Management of Hypertension in Dialysis

Arterial hypertension is a highly frequent symptom in end-stage renal failure. This study was designed to evaluate the importance of total exchangeable sodium (NaE), plasma renin activity (PRA) and the adrenergic nervous system in the pathogenesis of high blood pressure. 86 patients were studied (26 with end-stage kidney disease and under conservative treatment and 60 on maintenance haemodialysis).

Under conservative treatment a simple linear regression analysis gave a correlation coefficient of 0.794 for NaE × log. PRA against mean arterial pressure (MAP). This data suggests that before the start of the haemodialytic treatment NaE and PRA are important determinants of hypertension.

In patients undergoing chronic heamodialysis the correlation between MAP and the product of NaE × log. PRA was lost. In hypertensive patients we have found indication of an increased adrenergic activity. In fact resting heart rate and two hours walking plasma catecholamines were significantly higher in hypertensive compared with normotensive patients on dialysis. A significant positive correlation was found between basal plasma noradrenaline levels and MAP in 34 patients treated with periodic haemodialysis when hypothyroid patients were excluded.

Arterial hypertension is a highly frequent symptom in end-stage renal failure and occurs in over 80% of all case histories (1, 2, 3, 4, 5).

This paper is a review of our experience concerned with the pathogenesis and management of hypertension in patients with chronic renal failure.

Genome-wide association study identifies CAMKID variants involved in blood pressure response to losartan: the SOPHIA study

Background: Essential hypertension arises from the combined effect of genetic and environmental factors. A pharmacogenomics approach could help to identify additional molecular mechanisms involved in its pathogenesis. Aim: The aim of SOPHIA study was to identify genetic polymorphisms regulating blood pressure response to the angiotensin II receptor blocker, losartan, with a whole-genome approach. Materials & methods: We performed a genome-wide association study on blood pressure response in 372 hypertensives treated with losartan and we looked for replication in two independent samples. Results: We identified a peak of association in CAMK1D gene (rs10752271, effect size -5.5 ± 0.94 mmHg, p = 1.2 × 10-8). CAMK1D encodes a protein that belongs to the regulatory pathway involved in aldosterone synthesis. We tested the specificity of rs10752271 for losartan in hypertensives treated with hydrochlorothiazide and we validated it in silico in the GENRES cohort. Conclusion: Using a genome-wide approach, we identified the CAMK1D gene as a novel locus associated with blood pressure response to losartan. CAMK1D gene characterization may represent a useful tool to personalize the treatment of essential hypertension.

Original submitted 7 May 2014; Revision submitted 29 July 2014

[Administrative databases of the Local Health Unit: possible use for clinical governance of chronic kidney disease]

Nowadays a large amount of medical data are available, although they are not always homogeneous, they arise from different backgrounds and are used for different purposes. The aggregation of these data could give huge boost to the epidemiology and, in particular, to nephrology. In many parts of Italy there is the aim to reorganize the hospital health care, as well as the territorial setting. In this framework, the role of nephrology is evaluated without data to support the ongoing decisions, therefore the linkage among the data stored in the administrative and clinical databases of the Local Health Unit could contribute to the planning of nephrological (but not only) activities, in order to ensure the best cost-effectiveness possible for each different reality.

Glycemic control and diabetes-related health care costs in type 2 diabetes; retrospective analysis based on clinical and administrative databases

Background

Diabetes is one of the most prevalent chronic diseases, and its prevalence is predicted to increase in the next two decades. Diabetes imposes a staggering financial burden on the health care system, so information about the costs and experiences of collecting and reporting quality measures of data is vital for practices deciding whether to adopt quality improvements or monitor existing initiatives. The aim of this study was to quantify the association between health care costs and level of glycemic control in patients with type 2 diabetes using clinical and administrative databases.

Methods

A retrospective analysis using a large administrative database and a clinical registry containing laboratory results was performed. Patients were subdivided according to their glycated hemoglobin level. Multivariate analyses were used to control for differences in potential confounding factors, including age, gender, Charlson comorbidity index, presence of dyslipidemia, hypertension, or cardiovascular disease, and degree of adherence with antidiabetic drugs among the study groups.

Results

Of the total population of 700,000 subjects, 31,022 were identified as being diabetic (4.4% of the entire population). Of these, 21,586 met the study inclusion criteria. In total, 31.5% of patients had very poor glycemic control and 25.7% had excellent control. Over 2 years, the mean diabetes-related cost per person was: €1291.56 in patients with excellent control; €1545.99 in those with good control; €1584.07 in those with fair control; €1839.42 in those with poor control; and €1894.80 in those with very poor control. After adjustment, compared with the group having excellent control, the estimated excess cost per person associated with the groups with good control, fair control, poor control, and very poor control was €219.28, €264.65, €513.18, and €564.79, respectively.

Conclusion

Many patients showed suboptimal glycemic control. Lower levels of glycated hemoglobin were associated with lower diabetes-related health care costs. Integration of administrative databases and a laboratory database appears to be suitable for showing that appropriate management of diabetes can help to achieve better resource allocation.

Adherence to statin treatment and health outcomes in an Italian cohort of newly treated patients: results from an administrative database analysis

BACKGROUND

Adherence to statin treatment is expected to be associated with health outcomes. Much of the available evidence is derived from studies conducted on selected populations (eg, Medicaid population), on specific cohorts of patients (eg, patients with diabetes mellitus or those who have experienced acute myocardial infarction [AMI]), or with respect to a single outcome (eg, only death or only AMI).

OBJECTIVE

The aim of this study was to evaluate the association between adherence to statin therapy and all-cause mortality and cardiovascular morbidity (AMI and stroke) in an unselected cohort of newly treated patients.

