Influence of blood pressure reduction on composite cardiovascular endpoints in clinical trials

Treatment of hypertension in the elderly: target the lowest well-tolerated blood pressure

INTRODUCTION

Antihypertensive treatment provides substantial benefits in older people. However, many challenges remain, including the ideal blood pressure (BP) target to be achieved. Because the elderly population is particularly vulnerable to adverse events, BP control should be carefully managed. Some studies have evaluated the cardiovascular effects of different BP targets in older patients, with mixed results and uncertainty about the most appropriate BP target. However, pooled analyses suggest that intensive BP lowering provides greater cardiovascular protection than less intensive strategies in elderly hypertensive patients.

AREAS COVERED

Understanding the balance between the risks and benefits of intensive BP targets and individualizing treatment is essential to ensure that older patients receive appropriate treatment to reduce the risk of cardiovascular complications. We reviewed data from clinical trials which investigated the protective effects of BP lowering drugs in elderly hypertensive patients aged ≥65 years.

EXPERT OPINION

Evidence suggests that age does not preclude an aggressive strategy for treating hypertension in elderly patients. Being 'tolerant' with one hand and 'intensive' with the other should become a universal standard in the management of elderly hypertensive patients. The lowest well-tolerated BP could be a simple and universally applicable BP target in the management of hypertensive patients, including the elderly.

Chronic Effects of Oral Cannabidiol Delivery on 24-h Ambulatory Blood Pressure in Patients with Hypertension (HYPER-H21-4): A Randomized, Placebo-Controlled, and Crossover Study

Background: Recent data indicate that cannabidiol (CBD), a nonintoxicating constituent of cannabis, is involved in several aspects of cardiovascular regulation, including blood pressure (BP). However, the impact of chronic CBD administration on 24-h BP and vascular health has not been previously examined in patients with hypertension. The primary aim of this randomized, triple-blind, placebo-controlled, and crossover study was to examine the influence of chronic CBD on 24-h ambulatory BP and arterial stiffness in hypertensive patients. Methods: Seventy patients with mild or moderate primary hypertension, who were untreated or receiving standard of care therapy, were randomly assigned to receive either 5 weeks of oral CBD or placebo-matched controls. Following a >2-week washout period, patients were crossed over to alternate therapy. The primary outcome of the study was dynamic in 24-h ambulatory BP and was assessed using two-way repeated measure analysis of variance. Results: Administration of CBD reduced average 24 h mean, systolic, and diastolic BP after 2.5 weeks (-3.22±0.90 mmHg [95% confidence interval -1.01 to -5.44 mmHg], -4.76±1.24 mmHg [-1.72 to -7.80 mmHg], and -2.25±0.80 mmHg [-0.30 to -6.01 mmHg], respectively (all p<0.05); however, these values largely remained stable following the uptitration of CBD dosing. There were no changes in liver enzymes or serious adverse events (AEs). There was no significant difference in pulse wave velocity (group×factor interaction: F=1.50, p=0.226) at different time points, regardless of the intervention arm. Conclusions: In conclusion, chronic administration of CBD reduces ambulatory BP in those with untreated and treated hypertension. In addition, lack of serious AEs implies safety and tolerability of the above-noted CBD formulation. ClinicalTrials.gov ID: NCT05346562, Registered April 6th 2022.

Association of intensive blood pressure management with cardiovascular outcomes in patients using multiple classes of antihypertensive medications: a post-hoc analysis of the STEP Trial

High medication burden is associated with poor treatment effect and high risk of cardiovascular outcomes. This study aimed to investigate the association between the antihypertensive medication burden and cardiovascular outcomes in the STEP trial. This post-hoc analysis of the STEP trial enrolled 8511 participants, including 8041 with low burden and 470 with high burden. High antihypertensive medication burden was defined as being treated with ≥3 different classes of prescribed antihypertensive medications. The primary outcome was a composite of cardiovascular outcomes. Fine-Gray model was used in this study. Among all participants, high antihypertensive medication burden was associated with a higher risk of the primary outcome compared with low medication burden (HR, 1.52; 95% CI, 1.03-2.24), which was consistent in the standard group (HR, 1.95; 95% CI, 1.20-3.18) and the intensive group (HR, 1.10; 95% CI, 0.57-2.13; Pinteraction = 0.18). The beneficial effects of intensive systolic blood pressure (SBP) control on the primary outcome remained significant in the high burden group (HR, 0.42; 95% CI, 0.19-0.95) and the low burden group (HR, 0.79; 95% CI, 0.63-0.98; Pinteraction = 0.18). At 24 months, the percentage of participants achieving the target SBP was lower in the high medication burden group (risk ratio, 0.93; 95% CI, 0.89-0.98). In both standard and intensive treatment groups, participants with a high medication burden were harder to achieve the target SBP (Pinteraction = 0.65). High antihypertensive medication burden was associated with worse SBP control and a greater risk of cardiovascular events. Intensive SBP control showed cardiovascular benefits in both medication burden groups. Trial registration: STEP ClinicalTrials.gov number, NCT03015311. Registered 2 January 2017.

Same-Day Primary Care Referral Versus Usual Care for Patients With Elevated Blood Pressures Seen in a Preoperative Clinic

Background While several studies have suggested that anesthesia and surgical care episodes provide an opportunity to improve the diagnosis and treatment of hypertension, few studies have implemented and tested pragmatic care coordination efforts for this population. The present study aimed to examine the effects of same-day primary care referral vs. usual care on outpatient hypertension treatment among patients with elevated preoperative clinic blood pressure (BP). Methodology With institutional review board approval of the project as a quality improvement (QI) initiative not requiring consent, we conducted a prospective QI project comparing same-day preoperative primary care referral vs. usual care within comparable cohorts of US Veterans presenting to a preoperative evaluation clinic with elevated BP for whom treatment assignment was based on prior primary care clinic affiliation. Outpatient BP, antihypertensive medications, and antihypertensive dosages at the initial visit and for one year after the initial preoperative clinic visit were followed in the electronic health record. Results Between June 1, 2018, and June 1, 2019, one of the two on-site primary care groups (Firm A) at our facility agreed to accommodate same-day BP referrals. Patients in the second primary care group received standard preoperative care (Firm B). Charts for the pseudo-randomized cohort of Firm A and B patients were compared after 12 months to assess for changes in BP and hypertension treatment. Firm A and B patients were similar in demographics. Overall, 68 (91%) Firm A patients were correctly referred for primary care appointments. Moreover, 28 of 68 (41.2%) patients adhered to the same-day referral recommendation, with the remainder declining to attend the primary care visit. BPs were similar between Firm A and Firm B groups at 3, 6, 9, and 12 months post-intervention. Firm A adherent patients (i.e., those attending the referral) received hypertension treatment intensification sooner than Firm A non-adherent and Firm B patients (median (interquartile range) days to intensification = 21 (0.5-103.5) vs. 154 (45.5-239) and 170 (48-220), respectively; p = 0.038 and p = 0.048, respectively). Conclusions Our protocol achieved a high degree of same-day primary care referral (91%) in hypertensive patients presenting at the preoperative clinic. Although this limited study did not demonstrate improved BP control in patients who received same-day primary care, this group did show increased rates of rapid treatment intensification which may infer improved long-term health outcomes. Further work examining logistical barriers to patients attending same-day referrals is warranted.

