Systolic and diastolic blood pressure control in antihypertensive drug trials

A Retrospective Observational Real-Word Analysis of the Adherence, Healthcare Resource Consumption and Costs in Patients Treated with Bisoprolol/Perindopril as Single-Pill or Free Combination

INTRODUCTION

The present real-world analysis aims to compare the drug utilization, hospitalizations and direct healthcare costs related to the use of single-pill combination (SPC) or free-equivalent combination (FEC) of perindopril and bisoprolol (PER/BIS) in a large Italian population.

METHODS

This observational retrospective analysis was based on administrative databases covering approximately 7 million subjects across Italy. All adult subjects receiving PER/BIS as SPC or FEC between January 2017-June 2020 were included. Subjects were followed for 1 year after the first prescription of PER/BIS as FEC (± 1 month) or SPC. Before comparing the SPC and FEC cohorts, propensity score matching (PSM) was applied to balance the baseline characteristics. Drug utilization was investigated as adherence (defined by the proportion of days covered, PDC) and persistence (evaluated by Kaplan-Meier curves). Hospitalizations and mean annual direct healthcare costs (due to drug prescriptions, hospitalizations and use of outpatient services) were analyzed during follow-up.

RESULTS

The original cohort included 11,440 and 6521 patients taking the SPC and FEC PER/BIS combination, respectively. After PSM, two balanced SPC and FEC cohorts of 4688 patients were obtained (mean age 70 years, approximately 50% male, 24% in secondary prevention). The proportion of adherent patients (PDC ≥ 80%) was higher for those on SPC (45.5%) than those on FEC (38.6%), p < 0.001. The PER/BIS combination was discontinued by 35.8% of patients in the SPC cohort and 41.7% in the FEC cohort (p < 0.001). The SPC cohort had fewer cardiovascular (CV) hospitalizations (5.3%) than the free-combination cohort (7.4%), p < 0.001. Mean annual total healthcare costs were lower in the SPC (1999€) than in the FEC (2359€) cohort (p < 0.001).

CONCLUSION

In a real-world setting, patients treated with PER/BIS SPC showed higher adherence, lower risk of drug discontinuation, reduced risk of CV hospitalization, and lower healthcare costs than those on FEC of the same drugs.

Feasibility of Bilinear Mechanical Characterization of the Abdominal Aorta in a Hypertensive Mouse Model

A change in elastin and collagen content is indicative of damage caused by hypertension, which changes the non-linear behavior of the vessel wall. This study was aimed at investigating the feasibility of monitoring the non-linear material behavior in an angiotensin II hypertensive mice model. Aortas from 13 hypertensive mice were imaged with pulse wave imaging (PWI) over 4 wk using a 40-MHz linear array. The pulse wave velocity was estimated using two wave features: (i) the maximum axial acceleration of the foot (PWV_dia) and (ii) the maximum axial acceleration of the dicrotic notch (PWV_end-sys). The Bramwell-Hill equation was used to derive the compliance at diastolic and end-systolic pressure. This study determined the potential of PWI in a hypertensive mouse model to image and quantify the non-linear material behavior in vivo. End-systolic compliance could differentiate between the sham and angiotensin II groups, whereas diastolic compliance could not, indicating that PWI can detect early collagen-dominated remodeling.

Correlation between Stroke Risk and Systolic Blood Pressure in Patients over 50 Years with Uncontrolled Hypertension: Results from the SYSTUP-India Study

Objectives

To assess mean systolic and diastolic blood pressure (SBP and DBP) levels in patients ≥50 years with uncontrolled hypertension (HTN) and evaluate the correlation between BP and stroke risk. It also assessed therapeutic drug classes prescribed in these patients.

Methods

A cross-sectional, observational study was conducted at 176 outpatient centers across India, including patients aged ≥50 years with elevated SBP (≥140 mmHg). The relationship between stroke risk, calculated using Stroke Riskometer™, and mean SBP, mean DBP, and other risk factors was evaluated using Pearson correlation coefficient and logistic regression analysis.

Results

The study included 3791 patients (men, 60.0%; mean age: 62.1 ± 8.3 years; mean BMI: 27 kg/m²) with mean SBP 157.3 ± 12.8 mmHg and mean DBP 89.8 ± 9.7 mmHg. Five-year stroke risk in 33.9% and 10-year stroke risk in 70% patients were moderate to severe. A ~4% increase in both 5- and 10-year stroke risk with each 1 mmHg increase in mean SBP (p < 0.0001) was seen. However, mean DBP did not exhibit any significant correlation with 5-year (p = 0.242) or 10-year (p = 0.8038) stroke risk. There was a positive correlation between mean SBP and patient age, comorbid diabetes, and smoking and alcohol habits (p < 0.0001). Comorbid diabetes and smoking increased 5- and 10-year stroke risk by 2- to 5-fold. Irrespective of the risk category, most patients received antihypertensive therapy with an angiotensin receptor blocker.

Conclusion

Findings corroborate an association between stroke risk and mean SBP. These real-world clinical findings indicate that efforts are required to improve primary prevention of stroke and reduce the prevalence of recurrent stroke in India.

Women discontinue antihypertensive drug therapy more than men. Evidence from an Italian population-based study

OBJECTIVE

Several factors affect adherence to antihypertensive drug treatment, but whether these factors include a sex difference is unclear. Aim of the study was to compare persistence with antihypertensive drug therapy between men and women in a large cohort of patients.

METHODS

The 60 526 residents of the Italian Lombardy Region aged 40-80 years newly treated with antihypertensive drugs during 2010 were identified and followed for 1 year after the first prescription. Discontinuation of treatment was defined as lack of prescription renewal for at least 90 days. Log-binomial regression models were fitted to estimate the risk ratio of treatment discontinuation in relation to sex. Other than for the whole population, analyses were stratified according to age, comorbidity status and the initial antihypertensive treatment strategy.

RESULTS

Thirty-seven percent of the patients discontinued the drug treatment during follow-up. Compared with women, men had a 10% lower risk of discontinuation of drug treatment (95% confidence interval: 8-12). Persistence on antihypertensive treatment was better in men than in women, this being the case in both younger (40-64 years) and older patients (65-80 years), in patients starting treatment with any major antihypertensive drug and in patients who had a low comorbidity status. There was no evidence that men and women had a different risk of treatment discontinuation when their comorbidity status was worse, or initial antihypertensive treatment was based on drug combinations.

CONCLUSION

Our data show that in a real-life setting, men are more persistent to antihypertensive drug therapy than women.

