Medication adherence and treatment-resistant hypertension: a review

Supporting General Practitioners and people with hypertension to maximise medication use to control blood pressure: the contribution of Collective Intelligence to the development of the 'Maximising Adherence, Minimising Inertia' (MIAMI) intervention

Background

Hypertension remains one of the most important modifiable risk factors for stroke and heart disease. Anti-hypertensive medications are effective, but are often not used to maximum benefit. Sub-optimal dosing by prescribers and challenges with medication-taking for patients remain barriers to effective blood pressure control.

Objectives

We aimed to systematically develop a theory-based complex intervention to support General Practitioners (GPs) and people with hypertension to maximise medication use to control blood pressure.

Methods

We used the three-phase Behaviour Change Wheel (BCW) as the overarching intervention development framework. Collective Intelligence methodology was used to operationalise the stakeholder input to Phases 2 and 3 of the BCW. This took the form of a Collective Intelligence workshop with 19 stakeholders from diverse backgrounds including lived experience, general practice, nursing, pharmacy and health psychology. Techniques such as barrier identification, idea-writing and scenario-based design were used to generate possible intervention options. Intervention options were then selected and refined using the Acceptability, Practicability, Effectiveness, Affordability, Side-effects and Equity (APEASE) criteria and guidance from the MIAMI Public and Patient Involvement Panel.

Results

The finalised MIAMI intervention consists of both GP and patient supports. GP supports include a 30-minute online training, information booklet and consultation guide (drop-down menu) embedded within the patient electronic health system. Patient supports include a pre-consultation plan, website, and a structured GP consultation with results from an Ambulatory Blood Pressure Monitor and urine chemical adherence test. The intervention components have been mapped to the intervention functions of the BCW and Behaviour Change Technique Ontology.

Conclusion

Collective Intelligence offered a novel method to operationalise stakeholder input to Phases 2 and 3 of the BCW. The MIAMI intervention is now at pilot evaluation stage.

Effectiveness of the knowledge, attitude, practice intervention model in the management of hypertension in the elderly

This study illustrated the effectiveness of the knowledge, attitude, practice (KAP) intervention model for community hypertension in the elderly by the community physician-led, describing the study design and baseline data. The aim of the study was to compare the changes in the elderly hypertensive population before and after the KAP intervention model by managing the elderly hypertensive patients for a period of 1 year. Basic information and risk factors affecting blood pressure control based on baseline data of recruited elderly hypertensive patients. The management approach consists of two parts: (1) the unified management of the community physician to whom the patient belongs; and (2) the management of the contracted patient by the community physician. The aim was to demonstrate the anti-hypertensive effectiveness (control rate, blood pressure reduction, and pulse pressure), the distribution of blood pressure types, and the change of the KAP in elderly hypertensive patients before and after the intervention. The KAP intervention model was administered to 2660 elderly hypertensive patients in a 1-year period. The blood pressure control rate improved by 54.03%. Mean values of overall systolic and diastolic blood pressure decreased by 16.00 and 5.31 mmHg, respectively. The proportion of isolated systolic hypertension (ISH) and systolic-diastolic hypertension (SDH) decreased by 29.14% and 24.81%, respectively. The KAP compliance improved significantly. These results suggest that the community physician-led KAP intervention model is effective in the management of hypertension in the elderly.

Systematic Review Article: New Drug Strategies for Treating Resistant Hypertension-the Importance of a Mechanistic, Personalized Approach

Resistant hypertension (RHT) is characterized by persistently high blood pressure (BP) levels above the widely recommended therapeutic targets of less than 140/90 mmHg office BP, despite life-style measures and optimal medical therapies, including at least three antihypertensive drug classes at maximum tolerated dose (one should be a diuretic). This condition is strongly related to hypertension-mediated organ damage and, mostly, high risk of hospitalization due to hypertension emergencies or acute cardiovascular events. Hypertension guidelines proposed a triple combination therapy based on renin angiotensin system blocking agent, a thiazide or thiazide-like diuretic, and a dihydropyridinic calcium-channel blocker, to almost all patients with RHT, who should also receive either a beta-blocker or a mineralocorticoid receptor antagonist, or both, depending on concomitant conditions and contraindications. Several other drugs may be attempted, when elevated BP levels persist in these RHT patients, although their added efficacy in lowering BP levels on top of optimal medical therapy is uncertain. Also, renal denervation has demonstrated to be a valid therapeutic alternative in RHT patients. More recently, novel drug classes and molecules have been tested in phase 2 randomised controlled clinical trials in patients with RHT on top of optimal medical therapy with at least 2-3 antihypertensive drugs. These novel drugs, which are orally administered and are able to antagonize different pathophysiological pathways, are represented by non-steroid mineralocorticorticoid receptor antagonists, selective aldosterone synthase inhibitors, and dual endothelin receptor antagonists, all of which have proven to reduce seated office and 24-h ambulatory systolic/diastolic BP levels. The main findings of randomized clinical trials performed with these drugs  as well as their potential indications for the clinical management of RHT patients are summarised in this systematic review article.

Prevalence, Risk Factors and Cardiovascular Comorbidities of Resistant Hypertension among Treated Hypertensives in a Nigerian Population

The true prevalence and cardiovascular comorbidities of resistant hypertension (RH) in Nigeria and Africa are not known. We sought to determine the prevalence and cardiovascular comorbidities of resistant hypertension in a treated Nigerian hypertensive population. We analyzed 1,378 patients with essential hypertension from a prospective clinical registry, the Federal Medical Centre Abuja Hypertension Registry. Resistant hypertension was defined as blood pressure ≥140/90 mmHg despite the use of ≥3 guideline-recommended antihypertensive medications including a diuretic, reninangiotensin system blocker and calcium-channel blocker at optimal or best-tolerated doses or blood pressure <140/90 mmHg on ≥4 antihypertensive medications. Resistant hypertension was confirmed with the use of home blood pressure monitoring while adherence was determined by monitoring prescription orders. The prevalence of resistant hypertension was 15.5%, with 12.3% as controlled resistant hypertension and 3.3% as uncontrolled resistant hypertension. Risk factors independently associated with the odds of resistant hypertension were male sex (adjusted odds ratio [AOR]: 1.62, 95% confidence interval [CI] 1.19-2.21, p = 0.002), obesity, and diabetes mellitus. Furthermore, patients with resistant hypertension were more likely to have heart failure with preserved ejection fraction (AOR: 3.36, 95% CI 1.25-9.07, p = 0.017), cerebrovascular disease, and chronic kidney disease. In our treated hypertensive cohort, resistant hypertension was associated with an increased risk of cerebrovascular disease, chronic kidney disease, and heart failure with preserved ejection fraction, and it appears this burden maybe 2-3 times more in those with resistant hypertension compared to those without. Concerted efforts to prevent or promptly treat resistant hypertension in our population will reduce cardiovascular comorbidities.

