Adherence to Antihypertensive Medications and Cardiovascular Morbidity Among Newly Diagnosed Hypertensive Patients

Antihypertensive Medication Adherence and Medical Costs, Health Care Use, and Labor Productivity Among People With Hypertension

BACKGROUND

Hypertension affects nearly half of US adults yet remains inadequately controlled in over three-quarters of these cases. This study aimed to assess the association between adherence to antihypertensive medications and total medical costs, health care use, and productivity-related outcomes.

METHODS AND RESULTS

We conducted cross-sectional analyses using MarketScan databases, which included individuals aged 18 to 64 years with noncapitated health insurance plans in 2019. Adherence was defined as ≥80% medication possession ratio for prescribed antihypertensive medications. We used a generalized linear model to estimate total medical costs, a negative binomial model to estimate health care use (emergency department visits and inpatient admissions), an exponential hurdle model to estimate productivity-related outcomes (number of sick absences, short-term disability, long-term disability), and a 2-part model to estimate productivity-related costs in 2019 US dollars. All models were adjusted for age, sex, urbanicity, census region, and comorbidities. We reported average marginal effects for outcomes related to antihypertensive medication adherence. Among 379 503 individuals with hypertension in 2019, 54.4% adhered to antihypertensives. Per person, antihypertensive medication adherence was associated with $1441 lower total medical costs, $11 lower sick absence costs, $291 lower short-term disability costs, and $69 lower long-term disability costs. Per 1000 individuals, medication adherence was associated with lower health care use, including 200 fewer emergency department visits and 90 fewer inpatient admissions, and productivity-related outcomes, including 20 fewer sick absence days and 442 fewer short-term disability days.

CONCLUSIONS

Adherence to antihypertensives was consistently associated with lower total medical costs, reduced health care use, and improved productivity-related outcomes.

Association between medication adherence and blood pressure control and factors associated with antihypertensive medication adherence in the Melaka Tengah District: A cross-sectional survey

Introduction

The burden of cardiovascular disease and early morbidity and mortality is exacerbated by hypertension. According to the 2019 National Health and Morbidity Survey, 30% of adults in Malaysia aged over 18 years had hypertension. Our study aimed to investigate the association between medication adherence and blood pressure control and the factors associated with antihypertensive medication adherence.

Methods

This cross-sectional study was conducted among adult patients with hypertension who had been under treatment at public primary health clinics in the Melaka Tengah District. A self-administered questionnaire was used, and blood pressure was measured. Descriptive and multivariate logistic regression analyses were conducted using the Statistical Package for the Social Sciences (version 28).

Results

A total of 1531 patients were recruited in this study. Among them, 74.1% had good antihypertensive medication adherence, and 51.4% had their blood pressure controlled. Medication adherence was significantly associated with blood pressure control (P<0.005). The multivariate analysis showed that the determinants for antihypertensive medication non-adherence were Malay ethnicity, secondary education, farther distance from the clinic, experience of side effects of antihypertensive medications, concern about long-term side effects and usage of alternative medicine (P<0.05). Taking multiple antihypertensive medications was the only factor associated with uncontrolled blood pressure (P<0.05).

Conclusion

Addressing issues on medication adherence is important to ensure blood pressure control. The factors associated with non-adherence should be closely monitored to improve blood pressure control and prevent adverse health outcomes. Single-pill combination antihypertensive medications are encouraged to reduce pill burden and improve blood pressure control.

Factors associated with suboptimal adherence to antihypertensive medication: Cross-sectional study using nationally representative databases

Suboptimal adherence to antihypertensive medication is a major challenge in controlling blood pressure. However, limited studies exist on suboptimal adherence to hypertension, especially in Korea. This study investigates factors associated with suboptimal adherence, including non-treatment and non-adherence. Study populations were collected from the Korea National Health and Nutrition Examination Survey (KNHANES) from 2007 to 2021. Participants were classified into three groups based on treatment and adherence to antihypertensive medication using a self-reported questionnaire. Multivariable adjusted logistic regression analysis was performed using KNHANES data to investigate associations for suboptimal adherence with covariates. In KNHANES, the adherent, non-adherent, and non-treatment groups consisted of 13,831 (92.8 %), 460 (3.1 %), and 612 (4.1 %) subjects, respectively. In the adjusted model, age, hypertension diagnosis duration, diabetes, dyslipidemia, and high hemoglobin levels were associated with receiving treatment. Older age, longer hypertension diagnosis duration, comorbid diabetes mellitus, and ischemic heart disease were associated with adherence. This study showed the characteristics of non-adherent and non-treatment hypertensive patient groups in Korea. Based on this study, further individualized health interventions are required.

Phase III randomized clinical trial of efficacy and safety of amlodipine and candesartan cilexetil combination for hypertension treatment

Effective antihypertensive therapy is essential for achieving optimal blood pressure (BP) control and reducing cardiovascular events. This double-blind, multicenter, randomized trial aimed to compare the antihypertensive efficacy and safety of a combination of amlodipine (AML) and candesartan cilexetil (CC) versus AML monotherapy in patients with essential hypertension (HTN). After a 4-week run-in period with AML 5 mg, patients whose HTN remained uncontrolled (diastolic BP [DBP]) ≥ 90 mmHg and < 120 mmHg) were randomized to receive either AML + CC or AML alone for 8 weeks. Efficacy was assessed by measuring changes in DBP and systolic BP (SBP). The primary safety measure was the incidence of adverse events (AEs). A total of 174 participants were included in the efficacy analysis. After 8 weeks, DBP decreased by -9.92 ± 0.86 mmHg in the AML + CC arm and - 2.08 ± 0.86 mmHg in the AML arm (p < 0.0001). SBP decreased by -14.27 ± 1.39 mmHg in the AML + CC arm versus - 2.77 ± 1.39 mmHg in the AML arm (p < 0.0001). AEs occurred in 11.24% of the AML + CC group and 5.62% of the AML group (p = 0.1773). AML + CC combination therapy demonstrated superior efficacy with good tolerance, making it a promising option for patients with inadequately controlled hypertension on amlodipine alone.

Awareness of Being Prescribed Antihypertensive Medications and Cardiovascular Outcomes

BACKGROUND

Hypertension is a major cause of cardiovascular disease (CVD). In patients with hypertension, unawareness of the disease often results in poor blood pressure control and increases the risk of CVD. However, data in nationwide surveys regarding the proportion of unaware individuals and the implications of such on their clinical outcomes are lacking. We aimed to clarify the association between unawareness of being prescribed antihypertensive medications among individuals taking antihypertensive medications and the subsequent risk of developing CVD.

METHODS AND RESULTS

This retrospective cohort study analyzed data from the JMDC Claims Database, including 313,715 individuals with hypertension treated with antihypertensive medications (median age 56 years). The primary endpoint was a composite of myocardial infarction, angina pectoris, stroke, heart failure, and atrial fibrillation. Overall, 19,607 (6.2%) individuals were unaware of being prescribed antihypertensive medications. During the follow-up period, 33,976 composite CVD endpoints were documented. Despite their youth, minimal comorbidities, and the achievement of better BP control with a reduced number of antihypertensive prescriptions, unawareness of being prescribed antihypertensive medications was associated with a greater risk of developing composite CVD. Hazard ratios of unawareness of being prescribed antihypertensive medications were 1.16 for myocardial infarction, 1.25 for angina pectoris, 1.15 for stroke, 1.36 for heart failure, and 1.28 for atrial fibrillation. The results were similar in several sensitivity analyses, including the analysis after excluding individuals with dementia.

CONCLUSIONS

Among individuals taking antihypertensive medications, assessing the awareness of being prescribed antihypertensive medications may help identify those at high risk for CVD-related events.

Renal sympathetic denervation 2024 in Austria: recommendations from the Austrian Society of Hypertension : Endorsed by the Austrian Society of Nephrology and the Working Group of Interventional Cardiology of the Austrian Society of Cardiology

Renal sympathetic denervation (RDN) is an interventional supplement to medical treatment in patients with arterial hypertension. While the first sham-controlled trial, SYMPLICITY HTN‑3 was neutral, with improved procedural details, patient selection and follow-up, recent randomized sham-controlled trials of second-generation devices show a consistent blood pressure lowering effect of RDN, as compared to sham controls. These new data and the recent U.S. Food and Drug Administration (FDA) premarket approval of two RDN devices are the basis for the present recommendations update.This joint position paper from the Austrian Society of Hypertension, together with the Austrian Society of Nephrology and the Working Group of Interventional Cardiology from the Austrian Society of Cardiology includes an overview about the available evidence on RDN and gives specific recommendations for the work-up, patient selection, pretreatment, procedural management and follow-up in patients undergoing RDN in Austria. Specifically, RDN may be used in clinical routine care, together with lifestyle measures and antihypertensive drugs, in patients with resistant hypertension (i.e. uncontrolled blood pressure on 3 antihypertensive drugs) and in those with uncontrolled hypertension, after adequate work-up, if institutional, patient-related and procedural conditions are fulfilled.

