Outcome of treatment with antidepressants in patients with hypertension and undetected depression

Developing practical recommendations for drug-disease interactions in patients with hypertension

Background

Hypertension, a significant risk factor for cardiovascular diseases, demands proactive management as cardiovascular diseases remain the leading cause of death worldwide. Reducing systolic and diastolic blood pressure levels below recommended reference values of <140/90 mmHg can lead to a significant reduction of the risk of CVD and all-cause mortality. However, treatment of hypertension can be difficult and the presence of comorbidities could further complicate this treatment. Drugs used to manage these comorbidities may inadvertently have an impact on blood pressure, resulting in a phenomenon known as drug-disease interaction. This study aims to assess the safety of medication that can affect blood pressure in patients with hypertension and provide practical recommendations for healthcare professionals.

Methods

For the development of recommendations for the drug-disease interaction (DDSI) hypertension, a six-step plan that combined literature selection and multidisciplinary expert opinion was used. The process involved (1) defining the scope of the DDSI and selecting relevant drugs, (2) collecting evidence, (3) data-extraction, (4) reaching of expert consensus, (5) publication and implementation of the recommendations in healthcare systems and (6) updating the information.

Results

An increase of 10 mmHg in systolic blood pressure and 5 mmHg in diastolic blood pressure was defined as clinically relevant. Corticosteroids, danazol, and yohimbine caused a clinically relevant DDSI with hypertension. Several other drugs with warnings for hypertension in the official product information were assessed to have no clinically relevant DDSI due to minor influence or lack of data on blood pressure. Drugs with evidence for a relevant change in blood pressure which are prescribed under close monitoring of blood pressure according to clinical guidelines, were deemed to be not clinically relevant for signalling.

Conclusion

This study provides specific recommendations that can be implemented directly in clinical practice, for example, in clinical decision support systems, potentially resulting in safer drug use in patients with hypertension and better healthcare by reducing alert fatigue. Future research should focus on evaluating the effectiveness of implementation strategies and their impact on reducing unsafe use of medication in patients with hypertension.

Brain deficit patterns of metabolic illnesses overlap with those for major depressive disorder: A new metric of brain metabolic disease

Metabolic illnesses (MET) are detrimental to brain integrity and are common comorbidities in patients with mental illnesses, including major depressive disorder (MDD). We quantified effects of MET on standard regional brain morphometric measures from 3D brain MRI as well as diffusion MRI in a large sample of UK BioBank participants. The pattern of regional effect sizes of MET in non-psychiatric UKBB subjects was significantly correlated with the spatial profile of regional effects reported by the largest meta-analyses in MDD but not in bipolar disorder, schizophrenia or Alzheimer's disease. We used a regional vulnerability index (RVI) for MET (RVI-MET) to measure individual's brain similarity to the expected patterns in MET in the UK Biobank sample. Subjects with MET showed a higher effect size for RVI-MET than for any of the individual brain measures. We replicated elevation of RVI-MET in a sample of MDD participants with MET versus non-MET. RVI-MET scores were significantly correlated with the volume of white matter hyperintensities, a neurological consequence of MET and age, in both groups. Higher RVI-MET in both samples was associated with obesity, tobacco smoking and frequent alcohol use but was unrelated to antidepressant use. In summary, MET effects on the brain were regionally specific and individual similarity to the pattern was more strongly associated with MET than any regional brain structural metric. Effects of MET overlapped with the reported brain differences in MDD, likely due to higher incidence of MET, smoking and alcohol use in subjects with MDD.

Antidepressant treatment and blood pressure control in patients with comorbid depression and treatment resistant hypertension

BACKGROUND

Though inconsistent, the majority of studies support an association between depression and incident hypertension and poor blood pressure control. However, none have investigated whether antidepressant medication (ADM) therapy is associated with blood pressure control in patients with comorbid depression and treatment resistant hypertension.

METHODS

Optum® de-identified Electronic Health Record data (2010-2018) were used to create a retrospective cohort of patients (≥18 years of age) with comorbid depression and treatment resistant hypertension. Patients were categorized into adequate ADM, inadequate ADM and no ADM treatment. A modified Poisson regression approach with robust error variance was used to estimate the association between ADM status and blood pressure control before and after adjusting for covariates.

RESULTS

Patients were, on average, 55.7 (SD ± 9.9) years of age, 63.9% were female, 76.2% were white and 19.2% Black race. In crude models, inadequate ADM (RR = 1.06; 95%CI:1.01-1.11) and adequate ADM (RR = 1.08; 95%CI:1.03-1.14), compared to no ADM treatment, were associated with blood pressure control. After adjusting for covariates this relationship was attenuated and no longer significant.

