Difference in blood pressure response to ACE-Inhibitor monotherapy between black and white adults with arterial hypertension: a meta-analysis of 13 clinical trials

Analysis of the combined effect of rs699 and rs5051 on angiotensinogen expression and hypertension

Background

Hypertension (HTN) involves genetic variability in the renin-angiotensin system and influences antihypertensive response. We previously reported that angiotensinogen (AGT) messenger RNA (mRNA) is endogenously bound by miR-122-5p and rs699 A > G decreases reporter mRNA in the microRNA functional-assay PASSPORT-seq. The AGT promoter variant rs5051 C > T is in linkage disequilibrium (LD) with rs699 A > G and increases AGT transcription. The independent effect of these variants is understudied due to their LD therefore we aimed to test the hypothesis that increased AGT by rs5051 C > T counterbalances AGT decreased by rs699 A > G, and when these variants occur independently, it translates to HTN-related phenotypes.

Methods

We used in silico, in vitro, in vivo, and retrospective models to test this hypothesis.

Results

In silico, rs699 A > G is predicted to increase miR-122-5p binding affinity by 3%. Mir-eCLIP results show rs699 is 40-45 nucleotides from the strongest microRNA-binding site in the AGT mRNA. Unexpectedly, rs699 A > G increases AGT mRNA in an AGT-plasmid-cDNA HepG2 expression model. Genotype-Tissue Expression (GTEx) and UK Biobank analyses demonstrate liver AGT expression and HTN phenotypes are not different when rs699 A > G occurs independently from rs5051 C > T. However, GTEx and the in vitro experiments suggest rs699 A > G confers cell-type-specific effects on AGT mRNA abundance, and suggest paracrine renal renin-angiotensin-system perturbations could mediate the rs699 A > G associations with HTN.

Conclusions

We found that rs5051 C > T and rs699 A > G significantly associate with systolic blood pressure in Black participants in the UK Biobank, demonstrating a fourfold larger effect than in White participants. Further studies are warranted to determine if altered antihypertensive response in Black individuals might be due to rs5051 C > T or rs699 A > G. Studies like this will help clinicians move beyond the use of race as a surrogate for genotype.

"We are not invited": Australian focus group results on how to improve ethnic diversity in trials

OBJECTIVES

Lack of ethnic diversity in trials may contribute to health disparities and to inequity in health outcomes. The primary objective was to investigate the experiences and perspectives of ethnically diverse populations about how to improve ethnic diversity in trials.

STUDY DESIGN AND SETTING

Qualitative data were collected via 16 focus groups with participants from 21 ethnically diverse communities in Australia. Data collection took place between August and September 2022 in community-based settings in six capital cities: Sydney, Melbourne, Perth, Adelaide, Brisbane, and Darwin, and one rural town: Bordertown (South Australia).

RESULTS

One hundred and fifty-eight purposively sampled adults (aged 18-85, 49% women) participated in groups speaking Tamil, Greek, Punjabi, Italian, Mandarin, Cantonese, Karin, Vietnamese, Nepalese, and Arabic; or English-language groups (comprising Fijian, Filipino, African, and two multicultural groups). Only 10 participants had previously taken part in medical research including three in trials. There was support for medical research, including trials; however, most participants had never been invited to participate. To increase ethnic diversity in trial populations, participants recommended recruitment via partnering with communities, translating trial materials and making them culturally accessible using audiovisual ways, promoting retention by minimizing participant burden, establishing trust and rapport between participants and researchers, and sharing individual results. Participants were reluctant to join studies on taboo topics in their communities (eg, sexual health) or in which physical specimens (eg, blood) were needed. Participants said these barriers could be mitigated by communicating about the topic in more culturally cognizant and safe ways, explaining how data would be securely stored, and reinforcing the benefit of medical research to humanity.

CONCLUSION

Participants recognized the principal benefits of trials and other medical research, were prepared to take part, and offered suggestions on recruitment, consent, data collection mechanisms, and retention to enable this to occur. Researchers should consider these community insights when designing and conducting trials; and government, regulators, funders, and publishers should allow for greater innovation and flexibility in their processes to enable ethnic diversity in trials to improve.

