Antihypertensive Medication Use Among US Adults With Hypertension

Do antihypertensive medications have an effect on dental implants? A systematic review

PURPOSE

The purpose of this systematic review was to compare the clinical outcomes of dental implants in users of antihypertensive medication with those of nonusers.

METHODS

This systematic review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and was registered in the International Prospective Register of Systematic Reviews under the number CRD42022319336. The electronic databases Medline (PubMed) and Central Cochrane were searched for relevant scientific literature published in English through May 2022. The focused question was, "Do patients taking antihypertensive medications have a similar impact on the clinical outcome and survival of dental implants compared with nonusers?".

RESULTS

A total of 49 articles were found, of which 3 articles were finally selected for a qualitative synthesis. The three studies included 959 patients. In all three studies, the commonly used medication was renin-angiotensin system (RAS) inhibitors. Two studies mentioned implant survival rate, which was 99.4% in antihypertensive medication users and 96.1% in the nonusers. One study found a higher implant stability quotient (ISQ) in patients taking antihypertensive medication (75.7 ± 5.9) compared with patients not taking antihypertensive medication (73.7 ± 8.1).

CONCLUSIONS

The limited available evidence showed that patient taking antihypertensive medications had comparable success rate and implant stability to patients not taking medications. The studies included patients taking different antihypertensive medications, so a drug-specific conclusion regarding the clinical outcome of dental implants is not possible. Further studies are needed, including patients taking certain antihypertensive medications, to determine their effects on dental implants.

Trends of Antihypertensive Prescription Among US Adults From 2010 to 2019 and Changes Following Treatment Guidelines: Analysis of Multicenter Electronic Health Records

BACKGROUND

Guidelines for the use of antihypertensives changed in 2014 and 2017. To understand the effect of these guidelines, we examined trends in antihypertensive prescriptions in the United States from 2010 to 2019 using a repeated cross-sectional design.

METHODS AND RESULTS

Using electronic health records from 15 health care institutions for adults (20-85 years old) who had ≥1 antihypertensive prescription, we assessed whether (1) prescriptions of beta blockers decreased after the 2014 Eighth Joint National Committee (JNC 8) report discouraged use for first-line treatment, (2) prescriptions for calcium channel blockers and thiazide diuretics increased among Black patients after the JNC 8 report encouraged use as first-line therapy, and (3) prescriptions for dual therapy and fixed-dose combination among patients with blood pressure ≥140/90 mm Hg increased after recommendations in the 2017 Hypertension Clinical Practice Guidelines. The study included 1 074 314 patients with 2 133 158 prescription episodes. After publication of the JNC 8 report, prescriptions for beta blockers decreased (3% lower in 2018-2019 compared to 2010-2014), and calcium channel blockers increased among Black patients (20% higher in 2015-2017 and 41% higher in 2018-2019, compared to 2010-2014), in accordance with guideline recommendations. However, contrary to guidelines, dual therapy and fixed-dose combination decreased after publication of the 2017 Hypertension Clinical Practice Guidelines (9% and 11% decrease in 2018-2019 for dual therapy and fixed-dose combination, respectively, compared to 2015-2017), and thiazide diuretics decreased among Black patients after the JNC 8 report (6% lower in 2018-2019 compared to 2010-2014).

CONCLUSIONS

Adherence to guidelines on prescribing antihypertensive medication was inconsistent, presenting an opportunity for interventions to achieve better blood pressure control in the US population.

Antihypertensive Use and the Risk of Cataract in Patients with Hypertension: A Nationwide Case-control Study

PURPOSE

This study aims to investigate the association between antihypertensive use and the risk of cataract in a matched case-control study.

METHODS

We analysed the Korean National Health Insurance Service-Health Screening Cohort database from 2002 to 2013. We defined 'cases' as patients prescribed antihypertensives and underwent their first eye cataract surgery between 2010 and 2013. 'Controls' were patients prescribed antihypertensives and no history of cataract surgery or diagnosis between 2002 and 2013. Four controls were matched to each case by several variables. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated for cataract risk using a conditional logistic regression model after adjustment.

RESULTS

The analyses comprised 12,166 cases and 48,664 controls. The adjusted ORs for cataracts were 1.18 (95% CI: 1.12-1.24) in thiazide diuretics, 1.12 (95% CI: 1.07-1.18) in beta-blockers, 0.94 (95% CI: 0.90-1.00) in calcium channel blockers, 1.22 (95% CI: 1.14-1.30) in angiotensin-converting enzyme (ACE) inhibitors, and 0.97 (95% CI: 0.91-1.03) in angiotensin II receptor blockers compared to 'non-use' of each antihypertensive.

CONCLUSION

In a nationwide case-control study, the use of thiazide diuretics, beta-blockers, or ACE inhibitors do not represent minimal clinical important difference in the risk of cataract and the use of calcium channel blockers or angiotensin II receptor blockers is not associated with an increased risk of cataracts compared to non-use of each antihypertensive. Given the benefits of treating hypertension, such as the reduction in further complications, we suggest there is no need to change current clinical practice for antihypertensives.

Comparison of Clinical Outcomes and Safety Associated With Chlorthalidone vs Hydrochlorothiazide in Older Adults With Varying Levels of Kidney Function

IMPORTANCE

Thiazide diuretics are commonly prescribed for the treatment of hypertension, a disease highly prevalent among older individuals and in those with chronic kidney disease. How specific thiazide diuretics compare in regard to safety and clinical outcomes in these populations remains unknown.

OBJECTIVE

To compare safety and clinical outcomes associated with chlorthalidone or hydrochlorothiazide use among older adults with varying levels of kidney function.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study was conducted in Ontario, Canada, from 2007 to 2015. Participants included adults aged 66 years or older who initiated chlorthalidone or hydrochlorothiazide during this period. Data were analyzed from December 2019 through September 2020.

EXPOSURES

New chlorthalidone users were matched 1:4 with new hydrochlorothiazide users by a high-dimensional propensity score. Time-to-event models accounting for competing risks examined the associations between chlorthalidone vs hydrochlorothiazide use and the outcomes of interest overall and within estimated glomerular filtration rate (eGFR) categories (≥60, 45-59, and <45 mL/min/1.73 m2).

MAIN OUTCOMES AND MEASURES

The outcomes of interest were adverse kidney events (ie, eGFR decline ≥30%, dialysis, or kidney transplantation), cardiovascular events (composite of myocardial infarction, coronary revascularization, heart failure, or atrial fibrillation), all-cause mortality, and electrolyte anomalies (ie, sodium or potassium levels outside reference ranges).

RESULTS

After propensity score matching, the study cohort included 12 722 adults (mean [SD] age, 74 [7] years; 7063 [56%] women; 5659 [44%] men; mean [SD] eGFR, 69 [19] mL/min/1.73 m2), including 2936 who received chlorthalidone and 9786 who received hydrochlorothiazide. Chlorthalidone use was associated with a higher risk of eGFR decline of 30% or greater (hazard ratio [HR], 1.24 [95% CI, 1.13-1.36]) and cardiovascular events (HR, 1.12 [95% CI, 1.04-1.22]) across all eGFR categories compared with hydrochlorothiazide use. Chlorthalidone use was also associated with a higher risk of hypokalemia compared with hydrochlorothiazide use, which was more pronounced among those with higher eGFR (eGFR ≥60 mL/min/1.73 m2: HR, 1.86 [95% CI, 1.67-2.08]; eGFR 45-59 mL/min/1.73 m2: HR, 1.57 [95% CI, 1.25-1.96]; eGFR <45 mL/min/1.73 m2: HR, 1.10 [95% CI, 0.84-1.45]; P for interaction = .001). No significant differences were observed between chlorthalidone and hydrochlorothiazide for dialysis or kidney transplantation (HR, 1.44 [95% CI, 0.88-2.36]), all-cause mortality (HR, 1.10 [95% CI, 0.93-1.29]), hyperkalemia (HR, 1.05 [95% CI, 0.79-1.39]), or hyponatremia (HR, 1.14 [95% CI, CI 0.98-1.32]).

CONCLUSIONS AND RELEVANCE

This cohort study found that among older adults, chlorthalidone use was associated with a higher risk of eGFR decline, cardiovascular events, and hypokalemia compared with hydrochlorothiazide use. The excess risk of hypokalemia with chlorthalidone was attenuated in participants with reduced kidney function. Placed in context with prior observational studies comparing the safety and clinical outcomes associated with thiazide diuretics, these results suggest that there is no evidence to prefer chlorthalidone over hydrochlorothiazide.

Age-related tilt test responses in patients with suspected reflex syncope

AIMS

Tilt testing (TT) is recognized to be a valuable contribution to the diagnosis and the pathophysiology of vasovagal syncope (VVS). This study aimed to assess the influence of age on TT responses by examination of a large patient cohort.

METHODS AND RESULTS

Retrospective data from three experienced European Syncope Units were merged to include 5236 patients investigated for suspected VVS by the Italian TT protocol. Tilt testing-positivity rates and haemodynamics were analysed across age-decade subgroups. Of 5236 investigated patients, 3129 (60%) had a positive TT. Cardioinhibitory responses accounted for 16.5% of positive tests and were more common in younger patients, decreasing from the age of 50-59 years. Vasodepressor (VD) responses accounted for 24.4% of positive tests and prevailed in older patients, starting from the age of 50-59. Mixed responses (59.1% of cases) declined slightly with increasing age. Overall, TT positivity showed a similar age-related trend (P = 0.0001) and was significantly related to baseline systolic blood pressure (P < 0.001). Tilt testing was positive during passive phase in 18% and during nitroglycerine (TNG)-potentiated phase in 82% of cases. Positivity rate of passive phase declined with age (P = 0.001), whereas positivity rate during TNG remained quite stable. The prevalence of cardioinhibitory and VD responses was similar during passive and TNG-potentiated TT, when age-adjusted.