CONCLUSIONS

The modest association between ADM therapy and blood pressure control in patients with treatment resistant hypertension is largely explained by traditional risk factors for hypertension such as obesity and older age. Treating depression is not a robust factor in blood pressure control among those with treatment resistant hypertension.

Metabolomic characteristics of spontaneously hypertensive rats under chronic stress and the treatment effect of Danzhi Xiaoyao Powder, a traditional Chinese medicine formula

OBJECTIVE

Numerous studies have demonstrated the close relationship between chronic stress and blood pressure (BP). Hypertensive subjects exhibit exaggerated reactions to stress, especially higher BP. The mechanisms by which stress affects pre-existing hypertension still need to be explored. Danzhi Xiaoyao Powder (DP), a historical traditional Chinese medicine formula, is a promising treatment for BP control in hypertensive patients under stress. The present study investigated the metabolomic disruption caused by chronic stress and the treatment effect and mechanism of DP.

METHODS

Spontaneously hypertensive rats (SHRs) were subjected to chronic restraint stress (CRS) for 4 weeks. BP was measured via the tail-cuff method, and anxiety-like behavior was quantified using the elevated-plus-maze test. Meanwhile, DP was administered intragastrically, and its effects were observed. Global metabolomic analysis was performed using ultra-high-performance liquid chromatography-quadrupole time-of-flight mass spectrometry, followed by multivariate statistical analysis to detect differential metabolites and pathways.

RESULTS

DP alleviated the CRS-induced increase in BP and anxiety-like behavior. Systematic metabolic differences were found among the three study groups. A total of 29 differential plasma metabolites were identified in both positive- and negative-ion modes. These metabolites were involved in triglyceride metabolism, amino acid (phenylalanine, tryptophan, and glycine) metabolism, and steroid hormone pathways.

CONCLUSION

These findings expose the metabolomic disturbances induced by chronic stress in SHRs and suggest an innovative treatment for this disorder.

Assessment of psychiatric comorbidities and serotonergic or noradrenergic medication use on blood pressure using 24-hour ambulatory blood pressure monitoring

In this study, the authors aimed to assess both nighttime and daytime blood pressure (BP) variability using 24-hour ambulatory BP monitoring (ABPM) in persons with and without psychiatric conditions and with or without selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) treatment. In this retrospective study, patients who underwent psychiatric evaluation and ABPM within 6 months of each other between January 1, 2012 and December 31, 2017 were identified using billing data. Participants were divided into three groups-participants with no psychiatric diagnosis and no psychiatric medicine (-Diagnosis/-Medication), those with psychiatric diagnosis and on SSRIs/SNRIs (+Diagnosis/+Medication), and psychiatric diagnosis but no psychiatric medications (+Diagnosis/-Medication). Day and nighttime systolic and diastolic BPs were compared between groups controlling for relevant variables using multivariable linear regression models. A total of 475 participants met inclusion criteria including 135 in the -Diagnosis/-Medication group, 232 in the +Diagnosis/+Medication group, and 108 in the +Diagnosis/-Medication group. In adjusted multivariable analysis, the +Diagnosis/+Medication group had higher nighttime systolic BP (median 120 vs 110 mm (Hg); p = .01) and nighttime diastolic BP (median 68 vs 63 mm (Hg); p = .006) as compared to -Diagnosis/-Medication. No statistically significant differences in BPs between the -Diagnosis/-Medication and +Diagnosis/-Medication groups were observed, after adjustment. Use of SSRIs/SNRIs was associated with significantly higher nocturnal systolic and diastolic BP among patients with psychiatric diagnosis using SSRIs/SNRIs but not associated with psychiatric diagnosis without SSRI/SNRI use. SSRIs/SNRIs use may be associated with higher BP levels and this merits future prospective studies using ABPM to assess day and nighttime BP changes with SSRIs/SNRIs use.

Impact of major depression on cardiovascular outcomes for individuals with hypertension: prospective survival analysis in UK Biobank

OBJECTIVES

To assess whether a history of major depressive disorder (MDD) in middle-aged individuals with hypertension influences first-onset cardiovascular disease outcomes.

DESIGN

Prospective cohort survival analysis using Cox proportional hazards regression with a median follow-up of 63 months (702 902 person-years). Four mutually exclusive groups were compared: hypertension only (n=56 035), MDD only (n=15 098), comorbid hypertension plus MDD (n=12 929) and an unaffected (no hypertension, no MDD) comparison group (n=50 798).

SETTING

UK Biobank.

PARTICIPANTS

UK Biobank participants without cardiovascular disease aged 39-70 who completed psychiatric questions relating International Classification of Diseases-10 Revision (ICD-10) diagnostic criteria on a touchscreen questionnaire at baseline interview in 2006-2010 (n=134 860).

