Drug adherence and psychosocial characteristics of patients presenting with hypertensive urgency at the emergency department

Chemical adherence testing in the clinical management of hypertension: a scoping review

Background

Despite growing use, questions remain surrounding the utility, acceptability and feasibility of chemical adherence testing (CAT) as part of hypertension management in clinical practice.

Objectives

This scoping review aimed to (i) identify and summarise studies using CAT in hypertension management, and (ii) describe and critically evaluate how CAT is currently being used in the clinical management of hypertension.

Eligibility criteria

Peer-reviewed and published studies in English, reporting original research in any setting, with any study design, were included. Search concepts included hypertension, medication adherence, CAT, and their synonyms.

Sources of evidence

Searches were carried out using Ovid Medline, EMBASE, and PsycInfo (EBSCO), alongside manual searching of reference lists. Using Covidence software, we screened titles and abstracts, followed by full-text articles. Data from the included articles were tabulated and summarised.

Results

Of the 618 studies identified, 48 were included. The studies cover diverse clinical settings, and were mostly observational in design. 7 studies reporting adherence analyses within clinical trials for hypertension therapies. The use of theoretical frameworks to guide reporting was rare, and there was considerable variation in key terminology and definitions, most notably in the definition of adherence.

Conclusion

The current body of evidence demonstrates considerable variability in the approach to implementing CAT for hypertension management in clinical practice, and a paucity of randomised controlled trials to evaluate its impact. Future research could (i) adopt a cohesive theoretical framework including clear operational definitions to standardise the approach to this important topic; (ii) further explore the impact of CAT on clinical outcomes using RCTs.

Not obtaining a medication the first time it is prescribed: primary non-adherence to cardiovascular pharmacotherapy

Primary medication non-adherence describes the situation when a first prescription for a new medication is never filled. Primary non-adherence is an important, yet understudied aspect of reduced effectiveness of pharmacotherapy. This review summarizes the frequency, impact, reasons, predictors, and interventions regarding primary non-adherence to cardiovascular/cardiometabolic drugs. The current literature reveals a high prevalence of primary non-adherence. The individual risk of primary non-adherence is determined on multiple factors, e.g., primary non-adherence of lipid-lowering drugs is higher compared to antihypertensive medications. However, the overall rate of primary non-adherence is > 10%. Additionally, this review identifies specific areas for research to better understand why patients forgo evidence-based beneficial pharmacotherapy and to explore targeted interventions. At the same time, measures to reduce primary non-adherence-once proven to be effective-may represent an important new opportunity to reduce cardiovascular diseases.

The role of depression and antidepressant treatment in antihypertensive medication adherence and persistence: Utilising electronic health record data

Higher blood pressure levels in patients with depression may be associated with lower adherence to antihypertensive medications (AHMs). Here, we use electronic health record (EHR) data from the Estonian Biobank (EstBB) to investigate the role of lifetime depression in AHM adherence and persistence. We also explore the relationship between antidepressant initiation and intraindividual change in AHM adherence among hypertension (HTN) patients with newly diagnosed depression. Diagnosis and pharmacy refill data were obtained from the National Health Insurance database. Adherence and persistence to AHMs were determined for hypertension (HTN) patients initiating treatment between 2009 and 2017 with a three-year follow-up period. Multivariable regression was used to explore the associations between depression and AHM adherence or persistence, adjusting for sociodemographic, genetic, and health-related factors. A linear mixed-effects model was used to estimate the effect of antidepressant treatment initiation on antihypertensive medication adherence, adjusting for age and sex. We identified 20,724 individuals with newly diagnosed HTN (6294 depression cases and 14,430 controls). Depression was associated with 6% lower probability of AHM adherence (OR = 0.943, 95%CI = 0.909-0.979) and 12% lower odds of AHM persistence (OR = 0.876, 95%CI = 0.821-0.936). Adjusting for sociodemographic, genetic, and health-related factors did not significantly influence these associations. AHM adherence increased 8% six months after initiating antidepressant therapy (N = 132; β = 0.078; 95%CI = 0.025-0.131). Based on the EHR data on EstBB participants, depression is associated with lower AHM adherence and persistence. Additionally, antidepressant therapy may help improve AHM adherence in patients with depression.

Hypertensive crisis: diagnosis, presentation, and treatment

PURPOSE OF REVIEW

Hypertensive crisis (HTN-C) is a condition of increasing prevalence. It carries significant morbidity and mortality, and prompt recognition and treatment are crucial. There is a paucity of controlled trials, so a working knowledge of the most recent literature in the area of HTN-C is helpful.

