Lack of effective blood pressure control among an elder hypertensive population in Buenos Aires

The rising prevalence of self-reported hypertension among Chinese subjects: a population-based study from 121 895 household interviews

BACKGROUND

Hypertension is one of the most important public health issues worldwide.

AIM

We assessed the prevalence rates of self-reported hypertension in Hong Kong between 2001 and 2008 and evaluated factors associated with its prevalence.

DESIGN

Serial cross-sectional surveys.

METHODS

Territory-wide Household surveys in the Hong Kong population in the years 2001, 2002, 2005 and 2008 were included. Population-adjusted prevalence of self-reported hypertension were compared across calendar years. The independent association of these variables with hypertension was evaluated by multivariate regression analysis with self-reported hypertension as a binary outcome.

RESULTS

There were 121 895 subjects interviewed, among which 103 367 were adults aged ≥15 years. The age- and gender-adjusted prevalence of self-reported hypertension in 2001, 2002, 2005 and 2008 among male adults was 4.73, 6.68, 7.96 and 9.82%, respectively, and among female adults, the prevalence was 6.13, 8.28, 10.00 and 11.58%, respectively. Advanced age (adjusted odds ratios [AOR]: 47.1, 95% CI 33.6-66.0 for the age group 40-65 years; AOR 256.2, 95% CI 182.4-360.0 for the age group 66-100 years; referent 0-39 years), female gender (AOR 0.81, 95% CI 0.74-0.88 for male) and a low median household income (AOR 1.56, 95% CI 1.31-1.85 for income ≤ US$1289; referent ≥ US$6444) were significantly associated with hypertension (all P < 0.001).

CONCLUSIONS

This is the first study to show differences between socioeconomic groups in this Chinese population with higher rates among women and the less affluent. Similarly, it is the first to show gender differences with higher rates among women.

Cost-effectiveness of a hypertension management programme in an elderly population: a Markov model

BACKGROUND

Mounting evidence shows that multi-intervention programmes for hypertension treatment are more effective than an isolated pharmacological strategy. Full economic evaluations of hypertension management programmes are scarce and contain methodological limitations. The aim of the study was to evaluate if a hypertension management programme for elderly patients is cost-effective compared to usual care from the perspective of a third-party payer.

METHODS

We built a cost-effectiveness model using published evidence of effectiveness of a comprehensive hypertension programme vs. usual care for patients 65 years or older at a community hospital in Buenos Aires, Argentina. We explored incremental cost-effectiveness between groups. The model used a life-time framework adopting a third-party payer's perspective. Incremental cost-effectiveness ratio (ICER) was calculated in International Dollars per life-year gained. We performed a probabilistic sensitivity analysis (PSA) to explore variable uncertainty.

RESULTS

The ICER for the base-case of the "Hypertension Programme" versus the "Usual care" approach was 1,124 International Dollars per life-year gained. PSA did not significantly influence results. The programme had a probability of 43% of being dominant (more effective and less costly) and, overall, 95% chance of being cost-effective.

DISCUSSION

Results showed that "Hypertension Programme" had high probabilities of being cost-effective under a wide range of scenarios. This is the first sound cost-effectiveness study to assess a comprehensive hypertension programme versus usual care. This study measures hard outcomes and explores robustness through a probabilistic sensitivity analysis.

CONCLUSIONS

The comprehensive hypertension programme had high probabilities of being cost-effective versus usual care. This study supports the idea that similar programmes could be the preferred strategy in countries and within health care systems where hypertension treatment for elderly patients is a standard practice.

Prevalence, awareness, treatment and control of hypertension in a rural Nicaraguan sample

The prevalence, awareness, treatment and control of hypertension were assessed in 1303 persons who attended a free vision care clinic in rural Nicaragua. The prevalence of hypertension was 37.8% in men and 43.2% in women. Hypertension was found to be a highly prevalent disease in this group, and presumably in the local population, with low levels of awareness and control.

Hypertension: a review for clinicians

Despite the existence of a variety of consistent hypertension guidelines,the issue of inadequate management of the condition persists. The challenge for health care professionals is not only to understand and adopt the guidelines but also to take a holistic approach to patient care. In addition, clinicians need to encourage adherence to medication protocols, which will hopefully lead to an overall reduction in morbidity and mortality associated with hypertension. It is the clinician's professional responsibility to be cognizant of the emerging research on vasoactive substances as new drugs are being developed that will effect endothelial receptors. It is important that clinicians are trained appropriately in blood pressure measurement and risk factor identification and intervention.

Narrowing the Gap in Hypertension: Effectiveness of a Complex Antihypertensive Program in the Elderly

Hypertension control is a difficult goal to achieve in common practice even when its benefits have been widely proved. We assessed the effectiveness of a Complex Antihypertensive Intervention Program in the Elderly (CAPE). A program trial of 500 elderly hypertensive patients was conducted. 250 were followed by primary care physicians and intervened by the CAPE and 250 received usual care. The program included an organizational change with the addition of an office where patients had their blood pressure measured, were appointed to join educational sessions and received verbal and printed advice before medical attendance. Data was systematically recorded in the electronic medical record which functioned as a physician reminder during the visit. Differences in systolic blood pressure level and in percentage of well-controlled (<140/90 mm Hg) patients between groups were measured after 12 months of follow-up. The difference of mean change in systolic blood pressure between groups was 7.1 mm Hg (95% confidence interval, 4-10 mm Hg). Sixty-seven percent of patients in the intervention group were well-controlled, as were 51% of patients in the control group (p < 0.001). Patients who attended educational sessions showed the lowest odd ratio (0.25; 95% confidence interval, 0.11-0.54) for blood pressure above 140/90 mm Hg in multivariate analysis after adjusting for age, sex, initial systolic blood pressure level, and changes in antihypertensive treatment. These results support the effectiveness of our complex intervention program. Routine clinical care of hypertension can be improved with simple strategies that go beyond pharmacotherapy, tending to overcome clinical inertia.

