Hypertension in special populations

The use of herbal and dietary supplement among community-dwelling elderly in a suburban town of Malaysia

BACKGROUND

The use of herbal and dietary supplement (HDS) in health and disease management has gained global attention. HDS are generally accepted by the public and are associated with positive health behaviours. However, several reports have been documented with regards to their potential adverse effects and interaction with conventional medicines. Limited data is currently available on the use of HDS among elderly population in Malaysia. This present study aims to investigate the prevalence of and pattern of HDS use among a sample of community-dwelling elderly in a suburban town in Malaysia.

METHODS

A cross-sectional survey was conducted between March and May 2019 among the elderly aged ≥60 years old. The participants with the following criteria were included in the study: aged ≥60 years, residing in Puncak Alam and able to understand Malay or English language. Data were collected using a pre-validated questionnaire. All statistical analysis was conducted using IBM SPSS ver. 23.

RESULTS

Overall, 336 out of 400 elderly responded to the survey, achieving a response rate of 84%. This study observed that almost 50% of the respondents were using at least one type of HDS in the past one month of the survey. Among HDS non-users, most of them preferred to use modern medicines (62.6%, 114/182). Among the HDS users, 75.3% (116/154) were using at least one type of modern medicine (prescription or over-the-counter medicine). Multivariate analysis showed that having good to excellent perceived health (adjusted OR = 2.666, 95% CI = 1.592-4.464), having felt sick at least once in the past one month (adjusted OR = 2.500, 95% CI = 1.426-4.383), and lower body mass index (adjusted OR = 0.937, 95% CI = 0.887-0.990) were associated with HDS use. It was noted that only a small percentage of HDS users (16.2%, 25/154) had informed healthcare providers on their HDS use.

CONCLUSION

The use of HDS is common among the elderly sampled. Hence, healthcare providers should be more vigilant in seeking information of HDS use for disease management in their elderly patients. Campaigns that provide accurate information regarding the appropriate use of HDS among the elderly are pertinent to prevent misinformation of the products.

Antihypertensive agent utilization patterns among patients with uncontrolled hypertension in the United States

Hypertension affects approximately one-third of the US adults. This study investigated antihypertensive utilization patterns among hypertensive patients who were prescribed treatment, yet still experienced uncontrolled hypertension. Data from the Decision Resources Group Real World Evidence Data Repository US database (2015-2016) were used to construct a cohort of uncontrolled hypertension patients to observe antihypertensive utilization patterns. Results for 5059 patients, with an average age of 57.8 (SD = 13.7), who had, on average 2.4 agents prescribed. Approximately half (51.9%) were female, and most were White (86.8%). More than one-third (N = 1877; 37.1%) of patients were diagnosed with diabetes mellitus (DM) or chronic kidney disease (CKD) that could independently contribute to increased cardiovascular complications. Overall, the most common treatments prescribed, as percent of agents and as percent of patients, respectively, were diuretics (24.9%; 59.6%), followed by angiotensin-converting enzyme inhibitors (ACEIs) (23.8%; 56.9%), beta-blockers (BBs) (18.7%; 44.8%), calcium channel blockers (CCBs) (15.4%; 36.8%), and angiotensin II receptor blockers (ARBs) (13.5%; 32.3%). Approximately one-tenth (10.5%) of the prescriptions were written for fixed-dose combination therapies. Among patients diagnosed with DM and CKD (N = 200), the order of the most common agents was the same as the overall cohort. Only 5.6% of prescriptions written for these patients were fixed-dose combination therapy. Based on clinical guidelines, which suggest using ACEIs, ARBs, or CCBs as first-line therapy, and fixed-dose combination therapy to increase adherence, this indicates over-prescribing of BBs and under-prescribing of fixed-dose combination therapy. These findings illustrate the need to further investigate challenges faced by patients and providers in treatment decision-making.