Evidence-Supported Interventions for Reducing Secondary Stroke Risk in Sub-Saharan Africa: A Systematic Review

The study set out to perform a systematic literature review of evidence-based interventions that target the reduction of secondary stroke risk in Africa. The review analyzed longitudinal intervention studies conducted in Sub-Saharan Africa, focusing on adult participants who had suffered a prior stroke. It encompassed publications and peer-reviewed papers sourced from reputable databases, including PubMed, Ovid, Cochrane, and Web of Science. Three randomized clinical trial (RCT) studies were included with sample sizes ranging from 16 to 400 participants, mean age ranged between 50 and 66 years, with 64.5% male participants. All studies applied multidisciplinary team interventions of enhanced patient follow-up involving care givers, nurse educators, physicians, and social workers. Interventions ranged from comprehensive patient education, tracking of medication adherence and enforcing healthy lifestyle behaviors (regular exercise, regular BP checks, and dietary changes). We found a decrease in Systolic Blood Pressure over time in 2 of 3 treatment groups, an improvement in medical adherence in all treatment groups, and a decrease in cholesterol levels in 1 treatment group. Evidence-based interventions involving multidisciplinary teams and comprehensive patient education were found to demonstrate promising results in reducing secondary stroke risk in Africa, leading to significant improvements in medical adherence and reductions in systolic blood pressure in the majority of treatment groups. However, more research is required to confirm the influence of these interventions on cholesterol levels and to establish their lasting advantages in preventing strokes among African communities.

Effects of "Football and Nutrition for Health" program on body composition, physical fitness, eating behaviours, nutritional knowledge, and psychological status among 7 to 10 years school children

Introduction

Noncommunicable diseases and obesity are between the major health threat due to consumption of unhealthy foods and limited time spent on physical activities, a situation of particular concern among children. Since children spend most of their time at school, this study intends to investigate the effect of a school intervention program, which combines recreational football and nutrition education, on body composition, physical fitness, physical activity, blood pressure and heart rate, eating behaviours, nutritional knowledge, and psychological status in elementary school children.

Methods

A total of 67 children, between 7 and 10 years old, were allocated into three groups: the Football Group (FG) which held 2 weekly sessions of 60 min of recreational football, the Nutrition and Football Group (NFG) which held 2 sessions per week of 60 min of recreational football plus 60 min of nutritional education and the Control Group (CG) which maintained its usual curriculum. The intervention lasted 12 weeks. All measurements were collected before and after the intervention.

Results

Intervention groups significantly (p < 0.05) improved BMI Z-score, rest heart rate, horizontal jump and shuttle test, physical activity level, and psychosocial health. The NFG group significantly decreased (p < 0.05) waist-to-height ratio and blood pressure, and significantly increased (p < 0.05) nutritional knowledge, fruit, and fish consumption. While FG significantly decreased (p < 0.05) the percentage of fat mass and significantly increased (p < 0.05) muscle mass and performance in the 20 m sprint.

Discussion

The results have shown to improve nutritional status, explosive strength, aerobic and neuromuscular fitness, as well as increase the level of physical activity. The nutritional education sessions contributed to increase nutritional knowledge and to improve the consumption of healthy food groups in a ludic-educational way. The "Football and Nutrition for Health" program was able to induce short-term improvements in several health markers, highlighting the role of the school curriculum in children's health.

Effect of a Community-Based Program to Accelerate Referral to Physicians for Individuals at High-Risk of Lifestyle-Related Diseases: A Cluster Randomized Trial

AIM

A cluster randomized trial was conducted within 43 Japanese municipalities (21 intervention and 22 usual care) to examine whether the standardized health counseling for individuals at high cardiovascular risk screened at community sites accelerates clinic visits to strengthen the primary health care system.

METHODS

Among high-risk individuals aged 40-74 years screened by health checkups, 8,977 and 6,733 were allocated to the intervention and usual care groups, respectively, who were not under medical treatment but had high levels of blood pressure (systolic/diastolic ≥ 160/100 mmHg), hemoglobin A1c or glucose (≥ 7.0% or corresponding glucose levels), LDL-cholesterol (≥ 180 mg/dL for men), and/or proteinuria of ≥ 2+. The intervention was performed from May 2014 to March 2016 under a standardized health counseling program based on the health belief model primarily by public health nurses. The usual care group was provided with local counseling protocols.

RESULTS

The cumulative proportions of clinic visits for 12 months after health checkups were 58.1% (95% confidence interval, 57.0%, 59.3%) versus 44.5% (43.2%, 45.8%), with the probability ratio of clinic visits between the groups being 1.46 (1.24, 1.72). The between-group differences between the baseline and 1-year surveys were -1.50 (-2.59, -0.41) mmHg for diastolic blood pressure in the hypertension category, -0.30% (-0.53%, -0.07%) for HbA1c in the diabetes category, -0.37 (-0.48, -0.27) mmol/L for LDL-cholesterol in the dyslipidemia category, and none for proteinuria.

CONCLUSION

Standardized health counseling for high-risk individuals accelerated clinic visits, with larger reductions in blood pressure, HbA1c, and LDL-cholesterol levels. The nationwide use of counseling after health checkups for high-risk individuals could help in controlling risk factors and in preventing lifestyle-related diseases.

The Influence of Oral Cannabidiol on 24-h Ambulatory Blood Pressure and Arterial Stiffness in Untreated Hypertension: A Double-Blind, Placebo-Controlled, Cross-Over Pilot Study

INTRODUCTION

Studies reveal that cannabidiol may acutely reduce blood pressure and arterial stiffness in normotensive humans; however, it remains unknown if this holds true in patients with untreated hypertension. We aimed to extend these findings to examine the influence of the administration of cannabidiol on 24-h ambulatory blood pressure and arterial stiffness in hypertensive individuals.

METHODS

Sixteen volunteers (eight females) with untreated hypertension (elevated blood pressure, stage 1, stage 2) were given oral cannabidiol (150 mg every 8 h) or placebo for 24 h in a randomised, placebo-controlled, double-blind, cross-over study. Measures of 24-h ambulatory blood pressure and electrocardiogram (ECG) monitoring and estimates of arterial stiffness and heart rate variability were obtained. Physical activity and sleep were also recorded.

RESULTS

Although physical activity, sleep patterns and heart rate variability were comparable between groups, arterial stiffness (~ 0.7 m/s), systolic blood pressure (~ 5 mmHg), and mean arterial pressure (~ 3 mmHg) were all significantly (P < 0.05) lower over 24 h on cannabidiol when compared to the placebo. These reductions were generally larger during sleep. Oral cannabidiol was safe and well tolerated with no development of new sustained arrhythmias.

CONCLUSIONS

Our findings indicate that acute dosing of cannabidiol over 24 h can lower blood pressure and arterial stiffness in individuals with untreated hypertension. The clinical implications and safety of longer-term cannabidiol usage in treated and untreated hypertension remains to be established.

The predictive value of interarm systolic blood pressure differences in patients with vascular disease: Sub-analysis of the COMPASS trial

BACKGROUND AND AIMS

Systolic blood pressure interarm difference (IAD) predicts cardiovascular morbidity and mortality in primary prevention populations. We examined the predictive value of IAD and the effects of treatment with the combination of rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily versus aspirin 100 mg once daily according to IAD in patients with chronic coronary artery disease or peripheral artery disease.

METHODS

COMPASS trial patients with IAD <15 mmHg and IAD >15 mmHg were compared with respect to thirty-month incidence risk of: 1) composite of stroke, myocardial infarction, or cardiovascular death (MACE), 2) composite of acute limb-ischemia or vascular amputation (MALE), 3) composite of MACE or MALE, and 4) effects of treatment with the combination versus aspirin alone on these outcomes.

RESULTS

24,539 patients had IAD<15 mmHg and 2,776 had IAD ≥15 mmHg. Relative to patients with IAD ≥15 mm Hg, those with IAD<15 mmHg had similar incidence rates for all measured outcomes including the composite of MACE or MALE (HR 1.12 [95% CI: 0.95 to 1.31], p = 0.19), with the exception of stroke (HR 1.38 [95% CI: 1.02 to 1.88], p = 0.04). Compared to aspirin alone, the combination consistently reduced the composite of MACE or MALE in both IAD <15 mmHg (HR 0.74 [95% CI: 0.65-0.85], p < 0.0001, ARR = -23.1) and IAD>15 mmHg (HR 0.65 [95% CI: 0.44-0.96], p = 0.03; ARR = -32.6, p interaction = 0.53) groups.

