Beta-blockers for hypertension

Desprescribing antihypertensives in older people in primary care: subgroup analysis of the MINOR randomised clinical trial

BACKGROUND

Polypharmacy is often required for older adults with hypertension, and excessive treatment is associated with a high risk of adverse reactions, including hypotension.

AIM

To evaluate the deprescribing of antihypertensive medications guided by pharmacists using home blood pressure monitoring in older adults with hypotension.

METHOD

A subgroup of older adults with signs or symptoms of hypotension, included in the MINOR clinical trial, was analysed. In the MINOR procedures, each patient was provided with a device to conduct blood pressure measurement at home for 1 week, following which a report was generated and shared with pharmacists (intervention group) or family physicians (control group). In the intervention group, a pharmacist suggested optimising pharmacotherapy; meanwhile, in the control group, a family physician alone determined the necessary treatment adjustments. Differences in mean blood pressure, the patients with symptoms/signs of hypotension, and the antihypertensive medication deprescribing between both groups were analysed.

RESULTS

Seventy-two patients were evaluated (35, control group; 37, intervention group). The intervention group showed a significant reduction in medication prescriptions (- 28.6%; P < 0.001), especially beta-blockers (- 74.2%), loop diuretics (- 83.3%), and aldosterone antagonists (- 80%). The mean office blood pressure in the intervention group increased (14.1 mmHg systolic and 6.9 mmHg diastolic), remaining below the target range (140/90 mmHg). The intervention group showed a significantly reduction in hypotensive symptoms than the control group (64.9% vs. 20%) (P < 0.001).

CONCLUSION

The data highlight an important role for pharmacists in optimizing hypertension management in older people. Deprescribing antihypertensives can limit symptomatic hypotension.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov under number NCT04861727.

Higher blood pressure targets for hypertension in older adults

BACKGROUND

This is an update of the original Cochrane review, published in 2017. Eight out of 10 major antihypertensive trials in adults, 65 years of age or older, attempted to achieve a target systolic blood pressure (BP) of < 160 mmHg. Collectively, these trials demonstrated cardiovascular benefit for treatment, compared to no treatment, for older adults with BP > 160 mmHg. However, an even lower BP target of < 140 mmHg is commonly applied to all age groups. Yet the risk and benefit of antihypertensive therapy can be expected to vary across populations, and some observational evidence suggests that older adults who are frail might have better health outcomes with less aggressive BP lowering. Current clinical practice guidelines are inconsistent in target BP recommendations for older adults, with systolic BP targets ranging from < 130 mmHg to < 150 mmHg. The 2017 review did not find compelling evidence of a reduction in any of the primary outcomes, including all-cause mortality, stroke, or total serious cardiovascular adverse events, comparing a lower BP target to a higher BP target in older adults with hypertension. It is important to update this review to explore if new evidence exists to determine whether older adults might do just as well, better, or worse with less aggressive pharmacotherapy for hypertension.

OBJECTIVES

To assess the effects of a less aggressive blood pressure target (in the range of < 150 to 160/95 to 105 mmHg), compared to a conventional or more aggressive BP target (of < 140/90 mmHg or lower) in hypertensive adults, 65 years of age or older.

SEARCH METHODS

For this update, Cochrane Hypertension's Information Specialist searched the following databases for randomised controlled trials up to June 2024: Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE Ovid, and Embase Ovid, and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov for ongoing trials. We also contacted authors of relevant papers requesting information on further published and unpublished work. The searches had no language restrictions.

SELECTION CRITERIA

We included randomised trials of hypertensive older adults (≥ 65 years) that spanned at least one year, and reported the effect on mortality and morbidity of a higher or lower systolic or diastolic BP treatment target. Higher BP targets ranged from systolic BP < 150 to 160 mmHg or diastolic BP < 95 to 105 mmHg; lower BP targets were 140/90 mmHg or lower, measured in an ambulatory, home, or office setting.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and selected trials for inclusion, assessed risk of bias and certainty of the evidence, and extracted data. We combined data for dichotomous outcomes using the risk ratio (RR) with 95% confidence interval (CI). For continuous outcomes, we used mean difference (MD). Primary outcomes were all-cause mortality, stroke, institutionalisation, and serious cardio-renal vascular adverse events. Secondary outcomes included cardiovascular mortality, non-cardiovascular mortality, unplanned hospitalisation, each component of cardiovascular serious adverse events separately (including cerebrovascular disease, cardiac disease, vascular disease, and renal failure), total serious adverse events, total minor adverse events, withdrawals due to adverse effects, systolic BP achieved, and diastolic BP achieved.

MAIN RESULTS

With the addition of one new trial, we included four trials in this updated review (16,732 older adults with a mean age of 70.3 years). Of these, one trial used a combined systolic and diastolic BP target and compared a higher target of < 150/90 mmHg to a lower target of < 140/90 mmHg, and two trials utilised a purely systolic BP target, and compared a systolic BP < 150 mmHg (1 trial) and a systolic BP < 160 mmHg (1 trial), to a systolic BP < 140 mmHg. The fourth and newest trial also utilised a systolic BP target, but also introduced a lower limit for systolic BP. It compared systolic BP in the target range of 130 to 150 mmHg to a lower target range of 110 to 130 mmHg. The evidence shows that treatment to the lower BP target over two to four years may result in little to no difference in all-cause mortality (RR 1.14, 95% CI 0.95 to 1.37; 4 studies, 16,732 participants; low-certainty evidence), but the lower BP target does reduce stroke (RR 1.33, 95% CI 1.06 to 1.67; 4 studies, 16,732 participants; high-certainty evidence), and likely reduces total serious cardiovascular adverse events (RR 1.25, 95% CI 1.09 to 1.45; 4 studies, 16,732 participants; moderate-certainty evidence). Adverse effects were not available from all trials, but the lower BP target likely does not increase withdrawals due to adverse effects (RR 0.99, 95% CI 0.74 to 1.33; 3 studies, 16,008 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

When comparing a higher BP target, in the range of < 150 to 160/95 to 105 mmHg, to a lower BP target of 140/90 or lower, over two to four years of follow-up, there is high-certainty evidence that the lower BP target reduces stroke, and moderate-certainty evidence that the lower BP target likely reduces serious cardiovascular events. The effect on all-cause mortality is unclear (low-certainty evidence), and the lower BP target likely does not increase withdrawals due to adverse effects (moderate-certainty evidence). Although additional research is warranted in those who are 80 years of age and older, and those who are frail (in whom risks and benefits may differ), conventional BP targets may be appropriate for the majority of older adults.

Outpatient management of essential hypertension: a review based on the latest clinical guidelines

Background: Essential hypertension, a prevalent cardiovascular condition, poses a significant health burden worldwide. Based on the latest American clinical guidelines, half of adults in the United States have hypertension. Of these, only about a half are treated and about a quarter are adequately controlled for hypertension. Given its impact on morbidity and mortality, ensuring effective management of high blood pressure is crucial to reduce associated risks and improve patient outcomes.Objective: This review aims to provide a comprehensive and up-to-date summary of the latest cardiology guidelines and evidence-based research on essential hypertension, with a focus on guiding outpatient clinical practice.Methods: The review evaluates both non-pharmacological approaches and pharmacological interventions to offer clinicians practical insights. Notably, it emphasizes the importance of individualized treatment plans tailored to patients' specific risk profiles and comorbidities.Results: By consolidating the latest advancements in hypertension management, this review provides clinicians with an up-to-date reference, offering a nuanced understanding of treatment goals and strategies.Conclusion: Through the incorporation of evidence-based recommendations, healthcare practitioners can optimize patient care, mitigate potential complications, and improve overall outcomes in essential hypertension.

The natural history of hypertension in older adults: a study of two Finnish generational cohorts born 20 years apart

BACKGROUND

We conducted a comparative analysis of hypertension prevalence, progression, and treatment in two Finnish population-based cohorts comprising older adults born 20 years apart. The study covered data from pre- and post-HYVET Study eras and spanned the onset of the COVID-19 pandemic.

METHODS

All 70-year-old home-dwelling citizens of Turku, in Southwest Finland, were invited to participate in the survey in 1990 (1920-born TUVA cohort) and in 2010 (1940-born UTUVA cohort) with a 25-year follow-up plan. The analyses included those with available data for systolic and diastolic blood pressure (BP), yielding 1015 TUVA and 888 UTUVA participants at baseline. Biomarkers associated with BP were analysed with t- and chi-square tests.

RESULTS

At baseline, 83.4% of TUVA and 74.3% of UTUVA participants had uncontrolled BP, with respective antihypertensive medication usage at 36.0% and 55.9% (p < .001 for both between-cohort differences). Systolic BP exhibited an inverted U-shaped trajectory, with TUVA initially 7.8 mmHg higher at 155.4 mmHg than UTUVA (p < .001). However, by the ages 80-82, the difference in systolic BP trajectories between the cohorts was attenuated to 4.0 mmHg (p = .03). Diastolic BP differences were less clinically significant. UTUVA demonstrated higher use of all five conventional antihypertensive categories than TUVA (p ≤ .02 for all categories).

CONCLUSIONS

In the early years of older adulthood, the 1940-born cohort showed a positive trend in hypertension management, yet maintained a 74.3% baseline rate of uncontrolled BP. Furthermore, by the ages 81-82, the benefits observed over the 1920-born cohort had lessened, influenced by the COVID-19 pandemic or other lasting factors. Heightened efforts to improve hypertension treatment in older adults remain crucial in the post-HYVET era.