Is the response to antihypertensive drugs heterogeneous? Rationale for personalized approach

Arterial hypertension represents the most important cardiovascular risk factor with a direct responsibility for a large share of cardiovascular mortality and morbidity in the world. Despite the wide availability of antihypertensive therapies with documented effectiveness, blood pressure control still remains largely unsatisfactory in large segments of the population. Guidelines for the management of arterial hypertension suggest the preferential use of five classes of drugs-angiotensin-converting enzyme inhibitors, angiotensin II type I receptor inhibitors, calcium channel blockers, thiazide/thiazide-like diuretics, and beta-blockers-recommending the use of combination therapy, preferably in pre-established combinations, for the majority of hypertensive patients. The evidence of a non-negligible heterogeneity in the response to different antihypertensive drugs in different patients suggests the opportunity for personalization of treatment. The notable phenotypic heterogeneity of the population of hypertensive patients in terms of genetic structure, behavioural aspects, exposure to environmental factors, and disease history imposes the need to consider all the potential determinants of the response to a specific pharmacological treatment. The progressive digitalization of healthcare systems is making enormous quantities of data available for machine learning systems which will allow the development of management algorithms for truly personalized antihypertensive therapy in the near future.

Analysis of the Combined Effect of rs699 and rs5051 on Angiotensinogen Expression and Hypertension

Hypertension (HTN) involves genetic variability in the renin-angiotensin system and characterizing this variability will help advance precision antihypertensive treatments. We previously reported that angiotensinogen (AGT) mRNA is endogenously bound by mir-122-5p and that rs699 A>G significantly decreases reporter mRNA in the functional mirSNP assay PASSPORT-seq. The AGT promoter variant rs5051 C>T is in linkage disequilibrium (LD) with rs699 A>G and increases AGT transcription. We hypothesized that the increased AGT by rs5051 C>T counterbalances AGT decrease by rs699 A>G, and when these variants occur independently, would translate to HTN-related phenotypes. The independent effect of each of these variants is understudied due to their LD, therefore, we used in silico, in vitro, in vivo, and retrospective clinical and biobank analyses to assess HTN and AGT expression phenotypes where rs699 A>G occurs independently from rs5051 C>T. In silico, rs699 A>G is predicted to increase mir-122-5p binding strength by 3%. Mir-eCLIP assay results show that rs699 is 40-45 nucleotides from the strongest microRNA binding site in the AGT mRNA. Unexpectedly, rs699 A>G increases AGT mRNA in a plasmid cDNA HepG2 expression model. GTEx and UK Biobank analyses demonstrate that liver AGT expression and HTN phenotypes were not different when rs699 A>G occurs independently from rs5051 C>T, allowing us to reject the original hypothesis. However, both GTEx and our in vitro experiments suggest rs699 A>G confers cell-type specific effects on AGT mRNA abundance. We found that rs5051 C>T and rs699 A>G significantly associate with systolic blood pressure in Black participants in the UK Biobank, demonstrating a 4-fold larger effect than in White participants. Further studies are warranted to determine if the altered antihypertensive response in Black individuals might be due to rs5051 C>T or rs699 A>G. Studies like this will help clinicians move beyond the use of race as a surrogate for genotype.

Suboptimal blood pressure control and its associated factors among people living with diabetes mellitus in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Suboptimal blood pressure control among people living with diabetes mellitus (DM) is one of the primary causes of cardiovascular complications and death in sub-Saharan Africa (SSA). However, there is a paucity of evidence on the prevalence and associated factors of suboptimal blood pressure control in SSA. Therefore, this review aimed to estimate its pooled prevalence and associated factors among people living with DM in SSA.  METHODS: We systematically searched PubMed, African Journals OnLine, HINARI, ScienceDirect, Google Scholar, and direct Google to access observational studies conducted in SSA. Microsoft Excel spreadsheet was used to extract the data, which was exported into STATA/MP version 16.0 for further analyses. Heterogeneity across studies was checked using Cochran's Q test statistics and I² test, and small study effect was checked using Funnel plot symmetry and Egger's statistical test at a 5% significant level. A random-effects model was used to estimate the pooled prevalence and associated factors of suboptimal blood pressure control at a 95% confidence interval (CI) and significance level of p < 0.05.

RESULTS

Of the 7329 articles retrieved, 21 articles were eligible for the meta-analysis. After performing random-effects model, the pooled prevalence of suboptimal blood pressure control was 69.8% (95% CI: 63.43, 76.25%). Poor adherence to antihypertensive treatment (OR = 1.7; 95% CI: 1.03-2.80, I² = 0.0%, p = 0.531) and overweight (OR = 2.4, 95% CI: 1.57-3.68, I² = 0.00%, p = 0.47) were significantly associated with suboptimal blood pressure control.

CONCLUSIONS

The prevalence of suboptimal blood pressure control among diabetic patients in SSA was high, and poor adherence to antihypertensive treatment and overweight were significantly associated with suboptimal blood pressure control. Hence, there is an urgent need for initiatives to improve and control hypertension, and preventive measures should concentrate on modifiable risk factors.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020187901.