RECENT FINDINGS

Novel serological markers, including serum corin, have been found to aid in the early identification of end-organ damage from severely elevated blood pressure (BP). In the area of BP following thrombolysis for ischemic stroke, lower target BP (130-140 mmHg) is associated with some improved outcomes. Two large trials of lower BP following mechanical thrombectomy in stroke have failed to show improved outcomes; however, observed data show benefits at lower than currently recommended levels. Clevidipine, a calcium channel blocker marketed for unique use in HTN-C, was found to be noninferior to the generic less expensive nicardipine. Oral nifedipine was found to be the most effective agent for sustained BP reduction in preeclampsia.

SUMMARY

HTN-C remains an area with few prospective randomized trials, but there is active research on identifying lower goals for specific clinical scenarios. Ideal therapeutic agents should be tailored for specific end-organ damage.

Hypertension urgencies in the SPYRAL HTN-OFF MED Pivotal trial

The SPYRAL HTN-OFF MED Pivotal trial ( https://clinicaltrials.gov/ct2/show/NCT02439749 ) demonstrated significant reductions in blood pressure (BP) after renal denervation (RDN) compared to sham control in the absence of anti-hypertensive medications. Prior to the 3-month primary endpoint, medications were immediately reinstated for patients who met escape criteria defined as office systolic BP (SBP) ≥ 180 mmHg or other safety concerns. Our objective was to compare the rate of hypertensive urgencies in RDN vs. sham control patients. Patients were enrolled with office SBP ≥ 150 and < 180 mmHg, office diastolic BP (DBP) ≥ 90 mmHg and mean 24 h SBP ≥ 140 and < 170 mmHg. Patients had been required to discontinue any anti-hypertensive medications and were randomized 1:1 to RDN or sham control. In this post-hoc analysis, cumulative incidence curves with Kaplan-Meier estimates of rate of patients meeting escape criteria were generated for RDN and sham control patients. There were 16 RDN (9.6%) and 28 sham control patients (17.0%) who met escape criteria between baseline and 3 months. There was a significantly higher rate of sham control patients meeting escape criteria compared to RDN for all escape patients (p = 0.032), as well as for patients with a hypertensive urgency with office SBP ≥ 180 mmHg (p = 0.046). Rate of escape was similar between RDN and sham control for patients without a measured BP exceeding 180 mmHg (p = 0.32). In the SPYRAL HTN-OFF MED Pivotal trial, RDN patients were less likely to experience hypertensive urgencies that required immediate use of anti-hypertensive medications compared to sham control.

Cardiovascular prognosis in patients admitted to an emergency department with hypertensive emergencies and urgencies

BACKGROUND

At present, few data are available on the prognosis of hypertensive emergencies and urgencies admitted to emergency departments.

AIM

The aim of our study was to evaluate the incidence of total and cardiovascular events during follow-up in hypertensive patients admitted to the emergency departments of Brescia Hospital (Northern Italy) with hypertensive emergencies or urgencies from 1 January to 31 December 2015.

METHODS

Medical records of patients aged more than 18 years, admitted to the emergency department with SBP values at least 180 mmHg (SBP) and/or DBP values at least 120 mmHg (DBP) were collected and analysed (18% of patients were classified as 'hypertensive emergency' and 82% as 'hypertensive urgency'). Data in 895 patients (385 men and 510 women, mean age 70. 5 ± 15 years) were analysed; the mean duration of follow-up after admission to the emergency department was 12 ± 5 months.

RESULTS

During the follow-up, 96 cardiovascular events (28 fatal) occurred (20 cardiac events, 30 cerebrovascular events, 26 hospital admission for heart failure, 20 cases of new onset kidney disease). In 40 patients (4.5%), a new episode of acute blood pressure rise with referral to the emergency department was recorded. Cardiovascular mortality and morbidity were greater in patients with a previous hypertensive emergency (14.5 vs. 4.5% in patients with hypertensive emergency and urgency, respectively, chi-square, P < 0.0001). Similar results were obtained when the occurrence of cerebrovascular or renal events were considered separately.

CONCLUSION

Admission to the emergency department for hypertensive emergencies and urgencies identifies hypertensive patients at increased risk for fatal and nonfatal cardiovascular events. Our findings add some new finding suggesting that further research in this field should be improved aiming to define, prevent, treat and follow hypertensive urgencies and emergencies.