Factors predicting medication adherence among coronary artery disease patients in Saudi Arabia: A descriptive study

OBJECTIVES

To measure medication adherence among coronary artery disease (CAD) patients and identify sociodemographic factors that are medication adherence predictors.

METHODS

A cross-sectional correlation design was carried out, following the STROBE guidelines. The study was carried out in a specialized cardiac center in the western region of Saudi Arabia between March 2019 and January 2020. A total of 278 patients completed the study survey.

RESULTS

The majority of participants (59.4%) reported moderate medication adherence, and the remainder reported poor (30.6%) and good (10%) medication adherence. It was found that women patients, patients with higher education levels, non-smokers, patients who regularly followed-up with their cardiologist, and patients with family support showed significantly higher medication adherence. Four of the sociodemographic variables (gender, number of doctor visits, family support, and education level) predicted medication adherence.

CONCLUSION

Approximately 30% of the participants reported poor medication adherence. The number of cardiologist visits and the level of family support were 2 of the factors found to be associated with medication adherence.

Factors Influencing Medication Adherence in Elderly Patients with Hypertension: A Single Center Study in Western China

Purpose

To develop and empirically test a conceptual model that explains the factors influencing antihypertensive medication adherence behavior in elderly patients in a city in western China.

Patients and Methods

The conceptual model was based on the Theory of Planned Behavior and the Health Belief Model and was empirically tested using cross-sectional survey data from Nanchong City, a city in western China, collected between October and December 2020. Data were analyzed using structural equation modeling.

Results

Behavioral intentions were the main predictor of medication adherence behavior (path coefficient of 0.353). Perceived benefits and perceived barriers directly (path coefficient = 0.201 and -0.150, respectively), and indirectly (path coefficient = 0.118 and -0.060) through behavioral intentions, influenced medication adherence behavior. Perceived susceptibility (path coefficient = 0.390) and perceived severity (path coefficient = 0.408) influenced behavioral attitudes, which influenced behavioral intentions (path coefficient = 0.298).

Conclusion

The conceptual model demonstrates a robust ability to predict and explain medication adherence behavior among elderly patients with hypertension, facilitating the adoption and maintenance of changes in adherence behavior and the potential for preventing disease progression and improving quality of life.

The association between drug therapy problems and blood pressure control of patients with hypertension in public health center setting

Background: Patients with hypertension are at risk of experiencing Drug Therapy Problems (DTPs). However, few have studied the pattern of DTPs in Indonesian public health center (PHC) and how it affected the blood pressure control. Objective: This study aims to identify DTPs and its association to blood pressure control among patients with hypertension in Indonesian PHCs. Methods: A descriptive, observational and cross-sectional study involving 150 selected persistent hypertensive patients was conducted from August to December 2019 in 63 PHCs in Surabaya. A questionnaire asking patients’ experiences during treatment of hypertension was used. Chi-square test was used to analyze the association between DTPs and blood pressure control. Results: The majority of respondents were aged 50-65 (54.7%), female (76%), only half has controlled blood pressure (52.7%) and most of them used three to four medicines at the same time (57.3%). A total 563 DTPs was identified with 15.6% was unnecessary drug use, 11.4% indicated need for additional drug therapy, one-fifth experienced dosage too low (21.5%) and non-adherence (19.2%) and 26% suffered from adverse drug reactions. There was a significant association between number of DTPs and blood pressure control (P<0.05). Conclusion: Most patients experienced more than two DTPs and undertook more than three medicines at the same time. There is a significant association between the number of DTPs in hypertensive patient and the blood pressure control.

A Subgroup Meta-Analysis Comparing the Renal Denervation Sham-Controlled Randomized Trials Among Those With Resistant and Nonresistant Hypertension

Renal denervation (RD) has been investigated as an invasive blood pressure (BP) lowering treatment for hypertension (HTN). Resistant HTN (RHTN) has been defined as uncontrolled BP despite use of 3 antihypertensive medications of different classes, including a diuretic, at maximum tolerated doses. The impact of RD on RHTN remains under investigation. Ten sham-controlled trials testing RD were included in this trial-level analysis. A prespecified subgroup analysis was conducted to test whether efficacy of RD differed in patients with and without RHTN. The primary end points were change in 24-hour ambulatory systolic (SBP) and diastolic (DBP) using raw mean difference (RMD) between sham control and RD. Ten studies (6 RHTN and 4 nonresistant HTN) were identified that included 1,544 participants (1,001 RHTN and 543 essential HTN) with cumulative mean age (±SD) of 57 years (±3). Cochran risk of bias assessment showed 69% of the domains to be at low risk of bias. The RMD for 24-hour SBP between RD and sham control was statistically significant for nonresistant HTN trials (-4.19 mm Hg; 95% confidence interval [CI] -6.07 to -2.30) but was not statistically significant for RHTN trials (-1.86 mm Hg; 95% CI - 3.89 to 0.16). Despite the numerical difference in the subgroups, the interaction between subgroups failed to reach statistical significance (p = 0.10). The RMD for 24-hour DBP between RD and sham control was statistically significant for nonresistant HTN trials (-2.60 mm Hg; 95% CI -3.79 to -1.42) but was not statistically significant for RHTN trials (-0.67 mm Hg; 95% CI -1.84 to 0.50). The interaction between subgroups was statistically significant (p = 0.02). Our analysis indicates RD is a less effective intervention for patients with RHTN. These data may be beneficial for clinicians to consider when assessing patients with RHTN for RD.

The effect of the multimodal intervention on blood pressure in patients with first ischemic stroke: A randomized controlled trial

Background

Multimodal intervention is currently promoted to control blood pressure in patients with first ischemic stroke. However, a dearth of studies has examined the influence of the intervention among patients with ischemic stroke, particularly in Thailand.

Objective

This study aimed to determine the effect of the multimodal intervention on blood pressure in patients with first ischemic stroke.

Methods

A randomized controlled trial was conducted. Sixty participants were randomly selected from two tertiary hospitals in Thailand. Eligible participants were randomly assigned into an experimental group (n = 30) and a control group (n = 30). The experimental group was provided with the multimodal intervention, while the control group was given the usual care. Data were collected from May 2021 to October 2021 at baseline (pre-test), 4^th week, 8^th week, and 12^th week using the demographic data form and sphygmomanometer. The data were analyzed using the Chi-square test, t-test, and repeated measure analysis of variance (ANOVA).

Results

The participants' blood pressures after receiving the multimodal intervention were lower than those before receiving the multimodal intervention. Both systolic and diastolic blood pressure were statistically significantly decreased over time, starting from baseline to the 8^th week and 12^th week (p <0.001). In addition, the participants' mean scores of systolic blood pressure (F (1, 58) = 4.059, p = 0.049) and diastolic blood pressure (F (1, 58) = 4.515, p = 0.038) were lower than the control group.

