Changes in the rates of awareness, treatment and control of hypertension in Canada over the past two decades

Differences in Antihypertensive Medication Prescription Profiles Between 2009 and 2021: A Retrospective Cohort Study of CARTaGENE

Background

Although blood pressure (BP) control is critical to prevent cardiovascular diseases, hypertension control rates in Canada are in decline.

Objective

To assess this issue, we sought to evaluate the differences in antihypertensive medication prescription profiles in the province of Quebec between 2009 and 2021.

Design

This is a retrospective cohort study.

Setting

We used data from the CARTaGENE population-based cohort linked to administrative health databases.

Patients

Participants with any drug claim in the 6 months prior to the end of follow-up were included.

Measurements

Guideline-recommended antihypertensive drug prescription profiles were assessed at the time of enrollment (2009-2010) and end of follow-up (March 2021).

Methods

Prescriptions practices from the 2 time periods were compared using Pearson's chi-square tests. A sensitivity analysis was performed by excluding participants in which antihypertensive drugs may not have been prescribed solely to treat hypertension (presence of atrial fibrillation/flutter, ischemic heart disease, heart failure, chronic kidney disease, or migraines documented prior to or during follow-up).

Results

Of 8447 participants included in the study, 31.4% and 51.3% filled prescriptions for antihypertensive drugs at the beginning and end of follow-up. In both study periods, guideline-recommended monotherapy was applied in most participants with hypertension (77.9% vs 79.5%, P = .3), whereas optimal 2 and 3-drug combinations were used less frequently (62.0% vs 61.4%, P = .77, 51.9% vs 46.7%, P = .066, respectively). Only the use of long-acting thiazide-like diuretics (9.5% vs 27.7%, P < .001) and spironolactone as a fourth-line agent (8.3% vs 15.9%, P = .054) increased with time but nonetheless remained infrequent. Results were similar in the sensitivity analysis.

Limitations

Specific indication of the prescribed antihypertensive medications and follow-up BP data was not available.

Conclusions

Application of hypertension guidelines for the choice of antihypertensive drugs remains suboptimal, highlighting the need for education initiatives. This may be an important step to raise BP control rates in Canada.

Predictors of Control Status of Hypertension in India: A Systematic Review and Meta-analysis

Predictors of hypertension (HTN) control status have not been well understood in India. This information is crucial for policymakers and program managers to devise newer HTN control strategies and implement relevant policies and programs. Therefore, we undertook this meta-analysis to estimate the effect of various factors on the control status of HTN in India. We systematically searched PubMed and Embase for observational studies and community-based trials published between April 2013 and March 2021 conducted among people (≥ 15 years) with hypertension in India. Quality of studies was assessed using Newcastle Ottawa (NO) scale. Meta-analysis was performed using random effects model. We reported the effect of various factors on the prevalence of controlled HTN using pooled odds ratio (OR) with 95% confidence interval (CI). Of the 842 studies screened, we analyzed nine studies that included 2,441 individuals. Based on the NO scale, majority (90%) of studies had a low risk of bias. The odds of having controlled HTN were significantly higher among women (OR 1.78, 95% CI 1.62-1.95), those aged > 45 years (OR 1.69, 95% CI 1.44-1.97), and those residing in urban parts of India (OR 1.74; 95% CI 1.48-2.03). These measures varied considerably across different regions of the country. Very few studies reported data on the relationship between behavioural risk factors of non-communicable diseases (NCDs) and HTN control status. We did not find any statistically significant differences between behavioural risk factors of NCDs and HTN control status. To improve HTN control in India, the ongoing/newer HTN control programs need to target men, those aged 15-45, and rural residents. Future studies on HTN control determinants should report disaggregated data and use standardized definitions for behavioral risk factors to enhance reliability and comprehensiveness of findings on the determinants of HTN control in future reviews.

Screening for hypertension in adults: protocol for evidence reviews to inform a Canadian Task Force on Preventive Health Care guideline update

PURPOSE

To inform updated recommendations by the Canadian Task Force on Preventive Health Care on screening in a primary care setting for hypertension in adults aged 18 years and older. This protocol outlines the scope and methods for a series of systematic reviews and one overview of reviews.

METHODS

To evaluate the benefits and harms of screening for hypertension, the Task Force will rely on the relevant key questions from the 2021 United States Preventive Services Task Force systematic review. In addition, a series of reviews will be conducted to identify, appraise, and synthesize the evidence on (1) the association of blood pressure measurement methods and future cardiovascular (CVD)-related outcomes, (2) thresholds for discussions of treatment initiation, and (3) patient acceptability of hypertension screening methods. For the review of blood pressure measurement methods and future CVD-related outcomes, we will perform a de novo review and search MEDLINE, Embase, CENTRAL, and APA PsycInfo for randomized controlled trials, prospective or retrospective cohort studies, nested case-control studies, and within-arm analyses of intervention studies. For the thresholds for discussions of treatment initiation review, we will perform an overview of reviews and update results from a relevant 2019 UK NICE review. We will search MEDLINE, Embase, APA PsycInfo, and Epistemonikos for systematic reviews. For the acceptability review, we will perform a de novo systematic review and search MEDLINE, Embase, and APA PsycInfo for randomized controlled trials, controlled clinical trials, and observational studies with comparison groups. Websites of relevant organizations, gray literature sources, and the reference lists of included studies and reviews will be hand-searched. Title and abstract screening will be completed by two independent reviewers. Full-text screening, data extraction, risk-of-bias assessment, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) will be completed independently by two reviewers. Results from included studies will be synthesized narratively and pooled via meta-analysis when appropriate. The GRADE approach will be used to assess the certainty of evidence for outcomes.

