Age-Related Difference in the Sleep Pressure-Lowering Effect Between an Angiotensin II Receptor Blocker and a Calcium Channel Blocker in Asian Hypertensives

Clinical studies on pharmacological treatment of hypertension in Japan

Differences in the epidemiology and phenotypes of hypertension in Japan compared with Western countries mean that optimal approaches to the pharmacological management of hypertension should be based on local data. Fortunately, there is a large body of evidence from studies conducted in Japanese populations to inform guidelines and treatment decisions. This article highlights treatment recommendations and BP targets for Japanese patients with hypertension, and summarizes key literature supporting these recommendations. The latest version of the Japanese Society of Hypertension (JSH) guidelines is consistent with US and European guidelines in recommending that the general BP target should be <130/80 mmHg for office blood pressure (BP) and <125/75 mmHg for home BP. There is good local evidence to support these targets. The JSH guidelines also strongly recommend that antihypertensive therapy is managed and monitored based on home BP, due to the closer association of this parameter with cardiovascular risk compared with office BP. Japan is a leader in out-of-office BP research, meaning that there is good evidence for the Japanese recommendations. Key features of antihypertensive agents for use in Japanese patients with hypertension include the ability to reduce stroke risk provide antihypertensive efficacy throughout the 24-h dosing period. Calcium channel blockers appear to be particularly effective in Asian populations, and are the most commonly prescribed agents in Japan. Again consistent with international recommendations, antihypertensive therapy should be started with a combination of agents to maximize the chances of achieving target BP.

Associations between novel anthropometric measures and the prevalence of hypertension among 45,853 adults: A cross-sectional study

AIMS

Traditional anthropometric measures, including body mass index (BMI), are insufficient for evaluating the risk of hypertension. We aimed to investigate the association between novel anthropometric indices and hypertension risk in a large population in the United States.

METHODS

Forty-five thousand eight hundred fifty-three participants from the National Health and Nutrition Examination Survey (NHANES) (1999-2018) were enrolled. Social demographic information, lifestyle factors, blood biochemical measurements and anthropometric indices, including body weight, body mass index (BMI), waist circumference, waist-to-height ratio (WtHR), conicity index (CI), a body shape index (ABSI), body roundness index (BRI) and lipid accumulation product (LAP) were collected. Multivariable logistic regression and restricted cubic spline were adopted to investigate the associations between hypertension risk and anthropometric indices. We also performed receiver operating characteristic (ROC) curve analyses to further evaluate the discriminatory powers of anthropometric measurements for screening hypertension risk. Moreover, participants were randomly assigned to the training group and the validation group in a ratio of 3 to 1. A nomogram model based on anthropometric measures was established and validated in the training group and validation group, respectively.

RESULTS

All of the anthropometric measurements investigated were positively and independently associated with the hypertension risk. Among all anthropometric indices, per-SD increment in ABSI had the highest OR (OR: 3.4; 95% CI: 2.73-4.24) after adjusting for age, sex, race/ethnicity, education, smoking, drinking, diabetes, and eGFR. Moreover, results from restricted cubic splines revealed the non-linear association between anthropometric measurements and hypertension risk. In ROC analyses, CI had superior discriminatory power for hypertension (area under the curve: 0.71; 95% CI: 0.706-0.715; optimal cutoff value: 1.3) compared with other indices. Nomogram model based on age, sex, diabetes, CI and LAP showed favorable predicting ability of hypertension risk with an AUC (95% CI) in training group of 80.2% (79.7-80.6%), and the AUC (95% CI) in validation group was 79.5% (78.3-80.1%). Meanwhile, calibration plot showed good consistency.

CONCLUSIONS

Anthropometric measurements including BMI, WtHR, CI, ABSI, BRI and LAP are closely associated with hypertension risk in the present study. For better prevention and treatment of hypertension, more attention should be paid to anthropometric indices, especially novel anthropometric indices.

Guidance on ambulatory blood pressure monitoring: A statement from the HOPE Asia Network

Hypertension is an important public health issue due to its association with a number of serious diseases, including cardiovascular disease and stroke. The importance of evaluating hypertension taking into account different blood pressure (BP) profiles and BP variability (BPV) is increasingly being recognized, and is particularly relevant in Asian populations given the specific features of hypertension in the region (including greater salt sensitivity and a high rate of nocturnal hypertension). Ambulatory BP monitoring (ABPM) is the gold standard for diagnosing hypertension and assessing 24-hour BP and provides data on several important parameters that cannot be obtained using any other form of BP measurement. In addition, ABPM parameters provide better information on cardio- and cerebrovascular risk than office BP. ABPM should be used in all patients with elevated BP, particularly those with unstable office or home BP, or who are suspected to have white-coat or masked hypertension. ABPM is also an important part of hypertension diagnosis and monitoring in high-risk patients. ABPM needs to be performed using a validated device and good practice techniques, and has a role both in hypertension diagnosis and in monitoring the response to antihypertensive therapy to ensure strict BP control throughout the 24-hour period. Use of ABPM in clinical practice may be limited by cost and accessibility, and practical education of physicians and patients is essential. The ABPM evidence and practice points in this document are based on the Hypertension Cardiovascular Outcome Prevention and Evidence (HOPE) Asia Network expert panel consensus recommendations for ABPM in Asia.

