High rates of non-adherence to antihypertensive treatment revealed by high-performance liquid chromatography-tandem mass spectrometry (HP LC-MS/MS) urine analysis

Optimizing hypertension management: the impact of drug class, socioeconomic factors, and simplified regimens on medication adherence. VATAHTA study

BACKGROUND

Medication adherence is essential for managing hypertension, yet many patients fail to follow prescribed treatments. This study examines the relationships between drug class, treatment complexity, socioeconomic factors, and adherence in hypertensive patients from Argentina.

METHODS

A multicentre, cross-sectional study was conducted with 1144 hypertensive patients from the Cuyo region. Adherence was assessed using the Morisky Medication Adherence Scale (MMAS-8). The impact of drug classes, number of prescribed drugs, dosing frequency, and socioeconomic factors (education, home ownership, employment status) on adherence was analysed using multivariate logistic regression. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated.

RESULTS

Patients on fixed-dose combinations demonstrated better adherence than those on monotherapy (OR 1.30, 95% CI: 1.15-1.45). Higher education (OR 1.20, 95% CI: 1.05-1.35) and home ownership (OR 1.15, 95% CI: 1.02-1.28) were associated with improved adherence, while unemployment was linked to reduced adherence. Patients taking more than three drugs showed lower adherence (OR 0.85, 95% CI: 0.75-0.95), and more frequent dosing (more than twice daily) was linked to reduced adherence (OR 0.78, 95% CI: 0.68-0.90). Beta-blockers (OR 2.5, 95% CI: 2.0-3.0) and potassium-sparing diuretics (OR 1.7, 95% CI: 1.3-2.1) were associated with the highest adherence, while ACE inhibitors such as ramipril (OR 0.75, 95% CI: 0.60-0.90) were linked to lower adherence.

CONCLUSION

Simplified regimens, particularly fixed-dose combinations, and the selection of drugs with favourable adherence profiles, like beta-blockers and potassium-sparing diuretics, can improve adherence. Addressing socioeconomic barriers should also be prioritized.

A Study Of the effect of Sex on drug dosing, concentrations, and pharmacogenomics in the Montreal Heart Institute Hospital Cohort (SOS-PGx): methodology and research progress

BACKGROUND

Women are underrepresented in drug development trials and there is no sex-tailored drug regimen for most medications. It has been repeatedly shown that women have more adverse drug reactions than men for several medications. These differences could be explained by higher dose-adjusted drug concentrations in women. Thus, we aim to identify sex-related differences and to characterize the clinical and genetic predictors of these differences in drug concentrations, dosing, and adherence for 47 commonly used drugs in a large cohort. The objective of this article is to present an overview of the methods and characteristics of the study population.

METHODS

We performed a cross-sectional study that included 10,082 men and women of European ancestry aged ≥ 18 years from the Montreal Heart Institute Hospital Cohort taking at least one of the 47 medications regularly.

RESULTS

Of the 10,082 participants included, 36% were women. Women had lower weight, height, waist girth, and body mass index than men, but they had higher hip girth (all p < 0.001). Men had a higher level of education and annual income and were more likely to be employed full-time compared to women. Furthermore, men had a higher prevalence of hypertension, type 2 diabetes, dyslipidemia, and myocardial infarction (all p < 0.001) and were more likely receiving lipid-lowering agents, beta-blockers, antidiabetic drugs, and angiotensin-converting enzyme inhibitors. Conversely, proton pump inhibitors were more prevalent in women. Interestingly, nearly half of the women had a history of drug allergy or intolerance, compared with less than one-third of the men (p < 0.001).

CONCLUSION

This study has a high potential in understanding eventual sex differences in drug dosing requirements and will most likely provide useful information to personalize drug regimens in women.

Adherence to antihypertensive medications in Omani patients: a comparison of drug biochemical analysis and the Morisky Medication Adherence Scale

BACKGROUND

Medication nonadherence is a major risk factor for suboptimal or failed hypertension pharmacologic therapy.

OBJECTIVE

To determine the nonadherence rate to antihypertensive medications using high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS) and the self-reported Morisky Medication Adherence Scale (MMAS).

METHODS

This study used a prospective cross-sectional cohort design. Patients with hypertension aged ≥18 years and prescribed at least one antihypertensive medication were recruited from an outpatient hypertensive clinic at a tertiary healthcare institution in Oman. Adherence was assessed using LC-MS/MS urine analysis and the MMAS.

RESULTS

In total, 162 patients completed the MMAS questionnaire and provided urine samples for LC-MS/MS analysis. The overall mean age of the cohort was 55 ± 13 years, and 57% of the patients were men. The mean systolic and diastolic blood pressures were 146 ± 18 mmHg and 79 ± 10 mmHg, respectively. Using the MMAS method, 65% of the patients reported nonadherence. However, LC-MS/MS analysis revealed that only 27% of the patients were nonadherent. The adherent group by LC-MS/MS had significantly lower systolic ( P  = 0.026) and diastolic blood pressures ( P  < 0.001) than the nonadherent group, whereas no differences were observed using the MMAS method. There was weak or no agreement between the MMAS and LC-MS/MS results ( P  = 0.142).

CONCLUSION

Almost one-fourth of our patients with hypertension were nonadherent to their medications. There was a weak concordance between the MMAS and LC-MS/MS methods in detecting medication nonadherence. Further research into noninvasive convenient adherence scales or methods and their correlations with LC-MS/MS analysis is warranted.

Investigation and management of resistant hypertension: British and Irish Hypertension Society position statement

People living with resistant hypertension (RH) are at high risk of adverse cardiovascular events. The British and Irish Hypertension Society has identified suspected RH as a condition for which specialist guidance may improve rates of blood pressure control and help clinicians identify those individuals who may benefit from specialist review. In this position statement we provide a practical approach for the investigation and management of adults with RH. We highlight gaps in the current evidence and identify important future research questions. Our aim is to support the delivery of high-quality and consistent care to people living with RH across the UK and Ireland.

Cardiovascular medication adherence testing in patients living with HIV: A single-centre observational study

INTRODUCTION

People with HIV (PWH) are at an increased risk of developing cardiovascular disease (CVD) compared to HIV-negative individuals. We sought to evaluate the adherence to medications for CVD in PWH and identify factors associated with non-adherence to these medications.

METHODS

We conducted a cross-sectional study at the University Hospitals of Leicester NHS Trust between 16 April 2019 and 8 November 2022. We recruited consecutive PWH, who were attending a routine follow-up outpatient appointment and were prescribed at least one medication for CVD. In addition, we included urinary adherence results of patients with samples collected as part of routine clinical care. We used liquid chromatography-tandem mass spectrometry (LC-MS/MS) to assess if their prescribed medications (antihypertensives, diuretics, beta-blockers, lipid-lowering agents, antiplatelets, anticoagulants, antidiabetic medications) were present in the participant's urine sample. Multivariable models were used to identify demographic or clinical features that were associated with non-adherence.

RESULTS

A total of 162 PWH were included in the analysis. Median age was 55 [interquartile range (IQR): 50-61] years, 63% were male, average time living with HIV was 15 years (IQR: 11-19) and the majority (98%) had an undetectable HIV viral load. In approximately one-third of patients (59/162), at least one prescribed medication of interest was not detected in urine. Non-adherence to lipid-lowering agents was common (35/88, 40%). On multivariable logistic regression, the number of prescribed cardiovascular medications, was associated with medication non-adherence [medication non-adherence, per one medication increase: adjusted odds ratio (95% confidence interval) = 1.78 (1.34-2.36); p < 0.001].

CONCLUSION

We found sub-optimal adherence to medications for CVD in PWH. In order to maximize the clinical benefit of statin therapy in PWH, factors requiring consideration include: improved medication adherence, awareness of polypharmacy, educational interventions and quantitative assessment of sub-optimal adherence through chemical adherence testing.

Supporting GPs and people with hypertension to maximise medication use to control blood pressure: a pilot cluster RCT of the MIAMI intervention

BACKGROUND

Hypertension, or high blood pressure, is a key modifiable risk factor for heart disease and stroke. International guidelines have highlighted 'poor adherence to treatment' and 'physician inertia' as major barriers to effective blood pressure management. The Maximising Adherence, Minimising Inertia (MIAMI) intervention, a theory-based complex intervention, supports General Practitioners (GPs) and people with hypertension in maximising medication use to manage blood pressure. This pilot cluster randomised control trial (RCT) aimed to collect and analyse feasibility data to refine the MIAMI intervention and assess the feasibility of a definitive RCT.