The Patterns of Non-adherence to Medication in the Management of Cardiovascular Disease: A Descriptive Study

INTRODUCTION

Cardiovascular diseases (CVDs) such as hypertension, ischemic heart disease, and stroke are highly prevalent and have a significant impact on quality of life and the healthcare economy. This study aimed to evaluate adherence to medication regimens in CVD patients.

MATERIALS AND METHODS

A cross-sectional descriptive study of 203 patients was conducted using a semi-structured questionnaire which included an eight item Morisky Medication Adherence Scale (MMAS-8) to assess medication compliance.

RESULTS

The survey included 203 patients, 164 (81%) males and 39 (19%) females. Overall, 156 (76.8%) had medical insurance, while only 47 (23.2%) were not medically insured. In total, 161 patients (79.3%) adhered to the medical regimen.

CONCLUSION

Most participants adhered to their treatment regimen in the present study. However, inadequate knowledge regarding side effects and abrupt discontinuation of medications without physician consultation was reported to a high degree. These findings highlight the areas for improvement in healthcare to improve medication adherence rates.

Identifying personalized barriers for hypertension self-management from TASKS framework

OBJECTIVE

Effective management of hypertension requires not only medical intervention but also significant patient self-management. The challenge, however, lies in the diversity of patients' personal barriers to managing their condition. The objective of this research is to identify and categorize personalized barriers to hypertension self-management using the TASKS framework (Task, Affect, Skills, Knowledge, Stress). This study aims to enhance patient-centered strategies by aligning support with each patient's specific needs, recognizing the diversity in their unique circumstances, beliefs, emotional states, knowledge levels, and access to resources. This research is based on observations from a single study focused on eight patients, which may have been a part of a larger project.

RESULTS

The analysis of transcripts from eight patients and the Global Hypertension Practice Guidelines revealed 69 personalized barriers. These barriers were distributed as follows: emotional barriers (49%), knowledge barriers (24%), logical barriers (17%), and resource barriers (10%). The findings highlight the significant impact of emotional and knowledge-related challenges on hypertension self-management, including difficulties in home blood pressure monitoring and the use of monitoring tools. This study emphasizes the need for tailored interventions to address these prevalent barriers and improve hypertension management outcomes.

Level of medication adherence and its determinants of cardiovascular disease patients attending at specialized teaching hospitals of Amhara regional state, Ethiopia: a multicenter cross-sectional study

Background

Non-adherence to medication in patients with cardiovascular disease continues to be a main cause of suboptimal management, increased morbidity and mortality, and increased healthcare expenses. The present study assessed the level of medication adherence and its determinants of cardiovascular disease patients.

Methods

An institutional-based multicenter cross-sectional study was conducted with patients with cardiovascular disease in Northwest Ethiopian teaching hospitals. The level of medication adherence was evaluated using a standardized questionnaire of the Adherence in Chronic Disease Scale (ACDS). To find determinants of the level of medication adherence, an ordinal logistic regression model was employed. Statistics were significant when P ≤ 0.05 at a 95% confidence interval (CI).

Results

In the end, 336 participants were included in the research. According to this study, one-third of patients had low medication adherence, half had medium adherence, and one-fifth had high medication adherence. Elderly patients [adjusted odds ratio (AOR) = 2.691; 95% confidence interval (CI), 1.704-4.251; P < 0.000], marital status (AOR = 1.921; 95% CI, 1.214-3.039; P = 0.005), alcoholic patients (AOR = 2.782; 95% CI, 1.745-4.435; P < 0.000), Patients without physical activity (AOR = 1.987; 95% CI 1.251-3.156; P = 0.004), non health insurances (AOR = 1.593; 95% CI 1.003-2.529; P = 0.049), sever Charles comorbidity index (AOR = 2.486; 95% CI 1.103-5.604; P = 0.028), patients with polypharmacy (AOR = 2.998 (1.817-4.947) P < 0.000) and, manypolypharmacy (AOR = 3.031 (1.331-6.898) P = 0.008) were more likely to have low medication adherence.

Conclusion

The current study concluded that one-third of study participants had low medication adherence. Older age, marital status, drinker, physical inactivity, drug source, comorbidity, and polypharmacy all contributed to the low level of medication adherence. To improve patients with cardiovascular disease's adherence to their medications, intervention is necessary.

Cost-effectiveness of single-pill and separate-pill administration of antihypertensive triple combination therapy: a population-based microsimulation study

BACKGROUND

Single-pill combination (SPC) of three antihypertensive drugs has been shown to improve adherence to therapy compared with free combinations, but little is known about its long-term costs and health consequences. This study aimed to evaluate the lifetime cost-effectiveness profile of a three-drug SPC of an angiotensin-converting enzyme inhibitor, a calcium-channel blocker, and a diuretic vs the corresponding two-pill administration (a two-drug SPC plus a third drug separately) from the Italian payer perspective.

METHODS

A cost-effectiveness analysis was conducted using multi-state semi-Markov modeling and microsimulation. Using the healthcare utilization database of the Lombardy Region (Italy), 30,172 and 65,817 patients aged ≥ 40 years who initiated SPC and two-pill combination, respectively, between 2015 and 2018 were identified. The observation period extended from the date of the first drug dispensation until death, emigration, or December 31, 2019. Disease and cost models were parametrized using the study cohort, and a lifetime microsimulation was applied to project costs and life expectancy for the compared strategies, assigning each of them to each cohort member. Costs and life-years gained were discounted by 3%. Probabilistic sensitivity analysis with 1,000 samples was performed to address parameter uncertainty.

RESULTS

Compared with the two-pill combination, the SPC increased life expectancy by 0.86 years (95% confidence interval [CI] 0.61-1.14), with a mean cost differential of -€12 (95% CI -9,719-8,131), making it the dominant strategy (ICER = -14, 95% CI -€15,871-€7,113). The cost reduction associated with the SPC was primarily driven by savings in hospitalization costs, amounting to €1,850 (95% CI 17-7,813) and €2,027 (95% CI 19-8,603) for patients treated with the SPC and two-pill combination, respectively. Conversely, drug costs were higher for the SPC (€3,848, 95% CI 574-10,640 vs. €3,710, 95% CI 263-11,955). The cost-effectiveness profile did not significantly change according to age, sex, and clinical status.

CONCLUSIONS

The SPC was projected to be cost-effective compared with the two-pill combination at almost all reasonable willingness-to-pay thresholds. As it is currently prescribed to only a few patients, the widespread use of this strategy could result in benefits for both patients and the healthcare system.

Adherence to antihypertensive medication and its associated factors among patients with hypertension attending a tertiary hospital in Kathmandu, Nepal

Hypertension is a major risk factor for cardiovascular disease, which is the leading cause of premature mortality and morbidity globally. Despite the evidences of the availability of effective treatment for hypertension, its management remains suboptimal. Medication adherence is the most crucial factor for blood pressure control. It is important to identify the factors associated with adherence to antihypertensive treatment for better management. Hence, this study assessed the level of antihypertensive medication adherence and its associated factors among patients with hypertension visiting a tertiary-level hospital in Kathmandu, Nepal. An analytical cross-sectional study was carried out among 308 diagnosed patients with hypertension who were prescribed antihypertensive medication. The Morisky Medication Adherence Scale (MMAS-8) was used to assess medication adherence. Data was collected through face-to-face interviews and analysed using SPSS v26. A bivariate and multivariate logistic regression model was used to assess the factors associated with low medication adherence. More than half (61%) of the study participants had moderate to high levels of medication adherence. Upon bivariate analysis, there was a significant association between presence of side effects, blood pressure status, forgetfulness, high cost, fear of taking medicine lifelong and irregular follow-up with a low level of adherence. Upon multivariate the logistic regression analysis, forgetfulness [Adjusted Odd's Ratio (AOR) 22.5, 95% Confidence Interval(CI) 10.56-47.86], high cost (AOR 3.8, 95%CI 1.25-11.60) and fear of taking medicines lifelong (AOR 6.04, 95%CI 2.96-12.33) were found to be associated factors of low level of adherence. There is an urgency to develop evidence-based strategies to improve the level of adherence to antihypertensive medications among patients with hypertension. Strategies like reminder messaging, setting alarms, expanding the scope of national health insurance and proper counselling to reduce fear could help to improve medication adherence. Hence, the feasibility and effectiveness of such intervention should be explored in future studies.

Extemporaneous combination therapy with nebivolol/ramipril for the treatment of hypertension: a real-world evidence study in Europe

OBJECTIVES

To describe the clinical characteristics and treatment adherence in European adult hypertensive patients starting treatment with the extemporaneous combination of nebivolol and ramipril (NR-EXC).