Off-label use of medicines in South Africa: a review

BACKGROUND

Off-label use of medicinal products has become an important part of mainstream and legitimate medical practice worldwide. This practice is common in oncology, obstetrics, paediatrics, and in the management of infectious diseases (notably HIV), and inflammatory conditions as well as in rare and/or orphan diseases. However, the off-label use of medicines recently-raised many clinical and legal difficulties, not only among medical practitioners but also among pharmacists and other healthcare professionals.

AIM

This paper, therefore, highlights the advantages (such as cost saving for both the patient and the country/insurance that is paying for the medication) and disadvantages (insufficient evidence available) of the use of medicines to treat specific conditions or indications for which they are currently not registered.

CONCLUSION

Off-label drug use can be likened to a double-edged sword, offering valuable opportunities for medical practitioners while carrying potential risks. When the scientific basis for off-label use is unclear, it may place patients at risk of unapproved experimentation, unforeseen health hazards, and ineffective treatments. Hence, there is a pressing need in South Africa for clear regulatory guidelines on off-label drug use. Additionally, the timely review and approval of new indications for medicines, backed by robust scientific evidence, are essential. This would reduce the significant burden and inherent risks faced by medical practitioners when using medicines off-label to provide compassionate care.

Guideline-directed antihypertensive medication use among young adult participants with uncontrolled hypertension at enrollment in the MyHEART study

BACKGROUND

Hypertension is a major risk factor for heart disease, heart failure and stroke. Lifestyle changes are recommended as first-line treatment for management of high blood pressure for young adults, when 10-year atherosclerotic cardiovascular disease risk score is < 10%. If lifestyle changes alone do not control blood pressure, then providers have access to four classes of first-line blood pressure lowering agents to treat hypertension, when other contra-indications are not present.

METHODS

This is a cross-sectional, retrospective, secondary analysis performed of the MyHEART trial on study participants at enrollment to determine they were prescribed anti-hypertensive medication. Of those prescribed medications, we aimed to determine the frequency first-line medications including thiazide or thiazide-like diuretics, angiotensin converting-enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers were prescribed. This analysis categorized participants into four medication status categories: no antihypertensive medication, prescribed only first-line antihypertensives, prescribed only non-first-line antihypertensives, and prescribed a combination of first-line and non-first-line antihypertensives. Participant clinical and sociodemographic factors by medication use were evaluated. Linear regression models were fit to determine the association between antihypertensive medication and blood pressure.

RESULTS

At enrollment, 157/311 (50.5%) participants were not on antihypertensives. Of the 154 on antihypertensives, reported use included monotherapy 97/154 (63.0%), combined therapy 57/154 (37.0%), only first-line antihypertensive 111/154 (72.0%), and only non-first-line antihypertensives 21/154 (13.6%), and combination of first-line and non-first-line antihypertensives 22/154 (14.2%). Antihypertension medication use varied based on age (p < 0.001), sex (p = 0.008), race (p = 0.001), body mass index (BMI) kg/m2 (p = 0.016), anxiety and/or depression (p = 0.048), diabetes (p = 0.007), and sodium intake (p = 0.042). Participants with only first-line medications had lower in-office systolic (-4.66 mmHg, CI -8.31 to -1.02, p = 0.013) and diastolic (-3.51 mmHg, CI -6.30 to -0.71, p = 0.015), and lower ambulatory diastolic (-2.12 mmHg, CI -4.15 to -0.09, p = 0.041) blood pressure than those without antihypertensives.

CONCLUSIONS

Among MyHEART study participants, all of which had uncontrolled hypertension, 50.5% were not on an antihypertensive at enrollment. This finding supports the call to improve management of blood pressure earlier in life to potentially contribute to the reduction of long-term cardiovascular disease. Of the participants who were prescribed blood pressure medication, providers prescribed guideline-based antihypertensive therapy the majority of the time, however, this study indicates there may be an opportunity to increase the use of first-line, guideline-based antihypertensives, regardless of age, sex, or type of hypertension to lower long-term cardiovascular risk.

TRIAL REGISTRATION

https://www.

CLINICALTRIALS

gov Identifier: NCT03158051, registered 5-15-2017. IRB approval obtained: IRB # 2017 - 0372.

Association between beta-blocker atenolol use and prostate cancer upgrading in active surveillance

Objectives

The objective of this study is to investigate the association between the use of beta-adrenergic antagonist atenolol and risk of pathologic upgrade in patients on active surveillance, considering growing literature implicating adrenergic innervation with disease progression mediated through beta-adrenergic signalling.

Patients and Methods

Men with low-risk or favourable intermediate-risk prostate cancer who were placed on an active surveillance protocol between 2006 and 2020 across three diverse urban hospitals were included. Exposure was duration of atenolol use, and outcome was pathologic grade group upgrading (to GG ≥ 3) on final prostate biopsy. Cox proportional hazard regression models were used to determine the associations between atenolol use and risk of upgrading with time, on a per-examination basis.

Results

A total of 467 men with initial GG ≤ 2 were included. Postdiagnosis atenolol use was associated with a decreased risk of pathologic upgrade to GG ≥ 3 on final repeat biopsy (HR 0.81, 95% CI 0.39-0.98). Longer duration of postdiagnosis atenolol use (>2 years) and greater cumulative atenolol dose (>730 defined daily doses) were associated with a more pronounced decreased risk of upgrade to GG ≥ 3 (HR 0.41, 95% CI 0.05-0.88, and HR 0.32, 95% CI 0.15-0.99, respectively). Initiation of atenolol use prior to prostate cancer diagnosis had a slightly greater protective effect than drug initiation postdiagnosis (HR 0.79, 95% CI 0.43-0.98, and HR 0.83, 95% CI 0.30-0.99, respectively).

Conclusions

Beta-adrenergic blockade with atenolol use in men on active surveillance is associated with a reduced risk for clinically significant grade group pathologic upgrade.

Trends in Initial Antihypertensive Medication Prescribing Among >2.8 Million Veterans Newly Diagnosed With Hypertension, 2000 to 2019

BACKGROUND

Among patients diagnosed with high blood pressure (BP), initial dual therapy has been recommended for patients with high pretreatment systolic BP (≥160 mm Hg) since 2003, and first-line β-blocker use without a compelling condition has fallen out of favor in US guidelines.

METHODS AND RESULTS

This serial cross-sectional study of national Veterans Health Administration data included adult Veterans with incident hypertension initiating antihypertensive medication between January 1, 2000, and December 31, 2019. We assessed annual trends in initial regimens dispensed (index date: first antihypertensive dispense date) by number of classes and unique class combinations used overall and by pretreatment systolic BP (<140, 140 to <160, and ≥160 mm Hg), as well as trends in subgroups (age, sex, race and ethnicity, and comorbidities warranting β-blocker use). Among 2 832 684 eligible Veterans (average age 61 years, 95% men, 65% non-Hispanic White, and 8% with cardiovascular disease), from 2000-2004 to 2015-2019, initial monotherapy increased across all pretreatment systolic BP levels (<140 mm Hg: 62.1% to 66.4%; 140 to <160 mm Hg: 70.7% to 76.8%; ≥160 mm Hg: 64.2% to 69.7%). Initiation of dual therapy decreased across all pretreatment systolic BP levels (<140 mm Hg: 25.0% to 24.2%; 140 to <160 mm Hg: 20.4% to 17.6%; ≥160 mm Hg: 22.7% to 22.0%). Among 2 521 696 Veterans (89% of overall) without a β-blocker-indicated condition in 2015 to 2019, 20% initiated a β-blocker, most commonly as monotherapy.

CONCLUSIONS

More than half of US Veterans diagnosed with hypertension with a pretreatment systolic BP ≥160 mm Hg were started on antihypertensive monotherapy. There are disparities between guideline-recommended first-line treatments and the actual regimens initiated for newly diagnosed Veterans with hypertension.

Beta-blocker use and breast cancer outcomes: a meta-analysis

PURPOSE

Beta blockers (BBs) are commonly used cardiovascular medications, and their association with breast cancer outcomes has been examined in several previous observational studies and meta-analyses. In this study, an updated meta-analysis was undertaken to ascertain the association between BBs and both breast cancer death (BCD) and breast cancer recurrence (BCR).

METHODS

Articles were sourced from various databases up until the 14th of August 2023. Effect estimates were pooled using the random effects model, and the Higgins I2 statistic was computed to ascertain heterogeneity. Subgroup analyses were conducted by the potential for immortal time bias (ITB), the exposure period (prediagnosis vs postdiagnosis), and type of BB (selective vs non-selective). Publication bias was assessed using funnel plots and Egger's regression tests.

RESULTS

Twenty-four studies were included. Pooled results showed that there was no statistically significant association between BB use and both BCD (19 studies, hazard ratio = 0.90, 95% CI 0.78-1.04) and BCR (16 studies, HR = 0.87, 95% CI 0.71-1.08). After removing studies with ITB, the associations were attenuated towards the null. There was no effect modification for either outcome when stratifying by the exposure period or type of BB. There was clear evidence of publication bias for both outcomes.

CONCLUSION

In this meta-analysis, we found no evidence of an association between BB use and both BCD and BCR. Removing studies with ITB attenuated the associations towards the null, but there was no effect modification by the exposure period or type of BB.

