Expert recommendations on the challenges of hypertension in Asia

Guidance on ambulatory blood pressure monitoring: A statement from the HOPE Asia Network

Hypertension is an important public health issue due to its association with a number of serious diseases, including cardiovascular disease and stroke. The importance of evaluating hypertension taking into account different blood pressure (BP) profiles and BP variability (BPV) is increasingly being recognized, and is particularly relevant in Asian populations given the specific features of hypertension in the region (including greater salt sensitivity and a high rate of nocturnal hypertension). Ambulatory BP monitoring (ABPM) is the gold standard for diagnosing hypertension and assessing 24-hour BP and provides data on several important parameters that cannot be obtained using any other form of BP measurement. In addition, ABPM parameters provide better information on cardio- and cerebrovascular risk than office BP. ABPM should be used in all patients with elevated BP, particularly those with unstable office or home BP, or who are suspected to have white-coat or masked hypertension. ABPM is also an important part of hypertension diagnosis and monitoring in high-risk patients. ABPM needs to be performed using a validated device and good practice techniques, and has a role both in hypertension diagnosis and in monitoring the response to antihypertensive therapy to ensure strict BP control throughout the 24-hour period. Use of ABPM in clinical practice may be limited by cost and accessibility, and practical education of physicians and patients is essential. The ABPM evidence and practice points in this document are based on the Hypertension Cardiovascular Outcome Prevention and Evidence (HOPE) Asia Network expert panel consensus recommendations for ABPM in Asia.

Traditional Chinese Medicine for Essential Hypertension: A Clinical Evidence Map

We systematically retrieved and summarised clinical studies on traditional Chinese medicine (TCM) for the prevention and treatment of essential hypertension (EH) using the evidence map. We aimed to explore the evidence distribution, identify gaps in evidence, and inform on future research priorities. Clinical studies, systematic reviews, guidelines, and pathway studies related to TCM for the prevention and treatment of EH, published between January 2000 and December 2019, were included from databases CNKI, WanFang Data, VIP, PubMed, Embase, and Web of Science. The distribution of evidence was analysed using text descriptions, tables, and graphs. A total of 9,403 articles were included, including 5,920 randomised controlled studies (RCTs), 16 guidelines, expert consensus and path studies, and 139 systematic reviews (SRs). The articles publishing trend increased over time. This study showed that the intervention time of TCM was concentrated at 4–8 weeks, mainly through Chinese herbal medicine (CHM) for the prevention and treatment of elderly hypertension and the complications. A Measurement Tool to Assess Systematic Reviews (AMSTAR) scores of the included reviews ranged from 2 to 10. Most of the SRs had a potentially positive effect (n = 120), mainly in 5–8 score. Primary studies and SRs show potential benefits of TCM in lowering blood pressure, lowering the TCM syndrome and symptom differentiation scores (TCM-SSD scores), improving the total effective rate, and reducing the adverse events. The adjunctive effect of TCM on improving the total effective rate, lowering the blood pressure, lowering the TCM-SSD scores, and lowering the adverse effects was only supported by low-quality evidence in this research. The evidence map was used to show the overall research on TCM for the treatment of EH; however, due to the existing problems of the primary studies, the current research conclusion needs further research with higher quality and standardisation.

Fixed and Low-Dose Combinations of Blood Pressure-Lowering Agents: For the Many or the Few?

Despite the widespread availability of several effective classes of drugs, systemic arterial hypertension remains poorly controlled in the majority of patients worldwide. In this article, we discuss the different modalities and effects of combination therapy and possible future research questions. Treatment with a single antihypertensive agent can effectively reduce blood pressure in only a limited number of patients, while most require therapy with two or more agents to achieve target levels. As initial therapy, American and European guidelines suggest a combination of two antihypertensive drugs and the use of a third antihypertensive drug when hypertension is still uncontrolled. Initial combination therapy is recommended in high-risk patients for an immediate blood pressure response, improved tolerability and possibly increased patient adherence. In addition to the potential benefits of combining different drug classes with synergistic pharmacological and physiological actions, this approach is useful for increasing the patient compliance with treatment, in particular if provided at fixed doses in a single pill. The minimisation of side effects is critical for the long-term treatment of a largely asymptomatic condition such as systemic hypertension. Low-dose combinations of different drugs from classes with complementary actions may provide the best ratio of lower side effects and improved tolerability with a significant blood pressure reduction, particularly in high-risk patients. This approach could be aided by a multidisciplinary lifestyle intervention on risk factors.

Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: The HOPE Asia Network

Hypertension is an important public health issue because of its association with a number of significant diseases and adverse outcomes. However, there are important ethnic differences in the pathogenesis and cardio-/cerebrovascular consequences of hypertension. Given the large populations and rapidly aging demographic in Asian regions, optimal strategies to diagnose and manage hypertension are of high importance. Ambulatory blood pressure monitoring (ABPM) is an important out-of-office blood pressure (BP) measurement tool that should play a central role in hypertension detection and management. The use of ABPM is particularly important in Asia due to the specific features of hypertension in Asian patients, including a high prevalence of masked hypertension, disrupted BP variability with marked morning BP surge, and nocturnal hypertension. This HOPE Asia Network document summarizes region-specific literature on the relationship between ABPM parameters and cardiovascular risk and target organ damage, providing a rationale for consensus-based recommendations on the use of ABPM in Asia. The aim of these recommendations is to guide and improve clinical practice to facilitate optimal BP monitoring with the goal of optimizing patient management and expediting the efficient allocation of treatment and health care resources. This should contribute to the HOPE Asia Network mission of improving the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia.

Determinants of hypertension treatment adherence among a Chinese population using the therapeutic adherence scale for hypertensive patients

To assess the adherence level of antihypertensive treatment and identify any associated risk factors in a sample of hypertensive patients from China.A cross-sectional study involving 488 Chinese hypertensive patients was conducted in a tertiary hospital in Xi'an, China. Data were collected regarding socio-demographic factors and hypertension-related clinical characteristics. The adherence to treatment was assessed using the previously validated instrument: therapeutic adherence scale for hypertensive patients.A total of 27.46% of patients were compliant with their antihypertensive treatments. Three factors were identified to be independently associated with antihypertensive treatment adherence: gender (P = .034), residence (P = .029), duration of high blood pressure (P < .001). Gender, residence, occupation, and the duration of antihypertensive drugs treatment used were found to have significant effects on treatment adherence in certain categories.Treatment adherence among hypertensive patients in China was poor. More attention and effective strategies should be designed to address factors affecting treatment adherence. Education about hypertension knowledge should be strengthened for patients. Moreover, the importance of lifestyle modification during hypertension treatment is often neglected by patients, therefore, there is an urgent need to educate hypertensive patients about the adherence to lifestyle modifications.

Effectiveness and Adherence to Treatment with Perindopril/Indapamide/Amlodipine Single-Pill Combination in a Greek Population with Hypertension

BACKGROUND

Despite the overwhelming evidence and the established benefits of antihypertensive treatment, adherence to treatment remains low.

OBJECTIVE

To assess the adherence to treatment with a perindopril/indapamide/amlodipine single-pill combination (SPC), its effectiveness on blood pressure (BP) reduction, as well as the safety and tolerability of this SPC over a 4-month treatment period.

METHODS

This multicenter, non-interventional study prospectively included 2285 hypertensive patients on perindopril/indapamide/amlodipine SPC. The data were recorded at baseline, 1 month, and 4 months.

RESULTS

Of the 2285 hypertensive patients included in the study, 50.5% were at "high/very high risk". Mean systolic (SBP)/diastolic (DBP) decreased from 162.3 ± 13.3/93.1 ± 9.3 mmHg at baseline to 129.7 ± 8.3/78.6 ± 7.1 mmHg at 4 months (p < 0.001). Patients with higher baseline BP levels showed greater BP reduction. Patients with hypertension stages 1, 2, and 3 showed mean SBP/DBP reductions of 21.5/10.4 mmHg, 34.2/14.7 mmHg, and 51.2/22.5 mmHg, respectively, at study end (p < 0.001). Only 26 patients (1.1%) prematurely discontinued treatment (0.58% due to an adverse reaction or event).