CONCLUSIONS

Unlike primary prevention populations, measuring IAD for risk stratification purposes does not appear to be useful in patients with established vascular disease.

Deprescribing Antihypertensive Medications in Older People: A Narrative Review, Part 1

The problem of polypharmacy is complex, pervasive, and expanding. Appropriate prescribing of antihypertensive therapy for older people might help reduce medication burden, but it begins with a better understanding of what the evidence offers and where the evidence is quiet.In the first of this three-part series on antihypertensive medications for older people, we will trace the history of treating blood pressure with medication, from the expert opinion opposing treatment, to the observational data that led to paradigm shifts. We will follow the trail of evidence to randomized controlled trials (RCT) demonstrating the clear benefit of better control of blood pressure for all adults, regardless of age.RCT first evaluated any treatment against placebo, then began comparing one medication with another, and finally, more intensive control compared with less intensive control. Eventually professional societies bundled the evidence into guidelines to help busy prescribers and pharmacists wisely advise the consumers at the coal-face.In this first part of this series, we will present the evidence that favors intensive therapy in older people, that lower is better. In the second part, we will present evidence that highlights the dangers of going too low, and that stopping blood pressure-lowering medication might help. In the third part, we will discuss the evidence, new and old, that shows what happens when you stop.

Antihypertensive effects of rosuvastatin in patients with hypertension and dyslipidemia: A systemic review and meta-analysis of randomized studies

Some studies have suggested the antihypertensive effects of statins, a class of lipid-lowering agents, particularly in patients with hypertension. However, the evidence for the role of statins in blood pressure (BP) lowering is controversial, and no meta-analysis of rosuvastatin therapy has been conducted to assess its BP-lowering effects. Therefore, the aim of this meta-analysis of randomized controlled trials (RCTs) was to investigate the effects of rosuvastatin on systolic blood pressure (SBP) and diastolic blood pressure (DBP) in patients with hypertension. We systematically searched the electronic databases MEDLINE, EMBASE, and Cochrane Library to identify RCTs in which patients were assigned to groups of rosuvastatin plus antihypertensive agents vs. antihypertensive agents. The three authors independently selected the studies, extracted data, and assessed methodological quality. We included five RCTs in this meta-analysis with 288 patients treated with rosuvastatin and 219 patients without rosuvastatin. The mean DBP in the rosuvastatin group was significantly lower than that in the non-rosuvastatin group by -2.12 mmHg (95% confidence interval (CI) -3.72 to -0.52; Pfixed-effects model = 0.009; I2 = 0%, Pheterogeneity = 0.97). Rosuvastatin treatment also lowered the mean SBP compared with the non-rosuvastatin treatment by -2.27 mmHg, but not significantly (95% CI - 4.75 to 0.25; Pfixed-effects model = 0.08; I2 = 0%, Pheterogeneity = 0.82). In this study, we reviewed the antihypertensive effects of rosuvastatin in patients with hypertension and dyslipidemia. We demonstrated a modest significant reduction of DBP and a trend toward a lowered SBP in patients with hypertension with rosuvastatin therapy. Rosuvastatin could be beneficial to control hypertension and, consequently, contribute toward reducing the risk of cardiovascular events in patients with hypertension and dyslipidemia.

Assessment of chronic disease management mode (CDMM) on participants with primary hypertension

Objective

Hypertension requires continuous and long‐term care to prevent associated complications. Chronic disease management mode (CDMM) was developed to improve patients' self‐management. We aimed to evaluate quality of care and clinical outcomes of CDMM versus routine care.

Methods

300 patients aged >30 years with primary hypertension were randomly allocated to the CDMM intervention group (n = 162) or the usual care control group (n = 138). CDMM comprised nursing consultations, telephone contact, online WeChat link, health education, and appropriate referrals during hospitalisation and after discharge. QLICD‐HY (V 2.0) scale was used to evaluate the quality of life. Care outcomes were biochemical parameters, body mass index, blood pressure levels, waist circumference, psychological indicators and quality of life assessed on admission (baseline) and one month post‐care for both groups. Data were collected and analysed using SPSS 20.0.

Results

After one month, the intervention group had 6 mm Hg (95% CI: −5.12 to −9.08) lower SBP and 0.6 mM/L (95% CI: −0.52 to −0.68) lower LDL than the control group. In terms of improvements in BMI, UmAlb or waist circumference, there were no differences between both groups. The intervention group scored better on psychological indicators than controls (P < 0.05), and scores reflecting social and psychological function in the intervention group were significantly higher than scores at baseline, and higher than scores of controls after one month (P < 0.05). In the control group, there was no statistically significant difference between the scores at baseline and after one month.

Conclusions

Under CDMM hypertension care, improvement of blood pressure and LDL was clinically significant. Intervention care further improves social and psychological function among participants with primary hypertension.

Cannabis is associated with blood pressure reduction in older adults - A 24-hours ambulatory blood pressure monitoring study

BACKGROUND

Medical cannabis use is increasing rapidly in the past several years, with older adults being the fastest growing group. Nevertheless, the evidence for cardiovascular safety of cannabis use is scarce. The aim of this study was to assess the effect of cannabis on blood pressure, heart rate, and metabolic parameters in older adults with hypertension.

METHODS

We conducted a prospective study of patients aged 60 years or more with hypertension and a new prescription of cannabis. We have performed the following assessments: 24-hours ambulatory blood pressure monitoring, ECG, blood tests, and anthropometric measurements prior to the initiation of cannabis therapy and 3 months afterward. The primary outcome was change in mean 24-h blood pressure at 3 months.

RESULTS

Twenty-six patients with a mean age of 70.42 ± 5.37 years, 53.8% females completed the study. At 3 months follow-up, the mean 24-hours systolic and diastolic blood pressures were reduced by 5.0 mmHg and 4.5 mmHg, respectively (p<0.001 for both). The nadir for the blood pressure and heart rate was achieved at 3 hours post-administration. The proportion of normal dippers changed from 27.3% before treatment to 45.5% afterward. No significant changes were seen in the different metabolic parameters assessed by blood tests, anthropometric measurements, or ECG exam.

CONCLUSION

amongst older adults with hypertension, cannabis treatment for 3 months was associated with a reduction in 24-hours systolic and diastolic blood pressure values with a nadir at 3 hours after cannabis administration.

Efficacy of synbiotic interventions on blood pressure: a systematic review and meta-analysis of clinical trials

PURPOSE

The present systematic review and meta-analysis aimed to evaluate the effect of synbiotic interventions on blood pressure levels in adults.

METHODS

A systematic literature search was conducted in the databases of MEDLINE, Scopus, Web of Science, and Cochrane through March 2020 to identify all randomized control trials (RCTs) investigating the effects of synbiotic interventions on blood pressure parameter, including systolic (SBP) and diastolic blood pressure (DBP). Grading of Recommendations Assessment, Development and Evaluation (GRADE) scale was used to assess the certainty of evaluated outcomes and determine the strength of recommendations.

RESULTS

Eleven RCTs were included in the meta-analysis. Synbiotic interventions significantly reduced SBP (-3.02 mmHg; 95% CI: -4.84, -1.21; I² = 55%) without changing DBP levels (-0.57 mmHg; 95% CI: -1.78, 0.64; I² = 50%). Subgroup analyses revealed that the SBP-lowering effects of synbiotic interventions were more pronounced wherein trials were longer (≥12 weeks), synbiotic interventions were administrated as a supplement, and participants were younger (<50 years old). Also, a significant improvement in both SBP and DBP levels was evident in subgroups with a lower (<30 kg/m²) body mass index.

CONCLUSIONS

Synbiotic interventions may significantly improve SBP levels in adults.