The Efficacy of Renal Denervation in Treating Resistant Hypertension: A Systematic Review

Resistant hypertension is blood pressure (BP) that is persistently above target in spite of the maximally tolerated usage of at least three anti-hypertensives simultaneously. The sympathetic nervous system is instrumental in blood pressure (BP) regulation. Renal (sympathetic) denervation involves using ablative energy to disrupt the sympathetic nerves in renal arteries. This systematic review examines the efficacy of this treatment modality. Abiding by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, we conducted an extensive literature search in five databases, Cochrane Library, Google Scholar, PubMed, PubMed Central (PMC), and ScienceDirect, to retrieve studies that are free, open access, and published in English done within the past four years. Nineteen articles passed critical appraisal. These articles were randomized controlled trials (RCT), a case report, a cross-sectional study, a cohort study, and previous reviews. Renal denervation (RDN) was generally superior to sham control in patients with resistant hypertension for reducing various systolic blood pressure (SBP) measures, including 24-hour ambulatory, daytime, and nighttime SBP. The efficacy was highest in patients whose baseline SBP was higher. BP reduction was sustained for years post-procedure. The procedure had a good safety profile with no severe complications. Future studies should compare the efficacy of different types of renal denervation, such as ethanol ablation versus radiofrequency ablation, and renal denervation against other procedure-based treatment modalities, such as carotid baroreceptor stimulation and transcranial direct current stimulation.

Comorbidity and Medication Trends in Chronic Kidney Disease and Incident Atrial Fibrillation: A Nationwide Cohort Study

INTRODUCTION

Chronic kidney disease (CKD) is associated with an increased incidence of atrial fibrillation (AF). Also, patients with AF are prone to adverse kidney outcomes. We examined comorbidities and medication use in patients with CKD and incident AF.

METHODS

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) is a nationwide retrospective register-linkage study including data from 168,233 patients with incident AF from 2007 to 2018, with laboratory data from 2010 onwards. Estimated glomerular filtration rate (eGFR) was available for 124,936 patients. The cohort was divided into 5 CKD stages with separate groups for dialysis and kidney transplantation.

RESULTS

At AF diagnosis eGFR <60 mL/min/1.73 m2 was found in 27%, while 318 (0.3%) patients were on dialysis, and 188 (0.2%) had a functioning kidney transplant. Lowering eGFR yielded more comorbidities and medications. During 2010-2018 in patients with eGFR <60 mL/min/1.73 m2 prevalence of hypertension, dyslipidaemia, and diabetes increased from 82 to 88%, from 50 to 66% and from 25 to 33%, respectively (<0.001). Throughout the observation period, lipid-lowering medication was underused.

CONCLUSION

More than one-fourth of patients with incident AF also had CKD stage 3-5 (eGFR <60 mL/min/1.73 m2). Both comorbidities and medication use increased with worsening kidney function. Prevalence of major cardiovascular (CV) risk factors increased during 2010-2018, but the use of survival-affecting medications, such as lipid-lowering medication, was suboptimal at all stages of CKD. More attention should be given to the optimal treatment of risk factors in this high CV risk population.

Comprehensive analysis of prohibited substances and methods in sports: Unveiling trends, pharmacokinetics, and WADA evolution

This review systematically compiles sports-related drugs, substances, and methodologies based on the most frequently detected findings from prohibited lists published annually by the World Anti-Doping Agency (WADA) between 2003 and 2021. Aligned with structure of the 2023 prohibited list, it covers all proscribed items and details the pharmacokinetics and pharmacodynamics of five representatives from each section. Notably, it explores significant metabolites and metabolic pathways associated with these substances. Adverse analytical findings are summarized in tables for clarity, and the prevalence is visually represented through charts. The review includes a concise historical overview of doping and WADA's role, examining modifications in the prohibited list for an understanding of evolving anti-doping measures.

Effects of Nebivolol therapy on hemodynamic parameters and lipid profile compared to other beta blockers in patients with essential hypertension: a systematic review and meta-analysis

Background

Besides being commonly used to treat high blood pressure, beta blockers are a family of drugs that are primarily used to regulate irregular cardiac rhythms. Nebivolol is a third generation of beta blockers, which is highly cardioselective, about three times as selective as bisoprolol. In this study, we aimed to evaluate Nebivolol's effectiveness and safety in comparison to other beta blockers.

Methods

We searched the online databases PubMed, ScienceDirect, and Cochrane Library for relevant RCTs evaluating Nebivolol's effect on hypertension management. Relative risk (WRR) and weighted mean difference (WMD), with a 95% confidence interval (CI) were utilized to quantify the impact of nebivolol medication in the treatment of hypertension using a random effects model.

Results

Twelve RCTs are included in the study, the patient numbers in every attempt ranged from 42-273 and 1456 patients in all were included in this review. Nebivolol does not significantly reduce SBP, DBP and HR compared to other beta blockers (WMD -0.57 mmHg, 95% CI [-1.55; 0.42 mmHg] p=0.12; WMD -0.27 mmHg, 95% CI [-1.36; 0.82 mmHg] p=0.63 ; WMD 0.10 BPM, 95% CI [-4.11;1.31 BPM] p=0.96, respectively). Patients treated with Nebivolol has significantly lower LDL-C (WMD -8.88 mg/dL, 95% CI [-15.28; -2.48 mg/dL] p=0.007) and significantly higher HDL-C (WMD 2.30 mg/dL, 95% CI [0.75; 3.84 mg/dL] p=0.004.

Conclusions

According to this study's findings, nebivolol is well tolerated and decreases LDL-C. And higher HDL-C than other beta blocker agents. This review does not recommend nebivolol as first-line treatment in hypertension as Nebivolol does not significantly reduce blood pressure and HR of patients.

Beta-Blockers and Their Current Role in Maternal and Neonatal Health: A Narrative Review of the Literature

Beta-blockers are a class of medications that act on beta-adrenergic receptors and are categorized as cardio-selective and non-selective. They are principally used to treat cardiovascular conditions such as hypertension and arrhythmias. Beta-blockers have also been used to treat non-cardiogenic indications in non-pregnant individuals and the pediatric population. In pregnancy, labetalol is the mainstay treatment for hypertension and other cardiovascular indications. However, contraindications to certain sub-types of beta-blockers include bradycardia, heart failure, obstructive lung diseases, and hemodynamic instability. There is conflicting evidence of the adverse effects on fetal and neonatal health due to a scarce safety and efficacy profile, and further studies are necessary to understand the pharmacokinetics of the different classes of beta-blockers in pregnancy and fetal health. Understanding the hemodynamic changes during the stages of pregnancy is important to target a more beneficial therapy for both mother and fetus as well as better neonatal outcomes. Beta-blocker use in the pediatric population is less documented in studies but does have the potential to treat various cardiogenic and non-cardiogenic conditions. Future comprehensive studies would further benefit the direction of beta-blocker treatment during pregnancy in neonates and pediatrics.

The Combination of Beta-Blockers and ACE Inhibitors Across the Spectrum of Cardiovascular Diseases

Cardiovascular disease is the leading cause of mortality worldwide, affecting a wide range of patients at different stages across the cardiovascular continuum. Hypertension is one of the earliest risk factors in this continuum and can be controlled in most patients with currently available antihypertensive agents. However, goals are often not met because treatments are not optimized in terms of tailoring therapy to individual patients based on their hypertension subclass and cardiovascular risk profile and initiating early use of adapted-dose, single-pill combinations. In this context, beta-blockers in combination with angiotensin-converting enzyme (ACE) inhibitors are of special interest as a result of their complementary actions on the sympathetic nervous system and renin-angiotensin-aldosterone system, two interlinked pathways that influence cardiovascular risk and disease outcomes. In addition to their antihypertensive actions, beta-blockers are used to manage arrhythmias and treat angina pectoris and heart failure, while ACE inhibitors provide cardioprotection in patients with acute coronary syndromes and treat congestive heart failure. A broad range of patients may therefore receive the combination in routine clinical practice. This paper examines the supporting evidence for beta-blockers and ACE inhibitors in each of the above indications and considers the rationale for combining these agents into a single pill, using data from bisoprolol and perindopril randomized controlled trials as supporting evidence. Combining these established antihypertensive agents into a single pill continues to provide effective blood pressure lowering and improved cardiovascular outcomes while allowing a greater proportion of patients to rapidly achieve treatment targets.

First-line diuretics versus other classes of antihypertensive drugs for hypertension

BACKGROUND

Different first-line drug classes for patients with hypertension are often assumed to have similar effectiveness with respect to reducing mortality and morbidity outcomes, and lowering blood pressure. First-line low-dose thiazide diuretics have been previously shown to have the best mortality and morbidity evidence when compared with placebo or no treatment. Head-to-head comparisons of thiazides with other blood pressure-lowering drug classes would demonstrate whether there are important differences.

OBJECTIVES

To compare the effects of first-line diuretic drugs with other individual first-line classes of antihypertensive drugs on mortality, morbidity, and withdrawals due to adverse effects in patients with hypertension. Secondary objectives included assessments of the need for added drugs, drug switching, and blood pressure-lowering.

SEARCH METHODS

Cochrane Hypertension's Information Specialist searched the Cochrane Hypertension Specialized Register, CENTRAL, MEDLINE, Embase, and trials registers to March 2021. We also checked references and contacted study authors to identify additional studies. A top-up search of the Specialized Register was carried out in June 2022.

