% Cl 0.70 to 0.94; p = 0.005) individuals were less likely than white individuals to have their treated BP controlled. Among nondiabetic hypertensive subjects with controlled BP, the most frequently prescribed therapy was a β-blocker or an angiotensin-converting enzyme (ACE) inhibitor across race/ethnicities; however, those who were black were most frequently prescribed a diuretic or calcium channel blocker. Among diabetic patients with controlled BP, the most frequently prescribed therapy was an ACE inhibitor, regardless of race/ethnicity.

Conclusions:

Potential disparities, particularly among diabetic individuals and those of minority race/ethnicity, were found with regard to BP control and the agents used to treat hypertension. Future studies should address these disparities by designing interventions to improve the treatment of hypertension in high-risk populations.

Switching patients with uncontrolled hypertension on amlodipine 10 mg to single-pill combinations of telmisartan and amlodipine: results of the TEAMSTA-10 study

OBJECTIVE

To evaluate the efficacy and safety of two different strengths of single-pill combinations of the angiotensin II receptor blocker telmisartan 40 or 80 mg (T40 or T80) and the calcium channel blocker amlodipine 10 mg (A10) compared with that of A10 monotherapy in a hypertensive patient population whose blood pressure was not controlled by A10.

RESEARCH DESIGN AND METHODS

An 8-week, randomized, double-blind, controlled study to compare the efficacy and safety of single-pill combinations of T40/A10 or T80/A10 versus A10 monotherapy in 947 patients with uncontrolled hypertension (diastolic blood pressure [DBP] ≥90 mmHg after 6 weeks' A10).

MAIN OUTCOME MEASURES

The primary end point was change from baseline in seated in-clinic trough cuff DBP after 8 weeks. Secondary efficacy end points included change from baseline in seated in-clinic trough cuff systolic blood pressure (SBP), and the proportion of patients achieving SBP/DBP response (<140/90 mmHg or ≥10/15 mmHg reduction) and SBP/DBP goal (<140/90 mmHg) after 8 weeks' treatment. Adverse events were recorded throughout.

RESULTS

In a patient population who had failed to achieve DBP goal with A10, T40/A10 and T80/A10 resulted in significantly greater (P < 0.0001) reductions in seated trough SBP/DBP versus A10 (-3.7/-2.8 mmHg; -3.9/-2.8 mmHg), significantly higher SBP/DBP goal rates versus A10 (58.8/63.7% and 60.3/66.5% vs. 50.2/51.1%), and significantly higher SBP/DBP response rates with T40-80/A10 versus A10 (64.7/66.0% and 65.8/68.7% vs. 54.1/53.4%). T40-80/A10 were well tolerated. Rates of peripheral edema adverse events were low (6.7-8.5%) and not significantly different between the treatment groups; however, patients were pre-screened for intolerance to A10.

CONCLUSIONS

Switching patients who fail to achieve blood pressure goal with A10 to a single-pill combination of T40/A10 or T80/A10 results in superior SBP/DBP reductions, and SBP/DBP goal and response rates.

Evening versus morning dosing regimen drug therapy for hypertension

BACKGROUND

Variation in blood pressure levels display circadian rhythms. The morning surge in blood pressure is known to increase the risk of myocardial events in the first several hours post awakening. A systematic review of the administration-time-related-effects of evening versus morning dosing regimen of antihypertensive drugs in the management of patients with primary hypertension has not been conducted.

OBJECTIVES

To evaluate the administration-time-related-effects of antihypertensive drugs administered as once daily monotherapy in the evening versus morning administration regimen on all cause mortality, cardiovascular morbidity and reduction of blood pressure in patients with primary hypertension.

SEARCH STRATEGY

We searched Cochrane CENTRAL on Ovid (4th Quarter 2009), Ovid MEDLINE (1950 to October 2009), EMBASE (1974 to October 2009), the Chinese Biomedical literature database (1978 to 2009) and the reference lists of relevant articles. No language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials comparing the administration-time-related effects of evening with morning dosing monotherapy regimens in patients with primary hypertension were included. Patients with known secondary hypertension, shift workers or white coat hypertension were excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed trial quality. Disagreements were resolved by discussion or a third reviewer. Data synthesis and analysis were done using RevMan 5.1. Random effects meta-analysis and sensitivity analysis were conducted.

