1
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Palermiti A, Pappaccogli M, Rabbia F, D'Avolio A, Veglio F. Multiple drug intolerance in antihypertensive patients: what is known and what is missing. J Hypertens 2024; 42:1289-1297. [PMID: 38690922 DOI: 10.1097/hjh.0000000000003737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Drug allergy and intolerance are increasingly recognized as significant public health concerns, leading to adverse reactions in patients undergoing pharmacological treatments. Multiple drug intolerance syndrome (MDIS), characterized by adverse reactions to at least three different drug classes without a clear immunological mechanism, poses a substantial challenge, particularly in hypertensive patients. Despite its link to suboptimal adherence and uncontrolled blood pressure, MDIS in the context of hypertension remains insufficiently explored. This review synthesizes existing literature on MDIS, emphasizing clinical characteristics, pathogenesis, and psychiatric comorbidity. Furthermore, it delves into MDIS in the context of hypertension, highlighting the importance of a multidisciplinary approach in diagnosis and management, including innovative therapeutic strategies such as novel therapeutic algorithms or renal denervation. The review concludes by emphasizing the necessity for further research and clinical trials to enhance our understanding and address MDIS, especially in hypertensive patients.
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Affiliation(s)
| | - Marco Pappaccogli
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Franco Rabbia
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Franco Veglio
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
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2
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Stabile E, Muiesan ML, Ribichini FL, Sangiorgi G, Taddei S, Versaci F, Villari B, Bacca A, Benedetto D, Fioretti V, Laurenzano E, Scapaticci M, Saia F, Tarantini G, Grassi G, Esposito G. Italian Society of Interventional Cardiology (GISE) and Italian Society of Arterial Hypertension (SIIA) Position Paper on the role of renal denervation in the management of the difficult-to-treat hypertension. Minerva Cardiol Angiol 2024; 72:313-328. [PMID: 38535984 DOI: 10.23736/s2724-5683.23.06433-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Renal denervation (RDN) is a safe and effective strategy for the treatment of difficult to treat hypertension. The blood pressure (BP)-lowering efficacy of RDN is comparable to those of many single antihypertensive medications and it allows to consider the RDN as a valuable option for the treatment of difficult to treat hypertension together with lifestyle modifications and medical therapy. A multidisciplinary team is of pivotal importance from the selection of the patient candidate for the procedure to the post-procedural management. Further studies are needed to investigate the effect of RDN on clinical outcomes and to better identify the predictors of BP response to RDN in order to recognize the patients who are more likely to benefit from the procedure.
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Affiliation(s)
- Eugenio Stabile
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
| | - Maria L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Flavio L Ribichini
- Division of Cardiovascular Medicine, Department of Medicine, University of Verona, Verona, Italy
| | | | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Bruno Villari
- Division of Cardiology, Sacro Cuore di Gesù Hospital, Benevento, Italy
| | - Alessandra Bacca
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Daniela Benedetto
- Division of Cardiology, Tor Vergata University Hospital, Rome, Italy
| | - Vincenzo Fioretti
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | | | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, IRCCS University Hospital of Bologna, Policlinico S. Orsola, Bologna, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Guido Grassi
- Clinica Medica, University of Milano-Bicocca, Milan, Italy
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy -
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3
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Burnier M. Physician and patient adherence in hypertension trials: a point of view on an important issue to resolve. Expert Rev Pharmacoecon Outcomes Res 2024; 24:749-758. [PMID: 38836304 DOI: 10.1080/14737167.2024.2363401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/30/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Randomized controlled trials (RCTs) are important sources of evidence that strongly influence guidelines for patient management, including for elevated blood pressure in adults. AREAS COVERED Critical questions regarding the interpretation of hypertension trial results have recently increased, especially for concerns over methodology. In particular, investigator adherence to the protocol and patient adherence to investigational drugs are often far from optimal. These issues may be ignored or underreported because physicians' behavior during trials is often not monitored and patients' medication adherence is neither measured adequately nor reported or analyzed in the final report or in the publication. This situation may lead to misinterpretations of study results and misevaluations of the safety and efficacy profile of new drugs. In this short review, the problem of measuring, reporting, and analyzing drug adherence in RCTs is discussed and illustrated with several examples in the field of hypertension. EXPERT OPINION The main conclusion is that drug adherence should always be measured in clinical trials, possibly with more than one method. In addition, prespecified analyses of adherence data should be included in the statistical plan of all trials to improve their overall quality.
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Affiliation(s)
- Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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4
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Schiffrin EL, Fisher NDL. Diagnosis and management of resistant hypertension. BMJ 2024; 385:e079108. [PMID: 38897628 DOI: 10.1136/bmj-2023-079108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Resistant hypertension is defined as blood pressure that remains above the therapeutic goal despite concurrent use of at least three antihypertensive agents of different classes, including a diuretic, with all agents administered at maximum or maximally tolerated doses. Resistant hypertension is also diagnosed if blood pressure control requires four or more antihypertensive drugs. Assessment requires the exclusion of apparent treatment resistant hypertension, which is most often the result of non-adherence to treatment. Resistant hypertension is associated with major cardiovascular events in the short and long term, including heart failure, ischemic heart disease, stroke, and renal failure. Guidelines from several professional organizations recommend lifestyle modification and antihypertensive drugs. Medications typically include an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, a calcium channel blocker, and a long acting thiazide-type/like diuretic; if a fourth drug is needed, evidence supports addition of a mineralocorticoid receptor antagonist. After a long pause since 2007 when the last antihypertensive class was approved, several novel agents are now under active development. Some of these may provide potent blood pressure lowering in broad groups of patients, such as aldosterone synthase inhibitors and dual endothelin receptor antagonists, whereas others may provide benefit by allowing treatment of resistant hypertension in special populations, such as non-steroidal mineralocorticoid receptor antagonists in patients with chronic kidney disease. Several device based approaches have been tested, with renal denervation being the best supported and only approved interventional device treatment for resistant hypertension.
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Affiliation(s)
- Ernesto L Schiffrin
- Lady Davis Institute for Medical Research and Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Naomi D L Fisher
- Department of Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA, USA
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5
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Nelson AJ, Pagidipati NJ, Bosworth HB. Improving medication adherence in cardiovascular disease. Nat Rev Cardiol 2024; 21:417-429. [PMID: 38172243 DOI: 10.1038/s41569-023-00972-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Abstract
Non-adherence to medication is a global health problem with far-reaching individual-level and population-level consequences but remains unappreciated and under-addressed in the clinical setting. With increasing comorbidity and polypharmacy as well as an ageing population, cardiovascular disease and medication non-adherence are likely to become increasingly prevalent. Multiple methods for detecting non-adherence exist but are imperfect, and, despite emerging technology, a gold standard remains elusive. Non-adherence to medication is dynamic and often has multiple causes, particularly in the context of cardiovascular disease, which tends to require lifelong medication to control symptoms and risk factors in order to prevent disease progression. In this Review, we identify the causes of medication non-adherence and summarize interventions that have been proven in randomized clinical trials to be effective in improving adherence. Practical solutions and areas for future research are also proposed.
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Affiliation(s)
- Adam J Nelson
- Victorian Heart Institute, Melbourne, Victoria, Australia
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Hayden B Bosworth
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.
- Population Health Sciences, Duke University, Durham, NC, USA.
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6
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Fadl Elmula FEM, Mariampillai JE, Heimark S, Kjeldsen SE, Burnier M. Medical Measures in Hypertensives Considered Resistant. Am J Hypertens 2024; 37:307-317. [PMID: 38124494 PMCID: PMC11016838 DOI: 10.1093/ajh/hpad118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Patients with resistant hypertension are the group of hypertensive patients with the highest cardiovascular risk. METHODS All rules and guidelines for treatment of hypertension should be followed strictly to obtain blood pressure (BP) control in resistant hypertension. The mainstay of treatment of hypertension, also for resistant hypertension, is pharmacological treatment, which should be tailored to each patient's specific phenotype. Therefore, it is pivotal to assess nonadherence to pharmacological treatment as this remains the most challenging problem to investigate and manage in the setting of resistant hypertension. RESULTS Once adherence has been confirmed, patients must be thoroughly worked-up for secondary causes of hypertension. Until such possible specific causes have been clarified, the diagnosis is apparent treatment-resistant hypertension (TRH). Surprisingly few patients remain with true TRH when the various secondary causes and adherence problems have been detected and resolved. Refractory hypertension is a term used to characterize the treatment resistance in hypertensive patients using ≥5 antihypertensive drugs. All pressor mechanisms may then need blockage before their BPs are reasonably controlled. CONCLUSIONS Patients with resistant hypertension need careful and sustained follow-up and review of their medications and dosages at each term since medication adherence is a very dynamic process.
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Affiliation(s)
- Fadl Elmula M Fadl Elmula
- Division of Medicine, Ullevaal University Hospital, Cardiorenal Research Centre, Oslo, Norway
- Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, KSA
| | | | - Sondre Heimark
- Division of Medicine, Ullevaal University Hospital, Cardiorenal Research Centre, Oslo, Norway
- Medical Faculty, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Nephrology, Ullevaal University Hospital, Oslo, Norway
| | - Sverre E Kjeldsen
- Division of Medicine, Ullevaal University Hospital, Cardiorenal Research Centre, Oslo, Norway
- Medical Faculty, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Ullevaal University Hospital, Oslo, Norway
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Peeters LE, Kappers M, Hesselink D, van der Net J, Hartong S, van de Laar R, Ezzahti M, van de Ven P, van der Meer I, de Bruijne E, Kroon A, Indhirajanti-Tomasoa S, van der Linde N, Bahmany S, Boersma E, Massey EK, van Dijk L, van Gelder T, Koch BC, Versmissen J. Antihypertensive drug concentration measurement combined with personalized feedback in resistant hypertension: a randomized controlled trial. J Hypertens 2024; 42:169-178. [PMID: 37796233 PMCID: PMC10713002 DOI: 10.1097/hjh.0000000000003585] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/31/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Adherence to antihypertensive drugs (AHDs) is crucial for controlling blood pressure (BP). We aimed to determine the effectiveness of measuring AHD concentrations using a dried blood spot (DBS) sampling method to identify nonadherence, combined with personalized feedback, in reducing resistant hypertension. METHODS We conducted a multicenter, randomized, controlled trial (RHYME-RCT, ICTRP NTR6914) in patients with established resistant hypertension. Patients were randomized to receive either an intervention with standard of care (SoC) or SoC alone. SoC consisted of BP measurement and DBS sampling at baseline, 3 months (t3), 6 months (t6), and 12 months (t12); AHD concentrations were measured but not reported in this arm. In the intervention arm, results on AHD concentrations were discussed during a personalized feedback conversation at baseline and t3. Study endpoints included the proportion of patients with RH and AHD adherence at t12. RESULTS Forty-nine patients were randomized to receive the intervention+SoC, and 51 were randomized to receive SoC alone. The proportion of adherent patients improved from 70.0 to 92.5% in the intervention+SoC arm ( P = 0.008, n = 40) and remained the same in the SoC arm (71.4%, n = 42). The difference in adherence between the arms was statistically significant ( P = 0.014). The prevalence of resistant hypertension decreased to 75.0% in the intervention+SoC arm ( P < 0.001, n = 40) and 59.5% in the SoC arm ( P < 0.001, n = 42) at t12; the difference between the arms was statistically nonsignificant ( P = 0.14). CONCLUSION Personalized feedback conversations based on DBS-derived AHD concentrations improved AHD adherence but did not reduce the prevalence of RH.
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Affiliation(s)
- Laura E.J. Peeters
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam
| | | | - D.A. Hesselink
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam
| | - J.B. van der Net
- Albert Schweitzer Hospital, Department of Internal Medicine, Dordrecht
| | - S.C.C. Hartong
- Albert Schweitzer Hospital, Department of Internal Medicine, Dordrecht
| | - R. van de Laar
- Ikazia Hospital, Department of Internal Medicine, Rotterdam
| | - M. Ezzahti
- Bravis Hospital, Department of Internal Medicine, Bergen op Zoom
| | | | | | - E.L.E. de Bruijne
- IJsselland Hospital, Department of Internal Medicine, Capelle aan den Ijssel
| | - A.A. Kroon
- Maastricht University Medical Center, Department of Internal Medicine, Maastricht
| | | | | | - S. Bahmany
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
| | - E. Boersma
- Erasmus MC, University Medical Center Rotterdam, Department of Cardiology, Rotterdam
| | - E. K. Massey
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam
| | - L. van Dijk
- Nivel, Netherlands Institute for Health Services Research, Department Pharmaceutical Care, Utrecht
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - T. van Gelder
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam
| | - Birgit C.P. Koch
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam
| | - Jorie Versmissen
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam
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8
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Burnier M. The role of adherence in patients with chronic diseases. Eur J Intern Med 2024; 119:1-5. [PMID: 37479633 DOI: 10.1016/j.ejim.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
In the long-term management of chronic diseases, adherence and persistence to prescribed medications are continuous challenges in order to obtain all the potential benefits of drug therapies. Suboptimal drug adherence and discontinuations of therapies remain the most frequent reasons why several diseases are poorly controlled in the population. One the main issue is that physicians are relatively limited in time and tools to detect patients with a poor adherence. The present review discusses present and future strategies that are now available or are being developed to detect and to support adherence in patients with chronic diseases and provides some simple clues to identify patients at high risk of discontinuation in the clinic.