CONCLUSIONS

Age significantly impacts the haemodynamic pattern of TT responses, starting from the age of 50. Conversely, TT phase-passive or TNG-potentiated-does not significantly influence the type of response, when age-adjusted. Vagal hyperactivity dominates in younger patients, older patients show tendency to vasodepression.

Trends in Antihypertensive Medication Use Among Individuals With a History of Stroke and Hypertension, 2005 to 2016

Importance

Hypertension is a well-established, modifiable risk factor for stroke. National hypertension management trends among stroke survivors may provide important insight into secondary preventive treatment gaps.

Objective

To investigate the adequacy of blood pressure control among stroke survivors and antihypertensive treatment trends using National Health and Nutrition Examination Survey (NHANES) data.

Design, Setting, and Participants

Cross-sectional surveys conducted between 2005 and 2016 of nationally representative samples of the civilian US population were analyzed from March 2019 to January 2020. The NHANES is a large, nationally representative cross-sectional survey conducted in 2-year cycles in the United States. Evaluations include interviews, medication lists, physical examinations, and laboratory tests on blood samples. Among 221 982 140 adults 20 years or older in the NHANES from 2005 through 2016, a total of 4 971 136 had stroke and hypertension and were included in this analysis, with 217 011 004 excluded from the primary analysis.

Exposures

Hypertension was defined by self-report, antihypertensive medication use, or uncontrolled blood pressure (>140/90 mm Hg) on physical examination. Antihypertensive medication was classified as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, diuretics, β-blockers, calcium channel blockers, or other.

Main Outcomes and Measures

Weighted frequencies and means were reported using NHANES methods, estimating the proportion of individuals with stroke and hypertension. For all other analyses, 4 971 136 individuals with stroke and hypertension were examined, summarizing number and classes of antihypertensive medications, frequency of uncontrolled hypertension, and associations between antihypertensive classes and blood pressure control. Trends in antihypertensive medication use over time were examined.

Results

Among 4 971 136 individuals with a history of stroke and hypertension, the mean age was 67.1 (95% CI, 66.1-68.1) years, and 2 790 518 (56.1%) were women. In total, 37.1% (33.5%-40.8%) had uncontrolled blood pressure on examination, with 80.4% (82.0%-87.5%) taking antihypertensive medication. The most commonly used antihypertensive medications were angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (59.2%; 95% CI, 54.9%-63.4%) and β-blockers (43.8%; 95% CI, 40.3%-47.3%). Examining trends over time, diuretics have become statistically significantly less commonly used (49.4% in 2005-2006 vs 35.7% in 2015-2016, P = .005), with frequencies of other antihypertensive classes remaining constant.

Conclusions and Relevance

In this cross-sectional study that used national survey data, substantial undertreatment of hypertension was found in individuals with a history of stroke, and more than one-third had uncontrolled hypertension. Because hypertension is a major risk factor for stroke, these data demonstrate a missed opportunity nationally for secondary stroke prevention.

Impact of renin-angiotensin system inhibitors and beta-blockers on dental implant stability

BACKGROUND

Current experimental research suggests antihypertensive medication reduces the failure risk of dental implants due to enhanced bone remodeling. However, evidence from clinical studies evaluating the impact of antihypertensive medication on implant stability is lacking.

METHODS

We retrospectively analyzed 377 implants in 196 patients (46 implants inserted in antihypertensive drug users (AH) and 331 implants in non-users (NAH)) for implant stability measured by radiofrequency analysis, and we determined the implant stability quotient (ISQ). AH subgroups were stratified by the use of beta-blockers, renin-angiotensin system (RAS) inhibitors, and both of the aforementioned. The impact of antihypertensive medication on ISQ values at implant insertion (primary stability) and implant exposure (secondary stability) was analyzed by a linear regression model with a regression coefficient and its 95% confidence interval (95% CI), adjusted for potential confounders.

RESULTS

Time between implant insertion and implant exposure was 117.1 ± 56.6 days. ISQ values at insertion were 71.8 ± 8.7 for NAH and 74.1 ± 5.6 for AH, respectively. ISQ at exposure was 73.7 ± 8.1 for NAH and 75.7 ± 5.9 for AH. Regression analysis revealed that none of the AH subgroups were significantly related to ISQ at implant insertion. However, renin-angiotensin system inhibitors (RAS) were significantly associated with higher ISQ values at exposure (reg. coeff. 3.59, 95% CI 0.46-6.71 (p=0.025)).

CONCLUSIONS

Outcome of the present study indicates enhanced bone remodeling and osseointegration following dental implant insertion in patients taking RAS inhibitors than in non-users. Future randomized prospective studies must confirm these indicative results.

Meta-Analysis: Hemodynamic Responses to Sub-anesthetic Doses of Ketamine in Patients With Psychiatric Disorders

Ketamine, a medication traditionally used as an anesthetic, has increasingly been recognized as an effective treatment for psychiatric disorders. At sub-anesthetic doses (defined here as ≤ 0.5 mg/kg), ketamine treatment has been studied in patients with treatment-resistant depression (TRD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and social anxiety disorder (SAD). Transient increases in hemodynamic activity have been reported during and after ketamine treatment, which may be desirable properties in some anesthesia settings, but are generally undesirable in psychiatric settings. While ketamine doses used in psychiatry are lower than those used in anesthesia, there are published instances of early termination of psychiatric ketamine infusions due to elevations in blood pressure and heart rate. No unifying study has been conducted to examine the impact of sub-anesthetic ketamine doses on hemodynamic parameters [systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR)] in psychiatric populations and to evaluate these changes across adult age groups. Here, data from 15 articles comprising a total N = 2,252 ketamine or esketamine treatments in adult participants were used to conduct a meta-analysis of treatment-induced hemodynamic changes. Ketamine/esketamine produced modest but significant increases in the variables of interest with an average SBP increase of 12.61 mm Hg (95% CI 10.40-14.82 mm Hg, z = 11.18, p < 0.0001), average DBP increase of 8.49 mm Hg (95% CI 6.89-10.09 mmHg, z = 10.41, p < 0.0001), and average heart rate increase of 4.09 beats per minute (95% CI 0.55-7.63 BPM), z = 2.27, p = 0.0235). Stratified subgroup analysis indicated no significant differences between ketamine and esketamine effects on blood pressure. Further analysis indicated that there was no significant effect of age on ketamine-induced changes in SBP, DBP, and HR. Taken together these data show that sub-anesthetic ketamine and esketamine induce small but significant increases in hemodynamic parameters that are transient in nature in adult psychiatric populations. While these data are reassuring, it is important for each treatment case to fully explore potential cardiovascular risks prior to initiating treatment.

Antihypertensive Drugs and Risk of Cancer: Between Scylla and Charybdis

Antihypertensive drugs namely angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, beta blockers, and diuretics are among the most clearly documented regimens worldwide with an overall cardioprotective benefit. Given that malignancy is the second leading cause of mortality, numerous observational studies aimed to investigate the carcinogenic potential of these agents with conflicting results. The purpose of this review was to summarize current data in an effort to explore rare side effects and new mechanisms linking antihypertensive drugs with the risk of developing cancer.

Factors Affecting Hypertension in the Adult Population of the Marmara Region, Turkey: A Descriptive Field Study

INTRODUCTION

Hypertension is an increasingly prevalent global public health problem. Nutritional culture and lifestyle are among the factors related to hypertension. The aim of this study was to evaluate the prevalence and influential factors of hypertension in the adult population of the Marmara region, Turkey.

METHODS

The study was conducted in 10 provinces in the Marmara region between June 01, 2018, and November 30, 2018. Participants included 2353 patients over 18 years of age diagnosed with hypertension by any of the 30 family physicians working in the Family Health Centers in these provinces. After the participants provided written consent, a survey consisting of 25 questions was administered by their family physicians. SPSS 25.0 (IBM Corporation, Armonk, New York, United States) was used for all statistical analysis calculations.

RESULTS

The patients included 1449 females (61.6%) and 904 males (38.4%). Among the respondents, 1555 (73.1%) had primary hypertension etiology and 572 (26.9%) had secondary etiology. While 1614 patients (68.6%) did not exercise at all, 739 patients (31.4%) reported exercising; 1026 patients (43.9%) did not restrict salt in their diet; and 1134 patients (48.2%) had a family history of hypertension.

CONCLUSION

Since individual and environmental factors affect the etiology of hypertension, it is recommended that family physicians address these factors first as part of a holistic approach for hypertension prevention, diagnosis, treatment, and follow-up.

Pulse Oximeter Plethysmograph Variation During Hemorrhage in Beta-Blocker-Treated Swine

BACKGROUND

Beta-blockers blunt the stress response to hemorrhage. Our aim was to investigate the feasibility of noninvasive pulse oximeter plethysmographic waveform variation (PoPV) for predicting blood volume loss in an esmolol-treated swine hemorrhagic shock model.

MATERIALS AND METHODS

Controlled hemorrhage was induced in eight male domestic pigs. In four pigs, a total of 15% and 30% blood volume was drawn step-by-step over 10 min in each step (controlled hemorrhage-only pigs). In the other four pigs, the heart rate (HR) was reduced and maintained by 30% from baseline by esmolol infusion before controlled hemorrhage (esmolol-treated pigs). Diagnostic abilities of HR, pulse pressure variation (PPV), PoPV, and mean arterial pressure for 15% and 30% blood volume loss were determined by the area under the receiver operating characteristic curve (AUC).

RESULTS

PoPV was well correlated with PPV in controlled hemorrhage-only pigs (r = 0.717) and esmolol-treated pigs (r = 0.532). In controlled hemorrhage-only pigs, HR (AUC = 0.841 and 0.864), PPV (0.878 and 0.843), and PoPV (0.779 and 0.793) accurately predicted 15% and 30% of blood volume loss. In esmolol-treated pigs, the diagnostic ability of HR was decreased (AUC = 0.766 and 0.733). However, diagnostic abilities of PPV (0.848 and 0.804) and PoPV (0.808 and 0.842) were not deteriorated.

