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Mroz T, Griffin M, Cartabuke R, Laffin L, Russo-Alvarez G, Thomas G, Smedira N, Meese T, Shost M, Habboub G. Predicting hypertension control using machine learning. PLoS One 2024; 19:e0299932. [PMID: 38507433 PMCID: PMC10954144 DOI: 10.1371/journal.pone.0299932] [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: 08/03/2023] [Accepted: 02/17/2024] [Indexed: 03/22/2024] Open
Abstract
Hypertension is a widely prevalent disease and uncontrolled hypertension predisposes affected individuals to severe adverse effects. Though the importance of controlling hypertension is clear, the multitude of therapeutic regimens and patient factors that affect the success of blood pressure control makes it difficult to predict the likelihood to predict whether a patient's blood pressure will be controlled. This project endeavors to investigate whether machine learning can accurately predict the control of a patient's hypertension within 12 months of a clinical encounter. To build the machine learning model, a retrospective review of the electronic medical records of 350,008 patients 18 years of age and older between January 1, 2015 and June 1, 2022 was performed to form model training and testing cohorts. The data included in the model included medication combinations, patient laboratory values, vital sign measurements, comorbidities, healthcare encounters, and demographic information. The mean age of the patient population was 65.6 years with 161,283 (46.1%) men and 275,001 (78.6%) white. A sliding time window of data was used to both prohibit data leakage from training sets to test sets and to maximize model performance. This sliding window resulted in using the study data to create 287 predictive models each using 2 years of training data and one week of testing data for a total study duration of five and a half years. Model performance was combined across all models. The primary outcome, prediction of blood pressure control within 12 months demonstrated an area under the curve of 0.76 (95% confidence interval; 0.75-0.76), sensitivity of 61.52% (61.0-62.03%), specificity of 75.69% (75.25-76.13%), positive predictive value of 67.75% (67.51-67.99%), and negative predictive value of 70.49% (70.32-70.66%). An AUC of 0.756 is considered to be moderately good for machine learning models. While the accuracy of this model is promising, it is impossible to state with certainty the clinical relevancy of any clinical support ML model without deploying it in a clinical setting and studying its impact on health outcomes. By also incorporating uncertainty analysis for every prediction, the authors believe that this approach offers the best-known solution to predicting hypertension control and that machine learning may be able to improve the accuracy of hypertension control predictions using patient information already available in the electronic health record. This method can serve as a foundation with further research to strengthen the model accuracy and to help determine clinical relevance.
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Affiliation(s)
- Thomas Mroz
- Orthopaedics and Rheumatology Institute, Cleveland Clinic, Cleveland, OH, United States of America
- Center for Spine Health, Cleveland Clinic, Cleveland, OH, United States of America
| | - Michael Griffin
- Insight Enterprises Inc., Chandler, AZ, United States of America
| | - Richard Cartabuke
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, United States of America
| | - Luke Laffin
- Department of Cardiovascular Medicine, Center for Blood Pressure Disorders, Cleveland Clinic, Cleveland, OH, United States of America
| | - Giavanna Russo-Alvarez
- Department of Hospital Outpatient Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America
| | - George Thomas
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, OH, United States of America
| | - Nicholas Smedira
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, United States of America
| | - Thad Meese
- Department of Innovations Technology Development, Cleveland Clinic, Cleveland, OH, United States of America
| | - Michael Shost
- Center for Spine Health, Cleveland Clinic, Cleveland, OH, United States of America
- Case Western Reserve University School of Medicine, Cleveland, OH, United States of America
| | - Ghaith Habboub
- Center for Spine Health, Cleveland Clinic, Cleveland, OH, United States of America
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Sambah F, Malau-Aduli BS, Seidu AA, Malau-Aduli AEO, Emeto TI. Ghana's Adherence to PASCAR's 10-Point Action Plan towards Hypertension Control: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1425. [PMID: 36674181 PMCID: PMC9859290 DOI: 10.3390/ijerph20021425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/10/2023] [Indexed: 06/17/2023]
Abstract
The continuous increase in the prevalence of hypertension in Ghana has led to various interventions aimed at controlling the disease burden. Nonetheless, these interventions have yielded poor health outcomes. Subsequently, the Pan-African Society of Cardiology (PASCAR), established a 10-point action plan for inclusion in policies to aid control of hypertension. This scoping review assessed the adherence of health policies to the 10-point action plan towards hypertension control/reduction in Ghana. Eight health policies met the inclusion criteria and were assessed. The programme evaluation and policy design framework were used for synthesis and analysis of extracted data. Overall, there was poor adherence to hypertension control observed in the policies. Specifically, there were low levels of integrating hypertension control/reduction measures, a poor task-sharing approach, and poor financial resource allocations to tackle hypertension control/reduction in most of the policies. There was also low support for research to produce evidence to guide future interventions. For Ghana to achieve the global target of reducing hypertension by the year 2025, its health policies must adhere to evidence-based interventions in hypertension management/control. The study recommends a follow-up study among hypertension patients and healthcare professionals to evaluate the factors militating against hypertension management/control in Ghana.