Optimal blood pressure for the prevention of hypertensive nephropathy in nondiabetic hypertensive patients in Taiwan

Hypertension is a global health burden. However, clinical reference for the adequate management of blood pressure (BP) to prevent renal injury has yet to be established. Thus, this study aimed to investigate whether optimal control and maintenance of BP at < 140/90, < 130/80, or < 120/70 mmHg could prevent hypertensive nephropathy in nondiabetic hypertensive patients. A single-center observational study of 351 nondiabetic hypertensive patients was conducted in Taiwan. The average age of the participants was 64.0 years, and approximately 57.8% of the participants were men. Kidney function was assessed using estimated glomerular filtration rate (eGFR). The baseline eGFR was 83.8 ± 19.8 mL/min/1.73 m² . All patients were followed up every 3 months and underwent office BP measurement and blood sampling. Renal events were defined as> 25% and> 50% decline in eGFR. During an average follow-up period of 4.2 ± 2.3 years, a> 25% and> 50% decline in eGFR was noted in 49 and 11 patients, respectively. The Cox regression analysis revealed that a baseline BP ≥ 140/90 mmHg (hazard ratio [HR]: 1.965; 95% confidence interval [CI]: 1.099-3.514, P = 0.023) and ≥ 130/80 mmHg (HR: 2.799; 95% CI: 1.286-6.004, P = 0.009) increased the risk of> 25% decline in eGFR. Moreover, a baseline BP ≥ 140/90 mmHg (HR: 8.120; 95% CI: 1.650-39.956, P = 0.010) and follow-up BP ≥ 140/90 mmHg (HR: 6.402; 95% CI: 1.338-30.637, P = 0.020) increased the risk of> 50% decline in eGFR. In conclusion, a stringent baseline BP < 130/80 mmHg and a follow-up BP < 140/90 mmHg can be considered optimal cutoff values for clinical practice to prevent hypertensive nephropathy.

Modifications in drug adherence after switch to fixed-dose combination of perindopril/amlodipine in clinical practice. Results of a large-scale Italian experience. The amlodipine-perindopril in real settings (AMPERES) study

OBJECTIVE

The purpose of this study was to assess the changes in adherence to treatment, in patients who switched from perindopril and/or amlodipine as a monotherapy (single-pill therapy, SPT) or two-pill combinations to fixed-dose combination (FDC) therapy.

METHODS

A large retrospective cohort study, in three Italian Local Health Units, was performed. All adult subjects who received at least one prescription of anti-hypertensive drugs between January 1, 2010 and December 31, 2014 were selected. The date of the first anti-hypertensive prescription was defined as the index-date (ID). For each patient, we evaluated the anti-hypertensive therapy and the adherence to treatment during the two 12-month periods preceding and following the ID. Changes in the level of adherence have been compared in patients who switched to the FDC of perindopril/amlodipine after the ID, as well as in patients who did not.

RESULTS

A total of 24,020 subjects were initially included in the study. Subjects treated with the free dose combination switched more frequently to FDC of perindopril/amlodipine than subjects treated with SPT (p < .001). Adherence to treatment was found to be higher in the 3,597 subjects who switched to the perindopril/amlodipine FDC therapy, than in the 20,423 subjects who did not. A significant decrease in the number of concomitant anti-hypertensive drugs has been observed in patients treated with the same FDC.

CONCLUSIONS

The results show that perindopril/amlodipine FDC increases the rate of stay-on-therapy and reduces the number of concomitant anti-hypertensive drugs in subjects previously treated with the same drugs as a two-pill combination or as SPT.

Difficult-to-control hypertension: identification of clinical predictors and use of ICT-based integrated care to facilitate blood pressure control

Difficult-to-control (DTC) hypertension represents a burden in real life that can be partially solved through identification of the characteristics of clinical patterns and tailoring antihypertensive strategies, including ICT-enabled integrated care (ICT-IC). In the quest for clinical predictors of DTC hypertension, we screened 482 hypertensive patients who were consecutively referred to the departmental hypertension clinic. Following a data quality check, patients were divided into controlled (C, 49.37%) and uncontrolled (UC, 50.63%) groups based on their systolic blood pressure (BP) at follow-up. We then performed statistical analysis on the demographic, clinical, laboratory, and ultrasound data and observed that older age, female sex, higher BP levels, and a family history of hypertension were predictors of DTC hypertension. We then developed a pilot service of ICT-IC, including weekly home visits by nurses and patient education on self-monitoring of BP, heart rate, body weight, and oxygen saturation using 3G-connected devices. Self-monitored data were transmitted to the hospital servers on the electronic chart of the patient for remote assessment by the hospital hypertension specialists. A total of 20 UC patients (M/F = 10/10; age: 72.04 ± 2.17 years) were enrolled to verify the efficacy of BP control without changes in medical treatment. After 1 month of the ICT-IC program, BP was reduced both at the office assessment (systolic BP (SBP): 162.40 ± 2.23 mm Hg, beginning of the program vs. 138.20 ± 4.26 mm Hg at 1 month, p < 0.01) and at home (SBP: 149.83 ± 3.44, beginning of the program vs. 134.16 ± 1.67 mm Hg at 1 month, p < 0.01). We concluded that DTC hypertension can be predicted based on the clinical characteristics at the first visit. For these patients, ICT-IC is a feasible therapeutic strategy to achieve BP control.

Blood pressure targets in type 2 diabetes. Evidence against or in favour of an aggressive approach

When associated with high blood pressure, type 2 diabetes mellitus is characterised by a high risk of adverse cardiovascular (CV) and renal outcomes. However, both can be effectively reduced by antihypertensive treatment. Current guidelines on the treatment of hypertension emphasize the need to effectively treat high blood pressure in diabetic individuals, but their recommendations differ in terms of the optimal target blood pressure value to aim for in order to maximise CV and renal protection. In some guidelines the recommended target blood pressure values are <140/90 mmHg (systolic/diastolic), whereas in others, blood pressure values close or even less than 130/80 mmHg are recommended. This paper will discuss the evidence for and against a conservative or more aggressive blood pressure target for treated diabetic hypertensive individuals based on the evidence provided by randomised trials, trial meta-analyses and large observational studies. Based on the available evidence, it appears that blood pressure targets will probably have to be lower than <140/90 mmHg, and that values approaching 130/80 mmHg should be recommended. However, evidence in favour of even lower systolic values, i.e. <130 mmHg, is limited and is definitively against a reduction to <120 mmHg.

Prevalence of cardiometabolic risk factors among professional male long-distance bus drivers in Lagos, south-west Nigeria: a cross-sectional study

Background

Professional drivers are known to be at high risk of cardiovascular disease (CVD). This study was carried out to highlight these risk factors and their predictors among male long–distance professional bus drivers in Lagos, southwest Nigeria, with a view to improving health awareness in this group.

Methods

Socio–demographic data, anthropometric indices, blood pressure, fasting plasma blood glucose levels and lipid and physical activity profiles of 293 drivers were measured.

Results

Mean age of the study population was 48 ± 9.7 years; 71.0 and 19.5% of the drivers used alcohol and were smokers, respectively; and 50.9% were physically inactive. The prevalence of overweight and obesity was 41.7 and 21.1%, respectively, while 39.7 and 13.9% were hypertensive and diabetic, respectively. Ninety (31.3%) subjects had impaired fasting glucose levels while 56.3% had dyslipidaemia. Predictors of hypertension were age and body mass index (BMI). BMI only was a predictor of abnormal glucose profile.