CONCLUSIONS

The diagnostic ability of HR for blood volume loss was blunted by esmolol. However, those of PPV and PoPV were not altered. PoPV may be considered to be a useful noninvasive tool to predict blood volume loss in injured patients taking beta-blockers.

Underuse of Cardiovascular Medications in Individuals With Known Lower Extremity Peripheral Artery Disease: HCHS/SOL

Background

Underuse of cardiovascular medications for secondary prevention among individuals with peripheral artery disease (PAD) has been reported. Little is known about PAD treatment status in the Hispanic/Latino population in the United States, who may have limited access to health care and who have worse clinical outcomes than non‐Hispanic individuals.

Methods and Results

We studied the use of cardiovascular therapies in 1244 Hispanic/Latino individuals recruited from 4 sites in the United States, including 826 individuals who reported diagnosis of PAD by physician and 418 individuals with coronary artery disease alone, in the Hispanic Community Health Study/Study of Latinos. We compared the prevalence of using antiplatelet therapy, lipid‐lowering therapy and antihypertensive therapy by PAD and coronary artery disease status. Among those with PAD, we studied factors associated with taking cardiovascular medications, including demographic and socioeconomic factors, acculturation, access to health care and comorbidities, using multivariable regression models. The overall prevalence for individuals with PAD taking antiplatelet therapy, lipid‐lowering therapy and, among hypertensive individuals, antihypertensive therapy was 31%, 26% and 57%, respectively. Individuals of Mexican background had the lowest use for all classes of cardiovascular medications. Older age, number of doctor visits and existing hypertension and diabetes mellitus were significantly associated with taking cardiovascular therapies in adjusted models. Compared with those with PAD alone, individuals with PAD and concurrent coronary artery disease were 1.52 (95% CI, 1.20–1.93) and 1.74 (1.30–2.32) times more likely to use antiplatelet agents and statins according to multivariable analysis. No significant difference of antihypertensive medication use was found among PAD patients with or without coronary artery disease.

Conclusions

Hispanic/Latino individuals with known PAD underuse cardiovascular medications recommended in clinical guidelines. More efforts should be directed to improve treatment in this important group.

The effect of partial nephrectomy on blood pressure in patients with solitary kidney

PURPOSE

To determine the effect of partial nephrectomy (PN) in the solitary kidney on systolic and diastolic blood pressures (SBP and DBP, respectively), and use of antihypertensive medications.

METHODS

We performed a retrospective cohort study of solitary kidney patients who underwent PN for kidney cancer from 1999-2015. Primary outcomes evaluated were blood pressure (BP) and antihypertensive medication changes from baseline up to 5 years postoperatively. Using a multivariable mixed-effects model to account for repeated measurements, we evaluated the effect of PN on the outcome measurements while controlling for baseline patient, pathologic, and perioperative characteristics.

RESULTS

292 patients who underwent PN on solitary kidneys met inclusion criteria (median [range] age, 63 [24-84] years; 179 men [61%]). SBP decreased immediately postoperatively (- 1.7 mmHg [- 2.6, - 0.7], p < 0.001), and further decreased by 0.04 mmHg per year (p = 0.01) postoperatively, for a total change of - 1.9 [- 3.9, 0.2] mmHg at 5 years (p = 0.01). DBP decreased immediately postoperatively (- 2.2 mmHg [- 2.7, - 1.7], p < 0.001), and then rebounded by 0.37 mmHg per year (p = 0.003) postoperatively, for a total change of - 0.4 [- 1.5, 0.7] mmHg at 5 years (p = 0.003). Antihypertensive medication use increased at 5 years (0.35 more medications per patient, p < 0.001).

CONCLUSIONS

Our results suggest a minimal change in BP after PN, although patients increased antihypertensive medication use. This data suggests damage to renal parenchyma or hilar nerves during PN did not significantly impact BP regulation in our cohort.

Cost analysis and utilization of antihypertensive drug therapy in Saudi Arabia

Objectives

Mentioned study is carried out to assess the prescription pattern, utilization of drug and cost analysis of antihypertensive medications used in the treatment of hypertension in a private hospital in Saudi Arabia.

Methods

A retrospective cohort study was carried out in a private hospital in Saudi Arabia. Cost analysis and patterns of outpatient and inpatient antihypertensive drugs used among hypertensive patients between 1 January 2019 and 31 December 2019 were investigated, including incidence, prevalence, duration of use of therapy, class of antihypertensive drugs and therapy for cost-effective use.

Key findings

Monotherapy (78.32%) was leading trends of antihypertensive therapy that followed fixed dose combination with or without multidrug therapy (21.68%). The most frequent antihypertensive class to be prescribed was nonselective beta-blockers (39.36%) followed by calcium channel blockers (16.51%). The status in terms of cost utilized average per unit was the highest for telmisartan (3.371 (0.90) SR (USD)). The propranolol was most cost-effective (average cost per unit 1.43 (0.38) SR) in relative to the other antihypertensive prescribed.

Conclusion

Our study suggested that the prescription pattern of drugs used for the treatment of hypertension adhered with the JNC 8 guidelines. Monotherapy was reliably more recommended in the initial stages of hypertension. Higher percentage of patients (78.32%) was found to be on monotherapy. The Saudi Food and Drug Authority (SFDA) has overwhelmed for fixation of prices of drugs.

Trends in Antihypertensive Medication Monotherapy and Combination Use Among US Adults, National Health and Nutrition Examination Survey 2005-2016

Blood pressure (BP) control rates among US adults taking antihypertensive medication have not increased over the past decade. Many adults require 2 or more classes of antihypertensive medication to achieve guideline-recommended BP goals, but the proportion of US adults taking antihypertensive medication monotherapy, versus combination therapy, has not been quantified using contemporary data. We analyzed data from 2005 to 2008, 2009 to 2012, and 2013 to 2016 National Health and Nutrition Examination Surveys to determine trends in monotherapy and combinations of antihypertensive medication classes among US adults age ≥20 years with hypertension taking antihypertensive medication (n=7837). The proportion of US adults taking antihypertensive medication with uncontrolled BP (ie, systolic BP ≥140 or diastolic BP ≥90 mm Hg) was 32.3%, 30.2%, and 31.0% in 2005 to 2008, 2009 to 2012, and 2013 to 2016, respectively (Ptrend=0.37). Between 2005 to 2008 and 2013 to 2016, there was no evidence of changes in the proportions of US adults taking antihypertensive monotherapy (39.5%-40.4%, Ptrend=0.67), dual-therapy (37.9%-38.3%, Ptrend=0.75), triple-therapy (17.6%-16.5%, Ptrend=0.36), or quadruple-therapy (4.4%-4.3%, Ptrend=0.93). Between 2005 to 2008 and 2013 to 2016, there was no evidence of changes in the proportions of US adults with uncontrolled BP taking antihypertensive monotherapy (39.3%-40.6%, Ptrend=0.78). A high proportion of US adults with hypertension, including those with uncontrolled BP, are taking one antihypertensive medication class. Increasing the use of dual- and triple-therapy antihypertensive medication regimens may restore the upward trend in BP control rates among US adults.

Acquired angioedema induced by angiotensin-converting enzyme inhibitors - experience of a hospital-based allergy center

Angiotensin-converting enzyme inhibitors (ACEIs) represent an important group of pharmacological compounds, largely prescribed for more than 30 years. They have been extensively evaluated in clinical trials, demonstrating significant reduction of morbidity and mortality of patients with cardiovascular diseases, mainly high blood pressure, myocardial infarction, heart failure and stroke. Besides their beneficial effects and a general good safety profile, it was proven that ACEIs might also induce adverse effects in some patients, most notably angioedema (AE) and chronic cough. The occurrence rate of adverse events induced by ACEIs is low, but the number of suffering patients is relatively high, since ACEIs is one of the most frequently prescribed medication worldwide. The aim of our study was to evaluate clinical pattern, risk factors and general management of ACEI-induced angioedema in a cohort of patients addressed for allergist evaluation in one university hospital in Romania, during a period of 32 months. It was found that ACEI-induced angioedema (ACEI-AE) represented more than half of the total number of patients addressed for angioedema without urticaria, with variable clinical and time-patterns. Most of the patients were referred by general practitioners (GPs) with diagnosis of urticaria or other skin allergy and continued to take ACEIs for months and years after onset of angioedema. We concluded that the awareness of acquired, non-allergic angioedema induced by ACEI therapy in medical practice is still low and there is a need for improved knowledge and interdisciplinary collaboration in this field.

Trends in Angiotensin-Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Use among Those with Impaired Kidney Function in the United States

BACKGROUND

Although hypertension is common in CKD and evidence-based treatment of hypertension has changed considerably, contemporary and nationally representative information about use of angiotensin-converting enzyme (ACEs) inhibitors or angiotensin II receptor blockers (ARBs) in CKD is lacking.

METHODS

We examined ACE/ARB trends from 1999 to 2014 among 38,885 adult National Health and Nutrition Examination Survey participants with creatinine-based eGFR<60 ml/min per 1.73 m² or urinary albumin-to-creatinine ratio ≥30 mg/g.

RESULTS

Of 7085 participants with CKD, 34.9% used an ACE/ARB. Across four eras studied, rates of use rose significantly (rates were 25.5% in 1999-2002, 33.3% in 2003-2006, 39.0% in 2007-2010, and 40.1% in 2011-2014) but appeared to plateau after 2003. Among those with CKD, use was significantly greater among non-Hispanic white and black individuals (36.1% and 38.2%, respectively) and lower among Hispanic individuals (26.7%) and other races/ethnicities (29.3%). In age-, sex-, and race/ethnicity-adjusted models, ACE/ARB use was significantly associated with era (adjusted odds ratios [aOR], 1.41; 95% confidence interval [95% CI], 1.14 to 1.74 for 2003-2006, 1.84; 95% CI, 1.48 to 2.28 for 2007-2010, and 2.02; 95% CI, 1.61 to 2.53 for 2011-2014 versus 1999-2002); it also was significantly associated with non-Hispanic black versus non-Hispanic white race/ethnicity (aOR, 1.40; 95% CI, 1.19 to 1.66). Other multivariate associations included older age, men, elevated BMI, diabetes mellitus, treated hypertension, cardiac failure, myocardial infarction, health insurance, and receiving medical care within the prior year.

