Heterogeneity in Blood Pressure Response to 4 Antihypertensive Drugs: A Randomized Clinical Trial

Importance

Hypertension is the leading risk factor for premature death worldwide. Multiple blood pressure-lowering therapies are available but the potential for maximizing benefit by personalized targeting of drug classes is unknown.

Objective

To investigate and quantify the potential for targeting specific drugs to specific individuals to maximize blood pressure effects.

Design, Setting, and Participants

A randomized, double-blind, repeated crossover trial in men and women with grade 1 hypertension at low risk for cardiovascular events at an outpatient research clinic in Sweden. Mixed-effects models were used to assess the extent to which individuals responded better to one treatment than another and to estimate the additional blood pressure lowering achievable by personalized treatment.

Interventions

Each participant was scheduled for treatment in random order with 4 different classes of blood pressure-lowering drugs (lisinopril [angiotensin-converting enzyme inhibitor], candesartan [angiotensin-receptor blocker], hydrochlorothiazide [thiazide], and amlodipine [calcium channel blocker]), with repeated treatments for 2 classes.

Main Outcomes and Measures

Ambulatory daytime systolic blood pressure, measured at the end of each treatment period.

Results

There were 1468 completed treatment periods (median length, 56 days) recorded in 270 of the 280 randomized participants (54% men; mean age, 64 years). The blood pressure response to different treatments varied considerably between individuals (P < .001), specifically for the choices of lisinopril vs hydrochlorothiazide, lisinopril vs amlodipine, candesartan vs hydrochlorothiazide, and candesartan vs amlodipine. Large differences were excluded for the choices of lisinopril vs candesartan and hydrochlorothiazide vs amlodipine. On average, personalized treatment had the potential to provide an additional 4.4 mm Hg-lower systolic blood pressure.

Conclusions and Relevance

These data reveal substantial heterogeneity in blood pressure response to drug therapy for hypertension, findings that may have implications for personalized therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02774460.

Extent of a valsartan drug shortage and its effect on antihypertensive drug use in the Canadian population: a national cross-sectional study

BACKGROUND

Drug shortages represent a growing global problem, with potentially serious consequences to patients and the health care system. Our study investigates the impacts of a major recall and shortage of valsartan, an angiotensin receptor blocker (ARB), in July 2018 in Canada.

METHODS

We conducted a time-series analysis of antihypertensive drugs dispensed in Canada between 2015 and 2019 using commercially available retail prescription data. Using autoregressive integrated moving average (ARIMA) modelling, we evaluated the change in valsartan use after the recall. We also measured the overall use of ARBs, angiotensin-converting-enzyme (ACE) inhibitors and other antihypertensive drug classes for the same period.

RESULTS

After the recall in July 2018, valsartan use decreased 57.8%, from 362 231 prescriptions dispensed in June 2018 to 152 892 in September 2018 (difference = 209 339, p < 0.0001). Overall use of the ARB drug class decreased 2.0%, from 1 577 509 prescriptions dispensed in June 2018 to 1 545 591 in September 2018 (difference = 31 918, p = 0.0003), but use of non-valsartan ARBs increased 14.6%, from 1 215 278 to 1 392 699 prescriptions dispensed (difference = 177 421, p < 0.0001) in the same time frame. Although use of ACE inhibitors initially declined, this reduction was not sustained. The valsartan recall was not associated with a significant impact on use of other antihypertensive drug classes.

INTERPRETATION

Our findings illustrate the impact of a major drug shortage, with the immediate and substantial reduction of valsartan dispensed and cascading effects on other ARBs, though future research is warranted to understand the consequences of such extensive shortages on clinical outcomes and health system costs. Improved policy strategies are needed to address the underlying causes of drug shortages and to mitigate their effects.

Research on Beers Criteria and STOPP/START Criteria based on the FDA FAERS database

PURPOSE

Inappropriate medication criteria for the elderly have played an important role in ensuring the safety of medications for the elderly. Too few drugs included in the criteria cannot guarantee the safety of medication for the elderly. Too many drugs included in the criteria will result in less selective medication for the elderly. This paper uses real-world data to evaluate the relationship between antihypertensive drugs and falls, so as to provide references for experts and scholars to revise the criteria of potentially inappropriate medications for the elderly and clinical safe medication.

METHOD

We use the US Food and Drug Administration Adverse Event Reporting System (FDA FAERS) to evaluate the association between specific antihypertensive drugs in six categories (alpha-1 receptor blockers (α-1 blockers), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-receptor blockers (β-blockers), and diuretics) and falls by data mining algorithms, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), Medicines and Healthcare Products Regulatory Agency (MHRA), and the empirical Bayes geometric mean (EBGM) and compared with the relevant drugs included in the Beers Criteria and STOPP/START Criteria.

RESULT

There are a total of 5,157,172 co-occurrences found in 973,447 reports aged 65 years or older from 2016 to 2019 in the FDA FAERS database, and the number of co-occurrences of falls is 5917 for the six categories of 51 antihypertensive drugs. Four kinds of mining methods overlap detection of 12 kinds of positive signal drugs, none of which are not included in the Beers Criteria and 7 drugs are included in the STOPP/START Criteria; 1-3 kinds of mining methods overlap detection of positive signal drugs, a total of 12 kinds, and one drug is included in the Beers Criteria and 5 drugs are included in the STOPP/START Criteria; 22 drugs have fall adverse events, but no positive signal is detected, and 13 drugs are included in STOPP/START Criteria; and 5 drugs have no fall adverse events and 3 drugs are included in the STOPP/START Criteria.

CONCLUSION

The FAERS database was used to confirm the potential connection between some antihypertensive drugs and fall adverse events through data mining algorithms. The Beers Criteria did not clearly indicate the antihypertensive drugs that caused falls, and the antihypertensive drugs included in the STOPP/START Criteria were too extensive and did not include β-blockers and diuretics. It is recommended that experts and scholars use real-world data (such as FAERS, EudraVigilance, WHO VigiBase, and so on) to further explore the relationship between specific antihypertensive drugs and falls in the elderly, so as to revise and improve the criteria for inappropriate medications for the elderly.

Blood Pressure Management in Stroke

Hypertension is a well-established and modifiable risk factor for stroke and other cardiovascular diseases. Notably, stroke is the second leading cause of death worldwide and the second most common cause of disability-adjusted life-years. As such, we provide a viewpoint on blood pressure management in stroke and emphasize blood pressure control or management for first and recurrent stroke prevention, acute stroke treatment, and for prevention of cognitive impairment or dementia.