PRIMARY AND SECONDARY OUTCOME MEASURES

First-onset adverse cardiovascular outcomes leading to hospital admission or death (ICD-10 codes I20-I259, I60-69 and G45-G46), adjusted in a stepwise manner for sociodemographic, health and lifestyle features. Secondary analyses were performed looking specifically at stroke outcomes (ICD-10 codes I60-69 and G45-G46) and in gender-separated models.

RESULTS

Relative to controls, adjusted HRs for adverse cardiovascular outcomes were increased for the hypertension only group (HR 1.36, 95% CI 1.22 to 1.52) and were higher still for the comorbid hypertension plus MDD group (HR 1.66, 95% CI 1.45 to 1.9). HRs for the comorbid hypertension plus MDD group were significantly raised compared with hypertension alone (HR 1.22, 95% CI 1.1 to 1.35). Interaction measured using relative excess risk due to interaction (RERI) and likelihood ratios (LRs) were identified at baseline (RERI 0.563, 95% CI 0.189 to 0.938; LR p=0.0116) but not maintained during the follow-up.

LIMITATIONS

Possible selection bias in UK Biobank and inability to assess for levels of medication adherence.

CONCLUSIONS

Comorbid hypertension and MDD conferred greater hazard than hypertension alone for adverse cardiovascular outcomes, although evidence of interaction between hypertension and MDD was inconsistent over time. Future cardiovascular risk prediction tools may benefit from the inclusion of questions about prior history of depressive disorders.

Does care in a specialised stroke prevention clinic improve poststroke blood pressure control: a protocol for a randomised comparative effectiveness study

INTRODUCTION

Hypertension is a major risk factor for recurrent stroke, and blood pressure (BP) reduction is associated with decreased risk of stroke recurrence. However, many stroke survivors have poorly controlled BP after their initial stroke. The Stroke Transitions Education and Prevention (STEP) Clinic was established to provide a comprehensive approach to stroke risk factor reduction.

METHODS AND ANALYSIS

This randomised comparative effectiveness study was designed to assess the impact of care in the STEP clinic versus usual care on poststroke BP reduction. Eligible hospitalised patients with ischaemic stroke, haemorrhagic stroke or transient ischaemic attack are scheduled for a clinic screening visit within 4 weeks of discharge if they meet baseline inclusion criteria. At the clinic visit, patients who have uncontrolled BP, defined as automated office BP ≥135/85 mm Hg are randomised (1:1) to either the STEP clinic or usual care for management. STEP clinic patients receive instructions to self-monitor, a BP monitor, sleep apnoea screening, dietary counselling, review of BP monitoring records and adjustment of medications. Patients are followed by a neurologist and a stroke-trained nurse practitioner. Usual care participants are seen by a neurologist and recommendations for secondary prevention are sent to primary care providers. The primary outcome is the difference in mean daytime ambulatory systolic BP at 6 months, assessed using linear regression analysis. Secondary outcomes include 24 hours ambulatory BP, medication adherence and medication self-efficacy, and composite cardiovascular events.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Boards at the McGovern Medical School at the University of Texas Health Sciences Center and the Georgetown University School of Medicine. Uninsured and Spanish-speaking patients are included in the study.

TRIAL REGISTRATION NUMBER

NCT02591394; Pre-results.

Associations between depression, anxiety and medication adherence among patients with arterial hypertension: Comparison between persons exposed and non-exposed to radiation from the Semipalatinsk Nuclear Test Site

In this study, we investigated the association between depression, anxiety and medication adherence in patients with arterial hypertension living in East Kazakhstan region. The sample size included 795 patients, of whom 403 patients were exposed to radiation at the Semipalatinsk Nuclear Test Site from 1949 to 1989, while 395 patients were unexposed to radiation due to their very remote residence from the Site at the same period. Both exposed and unexposed patients showed no significant differences concerning body mass index, smoking habit, the presence of hypercholesterolemia, and hypertension grade. Patients with arterial hypertension previously exposed to radiation had significantly higher rates of low medication adherence, subclinical and clinical depression, situational anxiety of moderate and severe grade, and personal anxiety of moderate grade. A logistic regression analysis allowed us to identify the presence of significant positive association between medication adherence and anxiety in exposed patients (OR = 4041 (95%CI:1709-9556) p = 0.001) and marginal association (OR = 2998 (95%CI:1008-8915) p = 0.048) between the same parameters in unexposed patients. It might prove to be useful to introduce psychological and medical counseling with an emphasis on strengthening of medication adherence and to inform the local population about radiation effects and dosimetry data.