Global Burden, Regional Differences, Trends, and Health Consequences of Medication Nonadherence for Hypertension During 2010 to 2020: A Meta-Analysis Involving 27 Million Patients

Effectiveness of a two-component nutritional strategy for blood pressure control in individuals with hypertension users of a public health system: a randomized controlled clinical trial

OBJECTIVE

To evaluate the effectiveness of a nutritional strategy based on two components and adapted for the public health system on blood pressure, cardiometabolic features, self-care, qualify of life and diet quality in individuals with hypertension.

METHODS

NUPRESS was an open-label, parallel-group, superiority randomized controlled clinical trial in which participants at least 21 years with hypertension and poorly controlled blood pressure were randomly assigned (1 : 1 allocation ratio) to either an individualized dietary prescription according to nutritional guidelines (control group, n  = 205); or a two-component nutrition strategy, including a goal-directed nutritional counseling and mindfulness techniques (NUPRESS [intervention] group, n  = 205). Primary outcomes were SBP (mmHg) after 24 weeks of follow up and blood pressure control, defined as either having SBP more than 140 mmHg at baseline and achieving 140 mmHg or less after follow-up or having SBP 140 mmHg or less at baseline and reducing the frequency of antihypertensive drugs in use after follow-up.

RESULTS

In total, 410 participants were randomized and submitted to an intention-to-treat analysis regarding primary outcomes. Both groups decreased blood pressure, but after adjusting for baseline values, there was no significant difference between them on SBP [intervention-control difference: -0.03 (-3.01; 2.94); P  = 0.98] nor blood pressure control [odds ratio 1.27 (0.82; 1.97); P  = 0.28]. No differences between groups were also detected regarding secondary and tertiary outcomes.

CONCLUSION

There was no difference between a two-component nutritional strategy and an established dietary intervention on blood pressure in participants with hypertension.

Physician and patient adherence in hypertension trials: a point of view on an important issue to resolve

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.

The combination of high uric acid and high C-reactive protein increased the risk of cardiovascular disease: A 15-year prospective cohort study

BACKGROUND AND AIMS

Uric acid (UA) and C-reactive protein (CRP) may interact synergistically to accelerate the initiation and progression of cardiovascular disease (CVD). This study investigated the effects of a combination of high UA and high CRP on the risks of CVD.

METHODS AND RESULTS

A total of 90,270 participants recruited from the Kailuan study were included, who were divided into four groups according to the presence/absence of hyperuricemia and inflammation. Cox regression was applied to evaluate the hazard ratios (HRs) and 95% confidence intervals (95% CIs) of CVD. C-statistics, net classification index (NRI), and integrated discrimination improvement (IDI) were used to compare the incremental predictive of UA, CRP, and their combined effects on CVD. Mediation analysis was to explore the impact of CRP on the association between UA and CVD. Over a median follow-up of 14.95 years, we identified 11398 incident CVD cases. Compared to the low UA/low CRP group, the high UA/low CRP, low UA/high CRP and high UA/high CRP groups showed progressively higher risks of CVD, HR (95% CI): 1.18(1.10-1.27), 1.27(1.21-1.33) and 1.50 (1.33-1.69), respectively. The incorporation of UA and CRP into the traditional China-PAR model led to improvement in the C-statistic, NRI, and IDI, and was better than incorporation of either UA or CRP alone. Mediation analysis showed that CRP mediated the association between UA and CVD, accounting for 11.57% of the total effects.

CONCLUSIONS

High UA/high CRP is associated with increased risks of CVD. Incorporation of both UA and CRP provided additional value for risk stratification.

Novel approach to adherence assessment based on parent drug and metabolite pharmacokinetics: pilot study with spironolactone

AIM

The aim of this study was to evaluate adherence to spironolactone in a group of unselected patients with arterial hypertension by analysis of measured serum spironolactone and canrenone concentrations according to a proposed two-step decision scheme based on pharmacokinetic considerations.