METHODS

We performed a population-based retrospective cohort study that included adult patients with a first prescription of a statin from January 1, 2004, through December 31, 2006, using data from the administrative databases of the Local Health Unit of Florence in Italy. Adherence to statin treatment was estimated as the proportion of days covered (PDC) by filled prescriptions and classified as low (PDC, 21%-40%), intermediate-low (PDC, 41%-60%), intermediate-high (PDC, 61%-80%), and high (PDC, >80%). Cases with PDC ≤20% were excluded. A Cox regression model was used to investigate the association between adherence to treatment and all-cause mortality and hospitalization for AMI or stroke.

RESULTS

The cohort consisted of 19,232 patients (9823 men and 9409 women) aged 18 to 102 years (mean [SD], 66.5 [11.4] years): 20.1% had been previously hospitalized for cardiovascular events and 17.6% had been treated with hypoglycemic drugs. Adherence to statins was low in 4427 patients (23.0%), intermediate-low in 3117 (16.2%), intermediate-high in 3784 (19.7%), and high in 7904 (41.1%). Lower-adherent patients were younger and had fewer comorbidities compared with higher-adherent patients. In our multivariable analyses, high adherence was significantly associated with decreased risk of all-cause death, AMI, or stroke. Compared with low adherence (hazard ratio [HR] = 1), the risk was lower in intermediate-low adherence (HR = 0.83; 95% confidence interval [CI], 0.71-0.98; P < 0.05) and much lower in intermediate-high (HR = 0.60; 95% CI, 0.51-0.70; P < 0.001) and high adherence (HR = 0.61; 95% CI, 0.54-0.71; P < 0.001).

CONCLUSIONS

In this Italian cohort of newly treated patients, suboptimal adherence to statins occurred in a substantial proportion of patients and was associated with increased risk of adverse health outcomes.

Adherence to statin treatment and health outcomes in an Italian cohort of newly treated patients: results from an administrative database analysis

BACKGROUND

Adherence to statin treatment is expected to be associated with health outcomes. Much of the available evidence is derived from studies conducted on selected populations (eg, Medicaid population), on specific cohorts of patients (eg, patients with diabetes mellitus or those who have experienced acute myocardial infarction [AMI]), or with respect to a single outcome (eg, only death or only AMI).

OBJECTIVE

The aim of this study was to evaluate the association between adherence to statin therapy and all-cause mortality and cardiovascular morbidity (AMI and stroke) in an unselected cohort of newly treated patients.

METHODS

We performed a population-based retrospective cohort study that included adult patients with a first prescription of a statin from January 1, 2004, through December 31, 2006, using data from the administrative databases of the Local Health Unit of Florence in Italy. Adherence to statin treatment was estimated as the proportion of days covered (PDC) by filled prescriptions and classified as low (PDC, 21%-40%), intermediate-low (PDC, 41%-60%), intermediate-high (PDC, 61%-80%), and high (PDC, >80%). Cases with PDC ≤20% were excluded. A Cox regression model was used to investigate the association between adherence to treatment and all-cause mortality and hospitalization for AMI or stroke.

RESULTS

The cohort consisted of 19,232 patients (9823 men and 9409 women) aged 18 to 102 years (mean [SD], 66.5 [11.4] years): 20.1% had been previously hospitalized for cardiovascular events and 17.6% had been treated with hypoglycemic drugs. Adherence to statins was low in 4427 patients (23.0%), intermediate-low in 3117 (16.2%), intermediate-high in 3784 (19.7%), and high in 7904 (41.1%). Lower-adherent patients were younger and had fewer comorbidities compared with higher-adherent patients. In our multivariable analyses, high adherence was significantly associated with decreased risk of all-cause death, AMI, or stroke. Compared with low adherence (hazard ratio [HR] = 1), the risk was lower in intermediate-low adherence (HR = 0.83; 95% confidence interval [CI], 0.71-0.98; P < 0.05) and much lower in intermediate-high (HR = 0.60; 95% CI, 0.51-0.70; P < 0.001) and high adherence (HR = 0.61; 95% CI, 0.54-0.71; P < 0.001).

CONCLUSIONS

In this Italian cohort of newly treated patients, suboptimal adherence to statins occurred in a substantial proportion of patients and was associated with increased risk of adverse health outcomes.

Adherence to antihypertensive medications and health outcomes among newly treated hypertensive patients

Objective:

To evaluate adherence to antihypertensive therapy (AHT) and the association between adherence to AHT, all-cause mortality, and cardiovascular (CV) morbidity in a large cohort of patients newly treated with antihypertensives in a clinical practice setting.

Methods:

An administrative database kept by the Local Health Unit of Florence (Italy) listing patient baseline characteristics, drug prescription, and hospital admission information was used to perform a population-based retrospective study including patients newly treated with antihypertensives, ≥18 years of age, with a first prescription between January 1, 2004 and December 31, 2006. Patients using antihypertensives for secondary prevention of CV disease, occasional spot users, and patients with early CV events, were excluded from the study cohort. Adherence to AHT was calculated and classified as poor, moderate, good, and excellent. A Cox regression model was conducted to determine the association among adherence to AHT and risk of all-cause mortality, stroke, or acute myocardial infarction.

Results:

A total of 31,306 patients, 15,031 men (48.0%), and 16,275 women (52.0%), with a mean age of 60.2 ± 14.5 years was included in the study. Adherence to AHT was poor in 8038 patients (25.7% of included patients), moderate in 4640 (14.8%), good in 5651 (18.1%), and excellent in 12,977 (41.5%). Compared with patients with poor adherence (hazard ratio [HR] = 1), the risk of all-cause death, stroke, or acute myocardial infarction was significantly lower in patients with good (HR = 0.69, P < 0.001) and excellent adherence (HR = 0.53, P < 0.001).