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Affiliation(s)
- Francis Sambah
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia
- Department of Sports and Exercise Science, College of Health and Allied Sciences, University of Cape Coast, Cape Coast P.O. Box UC 182, Ghana
| | - Bunmi S. Malau-Aduli
- College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia
| | - Abdul-Aziz Seidu
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia
| | - Aduli E. O. Malau-Aduli
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia
| | - Theophilus I. Emeto
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia
- World Health Organization Collaborating Center for Vector-Borne and Neglected Tropical Diseases, James Cook University, Townsville, QLD 4811, Australia
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Smith SM, Winterstein AG, Gurka MJ, Walsh MG, Keshwani S, Libby AM, Hogan WR, Pepine CJ, Cooper‐DeHoff RM. Initial Antihypertensive Regimens in Newly Treated Patients: Real World Evidence From the OneFlorida+ Clinical Research Network. J Am Heart Assoc 2022; 12:e026652. [PMID: 36565195 PMCID: PMC9973585 DOI: 10.1161/jaha.122.026652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Knowledge of real-world antihypertensive use is limited to prevalent hypertension, limiting our understanding of how treatment evolves and its contribution to persistently poor blood pressure control. We sought to characterize antihypertensive initiation among new users. Methods and Results Using Medicaid and Medicare data from the OneFlorida+ Clinical Research Consortium, we identified new users of ≥1 first-line antihypertensives (angiotensin-converting enzyme inhibitor, calcium channel blocker, angiotensin receptor blocker, thiazide diuretic, or β-blocker) between 2013 and 2021 among adults with diagnosed hypertension, and no antihypertensive fill during the prior 12 months. We evaluated initial antihypertensive regimens by class and drug overall and across study years and examined variation in antihypertensive initiation across demographics (sex, race, and ethnicity) and comorbidity (chronic kidney disease, diabetes, and atherosclerotic cardiovascular disease). We identified 143 054 patients initiating 188 995 antihypertensives (75% monotherapy; 25% combination therapy), with mean age 59 years and 57% of whom were women. The most commonly initiated antihypertensive class overall was angiotensin-converting enzyme inhibitors (39%) followed by β-blockers (31%), calcium channel blockers (24%), thiazides (19%), and angiotensin receptor blockers (11%). With the exception of β-blockers, a single drug accounted for ≥75% of use of each class. β-blocker use decreased (35%-26%), and calcium channel blocker use increased (24%-28%) over the study period, while initiation of most other classes remained relatively stable. We also observed significant differences in antihypertensive selection across demographic and comorbidity strata. Conclusions These findings indicate that substantial variation exists in initial antihypertensive prescribing, and there remain significant gaps between current guideline recommendations and real-world implementation in early hypertension care.