MATERIALS AND METHODS

Simulation of serum concentration-time profiles of spironolactone and canrenone based on population pharmacokinetic parameters described in literature and a body weight-normalized spironolactone dose / canrenone level nomogram derived from a group of adherent patients with conservatively treated primary hyperaldosteronism, were used to create a two-step decision scheme. 71 outpatients treated with spironolactone for resistant hypertension with spironolactone and canrenone serum concentrations measured between 2018 and 2021 were analyzed according to the proposed scheme. We compared our proposed methodology to the standard approach for adherence testing.

RESULTS

With the most sensitive traditional approach to adherence assessment through detectable serum concentrations of spironolactone and/or canrenone, 9 (12.7%) non-adherent patients were identified. With our two-step assessment of adherence, we were able to identify 18 (25.4%) non-adherent patients.

CONCLUSION

Consideration of the pharmacokinetic properties of parental drug and its metabolite led to improved sensitivity in non-adherence detection in patients with arterial hypertension. This approach enables better interpretation of measured spironolactone and canrenone serum concentrations and should be used in clinical practice.

Cognitive Function and Medication Adherence in Older Adults With H-Type Hypertension: The Mediating Effect of Metamemory

PURPOSE

Medication adherence in adults with H-type hypertension plays a crucial role in lowering blood pressure and treating complications. Cognitive function has been identified as a significant influencing factor for medication adherence, whereas excessive levels of homocysteine can impair cognitive function. Metamemory, which is influenced by cognitive function, also affects medication adherence. However, the complex relationship among these factors remains poorly understood among adults with H-type hypertension. Therefore, we hypothesize that metamemory serves as a mediator for the impact of cognitive function on medication adherence.

METHOD

A total of 232 adults with H-type hypertension were enrolled to provide cognitive function scores, metamemory scores, and medication adherence rates.

RESULTS

A pairwise correlation exists among cognitive function, metamemory, and medication adherence. Metamemory partially mediates (57.5%) the relationship between cognitive function and medication adherence.

CONCLUSION

Our findings suggest that interventions targeting improvements in metamemory may enhance medication adherence among individuals with H-type hypertension. [Journal of Gerontological Nursing, 50(6), 44-52.].

Risk Factors for Non-Adherence to Medication for Liver Transplant Patients: An Umbrella Review

Background/Objectives: Liver Transplantation (LT) is the second most common solid organ transplantation. Medication adherence on LT patients is key to avoiding graft failure, mortality, and important quality of life losses. The aim of this study is to identify risk-factors for non-adherence to treatment of liver transplant patients according to reliable published evidence. Methods: An umbrella review within the context of adherence to immunosuppressant medication of LT patients, was conducted. The review was performed in accordance with the principles of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Results: A total of 11 articles were finally included for the review. Non-adherence factors were identified and allocated using the WHO classification of factors for non-adherence. Each of these groups contains a subset of factors that have been shown to influence adherence to medication, directly or indirectly, according to literature findings. Conclusions: The results of the review indicate that sociodemographic factors, factors related to the patient, factors related to the treatment, condition-related and health system-related factors are good categories of predictors for both adherence and non-adherence to immunosuppressive medication in LT patients. This list of factors may help physicians in the treating and recognizing of patients with a potential risk of non-adherence and it could help in the designing of new tools to better understand non-adherence after LT and targeted interventions to promote adherence of LT patients.

Gender Differences in Cardiac Organ Damage in Arterial Hypertension: Assessing the Role of Drug Nonadherence

INTRODUCTION

Cardiac organ damage like left ventricular (LV) hypertrophy and left atrial (LA) enlargement is more prevalent in women than men with hypertension, but the mechanisms underlying this gender difference remain unclear.

METHODS

We tested the association of drug nonadherence with the presence of LV hypertrophy and LA enlargement by echocardiography in 186 women and 337 men with uncontrolled hypertension defined as daytime systolic blood pressure (BP) ≥ 135mmHg despite the prescription of at least two antihypertensive drugs. Drug adherence was assessed by measurements of serum drug concentrations interpreted by an experienced pharmacologist. Aldosterone-renin-ratio (ARR) was measured on actual medication.