Conclusion

Professional male long–distance bus drivers in this study showed a high prevalence of a cluster of risk factors for CVD.

Achieved blood pressure and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials

BACKGROUND

Studies have challenged the appropriateness of accepted blood pressure targets. We hypothesised that different levels of low blood pressure are associated with benefit for some, but harm for other outcomes.

METHODS

In this analysis, we assessed the previously reported outcome data from high-risk patients aged 55 years or older with a history of cardiovascular disease, 70% of whom had hypertension, from the ONTARGET and TRANSCEND trials investigating ramipril, telmisartan, and their combination, with a median follow-up of 56 months. Detailed descriptions of randomisation and intervention have already been reported. We analysed the associations between mean blood pressure achieved on treatment; prerandomisation baseline blood pressure; or time-updated blood pressure (last on treatment value before an event) on the composite outcome of cardiovascular death, myocardial infarction, stroke, and hospital admission for heart failure; the components of the composite outcome; and all-cause death. Analysis was done by Cox regression analysis, ANOVA, and χ². These trials were registered with ClinicalTrials.gov, number NCT00153101.

FINDINGS

Recruitment for ONTARGET took place between Dec 1, 2001, and July 31, 2008. TRANSCEND took place between Nov 1, 2001, and May 30, 2004. 30 937 patients were recruited from 733 centres in 40 countries and followed up for a median of 56 months. In ONTARGET, 25 127 patients known to be tolerant to angiotensin-converting-enzyme (ACE)-inhibitors were randomly assigned after a run-in period to oral ramipril 10 mg/day (n=8407), telmisartan 80 mg/day (n=8386), or the combination of both (n=8334). In TRANSCEND, 5810 patients who were intolerant to ACE-inhibitors were randomly assigned to oral telmisartan 80 mg/day (n=2903) or placebo (n=2907). Baseline systolic blood pressure (SBP) 140 mm Hg or higher was associated with greater incidence of all outcomes compared with 120 mm Hg to less than 140 mm Hg. By contrast, a baseline diastolic blood pressure (DBP) less than 70 mm Hg was associated with the highest risk for most outcomes compared with all DBP categories 70 mm Hg or more. In 4052 patients with SBP less than 120 mm Hg on treatment, the risk of the composite cardiovascular outcome (adjusted hazard ratio [HR] 1·14, 95% CI 1·03-1·26), cardiovascular death (1·29, 1·12-1·49), and all deaths (1·28, 1·15-1·42) were increased compared with those in whom SBP was 120-140 mm Hg during treatment (HR 1 for all outcomes, n=16099). No harm or benefit was observed for myocardial infarction, stroke, or hospital admission for heart failure. Mean achieved SBP more accurately predicted outcomes than baseline or time-updated SBP, and was associated with the lowest risk at approximately 130 mm Hg, and at 110-120 mm Hg risk increased for the combined outcome, cardiovascular death, and all-cause death except stroke. A mean DBP less than 70 mm Hg (n=5352) during treatment was associated with greater risk of the composite primary outcome (HR 1·31, 95% CI 1·20-1·42), myocardial infarction (1·55, 1·33-1·80), hospital admission for heart failure (1·59, 1·36-1·86) and all-cause death (1·16, 1·06-1·28) than a DBP 70-80 mm Hg (14 305). A pretreatment and mean on-treatment DBP of about 75 mm Hg was associated with the lowest risk.

INTERPRETATION

Mean achieved SBP less than 120 mm Hg during treatment was associated with increased risk of cardiovascular outcomes except for myocardial infarction and stroke. Similar patterns were observed for DBP less than 70 mm Hg, plus increased risk for myocardial infarction and hospital admission for heart failure. Very low blood pressure achieved on treatment was associated with increased risks of several cardiovascular disease events. These data suggest that the lowest blood pressure possible is not necessarily the optimal target for high-risk patients, although it is not possible to rule out some effect of reverse causality.

FUNDING

Boehringer Ingelheim.

Impact of Empagliflozin on Blood Pressure in Patients With Type 2 Diabetes Mellitus and Hypertension by Background Antihypertensive Medication

In the EMPA-REG BP trial, empagliflozin 10 mg and 25 mg once daily reduced glycohemoglobin, blood pressure (BP), and weight versus placebo in patients with type 2 diabetes mellitus and hypertension. Patients received placebo (n=271), empagliflozin 10 mg (n=276), or empagliflozin 25 mg (n=276) for 12 weeks (n=full analysis set). This present analysis investigated changes from baseline to week 12 in mean 24-hour systolic BP (SBP) and diastolic BP (DBP) in patients receiving 0, 1, or ≥2 antihypertensive medications and patients receiving/not receiving diuretics or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. Compared with placebo, empagliflozin 10 mg and 25 mg reduced mean 24-hour SBP/DBP in patients receiving 0 (10 mg: −3.89/−2.58 mm Hg; 25 mg: −3.77/−2.45 mm Hg), 1 (10 mg: −4.74/−1.97 mm Hg; 25 mg: −4.27/−1.81 mm Hg), or ≥2 (10 mg: −2.36/−0.68 mm Hg; 25 mg: −4.17/−1.54 mm Hg) antihypertensives. The effect of empagliflozin was not significantly different between subgroups by number of antihypertensives for changes in SBP (interaction P value 0.448) or DBP (interaction P value 0.498). Empagliflozin reduced 24-hour mean SBP/DBP irrespective of diuretic or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use, with no significant difference between subgroups by use/no use of diuretics (interaction P values 0.380 [systolic]; 0.240 [diastolic]) or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (interaction P values 0.900 [systolic]; 0.359 [diastolic]). In conclusion, in patients with type 2 diabetes mellitus and hypertension, empagliflozin for 12 weeks reduced SBP and DBP versus placebo, irrespective of the number of antihypertensives and use of diuretics or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers.

Clinical Trial Registration—

URL: https://clinicaltrials.gov . Unique identifier: NCT01370005.

Diagnostic and therapeutic problems of isolated systolic hypertension

Prevalence of isolated systolic hypertension increases with age, due to progressive elevation of SBP, and is a major risk factor for cardiovascular morbidity and mortality. Extensive research has shown that lowering SBP improves cardiovascular outcomes in patients with isolated systolic hypertension, yet SBP control rates remain largely inadequate regardless of antihypertensive treatment. Arterial stiffness is a major determinant of elevated SBP resulting from structural changes in the vascular system, mediated by neurohormonal alterations that occur with vascular ageing. Clinical data have demonstrated an independent association between arterial stiffness and cardiovascular outcomes. Therefore, arterial stiffness has the potential to be an important therapeutic target in the management of isolated systolic hypertension. Current antihypertensive treatments have limited effects on arterial stiffness, so the development of new treatments addressing neurohormonal alterations central to vascular ageing is important. Such therapies may represent effective strategies in the future management of SBP.