METHOD

A pilot cluster RCT with a MIAMI intervention arm and usual care control arm was conducted. Quantitative data collection consisting of clinical measures and a self-report questionnaire took place at baseline and twelve week follow up. Semi-structured interviews with GP and patient participants were conducted. Fidelity (as measured by a protocol checklist and through qualitative interviews) and health economics costings were assessed.

RESULTS

Six GP practices (intervention arm n = 3, control arm n = 3) and 52 patients (intervention arm n = 25, control arm n = 27) took part. All six GP practices and 92% of patients were retained. Fidelity, as measured by a checklist and through qualitative interviews, was good but three deviations from protocol were identified. Outcomes and measures used were acceptable. The implementation cost of the MIAMI intervention was estimated at €490 per participant. The qualitative data demonstrated that the intervention was considered acceptable and feasible by both GP and patient participants, except for the urine test component, which GPs found difficult to incorporate into practice due to logistical challenges.

CONCLUSIONS

The MIAMI intervention was considered largely acceptable and feasible. Some changes to both intervention components and trial processes are required but with these in place a definitive RCT could be considered worthwhile.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN85009436, registered 17/1/23.

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

Background

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

Objectives

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

Eligibility criteria

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

Sources of evidence

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

Results

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

Conclusion

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

Supporting General Practitioners and people with hypertension to maximise medication use to control blood pressure: the contribution of Collective Intelligence to the development of the 'Maximising Adherence, Minimising Inertia' (MIAMI) intervention

Background

Hypertension remains one of the most important modifiable risk factors for stroke and heart disease. Anti-hypertensive medications are effective, but are often not used to maximum benefit. Sub-optimal dosing by prescribers and challenges with medication-taking for patients remain barriers to effective blood pressure control.

Objectives

We aimed to systematically develop a theory-based complex intervention to support General Practitioners (GPs) and people with hypertension to maximise medication use to control blood pressure.

Methods

We used the three-phase Behaviour Change Wheel (BCW) as the overarching intervention development framework. Collective Intelligence methodology was used to operationalise the stakeholder input to Phases 2 and 3 of the BCW. This took the form of a Collective Intelligence workshop with 19 stakeholders from diverse backgrounds including lived experience, general practice, nursing, pharmacy and health psychology. Techniques such as barrier identification, idea-writing and scenario-based design were used to generate possible intervention options. Intervention options were then selected and refined using the Acceptability, Practicability, Effectiveness, Affordability, Side-effects and Equity (APEASE) criteria and guidance from the MIAMI Public and Patient Involvement Panel.

Results

The finalised MIAMI intervention consists of both GP and patient supports. GP supports include a 30-minute online training, information booklet and consultation guide (drop-down menu) embedded within the patient electronic health system. Patient supports include a pre-consultation plan, website, and a structured GP consultation with results from an Ambulatory Blood Pressure Monitor and urine chemical adherence test. The intervention components have been mapped to the intervention functions of the BCW and Behaviour Change Technique Ontology.

Conclusion

Collective Intelligence offered a novel method to operationalise stakeholder input to Phases 2 and 3 of the BCW. The MIAMI intervention is now at pilot evaluation stage.

e-Health education for patients and health professionals in the field of vascular disease

e-Health, defined as "the use of new information and communication technologies (ICT) to improve or support health and health care," has grown in popularity over recent years as a cost-efficient, rapidly adaptable tool to deliver health care education to a wide audience. In the field of vascular disease, for which early detection and risk factor management may greatly influence patient outcomes, application of e-Health educational resources may provide innovative solutions to facilitate evidence-based and patient-centered care provision of care; to enable patients to take a more active role in the management of their long-term vascular health conditions; and to augment their preparation for, and recovery from, surgical procedures.

Predicting factors of blood pressure normalization in hypertensive patients after short-term follow-up

Introduction

Normalization of blood pressure in hypertensive patients is a major challenge for practitioners. Knowledge of the factors associated with normalization of blood pressure could help optimize management of these hypertensive patients. In this study, we analysed the factors predictive of this in a population of hypertensive patients followed as outpatients in a specialised department.

Patients and methods

Retrospective and analytic study (January 2021-May 2022) of adult hypertensive patients over 40 years old who had been receiving antihypertensive treatment as outpatients in the Cardiology Department of the Bouake Teaching Hospital for at least 6 months. We studied the epidemiological and clinical parameters as well as the factors involved in the normalization of blood pressure in this population. Statistical analysis was performed using SPPS version 26 software (SPSS Inc., Chicago, IL, USA).

Results

We collected 194 patients records (57.7% women). The mean age was 59.13 years [extremes: 40-89 years]. One hundred and nine (56.2%) patients had a low socioeconomic status and 151 (77.83%) had at least 2 cardiovascular risk factors. The mean systolic blood pressure on admission was 171.12 ± 22.38 mmHg [extremes: 140-259 mmHg] and the mean diastolic blood pressure was 97.98 ± 17.83 mmHg [extremes: 60-168 mmHg]. First-line treatment consisted of dual anti-hypertensive therapy (n = 133; 68.55%) and fixed combination (n = 152; 78.35%). Only 25.25% (n = 49) of patients achieved normalization of blood pressure with therapeutic adherence estimated at 37.62% (n = 73). In multivariate analysis adjusted for anti-hypertensive treatment adherence, age (OR = 1.03; 95% CI = 1.002-1.059; p = 0.039), absence of alcoholism (OR = 9.48; 95% CI = 2.13-42.11; p = 0.003), number of cardiovascular risk factors <2 (OR = 1.52; 95% CI = 1.06-2.16; p = 0.021), normalization of uricemia (OR = 1.05; 95% CI = 1.00-1.11; p = 0.039) and natraemia (OR = 1.01; 95% CI = 1.00-1.03; p = 0.021), dual therapy (OR = 0.40; 95% CI = 0.18-0.90; p = 0.027), change in treatment for optimization (OR = 4.22; 95% CI = 1.71-10.37; p = 0.002), intellectual education (OR = 10.40; 95% CI = 4.31-25.10; p < 0.001) and health insurance (OR = 0.09; 95% CI = 0.04-0.21; p < 0.001) were the main factors predicting normalization of blood pressure.

Conclusion

Control of cardiovascular risk factors and compliance with treatment are the main factors in normalizing blood pressure.

Non-adherence to cardiometabolic medication as assessed by LC-MS/MS in urine and its association with kidney and cardiovascular outcomes in type 2 diabetes mellitus

AIMS/HYPOTHESIS

Non-adherence to medication is a frequent barrier in the treatment of patients with type 2 diabetes mellitus, potentially limiting the effectiveness of evidence-based treatments. Previous studies have mostly relied on indirect adherence measures to analyse outcomes based on adherence. The aim of this study was to use LC-MS/MS in urine-a non-invasive, direct and objective measure-to assess non-adherence to cardiometabolic drugs and analyse its association with kidney and cardiovascular outcomes.

METHODS

This cohort study includes 1125 participants from the PROVALID study, which follows patients with type 2 diabetes mellitus at the primary care level. Baseline urine samples were tested for 79 cardiometabolic drugs and metabolites thereof via LC-MS/MS. An individual was classified as totally adherent if markers for all drugs were detected, partially non-adherent when at least one marker for one drug was detected, and totally non-adherent if no markers for any drugs were detected. Non-adherence was then analysed in the context of cardiovascular (composite of myocardial infarction, stroke and cardiovascular death) and kidney (composite of sustained 40% decline in eGFR, sustained progression of albuminuria, kidney replacement therapy and death from kidney failure) outcomes.

RESULTS

Of the participants, 56.3% were totally adherent, 42.0% were partially non-adherent, and 1.7% were totally non-adherent to screened cardiometabolic drugs. Adherence was highest to antiplatelet and glucose-lowering agents and lowest to lipid-lowering agents. Over a median (IQR) follow-up time of 5.10 (4.12-6.12) years, worse cardiovascular outcomes were observed with non-adherence to antiplatelet drugs (HR 10.13 [95% CI 3.06, 33.56]) and worse kidney outcomes were observed with non-adherence to antihypertensive drugs (HR 1.98 [95% CI 1.37, 2.86]).