RESULTS

Women had a higher prevalence of LV hypertrophy (46% vs. 33%) and LA enlargement (79% vs 65%, both p < 0.05) than men, while drug nonadherence (8% vs. 9%, p > 0.514) did not differ. Women were older and had lower serum renin concentration and higher ARR than men, while 24-h systolic BP (141 ± 9 mmHg vs. 142 ± 9 mmHg), and the prevalences of obesity (43% vs. 50%) did not differ (all p > 0.10). In multivariable analyses, female gender was independently associated with a two-fold increased risk of LV hypertrophy (OR 2.01[95% CI 1.30-3.10], p = 0.002) and LA enlargement (OR 1.90 [95% CI 1.17-3.10], p = 0.010), while no association with drug nonadherence was found. Higher ARR was independently associated with LV hypertrophy in men only (OR 2.12 [95% CI 1.12-4.00] p = 0.02).

CONCLUSIONS

Among patients with uncontrolled hypertension, the higher prevalence of LV hypertrophy and LA enlargement in women was not explained by differences in drug nonadherence.

REGISTRATION

URL:  https://www.

CLINICALTRIALS

gov ; Unique identifier: NCT03209154.

The Rationale for Using Fixed-Dose Combination Therapy in the Management of Hypertension in Colombia: A Narrative Review

Hypertension is a major risk factor for cardiovascular disease and the leading cause of death in Colombia. While the rate of hypertension awareness in Colombia is generally high, rates of treatment initiation, adherence, and blood pressure (BP) control are suboptimal. Major international hypertension guidelines recommend starting treatment with a combination of antihypertensive agents, and the use of a single-pill combination (SPC) to maximize adherence. In contrast, Colombian hypertension guidelines recommend starting treatment with diuretic monotherapy in most patients, and only initiating combination therapy in those with BP > 160/100 mmHg. Therefore, the aim of the current narrative review is to examine the rationale for using SPCs to treat hypertension in Colombia, in the context of the major issues for BP control there. There is evidence of widespread therapeutic inertia in hypertension management, particularly in primary care, in Colombia. Moreover, combination therapy, angiotensin-converting enzyme inhibitors, and long-acting calcium channel blockers, which are internationally recommended as first-line drug therapies, are underutilized there. Adherence to antihypertensive therapy is low in Colombia and may be enhanced by use of SPCs as well as better patient education and follow-up. While there are promising national initiatives to improve BP management, more needs to be done by individual physicians. Antihypertensive SPCs are available on the national essential medicines list and may help to overcome some of the problems with suboptimal adherence, therapeutic inertia, and low rates of BP control that contribute to the high cardiovascular death rate in Colombia.

Medication Adherence Among Patients With Kidney Disease: An Umbrella Review

Chronic kidney disease (CKD) imposes a significant medication burden on patients due to the necessity of multiple treatments to slow disease progression, manage coexisting conditions, and address complications. The complex medication regimen, in turn, has implications for clinical and patient-centered outcomes. This umbrella review provides comprehensive evidence on extent of medication nonadherence among adults with CKD, as well as associated risk factors, outcomes, and the effectiveness of interventions by synthesizing evidence from published systematic reviews and/or meta-analyses. We identified 37 works that met our inclusion criteria. These reviews covered various aspects of treatment adherence in people with CKD, which can be categorized into four main themes: (i) prevalence of treatment nonadherence; (ii) factors associated with (non)adherent behaviors; (iii) outcomes associated with treatment (non)adherence; and (iv) interventions to improve treatment adherence or overall self-management practices. Approximately half of the included studies (15/34) focused on interventions aimed at improving medication adherence or overall CKD management, while outcomes associated with medication (non)adherence were relatively underexplored in the literature. The reported prevalence rates of medication nonadherence varied widely among reviews and stages of CKD. The determinants of adherence identified included socioeconomic variables, disease or clinical conditions, and psychosocial factors. Common interventions to improve adherence included nurse-led interventions, pharmaceutical services, and eHealth technologies, which had varying effects on medication adherence or dialysis sessions.

The role of adherence in patients with chronic diseases

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.