SELECTION CRITERIA

Randomized active comparator trials of at least one year's duration were included. Trials had a clearly defined intervention arm of a first-line diuretic (thiazide, thiazide-like, or loop diuretic) compared to another first-line drug class: beta-blockers, calcium channel blockers, alpha adrenergic blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, direct renin inhibitors, or other antihypertensive drug classes. Studies had to include clearly defined mortality and morbidity outcomes (serious adverse events, total cardiovascular events, stroke, coronary heart disease (CHD), congestive heart failure, and withdrawals due to adverse effects).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 20 trials with 26 comparator arms randomizing over 90,000 participants. The findings are relevant to first-line use of drug classes in older male and female hypertensive patients (aged 50 to 75) with multiple co-morbidities, including type 2 diabetes. First-line thiazide and thiazide-like diuretics were compared with beta-blockers (six trials), calcium channel blockers (eight trials), ACE inhibitors (five trials), and alpha-adrenergic blockers (three trials); other comparators included angiotensin II receptor blockers, aliskiren (a direct renin inhibitor), and clonidine (a centrally acting drug). Only three studies reported data for total serious adverse events: two studies compared diuretics with calcium channel blockers and one with a direct renin inhibitor. Compared to first-line beta-blockers, first-line thiazides probably result in little to no difference in total mortality (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.84 to 1.10; 5 trials, 18,241 participants; moderate-certainty), probably reduce total cardiovascular events (5.4% versus 4.8%; RR 0.88, 95% CI 0.78 to 1.00; 4 trials, 18,135 participants; absolute risk reduction (ARR) 0.6%, moderate-certainty), may result in little to no difference in stroke (RR 0.85, 95% CI 0.66 to 1.09; 4 trials, 18,135 participants; low-certainty), CHD (RR 0.91, 95% CI 0.78 to 1.07; 4 trials, 18,135 participants; low-certainty), or heart failure (RR 0.69, 95% CI 0.40 to 1.19; 1 trial, 6569 participants; low-certainty), and probably reduce withdrawals due to adverse effects (10.1% versus 7.9%; RR 0.78, 95% CI 0.71 to 0.85; 5 trials, 18,501 participants; ARR 2.2%; moderate-certainty). Compared to first-line calcium channel blockers, first-line thiazides probably result in little to no difference in total mortality (RR 1.02, 95% CI 0.96 to 1.08; 7 trials, 35,417 participants; moderate-certainty), may result in little to no difference in serious adverse events (RR 1.09, 95% CI 0.97 to 1.24; 2 trials, 7204 participants; low-certainty), probably reduce total cardiovascular events (14.3% versus 13.3%; RR 0.93, 95% CI 0.89 to 0.98; 6 trials, 35,217 participants; ARR 1.0%; moderate-certainty), probably result in little to no difference in stroke (RR 1.06, 95% CI 0.95 to 1.18; 6 trials, 35,217 participants; moderate-certainty) or CHD (RR 1.00, 95% CI 0.93 to 1.08; 6 trials, 35,217 participants; moderate-certainty), probably reduce heart failure (4.4% versus 3.2%; RR 0.74, 95% CI 0.66 to 0.82; 6 trials, 35,217 participants; ARR 1.2%; moderate-certainty), and may reduce withdrawals due to adverse effects (7.6% versus 6.2%; RR 0.81, 95% CI 0.75 to 0.88; 7 trials, 33,908 participants; ARR 1.4%; low-certainty). Compared to first-line ACE inhibitors, first-line thiazides probably result in little to no difference in total mortality (RR 1.00, 95% CI 0.95 to 1.07; 3 trials, 30,961 participants; moderate-certainty), may result in little to no difference in total cardiovascular events (RR 0.97, 95% CI 0.92 to 1.02; 3 trials, 30,900 participants; low-certainty), probably reduce stroke slightly (4.7% versus 4.1%; RR 0.89, 95% CI 0.80 to 0.99; 3 trials, 30,900 participants; ARR 0.6%; moderate-certainty), probably result in little to no difference in CHD (RR 1.03, 95% CI 0.96 to 1.12; 3 trials, 30,900 participants; moderate-certainty) or heart failure (RR 0.94, 95% CI 0.84 to 1.04; 2 trials, 30,392 participants; moderate-certainty), and probably reduce withdrawals due to adverse effects (3.9% versus 2.9%; RR 0.73, 95% CI 0.64 to 0.84; 3 trials, 25,254 participants; ARR 1.0%; moderate-certainty). Compared to first-line alpha-blockers, first-line thiazides probably result in little to no difference in total mortality (RR 0.98, 95% CI 0.88 to 1.09; 1 trial, 24,316 participants; moderate-certainty), probably reduce total cardiovascular events (12.1% versus 9.0%; RR 0.74, 95% CI 0.69 to 0.80; 2 trials, 24,396 participants; ARR 3.1%; moderate-certainty) and stroke (2.7% versus 2.3%; RR 0.86, 95% CI 0.73 to 1.01; 2 trials, 24,396 participants; ARR 0.4%; moderate-certainty), may result in little to no difference in CHD (RR 0.98, 95% CI 0.86 to 1.11; 2 trials, 24,396 participants; low-certainty), probably reduce heart failure (5.4% versus 2.8%; RR 0.51, 95% CI 0.45 to 0.58; 1 trial, 24,316 participants; ARR 2.6%; moderate-certainty), and may reduce withdrawals due to adverse effects (1.3% versus 0.9%; RR 0.70, 95% CI 0.54 to 0.89; 3 trials, 24,772 participants; ARR 0.4%; low-certainty). For the other drug classes, data were insufficient. No antihypertensive drug class demonstrated any clinically important advantages over first-line thiazides.

AUTHORS' CONCLUSIONS

When used as first-line agents for the treatment of hypertension, thiazides and thiazide-like drugs likely do not change total mortality and likely decrease some morbidity outcomes such as cardiovascular events and withdrawals due to adverse effects, when compared to beta-blockers, calcium channel blockers, ACE inhibitors, and alpha-blockers.

Chronic cerebral hypoperfusion: a critical feature in unravelling the etiology of vascular cognitive impairment

Vascular cognitive impairment (VCI) describes a wide spectrum of cognitive deficits related to cerebrovascular diseases. Although the loss of blood flow to cortical regions critically involved in cognitive processes must feature as the main driver of VCI, the underlying mechanisms and interactions with related disease processes remain to be fully elucidated. Recent clinical studies of cerebral blood flow measurements have supported the role of chronic cerebral hypoperfusion (CCH) as a major driver of the vascular pathology and clinical manifestations of VCI. Here we review the pathophysiological mechanisms as well as neuropathological changes of CCH. Potential interventional strategies for VCI are also reviewed. A deeper understanding of how CCH can lead to accumulation of VCI-associated pathology could potentially pave the way for early detection and development of disease-modifying therapies, thus allowing preventive interventions instead of symptomatic treatments.

Lasmiditan in Japanese Patients with Common Migraine Comorbidities or Concomitant Medications: A Post Hoc Safety and Efficacy Analysis from the MONONOFU Study

Background

Migraine is often comorbid with other disorders. People with migraine may be prescribed one or more concomitant medications. This post hoc analysis assessed the safety and efficacy of lasmiditan in Japanese people with migraine comorbidities or using concomitant medications.

Patients and Methods

The MONONOFU study was a Phase 2, randomized, placebo-controlled, multicenter study of lasmiditan for acute migraine treatment in Japanese adults. Patients reported comorbidities (pre-existing or coexisting conditions) during screening. Concomitant medications (any drugs taken ±48 hours of the study drug) and treatment-emergent adverse events (TEAEs) were recorded in a paper diary. Study drug efficacy (pain freedom 2 hours after administration of study drug) was reported in an eDiary. Logistic regression models were used for subgroup analyses of safety (incidence of TEAEs) and efficacy (pain freedom at 2 hours post dose) of lasmiditan in relation to presence/absence of comorbidities, and safety in relation to concomitant medications.

Results

Common comorbidities (occurring in ≥10% of any lasmiditan dose group) were seasonal allergies, allergic rhinitis, tension-type headache, cervicobrachial syndrome, dysmenorrhea, nasopharyngitis, musculoskeletal stiffness, chronic gastritis, constipation, and insomnia. There was no significant interaction of treatment with comorbidity for safety or efficacy. There was also no significant interaction between treatment and concomitant medication groups of special interest (acetaminophen/nonsteroidal anti-inflammatory drugs, triptans, antiemetics, central nervous system depressant medications, serotonergic medications, antiepileptics, antihypertensive medications, Chinese herbal medicines, and contraceptives) for incidence of TEAEs.

Conclusion

In Japanese people with migraine, the safety of lasmiditan appeared to be independent of common comorbidities and concomitant medications; efficacy appeared to be independent of comorbid conditions.

Clinical Trials Registration

NCT03962738 (ClinicalTrials.gov).

Ivabradine in patients with acute ST-elevation myocardial infarction: a meta-analysis of randomized controlled trials

BACKGROUND

Elevated resting heart rate (HR) predicts poor outcomes in patients with coronary artery disease. Ivabradine has been recommended as a second-line anti-anginal agent in chronic coronary syndrome, while there are no clear indications for acute ST-elevation myocardial infarction (STEMI).

RESULTS

We systematically searched PubMed, Medline, EMBASE, Clinical Trials.gov, and the Cochrane Central Register of Controlled Trials with search terms Ivabradine and Acute myocardial infarction. There are two study outcomes from this study: therapeutic and safety effects. Therapeutic effects include the efficacy of Ivabradine on HR, all-cause mortality, heart failure incidence, left ventricular function and remodeling. Safety effects include troponin levels and ischemic events (recurrent angina pectoris). A total of 6 RCTs was included and showed that Ivabradine was associated with greater resting HR reduction [MD - 5.40; 95%CI - 8.60, - 2.20], improvement of left ventricular ejection fraction [MD 2.98; 95%CI 0.44, 5.51], and left ventricular end systolic volume [MD - 3.81; 95%CI - 6.88, - 0.75]. However, Ivabradine had no impact on all-cause mortality [OR 0.76; 95%CI 0.35, 1.67], heart failure incidence [OR 0.61; 95%CI 0.21, 1.80], and recurrent angina pectoris [OR 0.71; 95%CI 0.50, 1.00].