Clinical Evaluation of the Polygenetic Background of Blood Pressure in the Population-Based Setting

The clinical value of the polygenetic component of blood pressure (BP) is commonly questioned. We evaluated a genetic risk score for BP (BP-GRS858), based on the most recently published genome-wide association studies variants that were significantly associated with either systolic BP or diastolic BP, for prediction of hypertension and cardiovascular end points. The genotyping was performed in 2 urban-based prospective cohorts: the Malmö Diet and Cancer (n=29 295) and the Malmö Preventive Project (n=9367) and a weighted BP-GRS858 based on 858 SNPs was calculated. At baseline, we found a difference of 9.0 mm Hg (systolic BP) and 4.8 mm Hg (diastolic BP) between the top and the bottom quartile of BP-GRS858. In Malmö Preventive Project, the top versus bottom quartile of BP-GRS858 was associated with a doubled risk of incident hypertension (odds ratio, 2.05 [95% CI, 1.75-2.39], P=1.4×10-21), a risk higher than that of body mass index, as evaluated in quartiles. In Malmö Diet and Cancer, significant association was found between the age and sex-adjusted BP-GRS858 and the incidence of total cardiovascular events, stroke, coronary artery disease, heart failure, atrial fibrillation, and total mortality. Most of these associations remained significant after adjusting for traditional risk factors, including hypertension. BP-GRS858 could contribute predictive information regarding future hypertension, with an effect size comparable to other well-known risk factors such as obesity, and predicts cardiovascular events. Given that the exposure to high polygenetic risk starts at birth, we suggest that the BP-GRS858 might be useful to identify children or adolescents who would benefit from early hypertension screening and treatment.

Risk of Cardiovascular Outcomes and Antihypertensive Triple Combination Therapy Among Elderly Patients with Hypertension Enrolled in a Medicare Advantage Plan (MAP)

OBJECTIVES

The aim was to evaluate the risk of cardiovascular-specific hospitalizations with different types of antihypertensive triple combination therapy among patients enrolled in a Medicare Advantage Plan (MAP).

METHODS

A retrospective cohort study was conducted among patients with hypertension enrolled in a Texas MAP between January 2014 and December 2016. Antihypertensive combination therapy users were classified into three treatment groups: single-pill triple combination, fixed-dose dual combination plus a third agent, and free triple combination. Group differences were assessed using Chi-square tests for binary variables and Student's t tests for continuous variables. Cox proportional hazards model was performed to assess the association between type of combination therapy and risk of cardiovascular-specific hospitalization adjusting for potential confounders.

RESULTS

A total of 10,836 triple combination users were identified. The risk of cardiovascular disease (CVD) hospitalization for the fixed-dose dual combination plus a third agent group [hazard ratio (HR) 3.82, 95% confidence interval (CI) 1.80-8.12] and for the free triple combination therapy group (HR 3.65, 95% CI 1.43-9.31) was significantly higher than for the single-pill triple combination group.

CONCLUSION

Single-pill triple combination therapy was significantly associated with a lower risk of CVD hospitalizations in comparison to other types of triple combination therapy.

The 2020 International Society of Hypertension global hypertension practice guidelines - key messages and clinical considerations

The International Society of Hypertension (ISH) has recently developed practice guidelines for the management of hypertension in adults aged ≥18 years. Conceptually, the 2020 ISH Guidelines are closer to the 2018 ESC/ESH Guidelines rather than to the 2017 ACC/AHA Guidelines. The ISH Guidelines have two distinctive features when compared with the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) Guidelines and the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines. First, they are written in a concise and easy-to-read style; second, they focuses on practical issues related to the management of hypertension in 'high-income' as well as in 'low-income' countries, where there is limited access to resources for the diagnosis and treatment of hypertension. In our opinion, the 2020 ISH Guidelines share with the 2018 ESC/ESH Guidelines an important limitation which may impair the retention of these key aspects of Guidelines by physicians, with consequent difficult adoption in clinical practice. It consists in the definition of several blood pressure targets in relation to age, target organ damage and concomitant disease. We believe that results of randomized clinical trials and meta-analysis do not support the recommendation of differential BP targets, as well as of rigid 'safety boundaries'. This review critically examines similarities and differences across the three major Hypertension Guidelines, which include the definition of hypertension, drug treatment, and blood pressure targets, with emphasis on key messages relevant for clinical practice.

Frequency & factors associated with apparent resistant hypertension among Ghanaians in a multicenter study

Apparent resistant hypertension (ARH) is rife among people living with hypertension and is associated with significant morbidity and mortality. There is however paucity of data from sub-Saharan Africa on the burden of ARH. We sought to report on the frequency and factors associated with ARH among a cohort of Ghanaians with hypertension. A cross-sectional study involving 2912 participants with hypertension enrolled at five health facilities in Ghana. ARH was defined as either office BP ≥ 140/90 mm Hg on 3 or more antihypertensive medications or on 4 or more antihypertensive medications regardless of BP. Factors associated with ARH were evaluated in a multivariate logistic regression model. We found 550 out of 2,912 (18.9%) of study participants had ARH. Out of these 550 subjects, 511 (92.9%) were on 3 or more antihypertensive medications with BP ≥ 140/90 mm Hg and 39 (7.1%) were on 4 or more antihypertensive medications with BP ≥ 140/90 mm Hg. The prevalence of ARH was 15.5% among elderly aged 75 + years (n = 341), 20.7% among 65-74 years (n = 588), and 18.9% among those ≤ 64 years (n = 1983). The adjusted odds ratio (95% CI) of factors independently associated with ARH was duration of hypertension, 1.05 (1.03-1.06) for each year rise; eGFR < 60 mL/min, 1.73 (1.33-2.25); and diabetes mellitus, 0.59 (0.46-0.76). Attaining secondary level education and residence in a peri-urban setting were significantly associated with ARH though not in a dose-dependent manner. ARH is rife among Ghanaians and may negatively impact on cardiovascular outcomes in the long term.

Effect of student-led health interventions on patient outcomes for those with cardiovascular disease or cardiovascular disease risk factors: a systematic review

Background

As the need for health care services rise, alternative service delivery models such as student-led health interventions become attractive alternatives to alleviate the burden on healthcare. Predominantly, student-led health interventions were free clinics servicing socially disadvantaged communities in the USA. A 2015 systematic review identified that students value these student-run clinics and reported skill and knowledge attainment from participating. Previous research has reported on patient satisfaction outcomes, but less frequently about the clinical outcomes patients accrue from these student-delivered services. As cardiovascular disease is the leading cause of death worldwide, this review aimed to explore the effectiveness of student-led health interventions through examining their impact on objective clinical outcomes, using the case of patients at risk of, or with, cardiovascular disease.

Methods

A systematic literature search was conducted in eight electronic databases to identify student-led health interventions conducted on adults with a cardiovascular disease risk factor or established cardiovascular disease, and a clinical outcome of interest. Through double-blinded screening and data extraction, sixteen studies were identified for synthesis.

Results

The majority of student-led health interventions for patients at risk of cardiovascular disease demonstrated a positive impact on patient health. Statistically significant changes amongst patients at risk of cardiovascular disease appeared to be associated with student-led individualised intervention or group-based interventions amongst patients with diabetes or those who are overweight or obese. The evidence was of moderate quality, as included studies lacked a control group for comparison and detail to enable the intervention to be replicated.

Conclusions

Future research applying a student-led health intervention through a randomised control trial, with rigorous reporting of both student and patient interventions and outcomes, are required to further understand the effectiveness of this alternative service delivery model.

The evaluation of a nurse-led hypertension management model in an urban community healthcare: A randomized controlled trial

BACKGROUND

Hypertension is a silent disease of the masses with an increasing prevalence and poor control rates. This study aims to establish and test the efficacy of a nurse-led hypertension management model in the community.

METHODS

A single-blind, randomized controlled trial was performed. 156 hypertensive patients with uncontrolled blood pressure were equally and randomly allocated into 2 groups. Patients in the study group received a 12-week period of hypertension management. Blood pressure, self-care behaviors, self-efficacy, and satisfaction were assessed at the start of recruitment, 12 and 16 weeks thereafter.