New trials in resistant hypertension: mixed blessing stories

Resistant hypertension (RH) is linked to an increased risk of cardiovascular and renal complications. Treatment options include non-pharmacological interventions, such as lifestyle modifications, and the use of specific antihypertensive drug combinations, including diuretics. Renal denervation is another option for treatment-resistant hypertension. New compounds targeting different pathways involved in RH-including inhibitors of aminopeptidase A, endothelin antagonists and selective aldosterone synthase inhibitors-have been tested in clinical trials in this condition. The centrally acting drug firibastat, targeting the brain renin-angiotensin system, failed to demonstrate significant effectiveness in reducing blood pressure (BP) in patients with difficult-to-treat and RH in the Firibistat in Resistant Hypertension (FRESH) trial. Aprocitentan, a dual endothelin A and B receptor antagonist, showed a moderate but statistically significant decrease in BP in patients with RH in the Parallel-Group, Phase 3 Study with Aprocitentan in Subjects with Resistant Hypertension (PRECISION) trial. However, concerns remain about potential adverse events, such as fluid retention. The use of baxdrostat, a selective aldosterone synthase inhibitor, showed promising results in reducing BP in patients with treatment-resistant hypertension in the Baxdrostat in Resistant Hypertension (BrigHTN) trial. However, a subsequent trial, HALO, failed to meet its primary endpoint. The unexpected results may be influenced by factors such as patient adherence and white-coat hypertension. Despite the disappointing results from HALO, the potential benefits of inhibiting aldosterone synthesis remain to be fully understood. In conclusion, managing RH remains challenging, and new compounds like firibastat, aprocitentan and baxdrostat have shown varied effectiveness. Further research is needed to improve our understanding and treatment of this condition.

Posterior reversible encephalopathy syndrome due to nonadherence to antihypertensive treatment: A case report from Nepal

Key Clinical Message

Posterior reversible encephalopathy syndrome may occur secondary to abrupt cessation of antihypertensive therapy. A gradual reduction in blood pressure and counseling regarding medication adherence are crucial to prevent adverse consequences.

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a reversible clinical radiographic syndrome with headache, hypertensive encephalopathy, seizures, and visual disturbances as common modes of presentation. PRES can be attributed to several risk factors. We reported the case of a 66-year-old Asian female with PRES following nonadherence to antihypertensive treatment. Initially, her computed tomography scan of the head was normal. After 48 h, we again ordered a head CT scan, which showed lesions suggestive of hypertensive encephalopathy. We immediately reduced 20%-25% of mean arterial pressure, followed by a gradual blood pressure lowering to avoid adverse consequences. We did a follow-up CT scan of the head at 2 weeks, showing the resolution of early lesions. Hence, we made a diagnosis of PRES. In these patients, it is crucial to ensure medication adherence to avoid complications.

Prevalence of and factors associated with uncontrolled hypertension among patients with early chronic kidney disease attending tertiary hospitals in Dodoma, Tanzania: a cross-sectional study

OBJECTIVE

To determine the prevalence of uncontrolled hypertension and its associated factors among patients with early chronic kidney disease (CKD) attending medical outpatient clinics at tertiary hospitals in Dodoma, Tanzania.

DESIGN

Cross-sectional study.

SETTING

Two tertiary hospitals in Dodoma, Tanzania.

PARTICIPANTS

The participants in this study were adult patients (≥18 years) with early CKD stages (1, 2 and 3) who were attending nephrology and medical outpatient clinics from November 2020 to March 2021. Patients who had been attending the clinic for at least 3 months, had baseline clinical data on their files, had estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2 and who provided written informed consent were eligible. A total of 352 patients were enrolled, of whom 182 were men and 170 were women.

OUTCOME MEASURE

The dependent variable was uncontrolled hypertension among patients with early CKD, based on blood pressure measurements.

RESULTS

The prevalence of hypertension was 58.5% (206 of 352) and the prevalence of uncontrolled hypertension was 58.3% (120 of 206). Among patients with uncontrolled hypertension, 88.3% (106 of 120) had CKD stage 3, 80.2% (96 of 120) reported non-adherence to antihypertensives, 76.7% (92 of 120) were overweight or obese, 72.5% (87 of 120) reported current alcohol use and 26.7% (32 of 120) had diabetes mellitus. Factors that contributed to higher odds of uncontrolled hypertension were: age ≥50 years (OR=5.17, 95 % CI 2.37 to 13.33, p=0.001), alcohol use (OR=11.21, 95% CI 3.83 to 32.84, p=0.001), non-adherence to antihypertensives (OR=10.19, 95% CI 4.22 to 24.61, p=0.001), overweight/obesity (OR=6.28, 95% CI 2.54 to 15.53, p=0.001) and CKD stage 3 (OR=3.52, 95% CI 1.32 to 9.42, p=0.012).