Evaluating the Safety and Tolerability of Azilsartan Medoxomil Alone or in Combination With Chlorthalidone in the Management of Hypertension: A Systematic Review

BACKGROUND

Azilsartan medoxomil (AZM) is the newest representative in the class of angiotensin receptor blockers. Azilsartan medoxomil in combination with the older diuretic chlorthalidone (CLD) in fixed-doses of AZM/CLD 40/12.5 mg and 40/25 mg has been approved by the FDA for use in patients with essential hypertension. We sought to evaluate the safety and tolerability of AZL-M alone and in combination with CLD.

METHODS

We conducted a search in PubMed using the keywords 'azilsartan', 'azilsartan medoxomil', 'chlorthalidone, 'safety', 'tolerability' in order to find scientific studies evaluating the safety of these drugs. We included studies reporting side effects of these drugs, alone or in combination, in comparison to placebo or other antihypertensive medications. For our systematic review, we followed the PRISMA guidelines.

RESULTS

Azilsartan medoxomil is a potent antihypertensive medicine with an acceptable safety profile. The most commonly reported adverse events are dizziness, headache, fatigue, upper respiratory tract infection and urinary tract infection. Chlorthalidone is more potent and has a considerably longer duration of action than the most commonly prescribed diuretic hydrochlorothiazide. Safety and tolerability between these two drugs are similar except higher serum uric acid and lower potassium levels with chlorthalidone.

CONCLUSION

The combination of azilsartan medoxomil with chlorthalidone has been shown to be effective in lowering blood pressure with an acceptable safety and tolerability profile. This fixeddose combination is an attractive treatment option for hypertension management.

Azilsartan: Current Evidence and Perspectives in Management of Hypertension

Hypertension continues to be global pandemic with huge mortality, morbidity, and financial burden on the health system. Unfortunately, most patients with hypertension would eventually require two or more drugs in combination to achieve their target blood pressure (BP). To this end, emergence of more potent antihypertensive drugs is a welcome sign. Angiotensin receptor blockers (ARBs) are cornerstones of hypertension management in daily practice. Among all ARBs, azilsartan is proven to be more potent in most of the head-to-head trials till date. Azilsartan is the latest ARB approved for hypertension with greater potency and minimal side effects. This review highlights the role of azilsartan in management of hypertension in the current era.

Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: The HOPE Asia Network

Hypertension is an important public health issue because of its association with a number of significant diseases and adverse outcomes. However, there are important ethnic differences in the pathogenesis and cardio-/cerebrovascular consequences of hypertension. Given the large populations and rapidly aging demographic in Asian regions, optimal strategies to diagnose and manage hypertension are of high importance. Ambulatory blood pressure monitoring (ABPM) is an important out-of-office blood pressure (BP) measurement tool that should play a central role in hypertension detection and management. The use of ABPM is particularly important in Asia due to the specific features of hypertension in Asian patients, including a high prevalence of masked hypertension, disrupted BP variability with marked morning BP surge, and nocturnal hypertension. This HOPE Asia Network document summarizes region-specific literature on the relationship between ABPM parameters and cardiovascular risk and target organ damage, providing a rationale for consensus-based recommendations on the use of ABPM in Asia. The aim of these recommendations is to guide and improve clinical practice to facilitate optimal BP monitoring with the goal of optimizing patient management and expediting the efficient allocation of treatment and health care resources. This should contribute to the HOPE Asia Network mission of improving the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia.

Role of Acetyl Salicylic Acid in Controlling the DOCA-Salt Induced Hypertension in Rats by Stimulating the Synthesis of r-Cortexin in the Kidney

INTRODUCTION

Hypertension is a metabolic disease which is caused by vasoconstriction and that results into elevated blood pressure. A chronic hypertensive condition affects and even damages to various systems in the body. Presence of renal cortexin (r-cortexin), an antihypertensive protein, which is released from the kidney cortex controls the blood pressure. The effect of r-cortexin was mediated through nitric oxide (NO), a universal vasodilating agent.

AIM

In our study, acetyl salicylic acid (aspirin), a well-known activator of the endothelial nitric oxide synthase (eNOS) induced r-cortexin synthesis.