Pre-Eclampsia and Eclampsia: An Update on the Pharmacological Treatment Applied in Portugal

Pre-eclampsia and eclampsia are two hypertensive disorders of pregnancy, considered major causes of maternal and perinatal death worldwide. Pre-eclampsia is a multisystemic disease characterized by the development of hypertension after 20 weeks of gestation, with the presence of proteinuria or, in its absence, of signs or symptoms indicative of target organ injury. Eclampsia represents the consequence of brain injuries caused by pre-eclampsia. The correct diagnosis and classification of the disease are essential, since the therapies for the mild and severe forms of pre-eclampsia are different. Thus, this review aims to describe the most advisable antepartum pharmacotherapy for pre-eclampsia and eclampsia applied in Portugal and based on several national and international available guidelines. Slow-release nifedipine is the most recommended drug for mild pre-eclampsia, and labetalol is the drug of choice for the severe form of the disease. Magnesium sulfate is used to prevent seizures caused by eclampsia. Corticosteroids are used for fetal lung maturation. Overall, the pharmacological prevention of these diseases is limited to low-dose aspirin, so it is important to establish the safest and most effective available treatment.

Considerations in women with hypertension

Cardiovascular disease is the most common cause of death in women in the United States, and hypertension is a major contributor to cardiovascular mortality. The incidence of hypertension in women is steadily increasing, paralleling the epidemics of obesity and diabetes. Blood pressure control rates among women are suboptimal, even when secondary causes are identified and treated. There are few high-quality data describing specific hypertension-related outcomes in women. Some data comparing hypertensive women to age-matched men suggest advantages to sex-specific strategies, but further study is needed to determine optimal regimens for women throughout their lives. Pregnancy and menopause present unique, complex challenges in hypertension management.

CAM use among older adults age 65 or older with hypertension in the United States: general use and disease treatment

OBJECTIVES

Hypertension (HT) is a common condition among older adults that greatly increases morbidity and mortality risk. Although a number of antihypertensive therapies are currently available, adherence and control are low. The purpose of this study was to assess the use of complementary and alternative medicine (CAM) among older adults with HT.

DESIGN

Using a nationally representative cross-sectional survey, the authors examined the prevalence of CAM use among older adults with and without diagnosed HT and the degree to which CAM is used specifically for HT treatment.

SUBJECTS

Subjects were 5821 adults age > or = 65 who participated in the 2002 National Health Interview Survey (NHIS), including the Alternative Health supplement.

OUTCOME MEASURES

HT status was assessed by self-report. CAM use was classified as any CAM use, use of four CAM modalities, and specific CAM therapies.

RESULTS

Any CAM use was higher for persons with HT compared to those without diagnosed HT (69.5% versus 65.6%). Only 7.8% of CAM users reported using CAM to treat HT. Homeopathic treatment (16.7%), healing ritual (14.5%), and diet-based therapies (13.0%) were the most common HT therapies. Frequency of use of specific types of CAM therapies did not differ by HT status other than for biologically based therapies, which were used less often by those with HT.

CONCLUSIONS

CAM use is high among older adults with HT, but the vast majority of CAM is used for treating or preventing other conditions. Healthcare providers treating patients with HT should be aware of CAM among their patients.

Amlodipine Added to Quinapril vs Quinapril Alone for the Treatment of Hypertension in Diabetes: The Amlodipine in Diabetes (ANDI) Trial

This randomized, comparative, parallel-group trial investigated strategies of blood pressure (BP)-lowering in patients with diabetes and hypertension. Patients not reaching goal BP (<130/80 mm Hg) after 4-week open-label treatment with quinapril 20 mg/d (n=374) received 40 mg/d quinapril (n=167) or 20 mg/d quinapril plus amlodipine besylate (5 mg/d; n=162) for 6 weeks. Patients receiving combination therapy vs monotherapy had significantly greater reductions in mean +/- SE sitting systolic BP (9.9+/-1.0 mm Hg vs 4.3+/-1.1 mm Hg; P<.001) and diastolic BP (6.5+/-0.6 mm Hg vs 2.7+/-0.6 mm Hg; P<.001). No significant differences between groups were observed in percentage of patients achieving goal BP (10.1% with combination therapy vs 8.2% with monotherapy). A clinically neutral effect was observed on high-sensitivity C-reactive protein in both groups. Treatments were well tolerated; fewer than 3% of patients in any group discontinued due to treatment-emergent or treatment-related adverse events. In diabetic hypertensive patients, 20 mg/d quinapril plus 5 mg/d amlodipine besylate was a more effective BP-lowering strategy than monotherapy with 40 mg/d quinapril.