CONCLUSIONS

Perindopril/indapamide/amlodipine SPC decreased BP levels rapidly and significantly. The degree of BP reduction was associated with the severity of hypertension and/or with total cardiovascular risk at baseline. Simplifying the drug regimen by using this SPC improved adherence and showed excellent tolerability.

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.

The adoption of hypertension reference framework: An investigation among primary care physicians of Hong Kong

Background

The Hong Kong Government released a Reference Framework (RF-HT) for Hypertension Care for Adults in Primary Care Settings since 2010. No studies have evaluated its adoption by primary care physicians (PCPs) since its release.

Aim

We aimed to evaluate the level of PCPs’ adoption of the RF-HT and the potential barriers of its use in family practice.

Design and setting

A cross-sectional study was conducted by a self-administered validated survey among all PCPs in Hong Kong through various means.

Methods

We assessed the level of and factors associated with its adoption by multivariate logistic regression modelling.

Result

A total of 3,857 invitation episodes were sent to 2,297 PCPs in 2014–2015. We received 383 completed questionnaires. The average score of adoption was 3.43 out of 4.00, and 47.5% of PCPs highly adopted RF-HT in their daily consultations. Male practitioners (adjusted odds ratio [aOR] = 0.524, 95% CI = 0.290–0.948, p = 0.033) and PCPs of public sector (aOR = 0.524, 95% CI = 0.292–0.940, p = 0.030) were significantly less likely to adopt the RF-HT. PCPs with higher training completion or being academic fellow are more likely to adopt RF-HT than those who were “nil to basic training completion” (aOR = 0.479, 95% CI = 0.269–0.853, p = 0.012) or “higher trainee” (aOR = 0.302, 95% CI = 0.093–0.979, p = 0.046). Three most-supported suggestions on RF-HT improvement were simplification of RF-HT, provision of pocket version and promoting in patients.

Conclusion

Among PCP respondents, the adoption level of the RF-HT was high. These findings also highlighted some factors associated with its adoption that could inform targeted interventions for enhancing its use in clinical practice.

Clinical Pharmacokinetics of Sacubitril/Valsartan (LCZ696): A Novel Angiotensin Receptor-Neprilysin Inhibitor

Sacubitril/valsartan (LCZ696) is indicated for the treatment of heart failure with reduced ejection fraction. Absorption of sacubitril/valsartan and conversion of sacubitril (prodrug) to sacubitrilat (neprilysin inhibitor) was rapid with maximum plasma concentrations of sacubitril, sacubitrilat, and valsartan (angiotensin receptor blocker) reaching within 0.5, 1.5-2.0, and 2.0-3.0 h, respectively. With a two-fold increase in dose, an increase in the area under the plasma concentration-time curve was proportional for sacubitril, ~1.9-fold for sacubitrilat, and ~1.7-fold for valsartan in healthy subjects. Following multiple twice-daily administration, steady-state maximum plasma concentration was reached within 3 days, showing no accumulation for sacubitril and valsartan, while ~1.6-fold accumulation for sacubitrilat. Sacubitril is eliminated predominantly as sacubitrilat through the kidney; valsartan is eliminated mainly by biliary route. Drug-drug interactions of sacubitril/valsartan were evaluated with medications commonly used in patients with heart failure including furosemide, warfarin, digoxin, carvedilol, levonorgestrel/ethinyl estradiol combination, amlodipine, omeprazole, hydrochlorothiazide, intravenous nitrates, metformin, statins, and sildenafil. Co-administration with sacubitril/valsartan increased the maximum plasma concentration (~2.0-fold) and area under the plasma concentration-time curve (1.3-fold) of atorvastatin; however, it did not affect the pharmacokinetics of simvastatin. Age, sex, or ethnicity did not affect the pharmacokinetics of sacubitril/valsartan. In patients with heart failure vs. healthy subjects, area under the plasma concentration-time curves of sacubitril, sacubitrilat, and valsartan were higher by approximately 1.6-, 2.1-, and 2.3-fold, respectively. Renal impairment had no significant impact on sacubitril and valsartan area under the plasma concentration-time curves, while the area under the plasma concentration-time curve of sacubitrilat correlated with degree of renal function (1.3-, 2.3-, 2.9-, and 3.3-fold with mild, moderate, and severe renal impairment, and end-stage renal disease, respectively). Moderate hepatic impairment increased the area under the plasma concentration-time curves of valsartan and sacubitrilat ~2.1-fold.