RESULTS

After the intervention, blood pressure of patients in the study group had greater improvement in self-care behaviors and a higher level of satisfaction with the hypertensive care compared to the control group (both P < .05).

CONCLUSIONS

The nurse-led hypertension management model is feasible and effective for patients with uncontrolled blood pressure in the community.

Effectiveness of diet and physical activity interventions among Chinese-origin populations living in high income countries: a systematic review

BACKGROUND

This review examines the effectiveness of diet and physical activity interventions to reduce cardiometabolic risk among Chinese immigrants and their descendants living in high income countries. The objective of this review is to provide information to help build future interventions aimed at improving diet and increasing physical activity levels among Chinese immigrants.

METHODS

Outcomes included BMI, weight, waist circumference (WC), waist-hip ratio (WHR), cholesterol (LDL, HDL), systolic and diastolic blood pressure (SBP, DBP), hemoglobin A1c (HgbA1c), fasting blood glucose (FBG), and HOMA-IR. Six databases were systematically searched from database inception to date of search (February 2020). Meta-analyses used random effect models to estimate pooled effects of outcomes with 95% confidence intervals. The outcomes assessed were changes in mean outcomes (post-intervention versus baseline) among the intervention group versus control groups.

RESULTS

Twenty-one articles were included for synthesis, and eight of these were included in the meta-analysis. Among children/adolescents, there were no significant effects of intervention for any of the outcomes having sufficient data for meta-analysis (BMI, WHR, SBP, and DBP). Among adults, the pooled effect including three studies showed significant changes in BMI (effect size = - 1.14 kg/m2; (95% CI: - 2.06, - 0.21), I2 = 31%). There were also significant effects of intervention among adults in terms of changes in SBP and DBP, as the pooled effect across three studies was - 6.08 mmHg (95% CI - 9.42, - 2.73), I2 = 0% and - 3.81 mmHg (95% CI: - 6.34, - 1.28), I2 = 0%, respectively. Among adults there were no other significant effects among the meta-analyses conducted (weight, WC, LDL, HgbA1c, and FBG).

CONCLUSIONS

This review is the first to summarize the effectiveness of diet and physical activity interventions specifically designed for Chinese immigrants living in high income countries. There were clinically meaningful changes in BMI and blood pressure among adults, but evidence was weak for other cardiometabolic outcomes (weight, WC, LDL, HgbA1c, and FBG), and among children, there was no evidence of effect for any cardiometabolic outcomes. Given our mixed findings, more work is needed to support the design of successful interventions, particularly those targeting children and their families.

TRIAL REGISTRATION

The systematic review protocol was registered in PROSPERO on December 17, 2018, the international prospective register of systematic reviews (registration number: CRD42018117842 ).

Treatment strategies for isolated systolic hypertension in elderly patients

INTRODUCTION

Hypertension is a major and modifiable risk factor for cardiovascular disease. Its prevalence is rising as the result of population aging. Isolated systolic hypertension mostly occurs in older patients accounting for up to 80% of cases.

AREAS COVERED

The authors systematically review published studies to appraise the scientific and clinical evidence supporting the role of blood pressure control in elderly patients with isolated systolic hypertension, and to assess the influence of different drug treatment regimens on outcomes.

EXPERT OPINION

Antihypertensive treatment of isolated systolic hypertension significantly reduces the risk of morbidity and mortality in elderly patients. Thiazide diuretics and dihydropyridine calcium-channel blockers are the primary compounds used in randomized clinical trials. These drugs can be considered as first-line agents for the management of isolated systolic hypertension. Free or fixed combination therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and calcium-channel blockers or thiazide-like diuretics should also be considered, particularly when compelling indications such as coronary artery disease, chronic kidney disease, diabetes, and congestive heart failure coexist. There is also hot scientific debate on the optimal blood pressure target to be achieved in elderly patients with isolated systolic hypertension, but current recommendations are scarcely supported by evidence.

Management of hypertension in the very old: an intensive reduction of blood pressure should be achieved in most patients

There is large evidence that treatment of hypertension significantly reduces the risk of morbidity and mortality in the elderly. Although it is generally accepted that the benefit of antihypertensive treatment is largely explained by the reduction in systolic blood pressure, the optimal blood pressure target in elderly patients is still a topic of debate. Unfortunately, the clinical trials which demonstrated the benefit of antihypertensive treatment in old and very old patients with hypertension included relatively fit patients since frail patients were generally excluded. Available data suggest that when treating older adults, and especially frail older hypertensive adults, extra caution is appropriate in the setting of significant adverse events. Nonetheless, recent observations demonstrated a similar benefit from a more intensive compared with a less intensive blood pressure lowering in both fit and frail older adults. Of note, the rate of serious adverse events appears not dissimilar in the two treatment strategies, and not associated to frailty. Taken together, these findings support the concept that an intensive therapeutic strategy appears reasonable even in elderly hypertensive patients, particularly when the treatment is well tolerated.

Clinical applications for out-of-office blood pressure monitoring

Hypertension is one of the most common chronic diseases as well as the leading risk factor for cardiovascular disease (CVD). Efficient screening and accurate blood pressure (BP) monitoring are the basic methods of detection and management. However, with developments in electronic technology, BP measurement and monitoring are no longer limited to the physician's office. Epidemiological and clinical studies have documented strong evidence for the efficacy of out-of-office BP monitoring in multiple fields for managing hypertension and CVD. This review discusses applications for out-of-office BP monitoring, including home blood pressure monitoring (HBPM) and ambulatory blood pressure monitoring (ABPM), based on recent epidemiological data and clinical studies regarding the following factors: the detection of abnormal BP phenotypes, namely, white coat hypertension and masked hypertension; stronger ability to determine the prognosis for target organ damage and mortality; better BP control; screening for hypotension; and unique approaches to identifying circadian BP patterns and BP variability.

Association of Total Medication Burden With Intensive and Standard Blood Pressure Control and Clinical Outcomes: A Secondary Analysis of SPRINT

Total medication burden (antihypertensive and nonantihypertensive medications) may be associated with poor systolic blood pressure (SBP) control. We investigated the association of baseline medication burden and clinical outcomes and whether the effect of the SBP intervention varied according to baseline medication burden in SPRINT (Systolic Blood Pressure Intervention Trial). Participants were randomized to intensive or standard SBP goal (below 120 or 140 mm Hg, respectively); n=3769 participants with high baseline medication burden (≥5 medications) and n=5592 with low burden (<5 medications).

PRIMARY OUTCOME

differences in SBP.

SECONDARY OUTCOMES

8-item Morisky Medication Adherence Scale and modified Treatment Satisfaction Questionnaire for Medications measured at baseline and 12 months and incident cardiovascular disease events and serious adverse events throughout the trial. Participants in the intensive group with high versus low medication burden were less likely to achieve their SBP goal at 12 months (risk ratio, 0.91; 95% CI, 0.85-0.97) but not in the standard group (risk ratio, 0.98; 95% CI, 0.93-1.03; Pinteraction<0.001). High medication burden was associated with increased cardiovascular disease events (hazard ratio, 1.39; 95% CI, 1.14-1.70) and serious adverse events (hazard ratio, 1.34; 95% CI, 1.24-1.45), but the effect of intensive versus standard treatment did not vary between medication burden groups (Pinteraction>0.5). Medication burden had minimal association with adherence or satisfaction. High baseline medication burden was associated with worse intensive SBP control and higher rates of cardiovascular disease events and serious adverse events. The relative benefits and risks of intensive SBP goals were similar regardless of medication burden.

CLINICAL TRIAL REGISTRATION- URL

http://www.

CLINICALTRIALS

gov. Unique identifier: NCT01206062.

