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Lin J, de Oliveira Costa J, Pearson SA, Buckley NA, Brieger D, Schutte AE, Schaffer AL, Falster MO. Impact of coordinated care on adherence to antihypertensive medicines among adults experiencing polypharmacy in Australia. J Hypertens 2024; 42:1248-1255. [PMID: 38704239 PMCID: PMC11139236 DOI: 10.1097/hjh.0000000000003721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/26/2024] [Accepted: 03/04/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Adherence to antihypertensives is key for blood pressure control. Most people with hypertension have several comorbidities and require multiple medicines, leading to complex care pathways. Strategies for coordinating medicine use can improve adherence, but cumulative benefits of multiple strategies are unknown. METHODS Using dispensing claims for a 10% sample of eligible Australians, we identified adult users of antihypertensives during July 2018-June 2019 who experienced polypharmacy (≥5 unique medicines). We measured medicine use reflecting coordinated medicine management in 3 months before and including first observed dispensing, including: use of simple regimens for each cardiovascular medicine; prescriber continuity; and coordination of dispensings at the pharmacy. We measured adherence (proportion of days covered) to antihypertensive medicines in the following 12 months, and used logistic regression to assess independent associations and interactions of adherence with these measures of care. RESULTS We identified 202 708 people, of which two-thirds (66.6%) had simple cardiovascular medicine regimens (one tablet per day for each medicine), two-thirds (63.3%) were prescribed >75% of medicines from the same prescriber, and two-thirds (65.5%) filled >50% of their medicine on the same day. One-third (28.4%) of people experienced all three measures of coordinated care. Although all measures were significantly associated with higher adherence, adherence was greatest among people experiencing all three measures (odds ratio = 1.63; 95% confidence interval: 1.55-1.72). This interaction was driven primarily by effects of prescriber continuity and dispensing coordination. CONCLUSIONS Coordinating both prescribing and dispensing of medicines can improve adherence to antihypertensives, which supports strategies consolidating both prescribing and supply of patients' medicines.
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Affiliation(s)
- Jialing Lin
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales
| | - Juliana de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales
| | | | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital
- Faculty of Medicine and Health, University of Sydney
| | - Aletta E. Schutte
- School of Population Health, University of New South Wales
- The George Institute for Global Health, Sydney, Australia
- Hypertension in Africa Research Team (HART), MRC Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom
- MRC/WITS Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrea L. Schaffer
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales
| | - Michael O. Falster
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales
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Majert J, Nazarzadeh M, Ramakrishnan R, Bidel Z, Hedgecott D, Perez-Crespillo A, Turpie W, Akhtar N, Allison M, Rao S, Gudgin B, McAuley M, A'Court C, Billot L, Kotecha D, Potter J, Rahimi K. Efficacy of decentralised home-based antihypertensive treatment in older adults with multimorbidity and polypharmacy (ATEMPT): an open-label randomised controlled pilot trial. THE LANCET. HEALTHY LONGEVITY 2024; 5:e172-e181. [PMID: 38342123 DOI: 10.1016/s2666-7568(23)00259-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND Older patients with multimorbidity and polypharmacy have been under-represented in clinical trials. We aimed to assess the effect of different intensities of antihypertensive treatment on changes in blood pressure, major safety outcomes, and patient-reported outcomes in this population. METHODS ATEMPT was a decentralised, two-armed, parallel-group, open-label randomised controlled pilot trial conducted in the Thames Valley area, South East England. Individuals aged 65 years or older with multimorbidity (three or more chronic conditions) or polypharmacy (five or more types of medications) and a systolic blood pressure of 115-165 mm Hg were eligible for inclusion. Participants were identified through a search of national hospital discharge databases, identification of patients registered with an online pharmacy, and via targeted advertising on social media platforms. Participants were randomly assigned to receive up to two more classes versus up to two fewer classes of antihypertensive medications. Apart from routine home visits for conducting the baseline assessment, all communication, monitoring, and management of participants by the trial team was conducted remotely. The primary outcome was change in home-measured blood pressure. FINDINGS Between Dec 15, 2020, and Aug 31, 2022, 230 participants were randomly assigned (n=126 to more vs n=104 to fewer antihypertensive medications). The frequency of serious adverse events was similar across both groups; no cardiovascular events occurred in the more antihypertensive drugs group, compared with six in the fewer antihypertensive drugs group, of which two were fatal. Over a 13-month follow-up period, the mean systolic blood pressure in the group allocated to receive more antihypertensive medications decreased from 134·5 mm Hg (SD 10·7) at baseline to 122·1 mm Hg (10·5). By contrast, in the group allocated to receive fewer antihypertensive medications, it remained relatively unchanged, moving from 134·8 mm Hg (SD 11·2) at baseline to 132·9 mm Hg (15·3); this corresponded to a mean difference of -10·7 mm Hg (95% CI -17·5 to -4·0). INTERPRETATION Remotely delivered antihypertensive treatment substantially reduced systolic blood pressure in older adults who are often less represented in trials, with no increase in the risk of serious adverse events. The results of this trial will inform a larger clinical trial focusing on assessing major cardiovascular events, safety, physical functioning, and cognitive function that is currently in the planning stages. These results also underscore the efficiency of decentralised trial designs, which might be of broader interest in other settings. FUNDING National Institute for Health Research Oxford Biomedical Research Centre and the Oxford Martin School.