Single-Pill Combination of Perindopril/Indapamide/Amlodipine in Patients with Uncontrolled Hypertension: A Randomized Controlled Trial

INTRODUCTION

Patients with hypertension often require a combination of three antihypertensive agents to achieve blood pressure control, but very few single-pill triple combinations are available. The aim of this study was to determine whether a single-pill triple combination of perindopril, indapamide, and amlodipine was as effective as a dual-pill combination of perindopril/indapamide plus separate amlodipine at reducing blood pressure in patients with uncontrolled, essential hypertension.

METHODS

This international, multicenter, open-label, randomized controlled trial was conducted in men or women aged ≥18 years old with confirmed essential hypertension (SBP ≥140 and <160 mmHg and DBP ≥90 and <100 mmHg), uncontrolled on maximal dose antihypertensive monotherapy or with a single dose of dual therapy. Patients were randomly assigned to: single-pill triple combination of perindopril 5 mg/indapamide 1.25 mg/amlodipine 5 mg (Per/Ind/Aml) or dual-pill combination perindopril 5 mg/indapamide 1.25 mg + amlodipine 5 mg (Per/Ind + Aml) once daily for 12 weeks. The primary endpoint was change in office supine SBP and DBP from baseline to week 12. The proportion of responders defined as those with normalized BP (SBP <140 mmHg and DBP <90 mmHg), and/or decrease of SBP ≥20 mmHg, and/or decrease of DBP ≥10 mmHg at week 12 (W12) compared with baseline was also assessed. Secondary efficacy endpoints included change in office supine SBP and DBP, response, and BP control at weeks 4 and 8. The tolerability of the treatments was also assessed.

RESULTS

A total of 148 patients were randomized: 75 to Per/Ind/Aml and 73 to Per/Ind + Aml. Mean supine SBP and DBP were 149.1 ± 4.7 and 94.1 ± 3.1 mmHg, respectively, with no relevant between-group difference. At week 12, both triple-therapy regimens were associated with clinically significant reductions in SBP compared with baseline (-21.5 ± 11.7 and -20.0 ± 12.9 mmHg, respectively). Reductions in office supine DBP were also clinically significant (-15.3 ± 7.8 and -14.8 ± 9.0 mmHg, respectively). The proportion of treatment responders was high in both groups: 89.2 and 87.1%, respectively. The reduction in office supine SBP/DBP was already evident at week 4 and maintained for the duration of the study in both groups. The majority of patients were treatment responders at week 4 (89.2 and 82.9%, respectively) and had achieved BP control (87.8 vs. 78.6%, respectively), which was maintained until week 12 in both treatment groups. Both treatments were well tolerated with no between-group differences.

CONCLUSIONS

In adult patients with uncontrolled essential hypertension on treatment, single-pill triple-combination therapy with Per/Ind/Aml is as effective as the same dose dual-pill combination of Per/Ind + Aml. Both treatments were associated with clinically significant BP reductions compared with baseline and were well tolerated. Clinical trials number: http://www.controlled-trials.com ISRCTN: 16442558.

FUNDING

Les Laboratoires Servier.