Conclusions:

These findings indicate that suboptimal adherence to AHT occurs in a substantial proportion of patients and is associated with poor health outcomes already in primary prevention of CV diseases. For health authorities, this preliminary evidence underlines the need for monitoring and improving medication adherence in clinical practice.

Colour-Doppler US evaluation of patients with hypertension and nephropathy

PURPOSE

The objective of this study was to assess the utility of colour-Doppler ultrasound (CDUS) in the investigation of patients with hypertension and nephropathy and to determine the association between hemodynamically significant stenoses of the renal arteries and abdominal aorta aneurysms (AAA).

MATERIALS AND METHODS

Between January 2000 and December 2004, 467 patients (205 women and 262 men, age range 20-96 years) with hypertension and chronic renal failure were referred to us for CDUS evaluation of renal morphology and haemodynamics and identification of haemodynamically significant stenoses of the renal arteries.

RESULTS

Of the 467 patients examined by CDUS, 159 (34%) showed no signs of renal artery stenosis (RAS) or nephropathy and were therefore started on medical therapy. The remaining 308 (66%) exhibited signs of haemodynamically significant stenoses of the renal arteries or of nephropathy. AAA was identified in 19 of the 333 patients (5.7%) without haemodynamically significant renal artery stenoses and in 15 of the 134 patients (11.2%) with renal artery stenoses.

CONCLUSIONS

Our results confirm the fundamental role of CDUS in the management of patients with suspected or known renovascular disease. The information provided by CDUS on renal hemodynamics is fundamental for a correct clinical approach.

The relationship between body weight and drug costs: An Italian population-based study

OBJECTIVES

This study determined the prevalence of 3 categories of body mass index (BMI)--normal weight, overweight, and obesity--in a sample of subjects from general clinical practice in Ravenna, Italy, and evaluated the impact of comorbidities associated with overweight and obesity on the costs of drug treatment from the perspective of the Italian national health system.

METHODS

This was a cross-sectional study conducted in a sample of subjects aged > or =18 years from 10 general practices in the Ravenna local health unit (LHU) in 2001-2002. Subjects were invited to attend a screening visit at which weight and height were measured for determination of BMI, blood pressure was measured, and a fasting blood sample was obtained for laboratory tests. The screening examinations were conducted by 2 physicians at a dedicated practice. Normal weight, overweight, and obesity were defined as a BMI < or =24.9, between 25 and 29.9, and > or =30 kg/m2, respectively. The costs of classes of drug treatment that were reimbursable to the LHU in the 12 months before the screening examination were evaluated using the Ravenna LHU administrative databases. Drug treatments were classified as antihypertensive agents, statins, NSAIDs, gastroprotective drugs, antidiabetic agents, respiratory drugs, antiplatelet agents, antidepressants, and all other drugs. The data were analyzed by age group.

RESULTS

Of the 2622 subjects in the sample, 1256 (47.9%) had a normal BMI, 918 (35.0%) were overweight, and 448 (17.1%) were obese. The prevalence of overweight and obesity increased in relation to age up to 50-59 years (P < 0.001), after which it remained stable. Overweight and obese subjects had significantly more exposure to individual and multiple drug treatments compared with subjects with normal weight (P < 0.001). By type of drug treatment, 16.7% of normal-weight subjects, 35.6% of overweight subjects, and 51.8% of obese subjects were exposed to antihypertensives; 4.1%, 8.7%, and 12.1%, respectively, to statins; 14.2%, 22.0%, and 29.0% to NSAIDs; and 1.0%, 4.7%, and 9.4% to antidiabetics. The mean annual cost of drugs was Euro 132.71 in normal-weight subjects, Euro 246.19 in overweight subjects, and Euro 335.64 in obese subjects (P < 0.001). After adjustment for differences in age distribution between the study sample and the overall population of Ravenna, the estimated excess drug costs associated with overweight and obesity in Ravenna were Euro 5,661,126.20 and Euro 6,688,099.85, respectively.

CONCLUSIONS

In this study sample, the prevalence of overweight increased by approximately 10% and the prevalence of obesity increased by approximately 5% with each decade of age up to 60 years, after which it remained stable at approximately 40% and approximately 20%, respectively. Overweight and obesity were associated with increased drug exposure and costs in all age groups considered.

Underuse of lipid-lowering drugs and factors associated with poor adherence: a real practice analysis in Italy

BACKGROUND

Many studies have indicated the adequate use of lipid-lowering drugs (LLDs) as a factor in reducing the risk of cardiovascular disease. However, in clinical practice, a very high percentage of patients are not adequately treated.

OBJECTIVE

To analyze the management of hypercholesterolemia in a non-experimental setting and to estimate the factors associated with poor adherence to treatment.

METHODS

A longitudinal study was performed using clinical and demographic data recorded in the General Practitioners' database. The sample included all patients, aged 30 years or over, with total blood cholesterol measured between 1 January and 31 December 2000. Utilization of LLDs was defined as the standardized daily dose of the drugs purchased during the 12 months preceding the cholesterol measurement.

RESULTS

The study included 4764 patients (mean age 59.4+/-14.1 years, 40.7% males). Of the subjects with a total cholesterol higher than a 6.5 mmol/l, approximately 17% were treated with LLDs. About 39% of the patients with previous atherosclerotic diseases were taking statins. Analysis of patients taking LLDs showed that 40.6% of subjects took less than half of the defined daily dose. Factors associated with poor adherence to treatment were: absence of previous atherosclerotic diseases, absence of concomitant diseases, and smoking. A total cholesterol of less than 5 mmol/l was achieved in 19.9% of patients.

CONCLUSIONS

Analyzing the data contained in the general medicine database made it possible to evaluate the use of LLDs in clinical practice and to establish the need to pay greater attention to achieving the objective set by the treatment.