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Affiliation(s)
- Steven M. Smith
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL,Division of Cardiovascular Medicine, Department of Medicine, College of MedicineUniversity of FloridaGainesvilleFL,Center for Integrative Cardiovascular and Metabolic DiseaseUniversity of FloridaGainesvilleFL
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Matthew J. Gurka
- Department of Health Outcomes and Biomedical Informatics, College of MedicineUniversity of FloridaGainesvilleFL
| | - Marta G. Walsh
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Shailina Keshwani
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Anne M. Libby
- Department of Emergency Medicine, School of MedicineUniversity of Colorado DenverAuroraCO
| | - William R. Hogan
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Carl J. Pepine
- Division of Cardiovascular Medicine, Department of Medicine, College of MedicineUniversity of FloridaGainesvilleFL
| | - Rhonda M. Cooper‐DeHoff
- Division of Cardiovascular Medicine, Department of Medicine, College of MedicineUniversity of FloridaGainesvilleFL,Center for Integrative Cardiovascular and Metabolic DiseaseUniversity of FloridaGainesvilleFL,Department of Pharmacotherapy and Translational Research, College of PharmacyUniversity of FloridaGainesvilleFL
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Hassanein M, Akbar MAJ, Al-Shamiri M, Amir A, Amod A, Chudleigh R, Elhadd T, Heshmat H, Jibani M, Al Saleh YM. Management of Diabetes and Hypertension within the Gulf Region: Updates on Treatment Practices and Therapies. Diabetes Ther 2022; 13:1253-1280. [PMID: 35679010 PMCID: PMC9178531 DOI: 10.1007/s13300-022-01282-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/17/2022] [Indexed: 11/20/2022] Open
Abstract
Cardiovascular disease (CVD) is a leading cause of death globally, driven by the high rates of risk factors, such as diabetes and hypertension. As the prevalence of these risk factors is particularly high in the Gulf region, better diagnosis and management of type 2 diabetes (T2D) and hypertension has the potential to dramatically reduce adverse cardiovascular outcomes for individuals in that part of the world. This article provides a summary of presentations made during the EVIDENT summit, a virtual symposium on Evidence in Diabetes and Hypertension, held in September 2021, including a review of the various guidelines for both T2D and hypertension, as well as recent findings relevant to the safety and efficacy for therapies relating to these conditions. Of relevance to the Gulf region, the risk of hypoglycaemia with sulfonylureas during Ramadan was reviewed. For the management of T2D, sulfonylureas have been a long-standing medication used to achieve glycaemic control; however, differences have emerged between early and later generations, with recent studies suggesting improvements in the safety profiles of late-generation sulfonylureas. For patients with hypertension, incremental therapy changes are recommended to reduce the risk of cardiovascular complications that are associated with increasing blood pressure. For first-line therapy, angiotensin-converting enzyme inhibitors (ACEi), such as perindopril, have been demonstrated to reduce the risk of cardiovascular and all-cause mortality. The addition of calcium channel blockers and diuretics to ACEi has been shown to be effective in patients with poorly controlled hypertension. The different renin-angiotensin-aldosterone system inhibitors are reviewed, and the benefit of combination therapies, including amlodipine and indapamide in patients with difficult-to-control hypertension, is investigated. The benefits of lifestyle modifications for these patients are also discussed, with important clinical considerations that are expected to inform patient management in daily clinical practice.
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Affiliation(s)
- Mohamed Hassanein
- Endocrine Department, Dubai Hospital/Dubai Health Authority, Alkhaleej Road, PO Box 7272, Dubai, United Arab Emirates.
- Gulf Medical University, Ajman, United Arab Emirates.
| | | | - Mostafa Al-Shamiri
- Cardiac Sciences Department, Medical College, King Saud University, Riyadh, Saudi Arabia
| | - Ashraf Amir
- International Medical Center Hospital (IMC), Jeddah, Saudi Arabia
| | - Aslam Amod
- Nelson R. Mandela School of Medicine & Life Chatsmed Garden Hospital, Durban, South Africa
| | | | | | - Hussien Heshmat
- Cardiology Department, Cairo University, Cairo, Egypt
- Fujairah Hospital Emirates Health Service, Fujairah, United Arab Emirates
| | | | - Yousef M Al Saleh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, 22490, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, 11481, Saudi Arabia
- Department of Medicine, King Abdulaziz Medical City, Ministry of National Gurad Health Affairs, Riyadh, 14611, Saudi Arabia
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Sabuncu T, Sonmez A, Eren MA, Sahin I, Çorapçioğlu D, Üçler R, Akin Ş, Haymana C, Demirci İ, Atmaca A, Ersöz HÖ, Satman I, Bayram F. Characteristics of patients with hypertension in a population with type 2 diabetes mellitus. Results from the Turkish Nationwide SurvEy of Glycemic and Other Metabolic Parameters of Patients with Diabetes Mellitus (TEMD Hypertension Study). Prim Care Diabetes 2021; 15:332-339. [PMID: 33277201 DOI: 10.1016/j.pcd.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/05/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The present survey aimed to find out the demographical and clinical characteristics of patients with hypertension in a population with type 2 diabetes mellitus (T2DM) in Turkey. METHODS Patients with T2DM who were followed-up in tertiary endocrine units for at least last one year were recruited. Demographic, clinical and biochemical data of the patients were collected. Hypertension was defined as taking anti-hypertensive medications or having office arterial blood pressure (ABP) ≥140/90 mmHg or home ABP ≥ 130/80 mmHg. RESULTS A total of 4756 (58.9% women) diabetic patients were evaluated. The percentage of patients with hypertension was 67.5% (n = 3212). Although 87.4% (n = 2808) of hypertensive patients were under treatment, blood pressure was on target in 52.7% (n = 1479) of patients. Hypertension proportions were higher in woman (p = 0.001), older, more obese, and those who had longer diabetes duration, lower education levels, higher frequency of hypoglycemic events (all p < 0.001) and higher triglyceride levels (p = 0.003). LDL cholesterol level and the percentage of smokers were lower in hypertensive group than in non-hypertensive group (both p < 0.001). The percentage of macro and microvascular complications was higher in the hypertensive group than in the normotensive one (both p < 0.001). In multivariate logistic regression analysis, being a woman (OR: 1.26, 95% CI: 1.04-1.51, p = 0.016), smoking (OR: 1.38, 95% CI: 1.05-1.80, p = 0.020), regular physical activity (OR: 1.24, 95% CI: 1.01-1.53, p = 0.039) and the presence of macrovascular complications (OR: 1.38 95% CI: 1.15-1.65, p = 0.001) were the significant predictors of good ABP regulation. The ratios of masked and white coat hypertension were 41.2% and 5.7%, respectively. CONCLUSION Our findings indicate that two-thirds (67.5%) of adult patients with T2DM have hypertension. Co-existence of hypertension increases the frequency of macro and microvascular diabetic complications in these patients. Despite the critical role of hypertension in morbidity and mortality, only half of the patients have favorable ABP levels. Masked hypertension seems to be another important issue in this population.