DISCUSSION

The results of the evidence reviews will be used to inform Canadian recommendations on screening for hypertension in adults aged 18 years and older.

SYSTEMATIC REVIEW REGISTRATION

This protocol is registered on PROSPERO and is available on the Open Science Framework (osf.io/8w4tz).

A Cross-Sectional Study on the Associations between Depression and Anxiety, Medication Use for These Diseases and Physical Activity Level in Spanish People with Hypertension

Hypertension (HTN) has a high prevalence in the overall population, affecting people's mental health. Physical Activity (PA) has proven to be an effective tool to improve mental health. This study analyzed the associations between Depression and Anxiety prevalence, medication use for these disorders (antidepressants and anxiolytics) and Physical Activity Level (PAL) in people with HTN. A cross-sectional study was conducted with data from the Spanish National Health Survey 2017 (ENSE2017) with a final sample of 3228 individuals over 15 years of age with HTN who resided in Spain. Data normality was assessed through the Kolmogorov-Smirnov test. Associations between Depression and Anxiety prevalence, antidepressant and anxiolytic use and PAL were studied using a chi-square test. Possible differences between Depression and Anxiety prevalence and medication use according to the PAL were analyzed with a z-test for independent proportions. Depression or Anxiety and antidepressant and anxiolytic use odds ratios (OR) were calculated for every PAL group, taking the "Very Active" group as a reference. Risk factors were evaluated using multiple binary logistic regression. Dependency relationships were found between Depression and Anxiety prevalence, antidepressant and anxiolytic use and PAL (p < 0.001). The Inactive group displayed the highest prevalence and medication use according to their PAL (p < 0.05). Higher ORs for Depression or Anxiety and pharmacological treatments used were also found in the Inactive group compared to the other PAL groups.

The prevalence of hypertension and its associated risk factors among older adults in Ghana

Background

Hypertension is a worldwide health issue that primarily affects the elderly in our society. However, in comparison to the developed world, the prevalence of hypertension is higher in Sub-Saharan Africa.

Objective

This paper examines the prevalence of hypertension and its associated risk factors among older adults in Ghana.

Methods

Using the World Health Organization's study on global AGEing and adult health (WHO SAGE) Wave 1 cross-sectional data collected via in-person structured interviews; paper and pencil interviews (PAPI) from ten administrative regions of Ghana using stratified multistage cluster design from respondents aged 50+ grouped by decade, this study analyzed a nationally representative sub-sample of 3,997 respondents employing binary logistic regression. Odds ratios (OR) and 95% confidence intervals (95% CI) were used to estimate risk factors associated with hypertension (blood pressure ≥ 130/80 mm/Hg).

Results

There was a 53.72% hypertension prevalence rate among older adults. Hypertension prevalence tends to increase with increasing age. The prevalence of hypertension was associated with residency (B = -0.18, OR = 0.84, p < 0.017), with urban residents being more at risk of hypertension than rural residents. The prevalence of hypertension increased with overweight (B = 0.66, OR = 1.94, p < 0.001) and obesity (B = 0.82, OR = 2.28, p < 0.001). The amount of fruit and vegetable intake was insignificant but had an inverse relationship with hypertension prevalence.

Conclusion

This study has shown that demographic and lifestyle factors significantly affect and explain the hypertension risk among older adults. Medical factors, such as chronic diseases, were largely insignificant and accounted for less hypertension prevalence. Therefore, when interpreting test findings in clinical practice, such as hypertension, it is essential to consider demographic and lifestyle factors. In addition, health policies and primary interventions that seek to improve the standard of living, lifestyle, and wellbeing of older adults need to be critically considered moving forward to lower hypertension prevalence among older adults in Ghana.

Mortality Rate and Years of Life Lost due to Hypertension in the South of Iran between 2004 and 2019: A Population-Based Study

INTRODUCTION

Hypertension is known worldwide as a preventable significant risk factor for cardiovascular diseases and their mortality. This study was designed to determine the mortality rate and years of life lost (YLL) due to hypertension in Fars Province.

METHOD

In this cross-sectional study, we extracted all death reports due to hypertension based on age, gender, and the year of death based on ICD-10 from the EDRS system (Electronic Death Registration System). The YLL analysis due to premature death related to hypertension was executed by the 2015 YLL template from WHO in EXCEL 2016 software. To examine the trend of crude and standardized mortality rates and YLL rates for different years, joinpoint regression was used based on the log-linear model.

RESULTS

In the 16 years that the study was done (2004-2019), 13443 death cases occurred in the Fars Province, 51.0% of which (6859 cases) were in females and 48.5% (6515 cases) of which were in the 80+ age group. Total YLL due to hypertension in these 16 years of study was 61,344 (1.9 per 1000) in males, 64,903 (2.1 per 1000) in females, and 126,247 (2.0 in 1000) in both genders. According to the joinpoint regression analysis, the 16-year trend of YLL rate due to premature mortality was increasing: the average annual percent change (AAPC) was 4.9% (95% CI -2.6 to 12.85, p value=0.205) for males and 8.4% (95% CI 5.2 to 11.7, p value <0.001) for females.

CONCLUSION

Considering the increasing trend in crude and standardized mortality rates and YLL due to hypertension, it is important for policymakers and decision makers of Health Policy Centers to promote and inform people about the importance of hypertension control and to familiarize them with proper, preventive interventions such as the importance of a healthy diet, routine physical activity, and routine learning programs for different groups in the society especially for people at a higher risk of hypertension.