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Affiliation(s)
- Jeannette Majert
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Milad Nazarzadeh
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zeinab Bidel
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Deborah Hedgecott
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | | | - Wendy Turpie
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Naseem Akhtar
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Moira Allison
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Shishir Rao
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | | | | | - Christine A'Court
- Nuffield Department of Primary Health Sciences, University of Oxford, Oxford, UK
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre & NHS West Midlands Secure Data Environment, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Potter
- Department of Medicine, University of East Anglia, Norwich, UK
| | - Kazem Rahimi
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK.
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3
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Rao S, Nazarzadeh M, Canoy D, Li Y, Huang J, Mamouei M, Salimi-Khorshidi G, Schutte AE, Neal B, Smith GD, Rahimi K. Sodium-based paracetamol: impact on blood pressure, cardiovascular events, and all-cause mortality. Eur Heart J 2023; 44:4448-4457. [PMID: 37611115 PMCID: PMC10635668 DOI: 10.1093/eurheartj/ehad535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND AND AIMS Effervescent formulations of paracetamol containing sodium bicarbonate have been reported to associate with increased blood pressure and a higher risk of cardiovascular diseases and all-cause mortality. Given the major implications of these findings, the reported associations were re-examined. METHODS Using linked electronic health records data, a cohort of 475 442 UK individuals with at least one prescription of paracetamol, aged between 60 and 90 years, was identified. Outcomes in patients taking sodium-based paracetamol were compared with those taking non-sodium-based formulations of the same. Using a deep learning approach, associations with systolic blood pressure (SBP), major cardiovascular events (myocardial infarction, heart failure, and stroke), and all-cause mortality within 1 year after baseline were investigated. RESULTS A total of 460 980 and 14 462 patients were identified for the non-sodium-based and sodium-based paracetamol exposure groups, respectively (mean age: 74 years; 64% women). Analysis revealed no difference in SBP [mean difference -0.04 mmHg (95% confidence interval -0.51, 0.43)] and no association with major cardiovascular events [relative risk (RR) 1.03 (0.91, 1.16)]. Sodium-based paracetamol showed a positive association with all-cause mortality [RR 1.46 (1.40, 1.52)]. However, after further accounting of other sources of residual confounding, the observed association attenuated towards the null [RR 1.08 (1.01, 1.16)]. Exploratory analyses revealed dysphagia and related conditions as major sources of uncontrolled confounding by indication for this association. CONCLUSIONS This study does not support previous suggestions of increased SBP and an elevated risk of cardiovascular events from short-term use of sodium bicarbonate paracetamol in routine clinical practice.
