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Zijp TR, Izzah Z, Touw DJ, van Boven JFM. Medication Adherence Monitoring Using Alternative Sample Matrices: Bridging the Gap Between Analytical Validation and Clinical Interpretation. Ther Drug Monit 2024; 46:554-555. [PMID: 38845090 PMCID: PMC11232933 DOI: 10.1097/ftd.0000000000001220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Affiliation(s)
- Tanja R Zijp
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Zamrotul Izzah
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
- Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia ; and
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Job F M van Boven
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Medication Adherence Expertise Center of the Northern Netherlands (MAECON), Groningen, the Netherlands
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Versmissen J, van Steenkiste J, Koch BCP, Peeters LEJ. 'Under pressure': The role of therapeutic drug monitoring in the treatment of hypertension. Br J Clin Pharmacol 2024; 90:1884-1891. [PMID: 38845455 DOI: 10.1111/bcp.16125] [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: 02/01/2024] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 07/31/2024] Open
Abstract
Antihypertensive drugs do not qualify as optimal candidates for therapeutic drug monitoring (TDM), given their obvious physiological effect, the absence of a clear relationship between drug concentrations and pharmacodynamic outcomes and their wide therapeutic range. However, since non-adherence is a major challenge in hypertension management, using drug concentrations can be of value to identify non-adherence as a first step towards better blood pressure control. In this article we discuss the key challenges associated with measuring and interpreting antihypertensive drug concentrations that are important when TDM is used to improve non-adherence. Additionally, we elaborate on the role of TDM in optimizing antihypertensive drug treatment besides addressing non-adherence by highlighting its value in specific patient groups with altered pharmacokinetic parameters such as female vs. male or elderly patients.
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Affiliation(s)
- Jorie Versmissen
- Department of Hospital Pharmacy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Job van Steenkiste
- Department of Hospital Pharmacy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
- Maasstad hospital, Department of Internal Medicine, Rotterdam, the Netherlands
- Department of Management Sciences, Open University Netherlands, Heerlen, the Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Laura E J Peeters
- Department of Hospital Pharmacy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Maasstad hospital, Rotterdam, the Netherlands
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Agwuegbo CC, Antia AU, Shamaki GR, Bob-Manuel T. Controversies related to renal artery denervation and devices. Curr Opin Cardiol 2024; 39:244-250. [PMID: 38567924 DOI: 10.1097/hco.0000000000001146] [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: 06/05/2024]
Abstract
PURPOSE OF REVIEW This review article discusses the controversies, strengths, and limitations of the current literature on renal artery denervation in the management of resistant hypertension, as well as the future directions of this intervention. RECENT FINDINGS There have been conflicting data from the different randomized control trials assessing the efficacy of renal artery denervation in the management of resistant hypertension. SUMMARY Renal artery denervation is achieved by ablating the sympathetic nerves surrounding the renal arteries using endovascular ultrasound, radiofrequency, or alcohol. Our review article highlights that renal artery denervation is generally effective in improving blood pressure in patients with resistant hypertension. The Food and Drug Administration (FDA) has recently approved the ReCor Medical Paradise system, and the Symplicity Spyral RDN systems for renal artery denervation.
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Affiliation(s)
| | | | | | - Tamunoinemi Bob-Manuel
- Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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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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Katsukunya JN, Jones E, Soko ND, Blom D, Sinxadi P, Rayner B, Dandara C. Genetic Variation in ABCB1, ADRB1, CYP3A4, CYP3A5, NEDD4L and NR3C2 Confers Differential Susceptibility to Resistant Hypertension among South Africans. J Pers Med 2024; 14:664. [PMID: 39063918 PMCID: PMC11277774 DOI: 10.3390/jpm14070664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/13/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024] Open
Abstract
Resistant hypertension (RHTN) prevalence ranges from 4 to 19% in Africa. There is a paucity of data on the role of genetic variation on RHTN among Africans. We set out to investigate the role of polymorphisms in ABCB1, ADRB1, CYP3A4, CYP3A5, NEDD4L, and NR3C2, on RHTN susceptibility among South Africans. Using a retrospective matched case-control study, 190 RHTN patients (cases: blood pressure (BP) ≥ 140/90 mmHg on ≥3 anti-hypertensives or BP < 140/90 mmHg on >3 anti-hypertensives) and 189 non-RHTN patients (controls: <3 anti-hypertensives, BP < 140/90 or ≥140/90 mmHg), 12 single nucleotide polymorphisms were genotyped using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP), quantitative PCR and Sanger sequencing. Genetic association analyses were conducted using the additive model and multivariable logistic regression. Homozygosity for CYP3A5 rs776746C/C genotype (p = 0.02; OR: 0.44; CI: 0.22-0.89) was associated with reduced risk for RHTN. Homozygous ADRB1 rs1801252G/G (p = 0.02; OR: 3.30; CI: 1.17-10.03) and NEDD4L rs4149601A/A genotypes (p = 0.001; OR: 3.82; CI: 1.67-9.07) were associated with increased risk for RHTN. Carriers of the of ADRB1 rs1801252-rs1801253 G-C haplotype had 2.83-fold odds of presenting with RHTN (p = 0.04; OR: 2.83; CI: 1.05-8.20). These variants that are associated with RHTN may have clinical utility in the selection of antihypertensive drugs in our population.
