Hypertension Guidelines and Interventions

Hypertension remains one of the most prevalent conditions encountered in the primary care setting and is a major contributor to cardiovascular disease in the United States. This reality underscores the importance for primary care clinicians to have an understanding of hypertension guidelines, interventions, and population-based considerations. This article provides a succinct overview of hypertension guidelines, reviews guideline-informed approaches to hypertension screening, diagnosis, and treatment, and concludes with a thoughtful discussion of population-based considerations.

Presentation of the obsolete drug reserpine in three German-language pharmacology textbooks

For several decades, reserpine was used to treat hypertension and, to a limited extent, psychoses. Over time, however, the indication became more and more restricted to the point of obsolescence. This study examines the extent to which textbooks are up to date in their content and oriented towards therapeutic guidelines, using the obsolete drug reserpine as a paradigm. Three German pharmacology textbook series were examined for the coverage of reserpine from 1964-2023: Allgemeine und Spezielle Pharmakologie und Toxikologie (Aktories), Allgemeine und Spezielle Pharmakologie und Toxikologie (Karow) and Pharmakologie und Toxikologie (Lüllmann). We compared the textbook content with data on reserpine prescriptions and hypertension guidelines and analysed the relevance of reserpine in examinations using German federal exam questions by the Institute for medical and pharmaceutical exam questions (IMPP). The textbooks differ conceptually from each other. The indication of reserpine for hypertension has become more restricted over time in all three textbooks, yet they partially show discrepancies with hypertension guidelines. The reserpine prescription figures show a strong decline , and reserpine has not been queried by the IMPP, which underlines the obsolescence of the drug. Overall, our study shows that the presentation of a representative obsolete drug in pharmacology textbooks lags current medical practice. We also unmasked more differences in the presentation of an obsolete drug in standard textbooks than anticipated. In conclusion, the analysis of obsolete drugs in pharmacology textbooks is an informative way of assessing how up-to-date they are.

[Comprehensive Therapeutic Approach to Hypertension. Recommendations for Central America and the Caribbean]

Latin American hypertension guidelines, tailored to the needs of countries of Central and South America, should be applied and known by most Latin American physicians. The knowledge and implementation of the Guidelines is one of the greatest challenges of hypertension societies in Latin America such as the Central American and Caribbean Society of Arterial Hypertension (SCCH), the Latin American Society of Hypertension (LASH) and the Inter-American Society of Cardiology (SIAC). In 2020, the Inter-American Society of Cardiology (SIAC) published its position on the current Guidelines for Arterial Hypertension due to the need to standardize the evaluation, diagnosis, treatment and control of hypertension, establishing recommendations that should be adopted in all Latin American countries, aimed at optimizing the management of cardiovascular risk and achieving a substantial improvement in the reduction of cardiovascular events and mortality. This document intends to reinforce all proposals by the LASH guidelines and the position of the SIAC in relation to the therapeutic approach and pharmacological recommendations for patients with hypertension (HT), in order to achieve better HT control in the Central American and Caribbean area, and the consequently prognosis improvement of cardiovascular disease in the area.

Impact of within-visit systolic blood pressure change patterns on blood pressure classification: the Cardiovascular Risk in Young Finns Study

AIMS

Most international guidelines recommend that repeat blood pressure (BP) readings are required for BP classification. Two international guidelines diverge from this by recommending that no further BP measurements are required if the first clinic BP is below a hypertension threshold. The extent to which within-visit BP variability patterns change over time, and whether this could impact BP classification is unknown. We sought to examine this.

METHODS AND RESULTS

Data were from the Cardiovascular Risk in Young Finns Study, a prospective cohort study. Up to 2799 participants were followed from childhood (9-15 years) to adulthood (18-49 years) over up to six visits. Patterns of within-visit systolic BP (SBP) variability were defined as no-change, decrease, increase between consecutive readings (with 5 mmHg change thresholds). Classification of SBP (normal, high-normal, hypertension) using the first reading was compared with repeat readings. On average, SBP decreased with subsequent measures, but with major individual variability (no-change: 56.9-62.7%; decrease: 24.1-31.6%; increase: 11.5-16.8%). Patterns of SBP variability were broadly similar from childhood to adulthood, with the highest prevalence of an increase among participants categorized with normal SBP (12.6-20.3%). The highest prevalence of SBP reclassification occurred among participants with hypertension (28.9-45.3% reclassified as normal or high-normal). The prevalence of reclassification increased with the magnitude of change between readings.

CONCLUSION

There is a major individual variation of within-visit SBP change in childhood and adulthood and can influence BP classification. This highlights the importance of consistency among guidelines recommending that repeat BP measurements are needed for BP classification.

Over-Prescription of the Imidazoline Receptor Agonists: Evidence for Restriction of the Therapeutic Indication

BACKGROUND

Major antihypertensive drug classes (but not Imidazoline Receptor Agonists) have been demonstrated to reduce cardiovascular morbidity and mortality. In 2017, Latvia and Lithuania had the highest cardiovascular mortality among the Eastern, Central, Northern, and Western Member States of the European Union (EU). Cardiovascular mortality in Estonia is much lower than in Lithuania and Latvia.