Erratum to: Clinical Pharmacokinetics of Sacubitril/Valsartan (LCZ696): A Novel Angiotensin Receptor-Neprilysin Inhibitor

Sacubitril/valsartan (LCZ696) is indicated for the treatment of heart failure with reduced ejection fraction. Absorption of sacubitril/valsartan and conversion of sacubitril (prodrug) to sacubitrilat (neprilysin inhibitor) was rapid with maximum plasma concentrations of sacubitril, sacubitrilat, and valsartan (angiotensin receptor blocker) reaching within 0.5, 1.5-2.0, and 2.0-3.0 h, respectively. With a twofold increase in dose, an increase in the area under the plasma concentration-time curve was proportional for sacubitril, ~1.9-fold for sacubitrilat, and ~1.7-fold for valsartan in healthy subjects. Following multiple twice-daily administration, steady-state maximum plasma concentration was reached within 3 days, showing no accumulation for sacubitril and valsartan, while ~1.6-fold accumulation for sacubitrilat. Sacubitril is eliminated predominantly as sacubitrilat through the kidney; valsartan is eliminated mainly by biliary route. Drug-drug interactions of sacubitril/valsartan were evaluated with medications commonly used in patients with heart failure including furosemide, warfarin, digoxin, carvedilol, levonorgestrel/ethinyl estradiol combination, amlodipine, omeprazole, hydrochlorothiazide, intravenous nitrates, metformin, statins, and sildenafil. Co-administration with sacubitril/valsartan increased the maximum plasma concentration (~2.0-fold) and area under the plasma concentration-time curve (1.3-fold) of atorvastatin; however, it did not affect the pharmacokinetics of simvastatin. Age, sex, or ethnicity did not affect the pharmacokinetics of sacubitril/valsartan. In patients with heart failure vs. healthy subjects, area under the plasma concentration-time curves of sacubitril, sacubitrilat, and valsartan were higher by approximately 1.6-, 2.1-, and 2.3-fold, respectively. Renal impairment had no significant impact on sacubitril and valsartan area under the plasma concentration-time curves, while the area under the plasma concentration-time curve of sacubitrilat correlated with degree of renal function (1.3-, 2.3-, 2.9-, and 3.3-fold with mild, moderate, and severe renal impairment, and end-stage renal disease, respectively). Moderate hepatic impairment increased the area under the plasma concentration-time curves of valsartan and sacubitrilat ~2.1-fold.

The 2014 hypertension guidelines: implications for patients and practitioners in Asia

Hypertension is a global public health issue and a major cause of morbidity and mortality. Because of population growth and ageing, the number of people with uncontrolled hypertension rose from 600 million in 1980 to nearly 1 billion in 2008. Furthermore, the number of adults with hypertension in 2025 has also been predicted to increase by about 60% to a total of 1.56 billion. The prevalence of hypertension in most Asian countries has increased over the last 30 years and more dramatically in the last 10 years. Several factors contributed to such changes in Asia, but acculturation to Western lifestyle, modernisation and urbanisation are considered key contributing factors. There are some unique features in regards to cardiovascular risk in Asia. Specifically, Asian regions have disproportionately higher mortality and morbidity from stroke compared with Western countries. Furthermore, the relationship between blood pressure level and risk of stroke is stronger in Asia than in Western regions. Although evidence-based and qualified guidelines for hypertension diagnosis and management have been released recently from Europe and North America, the unique features of Asian patients with hypertension raise concerns in regards to the real clinical applicability of Western guidelines in Asian populations. Specifically, it is not yet clear to what extent the new blood pressure target proposed by Western guidelines for high risk and elderly hypertensive individuals apply to Asian populations.

Association between urinary 8-OHdG and pulse wave velocity in hypertensive patients with type 2 diabetes mellitus

INTRODUCTION

Oxidative stress, assessed using 8-hydroxy-2'-deoxyguanosine (8-OHdG), can be associated with arterial stiffness in patients with type 2 diabetes mellitus (T2DM) and/or hypertension (HT). We investigated the correlation between urinary 8-OHdG and pulse wave velocity (PWV) in hypertensive and non-hypertensive T2DM patients with fair glycaemic control to determine the clinical significance of HT as a comorbidity in the diabetic state.

METHODS

Clinical data, including traditional cardiovascular risk factors, diabetic complications, prescribed agents, urinary 8-OHdG level and brachial-ankle PWV, was collected from T2DM patients with and without HT.