European and US guidelines for arterial hypertension: similarities and differences

Hypertension is one of the most common chronic diseases in adults and a leading cause of disability and mortality worldwide. Recently, new Guidelines for the diagnosis and management of hypertension have been released in Europe and in the United States, with changes regarding how to diagnose and treat the condition, and the extent to which intensive blood pressure control should be pursued. Important differences between the Guidelines exist in the classification of blood pressure levels and definition of treatment goals. Diagnosis of hypertension starts at 140/90 mmHg for the European Guidelines, and 130/80 mmHg for the US Guidelines. Besides, the European guidelines introduced the concept of "safety boundaries", consisting of BP thresholds not to be exceeded towards lower levels (120 mmHg for age < 65 years, 130 mmHg for older people) because of the fear of important adverse events associated with overtreatment. Such discrepancies can indeed have an impact on treatment attitudes and outcome incidence. Hence, we appraised facts in favor and against each of these controversial issues. In conclusion we believe that, instead of fixing rigid BP targets and boundaries, modern hypertension management should be aimed to achieve in each patient an optimal balance between intensive BP reduction and treatment safety.

Managing hypertension in 2018: which guideline to follow?

Hypertension is a global public health issue and a major cause of morbidity and mortality. Its prevalence is increasing in many Asian countries, with a number of countries with blood pressure above the global average. Although the average systolic blood pressure is decreasing worldwide since the 1980s at the rate of about 1 mm Hg systolic blood pressure per decade, it is increasing in low-income and middle-income countries, especially in the East and South Asian population. Of note, the much larger base Asian population results in a considerably larger absolute number of individuals affected. When compared with Western countries, hypertension among Asian populations has unique features in terms of its onset, clustering of associated cardiovascular risk factors, complications and outcomes. Moreover, only a minority of hypertensive individuals are receiving treatment and achieving control. Projected number of deaths related to hypertension dramatically increased in the last 25 years in some Asian regions with a disproportionately high mortality and morbidity from stroke compared with Western countries. The relation between blood pressure and the risk of stroke is stronger in Asia than in Western regions. Although new Guidelines for hypertension diagnosis and management have been recently released from Europe and North America, the unique features of Asian hypertensive patients raise concerns on the clinical applicability of Western Guidelines to Asian populations. To this purpose, we critically reviewed key elements from the most updated Guidelines. We also discussed their core concepts to verify the impact on hypertension prevention and management in Asian countries.

School-Based Exercise Programs and Cardiometabolic Risk Factors: A Meta-analysis

CONTEXT

The effects of school-based physical activity (PA) programs on different cardiometabolic risk factors and the most appropriate features of PA programs to achieve maximum effectiveness are unclear.

OBJECTIVE

To provide a comprehensive synthesis of the effectiveness of school-based PA interventions on cardiometabolic risk factors in children.

DATA SOURCES

We identified studies from database inception to February 22, 2018.

STUDY SELECTION

We selected studies that were focused on examining the effect of school-based PA interventions on cardiometabolic risk factors in children.

DATA EXTRACTION

Random-effects models were used to calculate the pooled effect size (ES) for the included cardiometabolic risk factors (waist circumference [WC], triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, systolic blood pressure and diastolic blood pressure (DBP), and fasting insulin and glucose).

RESULTS

Nineteen randomized controlled trials (which included 11 988 children aged 3-12 years) were included in the meta-analysis. School-based PA programs were associated with a significant small improvement in WC (ES = -0.14; 95% confidence interval [CI]: -0.22 to -0.07; P < .001), DBP (ES = -0.21; 95% CI: -0.42 to -0.01; P = .040), and fasting insulin (ES = -0.12; 95% CI: -0.20 to -0.04; P = .003).

LIMITATIONS

Authors of few studies described the implementation conditions of their interventions in detail, and compliance rates were lacking in most studies. In addition, results by sex were provided in a small number of studies.

CONCLUSIONS

School-based PA interventions improve some cardiometabolic risk factors in children, such as WC, DBP, and fasting insulin.

New antihypertensive medications and clinical implications

Hypertension remains a global public health issue and is a leading preventable risk factor for many causes of mortality and morbidity. Although it is generally managed as an outpatient chronic disease, anaesthetists will inevitably encounter patients with hypertension, ranging from undiagnosed asymptomatic to chronic forms with end-organ damage(s). An understanding of perioperative management of anti-hypertensive pharmacotherapy is crucial. Although many drugs are familiar, new drug groups that have relevance for blood pressure control and perioperative care have evolved in recent years. This article also describes new antihypertensive agents currently available or under development that could impact perioperative management.

Development and evaluation of a nurse-led hypertension management model: A randomized controlled trial

BACKGROUND

The hypertension prevalence rate is increasing but the control rate is unsatisfactory. Nurse-led healthcare may be an effective way to improve outcomes for hypertensive patients but more evidence is required especially at the community level.

OBJECTIVE

This study aims to establish a nurse-led hypertension management model and to test its effectiveness at the community level.

DESIGN

A single-blind, randomized controlled trial was performed in an urban community healthcare center in China. Hypertensive patients with uncontrolled blood pressure (systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg) were randomly allocated into two groups: the study group (n=67) and the control group (n=67). The nurse-led hypertension management model included four components (delivery system design, decision support, clinical information system and self-management support). Patients in the control group received usual care. Patients in the study group received a 12-week period of hypertension management. The patient outcomes, which involved blood pressure, self-care behaviors, self-efficacy, quality of life and satisfaction, were assessed at three time points: the baseline, immediately after the intervention and 4 weeks after the intervention.

RESULTS

After the intervention, the blood pressure of patients in the study group decreased significantly compared to those in the control group, and the mean reduction of systolic/diastolic blood pressure in the study and control groups was 14.37/7.43mmHg and 5.10/2.69mmHg, respectively (p<0.01). In addition, patients in the study group had significantly greater improvement in self-care behaviors than those in the control group (p<0.01). The study group had a higher level of satisfaction with hypertensive care than the control group (p<0.01). No statistically significant difference in self-efficacy and quality of life was detected between the two groups after the intervention.

CONCLUSIONS

The nurse-led hypertension management model is feasible and effective in improving the outcomes of patients with uncontrolled blood pressure at the community level.

Achieved systolic blood pressure in older people: a systematic review and meta-analysis

BACKGROUND

It remains unclear into which level the systolic blood pressure (SBP) should be lowered in order to provide the best cardiovascular protection among older people. Hypertension guidelines recommendation on attaining SBP levels <150 mmHg in this population is currently based on experts' opinion. To clarify this issue, we systematically reviewed and quantified available evidence on the impact of achieving different SBP levels <150 mmHg on various adverse outcomes in subjects aged ≥60 years old receiving antihypertensive drug treatment.

METHODS

We searched 8 databases to identify randomized controlled trials (RCTs) and post-hoc analyses or subanalyses of RCTs reporting the effects of attaining different SBP levels <150 mmHg on the risk of stroke, acute myocardial infarction, heart failure, cardiovascular mortality and all-cause mortality in participants aged ≥60 years. We performed random-effects meta-analyses stratified by study design.

RESULTS

Eleven studies (> 33,600 participants) were included. Compared with attaining SBP levels ≥140 mmHg, levels of 130 to <140 mmHg were not associated with lower risk of outcomes in the meta-analysis of RCTs, whereas there was an associated reduction of cardiovascular mortality (RR 0.72, 95% CI 0.59-0.88) and all-cause mortality (RR 0.86, 95% CI 0.75-0.99) in the meta-analysis of post-hoc analyses or subanalyses of RCTs. Limited and conflicting data were available for the SBP levels of <130 mmHg and 140 to <150 mmHg.

CONCLUSIONS

Among older people, there is suggestive evidence that achieving SBP levels of 130 to <140 mmHg is associated with lower risks of cardiovascular and all-cause mortality. Future trials are required to confirm these findings and to provide additional evidence regarding the <130 and 140 to <150 mmHg SBP levels.