OBJECTIVE

To evaluate the consumption of Imidazoline Receptor Agonists in the Baltic States and its potential implications.

MATERIALS AND METHODS

The study included data on the sales of Imidazoline Receptor Agonists in Lithuania, Latvia, and Estonia; the marketing authorization databases of the competent authorities; the guidelines on the treatment of hypertension, and the reimbursement conditions.

RESULTS

The study showed a very high consumption of the Imidazoline Receptor Agonists in Lithuania and Latvia. From 2016 to 2019, the average consumption of Imidazoline Receptor Agonists in Lithuania was 15.5 times higher than in Estonia; in Latvia, it was 8.9 times higher than in Estonia. The guidelines recommend the use of the Imidazoline Receptors Agonists as one of the last options in hypertension therapy, but the marketing authorizations do not restrict their line of therapy.

CONCLUSIONS

Consumption of IRAs in Lithuania and Latvia is very high. The authorized use of the IRAs in the EU Member States is not in line with the guidelines on the management of arterial hypertension and therefore patients might be deprived of therapies that reduce the cardiovascular risk. The drug regulatory authorities of the EU should review the data on the safety and efficacy of the IRAs and restrict their therapeutic indications if necessary.

Comparison of the 2017 ACC/AHA Hypertension Guideline with Earlier Guidelines on Estimated Reductions in Cardiovascular Disease

PURPOSE OF REVIEW

To review the recommendations of the 2017 American College of Cardiology/American Heart Association hypertension guideline and to compare it with previous guidelines on potential cardiovascular disease (CVD) and mortality risk reductions.

RECENT FINDINGS

Compared with previous guidelines, the 2017 hypertension guideline increased the prevalence of hypertension and the number of adults recommended for antihypertensive therapy in the US population. Based on data from recent analyses, the new guideline effectively directs antihypertensive therapy toward individuals at higher CVD risk. Two recent analyses using US national data estimated that implementation of the 2017 hypertension guideline could further reduce hundreds of thousands of CVD events and deaths compared with previous guidelines. However, the new guideline might increase the number of adverse events. The new guideline also improves the number of individuals needed to treat to prevent CVD events and deaths, suggesting implementation is cost-effective. Implementation of the 2017 hypertension guideline is projected to substantially reduce CVD events and deaths in the USA but might increase the number of adverse events. Future research is needed to implement and scale up effective, equitable, and sustainable strategies for applying the new guideline in daily clinical practice.

Blood pressure goals: A moving target

Clinical guidelines on hypertension have evolved over the past several decades. Each recommends varying blood pressure (BP) cut-offs which define hypertension, determine the thresholds to initiate pharmacotherapy, and guide treatment targets. In addition, different techniques of measuring BP in clinical trials may further contribute to the discrepancies in the achieved BP targets. Physicians find it difficult to navigate through different recommendations for hypertension management based on studies among different age groups and patients with a variety of co-morbidities and target organ involvement. In 2003, JNC 7 recommended a BP goal of < 140/90 mmHg in the general population and < 130/80 mmHg in those with diabetes mellitus or renal disease. JNC 8 re-set the BP target at < 140/90 mmHg for all adults under the age of 60 regardless of co-morbidities, and an even higher target of < 150/90 mmHg for those 60 years or older without diabetes or chronic kidney disease. The more recent results of the Systolic BP Intervention Trial (SPRINT) have a significant influence on the 2017 American College of Cardiology (ACC) and American Heart Association (AHA) guideline which redefines hypertension as BP ≥ 130/80 mmHg. It emphasizes individualized cardiovascular risk assessment and recommends a more aggressive BP target of < 130/80 mmHg and a treatment threshold based on the age, co-morbidities, and cardiovascular risk. The 2017 ACC/AHA guideline also advocates proper BP measurement and provides the estimates of corresponding BP values for clinic, home, and ambulatory BP monitoring measurements. A higher prevalence of hypertension is expected based on the ACC/AHA 2017 guideline. Its implementation may potentially lead to better BP control through enhanced awareness, improved adherence, and more timely initiation and intensification of pharmacologic therapy. Although there is no one-size-fits-all BP target, the ACC/AHA 2017 guideline is simple, inclusive and practical. Nonetheless, more studies are warranted to help further individualize BP goals for elderly patients and those with certain co-morbidities or multiple cardiovascular risk factors.

Influence of blood pressure level and age on within-visit blood pressure variability in children and adolescents

Blood pressure (BP) is variable in children and this could affect BP assessment, but the magnitude of within-visit BP variability (BPV) over consecutive measurements has never been investigated. This study aimed to determine the direction and magnitude of, and factors affecting, within-visit BPV in children and adolescents. BP was recorded among 3047 children (aged 12 years [95%CI 12, 13], males 52%) from the 2011-2013 Australian Health Survey. BPV was defined as the absolute difference (∆SBP_ABS) between the first (SBP1) and second systolic BP (SBP2) and the overall variability in three measures when available (SBPV). On average, ∆SBP_ABS was 6.7 mmHg (95%CI 6.3, 7.0) and SBPV was 8.2% (95%CI 7.8, 8.6). ∆SBP_ABS was greater with higher BP levels but lower with older age. From first to second measurements, SBP decreased in 58% (95%CI 56, 60), did not change in 10% (95%CI 9, 12), and increased in 32% (95%CI 29, 34) of the population.