CONCLUSIONS

Ivabradine is safe and effective for resting HR reduction in patients with STEMI; however, it has no significant influence on mortality. These results suggest that an elevated HR is only a marker of risk but not a modifiable determinant of outcomes in patients who have suffered an acute myocardial infarction.

Blood-brain barrier permeable β-blockers linked to lower risk of Alzheimer's disease in hypertension

Alzheimer's disease is a neurodegenerative disorder in which the pathological accumulation of amyloid-β and tau begins years before symptom onset. Emerging evidence suggests that β-blockers (β-adrenergic antagonists) increase brain clearance of these metabolites by enhancing CSF flow. Our objective was to determine whether β-blocker treatments that easily cross the blood-brain barrier reduce the risk of Alzheimer's disease compared to less permeable β-blockers. Data from the Danish national registers were used to identify a retrospective cohort of individuals with hypertension, and those treated with β-blockers were included in the analysis. People with indications for β-blocker use other than hypertension (e.g. heart failure) were only retained in a sensitivity analysis. β-blockers were divided into three permeability groups: low, moderate and high. We used multivariable cause-specific Cox regression to model the effect of β-blocker blood-brain barrier permeability on time to dementia outcomes, adjusting for baseline comorbidities, demographics and socioeconomic variables. Death was modelled as a competing risk. The 10-year standardized absolute risk was estimated as the averaged person-specific risks per treatment. In a cohort of 69 081 (median age = 64.4 years, 64.8% female) people treated with β-blockers for hypertension, highly blood-brain barrier-permeable β-blockers were associated with reduced risk of Alzheimer's disease versus low permeability β-blockers (-0.45%, P < 0.036). This effect was specific to Alzheimer's diagnoses and did not extend to dementia in general. Propensity score analysis matching high and low blood-brain barrier-permeable patients also detected a decreased Alzheimer's risk (-0.92%, P < 0.001) in the high permeability group compared to the low, as did a 1-year landmark analysis (-0.57%, P < 0.029) in which events within the first year of follow-up were ignored as likely unrelated to treatment. Our results suggest that amongst people taking β-blockers for hypertension, treatment with highly blood-brain barrier permeable β-blockers reduces the risk of Alzheimer's disease compared to low permeability drugs. Our findings support the hypothesis that highly permeable β-blockers protect against Alzheimer's disease by promoting waste brain metabolite clearance.

A Clinical-Epidemiological Study on Beta-Blocker Poisonings Based on the Type of Drug Overdose

Background

Beta-blockers carry a high risk of potentially causing fatal poisoning if overdosed. We aimed to assess the clinical and epidemiological characteristics of patients with beta-blocker poisoning.

Methods

Patients were categorized based on the type of drug poisoning into propranolol, other beta-blockers, and the combination of beta-blocker groups, respectively. Demographic data, drug toxicity, and clinical, laboratory, and treatment information of different groups were compared.

Results

During the study period, 5086 poisoned patients were hospitalized, of whom 255 (5.1%) had beta-blocker poisoning. Most patients were women (80.8%), married (50.6%), with a history of psychiatric disorders (36.5%), previous suicide attempts (34.6%), and intentional type of exposure (95.3%). The mean ± SD age of the patients was 28.94 ± 11.08 years. Propranolol toxicity was the most common among different beta-blockers (84.4%). There was a significant difference in age, occupation, education level, and history of psychiatric diseases with respect to the type of beta-blocker poisoning (P < 0.05). We observed changes in the consciousness level and need for endotracheal intubation only in the third group (combination of beta-blockers). Only 1 (0.4%) patient had a fatal outcome in toxicity with the combination of beta-blockers.

Conclusion

Beta-blocker poisoning is not common in our poisoning referral center. Propranolol toxicity was most common among different beta-blockers. Although symptoms are not different among defined beta-blocker groups, more severe symptoms are observed in the combination of the beta-blocker group. Only one patient had a fatal outcome in the toxicity with the combination of the beta-blocker group. Therefore, poisoning circumstances have to investigate thoroughly to screen coexposure with combined drugs.

Potential Pharmacokinetic Interactions of Common Cardiovascular Drugs and Selected European and Latin American Herbal Medicines: A Scoping Review

BACKGROUND

Herb-drug interactions are nowadays an important decision factor in many healthcare interventions. Patients with cardiovascular risk factors such as hyperlipidemia and hypertension are usually prescribed long-term treatments. We need more informed decision tools to direct future clinical research and decision making to avoid HDI occurrences in this group.

METHODS

A scoping review was conducted using data from online databases such as PUBMED, the National Library of Medicine, and the electronic Medicines Compendium. Included studies consisted of the reported effects on Phase 1/2 and P-glycoprotein of herbal medicines listed in the medicines agencies of Latin America and Europe and drugs used for cardiovascular conditions (statins, diuretics, beta blockers, calcium channel blockers, and ACE inhibitors). The cross tabulation of the results allowed for finding potential HDI.

RESULTS AND CONCLUSIONS

as per the preclinical data reviewed here, we encourage more clinical research on whether drugs with apparently very low interaction risk, such as pravastatin, nadolol, and nimodipine/nitrendipine, may help prevent HDI when statins, beta blockers, and calcium channel blockers, respectively, are prescribed for long-term treatments.

Proximal aortic stiffness modifies the relationship between heart rate and backward wave and hence central arterial pulse pressure

AIMS

A lower heart rate (HR) increases central blood pressure through enhanced backward wave pressures (Pb). We aimed to determine whether these relationships are modified by increases in aortic stiffness.

METHODS

Using non-invasive central pressure, aortic velocity and diameter measurements in the outflow tract (echocardiography), we assessed the impact of aortic stiffness on relationships between HR and arterial wave morphology in 603 community participants < 60 years of age, 221 ≥ 60 years, and in 287 participants with arterial events [stroke and critical limb ischemia (CLI)].

RESULTS

As compared to community participants < 60 years, those ≥ 60 years or with events had increased multivariate adjusted proximal aortic characteristic impedance (Zc) and carotid femoral pulse wave velocity (PWV) (p < 0.05 to < 0.0001). Community participants ≥ 60 years and those with events also had a greater slope of the inverse relationship between HR and Pb (p < 0.001 for comparison). While in community participants < 60 years, no interaction between indexes of aortic stiffness and HR occurred, in those ≥ 60 years (p < 0.02) and in those with arterial events (p = 0.001), beyond aortic root diameter, an interaction between Zc and HR, but not between PWV and HR independently associated with Pb. This translated into stepwise increases in the slope of HR-Pb relationships at incremental tertiles of Zc. Although HR was inversely associated with the systemic reflection coefficient in community participants ≥ 60 years (p < 0.0001), adjustments for the reflection coefficient failed to modify HR-Pb relations.

CONCLUSION

Beyond the impact on systemic wave reflection, increases in proximal aortic stiffness enhance the adverse effects of HR on Pb and hence central BP.

Hypertension Management in Patients with Chronic Kidney Disease

Hypertension and chronic kidney disease are closely linked. Patients with chronic kidney disease have hypertension almost universally and uncontrolled hypertension accelerates the decline in kidney function. The pathophysiology of hypertension in chronic kidney disease is complex, but is largely related to reduced nephron mass, sympathetic nervous system overactivation, involvement of the renin-angiotensin-aldosterone system, and generalized endothelial dysfunction. Consensus guidelines for blood pressure targets have adopted a blood pressure <120/80 mm Hg in native chronic kidney disease and <130/80 mm Hg in kidney transplant recipients. Guidelines also strongly advocate for renin-angiotensin-aldosterone system blockade as the first-line therapy.

Evaluation of a Beta-Blocker-Edema-Loop Diuretic Prescribing Cascade: A Prescription Sequence Symmetry Analysis

BACKGROUND

Drug-related adverse events associated with antihypertensive therapy may result in subsequent prescribing of other potentially harmful medications, known as prescribing cascades. The aim of this study was to assess the magnitude and characteristics of a beta-blocker-edema-loop diuretic prescribing cascade.

METHODS

A prescription sequence symmetry analysis was used to assess loop diuretic initiation before and after initiation of beta-blockers among patients 20 years or older without heart failure, atrial fibrillation, other arrythmias, or use of calcium channel blocker within a U.S. private insurance claims database (2005-2018). The temporality of loop diuretic initiation relative to a beta-blocker or negative control (renin-angiotensin system blocker) initiation was tabulated. Secular trend-adjusted sequence ratios (aSRs) with 95% confidence intervals (CIs) compared the initiation of loop diuretic 90 days before and after initiation of beta-blockers.

RESULTS

Among 988,675 beta-blocker initiators, 9,489 patients initiated a new loop diuretic prescription 90 days after and 5,245 patients before beta-blocker initiation, resulting in an aSR of 1.78 (95% CI, 1.72-1.84). An estimated 1.72 beta-blocker initiators per 100 patient-years experienced the prescribing cascade in the first 90 days. The aSR was disproportionately higher among older adults (aSR 1.97), men (aSR 2.25), and patients who initiated metoprolol tartrate (aSR 2.48), labetalol (aSR 2.18), or metoprolol succinate (aSR 2.11). Negative control results (aSR 1.09, 95% CI, 1.05-1.13) generally corroborated our findings, but suggested modest within-person time-varying confounding.

CONCLUSIONS

We observed excess use of loop diuretics following beta-blocker initiation that was only partially explained by secular trends or hypertension progression.