CONCLUSIONS

Rates of ACE/ARB use increased in the early 2000s among United States adults with CKD, but for unclear reasons, use appeared to plateau in the ensuing decade. Research examining barriers to care and other factors is needed.

Twenty-year trends in cardiovascular risk among men and women in the United States

BACKGROUND

Relative to men, women have experienced slower improvement in mortality in the US in recent decades.

AIMS

We investigated 20-year trends in cardiovascular risk for men and women age 40 and over in the US to determine whether there was differential change in risk for men and women.

METHODS

Using the National Health and Nutrition Examination Survey (NHANES), we estimated total cardiovascular risk, the prevalence of individual risk factors, and potential factors contributing to change in risk.

RESULTS

Men showed steady reductions in cardiovascular risk over the 20 years; women experienced increased risk from 1990 to 2000, but decreased risk from 2000 to 2010. Sex differences in cardiovascular risk changed so that there was no significant difference by sex at any age over 50 in 2010. Large decreases in the prevalence of high risk lipids were important causes of reduction in risks for both sexes; changes in blood pressure were less important, except for women in the 2000-2010 period when they equaled the effect of changing lipids. Increasing medication usage and effectiveness drove improvements in blood pressure and total cholesterol for both sexes. In 2010 there was no difference between men and women in the use of antihypertensives or cholesterol-lowering medications. Metabolic risk, as indexed by obesity and HbA1c, increased over time and went against the trend in the summary measure. Diabetes, smoking, and hormone therapy use did not explain changes in high blood pressure or high total cholesterol for either gender.

CONCLUSIONS

Recent decreases in cardiovascular risk may lead to future reduction in cardiovascular events and mortality among both women and men.

Replication and reproducibility issues in the relationship between C-reactive protein and depression: A systematic review and focused meta-analysis

One of the most common inflammatory markers examined in depression is C-reactive protein (CRP). However, the magnitude of the association between CRP and depression when controlling for potentially confounding factors such as age, sex, socio-economic status, body mass index, medication and other substance use, and medical illness, is unclear. Inconsistencies in other methodological practices, such as sample collection, assaying, and data cleaning and transformation, may contribute to variations in results. We aggregate studies that examined the association between CRP and depression in two ways. First, a systematic review summarizes how studies of CRP and depression have reported on methodological issues. Second, a tiered meta-analysis aggregates studies that have adhered to various levels of methodological rigor. Findings from the systematic review indicate a lack of protocol detail provided. The effect between depression and CRP was small, but highly significant across all stages of the meta-analysis (p < 0.01). The effect size in the most methodologically rigorous stage of the meta-analysis, which included studies controlling for age, sex, obesity, medical conditions and substance, medication, or psychosocial factors, was small (r = 0.05). There were also only 26 articles in this stage (13% of studies from the systematic review), suggesting that more studies that consistently account for these confounding factors are needed. Additionally, an a priori quality score of methodological rigor was a significant moderator in this stage of the meta-analysis. The effect size was strikingly attenuated (r = 0.005) and non-significant in studies with higher quality scores. We describe a set of recommended guidelines for future research to consider, including sample collection and assaying procedures, data cleaning and statistical methods, and control variables to assess.

Predictors of inadequate bowel preparation for colonoscopy: a systematic review and meta-analysis

The aim of this study was to investigate factors contributing to poor bowel preparation in patients undergoing colonoscopy procedures. We used a reproducible search strategy to identify studies, searching 10 medical databases, including PubMed, Ovid, Medline, and Cochrane Library Database for reports published between 2000 and 2016. Fully published studies, evaluating risk factors for inadequate bowel preparation, were included. Two reviewers independently scored the identified studies for methodology and abstracted pertinent data. Pooling was conducted with both fixed-effects and random-effects models; results were presented from the random effects model when heterogeneity was significant. Odds ratios (OR) estimates with 95% confidence interval were calculated. Heterogeneity was assessed by I statistics. Twenty-four studies with a total of 49 868 patients met the inclusion criteria. Age (OR: -1.20), male sex (OR: 0.85), inpatient status (OR: 0.57), diabetes mellitus (OR: 0.58), hypertension (OR: 0.58), cirrhosis (OR: 0.49), narcotic use (OR: 0.59), constipation (OR: 0.61), stroke (OR; 0.51), and tricyclic antidepressant (TCA) use (0.51), were associated with inadequate bowel preparation. In our sensitivity analysis comparing Western and Asian countries, we found that diabetes, cirrhosis, male sex, history of stroke and TCA use were stronger risk factors for inadequate bowel preparation in Western countries than in Asian countries. We also found that history of stroke, TCA use, and race were risk factors for inadequate bowel preparation in patients receiving conventional bowel preparation compared with those receiving split-dose bowel preparation. Multiple risk factors affect the quality of bowel preparation and specific risk factors can be intervened upon, in different populations, to optimize preparation.

Impact of 2017 ACC/AHA guidelines on prevalence of hypertension and eligibility for antihypertensive treatment in United States and China: nationally representative cross sectional study

OBJECTIVE

To examine the effect of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines on the prevalence of hypertension and eligibility for initiation and intensification of treatment in nationally representative populations from the United States and China.

DESIGN

Observational assessment of nationally representative data.

SETTING

US National Health and Nutrition Examination Survey (NHANES) for the most recent two cycles (2013-14, 2015-16) and China Health and Retirement Longitudinal Study (CHARLS) (2011-12).

PARTICIPANTS

All 45-75 year old adults who would have a diagnosis of hypertension and be candidates for treatment on the basis of the ACC/AHA guidelines, compared with current guidelines.

MAIN OUTCOME MEASURES

Diagnosis of hypertension and candidacy for initiation and intensification of antihypertensive treatment.

RESULTS

Adoption of the 2017 ACC/AHA hypertension guidelines in the US would label 70.1 (95% confidence interval 64.9 to 75.3) million people in the 45-75 year age group as having hypertension, representing 63% (60.6% to 65.4%) of the population in this age group. Their adoption in China would lead to labeling of 266.9 (252.9 to 280.8) million people or 55% (53.4% to 56.7%) of the same age group as having hypertension. This would represent an increase in prevalence of 26.8% (23.2% to 30.9%) in the US and 45.1% (41.3% to 48.9%) in China. Furthermore, on the basis of treatment patterns and current guidelines, 8.1 (6.5 to 9.7) million Americans with hypertension are untreated, which would be expected to increase to 15.6 (13.6 to 17.7) million after the implementation of the ACC/AHA guidelines. In China, on the basis of current treatment patterns, 74.5 (64.1 to 84.8) million patients with hypertension are untreated, estimated to increase to 129.8 (118.7 to 140.9 million. In addition, the ACC/AHA guidelines would label 8.7 (6.0 to 11.5) million adults in the US and 51 (40.3 to 61.6) million in China as having hypertension that would not require antihypertensive treatment, compared with 1.5 (1.2 to 2.1) million and 23.4 (12.1 to 35.1) million with the current guidelines. Finally, even among people receiving treatment, the proportion that are candidates for intensification of treatment is estimated to increase by 13.9 (12.2 to 15.6) million (from 24.0% to 54.4% of treated patients) in the US, and 30 (24.3 to 35.7) million (41.4% to 76.2% of treated patients) in China, if the ACC/AHA treatment targets are adopted.

CONCLUSIONS

If adopted, the 2017 ACC/AHA hypertension guidelines will markedly increase the number of people labeled as having hypertension and treated with drugs in both the US and China, leading to more than half of those aged 45-75 years in both countries being considered hypertensive.

Recent trends in the prevalence of chronic kidney disease: not the same old song

PURPOSE OF REVIEW

We aim to review recent updates on the epidemiology of chronic kidney disease (CKD).

RECENT FINDINGS

Recent analyses from the National Health and Nutritional Examination survey describe the temporal trend in CKD prevalence in US adults. The overall prevalence of estimated glomerular filtration rate less than 60 ml/min/1.73 m increased from 4.8% in 1988-1994 to 6.9% in 2003-2004, but has since stabilized at 6.4-6.9% up to 2011-2012. Prevalence of CKD stages 1-4 has also stabilized at ∼14% of adults since 2003-2004. The prevalence of diabetic kidney disease - defined as estimated glomerular filtration rate less than 60 ml/min/1.73 m and/or microalbuminuria among adults with diabetes - has similarly plateaued since the early to mid-2000s at ∼26-27%. There is continued rise in CKD and diabetic kidney disease prevalence among blacks and Mexican-Americans, however, in the last decade. Worldwide, a similar pattern of stable prevalence of CKD since the early 2000s is seen in England, Norway, and Korea. Despite these optimistic findings, there are several emerging at-risk populations. Rapid increases in diabetes and hypertension in China may signal an impending growth in CKD. In parts of Central America, there is emergence of very high CKD prevalence among agricultural workers - suspected to be due to occupational and environmental exposures.

SUMMARY

Collective efforts to undermine risk factors, such as better control of hypertension and diabetes, have likely helped to abate the growth in CKD in several developed countries within the last decade. More worldwide high-quality and geographically granular data collection on CKD would help to monitor the epidemiology of CKD and potentially assist in identifying impactful interventions.