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Affiliation(s)
- Jonathan N. Katsukunya
- Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa; (J.N.K.); (N.D.S.)
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation, South African Medical Research Council, Cape Town 7501, South Africa; (E.J.); (D.B.); (P.S.); (B.R.)
| | - Erika Jones
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation, South African Medical Research Council, Cape Town 7501, South Africa; (E.J.); (D.B.); (P.S.); (B.R.)
- Department of Medicine, Division of Nephrology and Hypertension, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa
| | - Nyarai D. Soko
- Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa; (J.N.K.); (N.D.S.)
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation, South African Medical Research Council, Cape Town 7501, South Africa; (E.J.); (D.B.); (P.S.); (B.R.)
- Department of Pharmaceutical Technology, School of Allied Health Sciences, Harare Institute of Technology, Harare P.O. Box BE 277, Zimbabwe
| | - Dirk Blom
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation, South African Medical Research Council, Cape Town 7501, South Africa; (E.J.); (D.B.); (P.S.); (B.R.)
- Department of Medicine, Division of Lipidology and Cape Heart Institute, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa
| | - Phumla Sinxadi
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation, South African Medical Research Council, Cape Town 7501, South Africa; (E.J.); (D.B.); (P.S.); (B.R.)
- Department of Medicine, Division of Clinical Pharmacology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa
| | - Brian Rayner
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation, South African Medical Research Council, Cape Town 7501, South Africa; (E.J.); (D.B.); (P.S.); (B.R.)
- Department of Medicine, Division of Nephrology and Hypertension, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa; (J.N.K.); (N.D.S.)
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation, South African Medical Research Council, Cape Town 7501, South Africa; (E.J.); (D.B.); (P.S.); (B.R.)
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Zeijen VJM, Peeters LEJ, Asman A, Boersma E, Massey EK, van Dijk L, Daemen J, Versmissen J. Quality-of-life and beliefs about medication in relation to a therapy adherence intervention in resistant hypertension: the Resistant HYpertension: MEasure to ReaCh Targets trial. J Hypertens 2024:00004872-990000000-00479. [PMID: 38780122 DOI: 10.1097/hjh.0000000000003780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To assess the impact of personalized feedback on therapy adherence testing results on quality of life and beliefs about medication in patients with resistant hypertension, as well as to identify patient-oriented predictors of therapy adherence. METHODS This study was a prespecified post hoc analysis of the multicenter randomized controlled trial Resistant HYpertension: MEasure to ReaCh Targets (RHYME-RCT). Patients were randomized to a personalized feedback conversation on measured antihypertensive drug levels additional to standard-of-care, or standard-of-care only. The primary outcomes consisted of EuroQol EQ-5D-5L and Beliefs about Medicine Questionnaire (BMQ) scores at 12 months. RESULTS A total of 56 patients with median age 61.5 [25th-75th percentile: 55.8-69.3] years (21.4% women) were included. Mean blood pressure ±SD was 149.8/84.1 ± 14.9/13.8 mmHg while being on a median of 5.6 [4.8-7.3] defined daily dosages (DDD) of antihypertensive drugs. At 12 months, no differences were observed in EQ-5D-5L index (0.81 [0.69-0.89] vs. 0.89 [0.73-1.00]; P = 0.18) and visual analogue scale score on general patient-perceived health (70 [60-80] vs. 70 [60-82]; P = 0.53) between the intervention-arm and the standard-of-care only-arm. Likewise, individual EQ-5D-5L domain scores and BMQ scores did not differ between both arms. Irrespective of the intervention, independent positive predictors of the percentage adherence were patient age, EQ-5D-5L index score, BMQ-specific necessity score and concern score, whereas the total number of drugs prescribed was a negative predictor. CONCLUSION Within this prespecified subanalysis of the randomized RHYME-RCT trial, implementation of a personalized feedback conversation targeting therapy adherence did not improve health-related quality-of-life and beliefs about medication in patients with resistant hypertension.