Evaluating a tool to improve engagement and recruitment of under-served groups in trials

BACKGROUND

Despite substantial awareness that certain groups (e.g. ethnic minorities) are under-represented and under-served in trials, limited progress has been made in addressing this. As well as a public service and ethical duty to recruit and engage under-served groups in relevant research, importantly, there are clear scientific benefits, for example, increased generalisability. The key aims of the current study were to explore the following: general barriers and facilitators to enhancing the recruitment of under-served groups into trials, the usability and value of a specific tool (INCLUDE Ethnicity Framework) to support engagement and recruitment of under-served groups, and ways of engaging diverse patient, public and community involvement and engagement (PCIE) groups.

METHODS

Firstly, researchers completed a brief survey in relation to a specific trial in which they were involved (N = 182, 38% response rate). A second stage involved sampling survey respondents and asking them to complete the INCLUDE Ethnicity Framework and then a remote semi-structured interview (N = 15). Qualitative data were analysed using thematic analysis. Finally, we conducted a consultation process with PCIE contributors primarily to develop guidelines for discussing the INCLUDE Ethnicity Framework with PCIE representatives.

RESULTS

Researchers recognised the importance of increasing engagement and recruitment of under-served groups within trials, but varied in their knowledge, ability and commitment to implementation in practice. The INCLUDE Ethnicity Framework was described by some as raising their awareness of how inclusion could be improved. Respondents highlighted a need for shared resources and wider structural change to facilitate such engagement. PCIE was identified, in the survey and interviews, as the most common method of trying to improve recruitment of under-served groups. However, researchers also commonly highlighted that PCIE groups were sometimes not very diverse.

CONCLUSIONS

There is a need for researchers to consider the funding and time resources required for diverse and inclusive recruitment to trials and for funders to enable this. The INCLUDE Ethnicity Framework can help to raise awareness of inclusion challenges. This study indicates that it is important to take proactive steps to involve relevant under-served groups in PCIE and practical suggestions are made to facilitate this.

Use of Perindopril Arginine/Indapamide/Amlodipine in the Management of Hypertension in Two Sub-Saharan African Island Countries of Madagascar and Mauritius

INTRODUCTION

Most patients with hypertension in sub-Saharan Africa require two or more drugs to control their blood pressure. Triple fixed-dose combination therapy of perindopril arginine/indapamide/amlodipine is more effective in lowering blood pressure, offers better target organ protection and has increased adherence compared to monotherapy and free combination therapy, and is safe to use. This observational study evaluates the effectiveness of perindopril arginine/indapamide/amlodipine in controlling blood pressure at least 1 month after treatment initiation and assesses patient- and physician- reported drug tolerance over a 3-month period in Madagascar and Mauritius.

METHODS

A total of 198 patients with hypertension in ambulatory care who had been on fixed-dose combination of perindopril arginine, indapamide, and amlodipine for at least 4 weeks were included. The main outcome measures were changes in systolic and diastolic blood pressure, attainment of blood pressure control under 140/90 mmHg and 130/80 mmHg, self-reported drug tolerance by the patient, and perceived drug tolerance by the treating physician. Data was collected at 1 month and 3 months.

RESULTS

Mean systolic blood pressure was significantly lower at the 1-month (- 3.4 mmHg, p = 0.002) and 3-month (- 8.5 mmHg, p < 0.0001) visits. Diastolic blood pressure also decreased significantly (- 2.4 mmHg at 1-month, p = 0.017 and - 5.4 mmHg at the 3-month visits, p < 0.0001). At 3 months, 80.4% of the patients attained blood pressure targets less than 140/90 mmHg and 42.7% attained targets less than 130/80 mmHg on the basis of their baseline blood pressure. Excellent drug tolerance was reported by more than 90% of patients and physicians at the 1-month visit and by more than 95% at the 3-month visit.

CONCLUSION

Triple fixed-dose therapy of perindopril arginine/indapamide/amlodipine continues to show additional blood pressure-lowering capacity even months after initiating the treatment in patients with hypertension in Madagascar and Mauritius. It is also well tolerated by patients with hypertension and assessed as safe to use by physicians.

Diferenças Raciais no Controle da Pressão Arterial em Usuários de Anti-Hipertensivos em Monoterapia: Resultados do Estudo ELSA-Brasil

Fundamento

Aparentemente, a pior resposta a algumas classes de anti-hipertensivos, especialmente inibidores da enzima conversora da angiotensina e bloqueadores de receptor de angiotensina, pela população negra, explicaria, pelo menos parcialmente, o pior controle da hipertensão entre esses indivíduos. Entretanto, a maioria das evidências vêm de estudos norte-americanos.

Objetivos

Este estudo tem o objetivo de investigar a associação entre raça/cor da pele autorrelatadas e controle de PA em participantes do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) utilizando várias classes de anti-hipertensivos em monoterapia.