Relationship between body weight, quality of life and cardiovascular risk factors: a general population based Italian experience

BACKGROUND

Within the framework of the Progetto Faenza, the aim of this study was to evaluate the effect of cardiovascular risk factors (CVRF) on the health-related Quality of Life (H-rQoL) of a cohort of patients in the province of Ravenna, on the basis of body mass index (BMI).

METHODS

The following data were collected for each subject: age, sex, weight, height, glycemia, cholesterol (total, HDL and LDL), creatinine, uricemia, systolic arterial pressure (SAP) and diastolic arterial pressure (DAP), presence/absence of previous CV disorders, arterial hypertension, diabetes, antihypertensive therapy, smoking habits and physical exercise. To evaluate the H-rQoL the SF-36 general health survey questionnaire was used, filled in by the patient at the first examination. To test the significance of the differences between the groups (divided by classes of Body Mass Index) as regards the metabolic indicators, a univariate analysis of variance was performed; on the other hand, to assess which factors affect H-rQoL a multivariate analysis was carried out, considering p<0.05 as significant. The results are expressed as +/- 1SD.

RESULTS

Of the 1108 subjects enrolled in the study, 343 subjects (31.2%), including 154 males with a mean age of 44.9 +/- 14.9 years, filled in the SF-36 questionnaire. A BMI within the normal range corresponds to a more satisfactory metabolic (p<0.05) and QoL (p=0.001) picture. Age (p<0.001), presence of previous CV disorders (p=0.005), the use of antihypertensive drugs (p=0.041) and physical exercise (p=0.002) correlated significantly with H-rQoL values.

CONCLUSIONS

Health condition and perception are significantly affected by a clinical situation characterized by excess weight.

Efficacy and tolerability of manidipine in the treatment of hypertension in patients with non-diabetic chronic kidney disease without glomerular disease. Prospective, randomized, double-blind study of parallel groups in comparison with enalapril

BACKGROUND

Calcium channel blockers (CCBs) are effective blood pressure lowering agents, giving rise to a prevalent dilation of the afferent arteriole. Manidipine, a long-lasting dihydropyridine CCB, demonstrates its action not only on the afferent arteriole, but also on the efferent one. This suggests theoretically a renoprotective effect in patients with chronic kidney diseases (CKD).

METHODS

This was a multicenter, prospective, randomized, double-blind, parallel group study, to evaluate the efficacy and tolerability of manidipine (M; 10-20 mg/day), in comparison with enalapril (E; 10-20 mg/day) in the treatment of hypertension in 136 patients with CKD secondary to primary renoparenchymal disease. Changes in blood pressure values from baseline were considered as the primary outcome of the study. Proteinuria changes and the rate of renal function decline were also evaluated.

RESULTS

During a 48-week follow-up, mean SBP decreased from 155+/-11.7 to 138.7+/-13.9 mmHg in M and from 157.3 +/-11.8 to 134.2+/-13.9 mmHg in E; mean DBP decreased from 100.3+/-4.2 to 86.1+/-6.5 mmHg in M and from 100.3+/-4.2 to 84.7+/-6.3 mmHg in E. Proteinuria remained unchanged in M (from 1.6+/-1.59 to 1.62+/-1.79 g/24h), and decreased significantly in E (from 1.37+/-1.45 g/24h to 1+/-1.55 g/24h). No significant difference was observed in the rate of renal function decline in the two groups.

CONCLUSIONS

Manidipine was safe and effective, obtaining a significant reduction in SBP and DBP from baseline. Although patients treated with enalapril showed a better antiproteinuric response, the two treatments were equally effective in reducing the rate of CRF progression in patients without glomerular disease.

Risk factors for uncontrolled hypertension in Italy

To identify factors related to poor control of blood pressure in primary care, we designed a retrospective case-control analysis of clinical and demographic data recorded in the General Practitioners (GP) database. Study data were provided on a voluntary basis by 21 GPs from a practice-based network in primary care. The study included 2519 hypertensive patients enrolled between January 1 and December 31, 2000. The interventions were antihypertensive medication, and the main outcome measures were control of systolic and diastolic blood pressure (BP). The independent variables considered were: age of patient and GP; patient gender, body mass index, history of smoking, diabetes mellitus, or cholesterol tests; family history of hypertension; previous visits for cardiologic, nephrologic, or vascular surgery evaluation; prior hospitalizations for myocardial infarction or heart failure, and number of admissions for surgery; length of patient follow-up, type of antihypertensive medication, mean daily dosage, adherence to the drug regimen, and number of other medications currently being taken by the patient. Blood pressure was uncontrolled (>140/90 mmHg) in 1525 (60%) of the 2519 hypertensive patients enrolled. The presence of diabetes mellitus, increasing patient age, and increasing GP age significantly increased the risk of uncontrolled BP. Factors significantly associated with a reduced risk of uncontrolled BP were the number of other medications currently being taken by the patient and a prior history of MI. We conclude that the failure of antihypertensive medication to adequately control BP is determined by both the patient's characteristics and factors related to the patient-doctor relationship. Successful treatment of hypertension requires patient adherence to the regimen that has been agreed on by the patient and the physician.

The pandora project: cost of hypertension from a general practitioner database

AIM

The Pandora Project is a longitudinal database--implemented by general practitioners since June 1997 in the Ravenna area (Italy)--providing information on patients with hypertension. Data from 1,651 patients were followed up for I year in order to investigate the cost of hypertension. Only direct medical costs were considered in the perspective of the National Healthcare System.