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Affiliation(s)
- Shishir Rao
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
| | - Milad Nazarzadeh
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
| | - Dexter Canoy
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Yikuan Li
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
| | - Jing Huang
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Department of Occupational and Environmental Health Sciences, School of Public Health, Peking University, Beijing, China
| | - Mohammad Mamouei
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
| | - Gholamreza Salimi-Khorshidi
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
| | - Aletta E Schutte
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - George Davey Smith
- Medical Research Council Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, University of Bristol, Bristol, UK
| | - Kazem Rahimi
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
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Ji E, Ahn S, Choi JY, Kim CH, Kim KI. Effect of multimorbidity on hypertension management. Sci Rep 2023; 13:18764. [PMID: 37907571 PMCID: PMC10618203 DOI: 10.1038/s41598-023-44813-0] [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: 04/12/2023] [Accepted: 10/12/2023] [Indexed: 11/02/2023] Open
Abstract
Multimorbidity, the coexistence of multiple health conditions, is associated with functional decline, disability, and mortality. We aimed to investigate the effects of multimorbidity on hypertension treatment and control rates by analyzing data from the Korean National Health and Nutrition Examination Survey database, which is a cross-sectional, nationally representative survey conducted by the Korean government. Multimorbidity, defined as having two or more chronic diseases, was evaluated by blood pressure measurements, blood chemistry examinations, and questionnaires. We classified the participants according to the number of multimorbidities from 0 to ≥ 6. Association analysis was performed to identify the patterns of multimorbidity related to hypertension control. From 2016 to 2020, 30,271 adults (≥ 20 years) were included in the analysis (age: 52.1 ± 16.8 years, male: 44.0%), and 14,278 (47.2%) had multimorbidity. The number of chronic conditions was significantly higher in older adults, women, and hypertensive patients. Multimorbidity was associated with hypertension treatment. The number of chronic conditions was significantly higher in controlled compared to uncontrolled patients (3.6 ± 1.7 vs 2.9 ± 1.6, p < 0.001). But the control rate of hypertension among treated patients was lower in patients with multimorbidity (75.6% in hypertension only group vs 71.8% in multimorbidity group, p = 0.009). Multimorbidity patterns showed distinct features in treated and controlled hypertensive patients. In conclusion, multimorbidity has a beneficial effect on the treatment of hypertension, but the control rate of systolic blood pressure was lower among the patients with multimorbidity. More attention should be paid to the hypertensive patients with multimorbidity to improve the control rate of hypertension.
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Affiliation(s)
- Eunjeong Ji
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soyeon Ahn
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jung-Yeon Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Cheol-Ho Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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5
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Liu H, Wang Y, Zhang B, Liu J, Huo Y, Cao S, Wu S, Wan Y, Xie X, Zeng L, Yan H, Dang S, Mi B. Associations between long-term blood pressure trajectory and all-cause and CVD mortality among old people in China. Front Cardiovasc Med 2023; 10:1157327. [PMID: 37663420 PMCID: PMC10471127 DOI: 10.3389/fcvm.2023.1157327] [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: 02/02/2023] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Background Optimal blood pressure (BP) management strategy among the elderly remains controversial, with insufficient consideration of long-term BP trajectory. This study aimed to identify BP trajectory patterns as well as terminal BP trajectory among the Chinese elderly and to explore the relationships between BP trajectories and all-cause mortality and cardiovascular disease (CVD) mortality. Methods We included 11,181 participants older than 60 at baseline (mean age, 80.98 ± 10.71) with 42,871 routine BP measurements from the Chinese Longitudinal Healthy Longevity Survey. Latent class trajectory analysis and Cox proportional hazard model were conducted to identify trajectory patterns and their associations with mortality. Furthermore, we also applied mixed-effects model to identify terminal BP trajectories among the elderly. Results Compared with stable at normal high level trajectory, excess systolic BP (SBP) trajectory with decreasing trend was associated with a 34% (HR = 1.34, 95% CI: 1.23-1.45) higher risk of all-cause mortality. Considering the competing risk of non-CVD death, excess BP trajectory with decreasing trend had a more pronounced effect on CVD mortality, in which HR (95% CI) was 1.67 (1.17, 2.37). Similar results were also found in diastolic BP (DBP), pulse pressure (PP), and mean arterial pressure (MAP) trajectories. We further conducted a mixed-effects model and observed that SBP and PP trajectories first increased and began to decline slightly six years before death. In contrast, DBP and MAP showed continuous decline 15 years before death. Conclusion Long-term BP trajectory was associated with all-cause mortality, especially CVD mortality. Keeping a stable BP over time may be an important way for CVD prevention among the elderly.