Antihypertensive Prescription Pattern and Compliance to JNC 7 and JNC 8 at Tertiary Care Government Hospital, Hyderabad, India: A Cross-sectional Retrospective Study

Background: The monitoring of hypertension treatment can provide insight into the rational drug use pattern. The objective of this study was to examine the antihypertensive medication use among South Indian adults with hypertension in compliance with the hypertension treatment guidelines (Seventh Joint National Committee [JNC 7] and JNC 8). Methods and Results: A total of 550 hypertensive people aged >25 years were included in this retrospective cross-sectional study. The order of drugs prescribed in the year 2012 was beta blockers (BB) > calcium channel blockers (CCB) > CCB + BB > angiotensin receptor blockers (ARB) > angiotensin-converting enzyme inhibitors (ACEI) > thiazide diuretics, whereas in the year 2014, the order has changed drastically, namely, ACEI > CCB > ARB > BB > thiazide diuretics (P < .001). Most notably, there was a large increase in the use of monotherapy (from 56.9% to 82.5%, P < .001). The usage of BB has simply moved from the first position to the last position in concordance with JNC 8 guidelines, whereas use of thiazide diuretics was found to be the least preferred drug in the 2012 prescriptions, thus deviating from JNC 7 guidelines. The use of generic names (28.3% vs 11.3%) and National List of Essential Medicines (NLEM) compliance (79.3% vs 60.9%) were significantly more in the calendar year 2012 than in the calendar year 2014 (P < .001). Conclusions: Antihypertensive medication use has gone through wide variations among south Indian adults with hypertension. Combination therapy regimens must be adopted as per the guidelines for achievement of blood pressure goals.

Contemporary Epidemiology of Heart Failure in Fee-For-Service Medicare Beneficiaries Across Healthcare Settings

BACKGROUND

To assess the current landscape of the heart failure (HF) epidemic and provide targets for future health policy interventions in Medicare, a contemporary appraisal of its epidemiology across inpatient and outpatient care settings is needed.

METHODS AND RESULTS

In a national 5% sample of Medicare beneficiaries from 2002 to 2013, we identified a cohort of 2 331 939 unique fee-for-service Medicare beneficiaries ≥65-years-old followed for all inpatient and outpatient encounters over a 10-year period (2004-2013). Preexisting HF was defined by any HF encounter during the first year, and incident HF with either 1 inpatient or 2 outpatient HF encounters. Mean age of the cohort was 72 years; 57% were women, and 86% and 8% were white and black, respectively. Within this cohort, 518 223 patients had preexisting HF, and 349 826 had a new diagnosis of HF during the study period. During 2004 to 2013, the rates of incident HF declined 32%, from 38.7 per 1000 (2004) to 26.2 per 1000 beneficiaries (2013). In contrast, prevalent (preexisting + incident) HF increased during our study period from 162 per 1000 (2004) to 172 per 1000 beneficiaries (2013) (P_trend <0.001 for both). Finally, the overall 1-year mortality among patients with incident HF is high (24.7%) with a 0.4% absolute decline annually during the study period, with a more pronounced decrease among those diagnosed in an inpatient versus outpatient setting (P_interaction <0.001) CONCLUSIONS: In recent years, there have been substantial changes in the epidemiology of HF in Medicare beneficiaries, with a decline in incident HF and a decrease in 1-year HF mortality, whereas the overall burden of HF continues to increase.

Methods to estimate underlying blood pressure: The Atherosclerosis Risk in Communities (ARIC) Study

Antihypertensive medications complicate studies of blood pressure (BP) natural history; BP if untreated (“underlying BP”) needs to be estimated. Our objectives were to compare validity of five missing data imputation methods to estimate underlying BP and longitudinal associations of underlying BP and age. We simulated BP treatment in untreated hypertensive participants from Atherosclerosis Risk in Communities (ARIC) in visits 1–5 (1987–2013) using matched treated hypertensive participants. The underlying BP was imputed: #1, set as missing; #2, add 10 mmHg for systolic, 5 mmHg for diastolic; #3, add medication class-specific constant; #4, truncated normal regression; and #5, truncated normal regression including prior visit data. Longitudinal associations were estimated using linear mixed models of imputed underlying BP for simulated treated and measured BP for untreated participants. Method 3 was the best-performing for systolic BP; lowest relative bias (5.3% for intercept at age 50, 0% for age coefficient) and average deviation from expected (0.04 to -1.79). Method 2 performed best for diastolic BP; lowest relative bias (0.6% intercept at age 50, 33.3% age <60, 9.1% age 60+) and average deviation (-1.25 to -1.68). Methods 4 and 5 were comparable or slightly inferior. In conclusion, constant addition methods yielded valid and precise underlying BP and longitudinal associations.

Is There a Relationship Between Part D Medication Adherence and Part C Intermediate Outcomes Star Ratings Measures?

BACKGROUND

Improvements in the Centers for Medicare & Medicaid Services (CMS) star ratings Part D medication adherence measures may affect performance in Part C intermediate outcome measures for which the Part D targeted medication classes are prescribed.

OBJECTIVE

To determine if Part D medication adherence measures are associated with corresponding Part C intermediate outcome measures.

METHODS

This was a cross-sectional analysis using the CMS 2015 star ratings report (based on 2013 benefit year plan data) for Medicare contracts. The measures of interest included the Part D adherence measures for diabetes medications, antihypertensive agents, and statins and the Part C intermediate outcome measures for controlled blood sugar, blood pressure, and cholesterol. All Medicare Advantage Prescription Drug (MAPD) contracts with complete data for all Part C and D measures of interest were included. Contracts with ≥ 25% of total enrollment with MA-only benefit were excluded. Linear and logistic regression models were used to assess the association between 2015 Part D adherence measures and Part C intermediate outcome measures (n = 366). The regression models were adjusted for low-income subsidy (LIS) beneficiary enrollment and log-transformed (natural logarithm) total contract enrollment.

RESULTS

Bivariate linear regression models demonstrated moderate positive associations between each of the 2015 Part D adherence scores and related 2015 Part C measures that explained 27%-29% (R(2)) of variance. Including LIS and total contract enrollment in the regression models increased the R2 to 30%-36%. The multivariate logistic regression models showed that each percentage point of improvement in the 2015 Part D adherence measures was associated with a 4.13 to 4.69 greater odds of performing in the top quartile in corresponding 2015 Part C measures.

CONCLUSIONS

Moderate positive associations were observed between the Part D and Part C scores in the same benefit year. MAPD plans may observe improved Part C intermediate outcome measures with strategies that improve Part D medication adherence measures.

DISCLOSURES

This study was conducted by MedImpact Healthcare Systems, San Diego, California, without external funding. All authors are employees of MedImpact Healthcare Systems. Erickson reports advisory board fees from Sanofi and AstraZeneca. Ta, Erickson, and Patel were responsible for study concept and design and data interpretation, with assistance from Qiu. Qiu and Ta took the lead in data collection, assisted by Erickson. Ta wrote the manuscript, which was revised by Erickson and Patel.

Cost-benefit effectiveness of angiotensin-II receptor blockers in patients with uncomplicated hypertension: A comparative analysis

OBJECTIVE

The treatment of hypertensive patients (HTs) requires a long-term commitment of compliance for the patient and resources by the healthcare system. This poses an economic dilemma in countries where universal healthcare is standard. The aim of this study was to evaluate the costs/health benefit and effectiveness of treatment with angiotensin-II receptor blockers (ARBs) in uncomplicated essential hypertension.

DESIGN AND METHODS

The daily and annual economic commitment for treating patients with ARBs was estimated using pharmacy dispensing records and the BP-lowering effects of candesartan, irbesartan, losartan, olmesartan, telmisartan and valsartan was evaluated retrospectively. In 114 HTs (mean age 59.4±13.5year, 57.5% men), the BP-lowering effect of ARBs as in monotherapy and in fixed-dose combination (FDC) with hydrochlorothiazide at the doses commonly used in the market to reach BP control (i.e. BP <140/90mmHg) was analyzed. The BP lowering-effect was evaluated after an average of 6-month follow-up consulting medical professionals. Analysis of variance for repeated measures was provided.

RESULTS

Treatment with candesartan (14.1%) and olmesartan (32,4%) versus other ARBs resulted in a significant decrease in BP as for mono- than for FDC therapy. Our studies suggest that daily (data not shown) and annual costs of olmesartan were higher than candesartan as in mono- (4577.71±1120.55 vs. 894.25±127.75 €) than for FDC therapy (5715.90±459.90 vs. 1580.45±113.15 €).

CONCLUSIONS

Treatment: of BP with candesartan appears to be the most favorable option in terms of cost-effectiveness coupled with favorable health outcomes. These data have some limitations, but open the question if candesartan should be preferred to olmesartan in BP management. Further prospective studies comparing ARBs based on their effect on BP control in uncomplicated HTs are needed for validation.

Effect of Race and Ethnicity on Antihypertensive Medication Utilization Among Women in the United States: Study of Women's Health Across the Nation (SWAN)

Background

Antihypertensive medication use may vary by race and ethnicity. Longitudinal antihypertensive medication use patterns are not well described in women.

Methods and Results

Participants from the Study of Women's Health Across the Nation (SWAN), a prospective cohort of women (n=3302, aged 42–52), who reported a diagnosis of hypertension or antihypertensive medication use at any annual visit were included. Antihypertensive medications were grouped by class and examined by race/ethnicity adjusting for potential confounders in logistic regression models. A total of 1707 (51.7%) women, mean age 50.6 years, reported hypertension or used antihypertensive medications at baseline or during follow‐up (mean 9.1 years). Compared with whites, blacks were almost 3 times as likely to receive a calcium channel blocker (odds ratio, 2.92; 95% CI, 2.24–3.82) and twice as likely to receive a thiazide diuretic (odds ratio, 2.38; 95% CI, 1.93–2.94). Blacks also had a higher probability of reporting use of ≥2 antihypertensive medications (odds ratio, 1.95; 95% CI, 1.55–2.45) compared with whites. Use of angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers and thiazide diuretics increased over time for all racial/ethnic groups. Contrary to our hypothesis, rates of β‐blocker usage did not decrease over time.

Conclusions

Among this large cohort of multiethnic midlife women, use of antihypertensive medications increased over time, with angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers becoming the most commonly used antihypertensive medication, even for blacks. Thiazide diuretic utilization increased over time for all race/ethnic groups as did use of calcium channel blockers among blacks; both patterns are in line with guideline recommendations for the management of hypertension.