FINDINGS

At enrollment, 552 patients were classified as normotensive, 1,099 as hypertensive. After 1 year, among normotensive group, 352 patients remained normotensive and 200 became hypertensive; among hypertensive group, 323 patients became normotensive and 776 remained hypertensive. The average total cost per patient at follow-up was 779.59 Euros. About 46% of total cost was due to anti-hypertensive therapy, irrespective of the evolution of blood pressure levels registered, whilst other direct costs represented 54% of total patient cost in all cohorts. It is possible that co-morbidities play a significant role in this situation. Patient aged 80-89 years generate higher costs. Even if further investigation is needed on the burden of comorbidity on a per-patient cost of hypertension, this work provides evidence that the average total cost per patient is likely to increase with age and co-morbidities. Key words: cost-of-illness, costs, economics, hypertension.

A retrospective, population-based analysis of persistence with antihypertensive drug therapy in primary care practice in Italy

BACKGROUND

Many hypertensive patients discontinue drug therapy despite the increased cardiovascular risk associated with inadequately controlled hypertension. However, most experiments do not address this premature discontinuation of therapy, making it difficult to project the appropriateness of antihypertensive drugs in real-world use.

OBJECTIVE

The goal of this study was to assess patients' persistence with antihypertensive drug therapy in a nonexperimental setting.

METHODS

An administrative database kept by the Local Health Unit of Ravenna, Ravenna, Italy, listing patient baseline characteristics, drug prescriptions, and hospital admissions was used to perform a population-based, retrospective study. The study included all patients who met the following criteria from January I through December 31, 1997: new user of antihypertensive drugs; > or = 20 years of age; receiving a first prescription for a diuretic, beta-blocker, calcium channel blocker, angiotensin II-receptor antagonist (AIIA), or angiotensin-converting enzyme inhibitor. All prescriptions for antihypertensive drugs filled during the 12-month follow-up period were used to define patients as continuers, switchers, or discontinuers on the basis of their persistence with therapy.

RESULTS

A total of 16,783 patients were included in the study analyses: 7,409 men (44.1%) and 9,374 women (55.9%), with an average age of 56.1 +/- 18.3 years (range, 20-105 years). Of this study population, 64.9% (n = 10,894) discontinued treatment over the course of follow-up, 26.9% (n = 4508) continued treatment with the initially prescribed medication (with 5.1% [n = 862] adding another medication for combination therapy), and 8.2% (n = 1381) switched medications. Patients initially prescribed AIIAs were more likely to continue treatment than those initiated on other types of antihypertensives (P < 0.001). Discontinuation was associated with younger age, lower prevalence of concurrent chronic pharmacotherapies, and lower prevalence of previous hospitalizations for cardiovascular disease (all P < 0.001).

CONCLUSIONS

Health care claims data are a powerful tool for measuring continuation of therapy, providing detailed, populationwide epidemiologic and economic information for analyzing antihypertensive drug treatment. Further studies are required to relate pharmacotherapy to outcomes.

Long-term persistence with antihypertensive drugs in new patients

The objective of this study was to investigate stay-on-therapy patterns over 3 years among patients prescribed different classes of antihypertensive drugs for the first time. A retrospective analysis of information recorded in the drugs database of the Local Health Unit of Ravenna (Italy) was carried out on 7312 subjects receiving a first prescription for diuretics, beta-blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II antagonists between 1 January and 31 December 1997. Patients were followed up for 3 years. All prescriptions of antihypertensive drugs filled during the follow-up periods were considered. The patients continuing or discontinuing the initial treatment, the duration of treatment, and the doses taken were all calculated, as well as main factors influencing the persistence rate. The drugs prescribed were predominantly ACE-inhibitors, followed by calcium channel blockers, diuretics, beta-blockers and angiotensin II antagonists. A total of 57.9% of patients continued their initial treatment during the 3-year follow-up period, 34.5% discontinued the treatment, whilst 7.6% were restarted on a treatment in the third year. Persistence with treatment was influenced by: age of patient (persistence rate increasing proportionately with advancing years), type of drug first prescribed (persistence rate higher with angiotensin II antagonists, progressively lower with ACE-inhibitors, beta-blockers, calcium channel blockers and diuretics), gender of patient (persistence was better in males), age of general practitioner (GP) (the younger the GP, the better the persistence rate) and gender of GP (better stay-on-therapy rate with male GP prescribing). In the case of patients treated continuously, mean daily dose increased progressively over the 3 years. With adequate markers, helpful data can be collected from prescription claims databases for the purpose of monitoring the persistence of patients in continuing their medication, and the quality of antihypertensive treatment in a general practice setting.

Assessment of antihypertensive drug use in primary care in Ravenna, Italy, based on data collected in the PANDORA project

BACKGROUND

In the clinical-practice setting, only a small percentage of patients treated with antihypertensive drugs become normotensive. Furthermore, the diversity of drug classes used makes comparison of treatments difficult.

OBJECTIVE

The goal of this study was to characterize the types and efficacy of antihypertensive treatments used in primary care in the area of Ravenna, Italy. The study was conducted in the context of the PANDORA Project, an open-ended global outcome study.

METHODS

Data were gathered from general practitioners (GPs) and were stored by the GPs or through links with national health service databases. The population of interest was patients with essential hypertension taking antihypertensive medication, each of whom was observed for 365 days. Blood pressure was measured in the morning or afternoon using an automated device, in accordance with normal clinical practice. At each office visit, the GP reviewed and made any necessary adjustments to the patient's antihypertensive treatment. Antihypertensive drug use was assessed by calculating the mean daily dose (MDD) of the prescribed drug and the duration of treatment (DT). A DT > or = 273 days constituted continuous therapy, and a DT <273 days constituted discontinuous therapy. Adverse events were not collected.