CONCLUSION

Uncontrolled hypertension was highly prevalent among patients with early CKD in this setting and was associated with age, current alcohol use, non-adherence to antihypertensives, overweight/obesity and declining eGFR.

Antihypertensives associated adverse events: a review of mechanisms and pharmacogenomic biomarkers available evidence in multi-ethnic populations

Hypertension remains a significant health burden worldwide, re-emphasizing the outstanding need for more effective and safer antihypertensive therapeutic approaches. Genetic variation contributes significantly to interindividual variability in treatment response and adverse events, suggesting pharmacogenomics as a major approach to optimize such therapy. This review examines the molecular mechanisms underlying antihypertensives-associated adverse events and surveys existing research on pharmacogenomic biomarkers associated with these events. The current literature revealed limited conclusive evidence supporting the use of genetic variants as reliable indicators of antihypertensive adverse events. However, several noteworthy associations have emerged, such as 1) the role of ACE variants in increasing the risk of multiple adverse events, 2) the bradykinin pathway's involvement in cough induced by ACE inhibitors, and 3) the impact of CYP2D6 variants on metoprolol-induced bradycardia. Nonetheless, challenges persist in identifying biomarkers for adverse events across different antihypertensive classes, sometimes due to the rarity of certain events, such as ACE inhibitors-induced angioedema. We also highlight the main limitations of previous studies that warrant attention, including using a targeted gene approach with a limited number of tested variants, small sample sizes, and design issues such as overlooking doses or the time between starting treatment and the onset of adverse events. Addressing these challenges requires collaborative efforts and the integration of technological advancements, such as next-generation sequencing, which can significantly enhance research outcomes and provide the needed evidence. Furthermore, the potential combination of genomic biomarker identification and machine learning is a promising approach for tailoring antihypertensive therapy to individual patients, thereby mitigating the risk of developing adverse events. In conclusion, a deeper understanding of the mechanisms and the pharmacogenomics of adverse events in antihypertensive therapy will likely pave the way for more personalized treatment strategies to improve patient outcomes.

Symptoms in Hypertensive Patients Presented to the Emergency Medical Service: A Comprehensive Retrospective Analysis in Clinical Settings

BACKGROUND

Hypertension is a prevalent condition with a variety of accompanying symptoms. Gender differences, specific blood pressure readings, and early signs of organ complications present intricate interplays in hypertensive individuals.

OBJECTIVE

This study aimed to investigate the relationship between hypertension and its accompanying symptoms, emphasizing gender-specific differences and potential indicators of organ complications.

METHODS

Data from 2002 participants were analyzed from a retrospective study, focusing on the presentation of symptoms, blood pressure values, and potential organ complications associated with these symptoms.

RESULTS

Of the participants, 68.8% were women with an average age of 69. Women were, on average, 8 years older than men. The average systolic blood pressure (SBP) was 188 mmHg. High-blood pressure was accompanied by symptoms in 84.9% of participants. Among those with an SBP > 180 mmHg, headaches were reported by 24.7%, and dizziness by 15.7%. Interestingly, as SBP increased, heart palpitations reports diminished with a mere 4.8% of those with SBP > 180 mmHg noting this symptom. Younger men exhibited increased chest pain and heart palpitations, while younger women more commonly reported headaches and nausea/vomiting. A significant relationship was identified between pulse pressure (PP) and symptoms, with dizziness in women and chest pain/discomfort in men being most pronounced.

CONCLUSIONS

The study underlines the importance of in-depth research on hypertensive individuals for improved symptom recognition and management. The data highlight the gender and age-specific symptom presentations and their correlation with blood pressure metrics, suggesting a need for patient-specific intervention strategies.