METHODS

Retrospective database analysis of patients receiving NR-EXC treatment across five European countries (Italy, Germany, France, Poland, Hungary) over a period ranging from 3 to 9 years (until 30 June 2020) according to data availability for the different data sources. Patient demographics, comorbidities, and treatment adherence were evaluated.

RESULTS

We identified 592,472 patients starting NR-EXC. Most of them were over 60 years of age, with ramipril most commonly prescribed at 5 mg (from 30.0 to 57.2% of patients across the databases). Notable comorbidities included diabetes (19.2%) and dyslipidemia (18.2%). The study population was also highly subjected to polytherapy with antithrombotics, lipid-lowering agents, and other lowering blood pressure agents as the most co-prescribed medications, as resulted from Italian database. Up to 59% of the patients did not request a cardiologic visit during the study period. Adherence to therapy was low in 56.3% of the patients, and it was high only in 11.1% of them.

CONCLUSIONS

The combination of nebivolol and ramipril is frequently prescribed in Europe, but adherence to treatment is suboptimal. The transition to a single pill combination could enhance treatment adherence and streamline regimens, potentially leading to significant benefits. Improved adherence not only correlates with better blood pressure control but also reduces the risk of cardiovascular events, underscoring the importance of this development.

Extemporaneous combination therapy with nebivolol/amlodipine for the treatment of hypertension: a real-world evidence study in Europe

OBJECTIVE

The investigation of the real-world use of the extemporaneous combination of nebivolol and amlodipine (NA-EXC) in adult patients diagnosed with hypertension in Europe.

METHODS

Retrospective analysis of data extracted from seven databases of patient medical records and prescriptions from Italy, Germany, France, Hungary, and Poland, to determine the prevalence and incidence of NA-EXC use and to estimate the number of patients potentially eligible for a single-pill combination of the two antihypertensives. Secondary objectives included: the description of the population of NA-EXC users and the assessment of their adherence to treatment based on the proportion of days covered.

RESULTS

The use of NA-EXC was found to be common in Europe and ranged between 2.9% to 9.9% of all patients identified in the databases with a prescription of nebivolol and/or amlodipine. The estimated numbers of patients potentially eligible in 2019 for a single-pill combination of nebivolol and amlodipine in Italy and Germany were, respectively, 178,133 and 113,240. Users of NA-EXC were mostly aged 70-79 years, had metabolic disorders and other comorbidities; >70% of them had received ≥2 concomitant medications before starting NA-EXC. Adherence to NA-EXC was defined as high only in 15.6% to 35% of patients.

CONCLUSIONS

The extemporaneous combination of nebivolol and amlodipine is commonly prescribed in Europe, however adherence to the therapy is poor. The development of a single-pill combination of nebivolol and amlodipine may improve adherence by reducing the number of pills administered to patients and thus simplifying treatment regimens.

Frequency of missed doses and its effects on the regulation of glucose levels in patients with type 2 diabetes: A retrospective analysis

This study aimed to investigate the association between medication adherence to oral hypoglycemic agents (OHAs) and HbA1c levels in patients with type 2 diabetes mellitus (T2DM) for more than 48 weeks, as well as the factors affecting long-term adherence to OHAs. This retrospective study included 83 patients who had been receiving OHAs for T2DM for ≥48 weeks. Medication adherence values (MAVs) were calculated using the following formula: (total prescription days - prescription days of OHAs brought at admission)/(days from the initiation of OHAs to hospitalization). We assessed the association between HbA1c and MAVs using the Jonckheere-Terpstra test. Furthermore, we examined the association between patient- and medication-related factors and MAVs affecting HbA1c levels. Based on the results, MAVs were categorized as MAV ≤0.86 and MAV >0.86, and factors affecting MAVs were analyzed. Logistic regression analysis revealed that the total number of medications, the number of nonhypoglycemic agents, and a family history of diabetes were independent determinants of MAV ≤0.86 (P < .05). Multiple regression analyses indicated that the number of dosages per day and the timing of OHA administration at lunch were independent determinants of lower MAVs (P < .05). Our findings suggest that poor medication adherence is associated with elevated HbA1c levels in T2DM patients. Independent factors contributing to poor adherence include a lower number of prescribed medications, fewer nonhypoglycemic agents, no family history, a higher daily dosage frequency, and the administration of OHAs at lunch.

Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on the simplification of the drug regimen for secondary cardiovascular prevention

The issue of suboptimal drug regimen adherence in secondary cardiovascular prevention presents a significant barrier to improving patient outcomes. To address this, the utilization of drug combinations, specifically single pill combinations (SPCs) and polypills, was proposed as a strategy to simplify treatment regimens. This approach aims to enhance treatment accessibility, affordability, and adherence, thereby reducing healthcare costs and improving patient health. The document is an Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on simplifying drug regimens for secondary cardiovascular prevention. It discusses the underuse of treatments despite available, effective, and accessible options, highlighting a significant gap in secondary prevention across different socio-economic statuses and countries. The statement explores barriers to implementing evidence-based treatments, including patient, healthcare provider, and system-related challenges. The paper also reviews international guidelines, the role of SPCs and polypills in clinical practice, and their economic impact, advocating for their use in secondary prevention to improve patient outcomes and adherence.

Medication adherence and associated factors in newly diagnosed hypertensive patients in Japan: the LIFE study

Hypertension is the leading cardiovascular risk factor worldwide. However, in Japan, only 30% of patients have their blood pressure controlled under 140/90 mmHg, and nonadherence to antihypertensives is thought to be a reason for the poor control of hypertension. We therefore sought to assess the adherence to hypertension treatment and to evaluate factors influencing patients' adherence in a large, representative sample of the Japanese population. To this end, we analyzed claims data from the LIFE Study database, which includes 112 506 Japanese adults with newly diagnosed hypertension. Medication adherence was measured for a year postdiagnosis using the proportion of days covered (PDC) method. Factors associated with adherence to antihypertensives were also assessed. Among the total 112 506 hypertensive patients, the nonadherence rate (PDC ≤ 80%) for antihypertensives during the first year after initiation of the treatment was 26.2%. Younger age [31-35 years: odds ratio (OR), 0.15; 95% confidence interval (95% CI), 0.12-0.19 compared with 71-74-year-old patients], male gender, monotherapy, and diuretics use [OR, 0.87; 95% CI, 0.82-0.91 compared with angiotensin II receptor blockers (ARBs)] were associated with poor adherence in the present study. Cancer comorbidity (OR, 0.84; 95% CI, 0.79-0.91 compared with no comorbidity), prescription at a hospital, and living in a medium-sized to regional city were also associated with poor adherence. Our present findings showing the current status of adherence to antihypertensive medications and its associated factors using claims data in Japan should help to improve adherence to antihypertensives and blood pressure control.

Lifetime costs of overweight and obesity in Italy

We use longitudinal electronic clinical data on a large representative sample of the Italian population to estimate the lifetime profile costs of different BMI classes - normal weight, overweight, and obese (I, II, and III) - in a primary care setting. Our research reveals that obese patients generate the highest cost differential throughout their lives compared to normal weight patients. Moreover, we show that overweight individuals spend less than those with normal weight, primarily due to reduced expenditures beginning in early middle age. Our estimates could serve as a vital benchmark for policymakers looking to prioritize public interventions that address the obesity pandemic while considering the increasing obesity rates projected by the OECD until 2030.

Generic substitution of amlodipine is not associated with increased risk of mortality or adverse cardiovascular events: An observational cohort study

This study aims to assess clinical outcomes following switching from originator to generic amlodipine. This population-based, matched, cohort study included users of originator amlodipine using claims data during 2018-2020 from a health system in Tianjin, China, in which usage of generic amlodipine was promoted by a drug procurement policy, the national volume-based procurement. Non-switchers refer to those remained on originator after the policy, while pure-switchers were those who switched to and continued using generic amlodipine, and back-switchers were those switched to generic amlodipine but then back to the originator. Propensity score matching generates comparable non-switchers and pure-switchers pairs, and non-switchers and back-switchers pairs. The primary outcome was major adverse cardiovascular events (MACEs), defined as all-cause mortality, stroke, and myocardial infarction during follow-up (April 1, 2019 to December 30, 2020). Secondary outcomes included heart failure, atrial fibrillation, and adherence to amlodipine. The hazard ratio (HR) for each clinical outcome was assessed through Cox proportional hazard regression. In total, 5943 non-switchers, 2949 pure-switchers, and 3061 back-switchers were included (mean age: 62.9 years; 55.5% men). For the matched pairs, pure-switchers (N = 2180) presented no additional risks of clinical outcomes compared to non-switchers (N = 4360) (e.g., MACEs: 2.86 vs. 2.95 events per 100 person-years; HR = 0.97 [95%CI: 0.70-1.33]). Back-switchers (N = 1998) also presented no additional risk compared to non-switchers (N = 3996) for most outcomes except for stroke (HR = 1.55 [95%CI: 1.03-2.34]). Pure-switchers and back-switchers all had better amlodipine adherence than non-switchers. Generic substitution of amlodipine is not associated with increased risk of cardiovascular events or all-cause mortality, but improves medicine adherence.