Nifedipine GITS/Candesartan Combination Therapy Lowers Blood Pressure Across Different Baseline Systolic and Diastolic Blood Pressure Categories: DISTINCT Study Subanalyses

DISTINCT was an 8‐week, double‐blind, randomized study to investigate the antihypertensive efficacy and safety of various nifedipine gastrointestinal treatment system (GITS)/candesartan cilexetil (N/C) dose combinations, vs respective monotherapies or placebo, in patients with diastolic blood pressure (DBP) ≥95 to <110 mm Hg. The current prespecified analysis compared BP reduction in participants with mild vs moderate baseline hypertension (ie, systolic [S]BP <160 mm Hg vs ≥160 mm Hg and DBP <100 mm Hg vs ≥100 mm Hg). A total of 1362 patients were analyzed by descriptive statistics. In all patient subgroups investigated, the NC combinations (ie, N: 20, 30, or 60 mg; C: 4, 8, 16, or 32 mg daily) provided greater SBP and DBP lowering and higher rates of BP control (defined as BP <140/90 mm Hg) than respective monotherapies or placebo, with greatest absolute BP reductions observed in the moderately elevated SBP or DBP subgroups. A trend to dose‐response relationship was observed in each subgroup. In each SBP and DBP subgroup, treatment‐related vasodilatory events (flushing, headache, or edema) were less frequent for patients receiving NC combination therapy than N monotherapy. These analyses support the use of calcium antagonist and angiotensin receptor blocker combination therapy in patients with both mild and moderate hypertension, for whom effective BP normalization and good drug tolerance would greatly reduce the risk of cardiovascular events.

Effects of exercise intensity on postexercise hypotension after resistance training session in overweight hypertensive patients

Among all nonpharmacological treatments, aerobic or resistance training (RT) has been indicated as a significantly important strategy to control hypertension. However, postexercise hypotension responses after intensity alterations in RT are not yet fully understood. The purpose of this study was to compare the outcomes of differing intensities of RT on hypertensive older women. Twenty hypertensive older women participated voluntarily in this study. After a maximum voluntary contraction test (one repetition maximum) and determination of 40% and 80% experimental loads, the protocol (3 sets/90″ interset rest) was performed in a single session with the following exercises: leg press, leg extension, leg curl, chest press, elbow flexion, elbow extension, upper back row, and abdominal flexion. Systolic and diastolic blood pressures were evaluated at rest, during exercise peak, and after 5, 10, 15, 30, 45, and 60 minutes of exercise and compared to the control. Both experimental loads were effective (P<0.01) in promoting postexercise systolic hypotension (mmHg) compared to controls, after 30, 45, and 60 minutes, respectively, at 40% (113±2, 112±4, and 110±3 mmHg) and 80% (111±3, 111±4, and 110±4 mmHg). Both procedures promoted hypotension with similar systolic blood pressures (40%: -11%±1.0% and 80%: -13%±0.5%), mean arterial blood pressures (40%: -12%±5.5% and 80%: -12%±3.4%), and rate-pressure products (40%: -15%±2.1% and 80%: -17%±2.4%) compared to control measures (systolic blood pressure: 1%±1%, mean arterial blood pressure:\ 0.6%±1.5%, rate-pressure product: 0.33%±1.1%). No differences were found in diastolic blood pressure and heart rate measures. In conclusion, hypertensive older women exhibit postexercise hypotension independently of exercise intensity without expressed cardiovascular overload during the session.

Hypertension

Raised blood pressure is the biggest single contributor to the global burden of disease and to global mortality. The numbers of people affected and the prevalence of high blood pressure worldwide are expected to increase over the next decade. Preventive strategies are therefore urgently needed, especially in less developed countries, and management of hypertension must be optimised. Genetic advances in some rare causes of hypertension have been made lately, but the aggregate effect on blood pressure of all the genetic loci identified to date is small. Hence, intervention on key environmental determinants and effective implementation of trial-based therapies are needed. Three-drug combinations can control hypertension in about 90% of patients but only if resources allow identification of patients and drug delivery is affordable. Furthermore, assessment of optimal drug therapy for each ethnic group is needed.

Treatment of Hypertensive Patients With Diabetes and Microalbuminuria With Combination Indapamide SR/Amlodipine: Retrospective Analysis of NESTOR

BACKGROUND

Combination treatments for hypertension most often include a renin-angiotensin-aldosterone system (RAAS) inhibitor. However, systolic blood pressure (SBP) remains difficult to control. Non-RAAS-inhibiting strategies such as calcium channel blocker/thiazide-like diuretic combinations may offer effective alternatives.

METHODS

Hypertensive diabetic patients with microalbuminuria were included in this retrospective, post-hoc analysis of the Natrilix SR Versus Enalapril Study in Hypertensive Type 2 Diabetics With MicrOalbuminuRia (NESTOR) trial if they were uncontrolled on monotherapy (indapamide slow release (SR) 1.5 mg or enalapril 10mg) and had been given add-on amlodipine 5 mg. Patients uncontrolled with monotherapy/amlodipine 5mg were uptitrated to 10 mg.

RESULTS

After 52 weeks, supine SBP/diastolic BP (DBP) decreased from baseline by 26±13/14±9 mm Hg in the indapamide SR/amlodipine group (n = 135) and by 21±14/11±9 mm Hg in the enalapril/amlodipine group (n = 156) (P = 0.006 for ΔSBP). In the amlodipine 10mg subgroup, SBP/DBP decreased from baseline by 26±13/13±9 mm Hg in the indapamide SR/amlodipine group (n = 62) and by 20±13/12±8 mm Hg in the enalapril/amlodipine group (n = 77) (P = 0.02 for ΔSBP). Treatment with indapamide SR/amlodipine was well tolerated. Few patients experienced edema, with no between-group differences. As expected with diuretics, slight changes in kalemia and in uricemia were observed in the indapamide SR/amlodipine group. Changes in fasting glucose, lipids, natremia, and creatinine clearance were similar between groups.

CONCLUSIONS

Indapamide SR/amlodipine results in superior SBP reduction with a safety profile in line with that of its components and tolerability equivalent to that of an angiotensin-converting enzyme inhibitor/amlodipine strategy.

Carotid Baroreceptor Stimulation in Resistant Hypertension and Heart Failure

A significant number of hypertensive subjects fail to achieve adequate blood pressure control despite adherence to maximal doses of several antihypertensive drugs. In the same way although medical and device therapies continue to improve the clinical course of heart failure patients, morbidity, mortality and healthcare costs remain high. Electrical stimulation of the carotid sinus is a new interesting approach for the treatment of resistant hypertension and heart failure. The purpose of this paper is to overview the argument starting from physiological background and evaluating the clinical results obtained with this approach in these pathophysiological conditions.