CONCLUSIONS

BP is highly variable in children and adolescents, with the magnitude of variability being associated with both age and BP level. SBP increases on repeat measurement in a substantial proportion of the population. The optimal protocol of BP assessment to address this increased BPV needs to be determined. What is Known: • Diagnosis of elevated blood pressure (BP) is based on strict probabilistic criteria, the difference between the 90th (pre-hypertension) and 95th (hypertension) percentiles only being 3-4 mmHg. • BP variability could affect BP classification among children and adolescents. What is New: • The magnitude of BP change among children and adolescents is highly affected by BP level and age. • BP does not always drop on consecutive measurements, and evidence-based BP assessment protocols should be established to avoid misdiagnosis of hypertension.

Treatment of hypertension: The ESH/ESC guidelines recommendations

Effective cardiovascular prevention in the hypertensive setting needs the achievement of a tight blood pressure (BP) control with appropriate lifestyle measures and anti-hypertensive therapy. In fact, the ultimate goal of treatment strategies is the reduction of the excess of cardiovascular mortality and morbidity related to chronically elevated BP. In this chapter we will review the recommendations provided by the latest ESH/ESC guidelines focusing on the non-pharmacological and pharmacological treatment of hypertension. The first part will be focalized on the BP targets to be achieved by the treatment in the general hypertensive population and in specific clinical settings. In the second part, we will also depict the life-style changes with proven anti-hypertensive efficacy. In the third part we will describe the general principles of pharmacological therapy recommended in the general population and in special conditions. Finally we will make a brief comment on the new hypertension guidelines that will be published in 2017.

Current Practice of Hypertension in India: Focus on Blood Pressure Goals

INTRODUCTION

Recommended Blood Pressure (BP) goals in elderly and those with co-morbid conditions like Diabetes Mellitus (DM) and Chronic Kidney Disease (CKD) vary in different Hypertension (HTN) management guidelines.

AIM

To understand currently followed BP goals and practices among the physicians involved in management of HTN in India.

MATERIALS AND METHODS

A cross-sectional, observational survey was conducted at 66^th annual conference of Cardiological Society of India (CSICON-2014, Hyderabad). A structured questionnaire related to the BP goals and HTN practices was provided and responses from voluntarily participating physicians were collected. Data was analysed with descriptive statistics.

RESULTS

Two-hundred sixty physicians completed this survey. In their routine clinical practice, physicians most frequently referred to Joint National Committee (JNC) guidelines (63.85%) followed by Indian guidelines on HTN (14.23%). In patients aged 60 years and above, BP goal <140/90mmHg and <150/90mmHg was aimed by 43.46% and 33.85% of the physicians respectively. In HTN with Type 2 DM (T2DM), most physicians (61.92%) had a BP goal of <130/80mmHg. A target BP <130/80mmHg was aimed by 48.08% physicians in CKD without proteinuria and 68.85% physicians in CKD with proteinuria. In newly diagnosed hypertensives, treatment modification was practiced after 15, 20 and 30 days by 37.31%, 16.15% and 35.77% of the physicians respectively. Beta-blockers were considered as third-line agents in HTN without co-morbidities by 45% physicians. Ambulatory BP Monitoring (ABPM) is practiced only in few patients (<5%) by most (71.93%) physicians.

CONCLUSION

In practice, Indian physicians follow lower BP goals when compared to the recommendations from the most referred JNC guidelines. Increasing physicians' awareness to the changes in recommendations is the need.

The approach of general practitioners in Lagos to the detection and evaluation of hypertension

INTRODUCTION

Hypertension (HTN) control is a major public health and clinical challenge. A number of guidelines exist globally to assist in tackling this challenge. The aim of this study was to determine conformity of the HTN detection and evaluation practices of a sample of Lagos-based general practitioners (GPs) to international guidelines.

METHODS

Self-administered structured questionnaires were used to collect data from a cohort of GPs attending continuing medical education programs in Lagos.

RESULTS

Out of the 460 GPs that were approached, 435 agreed to participate in the study, with questionnaires from 403 GPs analyzed. The average age and number of years post-registration of the GPs were 40.0 ± 11.3 years and 14.3 ± 11.1 years, respectively. Two thirds (n = 269) were in private practice. Their daily average total and HTN patients' loads were 17.4 ± 14.3 and 4.4 ± 3.5, respectively. Awareness of HTN guidelines was 46.7% (n = 188), while 18.1% (n = 73) was able to name one or more HTN guidelines. The approaches of these GPs to the detection and evaluation of HTN and their relationships to the GPs' experience were heterogeneous.

DISCUSSION

The approach of the GPs to detection and evaluation of HTN though heterogeneous is unsatisfactory and may partly contribute to poor HTN control in Nigeria. Strengthening the capacity of GPs in this regard through continuous medical education may greatly improve HTN control.