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Affiliation(s)
| | - Laura E J Peeters
- Department of Internal Medicine
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam
| | - Azra Asman
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam
| | | | | | - Liset van Dijk
- Netherlands Institute for Health Services Research (NIVEL), Utrecht
- Department of PharmacoTherapy, Epidemiology and Economics (PTEE), Groningen Research Institute of Pharmacy, Faculty of Science and Engineering, University of Groningen, Groningen, the Netherlands
| | | | - Jorie Versmissen
- Department of Internal Medicine
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam
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Jacobs CM, Radosa JC, Wagmann L, Zimmermann JSM, Kaya AC, Aygün A, Edel T, Stotz L, Ismaeil M, Solomayer EF, Meyer MR. Towards clinical adherence monitoring of oral endocrine breast cancer therapies by LC-HRMS-method development, validation, comparison of four sample matrices, and proof of concept. Anal Bioanal Chem 2024; 416:2969-2981. [PMID: 38488952 PMCID: PMC11045636 DOI: 10.1007/s00216-024-05244-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/17/2024]
Abstract
Oral endocrine therapies (OET) for breast cancer treatment need to be taken over a long period of time and are associated with considerable side effects. Therefore, adherence to OET is an important issue and of high clinical significance for breast cancer patients' caregivers. We hypothesized that a new bioanalytical strategy based on liquid chromatography and high-resolution mass spectrometry might be suitable for unbiased adherence monitoring (AM) of OET. Four different biomatrices (plasma, urine, finger prick blood by volumetric absorptive microsampling (VAMS), oral fluid (OF)) were evaluated regarding their suitability for AM of the OET abemaciclib, anastrozole, exemestane, letrozole, palbociclib, ribociclib, tamoxifen, and endoxifen. An analytical method was developed and validated according to international recommendations. The analytical procedures were successfully validated in all sample matrices for most analytes, even meeting requirements for therapeutic drug monitoring. Chromatographic separation of analytes was achieved in less than 10 min and limits of quantification ranged from 1 to 1000 ng/mL. The analysis of 25 matching patient samples showed that AM of OET is possible using all four matrices with the exception of, e.g., letrozole and exemestane in OF. We were able to show that unbiased bioanalytical AM of OET was possible using different biomatrices with distinct restrictions. Sample collection of VAMS was difficult in most cases due to circulatory restraints and peripheral neuropathy in fingers and OF sampling was hampered by dry mouth syndrome in some cases. Although parent compounds could be detected in most of the urine samples, metabolites should be included when analyzing urine or OF. Plasma is currently the most suitable matrix due to available reference concentrations.
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Affiliation(s)
- Cathy M Jacobs
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, Homburg, Germany
| | - Julia C Radosa
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Saarland, Germany
| | - Lea Wagmann
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, Homburg, Germany
| | - Julia S M Zimmermann
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Saarland, Germany
| | - Askin C Kaya
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Saarland, Germany
| | - Aylin Aygün
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Saarland, Germany
| | - Tatjana Edel
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Saarland, Germany
| | - Lisa Stotz
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Saarland, Germany
| | - Mohamed Ismaeil
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Saarland, Germany
| | - Erich-Franz Solomayer
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Saarland, Germany
| | - 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, Germany.
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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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9
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Peeters LEJ, van Gelder T, van Dijk L, Koch BCP, Versmissen J. Lessons learned from conducting a randomized controlled trial to improve non-adherence to antihypertensive drug treatment. Blood Press 2023; 32:2281316. [PMID: 38010821 DOI: 10.1080/08037051.2023.2281316] [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: 10/18/2023] [Accepted: 11/03/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE Hypertension significantly contributes to cardiovascular diseases and premature deaths. Effective treatment is crucial to reduce cardiovascular risks, but poor adherence to antihypertensive drugs is a major issue. Numerous studies attempted to investigate interventions for identifying non-adherence, but often failed to address the issue effectively. The RHYME-RCT trial sought to bridge this gap by measuring non-adherence by determining antihypertensive drug concentrations in blood through a dried blood spot (DBS) method in patients with resistant hypertension. This measurement was followed by personalized feedback to improve adherence. During the course of this trial several challenges emerged, including selection bias, the gatekeeper role of physicians, the Hawthorne effect and the role of randomization. AIM This communication aims to inform fellow researchers and clinicians of challenges that can arise when conducting clinical trials to improve adherence and offer insights for refining study designs to avoid these issues in forthcoming adherence studies.
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Affiliation(s)
- L E J Peeters
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy, the Netherlands
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, the Netherlands
| | - T van Gelder
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy, the Netherlands
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, the Netherlands
| | - L van Dijk
- Nivel, Netherlands Institute for Health Services Research, Department Healthcare from the Perspective of Patients, Clients and Citizens, Utrecht, the Netherlands
- University of Groningen, Department of PharmacoTherapy, -Epidemiology & -Economics (PTEE), Groningen Research Institute of Pharmacy, Faculty of Science and Engineering, University of Groningen, Groningen, the Netherlands
| | - B C P Koch
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, the Netherlands
| | - J Versmissen
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy, the Netherlands
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, the Netherlands
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10
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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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11
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Seleznev S, Shchulkin A, Mylnikov P, Yakusheva E, Nikulina N. Therapeutic Drug Monitoring in Arterial Hypertension. J Pers Med 2023; 13:jpm13050815. [PMID: 37240985 DOI: 10.3390/jpm13050815] [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: 03/29/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: This study was planned to assess the concentration of antihypertensive drugs (AHD) in the blood serum in patients with controlled and uncontrolled arterial hypertension (AH). (2) Methods: We assessed 46 patients with AH. Based on the results of 24 h blood pressure monitoring (ABPM), the patients were randomized into two groups. The first group consisted of the patients with controlled AH; the second group consisted of the patients with uncontrolled AH. Venous blood was taken in both groups of patients in the morning before and 2 h after taking drugs to assess the concentration of lisinopril, amlodipine, valsartan, and indapamide. (3) Results. The first group included 27 patients, and the second group 19 patients. In patients with uncontrolled AH, the median concentrations of lisinopril, indapamide, amlodipine, and valsartan before and after taking the drugs did not differ from patients who reached the target BP values. (p > 0.05). In some patients with uncontrolled and controlled (shown for the first time) AH the concentration of AHD was below the limit of quantitative determination. (4) Conclusions. The obtained results indicate that the pharmacokinetics of AHD, apparently, does not play a significant role in the development of ineffectiveness of the ongoing therapy for AH. Therapeutic drug monitoring can be used to test adherence to the treatment.