Métodos

O estudo envolveu uma análise transversal, realizada com participantes da linha de base do ELSA-Brasil. O controle de pressão arterial foi a variável de resposta, participantes com valores de PA ≥140/90 mmHg foram considerados descontrolados em relação aos níveis de pressão arterial. A raça/cor da pele foi autorrelatada (branco, pardo, negro). Todos os participantes tiveram que responder perguntas sobre uso contínuo de medicamentos. A associação entre o controle de PA e raça/cor da pele foi estimada por regressão logística. O nível de significância adotado nesse estudo foi de 5%.

Resultados

Do total de 1.795 usuários de anti-hipertensivos em monoterapia na linha de base, 55,5% se declararam brancos, 27,9%, pardos e 16,7%, negros. Mesmo depois de padronizar em relação a variáveis de confusão, negros em uso de inibidores da enzima conversora de angiotensina (IECA), bloqueadores de receptor de angiotensina (BRA), diuréticos tiazídicos (DIU tiazídicos) e betabloqueadores (BB) in monoterapia tinham controle de pressão arterial pior em comparação a brancos.

Conclusões

Os resultados deste estudo sugerem que, nesta amostra de brasileiros adultos utilizando anti-hipertensivos em monoterapia, as diferenças de controle de pressão arterial entre os vários grupos raciais não são explicadas pela possível eficácia mais baixa dos IECA e BRA em indivíduos negros.

Treating hypertension in Black patients

ABSTRACT

For the first time in its history, the Eighth Joint National Committee (JNC-8) published hypertension guidelines that varied depending on patient race, with different treatment recommendation for Black and non-Black patients. Although initial therapy in non-Black patients is to be carried out with one of four agents-thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs)-the recommendation for Black patients removed ACE inhibitors and ARBs from the algorithm. This article reviews some of the physiologic theories for the difference in recommendations and discusses potential complications with race-based treatment algorithms.

Developing the INCLUDE Ethnicity Framework-a tool to help trialists design trials that better reflect the communities they serve

Background

Ensuring that a trial is designed so that its participants reflect those who might benefit from the results, or be spared harms, is key to the potential benefits of the trial reaching all they should. This paper describes the process, facilitated by Trial Forge, that was used between July 2019 and October 2020 to develop the INCLUDE Ethnicity Framework, part of the wider INCLUDE initiative from the National Institute for Health Research to improve inclusion of under-served groups in clinical research studies.

Methods

Development of the Framework was done in seven phases: (1) outline, (2) initial draft, (3) stakeholder meeting, (4) modify draft, (5) Stakeholder feedback, (6) applying the Framework and (7) packaging. Phases 2 and 3 were face-to-face meetings. Consultation with stakeholders was iterative, especially phases 4 to 6. Movement to the next phase was done once all or most stakeholders were comfortable with the results of the current phase. When there was a version of the Framework that could be considered final, the Framework was applied to six trials to create a set of examples (phase 6). Finally, the Framework, guidance and examples were packaged ready for dissemination (phase 7).

Results

A total of 40 people from stakeholder groups including patient and public partners, clinicians, funders, academics working with various ethnic groups, trial managers and methodologists contributed to the seven phases of development. The Framework comprises two parts. The first part is a list of four key questions:

Who should my trial apply to?

Are the groups identified likely to respond in different ways?

Will my study intervention make it harder for some groups to engage?

Will the way I have designed the study make it harder for some groups to engage?

The second part is a set of worksheets to help trial teams address these questions. The Framework can be used for any stage of trial, for a healthcare intervention in any disease area. The Framework was launched on 1st October 2020 and is available open access at the Trial Forge website: https://www.trialforge.org/trial-forge-centre/include/.

Conclusion

Thinking about the number of people in our trials is not enough: we need to start thinking more carefully about who our participants are.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05276-8.

The DANish randomized, double-blind, placebo controlled trial in patients with chronic HEART failure (DANHEART): A 2 × 2 factorial trial of hydralazine-isosorbide dinitrate in patients with chronic heart failure (H-HeFT) and metformin in patients with chronic heart failure and diabetes or prediabetes (Met-HeFT)

OBJECTIVES

The DANHEART trial is a multicenter, randomized (1:1), parallel-group, double-blind, placebo-controlled study in chronic heart failure patients with reduced ejection fraction (HFrEF). This investigator driven study will include 1500 HFrEF patients and test in a 2 × 2 factorial design: 1) if hydralazine-isosorbide dinitrate reduces the incidence of death and hospitalization with worsening heart failure vs. placebo (H-HeFT) and 2) if metformin reduces the incidence of death, worsening heart failure, acute myocardial infarction, and stroke vs. placebo in patients with diabetes or prediabetes (Met-HeFT).