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Affiliation(s)
- Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Switzerland; Hypertension Research Foundation, Switzerland.
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9
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Rabbitt L, Curneen J, Hobbins A, Browne D, Joyce M, Lappin D, McEvoy JW, Gillespie P, Dennedy MC. A cost-analysis of managing secondary and apparent treatment-resistant hypertension in a specialist multidisciplinary hypertension clinic. J Hypertens 2024; 42:58-69. [PMID: 38009268 DOI: 10.1097/hjh.0000000000003535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
OBJECTIVES A knowledge gap exists around the costs and budget impact of specialist hypertension clinics. This study reports on the cost of providing care in a multidisciplinary hypertension clinic staffed by nephrologist, endocrinologist and cardiologist, which manages patients with suspected secondary hypertension and/or apparent treatment-resistant hypertension. The aim of this study is to provide the evidence required to inform policy and planning care pathways for this patient group. METHODS A cost analysis from a healthcare provider perspective using micro-costing techniques was conducted to estimate the direct implementation costs of existing standard practice for the care pathway of patients attending the multidisciplinary hypertension clinic. Sixty-five patients originally recruited for a study of medication adherence in hypertension were included in the sample. RESULTS The total care-pathway cost per patient, taking into account clinic visits, clinical reviews, investigations and MDT discussion, was estimated to be €3277, on average. For the patient subgroups, the average cost was €5644 for patients diagnosed with primary aldosteronism and €1446 for patients diagnosed with essential hypertension. CONCLUSION There is significant cost associated with providing specialized hypertension care for patients with apparent treatment-resistant hypertension. Given the high rates of nonadherence in this population, it is likely that some of this cost could be avoided with better detection and management of medication adherence in this challenging population. Future studies should consider the cost-effectiveness of this or similar models of care by exploring the benefit to patients and the wider healthcare context of providing care of this type.
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Affiliation(s)
- Louise Rabbitt
- Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway
| | - James Curneen
- Department of Clinical Pharmacology and Therapeutics, St James' Hospital, Dublin
| | - Anna Hobbins
- Centre for Research in Medical Devices (CÚRAM, SFI 13/RC/2073_P2) and Health Economics and Policy Analysis Centre, University of Galway, Ireland
| | | | - Mary Joyce
- Centre for Endocrinology, Diabetes and Metabolism
| | - David Lappin
- Department of Nephrology, Saolta University Healthcare Group (SUHCG), Galway University Hospitals
| | - John William McEvoy
- Department of Cardiology, School of Medicine, University of Galway
- National Institute for Prevention and Cardiovascular Health, Galway, Ireland
| | - Paddy Gillespie
- Centre for Research in Medical Devices (CÚRAM, SFI 13/RC/2073_P2) and Health Economics and Policy Analysis Centre, University of Galway, Ireland
| | - Michael Conall Dennedy
- Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway
- Centre for Endocrinology, Diabetes and Metabolism
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10
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Filippone EJ, Naccarelli GV, Foy AJ. Controversies in Hypertension V: Resistant and Refractory Hypertension. Am J Med 2024; 137:12-22. [PMID: 37832756 DOI: 10.1016/j.amjmed.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023]
Abstract
Apparent resistant hypertension, defined as uncontrolled office blood pressure despite ≥ 3 antihypertensive medications including a diuretic or use of ≥ 4 medications regardless of blood pressure, occurs in ≤ 15% of treated hypertensives. Apparent refractory hypertension, defined as uncontrolled office pressure despite use of 5 or more medications including a diuretic, occurs in ≤ 10% of resistant cases. Both are associated with increased comorbidity and enhanced cardiovascular risk. To rule out pseudo-resistant or pseudo-refractory hypertension, employ guideline-based methodology for obtaining pressure, maximize the regimen, rule out white-coat effect, and assess adherence. True resistant hypertension is characterized by volume overload and aldosterone excess, refractory by enhanced sympathetic tone. Spironolactone is the preferred agent for resistance, with lower doses. Spironolactone, potassium binders, or both, are preferred if the estimated glomerular filtration rate is below 45. If significant albuminuria, finerenone is indicated. The optimal treatment of refractory hypertension is unclear, but sympathetic inhibition (α-β blockade, centrally acting sympathoinhibitors, or both) seems reasonable. Renal denervation has shown minimal benefit for resistance, but its role in refractory hypertension remains to be defined.
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Affiliation(s)
- Edward J Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa.
| | - Gerald V Naccarelli
- Department of Medicine, Penn State University Heart and Vascular Institute, Penn State M.S. Hershey Medical Center and College of Medicine, Hershey, Pa
| | - Andrew J Foy
- Department of Medicine, Penn State University Heart and Vascular Institute, Penn State M.S. Hershey Medical Center and College of Medicine, Hershey, Pa
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11
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Akumwami S, Morishita A, Iradukunda A, Kobara H, Nishiyama A. Possible organ-protective effects of renal denervation: insights from basic studies. Hypertens Res 2023; 46:2661-2669. [PMID: 37532952 DOI: 10.1038/s41440-023-01393-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/22/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023]
Abstract
Inappropriate sympathetic nervous activation is the body's response to biological stress and is thought to be involved in the development of various lifestyle-related diseases through an elevation in blood pressure. Experimental studies have shown that surgical renal denervation decreases blood pressure in hypertensive animals. Recently, minimally invasive catheter-based renal denervation has been clinically developed, which results in a reduction in blood pressure in patients with resistant hypertension. Accumulating evidence in basic studies has shown that renal denervation exerts beneficial effects on cardiovascular disease and chronic kidney disease. Interestingly, recent studies have also indicated that renal denervation improves glucose tolerance and inflammatory changes. In this review article, we summarize the evidence from animal studies to provide comprehensive insight into the organ-protective effects of renal denervation beyond changes in blood pressure.
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Affiliation(s)
- Steeve Akumwami
- Department of Anesthesiology, Faculty of Medicine, Kagawa University, Kagawa, Japan
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Asahiro Morishita
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | | | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Akira Nishiyama
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan.
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12
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Lauder L, Mahfoud F. Adherence to antihypertensive medication in renal denervation trials: new studies, old problems? Hypertens Res 2023; 46:2543-2544. [PMID: 37612371 PMCID: PMC10625897 DOI: 10.1038/s41440-023-01389-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/03/2023] [Accepted: 07/03/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes, Saarland University, Homburg, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes, Saarland University, Homburg, Germany.
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13
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Peacock E, Muntner P, Craig LS, Silver J, Mills KT, Chen J, Shi L, Whelton PK, He J, Krousel-Wood M. Defining Meaningful Change in Antihypertensive Medication Adherence in Adults with Established Hypertension: Implications for Clinical Practice. Med Clin North Am 2023; 107:e39-e52. [PMID: 38609280 PMCID: PMC11233029 DOI: 10.1016/j.mcna.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Uncontrolled hypertension and low antihypertensive medication adherence remain significant clinical challenges. There is a critical need to detect meaningful change in adherence in clinical settings. The authors determined that a ≥2-point change in the 4-item Krousel-Wood Medication Adherence Scale score represents meaningful change in antihypertensive medication adherence. Among a sample of participants in an ongoing clinical trial, 5.9% experienced a decline in adherence, which was associated with higher blood pressure (BP) and a higher prevalence of uncontrolled BP at 6 months. Meaningful change in medication adherence behavior may be key in managing hypertension to improve BP control and health outcomes.
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Affiliation(s)
- Erin Peacock
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA; Center for Health Outcomes, Implementation, and Community-Engaged Science, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL 35233, USA
| | - Leslie S Craig
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA
| | - Julia Silver
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA
| | - Katherine T Mills
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Jing Chen
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA; Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Lizheng Shi
- Department of Health Policy and Management, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Marie Krousel-Wood
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA; Center for Health Outcomes, Implementation, and Community-Engaged Science, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA; Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
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Hosohata K. Impact of medication adherence on renal denervation trials in resistant hypertensive patients. Hypertens Res 2023; 46:2419-2420. [PMID: 37532954 DOI: 10.1038/s41440-023-01381-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/25/2023] [Accepted: 07/01/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Keiko Hosohata
- Education and Research Center for Clinical Pharmacy, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University, 4-20-1 Nasahara, Takatsuki, Osaka, 569-1094, Japan.
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15
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Kociánová E, Táborský M, Václavik J. A practical approach to assessment of non-adherence to antihypertensive treatment. J Hypertens 2023; 41:1371-1375. [PMID: 37345493 DOI: 10.1097/hjh.0000000000003492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
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.
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Affiliation(s)
- Eva Kociánová
- First Department of Internal Medicine - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc
| | - Miloš Táborský
- First Department of Internal Medicine - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc
| | - Jan Václavik
- University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
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16
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Townsend RR. One More Step in the Renal Denervation Trek. Am J Nephrol 2023; 55:316-318. [PMID: 37651991 DOI: 10.1159/000533885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/24/2023] [Indexed: 09/02/2023]
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17
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Weber MA, Hering D, Nikoleishvili D, Imedadze A, Dughashvili G, Klimiashvili Z, Bekaia E, Shengelia T, Kabalava M, Goguadze O, Emukhvari T, Druker V, Buelna T, Heuser R, Hashemian S, Provanzano R. Durability of the Blood Pressure Effects of Renal Pelvic Denervation in Patients with Hypertension during a 12-Month Observation. Am J Nephrol 2023; 55:319-328. [PMID: 37651994 DOI: 10.1159/000533569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/08/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION We previously completed a trial of renal pelvic denervation for treating hypertension that reduced blood pressure by the 2-month primary endpoint. However, information on the durability of effectiveness is a critical requirement for device therapy and we now report data up to 12 months. METHODS This was an open-label, single-arm feasibility study in patients with increased blood pressure despite taking an average of 2.7 medications. The key endpoint reported here was ambulatory blood pressure at 12 months following renal pelvic denervation. RESULTS In the 17 patients (mean age: 56) studied, there was a reduction from the baseline of 148 + 8.7 mm Hg in the primary endpoint of mean daytime systolic blood pressure at 12 months of 19.1 (26.7, 11.6) mm Hg, p < 0.001, as compared with the 2-month result of 19.4 (24.9, 14.0) mm Hg. The 24-h systolic blood pressure fell by 19.3 (26.7, 11.9), p < 0.001, and nighttime systolic fell by 18.7 (27.5, 9.8), p < 0.001, mm Hg at 12 months. Diastolic pressures also fell significantly from baseline at 12 months. As well, automated office systolic blood pressure was reduced from the baseline of 156.5 ± 12.3 by 24.8 (33.2, 16.8) mm Hg, p < 0.001, at 12 months as compared with 22.4 (31.5, 13.3) at 2 months. All blood pressure changes at 12 months were not different from those at 2 months, thus confirming the durability of the procedure. There were no serious procedural, clinical, or laboratory adverse events related to the intervention. Serum creatinine fell from 1.03 ± 0.22 to 0.82 ± 0.16 mg/dL, and estimated glomerular filtration rate rose from 79.6 ± 17.8 to 96.3 ± 16.4 mL/min/1.73 m2 by 12 months, again sustaining effects seen at 2 months. CONCLUSION These findings provide evidence that the significant blood pressure-lowering effects of renal pelvic denervation are durable and safe for at least 1 year and provide the basis for a pivotal randomized blinded trial to further define the safety and effectiveness of this procedure.