RESULTS

There were 76 patients (45 men, 31 women; mean age 61 years; mean haemoglobin A1c level 6.5%) in the study cohort. T2DM patients with HT had significantly higher mean PWV than patients without HT (1,597 cm/s vs 1,442 cm/s; p < 0.05). Patients with HT showed no significant difference in 8-OHdG levels relative to those without HT (median 7.9 ng/mg creatinine vs 8.8 ng/mg creatinine; p > 0.05). Simple linear correlation and stepwise multiple linear regression analyses revealed that 8-OHdG levels correlated independently, significantly and positively with PWV among T2DM patients with HT (r = 0.33, p < 0.05; β= 0.23, p < 0.05). No significant correlation was observed between 8-OHdG levels and PWV among T2DM patients without HT.

CONCLUSION

In the hypertensive state, oxidative stress can be responsible for the development of arterial stiffness, even in patients with fairly well controlled T2DM. Oxidative stress management may be necessary for the prevention of cardiovascular disease in this population.

Systolic hypertension: an increasing clinical challenge in Asia

Systolic hypertension, the predominant form of hypertension in patients aged over 50-60 years, is a growing health issue as the Asian population ages. Elevated systolic blood pressure is mainly caused by arterial stiffening, resulting from age-related vascular changes. Elevated systolic pressure increases the risk of cardiovascular disease, mortality and renal function decline, and this risk may increase at lower systolic pressure levels in Asian than Western subjects. Hence, effective systolic pressure lowering is particularly important in Asians yet blood pressure control remains inadequate despite the availability of numerous antihypertensive medications. Reasons for poor blood pressure control include low awareness of hypertension among health-care professionals and patients, under-treatment, and tolerability problems with antihypertensive drugs. Current antihypertensive treatments also lack effects on the underlying vascular pathology of systolic hypertension, so novel drugs that address the pathophysiology of arterial stiffening are needed for optimal management of systolic hypertension and its cardiovascular complications.

Perception of hypertension management by patients and doctors in Asia: potential to improve blood pressure control

BACKGROUND

Hypertension is one of the world's most common health conditions and is a leading risk factor for mortality. Although blood pressure can be modified, there is a large proportion of patients whose blood pressure remains uncontrolled. The aim of this study, termed Edvantage 360°, was to gain a deeper understanding of hypertension management in Asia from the perspective of patients and doctors, and to propose strategies to improve blood pressure control.

METHODS

Conducted in Hong Kong, Indonesia, Malaysia, the Philippines, South Korea, Taiwan, and Thailand, Edvantage 360° was a mixed-methods observational study that used both qualitative and quantitative elements: qualitative interviews and focus groups with patients (N = 110), quantitative interviews with patients (N = 709), and qualitative interviews with doctors (N = 85).

RESULTS

This study found that, although there is good understanding of the causes and consequences of hypertension among Asian patients, there is a lack of urgency to control blood pressure. Doctors and patients have different expectations of each other and a divergent view on what constitutes successful hypertension management. We also identified a fundamental gap between the beliefs of doctors and patients as to who should be most responsible for the patients' hypertension management. In addition, because patients find it difficult to comply with lifestyle modifications (often because of a decreased understanding of the changes required), adherence to medication regimens may be less of a limiting factor than doctors believe.

CONCLUSIONS

Doctors may provide better care by aligning with their patients on a common understanding of successful hypertension management. Doctors may also find it helpful to provide a more personalized explanation of any needed lifestyle modifications. The willingness of the doctor to adjust their patient interaction style to form a 'doctor-patient team' is important. In addition, we recommend that doctors should not attribute ineffectiveness of the treatment plan to patient non-adherence to medications, but rather adjust the medication regimen as needed.

Real-world effectiveness of amlodipine/valsartan and amlodipine/valsartan/hydrochlorothiazide in high-risk patients and other subgroups

Background

The clinical EXCITE (EXperienCe of amlodIpine and valsarTan in hypErtension) study reported clinically relevant blood pressure (BP) reductions across all doses of amlodipine/valsartan (Aml/Val) and Aml/Val/hydrochlorothiazide (HCT) single-pill combinations. The study prospectively observed a multiethnic population of hypertensive patients for 26 weeks who were treated according to routine clinical practice. Here, we present the results in high-risk subgroups including the elderly, obese patients, and patients with diabetes or isolated systolic hypertension. In addition, we present a post hoc analysis as per prior antihypertensive monotherapy and dual therapy.

