State of Hypertension Management in the United States: Confluence of Risk Factors and the Prevalence of Resistant Hypertension

'Inequalities in prevalence of hypertension, prehypertension, anti-hypertensive coverage, awareness, and effective treatment in 429 districts of Iran; a population-based STEPS 2016 small area spatial estimation model'

Purpose

While many studies have reported hypertension (HTN) and pre-hypertension (PHTN) in large geographic locations of Iran, information regarding district levels is missing. We aimed to examine inequalities in the prevalence of hypertension, prehypertension, anti-hypertensive coverage, awareness, and effective treatment of adults in districts of Iran.

Methods

We used 27,165 participants' data from the STEPS 2016 study in Iran. A small area estimation model was carried out to predict HTN in the 429 districts of Iran. HTN and PHTN were defined based on the American Heart Association Guideline. Awareness of being hypertensive, treatment coverage, and effective treatment were also estimated.

Results

HTN's crude prevalence was estimated to be in the range of 11.5-42.2% in districts. About PHTN, it was estimated to be 19.9-56.1%. Moreover, for awareness, treatment coverage, and effective treatment crude estimates ranged from 24.3 to 79.9%, 9.1 - 64.6%, and 19.5 - 68.3%, respectively, indicating inequalities in the distribution of aforementioned variables in 429 districts of Iran. Overall, better conditions were detected in central geographical locations and in females.

Conclusion

The inequality of increased blood pressure disorder and related measures are high in districts of Iran and pave the way for policymakers and local health organizers to use the findings of this study to address the inequity of existing resources and improve HTN control.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01186-5.

Prevalence, predictors, and outcomes of both true- and pseudo-resistant hypertension in the action to control cardiovascular risk in diabetes trial: a cohort study

Resistant hypertension (RH) has been poorly studied due to the difficulty in distinguishing it from nonadherence-the exclusion of which is necessary to accurately diagnose RH. Therefore, little is known about the prevalence, predictors, and outcomes of true RH. We evaluated 1838 patients from the standard blood pressure (BP) arm of the Action to Control Cardiovascular Risk in Diabetes Trial. We classified patients into three groups: "true RH", "pseudo-RH" (i.e., patients with BP levels that would classify them as RH but who were non-adherent), and "other" (i.e., those who could not be classified as having "true RH" or "pseudo-RH"). We examined predictors of true and pseudo-RH and the relationship between true RH and the composite outcome of nonfatal MI, nonfatal stroke, or cardiovascular death. Among 1838 participants with complete information, 489 (26.6%) met the definition of true RH, and 94 (16.1%) RH patients had "pseudo-RH" on ≥1 visit over the first 12 months. Predictors of RH included: baseline SBP ≥ 160 mmHg (OR = 8.79; 95% CI: 5.70-13.68) and baseline SBP between 140-159 (OR = 2.91; 95% CI: 2.13-4.00) compared to SBP < 140, additional baseline BP medication (OR = 3.40; 95% CI: 2.83-4.11), macroalbuminuria (OR = 2.35; 95% CI: 1.50-3.67), CKD (OR = 1.53; 95% CI: 0.99-2.33), history of stroke (OR = 1.73; 95% CI: 1.04-2.82), and black race (OR = 1.39; 95% CI: 1.02-1.88); the cross-validated C-statistic was 0.80. "True RH" patients had a 65% increased hazard in composite outcome (HR = 1.65; 95% CI: 1.13-2.42). In conclusion, the majority of patients classified as having RH had "true RH," which was more common among those who are black, have macroalbuminuria, CKD, stroke, higher baseline SBP, and are taking more baseline antihypertensives. These patients are at increased risk for cardiovascular and mortality events.

Fetal programming and the angiotensin-(1-7) axis: a review of the experimental and clinical data

Hypertension is the primary risk factor for cardiovascular disease that constitutes a serious worldwide health concern and a significant healthcare burden. As the majority of hypertension has an unknown etiology, considerable research efforts in both experimental models and human cohorts has focused on the premise that alterations in the fetal and perinatal environment are key factors in the development of hypertension in children and adults. The exact mechanisms of how fetal programming events increase the risk of hypertension and cardiovascular disease are not fully elaborated; however, the focus on alterations in the biochemical components and functional aspects of the renin-angiotensin (Ang) system (RAS) has predominated, particularly activation of the Ang-converting enzyme (ACE)-Ang II-Ang type 1 receptor (AT1R) axis. The emerging view of alternative pathways within the RAS that may functionally antagonize the Ang II axis raise the possibility that programming events also target the non-classical components of the RAS as an additional mechanism contributing to the development and progression of hypertension. In the current review, we evaluate the potential role of the ACE2-Ang-(1-7)-Mas receptor (MasR) axis of the RAS in fetal programming events and cardiovascular and renal dysfunction. Specifically, the review examines the impact of fetal programming on the Ang-(1-7) axis within the circulation, kidney, and brain such that the loss of Ang-(1-7) expression or tone, contributes to the chronic dysregulation of blood pressure (BP) and cardiometabolic disease in the offspring, as well as the influence of sex on potential programming of this pathway.

Resistant hypertension in elderly: a clinical manifestation of heart failure with preserved ejection fraction? retrospective single-center analysis

Background: Resistant hypertension (RHT) is defined as high blood pressure despite three antihypertensive medications one being a diuretic. RHT is a common clinical problem and as a subgroup has not been studied widely. The present study has investigated patient demographics and if the RHT might be a clinical presentation of heart failure with preserved ejection fraction (HFPEF) in elderly. Method: The outpatient data between January and June 2015 of Izmir Kemalpasa State hospital's hypertension specialty clinic has been reviewed retrospectively. The patients with pseudo-RHT are excluded. Among 957 patients, 68 patients have been identified as true RHT with a left ventricle ejection fraction ≥50%. HFPEF is defined according to the latest guideline. Instead of a common cut-off level for NT-proBNP, age and gender-related cut-off levels have been used. Results: The mean age was 63.24 ± 12.05 years. Among 68 patients, 49 were female. While only 3 patients in younger group (8.8%) had elevated levels of NT-proBNP, 22 of older RHT patients (64.7%) had high levels. NT-proBNP levels were disproportionally high in elderly (p < 0.001) and high levels in RHT patients were related to a larger left atrial diameter (p < 0.001). Conclusion: The underlying mechanism might be different in RHT according to age. Hypervolemia might be the key factor in older RHT patients but not in younger patients. The current study suggests RHT in elderly can be a clinical presentation of HFPEF, and they should be investigated and treated accordingly. Because of single-center results and limited patients, further studies are needed.