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Affiliation(s)
- Huimeng Liu
- Department of Occupational and Environmental Health, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an, China
| | - Yutong Wang
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an, China
- Global Health Institute, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Binyan Zhang
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an, China
- Global Health Institute, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Jingchun Liu
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an, China
- Global Health Institute, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Yating Huo
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an, China
- Global Health Institute, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Suixia Cao
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an, China
- Global Health Institute, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Shaowei Wu
- Department of Occupational and Environmental Health, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Yong Wan
- Department of Geriatric Surgery, First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Xinming Xie
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi'an, China
| | - Lingxia Zeng
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an, China
- Global Health Institute, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Hong Yan
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an, China
- Global Health Institute, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Shaonong Dang
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an, China
- Global Health Institute, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Baibing Mi
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an, China
- Global Health Institute, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Geriatric Surgery, First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, China
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi'an, China
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6
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Nguyen TN, Kalia S, Hanlon P, Jani BD, Nicholl BI, Christie CD, Aliarzadeh B, Moineddin R, Harrison C, Chow C, Fortin M, Mair FS, Greiver M. Multimorbidity and Blood Pressure Control in Patients Attending Primary Care in Canada. J Prim Care Community Health 2023; 14:21501319231215025. [PMID: 38097504 PMCID: PMC10725138 DOI: 10.1177/21501319231215025] [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: 09/22/2023] [Revised: 10/27/2023] [Accepted: 11/01/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND There has been conflicting evidence on the association between multimorbidity and blood pressure (BP) control. This study aimed to investigate this associations in people with hypertension attending primary care in Canada, and to assess whether individual long-term conditions are associated with BP control. METHODS This was a cross-sectional study in people with hypertension attending primary care in Toronto between January 1, 2017 and December 31, 2019. Uncontrolled BP was defined as systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg. A list of 11 a priori selected chronic conditions was used to define multimorbidity. Multimorbidity was defined as having ≥1 long-term condition in addition to hypertension. Logistic regression models were used to estimate the association between multimorbidity (or individual long-term conditions) with uncontrolled BP. RESULTS A total of 67 385 patients with hypertension were included. They had a mean age of 70, 53.1% were female, 80.6% had multimorbidity, and 35.7% had uncontrolled BP. Patients with multimorbidity had lower odds of uncontrolled BP than those without multimorbidity (adjusted OR = 0.72, 95% CI 0.68-0.76). Among the long-term conditions, diabetes (aOR = 0.73, 95%CI 0.70-0.77), heart failure (aOR = 0.81, 95%CI 0.73-0.91), ischemic heart disease (aOR = 0.74, 95%CI 0.69-0.79), schizophrenia (aOR = 0.79, 95%CI 0.65-0.97), depression/anxiety (aOR = 0.91, 95%CI 0.86-0.95), dementia (aOR = 0.87, 95%CI 0.80-0.95), and osteoarthritis (aOR = 0.89, 95%CI 0.85-0.93) were associated with a lower likelihood of uncontrolled BP. CONCLUSION We found that multimorbidity was associated with better BP control. Several conditions were associated with better control, including diabetes, heart failure, ischemic heart disease, schizophrenia, depression/anxiety, dementia, and osteoarthritis.