CONCLUSIONS/INTERPRETATION

This analysis shows that non-adherence to cardiometabolic drug regimens is common in type 2 diabetes mellitus and negatively affects kidney and cardiovascular outcomes.

Physician and patient adherence in hypertension trials: a point of view on an important issue to resolve

INTRODUCTION

Randomized controlled trials (RCTs) are important sources of evidence that strongly influence guidelines for patient management, including for elevated blood pressure in adults.

AREAS COVERED

Critical questions regarding the interpretation of hypertension trial results have recently increased, especially for concerns over methodology. In particular, investigator adherence to the protocol and patient adherence to investigational drugs are often far from optimal. These issues may be ignored or underreported because physicians' behavior during trials is often not monitored and patients' medication adherence is neither measured adequately nor reported or analyzed in the final report or in the publication. This situation may lead to misinterpretations of study results and misevaluations of the safety and efficacy profile of new drugs. In this short review, the problem of measuring, reporting, and analyzing drug adherence in RCTs is discussed and illustrated with several examples in the field of hypertension.

EXPERT OPINION

The main conclusion is that drug adherence should always be measured in clinical trials, possibly with more than one method. In addition, prespecified analyses of adherence data should be included in the statistical plan of all trials to improve their overall quality.

Is Renal Denervation Effective in Treating Resistant Hypertension?

Resistant hypertension is diagnosed in patients whose blood pressure target is unmet despite the use of three or more antihypertensive medications. Systemic sympathetic hyperactivation is associated with the development of resistant hypertension. As the kidney is largely pervasive of the sympathetic nervous system renal denervation procedure was developed to control blood pressure by attenuating the renal and systemic sympathetic hyperactivity. Renal denervation is a minimally invasive procedure that uses radiofrequency or ultrasound energy waves to reduce the activity of the renal artery nerves. Previous clinical trials have shown conflicting results regarding the efficacy of the procedure. Symplicity HTN-1 and -2 trials showed effective blood pressure lowering results in the renal denervation group with a good safety profile. However, the Symplicity HTN-3 trial showed no difference in blood pressure lowering effect between the renal denervation and control Sham procedure groups. Notwithstanding, some recent clinical trials with Sham control and meta-analysis showed clinical benefits of renal denervation. Other clinical benefits of renal denervation include glucose control, cardiovascular protective effect, reduction of obstructive sleep apnea, and neuralgia control. A subset of patients with satisfactory blood pressure control response to the procedure may experience improved glucose control due to the overall reduced sympathetic activity and insulin resistance. Sympathetic activity control after renal denervation has cardioprotective effects, especially for those with arrhythmia and left ventricular hypertrophy. Also, renal denervation could be helpful in renalorigin pain control. Renal denervation is an effective, safe, non-invasive procedure with many clinical benefits beyond blood pressure control. Further development in the procedure technique and selection of target patients are needed for wider clinical use of renal denervation in resistant hypertension.

Extemporaneous combination therapy with nebivolol/amlodipine for the treatment of hypertension: a real-world evidence study in Europe

OBJECTIVE

The investigation of the real-world use of the extemporaneous combination of nebivolol and amlodipine (NA-EXC) in adult patients diagnosed with hypertension in Europe.

METHODS

Retrospective analysis of data extracted from seven databases of patient medical records and prescriptions from Italy, Germany, France, Hungary, and Poland, to determine the prevalence and incidence of NA-EXC use and to estimate the number of patients potentially eligible for a single-pill combination of the two antihypertensives. Secondary objectives included: the description of the population of NA-EXC users and the assessment of their adherence to treatment based on the proportion of days covered.

RESULTS

The use of NA-EXC was found to be common in Europe and ranged between 2.9% to 9.9% of all patients identified in the databases with a prescription of nebivolol and/or amlodipine. The estimated numbers of patients potentially eligible in 2019 for a single-pill combination of nebivolol and amlodipine in Italy and Germany were, respectively, 178,133 and 113,240. Users of NA-EXC were mostly aged 70-79 years, had metabolic disorders and other comorbidities; >70% of them had received ≥2 concomitant medications before starting NA-EXC. Adherence to NA-EXC was defined as high only in 15.6% to 35% of patients.

CONCLUSIONS

The extemporaneous combination of nebivolol and amlodipine is commonly prescribed in Europe, however adherence to the therapy is poor. The development of a single-pill combination of nebivolol and amlodipine may improve adherence by reducing the number of pills administered to patients and thus simplifying treatment regimens.

Medical Measures in Hypertensives Considered Resistant

BACKGROUND

Patients with resistant hypertension are the group of hypertensive patients with the highest cardiovascular risk.

METHODS

All rules and guidelines for treatment of hypertension should be followed strictly to obtain blood pressure (BP) control in resistant hypertension. The mainstay of treatment of hypertension, also for resistant hypertension, is pharmacological treatment, which should be tailored to each patient's specific phenotype. Therefore, it is pivotal to assess nonadherence to pharmacological treatment as this remains the most challenging problem to investigate and manage in the setting of resistant hypertension.

RESULTS

Once adherence has been confirmed, patients must be thoroughly worked-up for secondary causes of hypertension. Until such possible specific causes have been clarified, the diagnosis is apparent treatment-resistant hypertension (TRH). Surprisingly few patients remain with true TRH when the various secondary causes and adherence problems have been detected and resolved. Refractory hypertension is a term used to characterize the treatment resistance in hypertensive patients using ≥5 antihypertensive drugs. All pressor mechanisms may then need blockage before their BPs are reasonably controlled.

CONCLUSIONS

Patients with resistant hypertension need careful and sustained follow-up and review of their medications and dosages at each term since medication adherence is a very dynamic process.

RNA interference in the era of nucleic acid therapeutics

Two decades of research on RNA interference (RNAi) have transformed a breakthrough discovery in biology into a robust platform for a new class of medicines that modulate mRNA expression. Here we provide an overview of the trajectory of small-interfering RNA (siRNA) drug development, including the first approval in 2018 of a liver-targeted siRNA interference (RNAi) therapeutic in lipid nanoparticles and subsequent approvals of five more RNAi drugs, which used metabolically stable siRNAs combined with N-acetylgalactosamine ligands for conjugate-based liver delivery. We also consider the remaining challenges in the field, such as delivery to muscle, brain and other extrahepatic organs. Today's RNAi therapeutics exhibit high specificity, potency and durability, and are transitioning from applications in rare diseases to widespread, chronic conditions.

Adult hypertension referral pathway and therapeutic management: British and Irish Hypertension Society position statement

In the UK, most adults with hypertension are managed in Primary Care. Referrals to Secondary Care Hypertension Specialists are targeted to patients in whom further investigations are likely to change management decisions. In this position statement the British and Irish Hypertension Society provide clinicians with a framework for referring patients to Hypertension Specialists. Additional therapeutic advice is provided to optimise patient management whilst awaiting specialist review. Our aim is to ensure that referral criteria to Hypertension Specialists are consistent across the UK and Ireland to ensure equitable access for all patients.

The role of adherence in patients with chronic diseases

In the long-term management of chronic diseases, adherence and persistence to prescribed medications are continuous challenges in order to obtain all the potential benefits of drug therapies. Suboptimal drug adherence and discontinuations of therapies remain the most frequent reasons why several diseases are poorly controlled in the population. One the main issue is that physicians are relatively limited in time and tools to detect patients with a poor adherence. The present review discusses present and future strategies that are now available or are being developed to detect and to support adherence in patients with chronic diseases and provides some simple clues to identify patients at high risk of discontinuation in the clinic.

Controversies in Hypertension V: Resistant and Refractory Hypertension

Apparent resistant hypertension, defined as uncontrolled office blood pressure despite ≥ 3 antihypertensive medications including a diuretic or use of ≥ 4 medications regardless of blood pressure, occurs in ≤ 15% of treated hypertensives. Apparent refractory hypertension, defined as uncontrolled office pressure despite use of 5 or more medications including a diuretic, occurs in ≤ 10% of resistant cases. Both are associated with increased comorbidity and enhanced cardiovascular risk. To rule out pseudo-resistant or pseudo-refractory hypertension, employ guideline-based methodology for obtaining pressure, maximize the regimen, rule out white-coat effect, and assess adherence. True resistant hypertension is characterized by volume overload and aldosterone excess, refractory by enhanced sympathetic tone. Spironolactone is the preferred agent for resistance, with lower doses. Spironolactone, potassium binders, or both, are preferred if the estimated glomerular filtration rate is below 45. If significant albuminuria, finerenone is indicated. The optimal treatment of refractory hypertension is unclear, but sympathetic inhibition (α-β blockade, centrally acting sympathoinhibitors, or both) seems reasonable. Renal denervation has shown minimal benefit for resistance, but its role in refractory hypertension remains to be defined.