Perception of risk of hypertension related complications and adherence to antihypertensive drugs: a primary healthcare based cross-sectional study

BACKGROUND

Blood pressure control is suboptimal in more than half of treated hypertensive patients. The purpose of this study was to assess perceived risk of high blood pressure sequelae and adherence to medications in known cases of hypertension.

METHODS

A cross-sectional study was designed using a sample of 600 hypertensive patients who were randomly selected from 32 primary healthcare centers in Shiraz, Iran. A structured interviewer-administered questionnaire was used to collect data. Participants were asked about their basic demographic information, smoking history, access to healthcare services, duration of antihypertensive therapy, number of drugs taken concurrently and their perceived risk of hypertension-related complications. The outcome of interest was adherence to antihypertensive medications measured by the Persian version of the Morisky Medication Adherence Scale (MMAS-8). Multivariate logistic regression analysis was used to identify independent factors associated with better adherence.

RESULTS

Nearly half (48.8%) of participants had uncontrolled hypertension. Just over one fifth (22.3%) of all the patients reported high adherence to antihypertensive medications. Independent factors associated with better adherence to antihypertensive medications were higher educational level (OR: 1.71, CI 95%: 1.06-2.75), being a never smoker (OR: 1.62, CI 95%: 1.06-2.46), having easy access to healthcare services (OR: 1.91, CI 95%: 1.10-3.35), lower mean treatment duration (OR: 0.96, CI 95%: 0.92-0.99), and having higher perceived risk of hypertension-related complications (OR:2.34, CI 95%: 1.52-3.60).

CONCLUSION

High perceived risk of hypertension-related complications is significantly associated with adherence to antihypertensive therapy. Our findings suggest that primary care physicians should regularly emphasize on negative consequences of uncontrolled/poorly controlled blood pressure while visiting hypertensive patients.

Longitudinal trends in blood pressure, prevalence, awareness, treatment, and control of hypertension in the Czech population. Are there any sex differences?

Background

Hypertension is the most common cardiovascular disease which substantially increases cardiovascular morbidity and mortality. Despite the broad availability of antihypertensive medication, control of hypertension is not satisfactory worldwide.

Objective

The study aim was to assess longitudinal trends in blood pressure, prevalence, awareness, treatment, and control of hypertension in a representative population sample of the Czechia from 1985 to 2016/2017, focusing on sex differences.

Methods

A total of 7,606 men and 8,050 women aged 25–64 years were screened for major CV risk factors in seven independent cross-sectional surveys run consistently in the same six country districts of the Czechia between 1985 and 2016/2017. The population samples were randomly selected.

Results

Over a study period of 31/32 years, there was a significant decline in systolic and diastolic blood pressure in both sexes, whereas the prevalence of hypertension decreased only in women. There was an increase in hypertension awareness in both sexes over the entire study period with consistently higher rates in women. The proportion of individuals treated with antihypertensive drugs increased significantly in both sexes throughout the study, again with consistently higher rates in women. Control of hypertension increased significantly over the study period with consistently higher rates in women. The age-adjusted trends in blood pressure, prevalence, awareness, and treatment of hypertension were significantly different in men and women, always in favor of women. The age-adjusted trends in control of hypertension in treated patients were equally poor in both sexes.

Conclusion

There are significant differences in longitudinal trends in blood pressure, prevalence, awareness, treatment, and control of hypertension between men and women, always in favor of women except for the control of hypertension in treated patients, where it is equally poor in both sexes.

Ups and downs of hypertension control in Canada: critical factors and lessons learned

As the leading risk for death, population control of increased blood pressure represents a major challenge for all countries of the Americas. In the early 1990’s, Canada had a hypertension control rate of 13%. The control rate increased to 68% in 2010, accompanied by a sharp decline in cardiovascular disease. The unprecedented improvement in hypertension control started around the year 2000 when a comprehensive program to implement annually updated hypertension treatment recommendations started. The program included a comprehensive monitoring system for hypertension control. After 2011, there was a marked decrease in emphasis on implementation and evaluation and the hypertension control rate declined, driven by a reduction in control in women from 69% to 49%. A coalition of health and scientific organizations formed in 2011 with a priority to develop advocacy positions for dietary policies to prevent and control hypertension. By 2015, the positions were adopted by most federal political parties, but implementation has been slow.

This manuscript reviews key success factors and learnings. Some key success factors included having broad representation on the program steering committee, multidisciplinary engagement with substantive primary care involvement, unbiased up to date credible recommendations, development and active adaptation of education resources based on field experience, extensive implementation of primary care resources, annual review of the program and hypertension indicators and developing and emphasizing the few interventions important for hypertension control. Learnings included the need for having strong national and provincial government engagement and support, and retaining primary care organizations and clinicians in the implementation and evaluation.

Telemonitoring and protocolized case management for hypertensive community dwelling older adults (TECHNOMED): a randomized controlled trial

BACKGROUND

Home blood pressure (BP) telemonitoring combined with case management leads to BP reductions in individuals with hypertension. However, its benefits are less clear in older (age ≥ 65 years) adults.

METHODS

Twelve-month, open-label, randomized trial of community-dwelling older adults comparing the combination of home BP telemonitoring (HBPM) and pharmacist-led case management, vs. enhanced usual care with HBPM alone. The primary outcome was the proportion achieving systolic BP targets on 24-h ambulatory BP monitoring (ABPM). Changes in HBPM were also examined. Logistic and linear regressions were used for analyses, adjusted for baseline BP.