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Affiliation(s)
- Sergey Seleznev
- Department of Hospital Therapy with a Course of Medical and Social Expertise, Ryazan State Medical University, Ryazan 390026, Russia
| | - Alexey Shchulkin
- Department of Pharmacology, Ryazan State Medical University, Ryazan 390026, Russia
| | - Pavel Mylnikov
- Department of Pharmacology, Ryazan State Medical University, Ryazan 390026, Russia
| | - Elena Yakusheva
- Department of Pharmacology, Ryazan State Medical University, Ryazan 390026, Russia
| | - Natalia Nikulina
- Department of Hospital Therapy with a Course of Medical and Social Expertise, Ryazan State Medical University, Ryazan 390026, Russia
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Sharma JR, Dludla PV, Dwivedi G, Johnson R. Measurement Tools and Utility of Hair Analysis for Screening Adherence to Antihypertensive Medication. Glob Heart 2023; 18:17. [PMID: 36968302 PMCID: PMC10038111 DOI: 10.5334/gh.1191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 02/16/2023] [Indexed: 03/29/2023] Open
Abstract
Poor adherence to the prescribed antihypertensive therapy is an understated public health problem and is one of the main causes of the high prevalence of uncontrolled hypertension in sub-Saharan Africa. Medication adherence is vital for the effectiveness of antihypertensive treatment and is key to ameliorating the clinical outcomes in hypertensive patients. However, it has often been ignored because the current methods used to assess medication adherence are not reliable, limiting their utilization in clinical practice. Therefore, the identification of the most accurate and clinically feasible method for measuring medication adherence is critical for tailoring effective strategies to improve medication adherence and consequently achieve blood pressure goals. This review not only explores various available methods for estimating medication adherence but also proposes therapeutic drug monitoring in hair for the measurement of medication adherence to the antihypertensive medication period.
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Affiliation(s)
- Jyoti R. Sharma
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg 7505, South Africa
| | - Phiwayinkosi V. Dludla
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg 7505, South Africa
| | - Girish Dwivedi
- Medical School, University of Western Australia, Harry Perkins Institute of Medical Sciences, Fiona Stanley Hospital, Verdun Street, Nedlands WA, 6009, Australia
| | - Rabia Johnson
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg 7505, South Africa
- Centre for Cardio-Metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa
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13
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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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14
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Jacobs CM, Kunz M, Mahfoud F, Wagmann L, Meyer MR. Closing the gap - development of an analytical methodology using volumetric absorptive microsampling of finger prick blood followed by LC-HRMS/MS for adherence monitoring of antihypertensive drugs. Anal Bioanal Chem 2023; 415:167-177. [PMID: 36318313 PMCID: PMC9816235 DOI: 10.1007/s00216-022-04394-9] [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: 08/24/2022] [Revised: 10/06/2022] [Accepted: 10/19/2022] [Indexed: 01/07/2023]
Abstract
Volumetric absorptive microsampling (VAMS), an emerging microsampling technique, is a promising tool for adherence monitoring. This study focused on development of an analytical methodology to improve VAMS-based strategies for adherence assessment by analyzing angiotensin-converting-enzyme (ACE) inhibitors, loop diuretics, a potassium-sparing diuretic, and a thiazide diuretic. Development included sample preparation, chromatographic conditions, mass spectrometry settings, validation, and demonstrating proof of concept. Quantification of analytes, by name furosemide, hydrochlorothiazide, lisinopril, torasemide, and the active metabolites, canrenone, enalaprilat, and ramiprilat in finger prick blood (FPB), was validated based on international guidelines. Selectivity, carryover, and within/between-run accuracy and precision were in accordance with the recommendations. The matrix effect was evaluated at three different hematocrit levels (HT: 20%, 40%, 60%) and the coefficients of variation did not exceed 15%. Dilution integrity (1:10 and 1:20) was given for all analytes except lisinopril, yet for lisinopril, the therapeutic range was already covered by the calibration range. Long-term stability in VAMS tips was tested for 2 weeks at 24 °C in the dark and revealed no degradation of analytes. The proof of concept was performed by analyzing 35 intakes of ACE-inhibitors and diuretics in 18 VAMS and matched plasma samples. Hereby, determined concentration in FPB and plasma cannot be used interchangeably, and thus specific reference ranges for whole blood must be established. Nevertheless, the VAMS-based strategy was shown to be suitable for assessing adherence of all classes of antihypertensive drugs used in the guidelines to manage hypertension.