Conclusion

The multimodal intervention is effective in controlling blood pressure. Therefore, nurses should educate patients with ischemic stroke to manage systolic and diastolic blood pressure, facilitate the patient's participation in the exercise program, and monitor the patients via telephone to continue blood pressure control.

Trial Registry

Thai Clinical Trials Registry (TCTR) identifier number 20210318001.

Towards an integrated blood pressure self-monitoring solution for stroke/TIA in Ireland: a mixed methods feasibility study for the TASMIN5S IRL randomised controlled trial

BACKGROUND

Optimising blood pressure (BP) control is one of the most important modifiable risk factors in preventing subsequent stroke where the risk increases by one-third for every 10 mmHg rise in systolic BP. This study evaluated the feasibility and potential effectiveness of blood pressure self-monitoring with planned medication titration, to inform a definitive trial of the intervention, in patients with a previous stroke or transient ischaemic attack (TIA).

METHODS

Patients with a history of stroke/TIA and sub-optimal BP control were invited to take part in a mixed methods feasibility study for a randomised controlled trial. Those meeting the inclusion criteria with systolic BP >130 mmHg were randomised to a self-monitoring intervention group or usual care group. The intervention involved self-monitoring BP twice a day for 3 days within a 7-day period, every month, following text message reminders. Treatment escalation, based on a pre-agreed plan by the general practitioner (GP) and patient, was initiated according to the results of these readings. Semi-structured interviews were carried out with patients and clinicians and analysed thematically.

RESULTS

Of those identified, 47% (32/68) attended for assessment. Of those assessed, 15 were eligible for recruitment and were consented and randomised to the intervention or control group on a 2:1 basis. Of those randomised, 93% (14/15) completed the study and there were no adverse events. Systolic BP was lower in the intervention group at 3 months. Participants found the intervention acceptable and easy to use. GPs found it easy to incorporate into their practice activity without increasing workload.

CONCLUSIONS

TASMIN5S, an integrated blood pressure self-monitoring intervention in patients with a previous stroke/TIA, is feasible and safe to deliver in primary care. A pre-agreed three-step medication titration plan was easily implemented, increased patient involvement in their care, and had no adverse effects. This feasibility study provides important information to inform a definitive trial to determine the potential effectiveness of the intervention in patients post-stroke or TIA.

TRIAL REGISTRATION

ISRCTN57946500 . Registered on 12/08/2019.

Controversies in Hypertension II: The Optimal Target Blood Pressure

The optimal target blood pressure in the treatment of hypertension is undefined. Whether more intense therapy is better than standard, typically <140/90 mm Hg, is controversial. The most recent American guidelines recommend ≤130/80 mm Hg for essentially all adults. There have been at least 28 trials targeting more versus less intensive therapy, including 13 aimed at reducing cardiovascular events and mortality, 11 restricted to patients with chronic kidney disease, and 4 with surrogate endpoints. We review these trials in a narrative fashion due to significant heterogeneity in targets chosen, populations studied, and primary endpoints. Most were negative, although some showed significant benefit to more intense therapy. When determining the optimal pressure for an individual patient, additional factors should be considered, including age, frailty, polypharmacy, baseline blood pressure, and the diastolic blood pressure J-curve. We discuss these modifying factors in detail. Whereas the tenet "lower is better" is generally true, one size does not fit all, and blood pressure control must be individualized.

Opinions on hypertension care and therapy adherence at the healthcare provider and healthcare system level: a qualitative study in the Hague, Netherlands

OBJECTIVES

Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood pressure is common despite use of these medications. One explanation is therapy non-adherence. Therapy non-adherence can be addressed at the individual level, the level of the healthcare provider and at the healthcare system level. Since the latter two levels are often overlooked, we wished to explore facilitators and barriers on each of these levels in relation to hypertension care for people with hypertension, with a specific focus on therapy adherence.

DESIGN

Qualitative study using focus groups of healthcare providers. Data were analysed using the theoretical domains framework (TDF) and the behaviour change wheel.

SETTING AND PARTICIPANTS

Participants were from a highly urbanised city environment (the Hague, Netherlands), and included nine primary care physicians, six practice nurses and five secondary care physicians involved in hypertension care.

RESULTS

Nine domains on the TDF were found to be relevant at the healthcare provider level ('knowledge', 'physical, cognitive and interpersonal skills', 'memory, attention and decision processes', 'professional, social role and identity', 'optimism', 'beliefs about consequences', 'intention', 'emotion' and 'social influences') and two domains ('resources' and 'goals') were found to be relevant at the system level. Facilitators for these domains were good interpersonal skills, paying attention to behavioural factors such as medication use, and the belief that treatment improves health outcomes. Barriers were related to time, interdisciplinary collaboration, technical and financial issues, availability of blood pressure devices and education of people with hypertension.

CONCLUSIONS

This study highlighted a need for better collaboration between primary and secondary care, for more team-based care including pharmacists and social workers, tools to improve interpersonal skills and more time for patient-healthcare provider communication.

Mobile Health Applications and Medication Adherence of Patients With Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

Current evidence has revealed the beneficial effects of mobile health applications on systolic and diastolic blood pressure. However, there is still no solid evidence of the underlying factors for these outcomes, and hypertension treatment is performed mainly by medication intake. This study aims to analyze the impacts of health applications on medication adherence of patients with hypertension and understand the underlying factors.

METHODS

A systematic review and meta-analysis were conducted considering controlled clinical trials published, without year filter, through July 2020. The searches were performed in the electronic databases of Scopus, MEDLINE, and BVSalud. Study characteristics were extracted for qualitative synthesis. The meta-analysis examined medication-taking behavior outcomes using the generic inverse-variance method to combine multiple variables.

RESULTS

A total of 1,199 records were identified, of which 10 studies met the inclusion criteria for qualitative synthesis, and 9 met the criteria for meta-analysis with 1,495 participants. The analysis of mean changes revealed significant improvements in medication adherence (standardized mean difference=0.41, 95% CI=0.02, 0.79, I²=82%, p=0.04) as well as the analysis of the values measured after follow-up (standardized mean difference=0.60, 95% CI=0.30, 0.90, I²=77%, p<0.0001). Ancillary improvements were also identified, such as patients' perceived confidence, treatment self-efficacy and self-monitoring, acceptance of technology, and knowledge about the condition and how to deal with health issues.

DISCUSSION

There is evidence that mobile health applications can improve medication adherence in patients with hypertension, with broad heterogeneity between studies on the topic. The use of mobile health applications conceivably leads to ancillary improvements inherent to better medication adherence.