Congenital Heart Disease: The State-of-the-Art on Its Pharmacological Therapeutics

Congenital heart disease is one of the most common causes of death derived from malformations. Historically, its treatment has depended on timely diagnosis and early pharmacological and surgical interventions. Survival rates for patients with this disease have increased, primarily due to advancements in therapeutic choices, but mortality remains high. Since this disease is a time-sensitive pathology, pharmacological interventions are needed to improve clinical outcomes. Therefore, we analyzed the applications, dosage, and side effects of drugs currently used for treating congenital heart disease. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and potassium-sparing diuretics have shown a mortality benefit in most patients. Other therapies, such as endothelin receptor antagonists, phosphodiesterase-5 inhibitors, prostaglandins, and soluble guanylyl cyclase stimulators, have benefited patients with pulmonary artery hypertension. Likewise, the adjunctive symptomatic treatment of these patients has further improved the outcomes, since antiarrhythmics, digoxin, and non-steroidal anti-inflammatory drugs have shown their benefits in these cases. Conclusively, these drugs also carry the risk of troublesome adverse effects, such as electrolyte imbalances and hemodynamic compromise. However, their benefits for survival, symptom improvement, and stabilization outweigh the possible complications from their use. Thus, cases must be assessed individually to accurately identify interventions that would be most beneficial for patients.

Anti-hypertensive medications and risk of colorectal cancer: a systematic review and meta-analysis

PURPOSE

Antihypertensive medications may impact colorectal cancer risk. We conducted a systematic review and meta-analysis of associations, with colorectal cancer risk, of five classes of antihypertensive medications: angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers (CCBs), and diuretics.

METHODS

A systematic search was conducted in MEDLINE, Embase, Web of Science, and the Cochrane library to identify relevant studies evaluating associations of ACEIs, ARBs, BBs, CCBs, and diuretics with colorectal cancer risk. Meta-analytic risk ratios (RRs) and corresponding 95% confidence intervals (95% CIs) were calculated using the inverse variance method.

RESULTS

No overall significant associations with colorectal cancer risk were observed; ACEIs (5 studies) RR 1.05, 95% CI 0.91-1.23, ARBs (5 studies) RR 0.94, 95% CI 0.80-1.11, BBs (4 studies) RR 1.00, 95% CI 0.92-1.08, CCBs (4 studies) RR 1.02, 95% CI 0.88-1.18, and diuretics (6 studies) RR 1.02, 95% CI 0.90-1.17. There was considerable heterogeneity across studies, partly explained by differences in study design and location. When stratified by study location, there was significantly reduced colorectal cancer risk for ARB use in Asian populations (2 studies, RR 0.69, 95% CI 0.58-0.83).

CONCLUSION

No significant colorectal cancer risk with ACEIs, BBs, CCBs, or diuretics was observed. ARB use may be associated with decreased risk of colorectal cancer in Asian populations, although additional studies in diverse populations are needed to confirm associations and help understand possible reasons for geographical differences.

Beta-Blocker Use in Older Hospitalized Patients Affected by Heart Failure and Chronic Obstructive Pulmonary Disease: An Italian Survey From the REPOSI Register

Beta (β)-blockers (BB) are useful in reducing morbidity and mortality in patients with heart failure (HF) and concomitant chronic obstructive pulmonary disease (COPD). Nevertheless, the use of BBs could induce bronchoconstriction due to β2-blockade. For this reason, both the ESC and GOLD guidelines strongly suggest the use of selective β1-BB in patients with HF and COPD. However, low adherence to guidelines was observed in multiple clinical settings. The aim of the study was to investigate the BBs use in older patients affected by HF and COPD, recorded in the REPOSI register. Of 942 patients affected by HF, 47.1% were treated with BBs. The use of BBs was significantly lower in patients with HF and COPD than in patients affected by HF alone, both at admission and at discharge (admission, 36.9% vs. 51.3%; discharge, 38.0% vs. 51.7%). In addition, no further BB users were found at discharge. The probability to being treated with a BB was significantly lower in patients with HF also affected by COPD (adj. OR, 95% CI: 0.50, 0.37-0.67), while the diagnosis of COPD was not associated with the choice of selective β1-BB (adj. OR, 95% CI: 1.33, 0.76-2.34). Despite clear recommendations by clinical guidelines, a significant underuse of BBs was also observed after hospital discharge. In COPD affected patients, physicians unreasonably reject BBs use, rather than choosing a β1-BB. The expected improvement of the BB prescriptions after hospitalization was not observed. A multidisciplinary approach among hospital physicians, general practitioners, and pharmacologists should be carried out for better drug management and adherence to guideline recommendations.

Metabolic Syndrome and Male Fertility: Beyond Heart Consequences of a Complex Cardiometabolic Endocrinopathy

Metabolic syndrome (MetS) is a highly prevalent condition among adult males, affecting up to 41% of men in Europe. It is characterized by the association of obesity, hypertension, and atherogenic dyslipidemia, which lead to premature morbidity and mortality due to cardiovascular disease (CVD). Male infertility is another common condition which accounts for about 50% of cases of couple infertility worldwide. Interestingly, male infertility and MetS shares several risk factors (e.g., smoking, ageing, physical inactivity, and excessive alcohol consumption), leading to reactive oxygen species (ROS) production and increased oxidative stress (OS), and resulting in endothelial dysfunction and altered semen quality. Thus, the present narrative review aims to discuss the pathophysiological mechanisms which link male infertility and MetS and to investigate the latest available evidence on the reproductive consequences of MetS.

2022 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension

Hypertension is the most important modifiable cause of cardiovascular (CV) disease and all-cause mortality worldwide. Despite the positive correlations between blood pressure (BP) levels and later CV events since BP levels as low as 100/60 mmHg have been reported in numerous epidemiological studies, the diagnostic criteria of hypertension and BP thresholds and targets of antihypertensive therapy have largely remained at the level of 140/90 mmHg in the past 30 years. The publication of both the SPRINT and STEP trials (comprising > 8,500 Caucasian/African and Chinese participants, respectively) provided evidence to shake this 140/90 mmHg dogma. Another dogma regarding hypertension management is the dependence on office (or clinic) BP measurements. Although standardized office BP measurements have been widely recommended and adopted in large-scale CV outcome trials, the practice of office BP measurements has never been ideal in real-world practice. Home BP monitoring (HBPM) is easy to perform, more likely to be free of environmental and/or emotional stress, feasible to document long-term BP variations, of good reproducibility and reliability, and more correlated with hypertension-mediated organ damage (HMOD) and CV events, compared to routine office BP measurements. In the 2022 Taiwan Hypertension Guidelines of the Taiwan Society of Cardiology (TSOC) and the Taiwan Hypertension Society (THS), we break these two dogmas by recommending the definition of hypertension as ≥ 130/80 mmHg and a universal BP target of < 130/80 mmHg, based on standardized HBPM obtained according to the 722 protocol. The 722 protocol refers to duplicate BP readings taken per occasion ("2"), twice daily ("2"), over seven consecutive days ("7"). To facilitate implementation of the guidelines, a series of flowcharts encompassing assessment, adjustment, and HBPM-guided hypertension management are provided. Other key messages include that: 1) lifestyle modification, summarized as the mnemonic S-ABCDE, should be applied to people with elevated BP and hypertensive patients to reduce life-time BP burden; 2) all 5 major antihypertensive drugs (angiotensin-converting enzyme inhibitors [A], angiotensin receptor blockers [A], β-blockers [B], calcium-channel blockers [C], and thiazide diuretics [D]) are recommended as first-line antihypertensive drugs; 3) initial combination therapy, preferably in a single-pill combination, is recommended for patients with BP ≥ 20/10 mmHg above targets; 4) a target hierarchy (HBPM-HMOD- ambulatory BP monitoring [ABPM]) should be considered to optimize hypertension management, which indicates reaching the HBPM target first and then keeping HMOD stable or regressed, otherwise ABPM can be arranged to guide treatment adjustment; and 5) renal denervation can be considered as an alternative BP-lowering strategy after careful clinical and imaging evaluation.

Mechanisms and Clinical Implications of Endothelial Dysfunction in Arterial Hypertension

The endothelium is composed of a monolayer of endothelial cells, lining the interior surface of blood and lymphatic vessels. Endothelial cells display important homeostatic functions, since they are able to respond to humoral and hemodynamic stimuli. Thus, endothelial dysfunction has been proposed as a key and early pathogenic mechanism in many clinical conditions. Given the relevant repercussions on cardiovascular risk, the complex interplay between endothelial dysfunction and systemic arterial hypertension has been a matter of study in recent years. Numerous articles have been published on this issue, all of which contribute to providing an interesting insight into the molecular mechanisms of endothelial dysfunction in arterial hypertension and its role as a biomarker of inflammation, oxidative stress, and vascular disease. The prognostic and therapeutic implications of endothelial dysfunction have also been analyzed in this clinical setting, with interesting new findings and potential applications in clinical practice and future research. The aim of this review is to summarize the pathophysiology of the relationship between endothelial dysfunction and systemic arterial hypertension, with a focus on the personalized pharmacological and rehabilitation strategies targeting endothelial dysfunction while treating hypertension and cardiovascular comorbidities.

Acupoint application therapies for essential hypertension: a systematic review and Meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of acupoint application therapies (AA) for hypertension.

METHODS

We searched PubMed, EMBASE, the Cochrane Center Controlled Trials Register, Chinese National Knowledge Infrastructure, Chinese Scientific Journal Database, and Wanfang Med Online Database from their inceptions to October 7, 2019. No language restriction was applied. We included randomized clinical trials testing AA against Western Medicine, AA versus placebo, AA combined with Western Medicine versus Western Medicine. Study selection, data extraction, quality assessment, and data analyses were conducted according to the Cochrane standards.