Evaluating the treatment of hypertension in diabetes mellitus: a need for better control?

OBJECTIVES

To determine how well and to what extent blood pressure (BP) is controlled in diabetic hypertensive patients treated by primary care doctors, and to evaluate drug therapy in the backdrop of risk factors and laboratory findings.

METHODS

A therapeutic audit of the medical records of diabetic hypertensives from nine primary care health centres in Bahrain.

RESULTS

In 266 diabetic hypertensives (82 males and 184 females), the recommended target BP < 130/< 85 mmHg (WHO/ISH guidelines, 1999) was achieved in 20 (9.8%) with a BP of 119 +/- 4/76 +/- 5 mmHg. Among those who did not achieve target BP, 70 (34.5%) lacked systolic BP control (BP = 153 +/- 17/79 +/- 3 mmHg), four (2%) lacked diastolic BP control (BP = 123 +/- 3/86 +/- 3 mmHg) and 109 (53.7%) lacked both systolic and diastolic BP control (BP = 158 +/- 20/94 +/- 7 mmHg). The mean age of the group achieving target BP was significantly lower than the group which lacked systolic BP control (51.6 +/- 9 vs. 63.5 +/- 9 years; P < 0.0001). While there were no significant differences in fasting blood glucose, glycosylated haemoglobin, triglycerides, urea, creatinine, uric acid and serum electrolytes between the group achieving target BP vs. groups without target BP, a significant difference in total cholesterol was seen.

PATIENTS

with ischaemic heart disease and/or isolated systolic hypertension did not achieve the target BP. Antihypertensive monotherapy was prescribed in 145 (54.5%) patients, whereas two- and three-drug combinations were prescribed in 32.3 and 8.2% of patients, respectively. As monotherapy, angiotensin-converting enzyme (ACE) inhibitors were the most frequently prescribed drugs followed by beta-blockers, calcium channel blockers (CCBs) and diuretics. As two-drug combinations, an ACE inhibitor with a beta-blocker/diuretic and a beta-blocker with a CCB/diuretic were usually prescribed.

CONCLUSIONS

According to the WHO/ISH 1999 guidelines, approximately one out of 10 diabetic hypertensives achieved target BP control. In many instances, the drug therapy prescribed was inappropriate considering the comorbidity in patients and their laboratory findings. Improved BP control is needed in treating high-risk groups such as patients with diabetes mellitus, and efforts should be made to improve the treatment of hypertension in the primary care setting.

Prevalence of hyperhomocysteinemia in an elderly population

BACKGROUND

Currently, total hyperhomocysteinemia (tHHcy) is a well-known condition linked to a higher risk of vascular disease. Prevalence of HHcy increases in elderly persons as the risk associated with it persists. Because factors can be potentially reduced in the elderly, it is important to carry out epidemiologic studies of HHcy.

PROCEDURE

Previously we described the prevalence of hypertension control in an elder population; now, in an observational cross-sectional simple blind study, total homocysteine (tHcy) concentration was determined in 196 of 400 patients from the original cohort.

RESULTS

Mean Hcy concentration was 13.2 ,amol/L (95% confidence interval 12.4-14.0; range, 5.0 to 48.9); 15.0 ,imol/L for men and 12.3 pAmol/L for women. Mean serum folic acid levels were 4.9 + 3.1 ng/mL (range, 2.0 to 20.0 ng/mL), and vitamin B12 levels were 384.8 314.1 pg/mL (range, 48.0 to 1500.0 pg/mL). Taking into account the reference values established by the Third National Health and Nutrition Examination Survey III study, HHcy was detected in 69.8% of all the subjects evaluated. The study showed that 76.2% of the men and 66.4% of the women had high Hcy levels.

CONCLUSIONS

The very high prevalence of tHHcy in the elderly population, and the consequent risks associated with it suggest that although there are no trials that effectively prove the benefit of tHcy decrease, nutritional intervention is still justified.

Plasmatic homocysteine response to vitamin supplementation in elderly people

Homocysteine (Hcy) increase is now widely accepted as a risk factor for vascular disease. The effects of folic acid (FA) and vitamins B12 and B6 in lowering Hcy have been extensively studied, but there is still little data on the response to FA dietary administration. Our purpose was to evaluate the impact of the diet and the degree of response to different doses of pharmacological FA supplementation. In a prospective, randomized, and simple blind study, 50 elderly subjects were given a 400-microg/day FA diet and were randomly assigned to one of the following treatments: Group I = placebo tablet; Group II = tablet containing 1-mg folic acid, 1-mg B12, and 25-mg B6; and Group III = tablet containing 2.5-mg folic acid and same B6 and B12 doses as Group II. Forty-four subjects completed the study, and their plasmas were evaluated. Hcy concentration significantly decreased even in patients with normal basal values, and there were no differences in the response between individuals receiving diet plus placebo and those receiving diet plus pharmacological supplementation. After the treatment, the mean decrease of plasmatic Hcy levels was 10.8 (9.4, 12.5) micromol/l, geometric mean [95% confidence interval (95% CI)], and particularly, the values for Group I were 10.6 (7.4, 14.8) micromol/l. In 31% of the subjects, the post-treatment Hcy levels were less than or = 5 micromol/l. These results show that a special diet, with or without pharmacological FA and B12 and B6 supplementation, significantly decreases the Hcy levels in elderly people. Therefore, a diet with high contents of FA might have an enormous impact on the morbidity and mortality of atherothrombosis.