Comparison of Antihypertensive Drug Classes for Dementia Prevention

BACKGROUND

Hypertension in midlife is associated with increased risk of Alzheimer disease and vascular dementia late in life. In addition, some antihypertensive drugs have been proposed to have cognitive benefits, independent of their effect on hypertension. Consequently, there is potential to repurpose antihypertensive drugs for the prevention of dementia. This study systematically compared seven antihypertensive drug classes for this purpose, using the Clinical Practice Research Datalink.

METHODS

We assessed treatments for hypertension in an instrumental variable analysis to address potential confounding and reverse causation. We used physicians' prescribing preference as an ordinal instrument, defined by the physicians' last seven prescriptions. Participants considered were new antihypertensive users between 1996 and 2016, aged 40 and over.

RESULTS

We analyzed 849,378 patients, with total follow up of 5,497,266 patient-years. We estimated that β-adrenoceptor blockers and vasodilator antihypertensives conferred small protective effects-for example, β-adrenoceptor blockers were associated with 13 (95% confidence interval = 6, 20) fewer cases of any dementia per 1000 treated compared with other antihypertensives.

CONCLUSIONS

We estimated small differences in the effects of antihypertensive drug classes on dementia outcomes. We also show that the magnitude of the differences between drug classes is smaller than that previously reported. Future research should look to implement other causal analysis methods to address biases in conventional observational research, with the ultimate aim of triangulating the evidence concerning this hypothesis.

Antihypertensive drugs use over a 5-year period among children and adolescents in Beijing, China: An observational study

Evidence on the prescription patterns of antihypertensive drug use in children and adolescents in China is scarce. A descriptive analysis of the Beijing Medical Claim Data, which covered over 95% of the urban residents, was conducted to investigate antihypertensive prescribing patterns and trends in children and adolescents aged under 18 from 2009 to 2014 in Beijing, China. An additional meta-analysis of trends in hypertension prevalence was conducted to compare trends with antihypertensive medications.A total of 11,882 patients received at least 1 prescription for antihypertensive drugs from 2009 to 2014. The number of annual antihypertensive users increased from 2009 to 2012, then declined steadily until 2014, which was consistent with the trend of the hypertension prevalence estimated from the meta-analysis. β-receptor blockers, thiazide diuretics, and angiotensin-converting enzyme inhibitors were the 3 most commonly prescribed antihypertensive drugs. More boys took the antihypertensive drugs than girls. For users aged under 3 years, thiazide diuretics, α-receptor blockers, and angiotensin-converting enzyme inhibitors were the most prescribed drugs, while β-receptor blockers, thiazide diuretics were the most used drugs for users above 3 years.In conclusion, antihypertensive drug prescribing for children and adolescents increased from 2009 to 2014, with different characteristics in different subgroups.

Diagnosis and Prevention of Hypertensive Heart Failure

Elevated blood pressure (BP) has a strong and continuous association with Stage B and C heart failure (HF) and carries the highest attributable risk for HF. Intensive treatment of hypertension is crucial, as progression from hypertension (Stage A HF) to left ventricular hypertrophy (LVH) or other structural damage (Stage B HF) is common despite therapy. Echo cardiography is the modality of choice to detect Stage B HF. Ideally, Stage B HF should be prevented. However, regression of established LVH and other structural damage is feasible and improves prognosis. Despite differences among antihypertensive agents, control of BP remains the most important goal.

Effect of Different Classes of Antihypertensive Drugs on Endothelial Function and Inflammation

Hypertension is characterized by structural and functional changes in blood vessels that travel with increased arterial stiffness, vascular inflammation, and endothelial dysfunction. Some antihypertensive drugs have been shown to improve endothelial function and reduce levels of inflammatory markers regardless of the effect of blood pressure lowering. Third-generation β-blockers, such as nebivolol and carvedilol, because they have additional properties, have been shown to improve endothelial function in patients with hypertension. Calcium channel antagonists, because they have antioxidant effects, may improve endothelial function and vascular inflammation.The Angiotensin Receptor Blocker (ARBs) are able to improve endothelial dysfunction and vascular inflammation in patients with hypertension and other cardiovascular diseases. Angiotensin converting enzyme (ACE) inhibitors have shown beneficial effects on endothelial function in patients with hypertension and other cardiovascular diseases, however there are few studies evaluating the effect of treatment with this class on the reduction of C-reactive protein (CRP) levels. Further studies are needed to assess whether treatment of endothelial dysfunction and vascular inflammation may improve the prognosis of patients with essential hypertension.

Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study

OBJECTIVES

To assess how often older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment, and to identify markers of appropriateness for these intensifications.

DESIGN

Retrospective cohort study.

SETTING

US Veterans Administration Health System.

PARTICIPANTS

Patients aged 65 years or over with hypertension admitted to hospital with non-cardiac conditions between 2011 and 2013.

MAIN OUTCOME MEASURES

Intensification of antihypertensive treatment, defined as receiving a new or higher dose antihypertensive agent at discharge compared with drugs used before admission. Hierarchical logistic regression analyses were used to control for characteristics of patients and hospitals.

RESULTS

Among 14 915 older adults (median age 76, interquartile range 69-84), 9636 (65%) had well controlled outpatient blood pressure before hospital admission. Overall, 2074 (14%) patients were discharged with intensified antihypertensive treatment, more than half of whom (1082) had well controlled blood pressure before admission. After adjustment for potential confounders, elevated inpatient blood pressure was strongly associated with being discharged on intensified antihypertensive regimens. Among patients with previously well controlled outpatient blood pressure, 8% (95% confidence interval 7% to 9%) of patients without elevated inpatient blood pressure, 24% (21% to 26%) of patients with moderately elevated inpatient blood pressure, and 40% (34% to 46%) of patients with severely elevated inpatient blood pressure were discharged with intensified antihypertensive regimens. No differences were seen in rates of intensification among patients least likely to benefit from tight blood pressure control (limited life expectancy, dementia, or metastatic malignancy), nor in those most likely to benefit (history of myocardial infarction, cerebrovascular disease, or renal disease).

CONCLUSIONS

One in seven older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment. More than half of intensifications occurred in patients with previously well controlled outpatient blood pressure. More attention is needed to reduce potentially harmful overtreatment of blood pressure as older adults transition from hospital to home.

Resistant Hypertension: Time to Consider the Best Fifth Anti-Hypertensive Treatment

PURPOSE OF REVIEW

Resistant hypertension (RH) is a growing clinical condition worldwide associated with target-organ damage and poor prognosis compared to non-resistant counterparts. The purpose of this review is to perform a critical evaluation of preferable drug choices for managing RH highlighting the evidence that significant proportion of patients remained uncontrolled despite using four anti-hypertensive drugs.