Preferred Fourth-Line Pharmacotherapy for Resistant Hypertension: Are We There Yet?

Resistant hypertension (RH) is defined as blood pressure (BP) that remains above target levels despite adherence to at least three different antihypertensive medications, typically including a diuretic. Epidemiological studies estimate that RH is increasing in prevalence, and is associated with detrimental health outcomes. The pathophysiology underlying RH is complex, involving multiple, overlapping contributors including activation of the renin-angiotensin aldosterone system and the sympathetic nervous system, volume overload, endothelial dysfunction, behavioural and lifestyle factors. Hypertension guidelines currently recommend specific pharmacotherapy for 1st, 2nd and 3rd-line treatment, however no specific fourth-line pharmacotherapy is provided for those with RH. Rather, five different antihypertensive drug classes are generally suggested as possible alternatives, including: mineralocorticoid receptor antagonists, α1-adrenergic antagonists, α2-adrenergic agonists, β-blockers, and peripheral vasodilators. Each of these drug classes vary in their efficacy, tolerability and safety profile. This review summarises the available data on each of these drug classes as a potential fourth-line drug and reveals a lack of robust clinical evidence for preferred use of most of these classes in the setting of RH. Moreover, there is a lack of direct comparative trials that could assist in identifying a preferred fourth-line pharmacologic approach and in providing evidence for hypertensive guidelines for adequate treatment of RH.

Sugar-sweetened beverages and school students' hypertension in urban areas of Nanjing, China

Literature showed that sugar-sweetened beverages (SSBs) could increase the risk of developing hypertension in school students, but there is no reported evidence from China yet, so this study aims to investigate the association of the SSBs consumption and school students' hypertension in urban areas of Nanjing, China. A cross-sectional survey was conducted among primary and junior high school students selected from 32 primary schools and 16 junior high schools using a multi-stage random sampling method, with a total number of 10,091 participants involved. The mean age of Grade 4 is 9.04 ± 0.38, while the mean age of Grade 7 is 12.03 ± 0.41. Blood pressure was measured and SSBs consumption was reported using a validated questionnaire. The overall prevalence of hypertension was 4.5% among the participants. After adjustment for school, parental education, physical activity, diet intake including meat and snacks, participants who had an experience of SSBs intake were at a higher risk of developing hypertension (odds ratio (OR) = 1.40, 95% confidence interval (CI) = 1.15, 1.70) compared with those who had no experience of SSBs intake. A significant association between the consumption of SSBs and hypertension was observed among the students who were at a healthy weight (OR = 1.78, 95% CI = 1.20, 2.65), as well as who were overweight or obese (OR = 1.28, 95% CI = 1.01, 1.61). SSBs may play a contributing role in developing childhood hypertension in this population in China, which is of important implications for future population-based childhood hypertension intervention in China and other countries.

The association between serum uric acid and blood pressure in different age groups in a healthy Chinese cohort

High serum uric acid (sUA) has been reported to be a risk factor for hypertension however, whether this is the case for all age groups is not clear. We examined the association between sUA concentrations and systolic and diastolic blood pressure (SBP and DBP) in different age groups in a cohort of healthy Chinese participants.A total of 1082 healthy participants aged from 41 to 70 years were included. sUA concentration was measured by the uricase-peroxidase method. SBP and DBP were assessed using mercury sphygmomanometry. Hypertension was defined as SBP ≥140 mm Hg or DBP ≥90 mm Hg. Hyperuricemia (HUA) was defined as sUA concentration of >7 mg/dL in men and >6 mg/dL in women. The association between sUA concentration and SBP and DBP was examined using Pearson's correlation test, multivariate linear regression, and logistic regression analysis.The prevalence of hypertension and HUA increased with age (P < .001). Hypertension was more common in participants that had HUA than in those that did not (38.95% vs 30.16%, P = .02). Higher sUA was significantly associated with higher SBP and DBP in the 41- to 50-year-old participants (SBP, β = 0.35, P < .001; DBP, β = .29, P < .001; after adjustment for age, sex, total cholesterol, estimated glomerular filtration rate, and fasting plasma glucose). HUA was also a risk factor for hypertension in this age group (odds ratio 1.425, 95% confidence interval, 1.217-1.668, P < .001). There was no association between sUA concentration and SBP and DBP in the other age groups.In this population of healthy Chinese participants, sUA concentration was positively associated with hypertension only in the 41- to 50-year-old group. Lowering uric acid in this age group may help to reduce the incidence of hypertension.

Race, obesity, and the renin-angiotensin-aldosterone system: treatment response in children with primary hypertension

BACKGROUND

Pediatric primary hypertension (HTN) is increasingly recognized, but the effect of patient characteristics such as obesity and race on treatment outcomes is not well described. The renin-angiotensin-aldosterone system (RAAS) may also contribute to HTN. We hypothesized patient parameters of these factors, including baseline RAAS, influence blood pressure (BP) response to pharmacological treatment in HTN.

METHODS

This was a retrospective cohort of 102 consecutive patients with HTN. Primary outcomes were changes per year in systolic and diastolic BP (SBP, DBP). Secondary outcome was change per year in left ventricular mass index (LVMI). We evaluated whether baseline plasma renin activity (PRA), aldosterone, renin-to-aldosterone ratio, overweight/obesity, race, initial drug choice, and multidrug therapy were associated with the outcomes using general linear regression models adjusted for confounding variables.