METHODS

Symptomatic, optimally treated HFrEF patients with LVEF ≤40% are randomized to active vs. placebo treatment. Patients can be randomized in either both H-HeFT and Met-HeFT or to only one of these study arms. In this event-driven study, it is anticipated that 1300 patients should be included in H-HeFT and 1100 in Met-HeFT and followed for an average of 4 years.

RESULTS

As of May 2020, 296 patients have been randomized at 20 centers in Denmark.

CONCLUSION

The H-HeFT and Met-HeFT studies will yield new knowledge about the potential benefit and safety of 2 commonly prescribed drugs with limited randomized data in patients with HFrEF.

Association of West African ancestry and blood pressure control among African Americans taking antihypertensive medication in the Jackson Heart Study

African Americans have a wide range of continental genetic ancestry. It is unclear whether racial differences in blood pressure (BP) control are related to ancestral background. The authors analyzed data from the Jackson Heart Study, a cohort exclusively comprised of self-identified African Americans, to assess the association between estimated West African ancestry (WAA) and BP control (systolic and diastolic BP < 140/90 mm Hg). Three nested modified Poisson regression models were used to calculate prevalence ratios for BP control associated with the three upper quartiles, separately, vs the lowest quartile of West African ancestry. The authors analyzed data from 1658 participants with hypertension who reported taking all of their antihypertensive medications in the previous 24 hours. WAA was estimated using 389 ancestry informative markers and categorized into quartiles (Q1: <73.7%, Q2: >73.7%-81.0%, Q3: >81.0%-86.3%, and Q4: >86.3%). The proportion of participants with controlled BP in the lowest-to-highest WAA quartile was 75.2%, 76.1%, 76.6%, and 74.4%. The prevalence ratios (95% CI) for controlled BP comparing Q2, Q3, and Q4 to Q1 of WAA were 1.00 (0.93-1.08), 1.02 (0.94-1.10), and 0.99 (0.91-1.07), respectively. Among African Americans in the Jackson Heart Study taking antihypertensive medication, BP control rates did not differ across quartiles of WAA.

Antihypertensive agents: a long way to safe drug prescribing in children

Recently updated clinical guidelines have highlighted the gaps in our understanding and management of pediatric hypertension. With increased recognition and diagnosis of pediatric hypertension, the use of antihypertensive agents is also likely to increase. Drug selection to treat hypertension in the pediatric patient population remains challenging. This is primarily due to a lack of large, well-designed pediatric safety and efficacy trials, limited understanding of pharmacokinetics in children, and unknown risk of prolonged exposure to antihypertensive therapies. With newer legislation providing financial incentives for conducting clinical trials in children, along with publication of pediatric-focused guidelines, literature available for antihypertensive agents in pediatrics has increased over the last 20 years. The objective of this article is to review the literature for safety and efficacy of commonly prescribed antihypertensive agents in pediatrics. Thus far, the most data to support use in children was found for angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), and calcium channel blockers (CCB). Several gaps were noted in the literature, particularly for beta blockers, vasodilators, and the long-term safety profile of antihypertensive agents in children. Further clinical trials are needed to guide safe and effective prescribing in the pediatric population.

Rationale and design of a multicenter Chronic Kidney Disease (CKD) and at-risk for CKD electronic health records-based registry: CURE-CKD

BACKGROUND

Chronic kidney disease (CKD) is a global public health problem, exhibiting sharp increases in incidence, prevalence, and attributable morbidity and mortality. There is a critical need to better understand the demographics, clinical characteristics, and key risk factors for CKD; and to develop platforms for testing novel interventions to improve modifiable risk factors, particularly for the CKD patients with a rapid decline in kidney function.

METHODS

We describe a novel collaboration between two large healthcare systems (Providence St. Joseph Health and University of California, Los Angeles Health) supported by leadership from both institutions, which was created to develop harmonized cohorts of patients with CKD or those at increased risk for CKD (hypertension/HTN, diabetes/DM, pre-diabetes) from electronic health record data.

RESULTS

The combined repository of candidate records included more than 3.3 million patients with at least a single qualifying measure for CKD and/or at-risk for CKD. The CURE-CKD registry includes over 2.6 million patients with and/or at-risk for CKD identified by stricter guide-line based criteria using a combination of administrative encounter codes, physical examinations, laboratory values and medication use. Notably, data based on race/ethnicity and geography in part, will enable robust analyses to study traditionally disadvantaged or marginalized patients not typically included in clinical trials.