RECENT FINDINGS

Until recently, the fourth drug therapy was main derived from personal opinion or small interventional studies. The recent data derived from two multicentric randomized trials, namely PATHWAY-2 and ReHOT, pointed spironolactone as the preferable fourth drug therapy in patients with confirmed RH as compared to bisoprolol and doxazosin (PATHWAY-2) as well as clonidine (ReHOT). However, significant proportion of patients (especially observed in ReHOT trial that used 24-h ambulatory blood pressure monitoring) did not achieve optimal blood pressure with the fourth drug. This finding underscores the need of new approaches and treatment options in this important research area. The current evidence pointed that significant proportion of RH patients are requiring more than four drugs for controlling BP. This statement is particularly true considering the new criteria proposed by the 2017 Guidelines for diagnosing RH (> 130 × 80 mmHg). New combinations, drugs, or treatments should be tested aiming to reduce the RH burden. Based on the aforementioned multicentric trials, we proposed the first five preferable anti-hypertensive classes in the overall context of RH.

Hypertension Canada's 2018 Guidelines for the Management of Hypertension in Pregnancy

We present Hypertension Canada's inaugural evidence-based Canadian recommendations for the management of hypertension in pregnancy. Hypertension in pregnancy is common, affecting approximately 7% of pregnancies in Canada, and requires effective management to reduce maternal, fetal, and newborn complications. Because of this importance, these guidelines were developed in partnership with the Society of Obstetricians and Gynaecologists of Canada with the main common objective of improving the management of women with hypertension in pregnancy. Guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children are published separately. In this first Hypertension Canada guidelines for hypertension in pregnancy, 7 recommendations for the management of nonsevere and severe hypertension in pregnancy are presented. For nonsevere hypertension in pregnancy (systolic blood pressure 140-159 mm Hg and/or diastolic blood pressure 80-109 mm Hg), we provide guidance for the threshold for initiation of antihypertensive therapy, blood pressure targets, as well as first- and second-line antihypertensive medications. Severe hypertension (systolic blood pressure ≥ 160 mm Hg and/or diastolic blood pressure ≥ 110 mm Hg) requires urgent antihypertensive therapy to reduce maternal, fetal, and newborn adverse outcomes. The specific evidence and rationale underlying each of these guidelines are discussed.

Incremental effects of antihypertensive drugs: instrumental variable analysis

OBJECTIVES

To assess the incremental effects of adding extra antihypertensive drugs from a new class to a patient's regimen.

DESIGN

Instrumental variable analysis of data from SPRINT (Systolic Blood Pressure Intervention Trial). To account for confounding by indication-when treatments seem less effective if they are administered to sicker patients-randomization status was used as the instrumental variable. Patients' randomization status was either intensive (systolic blood pressure target <120 mm Hg) or standard (systolic blood pressure target <140 mm Hg) treatment. Results from instrumental variable models were compared with those from standard multivariable models.

SETTING

Secondary data analysis of a randomized clinical trial conducted at 102 sites in 2010-15.

PARTICIPANTS

9092 SPRINT participants with hypertension and increased cardiovascular risk but no history of diabetes or stroke.

MAIN OUTCOMES MEASURES

Systolic blood pressure, major cardiovascular events, and serious adverse events.

RESULTS

In standard multivariable models not adjusted for confounding by indication, addition of an antihypertensive drug from a new class was associated with modestly lower systolic blood pressure (-1.3 mm Hg, 95% confidence interval -1.6 to -1.0) and no change in major cardiovascular events (absolute risk of events per 1000 patient years, 0.5, 95% confidence interval -1.5 to 2.3). In instrumental variable models, the addition of an antihypertensive drug from a new class led to clinically important reductions in systolic blood pressure (-14.4 mm Hg, -15.6 to -13.3) and fewer major cardiovascular events (absolute risk -6.2, -10.9 to -1.3). Incremental reductions in systolic blood pressure remained large and similar in magnitude for patients already taking drugs from zero, one, two, or three or more drug classes. This finding was consistent across all subgroups of patients. The addition of another antihypertensive drug class was not associated with adverse events in either standard or instrumental variable models.

CONCLUSIONS

After adjustment for confounding by indication, the addition of a new antihypertensive drug class led to large reductions in systolic blood pressure and major cardiovascular events among patients at high risk for cardiovascular events but without diabetes. Effects on systolic blood pressure persisted across all levels of baseline drug use and all subgroups of patients.

Visit-to-Visit Office Blood Pressure Variability and Cardiovascular Outcomes in SPRINT (Systolic Blood Pressure Intervention Trial)

Studies of visit-to-visit office blood pressure (BP) variability (OBPV) as a predictor of cardiovascular events and death in high-risk patients treated to lower BP targets are lacking. We conducted a post hoc analysis of SPRINT (Systolic Blood Pressure Intervention Trial), a well-characterized cohort of participants randomized to intensive (<120 mm Hg) or standard (<140 mm Hg) systolic BP targets. We defined OBPV as the coefficient of variation of the systolic BP using measurements taken during the 3-,6-, 9-, and 12-month study visits. In our cohort of 7879 participants, older age, female sex, black race, current smoking, chronic kidney disease, and coronary disease were independent determinants of higher OBPV. Use of thiazide-type diuretics or dihydropyridine calcium channel blockers was associated with lower OBPV whereas angiotensin-converting enzyme inhibitors or angiotensin receptor blocker use was associated with higher OBPV. There was no difference in OBPV in participants randomized to standard or intensive treatment groups. We found that OBPV had no significant associations with the composite end point of fatal and nonfatal cardiovascular events (n=324 primary end points; adjusted hazard ratio, 1.20; 95% confidence interval, 0.85-1.69, highest versus lowest quintile) nor with heart failure or stroke. The highest quintile of OBPV (versus lowest) was associated with all-cause mortality (adjusted hazard ratio, 1.92; confidence interval, 1.22-3.03) although the association of OBPV overall with all-cause mortality was marginal (P=0.07). Our results suggest that clinicians should continue to focus on office BP control rather than on OBPV unless definitive benefits of reducing OBPV are shown in prospective trials.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01206062.