Aerobic exercise training does not alter vascular structure and function in chronic obstructive pulmonary disease

NEW FINDINGS

What is the central question of this study? Chronic obstructive pulmonary disease (COPD) is associated with endothelial dysfunction, arterial stiffness and systemic inflammation, which are linked to increased cardiovascular disease risk. We asked whether periodized aerobic exercise training could improve vascular structure and function in patients with COPD. What is the main finding and its importance? Eight weeks of periodized aerobic training did not improve endothelial function, arterial stiffness or systemic inflammation in COPD, despite improvements in aerobic capacity, blood pressure and dyspnoea. Short-term training programmes may not be long enough to improve vascular-related cardiovascular risk in COPD. Chronic obstructive pulmonary disease (COPD) has been associated with endothelial dysfunction and arterial stiffening, which are predictive of future cardiovascular events. Although aerobic exercise improves vascular function in healthy individuals and those with chronic disease, it is unknown whether aerobic exercise can positively modify the vasculature in COPD. We examined the effects of 8 weeks of periodized aerobic training on vascular structure and function and inflammation in 24 patients with COPD (age, 69 ± 7 years; forced expiratory volume in 1 second as a percentage of predicted (FEV₁ %pred), 68 ± 19%) and 20 matched control subjects (age, 64 ± 5 years; FEV₁ %pred, 113 ± 16%) for comparison. Endothelial function was measured using brachial artery flow-mediated dilatation, whereas central and peripheral pulse wave velocity, carotid artery intima-media thickness, carotid compliance, distensibility and β-stiffness index were measured using applanation tonometry and ultrasound. Peak aerobic power (V̇O2 peak ) was measured using an incremental cycling test. Upper and lower body cycling training was performed three times per week for 8 weeks, and designed to optimize vascular adaptation by increasing and sustaining vascular shear stress. Flow-mediated dilatation was not increased in COPD patients (+0.15 ± 2.27%, P = 0.82) or control subjects (+0.34 ± 3.20%, P = 0.64) and was not different between groups (P = 0.68). No significant improvements in central pulse wave velocity (COPD, +0.30 ± 1.79 m s^-1 versus control subjects, -0.34 ± 1.47 m s^-1 ) or other markers of vascular structure or function were found within or between groups. The V̇O2 peak increased significantly in COPD and control subjects, and was greater in control subjects (1.6 ± 1.4 versus 4.1 ± 3.7 ml kg min^-1 , P = 0.003), while blood pressure and dyspnoea were reduced in COPD patients (P < 0.05). These findings demonstrate that 8 weeks of aerobic training improved cardiorespiratory fitness and blood pressure in COPD but had little effect on other established markers of cardiovascular disease risk.

Guideline for the diagnosis and management of hypertension in adults - 2016

The National Heart Foundation of Australia has updated the Guide to management of hypertension 2008: assessing and managing raised blood pressure in adults (updated December 2010). Main recommendations For patients at low absolute cardiovascular disease risk with persistent blood pressure (BP) ≥ 160/100 mmHg, start antihypertensive therapy. The decision to treat at lower BP levels should consider absolute cardiovascular disease risk and/or evidence of end-organ damage, together with accurate BP assessment. For patients at moderate absolute cardiovascular disease risk with persistent systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, start antihypertensive therapy. Treat patients with uncomplicated hypertension to a target BP of < 140/90 mmHg or lower if tolerated. Changes in management as a result of the guideline Ambulatory and/or home BP monitoring should be offered if clinic BP is ≥ 140/90 mmHg, as out-of-clinic BP is a stronger predictor of outcome. In selected high cardiovascular risk populations, aiming for a target of < 120 mmHg systolic can improve cardiovascular outcomes. If targeting < 120 mmHg, close follow-up is recommended to identify treatment-related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury. Why the changes have been made A 2015 meta-analysis of patients with uncomplicated mild hypertension (systolic BP range, 140-169 mmHg) demonstrated that BP-lowering therapy is beneficial (reduced stroke, cardiovascular death and all-cause mortality). A 2015 trial comparing lower with higher blood pressure targets in selected high cardiovascular risk populations found improved cardiovascular outcomes and reduced mortality, with an increase in some treatment-related adverse events.

In vitro and in vivo postmarketing surveillance of valsartan, alone or in combination with amlodipine or hydrochlorothiazide, among Palestinian hypertensive patients

OBJECTIVES

The objectives of this study were to evaluate the general quality of the most prescribed products of valsartan (VL; alone or in combination) and to evaluate their efficacy and safety among Palestinian population through in vivo postmarketing surveillance.

PATIENTS AND METHODS

The first part was pharmacopeial quality control assay, including dissolution, disintegration, friability, and weight uniformity for VL. The second part was a 3-month cardiology clinics, observational, postmarketing surveillance pilot study that included 103 hypertensive patients who were prescribed 80 mg or 160 mg of VL as monotherapy or combination therapy. The end points were reduction in blood pressure (BP) and the rate of incidence of adverse effects (AEs) at weeks 4 and 8.

RESULTS

According to our quality control tests, all VL products showed high-quality standards according to the international guidelines. A reduction in BP was observed at weeks 4 and 8, and no significant difference was observed between the strengths of 80 mg and 160 mg. Higher BP reduction was observed after the use of combination therapy. Moreover, VL was well tolerated; most of the AEs were of mild-to-moderate intensity. In general, the most frequently reported AEs included headache (17.5%), dizziness (11.75%), and weakness (11.7%). No serious AEs or death cases were reported during the study period.

CONCLUSION

High quality of VL tablet products was used; hence, the observed efficacy and safety results should be related to patient's factors and not due to any product defects or substandard quality. Moreover, VL is an effective treatment for essential hypertension.

Novelty in hypertension in children and adolescents: focus on hypertension during the first year of life, use and interpretation of ambulatory blood pressure monitoring, role of physical activity in prevention and treatment, simple carbohydrates and uric acid as risk factors

The present article intends to provide an update of the article "Focus on prevention, diagnosis and treatment of hypertension in children and adolescents" published in 2013 (Spagnolo et al., Ital J Pediatr 39:20, 2013) in this journal. This revision is justified by the fact that during the last years there have been several new scientific contributions to the problem of hypertension in pediatric age and during adolescence. Nevertheless, for what regards some aspects of the previous article, the newly acquired information did not require substantial changes to what was already published, both from a cultural and from a clinical point of view. We felt, however, the necessity to rewrite and/or to extend other parts in the light of the most recent scientific publications. More specifically, we updated and extended the chapters on the diagnosis and management of hypertension in newborns and unweaned babies, on the use and interpretation of ambulatory blood pressure monitoring, and on the usefulness of and indications for physical activity. Furthermore, we added an entirely new section on the role that simple carbohydrates (fructose in particular) and uric acid may play in the pathogenesis of hypertension in pediatric age.

'FIFA 11 for Health' for Europe. II: effect on health markers and physical fitness in Danish schoolchildren aged 10-12 years

Objectives

To evaluate whether a modified ‘FIFA 11 for Health’ programme for non-communicable diseases had effects on body composition, blood pressure and physical fitness of Danish schoolchildren aged 10–12 years.

Design

A cluster-randomised controlled study with 7 intervention and 2 control schools.

Participants

546 Danish 5th grade municipal schoolchildren allocated to an intervention group (IG; n=402: 11.1±0.4 (±SD) years, 150.1±7.0 cm, 41.3±8.4 kg) and a control group (CG; n=144: 11.0±0.5 years, 151.2±7.8 cm, 41.3±9.0 kg).

Intervention

As part of the physical education (PE) curriculum, IG carried out 2 weekly 45 min ‘FIFA 11 for Health’ sessions focusing on health issues, football skills and 3v3 games. CG continued regular school PE activities. Measurements of body composition, blood pressure at rest, Yo-Yo intermittent recovery level 1 children's test (YYIR1C), balance, jump and sprint performance were performed before and after the 11-week study period.