RESULTS

Twenty-one GPs took part in the study. The study population included 969 patients (443 men, 526 women), all of them white, whose ages ranged from 23 to 88 years. At enrollment, 327 patients were normotensive (blood pressure <140/90 mm Hg) and 642 were hypertensive despite drug treatment. More than 25 treatment regimens were identified. Over the course of follow-up, 49 patients had discontinuous therapy and 920 had continuous therapy. Among those who had continuous therapy, 117 (12.7%) took an MDD of <0.5 tablet/d; 297 (32.3%) took > or = 0.5 and <1 tablet/d; 364 (39.6%) took > or = 1 and <2 tablets/d; and 142 (15.4%) took > or = 2 tablets/d. At the end of the observation period, the proportion of normotensive patients had increased by 5.7% (P < 0.001).

CONCLUSION

Based on the findings of this study, improper use of antihypertensive drug therapy appears to be one of the reasons for the relatively small proportion of patients who attain blood pressure control with treatment.

Cardiovascular risk in hypertensive patients: results of the Pandora project

BACKGROUND

The aim of the Pandora project is to collect epidemiological information, check diagnostic and therapeutic pathways, and assess outcomes in a large hypertensive population. This report presents the results on patients enrolled in the study between 1997-1999.

METHODS

Twenty-one general practitioners working in the Ravenna Local Health Service took part in the study. They were supplied with IBM compatible PCs and were trained to enter the patient's data (age, gender, familiarity for cardiovascular diseases, smoking, hospitalisations for cardiovascular disorders, diabetes, blood pressure, total cholesterolemia, creatininemia, antihypertensive therapy) on So.Ge.Pa. software. Cardiovascular risk factors were assessed according to the WHO - ISH joint committee recommendations.

RESULTS

2,608 treated hypertensive patients were enrolled, 65% of whom showed inadequate blood pressure control. The prevalence of inadequate BP control was higher in patients on multiple-drug antihypertensive therapy compared with those on monotherapy (71.9% vs. 47.9%), in older than in younger patients (70.7% vs. 56.1%) and in patients with three cardiovascular risk factors, or diabetes, or affected target organs, compared to those with two or less risk factors (72.4% vs. 63.3%), (p < 0.001 for all). 63.6% of patients were at risk for age, 36.6% for family history of cardiovascular diseases and 31.7% for severe hypercholesterolemia.

CONCLUSIONS

BP control was inadequate in a large percentage of patients, but it was particularly unsatisfactory in the elderly and in patients with high cardiovascular risk. A cluster of cardiovascular risk factors was found in both adequately and inadequately controlled hypertensive patients.

Effects of clinical and individual variables on quality of life in chronic renal failure patients

BACKGROUND

The purpose of this study was to assess the effects of baseline characteristics of patients, chronic renal failure and its treatment on quality of life.

METHODS

To investigate the health status we used a questionnaire, the SF-36, during individual interviews. The study involved i) a cross-sectional observational stage, lasting from 1 Sept. 1997 to 30 April 1999, on all the patients undergoing conservative treatment, hemodialysis, peritoneal dialysis and kidney transplantation in district of Ravenna, and ii) a longitudinal stage, when the subjects were administered two questionnaires at an interval of at least 16 months. The quality of life data collected during the cross-sectional stage were analyzed to establish any correlations between age, type of treatment of chronic renal failure and hemoglobin levels. Patients under dialysis were also examined for any interference caused by the center where dialysis was done.

RESULTS

Multivariate analysis on the data collected during the cross-sectional stage showed that chronic renal failure treatment and age affected the quality of life scores for the following parameters: physical activity, bodily pain, general health and vitality (age was inversely related to the scores). Transplanted patients and those on conservative treatment enjoyed the best overall quality of life, followed by those on peritoneal dialysis and those on hemodialysis. The physical domain scores were strongly associated with age, hemoglobin and diabetes. Multivariate analysis of the longitudinal study indicated that the interval between the beginning and the end of the observation period, age and diabetes greatly influenced quality of life.

CONCLUSIONS

The data confirmed that age and diabetes have a strong influence on the quality of life and that the long period of treatment, with the absence of any prospect of resolving the clinical situation, has a negative effect on the quality of life in uremic patients.

Pharmacoutilization of antihypertensive drugs: a model of analysis

OBJECTIVES

To identify clinical and economic indicators of pharmacoutilization of antihypertensive drugs.

PATIENTS AND METHODS

4614 subjects receiving a first prescription for amlodipine, atenolol, fosinopril, indapamide, or losartan were included in the study. All prescriptions filled during the study period from January 1, 1997 to December 31, 1998 were considered. A retrospective analysis was carried out on information recorded in the drug database. The percentage of patients continuing, discontinuing, and switching the initial treatment, duration of treatment, and doses used were calculated together with total costs.

RESULTS

A large proportion of patients (65.1%) discontinued the treatment. From the analysis of the mean daily dose taken by patients who continued the treatment, it was found that many subjects took a drug dosage which was below the therapeutic dose range, whereas the administration of doses above the therapeutic range occurred only occasionally. Continuation of treatment accounted for 48.1% of total costs, switching accounted for 20.8%, and discontinuation represented 31.1% of total expenditures.

CONCLUSIONS

With adequate markers, helpful data can be collected for monitoring the quality of antihypertensive drug prescriptions and the rational usage of resources in the general practice setting.

The PANDORA project: results of the cost of illness analysis

AIMS

To evaluate the cost of illness from hypertension for the Italian National Health System (NHS).

METHODS AND RESULTS

A prospective analysis was carried out on clinical and economic data recorded in the general practitioners' (GPs) database. Twenty-one GPs working in the Ravenna area in Italy took part in the project on a voluntary basis. The study included 1047 hypertensive patients enrolled between 1 June and 31 December 1997 and continued for 365 days from the date of enrolment. The following costs were calculated: antihypertensive drugs, laboratory tests and instrumental procedures, GP visits for blood pressure control, specialist visits, casualty visits, hospitalisation due to cardiovascular problems. In the whole sample, the most relevant cost is due to antihypertensive drugs (42.7%), followed by hospital admission (28.4%), GP visits (15.1%) and tests (10.6%). The total mean cost was significantly lower in incident (no previous treatment) than in prevalent patients (already treated) (457 512 vs 725 573 Italian Lira (ITL), P < 0.05) and in older rather than in younger patients (1171 410 vs 796 452 (ITL) P < 0.05). (In the text the equivalent is given in Euros, Pounds Sterling and US dollars).