RESULTS

Enrollment was stopped early due to coronavirus disease 2019. Participants randomized to intervention (n = 61) and control (n = 59) groups were mostly female (77%), with mean age 79.5 years. The adjusted odds ratio for ABPM BP target achievement was 1.48 (95% confidence interval 0.87-2.52, P = 0.15). At 12 months, the mean difference in BP changes between intervention and control groups was -1.6/-1.1 for ABPM (P-value 0.26 for systolic BP and 0.10 for diastolic BP), and -4.9/-3.1 for HBPM (P-value 0.04 for systolic BP and 0.01 for diastolic BP), favoring the intervention. Intervention group participants had hypotension (systolic BP < 110) more frequently (21% vs. 5%, P = 0.009), but no differences in orthostatic symptoms, syncope, non-mechanical falls, or emergency department visits.

CONCLUSIONS

Home BP telemonitoring and pharmacist case management did not improve achievement of target range ambulatory BP, but did reduce home BP. It did not result in major adverse consequences.

Modifiable and Non-modifiable Factors Associated with Low Awareness of Hypertension Treatment in Indonesia: A Cross-Sectional Population-Based National Survey

Introduction:

Low awareness about hypertension treatment is recognized as a significant cause of treatment failure. Therefore, identifying its underlying factors is essential for developing effective intervention strategies. This study aims to identify the modifiable and non-modifiable factors associated with low awareness about hypertension treatment.

Method:

This national, cross-sectional, population-based survey used publicly available data from the Indonesian Family Life Survey (IFLS-5) for 2014 among respondents with hypertension aged ≥15 years. Depression and insomnia, as modifiable factors, were assessed using the Centre for Epidemiologic Studies—Depression (CES-D) and the Patient-Recorded Outcomes Measurement Information System (PROMIS) questionnaire, respectively. Non-modifiable factors, such as sociodemographic information, were obtained from self-reported data. Logistic regression analysis was used to assess the association between these factors and low awareness about hypertension treatment. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported.

Result:

The study recruited 7,920 respondents, the majority of whom were female (53.8%) and aged <60 years (71.1%). The prevalence of low awareness of hypertension treatment was 87.1% (51.8% in women and 48.2% in men). Being an elderly (OR: 1.60, 95%CI 1.36–1.88), being irregularly blood pressure control (OR: 4.40, 95% CI 3.78–5.13), having depressive symptoms (OR: 1.35, 95% CI 1.12–1.62), having insomnia (OR: 1.31, 95% CI 1.11–1.53), and having low satisfaction with health care (OR: 1.28, 95% CI 1.08–1.51) were associated with low awareness of hypertension treatment. Surprisingly, respondents with strong religiosity (OR: 1.62; 95% CI 1.25–2.09) were more likely to display low awareness of hypertension treatment.

Conclusion:

The main factors associated with low awareness of hypertension treatment are modifiable. Thus, health care professionals should integrate more patient-specific factors when designing tailored interventions.

Hypertension in China: burdens, guidelines and policy responses: a state-of-the-art review

Hypertension is a leading risk factor of cardiovascular disease and it is becoming increasingly prevalent globally. Correspondingly, the Chinese government and public health institutions have issued a series of policy documents and guidelines for hypertension. However, no comprehensive review of such documents has been conducted. Hence, this review aims to provide an up-to-date and comprehensive assessment of not only the disease burden, but also hypertension management policies and guidelines in China. A total of 15 epidemiological studies based on national population surveys, 15 Chinese Hypertension Guidelines, and seven policy documents were identified. We found a larger burden of hypertension in men, while the awareness, treatment, and control rates have remained low in both sexes. The ranges of hypertension prevalence, awareness, treatment, and control rate among hypertensive patients were 18.0-44.7%, 23.6-56.2%, 14.2-48.5%, and 4.2-30.1% respectively. Chinese hypertension guidelines provide evidence-based instructions to healthcare practitioners over hypertension management in which primary healthcare is increasingly emphasized. Finally, the policy documents set national goals for hypertension management and standardized the services provided in primary healthcare. The findings highlight the importance of integrating new guidelines into hypertension management provided by primary healthcare practitioners and the need to evaluate the implementation of guidelines and policies.

Hypertension Prevalence, Awareness, and Control Among Parents of School-Aged Children in the United Arab Emirates

BACKGROUND

Increased blood pressure (BP) is a major cardiovascular disease risk factor. The study aimed to determine the prevalence and predictors of hypertension and its awareness and control among parents of school-aged children in the United Arab Emirates (UAE).

METHODS

A total of 605 parents participated in this cross-sectional study. Information on socio-demographics, lifestyle factors, and history of chronic disease were collected through an adapted version of the World Health Organization STEPS questionnaire. Fasting blood glucose samples, BP measurements, body mass index (BMI), and waist and hip circumference were obtained using standard measurement protocols. Prevalence of hypertension was identified in the cohorts by defining hypertension using the 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines (BP≥130/80 mmHg) and the World Health Organization-International Society of Hypertension Guidelines Orchid (BP≥140/90 mmHg) in association with antihypertensive medication use.

RESULTS

The mean age of participants was 42.9±7.9 years. The prevalence of hypertension was 37.2% (95% CI: 33.5-41.2) and 18.0% (95% CI: 15.2-21.3), using the 2017 and the previous WHO definitions, respectively. Little over half of the sample (51.5%) who were aware of having hypertension reported using antihypertensive medications. Of those reporting the use of antihypertensive medications in the past two days, 13 of 33 patients (39.4%) had their hypertension under control (<140/90 mmHg). The independent correlates of hypertension included age [(adjusted odds ratio (AOR): 1.09 (1.05-1.13], male sex [AOR: 2.48 (1.41-4.34], college or higher education [AOR: 0.22 (0.09-0.56)], family history of hypertension [AOR: 2.03 (1.17-3.53)], obesity [AOR: 3.15 (1.24-7.12)], and moderate or vigorous physical activity [AOR: 0.50 (0.26-0.98)].