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Affiliation(s)
- Michael A Weber
- Downstate Medical Center, State University of New York, Brooklyn, New York, USA
| | - Dagmara Hering
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
- Department of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland
| | | | | | | | | | - Eter Bekaia
- Israeli-Georgian Medical Research Clinic Helsicore, Tbilisi, Georgia
| | | | - Mamuka Kabalava
- Israeli-Georgian Medical Research Clinic Helsicore, Tbilisi, Georgia
| | | | - Tamar Emukhvari
- Israeli-Georgian Medical Research Clinic Helsicore, Tbilisi, Georgia
| | | | | | - Richard Heuser
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
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18
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Peeters LE, Hesselink DA, Lafeber M, Severs D, van den Hoogen MW, Sonneveld MA, Ramakers CR, Bahmany S, van Gelder T, Koch BC, Versmissen J. Monitoring antihypertensive drug concentrations to determine nonadherence in hypertensive patients with or without a kidney transplant. J Hypertens 2023; 41:1239-1244. [PMID: 37195099 PMCID: PMC10328507 DOI: 10.1097/hjh.0000000000003459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/12/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Nonadherence to antihypertensive drugs (AHDs) is a major contributor to pseudo-resistant hypertension. The primary objective of this study was to determine the prevalence of nonadherence to AHDs among patients visiting the nephrology and vascular outpatient clinics. METHODS Patients were eligible to participate in this prospective observational study if they used at least two AHDs that could be measured with a validated UHPLC-MS/MS method and had an office blood pressure at least 140 and/or at least 90 mmHg. For resistant hypertension, included patients had to use at least three AHDs including a diuretic or four AHDs. Adherence was assessed by measuring drug concentrations in blood. The complete absence of drug in blood was defined as nonadherence. A posthoc analysis was performed to determine the influence of a having a kidney transplant on the adherence rates. RESULTS One hundred and forty-two patients were included of whom 66 patients fulfilled the definition of resistant hypertension. The overall adherence rate to AHDs was 78.2% ( n = 111 patients), with the highest adherence rate for irbesartan (100%, n = 9) and lowest adherence rate for bumetanide ( n = 69%, n = 13). In further analysis, only kidney transplantation could be identified as an important factor for adherence (adjusted odds ratio = 3.35; 95% confidence interval 1.23-9.09). A posthoc analysis showed that patients with a kidney transplant were more likely to be adherent to AHDs (non-KT cohort 64.0% vs. KT-cohort 85.7%, χ 2 (2) = 10.34, P = 0.006). CONCLUSION The adherence rate to AHDs in hypertensive patients was high (78.2%) and even higher after a kidney transplant (85.7%). Furthermore, patients after kidney transplant had a lower risk of being nonadherent to AHDs.
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Affiliation(s)
- Laura E.J. Peeters
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Vascular Medicine
| | - Dennis A. Hesselink
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Nephrology and Transplantation
- Erasmus MC, University Medical Center Rotterdam, Erasmus MC Transplant Institute
| | - Melvin Lafeber
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Vascular Medicine
| | - David Severs
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Nephrology and Transplantation
- Erasmus MC, University Medical Center Rotterdam, Erasmus MC Transplant Institute
| | - Martijn W.F. van den Hoogen
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Nephrology and Transplantation
| | - Michelle A.H. Sonneveld
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Vascular Medicine
| | - Christian R.B. Ramakers
- Erasmus MC, University Medical Center Rotterdam, Department of Clinical Chemistry, Rotterdam, the Netherlands
| | - Soma Bahmany
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
| | - Teun van Gelder
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Nephrology and Transplantation
- Erasmus MC, University Medical Center Rotterdam, Erasmus MC Transplant Institute
| | - Birgit C.P. Koch
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
| | - Jorie Versmissen
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Vascular Medicine
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19
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Schmieder RE, Wassmann S, Predel HG, Weisser B, Blettenberg J, Gillessen A, Randerath O, Mevius A, Wilke T, Böhm M. 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. Hypertension 2023; 80:1127-1135. [PMID: 36987918 PMCID: PMC10112936 DOI: 10.1161/hypertensionaha.122.20810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/21/2023] [Indexed: 03/30/2023]
Abstract
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.
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Affiliation(s)
- Roland E. Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University Erlangen Nürnberg, Germany (R.E.S.)
| | - Sven Wassmann
- Cardiology Pasing, Faculty of Medicine, Munich and University of the Saarland, Homburg/Saar, Germany (S.W.)
| | - Hans-Georg Predel
- Institute of Cardiology and Sports Medicine, German Sport University, Cologne, Germany (H.-G.P.)
| | - Burkhard Weisser
- Institute of Sports Science, Christian-Albrechts-Universität zu Kiel, Germany (B.W.)
| | | | - Anton Gillessen
- Herz-Jesu-Hospital, Department of Internal Medicine, Münster (A.G.)
| | - Olaf Randerath
- Medical Department, APONTIS PHARMA Deutschland GmbH & Co. KG, Monheim, Germany (O.R.)
| | - Antje Mevius
- Institut für Pharmakoökonomie und Arzneimittellogistik (IPAM), Wismar, Germany (A.M., T.W.)
| | - Thomas Wilke
- Institut für Pharmakoökonomie und Arzneimittellogistik (IPAM), Wismar, Germany (A.M., T.W.)
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany (M.B.)
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20
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Peeters LEJ, Kappers MHW, Boersma E, Massey EK, van Dijk L, van Gelder T, Koch BCP, Versmissen J. The effect of combining therapeutic drug monitoring of antihypertensive drugs with personalised feedback on adherence and resistant hypertension: the (RHYME-RCT) trial protocol of a multi-centre randomised controlled trial. BMC Cardiovasc Disord 2023; 23:87. [PMID: 36788491 PMCID: PMC9926861 DOI: 10.1186/s12872-023-03114-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Adherence to antihypertensive drugs (AHDs) is important for adequate blood pressure control. Not taking these drugs as prescribed is one of the main underlying causes for resistant hypertension (RH), which in turn leads to an increased risk of cardiovascular events, stroke and kidney damage. Therefore, correct identification of patients that are non-adherent to AHDs is crucial to improve clinical outcome. For this goal, therapeutic drug monitoring is the most reliable method. The primary objective of this trial is to investigate whether monitoring of drug concentrations with a dried blood spot (DBS) sampling method combined with personalised feedback leads to a decrease in prevalence of RH after 12 months due to an increase in adherence. Secondary objectives include the difference over time in the number of required AHDs as well as the defined daily dose (DDD). Lastly, the cost-utility of SoC versus the intervention in RH is determined. METHODS This is a multi-centre single-blinded randomised controlled trial (RHYME-RCT). First, at an eligibility visit, DBS sampling, to monitor drug concentrations in blood, and a 24-h ambulatory blood pressure measurement (24-h ABPM) are performed simultaneously. Patients with a daytime systolic blood pressure (SBP) > 135 and/or diastolic blood pressure (DBP) > 85 mmHg are randomised to SoC or intervention + SoC. The intervention is performed by the treating physician and includes information on drug concentrations and a comprehensive personalised feedback conversation with the use of a communication tool. The follow-up period is one year with visits at 3, 6 and 12 months randomisation and includes 24-h ABPM and DBS sampling. DISCUSSION This will be the first trial that focusses specifically on patients with RH without taking into account suspicion of non-adherence and it combines monitoring of AHD concentrations to identify non-adherence to AHDs with a comprehensive feedback to improve non-adherence. Furthermore, if this trial shows positive outcomes for the intervention it can be directly implemented in clinical practice, which would be a great improvement in the treatment of RH. TRIAL REGISTRATION RHYME-RCT is registered in the Dutch Trial Register on 27/12/2017 (NTR6914) and can be found in the International Clinical Trials Registry Platform.
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Affiliation(s)
- L. E. J. Peeters
- grid.5645.2000000040459992XDepartment of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands ,grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M. H. W. Kappers
- grid.413711.10000 0004 4687 1426Department of Internal Medicine, Amphia Hospital, Breda, The Netherlands
| | - E. Boersma
- grid.5645.2000000040459992XDepartment of Cardiology, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - E. K. Massey
- grid.5645.2000000040459992XDepartment of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - L. van Dijk
- grid.416005.60000 0001 0681 4687Department Pharmaceutical Care, Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands ,grid.4830.f0000 0004 0407 1981Unit of PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - T. van Gelder
- grid.5645.2000000040459992XDepartment of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands ,grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - B. C. P. Koch
- grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J. Versmissen
- grid.5645.2000000040459992XDepartment of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands ,grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
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21
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Parati G, Goncalves A, Soergel D, Bruno RM, Caiani EG, Gerdts E, Mahfoud F, Mantovani L, McManus RJ, Santalucia P, Kahan T. New perspectives for hypertension management: progress in methodological and technological developments. Eur J Prev Cardiol 2023; 30:48-60. [PMID: 36073370 DOI: 10.1093/eurjpc/zwac203] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/21/2022] [Accepted: 09/05/2022] [Indexed: 01/14/2023]
Abstract
Hypertension is the most common and preventable risk factor for cardiovascular disease (CVD), accounting for 20% of deaths worldwide. However, 2/3 of people with hypertension are undiagnosed, untreated, or under treated. A multi-pronged approach is needed to improve hypertension management. Elevated blood pressure (BP) in childhood is a predictor of hypertension and CVD in adulthood; therefore, screening and education programmes should start early and continue throughout the lifespan. Home BP monitoring can be used to engage patients and improve BP control rates. Progress in imaging technology allows for the detection of preclinical disease, which may help identify patients who are at greatest risk of CV events. There is a need to optimize the use of current BP control strategies including lifestyle modifications, antihypertensive agents, and devices. Reducing the complexity of pharmacological therapy using single-pill combinations can improve patient adherence and BP control and may reduce physician inertia. Other strategies that can improve patient adherence include education and reassurance to address misconceptions, engaging patients in management decisions, and using digital tools. Strategies to improve physician therapeutic inertia, such as reminders, education, physician-peer visits, and task-sharing may improve BP control rates. Digital health technologies, such as telemonitoring, wearables, and other mobile health platforms, are becoming frequently adopted tools in hypertension management, particularly those that have undergone regulatory approval. Finally, to fight the consequences of hypertension on a global scale, healthcare system approaches to cardiovascular risk factor management are needed. Government policies should promote routine BP screening, salt-, sugar-, and alcohol reduction programmes, encourage physical activity, and target obesity control.
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Affiliation(s)
- Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, 20149 Milano, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza (MB), Italy
| | | | - David Soergel
- Cardiovascular, Renal, and Metabolic Drug Development, Novartis, Basel, CH 4056, Switzerland
| | - Rosa Maria Bruno
- Paris Cardiovascular Research Centre (PARCC-INSERM U970) & Université de Paris, Paris 75015, France
| | - Enrico Gianluca Caiani
- Politecnico di Milano, Electronics, Information and Bioengineering Department, Institute of Electronics, Computer and Telecommunication Engineering (IEIIT), National Research Council of Italy (CNR), Milan 20133 & 24-10129, Italy
| | - Eva Gerdts
- Department of Clinical Science, University of Bergen, Bergen NO-5020, Norway
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Hospital, Homburg 66123, Germany
| | - Lorenzo Mantovani
- Value-based Healthcare Unit, IRCCS MultiMedica Research Hospital, University of Milan, Milan, Italy
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6HD, UK
| | - Paola Santalucia
- Italian Association Against Thrombosis and Cardiovascular Diseases (ALT Onlus), Milan 20123, Italy
| | - Thomas Kahan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm SE 182 88, Sweden.,Department of Cardiology, Danderyd University Hospital Corp, Stockholm SE 182 88, Sweden
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22
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The position of renal denervation in treatment of hypertension: an expert consensus statement. Neth Heart J 2023; 31:3-11. [PMID: 36001280 PMCID: PMC9807711 DOI: 10.1007/s12471-022-01717-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 01/07/2023] Open
Abstract
Hypertension is an important risk factor for cardiovascular disease. In the Netherlands, there are approximately 2.8 million people with hypertension. Despite treatment recommendations including lifestyle changes and antihypertensive drugs, most patients do not meet guideline-recommended blood pressure (BP) targets. In order to improve BP control and lower the risk of subsequent cardiovascular events, renal sympathetic denervation (RDN) has been introduced and studied as a non-pharmacological approach. While early data on the efficacy of RDN showed conflicting results, improvements in treatment protocols and study design resulted in robust new evidence supporting the potential of the technology to improve patient care in hypertensive subjects. Recently, 5 randomised sham-controlled trials demonstrated the safety and efficacy of the technology. Modelling studies have further shown that RDN is cost-effective in the Dutch healthcare setting. Given the undisputable disease burden along with the shortcomings of current therapeutic options, we postulate a new, clearly framed indication for RDN as an adjunct in the treatment of hypertension. The present consensus statement summarises current guideline-recommended BP targets, proposed workup and treatment for hypertension, and position of RDN for those patients with primary hypertension who do not meet guideline-recommended BP targets (see central illustration).
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23
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Groenland EH, Dasgupta I, Visseren FLJ, van der Elst KCM, Lorde N, Lawson AJ, Bots ML, Spiering W. Clinical characteristics do not reliably identify non-adherence in patients with uncontrolled hypertension. Blood Press 2022; 31:178-186. [PMID: 35899383 DOI: 10.1080/08037051.2022.2104215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
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.