Screening for Hypertension and Lowering Blood Pressure for Prevention of Cardiovascular Disease Events

Hypertension affects 1 in 3 American adults. Blood pressure (BP)-lowering therapy reduces the risk of cardiovascular disease. The United States Preventive Services Task Force recommends all adults be screened for hypertension. Most patients whose office BP is elevated should have out-of-office monitoring to confirm the diagnosis. Ambulatory BP monitoring is preferred for out-of-office measurement, but home BP monitoring is a reasonable alternative. Guidelines for treatment are stratified by age (<60 vs >60 years) and include cutoffs for recommended treatment BPs and target BP goals. Quality of hypertension care is improved by incorporating population health management using registries and medication titration.

Changes in Kidney Function in a Population With Essential Hypertension in Real Life Settings

INTRODUCTION

Hypertension has been identified as one of the commonest modifiable determinants for chronic kidney disease progression. A variety of antihypertensive drugs are available and their effect on kidney function has been investigated by a large number of randomized controlled trials. Observational studies, although scarcely been used, outpatient can reflect everyday practice, where drug exposures vary over time, and may provide an alternative for detecting longitudinal changes in kidney function.

MATERIALS AND METHODS

We applied mixed model repeated measures analysis to investigate the effect of antihypertensive drug categories and their combinations on kidney function change over time in a cohort of 779 patients with essential hypertension, using the data from a Greek hypertension outpatient clinic. Antihypertensive drugs were grouped in 5 categories. Their effect was evaluated and their combinations with and without renin-angiotensin-system inhibitors (RASI) to each other. In addition, the combination of RASI with calcium channel blockers (CCBs) was studied.

RESULTS

Diuretics, RASI, CCBs, and beta-blockers had a significant renoprotective and blood pressure lowering effect. Combinations with RASI had a smaller beneficial effect on kidney function compared to CCBs (0.75 mL/min/1.73 m2 per year of drug use versus 0.97 mL/min/1.73 m2). There was no additional effect when combining RASI with CCBs. However, the lowering effect on systolic blood pressure was greater (-0.83 mm Hg per year of drug use, P < .001).

CONCLUSIONS

RASI were found to have a smaller, although significant, renoprotective effect. There was no additional effect on kidney function when combining RASI with CCBs.

Classes of antihypertensive agents and mortality in hypertensive patients with type 2 diabetes-Network meta-analysis of randomized trials

AIMS

The aim of this study was to evaluate the effects of antihypertensive drug classes in mortality in patients with type 2 diabetes.

METHODS

MEDLINE, EMBASE, Clinical Trials and Cochrane Library were searched for randomized trials comparing thiazides, beta-blockers, calcium channel blockers (CCBs), angiotensin-converting inhibitors (ACEi) and angiotensin-receptor blockers (ARBs), alone or in combination for hypertension treatment in patients with type 2 diabetes. Outcomes were overall and cardiovascular mortality. Network meta-analysis was used to obtain pooled effect estimate.

RESULTS

A total of 27 studies, comprising 49,418 participants, 5647 total and 1306 cardiovascular deaths were included. No differences in total or cardiovascular mortality were observed with isolated antihypertensive drug classes compared to each other or placebo. The ACEi and CCB combination showed evidence of reduction in cardiovascular mortality comparing to placebo [median HR, 95% credibility intervals: 0.16, 0.01-0.82], betablockers (0.20, 0.02-0.98), CCBs (0.21, 0.02-0.97) and ARBs (0.18, 0.02-0.91). In included trials, this combination was the treatment that most consistently achieved both lower systolic and diastolic end of study blood pressure.

CONCLUSIONS

There is no benefit of a single antihypertensive class in reduction of mortality in hypertensive patients with type 2 diabetes. Reduction of cardiovascular mortality observed in patients treated with ACEi and CCB combination may be related to lower blood pressure levels.

Comparative Effectiveness of Blood Pressure-lowering Drugs in Patients who have Already Suffered From Stroke: Traditional and Bayesian Network Meta-analysis of Randomized Trials

Hypertension is the most important risk factor for stroke and stroke recurrence. However, the preferred blood pressure (BP)-lowering drug class for patients who have suffered from a stroke has yet to be determined. To investigate the relative effects of BP-lowering therapies [angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blockers (ARB), β blockers, calcium channel blockers (CCBs), diuretics, and combinations of these drugs] in patients with a prior stroke history, we performed a systematic review and meta-analysis using both traditional frequentist and Bayesian random-effects models and meta-regression of randomized controlled trials (RCTs) on the outcomes of recurrent stroke, coronary heart disease (CHD), and any major adverse cardiac and cerebrovascular events (MACCE). Trials were identified from searches of published hypertension guidelines, electronic databases, and previous systematic reviews. Fifteen RCTs composed of 39,329 participants with previous stroke were identified. Compared with the placebo, only ACEI along with diuretics significantly reduced recurrent stroke events [odds ratio (OR) = 0.54, 95% credibility interval (95% CI) 0.33-0.90]. On the basis of the distribution of posterior probabilities, the treatment ranking consistently identified ACEI along with diuretics as the preferred BP-lowering strategy for the reduction of recurrent stroke and CHD (31% and 35%, respectively). For preventing MACCE, diuretics appeared to be the preferred agent for stroke survivors (34%). Moreover, the meta-regression analysis failed to demonstrate a statistical significance between BP reduction and all outcomes (P = 0.1618 for total stroke, 0.4933 for CHD, and 0.2411 for MACCE). Evidence from RCTs supports the use of diuretics-based treatment, especially when combined with ACEI, for the secondary prevention of recurrent stroke and any vascular events in patients who have suffered from stroke.

[HYPERTENSIVE CRISIS: MODERN VIEW OF THE PROBLEM AND OPTIMIZATION OF DIAGNOSTIC AND THERAPEUTIC MODALITIES]

The data collected by Burdenko Military Hospital indicate that in the 1980s hypertensive crisis (HC) occurred in roughly 30% of the patients with AH. This value fell down to 16% by 2012, with a rise in the number of uncomplicated crises from 46 to 62%. Analysis of the causes behind these changes showed that half of the patients simply experienced an elevated arterial pressure with minimal clinical symptoms. The decrease in the number of complicated cases from 54 to 39% is doubtful bearing in mind that ICD-10 gives the status of nosological entities to complications of hypertensive crisis (stroke, myocardial infarction, etc.) but not to the HC syndrome proper requiring urgent hospitalization; due to this hypertensive crisis itself tends to be disregarded and not included in statistics. HC with acute clinically significant lesions of target organs requires intensive care or resuscitation using infusion of vasodilators and loop diuretics to stabilize arterial pressure. In case of uncomplicted HC and aggravation of hypertensive disease, the medications of choice are oral short-acting ACE inhibitors and imidazoline receptor agonists.