Advances in the Pathogenesis and Treatment of Resistant Hypertension

Hypertension is a prevalent chronic disease associated with an increased risk of cardiovascular (CV) premature death, and its severe form manifests as resistant hypertension (RH). The accurate prevalence of resistant hypertension is difficult to determine due to the discrepancy in data from various populations, but according to recent publications, it ranges from 6% to 18% in hypertensive patients. However, a comprehensive understanding of the pathogenesis and treatment of RH is essential. This review emphasizes the importance of identifying the causes of treatment resistance in antihypertensive therapy and highlights the utilization of appropriate diagnostic methods. We discussed innovative therapies such as autonomic neuromodulation techniques like renal denervation (RDN) and carotid baroreceptor stimulation, along with invasive interventions such as arteriovenous anastomosis as potential approaches to support patients with inadequate medical treatment and enhance outcomes in RH.

[Cardiovascular pharmacotherapy in old age]

Cardiovascular diseases are the most frequent cause of disability and death. Evidence-based pharmacotherapy is the basis for successful treatment of common diseases, such as hypertension, heart failure, coronary artery disease, and atrial fibrillation. The proportion of older people with several diseases (multimorbidity) who need five or more drugs daily (polypharmacy) is steadily increasing. Evidence on the efficacy and safety of drugs in these patients is, however, limited because they are often excluded or underrepresented in clinical trials. In addition, clinical guidelines mostly focus on single diseases and only occasionally deal with the challenges in the pharmacotherapy of older multimorbid patients with polypharmacy. This article describes the options and special features of pharmacotherapy for hypertension, chronic heart failure and dyslipidemia, as well as antithrombotic treatment in (very) old people.

Expression of LRG-1 in mice with hypertensive renal damage and its significance

OBJECTIVES

Long-term elevated blood pressure may lead to kidney damage, yet the pathogenesis of hypertensive kidney damage is still unclear. This study aims to explore the role and significance of leucine-rich alpha-2-glycoprotein-1 (LRG-1) in hypertensive renal damage through detecting the levels of LRG-1 in the serum and kidney of mice with hypertensive renal damage and its relationship with related indexes.

METHODS

C57BL/6 mice were used in this study and randomly divided into a control group, an angiotensin II (Ang II) group, and an Ang II+irbesartan group. The control group was gavaged with physiological saline. The Ang II group was pumped subcutaneously at a rate of 1.5 mg/(kg·d) for 28 days to establish the hypertensive renal damage model in mice, and then gavaged with equivalent physiological saline. The Ang II+irbesartan group used the same method to establish the hypertensive renal damage model, and then was gavaged with irbesartan. Immunohistochemistry and Western blotting were used to detect the expression of LRG-1 and fibrosis-related indicators (collagen I and fibronectin) in renal tissues. ELISA was used to evaluate the level of serum LRG-1 and inflammatory cytokines in mice. The urinary protein-creatinine ratio and renal function were determined, and correlation analysis was conducted.

RESULTS

Compared with the control group, the levels of serum LRG-1, the expression of LRG-1 protein, collagen I, and fibronectin in kidney in the Ang II group were increased (all P<0.01). After treating with irbesartan, renal damage of hypertensive mice was alleviated, while the levels of LRG-1 in serum and kidney were decreased, and the expression of collagen I and fibronectin was down-regulated (all P<0.01). Correlation analysis showed that the level of serum LRG-1 was positively correlated with urinary protein-creatinine ratio, blood urea nitrogen, and blood creatinine level in hypertensive kidney damage mice. Serum level of LRG-1 was also positively correlated with serum inflammatory factors including TNF-α, IL-1β, and IL-6.

CONCLUSIONS

Hypertensive renal damage mice display elevated expression of LRG-1 in serum and kidney, and irbesartan can reduce the expression of LRG-1 while alleviating renal damage. The level of serum LRG-1 is positively correlated with the degree of hypertensive renal damage, suggesting that it may participate in the occurrence and development of hypertensive renal damage.

