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Shen F, Jiang G, Philips S, Cantor E, Gardner L, Xue G, Cunningham G, Kassem N, O'Neill A, Cameron D, Suter TM, Miller KD, Sledge GW, Schneider BP. Germline predictors for bevacizumab induced hypertensive crisis in ECOG-ACRIN 5103 and BEATRICE. Br J Cancer 2024; 130:1348-1355. [PMID: 38347093 PMCID: PMC11014938 DOI: 10.1038/s41416-024-02602-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Bevacizumab is a beneficial therapy in several advanced cancer types. Predictive biomarkers to better understand which patients are destined to benefit or experience toxicity are needed. Associations between bevacizumab induced hypertension and survival have been reported but with conflicting conclusions. METHODS We performed post-hoc analyses to evaluate the association in 3124 patients from two phase III adjuvant breast cancer trials, E5103 and BEATRICE. Differences in invasive disease-free survival (IDFS) and overall survival (OS) between patients with hypertension and those without were compared. Hypertension was defined as systolic blood pressure (SBP) ≥ 160 mmHg (n = 346) and SBP ≥ 180 mmHg (hypertensive crisis) (n = 69). Genomic analyses were performed to evaluate germline genetic predictors for the hypertensive crisis. RESULTS Hypertensive crisis was significantly associated with superior IDFS (p = 0.015) and OS (p = 0.042), but only IDFS (p = 0.029; HR = 0.28) remained significant after correction for prognostic factors. SBP ≥ 160 mmHg was not associated with either IDFS or OS. A common single-nucleotide polymorphism, rs6486785, was significantly associated with hypertensive crisis (p = 8.4 × 10-9; OR = 5.2). CONCLUSION Bevacizumab-induced hypertensive crisis is associated with superior outcomes and rs6486785 predicted an increased risk of this key toxicity.
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Affiliation(s)
- Fei Shen
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Guanglong Jiang
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Santosh Philips
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erica Cantor
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Laura Gardner
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gloria Xue
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Nawal Kassem
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Anne O'Neill
- Dana Farber Cancer Institute - ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | - David Cameron
- Edinburgh Cancer Research Centre, Edinburgh, United Kingdom
| | - Thomas M Suter
- Swiss Cardiovascular Center, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Kathy D Miller
- Indiana University School of Medicine, Indianapolis, IN, USA
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Gaffey AE, Chang TE, Brandt CA, Haskell SG, Dhruva SS, Bastian LA, Levine A, Skanderson M, Burg MM. Blood Pressure Control and Maintenance in a Prospective Cohort of Younger Veterans: Roles of Sex, Race, Ethnicity, and Social Determinants of Health. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.22.24306203. [PMID: 38712220 PMCID: PMC11071551 DOI: 10.1101/2024.04.22.24306203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background Proactive blood pressure (BP) management is particularly beneficial for younger Veterans, who have a greater prevalence and earlier onset of cardiovascular disease than non-Veterans. It is unknown what proportion of younger Veterans achieve and maintain BP control after hypertension onset and if BP control differs by demographics and social deprivation. Methods Electronic health records were merged from Veterans who enrolled in VA care 10/1/2001-9/30/2017 and met criteria for hypertension - first diagnosis or antihypertensive fill. BP control (140/90 mmHg), was estimated 1, 2, and 5 years post-hypertension documentation, and characterized by sex, race, and ethnicity. Adjusted logistic regressions assessed likelihood of BP control by these demographics and with the Social Deprivation Index (SDI). Results Overall, 17% patients met criteria for hypertension (n=198,367; 11% of women, median age 41). One year later, 59% of men and 65% of women achieved BP control. After adjustment, women had a 72% greater odds of BP control than men, with minimal change over 5 years. Black adults had a 22% lower odds of BP control than White adults. SDI did not significantly change these results. Conclusions In the largest study of hypertension in younger Veterans, 41% of men and 35% of women did not have BP control after 1 year, and BP control was consistently better for women through 5 years. Thus, the first year of hypertension management portends future, long-term BP control. As social deprivation did not affect BP control, the VA system may protect against disadvantages observed in the general U.S. population.