MAIN RESULTS

21 randomized controlled trials (RCTs) in 1,993 patients with primary hypertension met the inclusion criteria for this review - ACEIs (5 trials), CCBs (7 trials), ARBs (6 trials), diuretics (2 trials), alpha-blockers (1 trial), and beta-blockers (1 trial). Meta-analysis showed significant heterogeneity across trials.No RCT reported on all cause mortality, cardiovascular mortality, cardiovascular morbidity and serious adverse events.There was no statistically significant difference for overall adverse events (RR=0.78, 95%CI: 0.37 to 1.65) and withdrawals due to adverse events (RR=0.53, 95%CI: 0.26 to 1.07).No significant differences were noted for morning SBP (-1.62 mm Hg, 95% CI: -4.19 to 0.95) and morning DBP (-1.21 mm Hg, 95% CI: -3.28 to 0.86); but 24-hour BP (SBP: -1.71 mm Hg, 95% CI: -2.78 to -0.65; DBP: -1.38 mm Hg, 95% CI: -2.13 to -0.62) showed a statistically significant difference.

AUTHORS' CONCLUSIONS

No RCT reported on clinically relevant outcome measures - all cause mortality, cardiovascular morbidity and morbidity. There were no significant differences in overall adverse events and withdrawals due to adverse events among the evening versus morning dosing regimens. In terms of BP lowering efficacy, for 24-hour SBP and DBP, the data suggests that better blood pressure control was achieved with bedtime dosing than morning administration of antihypertensive medication, the clinical significance of which is not known.

Hypertension in the elderly

Background. The incidence of hypertension in the Western countries is continuously increasing in the elderly population and remains the leading cause of cardiovascular and morbidity. Methods. we analysed some significant clinical trials in order to present the relevant findings on those hypertensive population. Results. Several studies (SYST-EUR, HYVET, CONVINCE, VALUE, etc.) have demonstrated the benefits of treatment (nitrendipine, hydrochrotiazyde, perindopril, indapamide, verapamil, or valsartan) in aged hypertensive patients not only concerning blood pressure values but also the other important risk factors. Conclusion. Hypertension is the most prevalent cardiovascular disorder in the Western countries, and the relevance of receiving pharmacological treatment of hypertension in aged patients is crucial; in addition, the results suggest that combination therapy—nitrendipine plus enalapril—could have more benefits than those observed with the use of nitrendipine alone.

Olive (Olea europaea) leaf extract effective in patients with stage-1 hypertension: comparison with Captopril

A double-blind, randomized, parallel and active-controlled clinical study was conducted to evaluate the anti-hypertensive effect as well as the tolerability of Olive leaf extract in comparison with Captopril in patients with stage-1 hypertension. Additionally, this study also investigated the hypolipidemic effects of Olive leaf extract in such patients. It consisted of a run-in period of 4 weeks continued subsequently by an 8-week treatment period. Olive (Olea europaea L.) leaf extract (EFLA(®)943) was given orally at the dose of 500 mg twice daily in a flat-dose manner throughout the 8 weeks. Captopril was given at the dosage regimen of 12.5 mg twice daily at start. After 2 weeks, if necessary, the dose of Captopril would be titrated to 25 mg twice daily, based on subject's response to treatment. The primary efficacy endpoint was reduction in systolic blood pressure (SBP) from baseline to week-8 of treatment. The secondary efficacy endpoints were SBP as well as diastolic blood pressure (DBP) changes at every time-point evaluation and lipid profile improvement. Evaluation of BP was performed every week for 8 weeks of treatment; while of lipid profile at a 4-week interval. Mean SBP at baseline was 149.3±5.58 mmHg in Olive group and 148.4±5.56 mmHg in Captopril group; and mean DBPs were 93.9±4.51 and 93.8±4.88 mmHg, respectively. After 8 weeks of treatment, both groups experienced a significant reduction of SBP as well as DBP from baseline; while such reductions were not significantly different between groups. Means of SBP reduction from baseline to the end of study were -11.5±8.5 and -13.7±7.6 mmHg in Olive and Captopril groups, respectively; and those of DBP were -4.8±5.5 and -6.4±5.2 mmHg, respectively. A significant reduction of triglyceride level was observed in Olive group, but not in Captopril group. In conclusion, Olive (Olea europaea) leaf extract, at the dosage regimen of 500 mg twice daily, was similarly effective in lowering systolic and diastolic blood pressures in subjects with stage-1 hypertension as Captopril, given at its effective dose of 12.5-25 mg twice daily.