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Affiliation(s)
- Eline H Groenland
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Indranil Dasgupta
- Renal Unit, Heartlands Hospital, Birmingham and Warwick Medical School, University of Warwick, Coventry, UK
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Kim C M van der Elst
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Nathan Lorde
- Department of Clinical Chemistry, Immunology and Toxicology, Heartlands Hospital University Hospitals Birmingham, UK
| | - Alexander J Lawson
- Department of Clinical Chemistry, Immunology and Toxicology, Heartlands Hospital University Hospitals Birmingham, UK
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, The Netherlands
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24
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Georges CMG, Ritscher S, Pappaccogli M, Petit G, Lopez-Sublet M, Bapolisi A, Di Monaco S, Wallemacq P, Rabbia F, Toennes SW, de Timary P, Persu A. Psychological determinants of drug adherence and severity of hypertension in patients with apparently treatment-resistant vs. controlled hypertension. Blood Press 2022; 31:169-177. [PMID: 35899361 DOI: 10.1080/08037051.2022.2099346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE In a pilot study including 35 patients with apparently treatment-resistant hypertension (ATRH), we documented associations between psychological profile, drug adherence and severity of hypertension. The current study aims to confirm and expand our findings in a larger and more representative sample of patients with ATRH, using controlled hypertensive patients as the comparator. MATERIALS AND METHODS Patients with ATRH were enrolled in hypertension centres from Brussels and Torino. The psychological profile was assessed using five validated questionnaires. Drug adherence was assessed by high-performance liquid chromatography-tandem mass spectrometry analysis of urine samples, and drug resistance by 24-hour ambulatory blood pressure was adjusted for drug adherence. RESULTS The study sample totalised 144 patients, including 81 ATRH and 63 controlled hypertensive patients. The mean adherence level was significantly lower in the "resistant" group (78.9% versus 92.7% in controlled patients, p-value = .022). In patients with ATRH, independent predictors of poor drug adherence were somatisation, smoking and low acceptance level of difficult situations, accounting for 41% of the variability in drug adherence. Independent predictors of severity of hypertension were somatisation, smoking, more frequent admissions to the emergency department and low acceptation, accounting for 63% of the variability in the severity of hypertension. In contrast, in patients with controlled hypertension, the single predictors of either drug adherence or severity of hypertension were the number of years of hypertension and, for the severity of hypertension, alcohol consumption, accounting for only 15-20% of the variability. CONCLUSION Psychological factors, mostly related to somatisation and expression of emotions are strong, independent predictors of both drug adherence and severity of hypertension in ATRH but not in controlled hypertensive patients.
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Affiliation(s)
- Coralie M G Georges
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Sabrina Ritscher
- Institute of Legal Medicine, Department of Forensic Toxicology, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Marco Pappaccogli
- Department of Medical Sciences, Internal Medicine and Hypertension Division, AOU Città della Salute e della Scienza, Turin, Italy
| | - Géraldine Petit
- Adult Psychiatry Department and Institute of Neuroscience, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Marilucy Lopez-Sublet
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.,Department of Internal Medicine, ESH Hypertension Excellence Center, CHU Avicenne AP-HP, Bobigny, France Bobigny
| | - Achille Bapolisi
- Adult Psychiatry Department and Institute of Neuroscience, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.,Université Catholique de Bukavu and Hôpital Provincial Général de Bukavu, Bukavu, Democratic Republic of Congo
| | - Silvia Di Monaco
- Department of Medical Sciences, Internal Medicine and Hypertension Division, AOU Città della Salute e della Scienza, Turin, Italy
| | - Pierre Wallemacq
- Clinical Chemistry Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Center for Toxicology and Applied Pharmacology, Université Catholique de Louvain, Brussels, Belgium
| | - Franco Rabbia
- Department of Medical Sciences, Internal Medicine and Hypertension Division, AOU Città della Salute e della Scienza, Turin, Italy
| | - Stefan W Toennes
- Institute of Legal Medicine, Department of Forensic Toxicology, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Philippe de Timary
- Adult Psychiatry Department and Institute of Neuroscience, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Alexandre Persu
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.,Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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25
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Georges CMG, Pappaccogli M, Fanelli E, Petit G, Ritscher S, Lopez-Sublet M, Bapolisi A, Wallemacq P, Rabbia F, de Timary P, Toennes SW, Persu A. Drug adherence and psychological factors in patients with apparently treatment-resistant hypertension: Yes but which ones? J Clin Hypertens (Greenwich) 2022; 24:1436-1443. [PMID: 36225118 PMCID: PMC9659872 DOI: 10.1111/jch.14575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 11/27/2022]
Abstract
The aim of the study was to assess drug adherence, as well as association of psychological factors with both drug adherence and severity of hypertension in two subtypes of patients with apparently treatment‐resistant hypertension (ATRH): younger patients with uncomplicated hypertension (YURHTN) versus patients ≥60‐year‐old and/or with a history of cardio‐ or cerebrovascular complication (OCRHTN). Drug adherence was assessed in urine by targeted Liquid Chromatography‐Mass Spectrometry. The severity of hypertension was assessed by 24‐h ambulatory blood pressure adjusted for the number of antihypertensive drugs and for drug adherence. Psychological profile was assessed using five validated questionnaires. The proportion of totally non‐adherent patients was three times higher (24.1 vs. 7.1%, P = 0.026) in the YURHTN (n = 54) than in OCRHTN subgroup (n = 43). Independent predictors of drug adherence in YURHTN were ability to use adaptive strategies, male sex and family history of hypertension, accounting for 39% of variability in drug adherence. In the same subgroup, independent predictors of severity of hypertension were somatization and lower recourse to planification, accounting for 40% of variability in the severity of hypertension. In contrast, in the OCRHTN subgroup, independent predictors of drug adherence and severity of hypertension were limited to the number of yearly admissions to the emergency room and the total number of prescribed drugs. In conclusion, poor drug adherence and altered psychological profiles appear to play a major role in younger patients with ATRH devoid of cardiovascular complication. This subgroup should be prioritized for chemical detection of drug adherence and psychological evaluation.
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Affiliation(s)
- Coralie M G Georges
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Marco Pappaccogli
- Department of Medical Sciences, Internal Medicine and Hypertension Division, AOU Città della Salute e della Scienza, Turin, Italy
| | - Elvira Fanelli
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.,Department of Medical Sciences, Internal Medicine and Hypertension Division, AOU Città della Salute e della Scienza, Turin, Italy
| | - Géraldine Petit
- Adult Psychiatry Department and Institute of Neuroscience, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Sabrina Ritscher
- Institute of Legal Medicine, Department of Forensic Toxicology, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Marilucy Lopez-Sublet
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.,AP-HP, Hôpital Avicenne, Department of Internal Medicine, ESH Excellence Centre, Bobigny, France
| | - Achille Bapolisi
- Adult Psychiatry Department and Institute of Neuroscience, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.,Université Catholique de Bukavu and Hôpital Provincial Général de Bukavu, Bukavu, Democratic Republic of Congo
| | - Pierre Wallemacq
- Clinical Chemistry Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Center for Toxicology and Applied Pharmacology, Université Catholique de Louvain, Brussels, Belgium
| | - Franco Rabbia
- Department of Medical Sciences, Internal Medicine and Hypertension Division, AOU Città della Salute e della Scienza, Turin, Italy
| | - Philippe de Timary
- Adult Psychiatry Department and Institute of Neuroscience, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Stefan W Toennes
- Institute of Legal Medicine, Department of Forensic Toxicology, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Alexandre Persu
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.,Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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26
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Halvorsen LV, Bergland OU, Søraas CL, Larstorp ACK, Hjørnholm U, Kjær VN, Kringen MK, Clasen PE, Haldsrud R, Kjeldsen SE, Rostrup M, Fadl Elmula FEM, Opdal MS, Høieggen A. Nonadherence by Serum Drug Analyses in Resistant Hypertension: 7-Year Follow-Up of Patients Considered Adherent by Directly Observed Therapy. J Am Heart Assoc 2022; 11:e025879. [PMID: 36073648 DOI: 10.1161/jaha.121.025879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Measurement of serum concentrations of drugs is a novelty found useful in detecting poor drug adherence in patients taking ≥2 antihypertensive agents. Regarding patients with treatment-resistant hypertension, we previously based our assessment on directly observed therapy. The present study aimed to investigate whether serum drug measurements in patients with resistant hypertension offer additional information regarding drug adherence, beyond that of initial assessment with directly observed therapy. Methods and Results Nineteen patients assumed to have true treatment-resistant hypertension and adherence to antihypertensive drugs based on directly observed therapy were investigated repeatedly through 7 years. Serum concentrations of antihypertensive drugs were measured by ultra-high-performance liquid chromatography-tandem mass spectrometry from blood samples taken at baseline, 6-month, 3-year, and 7-year visits. Cytochrome P450 polymorphisms, self-reported adherence and beliefs about medicine were performed as supplement investigations. Seven patients (37%) were redefined as nonadherent based on their serum concentrations during follow-up. All patients reported high adherence to medications. Nonadherent patients expressed lower necessity and higher concerns regarding intake of antihypertensive medication (P=0.003). Cytochrome P450 polymorphisms affecting metabolism of antihypertensive drugs were found in 16 patients (84%), 21% were poor metabolizers, and none were ultra-rapid metabolizers. Six of 7 patients redefined as nonadherent had cytochrome P450 polymorphisms, however, not explaining the low serum drug concentrations measured in these patients. Conclusions Our data suggest that repeated measurements of serum concentrations of antihypertensive drugs revealed nonadherence in one-third of patients previously evaluated as adherent and treatment resistant by directly observed therapy, thereby improving the accuracy of adherence evaluation. Registration URL: https://www.clinicaltrials.gov; unique identifier: NCT01673516.
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Affiliation(s)
- Lene V Halvorsen
- Section of Cardiovascular and Renal Research Oslo University Hospital, Ullevaal Oslo Norway
- Department of Nephrology Oslo University Hospital, Ullevaal Oslo Norway
- Institute of Clinical Medicine University of Oslo Norway
| | - Ola U Bergland
- Section of Cardiovascular and Renal Research Oslo University Hospital, Ullevaal Oslo Norway
| | - Camilla L Søraas
- Section of Cardiovascular and Renal Research Oslo University Hospital, Ullevaal Oslo Norway
- Section for Environmental and Occupational Medicine Oslo University Hospital, Ullevaal Oslo Norway
| | - Anne Cecilie K Larstorp
- Section of Cardiovascular and Renal Research Oslo University Hospital, Ullevaal Oslo Norway
- Department of Medical Biochemistry Oslo University Hospital, Ullevaal Oslo Norway
- Institute of Clinical Medicine University of Oslo Norway
| | - Ulla Hjørnholm
- Section of Cardiovascular and Renal Research Oslo University Hospital, Ullevaal Oslo Norway
| | - Vibeke N Kjær
- Section of Cardiovascular and Renal Research Oslo University Hospital, Ullevaal Oslo Norway
| | | | - Per-Erik Clasen
- Department of Pharmacology Oslo University Hospital, Ullevaal Oslo Norway
| | - Renate Haldsrud
- Department of Pharmacology Oslo University Hospital, Ullevaal Oslo Norway
| | - Sverre E Kjeldsen
- Section of Cardiovascular and Renal Research Oslo University Hospital, Ullevaal Oslo Norway
- Department of Cardiology Oslo University Hospital, Ullevaal Oslo Norway
- Institute of Clinical Medicine University of Oslo Norway
| | - Morten Rostrup
- Section of Cardiovascular and Renal Research Oslo University Hospital, Ullevaal Oslo Norway
- Department of Acute Medicine Oslo University Hospital, Ullevaal Oslo Norway
- Institute of Basic Medical Sciences University of Oslo Norway
| | - Fadl Elmula M Fadl Elmula
- Section of Cardiovascular and Renal Research Oslo University Hospital, Ullevaal Oslo Norway
- Department of Acute Medicine Oslo University Hospital, Ullevaal Oslo Norway
| | - Mimi S Opdal
- Department of Pharmacology Oslo University Hospital, Ullevaal Oslo Norway
- Institute of Clinical Medicine University of Oslo Norway
| | - Aud Høieggen
- Section of Cardiovascular and Renal Research Oslo University Hospital, Ullevaal Oslo Norway
- Department of Nephrology Oslo University Hospital, Ullevaal Oslo Norway
- Institute of Clinical Medicine University of Oslo Norway
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27
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Renal Denervation for Resistant Hypertension: A Concise Update on Treatment Options and the Latest Clinical Evidence. Cardiol Ther 2022; 11:385-392. [PMID: 35943714 PMCID: PMC9381663 DOI: 10.1007/s40119-022-00275-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/22/2022] [Indexed: 11/21/2022] Open
Abstract
Evidence from recent sham-controlled trials supports the use of endovascular renal denervation (RDN) to lower blood pressure in general as well as in treatment-resistant hypertension. According to recent studies, the effects of RDN are long lasting. Newer technologies using multipolar radiofrequency catheters and an additional ablation of the renal side branches as well as ultrasound with improved circumferential tissue penetration have made these advances possible. This has initiated a change of the perspective on RDN in clinical guidelines and has thereby set a cornerstone for a broader clinical application of RDN in the future.