RESULTS

Racially diverse (43% Hispanic, 28% black, 25% white) and predominantly overweight/obese (75%) patients were studied. Median length of follow-up was 14.5 months. Higher baseline aldosterone was associated with decreased SBP (-1.03 mmHg/year), DBP (-0.95 mmHg/year), and DBP z score (-0.07/year) during the study period. Higher baseline PRA was associated with decreased SBP z score (-0.04/year) and LVMI (-2.89 g/m^2.7/year). Stratified analyses revealed the relationships between baseline aldosterone and PRA, and annual reductions in outcomes were strengthened in nonobese and white patients.

CONCLUSIONS

Pretreatment aldosterone and PRA predicted short-term follow-up BP and LVMI, especially in nonobese and white patients. The RAAS profile could guide treatment of HTN and suggests consideration of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers as first-line treatment options.

African American Veterans Storytelling: A Multisite Randomized Trial to Improve Hypertension

BACKGROUND

Disparities in hypertension control persist for African American Veterans.

OBJECTIVE

To enhance cultural relevance of hypertension control self-management education, in a multisite, stratified randomized trial, we tested an interactive Veteran-to-Veteran storytelling digital video disk (DVD) intervention created with Veteran partners, versus an education-only DVD comparison.

METHODS

At 3 VA facilities, African American Veterans with uncontrolled hypertension were randomized to storytelling DVD intervention or didactic comparison DVD and followed for 6 months. We hypothesized that follow-up blood pressure (BP) would be lower among Veterans in the intervention group.

RESULTS

African American Veterans (N=619) were 92% male, 39% over age 65, most had a high-school education, over 50% of both the intervention and comparison group reported a household income of <$20,000, and 40% had less than adequate health literacy. At baseline, mean intervention and comparison group BPs were 138/80 and 139/81 mm Hg, respectively; at 6 months, mean systolic BP (SBP) increased by 0.1 in the intervention group and by 1.9 for the comparison group; diastolic BP fell by 0.1 in the intervention group and rose by 0.2 in the comparison group. No differences between the intervention and control groups were statistically significant (all P>0.3). Site differences were large; at one, the intervention group improved while the comparison groups deteriorated, resulting in 6.3 and 3.9 mm Hg more improvement for the intervention group in SBP and diastolic BP (P=0.06 and 0.04), respectively; at the other 2 sites, there were positive and negative changes, all small, in the 2 measures, with minimal differences-one site favored the comparison group and the other, the intervention (these comparisons did not approach statistical significance (all P>0.20). In a secondary analysis stratified by baseline BP, there was no intervention effect among those with uncontrolled BP, but intervention patients who were in control at baseline were more likely to stay in control, compared with comparison [SBP increase by 6.3 mm Hg (SD=14.4) among intervention, and by 10.9 mm Hg (SD=16.9) in comparison, P=0.02].

CONCLUSIONS

In this multisite trial, we did not find a significant overall storytelling intervention effect (Clinicaltrials.gov Reg. #NCT01276197).

Stroke paradox with SGLT-2 inhibitors: a play of chance or a viscosity-mediated reality?

Diabetes mellitus is a major risk factor for cardiovascular morbidity and mortality. Current therapeutic strategies have not provided constant beneficial cardiovascular-related results. Sodium-glucose co-transporters 2 (SGLT-2) inhibitors have emerged as a novel antidiabetic class of drugs that exert favourable results in a variety of other cardiovascular risk factors too, such as increased blood pressure and body weight. The Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes (EMPA-REG OUTCOME) study was the first trial that evaluated cardiovascular outcomes in patients with diabetes with the use of empagliflozin, a member of this new class of drugs. Empagliflozin was associated with remarkable reduction of cardiovascular morbidity and mortality and all-cause death. On the contrary, stroke incidence was slightly increased, although the result did not reach statistical significance. It could be assumed that a drug providing such beneficial effects on cardiovascular outcomes, would have also the same impact in stroke risk. This finding could theoretically be attributed to 'play of chance'. However, an increase of haematocrit was observed in EMPA-REG and other SGLT-2 inhibitors studies. Accumulating evidence suggests a direct association between increased haematocrit and stroke risk. Could this 'stroke paradox' be a result of the increased haematocrit levels noted with SGLT-2 inhibitors? The aim of this review is to critically assess both possibilities, given that increased stroke rates (if indeed true) should not be neglected and unattended.

Sodium-glucose cotransporter-2 inhibitors and blood pressure decrease: a valuable effect of a novel antidiabetic class?

Diabetes mellitus is a major issue of public health, affecting more than 300 million people worldwide. Inhibitors of the sodium-glucose cotransporter-2 (SGLT-2) in the renal proximal tubule are a novel class of agents for the treatment of type 2 diabetes mellitus. Inhibition of the SGLT-2 results in reduced glucose reabsorption and improvement in glycemic control. Alongside glucose excretion, SGLT-2 inhibitors also have mild natriuretic and diuretic effects, combining actions of a proximal tubule diuretic and an osmotic diuretic; these properties are expected to lead to small blood pressure (BP) reductions. Clinical studies with dapagliflozin, canagliflozin, empagliflozin, ipragliflozin, luseogliflozin, and tofogliflozin used either as monotherapy or add-on therapy and compared with placebo or active treatment have also examined the effect of these agents on BP as a secondary endpoint. Although with some differences between individual agents, all of the approved SGLT-2 inhibitors provided a mild but meaningful reduction in office SBP and DBP. Recent studies with the use of ambulatory blood pressure monitoring suggest that the magnitude of this BP reduction can be even greater. The aim of this review is to systematically summarize and present the studies reporting the effect of approved SGLT-2 inhibitors on BP.