RESULTS

Totally 41 trials with 3772 participants were included. The methodological quality of the included trials was evaluated as generally low. AA plus Western Medicine significantly lowered systolic blood pressure (BP) [weighted mean difference (): -10.36, 95% confidence intervals (): -12.62, -8.10; 0.000 01], diastolic BP (: -5.71, 95% : -7.30, -4.13; 0.000 01), and total effect [risk ratio (): 1.23, 95% : 1.15, 1.32; 0.000 01]. The BP-lowering effect of AA was significantly higher than that of placebo [systolic BP (SBP): -8.05, 95% : -8.67, -7.43; 0.000 01; diastolic BP (DBP): -6.66, 95% : -7.31, -6.01, 0.000 01]. The total effect also improved significantly from baseline with AA than placebo (: 10.85, 95% : 4.71, 24.98; 0.000 01). Traditional Chinese Medicine symptoms score were significantly reduced by AA compared with Western Medicine (: -1.75, 95% : -2.52, -0.99; 0.000 01), 10 trials reported adverse events, indicating that the safety of SSYX Capsule is still uncertain.

CONCLUSIONS

Application therapies may be considered a safe and beneficial for the treatment of hypertension and can reduce BP and improve the total effect. Further well-designed trials are needed to support our conclusions.

Post-diagnostic beta blocker use and breast cancer-specific mortality: a population-based cohort study

Purpose

Beta blockers (BB) have been associated with improved, worsened, or unchanged breast cancer outcomes in previous studies. This study examines the association between the post-diagnostic use of BBs and death from breast cancer in a large, representative sample of New Zealand (NZ) women with breast cancer.

Methods

Women diagnosed with a first primary breast cancer between 2007 and 2016 were identified from four population-based regional NZ breast cancer registries and linked to national pharmaceutical data, hospital discharges, and death records. The median follow-up time was 4.51 years. Cox proportional hazard models were used to estimate the hazard of breast cancer-specific death (BCD) associated with any post-diagnostic BB use.

Results

Of the 14,976 women included in analyses, 21% used a BB after diagnosis. BB use (vs non-use) was associated with a small and nonstatistically significant increased risk of BCD (adjusted hazard ratio: 1.11; 95% CI 0.95–1.29). A statistically significant increased risk confined to short-term use (0–3 months) was seen (HR = 1.40; 1.14–1.73), and this risk steadily decreased with increasing duration of use and became a statistically significant protective effect at 3 + years of use (HR = 0.55; 0.34–0.88).

Conclusion

Our findings suggest that any increased risk associated with BB use may be driven by risk in the initial few months of use. Long-term BB use may be associated with a reduction in BCD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06528-0.

Antihypertensive and cardioprotective effects of three generations of beta-adrenergic blockers: an historical perspective

There are currently, 3 generations of beta-adrenergic blockers for the treatment of hypertension and cardiovascular diseases. The 1^st generation caused vasoconstriction and bronchoconstriction due to β₁ + β₂ receptor blockade and unopposed α₁ receptors. The 2^nd generation of beta-blockers has lesser adverse effects than the 1^st generation with the 3^rd generation beta-blockers having much lesser effects than the other two generations. Current US and International guideline do not recommend beta-blockers as first line therapy of hypertension, but only in the presence of coronary artery disease or heart failure due to their lesser antihypertensive effect. These recommendations are disputed by several older and recent studies which have shown that the beta-blockers are effective and safe for the treatment of hypertension and could be used as first line therapy. To clarify this issue a Medline search of the English language literature was conducted between 2012 and 2021 and 30 pertinent papers were selected. The data from these studies show that the beta-blockers have inferior antihypertensive and stroke protective effect compared with the other classes of antihypertensive drugs and should be used as first line therapy only in patients with hypertension associated with coronary artery disease or heart failure. The information from these papers and collateral literature will be discussed in this perspective.

Real-World Effectiveness of Beta-Blockers versus Other Antihypertensives in Reducing All-Cause Mortality and Cardiovascular Events

AIM

The aim of the study was to compare the effectiveness of beta-blockers with other antihypertensive classes in reducing all-cause mortality, cardiovascular-related mortality and the risk of cerebrocardiovascular events.

METHODS

This noninterventional study was conducted within the UK Clinical Practice Research Datalink. Hypertensive patients who initiated antihypertensive monotherapy were allocated to one of five cohorts: beta-blockers; angiotensin-converting enzyme inhibitors (ACEi); angiotensin II receptor blockers (ARB); calcium channel blockers (CCB); and diuretics. Differences in outcomes were assessed using Cox proportional hazard models with competing risks.

RESULTS

A total of 44,404 patients were prescribed beta-blockers (75% atenolol), 132,545 ACEi, 12,018 ARB, 91,731 CCB, and 106,547 diuretics. At baseline, patients in the beta-blocker cohort presented more frequently with angina, arrhythmia, and atrial fibrillation. The risk of all-cause mortality was lower for those treated with ACEi, ARB, and CCB, and no difference was observed compared with diuretics (adjusted hazard ratio versus beta-blockers (98.75% CI), for ACEi 0.71 (0.61, 0.83), ARB 0.67 (0.51, 0.88), CCB 0.76 (0.66, 0.88), diuretics 1.06 (0.93, 1.22)). No differences were seen in the risk of cardiovascular mortality for patients treated with beta-blockers, ARB, CCB, and diuretics, while a lower risk in patients treated with ACEi was observed (ACEi 0.63 (0.43, 0.91), ARB 0.64 (0.32, 1.28), CCB 0.71 (0.49, 1.03), diuretics 0.97 (0.69, 1.37)).

CONCLUSIONS

These data add to the limited pool of evidence from real-world studies exploring the effectiveness of beta-blockers versus other antihypertensive classes. Discrepancies to previously published studies might be partly explained by differences in the selected populations and in the follow-up time.

Research Letter: Antihypertensive Drugs Market in India: An Insight on Size, Trends, and Prescribing Preferences in the Private Health Sector, 2016-2018

Background

India has a high burden of hypertension. While the private sector provides 70% of out-patient care in the country, a significant proportion of patients seeking care from the public sector buy drugs from private markets. This study aimed to describe India's private sector antihypertensive drugs market at the national and state levels over 2016-2018.

Methods

Antihypertensive drugs sales in India from 2016-2018 were analysed using a large nationally representative dataset for the private pharmaceuticals market. In addition, data for five states (Punjab, Madhya Pradesh, Kerala, Telangana, and Maharashtra) that were the foci of a large hypertension control program were studied.

Results

The Indian hypertension drug market grew at a rate of 6.9% from 2016 to 2018 with a total of 21,066 million pills sales in 2018. Single-pill combinations (SPCs) contributed to 39.1% of total sale volumes. The market comprised of 182 different antihypertensive drugs including 134 SPCs. Total volume of sales covered a maximum of 26% of treatment need for the estimated population with hypertension. Two-drug SPCs had the highest market share (36%), followed by calcium channel blockers (18%), beta-blockers (16%) and angiotensin receptor blockers (14%). Among SPCs, amlodipine+atenolol had highest sales (9.8%). Twenty-five drugs, a mix of single drugs and SPCs, accounted for 80% of total sales. There were large state-to-state variations in sales per capita, preferred therapeutic classes and drugs.

Conclusions

Despite the large antihypertensive drugs market, there exists a high unmet need for treatment in India. Inter-state differences in product sales indicate variable treatment practices, underscoring the need for private sector engagement to improve hypertension care practices aligned with national and international guidelines. SPCs contributed to a large share of the private market and inclusion of select antihypertensive SPCs in the national list of essential medications should be considered for the public health system.

Cardiovascular Effects of Snake Toxins: Cardiotoxicity and Cardioprotection

Snake venoms, as complex mixtures of peptides and proteins, affect various vital systems of the organism. One of the main targets of the toxic components from snake venoms is the cardiovascular system. Venom proteins and peptides can act in different ways, exhibiting either cardiotoxic or cardioprotective effects. The principal classes of these compounds are cobra cardiotoxins, phospholipases A2, and natriuretic, as well as bradykinin-potentiating peptides. There is another group of proteins capable of enhancing angiogenesis, which include, e.g., vascular endothelial growth factors possessing hypotensive and cardioprotective activities. Venom proteins and peptides exhibiting cardiotropic and vasoactive effects are promising candidates for the design of new drugs capable of preventing or constricting the development of pathological processes in cardiovascular diseases, which are currently the leading cause of death worldwide. For example, a bradykinin-potentiating peptide from Bothrops jararaca snake venom was the first snake venom compound used to create the widely used antihypertensive drugs captopril and enalapril. In this paper, we review the current state of research on snake venom components affecting the cardiovascular system and analyse the mechanisms of physiological action of these toxins and the prospects for their medical application.

β-Blockade for Patients with Hypertension, Ischemic Heart Disease or Heart Failure: Where are We Now?

β-blockers are a heterogeneous class of drugs, with varying selectivity/specificity for β1 vs β2 receptors, intrinsic sympathomimetic activity (ISA), and vasodilatory properties (through β2 stimulation, α receptor blockade or nitric oxide release). These drugs are indicated for the management of arterial hypertension, heart failure or ischemic heart disease (IHD; eg angina pectoris or prior myocardial infarction). Most of the benefit of β-blockade in these conditions arises from blockade of the β1 receptor, and, in practice, the addition of ISA appears to reduce the potential for improved clinical outcomes in people with heart failure or IHD. Aspects of the benefit/risk balance of β-blockers remain controversial, and recent meta-analyses have shed new light on this issue. We have reviewed the current place of cardioselective β-blockade in hypertension, IHD and heart failure, with special reference to the therapeutic profile of a highly selective β1-adrenoceptor blocker, bisoprolol.