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Affiliation(s)
- Allison E. Gaffey
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (Cardiovascular Medicine)
| | - Tiffany E. Chang
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Cynthia A. Brandt
- VA Connecticut Healthcare System, West Haven, CT
- Department of Biostatistics, Yale School of Medicine
| | - Sally G. Haskell
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (General Medicine), Yale School of Medicine
| | - Sanket S. Dhruva
- San Francisco Veterans Affairs Health Care System, San Francisco, CA
- Section of Cardiology, Department of Medicine, UCSF School of Medicine
| | - Lori A. Bastian
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (General Medicine), Yale School of Medicine
| | | | | | - Matthew M. Burg
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (Cardiovascular Medicine)
- Department of Anesthesiology, Yale School of Medicine
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Gupta A, Chouhdry H, Ellis SD, Young K, Mahnken J, Comfort B, Shanks D, McGreevy S, Rudy C, Zufer T, Mabry S, Woodward J, Wilson A, Anderson H, Loucks J, Chandaka S, Abu-El-Rub N, Mazzotti DR, Song X, Schmitz N, Conroy M, Supiano MA, Waitman LR, Burns JM. Design of a pragmatic randomized implementation effectiveness trial testing a health system wide hypertension program for older adults. Contemp Clin Trials 2024; 138:107466. [PMID: 38331381 DOI: 10.1016/j.cct.2024.107466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/22/2024] [Accepted: 02/05/2024] [Indexed: 02/10/2024]
Abstract
Hypertension control remains poor. Multiple barriers at the level of patients, providers, and health systems interfere with implementation of hypertension guidelines and effective lowering of BP. Some strategies such as self-measured blood pressure (SMBP) and remote management by pharmacists are safe and effectively lower BP but have not been effectively implemented. In this study, we combine such evidence-based strategies to build a remote hypertension program and test its effectiveness and implementation in large health systems. This randomized, controlled, pragmatic type I hybrid implementation effectiveness trial will examine the virtual collaborative care clinic (vCCC), a hypertension program that integrates automated patient identification, SMBP, remote BP monitoring by trained health system pharmacists, and frequent patient-provider communication. We will randomize 1000 patients with uncontrolled hypertension from two large health systems in a 1:1 ratio to either vCCC or control (usual care with education) groups for a 2-year intervention. Outcome measures including BP measurements, cognitive function, and a symptom checklist will be completed during study visits. Other outcome measures of cardiovascular events, mortality, and health care utilization will be assessed using Medicare data. For the primary outcome of proportion achieving BP control (defined as systolic BP < 130 mmHg) in the two groups, we will use a generalized linear mixed model analysis. Implementation outcomes include acceptability and feasibility of the program. This study will guide implementation of a hypertension program within large health systems to effectively lower BP.
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Affiliation(s)
- Aditi Gupta
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States; Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States.
| | - Hira Chouhdry
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Shellie D Ellis
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, United States
| | - Kate Young
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, KS, United States
| | - Jonathan Mahnken
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, KS, United States
| | - Branden Comfort
- Division of General Internal Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Denton Shanks
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Sheila McGreevy
- Division of General Internal Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Courtney Rudy
- Division of General Internal Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Tahira Zufer
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Sharissa Mabry
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Jennifer Woodward
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Amber Wilson
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Heidi Anderson
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Jennifer Loucks
- Department of Pharmacy, University of Kansas Health System, Kansas City, KS, United States
| | - Sravani Chandaka
- Division of Medical Informatics, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Noor Abu-El-Rub
- Division of Medical Informatics, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Diego R Mazzotti
- Division of Medical Informatics, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Xing Song
- Department of Biomedical Informatics, Biostatistics, and Medical Epidemiology, University of Missouri, Columbia, MO, United States
| | - Nolan Schmitz
- Department of Pharmacy, University of Kansas Health System, Kansas City, KS, United States
| | - Molly Conroy
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Mark A Supiano
- Geriatrics Division, Department of Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine and Center on Aging, University of Utah, Salt Lake City, UT, United States
| | - Lemuel R Waitman
- Department of Biomedical Informatics, Biostatistics, and Medical Epidemiology, University of Missouri, Columbia, MO, United States
| | - Jeffrey M Burns
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States
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Jacobs JA, Derington CG, Zheutlin AR, King JB, Cohen JB, Bucheit J, Kronish IM, Addo DK, Morisky DE, Greene TH, Bress AP. Association Between Self-Reported Medication Adherence and Therapeutic Inertia in Hypertension: A Secondary Analysis of SPRINT (Systolic Blood Pressure Intervention Trial). J Am Heart Assoc 2024; 13:e031574. [PMID: 38240275 PMCID: PMC11056166 DOI: 10.1161/jaha.123.031574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/06/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Therapeutic inertia (TI), failure to intensify antihypertensive medication when blood pressure (BP) is above goal, remains prevalent in hypertension management. The degree to which self-reported antihypertensive adherence is associated with TI with intensive BP goals remains unclear. METHODS AND RESULTS Cross-sectional analysis was performed of the 12-month visit of participants in the intensive arm of SPRINT (Systolic Blood Pressure Intervention Trial), which randomized adults to intensive (<120 mm Hg) versus standard (<140 mm Hg) systolic BP goals. TI was defined as no increase in antihypertensive regimen intensity score, which incorporates medication number and dose, when systolic BP is ≥120 mm Hg. Self-reported adherence was assessed using the 8-Item Morisky Medication Adherence Scale (MMAS-8) and categorized as low (MMAS-8 score <6), medium (MMAS-8 score 6 to <8), and high (MMAS-8 score 8). Poisson regressions estimated prevalence ratios (PRs) and 95% CIs for TI associated with MMAS-8. Among 1009 intensive arm participants with systolic BP >120 mm Hg at the 12-month visit (mean age, 69.6 years; 35.2% female, 28.8% non-Hispanic Black), TI occurred in 50.8% of participants. Participants with low adherence (versus high) were younger and more likely to be non-Hispanic Black or smokers. The prevalence of TI among patients with low, medium, and high adherence was 45.0%, 53.5%, and 50.4%, respectively. After adjustment, neither low nor medium adherence (versus high) were associated with TI (PR, 1.11 [95% CI, 0.87-1.42]; PR, 1.08 [95% CI, 0.84-1.38], respectively). CONCLUSIONS Although clinician uncertainty about adherence is often cited as a reason for why antihypertensive intensification is withheld when above BP goals, we observed no evidence of an association between self-reported adherence and TI.