Social problem solving training for African Americans: effects on dietary problem solving skill and DASH diet-related behavior change

OBJECTIVE

Hypertension continues to take its toll on millions of African Americans. Adhering to an eating plan called Dietary Approaches to Stop Hypertension (DASH) can significantly lower blood pressure. This study examined whether problem solving training in addition to education on DASH is more effective than education alone to help African Americans in an urban community college setting solve their own dietary problems and change eating behaviors that could affect blood pressure.

METHODS

A randomized, two groups, multiple post-test design was used. All participants (N=78, 59% female) completed a Problem Solving Instrument immediately post-intervention and a follow-up Telephone Interview 2 weeks later.

RESULTS

Fewer than half had normal blood pressure on screening. The Experimental Group identified and implemented significantly higher quality solutions to the second of their two problems than the Control Group. The intervention effect was the greatest for participants with blood pressure screenings above normal.

CONCLUSION

Problem solving training combined with nutrition information may help African Americans to deal more effectively with dietary problems especially when the problems are complex or less well-defined.

PRACTICE IMPLICATIONS

Dietary interventions that include a focus on everyday problem solving as well as knowledge acquisition can be developed in clinical, community health, school, and worksite settings.

Central serous chorioretinopathy after solid organ transplantation

PURPOSE

To describe the demographic and clinical characteristics of central serous chorioretinopathy (CSC) after solid organ transplantation.

DESIGN

Case series.

PARTICIPANTS

Fifteen patients who presented to the authors with CSC after solid organ transplantation.

METHODS

We performed a retrospective chart review to identify patient demographics and clinical features of disease, including angiographic changes.

MAIN OUTCOME MEASURES

Patterns of CSC. These patterns were compared with type of organ received, demographics, and visual outcome.

RESULTS

We identified 25 eyes of 7 women (46.7%) and 8 men (53.3%) that developed CSC after solid organ transplantation. Patient ages ranged from 27 to 55 years (median, 40). Seven of the 15 patients (46.7%) were Caucasian, including 3 Hispanic patients (20%). Of the 8 remaining patients (53.3%), 2 were African American (13.3%), 2 were Filipino (13.3%), and 4 were Asian (26.7%). The organs received included 13 kidneys (86.7%), 1 liver (6.7%), and 1 heart (6.7%). Systemic hypertension was reported in 14 of 15 patients (93.3%). All patients were receiving systemic immunosuppressive drugs at presentation; 14 of 15 (93.3%) were also receiving systemic corticosteroids. Visual acuity at presentation ranged from 20/20 to counting fingers. Patterns of CSC included (1) geographic or diffuse alterations in the retinal pigment epithelium (5 eyes; 2 bilateral, 1 unilateral), (2) focal CSC (6 eyes, all unilateral), (3) multifocal CSC (6 eyes; 2 bilateral, 2 unilateral), and (4) CSC with bullous retinal detachment (8 eyes, all bilateral). Follow-up, available for 21 affected eyes of 13 patients, ranged from 1 month to 6 years (median, 12 months). Compared with other solid organ transplant recipients at our institutions, renal transplant recipients (P = 0.003), as well as Hispanic and Asian patients (P = 0.05), were more prevalent in this cohort.

CONCLUSION

Central serous chorioretinopathy after solid organ transplantation varies in presentation and severity. Our observations support a role for choroidal vascular compromise in the pathogenesis of this disorder.

Hypertension in black patients: Special issues and considerations

The excess risk for hypertension in black Americans continues to be a major health concern. Although there is considerable information regarding these disease trends, many of the major underpinnings of the etiology of hypertension remain unclear. The excess mortality in blacks due to heart disease, renal failure, and stroke is clearly directly related to the excess burden of hypertension. Amid the recent findings about the pathophysiology of hypertension, some clear differences in the effects of overweight, salt sensitivity, and vascular biology emerge along ethnic lines. These differences may shed some light on the development of more effective treatment strategies. Based on our current knowledge, aggressive management of hypertension in blacks is critical. This review highlights what is known about various factors affecting hypertension and its treatment in black Americans.