CONCLUSION

Hypertension is prevalent among parents of school-going children. Improving lifestyle, health literacy, and introducing innovative models to raise awareness and education about hypertension are essential to achieve sustainable development goals (SDGs).

Prevalence of pre-hypertension and hypertension, awareness, treatment, and control of hypertension, and cardiovascular risk factors in postmenopausal women

BACKGROUND

Pre-hypertension (HTN) and HTN are risk factors for cardiovascular disease (CVD). Despite its importance, HTN is often underestimated and undiagnosed, especially in women. This study was designed to determine the prevalence of pre-HTN and HTN among a large sample of Iranian menopausal women.

METHODS

This repeated cross-sectional study was conducted on 1013 menopausal women aged 41 to 85 years in Isfahan, Iran, in the years 2001, 2007, and 2016. The participants were selected through multistage cluster random sampling. Awareness, treatment, and control of HTN were assessed using a validated researcher-made questionnaire. Blood pressure was determined via an arm digital blood pressure monitor.

RESULTS

The prevalence of HTN in the years 2001, 2007, and 2016 was 52.6%, 49.0%, and 51.6%, respectively; no significant changes were observed (P > 0.05). The prevalence of pre-HTN in these years was 56.6%, 53.3%, and 42.2%, respectively. In 2001 and 2007, respectively, 28.8% and 50.4% of menopausal women had HTN controlled by medication, and in 2016, 86.6% of women were aware of their disease and 62% of them had controlled HTN (P < 0.001).

CONCLUSION

The results showed that HTN and pre-HTN were highly prevalent among Iranian menopausal women and markedly increased with age. Interventional population-based approaches are needed to improve knowledge and efficient practice that may help to lower the risk of HTN and CVD in this at-risk population.

Knowledge, perception and practice of Québec nurses for ambulatory and clinic blood pressure measurement methods: are we there yet?

BACKGROUND

Guidelines regarding blood pressure measurement (BPM) methods, namely home (HBPM), ambulatory (ABPM), office (OBPM) and automated (AOBP) are published by Hypertension Canada and rely on accurate measurement technique. Nurses commonly perform BPM but their knowledge, perception and practice considering all methods is understudied. This study is the first to establish the picture of Québec nurses working in primary care settings concerning the four BPM methods.

METHODS

All nurses licensed to practice in primary care in Québec were targeted in our survey. Data were collected using a validated and pretested investigator-initiated questionnaire in English and French. A personalized e-mail invitation, and two reminders, including a link to a secured platform was sent in December 2019. A certificate of ethics was issued by UQTR.

RESULTS

A total of 453 nurses participated in the study. Median age was 40 ± 11 years, and 92% were women. The overall score on BPM methods knowledge was slightly below 50% (46% ± 23). The perception was mostly positive, with an overall score above 50% (73% ± 8). In practice, HBPM was recommended by 47% of nurses, and ABPM by 18%. Although AOBP is the preferred method in Canada, only 25% of the nurses use it, including the 57% that use an oscillometric device and 11% that use manual auscultation.

CONCLUSION

Nurses working in primary care play a central role in BPM. Our results highlight that overall knowledge and practice are suboptimal. Resources should, therefore, be allocated to ensure that initial training and continuing education are addressed.

Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension

High blood pressure is one of the most important risk factors for ischaemic heart disease, stroke, other cardiovascular diseases, chronic kidney disease and dementia. Mean blood pressure and the prevalence of raised blood pressure have declined substantially in high-income regions since at least the 1970s. By contrast, blood pressure has risen in East, South and Southeast Asia, Oceania and sub-Saharan Africa. Given these trends, the prevalence of hypertension is now higher in low-income and middle-income countries than in high-income countries. In 2015, an estimated 8.5 million deaths were attributable to systolic blood pressure >115 mmHg, 88% of which were in low-income and middle-income countries. Measures such as increasing the availability and affordability of fresh fruits and vegetables, lowering the sodium content of packaged and prepared food and staples such as bread, and improving the availability of dietary salt substitutes can help lower blood pressure in the entire population. The use and effectiveness of hypertension treatment vary substantially across countries. Factors influencing this variation include a country's financial resources, the extent of health insurance and health facilities, how frequently people interact with physicians and non-physician health personnel, whether a clear and widely adopted clinical guideline exists and the availability of medicines. Scaling up treatment coverage and improving its community effectiveness can substantially reduce the health burden of hypertension.

Opportunities and Challenges From Leading Trends in a Biomonitoring Project: Canadian Health Measures Survey 2007-2017

Background: Biomonitoring can be conducted by assessing the levels of chemicals in human bodies and their surroundings, for example, as was done in the Canadian Health Measures Survey (CHMS). This study aims to report the leading increasing or decreasing biomarker trends and determine their significance.

Methods: We implemented a trend analysis for all variables from CHMS biomonitoring data cycles 1–5 conducted between 2007 and 2017. The associations between time and obesity were determined with linear regressions using the CHMS cycles and body mass index (BMI) as predictors.