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Affiliation(s)
- Joshua A. Jacobs
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUTUSA
| | - Catherine G. Derington
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUTUSA
| | - Alexander R. Zheutlin
- Division of Cardiology, Feinberg School of Medicine,Northwestern UniversityChicagoILUSA
| | - Jordan B. King
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUTUSA
- Institute for Health ResearchKaiser Permanente ColoradoAuroraCOUSA
| | - Jordana B. Cohen
- Renal‐Electrolyte and Hypertension Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - John Bucheit
- Department of Pharmacotherapy and Outcomes ScienceVirginia Commonwealth University School of PharmacyRichmondVAUSA
| | - Ian M. Kronish
- Center for Behavioral Cardiovascular HealthColumbia University Irving Medical CenterNew YorkNYUSA
| | - Daniel K. Addo
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUTUSA
| | - Donald E. Morisky
- Department of Community Health Sciences UCLA Fielding School of Public HealthLos AngelesCAUSA
| | - Tom H. Greene
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUTUSA
| | - Adam P. Bress
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUTUSA
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Hundemer GL, Leung AA, Kline GA, Brown JM, Turcu AF, Vaidya A. Biomarkers to Guide Medical Therapy in Primary Aldosteronism. Endocr Rev 2024; 45:69-94. [PMID: 37439256 PMCID: PMC10765164 DOI: 10.1210/endrev/bnad024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 07/14/2023]
Abstract
Primary aldosteronism (PA) is an endocrinopathy characterized by dysregulated aldosterone production that occurs despite suppression of renin and angiotensin II, and that is non-suppressible by volume and sodium loading. The effectiveness of surgical adrenalectomy for patients with lateralizing PA is characterized by the attenuation of excess aldosterone production leading to blood pressure reduction, correction of hypokalemia, and increases in renin-biomarkers that collectively indicate a reversal of PA pathophysiology and restoration of normal physiology. Even though the vast majority of patients with PA will ultimately be treated medically rather than surgically, there is a lack of guidance on how to optimize medical therapy and on key metrics of success. Herein, we review the evidence justifying approaches to medical management of PA and biomarkers that reflect endocrine principles of restoring normal physiology. We review the current arsenal of medical therapies, including dietary sodium restriction, steroidal and nonsteroidal mineralocorticoid receptor antagonists, epithelial sodium channel inhibitors, and aldosterone synthase inhibitors. It is crucial that clinicians recognize that multimodal medical treatment for PA can be highly effective at reducing the risk for adverse cardiovascular and kidney outcomes when titrated with intention. The key biomarkers reflective of optimized medical therapy are unsurprisingly similar to the physiologic expectations following surgical adrenalectomy: control of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium without supplementation, and a rise in renin. Pragmatic approaches to achieve these objectives while mitigating adverse effects are reviewed.
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Affiliation(s)
- Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | - Alexander A Leung
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Gregory A Kline
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Fisher M, Harris A, Koonce T, Beck Dallaghan G, Coe CL. Implementing a Blood Pressure Measurement Curriculum for First-Year Medical Students. MEDICAL SCIENCE EDUCATOR 2023; 33:841-845. [PMID: 37546203 PMCID: PMC10403475 DOI: 10.1007/s40670-023-01825-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 08/08/2023]
Abstract
A core clinical skill medical students need to learn is obtaining an accurate blood pressure (BP) reading. We developed a standardized BP curriculum for first-year medical students. Medical students completed online modules and a hands-on skills session to learn BP skills. Pre- and post-surveys and an observed structured clinical encounter (OSCE) assessed student confidence and ability to accurately measure BP. Student confidence and mean OSCE scores (pre = 2.63, post = 6.51; p < 0.001) improved upon completion of the curriculum. The curriculum was feasible, well received, and improved student's skills for taking an accurate BP.
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Affiliation(s)
- Margaret Fisher
- University of North Carolina School of Medicine, Chapel Hill, NC USA
| | - Ariel Harris
- University of North Carolina School of Medicine, Chapel Hill, NC USA
| | - Thomas Koonce
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, NC USA
| | | | - Catherine L. Coe
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, NC USA
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