Hypertension in black patients: special issues and considerations

The excess risk of hypertension in black Americans continues to be a major health concern. Although there is considerable information regarding these disease trends, much of the major underpinnings of the etiology of hypertension remain unclear. The excess mortality in blacks due to heart disease, renal failure, and stroke are clearly directly related to the excess burden of hypertension. Amid the recent findings about the pathophysiology of hypertension, some clear differences in the effects of overweight, salt sensitivity, and vascular biology emerge along ethnic lines. These differences may shed some light on the development of more effective treatment strategies. Based on our current knowledge, aggressive management of hypertension in blacks is critical. This review highlights what is known about various factors affecting hypertension and its treatment in black Americans.

Trends in hypertension-related death in the United States: 1980-1998

Trends in hypertension-related mortality for groups by race/ethnicity, sex, and age have not been examined previously. National multiple-cause mortality files for 1980-1998 were analyzed for adult decedents with hypertension listed as one of 20 conditions causing death. Racial/ethnic comparisons of hypertension-related death were performed using age-standardized and age-specific rates in years (per 100,000). Age-standardized rate increased from 183.1 in 1980 to 243.7 in 1998, a relative increase of 33% and an average annual increase of 1.5% (p<0.0001). From 1981 to 1998, age-specific death rates increased for persons > or =85 years (average annual increase of 10.4% for blacks, 7.9% for whites), 75-84 years (5.9% for blacks, 3.6% for whites), and 65-74 years (3.2% for blacks, 1.4% for whites). By 1997-1998, blacks had greater death rates compared with whites at all ages. Over the past two decades, there has been a step-by-step increase in hypertension-related mortality, which has continued to show a male over female and black over white predominance. Prevention and control of hypertension must continue to be pursued as a strategy to reduce cardiovascular disease morbidity and mortality.

Hypertensive Disorders of Pregnancy

Hypertensive disorders occur in 6% to 8% of all pregnancies, are the second leading cause of maternal death, and contribute to significant neonatal morbidity and mortality. This is a problem not only in inpatient settings, as ambulatory and home-care nurses are increasingly being called upon to monitor women who are at high risk and may have hypertensive disorders. To prevent hypertension-induced problems in pregnant women, nurses must have strong assessment, advocacy, and counseling skills. Nurses also must provide care based on the latest national standards as described in this article.

Hypertension in adolescents: a review of diagnosis and management

Long-term hypertension contributes to significant cardiovascular and renal morbidity and mortality. Although chronic hypertension is much rarer in the adolescent population than in adults, identifying the hypertensive adolescent and intervening with risk factors such as obesity that may promote hypertension is important for the clinician treating adolescents. Since both primary and secondary causes of hypertension may exist in the adolescent, a thorough and sequential clinical and diagnostic evaluation must be undertaken, including screening urinalysis, blood chemistries, and renal sonography. There are pitfalls in interpreting casual blood pressure measurements in adolescents, and the role of ambulatory blood pressure monitoring is evolving. Lifestyle modifications, including diet, exercise, and limitation of sodium intake, remain the foundation of treatment. Commonly used medications include calcium channel blockers, angiotensin receptor blockers and converting enzyme inhibitors, beta blockers, and diuretics. When considering medication in the hypertensive adolescent, potential complications of therapy must be reviewed in light of the physical and psychosocial changes ongoing in this age group.

Diagnosis and treatment of hypertension in children and adolescents

PURPOSE

To provide nurse practitioners (NPs) with updated information regarding the etiology, diagnosis, and treatment of childhood hypertension.

DATA SOURCES

Extensive review of the scientific literature regarding hypertension, including the latest NIH recommendations.

CONCLUSIONS

Hypertension affects more than 350,000 American children. While the majority of hypertension in early childhood occurs from secondary causes, the incidence of essential hypertension in later childhood and adolescence is rising, raising concerns as elevated pressures in childhood "track" into adulthood. Early detection and treatment of elevated childhood pressures represent important steps in reducing long-term cardiovascular risk.

IMPLICATIONS FOR PRACTICE

NPs must be able to accurately differentiate between primary and secondary hypertension in childhood. Secondary hypertension requires prompt diagnosis and treatment, and controlling primary childhood hypertension has lifelong implications. Given the familial predisposition to hypertension, it is important for adult NPs to be aware of the risks faced by children of hypertensive patients.