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Affiliation(s)
- Cathy M. Jacobs
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, Homburg, Germany
| | - Michael Kunz
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany ,Institute for Medical Engineering and Science, MIT, Cambridge, MA USA
| | - Lea Wagmann
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, Homburg, Germany
| | - 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, Germany
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15
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Peeters LEJ, Bahmany S, Dekker T, Aliawi A, van Domburg B, Versmissen J, Koch BCP. Development and Validation of a Dried Blood Spot Assay Using UHPLC-MS/MS to Identify and Quantify 12 Antihypertensive Drugs and 4 Active Metabolites: Clinical Needs and Analytical Limitations. Ther Drug Monit 2022; 44:568-577. [PMID: 35383727 PMCID: PMC9275854 DOI: 10.1097/ftd.0000000000000984] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/27/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE As nonadherence to antihypertensive drugs (AHDs) can increase the risk of cardiovascular events, hospitalization, and higher costs, there is a need for a reliable, objective, and easy method to assess nonadherence in patients. The dried blood spot (DBS) sampling method used to measure drug concentrations meets these requirements. For detecting nonadherence, identification is more important than quantification. Owing to their use in clinical practice, it is important to measure multiple AHDs with a single method. Therefore, we developed and validated a single DBS method for 17 commonly used AHDs and 4 active metabolites using ultrahigh performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). METHODS Analytical validation of the DBS assay was performed in accordance with the guidelines on bioanalytical method validation of the European Medicines Agency and US Food and Drug Administration as well as the International Association of Therapeutic Drug Monitoring and Clinical Toxicology guidelines. RESULTS We validated 12 of the 17 AHDs according to the European Medicines Agency and Food and Drug Administration requirements for bioanalytical method validation. Eleven AHDs were validated for both identification and quantification of drug concentrations, whereas nifedipine was only validated for identification. However, 5 of the 17 AHDs were excluded due to suboptimal validation results. Lercanidipine was excluded due to nonlinearity, and all 4 AHDs measured in the negative mode of UHPLC-MS/MS were not in accordance with one or more of the acceptance criteria and were therefore excluded. CONCLUSIONS The described method accurately measured AHDs in DBS and can be used to determine nonadherence in patients. However, method validation revealed a challenging balance between analytical limitations and clinical needs when analyzing multiple drugs using the same method.
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Affiliation(s)
- Laura E. J. Peeters
- Departments of Department of Hospital Pharmacy and
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Soma Bahmany
- Departments of Department of Hospital Pharmacy and
| | - Tim Dekker
- Departments of Department of Hospital Pharmacy and
| | - Aya Aliawi
- Departments of Department of Hospital Pharmacy and
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16
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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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17
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Adequacy of blood pressure control in high-risk hypertensive patients: The DEGREE study. Int J Cardiol 2022; 352:137-143. [PMID: 35176408 DOI: 10.1016/j.ijcard.2022.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/24/2022] [Accepted: 02/10/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Hypertension is a modifiable risk factor in patients at the highest risk for cardiovascular events. New invasive treatment options are becoming available that might be particularly appealing for high-risk patients. Therefore, the aim of this study was to determine the prevalence of high-risk patients on routine therapy that do not meet guideline recommended ambulatory blood pressure (ABP) targets. METHODS This single-center, cross-sectional study was conducted at the Erasmus University Medical Center (Rotterdam, The Netherlands). Inclusion criteria were: (1) age 18-80 years, (2) drugs prescribed for hypertension or history of hypertension and (3) high cardiovascular risk as defined according to the European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines. Patients underwent standardized office blood pressure (OBP) and same-day 24-h ABP measurements. Blood pressure (BP) control was defined according to the 2018 ESC/ESH and 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. RESULTS A total of 100 patients were enrolled (median age 71 years, 35% female). Mean OBP was 142.2/81.9 ± 18.6/12.6 mmHg and mean 24-h ABP was 126.1/70.1 ± 14.3/9.2 mmHg. Patients were on 2.0 [25th-75th percentile: 1.0-3.3] Defined Daily Doses of antihypertensive drugs. ESC/ESH guideline 24-h ABP and OBP targets were not met in 41.8% (95%CI: 31.5-52.6%) and 52.7% (95%CI: 42.0-63.3%), respectively. ACC/AHA guideline 24-h ABP and OBP targets were not met in 59.3% (95%CI: 48.5-69.5%) and 79.1% (95%CI: 69.3-86.9%), respectively. CONCLUSIONS BP remains uncontrolled in 40-60% of high-risk hypertensive patients despite routine use of guideline-recommended therapy. Our findings support the search towards novel invasive BP lowering treatment options.