Social determinants of blood pressure control in a middle-income country in Latin America

Blood pressure (BP) control is a key intervention to decrease cardiovascular diseases (CVD), the main cause of death in low and middle-income countries (MIC). Scarce data on the determinants of BP control in Latin America are available. Our objective is to explore the role of gender, age, education, and income as social determinants of BP control in Argentina, a MIC with a universal health care system. We evaluated 1184 persons in two hospitals. Blood pressure was measured using automatic oscillometric devices. We selected those patients treated for hypertension. The average BP of less than 140/90 mmHg was considered a controlled BP. We found 638 hypertensive individuals, of whom 477 (75%) were receiving antihypertensive drugs, and of those, 248 (52%) had controlled BP. The prevalence of low education was more frequent in uncontrolled patients (25.3% vs. 16.1%; P < .01). We did not find association between household income, gender, and BP control. Older patients had less BP control (44% of those older than 75 years vs. 60.9% of those younger than 40; test for trend P < .05). Multivariate regression indicates low education (OR 1.71 95% CI [1.05, 2.79]; P = .03) and older age (OR 1.01; 95% IC [1.00, 1.03]) as independent predictors of the lack of BP control. We conclude that rates of BP control are low in Argentina. In a MIC with a universal health care system low education and old age but not household income are independent predictors of the lack of BP control.

Burden of cerebral small vessel disease and changes of diastolic blood pressure affect clinical outcome after acute ischemic stroke

Elevated and low blood pressure (BP) may lead to poor functional outcome after ischemic stroke, which is conflicting. Hence, there must be another factor-such as cerebral small vessel disease (cSVD) -interacting with BP and thus, affecting outcome. Here, we investigate the relationship between BP and cSVD regarding outcome after stroke. Data of 423/503 stroke patients were prospectively analyzed. Diastolic (DBP) and systolic BP (SBP) were collected on hospital admission (BPad) and over the first 72 h (BP72h). cSVD-burden was determined on MR-scans. Good functional outcome was defined as a modified Rankin Scale score ≤ 2 at hospital discharge and 12 months thereafter. cSVD was a predictor of poor outcome (OR 2.8; p < 0.001). SBPad, DBPad and SBP72h were not significantly associated with outcome at any time. A significant relationship was found between DBP72h, (p < 0.01), cSVD (p = 0.013) and outcome at discharge. At 12 months, we found a relationship between outcome and DBP72h (p = 0.018) and a statistical tendency regarding cSVD (p = 0.08). Changes in DBP72h were significantly related with outcome. There was a U-shaped relationship between DBP72h and outcome at discharge. Our results suggest an individualized stroke care by either lowering or elevating DBP depending on cSVD-burden in order to influence functional outcome.

Developing an Integrated Longitudinal Dataset for Patient-Centered Outcome Measures in Cost-Related Medication Nonadherence

BACKGROUND

Cost-related medication nonadherence (CRN) is an important patient-centered outcome measure. Longitudinal follow-up of CRN is rare.

OBJECTIVE

We propose to develop a novel integrated dataset to study CRN longitudinally.

RESEARCH DESIGN

A dataset of 2000 Medicare beneficiaries at high risk of hospitalization surveyed quarterly on CRN and followed up individually for 8 quarters between 2013 and 2018 was linked to Medicare files. A metric of CRN categorizing persistent, intermittent, and transient CRN during the 8 quarters was developed. An ordered logit model and a logit model were developed to assess the factors influencing CRN overall and persistent CRN, respectively.

RESULTS

A total of 1761 patients were included in the analysis, among whom 869 (49.3%) reported CRN at least once in the 8-quarter study period, 178 (10%) reported persistent CRN, 395 (22.4%) reported intermittent CRN, and 296 (16.8%) reported transient CRN. The conditional effect in the logit model for persistent CRN revealed that baseline dual eligibility was negatively associated (adjusted odds ratio = 0.45, P < 0.01) and depression positively associated (adjusted odds ratio = 1.55, P = 0.01) with persistent CRN. The marginal analysis in the ordered logit model revealed a clear pattern of higher probabilities of persistent and intermittent CRN at younger ages while transient CRN was flat. Among the 252 subjects who were deceased, 31 (12.3%) reported persistent CRN, compared with 147 (9.74%) who were alive (P = 0.21 by χ2 test).

CONCLUSIONS

A significant number of patients reported persistent CRN, including those who were at the end of life. Research is critically needed to understand behavioral patterns among the younger Medicare population.

Update on advanced interventional neuromodulatory approaches to lower blood pressure

Herein, we review interventional peripheral neuromodulatory approaches to reduce blood pressure (BP), specifically focusing on catheter-based renal denervation (RDN), as well as the latest data from recent clinical trials underpinning its clinical use. Given the apparent failure of established lifestyle measures and pharmacologic BP-lowering approaches to improve hypertension (HTN) control rates, the past decade has seen remarkable scientific efforts to explore the utility of interventional strategies for BP management. Experimental studies and human clinical trials have demonstrated the crucial role of the sympathetic nervous system in the development and mainenance of HTN - consequently, most recent interventional technologies aimed primarily at modulating neural pathways. Advanced approaches that were rigorously tested in human studies include RDN, endovascular baroreflex amplification, baroreflex activation therapy and cardiac neuromodulation stimulation.Amongst these, RDN is by far the most established technology. With recent robust evidence from clinical trials and real-world data showing the safety and efficacy of both ultrasound and radiofrequency-based approaches, a recent clinical consensus statement of the European Society of Cardiology Council on Hypertension and the European Association of Percutaneous Cardiovascular Interventions concludes that RDN represents an ancillary therapeutic option in patients with uncontrolled resistant HTN confirmed by ambulatory blood pressure measurement and in spite of attention to lifestyle changes and optimised pharmacological treatment. Furthermore, RDN could alos be considered for patienst unlikley to adhere to or tolerate long-term antihypertensive drug treatment. Very recent data indicate long-term safety and efficacy up to 10 years. Appropriate implementation of RDN into clinical practice is now warranted.For all other interventions additional data from adequately designed human studies are required to establish their safety and clinical utility for potential future use in routine practice.

Alcohol-mediated renal denervation in patients with hypertension in the absence of antihypertensive medications

BACKGROUND

Ultrasound and radiofrequency renal denervation (RDN) have been shown to safely lower blood pressure (BP) in hypertension.

AIMS

The TARGET BP OFF-MED trial investigated the efficacy and safety of alcohol-mediated renal denervation (RDN) in the absence of antihypertensive medications.

METHODS

This randomised, blinded, sham-controlled trial was conducted in 25 centres in Europe and the USA. Patients with a 24-hour systolic BP of 135-170 mmHg, an office systolic BP 140-180 mmHg and diastolic BP ≥90 mmHg on 0-2 antihypertensive medications were enrolled. The primary efficacy endpoint was the change in mean 24-hour systolic BP at 8 weeks. Safety endpoints included major adverse events up to 30 days.

RESULTS

A total of 106 patients were randomised; the baseline mean office BP following medication washout was 159.4/100.4±10.9/7.0 mmHg (RDN) and 160.1/98.3±11.0/6.1 mmHg (sham), respectively. At 8 weeks post-procedure, the mean (±standard deviation) 24-hour systolic BP change was â2.9±7.4 mmHg (p=0.009) versus â1.4±8.6 mmHg (p=0.25) in the RDN and sham groups, respectively (mean between-group difference: 1.5 mmHg; p=0.27). There were no differences in safety events between groups. After 12 months of blinded follow-up, with medication escalation, patients achieved similar office systolic BP (RDN: 147.9±18.5 mmHg; sham: 147.8±15.1 mmHg; p=0.68) with a significantly lower medication burden in the RDN group (mean daily defined dose: 1.5±1.5 vs 2.3±1.7; p=0.017).

CONCLUSIONS

In this trial, alcohol-mediated RDN was delivered safely but was not associated with significant BP differences between groups. Medication burden was lower in the RDN group up to 12 months.