Persistence with Antihypertensive Medications in Uncomplicated Treatment-Naïve Patients: Effects of Initial Therapeutic Classes

We aimed to assess one-year persistence with antihypertensive therapy (AHT) among newly treated uncomplicated hypertensive patients in Korea and to evaluate the effect of initial therapeutic classes on persistence. We retrospectively analyzed a random sample of 20% of newly treated uncomplicated hypertensive patients (n = 45,787) in 2012 from the National Health Insurance claims database. This group was classified into six cohorts based on initial AHT class. We then measured treatment persistence, allowing a prescription gap of 60 days. Adherence to AHT was assessed with the medication possession ratio. Calcium channel blockers (CCB, 43.7%) and angiotensin receptor blockers (ARB, 40.3%) were most commonly prescribed as initial monotherapy. Overall, 62.1% and 42.0% were persistent with any AHT and initial class at one year, respectively, and 64.2% were adherent to antihypertensive treatment. Compared with ARBs, the risk of AHT discontinuation was significantly increased with initial use of thiazide diuretics (hazard ratio [HR], 3.16; 95% confidence interval [CI] 2.96-3.74) and beta blockers (HR, 1.86; CI, 1.77-1.95) and was minimally increased with CCBs (HR, 1.12; CI, 1.08-1.15). In conclusion, persistence and adherence to AHT are suboptimal, but the differences are meaningful in persistence and adherence between initial AHT classes.

Long-Term Anti-Hypertensive Therapy and Stroke Prevention: A Meta-Analysis

BACKGROUND

Stroke causes approximately 6.7 million deaths worldwide per year and is the second leading cause of death. Pharmacotherapy for hypertension, an independent risk factor for stroke, significantly reduces the incidence of stroke. Although prior meta-analyses demonstrate various antihypertensive classes are superior to placebo in reducing stroke risk, which class is most effective is unclear.

METHODS

We conducted a systematic MEDLINE search including only randomized controlled trials (RCT) of antihypertensive medications published between 1999 and 2014 in adults with stroke as a primary or secondary outcome. Five classes compared against all others were angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), β-adrenoceptor antagonists (β-blockers), calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics (T-TLDs). Among 17 RCTs with 31 comparative arms, risk ratio was used to assess effect size, and a fixed- and random-effect model was used to calculate summary effect size, utilizing comprehensive meta-analysis statistical software version 2.0.

RESULTS

The 251,853 subjects (46 ± 11.4 % female; mean age 67.2 ± 6.8 years), were grouped as follows: ACEI 52,887; ARB 7278; ACEI/ARB 60,165; β-blocker 24,099; CCB 98,950; and T-TLD 68,639. The mean follow-up was 42.9 ± 15 months. A random-effect model was used to assess for summary effect size in ACEI, ACEI/ARB, ARB, and T-TLD groups. The summary risk ratio for stroke occurrence in the different antihypertensive drug classes were as follows: ACEIs 1.01 (95 % confidence interval [CI] 0.81-1.27; p = 0.92); ACEIs/ARBs 0.94 (95 % CI 0.78-1.13; p = 0.51); T-TLDs 0.90 (95 % CI 0.75-1.08; p = 0.25); ARBs 0.83 (95 % CI 0.59-1.18; p = 0.30); β-blockers 1.42 (95 % CI 1.26-1.61; p < 0.01); and CCBs 0.83 (95 % CI 0.79-0.89; p < 0.01).

CONCLUSION

Among the antihypertensive classes, CCBs were most effective in reducing the long-term incidence of stroke, whereas β-blockers were associated with significantly increased risk.

Antihypertensive drug class and adherence: an electronic monitoring study

BACKGROUND

Medication adherence is essential to optimizing blood pressure (BP) control. Prior research has demonstrated differences in pharmacy refill patterns according to antihypertensive drug class. No prior study has assessed the association between drug class and day-to-day adherence.

METHODS

Between 2011 and 2014, we enrolled a convenience sample of 149 patients with persistently uncontrolled hypertension from two inner-city clinics and concurrently measured adherence of up to four antihypertensive medications using electronic pillboxes during the interval between two primary care visits. The main outcome was mean percent of days adherent to each drug. Mixed effects regression analyses were used to assess the association between drug class and adherence adjusting for age, gender, race, ethnicity, education, health insurance, coronary artery disease, heart failure, chronic kidney disease, diabetes, number of medications, days monitored, and dosing frequency.

RESULTS

The mean age was 64 years; 72% women, 75% Hispanic, 88% prescribed ≥ 1 BP medication. In unadjusted analyses, adherence was lower for beta-blockers (70.9%) compared to angiotensin receptor blocking agents (75.0%, P = 0.11), diuretics (75.9%, P < 0.001), calcium channel blockers (77.6%, P < 0.001) and angiotensin-converting enzyme inhibitors (78.0%, P < 0.0001). In the adjusted analysis, only dosing frequency (P = 0.0001) but not drug class (P = 0.71) was associated with medication adherence.

CONCLUSIONS

Antihypertensive drug class was not associated with electronically measured adherence after accounting for dosing frequency amongst patients with uncontrolled hypertension. Low adherence to beta-blockers may have been due to the common practice of prescribing multiple daily dosing. Providers may consider using once daily formulations to optimize adherence and should assess adherence among all treated patients with uncontrolled hypertension.

[General substance classification and pharmacology of glaucoma]

The pharmaceutical therapy of glaucoma dates back to 1875 when Weber introduced pilocarpine into the medicinal treatment of glaucoma. Since then there has been a continuous development of topical antiglaucoma therapy whereby the main developments date back to the 1980s and 1990s. All forms of medicinal therapy aim at lowering the intraocular pressure and achieve this either by inhibiting aqueous humor secretion into the ciliary body or by enhancing physiological drainage routes along Schlemm's canal. This article gives an overview over the most important classes of antiglaucoma drugs, the indications and contraindications as well as pharmacological characteristics. The focus lies on the market of combination and generic drug preparations that is currently rapidly developing and therefore needs to be discussed in detail.