METHODS

The hypertensive rat model was prepared by injecting deoxy corticosterone acetate (DOCA). Synthesis of r-cortexin was measured by the anti-r-cortexin antibody which was raised in adult white Wister albino rat model. NO level was determined by using methemoglobin method and later confirmed by chemiluminescence method. Change in blood pressure was determined indirectly by using NIBP monitoring system.

RESULTS

Aspirin increased the r-cortexin expression from 64.36 ± 12.6 nM to 216.7 ± 21.31 nM in DOCA induced hypertensive rats. The mechanism was proved with the findings of increased level of NO from 0.4 to 1.9 µM. The DOCA induced blood pressure was also decreased from 139.39 ± 7.36 mm of Hg to 116.57 ± 6.89 mm of Hg in case of systolic blood pressure and in case of diastolic pressure from 110.41 ± 7 mm of Hg to 86.4 ± 2.76 mm of Hg that are quite approximate.

CONCLUSION

So, from this study it has been found that aspirin induces the r-cortexin synthesis in kidney cortex through the activation of eNOS in DOCA induced hypertensive rats.

Efficacy and tolerability of initial high vs low doses of S-(-)-amlodipine in hypertension

In an 8-week randomized trial of patients with mild or moderate hypertension, the authors investigated the efficacy and tolerability of initial high (5.0 mg/d) vs low (2.5 mg/d) doses of S-(-)-amlodipine (equivalent to 5 and 10 mg of racemic amlodipine, respectively). In the S-(-)-amlodipine 2.5-mg group (n=263), 24-hour ambulatory systolic/diastolic blood pressure (±standard deviation) decreased from 131.5±15.0/82.1±10.7 mm Hg at baseline to 126.0±13.5/78.5±9.5 mm Hg at 8 weeks of follow-up by a least square mean (±standard error) change of 6.0±0.6/3.8±0.4 mm Hg. In the S-(-)-amlodipine 5-mg group (n=260), the corresponding changes were from 133.6±13.7/83.1±9.9 mm Hg to 125.0±12.0/78.2±8.9 mm Hg by 8.1±0.6/4.7±0.4 mm Hg, respectively. The between-group differences in changes in 24-hour systolic/diastolic blood pressure were 2.1/0.9 (P=.02/.17) mm Hg. Similar trends were observed for daytime and nighttime ambulatory and clinic blood pressure. The incidence rate was similar for all adverse events. An initial high dose of S-(-)-amlodipine improved ambulatory blood pressure control with similar tolerability as an initial low dose in hypertension.

Azilsartan as a Potent Antihypertensive Drug with Possible Pleiotropic Cardiometabolic Effects: A Review Study

Background: Hypertension related cardiovascular (CV) complications could be amplified by the presence of metabolic co-morbidities. Azilsartan medoxomil (AZL-M) is the eighth approved member of angiotensin II receptor blockers (ARBs), a drug class of high priority in the management of hypertensive subjects with diabetes mellitus type II (DMII).

Methods: Under this prism, we performed a systematic review of the literature for all relevant articles in order to evaluate the efficacy, safety, and possible clinical role of AZL-M in hypertensive diabetic patients.

Results: AZL-M was found to be more effective in terms of reducing indices of blood pressure over alternative ARBs or angiotensin-converting enzyme (ACE) inhibitors with minimal side effects. Preclinical studies have established pleiotropic effects for AZL-M beyond its primary antihypertensive role through differential gene expression, up-regulation of membrane receptors and favorable effect on selective intracellular biochemical and pro-atherosclerotic pathways.

Conclusion: Indirect but accumulating evidence from recent literature supports the efficacy and safety of AZL-M among diabetic patients. However, no clinical data exist to date that evince a beneficial role of AZL-M in patients with metabolic disorders on top of its antihypertensive effect. Further clinical studies are warranted to assess the pleiotropic cardiometabolic benefits of AZL-M that are derived from preclinical research.

Evidence and Perspectives on the 24-hour Management of Hypertension: Hemodynamic Biomarker-Initiated 'Anticipation Medicine' for Zero Cardiovascular Event