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Affiliation(s)
- Tevfik Sabuncu
- Harran University, Faculty of Medicine, Department of Endocrinology and Metabolism, Sanliurfa, Turkey
| | - Alper Sonmez
- Health Sciences University, Gulhane Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Mehmet Ali Eren
- Harran University, Faculty of Medicine, Department of Endocrinology and Metabolism, Sanliurfa, Turkey.
| | - Ibrahim Sahin
- Inonu University, Faculty of Medicine, Department of Endocrinology and Metabolism, Malatya, Turkey
| | - Demet Çorapçioğlu
- Ankara University, Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Rıfkı Üçler
- Van Yüzüncü Yıl University, Faculty of Medicine, Department of Endocrinology and Metabolism, Van, Turkey
| | - Şafak Akin
- Ankara Memorial Hospital, Ankara, Turkey
| | - Cem Haymana
- Health Sciences University, Gulhane Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - İbrahim Demirci
- Health Sciences University, Gulhane Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Ayşegül Atmaca
- On Dokuz Mayıs University, Faculty of Medicine, Department of Endocrinology and Metabolism, Samsun, Turkey
| | - Halil Önder Ersöz
- Karadeniz Teknik University, Faculty of Medicine, Department of Endocrinology and Metabolism, Trabzon, Turkey
| | - Ilhan Satman
- Istanbul University, Faculty of Medicine, Department of Endocrinology and Metabolism, Istanbul, Turkey
| | - Fahri Bayram
- Erciyes University, Faculty of Medicine, Department of Endocrinology and Metabolism, Kayseri, Turkey
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Teramoto K, Nadruz W, Matsushita K, Claggett B, John JE, Skali H, Solomon S, Cheng S, Shah AM. Mid- to Late-Life Time-Averaged Cumulative Blood Pressure and Late-Life Cardiac Structure, Function, and Heart Failure. Hypertension 2020; 76:808-818. [PMID: 32536273 PMCID: PMC8262121 DOI: 10.1161/hypertensionaha.120.14833] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/13/2020] [Indexed: 01/09/2023]
Abstract
Limited data exist regarding systolic blood pressure (SBP) through mid- to late-life and late-life cardiac function and heart failure (HF) risk. Among 4578 HF-free participants in the ARIC study (Atherosclerosis Risk in Communities) attending the fifth visit (2011-2013; age 75±5 years), time-averaged cumulative SBP was calculated as the sum of averaged SBPs from adjacent consecutive visits (visits 1-5) indexed to total observation time (24±1 years). Calculations were performed using measured SBPs and also incorporating antihypertensive medication specific effect constants (underlying SBP). Outcomes included comprehensive echocardiography at visit 5 and post-visit 5 incident HF, HF with preserved ejection fraction, and reduced ejection fraction. Higher cumulative SBP was associated with greater left ventricular mass and worse diastolic measures (all P<0.001), associations that were stronger with underlying compared with cumulative SBP (all P<0.05). At 5.6±1.2 years follow-up post-visit 5, higher cumulative measured and underlying SBP were associated with incident HF (hazard ratio per 10 mm Hg for measured: 1.12 [1.01-1.24]; underlying: 1.19 [95% CI, 1.10-1.30]) and HF with preserved ejection fraction (measured: 1.15 [1.00-1.33]; underlying: 1.28 [1.14-1.45]), but not HF with reduced ejection fraction (measured: 1.11 [0.94-1.32]; underlying: 1.11 [0.96-1.24]). Associations with HF and HF with preserved ejection fraction were more robust with cumulative underlying compared with measured SBP (all P<0.05). Time-averaged cumulative SBP in mid to late life is associated with worse cardiac function and risk of incident HF, especially HF with preserved ejection fraction, in late life. These associations were stronger considering underlying as opposed to measured SBP, highlighting the importance of prevention and effective treatment of hypertension to prevent late-life cardiac dysfunction and HF.