CONCLUSION

Our study should be considered as preliminary, nevertheless it could represent a step towards the evaluation of the true cost of hypertension.

The Pandora Project: results of the pilot study

The Pandora Project was designed to develop a computer-assisted system to improve the appropriateness and effectiveness of hypertension treatment in clinical practice and to organize a database both for epidemiologic and economic assessments. The feasibility study was conducted by five general practitioners (GP) who enrolled 244 patients over a period of 6 months. The follow-up lasted 6 months. The computer system implemented provided a linkage among GP's office, hypertension unit, Ravenna Health Service databases, and a remote station. A total of 209 patients completed the follow-up period; 56% of patients were not normotensive despite the antihypertensive treatment. The prevalence of overweight, physical inactivity, and family history of high blood pressure and hypercholesterolemia was greater than 50%. Unplanned check-ups by GP occurred 9%. Six patients were admitted to the hospital eight times; 19 patients attended the casualty department 21 times. The mean total direct cost per patient was 567,800 Italian Lire (ITL) and increased to ITL 732,000 or to ITL 825,900 when lost productivity, calculated according to two different formulas, was added. This pilot study confirms the need and feasibility of implementing the Pandora Project in general practice in Ravenna.

Prevalence of hypertension in patients on peritoneal dialysis: results of an Italian multicentre study

BACKGROUND

The tenet that peritoneal dialysis is capable of either normalizing or improving blood pressure control in uraemic patients is based on outdated or monocentric experiences. Therefore, we assessed the prevalence of hypertension and the efficacy of antihypertensive therapy in a large, multicentric cohort of patients on peritoneal dialysis.

METHODS

Twenty seven out of the 50 centres belonging to the Italian Co-operative Peritoneal Dialysis Study Group took part in the study. The main patient selection criteria were: peritoneal dialysis therapy for at least 3 months and no peritonitis or changes in dialysis technique for at least 1 month. Clinical blood pressure was measured according to WHO/ISH guidelines. Ambulatory blood pressure monitoring was carried out using a SpaceLabs 90207 recorder. Hypertension was defined according to WHO/ISH criteria and staged according to the criteria of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC), 5th Report. Ambulatory blood pressure monitoring recordings were used to evaluate white-coat hypertension, blood pressure load and the dipping phenomenon.

RESULTS

Five hundred and four subjects were evaluated. Hypertension was prevalent in 88.1% of the population, and 362 out of 444 hypertensive patients were on antihypertensive therapy. JNC staging revealed that 188 patients had moderate to severe hypertension. Blood pressure load was pathological in 77.3% of the patients receiving antihypertensive treatment. White-coat hypertension was identified in 9.1% of the hypertensive patients not on antihypertensive therapy, and 53.1% of the patients were non-dippers.

CONCLUSIONS

The study demonstrates that hypertension is a dramatic, unsolved problem in uraemic patients treated with peritoneal dialysis, and casts doubts on the effectiveness of our current peritoneal dialysis strategies and pharmacological management of hypertension.

Sodium-lithium countertransport activity in red blood cells of patients with IgA nephropathy

In this paper we report some results of our studies on patients with immunoglobulin (Ig)A nephropathy regarding (1) the familiar aggregation of erythrocyte sodium-lithium (Na,Li) countertransport; (2) the association of Na,Li countertransport with the presence of arterial hypertension and lipid abnormalities; (3) the correlation between Na,Li countertransport activity and renal functional reserve; and (4) the preliminary results of a longitudinal study. In 13 families of patients with IgA nephropathy, selected because both parents were available, we found a significant correlation between midparent and offspring Na,Li countertransport activity (Spearman's rank correlation = 0.65; P = 0.023), but no husband-wife relationship. In 49 patients, the activity of Na,Li countertransport was significantly higher in erythrocytes from 20 hypertensive patients than from either 29 normotensive patients or from 36 healthy age- and sex-matched normal subjects. Hyperlipidemic patients had an erythrocyte Na,Li countertransport activity significantly higher than normolipidemic patients and controls. In 17 patients a significant inverse correlation was found between the peak variation of creatinine clearance over baseline value after an oral protein load and the erythrocyte Na,Li countertransport activity (Spearman r = 0.54; P = 0.03). In a longitudinal study of 36 patients followed from 12 to 36 months, those showing a progression toward renal failure had an erythrocyte Na,Li countertransport activity higher than median value. The results of our studies show that in patients with IgA nephropathy a high erythrocyte Na,Li countertransport rate, genetically determined, is associated with the presence of arterial hypertension and lipid abnormalities, and perhaps with a less favorable disease outcome.

Aggregation of erythrocyte sodium/lithium countertransport activity in families of patients with immunoglobulin A nephropathy

1. We evaluated the inheritance of erythrocyte Na+/Li+ countertransport activity in IgA nephropathy by assessing this parameter in 19 patients with biopsy-proven IgA nephropathy and in their 53 relatives (32 parents and 21 siblings). The possible use of erythrocyte Na+/Li+ countertransport activity as a marker of poor prognosis was also evaluated. 2. A significant correlation was found between 'familial' and proband Na+/Li+ countertransport activity, but not between that of spouses. 3. Mean blood pressure, although within the normal range, and Na+/Li+ countertransport activity were significantly higher in patients with proteinuria than in those without proteinuria. 4. Parents of proteinuric patients had a higher Na+/Li+ countertransport activity than parents of non-proteinuric patients. 5. In IgA nephropathy the inheritance of erythrocyte Na+/Li+ countertransport activity was preserved. Therefore genetic factors could play a role in the non-immunological progression of IgA nephropathy.