The impact of combinations of non-steroidal anti-inflammatory drugs and anti-hypertensive agents on blood pressure

Nowadays NSAIDs are the most frequently used groups of drugs, especially because of their availability. Their consumption is high among older people, who are much more sensitive to the side effects, and who are often also taking other drugs which can interact with them. Moreover, the majority of the older population is suffering from hypertension. This could well explain the commonly encountered experience of drug interaction between NSAIDs and antihypertensive drugs, which is very common in clinical practice. The severity of this drug interaction is classified as class C, with a recommendation to monitor therapy. However, even a minor long-term increase in blood pressure can significantly increase the risk of cardiovascular mortality, while mortality rates can possibly be reduced by sufficiently effective treatment of hypertension. Therefore, in clinical practice, this type of interaction should not be overlooked as a major cause of failure of hypertension treatment in older patients, as well in many cases in general. The present article focusses on the mechanism and the degree of influence on the blood pressure of particular types of antihypertensive agents used in combination with NSAID. Not all groups of antihypertensive drugs are affected to the same degree; some are more affected, and others, such as calcium channel blockers, are not affected at all. Similarly, not every NSAID increases blood pressure. Many studies, some of which are analyzed in this article, present evidence of the degree of the influence NSAIDs have on blood pressure.

Independent influence of overweight and obesity on the regression of left ventricular hypertrophy in hypertensive patients: a meta-analysis

Overweight and obesity are associated with adverse cardiovascular outcomes. However, the role of overweight and obesity in left ventricular hypertrophy (LVH) of hypertensive patients is controversial. The aim of the current meta-analysis was to evaluate the influence of overweight and obesity on LVH regression in the hypertensive population.Twenty-eight randomized controlled trials comprising 2403 hypertensive patients (mean age range: 43.8-66.7 years) were identified. Three groups were divided according to body mass index: normal weight, overweight, and obesity groups.Compared with the normal-weight group, LVH regression in the overweight and obesity groups was more obvious with less reduction of systolic blood pressure after antihypertensive therapies (P < 0.001). The renin-angiotensin system inhibitor was the most effective in regressing LVH in overweight and obese hypertensive patients (19.27 g/m, 95% confidence interval [15.25, 23.29], P < 0.001), followed by β-blockers, calcium channel blockers, and diuretics. In the stratified analysis based on blood pressure measurement methods and age, more significant LVH regression was found in 24-h ambulatory blood pressure monitoring (ABPM) group and in relatively young patients (40-60 years' old) group (P < 0.01).Overweight and obesity are independent risk factors for LVH in hypertensive patients. Intervention at an early age and monitoring by ABPM may facilitate therapy-induced LVH regression in overweight and obese hypertensive patients.

JNC 8: what's covered, what's not, and what else to consider

JNC 8 guidelines offer greater discretion in drug choice and modest relaxation of some BP targets. This review summarizes the recommendations and provides guidance on 2 patient populations that aren't addressed.

Antihypertensive medication classes used among medicare beneficiaries initiating treatment in 2007-2010

Background

After the 2003 publication of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines, there was a 5–10% increase in patients initiating antihypertensive medication with a thiazide-type diuretic, but most patients still did not initiate treatment with this class. There are few contemporary published data on antihypertensive medication classes filled by patients initiating treatment.

Methods and Findings

We used the 5% random Medicare sample to study the initiation of antihypertensive medication between 2007 and 2010. Initiation was defined by the first antihypertensive medication fill preceded by 365 days with no antihypertensive medication fills. We restricted our analysis to beneficiaries ≥65 years who had two or more outpatient visits with a hypertension diagnosis and full Medicare fee-for-service coverage for the 365 days prior to initiation of antihypertensive medication. Between 2007 and 2010, 32,142 beneficiaries in the 5% Medicare sample initiated antihypertensive medication. Initiation with a thiazide-type diuretic decreased from 19.2% in 2007 to 17.9% in 2010. No other changes in medication classes initiated occurred over this period. Among those initiating antihypertensive medication in 2010, 31.3% filled angiotensin-converting enzyme inhibitors (ACE-Is), 26.9% filled beta blockers, 17.2% filled calcium channel blockers, and 14.4% filled angiotensin receptor blockers (ARBs). Initiation with >1 antihypertensive medication class decreased from 25.6% in 2007 to 24.1% in 2010. Patients initiated >1 antihypertensive medication class most commonly with a thiazide-type diuretic and either an ACE-I or ARB.

Conclusion

These results suggest that JNC 7 had a limited long-term impact on the choice of antihypertensive medication class and provide baseline data prior to the publication of the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8).

Beta-blockers and depression in elderly hypertension patients in primary care

BACKGROUND AND OBJECTIVES

Previous findings regarding a possible association between beta-blocker use and depression are mixed. To our knowledge there have been no studies investigating the association of beta-blockers with depression in primary care hypertension patients without previous myocardial infarction. The aim of this study was to determine the relation between lipophilic beta-blocker use and depression in elderly primary care patients with hypertension.

METHODS

This was a cross-sectional study in primary care practices located in the South of The Netherlands. Primary care hypertension patients without previous myocardial infarction or heart failure (n=573), aged between 60 and 85 years (mean age=70±6.6), were included. All patients underwent a structured interview that included a self-report questionnaire to assess depression (PHQ-9), which was divided in four groups (PHQ-9 score of 0, 1--3, 4--8, 9 or higher).

RESULTS

A PHQ-9 score of 0 was more prevalent in non-beta-blocker users versus lipophilic beta-blocker users (46% versus 35%), a PHQ-9 score of 4--8 was less prevalent in non-beta-blocker users as compared with lipophilic beta-blocker users (14% versus 25%). A chi-squared test showed that lipophilic beta-blocker users as compared to non-beta-blockers users were more likely to be in a higher depression category. Ordinal regression showed a significant relationship between use of lipophilic beta-blockers and depression (OR=1.60, 95% CI=1.08--2.36) when adjusting for potential confounders.

CONCLUSIONS

Our findings show that primary care hypertension patients who use a lipophilic beta-blocker are more likely to have higher depression scores than those who do not use a lipophilic beta-blocker.

Anti-hypertensive medications and cardiovascular events in older adults with multiple chronic conditions

IMPORTANCE

Randomized trials of anti-hypertensive treatment demonstrating reduced risk of cardiovascular events in older adults included participants with less comorbidity than clinical populations. Whether these results generalize to all older adults, most of whom have multiple chronic conditions, is uncertain.

OBJECTIVE

To determine the association between anti-hypertensive medications and CV events and mortality in a nationally representative population of older adults.

DESIGN

Competing risk analysis with propensity score adjustment and matching in the Medicare Current Beneficiary Survey cohort over three-year follow-up through 2010.

PARTICIPANTS AND SETTING

4,961 community-living participants with hypertension.

EXPOSURE

Anti-hypertensive medication intensity, based on standardized daily dose for each anti-hypertensive medication class participants used.

MAIN OUTCOMES AND MEASURES

Cardiovascular events (myocardial infarction, unstable angina, cardiac revascularization, stroke, and hospitalizations for heart failure) and mortality.