There are notable differences between Asians and Westerners regarding hypertension (HTN) and the relationship between HTN and cardiovascular disease (CVD). Asians show greater morning surges in blood pressure (BP) and a steeper slope illustrating the link between higher BP and the risk of CVD events. It is thus particularly important for Asian hypertensives to achieve 24-h BP control, including morning and night-time control. There are three components of 'perfect 24-h BP control:' the 24-h BP level, nocturnal BP dipping, and BP variability (BPV), such as the morning BP surge that can be assessed by ambulatory BP monitoring. The morning BP-guided approach using home BP monitoring (HBPM) is the first step toward perfect 24-h BP control, followed by the control of nocturnal HTN. We have been developing new HBPM devices that can measure nocturnal BP. BPV includes different time-phase variability from the shortest beat-by-beat, positional, diurnal, day-by-day, visit-to-visit, seasonal, and yearly changes. The synergistic resonance of each type of BPV would produce a great dynamic BP surge (resonance hypothesis), which triggers a CVD event, especially in the high-risk patients with systemic hemodynamic atherothrombotic syndrome (SHATS). In the future, the innovative management of HTN based on the simultaneous assessment of the resonance of all of the BPV phenotypes using a beat by beat wearable 'surge' BP monitoring device (WSP) and an information and communication technology (ICT)-based data analysis system will produce a paradigm shift from 'dots' BP management to 'seamless' ultimate individualized 'anticipation medication' for reaching a zero CVD event rate.

Azilsartan medoxomil in the management of hypertension: an evidence-based review of its place in therapy

Background

Azilsartan (AZI) is a relatively new angiotensin receptor blocker available for the treatment of any stage of hypertension, which was eventually given in combination with chlorthalidone (CLT).

Objective

To review pharmacology and clinical role of AZI monotherapy and AZI/CLT or AZI/amlodipine combination therapies for hypertension management.

Methods

PubMed, Embase, and Cochrane Library were searched using search terms “ azilsartan”, “chlorthalidone,” “pharmacology,” “pharmacokinetics,” “pharmacodynamics,” “pharmacoeconomics,” and “cost-effectiveness.” To obtain other relevant information, US Food and Drug Association as well as manufacturer prescribing information were also reviewed.

Results

Randomized controlled trials demonstrated AZI to be superior to other sartans, such as valsartan, olmesartan, and candesartan, in terms of 24-hour ambulatory blood pressure monitoring (ABPM) reduction with respect. That beneficial effect of azilsartan was also associated with similar safety profiles. When compared to other antihypertensive drugs, azilsartan was found to be superior to any angiotensin-converting enzyme inhibitor, including ramipril, in terms of ABPM results, and noninferior to amlodipine in terms of sleep-BP control. The association of AZI and CLT was then found to be superior to other sartans + thiazide combination therapies in terms of both BP lowering and goal achievement. The combination of AZI and amlodipine has also been tested in clinical trials, but compared only with placebo, demonstrating its superiority in terms of efficacy and similarity in terms of safety.

Conclusion

Azilsartan is a safe and effective treatment option for every stage of hypertension, both alone or in fixed-dose combination tablets with chlorthalidone or amlodipine. Beneficial effects of AZI were also noted in patients with any degree of renal impairment. In addition, safety profiles of AZI were similar to that of the placebo.

Comparison of telmisartan/amlodipine and telmisartan/hydrochlorothiazide in the treatment of Japanese patients with uncontrolled hypertension: the TAT-Kobe study

OBJECTIVE

The aim of this study was to compare the efficacy and safety of telmisartan plus amlodipine with telmisartan plus hydrochlorothiazide for the treatment of uncontrolled hypertension.

METHODS

Japanese hypertensive patients with uncontrolled hypertension, despite taking angiotensin II receptor blockers, were assigned randomly to either a fixed-dose combination of telmisartan/amlodipine (n=36) or telmisartan/hydrochlorothiazide (n=39). The primary endpoint was the change in office blood pressure from the baseline value at 12 weeks.

RESULTS

Both telmisartan/amlodipine and telmisaratan/hydrochlorothiazide reduced the office blood pressure efficiently (systole: -25.5±12.1 vs. -24.3±15.0 mmHg, P=0.705; diastole: -10.8±13.8 vs. -11.4±12.3 mmHg, P=0.832). Treatment with telmisartan/hydrochlorothiazide resulted in the quicker onset of blood pressure-lowering effects compared with telmisartan/amlodipine. The target therapeutic blood pressure was similar in both groups at the 12-week visit. Home blood pressure measurements taken in the mornings and evenings were also similar in both groups. Compared with the telmisartan/amlodipine group, serum potassium and brain natriuretic peptide levels decreased and uric acid and hemoglobin A1c levels increased significantly in the telmisartan/hydrochlorothiazide group. Both treatment groups showed a significant reduction in urine albumin. However, the estimated glomerular filtration rate decreased slightly but significantly in the telmisartan/hydrochlorothiazide group alone. Severe adverse effects were not observed in both groups.

CONCLUSION

Combination therapy with telmisartan/amlodipine or telmisartan/hydrochlorothiazide led to efficient blood pressure reduction among Japanese patients with previously uncontrolled hypertension with angiotensin II receptor blocker monotherapy.