Diabetes, diabetic complications, and blood pressure targets

Association of diabetes with hypertension is frequent and it well known that high blood pressure potentiates the probability of diabetic patients to develop macrovascular and microvascular complications. Strong evidence obtained in a number of large scale prospective studies indicates that adequate blood pressure control in diabetic patients is highly beneficial for prevention of cardiovascular events. Nonetheless, only a limited proportion of hypertensive-diabetic individuals included in studies on anti-hypertensive treatment has met the predefined blood pressure goal. The optimal blood pressure goal to be pursued in diabetic patients with hypertension to guarantee effective protection from cardiovascular outcomes is still under intense debate and recommendations of current guidelines on hypertension treatment are still inconsistent. We comment here on the most important studies and conclude that current evidence does not conclusively support the need to reach a blood pressure target in hypertensive patients with diabetes different from nondiabetic hypertensive individuals.

Reasons for switching antihypertensive medication in general practice: a cross-sectional Czech nationwide survey

To improve blood pressure (BP) control of their patients, physicians either adjust or switch antihypertensive medication. Currently, there is only limited information available on why physicians decide to switch antihypertensive medications. A questionnaire-based survey was performed between November 2011 and March 2012 in the Czech Republic. General practitioners were asked to fill in questionnaires about their hypertensive patients whose antihypertensive medication they were planning to change. These questionnaires recorded data about patient demographic information, cardiovascular risk factors, BP values, and reasons for switching antihypertensive medication. Two hundred eight-six general practitioners surveyed a total of 4341 hypertensive patients. The mean age of the patients was 59.8 years, 68.9% of patients were overweight or obese. Uncontrolled office systolic and diastolic BP >140/90 mm Hg was present in 89.6% and 81.5% of patients, respectively, despite the fact that 49.4% of patients used a combination of 2 or more antihypertensive drugs. The most common reasons for switching medication were insufficient BP control (73.7%), followed by aiming for a better 24-hour effect (38.4%) and increased cardiovascular risk of the patients (37.7%). The major reason for switching antihypertensive treatment in general practice was insufficient BP control. Switching medication because of adverse drug effects is less frequent than reported a decade ago.

Blood pressure for optimal health-related quality of life in hypertensive patients

OBJECTIVE

The optimal blood pressure (BP) in terms of health-related quality of life (HRQoL) in patients treated for hypertension remains unknown. This study aimed to determine BP values associated with optimal HRQoL among younger (<65 years old) and older patients (≥65 years old) treated for hypertension.

METHODS

HRQoL was assessed using the 12-Item Short Form Health Survey in 11,498 unselected white patients treated for hypertension for at least 12 months.

RESULTS

BP values associated with highest Physical Component Summary (PCS) were similar for older patients and those less than 65 years old (125/80 and 125/75 mmHg, respectively). BP values associated with the highest Mental Component Summary (MCS) scores were slightly higher for older patients (123/80 and 115/75 mmHg, respectively). The scores varied depending on the number of antihypertensive drugs. Compared with patients prescribed monotherapy, SBP associated with the highest PSC scores was increased by 11 mmHg in patients taking two or three drugs, and by 15 mmHg in patients taking at least four drugs. However, DBP values associated with the highest PCS scores and BP values associated with the highest MCS scores showed little difference according to drug regimens. Results of multivariate regression analysis adjusted for BP control revealed that PCS score was more strongly associated with age, presence of multiple comorbidities and duration of antihypertensive therapy, whereas MCS score was more strongly associated with multiple comorbidities and number of antihypertensive drugs.

CONCLUSION

BP values associated with optimal HRQoL are similar in younger and older patients treated for hypertension and are within the recommended goals. However, BP values associated with optimal HRQoL increase with the number of antihypertensive drugs, reflecting severity of the disease. Therefore, therapeutic goals should be individualized to prevent HRQoL deterioration.

The COSEHC™ Global Vascular Risk Management quality improvement program: first follow-up report

The Global Vascular Risk Management (GVRM) Study is a 5-year prospective observational study of 87,863 patients (61% females) with hypertension and associated cardiovascular risk factors began January 1, 2010. Data are gathered electronically and cardiovascular risk is evaluated using the Consortium for Southeastern Hypertension Control™ (COSEHC™)-11 risk score. Here, we report the results obtained at the completion of 33 months since study initiation. De-identified electronic medical records of enrolled patients were used to compare clinical indicators, antihypertensive medication usage, and COSEHC™ risk scores across sex and diabetic status subgroups. The results from each subgroup, assessed at baseline and at regular follow-up periods, are reported since the project initiation. Inference testing was performed to look for statistically significant differences between goal attainments rates between sexes. At-goal rates for systolic blood pressure (SBP) were improved during the 33 months of the study, with females achieving higher goal rates when compared to males. On the other hand, at-goal control rates for total and low-density lipoprotein (LDL) cholesterol (chol) were better in males compared to females. Diabetic patients had lower at-goal rates for SBP and triglycerides but higher rates for LDL-chol. The LDL-chol at-goal rates were higher for males, while high-density lipoprotein (HDL)-chol rates were higher for females. Utilization of antihypertensive medications was similar during and after the baseline period for both men and women. Patients taking two or more antihypertensive medications had higher mean COSEHC™-11 scores compared to those on monotherapy. With treatment, hypertensive patients can reach SBP and cholesterol goals; however, population-wide improvement in treatment goal adherence continues to be a challenge for physicians. The COSEHC™ GVRM Study shows, however, that continuous monitoring and feedback to physicians of accurate longitudinal data is an effective tool in achieving better control rates of cardiovascular risk factors.

Vasorelaxant effects and mechanisms of action of Heracleum sphondylium L. (Apiaceae) in rat thoracic aorta

ETHNOPHARMACOLOGICAL RELEVANCE

Aerial parts of Heracleum sphondylium L. (HS) are used in traditional medicine to treat hypertension. To provide pharmacological basis for this use, we investigated the vasorelaxant effects of a dichloromethane extract of HS (HSDE) and the mechanisms involved.

MATERIALS AND METHODS

Activity of HSDE was evaluated on rat isolated thoracic aortic rings.

RESULTS

HSDE induced vasorelaxation in phenylephrine (PE, 10(-6)mol/L) and high KCl-(6×10(-2)mol/L) pre-contracted aortic rings that was independent on the presence of endothelium. HSDE markedly decreased extracellular Ca(2+)-induced contraction in high-KCl and PE pre-challenged rings. It also inhibited the intracellular Ca(2+) release sensitive to PE (10(-6)M). The relaxant effect of HSDE were blunted by 4-amino-pyridine (4-AP, 10(-3)mol/L), an inhibitor of voltage-dependent K(+) channels.

CONCLUSION

Our results provide the first evidence that a dichloromethane extract of Heracleum sphondylium L. exhibits vasorelaxant properties through endothelium-independent mechanisms involving the inhibition of Ca(2+) mobilization and changes in Kv channel conductances. These data argue for its use as antihypertensive therapy in traditional medicine.

