Longitudinal Community-Based Assessment of Blood Pressure Control Among Japanese Hypertensive Patients: Fukushima Research of Hypertension (FRESH)

Achievement of target blood pressure among community residents with hypertension and factors associated with therapeutic failure in the northern territory of Japan

OBJECTIVE

This study aimed to determine the rate of achieving the target blood pressure (BP) defined by Japanese hypertension management guidelines and to examine factors associated with achieving the target BP.

METHODS

This cross-sectional study, which was conducted between January 2012 and December 2015, examined the BP control status and associated factors among 9,016 Japanese community residents with hypertension. Residents were divided into the following six groups: G1, young, middle-aged, and early-phase elderly patients; G2, patients with cerebrovascular disease; G3, patients with coronary artery disease; G4, patients with chronic kidney disease with proteinuria; G5, patients with diabetes; and G6, patients with chronic kidney disease without proteinuria. BP target achievement rates were calculated for each group. A multivariate analysis identified factors associated with "therapeutic failure" of target BP.

RESULTS

The target BP was achieved by 52.6% participants in G1, 84.3% in G2, 50.6% in G3, 45.6% in G4, 48.7% in G5, and 75.0% in G6. The body mass index and receiving antilipidemic medication were associated with therapeutic failure.

CONCLUSION

This study shows that achievement rates for treatment goals among Japanese patients with hypertension are still low. Body mass index and treatment of dyslipidemia may be associated with the control of BP.

The effectiveness of hypertension management in China: a community-based intervention study

AIM

This study aimed to evaluate the effectiveness of hypertension management and analyse the factors associated with blood pressure reduction within China's primary healthcare system.

BACKGROUND

Hypertension is one of the leading risk factors for global disease burden and is strongly associated with cardiovascular diseases. In China, hypertension is a serious public health problem, but few studies have evaluated the effectiveness of hypertension management in China's primary healthcare system.

METHODS

The study sites were 24 primary healthcare institutions, selected using multistage stratified random sampling method. In each institution, hypertension patients aged at least 35 years who agreed to participate and had no disabilities or mental health problems were enrolled for hypertension management. Participants received comprehensive interventions in the primary healthcare system via a team. After a one-year intervention, data from 6575 hypertension patients were analysed to check the effectiveness of hypertension management and examined factors associated with hypertension control.

FINDINGS

There was an overall mean reduction of 4.5 mmHg in systolic blood pressure (SBP) and 1.9 mmHg in diastolic blood pressure (DBP). The blood pressure reduction after one year was greater in rural patients than in urban patients, 6.6 mmHg versus 3.4 mmHg for SBP and 2.6 mmHg versus 1.6 mmHg for DBP, respectively. The hypertension control rate also increased more in rural areas (22.1%) than in urban areas (10.6%) after the one-year intervention. Age, body mass index, region and being in an urban area had a significant negative association with the reduction of SBP (P < 0.05). Education level and baseline SBP showed a significant positive association (P < 0.05).

CONCLUSIONS

Community-based hypertension management by general practitioners was feasible and effective. The effectiveness of hypertension management in rural areas was greater than in urban areas. Intervention strategies should pay more attention to patients in rural areas and western China.

Changes in blood-pressure control among patients with hypertension from 2008 through 2011: surveys of actual clinical practice

We performed cross-sectional surveys to investigate changes in clinical practices regarding blood-pressure control in patients with hypertension from 2008 through 2011. Questionnaires regarding the care of patients with hypertension were mailed to members of the Kanagawa Physicians Association in Kanagawa Prefecture, Japan. Data were obtained on 675 patients in 2008, 332 in 2009, and 1,076 in 2011. The mean systolic blood pressure (BP) was significantly lower in 2011 than in 2008 (132.2±11.9 mm Hg versus 134.6±10.6 mm Hg). The office-measured target BP, according to the 2009 guidelines of the Japanese Society of Hypertension for the management of patients with hypertension, was achieved in 53.9% of patients in 2008, 55.1% in 2009, and 57.1% in 2011. In nonelderly patients (younger than 65 years), the achievement rate was significantly greater in 2011 (41.2%) than in 2008 (23.6%). This analysis showed that the factor most significantly associated with a decrease in office-measured BP was treatment with a larger number and higher doses of antihypertensive agents. To investigate changes in clinical practices according to the guidelines, further follow-up surveys are necessary.

Higher blood pressure control rate in a real life management program provided by the community health service center in China

BACKGROUND

Community health service center (CHSC) in China is always regarded as a good facility of primary care, which plays an important role in chronic non-communicable disease management. This study aimed to investigate the blood pressure (BP) control rate in a real life CHSC-based management program and its determinants.

METHODS

The study enrolled 3191 patients (mean age of 70 ± 10 years, 43% males) in a hypertension management program provided by the Yulin CHSC (Chengdu, China), which had been running for 9 years. Uncontrolled BP was defined as the systolic BP of ≥140 mmHg and/or the diastolic BP of ≥90 mmHg, and its associated factors were analyzed by using logistic regression.

RESULTS

The duration of stay in the program was 33 ± 25 months. When compared with the BP at entry, the recent BP was significantly lowered (147 ± 17 vs. 133 ± 8 mmHg; 83 ± 11 vs. 75 ± 6 mmHg) and the BP control rate was dramatically increased (32 vs. 85%) (all p < 0.001). The age of >70 years [1.40 (odds ratio), 1.15-1.71 (95% confidence interval)], female gender (0.76, 0.63-0.93), longer stay of >33 months (0.77, 0.63-0.94), doctor in charge (0.97, 0.95-0.99), and the use of calcium channel blocker (1.35, 1.09-1.67) were significantly related to uncontrolled BP at the recent follow up (all p < 0.05).

