Blood pressure control and risk of stroke in untreated and treated hypertensive patients screened from clinical practice: results of the ForLife study

Implementation of home blood pressure monitoring among French GPs: A long and winding road

BACKGROUND

To explore the perception of home blood pressure monitoring (HBPM) by general practitioners (GPs) in everyday practice in order to identify facilitators and barriers to its implementation in daily practice.

METHODS

A qualitative study comprising the conduct of six focus groups between October 2016 and February 2017, gathering 41 general practitioners in primary care practice in Lorraine (North Eastern France), with thematic and comprehensive analysis.

RESULTS

The first reasons given by GPs to explain their difficulties with HBPM (Home Blood Pressure Monitoring) implementation were the usual lack of time, material and human resources. However, all of these motives masked other substantial limiting factors including insufficient knowledge regarding HBPM, poor adherence to recommendations on HBPM and fear of losing their medical authority. GPs admitted that HBPM use could enhance patient observance and decrease therapeutic inertia. Despite this observation, most GPs used HBPM only at the time of diagnosis and rarely for follow-up. One explanation for GP reluctance towards HBPM may be, along with guidelines regarding hypertension, HBPM is perceived as being a binding framework and being difficult to implement. This barrier was more predominantly observed among aging GPs than in young GPs and was less frequent when GPs practiced in multidisciplinary health centers because the logistical barrier was no longer present.

DISCUSSION

In order to improve HBPM implementation in everyday practice in France, it is necessary to focus on GP training and patient education. We must also end "medical power" in hypertension management and turn to multidisciplinary care including nurses, pharmacists and patients.

Hypertension Survey in Italy: Novel Findings from the Campania Salute Network

The "Campania Salute" (CS) is a network system aimed at improving the management of essential hypertension by integrating the activity of general practitioners (GPs) with that of the hypertension specialists. It involves 23 outpatient hypertensive clinics distributed in different community hospitals of the Napoli's metropolitan area, 60 randomly selected GPs homogeneously distributed in the same area, and the Hypertension Clinic of the Federico II University in Naples (co-ordinating centre). Through the CS system it is possible to share clinical data collected during each visit at peripheral units (general practitioners and community hospitals hypertensive clinics), which manage low-risk hypertensive patients, and the co-ordinating centre, which mainly manages high-risk hypertensive patients. The co-ordinating centre works in co-operation with the peripheral units in the treatment and follow-up of all hypertensive patients. Since the first reports on the CS network activity, it has been evident the effectiveness of this network in ameliorating the clinical management of the hypertensive disease. CS network is also a large prospective registry that generated several scientific reports based on the longitudinal assessment of hypertensive patients during their treatment. Nowadays, as observed in the Health Search Database, the rate of BP control in Campania was 69.5%, almost reaching the "Objective 70%", a result that could be in part linked to the activity of the CS network.

Blood pressure control versus atrial fibrillation management in stroke prevention

Hypertension is one of the major risk factors for atrial fibrillation which in turn is the most prevalent concomitant condition in hypertensive patients. While both these pathological conditions are independent risk factors for stroke, the association of hypertension and atrial fibrillation increases the incidence of disabling strokes. Moreover, documented or silent atrial fibrillation doubles the rate of cardiovascular death. Lowering blood pressure is strongly recommended, particularly for primary stroke prevention. However, a relatively small percentage of hypertensive patients still achieve the recommended blood pressure goals. The management of atrial fibrillation with respect to stroke prevention is changing. New oral anticoagulants represent a major advancement in long-term anticoagulation therapy in non valvular atrial fibrillation. They have several benefits over warfarin, including improved adherence to the anticoagulation therapy. This is an important issue since non-adherence to stroke prevention medications is a risk factor for first and recurrent strokes.

Impact of hypertension on global cardiovascular risk stratification: analysis of a large cohort of outpatient population in Italy

BACKGROUND

Control of hypertension remains a major unmet need, worldwide.

HYPOTHESIS

To test whether the presence of hypertension may improve global cardiovascular (CV) risk stratification and achievement of therapeutic targets for CV risk factors in adult outpatients in Italy.

METHODS

Physicians were asked to submit data covering the first 10 consecutive adult outpatients. All data were centrally analyzed for global CV risk assessment and rates of control of major CV risk factors, mostly blood pressure (BP) levels, in different high-risk subgroups of hypertensive patients.