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Affiliation(s)
- Kanako Teramoto
- Division of Cardiology, St. Marianna University School of Medicine Hospital, Kanagawa, Japan
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Wilson Nadruz
- Cardiology Division, State University of Campinas, Campinas, São Paulo, Brazil
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jenine E. John
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Hicham Skali
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Scott Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Susan Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Amil M. Shah
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Hayibor LA, Zhang J, Duncan A. Association of binge drinking in adolescence and early adulthood with high blood pressure: findings from the National Longitudinal Study of Adolescent to Adult Health (1994–2008). J Epidemiol Community Health 2019; 73:652-659. [DOI: 10.1136/jech-2018-211594] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 02/22/2019] [Accepted: 03/03/2019] [Indexed: 11/03/2022]
Abstract
BackgroundAn investigation of the risk of high blood pressure (HBP) associated with heavy alcohol consumption in adolescence and early adulthood is lacking. Therefore, we aimed to investigate the association between binge drinking from adolescence to early adulthood and the risk of HBP in early adulthood.MethodsWe applied logistic regression to publicly available, population-representative data from waves I (1994–1995; ages 12–18) and IV (2007–2008; ages 24–32) of the National Longitudinal Study of Adolescent to Adult Health (n=5114) to determine whether past 12-month binge drinking in adolescence (wave I) and early adulthood (wave IV) was associated with HBP in early adulthood after adjusting for covariates, including smoking and body mass index. HBP was defined according to both the former and new classifications.ResultsHBP was significantly, positively associated with infrequent binge drinking (less than once a week) in adolescence based on the new classification (overall: OR 1.23, 95% CI 1.02 to 1.49; male: OR 1.35, 95% CI 1.00 to 1.81) and frequent binge drinking (heavy consumption) in adolescence based on the former classification (overall: OR= 1.64, 95% CI 1.22 to 2.22; male: OR= 1.79, 95% CI 1.23 to 2.60). The risk of HBP was high when participants engaged in frequent binge drinking in both adolescence and early adulthood, especially based on the former classification (overall: OR 2.43, 95% CI 1.13 to 5.20; female: OR 5.81, 95% CI 2.26 to 14.93).ConclusionBinge drinking in adolescence may increase risk of HBP in early adulthood. This association is independent of other important risk factors for HPB, such as smoking and obesity.
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Shahi N, Tobe SW. Thresholds and Targets for Hypertension Management in Adults With Type 2 Diabetes Should Remain at 130/80 mmHg: What's the Evidence? Can J Diabetes 2017; 42:166-172. [PMID: 29273294 DOI: 10.1016/j.jcjd.2017.10.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 10/03/2017] [Accepted: 10/10/2017] [Indexed: 10/18/2022]
Abstract
Hypertension and diabetes are common comorbidities and are both modifiable risk factors for cardiovascular disease and death. Lowering blood pressure reduces target organ damage and prevents cardiovascular disease outcomes. The harmonized Canadian clinical practice guidelines for managing hypertension in people with diabetes provides health-behaviour advice and medical therapy recommendations for a threshold blood pressure of 130/80 mmHg and above and to target blood pressure to below 130/80 mmHg. We have reviewed the studies supporting these recommendations and others, and they appear to be at odds with the guidelines, including those for elderly people and patients with pre-existing cardiovascular disease.