5E- and 5Z-farnesylacetones from Sargassum siliquastrum as novel selective L-type calcium channel blockers

A specific blocker of L-type Ca(2+) channels may be useful in decreasing arterial tone by reducing the open-state probability of L-type Ca(2+) channels. The aim of the present study was to evaluate the farnesylacetones, which are major active constituents of Sargassum siliquastrum, regarding their vasodilatation efficacies, selectivities toward L-type Ca(2+) channels, and in vivo antihypertensive activities. The application of 5E-(farnesylacetone 311) or 5Z-farnesylacetone (farnesylacetone 312) induced concentration-dependent vasodilatation effects on the basilar artery that was pre-contracted with depolarization and showed an ignorable potential role of endothelial-derived nitric oxide. We also tested farnesylacetone 311 or 312 to determine their pharmacological profiles for the blockade of native L-type Ca(2+) channels in basilar arterial smooth muscle cells (BASMCs) and ventricular myocytes (VMCs), cloned L- (α1C/β2a/α2δ), N- (α1B/β1b/α2δ), and T-type Ca(2+) channels (α1G, α1H, and α1I). Farnesylacetone 311 or 312 showed greater selectivity toward the L-type Ca(2+) channels among the tested voltage-gated Ca(2+) channels. The ranked order of the potency for farnesylacetone 311 was cloned α1C≒L-type (BASMC)≒L-type (VMCs)>α1B>α1H>α1I>α1G and that for farnesylacetone 312 was cloned α1C≒L-type (BASMCs)≒L-type (VMCs)>α1H>α1G>α1B>α1I. The oral administration of the farnesylacetone 311 (80mg/kg) conferred potent, long-lasting antihypertensive activity in spontaneous hypertensive rats, but it did not alter the heart rate.

Long-term safety and efficacy of telmisartan/amlodipine single pill combination in the treatment of hypertension

The use of multiple drug regimens is increasingly recognized as a tacit requirement for the management of hypertension, a necessity fueled in part by rising rates of metabolic syndrome and diabetes. By targeting complementary pathways, combinations of antihypertensive drugs can be applied to provide effective blood pressure control while minimizing side effects and reducing exposure to high doses of individual medications. In addition, combination therapies, including angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers (CCBs), have the added benefit of reducing cardiovascular mortality and morbidity over other dual therapies while providing equivalent blood pressure control. It is possible that angiotensin receptor blockers (ARBs), which unlike ACE inhibitors are minimally affected by upregulation of alternative pathways for angiotensin II accumulation following long-term treatment, would also provide such outcome benefits. At issue, however, is maintaining patient compliance, as adding medications is known to reduce adherence to treatment regimens. The purpose of this review is to summarize existing trial data for the long-term safety and efficacy of a recent addition to the armamentarium of dual-antihypertensive therapeutic options, the telmisartan/amlodipine single pill combination. The areas where long-term data are lacking, notably clinical information regarding minorities and women, will also be discussed.

Cost-effectiveness of enhancing adherence to therapy with blood pressure-lowering drugs in the setting of primary cardiovascular prevention

OBJECTIVE

To estimate the cost-effectiveness of enhancing adherence to blood pressure (BP)-lowering drug therapy in a large population without signs of preexisting cardiovascular (CV) disease.

METHODS

A cohort of 209,650 patients aged 40 to 79 years resident in the Italian Region of Lombardia and newly treated with BP-lowering drugs during 2000 to 2001 was followed from index prescription to 2007. During the follow-up, the 10,688 patients who experienced a hospitalization for a coronary or cerebrovascular event were identified (outcome). Adherence was measured by the proportion of days covered by the therapy with BP-lowering drugs. The cost-effectiveness of enhancing adherence was measured through the incremental cost-effectiveness ratio.

RESULTS

Enhancing adherence from 52% (baseline) to 60% and 80% led to a reduced rate for CV outcomes (from 85 to 83 and 77 events every 10,000 person-year, respectively) and increased the cost for drug therapy (from €1,325k to €1,507k and €1,934k every 10,000 person-year, respectively). The resulting incremental cost-effectiveness ratio decreased from €76k (95% confidence interval €74k-€77k) to €74k (95% confidence interval €72k-€75k) for each CV event avoided by enhancing adherence from baseline to 60% and 80%, respectively.

CONCLUSIONS

Enhancing adherence to BP-lowering medications in the setting of primary CV prevention might offer important benefits in reducing the risk of CV outcome, but at a substantial cost.

Triple combination therapy to improve blood pressure control: experience with olmesartan-amlodipine-hydrochlorothiazide therapy

INTRODUCTION

Effective treatment of hypertension is a key strategy for preventing and reducing the burden of hypertension-related cardiovascular diseases. In spite of these well-established concepts, hypertension remains poorly controlled, worldwide. Among the different pharmacological strategies required to improve blood pressure (BP) control, a more extensive use of combination therapy is progressively emerging as a cornerstone of a more effective treatment of hypertension. Among different drug combinations currently available for the clinical management of hypertension, those based on the association of drugs inhibiting the renin-angiotensin system, thiazide diuretics and calcium channel blockers have demonstrated to be very effective in lowering both systolic and diastolic, clinic and 24-h ambulatory BP levels with a good tolerability and safety profile.

AREAS COVERED

In the present manuscript the authors provide an overview of the evidence supporting the use of triple combination therapy with different classes of antihypertensive drugs, with a particular focus on those based on olmesartan medoxomil, a thiazide diuretic (hydrochlorothiazide) and a calcium channel blocker (amlodipine besylate).

EXPERT OPINION

Available data indicate that triple combination therapy based on olmesartan provides effective and sustained clinical and 24-h BP control in a high proportion of individuals among a broad range of hypertensive patients.

Differences in the classification of hypertensive controlled patient in primary care: Cross sectional study

Objectives

To examine differences in blood pressure control using the 2006 National Institute for Health and Clinical Excellence (NICE) guidelines and the 2007 Quality and Outcome Framework (QOF) standards.

Design

Cross-sectional study.

Setting

28 general practices located in Wandsworth, London.

Participants

Hypertensive patients aged 17 years and over.

Main outcomes measures

Percentage of hypertensive patients classified as a hypertensive controlled patient (HCP) by each standard.

Results

79.5% of patients were classified as a HCP by the QOF target and 60.7% by the NICE target. 93% and 14% of practices had more than 70% of patients classified as a HPC by using the QOF and NICE targets respectively. By applying the QOF target, men aged 45–64 years and 65 years and over had significantly higher probability of being classified as a HCP compared to those aged 17–44 years, OR 1.34 (1.08–.165) and OR 2.15 (1.61–2.87) respectively. Regardless of the target, for men the probability of being classified as a HCP increased with age.

Conclusion

Better achievement of blood pressure control targets is present when the less stringent QOF target is used. Men aged 65 years and over were more likely to be classified as a HCP. Greater consistency is needed between the clinical targets in QOF and NICE guidance.