RESULTS

Overall, 1078 physicians collected data of 9864 outpatients (46.7% females, age 66.1 ± 10.3 years) with valuable data on BP levels, among which 7147 (72.5%) had a diagnosis of hypertension and 2717 (27.5%) were normotensive subjects. Hypertensive patients were older and had a higher prevalence of major risk factors, including smoking, obesity, dyslipidemia, and family history of cardiovascular disease, as well as comorbidities, than did normotensive subjects (P < 0.001 for all comparisons). Despite worse control of BP (66.9% vs 36.2%, P < 0.001), high-density lipoprotein cholesterol (40.5% vs 37.4%, P < 0.005), triglycerides (72.1% vs 67.8%, P < 0.001), and fasting plasma glucose (71.2% vs 67.0%, P < 0.005), hypertension was associated with larger availability and frequency of diagnostic examinations and greater use of antihypertensive, glucose-lowering, and lipid-lowering drugs, as well as antiplatelet agents, compared with normotension (P < 0.001).

CONCLUSIONS

Presence of hypertension significantly improved clinical data collection and CV risk stratification. Such an approach, however, was not paralleled by better control of major CV risk factors.

Uptitrating amlodipine significantly reduces blood pressure in diabetic patients with hypertension: a retrospective, pooled analysis

Diabetic patients with hypertension are approximately twice as likely to develop cardiovascular disease as non-diabetic patients with hypertension. Given that hypertension affects ∼60% of patients with diabetes, effective blood pressure (BP) management is important in this high-risk population. This post-hoc analysis pooled data from six clinical studies to quantify additional BP efficacy achieved when titrating hypertensive diabetic patients from amlodipine 5 mg to 10 mg. Approximately half of the diabetic patients were male (44/98; 44.9%) with a mean (standard deviation [SD]) age of 60.6 (9.6) years and a baseline mean (standard error [SE]) systolic blood pressure/diastolic blood pressure (SBP/DBP) of 150.8 (1.30)/87.5 (0.94) mmHg while on amlodipine 5 mg (159.1 [1.40]/92.6 [0.94] mmHg prior to treatment). In comparison, 350/610 (57.4%) non-diabetic patients were male with a mean (SD) age of 58.7 (11.1) years and baseline mean (SE) SBP/DBP of 150.3 (0.62)/90.9 (0.41) mmHg while on amlodipine 5 mg (160.0 [0.67]/96.2 [0.45] mmHg prior to treatment). Increasing amlodipine from 5 mg to 10 mg lowered sitting SBP by -12.5 mmHg (95% confidence interval (CI): -15.5, -9.5; P<0.0001) and DBP by -6.0 mmHg (-7.4, -4.6; P<0.0001) in diabetic patients; and SBP by -12.4 mmHg (-13.5, -11.3; P<0.0001) and DBP by -7.3 mmHg (-8.0, -6.7; P<0.0001) in non-diabetic patients. In total, 12.0% (95% CI: 6.4, 20.0) of diabetic patients achieved their BP goal versus 46.4% (42.4, 50.4) of non-diabetic patients after titration to amlodipine 10 mg. Overall, 22.0% of diabetic patients experienced 31 adverse events (AEs) and 28.9% of non-diabetic patients experienced 282 AEs. Serious AEs were reported by one (1.0%) diabetic and five (0.8%) non-diabetic patients. In this analysis, increasing amlodipine from 5 mg to 10 mg produced a clinically significant reduction in the BP of diabetic hypertensive patients, similar to non-diabetic patients, highlighting the importance of optimizing amlodipine titration in this high-risk population.

ARTERIAL HYPERTENSION AMONG INDIVIDUALS OF 25–64 YEARS OLD: PREVALENCE, AWARENESS, TREATMENT AND CONTROL. BY THE DATA FROM ECCD

Aim. To study prevalence of arterial hypertension (AH), mean values of systolic and diastolic blood pressure (SBP, DBP), awareness of patients about their disease, medication consumption (MC) and efficacy of treatment in several regions of Russia.

Material and methods. Representative selections were made in 9 regions of Russia: men (n=5563), women (n=9737) of 25–64 y.o., studied in 2012–2013 with the response 80%. Systematic stratified multilevel random selection was formed with localilty criteria (Kisch method). The Questionnaire on the presence of AH included: awareness of the patient about his disease, drug intake. BP measurement was performed on the right arm by automatic tonometer Omron in sitting position after 5 minutes resting. The mean value of two measurements was used. BP defined as SBP ≥140 mmHg, DBP ≥90 mmHg, or if the patient had taken antihypertensive therapy. Efficacy of treatment — the part of patients (in %) who reached target BP. Control group — part of patients (in %) with BP <140/90 mmHg. Statistic data calculation was done with computer-based statistic software — SAS with standardising by age stratification of Europe.