Results

During the 11-week study period, systolic blood pressure (−3.5 vs 0.9 mm Hg), mean arterial blood pressure (−1.9 vs 0.4 mm Hg), body mass index (−0.02 vs 0.13 kg/m²) and body fat percentage (−0.83% vs −0.04%) decreased more (p<0.05) in IG than in CG. Within-group improvements (p<0.05) were observed in IG for 20 m sprint (4.09±0.29 to 4.06±0.28 s) and YYIR1C performance (852±464 to 896±517 m), but these changes were not significantly different from CG, and balance or jump performance remained unchanged in both groups.

Conclusions

The modified ‘FIFA 11 for Health’ programme has beneficial effects on body composition and blood pressure for Danish schoolchildren aged 10–12 years, thereby providing evidence that this football-based health education programme can directly impact participants' cardiovascular health profile.

Physical activity and cardiovascular risk factors in children: meta-analysis of randomized clinical trials

OBJECTIVE

To assess the effects of physical activity interventions in preventing cardiovascular risk factors in childhood through a systematic review and meta-analysis of randomized clinical trials (RCTs).

METHODS

A search of online databases (PubMed, EMBASE and Cochrane CENTRAL) was conducted from inception until June 2013. RCTs enrolling children 6-12years old conducted physical activity interventions longer than 6months, assessing their effect on body mass index (BMI), systolic (SBP) and diastolic blood pressure (DBP), total cholesterol (TC) and triglycerides (TG) were included. Data analysis was performed using a random-effects model.

RESULTS

Of 23.091 articles retrieved, 11 RCTs (10.748 subjects) were included. Physical activity interventions were not associated with reductions of BMI [-0.03kg/m(2) (95%CI -0.16, 0.13) I(2) 0%]. However, there was an association between the interventions and reduction of SBP [-1.25mmHg (95%CI -2.47, -0.02) I(2) 0%], DBP [-1.34mmHg (95%CI -2.57, -0.11) I(2) 43%] and TG [-0.09mmol/L (95%CI -0.14, -0.04) I(2) 0%], and increase of TC [0.14mmol/L (95%CI 0.01, 0.27) I(2) 0%].

CONCLUSION

As physical activity intervention programs lasting longer than 6months are associated with reductions in blood pressure levels and triglycerides, they should be considered to be included in prevention programs for cardiovascular diseases in schoolchildren.

Are we estimating the adverse effects of shock-wave lithotripsy on a faulty scale?

The adverse effect of shock-wave lithotripsy (SWL) for renal stones on blood pressure is currently defined as its post-treatment increase. On the contrary, we hypothesize that even mild, unilateral renal obstruction initiates an increase in blood pressure. Then, in absence of treatment-induced injury, the stone removal should decrease the blood pressure. We derived the formula to assess the expected change in the mean arterial pressure following relief of renal obstruction without affecting the kidney functions. The predictions were well replicated in the cohort of patients with renal stone treated with parenchyma-saving open surgery, with 6.4 mmHg decrease at 3 months. On the contrary, in SWL cohort, instead of the expected 4.7 mmHg decrease, the blood pressure was unchanged. In conclusion, the absence of decrease in blood pressure is a very common adverse effect of SWL, leading to an epidemiologically significant increase in the risk of arterial vascular events.

Tight Versus Standard Blood Pressure Control in Patients With Hypertension With and Without Cardiovascular Disease

An excessive blood pressure (BP) reduction might be dangerous in high-risk patients with cardiovascular disease. In the Studio Italiano Sugli Effetti CARDIOvascolari del Controllo della Pressione Arteriosa SIStolica (Cardio-Sis), 1111 nondiabetic patients with systolic BP ≥150 mm Hg were randomly assigned to a systolic BP target <140 mm Hg (standard control) or <130 mm Hg (tight control). We stratified patients by absence (n=895) or presence (n=216) of established cardiovascular disease at entry. Antihypertensive treatment was open-label and tailored to each patient’s needs. After 2-year follow-up, the primary end point of the study, electrocardiographic left ventricular hypertrophy, occurred less frequently in the tight than in the standard control group in the patients without (10.8% versus 15.2%) and with (14.1% versus 23.5%) established cardiovascular disease ( P for interaction=0.82). The main secondary end point, a composite of cardiovascular events and all-cause death, occurred less frequently in the tight than in the standard control group both in patients without (1.47 versus 3.68 patient-years; P =0.016) and with (7.87 versus 11.22 patient-years; P =0.049) previous cardiovascular disease. In a multivariable Cox model, allocation to tight BP control reduced the risk of cardiovascular events to a similar extent in patients with or without overt cardiovascular disease at randomization ( P for interaction=0.43). In conclusion, an intensive treatment aimed to lower systolic BP<130 mm Hg reduced left ventricular hypertrophy and improved clinical outcomes to a similar extent in patients with hypertension and without established cardiovascular disease.

Apparent and true resistant hypertension: definition, prevalence and outcomes

Resistant hypertension, defined as blood pressure (BP) remaining above goal despite the use of > or =3 antihypertensive medications at maximally tolerated doses (one ideally being a diuretic) or BP that requires > or =4 agents to achieve control, has received more attention with increased efforts to improve BP control rates and the emergence of device-based therapies for hypertension. This classically defined resistant group consists of patients with true resistant hypertension, controlled resistant hypertension and pseudo-resistant hypertension. In studies where pseudo-resistant hypertension cannot be excluded (for example, 24-h ambulatory BP not obtained), the term apparent resistant hypertension has been used to identify 'apparent' lack of control on > or =3 medications. Large, well-designed studies have recently reported the prevalence of resistant hypertension. Pooling prevalence data from these studies and others within North America and Europe with a combined sample size of >600,000 hypertensive participants, the prevalence of resistant hypertension is 14.8% of treated hypertensive patients and 12.5% of all hypertensives. However, the prevalence of true resistant hypertension, defined as uncontrolled both by office and 24-h ambulatory BP monitoring with confirmed medication adherence, may be more meaningful in terms of identifying risk and estimating benefit from newer therapies like renal denervation. Rates of cardiovascular events and mortality follow mean 24-h ambulatory BPs in patients with resistant hypertension, and true resistant hypertension represents the highest risk. The prevalence of true resistant hypertension has not been directly measured in large trials; however, combined data from smaller studies suggest that true resistant hypertension is present in half of the patients with resistant hypertension who are uncontrolled in the office. Our pooled analysis shows prevalence rates of 10.1% and 7.9% for uncontrolled resistant hypertension among individuals treated for hypertension and all hypertensive individuals, respectively.

Using an online, personalized program reduces cardiovascular risk factor profiles in a motivated, adherent population of participants

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of morbidity, mortality, and cost in Western society. Employer-sponsored work health programs (WHPs) and Web-based portals for monitoring and providing guidance based on participants' health risk assessments are emerging, yet online technologies to improve CVD health in the workplace are relatively unproven. We hypothesized that an online WHP, comprehensively addressing multiple facets of CVD, can be successfully implemented and improve the health of participants.

METHODS

A cohort of employees in Tennessee (n = 1,602) was subjected to a health risk assessment at baseline. Those who did not meet all 5 healthy benchmarks (n = 836)-body mass index, blood pressure, glucose, total cholesterol, and smoking status-were prospectively assigned to a Web-based personal health assistant and had repeat measurements taken at 90 days.

RESULTS

Of those who both completed the personal health assistant program and underwent baseline plus 90-day assessments (508/836, 61%), 75% were female, mean age was 46.5 ± 11.1 years, and the mean number of risk factors at baseline was 1.1 ± 0.9 with a mean 10-year Framingham Risk Score of 2.9%. This cohort demonstrated a significant reduction in total cholesterol (P < .0001), low-density lipoprotein cholesterol (P < .0001), triglycerides (P < .0001), systolic blood pressure (P = .009), glucose (P = .004), weight (P = .001), and body mass index (P = .001). Most of the participants improved at least 1 risk factor. Framingham Risk 10-year cardiovascular risk percentages were significantly reduced (P = .003).

CONCLUSIONS

This study in a prospective cohort of community-dwelling employees suggests that an online WHP can provide a viable means to improve surrogates of CVD risk factors.