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28
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Barriers to up-titrated antihypertensive strategies in 12 sub-Saharan African countries: the Multination Evaluation of hypertension in Sub-Saharan Africa Study. J Hypertens 2022; 40:1411-1420. [PMID: 35762480 DOI: 10.1097/hjh.0000000000003169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sub-Saharan Africa (SSA) faces the highest rate of hypertension worldwide. The high burden of elevated blood pressure (BP) in black people has been emphasized. Guidelines recommend two or more antihypertensive medications to achieve a BP control. We aimed to identify factors associated with prescription of up-titrated antihypertensive strategies in Africa. METHODS We conducted a cross-sectional study on outpatient consultations for hypertension across 12 SSA countries. Collected data included socioeconomic status, antihypertensive drugs classes, BP measures, cardiovascular risk factors and complication of hypertension. We used ordinal logistic regression to assess factors associated with prescription of up-titrated strategies. RESULTS The study involved 2123 treated patients with hypertension. Patients received monotherapy in 36.3 vs. 25.9%, two-drug in 42.2 vs. 45% and three and more drugs strategies in 21.5 vs. 29.1% in low (LIC) and middle (MIC) income countries, respectively. Patients with sedentary lifestyle [OR 1.4 (1.11-1.77)], complication of hypertension [OR 2.4 (1.89-3.03)], former hypertension [OR 3.12 (2.3-4.26)], good adherence [OR 1.98 (1.47-2.66)], from MIC [OR 1.38 (1.10-1.74)] and living in urban areas [OR 1.52 (1.16-1.99)] were more likely to be treated with up-titrated strategies. Stratified analysis shows that in LIC, up-titrated strategies were less frequent in rural than in urban patients (P for trend <0.01) whereas such difference was not observed in MIC. CONCLUSION In this African setting, in addition to expected factors, up-titrated drug strategies were associated with country-level income, patient location and finally, the interplay between both in LIC. These results highlight the importance of developing policies that seek to make multiple drug classes accessible particularly in rural and LIC.
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29
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Development of UHPLC-MS/MS methods to quantify 25 antihypertensive drugs in serum in a cohort of patients treated for hypertension. J Pharm Biomed Anal 2022; 219:114908. [DOI: 10.1016/j.jpba.2022.114908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/22/2022]
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30
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Persu A, Maes F, Toennes SW, Ritscher S, Georges C, Wallemacq P, Haratani N, Parise H, Fischell TA, Lauder L, Mahfoud F. Impact of drug adherence on blood pressure response to alcohol-mediated renal denervation. Blood Press 2022; 31:109-117. [PMID: 35575248 DOI: 10.1080/08037051.2022.2074367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PURPOSE While poor drug adherence is frequent in patients with resistant hypertension, detailed analyses of the impact of drug adherence on the success of renal denervation are scarce. We report drug adherence at baseline, changes in drug adherence, and the influence of these parameters on blood pressure changes at 6 and 12 months in patients treated with alcohol-mediated renal denervation as part of the Peregrine study. MATERIALS AND METHODS Urinary detection of antihypertensive drugs was performed using high-performance liquid chromatography-tandem mass spectrometry. Full adherence, partial adherence, and complete non-adherence were defined as 0, 1, or ≥2 drugs not detected, respectively. RESULTS Renal denervation was performed in 45 patients with uncontrolled hypertension on ≥3 antihypertensive medications (62% men, age 55 ± 10 years). At baseline, the proportion of fully, partially, and non-adherent patients was 62% (n = 28), 16% (n = 7), and 22% (n = 10), respectively. At 6 months, adherence improved by 21% (n = 9), remained unchanged at 49% (n = 21), and worsened by 30% (n = 13). Mean 24-h systolic blood pressure decreased by 10 ± 13, 10 ± 4, and 14 ± 19 mmHg in fully, partially, and non-adherent patients (p = 0.77), and by 14 ± 14, 8 ± 11, and 14 ± 18 mmHg in patients who improved, maintained, or decreased adherence, respectively (p = 0.35). The results at 12 months were similar. CONCLUSION About 40% of patients with apparently treatment-resistant hypertension were not fully adherent at baseline, and adherence decreased further in 30%. Nevertheless, mean blood pressure changes after renal denervation were similar irrespective of drug adherence. Our results suggest that such patients may benefit from alcohol-mediated renal denervation, irrespective of drug adherence. These findings are hypothesis-generating and need to be confirmed in ongoing sham-controlled trials.
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Affiliation(s)
- Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Frédéric Maes
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Stefan W Toennes
- Institute of Legal Medicine, Goethe University, Frankfurt, Germany
| | - Sabrina Ritscher
- Institute of Legal Medicine, Goethe University, Frankfurt, Germany
| | - Coralie Georges
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Pierre Wallemacq
- Clinical Chemistry Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | | | | | - Lucas Lauder
- Department of Internal Medicine III, Saarland University Medical Center, Homburg, Germany
| | - Felix Mahfoud
- Department of Internal Medicine III, Saarland University Medical Center, Homburg, Germany
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31
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Nikrýnová Nguyen TMP, Štrauch B, Petrák O, Krátká Z, Holaj R, Kurcová I, Marešová V, Pilková A, Hartinger J, Waldauf P, Zelinka T, Widimský J. Adherence and blood pressure control in patients with primary aldosteronism. Blood Press 2022; 31:58-63. [PMID: 35438025 DOI: 10.1080/08037051.2022.2061416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PURPOSE The aim of our study was to evaluate the adherence to mineralocorticoid receptor (MR) antagonists and other antihypertensive therapy and blood pressure control in conservatively treated patients with primary aldosteronism (PA). MATERIALS AND METHODS Conservatively treated subjects with previously confirmed PA (n-50, 64.5 ± 9 years of age, 24% women) were investigated via our outpatient hypertension clinic. All subjects underwent regular examinations in our clinic. In addition to basic laboratory and clinical parameters, 24 h ambulatory blood pressure monitoring (ABPM) (Spacelabs) was evaluated. Unplanned blood sampling for assessment of serum antihypertensive drug concentrations by the means of liquid chromatography-mass spectrometry was performed in all patients. In case of spironolactone, its active metabolite canrenone was also evaluated. Total non-compliance was then defined as the absence of all measured antihypertensive drugs. Partial non-compliance was calculated as the absence of serum levels of at least one, but not all antihypertensive drugs prescribed. RESULTS Good blood pressure control was detected (mean 24 h systolic/diastolic BP 130 ± 12/77 ± 9 mmHg). The average number of antihypertensive drugs was 3.9 ± 1.5. All subjects were treated by MR antagonists. 44% of patients received spironolactone (average daily dose 45 ± 20 mg) and in the remaining 56% of subjects eplerenone was administered (average daily dose 80 ± 30 mg) due to spironolactone side effects. Assessment of antihypertensive drug concentrations revealed full adherence in 80% of all subjects, partial nonadherence was noted in the remaining 20% of subjects. MR antagonist levels were detected in almost all subjects (49 out of 50). CONCLUSIONS Good blood pressure control and adherence to therapy were detected in conservatively treated patients with PA. Eplerenone had to be used quite often as male subjects did not tolerate dose escalation due to spironolactone side effects.
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Affiliation(s)
- Thi Minh Phuong Nikrýnová Nguyen
- Third Internal Department of Endocrinology and Metabolism, General University Hospital, Charles University, Prague, Czech Republic
| | | | - Ondřej Petrák
- Third Internal Department of Endocrinology and Metabolism, General University Hospital, Charles University, Prague, Czech Republic
| | - Zuzana Krátká
- Third Internal Department of Endocrinology and Metabolism, General University Hospital, Charles University, Prague, Czech Republic
| | - Robert Holaj
- Third Internal Department of Endocrinology and Metabolism, General University Hospital, Charles University, Prague, Czech Republic
| | - Ivana Kurcová
- Institute of Forensic Medicine and Toxicology, Toxicology Laboratory, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Věra Marešová
- Institute of Forensic Medicine and Toxicology, Toxicology Laboratory, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Alena Pilková
- Department of Clinical Pharmacology and Pharmacy, First Faculty of Medicine, Institute of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Hartinger
- Department of Clinical Pharmacology and Pharmacy, First Faculty of Medicine, Institute of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Petr Waldauf
- Department of Anesthesiology and Intensive Care Medicine, Third Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
| | - Tomáš Zelinka
- Third Internal Department of Endocrinology and Metabolism, General University Hospital, Charles University, Prague, Czech Republic
| | - Jiří Widimský
- Third Internal Department of Endocrinology and Metabolism, General University Hospital, Charles University, Prague, Czech Republic
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32
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Weil J. Renale Denervation – Phoenix aus der Asche. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1693-2156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDie arterielle Hypertonie ist eine häufige und meistens unzureichend behandelte Erkrankung, die für eine Vielzahl von kardiovaskulären Komplikationen verantwortlich ist. Aufgrund der
schlechten Therapieadhärenz resultieren Lebensstiländerungen und die medikamentöse Dauertherapie häufig nicht in einer ausreichenden Blutdrucksenkung. Die renale Denervation (RDN) hat damit
das Potenzial, die bisherigen Strategien zur Therapie der arteriellen Hypertonie sinnvoll zu ergänzen. Unlängst haben mehrere randomisierte, unabhängige Studien das biologische Konzept der
RDN eindeutig nachgewiesen. Dabei entspricht die erreichte Blutdrucksenkung im Mittel etwa dem eines Antihypertonikums. Unabhängig von der Therapietreue des Patienten ist die Wirkung
anhaltend. Weitere klinische Untersuchung werden derzeit durchgeführt, um die bisherigen Ergebnisse zu festigen und bislang ungeklärte Fragen zu beantworten.
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Affiliation(s)
- Joachim Weil
- Medizinische Klinik II, Sana Kliniken Lübeck GmbH, Lübeck, Deutschland
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33
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Hengel FE, Sommer C, Wenzel U. [Arterial Hypertension]. Dtsch Med Wochenschr 2022; 147:414-428. [PMID: 35345049 DOI: 10.1055/a-1577-8663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Arterial hypertension affects about one third of the German population with a prevalence increasing with age up to 60 %. Globally, more than a quarter gedoppelt of the population are considered hypertensive, resulting in a total of more than one billion people. Not only due to such high prevalence, but also because of its multiple cardiovascular, renal, ocular, and cognitive complications, arterial hypertension is a leading contributor to the global burden of disease and responsible for up to 10 million deaths worldwide. Contrary to the great importance of arterial hypertension resulting from such high prevalence and immense impact on health worldwide, awareness of disease is low in affected people. Less than every second patient knows about his or her disease status and less than 40 % of patients in Europe show adequate blood pressure control with a treatment target of < 140/90 mmHg despite antihypertensive treatment. This overview of arterial hypertension, its etiology, diagnostic tools, and therapeutic options aims to improve the understanding of arterial hypertension and to facilitate the diagnostic and therapeutic approach, eventually resulting in a better and more successful handling of patients with arterial hypertension.
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34
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Curneen JMG, Rabbitt L, Browne D, O'Donoghue DF, Alansari Y, Harhen B, Ghríofa AN, Ferguson J, McEvoy JW, Lappin D, Finn DP, O'Shea PM, Dennedy MC. Major disparities in patient-reported adherence compared to objective assessment of adherence using mass spectrometry: a prospective study in a tertiary-referral hypertension clinic. Br J Clin Pharmacol 2022. [PMID: 35199372 DOI: 10.1111/bcp.15292] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Abstract
AIM Many challenges exist in determining true rates of adherence to antihypertensive medications among individuals in a clinic setting. For the first time, we aimed to compare patient-reported antihypertensive adherence with objective evidence using mass spectrometry spot urinalysis in a tertiary referral clinic setting. METHODS A prospective observational single-centre cohort study was performed in a tertiary referral hypertension clinic, encompassing antihypertensive initiation and persistence. Patients were referred with apparent treatment-resistant hypertension or for suspected secondary causes. Participants completed a self-reported assessment of antihypertensive adherence and provided a spot urine sample. The presence of antihypertensive medications and/or their respective metabolites was evaluated using high performance liquid chromatography tandem mass spectrometry (LC-MS/MS). Patients were determined to be adherent if they demonstrated both self-reported adherence and objective mass spectrometry evidence. RESULTS Of all 105 eligible participants initially recruited, 73 (69.5%) met the eligibility criteria. Only 27.4% (95% CI 0.2-0.4) of participants demonstrated true adherence to their self-reported antihypertensives, despite 75.3% (0.6-0.8) reporting adherence. Greatest medication adherence was achieved with angiotensin II receptor blockers (ARBs) (61%), with calcium-channel blockers and mineralocorticoid antagonists demonstrating least adherence (38%). CONCLUSION In patients attending a tertiary hypertension clinic, the combined use of spot urine mass spectrometry and self-reporting identifies higher rates of non-adherence when compared to either modality alone. Both techniques should be combined for more accurate detection of medication adherence.