Design of a pragmatic randomized implementation effectiveness trial testing a health system wide hypertension program for older adults

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.

The role of renal denervation in cardiology and beyond: An updated comprehensive review and future directives

Renal denervation (RDN) is a minimally invasive intervention performed by denervation of the nervous fibers in the renal plexus, which decreases sympathetic activity. These sympathetic nerves influence various physiological functions that regulate blood pressure (BP), including intravascular volume, electrolyte composition, and vascular tone. Although proven effective in some trials, controversial trials, such as the Controlled Trial of Renal Denervation for Resistant Hypertension (SYMPLICITY-HTN3), have demonstrated contradictory results for the effectiveness of RDN in resistant hypertension (HTN). In the treatment of HTN, individuals with primary HTN are expected to experience greater benefits compared to those with secondary HTN due to the diverse underlying causes of secondary HTN. Beyond its application for HTN, RDN has also found utility in addressing cardiac arrhythmias, such as atrial fibrillation, and managing cases of heart failure. Non-cardiogenic applications of RDN include reducing the intensity of obstructive sleep apnea (OSA), overcoming insulin resistance, and in chronic kidney disease (CKD) patients. This article aims to provide a comprehensive review of RDN and its uses in cardiology and beyond, along with providing future directions and perspectives.

Management of Resistant Hypertension

Resistant hypertension (RH) is a severe form of hypertension associated with increased cardiovascular risk. Although true RH affects less than 10% of the patients receiving antihypertensive therapy, the absolute number is high and continues to increase. The workup of these patients requires screening for secondary hypertension and pseudoresistance, including poor adherence to prescribed medicines and the white-coat phenomenon. The treatment of RH consists of lifestyle modifications and pharmacological therapies. Lifestyle modifications include dietary adjustments, weight loss, physical activity, and limiting alcohol consumption; pharmacological therapies include diuretics, mineralocorticoid receptor antagonists, beta blockers, angiotensin receptor-neprilysin inhibitors, and others. Over the last 15 years, interventional approaches have emerged as adjunct treatment options; we highlight catheter-based renal denervation. This review summarizes the rationales and latest clinical evidence and, based thereon, proposes an updated algorithm for the management of RH.

Disparities in Hypertension Prevalence, Awareness, Treatment, and Control Among Women Living With and Without HIV in the US South

Background

Hypertension-related diseases are major causes of morbidity among women living with HIV. We evaluated cross-sectional associations of race/ethnicity and HIV infection with hypertension prevalence, awareness, treatment, and control.

Methods

Among women recruited into Southern sites of the Women's Interagency HIV Study (2013-2015), hypertension was defined as (1) systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg according to clinical guidelines when data were collected, (2) self-report of hypertension, or (3) use of antihypertensive medication. Awareness was defined as self-report of hypertension, and treatment was self-report of any antihypertensive medication use. Blood pressure control was defined as <140/90 mm Hg at baseline. Prevalence ratios for each hypertension outcome were estimated through Poisson regression models with robust variance estimators adjusted for sociodemographic, behavioral, and clinical risk factors.

Results

Among 712 women, 56% had hypertension and 83% were aware of their diagnosis. Of those aware, 83% were using antihypertensive medication, and 63% of those treated had controlled hypertension. In adjusted analyses, non-Hispanic White and Hispanic women had 31% and 48% lower prevalence of hypertension than non-Hispanic Black women, respectively. Women living with HIV who had hypertension were 19% (P = .04) more likely to be taking antihypertension medication when compared with women living without HIV.

Conclusions

In this study population of women living with and without HIV in the US South, the prevalence of hypertension was lowest among Hispanic women and highest among non-Hispanic Black women. Despite similar hypertension prevalence, women living with HIV were more likely to be taking antihypertensive medication when compared with women living without HIV.

Impact of poor medication adherence on clinical outcomes and health resource utilization in patients with hypertension and/or dyslipidemia: systematic review

INTRODUCTION

We aimed to summarize evidence on the effect of poor medication adherence on clinical outcomes and health resource utilization (HRU) among patients with hypertension and/or dyslipidemia.

AREAS COVERED

A systematic review of studies reporting clinical outcomes and HRU for patients by status of adherence to antihypertensives and/or lipid-lowering medications was searched using Embase, MEDLINE, and MEDLINE In-Process and supplemented by manual searches of conference abstracts. In total, 45 studies were included, with most being retrospective observational studies (n = 36). Patients with poor adherence to antihypertensives and lipid-lowering medications compared with those with good adherence showed less reduction of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-c) after 6-12 months follow-up (∆ systolic BP: 1.2 vs. -4.5 mmHg; ∆LDL-c: -14.0 to -18.9 vs. -34.1 to -42.0 mg/dL). Poor adherence was also significantly associated with a higher risk of cardiovascular events (HR: 1.1-1.9) and mortality (HR: 1.4-1.8) in patients with hypertension and dyslipidemia and increased HRU (i.e. outpatient visits, risk of cardiovascular-related and all-cause hospitalization, annual inpatient days, total health-care costs).

EXPERT OPINION

Poor adherence is associated with poor clinical outcomes and increased HRU, highlighting the need to enhance medication adherence in patients with hypertension and/or dyslipidemia.

The risk of withdrawal from hypertension treatment in coastal areas after the Great East Japan Earthquake: the TMM CommCohort Study

This study aimed to examine whether risk of withdrawal from HTTx was higher in coastal areas that were severely damaged by tsunami than in inland areas. We conducted a cross-sectional study of 9218 participants aged ≥20 years in Miyagi, Japan. The odds ratios (ORs) and confidence interval (CI) for withdrawal from HTTx in coastal and inland groups were compared using multivariate logistic regression analysis, adjusting for potential confounders. In total, 194 of 5860 and 146 of 3358 participants in the inland and coastal groups, respectively, withdrew from HTTx treatment. OR (95%CI) of withdrawal from HTTx in the coastal group was 1.46 (1.14-1.86) compared to the inland group. According to housing damage, ORs (95% CI) in the no damage, partially destroyed, and more than half destroyed coastal groups compared with the no damage inland group were 1.62 (1.04-2.50), 1.69 (1.17-2.45), and 1.08 (0.71-1.65), respectively. In conclusion, the risk of HTTx withdrawal for participants whose homes in coastal areas were relatively less damaged was significantly higher compared with those in inland areas, while the risk of HTTx withdrawal for participants whose homes were more than half destroyed was not. Post-disaster administrative support for disaster victims is considered vital for continuation of their treatment.

Extemporaneous combination therapy with amlodipine/zofenopril in hypertensive patients: a real-world data analysis in Italy

OBJECTIVES

To provide clinical characteristics and to quantify the number of patients receiving the extemporaneous combination of the calcium channel blocker amlodipine and the angiotensin converting enzyme inhibitor zofenopril in a real-world setting. This evidence can provide a snapshot of the potential users of the two molecules in a single pill combination (SPC).

METHODS

Retrospective observational study using data from the IQVIA Italian Longitudinal Patient Database. Adult patients firstly prescribed with amlodipine and zofenopril between 1 July 2011 and 30 June 2020 were identified and demographic and clinical characteristics were extracted. Treatment adherence was evaluated as proportion of days covered (PDC). The potential number of patients eligible for a SPC was calculated.

RESULTS

A population of 2394 hypertensive patients, mean age of 68.6 years ±12.7, 52.6% male were treated with amlodipine and zofenopril. The majority of patients (54.5%) were low adherent (PDC <40%), 25.9% were intermediate adherent and only 19.6% were high adherent (>80%) to therapy. Around 42,500 adult hypertensive patients were estimated to be prescribed the extemporaneous combination in 2019 in Italy, being potentially eligible for treatment with amlodipine and zofenopril SPC.

CONCLUSIONS

The administration of the extemporaneous combination of zofenopril and amlodipine in hypertensive patients is a common practice in Italy. The development of a SPC can be a viable treatment option to simplify therapy and to increase adherence in hypertensive patients who are already on the two monotherapies in combination.

Adherence and related cardiovascular outcomes to single pill vs. separate pill administration of antihypertensive triple-combination therapy

OBJECTIVE

To compare adherence to antihypertensive treatment between patients prescribed a three-drug single-pill combination (SPC) of perindopril/amlodipine/indapamide (P/A/I) vs. the combination of an angiotensin-converting enzyme inhibitor (ACEI), a calcium-channel blocker (CCB), and a diuretic (D) as a two-drug SPC plus a third drug given separately.