Blood pressure and metabolic efficacy of fixed-dose combination of perindopril and indapamide in everyday practice

The aim of the PICASSO study was to evaluate the efficacy and safety of fixed-dose perindopril 10 mg/indapamide 2.5 mg in everyday medical practice. In this 3-month, open-label, observational study, outpatients with primary hypertension who did not reach the blood pressure goal (< 140/90 mmHg) with antihypertensive treatment were enrolled if their treating physician had planned, as part of their ongoing therapy, to switch them to fixed-dose perindopril 10 mg/indapamide 2.5 mg. Blood pressure, heart rate, and metabolic parameters and - optionally - ambulatory blood pressure were measured. Data from 9257 patients were evaluated. Over the course of 3 months, mean blood pressure decreased from 159/93 mmHg to 132/80 mmHg (p < 0.001) and heart rate decreased from 79 to 73 beats/min (p < 0.001). The target blood pressure was reached by 72.7% of patients. Reductions in total cholesterol, low-density lipoprotein-cholesterol (LDL-c), triglycerides, fasting glucose and uric acid levels were clinically significant. Blood levels of high-density lipoprotein-cholesterol (HDL-c), sodium and potassium remained unchanged. Beneficial changes in metabolic parameters were primarily attributed to the reduction in therapy with drugs with unfavourable metabolic profiles (thiazides and beta-blockers). Perindopril/indapamide is an effective and safe antihypertensive treatment in everyday medical practice.

Blood pressure control in Italy: analysis of clinical data from 2005-2011 surveys on hypertension

INTRODUCTION

Blood pressure (BP) control is poorly achieved in hypertensive patients, worldwide.

AIM

We evaluated clinic BP levels and the rate of BP control in hypertensive patients included in observational studies and clinical surveys published between 2005 and 2011 in Italy.

METHODS

We reviewed the medical literature to identify observational studies and clinical surveys on hypertension between January 2005 and June 2011, which clearly reported information on clinic BP levels, rates of BP control, proportions of treated and untreated patients, who were followed in different clinical settings (mostly in general practice, and also in outpatient clinics and hypertension centres).

RESULTS

The overall sample included 158 876 hypertensive patients (94 907 women, mean age 56.6 ± 9.6 years, BMI 27.2 ± 4.2 kg/m(2), known duration of hypertension 90.2 ± 12.4 months). In the selected studies, average SBP and DBP levels were 145.7 ± 15.9 and 87.5 ± 9.7 mmHg, respectively; BP levels were higher in patients followed in hypertension centres (n = 10 724, 6.7%; 146.5 ± 17.3/88.5 ± 10.3 mmHg) than in those followed by general practitioners (n = 148 152, 93.3%; 143.5 ± 13.9/84.8 ± 8.9 mmHg; P < 0.01). More than half of the patients were treated (n = 91 318, 57.5%); among treated hypertensive patients, only 31 727 (37.0%) had controlled BP levels.

CONCLUSION

The present analysis confirmed inadequate control of BP in Italy, independently of the clinical setting. Although some improvement was noted compared with a similar analysis performed between 1995 and 2005, these findings highlight the need for a more effective clinical management of hypertension.

[Orthostatic hypotension: marker of severity and management of antihypertensive treatment]

Orthostatic Hypotension (OH) is an independent predictor of cardiovascular disease and of all-cause mortality. It is a marker of poor prognosis in older and middle-aged patients. It should be primarily sought, at diagnosis of hypertension, at therapeutic modification, and when suspected by symptoms. One must make therapeutic decisions in older patients, based on measured blood pressure in standing position. Before blaming the antihypertensive treatment, one must search for other contexts favoring orthostatic hypotension. The antihypertensive treatment in older patients should: be initiated with low dosages and subsequent dose titration, be associated to lifestyle changes, not be associated to medications that have the potential to induce Orthostatic Hypotension, include a clear information about Orthostatic Hypotension (recognition, preventive measures…).

An observational study to evaluate factors responsible and actions taken for hypertensive patients who are not at blood pressure goal: i-target Goal Study

To evaluate the percentage of hypertensive patients who could achieve target blood pressure (TBP) according to the guidelines in the context of recommended measures and the factors responsible for failure. A total of 589 hypertensive patients (59.0% female; mean age: 57.7 ± 10.4 years) were assessed twice for TBP achievement based on 2007 ESH/ESC guidelines and the investigators' view, in addition to the recommended measures and possible causes of failure in hypertension management in this national multi-center (n = 99), non-interventional observational study. Only 29.5% of the patients at the first visit and 46.8% at the second visit achieved the TBP levels specified by the guidelines. However, the investigators' evaluation indicated a higher achievement rate at the first (43.5%) as well as the second (69.1%) visit when compared with the guideline-based assessments (P < 0.001). The primary reasons identified by the investigators for the failure to reach TBP were non-compliance with dietary recommendations (61.6%) at the first visit and non-compliance with treatment (63.92%) at the second visit. Recommendations for lifestyle were the most commonly identified treatment plan by the investigators at both visits (62.9% and 66.1%, respectively). Although more patients achieved the TBP levels specified by the guidelines for the second visit compared with the first, effective blood pressure control was achieved only in 29.5% of our patients. Interestingly, the investigators had a more optimistic view about their patients' control of hypertension, which may have contributed to a poor achievement of TBP.

A new dimension in hypertension management with the amlodipine/perindopril combination

Recent guidelines are consistent in acknowledging that most hypertensive patients need at least two drugs for optimal blood pressure (BP) control. Trial data are available to support the use of a renin-angiotensin system (RAS) blocker (ie, an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker), plus a diuretic, a RAS blocker plus a calcium channel blocker (CCB), and a CCB plus a diuretic. The ACCOMPLISH trial demonstrated somewhat convincingly that an ACE inhibitor/CCB is superior to the same ACE inhibitor plus a thiazide. In the ASCOT trial, amlodipine/perindopril was superior to beta-blocker/thiazide in its effects on all major cardiovascular outcomes and new-onset diabetes. Further substudies of ASCOT provided plausible explanations for the benefits of amlodipine/perindopril strategy. In the CAFE substudy, amlodipine/perindopril was significantly more effective in the reduction of central BP as compared to atenolol/bendroflumethiazide, despite similar brachial BP reduction. More recently, analysis of long-term BP variability provided a further explanation for the reduction of cardiovascular events with amlodipine/perindopril in ASCOT. Thus, the combination of perindopril and amlodipine seems an ideal logical evidence-based pair of antihypertensive agents to select.

Blood pressure targets recommended by guidelines and incidence of cardiovascular and renal events in the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET)

BACKGROUND

Hypertension treatment guidelines recommend that blood pressure (BP) be lowered to <140/90 mm Hg, but that a reduction to <130/80 mm Hg be adopted in patients at high cardiovascular (CV) risk. We investigated the CV and renal benefits associated with these BP targets in the high-CV-risk population of the Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial (ONTARGET).