Access to and use of high blood pressure medications in Brazil

OBJECTIVE

To analyze the access to and use of medicines for high blood pressure among the Brazilian population according to social and demographic conditions.

METHODS

Analysis of data from Pesquisa Nacional Sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines), a nationwide cross-sectional, population-based study, with probability sampling, carried out between September 2013 and February 2014 in urban households in the five Brazilian regions. The study evaluated the access and use of medicines to treat people with high blood pressure. The independent variables were gender, age, socioeconomic status and Brazilian region. The study also described the most commonly used drugs and the percentage of people treated with one, two, three or more drugs. Point estimations and confidence intervals were calculated considering the sample weights and sample complex plan.

RESULTS

Prevalence of high blood pressure was 23.7% (95%CI 22.8-24.6). Regarding people with this condition, 93.8% (95%CI 92.8-94.8) had indication for drug therapy and, of those, 94.6% (95%CI 93.5-95.5) were using the medication at the time of interview. Full access to medicines was 97.9% (95%CI 97.3-98.4); partial access, 1.9% (95%CI 1.4-2.4); and no access, 0.2% (95%CI 0.1-0.4). The medication used to treat high blood pressure, 56.0% (95%CI 52.6-59.2) were obtained from SUS (Brazilian Unified Health System), 16.0% (95%CI 14.3-17.9) from Popular Pharmacy Program, 25.7% (95%CI 23.4-28.2) were paid for by the patients themselves and 2.3% (95%CI 1.8-2.9) were obtained from other locations. The five most commonly used drugs were, in descending order, hydrochlorothiazide, losartan, captopril, enalapril and atenolol. Of the total number of patients on treatment, 36.1% (95%CI 34.1-37.1) were using two medicines and 13.5% (95%CI 12.3-14.9) used three or more.

CONCLUSIONS

Access to medicines for the treatment of high blood pressure may be considered high and many of them are available free of charge. The most commonly used drugs are among those recommended as first-line treatment for high blood pressure control. The percentage of people using more than one drug seems to follow the behavior observed in other countries.

OBJETIVO

Analisar o acesso e a utilização de medicamentos para a hipertensão na população brasileira segundo condições sociais e demográficas. Análise dos dados da Pesquisa Nacional Sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos, estudo nacional de delineamento transversal de base populacional, com amostra probabilística, realizado entre setembro de 2013 e fevereiro de 2014 em domicílios urbanos nas cinco regiões do Brasil. Avaliou-se o uso e acesso aos medicamentos para os cuidados com pessoas que apresentam hipertensão arterial. As variáveis independentes utilizadas foram sexo, idade, nível socioeconômico e região do País. Também foram descritos os fármacos mais utilizados e a proporção de pessoas tratadas com um, dois, três ou mais fármacos. As estimativas de ponto e os intervalos de confiança foram calculados considerando os pesos amostrais e o plano complexo da amostra. A prevalência de hipertensão arterial foi de 23,7% (IC95% 22,8-24,6). Das pessoas com a condição, 93,8% (IC95% 92,8-94,8) tinham indicação de tratamento com medicamentos e, destes, 94,6% (IC95% 93,5-95,5) estavam usando os medicamentos no momento da entrevista. O acesso total aos medicamentos foi de 97,9% (IC95% 97,3-98,4); o acesso parcial, de 1,9% (IC95% 1,4-2,4); e o acesso nulo, de 0,2% (IC95% 0,1-0,4). Dos medicamentos utilizados para tratar a hipertensão, 56,0% (IC95% 52,6-59,2) foram obtidos no SUS, 16,0% (IC95% 14,3-17,9), no Programa Farmácia Popular, 25,7% (IC95% 23,4-28,2) pago do próprio bolso e 2,3% (IC95% 1,8-2,9) em outros locais. Os cinco fármacos mais utilizados foram, em ordem descrente, hidroclorotiazida, losartana, captopril, enalapril e atenolol. Do total de tratados, 36,1% (IC95% 34,1-37,1) estavam usando dois fármacos e 13,5% (IC95% 12,3-14,9) utilizavam três ou mais fármacos.

CONCLUSÕES

: O acesso aos medicamentos para tratamento da hipertensão pode ser considerado elevado e grande parte desses medicamentos é obtida gratuitamente. Os fármacos mais utilizados estão entre os preconizados como de primeira linha para o controle de hipertensão arterial. A proporção de pessoas utilizando mais de um fármaco parece seguir o comportamento observado em outros países.

Trends in Prevalence of Chronic Kidney Disease in the United States

Background

Trends in the prevalence of chronic kidney disease (CKD) are important for health care policy and planning.

Objective

To update trends in CKD prevalence.

Design

Repeated cross-sectional study.

Setting

NHANES (National Health and Nutrition Examination Survey) for 1988 to 1994 and every 2 years from 1999 to 2012.

Participants

Adults aged 20 years or older.

Measurements

Chronic kidney disease (stages 3 and 4) was defined as an estimated glomerular filtration rate (eGFR) of 15 to 59 mL/min/1.73 m2, estimated with the Chronic Kidney Disease Epidemiology Collaboration equation from calibrated serum creatinine measurements. An expanded definition of CKD also included persons with an eGFR of at least 60 mL/min/1.73 m2 and a 1-time urine albumin-creatinine ratio of at least 30 mg/g.

Results

The unadjusted prevalence of stage 3 and 4 CKD increased from the late 1990s to the early 2000s. Since 2003 to 2004, however, the overall prevalence has largely stabilized (for example, 6.9% prevalence in 2003 to 2004 and in 2011 to 2012). There was little difference in adjusted prevalence of stage 3 and 4 CKD overall in 2003 to 2004 versus 2011 to 2012 after age, sex, race/ethnicity, and diabetes mellitus status were controlled for (P = 0.26). Lack of increase in CKD prevalence since the early 2000s was observed in most subgroups and with an expanded definition of CKD that included persons with higher eGFRs and albuminuria.

Limitation

Serum creatinine and albuminuria were measured only once in each person.

Conclusion

In a reversal of prior trends, there has been no appreciable increase in the prevalence of stage 3 and 4 CKD in the U.S. population overall during the most recent decade.

Primary Funding Source

American Society of Nephrology Foundation for Kidney Research Student Scholar Grant Program, Centers for Disease Control and Prevention, and National Institutes of Health.

How does prescribing for antihypertensive products stack up against guideline recommendations? An Australian population-based study (2006-2014)

AIMS

We describe choice of first-line antihypertensive drug therapy and uptake of fixed-dose combinations (FDCs) in Australia, and investigate the impact of initiation on FDCs and other non-recommended first-line therapies on treatment discontinuation.

METHOD

This was a population-based retrospective cohort study using a random 10% sample of persons dispensed an Australian Pharmaceutical Benefits Scheme listed medicine from 1 July 2005 to 30 June 2014. The primary outcomes were adherence to Australian recommendations at initiation of antihypertensive therapy, discontinuation of initial therapy and discontinuation of any therapy in the first year after initiation.

RESULTS

In our sample of 55 937 persons initiating therapy, 42.0% did so outside Australian recommendations, including not initiating on recommended monotherapy (26.3%) and not initiating on the lowest recommended dose (30.6%). Only 1.7% of individuals who were dispensed an FDC established therapy on the free combination regimen (as recommended) prior to switching. After adjusting for covariates, persons initiating on non-recommended monotherapy (OR = 2.64, 95% CI 2.47-2.83) or FDCs of two or more antihypertensives (OR = 1.42, 95% CI 1.30-1.55), were more likely to discontinue all antihypertensive drug treatment in the first year compared to persons initiating on recommended monotherapy.

CONCLUSION

More than half of antihypertensive initiators conformed to Australian guidelines. Initiation on FDCs and other non-recommended treatments was associated with lower persistence on antihypertensive therapy in the first year. Long-term effectiveness and outcomes may be enhanced by initiating with low dose monotherapy.

Long-term use of calcium channel blocking drugs and breast cancer risk in a prospective cohort of US and Puerto Rican women

Background

In a recent case–control study, long-term use of calcium channel blocking drugs was associated with a greater-than-twofold increased breast cancer risk. If prospectively collected data confirm that calcium channel blocker use increases breast cancer risk, this would have major implications for hypertension treatment. The objective of this study was to determine whether women using calcium channel blockers for 10 years or more were at increased risk of developing breast cancer compared with women not using calcium channel blockers.

Methods

The Sister Study is a prospective volunteer cohort study of women from the USA and Puerto Rico designed to evaluate environmental and genetic risk factors for breast cancer. Beginning in 2003, women between the ages of 35 and 74 were recruited. They were eligible to participate if they had a sister with breast cancer but had not been diagnosed with breast cancer themselves. In total, 50,884 women enrolled in the cohort between 2003 and 2009; 50,757 women with relevant baseline data and available follow-up data are included in this study. The exposure of interest is current use of calcium channel blocking drugs and the reported duration of use at entry into the cohort. Secondary exposures of interest were the duration and frequency of use for all other subclasses of antihypertensive drugs. Our main outcome is a self-reported diagnosis of breast cancer during the study follow-up period. With patient permission, self-reported diagnoses were confirmed using medical records.

Results

Results showed 15,817 participants were currently using an antihypertensive drug, and 3316 women were currently using a calcium channel blocker at study baseline; 1965 women reported a breast cancer diagnosis during study follow-up. Using Cox proportional hazards modeling, we found no increased risk of breast cancer among women who had been using calcium channel blockers for 10 years or more compared with never users of calcium channel blockers (HR 0.88, 95 % CI 0.58–1.33).

Conclusions

We saw no evidence of increased risk of breast cancer from 10 years or more of current calcium channel blocker use. Our results do not support avoiding calcium channel blocking drugs in order to reduce breast cancer risk.

Electronic supplementary material

The online version of this article (doi:10.1186/s13058-016-0720-6) contains supplementary material, which is available to authorized users.