METHODS

Using the healthcare utilization database of the Lombardy Region (Italy), the 28 210 patients, aged at least 40 years, who were prescribed P/A/I SPC during 2015-2018 were identified and the date of the first prescription was defined as the index date. For each patient prescribed the SPC, a comparator who started ACEI/CCB/D treatment as a two-pill combination was considered. Adherence to the triple combination was assessed over the year after the index date as the proportion of the follow-up days covered by prescription (PDC). Patients who had a PDC >75% were defined as highly adherent to drug therapy. Log-binomial regression models were fitted to estimate the risk ratio of treatment adherence in relation to the drug treatment strategy.

RESULTS

About 59 and 25% of SPC and two-pill combination users showed high adherence, respectively. Compared with patients under a three-drug two-pill combination, those who were treated with the three-drug SPC had a higher propensity to be highly adherent to the triple combination (2.38, 95% confidence interval: 2.32-2.44). This was the case regardless of the sex, age, comorbidities, and number of co-treatments.

CONCLUSIONS

In a real-life setting, patients under three-drug SPC exhibited more frequently a high adherence to antihypertensive treatment than those prescribed a three-drug two-pill combination.

Perspectives on improving blood pressure control to reduce the clinical and economic burden of hypertension

The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.

A practical approach to assessment of non-adherence to antihypertensive treatment

Non-adherence to antihypertensive treatment is frequent, complicates the care of hypertensive patients, represents one of the major causes of treatment failure and is linked with the increased risk of cardiovascular events. Identifying a non-adherent patient is one of the recent daily-practice tasks for which the ideal solution has not yet been found. Presence of certain clinical red flags should prompt the clinician to consider non-adherence. Chemical adherence testing using serum or urine antihypertensive levels is regarded as the best method so far and should be used if available. Alternatively, the check for prescription refills in the patient electronic medical records, or directly observed therapy with subsequent ambulatory blood pressure monitoring may be used. We suggest a simple algorithm to guide the clinicians to detect non-adherence in the practice.

Drug switching in axial spondyloarthritis patients in Germany - a social listening analysis

Background

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease which primarily affects the axial skeleton resulting in chronic back pain and stiffness. According to the guideline, the first-line treatment includes non-steroidal anti-inflammatory drugs (NSAIDs), conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and non-pharmacological treatment. Second line treatment involves biological disease-modifying antirheumatic drugs (bDMARDs) such as tumour necrosis factor and interleukin-17 inhibitors.

Objectives

The aim of this social media listening research project was to analyse switches of medication and the reasons thereof to gain valuable insights into real-life journeys of patients suffering from axSpA.

Methods

Publicly available posts in German-speaking disease-specific forums were scanned for disease-specific keywords and commonly used drugs by axSpA patients on the Permea platform. Posts containing at least two key words were selected and switches between medications were manually labelled. A total of 287 scraped posts between 01 July 2010 and 04 Feb 2022 were analysed.

Results

The largest group of described medication switches was initially using bDMARDs. Switches to a different bDMARD, termination of medication and switches to glucocorticoids were most frequently named. Patients on NSAIDs switched to glucocorticoids, a different NSAID or bDMARD, whereas patients on csDMARDs most frequently changed to bDMARDs. In all medication groups the main reason for switching was insufficient efficacy and side effects. Additionally, for the medication groups bDMARDs, csDMARDs and corticosteroids, pregnancy and lactation were given as a reason for switching, whereas patients in the NSAID group never mentioned pregnancy and breastfeeding as a reason for switching treatment.

Conclusion

Our analysis shows medication switches based on real-life patient experiences shared with peers in a social listening setting. We also show medication switches differing from advised guidelines. Gathering real-life insights into patients' journey dealing with chronic diseases allows us to understand, and thereby improve patient care and treatment.

Perception of hypertension and adherence to hypertension treatment among patients attending a hospital in western Iran: A cross-sectional study

Background and Aims

Hypertension is the third leading cause of death in the world and is estimated to be increased by about 60% by 2025. Beliefs about hypertension can predict patient adherence to hypertension treatment. This study aims to investigate the perceptions of hypertension and adherence to hypertension treatment among patients in Khorramabad, Iran.

Methods

This is a descriptive/analytical study with a cross-sectional design. Participants were 265 patients with a history of hypertension referred to a hospital in Khorramabad, Lorestan Province in western Iran in 2020, who were selected using a convenience sampling method. A demographic form, the brief illness perception questionnaire-revised (BIPQ-R), and Morisky medication adherence scale (MMAS-8) were used for collecting data. The collected data were analyzed in SPSS v.22 software using descriptive statistics, Pearson's correlation test, independent t-test, one-way ANOVA, and regression analysis.

Results

The mean scores of BIPQ-R and MMAS-8 were 49.05 ± 15.45 (out of 80) and 3.69 ± 1.62 (out of 8), respectively. There was a significant relationship between the mean scores of MMAS-8 and BIPQ-R in total (p < 0.001). Perceptions of illness consequences (B = 4.59, p = 0.005), personal control (B = 0.190, p = 0.047), and symptoms (B = 1.77, p = 0.005) could significantly predict treatment adherence of patients. In illness perception, there were significant differences among patients with different places of residence (p = 0.032), educational levels (p = 0.001), and employment status (p = 0.010). In treatment adherence, there were significant differences among patients with different places of residence (p = 0.042) and educational levels (p = 0.045).

Conclusion

Treatment adherence of hypertensive patients in western Iran is at a low level, while their perception of hypertension is at a moderate level. Clinical physicians are recommended to pay attention to the perception of illness in these patients (especially unemployed and less educated patients living in rural areas) to improve their adherence to treatment and blood pressure control.

Antihypertensive Medication Adherence and Cardiovascular Outcomes in Patients With Cancer: A Nationwide Population-Based Cohort Study

Background Hypertension is an important cause of morbidity, which predisposes patients to major cardiovascular events and mortality. The aim of this study was to explore the association between adherence to antihypertensive medication and clinical outcomes in adult patients with cancer. Methods and Results Using the 2002 to 2013 Korean National Health Insurance Service-National Sample Cohort, we extracted adult patients with cancer treated with antihypertensive medications. Based on the medication possession ratio value, participants were divided into 3 groups: good (medication possession ratio ≥0.8), moderate (0.5≤ medication possession ratio <0.8), and poor (medication possession ratio <0.5) adherence groups. The primary outcomes were overall and cardiovascular mortality. The secondary outcome was cardiovascular events requiring hospitalization due to major cardiovascular diseases. Among 19 246 patients with cancer with concomitant hypertension, 66.4% were in the nonadherence group (26.3% were moderate and 40.0% were poor adherence group). Over a median of 8.4 years of follow-up, 2752 deaths and 6057 cardiovascular events occurred. Compared with the good adherence group, the moderate and poor adherence groups had a 1.85-fold and 2.19-fold increased risk for overall mortality, and 1.72-fold and 1.71-fold elevated risk for cardiovascular mortality, respectively, after adjustment for possible confounders. Furthermore, the moderate and poor adherence groups had a 1.33-fold and 1.34-fold elevated risk of new-onset cardiovascular events, respectively. These trends were consistent across cardiovascular event subtypes. Conclusions Nonadherence to antihypertensive medication was common in patients with cancer and was associated with worse clinical outcomes in adult patients with cancer with hypertension. More attention should be paid to improving adherence to antihypertensive medication among patients with cancer.

When blood pressure refuses to budge: exploring the complexity of resistant hypertension

Resistant hypertension, defined as blood pressure that remains above goal despite using three or more antihypertensive medications, including a diuretic, affects a significant proportion of the hypertensive population and is associated with increased cardiovascular morbidity and mortality. Despite the availability of a wide range of pharmacological therapies, achieving optimal blood pressure control in patients with resistant hypertension remains a significant challenge. However, recent advances in the field have identified several promising treatment options, including spironolactone, mineralocorticoid receptor antagonists, and renal denervation. In addition, personalized management approaches based on genetic and other biomarkers may offer new opportunities to tailor therapy and improve outcomes. This review aims to provide an overview of the current state of knowledge regarding managing resistant hypertension, including the epidemiology, pathophysiology, and clinical implications of the condition, as well as the latest developments in therapeutic strategies and future prospects.

Determinants of Adherence to Antihypertension Medications Among Patients at a Tertiary Care Hospital in Islamabad, Pakistan, 2019

INTRODUCTION

Medication nonadherence leads to poor health outcomes, frequent complications, and high economic impact. Our objective was to assess the determinants of adherence to medication regimens among patients with hypertension.

METHODS

We conducted a cross-sectional study of patients with hypertension attending the cardiology clinic of a tertiary care hospital in Islamabad, Pakistan. Data were collected by using semistructured questionnaires. A score of 7 or 8 on the 8-item Morisky Medication Adherence Scale was classified as good adherence, 6 as moderate, and less than 6 as nonadherence. Logistic regression was performed to determine covariates associated with medication adherence.