Results. Mean SBP and DBP were 130,7±0,1 mmHg and 81,6±0,1 mmHg respectively. Prevalence of AH — 44%, higher in men (p<0,001). Prevalence of AH was higher in rural area citizens in men — 51,8% vs 47,5% (р<0,02) and in women — 42,9% vs 40,2% (р<0,05). Awareness was 67,5% in men, 78,9% in women. Medications were taken by 60,9% of women and 39,5% of men. Effectively treated were 53,5% of women and 41,4% of men. With the age the part of effectively treated decreases (p<0,0005). BP is under control only in 1/3 of women and 14,4% of men.

Conclusion. The role of AH as one of the main modifiable risk factors of cardiovascular diseases is proved, however it is depressing that the percent of controlled AH is low. BP control is the main task of outpatient surveillance at every local outpatient department, where now less than a half of those affected are being observed.

Blood pressure control in Italian essential hypertensives treated by general practitioners

BACKGROUND

Adequate control of blood pressure (BP) is limited worldwide. This has serious consequences for public health because in hypertensive patients, uncontrolled BP is associated with a higher incidence of cardiovascular events, particularly stroke. The aim of this study was to investigate BP control in a cohort of treated patients with diagnosed hypertension, who were under general practitioner care in Italy.

METHODS

Data were collected by 2,643 physicians on 8,572 individual Italian patients. Office BP was measured 5 min after seating each patient and then 3-5 min later. For each patient, data such as medical history of patients, physical examination data, antihypertensive drug usage, and self-BP measurement frequency were obtained.

RESULTS

Male prevalence was 48.4%, and mean age was 64.3 ± 10.5 years. Based on the second measurement, BP control (<140/90 mm Hg) was observed in 33.5% of all patients (34.2% in men and 33.4% in women). BP control was much lower for systolic BP than for diastolic BP (35.9 vs. 61.3%, P < 0.0001); moreover, BP control was much more common in patients who were engaged in self-BP measurement (61.2 vs. 38.8%, P < 0.0001). A stricter BP control recommended by the guidelines of the European Society of Hypertension (ESH) and European Society of Cardiology (ESC) (<130/80 mm Hg) was observed in only 5.5% of diabetic patients.

CONCLUSIONS

In treated Italian hypertensives effective BP control remains uncommon largely due to the failure to appropriately reduce the systolic BP. The stricter values recommended by the ESH/ESC guidelines for diabetic patients are achieved only by a small fraction of hypertensive diabetic population.

Uncontrolled hypertension: highlights and perspectives from the European Society of Hypertension Satellite Symposium

The Padua ESH 2011 Satellite Symposium on uncontrolled hypertension was focused on why only a relatively small percentage of patients under treatment do not reach 'safe' blood pressure levels; the major reason being the modest use of combination therapy. It was also an occasion to discuss new pharmacological and nonpharmacological tools, some of which appear to be efficacious when even the 'appropriate' traditional therapeutic strategy fails to work.

Left atrial systolic force and outcome in asymptomatic mild to moderate aortic stenosis

BACKGROUND AND AIMS

In patients with chronic pressure overload due to hypertension or aortic valve stenosis (AS), higher left atrial systolic force (LASF) is associated with a high-risk cardiovascular (CV) phenotype. We tested LASF as prognostic marker in patients with AS.

METHODS

We used baseline and outcome data from 1,566 patients recruited in the Simvastatin and Ezetimibe in AS (SEAS) study evaluating the effect of placebo-controlled simvastatin and ezetimibe treatment on CV events. The primary outcome was a composite of major CV events, including CV death, aortic valve replacement, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure caused by progression of AS, coronary artery bypass grafting, percutaneous coronary intervention, and nonhemorrhagic stroke. LASF was calculated by Manning's method. High LASF was defined as >95th percentile (50 Kdynes/cm(2)) of the distribution within the study population.

RESULTS

During 4.3 years of follow-up, a major CV event occurred in 38 of 78 patients with high LASF (49%) and in 513 of 1,488 (34%) with normal LASF (P = 0.01). In multivariate Cox regression analysis, high LASF predicted higher rate of major CV events (Hazard ratio 1.43 [95% confidence interval 1.01-2.03] independent of aortic valve area and LV mass index. A simple risk score including absence or presence of these three variables allowed risk stratification into low, intermediate, high and very high risk for major CV events during follow-up (22%, 28%, 38%, and 53%, respectively).