Catheter-based ultrasound renal denervation in patients with resistant hypertension: the randomized, controlled REQUIRE trial

Renal denervation is a promising new non-pharmacological treatment for resistant hypertension. However, there is a lack of data from Asian patients. The REQUIRE trial investigated the blood pressure-lowering efficacy of renal denervation in treated patients with resistant hypertension from Japan and South Korea. Adults with resistant hypertension (seated office blood pressure ≥150/90 mmHg and 24-hour ambulatory systolic blood pressure ≥140 mmHg) with suitable renal artery anatomy were randomized to ultrasound renal denervation or a sham procedure. The primary endpoint was change from baseline in 24-hour ambulatory systolic blood pressure at 3 months. A total of 143 patients were included (72 renal denervation, 71 sham control). Reduction from baseline in 24-hour ambulatory systolic blood pressure at 3 months was not significantly different between the renal denervation (-6.6 mmHg) and sham control (-6.5 mmHg) groups (difference: -0.1, 95% confidence interval -5.5, 5.3; p = 0.971). Reductions from baseline in home and office systolic blood pressure (differences: -1.8 mmHg [p = 0.488] and -2.0 mmHg [p = 0.511], respectively), and medication load, did not differ significantly between the two groups. The procedure-/device-related major adverse events was not seen. This study did not show a significant difference in ambulatory blood pressure reductions between renal denervation and a sham procedure in treated patients with resistant hypertension. Although blood pressure reduction after renal denervation was similar to other sham-controlled studies, the sham group in this study showed much greater reduction. This unexpected blood pressure reduction in the sham control group highlights study design issues that will be addressed in a new trial. CLINICAL TRIAL REGISTRATION: NCT02918305 ( http://www.clinicaltrials.gov ).

Urine N-acetyl-Ser-Asp-Lys-Pro measurement as a versatile biomarker to assess adherence to angiotensin-converting enzyme inhibitors

BACKGROUND

Poor adherence to treatment is a major health issue in hypertension. The large number of drugs to be detected limits the implementation of chemical adherence testing by liquid chromatography/mass spectrometry (LC-MS/MS). AcSDKP, a peptide accumulating in the presence of angiotensin-converting-enzyme inhibitor (ACEI) treatment, has been validated as a proven marker of adherence by enzyme-linked immunosorbent assay. Our aim was to validate urine measurements of AcSDKP compared with active metabolites of various ACEI, measured simultaneously by LC-MS/MS.

METHOD

We first studied the time-dependent relationships between urinary perindoprilat and AcSDKP in a pharmacokinetic/pharmacodynamic study in healthy volunteers. We then compared the sensitivity and specificity of urinary AcSDKP vs. three ACEI active metabolites (enalaprilat, perindoprilat, ramiprilat) taken as reference to detect nonadherence in spot urine samples from a prospective cohort of hypertensive outpatients.

RESULTS

The urinary excretion profiles of AcSDKP and perindoprilat were similar, exhibited a significant correlation, and showed excellent agreement in healthy volunteers. In patients, we found a similar agreement between AcSDKP and the three ACEI metabolites urinary concentrations. The sensitivity and specificity for adherence assessment of urine AcSDKP was 92.2 and 100%, respectively. We observed a difference in the evaluation of good adherence between ACEI metabolites (85.7%) and AcSDKP (79.0%) because of discrepancies in samples where AcSDKP reached undetectability quicker than ACEI metabolites. This characteristic of AcSDKP is of particular interest and could better reflect the true adherence status of patients.

CONCLUSION

Overall, spot urine AcSDKP measurement by LC-MS/MS is a reliable marker of the intake of ACEI treatment and could substitute ACEI metabolites detection.

Barriers and Solutions to Improve Therapeutic Adherence from the Perspective of Primary Care and Hospital-Based Physicians

PURPOSE

To identify the barriers affecting treatment adherence in patients with chronic disease and to determine solutions through the physician's opinion of primary care and hospital settings.

METHODS

An observational study using the nominal group technique was performed to reach a consensus from experts. A structured face-to-face group discussion was carried out with physicians with more than 10 years of experience in the subject of treatment adherence/compliance in either the primary care setting or the hospital setting. The experts individually rated a list of questions using the Likert scale and prioritized the top 10 questions to identify barriers and seek solutions afterward. The top 10 questions that obtained the maximum score for both groups of experts were prioritized. During the final discussion group, participating experts analyzed the prioritized items and debated on each problem to reach consensual solutions for improvement.

RESULTS

A total of 17 professionals experts participated in the study, nine of them were from a primary care setting. In the expert group from the primary care setting, the proposed solution for the barrier identified as the highest priority was to simplify treatments, measure adherence and review medication. In the expert group from the hospital setting, the proposed solution for the barrier identified as the highest priority was training on motivational clinical interviews for healthcare workers undergraduate and postgraduate education. Finally, the expert participants proposed implementing an improvement plan with eight key ideas.

CONCLUSION

A consensual improvement plan to facilitate the control of therapeutic adherence in patients with chronic disease was developed, taking into account expert physicians' opinions from primary care and hospital settings about barriers and solutions to address therapeutic adherence in patients with chronic disease.

Nonadherence in Hypertension: How to Develop and Implement Chemical Adherence Testing

Nonadherence to antihypertensive medication is common, especially in those with apparent treatment-resistant hypertension (true treatment-resistant hypertension requires exclusion of nonadherence), and its routine detection is supported by clinical guidelines. Chemical adherence testing is a reliable and valid method to detect adherence, yet methods are unstandardized and are not ubiquitous. This article describes the principles of chemical adherence testing for hypertensive patients and provides a set of recommendations for centers wishing to develop the test. We recommend testing should be done in either of two instances: (1) in those who have resistant hypertension or (2) in those on 2 antihypertensives who have a less than 10 mm Hg drop in systolic blood pressure on addition of the second antihypertensive medication. Furthermore, we recommend that verbal consent is secured before undertaking the test, and the results should be discussed with the patient. Based on medications prescribed in United Kingdom, European Union, and United States, we list top 20 to 24 drugs that cover >95% of hypertension prescriptions which may be included in the testing panel. Information required to identify these medications on mass spectrometry platforms is likewise provided. We discuss issues related to ethics, sample collection, transport, stability, urine versus blood samples, qualitative versus quantitative testing, pharmacokinetics, instrumentation, validation, quality assurance, and gaps in knowledge. We consider how to best present, interpret, and discuss chemical adherence test results with the patient. In summary, this guidance should help clinicians and their laboratories in the development of chemical adherence testing of prescribed antihypertensive drugs.

Is the KDIGO Systolic Blood Pressure Target <120 mm Hg for Chronic Kidney Disease Appropriate in Routine Clinical Practice?