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Affiliation(s)
- James M G Curneen
- Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Louise Rabbitt
- Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Darragh Browne
- Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Darragh F O'Donoghue
- Department of Nephrology, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland
| | - Yousef Alansari
- Centre for Endocrinology, Diabetes and Metabolism, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland
| | - Brendan Harhen
- Discipline of Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Ailbhe Ní Ghríofa
- Centre for Endocrinology, Diabetes and Metabolism, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland
| | - John Ferguson
- Discipline of Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - John William McEvoy
- Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland Galway, Galway, Ireland.,Department of Cardiology, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland
| | - David Lappin
- Department of Nephrology, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland.,Discipline of Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - David P Finn
- Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland Galway, Galway, Ireland.,Discipline of Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Paula M O'Shea
- Discipline of Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland.,Department of Clinical Biochemistry, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland
| | - Michael Conall Dennedy
- Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland Galway, Galway, Ireland.,Discipline of Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland
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Brant LCC, Passaglia LG, Pinto-Filho MM, de Castilho FM, Ribeiro ALP, Nascimento BR. The Burden of Resistant Hypertension Across the World. Curr Hypertens Rep 2022; 24:55-66. [PMID: 35118612 DOI: 10.1007/s11906-022-01173-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Resistant hypertension (R-HTN) is related to worse cardiovascular, renal outcomes, and death compared to non R-HTN. We aimed to review the burden of R-HTN across the world, focusing on its prevalence, associated factors and outcomes, and the impact of treatment. RECENT FINDINGS R-HTN prevalence among hypertensive individuals varies around 10-20%, depending on the population and definition applied. R-HTN consistently relates to older age, chronic kidney disease, obesity, and obstructive sleep apnea - which are increasing in prevalence with global population aging. As such, R-HTN prevalence is also expected to rise. Infrequent use of ambulatory blood pressure monitoring to identify at higher risk individuals and poor adherence to treatment are still barriers in the approach of R-HTN. Available evidence suggests that 10-20% of patients with hypertension have R-HTN. However, the prevalence of true R-HTN using contemporaneous standardized definitions is still unknown. Novel strategies to address clinicians, patients and health system barriers to treatment inertia and adherence are fundamental to reduce the burden of R-HTN.
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Affiliation(s)
- Luisa Campos Caldeira Brant
- Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena, 190, Santa Efigênia, 30130-100, Belo Horizonte, MG, Brazil.
| | - Luiz Guilherme Passaglia
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena, 110, Santa Efigênia, 30130-100, Belo Horizonte, MG, Brazil
| | - Marcelo Martins Pinto-Filho
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena, 110, Santa Efigênia, 30130-100, Belo Horizonte, MG, Brazil
| | - Fabio Morato de Castilho
- Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena, 190, Santa Efigênia, 30130-100, Belo Horizonte, MG, Brazil.,Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena, 110, Santa Efigênia, 30130-100, Belo Horizonte, MG, Brazil
| | - Antonio Luiz Pinho Ribeiro
- Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena, 190, Santa Efigênia, 30130-100, Belo Horizonte, MG, Brazil
| | - Bruno Ramos Nascimento
- Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena, 190, Santa Efigênia, 30130-100, Belo Horizonte, MG, Brazil. .,Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena, 110, Santa Efigênia, 30130-100, Belo Horizonte, MG, Brazil.
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Hamrahian SM, Maarouf OH, Fülöp T. A Critical Review of Medication Adherence in Hypertension: Barriers and Facilitators Clinicians Should Consider. Patient Prefer Adherence 2022; 16:2749-2757. [PMID: 36237983 PMCID: PMC9552797 DOI: 10.2147/ppa.s368784] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Hypertension is a global public health problem, and its prevalence is increasing worldwide. Impacting all human societies and socioeconomic strata, it remains the major modifiable risk factor for global burden of cardiovascular disease all-cause mortality and the leading cause of loss of disability-adjusted life years. Despite increased awareness, the rate of blood pressure control remains unsatisfactory, particularly in low- to middle-income countries. Apparent treatment-resistant hypertension is associated with worse adverse health outcomes. It includes both true resistant and pseudo-resistant hypertension, which requires out-of-office blood pressure monitoring to exclude white-coat effect and confirmation of adherence to the agreed recommended antihypertensive therapy. The depth of medication non-adherence remains poorly recognized among medical practitioners, thus presenting an underestimated modifiable risk factor. Medication non-adherence is a complex and multidimensional variable with three quantifiable phases: initiation, implementation, and discontinuation, collectively called persistence. Non-adherence can be both intentional and non-intentional and usually involves several interconnected factors. Persistence declines over time in the treatment of chronic diseases like hypertension. The risk is higher in patients with new diagnosis, poor insurance status, polypharmacy, and multiple comorbidities, particularly psychiatric disorders. The World Health Organization divides the contributing factors impacting adherence into five categories. Screening and detection for medication non-adherence are challenging due to its dynamic nature and potential white-coat effect. Easy-to-conduct screening methods have low reliability and validity, whereas more reliable and valid methods are costly and difficult to perform. Medication non-adherence is associated with poor clinical outcome and potential negative impact on health-care costs. Evaluation of adherence should become an integral part of assessment of patients treated for hypertension. Medication adherence can significantly improve with a patient-centered approach, non-judgmental communication skills, and collaborative multidisciplinary management, including engagement of the patients in their care by self-blood pressure monitoring.
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Affiliation(s)
- Seyed Mehrdad Hamrahian
- Department of Medicine - Nephrology, Thomas Jefferson University, Philadelphia, PA, USA
- Correspondence: Seyed Mehrdad Hamrahian, Department of Medicine - Nephrology, Thomas Jefferson University, 33S 9th Street, Suite 700, Philadelphia, PA, 19107, USA, Tel +1 215-503 3000, Fax +1 215-503 4099, Email
| | - Omar H Maarouf
- Department of Medicine - Nephrology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Tibor Fülöp
- Department of Medicine - Nephrology, Medical University of South Carolina, Charleston, SC, USA
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Lane D, Lawson A, Burns A, Azizi M, Burnier M, Jones DJL, Kably B, Khunti K, Kreutz R, Patel P, Persu A, Spiering W, Toennes SW, Tomaszewski M, Williams B, Gupta P, Dasgupta I. Nonadherence in Hypertension: How to Develop and Implement Chemical Adherence Testing. Hypertension 2022; 79:12-23. [PMID: 34739765 DOI: 10.1161/hypertensionaha.121.17596] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nonadherence to antihypertensive medication is common, especially in those with apparent treatment-resistant hypertension (true treatment-resistant hypertension requires exclusion of nonadherence), and its routine detection is supported by clinical guidelines. Chemical adherence testing is a reliable and valid method to detect adherence, yet methods are unstandardized and are not ubiquitous. This article describes the principles of chemical adherence testing for hypertensive patients and provides a set of recommendations for centers wishing to develop the test. We recommend testing should be done in either of two instances: (1) in those who have resistant hypertension or (2) in those on 2 antihypertensives who have a less than 10 mm Hg drop in systolic blood pressure on addition of the second antihypertensive medication. Furthermore, we recommend that verbal consent is secured before undertaking the test, and the results should be discussed with the patient. Based on medications prescribed in United Kingdom, European Union, and United States, we list top 20 to 24 drugs that cover >95% of hypertension prescriptions which may be included in the testing panel. Information required to identify these medications on mass spectrometry platforms is likewise provided. We discuss issues related to ethics, sample collection, transport, stability, urine versus blood samples, qualitative versus quantitative testing, pharmacokinetics, instrumentation, validation, quality assurance, and gaps in knowledge. We consider how to best present, interpret, and discuss chemical adherence test results with the patient. In summary, this guidance should help clinicians and their laboratories in the development of chemical adherence testing of prescribed antihypertensive drugs.
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Affiliation(s)
- Dan Lane
- The Department of Chemical Pathology and Metabolic Diseases, Level 4, Sandringham Building, Leicester Royal Infirmary, United Kingdom (D.L., P.P., P.G.)
- Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Leicester, United Kingdom (D.L., K.K.)
| | - Alexander Lawson
- Department of Clinical Chemistry, Immunology and Toxicology, Heartlands Hospital University Hospitals Birmingham, United Kingdom (A.L.)
| | - Angela Burns
- Department of Clinical Biochemistry, Queen Elizabeth University Hospital, Glasgow, United Kingdom (A.B.)
| | - Michel Azizi
- Université de Paris, Inserm CIC1418, Paris, France (M.A.)
- APHP, Hypertension Unit, Hôpital Européen Georges Pompidou, Paris, France (M.A.)
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland (M.B.)
| | - Donald J L Jones
- Department of Cardiovascular Sciences, University of Leicester, Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom (D.J.L.J., P.P., P.G.)
| | - Benjamin Kably
- Université de Paris, France (B.K.)
- APHP, Pharmacology Unit, Hôpital Européen Georges Pompidou, Paris, France (B.K.)
| | - Kamlesh Khunti
- Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Leicester, United Kingdom (D.L., K.K.)
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Germany (R.K.)
| | - Prashanth Patel
- The Department of Chemical Pathology and Metabolic Diseases, Level 4, Sandringham Building, Leicester Royal Infirmary, United Kingdom (D.L., P.P., P.G.)
- Department of Cardiovascular Sciences, University of Leicester, Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom (D.J.L.J., P.P., P.G.)
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium/Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (A.P.)
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands (W.S.)
| | - Stefan W Toennes
- Institute of Legal Medicine, Department of Forensic Toxicology, University Hospital, Goethe University, Frankfurt, Germany (S.W.T.)
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (M.T.)
- Manchester Heart Centre, Manchester University National Health Service Foundation Trust, United Kingdom (M.T.)
| | - Bryan Williams
- Department of Cardiovascular Sciences, University College London, United Kingdom (B.W.)
| | - Pankaj Gupta
- The Department of Chemical Pathology and Metabolic Diseases, Level 4, Sandringham Building, Leicester Royal Infirmary, United Kingdom (D.L., P.P., P.G.)
- Department of Cardiovascular Sciences, University of Leicester, Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom (D.J.L.J., P.P., P.G.)
| | - Indranil Dasgupta
- Renal Unit, Heartlands Hospital, Birmingham and Warwick Medical School, University of Warwick, Coventry, United Kingdom (I.D.)
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Georges CMG, Devresse A, Ritscher S, Wallemacq P, Toennes SW, Kanaan N, Persu A. Adherence to antihypertensive drug treatment in kidney transplant recipients. Blood Press 2021; 30:411-415. [PMID: 34791967 DOI: 10.1080/08037051.2021.2004087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Hypertension is a common cardiovascular co-morbidity after kidney transplantation and contributes to shortened graft and patient survival outcomes. However, by contrast with adherence to immunosuppressive drugs, adherence to antihypertensive treatment in kidney transplant recipients has been seldom explored. The aim of the current study was to assess adherence to antihypertensive drugs in kidney transplant recipients from the Cliniques Universitaires Saint-Luc and to look for demographic and clinical characteristics associated with drug adherence. METHODS Demographic and clinical data were collected from medical files in a standardised case report form. Blood pressure was measured in the sitting position after 5 min rest, using validated oscillometric devices. Drug adherence was assessed by drug dosage in urine using liquid chromatography coupled with tandem mass spectrometry. RESULTS Our analysis included 53 kidney transplants recipients (75% of men, mean age: 57.2 ± 12.6 years, time since kidney transplantation: 9.5 ± 7.3 years, blood pressure: 130 ± 16/78 ± 11 mmHg on 2.1 ± 1.1 antihypertensive drugs). The proportion of patients showing full drug adherence, partial drug adherence, and total non-adherence to antihypertensive drugs was 79% (N = 42), 15% (N = 8), and 6% (N = 3), respectively. Adherent patients did not differ from less or non- adherers in any of the analysed characteristics. CONCLUSION The proportion of patients adhering to antihypertensive drug treatment among kidney transplant recipients appears similar to that reported for immunosuppressive drugs in renal transplanted patients (∼70%), but much higher than that observed in patients with drug-resistant hypertension (30-40%). Our results need further confirmation in a large, multicenter, prospective cohort.