RESULTS

We enrolled 450 patients with hypertension (mean age, 54.5 y; SD, 10.6). Medication adherence was good among 115 (25.6%) patients and moderate among 165 (36.7%); 170 (37.8%) patients were nonadherent. Most patients (72.7%) had uncontrolled hypertension. Nearly half (49.6%) were unable to afford monthly medication. In bivariate analysis, nonadherence was associated with female sex (odds ratio [OR], 1.44; P = .003) and long waiting times in the health care facility (OR, 2.93; P = .005); the presence of comorbidities (OR, 0.62; P = .01) was associated with good adherence. In multivariate analysis, nonadherence was associated with unaffordability of treatment (OR, 2.25; P = .002) and uncontrolled hypertension (OR, 3.16; P < .001). Good adherence determinants included adequate counseling (OR, 0.29; P < .001) and education (OR, 0.61; P = .02).

CONCLUSION

Addressing identified barriers, including medication affordability and patient counseling, should be included in Pakistan's national policy on noncommunicable disease.

Validation and optimization of the French Generic Adherence for Chronic Diseases Profile (GACID-P) using classical test and item response theory

BACKGROUND

The Generic Adherence for Chronic Diseases Profile is a French generic scale (GACID-P) developed to measure adherence in several disease areas such as cardiology, rheumatology, diabetes, cancer and infectiology.

METHOD

We aimed to study the measurement invariance of the Generic Adherence for Chronic Diseases Profile by an item response model, optimize the new instrument version from item response model and qualitative content analyses results, and validate the instrument. The metric properties of the optimized version were studied according to classical test theory and item response model analysis.

RESULTS

A sample of 397 patients consulting at two French hospitals (in diabetes, cardiology, rheumatology, cancerology and infectiology) and in four private practices was recruited; 314 (79%) patients also completed the questionnaire 15 days later. Factor analyses revealed four dimensions: "Forgetting to take medication", "Intention to comply with treatment", "Limitation of risk-related consumer habits" and "Healthy lifestyle". The item response model and content analyses optimized these four dimensions, regrouping 32 items in four dimensions of 25 items, including one item conditioned on tobacco use. The psychometric properties and scale calibration were satisfactory. One score per dimension was calculated as the sum of the items for the dimensions "Forgetting to take medication" and "Intention to comply with treatment" and as a weighted score according to the item response model analysis for the two other dimensions because of differential item functioning found for two items.

CONCLUSION

Four adherence profile scores were obtained. The instrument validity was documented by a theoretical approach and content analysis. The Generic Adherence for Chronic Diseases Profile is now available for research targeting adherence in a broad perspective.

Improved Persistence to Medication, Decreased Cardiovascular Events and Reduced All-Cause Mortality in Hypertensive Patients With Use of Single-Pill Combinations: Results From the START-Study

BACKGROUND

Single-pill combination improves adherence and persistence to medication in hypertension. It remains unclear whether this also reduces cardiovascular outcomes and all-cause mortality. We analyzed whether single-pill combinations are superior to identical multiple pills on persistence to medication, cardiovascular outcomes, and all-cause mortality.

METHODS

This was a retrospective claims data (German AOK PLUS) analysis. Data from hypertensive patients ≥18 years treated with renin-angiotensin system combinations given as single pill or identical multipills covering the years 2012 to 2018 were analyzed and followed up to at least 1 year. After 1:1 propensity score matching, persistence to medication, cardiovascular events, and all-cause mortality were compared using non-parametric tests. Results were reported as incidence rate ratios and hazard ratios.

RESULTS

After propensity score matching data from 57 998 patients were analyzed: 10 801 patients received valsartan/amlodipine, 1026 candesartan/amlodipine, 15 349 ramipril/amlodipine, and 1823 amlodipine/valsartan/hydrochlorothiazide as single pill or identical multipill. No relevant differences in patient characteristics were observed within the 4 groups. In all groups, a significant lower all-cause mortality, a significant a higher persistence to medication, a significant lower event rate in 15 out of 20 comparisons, and a tendency in the remaining 5 comparisons was observed under single pills compared with multipill combinations.

CONCLUSIONS

Antihypertensive combination therapy reduces all-cause mortality and cardiovascular events when provided as single pill compared to identical drugs as multipills. This strongly supports the European Society of Cardiology/European Society of Hypertension and International Society of Hypertension guidelines recommending the use of a single-pill combination and thus should be more rigorously implemented into daily clinical practice.

Implementing a home-based virtual hypertension programme-a pilot feasibility study

INTRODUCTION

Implementing a health system-based hypertension programme may lower blood pressure (BP).

METHODS

We performed a randomized, controlled pilot study to assess feasibility, acceptability, and safety of a home-based virtual hypertension programme integrating evidence-based strategies to overcome current barriers to BP control. Trained clinical pharmacists staffed the virtual collaborative care clinic (vCCC) to remotely manage hypertension using a BP dashboard and phone "visits" to monitor BP, adherence, side effects of medications, and prescribe anti-hypertensives. Patients with uncontrolled hypertension were identified via electronic health records. Enrolled patients were randomized to either vCCC or usual care for 3 months. We assessed patients' home BP monitoring behaviour, and patients', physicians', and pharmacists' perspectives on feasibility and acceptability of individual programme components.

RESULTS

Thirty-one patients (vCCC = 17, usual care = 14) from six physician clinics completed the pilot study. After 3 months, average BP decreased in the vCCC arm (P = 0.01), but not in the control arm (P = 0.45). The vCCC participants measured BP more (9.9 vs. 1.2 per week, P < 0.001). There were no intervention-related adverse events. Participating physicians (n = 6), pharmacists (n = 5), and patients (n = 31) rated all programme components with average scores of >4.0, a pre-specified benchmark. Nine adaptations in vCCC design and delivery were made based on potential barriers to implementing the programme and suggestions.

CONCLUSION

A home-based virtual hypertension programme using team-based care, technology, and a logical integration of evidence-based strategies is safe, acceptable, and feasible to intended users. These pilot data support studies to assess the effectiveness of this programme at a larger scale.

Frailty detection among primary care older patients through the Primary Care Frailty Index (PC-FI)

The prompt identification of frailty in primary care is the first step to offer personalized care to older individuals. We aimed to detect and quantify frailty among primary care older patients, by developing and validating a primary care frailty index (PC-FI) based on routinely collected health records and providing sex-specific frailty charts. The PC-FI was developed using data from 308,280 primary care patients ≥ 60 years old part of the Health Search Database (HSD) in Italy (baseline 2013-2019) and validated in the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K; baseline 2001-2004), a well-characterized population-based cohort including 3363 individuals ≥ 60 years old. Potential health deficits part of the PC-FI were identified through ICD-9, ATC, and exemption codes and selected through an optimization algorithm (i.e., genetic algorithm), using all-cause mortality as the main outcome for the PC-FI development. The PC-FI association at 1, 3 and 5 years, and discriminative ability for mortality and hospitalization were tested in Cox models. The convergent validity with frailty-related measures was verified in SNAC-K. The following cut-offs were used to define absent, mild, moderate and severe frailty: < 0.07, 0.07-0.14, 0.14-0.21, and ≥ 0.21. Mean age of HSD and SNAC-K participants was 71.0 years (55.4% females). The PC-FI included 25 health deficits and showed an independent association with mortality (hazard ratio range 2.03-2.27; p < 0.05) and hospitalization (hazard ratio range 1.25-1.64; p < 0.05) and a fair-to-good discriminative ability (c-statistics range 0.74-0.84 for mortality and 0.59-0.69 for hospitalization). In HSD 34.2%, 10.9% and 3.8% were deemed mildly, moderately, and severely frail, respectively. In the SNAC-K cohort, the associations between PC-FI and mortality and hospitalization were stronger than in the HSD and PC-FI scores were associated with physical frailty (odds ratio 4.25 for each 0.1 increase; p < 0.05; area under the curve 0.84), poor physical performance, disability, injurious falls, and dementia. Almost 15% of primary care patients ≥ 60 years old are affected by moderate or severe frailty in Italy. We propose a reliable, automated, and easily implementable frailty index that can be used to screen the primary care population for frailty.

Importance of adherence in the management of hypertension

The WHO indicates that lack of adherence is a matter of the highest priority in Public Health, and is the main cause of not obtaining all the benefits that medications can provide; it is at the origin of medical and psychosocial complications; reduces quality of life; it increases the probability of the appearance of drug resistance and wastes healthcare resources. The no adherence prevalence in hypertension (HTN) ranges between 55.5% with self-reporting and 46.6% with pill counting, and treatment abandonment occurs in 18.5% of patients. The electronic prescription has been validated in HTN using MEMS as a comparison, with sensitivity of 87% and specificity of 93.7%, with an area under the curve of 0.903. In 2019, almost 10 million deaths were directly attributed to HTN. No other disease causes as high a number of deaths and has as high a projected increase in deaths as cardiovascular disease (CVD). By 2030, it is projected that more than 22 million people/year will die from CVD, almost 5 million more than in 2012. In a predictive model for a period of 10 years in five European countries (Italy, Germany, France, Spain and England), the potential savings of increasing adherence to antihypertensive treatment to 70% has been estimated at 332 million euros (80 million in the case of Spain). The use of fixed combinations of two or three drugs is a good method to reduce non-adherence.