Results: There were 997 unique biomarkers identified and 86 biomarkers with significant trends across cycles. Nine of the 10 leading biomarkers with the largest decreases were environmental chemicals. The levels of 1,2,3-trimethyl benzene, dodecane, palmitoleic acid, and o-xylene decreased by more than 60%. All of the 10 chemicals with the largest increases were environmental chemicals, and the levels of 1,2,4-trimethylbenzene, nonanal, and 4-methyl-2-pentanone increased by more than 200%. None of the 20 biomarkers with the largest increases or decreases between cycles were associated with BMI.

Conclusions: The CHMS provides the opportunity for researchers to determine associations between biomarkers and time or BMI. However, the unknown causes of trends with large magnitudes of increase or decrease and their unclear impact on Canadians' health present challenges. We recommend that the CHMS plan future cycles on leading trends and measure chemicals with both human and environmental samples.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Poor Awareness of Hypertension in France: The CONSTANCES Population-Based Study

OBJECTIVES

We aimed to assess the hypertension (HTN) awareness and associated factors in France.

METHODS

We conducted a cross-sectional analysis using data from the CONSTANCES population-based cohort involving 87,808 volunteer participants included between 2012 and 2018. HTN was defined as average blood pressure (BP) over 140/90 or use of BP medication, awareness as self-reported HTN. Multivariable logistic regression models were used to identify the associated factors.

RESULTS

Overall, 27,160 hypertensive participants (men = 16,569) above 18 years old were analyzed. Hypertension awareness rate was 37.5%. In the multivariable regression model, awareness was predicted by female gender, age, prior cardiovascular disease (CVD), presence of diabetes mellitus (DM), presence of chronic kidney disease (CKD), level of education, and obesity or overweight. Older participants (P < 0.001), females (P < 0.001), participants with comorbidities (P < 0.001), were more likely to be aware when compared with younger participants, males and participants without comorbidities, respectively. The unawareness among participants without cardiometabolic factors (CMF, i.e., CVD, DM, CKD) was higher than participants with CMF (67% vs. 41%, respectively, P < 0.001). Moreover, some differences appeared in both genders in the association between awareness of HTN and health and lifestyle factors.

CONCLUSION

Our findings show that HTN awareness is low. Particular attention should be given to young men without comorbidities as these characteristics were predictors of poor awareness. Immediate action is required to improve HTN awareness in France.

A double-blind, randomized, crossover trial protocol of whole hemp seed protein and hemp seed protein hydrolysate consumption for hypertension

BACKGROUND

Primary hypertension accounts for almost 95% of all cases of high blood pressure and is a major modifiable risk factor for cardiovascular diseases. Lifestyle interventions have been shown to prevent hypertension. One of the prominent potential therapeutic lifestyle strategies to prevent or manage hypertension is increasing dietary protein as a macronutrient or as bioactive peptides. An emerging plant-based protein source that may have anti-hypertensive properties is hemp seed.

METHODS/DESIGN

A randomized, double-blind, crossover clinical trial will be conducted on 35 hypertensive participants aged 18-75 years, with a BMI between 18.5 and 40 kg/m², systolic blood pressure (SBP) between 130 and 160 mmHg and diastolic blood pressure (DBP) ≤ 110 mmHg. The trial will be conducted for a period of 22 weeks and will consist of three treatment periods of 6 weeks, separated by 2-week washout periods. The treatments will be consumed twice a day and consist of 25 g casein, hemp seed protein (HSP), or HSP plus HSP hydrolysate (HSP+). The primary outcome of this trial is 24-h SBP, measured on the first day of first phase and the last day of each phase. Office-measured blood pressure, pulse-wave velocity and augmentation index and anthropometrics will be determined at the first and last days of each period. Also, body composition will be assessed by dual x-ray absorptiometry (DXA) scan on the first day of the first phase and within the last 2 days of each treatment period. Blood samples will be collected on the first and last 2 days of each treatment phase whereas urine samples will be collected on the first day of the first phase plus the last day of each phase to be analyzed for specific biomarkers.

DISCUSSION

This trial protocol is designed to evaluate the hypotensive potential of consuming whole HSP, and HSP+, in comparison to casein protein. This study will be the first trial investigating the potential anti-hypertensive benefit of dietary hemp protein plus bioactive peptide consumption in humans.

TRIAL REGISTRATION

National Clinical Trial (NCT), ID: NCT03508895. Registered on 28 June 2018. Retrospectively registered on the publicly accessible Registry Databank at ClinicalTrials.gov (http://ClinicalTrials.gov).

Implementation of a community-based hypertension control program in Matanzas, Cuba

Increased blood pressure is a leading risk factor for death worldwide, and improving the control of hypertension is a major health goal to reduce non-communicable disease. Thus, in 2016, as part of a regional effort between the Pan American Health Organization and Cuban Ministry of Public Health to reduce cardiovascular risk and disease, a community demonstration project was implemented to enhance hypertension control. The intervention project was in a population of 25 868 people served by the Carlos Verdugo Martínez Polyclinic in Matanzas, Cuba. The project implemented interventions currently recommended in the World Health Organization HEARTS modules, including a standardized clinical training program with certification for blood pressure measurement, routine screening for hypertension in clinics and in the community, a simple directive pharmacologic treatment algorithm, and a registry with performance reporting and feedback. Qualitative and quantitative program monitoring and evaluation was established. In a 2010 national survey, the prevalence of hypertension and the rate of hypertension control were estimated to be 31% and 36%, respectively. Following less than one year of the full implementation of the program, the prevalence of hypertension, proportion of the hypertensive population registered as having hypertension, proportion of those drug-treated who were controlled, and estimated population rate of control were 30%, 90%, 68%, and 58%, respectively. Based on these positive results, the program has been expanded to include another demonstration program initiated in a second region. In addition, preliminary efforts to disseminate and scale-up aspects of the program to the full Cuban population have started.