Economic evaluation of a single-pill triple antihypertensive therapy with valsartan, amlodipine, and hydrochlorothiazide against its dual components

The aim of this study was to compare the cost-utility of the first available single-pill triple combination antihypertensive therapy containing valsartan (V), amlodipine (A) and hydrochlorothiazide (H), with each of the same components dual combinations in patients with moderate to severe hypertension.

A Markov model with eight health states was constructed. The short-term effect of antihypertensive treatment on blood pressure was extrapolated through the Hellenic SCORE and Framingham risk equations, estimating the long-term survival and quality-adjusted life-years (QALYs) saved. Costs and outcomes were evaluated over lifetime, divided into annual cycles and discounted at 3.0 % with 2013 as reference year. The analysis was conducted by the Greek third-party-payer perspective.

The triple combination treatment cost was estimated at €16,525 compared to €15,480 for V/A, €14,125 for V/H and €11,690 for A/H. The QALYs saved with the triple combination were 12.76 vs. 12.64, 12.61 and 12.38 for double combinations respectively. The incremental cost-effectiveness ratio of the triple combination versus V/A and A/H was far lower than the Greek GDP per capita (€8,690/QALY and €12,695/QALY, respectively) and really close for V/H (€16,192/QALY), suggesting V/A/H combination to be cost-effective. Extensive sensitivity analyses confirmed the robustness of the results. The probability that the triple combination is cost effective was more than 90 % at a willingness-to-pay threshold of €18,000/QALY.

This is the first study to evaluate the cost-utility of a single-pill triple combination. The single-pill V/A/H therapy is a cost-effective antihypertensive choice for the treatment of moderate to severe hypertension, compared to its dual components.

Association of hemoglobin levels with blood pressure and hypertension in a large population-based study: the Korea National Health and Nutrition Examination Surveys 2008-2011

BACKGROUND

We investigated the association of hemoglobin (Hb) concentrations with blood pressure (BP) and hypertension in the full range of Hb concentrations, after adjusting for other hypertension risk factors.

METHODS

The study population consisted of a total of 20,076 subjects (8721 men, 11,355 women) aged ≥20 y who participated in the Korea National Health and Nutrition Examination Surveys conducted between 2008 and 2011.

RESULTS

The systolic BP (SBP) and diastolic BP (DBP) increased by 2.6mmHg and 3.2mmHg with 1mmol/l increase in the Hb concentration, respectively, after adjusting for age, body mass index, total cholesterol, alcohol drinking, current smoking, mild renal dysfunction, and diabetes mellitus both in men with Hb concentrations of ≥8.1mmol/l (13.0g/dl) and women with a hemoglobin concentration ≥6.8mmol/l (11.0g/dl). In the multiple logistic regression analysis, the Hb concentration showed significant positive association with hypertension independently of other confounding factors both in men and women.

CONCLUSIONS

Hb concentration was positively associated with SBP and DBP in men with Hb concentrations ≥8.1mmol/l (13.0g/dl) and women with Hb concentrations ≥6.8mmol/l (11.0g/dl) in the general Korean population.

School performance affects adolescent blood pressure

Hypertension is a risk factor in many cardiovascular or cerebrovascular diseases. Adolescent hypertension may develop into adult hypertension. Examining the aetiologic factors of adolescent hypertension is crucial in its prevention and in managing its possible complications. The predominant view of aetiologic factors includes heredity, overweight/obesity, insulin resistance, gestational hypertension, diet, and intrauterine growth retardation. This article reported that children's academic grades in schools were positively correlated with adolescent blood pressure.

The prevalence, incidence, prognosis, and associated conditions of resistant hypertension

Resistant hypertension is a relevant condition gaining special attention given its clinical and economic impact. Although the true prevalence is unknown, clinical trials and population-based studies have shown that it is a common clinical problem that likely will increase in incidence with an aging and more obese population. A complex interaction of various risk factors including lifestyle, associated conditions, and identifiable secondary causes can lead to uncontrolled hypertension. Important factors including improper blood pressure measuring technique, poor medication adherence, and the white coat phenomenon can lead to pseudoresistance, or a false impression of treatment resistance, which must be excluded. Patients with true resistant hypertension have a greater risk for developing adverse cardiovascular events compared with those with controlled blood pressure, leading to an unfavorable prognosis without adequate treatment. This article reviews the current understanding of the epidemiology of resistant hypertension.

Systemic implementation strategies to improve hypertension: the Kaiser Permanente Southern California experience

The past decade has seen hypertension improving in the United States where control is approximately 50%. Kaiser Permanente has mirrored and exceeded these national advances in control. Integrated models of care such as Kaiser Permanente and the Veterans Administration health systems have demonstrated the greatest hypertension outcomes. We detail the story of Kaiser Permanente Southern California (KPSC) to illustrate the success that can be achieved with an integrated health system model that uses implementation, dissemination, and performance feedback approaches to chronic disease care. KPSC, with a large ethnically diverse population of more than 3.6 million, has used a stepwise approach to achieve control rates greater than 85% in those recognized with hypertension. This was accomplished through systemic implementations of specific strategies: (1) capturing hypertensive members into a hypertension registry; (2) standardization of blood pressure measurements; (3) drafting and disseminating an internal treatment algorithm that is evidence-based and is advocating of combination therapy; and (4) a multidisciplinary approach using medical assistants, nurses, and pharmacists as key stakeholders. The infrastructure, support, and involvement across all levels of the health system with rapid and continuous performance feedback have been pivotal in ensuring the follow-through and maintenance of these strategies. The KPSC hypertension program is continually evolving in these areas. With these high control rates and established infrastructure, they are positioned to take on different innovations and study models. Such potential projects are drafting strategies on resistant hypertension or addressing the concerns about overtreatment of hypertension.