Meticulous management of hypertension is important in chronic kidney disease (CKD) to reduce the risk of cardiovascular disease, mortality, and progression of CKD. The recently published Kidney Disease Improving Global Outcomes (KDIGO) guideline on blood pressure (BP) management in CKD stresses the importance of standardized BP measurement and strict control of BP. This is a useful document that will help to improve the management of hypertension in CKD globally. However, the recommendation of systolic BP target of <120 mm Hg by KDIGO is controversial. It is based on weak evidence derived mainly from a single randomized controlled trial and its CKD subgroup analysis. Here, we review the current evidence surrounding BP target in CKD. We argue that the target recommended by KDIGO is not generalizable to the majority of people with CKD. Standardized BP measurements are challenging to implement outside specialist hypertension and research clinics, and the target of <120 mm Hg BP systolic cannot be extrapolated to routine clinic BP measurements. If applied to routine BP measurement, this target will expose the multimorbid and frail CKD patients to the risk of adverse events including falls and fractures. Furthermore, it will not be achievable in the majority of CKD patients. The target recommended by KDIGO is an outlier among contemporary major international hypertension guidelines and is likely to perplex clinicians. We believe the KDIGO-recommended target systolic BP <120 mm Hg for CKD is inappropriate in the majority of CKD patients and it may even be harmful for patients managed in routine clinical practice.

Medication Adherence and Treatment-Resistant Hypertension in Newly Treated Hypertensive Patients in the United Arab Emirates

(1) Background: The present study aimed to analyze medication adherence and its effect on blood pressure (BP) control and assess the prevalence of treatment-resistant hypertension (TRH) among newly treated hypertensive patients in the United Arab Emirates (UAE); (2) Methods: A retrospective chart review was conducted to evaluate 5308 naïve hypertensive adults registered for the treatment across Abu Dhabi Health Services (SEHA) clinics in Abu Dhabi in 2017. After collecting data regarding basic details and BP measurements, patients were followed up for six months. Patients who did not reach BP targets despite taking three or more antihypertensive medications were defined as TRH; (3) Results: The overall adherence to antihypertensive treatment was 42%. At 6-month, a significant reduction in BP was observed in patients adherent to medications (systolic: -4.5 mm Hg and diastolic: -5.9 mm Hg) than those who were nonadherent to antihypertensive therapy (1.15 mm Hg and 3.59 mm Hg). Among 189 patients using three or more antihypertensive medications for six months, only 34% (n = 64) were adherent to the treatment, and only 13.7% (n = 26) reached the BP target. The prevalence of TRH was 20.1%; (4) Conclusions: Medication adherence and BP control among the participants were suboptimal. The study shows a high prevalence of TRH among newly treated hypertensives in the UAE. More extraordinary efforts toward improving adherence to antihypertensive therapy and more focus toward BP control and TRH are urgently needed.

A Scoping Review of Methods Used to Assess Medication Adherence in Patients with Chronic Conditions

BACKGROUND

Medication nonadherence of patients with chronic conditions is a complex phenomenon contributing to increased economic burden and decreased quality of life. Intervention development relies on accurately assessing adherence but no "gold standard" method currently exists.

PURPOSE

The present scoping review aimed to: (a) review and describe current methods of assessing medication adherence (MA) in patients with chronic conditions with the highest nonadherence rates (asthma, cancer, diabetes, epilepsy, HIV/AIDS, hypertension), (b) outline and compare the evidence on the quality indicators between assessment methods (e.g., sensitivity), and (c) provide evidence-based recommendations.

METHODS

PubMed, PsycINFO and Scopus databases were screened, resulting in 62,592 studies of which 71 met criteria and were included.

RESULTS

Twenty-seven self-report and 10 nonself-report measures were identified. The Medication Adherence Report Scale (MARS-5) was found to be the most accurate self-report, whereas electronic monitoring devices such as Medication Event Monitoring System (MEMS) corresponded to the most accurate nonself-report. Higher MA rates were reported when assessed using self-reports compared to nonself-reports, except from pill counts.

CONCLUSIONS

Professionals are advised to use a combination of self-report (like MARS-5) and nonself-report measures (like MEMS) as these were found to be the most accurate and reliable measures. This is the first review examining self and nonself-report methods for MA, across chronic conditions with the highest nonadherence rates and provides evidence-based recommendations. It highlights that MA assessment methods are understudied in certain conditions, like epilepsy. Before selecting a MA measure, professionals are advised to inspect its quality indicators. Feasibility of measures should be explored in future studies as there is presently a lack of evidence.

Physical Inactivity is Liable to the Increased Cardiovascular Risk and Impaired Cognitive Profile

BACKGROUND

Sedentary life-style is a significant public health issue. It increases the incidence of type-2 diabetes mellitus (DM2) and systemic arterial hypertension (SAH), which in turn may impair physical and mental health. In fact, disrupted glucose metabolism is characteristic of Alzheimer's dementia, and it is often dubbed as type-3 diabetes.

OBJECTIVE

The purpose of this study was to assess the level of activity, body composition, cardiovascular risk and cognitive profile of patients with DM2 and/or SAH. The study was cross-sectional design.

METHOD

The sample consisted of 120 individuals which 35% men and 65% women, with an average of 64±9 years old and 60±11 years old, respectively. Various parameters were evaluated such as anthropometric variables, pedometer recordings and brief cognitive screening battery (BCSB), which assesses the immediate memory, verbal fluency, learning, late memory and recognition. Chi-square and Fisher's exact test were applied to observe possible differences between men and women. In addition to Kruskall-Wallis, in the comparison between patients with SAH; DM2 and SAH + DM2.

RESULTS

A high rate of physical inactivity was found among those enrolled in this project. Females were characterized by increased body fat, whereas men displayed visceral fat excess. BCSB demonstrated reduced verbal fluency, late memory and recognition, with women presenting significantly worse results.

CONCLUSION

Low level of daily physical activity is apparently correlated with obesity, elevated cardiovascular risk, and cognitive dysfunction.

Adherence to antihypertensive medication after referral to secondary healthcare: A prospective cohort study

BACKGROUND

Nonadherence (NAd) to antihypertensive medication is associated with lack of blood pressure control and worsened long-term outcomes. Increased access to a programme for high-risk cardiovascular patients has the potential to reduce NAd and improve clinical outcomes. We evaluated implementation NAd prevalence and risk factors among severely hypertensive patients after 12-month-long access to secondary healthcare centres.

METHODS

The Morisky Green Levine Scale (MGLS) was used to analyse antihypertensive medication NAd in a prospective cohort of 485 patients. Logistic regression models evaluated the influence of ecological model factors on NAd.