DISCUSSION

CURE-CKD project is a unique multidisciplinary collaboration between nephrologists, endocrinologists, primary care physicians with health services research skills, health economists, and those with expertise in statistics, bio-informatics and machine learning. The CURE-CKD registry uses curated observations from real-world settings across two large healthcare systems and has great potential to provide important contributions for healthcare and for improving clinical outcomes in patients with and at-risk for CKD.

Non-Communicable Diseases on the Rise in Sub-Saharan Africa, the Underappreciated Threat of a Dual Disease Burden

In sub-Saharan Africa, the burden of non-communicable diseases (NCDs) remains under appreciated, but emerging evidence suggests it to be substantial. NCDs such as arterial hypertension, heart diseases, diabetes mellitus and chronic kidney diseases are especially relevant, and put additional strain on the already challenged health systems in this region. Moreover, NCDs appear to be associated with higher mortality and morbidity rates and are more common in younger population groups, in people from sub-Saharan Africa when compared to more developed countries. In this review, we summarize the current literature on the burden of NCDs in sub-Saharan Africa, and highlight the clinical implications of the most relevant etiologies, i.e. arterial hypertension, heart diseases, diabetes mellitus and chronic kidney diseases.

Angiotensin II receptor blocker attenuates stress pressor response in young adult African Americans

African Americans (AAs) are susceptible to hypertension (HTN) and its associated organ damage leading to adverse cardiovascular (CV) outcomes. Psychological stress is proposed to contribute to the development of HTN; however, the potential role of the renin-angiotensin system (RAS) in stress-related HTN in AAs is largely unknown. In this study, we tested the hypothesis that activation of RAS is a potential contributing factor for altered CV responses to stress, and suppression of angiotensin II (Ang II) activity will improve hemodynamic responses to a prolonged mental stressor in healthy young AAs. Utilizing a double-blind, randomized, crossover study design, 132 normotensive AAs (25 ± 7 years) were treated with either a placebo (PLC) or 150 mg/d irbesartan (an Ang II type 1 receptor blocker; ARB) for 1 week. On the final day of each treatment, hemodynamic measures and urinary sodium excretion (UNaV) were collected before, during and after a 45 minute-mental stress. The magnitude of stress-induced increase in blood pressure with ARB was blunted and delayed compared to PLC. Systolic blood pressure at the end of recovery on ARB was significantly lower compared to either PLC (110 ± 13 vs 117 ± 12 mm Hg respectively; P < 0.001) or the prestress level on ARB (P = 0.02). ARB treatment reduced overall vasoconstriction and improved poststress UNaV. ARB attenuated blood pressure responses to mental stress and improved the poststress BP recovery process which were partly linked to reduced overall vasoconstriction and improved stress-induced UNaV in young adult AAs prior to the development of disease conditions. These results suggest that treatment approaches that inhibit RAS action could have significant relevance to potentially lower susceptibility to stress responses and eventually the premature development of HTN in AAs.

Short-term effects of perindopril-amlodipine vs perindopril-indapamide on blood pressure control in sub-Saharan type 2 diabetic individuals newly diagnosed for hypertension: A double-blinded randomized controlled trial

Poor blood pressure (BP) control contributes to complications in sub-Saharan African (SSA) type 2 diabetic individuals. Experts have advocated the use of combination therapies for effective BP control in these patients. The suggested combinations should include a RAAS antagonist and either a CCB or a thiazide diuretic; however, their efficacy is yet to be established in SSA. We investigated the short-term effects of two combination therapies on BP control in SSA type 2 diabetic individuals. This was a double-blinded randomized controlled trial conducted at the Yaoundé Central Hospital (Cameroon) from October 2016 to May 2017. We included type 2 diabetic patients, newly diagnosed for hypertension. After baseline assessment and 24-hour ABPM, participants were allocated to receive either a fixed combination of perindopril + amlodipine or perindopril + indapamide for 42 days. Data analyses followed the intention-to-treat principle. We included fifteen participants (8 being females) in each group. Both combinations provided good circadian BP control after 6 weeks with similar efficacy. Twenty-four-hour SBP dropped from 144 to 145 mm Hg vs 128 to 126 mm Hg with perindopril-amlodipine and perindopril-indapamide, respectively (P = 0.003 for both groups). Twenty-four-hour DBP dropped from 85 to 78 mm Hg (P = 0.013) vs 89 to 79 mm Hg (P = 0.006) in the same respective groups. No significant adverse effect was reported. A fixed initial combination of perindopril-amlodipine or perindopril-indapamide achieved similar effective BP control after 6 weeks in SSA type 2 diabetic individuals with newly diagnosed hypertension. Therefore, these combinations can be used interchangeably in this indication.