Hypertension, use of antihypertensive medications, and risk of epithelial ovarian cancer

Few studies have examined the associations of hypertension and antihypertensive medications with ovarian cancer. In particular, beta-blockers, one of the most commonly prescribed medications to treat hypertension, may reduce ovarian cancer risk by inhibiting beta-adrenergic signaling. We prospectively followed 90,384 women in the Nurses' Health Study (NHS) between 1988-2012 and 113,121 NHSII participants between 1989-2011. Hypertension and use of antihypertensive medications were self-reported biennially. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). We documented 948 ovarian cancer cases during follow-up. Similar results were observed in the two cohorts. While hypertension was not associated with ovarian cancer risk (Pooled HR = 1.01; 95% CI = 0.88, 1.16), current use of any antihypertensive medication was associated with slightly increased risk compared to never users (Pooled HR = 1.18; 95% CI: 1.02, 1.37). This increased risk was primarily due to use of thiazide diuretics (Pooled HR = 1.37; 95% CI: 1.13, 1.68). No associations were observed for beta-blockers or angiotensin-converting-enzyme inhibitors. Calcium channel blockers (CCBs) were associated with suggestively reduced risk (NHS HR = 0.73; 95% CI: 0.53, 1.01), after adjusting for all antihypertensive medications. Associations were similar among hypertensive women and stronger for longer use of thiazide diuretics and CCBs. In conclusion, our results provided no evidence that beta-blockers were associated with reduced ovarian cancer risk. In contrast, we observed an increased risk for use of thiazide diuretics that should be confirmed in other studies.

Trends in Antihypertensive Medication Use and Blood Pressure Control Among Adults With Hypertension in Germany

BACKGROUND

Hypertension is a major risk factor for morbidity and mortality, therefore its control is of great importance. In this study we compare the use of antihypertensive medication among adults with hypertension in Germany 1998 and 2008-2011 and determine factors associated with use and control.

METHODS

Data from German Health Examination Surveys (GNHIES98 1998, n = 7,124 and DEGS1 2008-2011 n = 7,988, age 18-79 years) including standardized blood pressure (BP) measurements and Anatomical Therapeutic Chemical (ATC) medication codes were analyzed.

RESULTS

The use of antihypertensive medication among adults with hypertension in Germany increased from 54% to 72% in 1 decade. In 2008-2011, 67% of users were treated with polytherapy. The most commonly used antihypertensive class in 1998 was diuretics (43%) and in 2008-2011 beta-blockers (54%). Ramipril and metoprolol are currently the most commonly used monotherapy agents, while ramipril in combination with hydrochlorothiazide is the most frequent polytherapy. Being a woman, older age, having statutory health insurance, diabetes, coronary heart disease (CHD), stroke, and obesity were positively associated with antihypertensive use. The control rate among treated increased from 42% to 72%. Young women (18-54 years) had better control compared to older women or to men. Having CHD or stroke was positively associated with BP control.

CONCLUSIONS

Increased and improved antihypertensive use might be a main contributor to the decrease in BP observed in Germany in the last decade. However, there are still socio-demographic and health disparities in hypertension treatment and control.

Sex Disparity in Blood Pressure Levels Among Nigerian Health Workers

Sex disparity in hypertension prevalence is well established in developed nations; however, there is paucity of data on the distribution of hypertension prevalence between the sexes in developing countries. Therefore, the authors examined sex differences in hypertension prevalence and cardiovascular risk factors in a sample of 352 healthy hospital workers in Nigeria. The mean ages of the men and women were 37.2±7.9 and 44.7±9.1 years, respectively. Thirty-five percent of participants were hypertensive, with 54% on treatment and 70% with controlled blood pressure. Men had a higher prevalence of hypertension (38.4% vs 33.0%) and prehypertension (37.6% vs 29.7%). Women had significantly higher odds of developing hypertension and of being on treatment. Mean blood pressure and fasting plasma glucose values were higher in men, while women were more often older, obese, and dyslipidemic and had a lower mean estimated glomerular filtration rate (P<.0001). These findings indicate sex disparity in blood pressure among hospital employees. Sex-focused management of hypertension is therefore advocated for hospital employees.

Trends in Prescription Drug Use Among Adults in the United States From 1999-2012

IMPORTANCE

It is important to document patterns of prescription drug use to inform both clinical practice and research.

OBJECTIVE

To evaluate trends in prescription drug use among adults living in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Temporal trends in prescription drug use were evaluated using nationally representative data from the National Health and Nutrition Examination Survey (NHANES). Participants included 37,959 noninstitutionalized US adults, aged 20 years and older. Seven NHANES cycles were included (1999-2000 to 2011-2012), and the sample size per cycle ranged from 4861 to 6212.

EXPOSURES

Calendar year, as represented by continuous NHANES cycle.

MAIN OUTCOMES AND MEASURES

Within each NHANES cycle, use of prescription drugs in the prior 30 days was assessed overall and by drug class. Temporal trends across cycles were evaluated. Analyses were weighted to represent the US adult population.

RESULTS

Results indicate an increase in overall use of prescription drugs among US adults between 1999-2000 and 2011-2012 with an estimated 51% of US adults reporting use of any prescription drugs in 1999-2000 and an estimated 59% reporting use of any prescription drugs in 2011-2012 (difference, 8% [95% CI, 3.8%-12%]; P for trend <.001). The prevalence of polypharmacy (use of ≥5 prescription drugs) increased from an estimated 8.2% in 1999-2000 to 15% in 2011-2012 (difference, 6.6% [95% CI, 4.4%-8.2%]; P for trend <.001). These trends remained statistically significant with age adjustment. Among the 18 drug classes used by more than 2.5% of the population at any point over the study period, the prevalence of use increased in 11 drug classes including antihyperlipidemic agents, antidepressants, prescription proton-pump inhibitors, and muscle relaxants.

CONCLUSIONS AND RELEVANCE

In this nationally representative survey, significant increases in overall prescription drug use and polypharmacy were observed. These increases persisted after accounting for changes in the age distribution of the population. The prevalence of prescription drug use increased in the majority of, but not all, drug classes.

The association of antihypertensives with postural blood pressure and falls among seniors residing in the community: a case-control study

BACKGROUND

A drop in postural blood pressure (BP) may contribute to falls, while antihypertensives have been considered to induce postural drop or orthostatic hypotension (OH) and falls among older people. However, this relationship between antihypertensives, postural BP and the risk of falls has never been evaluated in a single study.

OBJECTIVE

To examine the association of postural BP changes and BP therapy with the risk of falls among community-dwelling older people in a case-control manner.

METHOD

Cases (n = 202) included participants aged ≥ 65 years with two falls or one injurious fall while controls (n = 156) included participants ≥ 65 years with no falls in the preceding 12 months. Antihypertensives usage and medical history were recorded. Supine BP measurements were obtained at 10 min rest and at 1, 2 and 3 min after standing. Orthostatic hypotension was defined as a reduction in BP of 20/10 mmHg within 3 min of standing.

RESULTS

Individual antihypertensive classes were not associated with falls. Minimal standing systolic BP (SBP) was significantly lower among fallers [128 (± 27·3) vs. 135·7 (± 24·7) mmHg; P = 0·01], but fallers were not more likely to fulfil the diagnostic criteria for OH. Diuretics were associated with OH and α-blockers were associated with minimal standing SBP. Univariate analysis revealed that the use of ≥ 2 antihypertensives was associated with recurrent and injurious falls [OR,1.97;CI,1.2-3.1], which was no longer significant aftermultivariateadjustment for age and number of comorbidities [OR, 1.6; CI, 0.95-2.6].

DISCUSSION

Minimal standing SBP or a lower SBP at 2 or 3minutes standing was associated with falls rather than OH using consensus definition. Association between ≥ 2 antihypertensives and falls was attenuated by increasing age and comorbidities. Our findings challenge previous assumptions that OH or the use of antihypertensives is associated with falls. Future studies should now seek to link these findings prospectively with falls in order to guide decision-making for BP lowering therapy among older patients.

National trends in the ambulatory treatment of hypertension in the United States, 1997-2012

Importance

Hypertension is common and costly. Over the past decade, new antihypertensive therapies have been developed, several have lost patent protection and additional evidence regarding the safety and effectiveness of these agents has accrued.

Objective

To examine trends in the use of antihypertensive therapies in the United States between 1997 and 2012.

Design, Setting and Participants

We used nationally representative audit data from the IMS Health National Disease and Therapeutic Index to examine the ambulatory pharmacologic treatment of hypertension.

Outcome Measures

Our primary unit of analysis was a visit where hypertension was a reported diagnosis and treated with a pharmacotherapy (treatment visit). We restricted analyses to the use of six therapeutic classes of antihypertensive medications among individuals 18 years or older.

Results

Annual hypertension treatment visits increased from 56.9 million treatment visits (95% confidence intervals [CI], 53.9–59.8) in 1997 to 83.3 million visits (CI 79.2–87.3) in 2008, then declined steadily to 70.9 million visits (CI 66.7–75.0) by 2012. Angiotensin receptor blocker utilization increased substantially from 3% of treatment visits in 1997 to 18% by 2012, whereas calcium channel blocker use decreased from 27% to 18% of visits. Rates of diuretic and beta-blocker use remained stable and represented 24%–30% and 14–16% of visits, respectively. Use of direct renin inhibitor accounted for fewer than 2% of annual visits. The proportion of visits treated using fixed-dose combination therapies increased from 28% to 37% of visits.

Conclusions

Several important changes have occurred in the landscape of antihypertensive treatment in the United States during the past decade. Despite their novel mechanism of action, the adoption rate of direct renin inhibitors remains low.

Utilization patterns of antihypertensive drugs among the chronic kidney disease population in the United States: a cross-sectional analysis of the national health and nutrition examination survey

PURPOSE

Antihypertensive drugs are prescribed to patients with chronic kidney disease (CKD) for their cardioprotective and renoprotective effects. Nationally representative information on the use of antihypertensive drugs among CKD patients is limited. The purpose of this study was to assess the utilization patterns of antihypertensive drugs among the CKD population (stages I-IV) in the United States.