Predictors of blood pressure control amongst primary care patients of a teaching hospital in Bauchi, North-Eastern Nigeria

Background

Poorly managed hypertension is still a serious global public health issue, despite medication. It is unclear what is causing treated hypertensive patients to have trouble achieving their target blood pressure (BP).

Aim

The goal of this study was to determine the predictors of BP control amongst hypertensive patients attending a teaching hospital in North-eastern Nigeria.

Materials and Methods

A cross-sectional study was conducted on 277 hypertensive patients from a tertiary healthcare institution. Data were analysed using version 20 of the Statistical Package for the Social Sciences (SPSS). Frequency and percentages were used to summarise data while Chi-square test was used to test for associations. To identify the factors linked to BP control, logistic regression was employed. At P < 0.05, predictors of BP control were found using adjusted odds ratios (AORs) with a 95% confidence interval (CI).

Results

The respondents' average age was 53.1 ± 14.6 years, of which 67.5% were female. The level of optimal BP control was 40.8%. Factors associated with reduced BP control include not currently married (AOR = 0.29 [95% CI: 0.16-0.53], P ≤ 0.0001), imperfect adherence (AOR = 0.37 [95% CI: 0.22-0.64], P ≤ 0.0001), taking more than two drugs (AOR = 0.3 [95% CI: 0.14-0.64], P = 0.001) and body mass index (BMI) ≥25 kg/m² (AOR = 0.40 [95% CI: 0.22-0.72], P = 0.002).

Conclusion

The optimal BP control is alarmingly low in this setting. Marital status, medication adherence, increased pill burden and BMI ≥25 kg/m² negatively affect the attainment of BP control.

Preference and Adherence to a Fixed-Dose Combination of Bisoprolol-Aspirin and Blood Pressure Control: Results of an Open-Label, Multicentre Study

This study assessed blood pressure (BP) control and adherence in patients given a fixed-dose combination (FDC) of bisoprolol (BIS) + aspirin (ASA) compared to those given these two drugs as separate tablets. Patients with hypertension and/or coronary heart disease treated with two-pill BIS (5−10 mg) and ASA (75−100 mg) were switched to FDC BIS + ASA (either 5/75 mg or 10/75 mg) ≥4 weeks prior to study initiation. Adherence was estimated from pill counts and patients’ diaries (1−2 months and 3 months after inclusion) and using Morisky’s Medication Adherence Scale (MMAS) at 3 months. BP control with the two treatments was compared. A total of 356 patients were enrolled (mean (SD) age: 64.3 ± 11.9 years, 56.5% male). Mean (SD) duration of prior treatment with two-pill BIS and ASA was 17.8 ± 26.6 months. FDC adherence was excellent or good (≥76%) in 98.3% and 98.0% of patients based on pill counts and patients’ diaries, respectively. Overall MMAS score was 3.1 ± 1.0. A significant decrease was observed in mean systolic BP, mean diastolic BP and heart rate over the 3-month period (all p < 0.001). FDC BIS + ASA was associated with excellent adherence and improved BP control. The majority (78.7%) of patients preferred the FDC.

Clinical characteristics do not reliably identify non-adherence in patients with uncontrolled hypertension

PURPOSE

Chemical adherence testing is a reliable method to assess adherence to antihypertensive drugs. However, it is expensive and has limited availability in clinical practice. To reduce the number and costs of chemical adherence tests, we aimed to develop and validate a clinical screening tool to identify patients with a low probability of non-adherence in patients with uncontrolled hypertension.

MATERIALS AND METHODS

In 495 patients with uncontrolled hypertension referred to the University Medical Centre Utrecht (UMCU), the Netherlands, a penalised logistic regression model including seven pre-specified easy-to-measure clinical variables was derived to estimate the probability of non-adherence. Non-adherence was defined as not detecting at least one of the prescribed antihypertensive drugs in plasma or urine. Model performance and test characteristics were evaluated in 240 patients with uncontrolled hypertension referred to the Heartlands Hospital, United Kingdom.

RESULTS

Prevalence of non-adherence to antihypertensive drugs was 19% in the UMCU and 44% in the Heartlands Hospital population. After recalibration of the model's intercept, predicted probabilities agreed well with observed frequencies. The c-statistic of the model was 0.63 (95%CI 0.53-0.72). Predicted probability cut-off values of 15%-22.5% prevented testing in 5%-15% of the patients, carrying sensitivities between 97% (64-100) and 90% (80-95), and negative predictive values between 74% (10-99) and 70% (50-85).

CONCLUSION

The combination of seven clinical variables is not sufficient to reliably discriminate adherent from non-adherent individuals to safely reduce the number of chemical adherence tests. This emphasises the complex nature of non-adherence behaviour and thus the need for objective chemical adherence tests in patients with uncontrolled hypertension.

Home blood pressure monitoring and adherence in patients with hypertension on primary prevention treatment: a survey of 1026 patients in general medicine in the Auvergne region

Background

Home blood pressure monitoring (HBPM) could improve blood pressure control through therapeutic adherence. The main objective of this study was to determine the link between HBPM used by hypertensive patients treated in primary care and their medication adherence.

Methods

Cross-sectional comparative study conducted in the Auvergne region from June to November 2016. Patients were recruited by general practitioners (GPs) selected at random. Adherence was evaluated according to the Girerd score.

Results

From a sample of eighty-two GPs including 1026 patients, 45% of patients reported owning an HBPM device. Among these, 18% knew the rule of 3 (3 measurements in the morning and 3 in the evening for 3 days) recommended by the French State Health Authority. There was no difference in adherence between patients using HBPM and those who did not. Patients with HBPM using the rule of 3 reported better adherence than patients without the device (p = 0.06), and those who did not perform self-measurements according to the rule of 3 (p = 0.01). Patients who used HBPM according to the rule of 3 were older (p = 0.006) and less smokers (p = 0.001) than the others. Their GPs were more often GP teachers (p < 0.001) who practiced in rural areas (p = 0.001).

Conclusion

The statistical link between medication adherence and HBPM for patients who apply the rule of 3, emphasizes the importance of the GP educating the patient on the proper use of HBPM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01725-8.

Insufficient blood pressure control is independently associated with increased arterial stiffness

Hypertension is a risk factor for atherosclerosis. Achieving the therapeutic target value of blood pressure (BP) prevents the onset of cardiovascular events; however, it is not clear how antihypertensive drug use and BP control status relate to arterial stiffness. The purpose of this study is to investigate the relationship between BP control status with or without antihypertensive drugs and arterial stiffness. Nine hundred eighty individuals (mean age: 68 ± 11 years) who participated in a community-based cohort study were enrolled. Arterial stiffness was evaluated using the cardio-ankle vascular index (CAVI). Higher BP was defined as a systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg. Participants were divided into four groups: normal, non higher BP without antihypertensive drugs (n = 421); untreated, higher BP without antihypertensive drugs (n = 174); good control, non higher BP with antihypertensive drugs (n = 209); and poor control, higher BP with antihypertensive drugs (n = 176). In multivariable logistic analysis adjusted for age, sex, dyslipidemia and diabetes mellitus medication use, obesity, smoking, alcohol drinking, and heart rate at the CAVI measurement for a high CAVI-using a borderline cutoff value of 8.0-the other three groups were significantly associated with a high CAVI when compared with the normal group. By contrast, multivariable logistic analysis of a high CAVI using an abnormal cutoff value of 9.0 demonstrated that the poor control and untreated groups were significantly associated with a high CAVI, whereas the good control group was not. In conclusion, even with antihypertensive drugs, poor BP control is independently associated with a high CAVI.

Medication Adherence and Cardiometabolic Control Indicators Among American Indian Adults Receiving Tribal Health Services: Protocol for a Longitudinal Electronic Health Records Study

BACKGROUND

American Indian adults have the highest prevalence of type 2 diabetes (T2D) in any racial or ethnic group and experience high rates of comorbidities. Uncontrolled cardiometabolic risk factors-insulin resistance, resulting in impaired glucose tolerance, dyslipidemia, and hypertension-increase the risk of mortality. Mortality is significantly reduced by glucose- and lipid-lowering and antihypertensive medication adherence. Medication adherence is low among American Indian adults living in non-Indian Health Service health care settings. Virtually nothing is known about the nature and extent of medication adherence among reservation-dwelling American Indian adults who primarily receive their medications without cost from Indian Health Service or tribal facilities. Electronic health records (EHRs) offer a rich but underused data source regarding medication adherence and its potential to predict cardiometabolic control indicators (C-MCIs). With the support of the Choctaw Nation of Oklahoma (CNO), we address this oversight by using EHR data generated by this large, state-of-the-art tribal health care system to investigate C-MCIs.