Non-cardiac comorbidities and mortality in patients with heart failure with reduced vs. preserved ejection fraction: a study using the Swedish Heart Failure Registry

BACKGROUND

Heart failure (HF) and non-cardiac comorbidities often coexist and are known to have an adverse effect on outcome. However, the prevalence and prognostic impact of non-cardiac comorbidities in patients with HF with reduced ejection fraction (HFrEF) vs. those with preserved (HFpEF) remain inadequately studied.

METHODS AND RESULTS

We used data from the Swedish Heart Failure Registry from 2000 to 2012. HFrEF was defined as EF < 50% and HFpEF as EF ≥ 50%. Of 31 344 patients available for analysis, 79.3% (n = 24 856) had HFrEF and 20.7% (n = 6 488) HFpEF. The outcome was all-cause mortality. We examined the association between ten non-cardiac comorbidities and mortality and its interaction with EF using adjusted hazard ratio (HR). Stroke, anemia, gout and cancer had a similar impact on mortality in both phenotypes, whereas diabetes (HR 1.57, 95% confidence interval [CI] [1.50-1.65] vs. HR 1.39 95% CI [1.27-1.51], p = 0.0002), renal failure (HR 1.65, 95% CI [1.57-1.73] vs. HR 1.44, 95% CI [1.32-1.57], p = 0.003) and liver disease (HR 2.13, 95% CI [1.83-2.47] vs. HR 1.42, 95% CI [1.09-1.85] p = 0.02) had a higher impact in the HFrEF patients. Moreover, pulmonary disease (HR 1.46, 95% CI [1.40-1.53] vs. HR 1.66 95% CI [1.54-1.80], p = 0.007) was more prominent in the HFpEF patients. Sleep apnea was not associated with worse prognosis in either group. No significant variation was found in the impact over the 12-year study period.

CONCLUSIONS

Non-cardiac comorbidities contribute significantly but differently to mortality, both in HFrEF and HFpEF. No significant variation was found in the impact over the 12-year study period. These results emphasize the importance of including the management of comorbidities as a part of a standardized heart failure care in both HF phenotypes.

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.

Job strain and the prevalence of uncontrolled hypertension among white-collar workers

To determine whether white-collar workers treated for hypertension who are exposed to psychosocial stressors at work have a higher prevalence of uncontrolled hypertension than unexposed workers, this study conducted three waves of data collection over a 5-year period (repeated cross-sectional design). The study sample was composed of 464 white-collar workers treated for hypertension. At each collection time, ambulatory blood pressure (ABP) was measured every 15 min during the workday. Uncontrolled hypertension was defined as a mean daytime systolic ABP ≥135 mmHg and/or diastolic ABP ≥85 mmHg for non-diabetic participants and systolic ABP ≥125 mmHg and/or diastolic ABP ≥75 mmHg for diabetic participants. Job strain was evaluated with Karasek's demand-latitude model using validated scales for psychological demands and decision latitude. Prevalence ratios (PR) and 95% confidence intervals (CI) were estimated using generalized estimating equations, adjusting for sociodemographic and lifestyle-related risk factors. Men with job strain (high demands and low latitude) and active jobs (high demands and high latitude) had a higher prevalence of uncontrolled hypertension (PR job strain = 1.46, 95% CI: 1.07-1.98 and PR active = 1.47, 95% CI: 1.12-1.94). When considered separately, high demands were associated with a higher prevalence of uncontrolled hypertension in both men (PR highest tertile = 1.60, 95% CI: 1.25-2.06) and women (PR highest tertile = 1.60, 95% CI: 1.03-2.47). Workers exposed to psychosocial stressors at work according to the demand-latitude model had a higher prevalence of uncontrolled hypertension. Reducing these frequent exposures could help to reduce the burden of uncontrolled hypertension.

High rate of hypertension control among treated patients attending a teaching primary healthcare centre in Jordan

INTRODUCTION

The purpose of this study was to determine the hypertension control rate and its associated factors among treated patients attending a teaching primary healthcare centre in Jordan.

STUDY DESIGN

We conducted a retrospective cohort study of 286 patients with HTN, treated with medications, who attended Jordan University of Science and Technology primary healthcare centre in Irbid, Jordan, from July through September 2018. Data were abstracted from the patient's medical records and personal interviews. Multivariate logistic regression analysis was used to examine independent factors associated with hypertension control.

RESULTS

Blood pressure control rate was 90.9% and was significantly higher among patients who were married (p=0.02), with higher income level (p<0.01), non-smokers (p=0.01), free of diabetes mellitus or dyslipidaemia (p=0.048), highly consuming fruits and vegetables (p<0.01), non-obese (p<0.01), adherent to blood pressure medications (p=0.02) and among patients on lower number of antihypertensive medications (p=0.01). Multivariate analysis with adjusted OR of factors associated with hypertension control were higher fruit and vegetable intake (p<0.01), higher income level (p=0.02) and medication adherence (p<0.01).

CONCLUSION

Participants in this study achieved a relatively high rate of blood pressure control. Associated factors with this rate were higher fruit and vegetable intake, higher income level and medication adherence. For better hypertension control, patients should be advised to adhere to their medications and consume more fruits and vegetables besides other lifestyle changes.