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Affiliation(s)
- Coralie M G Georges
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Arnaud Devresse
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Sabrina Ritscher
- Institute of Legal Medicine, Department of Forensic Toxicology, University Hospital, Goethe University, Frankfurt, Main, Germany
| | - Pierre Wallemacq
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Clinical Chemistry Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Center for Toxicology and Applied Pharmacology, Université Catholique de Louvain, Brussels, Belgium
| | - Stefan W Toennes
- Institute of Legal Medicine, Department of Forensic Toxicology, University Hospital, Goethe University, Frankfurt, Main, Germany
| | - Nada Kanaan
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Alexandre Persu
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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Pan J, Hu B, Wu L, Li Y. The Effect of Social Support on Treatment Adherence in Hypertension in China. Patient Prefer Adherence 2021; 15:1953-1961. [PMID: 34522088 PMCID: PMC8434919 DOI: 10.2147/ppa.s325793] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/24/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Treatment nonadherence is a major problem in the management of hypertension. There are many factors influencing the treatment adherence of hypertensive patients. The aim of this study was to examine the effect of social support on the treatment adherence in hypertension in China. PATIENTS AND METHODS A total of 453 patients with hypertension hospitalized in a tertiary hospital in Xi'an, China were invited to participate in this cross-sectional study. Data were collected by "modified Chinese Hill-Bone compliance to high blood pressure therapy scale" and "Chinese Family Support Scale". RESULTS It was found that 31.1% of patients were adherent with their antihypertensive treatments. Gender, duration of antihypertensive drug used, number of antihypertensive drugs used and social support were independently associated with hypertensive treatment adherence. Social support was strongly and positively associated with the hypertensive treatment adherence (P<0.001, OR = 0.752, 95% CI: 0.678-0.833). Family social support was provided to hypertensive patients mainly through their nuclear family, that is spouses, partner or children. Treatment adherence of hypertensive patients was positively correlated to the three subgroups of social support. It was found that social support provided to patients from social resource (r=0.568) had greater impact on treatment adherence than that from kinship (r=0.364) and nuclear family (r=0.262). CONCLUSION Treatment adherence of patients with hypertension was found to increase positively as their social support increased. In addition to the support given to patients from nuclear family members, other social support especially professional agencies and community organizations should also be promoted and strengthened.
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Affiliation(s)
- Jingjing Pan
- Department of Pharmacy, Xi’an People’s Hospital (Xi’an Fourth Hospital), Xi’an, People’s Republic of China
| | - Bin Hu
- Department of Pharmacy, Xi’an People’s Hospital (Xi’an Fourth Hospital), Xi’an, People’s Republic of China
| | - Lian Wu
- Department of Ophthalmology, Xi’an People’s Hospital (Xi’an Fourth Hospital), Xi’an, People’s Republic of China
| | - Yarong Li
- Department of Pharmacy, School of Pharmaceutical Sciences, Xi’an Medical University, Xian, People’s Republic of China
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Pecori A, Buffolo F, Burrello J, Mengozzi G, Rumbolo F, Avataneo V, D'Avolio A, Rabbia F, Bertello C, Veglio F, Mulatero P, Monticone S. Mineralocorticoid Receptor Antagonist Effect on Aldosterone to Renin Ratio in Patients With Primary Aldosteronism. J Clin Endocrinol Metab 2021; 106:e3655-e3664. [PMID: 33942084 DOI: 10.1210/clinem/dgab290] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Although current international guidelines recommend to avoid mineralocortcoid receptor antagonists in patients undergoing screening test for primary aldosteronism, a recent report suggested that mineralocorticoid receptor antagonist treatment can be continued without significant influence on screening results. OBJECTIVE We aimed to evaluate the effect of mineralocorticoid receptor antagonists on the aldosterone to renin ratio in patients with primary aldosteronism. METHODS We prospectively enrolled 121 patients with confirmed primary aldosteronism who started mineralocorticoid receptor antagonist (canrenone) treatment. Eighteen patients (11 with unilateral and 7 with bilateral primary aldosteronism) constituted the short-term study cohort and underwent aldosterone, renin, and potassium measurement after 2 and 8 weeks of canrenone therapy. The long-term cohort comprised 102 patients (16 with unilateral and 67 with bilateral primary aldosteronism, and 19 with undetermined subtype) who underwent hormonal and biochemical re-assessment after 2 to 12 months of canrenone therapy. RESULTS Renin and potassium levels showed a significant increase, and the aldosterone to renin ratio displayed a significant reduction compared with baseline after both a short- and long-term treatment. These effects were progressively more evident with higher doses of canrenone and after longer periods of treatment. We demonstrated that canrenone exerted a deep impact on the diagnostic accuracy of the screening test for primary aldosteronism: the rate of false negative tests was raised to 16.7%, 38.9%, 54.5%, and 72.5% after 2 weeks, 8 weeks, 2 to 6 months, and 7 to 12 months of mineralocorticoid receptor antagonist treatment, respectively. CONCLUSION Mineralocorticoid receptor antagonists should be avoided in patients with hypertension before measurement of renin and aldosterone for screening of primary aldosteronism.
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Affiliation(s)
- Alessio Pecori
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Fabrizio Buffolo
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Jacopo Burrello
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Giulio Mengozzi
- Department of Laboratory Medicine, AOU Città della Salute e della Scienza, Turin, Italy
| | - Francesca Rumbolo
- Department of Laboratory Medicine, AOU Città della Salute e della Scienza, Turin, Italy
| | - Valeria Avataneo
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Torino, Amedeo di Savoia Hospital, Torino, Italy
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Torino, Amedeo di Savoia Hospital, Torino, Italy
| | - Franco Rabbia
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Chiara Bertello
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Franco Veglio
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
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Burnier M, Prejbisz A, Weber T, Azizi M, Cunha V, Versmissen J, Gupta P, Vaclavik J, Januszewicz A, Persu A, Kreutz R. Hypertension healthcare professional beliefs and behaviour regarding patient medication adherence: a survey conducted among European Society of Hypertension Centres of Excellence. Blood Press 2021; 30:282-290. [PMID: 34392741 DOI: 10.1080/08037051.2021.1963209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Little is known on the beliefs, perceptions and practices of hypertension specialists in addressing non-adherence to therapy. Therefore, a survey was undertaken amongst healthcare professionals (HCPs) managing hypertension in the European Society of Hypertension (ESH) Centres of Excellence. MATERIALS AND METHODS Cross-sectional data were obtained between December 2020 and April 2021 using an online anonymous structured questionnaire including 26 questions/136 items, that was sent to all ESH Excellence centres. RESULTS Overall 67 from 187 centres (37.3%) responded and 200 HCPs from 30 countries answered the questionnaire. Participants (60% men) were mainly physicians (91%) and nurses (8%) from University hospitals (77%). Among physicians, 83% had >10 years professional experience. Average time dedicated to discuss medications was 1-5 min in 48% and 6-10 min in 29% of cases. Interviews with patients about adherence were the most frequently used assessment method. Chemical detection of medications in urine was available in 36% of centres. One third of physicians involved their patients regularly in treatment decisions. The most frequent methods to improve adherence included simplification of medication therapy, more frequent visits, and home blood pressure monitoring. CONCLUSIONS The level of implementation of tools to detect and improve adherence in hypertension management by HCPs in ESH excellence centres is low. Structured educational activities focussing on adherence management and access to the newest objective measures to detect non-adherence might improve these deficits.
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Affiliation(s)
- Michel Burnier
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Thomas Weber
- Cardiology Department, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Michel Azizi
- INSERM, CIC1418, Université de Paris, Paris, France.,Hypertension Department and DMU CARTE, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France
| | | | - Jorie Versmissen
- Departments of Internal Medicine and Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pankaj Gupta
- The Department of Chemical Pathology and Metabolic Diseases, Leicester Royal Infirmary, Leicester, UK
| | - Jan Vaclavik
- Department of Internal Medicine and Cardiology, Ostrava University Hospital, Ostrava, Czech Republic.,Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Reinhold Kreutz
- Institute of Clinical Pharmacology and Toxicology, Humboldt-Universität zu Berlin, Berlin, Germany
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Polychronopoulou E, Burnier M, Ehret G, Schoenenberger-Berzins R, Berney M, Ponte B, Erne P, Bochud M, Pechère-Bertschi A, Wuerzner G. Assessment of a strategy combining ambulatory blood pressure, adherence monitoring and a standardised triple therapy in resistant hypertension. Blood Press 2021; 30:332-340. [PMID: 34227452 DOI: 10.1080/08037051.2021.1907174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Poor adherence to drug therapy and inadequate drug regimens are two frequent factors responsible for the poor blood pressure (BP) control observed in patients with apparent resistant hypertension. We evaluated the efficacy of an antihypertensive management strategy combining a standardised therapy with three long acting drugs and electronic monitoring of drug adherence in patients with apparent resistant hypertension. MATERIALS AND METHODS In this multicentric observational study, adult patients with residual hypertension on 24 h ambulatory BP monitoring (ABMP) despite the use of three or more antihypertensive drugs could be included. Olmesartan/amlodipine (40/10 mg, single pill fixed-dose combination) and chlorthalidone (25 mg) were prescribed for 3 months in two separated electronic pills boxes (EPB). The primary outcome was 24 h ambulatory systolic BP (SBP) control at 3 months, defined as mean SBP <130 mmHg. RESULTS We enrolled 48 patients (36.0% women) of whom 35 had complete EPB data. After 3 months, 52.1% of patients had 24 h SBP <130 mmHg. 24 h SBP decreased by respectively -9.1 ± 15.5 mmHg, -22.8 ± 30.6 mmHg and -27.7 ± 16.6 mmHg from the tertile with the lowest adherence to the tertile with the highest adherence to the single pill combination (p = 0.024). A similar trend was observed with tertiles of adherence to chlorthalidone. Adherence superior to 90% was associated with 24 h systolic and diastolic blood pressure control in multiple logistic regression analysis (odds ratio = 14.1 (95% confidence interval 1.1-173.3, p = 0.039). CONCLUSIONS A simplified standardised antihypertensive therapy combined with electronic monitoring of adherence normalises SBP in about half of patients with apparent resistant hypertension. Such combined management strategy enables identifying patients who need complementary investigations and those who rather need a long-term support of their adherence.
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Affiliation(s)
- Erietta Polychronopoulou
- Service of Nephrology and Hypertension, Lausanne University Hospital and Lausanne University, CHUV, Lausanne, Switzerland
| | - Michel Burnier
- Service of Nephrology and Hypertension, Lausanne University Hospital and Lausanne University, CHUV, Lausanne, Switzerland
| | - Georg Ehret
- Cardiology, Geneva University Hospital, Switzerland
| | | | - Maxime Berney
- Service of Nephrology and Hypertension, Lausanne University Hospital and Lausanne University, CHUV, Lausanne, Switzerland
| | - Belen Ponte
- Hypertension Centre, Service of Nephrology and Hypertension, University Hospital, Geneva, Switzerland
| | - Paul Erne
- Faculty of Biomedical Science, Università della Svizzera Italiana, Lugano, Switzerland
| | - Murielle Bochud
- Unisanté, University Centre of General Medicine and Public Health, University of Lausanne, Lausanne, Switzerland
| | | | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and Lausanne University, CHUV, Lausanne, Switzerland
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Chepurnoĭ AG, Shugushev ZK, Maksimkin DA. [Second chance for renal artery denervation]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:32-40. [PMID: 34166342 DOI: 10.33529/angio2021219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The article is a review of contemporary randomized studies on radiofrequency denervation of renal arteries, followed by critical assessment of their advantages and disadvantages for possible optimization of endovascular treatment of resistant arterial hypertension.
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Affiliation(s)
- A G Chepurnoĭ
- Cardiovascular Surgery Department, People's Friendship University of Russia, Moscow, Russia
| | - Z Kh Shugushev
- Cardiovascular Surgery Department, People's Friendship University of Russia, Moscow, Russia
| | - D A Maksimkin
- Cardiovascular Surgery Department, People's Friendship University of Russia, Moscow, Russia
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Clinical Validation of a Dried Blood Spot Assay for 8 Antihypertensive Drugs and 4 Active Metabolites. Ther Drug Monit 2021; 42:460-467. [PMID: 31593031 DOI: 10.1097/ftd.0000000000000703] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Drug nonadherence is one of the major challenges faced by resistant hypertension patients, and identification of this problem is needed for optimizing pharmacotherapy. Dried blood spot (DBS) sampling is a minimally invasive method designed to detect and determine the degree of nonadherence. In this study, a DBS method for qualifying 8 antihypertensive drugs (AHDs) and 4 active metabolites was developed and validated using ultra high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). METHOD The DBS assay was validated analytically and clinically, in accordance with FDA requirements. Analytical validation was accomplished using UHPLC-MS/MS. For clinical validation, paired peak and trough levels of DBS and plasma samples were simultaneously collected and comparatively analyzed using Deming regression and Bland-Altman analyses. All concentrations below the set lower limit were excluded. Deming regression analysis was used to predict comparison bias between the collected plasma and DBS samples, with DBS concentrations corrected accordingly. RESULTS The UHPLC-MS/MS method for simultaneously measuring 8 AHDs and their metabolites in DBS, was successfully validated. With Deming regression no bias was observed in N = 1; constant bias was seen in N = 6 and proportional bias in N = 11 of the AHDs and metabolites. After correction for bias, only one metabolite (canrenone) met the 20% acceptance limit for quantification, after Bland-Altman analyses. In addition, amlodipine, valsartan, and [enalaprilate] met the 25% acceptance limit. CONCLUSIONS A novel DBS assay for simultaneously qualifying and quantifying 8 AHDs and their metabolites, has been successfully developed and validated. The DBS assay is therefore a suitable method to detect drug nonadherence. However, with the exception of canrenone, the interchangeable use of plasma and DBS sampling to interpret drug quantities should be avoided.