Contribution of single-pill combinations in the management of hypertension: perspectives from China, Europe and the USA

Uncontrolled hypertension is associated with an increased risk of adverse clinical vascular outcomes and death. Hypertension management guidelines from China and the USA recommend initiation of antihypertensive pharmacotherapy with a single drug for patients without severe hypertension at presentation. Current European hypertension guidelines take a different approach and recommend the use of combination therapy from the time of diagnosis of hypertension for most patients. This article reviews the burden of hypertension in these countries and summarises the evidence base for the use of antihypertensive combination therapy contained within a single tablet (single-pill combinations, SPC). Typically, half or less of populations from China, Europe and the USA who were found to have hypertension were aware of their condition, less than half of those receiving treatment, and fewer still achieved adequate blood pressure (BP) control. The reasons for the unaddressed burden of hypertension are complex and multifactorial, with contributions from factors related to patients, healthcare providers and healthcare systems. The use of SPCs of antihypertensive therapies helps to optimise adherence with therapy and is likely to result in superior BP control. There is a strong evidence base to support current European guideline recommendations on the initiation of antihypertensive therapy with SPCs for the majority of people with hypertension.

[Hypertension: Who to treat, to what extent and how?]

Hypertension is the modifiable risk factor causing the largest loss in healthy life-years. The risk of cardiovascular events increases exponentially with the level of blood pressure (BP), starting from 115mmHg for systolic BP. Out-of-office BP measurements (self-measurements or ambulatory BP measurements) are now preferred for the diagnosis and follow up. In the absence of a preferred indication, antihypertensive treatment is based on thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. These treatments are associated with a significant reduction in morbidity and mortality in people with office BP ≥ 140/90mmHg (self-measurements ≥ 135/85mmHg). For people at high cardiovascular risk, especially those with a history of cardiovascular disease, starting the treatment for an office BP ≥ 130/80mmHg is also beneficial (self-measurements ≥ 130/80mmHg as well). It is now common to start treatment with half-dose dual therapy, which is more effective and better tolerated than full-dose monotherapy. The clinical effect is assessed at 4 weeks and intensification, if required, is then usually done by switching to the same dual therapy at full-dose for both components.

Medication Adherence in Patients With Uncontrolled Hypertension & Hypertensive Crisis Presenting to a Hospital Setting in Karachi, Pakistan

BACKGROUND

Hypertension is an established risk factor for cardiovascular disease. Non-adherence to antihypertensive medications contributes to poorly controlled hypertension while also increasing the risk of hypertensive crisis. The aim of our study was thus to estimate the frequency of adherence to antihypertensive medications in our population and also see if an association exists between adherence and the development of a hypertensive crisis.

METHODS

This cross-sectional study was undertaken on patients admitted to Aga Khan University Hospital, Karachi, Pakistan, between July 2020 and March 2022. All patients with uncontrolled hypertension with systolic blood pressure >140 and diastolic blood pressure >90 who were admitted through the emergency department were included. A systolic blood pressure over 180mmHg or diastolic blood pressure over 120mmHg, with or without end-organ damage was used to define a hypertensive crisis. Adherence to medications was assessed using the 4-item Morisky Green Levine (MGL) scale. Each item was scored as 1 and then added together to get a final score out of 4 with a score of ≥3 signifying adherence while a cumulative score of 0, 1, or 2 was classified as non-adherence.

RESULTS

We found that 64% of the cohort were adherent to their medications while 93 (36%) were non-adherent. The most common comorbid condition was found to be diabetes mellitus (54.8%). Around 146 (64.6%) patients were on a single anti-hypertensive agent. Depression as calculated according to the hospital anxiety and depression scale (HADS) was seen in 133 (51.2%) of our cohort while 147 (56.5%) had anxiety. Similar rates of adherence were seen amongst males (49.1%) and females (50.9%). The highest level of adherence was seen in the 61 to 75 years age group (34.9%) and in those with university-level education (30.6%). We also found a statistically significant association between adherence to antihypertensive medications with anxiety (p-value=0.048). Moreover, in the hypertensive crisis group, 40.7% of the patients were adherent to their antihypertensive medications while 54.8% were found to be non-adherent, with the p-value reaching statistical significance (p-value=0.028).

CONCLUSION

We found a higher rate of adherence (64%) in this inpatient hypertensive population as compared to previous studies in our population. We also found that non-adherence is a risk factor for the development of a hypertensive crisis. Therefore, at clinic visits, physicians should assess their patient's adherence to antihypertensive medications to prevent the development of a hypertensive crisis.