RESULTS

Of 4,961 participants, 14.1% received no anti-hypertensives; 54.6% received moderate, and 31.3% received high, anti-hypertensive intensity. During follow-up, 1,247 participants (25.1%) experienced cardiovascular events; 837 participants (16.9%) died. Of deaths, 430 (51.4%) occurred in participants who experienced cardiovascular events during follow-up. In the propensity score adjusted cohort, after adjusting for propensity score and other covariates, neither moderate (adjusted hazard ratio, 1.08 [95% CI, 0.89-1.32]) nor high (1.16 [0.94-1.43]) anti-hypertensive intensity was associated with experiencing cardiovascular events. The hazard ratio for death among all participants was 0.79 [0.65-0.97] in the moderate, and 0.72 [0.58-0.91] in the high intensity groups compared with those receiving no anti-hypertensives. Among participants who experienced cardiovascular events, the hazard ratio for death was 0.65 [0.48-0.87] and 0.58 [0.42-0.80] in the moderate and high intensity groups, respectively. Results were similar in the propensity score-matched subcohort.

CONCLUSIONS AND RELEVANCE

In this nationally representative cohort of older adults, anti-hypertensive treatment was associated with reduced mortality but not cardiovascular events. Whether RCT results generalize to older adults with multiple chronic conditions remains uncertain.

[Analysis of the effect of antihypertensive drugs on left ventricular hypertrophy regression]

In a review article reflects the leading role of combined treatment of blockers of the renin-angiotensin-aldosterone system and dihydropyridine calcium antagonists in reducing left ventricular mass. The advantages of fixed combinations in the treatment of hypertensive patients, including those with left ventricular hypertrophy. The advantages of the low risk of side effects and high patient adherence to treatment using antagonists of angiotensin II receptor in comparison with other classes of antihypertensive drugs in selecting initial therapy, patients with hypertension, including the combination of drugs.

[Management of arterial hypertension in adults: 2013 guidelines of the French Society of Arterial Hypertension]

To improve the management of hypertension in the French population, the French Society of Hypertension has decided to update the national guidelines with the following characteristics: usefulness for practice, synthetic form, good readability, comprehensive writing for non-doctors, emphasizing the role of patient education in the management of hypertension, wide dissemination to health professionals and the population of hypertensive subjects, impact assessment among health professionals and the public health goals. These guidelines include the following 15 recommendations, divided in three chapters, according to the timing of the medical management.

BEFORE STARTING TREATMENT

1. Confirm the diagnosis, with blood pressure measurements outside the doctor's office. 2. Implement lifestyle measures. 3. Conduct an initial assessment. 4. Arrange a dedicated information and hypertension announcement consultation. INITIAL TREATMENT PLAN (FIRST 6 MONTHS): 5.

MAIN OBJECTIVE

control of blood pressure in the first 6 months (SBP: 130-139 and DBP<90 mm Hg). 6. Favour the five classes of antihypertensive agents that have demonstrated prevention of cardiovascular complications in hypertensive patients. 7. Individualized choice of the first antihypertensive treatment, taking into account persistence. 8. Promote the use of (fixed) combination therapy in case of failure of monotherapy. 9. Monitor safety.

LONG-TERM CARE PLAN

10. Uncontrolled hypertension at 6 months despite appropriate triple-drug treatment should require specialist's opinion after assessment of compliance and confirmation of ambulatory hypertension. 11. In case of controlled hypertension, visits every 3 to 6 months. 12. Track poor adherence to antihypertensive therapy. 13. Promote and teach how to practice home blood pressure measurement. 14. After 80 years, change goal BP (SBP<150 mm Hg) without exceeding three antihypertensive drugs. 15. After cardiovascular complication, treatment adjustment with maintenance of same blood pressure goal. We hope that a vast dissemination of these simple guidelines will help to improve hypertension control in the French population from 50 to 70 %, an objective expected to be achieved in 2015 in France.

Initial antihypertensive prescription and switching: a 5 year cohort study from 250,851 patients

Purpose

Adverse effects of antihypertensive therapy incur substantial cost. We evaluated whether any major classes of antihypertensive drugs were significantly associated with switching as a proxy measure of medication side effects in a large Chinese population in Hong Kong.

Methods

From a clinical database, all adult patients newly prescribed an antihypertensive mono-therapy in Hong Kong between the years 2001–2003 and 2005 were included. Those who paid only one visit, died or stayed in the cohort for <180 days after the prescription, or prescribed more than one antihypertensive agent were excluded. The factors associated with switching at 180 days were evaluated by multivariate regression analyses. Age, gender, payment status, service type, district of residence, drug class, systolic and diastolic blood pressure levels were predictor variables.

Results

From 250,851 subjects, 159,813 patients were eligible. A total of 6,163 (3.9%) switched their medications within 180 days. Patients prescribed thiazide diuretics had the highest switching rate (5.6%), followed by ACEIs (4.5%), CCBs (4.4%) and beta-blockers (3.2%). When compared with ACEIs, patients on thiazide diuretics were significantly more likely to be switchers (adjusted odds ratio [AOR] 1.49, 95% C.I. 1.31–1.69, p<0.001), whilst patients prescribed CCBs and beta-blockers were similarly likely to have switching. Following these patients up for 5 years showed that thiazide had the most marked increase in switching rate.

Conclusions

The higher rates of switching among thiazide diuretics in this study might raise a probably greater incidence of their adverse effects in this Chinese population, yet other factors might also influence switching rates. Patients prescribed thiazide diuretics for longer term should be observed for their intolerability.

[Pharmacotherapy of portal hypertension and its complications: analysis of efficacy of preparations for clinical practice and discussion of promising methods of treatment]

Bleeding from oesophageal varicose veins is the terminal stage of a sequence of complications of liver cirrhosis caused by progressive fibrosis, circulation blockade, and development of portal hypertension syndrome followed by collateral shunt. It leads to progressive vein dilation and their rupture. The main issue of today is to prevent the development of successive stages of portal hypertension, to search for therapeutic and surgical methods for marked reduction of pressure in the portal system, and to prevent the risk of hemorrhage from varicose veins. Another approach is to use local endoscopic treatment of varicose veins for prevention of their rupture. The authors analyse the efficacy of pharmacotherapy in patients with liver cirrhosis and portal hypertension and discuss the existing recommendations on the prevention of hemorrhage with special reference to the yet unsolved problems and prospects for the improvement of therapy.