Comparison of real-world adherence, healthcare resource utilization and costs for newly initiated valsartan/amlodipine single-pill combination versus angiotensin receptor blocker/calcium channel blocker free-combination therapy

OBJECTIVE

To compare adherence, healthcare costs and utilization of valsartan/amlodipine single-pill combination (SPC) and angiotensin-receptor blocker/calcium-channel blocker multiple-pill free-combination (ARB + CCB FC) therapy using real-world data.

METHODS

A retrospective study (January 1, 2007 to April 30, 2009) was conducted using US commercial healthcare insurance claims. Patients were assigned to two cohorts: 'valsartan/amlodipine SPC cohort' and 'ARB + CCB FC therapy cohort'. The primary endpoints were adherence and persistence. The secondary endpoints were 1-year healthcare costs and utilization.

RESULTS

Out of 12,628 eligible patients 3259 (26%) were included in the valsartan/amlodipine SPC cohort and 9369 (%74) in the ARB + CCB FC cohort. Risk-adjusted adherence rates were higher for valsartan/amlodipine SPC patients [OR: 1.38, 95% CI: (1.24, 1.53)]. The Cox proportional hazard model showed that valsartan/amlodipine SPC cohort patients were less likely to discontinue medication (HR: 0.87, p < 0.001). Comparison between the groups also yielded that total healthcare costs of valsartan/amlodipine SPC patients were 16-20% lower than ARB + CCB FC therapy patients (p < 0.0001).

LIMITATIONS

Since claims data are collected for payment purposes rather than research purposes, the study is bound by limitations for the retrospective analysis. For example, the presence of a claim for a filled prescription does not indicate that the medication was consumed or taken as prescribed. Data on health behaviors and patient lifestyle were not available. Over-the-counter medications and clinical disease severity were not available in the dataset. Incorrect coding is also a possibility. However, we have used previously validated datasets where these effects are minimal. Heterogeneity of the sample may create bias in our estimates, however, we have used advanced statistical methods to control for observed and unobserved bias.

CONCLUSION

The real-world use of valsartan/amlodipine SPC was associated with better adherence and persistence relative to ARB + CCB FC therapy among patients with hypertension. Moreover, patients taking single-pill combination therapy had lower healthcare costs and utilization.

Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria (Tables 1 and 2). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed.

CONCLUSIONS

Extensive evidence identifies a variety of specific factors that increase the risk of a first stroke and that provide strategies for reducing that risk.

Evaluation of pharmacokinetic interactions between amlodipine, valsartan, and hydrochlorothiazide in patients with hypertension

The steady-state pharmacokinetic (PK) interaction potential between amlodipine (10 mg), valsartan (320 mg), and hydrochlorothiazide (HCTZ; 25 mg) was evaluated in patients with hypertension in a multicenter, multiple-dose, open-label, 4-cohort, parallel-group study. Eligible patients were randomly allocated to the dual combination of valsartan + HCTZ, amlodipine + valsartan, or amlodipine + HCTZ and nonrandomly allotted to amlodipine + valsartan + HCTZ triple combination treatment. After 6 days of treatment with a half-maximal dose of different combinations, patients were up-titrated to the maximal drug doses from day 7 through day 17. PK parameters of corresponding analytes from the triple- and dual-treatment groups were estimated on day 17 and compared. Safety and tolerability of all treatments was assessed. The C ( ssmax ) and AUC(0-τ) values of amlodipine or HCTZ remained unaffected when administered with valsartan + HCTZ or valsartan + amlodipine, respectively. On the other hand, valsartan exposure increased by 10% to 25% when coadministered with HCTZ and amlodipine, which is not considered clinically relevant. In conclusion, there were no clinically relevant PK interactions with amlodipine, valsartan, and HCTZ triple combination compared with the corresponding dual combinations. All treatments were safe and well tolerated.