The uses and expenses of antihypertensive medications among hypertensive adults

BACKGROUND

The literature lacks information about the use and cost of prescribed antihypertensive medications, especially by the type and class of medication prescribed.

OBJECTIVE

This study investigated the uses and expenses of antihypertensive medications among hypertensive adults in the United States.

METHODS

Using the 2014-2015 Medical Expenditure Panel Survey data, adult men and nonpregnant women aged 18 or older who had a diagnosis code of hypertension and used any prescribed antihypertensive medication were included in the study (n = 10,971). Adults with hypertension who were using a single antihypertensive medication were defined as single medication users, and those using two or more medications were defined as multiple medication users. Medications were classified into angiotensin-converting-enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), thiazide-type diuretics (TDs), β-blockers (BBs), and others. The average annual total antihypertensive medication expenses and the expenditures of each medication class were estimated by using generalized linear models with a log link and gamma distribution and were adjusted to 2015 US dollars.

RESULTS

Among 10,971 hypertensive adults, 4759 (44.1%) were single medication users, and 6212 (55.9%) were multiple medication users. The average annual total cost for antihypertensive medications was $336 per person (95% confidence interval [CI] = $319-$353); $199 (95% CI = $177-$221) for single medication users and $436 (95% CI = $413-$459) for multiple medication users. The average annual costs for each medication class were estimated at $438 (95% CI = $384-$492) for ARBs and $49 for TDs (95% CI = $44-$55).

CONCLUSIONS

Users of multiple medications incurred more than twice the expense than single medication users. When comparing classes of medications, the cost for ARBs was the highest, whereas the cost for TDs was the lowest. This information can be used in evaluating the cost-effectiveness of antihypertension therapies.

A Review of ACE Inhibitors and ARBs in Black Patients With Hypertension

Objective: To review current guidelines and recent data evaluating the efficacy and safety of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in black hypertensive patients. Data Sources: Articles evaluating race-specific outcomes in hypertension were gathered using a MEDLINE search with keywords black, African American, ACE inhibitor, angiotensin receptor blocker, angiotensin system, and hypertension. Studies published from 2000 through April 2018 were reviewed. Study Selection and Data Extraction: Six guidelines, 8 monotherapy publications, and 5 combination therapy publications included race-specific results and were included in the review. The authors individually compared and contrasted the results from each publication. Data Synthesis: Numerous monotherapy trials indicate that black patients may have a reduced blood pressure (BP) response with ACE inhibitors or ARBs compared with white patients. Conversely, additional studies propose that race may not be the primary predictor of BP response. Reduced efficacy is not observed in trials involving combination therapy. Some studies suggest increased cardiovascular and cerebrovascular morbidity and mortality with ACE inhibitor or ARB monotherapy in black patients; however, data are conflicting. Relevance to Patient Care and Clinical Practice: This article clarifies vague guideline statements and informs clinicians on the appropriate use of ACE inhibitors or ARBs for hypertension treatment in black patients through an in-depth look into the evidence. Conclusions: Potentially reduced efficacy and limited outcomes data indicate that ACE inhibitors or ARBs should not routinely be initiated as monotherapy in black hypertensive patients. Use in combination with a calcium channel blocker or thiazide diuretic is efficacious in black patients, and there are no data showing that this increases or decreases cardiovascular or cerebrovascular outcomes.

Evaluation of the angiotensin II receptor blocker azilsartan medoxomil in African‐American patients with hypertension

The efficacy and safety of azilsartan medoxomil (AZL‐M) were evaluated in African‐American patients with hypertension in a 6‐week, double‐blind, randomized, placebo‐controlled trial, for which the primary end point was change from baseline in 24‐hour mean systolic blood pressure (BP). There were 413 patients, with a mean age of 52 years, 57% women, and baseline 24‐hour BP of 146/91 mm Hg. Treatment differences in 24‐hour systolic BP between AZL‐M 40 mg and placebo (−5.0 mm Hg; 95% confidence interval, −8.0 to −2.0) and AZL‐M 80 mg and placebo (−7.8 mm Hg; 95% confidence interval, −10.7 to −4.9) were significant (P≤.001 vs placebo for both comparisons). Changes in the clinic BPs were similar to the ambulatory BP results. Incidence rates of adverse events were comparable among the treatment groups, including those of a serious nature. In African‐American patients with hypertension, AZL‐M significantly reduced ambulatory and clinic BPs in a dose‐dependent manner and was well tolerated.