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18
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Sex Differences in Spironolactone and the Active Metabolite Canrenone Concentrations and Adherence. Biomedicines 2022; 10:biomedicines10010137. [PMID: 35052816 PMCID: PMC8773364 DOI: 10.3390/biomedicines10010137] [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: 10/28/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 12/07/2022] Open
Abstract
We aim to investigate sex differences in blood concentrations of spironolactone and the active metabolite canrenone in resistant hypertension patients. Furthermore, sex differences in adherence for spironolactone and other antihypertensive drugs (AHDs) were studied. The patients in this post hoc study had all participated in a single-blind randomized controlled trial called RHYME-RCT (Dutch Trial Register, NL6736). Concentrations in blood of several AHDs were assessed in RHYME-RCT to investigate adherence to treatment. This allowed for a comparison of drug exposure to spironolactone and canrenone between males and females. In linear regression models, no statistically significant sex differences (N = 35) in spironolactone (B =−10.23, SE = 7.92, p = 0.206) or canrenone (B = 1.24, SE = 10.96, p = 0.911) concentrations after adjustment for dose and time between sampling and intake were found. Furthermore, no statistically significant differences in non-adherence to spironolactone were found between sexes (N = 54, male 15% vs. female 38%, p = 0.100), but non-adherence to spironolactone was associated with non-adherence to other AHDs (p ≤ 0.001). Spironolactone and canrenone concentrations were not different between males and females with resistant hypertension. Although not statistically significant, females were twice as likely to be non-adherent to spironolactone compared to males, and thereby also more likely to be non-adherent to other AHDs.
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19
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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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20
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Peeters LE, van der Net JB, Schoenmakers-Buis K, van der Meer IM, Massey EK, van Dijk L, van Gelder T, Koch BC, Versmissen J. Introducing the importance and difficulties of a three-step approach to improve nonadherence to antihypertensive drugs: a case series. J Hypertens 2022; 40:189-193. [PMID: 34857710 PMCID: PMC8654304 DOI: 10.1097/hjh.0000000000003001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/26/2022]
Abstract
Nonadherence to antihypertensive drugs is an important reason for not reaching blood pressure goals. A possible method to improve nonadherence involves three essential steps: identification of nonadherent patients (step 1), determination of underlying causes (step 2) and a personalized solution (step 3). We present three unique cases to show the importance and difficulties of this three-step approach. Patients participated in a randomized controlled trial to improve nonadherence to antihypertensive drugs (RHYME-RCT, Dutch Trial Register NL6736). Drug level measurements were used to identify nonadherence to antihypertensive drugs and communication on drug levels was supported by a tailored feedback tool in these patients. These cases showed that a three-step approach of identifying nonadherence and determination of the underlying cause, can lead to a personalized solution to improve therapy even when nonadherence was excluded. Open communication with patients remains an essential part when improving nonadherence.
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Affiliation(s)
- Laura E.J. Peeters
- Department of Hospital Pharmacy
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam
| | | | | | | | - Emma K. Massey
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam
| | - Liset van Dijk
- Department Pharmaceutical Care, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam
| | - Birgit C.P. Koch
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam
| | - Jorie Versmissen
- Department of Hospital Pharmacy
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam
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21
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Jacobs CM, Kunz M, Mahfoud F, Wagmann L, Meyer MR. Evaluation and analytical applicability of a novel volumetric absorptive microsampling strategy for adherence monitoring of antihypertensive drugs by means of LC-HRMS/MS. Anal Chim Acta 2021; 1187:339137. [PMID: 34753562 DOI: 10.1016/j.aca.2021.339137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/13/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
Volumetric absorptive microsampling (VAMS), an emerging microsampling technique, is expected to overcome some disadvantages of dried blood spots. This study aimed to develop and evaluate a VAMS-based strategy for quantifying ten frequently prescribed antihypertensive drugs (AHD) (amlodipine, bisoprolol, candesartan, carvedilol, lercanidipine, losartan carboxylic acid, metoprolol, nebivolol, telmisartan, valsartan) in finger prick blood (FPB) within the scope of adherence monitoring. The straightforward workflow consisted of VAMS tip hydration and subsequent precipitation. Samples were analyzed by using reversed phase ultra-high performance liquid chromatography coupled to orbitrap mass spectrometry operating in parallel reaction monitoring mode. The analytical procedure was successfully validated based on international recommendations for most of the analytes. Selectivity and within/between-run accuracy and precision were in accordance with the recommendations. Internal standard normalized matrix factor met recommended criteria for all analytes at HT 20%, 40%, and 60% except for amlodipine were the CV exceeded 15% at HT 20% (CV 18%). Dilution integrity was given for all substances, covering the quantification in the upper part of the therapeutic range of selected AHD. Long-term stability in VAMS tips was tested and revealed degradation of lercanidipine after one week of storage at 24 °C. A proof of concept of the analytical applicability was done by quantification of selected AHD in VAMS tips and matched plasma samples. Results revealed that determined concentration in FPB by VAMS and plasma cannot be used interchangeably, and thus that specific reference ranges have to be established. However, a novel VAMS application was implemented in the context of adherence monitoring for at least the investigated AHD.
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Affiliation(s)
- Cathy M Jacobs
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, Homburg, Germany
| | - Michael Kunz
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany; Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA
| | - Lea Wagmann
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, Homburg, Germany
| | - 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, Germany.