CONCLUSIONS

Higher LASF provides additional prognostic information in patients with asymptomatic mild-to-moderate AS.

Impact of diabetes mellitus on the clinical management of global cardiovascular risk: analysis of the results of the Evaluation of Final Feasible Effect of Control Training and Ultra Sensitization (EFFECTUS) educational program

BACKGROUND

The Evaluation of Final Feasible Effect of Ultra Control Training and Sensitization (EFFECTUS) study is aimed at implementing global cardiovascular (CV) risk management in Italy.

HYPOTHESIS

To evaluate the impact of diabetes mellitus (DM) on attitudes and preferences for clinical management of global CV risk among physicians treating diabetic or nondiabetic patients.

METHODS

Involved physicians were asked to submit data into a study-designed case-report form, covering the first 10 adult outpatients consecutively seen in May 2006. All available clinical data were centrally analyzed for global CV risk assessment and CV risk profile characterization. Patients were stratified according to the presence or absence of DM.

RESULTS

Overall, 1078 physicians (27% female, ages 50 ± 7 y) collected data of 9904 outpatients (46.5% female, ages 67 ± 9 y), among whom 3681 (37%) had a diagnosis of DM at baseline. Diabetic patients were older and had higher prevalence of obesity, hypertension, dyslipidemia, and associated CV diseases than nondiabetic individuals (P<0.001). They had higher systolic blood pressure, total cholesterol, triglycerides, and creatinine levels, but lower high-density lipoprotein cholesterol levels than nondiabetic patients (P<0.001). Higher numbers of blood pressure and lipid-lowering drugs and antiplatelet agents were used in diabetic than in nondiabetic patients (P<0.001).

CONCLUSIONS

The EFFECTUS study confirmed higher CV risk and more CV drug prescriptions in diabetic than in nondiabetic patients. Presence of DM at baseline significantly improved clinical data collection. Such an approach, however, was not paralleled by a better control of global CV risk profile, which was significantly worse in the former than in the latter group.

Belgian global implementation of cardiovascular and stroke risk assessment study: methods and baseline data of the BELGICA-STROKE STUDY

OBJECTIVES

BELGICA-STROKE is a longitudinal study to enhance the use of online cardiovascular risk prediction scores based on the SCORE 10-year risk estimates for fatal cardiovascular disease (adapted for Belgium) and the Framingham 10-year stroke risk and to evaluate their impact on the cardiovascular risk profile of hypertensive patients. Methods and baseline characteristics are described here.

DESIGN

Prospective, multicenter study in primary care.

METHODS

General practitioners (N = 810) recruited consecutive hypertensive patients aged >40 years who were not at blood pressure goal and assessed them every 4 months. The estimated 10-year risks for fatal cardiovascular disease and stroke were available on a secured, specially designed study website. The calculated risk profile of a patient was modifiable by adding treatment goals in order to increase awareness and motivation of both physician and patient. An automated feedback on goal-level attainment and both cardiovascular risk scores was provided.

RESULTS

Mean age of the 15,744 patients was 66.3 years: 51.9% were men, 77.8% had excess weight, 19.4% were smokers, and 25.9% had diabetes. Left ventricle hypertrophy was present in 20.0%, atrial fibrillation in 5.8%. Mean blood pressure was 153.8/88.2 mmHg, mean cholesterol 211.5 mg/dl. Most patients (89.2%) received antihypertensive medication, of which 36.9% was monotherapy. Mean estimated 10-year stroke risk was 19.1%, and mean estimated 10-year fatal cardiovascular disease risk 5.9%.

CONCLUSIONS

The 10-year estimated stroke and fatal cardiovascular disease risks were moderate to high in hypertensive patients not at goal blood pressure, emphasizing the importance of global cardiovascular risk factor assessment.

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.

Blood pressure control and cardiovascular risk profile in hypertensive patients from central and eastern European countries: results of the BP-CARE study

AIMS

Limited information is available on office and ambulatory blood pressure (BP) control as well as on cardiovascular (CV) risk profile in treated hypertensive patients living in central and eastern European countries.