RESULTS

The majority of patients were female, had low health literacy, a low family income and a mean age of 61.8 ± 12.5 years. Prevalence of NAd fell from 57.1% at programme entry to 28.3% (P < .001) at the end of the study. After access to a secondary healthcare centre, we observed better blood pressure control, an increase in the number of pills/day and a higher number of antihypertensive medications. Predictive variables of NAd were age (OR 1.027; CI 1.003-1.051; P = .023), low health literacy (OR 1.987; CI 1.009-3.913; P = .047), systolic blood pressure (OR 1.010; CI 1.003-1.021; P = .049), dosages ≥ 2 times/day (OR 1.941; CI 1.091-3.451; P = .024) and patient satisfaction with the healthcare team (OR 0.711; IC 0.516-0.980; P = .037).

CONCLUSIONS

Greater access to health services is associated with a reduction in NAd to antihypertensive medication and better blood pressure control. NAd was correlated with modifiable variables such as treatment complexity and, for the first time, team satisfaction, suggesting that implementation of similar programmes may limit NAd in similar patient groups.

Hypertension Canada's 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children

Hypertension Canada's 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.

Real-life appraisal on blood pressure targets achievement in adult outpatients at high cardiovascular risk

BACKGROUND AND AIM

Although hypertension guidelines highlight the benefits of achieving the recommended blood pressure (BP) targets, hypertension control rate is still insufficient, mostly in high or very high cardiovascular (CV) risk patients. Thus, we aimed to estimate BP control in a cohort of patients at high CV risk in both primary and secondary prevention.

METHODS AND RESULTS

A single-center, cross-sectional study was conducted by extracting data from a medical database of adult outpatients aged 40-75 years, who were referred to our Hypertension Unit, Rome (IT), for hypertension assessment. Office BP treatment targets were defined according to 2018 ESC/ESH guidelines as: a)<130/80 mmHg in individuals aged 40-65 years; b)<140/80 mmHg in subjects aged >65 years. Primary prevention patients with SCORE <5% were considered to be at low-intermediate risk, whilst individuals with SCORE ≥5% or patients with comorbidities were defined to be at very high risk. Among 6354 patients (47.2% female, age 58.4 ± 9.6 years), 4164 (65.5%) were in primary prevention with low-intermediate CV risk, 1831 (28.8%) in primary prevention with high-very high CV risk and 359 (5.6%) in secondary prevention. In treated hypertensive outpatients, uncontrolled hypertension rate was significantly higher in high risk primary prevention than in low risk primary prevention and secondary prevention patients (18.4% vs 24.4% vs. 12.5%, respectively; P < 0.001). In high risk primary prevention diabetic patients only 10% achieved the recommended BP targets.

CONCLUSIONS

Our data confirmed unsatisfactory BP control among high-risk patients, both in primary and secondary prevention, and suggest the need for a more stringent BP control policies in these patients.

Factors That Influence Adherence to Medication in Adults With Congenital Heart Disease (ACHD)

Objective: Innovative operative and interventional procedures have improved survival in congenital heart disease (CHD), and today more than 90% of these children reach adulthood. Consequently, adherence and psychosocial issues are becoming increasingly important because non-adherence to treatment recommendations worsens morbidity and mortality. This study aimed to identify factors modifying adherence to medication in adult congenital heart disease (ACHD). Methods: This cross-sectional study included 451 outpatients (female 47.9%, average age ± SD: 37.9 ± 12 years) from the ACHD department, who completed a questionnaire assessing medication non-adherence and individual barriers to treatment. Further assessments included psychological well-being (Hospital Anxiety and Depression scale; HADS), childhood traumatization, sociodemographic, and clinical data. Binary logistic regression analysis calculated the impact of these factors on drug adherence. Results: Of the 451 patients 162 participants (35.9%) reported to be non-adherent. In univariate analysis non-adherence to treatment was associated with smoking (P = < 0.001) and internet addiction (P = 0.005). Further factors negatively influencing adherence were the presence of depressive symptoms (P = 0.002), anxiety (P = 0.004), and childhood traumatization (p = 0.002). Factors positively associated with adherence were older age (P = 0.003) and more advanced heart disease as indicated by NYHA class (P = 0.01), elevated NT-proBNP (P = 0.02), device therapy (P = 0.002) and intermittent arrhythmias (P = 0.01). In multivariate analysis especially psychopathological factors such as depression (P = 0.009), anxiety (P = 0.032) and childhood traumatization (P = 0.006) predicted non-adherence. Conclusion: Adherence is a critical issue in the long-term management of ACHD. Identifying modifiable factors that worsen adherence offers the opportunity for targeted interventions. Depressive symptoms, anxiety, and adverse childhood experiences are amenable to psychosocial interventions, as well as cigarette smoking. Our study suggests that a multimodal and interdisciplinary treatment concept for the long-term management of adults with congenital heart disease could be beneficial. Whether it will further improve morbidity and mortality, should be assessed in prospective interventions.

Individual interventions to improve adherence to pharmaceutical treatment, diet and physical activity among adults with primary hypertension. A systematic review protocol

INTRODUCTION

Hypertension is a chronic disease with 31% worldwide prevalence in adults. It has been associated with non-adherence to therapeutic regime with a negative impact on the prognosis of the disease and healthcare-associated costs. So, it is necessary to identify effective interventions to improve adherence among the afflicted population. The objective of this protocol is to describe the methods for a systematic review that will evaluate the effect of individual interventions so as to improve adherence to the prescribed pharmacological treatment, as well as to prescribed diet and physical activity in adults with primary hypertension.

METHODS AND ANALYSIS

A systematic search of studies will be conducted in PubMed/MEDLINE, BVS, CINAHL, Embase, Cochrane and Scopus databases. Randomised and non-randomised clinical studies conducted in human beings, published from 1 January 2009 to 13 December 2019, are to be included, in any language. Adherence to pharmacological treatment, diet and physical activity, measured by direct and indirect methods, will be the primary outcome. Two independent reviewers will select relevant studies and will extract the data following the Cochrane's Handbook for Systematic Reviews of Approach and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. Methodological quality will be evaluated using the risk-of-bias (RoB) 2 and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tools. Risk of bias will also be evaluated, and if the criteria are met, a meta-analysis will be finally performed.

ETHICS AND DISSEMINATION

Information to be analysed is of a grouped nature, and given that its sources are published studies, no ethics committee approval is required. Results will be published in scientific journals, and in conferences, seminars and symposiums. Copyrights will be addressed by giving due credit through bibliographic references.

PROSPERO REGISTRATION NUMBER

CRD42020147655.

Is there any Hope for Monitoring Adherence in an Efficient and Feasible Way for Resistant Hypertension Diagnosis and Follow-Up?