Calcium channel blockers versus other classes of drugs for hypertension

BACKGROUND

Calcium channel blockers (CCBs) are a relatively new antihypertensive class. The effect of first-line CCBs on the prevention of cardiovascular events, as compared with other antihypertensive drug classes, is unknown.

OBJECTIVES

To determine whether CCBs used as first-line therapy for hypertension are different from other first-line drug classes in reducing the incidence of major adverse cardiovascular events.

SEARCH STRATEGY

Electronic searches of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASEand the WHO-ISH Collaboration Register (up to May 2009) were performed. We also checked the references of published studies to identify additional trials.

SELECTION CRITERIA

Randomized controlled trial (RCT) comparing first-line CCBs with other antihypertensive classes, with at least 100 randomized hypertensive participants and with a follow-up of at least two years.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the included trials, evaluated the risk of bias and entered the data for analysis.

MAIN RESULTS

Eighteen RCTs (14 dihydropyridines, 4 non-dihydropyridines) with a total of 141,807 participants were included. All-cause mortality was not different between first-line CCBs and any other first-line antihypertensive classes. CCBs reduced the following outcomes as compared to beta-blockers: total cardiovascular events (RR 0.84, 95% CI [0.77, 0.92]), stroke (RR 0.77, 95% CI [0.67, 0.88]) and cardiovascular mortality (RR 0.90, 95% CI [0.81, 0.99]). CCBs increased total cardiovascular events (RR 1.05 , 95% CI [1.00, 1.09], p = 0.03) and congestive heart failure events (RR 1.37, 95% CI [1.25, 1.51]) as compared to diuretics. CCBs reduced stroke (RR 0.89, 95% CI [0.80, 0.98]) as compared to ACE inhibitors and reduced stroke (RR 0.85, 95% CI [0.73, 0.99]) and MI (RR 0.83, 95% CI [0.72, 0.96]) as compared to ARBs. CCBs also increased congestive heart failure events as compared to ACE inhibitors (RR 1.16, 95% CI [1.06, 1.27]) and ARBs (RR 1.20, 95% CI [1.06, 1.36]). The other evaluated outcomes were not significantly different.

AUTHORS' CONCLUSIONS

Diuretics are preferred first-line over CCBs to optimize reduction of cardiovascular events. The review does not distinguish between CCBs, ACE inhibitors or ARBs, but does provide evidence supporting the use of CCBs over beta-blockers. Many of the differences found in the current review are not robust and further trials might change the conclusions. More well-designed RCTs studying the mortality and morbidity of patients taking CCBs as compared with other antihypertensive drug classes are needed for patients with different stages of hypertension, different ages, and with different co-morbidities such as diabetes.

Effectiveness of a hospital-based vascular screening programme (SMART) for risk factor management in patients with established vascular disease or type 2 diabetes: a parallel-group comparative study

AIMS

Modification of vascular risk factors is effective in reducing mortality and morbidity in patients with symptomatic atherosclerosis; however, it is difficult to achieve and maintain. The aim of the Risk management in Utrecht and Leiden Evaluation (RULE) study was to assess risk factor status after referral in patients with established vascular disease or type 2 diabetes who took part in the multidisciplinary hospital-based vascular screening programme, Second Manifestations of ARTerial disease, compared with a group who did not participate in such a programme.

METHODS AND RESULTS

Patients with type 2 diabetes, coronary artery disease, cerebrovascular disease or peripheral arterial disease referred by general practitioners to the medical specialist at the University Medical Center (UMC) Utrecht (a setting with a vascular screening programme of systematic screening of risk factors followed by treatment advice) and the Leiden UMC (a setting without such a screening programme), were enrolled in the study. Blood pressure, levels of lipids, glucose and creatinine, weight, waist circumference and smoking status were measured in patients 12-18 months after referral to the two hospitals. A total of 604 patients were treated in the setting with a vascular screening programme and 566 in the setting without such a programme; 70% of all patients were male, with a mean age of 61 +/- 10 years. Amongst screened patients, systolic blood pressure [2.5 mmHg, 95% confidence interval (CI) 0.3-4.6] and the level of LDL cholesterol (0.3 mmol L(-1), 95% CI 0.2-0.4) were lower compared with the group that received usual care, after a median of 16 months from referral.