Role of ambulatory blood pressure monitoring in hypertension and diabetes

The prevalence of hypertension and diabetes are both rising in the USA and around the globe. The treatment of hypertension in the ambulatory setting begins with proper blood pressure measurement, and often the involvement of home blood pressure monitoring. If the diagnosis of hypertension is confirmed, then education on lifestyle modifications is the foundation to reaching blood pressure goals. If it is unclear, then ambulatory blood pressure monitoring should be performed to properly evaluate daily trends in blood pressure. The National Institute for Health and Clinical excellence (NICE) recommends 24-hour ambulatory blood pressure evaluation in all newly diagnosed patients with hypertension. The much-anticipated JNC 2013, while not likely to endorse this approach, will likely recommend an office goal systolic blood pressure of less than 140 mmHg in patients with diabetes as do the most recent American Diabetes Association clinical practice guidelines. All new guidelines are derived from a critical evidence based evaluation of the available data.

Does decreasing serum uric acid level prevent hypertension? - a nested RCT in cohort study: rationale, methods, and baseline characteristics of study cohort

BACKGROUND

Previous epidemiologic studies have demonstrated an association between uric acid and hypertension. Our objective was to conduct a prospective cohort study with a nested randomised controlled trial (RCT in cohort) that aims to identify the association of hyperuricemia with the development of hypertension and to examine the efficacy of dietary intervention in lowering uric acid level and prevention of hypertension.

METHODS/DESIGN

Participants were considered eligible to enrol for this cohort study if they were not diagnosed with hypertension until their last routine health examination. The characteristics of the eligible participants were analyzed. After enrolment, participants with prehypertension and hyperuricemia simultaneously were randomly distributed to either the intervention group or the control group. An education package of dietary intervention for lowering uric acid was delivered to the intervention group. The primary evaluation criterion was the first manifestation of hypertension.

DISCUSSION

Based on the results of their health examination in 2010, 19, 724 subjects met the inclusion criteria and this source population guaranteed the required minimum sample size for this study. The baseline characteristics of the study cohort showed that hyperuricemia was associated with prehypertension, and was independent of age, body mass index (BMI), and abdominal obesity in females; however, in males it was contrary.The impact of lowering uric acid on the prevention of hypertension is still inconclusive. This RCT in cohort study provides important data on the prevention of hypertension, especially in patients with a high risk for hypertension development. Results are expected to be available in 2015.

TRIAL REGISTRATION

The study is registered with the Chinese Clinical Trial Registry (ChiCTR-TRC-12002925).

Tolerability and pharmacokinetics of ACT-280778, a novel nondihydropyridine dual L/T-type calcium channel blocker: early clinical studies in healthy male subjects using adaptive designs

ACT-280778 is a novel nondihydropyridine dual L/T-type calcium channel blocker. Two clinical studies (AC-067-101 and AC-067-102) were conducted to characterize its safety, tolerability, and pharmacokinetics in healthy male subjects after oral administration of single and multiple doses. Both trials were single-center, randomized, double-blind, placebo-controlled, adaptive design, ascending-dose studies, in which ACT-280778 was administrated as single doses of 2, 5, 15, or 40 mg, or as once-daily doses of 5 or 15 mg for 7 days. Single and multiple doses up to and including 15 mg were well tolerated, and no serious or severe adverse event was reported in either study. A single dose of 40 mg was associated with abnormal electrocardiogram findings resulting in the discontinuation of further treatment at this dose or higher doses. ACT-280778 was rapidly absorbed, and larger than dose-proportional increases of the maximum plasma concentration and area under the plasma concentration-time curve were observed. Food intake delayed the time to maximum plasma concentration and doubled exposure. Urinary excretion of unchanged ACT-280778 was negligible, and accumulation at steady state was modest. Overall, pharmacokinetic and tolerability profiles of ACT-280778 observed in these 2 studies warranted further evaluation of ACT-280778 in a proof-of-concept study in patients with hypertension.

A high-salt diet further impairs age-associated declines in cognitive, behavioral, and cardiovascular functions in male Fischer brown Norway rats

Aging-associated declines in cognitive, emotional, and cardiovascular function are well known. Environmental stress triggers critical changes in the brain, further compromising cardiovascular and behavioral health during aging. Excessive dietary salt intake is one such stressor. Here, we tested the effect of high salt (HS) on anxiety, learning-memory function, and blood pressure (BP) in male Fischer brown Norway (FBN) rats. Adult (A; 2 mo) and old (O; 20 mo) male rats were fed normal-salt (NS; 0.4% NaCl) or HS (8% NaCl) diets for 4 wk after being implanted with telemeter probes for conscious BP measurement. Thereafter, tests to assess anxiety-like behavior and learning-memory were conducted. The rats were then killed, and samples of plasma, urine, and brain tissue were collected. We found that systolic BP was higher in O-NS (117 ± 1.2 mm Hg) than in A-NS (105 ± 0.8 mm Hg) rats (P < 0.05). Furthermore, BP was higher in O-HS (124 ± 1.4 mm Hg) than in O-NS (117 ± 1.2 mm Hg) rats (P < 0.05). Moreover, anxiety-like behavior (light-dark and open-field tests) was not different between A-NS and O-NS rats but was greater in O-HS rats than in A-NS, O-NS, or A-HS rats (P < 0.05). Short-term memory (radial arm water maze test) was similar in A-NS and O-NS rats but was significantly impaired in O-HS rats compared with A-NS, O-NS, or A-HS rats (P < 0.05). Furthermore, oxidative stress variables (in plasma, urine, and brain) as well as corticosterone (plasma) were greater in O-HS rats when compared with A-NS, O-NS, or A-HS rats (P < 0.05). The antioxidant enzyme glyoxalase-1 expression was selectively reduced in the hippocampus and amygdala of O-HS rats compared with A-NS, O-NS, or A-HS rats (P < 0.05), whereas other antioxidant enzymes, glutathione reductase 1, manganese superoxide dismutase (SOD), and Cu/Zn SOD remained unchanged. We suggest that salt-sensitive hypertension and behavioral derangement are associated with a redox imbalance in the brain of aged FBN rats.