PURPOSE OF REVIEW

Non-adherence to antihypertensive treatment is highly prevalent and represents a major factor affecting their effectiveness in hypertensive patients, thus contributing to apparent treatment resistance. It is however often overlooked because the methods to assess non-adherence are mainly subjective, limiting their usefulness in clinical practice. Non-adherence to treatment affects daily patient management, resulting in inappropriate, costly, and potentially harmful treatments and loss of the expected benefits from antihypertensive drugs.

RECENT FINDINGS

Specialized centers now use a combination of objective screening tools. Firstly, snapshots of adherence levels can be provided by analytical drug detection in various biological matrixes using liquid chromatography-tandem mass spectrometry (LC-MS/MS) and secondly electronic monitoring systems of drug delivery which provide longitudinal data on adherence. Routine utilization of those tools allows the detection of non-adherence in patients with resistant hypertension, thus enabling implementation of appropriate interventions to improve drug adherence and avoid unnecessary treatment intensification. Other complementary techniques, such as digital health feedback system with ingestible sensors, are currently evaluated. In the context of an increasing burden of uncontrolled and apparent treatment-resistant hypertension, detecting non-adherence to antihypertensive therapy is, as acknowledged by the latest guidelines, a top priority to implement in clinical practice but still faces medical conservatism and disbelief.

Lowered blood pressure targets identify new, uncontrolled hypertensive cases: patient characteristics and implications for services in Thailand

BACKGROUND

According to the new hypertension treatment guidelines blood pressure (BP) readings need to be kept below or equal to 130/80 mmHg in patients aged less than 65 years old. This study shows the change in proportion of identified cases of uncontrolled blood pressure in light of these changes.

METHODS

The data was collected from 248 hypertensive patients who had visited an outpatient clinic at the Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Thailand. Patients were classified into three groups: The 3 groups were: 1) controlled BP group (BP is 130/80 mmHg or lower); 2) newly identified uncontrolled group (BP between 130/80 mmHg and 140/90 mmHg) and 3) existing uncontrolled group (BP higher than 140/90 mmHg). Health behaviors, past history related to hypertensive disease and current pharmacological treatments were compared.

RESULTS

Of the total 248 patients, 56% were female and the mean age was 58.8 (sd 5.99) years old. Following application of the new guidelines, the group designated as uncontrolled increased from 21.7 to 74.2%, an additional 52.4% due to new BP targets. Higher BMI was associated with uncontrolled HT (p = 0.043). While the average number of medication taken was similar across the three groups, it was poor medication adherence (p < 0.013) which was associated with the uncontrolled disease.

CONCLUSIONS

Lower BP targets will increase the number of identified hypertensive patients. While intensifying pharmacological treatment may be considered, our study suggests that two behavioral factors should not be overlooked. Weight reduction and enhancement of medication adherence remains an important mainstream treatment strategy.

Blood pressure control in patients with a previous stroke/transient ischaemic attack in primary care in Ireland: a cross sectional study

BACKGROUND

Uncontrolled blood pressure (BP) is an important modifiable risk factor for recurrent stroke. Secondary prevention measures when implemented can reduce stroke re-occurrence by 80%. However, hypertension control rates remain sub-optimal, and little data is available from primary care where most management occurs. The aim of this study was to describe BP control in primary care-based patients with a previous stroke or transient ischaemic attack (TIA) in Ireland, and to concurrently examine antihypertensive medication-dosing.

METHODS

Study participants most recent office-based BP reading was compared with the NICE (NG136) and European Society of Hypertension/ European Society of Cardiology (ESH/ESC 2013) goal of BP < 140/90 mmHg. Optimal anti-hypertensive medication dosing was determined by benchmarking prescribed doses for each drug with the World Health Organisation-Defined Daily Dosing (WHO-DDD) recommendations.

RESULTS

We identified 328 patients with a previous stroke or TIA in 10 practices. Blood pressure was controlled in almost two thirds of patients when measured against the ESH/ESC and NICE guidelines (63.1%, n = 207). Of those with BP ≥140/90 (n = 116), just under half (n = 44, 47.3%) were adequately dosed in all anti-hypertensive medications when compared with the WHO-DDD recommendations.

CONCLUSION

Blood pressure control in patients post stroke/TIA appears sub-optimal in over one third of patients. A comparison of drug doses with WHO-DDD recommendations suggests that 47% of patients may benefit from drug-dose improvements. Further work is required to assess how best to manage blood pressure in patients with a previous stroke or TIA in Primary Care, as most consultations for hypertension take place in this setting.

Determinants of medication adherence among hypertensive patients using the Pender's health promotion model

BACKGROUND

Poor adherence in treatment and medication is a global issue in curing the chronic diseases such as hypertension. The present study was conducted to identify the factors related with medication adherence among hypertensive patients referred to the health centers of Borujerd based on the Pender's Health Promotion Model (HPM).

MATERIALS AND METHODS

This cross-sectional study was conducted on 463 patients who were referred to the comprehensive health centers of Borujerd city by cluster sampling method in 2019. The data were collected using a questionnaire including demographic variables and Pender's HPM constructs. Data were analyzed by SPSS 18 software using Pearson correlation coefficient and linear regression.

RESULTS

The mean and standard deviation of the participants' age was 63.29 ± 11.2 years. The results showed that hypertensive patients had a relatively desirable level of medication adherence behavior. Perceived barriers (β = -0.169), perceived self-efficacy (β = 0.196), activity related affect (β = 0.232), and following medication regimen (β = 0.225) were the best predictors of performing the medication adherence behavior. In total, different structures of the HPM explained 42.2% of the variation of medication adherence behavior changes.

CONCLUSIONS

According to the findings, the design of educational programs using HPM is recommended to increase the medication adherence among hypertensive patients.

Uncontrolled and apparent treatment resistant hypertension: a cross-sectional study of Russian and Norwegian 40-69 year olds

BACKGROUND

Uncontrolled hypertension is a major cardiovascular risk factor. We examined uncontrolled hypertension and differences in treatment regimens between a high-risk country, Russia, and low-risk Norway to gain better understanding of the underlying factors.

METHODS

Population-based survey data on 40-69 year olds with hypertension defined as taking antihypertensives and/or having high blood pressure (140+/90+ mmHg) were obtained from Know Your Heart Study (KYH, N = 2284), Russian Federation (2015-2018) and seventh wave of The Tromsø Study (Tromsø 7, N = 5939), Norway (2015-2016). Uncontrolled hypertension was studied in the subset taking antihypertensives (KYH: N = 1584; Tromsø 7: 2792)and defined as having high blood pressure (140+/90+ mmHg). Apparent treatment resistant hypertension (aTRH) was defined as individuals with uncontrolled hypertension on 3+ OR controlled on 4+ antihypertensive classes in the same subset.