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Maskell PD, Parks C, Button J, Liu H, McKeown DA. Clarification of the Correct Nomenclature of the Amino Metabolite of Clonazolam: 8-Aminoclonazolam. J Anal Toxicol 2021; 45:e1-e2. [PMID: 33150945 DOI: 10.1093/jat/bkaa169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/16/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- Peter D Maskell
- Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, UK
| | - Claire Parks
- Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, UK
| | - Jenny Button
- Chiron AS, Stiklestadveien 1, 7041 Trondheim, Norway
| | - Huiling Liu
- Chiron AS, Stiklestadveien 1, 7041 Trondheim, Norway
| | - Denise A McKeown
- Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, UK
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Burns AD, Alghamadi R, Iqbal A, Davies T, Lane D, Patel P, Gupta P. Urine Concentration Does Not Affect Biochemical Testing for Non-adherence. J Anal Toxicol 2021; 45:e1-e5. [PMID: 33300570 PMCID: PMC7953415 DOI: 10.1093/jat/bkaa192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/07/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022] Open
Abstract
Hypertension is one of the most important modifiable risk factor causing cardiovascular disease. Unfortunately, non-adherence to antihypertensive medications is frequently observed in hypertensive patients and can lead to an increase in morbidity and mortality. Until recently, there was no robust clinical method to objectively diagnose non-adherence. Recently, the detection of medications in urine or blood by mass spectrometry techniques such as liquid chromatography-tandem mass spectrometry (LC–MS-MS) has been accepted as the diagnostic method of choice for the detection of non-adherence. Despite this, it is unclear whether the concentration of urine can affect the detection of medications in urine. Therefore, this study aimed to assess the effect of urine concentration on detection of antihypertensive medications by LC–MS-MS in which urine creatinine is used as an independent marker of urine concentration. Biochemical adherence results for 22 different medications (1,709 prescriptions) in 463 different subjects were converted to an adherence score. The adherence score was defined as the ratio of the total number of subjects in which the drug was detected to the total number of subjects to whom the drug was prescribed. The adherence scores for each medication were correlated with urine creatinine concentration for each medication. Non-adherence was observed in 47.1% of samples with a mean urine creatinine concentration of these samples of 9.4 ± 7.1 mmol/L. There was no significant difference between the urine creatinine concentrations in the detected vs non-detected groups for each of the 22 medications. Furthermore, there are no differences in adherence scores across the urine creatinine concentration. This is the first study to demonstrate that urine creatinine concentration does not affect the results of the adherence screening by LC–MS-MS.
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Affiliation(s)
- A D Burns
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - R Alghamadi
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - A Iqbal
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.,Sheffield Hallam University, Sheffield, UK
| | - T Davies
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - D Lane
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.,Department of Health Sciences, University of Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - P Patel
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - P Gupta
- Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
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Madhur MS, Elijovich F, Alexander MR, Pitzer A, Ishimwe J, Van Beusecum JP, Patrick DM, Smart CD, Kleyman TR, Kingery J, Peck RN, Laffer CL, Kirabo A. Hypertension: Do Inflammation and Immunity Hold the Key to Solving this Epidemic? Circ Res 2021; 128:908-933. [PMID: 33793336 DOI: 10.1161/circresaha.121.318052] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Elevated cardiovascular risk including stroke, heart failure, and heart attack is present even after normalization of blood pressure in patients with hypertension. Underlying immune cell activation is a likely culprit. Although immune cells are important for protection against invading pathogens, their chronic overactivation may lead to tissue damage and high blood pressure. Triggers that may initiate immune activation include viral infections, autoimmunity, and lifestyle factors such as excess dietary salt. These conditions activate the immune system either directly or through their impact on the gut microbiome, which ultimately produces chronic inflammation and hypertension. T cells are central to the immune responses contributing to hypertension. They are activated in part by binding specific antigens that are presented in major histocompatibility complex molecules on professional antigen-presenting cells, and they generate repertoires of rearranged T-cell receptors. Activated T cells infiltrate tissues and produce cytokines including interleukin 17A, which promote renal and vascular dysfunction and end-organ damage leading to hypertension. In this comprehensive review, we highlight environmental, genetic, and microbial associated mechanisms contributing to both innate and adaptive immune cell activation leading to hypertension. Targeting the underlying chronic immune cell activation in hypertension has the potential to mitigate the excess cardiovascular risk associated with this common and deadly disease.
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Affiliation(s)
- Meena S Madhur
- Division of Clinical Pharmacology (M.S.M., F.E., M.R.A., A.P., J.I., J.P.V.B., D.M.P., C.D.S., C.L.L., A.K.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Division of Cardiovascular Medicine (M.S.M., M.R.A., D.M.P.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Department of Molecular Physiology and Biophysics, Vanderbilt University (M.S.M., C.D.S., A.K.)
| | - Fernando Elijovich
- Division of Clinical Pharmacology (M.S.M., F.E., M.R.A., A.P., J.I., J.P.V.B., D.M.P., C.D.S., C.L.L., A.K.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew R Alexander
- Division of Clinical Pharmacology (M.S.M., F.E., M.R.A., A.P., J.I., J.P.V.B., D.M.P., C.D.S., C.L.L., A.K.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Division of Cardiovascular Medicine (M.S.M., M.R.A., D.M.P.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ashley Pitzer
- Division of Clinical Pharmacology (M.S.M., F.E., M.R.A., A.P., J.I., J.P.V.B., D.M.P., C.D.S., C.L.L., A.K.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jeanne Ishimwe
- Division of Clinical Pharmacology (M.S.M., F.E., M.R.A., A.P., J.I., J.P.V.B., D.M.P., C.D.S., C.L.L., A.K.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Justin P Van Beusecum
- Division of Clinical Pharmacology (M.S.M., F.E., M.R.A., A.P., J.I., J.P.V.B., D.M.P., C.D.S., C.L.L., A.K.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - David M Patrick
- Division of Clinical Pharmacology (M.S.M., F.E., M.R.A., A.P., J.I., J.P.V.B., D.M.P., C.D.S., C.L.L., A.K.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Division of Cardiovascular Medicine (M.S.M., M.R.A., D.M.P.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Charles D Smart
- Division of Clinical Pharmacology (M.S.M., F.E., M.R.A., A.P., J.I., J.P.V.B., D.M.P., C.D.S., C.L.L., A.K.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Department of Molecular Physiology and Biophysics, Vanderbilt University (M.S.M., C.D.S., A.K.)
| | - Thomas R Kleyman
- Departments of Medicine, Cell Biology, Pharmacology and Chemical Biology, University of Pittsburgh, PA (T.R.K.)
| | - Justin Kingery
- Center for Global Health, Weill Cornell Medical College, NY (J.K., R.N.P.).,Department of Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania (J.K., R.N.P.)
| | - Robert N Peck
- Center for Global Health, Weill Cornell Medical College, NY (J.K., R.N.P.).,Department of Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania (J.K., R.N.P.).,Mwanza Intervention Trials Unit (MITU), Mwanza, Tanzania (R.N.P.)
| | - Cheryl L Laffer
- Division of Clinical Pharmacology (M.S.M., F.E., M.R.A., A.P., J.I., J.P.V.B., D.M.P., C.D.S., C.L.L., A.K.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Annet Kirabo
- Division of Clinical Pharmacology (M.S.M., F.E., M.R.A., A.P., J.I., J.P.V.B., D.M.P., C.D.S., C.L.L., A.K.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Department of Molecular Physiology and Biophysics, Vanderbilt University (M.S.M., C.D.S., A.K.)
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Directly Measured Adherence to Treatment in Chronic Heart Failure: LEVEL-CHF Registry. Am J Med Sci 2021; 361:491-498. [PMID: 33781390 DOI: 10.1016/j.amjms.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 11/08/2020] [Accepted: 12/04/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Currently, most available data on the medication adherence of patients with chronic heart failure are based on indirect methods. We examined the level of adherence to medical therapy using a direct method - serum drug level testing. METHODS We carried out a prospective single-centre registry of patients with chronic heart failure (LEVEL-CHF registry), in whom we analysed serum levels of the medications prescribed for the treatment of heart failure: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists. We labelled a patient as non-adherent if at least one serum level of a prescribed drug was unmeasurable (below the detection limit). Patients with all tested drugs identifiable in serum were labelled as adherent. We enrolled 274 patients (208 men and 66 women) mean age 62 years. RESULTS 82.5% of patients were adherent and 17.5% non-adherent to prescribed medications. 3.6% were completely non-adherent without any detectable drugs in serum. Patients aged <60 years were more likely to be non-adherent than older patients (OR 2.15). No other clinical or laboratory parameters predicted non-adherence. CONCLUSIONS A significant proportion of outpatients with chronic heart failure were non-adherent to treatment when assessed by a direct method of serum drug level testing. Non-adherence was more likely in younger patients.
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Lauder L, Ewen S, Glasmacher J, Lammert F, Reith W, Schreiber N, Kaddu-Mulindwa D, Ukena C, Böhm M, Meyer MR, Mahfoud F. Drug adherence and psychosocial characteristics of patients presenting with hypertensive urgency at the emergency department. J Hypertens 2021; 39:1697-1704. [PMID: 33734143 DOI: 10.1097/hjh.0000000000002842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify potentially targetable psychosocial factors associated with nonadherence to prescribed antihypertensive medications in patients presenting with hypertensive urgencies at an emergency department. METHODS This prospective study included patients treated with antihypertensive drugs who presented with hypertensive urgencies (SBP ≥180 mmHg and/or DBP ≥110 mmHg) at the emergency department of a tertiary referral clinic between April 2018 and April 2019. Health literacy was assessed using the Newest Vital Sign test. The Hospital Anxiety and Depression Scale (HADS) was used to quantify symptoms of anxiety and depression. Patients were classified nonadherent if less than 80% of the prescribed antihypertensive drugs were detectable in urine or plasma using liquid chromatography-high-resolution mass spectrometry. RESULTS A total of 104 patients (62% women) presenting with hypertensive urgencies with a median SBP of 200 mmHg (IQR 190-212) and DBP of 97.5 mmHg (IQR 87-104) were included. Twenty-five patients (24%) were nonadherent to their antihypertensive medication. Nonadherent patients were more often men (66 versus 23%, P = 0.039), prescribed higher numbers of antihypertensive drugs (median 3, IQR 3-4 versus 2, IQR 1-3; P < 0.001), and more often treated with calcium channel blockers (76 versus 25%; P < 0.001) and/or diuretics (64 versus 40%; P = 0.030). There was no difference in health literacy (P = 0.904) or the scores on the HADS subscales for depression (P = 0.319) and anxiety (P = 0.529) between adherent and nonadherent patients. CONCLUSION Male sex, higher numbers of antihypertensive drugs, and treatment with diuretics and/or calcium channel blockers were associated with nonadherence. We did not identify a specific psychosocial characteristic associated with nonadherence.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University.,Emergency Department, Universitätsklinikum des Saarlandes
| | - Julius Glasmacher
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University
| | | | | | - Naemi Schreiber
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University
| | - Dominic Kaddu-Mulindwa
- Department of Hematology, Oncology, Clinical Immunology, Rheumatology, Saarland University Medical Center
| | - Christian Ukena
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University
| | - Markus R Meyer
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University.,Institute for Medical Engineering and Science, MIT, Cambridge, Massachusetts, USA
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50
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Lauder L, Böhm M, Mahfoud F. The current status of renal denervation for the treatment of arterial hypertension. Prog Cardiovasc Dis 2021; 65:76-83. [PMID: 33587963 DOI: 10.1016/j.pcad.2021.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 02/08/2023]
Abstract
Despite the availability of safe and effective antihypertensive drugs, blood pressure (BP) control to guideline-recommended target values is poor. Several device-based therapies have been introduced to lower BP. The most extensively investigated approach is catheter-based renal sympathetic denervation (RDN), which aims to interrupt the activity of afferent and efferent renal sympathetic nerves by applying radiofrequency energy, ultrasound energy, or injection of alcohol in the perivascular space. The second generation of placebo-controlled trials have provided solid evidence for the BP-lowering efficacy of radiofrequency- and ultrasound-based RDN in patients with and without concomitant pharmacological therapy. In addition, the safety profile of RDN appears to be excellent in all registries and clinical trials. However, there remain unsolved issues to be addressed. This review summarizes the rationale as well as the current evidence and discusses open questions and possible future indications of catheter-based RDN.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany; Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA.
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