Methods

Patients prescribed Aml/Val or Aml/Val/HCT were assessed in this 26±8 week, noninterventional, multicenter study across 13 countries in the Middle East and Asia. Changes in mean sitting systolic BP, mean sitting diastolic BP, and overall safety were assessed.

Results

Of a total of 9,794 patients analyzed, 8,603 and 1,191 patients were prescribed Aml/Val and Aml/Val/HCT, respectively. Among these, 15.5% were elderly, 32.5% were obese, 31.3% had diabetes, and 9.8% had isolated systolic hypertension. Both Aml/Val and Aml/Val/HCT single-pill combinations, respectively, were associated with clinically relevant and significant mean sitting systolic/diastolic BP reductions across all subgroups: elderly patients (−32.2/−14.3 mmHg and −38.5/−16.5 mmHg), obese patients (−32.2/−17.9 mmHg and −38.5/−18.4 mmHg), diabetic patients (−30.3/−16.1 mmHg and −34.4/−16.6 mmHg), and patients with isolated systolic hypertension (−25.5/−4.1 mmHg and −30.2/−5.9 mmHg). Incremental BP reductions with Aml/Val or Aml/Val/HCT single-pill combinations were also observed in patients receiving prior monotherapy or dual therapy for hypertension. Overall, both Aml/Val and Aml/Val/HCT were generally well tolerated.

Conclusion

This large, multiethnic study supports the evidence that Aml/Val and Aml/Val/ HCT single-pill combinations are effective in diverse and clinically important subgroups of patients with hypertension.

The effectiveness of a life style modification and peer support home blood pressure monitoring in control of hypertension: protocol for a cluster randomized controlled trial

Background

Death rates due to hypertension in low and middle income countries are higher compared to high income countries. The present study is designed to combine life style modification and home blood pressure monitoring for control of hypertension in the context of low and middle income countries.

Methods

The study is a two armed, parallel group, un-blinded, cluster randomized controlled trial undertaken within lower income areas in Kuala Lumpur. Two housing complexes will be assigned to the intervention group and the other two housing complexes will be allocated in the control group. Based on power analysis, 320 participants will be recruited. The participants in the intervention group (n = 160) will undergo three main components in the intervention which are the peer support for home blood pressure monitoring, face to face health coaching on healthy diet and demonstration and training for indoor home based exercise activities while the control group will receive a pamphlet containing information on hypertension. The primary outcomes are systolic and diastolic blood pressure. Secondary outcome measures include practice of self-blood pressure monitoring, dietary intake, level of physical activity and physical fitness.

Discussion

The present study will evaluate the effect of lifestyle modification and peer support home blood pressure monitoring on blood pressure control, during a 6 month intervention period. Moreover, the study aims to assess whether these effects can be sustainable more than six months after the intervention has ended.

Is yangxue qingnao granule combined with antihypertensive drugs, a new integrative medicine therapy, more effective than antihypertensive therapy alone in treating essential hypertension?

Background. Yangxue Qingnao granule (YQG) combined with antihypertensive drugs, a new integrative medicine therapy, has been widely used for essential hypertension (EH) in China. This study aims to assess the current clinical evidence of YQG combined with antihypertensive drugs for EH. Methods. Randomized controlled trials(RCTs) published between 1996 and 2012 on YQG combined with antihypertensive drugs versus antihypertensive drugs in treating EH were retrieved from six major electronic databases, including The Cochrane Library, PubMed, Chinese National Knowledge Infrastructure, Chinese Scientific Journal Database, Chinese Biomedical Literature Database, and Wanfang Data. Meta-analysis was performed on the overall effects on blood pressure. Results. Twelve randomized trials were included. Methodological quality of the trials was evaluated as generally low. Meta-analysis showed that YQG combined with antihypertensive drugs demonstrated potential effect for lowing either SBP (MD: -7.31 [-11.75, -2.87]; P = 0.001) or DBP (MD: -5.21 [-8.19, -2.24]; P = 0.0006) compared to antihypertensive drugs alone. Conclusions. It indicated that YQG combined with antihypertensive drugs is more effective than antihypertensive drugs alone in treating EH. However, more RCTs of larger scale, multicentre/country, longer follow-up periods, and higher quality are required to verify the efficacy of integrative medicine therapy over all antihypertensive therapies.