Antihypertensive Class and Cardiovascular Outcomes in Patients With HIV and Hypertension

[Figure: see text].

The Use of Antihypertensive Drugs as Coadjuvant Therapy in Cancer

Cancer is a complex group of diseases that constitute the second largest cause of mortality worldwide. The development of new drugs for treating this disease is a long and costly process, from the discovery of the molecule through testing in phase III clinical trials, a process during which most candidate molecules fail. The use of drugs currently employed for the management of other diseases (drug repurposing) represents an alternative for developing new medical treatments. Repurposing existing drugs is, in principle, cheaper and faster than developing new drugs. Antihypertensive drugs, primarily belonging to the pharmacological categories of angiotensin-converting enzyme inhibitors, angiotensin II receptors, direct aldosterone antagonists, β-blockers and calcium channel blockers, are commonly prescribed and have well-known safety profiles. Additionally, some of these drugs have exhibited pharmacological properties useful for the treatment of cancer, rendering them candidates for drug repurposing. In this review, we examine the preclinical and clinical evidence for utilizing antihypertensive agents in the treatment of cancer.

Variation in hypertension clinical practice guidelines: a global comparison

BACKGROUND

Hypertension is the largest single contributor to the global burden of disease, affecting an estimated 1.39 billion people worldwide. Clinical practice guidelines (CPGs) can aid in the effective management of this common condition, however, inconsistencies exist between CPGs, and the extent of this is unknown. Understanding the differences in CPG recommendations across income settings may provide an important means of understanding some of the global variations in clinical outcomes related to hypertension.

AIMS

This study aims to analyse the variation between hypertension CPGs globally. It aims to assess the variation in three areas: diagnostic threshold and staging, treatment and target blood pressure (BP) recommendations in hypertension.

METHODS

A search was conducted on the MEDLINE repository to identify national and international hypertension CPGs from 2010 to May 2020. An additional country-specific grey-literature search was conducted for all countries and territories of the world as identified by the World Bank. Data describing the diagnosis, staging, treatment and target blood pressure were extracted from CPGs, and variations between CPGs for these domains were analysed.

RESULTS

Forty-eight CPGs from across all World Bank income settings were selected for analysis. Ninety-six per cent of guidelines defined hypertension as a clinic-based BP of ≥140/90 mmHg, and 87% of guidelines recommended a target BP of < 140/90 mmHg. In the pharmacological treatment of hypertension, eight different first-step, 17 different second-step and six different third-step drug recommendations were observed. Low-income countries preferentially recommended diuretics (63%) in the first-step treatment, whilst high-income countries offered more choice between antihypertensive classes. Forty-four per cent of guidelines, of which 71% were from higher-income contexts recommended initiating treatment with dual-drug therapy at BP 160/100 mmHg or higher.

CONCLUSION

This study found that CPGs remained largely consistent in the definition, staging and target BP recommendations for hypertension. Extensive variation was observed in treatment recommendations, particularly for second-line therapy. Variation existed between income settings; low-income countries prescribed cheaper drugs, offered less clinician choice in medications and initiated dual therapy at later stages than higher-income countries. Future research exploring the underlying drivers of this variation may improve outcomes for hypertensive patients across clinical contexts.

Comprehensive Comparative Effectiveness and Safety of First-Line β-Blocker Monotherapy in Hypertensive Patients: A Large-Scale Multicenter Observational Study

[Figure: see text].

Ten things to know about ten cardiovascular disease risk factors

Given rapid advancements in medical science, it is often challenging for the busy clinician to remain up-to-date on the fundamental and multifaceted aspects of preventive cardiology and maintain awareness of the latest guidelines applicable to cardiovascular disease (CVD) risk factors. The "American Society for Preventive Cardiology (ASPC) Top Ten CVD Risk Factors 2021 Update" is a summary document (updated yearly) regarding CVD risk factors. This "ASPC Top Ten CVD Risk Factors 2021 Update" summary document reflects the perspective of the section authors regarding ten things to know about ten sentinel CVD risk factors. It also includes quick access to sentinel references (applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the "ASPC Top Ten CVD Risk Factors 2021 Update" to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.

Nebivolol is more effective than atenolol for blood pressure variability attenuation and target organ damage prevention in L-NAME hypertensive rats

β-Adrenergic blockers are no longer recommended as first-line therapy due to the reduced cardioprotection of traditional β-blockers compared with other antihypertensive drugs. It is unknown whether third-generation β-blockers share the limitations of traditional β-blockers. The aim of the present study was to compare the effects of nebivolol or atenolol on central and peripheral systolic blood pressure (SBP) and its variability and target organ damage (TOD) in N-nitro-L-arginine methyl ester (L-NAME) hypertensive rats. Male Wistar rats were treated with L-NAME for 8 weeks together with oral administration of nebivolol 30 mg/kg (n = 8), atenolol 90 mg/kg (n = 8), or vehicle (n = 8). The control group was composed of vehicle-treated Wistar rats. SBP and its variability, as well as echocardiographic parameters, were assessed during the last 2 weeks of treatment. Tissue levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and transforming growth factor β (TGF-β), and histopathological parameters were evaluated in the left ventricle and aorta. Nebivolol had a greater ability than atenolol to decrease central SBP and mid-term and short-term blood pressure variability (BPV) in L-NAME rats. Echocardiographic analysis showed that nebivolol was more effective than atenolol on E/A wave ratio normalization. Compared with atenolol treatment, nebivolol had a greater protective effect on different TOD markers, inducing a decrease in collagen deposition and a reduction in the proinflammatory cytokines IL-6 and TNF-α in the left ventricle and aorta. Our findings suggest that the adverse hemodynamic profile and the reduced cardiovascular protection reported with traditional β-blockers must not be carried forward to third-generation β-blockers.

Utilization, Cost, and Affordability of Antihypertensive Therapy in Bulgaria

ACE- inhibitors, angiotensin receptor blockers, beta-blockers, Ca- antagonists are recommended as first-line monotherapy for hypertension. The aim of the current study is to analyze expenditures paid by the National Health Insurance Fund (NHIF) after introducing the budget cap cost-containment measure and its impact on affordability and utilization. The study is a retrospective, observational analysis of expenditure on main groups' antihypertensive medicines: beta blockers, calcium channel blockers, ACE- inhibitors, and AT receptor blockers. The cost paid by the NHIF two years before (2016-2017), and after (2018-2019) the introduction of the budget cap measure was evaluated. Utilization and affordability data covering antihypertensive therapy were retrospectively calculated and analyzed during 2016-2019. The reimbursed expenditures on sartans, ACE-inhibitors, and β-blockers decreased in absolute terms in 2019 compared to that in 2016. There are no statistically significant differences, excluding the group of sartans. The result reveals decreasing utilization of ACE-inhibitors and β-blockers, which is the most significant for enalapril and bisoprolol. Affordability increases during the observed period because less than a working day income is sufficient for monthly therapy. Patients with hypertension in Bulgaria have access to affordable first-line antihypertensive medicines. Despite the stable and low prices, utilization mainly decreases. The reimbursed amount is reduced with a low rate or remains similar to that found at the beginning of the observed period. The results of the implemented budget cap as a measure to control NHIF cost are not evident and not fully expressed on the market for the first-line antihypertensive therapy.

Antiretroviral Treatment and Antihypertensive Therapy

The presence of hypertension among the population with human immunodeficiency virus (HIV) has become a new threat to the health and well-being of people living with this disease, in particular, among those who received antiretroviral therapy. The estimated prevalence of high blood pressure in HIV-infected patients is significantly higher than the rate observed in HIV-uninfected subjects. The approach to the HIV-positive patient requires the assessment of individual cardiovascular risk and its consideration when designing the individualized target. On the other hand, the numerous pharmacological interactions of antiretroviral (ARV) drugs are essential elements to take into account. Serum levels of any kind of antihypertensive drugs may be influenced by the coadministration of protease inhibitors, non-nucleoside reverse transcriptase inhibitor, or other antiretroviral. Similarly, plasma concentrations of antiretroviral drugs can be increased by the concomitant use of calcium channel blockers or diuretics. In this regard, the treatment of high blood pressure in HIV patients should be preferentially based on ACE inhibitors or thiazide/thiazide-like diuretics or their combination.

Prediction of Major Depressive Disorder Following Beta-Blocker Therapy in Patients with Cardiovascular Diseases

Incident depression has been reported to be associated with poor prognosis in patients with cardiovascular disease (CVD), which might be associated with beta-blocker therapy. Because early detection and intervention can alleviate the severity of depression, we aimed to develop a machine learning (ML) model predicting the onset of major depressive disorder (MDD). A model based on L1 regularized logistic regression was trained against the South Korean nationwide administrative claims database to identify risk factors for the incident MDD after beta-blocker therapy in patients with CVD. We identified 50,397 patients initiating beta-blockers for CVD, with 774 patients developing MDD within 365 days after initiating beta-blocker therapy. An area under the receiver operating characteristic curve (AUC) of 0.74 was achieved. A history of non-selective beta-blockers and factors related to anxiety disorder, sleeping problems, and other chronic diseases were the most strong predictors. AUCs of 0.62–0.71 were achieved in the external validation conducted on six independent electronic health records and claims databases in the USA and South Korea. In conclusion, an ML model that identifies patients at high-risk for incident MDD was developed. Application of ML to identify susceptible patients for adverse events of treatment may serve as an important approach for personalized medicine.