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Affiliation(s)
- Tu N. Nguyen
- University of Sydney, Sydney, NSW, Australia
- University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | | | | | - Clara Chow
- University of Sydney, Sydney, NSW, Australia
| | | | | | - Michelle Greiver
- University of Toronto, Toronto, ON, Canada
- North York General Hospital, Toronto, ON, Canada
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7
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Rahimi K, Bidel Z, Nazarzadeh M, Copland E, Canoy D, Wamil M, Majert J, McManus R, Adler A, Agodoa L, Algra A, Asselbergs FW, Beckett NS, Berge E, Black H, Boersma E, Brouwers FPJ, Brown M, Brugts JJ, Bulpitt CJ, Byington RP, Cushman WC, Cutler J, Devereaux RB, Dwyer JP, Estacio R, Fagard R, Fox K, Fukui T, Gupta AK, Holman RR, Imai Y, Ishii M, Julius S, Kanno Y, Kjeldsen SE, Kostis J, Kuramoto K, Lanke J, Lewis E, Lewis JB, Lievre M, Lindholm LH, Lueders S, MacMahon S, Mancia G, Matsuzaki M, Mehlum MH, Nissen S, Ogawa H, Ogihara T, Ohkubo T, Palmer CR, Patel A, Pfeffer MA, Pitt B, Poulter NR, Rakugi H, Reboldi G, Reid C, Remuzzi G, Ruggenenti P, Saruta T, Schrader J, Schrier R, Sever P, Sleight P, Staessen JA, Suzuki H, Thijs L, Ueshima K, Umemoto S, van Gilst WH, Verdecchia P, Wachtell K, Whelton P, Wing L, Woodward M, Yui Y, Yusuf S, Zanchetti A, Zhang ZY, Anderson C, Baigent C, Brenner BM, Collins R, de Zeeuw D, Lubsen J, Malacco E, Neal B, Perkovic V, Rodgers A, Rothwell P, Salimi-Khorshidi G, Sundström J, Turnbull F, Viberti G, Wang J, Chalmers J, Davis BR, Pepine CJ, Teo KK. Age-stratified and blood-pressure-stratified effects of blood-pressure-lowering pharmacotherapy for the prevention of cardiovascular disease and death: an individual participant-level data meta-analysis. Lancet 2021; 398:1053-1064. [PMID: 34461040 PMCID: PMC8473559 DOI: 10.1016/s0140-6736(21)01921-8] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/06/2021] [Accepted: 08/06/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effects of pharmacological blood-pressure-lowering on cardiovascular outcomes in individuals aged 70 years and older, particularly when blood pressure is not substantially increased, is uncertain. We compared the effects of blood-pressure-lowering treatment on the risk of major cardiovascular events in groups of patients stratified by age and blood pressure at baseline. METHODS We did a meta-analysis using individual participant-level data from randomised controlled trials of pharmacological blood-pressure-lowering versus placebo or other classes of blood-pressure-lowering medications, or between more versus less intensive treatment strategies, which had at least 1000 persons-years of follow-up in each treatment group. Participants with previous history of heart failure were excluded. Data were obtained from the Blood Pressure Lowering Treatment Triallists' Collaboration. We pooled the data and categorised participants into baseline age groups (<55 years, 55-64 years, 65-74 years, 75-84 years, and ≥85 years) and blood pressure categories (in 10 mm Hg increments from <120 mm Hg to ≥170 mm Hg systolic blood pressure and from <70 mm Hg to ≥110 mm Hg diastolic). We used a fixed effects one-stage approach and applied Cox proportional hazard models, stratified by trial, to analyse the data. The primary outcome was defined as either a composite of fatal or non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring hospital admission. FINDINGS We included data from 358 707 participants from 51 randomised clinical trials. The age of participants at randomisation ranged from 21 years to 105 years (median 65 years [IQR 59-75]), with 42 960 (12·0%) participants younger than 55 years, 128 437 (35·8%) aged 55-64 years, 128 506 (35·8%) 65-74 years, 54 016 (15·1%) 75-84 years, and 4788 (1·3%) 85 years and older. The hazard ratios for the risk of major cardiovascular events per 5 mm Hg reduction in systolic blood pressure for each age group were 0·82 (95% CI 0·76-0·88) in individuals younger than 55 years, 0·91 (0·88-0·95) in those aged 55-64 years, 0·91 (0·88-0·95) in those aged 65-74 years, 0·91 (0·87-0·96) in those aged 75-84 years, and 0·99 (0·87-1·12) in those aged 85 years and older (adjusted pinteraction=0·050). Similar patterns of proportional risk reductions were observed for a 3 mm Hg reduction in diastolic blood pressure. Absolute risk reductions for major cardiovascular events varied by age and were larger in older groups (adjusted pinteraction=0·024). We did not find evidence for any clinically meaningful heterogeneity of relative treatment effects across different baseline blood pressure categories in any age group. INTERPRETATION Pharmacological blood pressure reduction is effective into old age, with no evidence that relative risk reductions for prevention of major cardiovascular events vary by systolic or diastolic blood pressure levels at randomisation, down to less than 120/70 mm Hg. Pharmacological blood pressure reduction should, therefore, be considered an important treatment option regardless of age, with the removal of age-related blood-pressure thresholds from international guidelines. FUNDING British Heart Foundation, National Institute of Health Research Oxford Biomedical Research Centre, Oxford Martin School.
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