A traditional Sami diet score as a determinant of mortality in a general northern Swedish population

OBJECTIVES

To examine the relationship between "traditional Sami" dietary pattern and mortality in a general northern Swedish population.

STUDY DESIGN

Population-based cohort study.

METHODS

We examined 77,319 subjects from the Västerbotten Intervention Program (VIP) cohort. A traditional Sami diet score was constructed by adding 1 point for intake above the median level of red meat, fatty fish, total fat, berries and boiled coffee, and 1 point for intake below the median of vegetables, bread and fibre. Hazard ratios (HR) for mortality were calculated by Cox regression.

RESULTS

Increasing traditional Sami diet scores were associated with slightly elevated all-cause mortality in men [Multivariate HR per 1-point increase in score 1.04 (95% CI 1.01-1.07), p=0.018], but not for women [Multivariate HR 1.03 (95% CI 0.99-1.07), p=0.130]. This increased risk was approximately equally attributable to cardiovascular disease and cancer, though somewhat more apparent for cardiovascular disease mortality in men free from diabetes, hypertension and obesity at baseline [Multivariate HR 1.10 (95% CI 1.01-1.20), p=0.023].

CONCLUSIONS

A weak increased all-cause mortality was observed in men with higher traditional Sami diet scores. However, due to the complexity in defining a "traditional Sami" diet, and the limitations of our questionnaire for this purpose, the study should be considered exploratory, a first attempt to relate a "traditional Sami" dietary pattern to health endpoints. Further investigation of cohorts with more detailed information on dietary and lifestyle items relevant for traditional Sami culture is warranted.

Prevalence and risk factors associated with prehypertension: identification of foci for primary prevention of hypertension

BACKGROUND AND RESEARCH OBJECTIVE

Prehypertension (pre-HT) has become an important public health issue in China because it identifies people at higher risk for hypertension (HT) and cardiovascular diseases. The aims of this study were to (1) examine the prevalence of pre-HT, (2) identify risk factors of pre-HT, and (3) identify factors that increase the likelihood of developing HT among the pre-HT group.

SUBJECT AND METHODS

This was a cross-sectional descriptive study. Community-dwelling residents of an urban district in Wuhan, central China (obtained from stratified random sampling), aged between 35 and 74 years completed the study. Data were collected by using a structured self-reporting questionnaire and a standardized protocol for blood pressure measurement and risk screening. Blood pressure categories were defined according to the results of the seventh report of the Joint National Committee on the Prevention, Detection and Treatment of High Blood Pressure.

RESULTS

Among the 1,448 participants, 618 (42.7%) had pre-HT. Multivariate logistic regression analysis revealed the risk factors of being overweight (adjusted odds ratio [aOR], 1.93; 95% confidence interval [CI], 1.26-2.98) or obese (aOR, 8.9; 95% CI, 1.14-62.3) and having above-optimal triglyceride level (aOR, 1.67; 95% CI, 1.24-2.26) were associated with pre-HT. Age and lower educational level were also associated with pre-HT risk. There was a clear trend toward an increased risk of HT among the pre-HT group with every 10-year increment in age starting from 45 years (aORs were 3.47, 6.82, and 7.58, respectively). Participants with Pre-HT currently engaging in sedentary work were also found to have a higher risk of developing HT. Other risk factors for HT included being overweight (aOR, 2.0; 95% CI, 1.50-2.68), a known family history of HT (aOR, 2.54; 95% CI, 1.98-3.26), and presence of diabetes mellitus (aOR, 2.51; 95% CI, 1.66-3.80).

CONCLUSION

Prehypertension is common among residents in an urban district in central China. Findings of this study serve to identify the at-risk groups. Targeting these people early with therapeutic lifestyle changes may provide important long-term benefit for HT prevention.