RESULTS

Among all those with hypertension regardless of treatment status, control of blood pressure was achieved in 22% of men (KYH and Tromsø 7), while among women it was 33% in Tromsø 7 and 43% in KYH. When the analysis was limited to those on treatment for hypertension, the percentage uncontrolled was higher in KYH (47.8%, CI 95 44.6-50.9%) than Tromsø 7 (38.2, 36.1-40.5%). The corresponding figures for aTRH were 9.8% (8.2-11.7%) and 5.7% (4.8-6.8%). Antihypertensive monotherapies were more common than combinations and used by 58% in Tromsø 7 and 44% in KYH. In both KYH and Tromsø 7, untreated hypertension was higher in men, those with no GP visit in the past year and problem drinkers. In both studies, aTRH was associated with older age, CVD history, obesity, and diabetes. In Tromsø 7, also male gender and any drinking. In KYH, also chronic kidney disease.

CONCLUSION

There is considerable scope for promoting combination therapies in line with European treatment guidelines in both study populations. The factors associated with untreated hypertension overlap with known correlates of treatment non-adherence and health check non-attendance. In contrast, aTRH was characterised by obesity and underlying comorbidities potentially complicating treatment.

Determinants of adherence to anti-hypertensive medications among adult hypertensive patients on follow-up in Hawassa Referral Hospital: A case-control study

Introduction

Hypertension is a global challenge which accounts for high morbidity and mortality rates in the world. The availability of effective anti-hypertensive medications does not result in a good outcome in controlling blood pressure which points towards poor adherence. Thus, this study was conducted to assess the determinants of adherence to anti-hypertensive medication among hypertensive patients on follow-up in Hawassa Referral Hospital.

Methods

Institution-based case-control study was conducted on a sample of 289 clients from February to May 2018. Census was conducted on 1600 clients to select cases and controls. Then, systematic random sampling was used to select study subjects, and adherence was measured by Morisky medication adherence scale. The associations of variables were analyzed using bivariable followed by multivariable logistic regression analyses.

Results

The respondent's adherence to medication was found to be 67% as measured by Morisky medication adherence scale. The multivariate logistic regression analysis showed that medication adherence was found to be better in younger age (<45) (AOR = 3.8), clients living in urban areas (AOR = 6.84), those clients who had good knowledge (AOR = 3.13), those with no co-morbidities (AOR = 3.14) and patients who controlled their blood pressure (<140/90) (AOR = 2.35).

Conclusions

The rate of medication adherence was found to be low, and hence educational interventions focusing on factors promoting adherence and patients' health support should be implemented.

Clinic Versus Ambulatory Blood Pressure in Resistant Hypertension: Impact of Antihypertensive Medication Nonadherence

Clinic-ambulatory blood pressure (BP) difference is influenced by patients- and device-related factors and inadequate clinic-BP measurement. We investigated whether nonadherence to antihypertensive medications may also influence this difference in a post hoc analysis of the DENERHTN trial (Renal Denervation for Hypertension). We pooled the data of 77 out of 106 evaluable patients with apparent resistant hypertension who received a standardized antihypertensive treatment and had both ambulatory BP and drug-screening results available at baseline after 1 month of standardized triple therapy and at 6 months on a median of 5 antihypertensive drugs. After drug assay samplings on study visits, patients took their antihypertensive treatment under supervision immediately after the start of the ambulatory BP recording, and supine clinic BP was measured 24 hours post-dosing; both allowed to calculate the clinic minus daytime ambulatory systolic BP (SBP) difference (clinic-SBP–day-SBP). A total of 29 (37.7%) were found nonadherent to medications at baseline and 38 (49.4%) at 6 months. At baseline, the mean clinic-SBP–day-SBP difference in the nonadherent group was 12.7 mm Hg (95% CI, 7.8–17.7 mm Hg, P <0.001). In contrast, clinic SBP was almost identical to day-SBP in the adherent group (clinic-SBP–day-SBP difference, 0.1 mm Hg; 95% CI, −3.3 to 3.5 mm Hg; P =0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mm Hg cutoff of clinic-SBP–day-SBP difference had 67% sensitivity and 69% specificity to predict nonadherence to the triple therapy at baseline. In conclusion, a large clinic-SBP–day-SBP difference may help discriminating between adherence and nonadherence to treatment in patients with resistant hypertension.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01570777.

Status of and strategies for improving adherence to COPD treatment

Despite the wide application of adherence as a concept, the definition, evaluation and improvement of the adherence to treatment by patients with chronic obstructive pulmonary disease (COPD) still present some challenges. First, it is necessary to clearly define the concepts of treatment adherence, compliance and persistence. Second, it is critical to consider the various methods of evaluating and quantifying adherence when interpreting adherence studies. In addition, the advantages and disadvantages of the different ways of measuring treatment adherence should be taken into account. Another subject of some debate is the number of variables associated with COPD treatment adherence. Adherence is a complex concept that goes beyond the dosage or the use of inhalation devices, and a number of variables are involved in determining adherence, from the clinical aspects of the disease to the patient's confidence in the doctor's expertise and the level of social support experienced by the patient. Notably, despite these challenges, the importance of adherence has been well established by clinical trials and routine clinical practice. The available evidence consistently shows the substantial impact that a lack of adherence has on the control of the disease and its long-term prognosis. For these reasons, the correct evaluation of therapeutic adherence should be a key objective in clinical interviews of patients. In recent years, various initiatives for improving adherence have been explored. All these initiatives have been based on patient education. Therefore, health care professionals should be aware of the issues pertaining to adherence and take the opportunity to educate patients each time they contact the health care system.

Renal sympathetic denervation for treatment of hypertension: where are we now in 2019?

PURPOSE OF REVIEW

Although sound physiological principles and surgical precedent underpin renal denervation as a therapy for treatment resistant hypertension, and early clinical studies had produced encouraging results, the first sham-controlled study (SYMPLICITY HTN-3) failed to achieve its primary efficacy endpoint. Lessons learnt from this trial, and the knowledge derived from further animal and autopsy work, have been applied in three recently published sham-controlled trials.

RECENT FINDINGS

These trials - SPYRAL OFF-MED, RADIANCE SOLO and SPYRAL ON-MED - using newer technologies, demonstrate a 5-10 mmHg incremental reduction in ambulatory SBP from RDN against sham-control, in patients with mild-to-moderate hypertension taking 0-3 drugs.

SUMMARY

These results provide proof of principle of the blood pressure-lowering effect of renal denervation. We now require data on long-term safety and durability of the procedure. Research is needed to identify predictive markers of response as about one-third of individuals do not respond to renal denervation. Hard-outcome data would be welcome but might be difficult to acquire. Individuals with treatment resistance are obvious treatment candidates, but RDN may also potentially benefit those with medication nonadherence and/or intolerance and those unwilling to take pills.