METHODS AND RESULTS

In 2008, a survey on 7860 treated hypertensive patients followed by non-specialist or specialist physicians was carried out in nine central and eastern European countries (Albania, Belarus, Bosnia, Czech Republic, Latvia, Romania, Serbia, Slovakia, and Ukraine). Cardiovascular risk assessment was based on personal history, clinic BP values, as well as target organ damage evaluation. Patients had a mean (±SD) age of 60.1 ± 11 years, and the majority of them (83.5%) were followed by specialists. Average clinic BP was 149.3 ± 17/88.8 ± 11 mmHg. About 70% of patients displayed a very high-risk profile. Electrocardiogram was performed in 99% of patients, echocardiography in 65%, carotid ultrasound in 24%, fundoscopy in 68%, and search for microalbuminuria in 10%. Ambulatory BP monitoring was performed in about one-fifth of the recruited patients. Despite the widespread use of combination treatment (87% of the patients), office BP control (<140/90 mmHg) was achieved in 27.1% only, the corresponding control rate for ambulatory BP (<130/80 mmHg) being 35.7%. Blood pressure control was (i) variable among different countries, (ii) worse for systolic than for diastolic BP, (iii) slightly better in patients followed by specialists than by non-specialists, (iv) unrelated to patients' age, and (v) more unsatisfactory in high-risk hypertensives and in patients with coronary heart disease, stroke, or renal failure.

CONCLUSION

These data provide evidence that in central and eastern European countries office and ambulatory BP control are unsatisfactory, particularly in patients at very high CV risk, and not differ from that seen in Western Europe. They also show that assessment of subclinical organ damage is quite common, except for microalbuminuria, and that combination drug treatment is frequently used.

Antihypertensive treatment and stroke prevention: from recent meta-analyses to the PRoFESS trial

Blood pressure control is the cornerstone of therapeutic interventions aimed at preventing first strokes and recurrent strokes. All antihypertensive drug classes may be useful in preventing cerebrovascular events, depending on their efficacy in lowering elevated blood pressure values and achieving blood pressure control. However, recent findings indicate that drugs acting on the renin-angiotensin system (-angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers) may exert cerebrovascular protective effects in addition to blood pressure reduction. This article examines the cerebrovascular protection provided by antihypertensive drug treatment in the light of the results of recent meta-analyses and of the findings of the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial.

Knowledge and Implementation of the New European Guide in the Management of Arterial Hypertension. The Cigema Survey

Knowledge of guideline implementation pitfalls allows anticipation and solving of problems and may help to promote implementation. The aims of this study were: 1) to find out how much is known among medical professionals about the recommendations for the Management of Arterial Hypertension; 2) to study in depth the extent of implementation and 3) to evaluate the manner in which this guide will be applied to daily medical practice. The Delphi method was used for this work. The total estimated sample size was 2,250 physicians. The carefully selected experts answered questionnaires in two or more rounds. The final sample size was 2,475 physicians. Results of the study are detailed in the article. Among the resultsIt is noteworthy that the guide is viewed as needed among all those who have been interviewed and this agreement about its need is generalised and that the improvement in medical practice, together with individual treatment and cardiovascular risk stratification are viewed positively in opinions reached by consensus by the majority of physicians, regardless of whether they are specialists or general practitioners. The main results of this study emphasize the fact that physicians need a guideline for the management of hypertensive patients and that most of physicians agree with them. The new guidelines on arterial hypertension management are widely known among physicians and there appears to be a global agreement regarding the need for the implementation of the new recommendations.

Estimated risk of a first stroke and conditioning factors in Spanish hypertensive women. The RIMHA study

Stroke is the leading cause of mortality in women in Spain. RIMHA is a cross-sectional multicenter study in hypertensive women aged 55 or more in primary care to estimate the 10-year risk for a first stroke. Clinical history, cardiovascular risk factors and diseases, electrocardiogram, blood samples and blood pressure (BP) were recorded. Stroke and coronary risk were estimated using the appropriate Framingham scales; 12875 patients were included (mean age 68.0+/-8.5 years, 29.1% with diabetes, 19.7% with cardiovascular disease). Electrocardiographic left ventricular hypertrophy (LVH) was present in 19.2% BP was controlled in 42.9% of non-diabetic (BP<140/90 mmHg) and 9.7% of diabetic patients (BP<130/80 mmHg). The 10-year risk (+/- SD) for a first stroke was estimated as 15.8+/-16.3%, and the coronary risk as 12.0+/-6.3. In the multivariate analysis, the most contributing factors for stroke risk estimation were age, systolic BP, LVH and atrial fibrillation. In conclusion, the 10-year estimated stroke risk for Spanish hypertensive women aged 55 years or more was higher than the estimated coronary risk, in accordance with the high rates of morbidity and mortality due to stroke among women in Spain. The most powerful risk factors were older age, poor BP control, LVH and atrial fibrillation.