CONCLUSIONS

This CHSC-run hypertension program provides an ideal platform of multi-intervention management, which is effective in achieving higher BP control rate in community patient population. However, the BP control status could be affected by age, gender and adherence of the patients, as well as practice behavior of the doctors.

Self-perception of glycemic control among Japanese type 2 diabetic patients: accuracy of patient perception and characteristics of patients with misperception

Aims

Some diabetic patients, despite reporting a good perception of their glycemic control, actually show poor control and this misperception might well hinder successful diabetes management. This study aimed to assess patients' self‐perception of glycemic control and to clarify factors associated with misperception of glycemic control status.

Methods

Baseline data from a hospital‐based prospective cohort of 519 type 2 diabetic patients were analyzed. Self‐perception of glycemic control and other items, including sociodemographic factors and blood test data, were determined from a self‐administered questionnaire and medical records. Factors associated with misperception were examined by age group (elderly [aged ≥ 65 years] vs non‐elderly [aged < 65 years]) using multiple logistic regression analysis.

Results

Among poorly controlled patients, misperception was higher in the elderly (glycated hemoglobin [HbA_1c] 7.4–8.3, 55.1%; HbA_1c >8.4, 44.8%) than in the non‐elderly (HbA_1c 7.4–8.3, 20.0%; HbA_1c >8.4, 18.9%). The factors significantly associated with misperception were as follows: high lifestyle regimen adherence in both age groups (non‐elderly group odds ratio [OR] 5.23; elderly group OR 5.15, respectively); high family support (OR = 7.32), failure to achieve blood pressure control (OR = 6.94) and having diabetic complications (OR = 0.06) among the non‐elderly; and long duration of diabetes (OR = 4.06) among the elderly.

Conclusions

For better management of diabetes, physicians should pay attention to the patient characteristics associated with misperception among uncontrolled diabetic patients, particularly among those who are elderly.

Combining antihypertensive and antihyperlipidemic agents - optimizing cardiovascular risk factor management

Clinical guidelines now recognize the importance of a multifactorial approach to managing cardiovascular (CV) risk. This idea was taken a step further with the concept of the Polypill™. There are, however, considerable patent, pharmacokinetic, pharmacodynamic, registration, and cost implications that will need to be overcome before the Polypill™ or other single-pill combinations of CV medications become widely available. However, a medication targeting blood pressure (BP) and lipids provides much of the proposed benefits of the Polypill™. A single-pill combination of the antihypertensive amlodipine besylate and the lipid-lowering medication atorvastatin calcium (SPAA) is currently available in many parts of the world. This review describes the rationale for this combination therapy and the clinical trials that have demonstrated that these two agents can be combined without the loss of efficacy for either agent or an increase in the incidence of adverse events. The recently completed Cluster Randomized Usual Care vs Caduet Investigation Assessing Long-term-risk (CRUCIAL trial) is discussed in detail. CRUCIAL was a 12-month, international, multicenter, prospective, open-label, parallel design, cluster-randomized trial, which demonstrated that a proactive intervention strategy based on SPAA in addition to usual care (UC) had substantial benefits on estimated CV risk, BP, and lipids over continued UC alone. Adherence with antihypertensive and lipid-lowering therapies outside of the controlled environment of clinical trials is very low (~30%–40% at 12 months). Observational studies have demonstrated that improving adherence to lipid-lowering and antihypertensive medications may reduce CV events. One means of improving adherence is the use of single-pill combinations. Real-world observational studies have demonstrated that patients are more adherent to SPAA than co-administered antihypertensive and lipid-lowering therapy, and this improved adherence translated to reduced CV events. Taken together, these findings suggest that SPAA can play an important role in helping physicians improve the management of CV risk in their patients.

Characteristics of antihypertensive medication and change of prescription over 1 year of follow up in Japan: Fukushima Research of Hypertension (FRESH)

BACKGROUND

The relationship between achieving target blood pressures and medication modification among hypertensive patients in Japan is relatively unknown. We examined the incidence of prescription changes and how the prescription changes influence success rates in achieving target blood pressures in a group of patients with uncontrolled hypertension.

METHODS

This prospective observational cohort study (July 2006 to May 2007) examined the association between blood pressure control and antihypertensive medication among 2,735 Japanese hypertensive patients who completed four seasonal follow-ups and whose medications were verified. The primary outcome was "therapeutic failure" at the third follow-up survey. Logistic regression analyzed how prescription changes may influence therapeutic failure risk. Common medication changes were estimated using follow-up data.

RESULTS

Median ages and proportion of males were 73 years and 43.8% vs. 69 years and 45.6% in those with controlled and those with uncontrolled hypertension at baseline, respectively. At baseline, 1,496 patients were uncontrolled, and 296 (18.0%) changed prescriptions during the follow-up period. Among patients with diabetes mellitus, renal disease, or organ damage and vascular complications, who were uncontrolled at baseline, prescription changes during the year significantly increased therapeutic failures at the third follow-up after adjusting for related variables. About half of the changes at each follow-up visit remained in the same class or combination category.

CONCLUSIONS

This study identified infrequent changes in prescription and minor modifications of medication even among uncontrolled hypertension. We highlight the importance of reviewing prescription content to maintain or improve blood pressure levels to achieve recommended treatment goals.