CONCLUSION

Systematic screening of risk factors, followed by evidence-based, tailored treatment advice contributed to slightly better risk factor reduction in patients with established vascular disease or type 2 diabetes. However, a large proportion of patients did not reach the treatment goals according to (inter)national guidelines. Systematic screening of vascular risk factors alone is not enough for adequate risk factor management in high-risk patients.

Optimal use of beta-blockers in high-risk hypertension: a guide to dosing equivalence

Hypertension is the number one diagnosis made by primary care physicians, placing them in a unique position to prescribe the antihypertensive agent best suited to the individual patient. In individuals with diabetes mellitus, blood pressure (BP) levels >130/80 mmHg confer an even higher risk for cardiovascular and renal disease, and these patients will benefit from aggressive antihypertensive treatment using a combination of agents. β-blockers are playing an increasingly important role in the management of hypertension in high-risk patients. β-blockers are a heterogeneous class of agents, and this review presents the differences between β-blockers and provides evidence-based protocols to assist in understanding dose equivalence in the selection of an optimal regimen in patients with complex needs. The clinical benefits provided by β-blockers are only effective if patients adhere to medication treatment long term. β-blockers with proven efficacy, once-daily dosing, and lower side effect profiles may become instrumental in the treatment of hypertensive diabetic and nondiabetic patients.

Urinary albumin excretion is associated with true resistant hypertension

Resistant (or refractory) hypertension (RH) is a clinical diagnosis based on blood pressure (BP) office measurements. About one third of subjects with suspected RH have indeed pseudo-resistant hypertension and 24-h ambulatory-blood pressure-monitoring aids to precisely identify them. Our aim was to determine those clinical, laboratory or echocardiographic variables that may be associated with subjects with sustained hypertension (namely true RH). We carried out a cross-sectional analysis of 143 patients consecutively enrolled with the clinical diagnosis of RH. All patients underwent clinical-demographic, laboratory evaluation, 2D-echocardiography and 24-h ambulatory-blood pressure-monitoring. Pseudo-resistant hypertension or white-coat RH was defined if office BP was > or =140 and/or 90 mm Hg and 24-h BP <130/80 mm Hg. One-hundred and three (72%) patients had true RH and 40 (28%) patients had white-coat RH. True RH patients had significantly higher diabetes prevalence and higher office-systolic blood pressure (SBP) levels. Regarding target organ damage, left ventricular mass index (LVMI) and 24-h urinary albumin excretion (UAE) were also higher in true RH after adjustment for possible confounders (P=0.031 and P=0.012, respectively). In a logistic regression analysis, only office-SBP (multivariate OR (95%CI): 1.030 (1.003-1.057), P=0.030) and UAE (multivariate OR (95% CI): 2.376 (1.225-4.608), P=0.010) were independently associated with true RH. We conclude that true resistant hypertension is associated with silent target organ damage, especially UAE. In patients with suspected RH, assessment of 24 h ambulatory BP is the most accurate way to detect a population with high risk for target-organ damage.

Safety and benefits of a tablet combining losartan and hydrochlorothiazide in Japanese diabetic patients with hypertension

This study was conducted to determine the effects of a tablet combining losartan/hydrochlorothiazide (L/HCTZ) in comparison with losartan alone in Japanese diabetic patients with hypertension. Thirty consecutive Japanese diabetic patients with hypertension were randomly assigned to group A, receiving losartan alone for the first 3 months, then L/HCTZ for the next 3 months, or group B, receiving L/HCTZ for the first 3 months, then losartan alone for the next 3 months. Clinical and biological parameters were obtained before, and 3 and 6 months after the start of this study. The decreases in systolic and diastolic blood pressure (BP) during treatment with L/HCTZ were significantly greater than in treatment with losartan alone. Both treatments significantly and similarly decreased urinary albumin excretion, the cardio-ankle vascular index (CAVI) and augmentation index (AI). There was no significant difference in metabolic change during both the mono- and combination pharmacotherapies. The tablet combining L/HCTZ significantly reduced systolic and diastolic BP compared with the losartan monotherapy, and offered benefits similar to losartan monotherapy for albuminuria, arterial stiffness assessed by the CAVI and AI, and metabolic effects. Thus, the L/HCTZ tablet could be a useful drug for Japanese diabetic patients with hypertension.