[Study of the stroke and coronary risks in hypertensive patients over 54 years of age in the primary care practice]

BACKGROUND AND OBJECTIVES

Quantification of stroke risk is not always performed in hypertensive patients in Primary Care.

METHODS

This was an epidemiological study in hypertensive patients aged 55 years and older attending primary care centres in Spain. The D'Agostino Stroke Risk Scale, using data from the Framingham Study, was used for assessment of stroke risk.

RESULTS

We analysed 4,945 patients (mean age, 66.8 years; 50.9% females). Mean blood pressure (BP) values were 145/86 mmHg in men and 143.7/84.7 mmHg in women (p < 0.001). The majority of patients (80.5%) showed high BP values that were above the values recommended in the guidelines, despite most of them (89.6%) receiving pharmacological antihypertensive treatment. 41% of patients were diabetics. The 10-year global risk of stroke was 22.5%, and was higher in men (28.6% vs. 16.8%; P < 0.001). The risk of stroke increased with age, being more marked in women. Several risk factors showed a statistically significant association with the risk of stroke. From higher to lower significance, these risk factors were: age, left ventricular hypertrophy (LVH), cardiovascular disease, systolic BP, auricular fibrillation, diabetes, cigarette smoking, control of BP, gender, and antihypertensive treatment. The 10-year coronary risk was higher in men (24.2% vs. 16.0%; p < 0.001) and was significantly related to the 10-year risk of stroke (r = 0.626).

CONCLUSIONS

The risk of stroke in the Spanish hypertensive population is high, and is significantly higher in men, although it shows a larger age-related increase in women. Linear regression analysis showed a moderate, but statistically significant, correlation between coronary risk and risk of stroke. Apart from all the variables included in the Framingham Stroke Risk Model, gender, control of BP, and antihypertensive treatment accounted significantly and independently as calculated risk factors for incidence of stroke.

Optimizing outcomes for patients with depression and chronic medical illnesses

Depression and comorbid chronic medical conditions such as coronary heart disease, diabetes mellitus, and osteoarthritis are frequently seen in the primary care setting, and the interaction of these illnesses can complicate diagnostic and treatment efforts. Although the etiologies of these bidirectional associations are not well understood, a number of negative outcomes are apparent, and challenges exist at patient, provider, and healthcare system levels to better recognize and treat depression in patients with chronic medical comorbidity. Such patients are more likely to present with somatic complaints, engage in unhealthy behaviors, harbor unhealthy thoughts or cognitions, and are less likely to comply with therapeutic recommendations. Primary care encounters often represent the only opportunities for these patients to address these issues and obtain the professional attention their depression requires. For clinicians, forging empathetic partnerships with patients, prescribing appropriate treatments, and closely monitoring symptoms and therapeutic progress are invaluable for optimal management of both affective and medical disorders. Further opportunities to improve care also exist at the healthcare system level, such as developing, funding, and implementing multimodal collaborative care models in the primary care setting.

Managing hypertension in cardiology practice according to risk profile

Cardiologists play a central role in managing hypertensive patients, although recent surveys reveal a marked discrepancy between cardiologists' appreciation of their patients' risk status and the measures taken to reduce that risk. The diagnosis and the management of hypertension, in fact, must be viewed today not in isolation, but as part of a patients' global cardiovascular (CV) risk, resulting from the concomitant presence of a variety of risk factors, organ damage (left ventricular hypertrophy, carotid or peripheral atherosclerosis, microalbuminuria or impaired glomerular filtration rate), and hypertension-related clinical conditions. The choice of timing and the intensity of antihypertensive treatment should be based on blood pressure (BP)-lowering efficacy and the propensity to favourably impact patient's individual absolute CV disease risk profile. As part of this paradigm shift in CV disease prevention strategy, cardiologists can take several key steps to help improve standards of hypertension control: (i) increase the awareness of total risk management; (ii) initiate an integrated management strategy tailored to the individual patient's global CV risk (e.g. hypertension, hypercholesterolaemia, diabetes, age, smoking and gender); (iii) use any elevation in BP as a gateway to begin total risk management and (iv) utilise combination therapies (particularly fixed-dose combinations) to achieve more rapid and persistent BP control and improve patient compliance/persistence with therapy. To help improve standards of hypertension control in the cardiology setting, this review examines the concept of treating hypertension using a global risk assessment approach and proposes effective hypertensive therapy as part of global risk management in patients typically seen in cardiology practice.