OBJECTIVE

Our specific aims are to determine, using 2018 EHR data, the bivariate relationships between medication adherence and C-MCIs, demographics, and comorbidities and each C-MCI and demographics and comorbidities; develop machine learning models for predicting future C-MCIs from the previous year's medication adherence, demographics, comorbidities, and common laboratory tests; and identify facilitators of and barriers to medication adherence within the context of social determinants of health (SDOH), EHR-derived medication adherence, and C-MCIs.

METHODS

Drawing on the tribe's EHR (2018-2021) data for CNO patients with T2D, we will characterize the relationships among medication adherence (to glucose- and lipid-lowering and antihypertensive drugs) and C-MCIs (hemoglobin A1c ≤7%, low-density lipoprotein cholesterol <100 mg/dL, and systolic blood pressure <130 mm Hg); patient demographics (eg, age, sex, SDOH, and residence location); and comorbidities (eg, BMI ≥30, cardiovascular disease, and chronic kidney disease). We will also characterize the association of each C-MCI with demographics and comorbidities. Prescription and pharmacy refill data will be used to calculate the proportion of days covered with medications, a typical measure of medication adherence. Using machine learning techniques, we will develop prediction models for future (2019-2021) C-MCIs based on medication adherence, patient demographics, comorbidities, and common laboratory tests (eg, lipid panel) from the previous year. Finally, key informant interviews (N=90) will explore facilitators of and barriers to medication adherence within the context of local SDOH.

RESULTS

Funding was obtained in early 2022. The University of Florida and CNO approved the institutional review board protocols and executed the data use agreements. Data extraction is in process. We expect to obtain results from aims 1 and 2 in 2024.

CONCLUSIONS

Our findings will yield insights into improving medication adherence and C-MCIs among American Indian adults, consistent with CNO's State of the Nation's Health Report 2017 goal of reducing T2D and its complications.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/39193.

Linkage between electronic prescribing data and pharmacy claims records to determine primary adherence: the case of antihypertensive therapy in the Lisbon and Tagus Valley Region, Portugal

BACKGROUND

Hypertension (HT) is highly prevalent and a major risk factor for cardiovascular disease. Over 42% of Portuguese adults have HT. Even though the benefits of antihypertensive (AHT) drugs have been demonstrated, HT control remains inadequate. One major reason is that patients often fail to take their medications as prescribed. This paper aims to determine primary adherence to AHT therapy in newly diagnosed and treated hypertensive patients in Primary Health Care (PHC) units of Lisbon and Tagus Valley Health Region.

METHODS

This study reports data from a population-based, retrospective, cohort study from patients diagnosed with HT in PHC units of Lisbon and Tagus Valley Region from 1 January to 31 March 2011, with no prior use of AHT drugs. Primary adherence rate was expressed as number of claims records/total number of prescriptions records. Data were collected from SIARS for each patient during a 2-year period.

RESULTS

Overall primary adherence rate was 58.5%, increasing with age. Rates were higher for men, living in the Lisbon Metropolitan Area and diagnosed with uncomplicated HT. Drugs acting on the renin-angiotensin system had the highest rates, increasing for fixed-dose combinations and diminishing with the increase of cost for the patient.

CONCLUSIONS

Overall, almost 1 out of 2 prescribed AHT drugs were not dispensed. Until this study, little was known in Portugal about primary adherence. Our findings imply that the potential benefits of AHT therapy cannot be fully realized in this population.

Laboratory testing and antihypertensive medication adherence following initial treatment of incident, uncomplicated hypertension: A real-world data analysis

In this study on medication adherence among newly diagnosed patients with uncomplicated, incident hypertension, we conducted a retrospective cohort study using available administrative and laboratory data from April 1, 2012 to March 31, 2017 in Alberta, Canada to understand the extent to which baseline laboratory assessment and/or subsequent follow-up was associated with persistence with antihypertensive therapy. We determined the frequency of baseline and follow-up testing and compared the rates of medication persistence by patient-, neighbourhood-, and treatment-related factors. Of 103 232 patients with newly diagnosed, uncomplicated hypertension who filled their first prescription within our study timeframe, 52.5% were non-persistent within 6 months. Persistent patients were more often female and residing in neighbourhoods with higher social status (with exception to rurality). Aside from older age, the strongest predictor of persistence was performance of laboratory testing related to hypertension with an apparent effect in which higher levels of medication persistence were seen with more frequent laboratory testing. We concluded that medication persistence was far from optimal, dropping off considerably after 6 months for more than half of patients. Medication persistence is a substantial barrier to realizing the full societal benefits of antihypertensive treatment. Ongoing follow up with patients, including laboratory testing, may be a critical component of better long term treatment persistence.

Use of initial and subsequent antihypertensive combination treatment in the last decade: analysis of a large Italian database

OBJECTIVE

The aim of the study was to assess the use of antihypertensive combination treatment, both as the initial and as a subsequent therapeutic step, in a large Italian population.

METHODS

The residents of the Lombardy Region (Italy), aged 40 years or older, who were newly treated with antihypertensive drugs during 2012, 2015 and 2018 were identified and the drug treatment strategy (monotherapy and combination of two, three and more than three antihypertensive drugs) was assessed at treatment initiation, and after 6 months, 1, 2, and 3 years of treatment. Data were also analysed after stratification for demographic and clinical categories.

RESULTS

About 100 000 patients were identified for each cohort. Monotherapy was the most common initial treatment strategy (75%), followed by two-drug single-pill combination (16%), two-drug free combination (6%), and combination of at least three drugs (3%). Use of two and three or more antihypertensive drugs increased during follow-up and reached about 32% (two drugs) and 11% (>2 drugs) of the patients after 3 years from treatment initiation. Among patients prescribed a two-drug combination, the single-pill was the most common approach, whereas the use of the three-drug single-pill combination was extremely rare. There were no substantial differences in the use of combination treatment between the three cohorts and the results were similar in all demographic and clinical categories.

CONCLUSION

Our data show that in a real-life population use of antihypertensive drug combinations is low. They also show that, contrary to guideline recommendations, antihypertensive combination treatment did not show any noticeable increase in recent years.

Medication Adherence and Blood Pressure Control Among Hypertensive Outpatients Attending a Tertiary Cardiovascular Hospital in Tanzania: A Cross-Sectional Study

Background

Notwithstanding the availability of effective treatments, asymptomatic nature and the interminable treatment length, adherence to medication remains a substantial challenge among patients with hypertension. Suboptimal adherence to BP-lowering agents is a growing global concern that is associated with the substantial worsening of disease, increased service utilization and health-care cost escalation. This study aimed to explore medication adherence and its associated factors among hypertension outpatients attending a tertiary-level cardiovascular hospital in Tanzania.

Methods

The pill count adherence ratio (PCAR) was used to compute adherence rate. In descriptive analyses, adherence was dichotomized and consumption of less than 80% of the prescribed medications was used to denote poor adherence. Logistic regression analyses was used to determine factors associated with adherence.

Results

A total of 849 outpatients taking antihypertensive drugs for ≥1 month prior to recruitment were randomly enrolled in this study. The mean age was 59.9 years and about two-thirds were females. Overall, a total of 653 (76.9%) participants had good adherence and 367 (43.2%) had their blood pressure controlled. Multivariate logistic regression analysis showed; lack of a health insurance (OR 0.5, 95% CI 0.3-0.7, p<0.01), last BP measurement >1 week (OR 0.6, 95% CI 0.4-0.8, p<0.01), last clinic attendance >1 month (OR 0.4, 95% CI 0.3-0.6, p<0.001), frequent unavailability of drugs (OR 0.6, 95% CI 0.3-0.9, p = 0.03), running out of medication before the next appointment (OR 0.6, 95% CI 0.4-0.9, p = 0.01) and stopping medications when asymptomatic (OR 0.6, 95% CI 0.4-0.8, p<0.001) to be independent associated factors for poor adherence.

Conclusion

A substantial proportion of hypertensive outpatients in this tertiary-level setting had good medication adherence. Nonetheless, observed suboptimal blood pressure control regardless of a fairly satisfactory adherence rate suggests that lifestyle modification plays a central role in hypertension management.

Health status and the Great Recession. Evidence from electronic health records

We investigate the impact of the Great Recession in Italy on the incidence of chronic diseases using new individual longitudinal data from Electronic Health Records. We exploit the exogenous shock in the economic conditions occurred in 2008 to estimate heterogeneous effects of an unprecedented rise in local unemployment rates in an individual fixed-effects model. Our results document that harsh economic downturns have a negative long-lasting effect on cardiovascular disease and a temporary effect on depression. This effect is heterogeneous across gender, increases with age and is stronger right before the retirement age. An important policy recommendation emerging from this study is that prolonged economic downturns constitute an additional external risk for individual health and not a temporary benefit.