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Affiliation(s)
- Niharika Shahi
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Sheldon W Tobe
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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Blood pressure-lowering efficacy and safety of perindopril/indapamide/amlodipine single-pill combination in patients with uncontrolled essential hypertension. J Hypertens 2017; 35:1481-1495. [DOI: 10.1097/hjh.0000000000001359] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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10
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Mancia G, Cha G, Gil-Extremera B, Harvey P, Lewin AJ, Villa G, Kjeldsen SE. Blood pressure-lowering effects of nifedipine/candesartan combinations in high-risk individuals: subgroup analysis of the DISTINCT randomised trial. J Hum Hypertens 2016; 31:178-188. [PMID: 27511476 PMCID: PMC5301082 DOI: 10.1038/jhh.2016.54] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 03/02/2016] [Accepted: 03/14/2016] [Indexed: 11/09/2022]
Abstract
The DISTINCT study (reDefining Intervention with Studies Testing Innovative Nifedipine GITS-Candesartan Therapy) investigated the efficacy and safety of nifedipine GITS/candesartan cilexetil combinations vs respective monotherapies and placebo in patients with hypertension. This descriptive sub-analysis examined blood pressure (BP)-lowering effects in high-risk participants, including those with renal impairment (estimated glomerular filtration rate<90 ml min-1, n=422), type 2 diabetes mellitus (n=202), hypercholesterolaemia (n=206) and cardiovascular (CV) risk factors (n=971), as well as the impact of gender, age and body mass index (BMI). Participants with grade I/II hypertension were randomised to treatment with nifedipine GITS (N) 20, 30, 60 mg and/or candesartan cilexetil (C) 4, 8, 16, 32 mg or placebo for 8 weeks. Mean systolic BP and diastolic BP reductions after treatment in high-risk participants were greater, overall, with N/C combinations vs respective monotherapies or placebo, with indicators of a dose-response effect. Highest rates of BP control (ESH/ESC 2013 guideline criteria) were also achieved with highest doses of N/C combinations in each high-risk subgroup. The benefits of combination therapy vs monotherapy were additionally observed in patient subgroups categorised by gender, age or BMI. All high-risk participants reported fewer vasodilatory adverse events in the pooled N/C combination therapy than the N monotherapy group. In conclusion, consistent with the DISTINCT main study outcomes, high-risk participants showed greater reductions in BP and higher control rates with N/C combinations compared with respective monotherapies and lesser vasodilatory side-effects compared with N monotherapy.
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Affiliation(s)
- G Mancia
- Unit and Department of Clinical Medicine, University of Milano-Bicocca, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - G Cha
- KRK Medical Research Institute, Dallas, TX, USA
| | | | - P Harvey
- Formerly in The Crouch Oak Family Practice, Addlestone, UK
| | - A J Lewin
- National Research Institute, Los Angeles, CA, USA
| | - G Villa
- Fondazione Salvatore Maugeri-IRCCS, Pavia, Italy
| | - S E Kjeldsen
- Oslo University Hospital Ullevaal, University of Oslo, Oslo, Norway
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Abstract
Untreated and uncontrolled hypertension (HTN) presents a major public health burden in the USA and worldwide. Despite the known risk for increased cardiovascular (CV) morbidity and mortality, blood pressure remains untreated and uncontrolled at alarming rates of between 20 and 40 % in patients with known HTN. Further, while cumulative evidence indicates that early onset of antihypertensive effect improves CV outcomes, the time to blood pressure (BP) control remains long. The objective of hypertension management cannot be simply to achieve and maintain the goal BP, but to do so quickly to improve short-term and long-term CV outcomes. In this review, we will (1) describe the magnitude of uncontrolled HTN, (2) identify the factors that contribute to uncontrolled BP in patients with the diagnosis of HTN, and (3) explore the rationale for and benefits of aggressive and immediate control of HTN.
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Pedro-Botet J, Chillarón JJ, Benaiges D, Flores-Le Roux JA. [Cardiovascular prevention in diabetes mellitus: A multifactorial challenge]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2015; 28:154-63. [PMID: 26655375 DOI: 10.1016/j.arteri.2015.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/07/2015] [Indexed: 12/21/2022]
Abstract
Patients with type2 diabetes mellitus have a high to very high cardiovascular risk, and often have other associated risk factors, such as hypertension, obesity and dyslipidaemia. Cardiovascular disease is the leading cause of morbidity and mortality in this population. An integrated control of all risk factors in patients with diabetes is essential for minimising the risk of macrovascular complications. Given the benefits of the multifactorial intervention strategies for cardiovascular prevention in diabetic patients, a review is presented on the therapeutic goals established for each risk factor in diabetes and the benefits of their control.