Apparent treatment-resistant hypertension among elderly Korean hypertensives: an insight from the HIT registry

The aim of this study was to determine the clinical characteristics of patients with resistant hypertension (RH) and predictors among elderly Korean hypertensives. This prospective, multi-center, observational study evaluated 2439 elderly hypertensive patients between December 2008 and November 2011, who visited secondary hypertension clinics for high blood pressure (BP). Patients were categorized as resistant if their BP was ≥140/90 mm Hg and if they reported using antihypertensive medications from three different drug classes, including a diuretic or drugs from ≥4 antihypertensive drug classes, regardless of BP. Characteristics of patients with RH were compared with those of patients who were controlled with one or two antihypertensive medications after 6-month antihypertensive treatment. In comparison with 837 patients with non-RH, 404 patients with RH were more likely to be aware of their status of high BP before enrollment and have a high baseline systolic BP ≥160 mm Hg, microalbuminuria, high body mass index (BMI) ≥24 kg m(-2) and diabetes mellitus (DM). In drug-naive patients, awareness of hypertension at baseline was the only independent predictor for RH. In elderly Korean hypertensives, BMI (≥24 kg m(-2)), baseline systolic BP (≥160 mm Hg), microalbuminuria, DM and awareness of hypertension showed an association with RH.

Simultaneous estimation of amlodipine and atenolol in human plasma: a sensitive LC–MS/MS method validation and its application to a clinical PK study

Background: A highly sensitive, specific and rapid LC–ESI-MS/MS method has been developed and validated for simultaneous quantification of amlodipine (AMD) and atenolol (ATL) in human plasma (200 µl) using AMD-d4 and ATL-d7, respectively, as an internal standard (IS) as per the regulatory guidelines. Results: The SPE method was used to extract the analytes and IS from human plasma. The chromatographic resolution of AMD, ATL and corresponding IS was achieved using an isocratic flow on a C18 column. The total chromatographic run time was 3 min. A linear response function was established for the range of concentrations 50–8000 pg/ml and 10–800 ng/ml for AMD and ATL, respectively, in human plasma. Conclusion: The intra- and inter-day accuracy and precision values for AMD and ATL met the acceptance as per regulatory guidelines. The validated assay was applied to a fixed-dose combination of AMD and ATL (Adopin-AT®) PK study in humans.

Prevalence and clinical profile of resistant hypertension among treated hypertensive subjects

We assessed prevalence and clinical characteristics of resistant hypertension (RH) and prevalence of false RH (white-coat effect [WCE] by home blood pressure [BP] monitoring), among a population of 302 treated hypertensive patients, mean age 66.6 (± 13.8), 67.5% women. Resistant hypertension was defined according to the American Heart Association criteria. Prevalence of RH was 10%, and the following five variables were independently associated with it: body mass index, diabetes, isolated systolic hypertension, orthostatic hypotension, and use of beta-blockers. Prevalence of WCE among subjects with office-RH was 27.6%. Our study identified easily measurable parameters related to RH. Standing BP should be systematically measured in individuals with RH.

Blood pressure control in Italian essential hypertensives treated by general practitioners

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effect of allopurinol on lowering blood pressure in hemodialysis patients with hyperuricemia

BACKGROUND

Hyperuricemia has been associated with the development of high blood pressure (BP). We studied the effects of allopurinol therapy in hyperuricemic hemodialysis (HD) patients with high BP.

MATERIALS AND METHODS

This single-blind, randomized cross-over clinical study involved 55 HD patients with serum uric acid level > 6.5 (men) and > 5.5 mg/dL (women). They were randomly divided in two groups, each of which went through two phases. Group-1 in phase-1 received 100 mg/day orally of allopurinol for three months; while Group-2 was given whatever medication they received prior to the study. After two months of washing period, the groups were crossed-over. The BP levels were measured before and after HD during the eight months study period.

RESULTS

Fifty-three patients completed the study (33 men and 20 women, with mean age of 55.8 years). Uric acid levels decreased significantly during the12 weeks of allopurinol therapy (7.71 ± 1.53 to 5.2 ± 1.2 P < 0.005). Overall, after the 12 weeks of allopurinol therapy, systolic and diastolic BP also significantly decreased in allopurinol group, 15.8% (139 to 117, P < 0.0005) and 8.6% (81 to 74, P <.0005), respectively. There were not significant changes in body mass index, blood urea nitrogen, creatinine, albumin, cholesterol, triglyceride, hemoglobin, liver enzymes and serum electrolytes level after treatment. Patients treated with allopurinol had a significant increase in the quality of dialysis (KT/V) (P: 0.043).

CONCLUSIONS

In HD patients, allopurinol treatment reduced BP. The results indicate a new potential therapeutic approach for controlling BP in HD patients.

A novel process for integrating patient stories into patient education interventions: incorporating lessons from theater arts

OBJECTIVE

Patient narratives, or stories, are an effective means of educating patients because they increase personal relevance and may reduce counter-arguing. However, such stories must seamlessly combine evidenced-based health information while being true to real patient experiences. The purpose of this paper is to describe the process of developing an educational intervention using African-American patients' success stories controlling hypertension.

METHODS

We identified a process to address stories development challenges.

RESULTS

(1) To help identify story tellers, we conducted a literature review and subsequently streamlined the process of storyteller identification through screening and telephone interviews. (2) To better elicit stories, we consulted with experts in storytelling and incorporated principles from theater. (3) To select stories, we used intervention mapping to map the intervention to theory and key clinical concepts, and also engaged members of the target community to ensure scientific criteria and maintain authenticity.

CONCLUSION

Using personal narratives as intervention requires weaving together science, theory and clinically sound content, while still being true to the art of storytelling. Through a careful process of identifying storytellers and story selection and drawing upon theater arts, creating stories for intervention can be streamlined while meeting the goals of authenticity and scientific soundness.