Nanosensors in the detection of antihypertension drugs, a golden step for medication adherence monitoring

Hypertension is associated with structural and functional changes in blood vessels with increased arteriosclerosis, vascular inflammation, and endothelial dysfunction. Decreased adherence (compliance) to antihypertensive medications contributes significantly to morbidity and mortality in hypertensive patients. Antihypertensive drugs (AHTDs) and lifestyle changes are the main cornerstones for treating hypertension. Several approaches have been described in the literature for determining AHTDs based on different analytical techniques. Amongst biosensors are one of the most attractive tools due to their inherent advantages. Biosensors are used for the detection of wide range of biomarkers as well as different drugs in past two decades. The main focus of the present study is to review the latest biosensors developed for the detection of AHTDs. Readers of the present study will be able to familiarize themselves with biosensors as advanced and modern diagnostic tools while reviewing the most widely used AHTDs. In the present study, the routine methods are first reviewed and while examining their advantages and disadvantages, biosensors have been introduced as ideal alternative tools.

A practical approach to assessment of non-adherence to antihypertensive treatment

Non-adherence to antihypertensive treatment is frequent, complicates the care of hypertensive patients, represents one of the major causes of treatment failure and is linked with the increased risk of cardiovascular events. Identifying a non-adherent patient is one of the recent daily-practice tasks for which the ideal solution has not yet been found. Presence of certain clinical red flags should prompt the clinician to consider non-adherence. Chemical adherence testing using serum or urine antihypertensive levels is regarded as the best method so far and should be used if available. Alternatively, the check for prescription refills in the patient electronic medical records, or directly observed therapy with subsequent ambulatory blood pressure monitoring may be used. We suggest a simple algorithm to guide the clinicians to detect non-adherence in the practice.

Blood pressure-lowering medication prescribing, its adherence to guidelines and relationship with blood pressure control at a family medicine department

Background

In many resource-constrained countries, control of blood pressure (BP) is low. Antihypertensive drug prescribing practices may influence BP control. However, adherence of prescribing to treatment guidelines may not be optimal in resource-constrained settings. The aim of this study was to evaluate the pattern of blood pressure-lowering medication prescribing, and how it adheres to treatment guidelines, and to identify the relationship between medication prescriptions and BP control.

Methods

It was a cross-sectional study of hypertensive outpatients at the Korle Bu Teaching Hospital (KBTH) Family Medicine department (FMD)/Polyclinic. Data was collected with a validated structured form. Adherence of "prescribing" to recommendations of the 2017 Standard Treatment Guidelines of Ghana and 2018 European Society of Cardiology guidelines was assessed using a composite measure. We analyzed data with SPSS.

Results

About 81% (247/304) of patients received two or more antihypertensive drugs. Most patients (41%; 267/651) received calcium channel blockers (CCB), and 21.8% (142/651), 15.7% (102/651) and 12.7% (83/651) were on diuretics, angiotensin-receptor blockers (ARBs) and angiotensin converting enzyme (ACE) inhibitors respectively. CCB plus RAS inhibitor (50%) was the most prescribed two-drug combination. Number of BP drugs per patient had a statistically significant inverse relationship with BP control (beta Coefficient = -0.402; 95% Cl: 1.252-2.470; p = 0.015). The composite adherence score was 0.73 (moderate adherence) but Single-pill combination (SPC) was poor (3.2%; n = 8).

Conclusion

Most patients received multiple-pill combination treatment, and overall adherence to guidelines was suboptimal, largely owing to complex drug therapy. Number of drugs predicted BP control. Our findings suggest a need to prioritize simplified treatment, and implement other strategies to improve hypertension guideline adherence. Further research on the influence of SPC on BP control may inform future hypertension guidelines in Ghana and elsewhere in Africa.

Longer time in blood pressure target range improves cardiovascular outcomes among patients with Type 2 diabetes: A secondary analysis of a randomized clinical trial

AIMS

To examine the prognostic value of time in target range (TIR) with adverse outcomes and validate it with common blood pressure (BP) metrics among patients with Type 2 diabetes mellitus.

METHODS

We performed a post hoc analysis of the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial. TIR for each subject was calculated using linear interpolation and an SBP target range of 110 to 130 mmHg. Cox models were used to assess the association of TIR and other BP metrics with the rate of clinical outcomes.

RESULTS

A higher TIR (61.9-100.0 %) was associated with a 46 % reduction in major adverse cardiovascular events (MACE) (hazard ratio [HR]:0.54; 95 % CI: 0.43, 0.67) compared with TIR 0-22.9 %. Results were similar for stroke (0.19; 0.10, 0.36), myocardial infarction (0.67; 0.51, 0.89), heart failure (0.47; 0.33, 0.66), cardiovascular death (0.63; 0.42, 0.93) and all-cause mortality (0.70; 0.54, 0.91). Further analyses suggested a curvilinear association of TIR with MACE, and this association was independent with baseline, final SBP, mean SBP, or visit-to-visit SBP variability.

CONCLUSIONS

Longer TIR is associated with lower cardiovascular risk and may add value as an outcome measure for hypertension control studies among patients with diabetes.

Contribution of single-pill combinations in the management of hypertension: perspectives from China, Europe and the USA

Uncontrolled hypertension is associated with an increased risk of adverse clinical vascular outcomes and death. Hypertension management guidelines from China and the USA recommend initiation of antihypertensive pharmacotherapy with a single drug for patients without severe hypertension at presentation. Current European hypertension guidelines take a different approach and recommend the use of combination therapy from the time of diagnosis of hypertension for most patients. This article reviews the burden of hypertension in these countries and summarises the evidence base for the use of antihypertensive combination therapy contained within a single tablet (single-pill combinations, SPC). Typically, half or less of populations from China, Europe and the USA who were found to have hypertension were aware of their condition, less than half of those receiving treatment, and fewer still achieved adequate blood pressure (BP) control. The reasons for the unaddressed burden of hypertension are complex and multifactorial, with contributions from factors related to patients, healthcare providers and healthcare systems. The use of SPCs of antihypertensive therapies helps to optimise adherence with therapy and is likely to result in superior BP control. There is a strong evidence base to support current European guideline recommendations on the initiation of antihypertensive therapy with SPCs for the majority of people with hypertension.

Comparison of the Determination of Some Antihypertensive Drugs in Clinical Human Plasma Samples by Solvent Front Position Extraction and Precipitation Modes

The determination of the selected antihypertensive drugs in human plasma samples with the novel solvent front position extraction (SFPE) technique is presented. The SFPE procedure combined with LC-MS/MS analysis was used for the first time to prepare a clinical sample containing the drugs mentioned above from different therapeutic groups. The effectiveness of our approach was compared with the precipitation method. The latter technique is usually used to prepare biological samples in routine laboratories. During the experiments, the substances of interest and the internal standard were separated from other matrix components using a prototype horizontal chamber for thin-layer chromatography/high-performance thin-layer chromatography (TLC/HPTLC) with a moving pipette powered by a 3D mechanism, which distributed the solvent on the adsorbent layer. Detection of the six antihypertensive drugs was performed by liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) in multiple reaction monitoring (MRM) mode. Results obtained by SFPE were very satisfactory (linearity R² ≥ 0.981; %RSD ≤ 6%; LOD and LOQ were in the range of 0.06-9.78 ng/mL and 0.17-29.64 ng/mL, respectively). The recovery was in the range of 79.88-120.36%. Intra-day and inter-day precision had a percentage coefficient of variation (CV) in the range of 1.10-9.74%. The procedure is simple and highly effective. It includes the automation of TLC chromatogram development, which significantly reduced the number of manual operations performed, the time of sample preparation and solvent consumption.

The effect of combining therapeutic drug monitoring of antihypertensive drugs with personalised feedback on adherence and resistant hypertension: the (RHYME-RCT) trial protocol of a multi-centre randomised controlled trial

BACKGROUND

Adherence to antihypertensive drugs (AHDs) is important for adequate blood pressure control. Not taking these drugs as prescribed is one of the main underlying causes for resistant hypertension (RH), which in turn leads to an increased risk of cardiovascular events, stroke and kidney damage. Therefore, correct identification of patients that are non-adherent to AHDs is crucial to improve clinical outcome. For this goal, therapeutic drug monitoring is the most reliable method. The primary objective of this trial is to investigate whether monitoring of drug concentrations with a dried blood spot (DBS) sampling method combined with personalised feedback leads to a decrease in prevalence of RH after 12 months due to an increase in adherence. Secondary objectives include the difference over time in the number of required AHDs as well as the defined daily dose (DDD). Lastly, the cost-utility of SoC versus the intervention in RH is determined.