METHODS

We conducted a retrospective cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) panels from 2005-2006, 2007-2008, and 2009-2010. The estimated glomerular filtration rate was calculated and kidney damage was assessed to identify participants with CKD. The demographic and clinical characteristics of the participants with CKD were reported, as were the antihypertensive drugs they used.

FINDINGS

A total weighted sample of 116,231,361 participants representative of the CKD population in the United States (stages I-IV) was identified. Less than one half of the participants with CKD in the NHANES were using antihypertensive drugs. β-blockers were the most commonly used and angiotensin II receptor blockers were the least used antihypertensive agents among participants with CKD. Age (≥70 years), awareness of hypertension or diabetes, and higher stage of CKD were associated with an increased likelihood of antihypertensive drug use among participants with CKD.

IMPLICATIONS

The results of our analyses suggest that antihypertensive drugs are underused in the CKD population, and the use of preferred agents (ie, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers) is low. Efforts should be directed toward emphasizing the importance of using antihypertensive drugs in the CKD population.

Anti hypertensive prescribing patterns and cost analysis for primary hypertension: a retrospective study

OBJECTIVE

The present study was conducted to analyze the current prescription pattern and cost analysis of antihypertensive drugs in hypertensive patients in a tertiary care hospital.

MATERIALS AND METHODS

A retrospective cross-sectional study was conducted in tertiary care hospital, Bangalore for three months and utilized 300 prescriptions for the analysis. The data analysed from the prescription included patients demographics, stage of hypertension according to JNC VII guidelines, type of drug therapy, class of anti-hypertensive, and cost effectiveness of therapy. Drug acquisition costs was calculated, using the cost of the cheapest available drug and the most commonly prescribed dosage, for each drug on a daily and annual basis. Total annual drug expenditure on buying required doses of all antihypertensive prescribed in the study population for a year was calculated.

RESULTS

Monotherapy (48.94%) was leading trends of antihypertensive therapy followed by fixed dose combination (35.04%) and polytherapy (16.01%). The most frequent antihypertensive class to be prescribed were CCBs (38.59%) followed by beta blockers (24.07%). The ranking in terms of cost utilized per year from the highest to the lowest found in this study was: alpha blockers> ACE-inhibitors> ARBs> CCBs> beta blockers > diuretics. The diuretics were most cost-effective (Cost per day: 5.89 ± 2.87; Cost per year: 2129.02 ± 1080.49) in relation to the other antihypertensive prescribed.

Pharmacokinetic interactions between topiramate and diltiazem, hydrochlorothiazide, or propranolol

Drug-drug interactions between topiramate and diltiazem, hydrochlorothiazide, or propranolol were evaluated along with safety/tolerability in three open-label studies. Healthy participants (aged 18-45 years) received topiramate 75 mg every 12 hours (q12h) and diltiazem 240 mg/day (study 1); topiramate 96 mg q12h and hydrochlorothiazide 25 mg/day (study 2); topiramate 100 mg q12h and propranolol 40-80 mg q12h (study 3). The pharmacokinetic parameters for topiramate, diltiazem (and active metabolites, desacetyldiltiazem [DEA], N-demethyl diltiazem [DEM]), hydrochlorothiazide, and propranolol (and its active metabolite) were assessed at steady state. Results showed no effect of diltiazem on topiramate pharmacokinetics. However, a modest reduction in systemic exposures of diltiazem and DEA (10-27%) occurred during coadministration with topiramate. Systemic exposure of DEM was unaffected. Furthermore, oral and renal clearance of topiramate decreased (22-30%) significantly (P < 0.05) during coadministration with hydrochlorothiazide, while systemic exposure increased by 27-29%. Topiramate had no effect on hydrochlorothiazide pharmacokinetics. The results demonstrated lack of pharmacokinetic interaction between topiramate and propranolol. Overall, no new safety concerns emerged when topiramate was coadministered with diltiazem, hydrochlorothiazide, or propranolol.

Vasodilators, blood pressure-lowering medications, and age-related macular degeneration: the Beaver Dam Eye Study

OBJECTIVE

To examine the association of vasodilator and antihypertensive medication use with the incidence of age-related macular degeneration (AMD).

DESIGN

Longitudinal population-based study.

PARTICIPANTS

Persons 43 to 86 years of age living in Beaver Dam, Wisconsin, from 1988 through 1990.

METHODS

Examinations were performed every 5 years over a 20-year period. There were 9676 total person-visits over the course of the study. Status of AMD was determined from grading retinal photographs.

MAIN OUTCOME MEASURES

Incidence of AMD.

RESULTS

The 5-year incidence of early AMD over the 20-year period was 8.4%; for late AMD, it was 1.4%; for pure geographic atrophy (GA), it was 0.6%; for exudative AMD, it was 0.9%; and for progression of AMD, it was 24.9%. While adjusting for age, gender, and other factors, using a vasodilator (hazard ratio [HR], 1.72; 95% confidence interval [CI], 1.25-2.38), particularly oral nitroglycerin (HR, 1.81; 95% CI, 1.14-2.90), was associated with an increased risk of early AMD. Using an oral β-blocker was associated with an increased hazard of incident exudative AMD (HR, 1.71; 95% CI, 1.04-2.82), but not pure GA (HR, 0.51; 95% CI, 0.20-1.29) or progression of AMD (HR, 0.92; 95% CI, 0.67-1.28) over the 20-year period.

CONCLUSIONS

Use of vasodilators is associated with a 72% increase in the hazard of incidence of early AMD, and use of oral β-blockers is associated with a 71% increase in the hazard of incident exudative AMD. If these findings are replicated, it may have implications for care of older adults because vasodilators and oral β-blockers are drugs that are used commonly by older persons.

Trends in serum lipids and hypertension prevalence among non-pregnant reproductive-age women: United States National Health and Nutrition Examination Survey 1999-2008

Cardiovascular disease is one of the leading causes of death among reproductive-age women. In this study, we examine trends in the prevalence of dyslipidemia, hypertension, and related clinicians' advice among reproductive-age women. We conducted trend analysis of these factors among non-pregnant women aged 20-49 years (n = 5,768) using National Health and Nutrition Examination Survey (NHANES) data obtained between 1999 and 2008. Multiple linear regression and logistic regression analyses were used to examine linear trends over a 10-year period after adjusting for covariates. A downward trend was observed for the proportion of women with abnormal levels of low density lipoprotein (LDL; P = 0.038) and high density lipoprotein (HDL; P = 0.008) cholesterol from 1999 to 2008. In contrast, no significant changes were observed in the prevalence of abnormal total cholesterol (P = 0.948) and triglyceride levels (P = 0.300), or hypertension (P = 0.632). Based on the self-reported data, upward trends were observed in the rates of cholesterol checking (P = 0.002), high cholesterol (P = 0.012), receiving clinicians' advice to use lipid-lowering agents (P < 0.001) and patients' compliance with their advice (P < 0.001). Although rates of self-reported hypertension did not change over time (P = 0.120), receiving clinicians' advice to use antihypertensive medications (P = 0.003) and patients' compliance with these medications (P = 0.015) also increased significantly. Overall improvements in LDL and HDL cholesterol over this time period could be due to increases in related awareness, receiving advice to use medications, and patients' compliance with this advice. Use of antihypertensive medication has also increased among reproductive-age women in the US.

Old habits die hard: a nationwide utilization study of short-acting nifedipine in Taiwan

BACKGROUND

To investigate the nationwide trend of ambulatory prescriptions of short-acting nifedipine on a PRN (pro re nata) order over a fifteen-year period in Taiwan.

METHODS

The systematic sampling claims datasets (0.2% sampling ratio) of ambulatory care visits within Taiwan's National Health Insurance from 1997 to 2011 were analyzed. The prescriptions of short-acting capsule-form nifedipine on a PRN order were stratified by the patient's age, the prescribing physician's specialty, and the setting of healthcare facility for each year.

RESULTS

During the study period, 8,189,681 visits were analyzed. While the utilization rate of calcium channel blockers changed with time from 2.8% (13,767/489,636) in 1997 to 5.1% (31,349/614,719) in 2011, that of short-acting nifedipine were from 1.0% (n = 5,070) to 0.2% (n = 1,246). However, short-acting capsule-form nifedipine on a PRN order still existed (from 447 prescriptions in 1997 to 784 in 2011). More than one half of these PRN nifedipines were prescribed by the internists and to the elderly patients; almost four-fifths of PRN nifedipines were prescribed during non-emergent consultations.

CONCLUSION

The physicians in Taiwan still had the habit of prescribing short-acting nifedipines for PRN use. The reason for such practices and the impact on patients' health deserve attention.

Assessment of arterial stiffness for clinical and epidemiological studies: methodological considerations for validation and entry into the European Renal and Cardiovascular Medicine registry

Epidemiological studies have highlighted the role of arterial stiffness as a risk factor for development of cardiovascular (CV) diseases. Moreover, aortic stiffness has been shown to be a significant predictive factor of all-cause and CV mortality in different populations including patients with end-stage renal disease. Pulse-wave velocity (PWV) is the most widely used technique to assess arterial stiffness. Although PWV can be measured on any artery or between any arterial sites, only carotid-to-femoral PWV, representing stiffness of the aorta and iliofemoral axes, has been shown to have predictive value for morbidity and mortality. The several available commercial devices differ according to the type of signal (pressure, distension, flow) or by recording both sites simultaneously or using ECG synchronization. It is also possible to directly measure arterial diameter changes during the cardiac cycle and link them to local pulse-pressure changes, which provides the pressure-diameter relationship and stress-strain relationship if arterial wall thickness is also measured. These techniques are based on high-precision vascular echo tracking or magnetic resonance imaging and applanation tonometry. This paper summarizes the basic principles of arterial haemodynamics and various methodologies to assess stiffness and the latest consensus recommendations for clinical applications.