Patient knowledge of blood pressure target is associated with improved blood pressure control in chronic kidney disease

OBJECTIVE

To describe patient hypertension knowledge and associations with blood pressure measurements.

METHODS

Patients with chronic kidney disease (CKD) were asked about the impact of high blood pressure on kidneys and their target blood pressure goal. Systolic blood pressure was measured using automated sphygmomanometers.

RESULTS

In 338 adults with hypertension and pre-dialysis CKD, the median [IQR] age was 59 [47,68] years, 45% [n = 152] were women, and 18% [n = 62] were non-white. Lower systolic blood pressure (SBP) was associated with female sex (SBP mmHg median [IQR] 132 [117,149] women vs. 137 [124,152] men; p = 0.04), less advanced CKD (SBP 134 [122,147] stages 1-2 vs. 132 [118,148] stage 3 vs. 140 [125,156] stages 4-5; p = 0.01), and patient ability to correctly identify SBP goal (SBP 134 [119,150] correct vs. 141 [125,154] incorrect; p = 0.05). In adjusted analysis, knowledge of blood pressure goal remained independently associated with lower SBP (-9.96 mmHg [-19.97, -1.95] in correct respondents vs. incorrect; p<0.001).

CONCLUSION

Patient knowledge of goal blood pressure is independently associated with improved blood pressure control.

PRACTICE IMPLICATIONS

Interventions to improve patient knowledge of specific blood pressure targets may have an important role in optimizing blood pressure management.

Predictors of resistant hypertension in an unselected sample of an adult male population in Italy

Prevalence, incidence and predictors of resistant hypertension (RH), (defined as blood pressure persistently above goal in spite of the concurrent use of three antihypertensive agents of different classes) in the general population remain largely unknown. A complete database including anthropometric and biochemical data was collected in 1994-1995 (baseline examination) in 1,019 participants (mean age 51.8, range: 25-79 years) and again in 2002-2004 in 794 male participants of the Olivetti Heart Study (OHS) in southern Italy. The incidence of RH over the average follow-up time of 7.9 years was 4.8% (38/794) in the whole study population and 10.1% (31/307) among hypertensive participants. Basal blood pressure (systolic, diastolic or pulse pressure), cholesterol and urinary albumin/creatinine ratio (ACR) significantly predicted the risk of developing RH using a logistic regression model that also included age as covariates. If in the same model we added basal pharmacological treatment, the fractional excretion of sodium (FENa) also became a statistically significant predictor, and this last model explained nearly 25% of the risk of developing RH. In this unselected sample of an adult male population, ACR (an early marker of organ damage), an elevated FENa (a proxy for dietary sodium intake), cholesterol and a higher basal blood pressure level were independent predictors of RH.

Use of carvedilol in hypertension: an update

β-blockers are effective antihypertensive agents and, together with diuretics, have been the cornerstone of pioneering studies showing their benefits on cardiovascular morbidity and mortality as a consequence of blood pressure reduction in patients with hypertension. However, evidence from recent meta-analyses have demonstrated no benefit afforded by atenolol compared with placebo in risk of mortality, myocardial infarction, or stroke, and a higher risk of mortality and stroke with atenolol/propranolol compared with other antihypertensive drug classes. Thus, the effect of these agents on cardiovascular morbidity and mortality in hypertensive patients, especially their use in uncomplicated hypertension, has remained largely controversial. However, it is recognized that the clinical studies used in these meta-analyses were mainly based on the older second-generation β-blockers, such as atenolol and metoprolol. Actually, considerable heterogeneity in, eg, pharmacokinetic, pharmacological, and physicochemical properties exists across the different classes of β-blockers, particularly between the second-generation and newer third-generation agents. Carvedilol is a vasodilating noncardioselective third-generation β-blocker, without the negative hemodynamic and metabolic effects of traditional β-blockers, which can be used as a cardioprotective agent. Compared with conventional β-blockers, carvedilol maintains cardiac output, has a reduced prolonged effect on heart rate, and reduces blood pressure by decreasing vascular resistance. Studies have also shown that carvedilol exhibits favorable effects on metabolic parameters, eg, glycemic control, insulin sensitivity, and lipid metabolism, suggesting that it could be considered in the treatment of patients with metabolic syndrome or diabetes. The present report provides an overview of the main clinical studies concerning carvedilol administered as either monotherapy or in combination with another antihypertensive or more frequently a diuretic agent, with particular focus on the additional benefits beyond blood pressure reduction.

The contribution of chronic kidney disease to the global burden of major noncommunicable diseases

Noncommunicable diseases (NCDs) are the most common causes of premature death and morbidity and have a major impact on health-care costs, productivity, and growth. Cardiovascular disease, cancer, diabetes, and chronic respiratory disease have been prioritized in the Global NCD Action Plan endorsed by the World Health Assembly, because they share behavioral risk factors amenable to public-health action and represent a major portion of the global NCD burden. Chronic kidney disease (CKD) is a key determinant of the poor health outcomes of major NCDs. CKD is associated with an eight- to tenfold increase in cardiovascular mortality and is a risk multiplier in patients with diabetes and hypertension. Milder CKD (often due to diabetes and hypertension) affects 5-7% of the world population and is more common in developing countries and disadvantaged and minority populations. Early detection and treatment of CKD using readily available, inexpensive therapies can slow or prevent progression to end-stage renal disease (ESRD). Interventions targeting CKD, particularly to reduce urine protein excretion, are efficacious, cost-effective methods of improving cardiovascular and renal outcomes, especially when applied to high-risk groups. Integration of these approaches within NCD programs could minimize the need for renal replacement therapy. Early detection and treatment of CKD can be implemented at minimal cost and will reduce the burden of ESRD, improve outcomes of diabetes and cardiovascular disease (including hypertension), and substantially reduce morbidity and mortality from NCDs. Prevention of CKD should be considered in planning and implementation of national NCD policy in the developed and developing world.