METHODS

This is a multi-centre single-blinded randomised controlled trial (RHYME-RCT). First, at an eligibility visit, DBS sampling, to monitor drug concentrations in blood, and a 24-h ambulatory blood pressure measurement (24-h ABPM) are performed simultaneously. Patients with a daytime systolic blood pressure (SBP) > 135 and/or diastolic blood pressure (DBP) > 85 mmHg are randomised to SoC or intervention + SoC. The intervention is performed by the treating physician and includes information on drug concentrations and a comprehensive personalised feedback conversation with the use of a communication tool. The follow-up period is one year with visits at 3, 6 and 12 months randomisation and includes 24-h ABPM and DBS sampling.

DISCUSSION

This will be the first trial that focusses specifically on patients with RH without taking into account suspicion of non-adherence and it combines monitoring of AHD concentrations to identify non-adherence to AHDs with a comprehensive feedback to improve non-adherence. Furthermore, if this trial shows positive outcomes for the intervention it can be directly implemented in clinical practice, which would be a great improvement in the treatment of RH.

TRIAL REGISTRATION

RHYME-RCT is registered in the Dutch Trial Register on 27/12/2017 (NTR6914) and can be found in the International Clinical Trials Registry Platform.

How to optimize the adherence to a guideline-directed medical therapy in the secondary prevention of cardiovascular diseases: a clinical consensus statement from the European Association of Preventive Cardiology

A key factor to successful secondary prevention of cardiovascular disease (CVD) is optimal patient adherence to treatment. However, unsatisfactory rates of adherence to treatment for CVD risk factors and CVD have been observed consistently over the last few decades. Hence, achieving optimal adherence to lifestyle measures and guideline-directed medical therapy in secondary prevention and rehabilitation is a great challenge to many healthcare professionals. Therefore, in this European Association of Preventive Cardiology clinical consensus document, a modern reappraisal of the adherence to optimal treatment is provided, together with simple, practical, and feasible suggestions to achieve this goal in the clinical setting, focusing on evidence-based concepts.

On the issue of low adherence of patients to antihypertensive therapy: the use of therapeutic drug monitoring of drugs: A review

Low adherence of patients to antihypertensive therapy remains an urgent problem and is recognized as the main cause of insufficient BP control at the population level. In this regard, to increase the motivation of patients in clinical practice, methods for assessing adherence (compliance) to drugs. Along with indirect assessment methods (questionnaires, self-reports, pill counts, etc.), which, however, do not always reflect the real patients adherence, more objective is the measurement of antihypertensive drug concentrations in physiological fluids therapeutic drug monitoring (TDM). For these purposes, methods of high-performance liquid chromatography with mass spectrometry were recently adapted, reference ranges of antihypertensive drug concentrations in blood serum and urine for standard doses of drugs were determined, as well as criteria for assessing complete or partial non-compliance. There have been a number of studies using TDM to assess adherence, which show a high rate of non-compliance (low compliance) of more than 50% of cases with a variability from 25 to 86.1%, with complete non-compliance 10.134.5% in patients with uncontrolled and/or resistant hypertension (3 antihypertensive drug). In a population of patients with a normal course of hypertension, taking 12 antihypertensive drug, the level of non-compliance according to the results of TDM did not exceed 10%. Comparison of the TDM method with indirect methods of assessing adherence did not reveal consistency; at the same time, the detection of antihypertensive drug better characterized the clinical problems of patients with arterial hypertension. In clinical practice, direct assessment methods (TDM) can be used to measure adherence in problem patients with uncontrolled hypertension and high cardiovascular risk despite optimal therapy.

Measuring adherence to antihypertensive medication using an objective test in older adults attending primary care: cross-sectional study

Analysis of urine samples using liquid chromatography-tandem mass spectrometry (LC-MS/MS) has previously revealed high rates of non-adherence to antihypertensive medication. It is unclear whether these rates represent those in the general population. This study aimed to investigate whether it is feasible to collect urine samples in a primary care setting and analyse them using LC-MS/MS to detect non-adherence to antihypertensive medication. This study used a prospective, observational cohort design. Consecutive patients were recruited opportunistically from five general practices in UK primary care. They were aged ≥65 years with hypertension and had at least one antihypertensive prescription. Participants were asked to provide a urine sample for analysis of medication adherence. Samples were sent to a laboratory via post and analysed using LC-MS/MS. Predictors of adherence to medication were explored with multivariable logistic regression. Of 349 consecutive patients approached for the study, 214 (61.3%) gave informed consent and 191 (54.7%) provided a valid urine sample for analysis. Participants were aged 76.2 ± 6.6 years and taking a median of 2 antihypertensive medications (IQR 1-3). A total of 27/191 participants (14.2%) reported not taking all of their medications on the day of urine sample collection. However, LC-MS/MS analysis of samples revealed only 4/27 (9/191 in total; 4.7%) were non-adherent to some of their medications. Patients prescribed more antihypertensive medications were less likely to be adherent (OR 0.24, 95%CI 0.09-0.65). Biochemical testing for antihypertensive medication adherence is feasible in routine primary care, although non-adherence to medication is generally low, and therefore widespread testing is not indicated.

Nonadherence by Serum Drug Analyses in Resistant Hypertension: 7-Year Follow-Up of Patients Considered Adherent by Directly Observed Therapy

Background Measurement of serum concentrations of drugs is a novelty found useful in detecting poor drug adherence in patients taking ≥2 antihypertensive agents. Regarding patients with treatment-resistant hypertension, we previously based our assessment on directly observed therapy. The present study aimed to investigate whether serum drug measurements in patients with resistant hypertension offer additional information regarding drug adherence, beyond that of initial assessment with directly observed therapy. Methods and Results Nineteen patients assumed to have true treatment-resistant hypertension and adherence to antihypertensive drugs based on directly observed therapy were investigated repeatedly through 7 years. Serum concentrations of antihypertensive drugs were measured by ultra-high-performance liquid chromatography-tandem mass spectrometry from blood samples taken at baseline, 6-month, 3-year, and 7-year visits. Cytochrome P450 polymorphisms, self-reported adherence and beliefs about medicine were performed as supplement investigations. Seven patients (37%) were redefined as nonadherent based on their serum concentrations during follow-up. All patients reported high adherence to medications. Nonadherent patients expressed lower necessity and higher concerns regarding intake of antihypertensive medication (P=0.003). Cytochrome P450 polymorphisms affecting metabolism of antihypertensive drugs were found in 16 patients (84%), 21% were poor metabolizers, and none were ultra-rapid metabolizers. Six of 7 patients redefined as nonadherent had cytochrome P450 polymorphisms, however, not explaining the low serum drug concentrations measured in these patients. Conclusions Our data suggest that repeated measurements of serum concentrations of antihypertensive drugs revealed nonadherence in one-third of patients previously evaluated as adherent and treatment resistant by directly observed therapy, thereby improving the accuracy of adherence evaluation. Registration URL: https://www.clinicaltrials.gov; unique identifier: NCT01673516.

The Association Between Medication Non-Adherence and Early and Late Readmission Rates for Patients with Acute Coronary Syndrome

Purpose

Unplanned hospital readmission forms costly, but preventable burdens on healthcare system. This study was designed to evaluate cardiovascular-related readmission rate after discharge of acute coronary syndrome (ACS) patients and its relationship with medication adherence at a university hospital, Saudi Arabia.

Methods

A total of 370 consecutive patients presenting with ACS were involved. The inclusion criteria were clinical and coronary angiography diagnostic data of ACS. Exclusion criteria included heart valve disease, myocarditis, hepatic disease, and history of acute infection during the previous two weeks. Patients were divided into index admission group (n = 291) and unplanned readmission group (n = 79). Readmission and medication adherence rates were evaluated during 1–30, 31–180, 181–365, and 366–548 days post-ACS discharge. Medication adherence was estimated with a (yes/no) questionnaire.

Results

The overall readmission rate was 21.4%; individual rates were 30.4%, 38.0%, 27.8%, and 3.8% and the overall medication adherence rate was 62.03%, while individual rates were 54.2%, 70.0%, 63.6%, and 33.3% during the four periods, respectively. There were strong correlations between medication non-adherence and readmission rates. Heart failure, ST-elevated myocardial infarction, unstable angina, cerebrovascular accident, and arrhythmia represented the top causes. Body mass index was higher in readmission group. There were significant correlations between smoking, hypertension, cerebrovascular accident, ischemic heart disease, previous stent, instent restenosis, and LDL-cholesterol as predictor factors and readmission rate.