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Affiliation(s)
- Juan Pedro-Botet
- Servicio de Endocrinología y Nutrición, Hospital del Mar, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, España.
| | - Juan J Chillarón
- Servicio de Endocrinología y Nutrición, Hospital del Mar, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, España
| | - David Benaiges
- Servicio de Endocrinología y Nutrición, Hospital del Mar, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, España
| | - Juana A Flores-Le Roux
- Servicio de Endocrinología y Nutrición, Hospital del Mar, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, España
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Mallat SG, Samra SA, Younes F, Sawaya MT. Identifying predictors of blood pressure control in the Lebanese population - a national, multicentric survey -- I-PREDICT. BMC Public Health 2014; 14:1142. [PMID: 25373466 PMCID: PMC4246605 DOI: 10.1186/1471-2458-14-1142] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 09/29/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Blood Pressure (BP) is not well controlled and factors that predict BP control are not well identified in Lebanon. Improvement of hypertension management requires an understanding of patients' characteristics and factors associated with uncontrolled BP. This national, multicentric, observational prospective study was designed to determine the predictors of BP control in patients followed up to 6 months. METHODS I-PREDICT study was conducted on 988 patients with newly diagnosed or uncontrolled hypertension. Socio-demographic and clinical characteristics were analyzed. The level of agreement between doctors' perceptions on BP control status and JNC VII guidelines was analyzed. RESULTS The predictor associated with poor BP control was diabetes (OR = 0.17, CI = 0.10-0.28 at month-1; OR = 0.15, CI = 0.10-0.24 at month-6). The predictors associated with better BP control at month-6 were the early control of BP at month-1 (OR = 10.39, CI = 6.18-17.47) and combination therapy prescribed at baseline and month-1 (OR = 15.14, CI = 1.09-208.46, P = 0.04). In the sub-group of diabetes, the predictors that were associated with better BP control at 6 months were following diet at V1 (OR = 2.27, CI = 1.01 to 5.12) and BP control at V2 (OR = 7.34, CT = 3.83 to 14.07). The predictors that were associated with poor BP control at 6 months were middle economic class (OR = 0.036, CI = 0.16-0.94) and upper economic class (OR = 0.036; CI = 0.13-0.93).The rate of BP control was significantly higher at month 6 versus month 1 (67.52% vs 44.08%, P = 0.001). Additional analysis showed poor agreement between the doctors' perceptions on BP control status and the guidelines. CONCLUSIONS Reaching an early BP control and combination therapy were significant predictors of better BP control, whereas diabetes was a significant predictor of poor BP control. A poor agreement between JNC VII guidelines and clinical practice was observed. I-PREDICT study identified factors that can be targeted for improving BP control.
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Affiliation(s)
- Samir G Mallat
- Department of Internal Medicine, American University of Beirut, Riad El-Solh, P,O, Box 11-0236, Beirut 11072020, Lebanon.
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O'Connor PJ, Magid DJ, Sperl-Hillen JM, Price DW, Asche SE, Rush WA, Ekstrom HL, Brand DW, Tavel HM, Godlevsky OV, Johnson PE, Margolis KL. Personalised physician learning intervention to improve hypertension and lipid control: randomised trial comparing two methods of physician profiling. BMJ Qual Saf 2014; 23:1014-22. [PMID: 25228778 DOI: 10.1136/bmjqs-2014-002807] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To assess the impact of personalised physician learning (PPL) interventions using simulated learning cases on control of hypertension and dyslipidaemia in primary care settings. METHODS A total of 132 primary care physicians, 4568 eligible patients with uncontrolled hypertension, and 15 392 eligible patients with uncontrolled dyslipidaemia were cluster-randomised to one of three conditions: (a) no intervention, (b) PPL-electronic medical record (EMR) intervention in which 12 PPL cases were assigned to each physician based on observed patterns of care in the EMR in the previous year, or (c) PPL-ASSESS intervention in which 12 PPL cases were assigned to each physician based on their performance on four standardised assessment cases. General and generalised linear mixed models were used to account for clustering and to model differences in patient outcomes in the study arms. RESULTS Among patients with uncontrolled hypertension at baseline, 49.1%, 46.6% and 47.3% (p=0.43) achieved blood pressure (BP) targets at follow-up. Among patients with uncontrolled dyslipidaemia at baseline, 37.5%, 37.3% and 38.1% (p=0.72) achieved low density lipoprotein cholesterol targets at follow-up in PPL-EMR, PPL-ASSESS and the control group, respectively. Although systolic (BP) (p<0.001) and lipid (p<0.001) values significantly improved during the study, the group-by-time interaction term showed no differential change in systolic BP values (p=0.51) or lipid values (p=0.61) among the three study arms. No difference in intervention effect was noted when comparing the PPL-EMR with the PPL-ASSESS intervention (p=0.47). CONCLUSIONS The two PPL interventions tested in this study did not lead to improved control of hypertension or dyslipidaemia in primary care clinics during a mean 14-month follow-up period. This null result may have been due in part to substantial overall improvement in BP and lipid control at the study sites during the study. TRIAL REGISTRATION NUMBER NCT00903071.