Effectiveness and safety of valsartan in children aged 6 to 16 years with hypertension

The effectiveness and safety of valsartan have not been assessed in hypertensive children. Therefore, hypertensive patients aged 6 to 16 years (n=261) were randomized to receive weight-stratified low- (10/20 mg), medium- (40/80 mg), or high-dose (80/160 mg) valsartan for 2 weeks. After 2 weeks, patients were randomized to a 2-week placebo-controlled withdrawal phase. Dose-dependent reductions in sitting systolic blood pressure (SSBP) and sitting diastolic blood pressure (SDBP) were observed after 2 weeks (low dose, -7.9/-4.6 mm Hg; medium dose, -9.6/-5.8 mm Hg; high dose, -11.5/-7.4 mm Hg [P<.0001 for all groups]). During the withdrawal phase, SSBP and SDBP were both lower in the pooled valsartan group than in the pooled placebo group (SSBP, -2.7 mm Hg [P=.0368]; SDBP, -3.0 mm Hg [P=.0047]). Similar efficacy was observed in all subgroups. Valsartan was well tolerated and headache was the most commonly observed adverse event during both the double-blind and 52-week open-label phases.

Common secondary causes of resistant hypertension and rational for treatment

Resistant hypertension is defined as uncontrolled blood pressure despite the use of three antihypertensive drugs, including a diuretic, in optimal doses. Treatment resistance can be attributed to poor adherence to antihypertensive drugs, excessive salt intake, physician inertia, inappropriate or inadequate medication, and secondary hypertension. Drug-induced hypertension, obstructive sleep apnoea, primary aldosteronism, and chronic kidney disease represent the most common secondary causes of resistant hypertension. Several drugs can induce or exacerbate pre-existing hypertension, with non-steroidal anti-inflammatory drugs being the most common due to their wide use. Obstructive sleep apnoea and primary aldosteronism are frequently encountered in patients with resistant hypertension and require expert management. Hypertension is commonly found in patients with chronic kidney disease and is frequently resistant to treatment, while the management of renovascular hypertension remains controversial. A step-by-step approach of patients with resistant hypertension is proposed at the end of this review paper.

Resistant hypertension workup and approach to treatment

Resistant hypertension is defined as blood pressure above the patient's goal despite the use of 3 or more antihypertensive agents from different classes at optimal doses, one of which should ideally be a diuretic. Evaluation of patients with resistive hypertension should first confirm that they have true resistant hypertension by ruling out or correcting factors associated with pseudoresistance such as white coat hypertension, suboptimal blood pressure measurement technique, poor adherence to prescribed medication, suboptimal dosing of antihypertensive agents or inappropriate combinations, the white coat effect, and clinical inertia. Management includes lifestyle and dietary modification, elimination of medications contributing to resistance, and evaluation of potential secondary causes of hypertension. Pharmacological treatment should be tailored to the patient's profile and focus on the causative pathway of resistance. Patients with uncontrolled hypertension despite receiving an optimal therapy are candidates for newer interventional therapies such as carotid baroreceptor stimulation and renal denervation.

Renin inhibition and microalbuminuria development: meaningful predictor of kidney disease progression

PURPOSE OF REVIEW

Microalbuminuria is an indicator of increased cardiovascular disease risk. Herein, we review microalbuminuria as a predictor of the onset and progression of renal disease in people with and without diabetes. We evaluate the data on the use of direct renin inhibitors (DRIs) for treatment of hypertension with microalbuminuria.

RECENT FINDINGS

It is known that DRIs have an antiproteinuric effect, whether used alone or with an angiotensin receptor blocker (ARB), independent of its hypotensive effects in patients with type 2 diabetes. A current study will determine if adding the DRI aliskiren to an angiotensin-converting enzyme inhibitor (ACEi) or an ARB will reduce cardiovascular and renal risk in patients with type 2 diabetes.

SUMMARY

DRIs are the latest addition to the class of renin-angiotensin-aldosterone system (RAAS) inhibitors available for patients with hypertension and kidney disease. Whether these drugs can improve upon the reduction of cardiovascular and renal risk with an ACEi or an ARB is unknown. Microalbuminuria is a surrogate marker for both cardiovascular and possibly renal endpoints. However, an ongoing issue is that the majority of patients with microalbuminuria will die of cardiovascular events before the onset of end-stage renal disease, limiting the value of using longitudinal measures of microalbuminuria progression as a measure of therapeutic benefit with newer RAAS-blocking drugs such as DRIs.

Diuretics in clinical practice. Part I: mechanisms of action, pharmacological effects and clinical indications of diuretic compounds

IMPORTANCE OF THE FIELD

Diuretics are among the most important drugs of our therapeutic armamentarium and have been broadly used for > 50 years, providing important help towards the treatment of several diseases. Although all diuretics act primarily by impairing sodium reabsorption in the renal tubules, they differ in their mechanism and site of action and, therefore, in their specific pharmacological properties and clinical indications. Loop diuretics are mainly used for oedematous disorders (i.e., cardiac failure, nephrotic syndrome) and for blood pressure and volume control in renal disease; thiazides and related agents are among the most prescribed drugs for hypertension treatment; aldosterone-blockers are traditionally used for primary or secondary aldosteronism; and other diuretic classes have more specific indications.

AREAS COVERED IN THIS REVIEW

This article discusses the mechanisms of action, pharmacological effects and clinical indications of the various diuretic classes used in everyday clinical practice, with emphasis on recent knowledge suggesting beneficial effects of certain diuretics on clinical conditions distinct from the traditional indications of these drugs (i.e., heart protection for aldosterone blockers).

WHAT THE READER WILL GAIN

Reader will gain insights into the effective use of diuretic agents for various medical conditions, representing their established or emerging therapeutic indications.

TAKE HOME MESSAGE

Knowledge of the pharmacologic properties and mechanisms of action of diuretic agents is a prerequisite for the successful choice and effective clinical use of these compounds.