Conclusion

The cardiovascular-related unplanned readmission rate post-ACS discharge was 21.4%, and medication non-adherence rate was 37.97%. There were strong correlations between them in the time frames from 1-month to 1.5-year post-discharge. The individual rates decreased by time, but the first month showed lower rates than the following 5 months and this indicated the role of factors other than medication non-adherence in readmission. The rates are generally consistent with the international levels but utilizing technology can further improve medication adherence and reduce readmission rates.

Bedtime dosing of antihypertensive medications: systematic review and consensus statement: International Society of Hypertension position paper endorsed by World Hypertension League and European Society of Hypertension

Antihypertensive drug therapy is one of the most efficient medical interventions for preventing disability and death globally. Most of the evidence supporting its benefits has been derived from outcome trials with morning dosing of medications. Accumulating evidence suggests an adverse prognosis associated with night-time hypertension, nondipping blood pressure (BP) profile and morning BP surge, with increased incidence of cardiovascular events during the first few morning hours. These observations provide justification for complete 24-h BP control as being the primary goal of antihypertensive treatment. Bedtime administration of antihypertensive drugs has also been proposed as a potentially more effective treatment strategy than morning administration. This Position Paper by the International Society of Hypertension reviewed the published evidence on the clinical relevance of the diurnal variation in BP and the timing of antihypertensive drug treatment, aiming to provide consensus recommendations for clinical practice. Eight published outcome hypertension studies involved bedtime dosing of antihypertensive drugs, and all had major methodological and/or other flaws and a high risk of bias in testing the impact of bedtime compared to morning treatment. Three ongoing, well designed, prospective, randomized controlled outcome trials are expected to provide high-quality data on the efficacy and safety of evening or bedtime versus morning drug dosing. Until that information is available, preferred use of bedtime drug dosing of antihypertensive drugs should not be routinely recommended in clinical practice. Complete 24-h control of BP should be targeted using readily available, long-acting antihypertensive medications as monotherapy or combinations administered in a single morning dose.

Medication Adherence among Patients with Chronic Diseases in Saudi Arabia

Introduction: The management of chronic illnesses commonly includes a long-term pharmacological approach. Although these medications effectively control disease, their full benefits are often not realized because approximately 50% of patients do not take their medications as prescribed. Medication adherence has become a big concern to clinicians and healthcare systems in Saudi Arabia and worldwide because of growing evidence associating nonadherence with adverse outcomes and higher costs of care. Despite it being a well-recognized problem, few studies have investigated medication adherence in Saudi Arabia. Therefore, this study aims to gain a better perspective on medication adherence among patients with chronic diseases in Saudi Arabia. Method: A questionnaire-based cross-sectional study was conducted among patients with chronic diseases in the Makkah region, Saudi Arabia, from 1 May to 31 July 2021. Patients aged 18 years and above who were taking prescribed or over-the-counter medications were included. Descriptive statistics were used to describe the participants’ characteristics, and categorical variables were reported as frequencies and percentages. A Chi-square test was used to test the relations between variables. Results: In total, 239 participants were included in the study. Females represented 62% of the participants. In terms of the history of chronic diseases, 44% had hypertension, 40% had diabetes mellitus, 21% had heart diseases and 9% had asthma. Nearly half (49%) of participants did not follow up regularly with a primary healthcare center and 42% said that they had forgotten to take their medications in the past. However, most of the participants (78%) stated that they took their medicine as instructed by their doctor or pharmacist, and 61% took their medications on time. The majority of participants (85%) said that the pharmacist explained the method of using the medications and the instructions for use, while 30% thought that the medications they took were too much. In regard to the reasons for medication nonadherence, having no specific reasons for medication nonadherence was the most common cause for nonadherence in our study. The relationship between patients taking medications as instructed by a healthcare provider (the doctor or pharmacist) and the healthcare provider giving clear instructions to patients about medication use was significant (p < 0.001). Conclusions: Failure to adhere is a significant problem that not only affects the patient but also the healthcare system. Additional research is needed to monitor medication adherence and identify factors contributing to this problem to provide successful strategies to improve medication adherence in Saudi Arabia.

Traditional Heart-Healthy Diet and Medication Adherence in the Norton Sound Region: An 18-Month Telehealth Intervention

INTRODUCTION

Innovations are needed for preventing cardiovascular disease (CVD) and for reaching diverse communities in remote regions. The current study reports on a telemedicine-delivered intervention promoting a traditional heart-healthy diet and medication adherence with Alaska Native men and women residing in the Norton Sound region of Alaska.

METHODS

Participants were 299 men and women with high blood pressure or high cholesterol smoking daily who were randomized to receive telemedicine-delivered counseling and printed materials on diet and medication adherence or on smoking and physical activity. Intervention contacts were at baseline and 3-, 6-, and 12-months follow-up, with a final assessment at 18 months. Nutrition outcomes were the ratio of heart-healthy foods and traditional heart-healthy foods relative to all foods reported on a 34-item food frequency questionnaire. Recent and typical adherence for heart medications were self-reported.

RESULTS

Intervention effects were significant for the heart-healthy foods ratio at 6 months only (p = 0.014) and significant for the traditional heart-healthy foods ratio at 6 months only for those aged 47+ (p = 0.031). For recent and typical medication adherence, there were no significant group differences by time.

DISCUSSION

In a remote region of Alaska, telemedicine proved feasible and acceptable for engaging Alaska Native men and women in counseling on CVD risk behaviors. The findings indicate that more touchpoints may be necessary to impart comprehensive lasting change in heart-healthy eating patterns. Medication adherence group differences were not significant; however, medication adherence was high overall.

High non-adherence rates to secondary prevention by chemical adherence testing in patients with TIA

INTRODUCTION

Transient ischaemic attack (TIA) clinics are important for secondary prevention of fatal or disabling stroke. Non-adherence to prescribed medications is an important reason for treatment failure but difficult to diagnose. This study ascertained the utility of a novel biochemical tool in the objective biochemical diagnosis of non-adherence.

METHODS

One-hundred consecutive urine samples collected from patients attending the TIA clinic, at a tertiary centre, were analysed for presence or absence of prescribed cardiovascular medications using liquid chromatography-mass spectrometry (LC-MS/MS). Patients were classified as adherent or non-adherent, respectively. Demographic and clinical characteristics were compared between the two cohorts. Univariate regression analyses were performed for individual variables and model fitting was undertaken for significant variables.

RESULTS

The mean duration of follow-up from the index event was 31 days [standard deviation (SD): 18.9]. The overall rate of non-adherence for at least one medication was 24%. In univariate analysis, the number of comorbidities [3.4 (SD: 1.9) vs. 2.5 (1.9), P = 0.032] and total number of all prescribed medications [6.0 (3.3) vs 4.4 (2.1), P = 0.032] were higher in the non-adherent group. On multivariate analysis, the total number of medications prescribed correlated with increased non-adherence (odds ratio: 1.27, 95% Confidence Intervals: 1.1-1.5, P = 0.01).

CONCLUSIONS

LC-MS/MS is a clinically useful tool for the diagnosis of non-adherence. Nearly a quarter of TIA patients were non-adherent to their cardiovascular medications Addressing non-adherence early may reduce the risk of future disabling cardiovascular events.