Advances in understanding the renin-angiotensin-aldosterone system (RAAS) in blood pressure control and recent pivotal trials of RAAS blockade in heart failure and diabetic nephropathy

The renin-angiotensin-aldosterone system (RAAS) plays a fundamental role in the physiology of blood pressure control and the pathophysiology of hypertension (HTN) with effects on vascular tone, sodium retention, oxidative stress, fibrosis, sympathetic tone, and inflammation. Fortunately, RAAS blocking agents have been available to treat HTN since the 1970s and newer medications are being developed. In this review, we will (1) examine new anti-hypertensive medications affecting the RAAS, (2) evaluate recent studies that help provide a better understanding of which patients may be more likely to benefit from RAAS blockade, and (3) review three recent pivotal randomized trials that involve newer RAAS blocking agents and inform clinical practice.

Phase 4 Studies in Heart Failure - What is Done and What is Needed?

Congestive heart failure (CHF) therapeutics is generated through a well-described evidence generating process. Phases 1 - 3 of this process are required prior to approval and widespread clinical use. Phase 3 in almost all cases is a methodologically sound randomized controlled trial (RCT). After this phase it is generally accepted that the treatment has a significant, independent and prognostically beneficial effect on the pathophysiological process. A major criticism of RCTs is the population to whom the result is applicable. When this population is significantly different from the trial cohort the external validity comes into question. Should the continuation of the evidence generating process continue these problems might be identified. Post marketing surveillance through phase 4 and comparative effectiveness studies through phase 5 trials are often underperformed in comparison to the RCT. These processes can help identify remote adverse events and define new hypotheses for community level benefits. This review is aimed at exploring the post-marketing scene for CHF therapeutics from an Australian health system perspective. We explore the phases of clinical trials, the level of evidence currently available and options for ensuring greater accountability for community level CHF clinical outcomes.

Provider Adherence to National Guidelines for Managing Hypertension in African Americans

Purpose. To evaluate provider adherence to national guidelines for the treatment of hypertension in African Americans. Design. A descriptive, preexperimental, quantitative method. Methods. Electronic medical records were reviewed and data were obtained from 62 charts. Clinical data collected included blood pressure readings, medications prescribed, laboratory studies, lifestyle modification, referral to hypertension specialist, and follow-up care. Findings. Overall provider adherence was 75%. Weight loss, sodium restriction, and physical activity recommendations were documented on 82.3% of patients. DASH diet and alcohol consumption were documented in 6.5% of participants. Follow-up was documented in 96.6% of the patients with controlled blood pressure and 9.1% in patients with uncontrolled blood pressure. Adherence in prescribing ACEIs in patients with a comorbidity of DM was documented in 70% of participants. Microalbumin levels were ordered in 15.2% of participants. Laboratory adherence prior to prescribing medications was documented in 0% of the patients and biannual routine labs were documented in 65% of participants. Conclusion. Provider adherence overall was moderate. Despite moderate provider adherence, BP outcomes and provider adherence were not related. Contributing factors that may explain this lack of correlation include patient barriers such as nonadherence to medication and lifestyle modification recommendations and lack of adequate follow-up. Further research is warranted.

Deficiency of angiotensinogen in hepatocytes markedly decreases blood pressure in lean and obese male mice

We recently demonstrated that adipocyte deficiency of angiotensinogen (AGT) ablated high-fat diet-induced elevations in plasma angiotensin II (Ang II) concentrations and obesity-hypertension in male mice. Hepatocytes are the predominant source of systemic AGT. Therefore, in this study, we defined the contribution of hepatocyte-derived AGT to obesity-induced elevations in plasma AGT concentrations and hypertension. Male Agt(fl/fl) mice expressing albumin-driven Cre recombinase were bred to female Agt(fl/fl) mice to generate Agt(fl/fl) or hepatocyte AGT-deficient male mice (Agt(Alb)). Mice were fed a low-fat or high-fat diet for 16 weeks. Hepatocyte AGT deficiency had no significant effect on body weight. Plasma AGT concentrations were increased in obese Agt(fl/fl) mice. Hepatocyte AGT deficiency markedly reduced plasma AGT and Ang II concentrations in lean and obese mice. Moreover, hepatocyte AGT deficiency reduced the content and release of AGT from adipose explants. Systolic blood pressure was markedly decreased in lean (by 18 mm Hg) and obese Agt(Alb) mice (by 54 mm Hg) compared with Agt(fl/fl) controls. To define mechanisms, we quantified effects of Ang II on mRNA abundance of megalin, an AGT uptake transporter, in 3T3-L1 adipocytes. Ang II stimulated adipocyte megalin mRNA abundance and decreased media AGT concentrations. These results demonstrate that hepatocytes are the predominant source of systemic AGT in both lean and obese mice. Moreover, reductions in plasma angiotensin concentrations in obese hepatocyte AGT-deficient mice may have limited megalin-dependent uptake of AGT into adipocytes for the production of Ang II in the development of obesity-hypertension.