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Bovée DM, Uijl E, Severs D, Rubio-Beltrán E, van Veghel R, Maassen van den Brink A, Joles JA, Zietse R, Cuevas CA, Danser AHJ, Hoorn EJ. Dietary salt modifies the blood pressure response to renin-angiotensin inhibition in experimental chronic kidney disease. Am J Physiol Renal Physiol 2021; 320:F654-F668. [PMID: 33586496 DOI: 10.1152/ajprenal.00603.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Chronic kidney disease contributes to hypertension, but the mechanisms are incompletely understood. To address this, we applied the 5/6th nephrectomy rat model to characterize hypertension and the response to dietary salt and renin-angiotensin inhibition. 5/6th nephrectomy caused low-renin, salt-sensitive hypertension with hyperkalemia and unsuppressed aldosterone. Compared with sham rats, 5/6th nephrectomized rats had lower Na+/H+ exchanger isoform 3, Na+-K+-2Cl- cotransporter, Na+-Cl- cotransporter, α-epithelial Na+ channel (ENaC), and Kir4.1 levels but higher serum and glucocorticoid-regulated kinase 1, prostasin, γ-ENaC, and Kir5.1 levels. These differences correlated with plasma renin, aldosterone, and/or K+. On a normal-salt diet, adrenalectomy (0 ± 9 mmHg) and spironolactone (-11 ± 10 mmHg) prevented a progressive rise in blood pressure (10 ± 8 mmHg), and this was enhanced in combination with losartan (-41 ± 12 and -43 ± 9 mmHg). A high-salt diet caused skin Na+ and water accumulation and aggravated hypertension that could only be attenuated by spironolactone (-16 ± 7 mmHg) and in which the additive effect of losartan was lost. Spironolactone also increased natriuresis, reduced skin water accumulation, and restored vasorelaxation. In summary, in the 5/6th nephrectomy rat chronic kidney disease model, salt-sensitive hypertension develops with a selective increase in γ-ENaC and despite appropriate transporter adaptations to low renin and hyperkalemia. With a normal-salt diet, hypertension in 5/6th nephrectomy depends on angiotensin II and aldosterone, whereas a high-salt diet causes more severe hypertension mediated through the mineralocorticoid receptor.NEW & NOTEWORTHY Chronic kidney disease (CKD) causes salt-sensitive hypertension, but the interactions between dietary salt and the renin-angiotensin system are incompletely understood. In rats with CKD on a normal-salt diet targeting aldosterone, the mineralocorticoid receptor (MR) and especially angiotensin II reduced blood pressure. On a high-salt diet, however, only MR blockade attenuated hypertension. These results reiterate the importance of dietary salt restriction to maintain renin-angiotensin system inhibitor efficacy and specify the MR as a target in CKD.
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Affiliation(s)
- Dominique M Bovée
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Estrellita Uijl
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Severs
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eloisa Rubio-Beltrán
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Richard van Veghel
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Antoinette Maassen van den Brink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert Zietse
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Catherina A Cuevas
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A H Jan Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewout J Hoorn
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Is Spironolactone the Preferred Renin-Angiotensin-Aldosterone Inhibitor for Protection Against COVID-19? J Cardiovasc Pharmacol 2020; 77:323-331. [PMID: 33278189 DOI: 10.1097/fjc.0000000000000960] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/14/2020] [Indexed: 12/13/2022]
Abstract
ABSTRACT The high mortality of specific groups from COVID-19 highlights the importance of host-viral interactions and the potential benefits from enhancing host defenses. SARS-CoV-2 requires angiotensin-converting enzyme (ACE) 2 as a receptor for cell entry and infection. Although both ACE inhibitors and spironolactone can upregulate tissue ACE2, there are important points of discrimination between these approaches. The virus requires proteolytic processing of its spike protein by transmembrane protease receptor serine type 2 (TMPRSS2) to enable binding to cellular ACE2. Because TMPRSS2 contains an androgen promoter, it may be downregulated by the antiandrogenic actions of spironolactone. Furin and plasmin also process the spike protein. They are inhibited by protease nexin 1 or serpin E2 (PN1) that is upregulated by angiotensin II but downregulated by aldosterone. Therefore, spironolactone should selectively downregulate furin and plasmin. Furin also promotes pulmonary edema, whereas plasmin promotes hemovascular dysfunction. Thus, a downregulation of furin and plasmin by PN1 could be a further benefit of MRAs beyond their well-established organ protection. We review the evidence that spironolactone may be the preferred RASSi to increase PN1 and decrease TMPRSS2, furin, and plasmin activities and thereby reduce viral cell binding, entry, infectivity, and bad outcomes. This hypothesis requires direct investigation.