Impact of medication adherence on the efficacy of Baroreflex activation therapy

Therapy adherence significantly determines the success of antihypertensive therapy, especially in patients with resistant hypertension. Our study investigates the impact of drug adherence on the efficacy of Baroreflex‐activation‐therapy (BAT). In this retrospective analysis, the authors measured blood pressure (BP) and antihypertensive medication adherence (by gas chromatography‐mass spectrometry [GC‐MS] urine analysis) before and 6 months after BAT initiation. Adherence was defined as detection of ≥80% intake of prescribed medication at the time of follow‐up. Response to BAT was defined as BP drop ≥5 mmHg in systolic 24 h‐ambulatory BP (ABP) after 6 months. Overall patients (n = 38) median medication adherence was low, but rose from 60% (IQR 25%–100%) to 75% (IQR 38%–100%; p = .0194). After 6 months of BAT, mean systolic and diastolic office BP (‐21 ± 25 mmHg and ‐9 ± 15 mmHg; p < .0001 and .0004) as well as 24 h‐ABP dropped significantly (‐9 ± 17 mmHg and ‐5 ± 12 mmHg; p = .0049 and .0280). After 6 months of BAT, 21 patients (60%) could be classified as responders. There was neither significant difference in mean office systolic (‐21 ± 23 mmHg vs. ‐21 ± 28 mmHg; p = .9581) nor in 24 h‐systolic ABP decrease (‐11 ± 19 mmHg vs. ‐7 ± 15 mmHg; p = .4450) comparing adherent and non‐adherent patients. Whereas Antihypertensive Therapeutic Index (ATI) was unchanged in non‐responders, it significantly decreased in responders (from 50 ± 16 to 46 ± 16; p = .0477). These data are the first to show that BAT‐initiation leads to a clear BP reduction independently of patients´ medication adherence. Response to BAT is associated with a significant lowering of ATI, which might contribute to an underestimation of BAT efficacy.

Impact of drug adherence on blood pressure response to alcohol-mediated renal denervation

PURPOSE

While poor drug adherence is frequent in patients with resistant hypertension, detailed analyses of the impact of drug adherence on the success of renal denervation are scarce. We report drug adherence at baseline, changes in drug adherence, and the influence of these parameters on blood pressure changes at 6 and 12 months in patients treated with alcohol-mediated renal denervation as part of the Peregrine study.

MATERIALS AND METHODS

Urinary detection of antihypertensive drugs was performed using high-performance liquid chromatography-tandem mass spectrometry. Full adherence, partial adherence, and complete non-adherence were defined as 0, 1, or ≥2 drugs not detected, respectively.

RESULTS

Renal denervation was performed in 45 patients with uncontrolled hypertension on ≥3 antihypertensive medications (62% men, age 55 ± 10 years). At baseline, the proportion of fully, partially, and non-adherent patients was 62% (n = 28), 16% (n = 7), and 22% (n = 10), respectively. At 6 months, adherence improved by 21% (n = 9), remained unchanged at 49% (n = 21), and worsened by 30% (n = 13). Mean 24-h systolic blood pressure decreased by 10 ± 13, 10 ± 4, and 14 ± 19 mmHg in fully, partially, and non-adherent patients (p = 0.77), and by 14 ± 14, 8 ± 11, and 14 ± 18 mmHg in patients who improved, maintained, or decreased adherence, respectively (p = 0.35). The results at 12 months were similar.

CONCLUSION

About 40% of patients with apparently treatment-resistant hypertension were not fully adherent at baseline, and adherence decreased further in 30%. Nevertheless, mean blood pressure changes after renal denervation were similar irrespective of drug adherence. Our results suggest that such patients may benefit from alcohol-mediated renal denervation, irrespective of drug adherence. These findings are hypothesis-generating and need to be confirmed in ongoing sham-controlled trials.

Prevalence, phenotypic characteristics and prognostic role of apparent treatment resistant hypertension in the German Chronic Kidney Disease (GCKD) study

Treatment resistant hypertension (TRH) appears of particular relevance in patients with chronic kidney disease (CKD). However, causes and consequences of TRH in CKD patients remain incompletely understood. Therefore, we analyzed the prevalence of apparent TRH (aTRH), and phenotypic characteristics and prognosis associated with aTRH among participants of the German Chronic Kidney Disease (GCKD) study. As insufficient medication adherence has been shown to be a frequent cause of pseudoresistance, we also assessed treatment adherence. Study participants were classified as having aTRH, controlled hypertension and uncontrolled hypertension based on study visit blood pressure and self-reported medication intake. Drug adherence was assessed by comparing self-reported antihypertensive medication with detectable urinary drug metabolites measured by mass spectroscopy. Out of 4901 individuals included in this study, 38% were classified as having aTRH. Male sex, older age, lower estimated glomerular filtration rate (eGFR), higher body mass index (BMI), higher urine albumin-to-creatinine ratio (UACR) and presence of diabetes mellitus were independently associated with higher prevalence of aTRH in a multivariable adjusted regression model. Patients classified as aTRH had higher risk for major adverse cardiovascular events and worsening of kidney disease compared to patients with no aTRH after multivariate adjustment for potential confounders. There was a high agreement between self-reported medication and detectable urinary drug metabolites. In conclusion, in a cohort of Caucasian patients with moderately severe CKD, aTRH was highly prevalent and, in most cases, likely not caused by low medication adherence. Furthermore, aTRH was linked to cardio-renal endpoints, emphasizing the need for improved management.

2022 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension

Hypertension is the most important modifiable cause of cardiovascular (CV) disease and all-cause mortality worldwide. Despite the positive correlations between blood pressure (BP) levels and later CV events since BP levels as low as 100/60 mmHg have been reported in numerous epidemiological studies, the diagnostic criteria of hypertension and BP thresholds and targets of antihypertensive therapy have largely remained at the level of 140/90 mmHg in the past 30 years. The publication of both the SPRINT and STEP trials (comprising > 8,500 Caucasian/African and Chinese participants, respectively) provided evidence to shake this 140/90 mmHg dogma. Another dogma regarding hypertension management is the dependence on office (or clinic) BP measurements. Although standardized office BP measurements have been widely recommended and adopted in large-scale CV outcome trials, the practice of office BP measurements has never been ideal in real-world practice. Home BP monitoring (HBPM) is easy to perform, more likely to be free of environmental and/or emotional stress, feasible to document long-term BP variations, of good reproducibility and reliability, and more correlated with hypertension-mediated organ damage (HMOD) and CV events, compared to routine office BP measurements. In the 2022 Taiwan Hypertension Guidelines of the Taiwan Society of Cardiology (TSOC) and the Taiwan Hypertension Society (THS), we break these two dogmas by recommending the definition of hypertension as ≥ 130/80 mmHg and a universal BP target of < 130/80 mmHg, based on standardized HBPM obtained according to the 722 protocol. The 722 protocol refers to duplicate BP readings taken per occasion ("2"), twice daily ("2"), over seven consecutive days ("7"). To facilitate implementation of the guidelines, a series of flowcharts encompassing assessment, adjustment, and HBPM-guided hypertension management are provided. Other key messages include that: 1) lifestyle modification, summarized as the mnemonic S-ABCDE, should be applied to people with elevated BP and hypertensive patients to reduce life-time BP burden; 2) all 5 major antihypertensive drugs (angiotensin-converting enzyme inhibitors [A], angiotensin receptor blockers [A], β-blockers [B], calcium-channel blockers [C], and thiazide diuretics [D]) are recommended as first-line antihypertensive drugs; 3) initial combination therapy, preferably in a single-pill combination, is recommended for patients with BP ≥ 20/10 mmHg above targets; 4) a target hierarchy (HBPM-HMOD- ambulatory BP monitoring [ABPM]) should be considered to optimize hypertension management, which indicates reaching the HBPM target first and then keeping HMOD stable or regressed, otherwise ABPM can be arranged to guide treatment adjustment; and 5) renal denervation can be considered as an alternative BP-lowering strategy after careful clinical and imaging evaluation.

Refractory Hypertension: a Narrative Systematic Review with Emphasis on Prognosis

PURPOSE OF REVIEW

To perform a narrative systematic review on refractory hypertension (RfHT) with particular emphasis on prognosis.

RECENT FINDINGS

There were 37 articles on RfHT, 13 non-systematic reviews, and 24 original studies. RfHT, a recently described extreme phenotype of anti-hypertensive treatment failure, shall be defined as uncontrolled out-of-office blood pressure (BP) levels despite the use of at least 5 anti-hypertensive drugs, including a long-acting diuretic and a mineraloreceptor antagonist. Its prevalence ranges from 0.5 to 4.3% of general treated hypertensives and between 3.6 and 51.4% of patients with resistant hypertension (RHT). RfHT is associated with younger age, African ancestry, obesity, hypertension-mediated organ damage and clinical cardiovascular diseases, and with some comorbidities, such as diabetes and obstructive sleep apnea. Its physiopathological mechanisms probably involve sympathetic overactivity and not volume overload. Patients with RfHT have a worse prognosis than non-refractory RHT individuals, with higher risks of adverse cardiovascular and renal outcomes and of mortality. RfHT represents a rare but true extreme phenotype of anti-hypertensive treatment failure distinct from RHT and with a significantly worse prognosis. Identifying such individuals is important to tailor specific interventions.