METHODS AND RESULTS

Patients were divided into 4 groups according to the proportion of in-treatment visits before the occurrence of an event (<25%->75%) in which BP was reduced to <140/90 or <130/80 mm Hg. After adjustment for demographic and clinical variables, a progressive increase in the proportion of visits in which BP was reduced to <140/90 or <130/80 mm Hg was associated with a progressive reduction in the risk of stroke, new onset of microalbuminuria or macroalbuminuria, and return to normoalbuminuria in albuminuric patients. An increased frequency of BP control to either target did not have any consistent effect on the adjusted risk of myocardial infarction and heart failure. The adjusted risk of CV events was reduced by increasing the frequency of BP control to <140/90 mm Hg, but not to <130/80 mm Hg. Similar findings were obtained for the achievement of the BP target in the visit preceding a CV event.

CONCLUSION

The more frequent achievement of the BP targets recommended by guidelines led to cerebrovascular and renal protection, but did not increase cardiac protection. Overall, CV protection was favorably affected by the less tight but not by the tighter BP target. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00153101.

A comparison of the efficacy and safety of irbesartan/hydrochlorothiazide combination therapy with irbesartan monotherapy in the treatment of moderate or severe hypertension in diabetic and obese hypertensive patients: a post-hoc analysis review

Hypertension is difficult to treat in patients with type 2 diabetes mellitus (T2DM) or obesity. Combination therapies are often required to effectively lower blood pressure (BP) and attain BP goals. In this post-hoc analysis of 2 prospective, randomized, controlled studies in patients with uncontrolled or untreated moderate or severe hypertension, the efficacy and safety of treatment with irbesartan/hydrochlorothiazide (HCTZ) and irbesartan was assessed in 2 separate analyses: patients with diabetes (n=143) and by obesity status (n=1125). Patients received irbesartan/HCTZ (150 mg/12.5 mg titrated to 300 mg/25 mg) or irbesartan (150 mg titrated to 300 mg) for 7 (severe hypertension study) or 12 (moderate hypertension study) weeks. Efficacy comparisons between treatment groups were performed using Fisher's exact tests. After 7 to 8 weeks of treatment, systolic BP (SBP)/diastolic BP (DBP) decreased in patients with diabetes by 26.9/17.8 mm Hg and 21.8/15.8 mm Hg after irbesartan/HCTZ and irbesartan treatment, respectively (P [SBP]=0.09, P [DBP]=0.27). In obese patients (n=544), SBP/DBP decreased by 29.4/20.2 mm Hg and 20.1/15.9 mm Hg after irbesartan/HCTZ and irbesartan treatment, respectively (P<0.0001). More patients with T2DM reached the BP goal of <130/80 mm Hg at week 7 to 8 in the irbesartan/HCTZ group than in the irbesartan group (12% vs 5%), although not statistically significant (P=0.22). Significantly more obese patients reached their respective BP goals in the irbesartan/HCTZ group than in the irbesartan group (48% vs 23%; P<0.0001). Treatment-emergent adverse event rates were similar between treatment groups regardless of the presence of diabetes or body mass index (BMI) status. In patients with moderate or severe hypertension and with a BMI ≥ 30 kg/m(2), initial treatment with irbesartan/HCTZ combination therapy was more effective than irbesartan monotherapy.

The ACQUIRE trial

Achievement of goal blood pressure values, particularly in high-risk categories of patients, still remains an unmet goal of the therapeutic approach to hypertension. The same conclusion can be drawn for patient adherence to antihypertensive drugs, which is a variable of major relevance for obtaining optimal blood pressure control in treated hypertensives. The ACQUIRE study has recently evaluated the efficacy and safety profile of either aliskiren monotherapy or aliskiren/hydrochlorothiazide combination treatment in a consistent number of stage 2 hypertensive patients, half of them complicated by obesity. The results show the effectiveness of aliskiren, particularly when combined with hydrochlothiazide, in achieving satisfactory blood pressure control. This is particularly the case for systolic blood pressure values, which have a major detrimental impact on cardiovascular risk profile and on cardiovascular events. The combination drug regimen, which can achieve early blood pressure control, was accompanied by an excellent side-effect and safety profile and thus was associated with a high adherence to treatment.

Comparison of the antihypertensive efficacy of irbesartan/HCTZ and valsartan/HCTZ combination therapy: impact of age and gender

This analysis aimed to explore whether low-dose irbesartan/hydrochlorothiazide (HCTZ) has superior blood pressure (BP)-lowering efficacy over low-dose valsartan/HCTZ in the elderly and across both genders. This is a post-hoc analysis of data from a multicenter, parallel group, open-label, blinded-endpoint study in patients with hypertension uncontrolled with HCTZ monotherapy. The reduction in systolic BP (SBP)/diastolic BP (DBP) and rate of BP control achieved following 8 weeks of treatment with irbesartan/HCTZ 150/12.5 mg or valsartan/HCTZ 80/12.5 mg were analyzed for older (≥65 years) vs. younger (<65 years) patients and for men vs. women. Blood pressure measurements were by home BP monitoring (HBPM). In the age and gender subgroups, both treatments significantly decreased home SBP and DBP (p < 0.0001). The reduction in home SBP and DBP was numerically greater with irbesartan/HCTZ compared to valsartan/HCTZ for all subgroups: the difference in DBP was significant for all except the elderly (p < 0.05), and the difference in SBP was significant in the elderly and in men (p < 0.03). In all subgroups, more patients achieved BP control (HBPM ≤135/85 mmHg) in the irbesartan/HCTZ arm (range 45%-58%) than in the valsartan/HCTZ arm (range, 23%-39%; p < 0.02). Both combination therapies were well tolerated and safety parameters were similar in both age and gender subgroups. More patients with mild or moderate hypertension, uncontrolled in HCTZ monotherapy alone, had their BP controlled with irbesartan/HCTZ 150/12.5 mg than with valsartan/HCTZ 80/12.5 mg, irrespective of age or gender.

Blood pressure control in resistant hypertension: new therapeutic options

Resistant hypertension, namely the hypertensive state characterized by the inability of multiple antihypertensive drug interventions to lower blood pressure to goal levels, represents a condition frequently detected in clinical practice. Its main features are represented by its heterogeneous etiology as well as its very high cardiovascular risk. This latter peculiarity has implemented the research for new approaches to the treatment of the disease. This article will focus on two of them, namely carotid baroreceptor electric stimulation and the renal denervation procedure. Clinical studies and large-scale clinical trials are presently ongoing with the aim of defining the long-term efficacy and safety profile of the two interventions.

Impact of new clinical trials on recent guidelines on hypertension management

Guidelines on hypertension diagnosis and treatment have been issued in 2007. Since then, a number of major intervention clinical trials have been designed, carried out, and completed with the aim of investigating unsolved issues related to the impact of the blood pressure-lowering intervention on cardiovascular risk and events. These include, among others, the nephroprotective properties of antihypertensive drugs, the blood pressure targets to be achieved during treatment in uncomplicated and more so in complicated hypertensive patients, the advantages of one drug combination versus another, and the benefits of antihypertensive drugs in the very elderly. All these questions have received a clear-cut answer by the results of recently performed clinical trials, which have been included in the 2009 update document of the European guidelines. This paper will be focused on the 2007 guidelines document and the 2009 update paper, highlighting the new concepts and recommendations provided by the most recent intervention trials.