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Affiliation(s)
- Patrick J O'Connor
- HealthPartners Institute for Education and Research and HealthPartners Centre for Chronic Care Innovation, Minneapolis, Minnesota, USA
| | - David J Magid
- Institute for Health Research, Kaiser Permanente, Denver, Colorado, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute for Education and Research and HealthPartners Centre for Chronic Care Innovation, Minneapolis, Minnesota, USA
| | - David W Price
- Institute for Health Research, Kaiser Permanente, Denver, Colorado, USA
| | - Stephen E Asche
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota, USA
| | - William A Rush
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota, USA
| | - Heidi L Ekstrom
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota, USA
| | - David W Brand
- Institute for Health Research, Kaiser Permanente, Denver, Colorado, USA
| | - Heather M Tavel
- Institute for Health Research, Kaiser Permanente, Denver, Colorado, USA
| | - Olga V Godlevsky
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota, USA
| | - Paul E Johnson
- Carlson School of Management, University of Minnesota, Minneapolis, Minnesota, USA
| | - Karen L Margolis
- HealthPartners Institute for Education and Research and HealthPartners Centre for Chronic Care Innovation, Minneapolis, Minnesota, USA
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Frontoni S, Solini A, Fioretto P, Natali A, Zuccalà A, Cosentino F, Penno G. The ideal blood pressure target to prevent cardiovascular disease in type 2 diabetes: a neutral viewpoint. Nutr Metab Cardiovasc Dis 2014; 24:577-584. [PMID: 24582686 DOI: 10.1016/j.numecd.2014.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 12/27/2013] [Accepted: 01/06/2014] [Indexed: 11/17/2022]
Abstract
Type 2 diabetes mellitus (T2DM) and essential hypertension are often associated, and retrospective data analyses suggest an association between lower blood pressure (BP) values and lower cardiovascular (CV) risk in patients with T2DM. However, the most recent intervention trials fail to demonstrate a further CV risk reduction, for BP levels <130/80 mm Hg, when compared to levels <140/90 mm Hg. Moreover, a J-shaped, rather than a linear, relationship of BP reduction with incident CV events has been strongly suggested. We here debate the main available evidences for and against the concept of 'the lower the better', in the light of the main intervention trials and meta-analyses, with a particular emphasis on the targets to be pursued in elderly patients. Finally, the most recent guidelines of the scientific societies are critically discussed.
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Affiliation(s)
- S Frontoni
- Department of Systems Medicine, University of Rome Tor Vergata - AFAR, Fatebenefratelli Hospital, Rome, Italy.
| | - A Solini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - P Fioretto
- Department of Medicine, University of Padova, Padova, Italy
| | - A Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Zuccalà
- Nephrology Dialysis Unit, Civil Hospital Imola, Imola, Italy
| | - F Cosentino
- Cardiology, Department of Clinical and Molecular Medicine, University of Rome Sapienza, Rome, Italy
| | - G Penno
- Department of Clinical and Experimental Medicine, Section of Diabetes and Metabolic Disease, University of Pisa, Pisa, Italy
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Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) is the leading cause of mortality in type 2 diabetes mellitus (T2DM), and modifying cardiovascular risk through lifestyle intervention and pharmacologic therapy is paramount. This review focuses on recent advances in treatment of classical (traditional) cardiovascular risk factors and highlights the impact of novel risk factors, including sleep disorders, socioeconomic status and chronic psychological stress on CVD in T2DM. RECENT FINDINGS Obesity is a substantial cardiovascular risk factor, and recently, large trials of lifestyle and surgical (e.g. gastric bypass) interventions impact on CVD in overweight and obese patients have been reported. Lifestyle intervention including low calorie diet and exercise reduced individual cardiovascular risk factors but did not decrease the rate of long-term cardiovascular events. Bariatric surgery was beneficial in reducing cardiovascular risk factors and long-term cardiovascular events. Sleep insufficiency, poor sleep quality and obstructive sleep apnoea lead to higher CVD and further research is needed to characterize the benefit of treating sleep disorders on long-term cardiovascular events in T2DM. Lastly, socioeconomic status and chronic psychological stress independently have a major impact on increasing CVD in T2DM, and public health policies to reduce this burden will be important to address over the coming decade. SUMMARY CVD in T2DM is multifactorial and requires a multifaceted approach in reducing known cardiovascular risks at the individual patient level through lifestyle, pharmacotherapy and surgical interventions and at the societal level through public health policies that support reduction in classical and novel cardiovascular risk factors.
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Affiliation(s)
- Joshua J. Joseph
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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