The broadening landscape for hypertension management

Several lines of evidence show that office blood pressure (BP) reduction can substantially decrease the risk of major cardiovascular events in hypertensive patients. It is also increasingly recognized that home and 24-hour ambulatory BPs provide additional prognostic information, and there is evidence to suggest that BP lowering over the 24-hour period is crucial for optimal risk reduction. However, BP is often difficult to control, even under the near-optimal conditions of clinical trials. Ideally, antihypertensive therapy should aim to control both office and out-of-office (i.e., 24-hour) BPs, and multiple risk factors in order to provide optimal cardiovascular risk reduction. This approach usually necessitates the use of polypharmacy with an attendant increase in costs and the risk of adverse events. For these reasons, increasing attention is being devoted to drugs that exert beneficial, BP-independent effects on target-organ damage or reduce the incidence of conditions (such as diabetes and metabolic syndrome) that are associated with high cardiovascular risk. Several studies have consistently shown that the incidence of new-onset diabetes is lower with angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and calcium antagonists than "older" drugs such as diuretics and beta-blockers. However, long-term studies examining target-organ protection may more fully illustrate the BP-independent benefits of specific antihypertensive agents.

A comparison of the efficacy and safety of irbesartan/HCTZ combination therapy with irbesartan and HCTZ monotherapy in the treatment of moderate hypertension

This prospective, double-blind, parallel-group study randomized patients with moderate hypertension (seated systolic blood pressure (SeSBP) 160-179 mm Hg when seated diastolic blood pressure (SeDBP) <110 mm Hg; or SeDBP 100-109 mm Hg when SeSBP <180 mm Hg) 3:1:1 to treatment with irbesartan 300 mg/hydrochlorothiazide (HCTZ) 25 mg combination therapy (n=328), irbesartan 300 mg monotherapy (n=106) or HCTZ monotherapy 25 mg (n=104). Treatment was initiated at half dose, with forced titration to full dose after two weeks followed by ten further weeks' treatment. The primary efficacy variable was the mean reduction in SeSBP from baseline to week 8. Baseline characteristics were similar between groups, with mean baseline blood pressure approximately 162/98 mm Hg; the mean age was 55 years. At week 8 there was a reduction in SeSBP of 27.1 mm Hg with irbesartan/HCTZ, compared with 22.1 mm Hg with irbesartan monotherapy (P=0.0016) and 15.7 mm Hg with HCTZ (P<0.0001). Both the rate of decline and the total degree of decline achieved were greatest with irbesartan/HCTZ and least with HCTZ. A significantly greater percentage of patients reached a treatment goal of SeSBP <140 mm Hg and SeDBP <90 mm Hg by week 8 with irbesartan/HCTZ (53.4%), compared with irbesartan (40.6%; P=0.0254) and HCTZ (20.2%; P<0.0001) alone. Treatment was well tolerated in all three-treatment groups with a slight increase in adverse events in the combination therapy group. In conclusion, irbesartan/HCTZ (300/25 mg) is well tolerated and achieves rapid and sustained reductions in both systolic blood pressure and diastolic blood pressure in patients with moderate hypertension.

An economic assessment of losartan-based versus atenolol-based therapy in patients with hypertension and left-ventricular hypertrophy: results from the Losartan Intervention For Endpoint reduction (LIFE) study adapted to The Netherlands

BACKGROUND

The Losartan Intervention For Endpoint reduction (LIFE) study was a randomized, doubleblind trial that compared the effects of losartan-based treatment with those of atenolol-based treatment on cardiovascular disease (CVD)-related morbidity and mortality in 9193 patients with hypertension and left-ventricular hypertrophy (LVH). Compared with atenolol, losartan reduced the combined risk for CVD-related morbidity and mortality by 13% (P = 0.021), and reduced the risk for stroke by 25% (P = 0.001), with comparable blood pressure control in both trial arms.

OBJECTIVE

The aim of this study was to analyze the cost-effectiveness of losartan compared with atenolol in the treatment of stroke from the Dutch health care perspective.

METHODS

Utilization of losartan and atenolol within the trial period (mean, 4.8 years) and an estimation of direct medical costs of stroke for The Netherlands were combined with estimates of reduction in life expectancy through stroke. Medication costs and stroke incidence during 5.5 years of patient follow-up were estimated separately, adjusted for the baseline degree of LVH and Framingham risk score. To estimate lifetime stroke costs, the cumulative incidence of stroke was multiplied by the lifetime direct medical costs attributable to stroke. All costs are in 2006 Dutch prices and discounted following the former (4% costs and effects) and new Dutch guideline (4% costs, 1.5% effects) for conducting pharmacoeconomic analyses.