Antiproteinuric effect of angiotensin-converting-enzyme inhibitors in patients with primary glomerular disease and normal renal function

The antiproteinuric efficacy of angiotensin-converting-enzyme inhibitors (ACEI) has been extensively investigated in patients with several types of nephropathy, but there are few data on the use of ACEI in patients with primary glomerular disease without renal function impairment. We evaluate the effect of long-term therapy with captopril on arterial pressure and proteinuria in 13 patients with primary glomerular disease, selected on the following criteria: persistent proteinuria greater than 600 mg/day, serum creatinine less than or equal to 1.5 mg/dl, no dietary restriction or antihypertensive or immunosuppressive therapy for at least 9 months prior to enrolment. Ten of 13 patients were normotensive. The treatment with captopril induced an early and persistent decrease in proteinuria (41%), and a significant increase in serum albumin. We did not find a significant correlation between changes in MAP and changes in protein loss or between variations in serum creatinine and in proteinuria. Our results demonstrate that captopril is effective in reducing proteinuria in patients with primary glomerular disease with normal renal function. Since the antiproteinuric effect is not associated to a concomitant decrease in arterial pressure, we presume that it might be due to a specific intrarenal action of captopril.

Cardiovascular and biochemical assessment in migraine patients submitted to tilt test

Ten migraine patients underwent a tilt test both during migraine attack and headache-free interval, and the following parameters were assessed: plasma levels of norepinephrine (NE), and serum dopamine beta hydroxylase (D beta H), systolic and diastolic blood pressure and heart rate (SBP, DBP, HR). SBP during the tilt test showed a fall greater than 30 mmHg in 2 cases in the headache-free interval and in 4 cases during migraine attack. In migraine patients in headache-free interval, tilt test increased NE and D beta H as it did in the control group, while in migraine attack tilt test increased NE and D beta H less than in the control group. This impairment of the sympathetic nervous system during the migraine attack is discussed.

Effect of bromocriptine treatment on prolactin, noradrenaline and blood pressure in hypertensive haemodialysis patients

Bromocriptine (2.5 mg/day orally) produced a significant fall in supine mean arterial pressure in nine hypertensive haemodialysis patients with high serum prolactin levels, without causing significant changes in heart rate. On bromocriptine, there was a significant decrease in the mean value of both serum prolactin and plasma noradrenaline, without significant changes in the mean value of plasma renin activity. A significant relationship was found between the changes in supine plasma noradrenaline and the changes in supine mean arterial pressure induced by bromocriptine. The increase in mean arterial pressure in response to the tilt test was greater on bromocriptine than on placebo although the changes in plasma noradrenaline were reduced by bromocriptine. Similar results were observed during the cold pressor test. These findings suggest that the arterial pressure-lowering effect of bromocriptine is related to the reduction in sympathetic out-flow. The parallel decrease in serum prolactin raises the question of the possible involvement of dopaminergic mechanisms in the development of hypertension in our patients. Moreover, bromocriptine seems to enhance the vascular response to endogenous noradrenaline.

Plasma noradrenaline and blood pressure in uremia

To evaluate a possible correlation between sympathetic activity and blood pressure in uremia, catecholamines and blood pressure were determined in 81 uremic patients. In 34 of these 81 patients, thyroid hormones were also measured. In 16 patients on maintenance dialysis, a longitudinal study was performed to compare long-term blood pressure and catecholamine variations. No correlation was found between mean blood pressure and noradrenaline in the 81 patients as a whole, but when male and female patients were evaluated separately, a significant correlation was found in the former group. In the 34 patients, a correlation between mean blood pressure and noradrenaline was found only when hypothyroid patients were excluded. Variations in mean blood pressure induced by chronic dialysis were related to noradrenaline changes in the 16 patients studied. In conclusion, sympathetic activity seems to be correlated to blood pressure in uremic patients.

Failure of naloxone in reversal hemodialysis-induced hypotension

In 5 uremic patients the role of opioid peptides in dialysis-induced hypotension was investigated through the administration of naloxone. An intravenous bolus injection of 1 mg of naloxone was administered immediately before starting a routine hemodialysis session and was repeated when the patients' systolic arterial pressure sank below 90 mm Hg. In our patients, naloxone had no effect on the resting arterial pressure or on dialysis-induced hypotension.

Parasympathetic activity assessed by diving reflex and by airway response to methacholine in bronchial asthma and rhinitis

It has been suggested that airway hyperreactivity in asthma is associated with increased parasympathetic tone. We have accordingly assessed parasympathetic responsiveness in five groups of subjects (17 normal controls, 8 patients with extrinsic rhinitis, 6 with intrinsic rhinitis, 10 extrinsic asthmatic patients, 7 intrinsic asthmatic patients) by examining their responses to both diving reflex and methacholine inhalation challenge. The mean fall in heart rate during the diving test was significantly greater in asthmatic subjects than in normal controls and in patients with rhinitis. The diving-induced bradycardia was significantly greater in intrinsic than in extrinsic asthmatic subjects. There was a good correlation between the drop in heart rate during diving test and the provocation dose of methacholine producing a 45% decrease in specific airway conductance both in patients with rhinitis and in asthmatic patients. There was a less good correlation between diving response and clinical severity score in the same asthmatic patients. These results indicate that intrinsic asthma is associated with a marked degree of cholinergic hyperreactivity. The diving test seems to provide an accurate method for the analysis of the parasympathetic system in asthma.