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Groenland EH, van Kleef MEAM, Bots ML, Visseren FLJ, van der Elst KCM, Spiering W. Plasma Trough Concentrations of Antihypertensive Drugs for the Assessment of Treatment Adherence: A Meta-Analysis. Hypertension 2020; 77:85-93. [PMID: 33249865 PMCID: PMC7720878 DOI: 10.1161/hypertensionaha.120.16061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Biochemical drug screening by liquid chromatography-tandem mass spectrometry in plasma is an accurate method for the quantification of plasma concentrations of antihypertensive medications in patients with hypertension. Trough concentrations could possibly be used as drug-specific cutoff values in the biochemical assessment of (non-)adherence. We performed a literature review and meta-analysis of pharmacokinetic studies to determine plasma trough concentrations of amlodipine, hydrochlorothiazide, and valsartan. PubMed was searched for pharmacokinetic studies up to September 2020. Eligible studies reported steady-state mean trough concentration and their variance. Pooled trough concentrations were estimated using a three-level random effects meta-analytic model. Moderator analyses were performed to explore sources of heterogeneity. One thousand three hundred eighteen potentially relevant articles were identified of which 45 were eligible for inclusion. The pooled mean trough concentration was 9.2 ng/mL (95% CI, 7.5–10.8) for amlodipine, 41.0 ng/mL (95% CI, 17.4–64.7) for hydrochlorothiazide, and 352.9 ng/mL (95% CI, 243.5–462.3) for valsartan. Substantial heterogeneity was present for all 3 pooled estimates. Moderator analyses identified dosage as a significant moderator for the pooled trough concentration of amlodipine (β1=0.9; P<0.05), mean age, and mean body weight for the mean trough concentration of hydrochlorothiazide (β1=2.2, P<0.05, respectively, β1=−4.0, P<0.05) and no significant moderators for valsartan. Plasma trough concentrations of amlodipine, hydrochlorothiazide, and valsartan, measured with liquid chromatography-tandem mass spectrometry, are highly heterogeneous over the different studies. Use of the pooled trough concentration as a cutoff in the biochemical assessment of adherence can result in inaccurate diagnosis of (non-)adherence, which may seriously harm the patient-physician relationship, and is therefore not recommended.
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Affiliation(s)
- Eline H Groenland
- From the Department of Vascular Medicine (E.H.G., M.E.A.M.v.K., F.L.J.V., W.S.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Monique E A M van Kleef
- From the Department of Vascular Medicine (E.H.G., M.E.A.M.v.K., F.L.J.V., W.S.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Frank L J Visseren
- From the Department of Vascular Medicine (E.H.G., M.E.A.M.v.K., F.L.J.V., W.S.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Kim C M van der Elst
- Department of Clinical Pharmacy (K.C.M.v.d.E.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Wilko Spiering
- From the Department of Vascular Medicine (E.H.G., M.E.A.M.v.K., F.L.J.V., W.S.), University Medical Center Utrecht, Utrecht University, the Netherlands
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Kably B, Billaud EM, Boutouyrie P, Azizi M. Is there any Hope for Monitoring Adherence in an Efficient and Feasible Way for Resistant Hypertension Diagnosis and Follow-Up? Curr Hypertens Rep 2020; 22:96. [PMID: 33052474 DOI: 10.1007/s11906-020-01105-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Non-adherence to antihypertensive treatment is highly prevalent and represents a major factor affecting their effectiveness in hypertensive patients, thus contributing to apparent treatment resistance. It is however often overlooked because the methods to assess non-adherence are mainly subjective, limiting their usefulness in clinical practice. Non-adherence to treatment affects daily patient management, resulting in inappropriate, costly, and potentially harmful treatments and loss of the expected benefits from antihypertensive drugs. RECENT FINDINGS Specialized centers now use a combination of objective screening tools. Firstly, snapshots of adherence levels can be provided by analytical drug detection in various biological matrixes using liquid chromatography-tandem mass spectrometry (LC-MS/MS) and secondly electronic monitoring systems of drug delivery which provide longitudinal data on adherence. Routine utilization of those tools allows the detection of non-adherence in patients with resistant hypertension, thus enabling implementation of appropriate interventions to improve drug adherence and avoid unnecessary treatment intensification. Other complementary techniques, such as digital health feedback system with ingestible sensors, are currently evaluated. In the context of an increasing burden of uncontrolled and apparent treatment-resistant hypertension, detecting non-adherence to antihypertensive therapy is, as acknowledged by the latest guidelines, a top priority to implement in clinical practice but still faces medical conservatism and disbelief.
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Affiliation(s)
- Benjamin Kably
- Université de Paris, F-75006, Paris, France
- Pharmacology Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Inserm U970, Paris Centre de Recherche Cardiovasculaire-PARCC, F-75015, Paris, France
| | - Eliane M Billaud
- Pharmacology Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Inserm U970, Paris Centre de Recherche Cardiovasculaire-PARCC, F-75015, Paris, France
| | - Pierre Boutouyrie
- Université de Paris, F-75006, Paris, France
- Pharmacology Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Inserm U970, Paris Centre de Recherche Cardiovasculaire-PARCC, F-75015, Paris, France
| | - Michel Azizi
- Université de Paris, F-75006, Paris, France.
- Hypertension Unit, DMU CARTE, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France.
- Inserm, CIC 1418, F-75015, Paris, France.
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26
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Burnier M. Dried Blood Spot to Screen for Antihypertensive Medications and to Asses Treatment Adherence. Hypertension 2020; 76:26-27. [PMID: 32520622 DOI: 10.1161/hypertensionaha.120.15111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michel Burnier
- From the Hypertension Research Foundation, Saint-Légier, Switzerland
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