RESULTS

With 4% discounting, prevention of stroke was associated with a gain of 3.7 life-years. As a consequence, losartan treatment was associated with 0.059 life-year gained (LYG) per patient treated with losartan. Losartan reduced stroke-related costs by 1,076 Euros (US $1,349) per patient. After inclusion of study medication cost, net cost per patient was 51 Euros ($64) higher for losartan than atenolol. The net cost per LYG was 864 Euros ($1083), which is below the Dutch pharmacoeconomic threshold of 20,000 Euros/LYG (~$25,000/LYG) for accepting interventions. The corresponding probability of a cost-effectiveness ratio below this Dutch threshold was 0.95. Discounting money and health following the new Dutch guideline resulted in an even more favorable cost-effectiveness for losartan.

CONCLUSIONS

Results from the present analysis suggest that, in The Netherlands, treatment with losartan compared with atenolol may well be a cost-effective intervention based on the reduced risk for stroke observed in the LIFE trial.

The need for combination antihypertensive therapy to reach target blood pressures: what has been learned from clinical practice and morbidity-mortality trials?

Pharmacological treatment of hypertension represents a cost-effective way for preventing cardiovascular and renal complications. To benefit maximally from antihypertensive treatment blood pressure (BP) should be brought to below 140/90 mmHg in every hypertensive patient, and even lower (< 130/80 mmHg) if diabetes or renal disease co-exists. Most of the time such targets cannot be reached using monotherapies. This is especially true in patients who exhibit a high cardiovascular risk. The co-administration of two agents acting by different mechanisms considerably increases BP control. Such preparations are not only efficacious, but also well tolerated, and some fixed low-dose combinations have a tolerability profile similar to placebo. This is for instance the case for the preparation containing the angiotensin-converting enzyme inhibitor perindopril (2 mg) and the diuretic indapamide (0.625 mg), a fixed low-dose combination that has recently been shown in controlled interventional trials to be more effective than monotherapies in reducing albuminuria, regressing cardiac hypertrophy and improving macrovascular stiffness. Fixed-dose combinations are becoming more and more popular and are even proposed by current hypertension guidelines as a first-line option to treat hypertensive patients.

Achieving blood pressure goals globally: five core actions for health-care professionals. A worldwide call to action

The prevalence of hypertension continues to rise across the world, and most patients who receive medical intervention are not adequately treated to goal. A Working Group including representatives of nine international health-care organizations was convened to review the barriers to more effective blood pressure control and propose actions to address them. The group concluded that tackling the global challenge of hypertension will require partnerships among multiple constituencies, including patients, health-care professionals, industry, media, health-care educators, health planners and governments. Additionally, health-care professionals will need to act locally with renewed impetus to improve blood pressure goal rates. The Working Group identified five core actions, which should be rigorously implemented by practitioners and targeted by health systems throughout the world: (1) detect and prevent high blood pressure; (2) assess total cardiovascular risk; (3) form an active partnership with the patient; (4) treat hypertension to goal and (5) create a supportive environment. These actions should be pursued with vigour in accordance with current clinical guidelines, with the details of implementation adapted to the economic and cultural setting.

Blood pressure reduction and cardiovascular outcomes: past, present, and future

Hypertension has not always been recognized as a harbinger of cardiovascular complications and premature death. Only 70 years ago, hypertension was considered the body's adaptation to sclerotic blood vessel disease and essential to maintain organ perfusion; thus, treatment was regarded as undesirable. Epidemiologic studies have since established a strong linear relation between blood pressure and cardiovascular disease (CVD), and randomized trials have documented that blood pressure reductions by antihypertensive drugs confer cardiovascular protection, making the hypertension-related risk a reversible risk. There is now a consensus that blood pressure should be reduced to <140/90 mm Hg in all patients and that a more aggressive blood pressure target (<130/80 mm Hg) should be pursued in those in whom the cardiovascular risk is high. Despite this, blood pressure control remains elusive in most individuals in the hypertensive population, which makes improvement of blood pressure control in this population a priority goal. This goal may meet with new challenges, however. Optimal blood pressure control may have to include the measurement of blood pressure every day, given the fluctuations of blood pressure and their prognostic importance independent of and in addition to that of classically measured blood pressure values.