[Principles of antihypertensive therapy in metabolic syndrome]

Clinical features of arterial hypertension in patients with metabolic syndrome are described with reference to antihypertensive therapy and the choice of adequate drugs for the purpose. Characteristics of the most frequently used preparations are presented along with algorithms for their application depending on clinical condition. Advantages of combined antihypertensive therapy in metabolic syndrome are substantiated, their most efficacious combinations are recommended.

[Hypertensive crisis: pathogenesis, clinic, treatment]

Contemporary data on mechanisms of development, types, and clinical picture of hypertensive crisis (HC) are presented. Algorithms of rational therapy of uncomplicated and complicated HC are considered. Appropriateness of the use in HC of antihypertensive drugs with multifactorial action is stressed. These drugs include urapidil - an antihypertensive agent with complex mechanism of action. Blocking mainly the postsynaptic 1-adrenoreceptors urapidil attenuates vasoconstrictor effect of catecholamines and decreases total peripheral resistance. Stimulation of 5HT1-receptors of medullary vasculomotor center promotes lowering of elevated vascular tone and prevents development of reflex tachycardia.

Orthostatic hypotension in treated hypertensive patients

INTRODUCTION

Orthostatic hypotension (OH) is a risk factor for morbidity and mortality and one of the causes of non compliance to treatment among medicated hypertensive subjects. Our objective was to assess the prevalence of OH among treated hypertensive patients and its association with clinical characteristics and antihypertensive drug class.

METHODS

This was a cross-sectional study in which we assessed the prevalence of OH, defined according to the American Autonomic Society and American Academy of Neurology guidelines, among adult treated hypertensive patients who performed a home blood pressure monitoring at our institution. We also determined the prevalence of OH according to age group (< 65, 65-79 and > 80), antihypertensive drug class, office and home hypertension control status.

RESULTS

We included 302 medicated patients in the study. Mean age was 66.6 (+13.8), 67% were women. We found a 9.7% global prevalence of OH, which was significantly higher among older individuals (3.6% among patients < 65 years-old, 12.2% in the 65-79 year-old group and 16.7% among octogenarians, p = 0.02) and those who consumed alpha-blockers (75 vs. 8.5%, p < 0.01). Uncontrolled hypertensive patients at office and/or at home had also a significantly higher prevalence of OH: uncontrolled vs. controlled office blood pressure (BP), 14.3 vs. 6.5%, p = 0.03 and uncontrolled vs. controlled home BP, 15.1 vs. 6.6%, p = 0.02. Remarkably, 64% of patients with OH had their BP under control when considering office-standing BP.

CONCLUSION

OH is a prevalent entity among treated hypertensive patients and systematic measurement of standing BP should be mandatory in the evaluation of these patients.

Antihypertensive drugs: a perspective on pharmaceutical price erosion and its impact on cost-effectiveness

OBJECTIVE

When comparators' prices decrease due to market competition and loss of exclusivity, the incremental clinical effectiveness required for a new technology to be cost-effective is expected to increase; and/or the minimum price at which it will be funded will tend to decrease. This may be, however, either unattainable physiologically or financially unviable for drug development. The objective of this study is to provide an empirical basis for this discussion by estimating the potential for price decreases to impact on the cost-effectiveness of new therapies in hypertension.

METHODS

Cost-effectiveness at launch was estimated for all antihypertensive drugs launched between 1998 and 2008 in the United Kingdom using hypothetical degrees of incremental clinical effectiveness within the methodologic framework applied by the UK National Institute for Health and Clinical Excellence. Incremental cost-effectiveness ratios were computed and compared with funding thresholds. In addition, the levels of incremental clinical effectiveness required to achieve specific cost-effectiveness thresholds at given prices were estimated.

RESULTS

Significant price decreases were observed for existing drugs. This was shown to markedly affect cost-effectiveness of technologies entering the market. The required incremental clinical effectiveness was in many cases greater than physiologically possible so, as a consequence, a number of products might not be available today if current methods of economic appraisal had been applied.

CONCLUSIONS

We conclude that the definition of cost-effectiveness thresholds is fundamental in promoting efficient innovation. Our findings demonstrate that comparator price attrition has the potential to put pressure in the pharmaceutical research model and presents a challenge to new therapies being accepted for funding.

Prevalence of resistant hypertension in the United States, 2003-2008

The prevalence of resistant hypertension is unknown. Much previous knowledge comes from referral populations or clinical trial participants. Using data from the National Health and Nutrition Examination Survey from 2003 through 2008, nonpregnant adults with hypertension were classified as resistant if their blood pressure was ≥140/90 mm Hg and they reported using antihypertensive medications from 3 different drug classes or drugs from ≥4 antihypertensive drug classes regardless of blood pressure. Among US adults with hypertension, 8.9% (SE: 0.6%) met criteria for resistant hypertension. This represented 12.8% (SE: 0.9%) of the antihypertensive drug-treated population. Of all drug-treated adults whose hypertension was uncontrolled, 72.4% (SE: 1.6%) were taking drugs from <3 classes. Compared with those with controlled hypertension using 1 to 3 medication classes, adults with resistant hypertension were more likely to be older, to be non-Hispanic black, and to have higher body mass index (all P<0.001). They were more likely to have albuminuria, reduced renal function, and self-reported medical histories of coronary heart disease, heart failure, stroke, and diabetes mellitus (P<0.001). Most (85.6% [SE: 2.4%]) individuals with resistant hypertension used a diuretic. Of this group, 64.4% (SE: 3.2%) used the relatively weak thiazide diuretic hydrochlorothiazide. Although not rare, resistant hypertension is currently found in only a modest proportion of the hypertensive population. Among those classified here as resistant, inadequate diuretic therapy may be a modifiable therapeutic target. Cardiovascular diseases, diabetes mellitus, obesity, and renal dysfunction were all common in this population.

[Achievements and problems of modern trials of antihypertensive drugs]

Most important value of lowering of substantially elevated arterial pressure (AP) for improvement of outcomes in patients with arterial hypertension (AH) was convincingly confirmed by large truly placebo controlled randomized clinical trials (RCT) with the use of mainly diuretics, and/or beta-adrenoblockers in the 60-80ths. Later comparative RCT confirmed equal antihypertensive efficacy of 5 main drug classes relative to AP level in brachial artery. In this review we discuss merit of auxiliary class-specific properties of antihypertensive agents potentially affecting prognosis besides AP lowering. We also discuss problems related to decline of significance of quantitative criteria of AH and consideration of AP level in general context of cardiovascular risk; problems of external validity of RCT; extrapolation of RCT results obtained in patients with complicated AH and very high cardiovascular risk on young patients with uncomplicated AH; significance of hard and surrogate end points.