Evolution of Blood Pressure Clinical Practice Guidelines: A Personal Perspective

Before the second half of the 20th century, most clinical decision making was based on expert opinion. By the 1960s, experience in actuarial and research cohort studies had provided strong evidence that blood pressure was an important risk factor for cardiovascular disease. The landmark 1967 and 1970 Veterans Administration Cooperative Study trials confirmed the value of antihypertensive drug therapy in preventing stroke, myocardial infarction, and heart failure in adults with high levels of diastolic blood pressure. They also provided an impetus to develop the first blood-pressure-related clinical practice guideline in 1977. In subsequent years, more structured and comprehensive blood-pressure guidelines have evolved to become a major resource in clinical and public health practice. Despite some limitations, these guidelines provide useful evidence-based guidance for diagnosis and management of high blood pressure. The core advice in most of the current comprehensive blood pressure guidelines is more similar than different. Modelling studies suggest that better adherence to guideline recommendations would result in a lower average blood pressure and substantial improvement in public health.

Hypertension Prevalence, Treatment and Control in Older Adults in a Brazilian Capital City

BACKGROUND

The diagnosis, treatment and control of arterial hypertension are fundamental for a reduction in cardiovascular outcomes, especially in the elderly. In Brazil, there are few studies that specifically identified these rates in the elderly population.

OBJECTIVE

To verify rates of prevalence, treatment and control of hypertension in elderly people living in the urban area of a Brazilian capital city.

METHODS

A cross-sectional, population-based, randomized, cluster-based study with 912 non-institutionalized elderly individuals (≥ 60 years), living in urban areas in the city of Goiania, Midwest Brazil. Predictor variables were: age, gender, socioeconomic and lifestyle aspects. Blood pressure measurements were performed at home; patients were considered as having arterial hypertension when SBP and/or DBP ≥ 140/90 mmHg or when using antihypertensive drugs (dependent variable). Rates of hypertension treatment and control were evaluated. Variable association analyses were performed by multivariate logistic regression and level of significance was set at 5%.

RESULTS

The prevalence of arterial hypertension was 74.9%, being higher (78.6%) in men (OR 1.4, 95% CI: 1.04-1.92); the treatment rate was 72.6%, with higher rates being observed in smokers (OR 2.06, 95% CI: 1.28-3.33). The rate of hypertension control was 50.8%,being higher in women (OR 1.57, 95% CI: 1.19-2.08).

CONCLUSION

The prevalence rates were high. Treatment and control rates were low and associated with gender, age and lifestyle, indicating the need for early and individual interventions.

The 2017 American College of Cardiology/American Heart Association vs Hypertension Canada High Blood Pressure Guidelines and Potential Implications

In this report we examine the differences between the 2017 Hypertension Canada and 2017 American College of Cardiology and American Heart Association (ACC/AHA) blood pressure (BP) guidelines regarding the proportions of individuals with a diagnosis of hypertension, BP above thresholds for treatment initiation, and BP below targets using the CARTaGENE cohort. Compared with the 2017 Canadian guidelines, the 2017 ACC/AHA guidelines would result in increases of 8.7% in hypertension diagnosis and 3.4% of individuals needing treatment, with 17.2% having a different BP target. In conclusion, implementing the 2017 ACC/AHA hypertension guidelines in Canada could result in major effects for millions of Canadians.

Non-cardiac comorbidities and mortality in patients with heart failure with reduced vs. preserved ejection fraction: a study using the Swedish Heart Failure Registry

Background

Heart failure (HF) and non-cardiac comorbidities often coexist and are known to have an adverse effect on outcome. However, the prevalence and prognostic impact of non-cardiac comorbidities in patients with HF with reduced ejection fraction (HFrEF) vs. those with preserved (HFpEF) remain inadequately studied.

Methods and results

We used data from the Swedish Heart Failure Registry from 2000 to 2012. HFrEF was defined as EF < 50% and HFpEF as EF ≥ 50%. Of 31 344 patients available for analysis, 79.3% (n = 24 856) had HFrEF and 20.7% (n = 6 488) HFpEF. The outcome was all-cause mortality. We examined the association between ten non-cardiac comorbidities and mortality and its interaction with EF using adjusted hazard ratio (HR). Stroke, anemia, gout and cancer had a similar impact on mortality in both phenotypes, whereas diabetes (HR 1.57, 95% confidence interval [CI] [1.50–1.65] vs. HR 1.39 95% CI [1.27–1.51], p = 0.0002), renal failure (HR 1.65, 95% CI [1.57–1.73] vs. HR 1.44, 95% CI [1.32–1.57], p = 0.003) and liver disease (HR 2.13, 95% CI [1.83–2.47] vs. HR 1.42, 95% CI [1.09–1.85] p = 0.02) had a higher impact in the HFrEF patients. Moreover, pulmonary disease (HR 1.46, 95% CI [1.40–1.53] vs. HR 1.66 95% CI [1.54–1.80], p = 0.007) was more prominent in the HFpEF patients. Sleep apnea was not associated with worse prognosis in either group. No significant variation was found in the impact over the 12-year study period.

Conclusions

Non-cardiac comorbidities contribute significantly but differently to mortality, both in HFrEF and HFpEF. No significant variation was found in the impact over the 12-year study period. These results emphasize the importance of including the management of comorbidities as a part of a standardized heart failure care in both HF phenotypes.

Facilitators and Barriers to Healthy Eating in Aged Chinese Canadians with Hypertension: A Qualitative Exploration

Objectives: To determine the facilitators and barriers influencing healthy eating behaviours among aged Chinese-Canadians with hypertension. Methods: After attending five weeks of dietary educational training (Dietary Approach to Stop Hypertension with Sodium (Na) Reduction for Chinese Canadians; DASHNa-CC), 30 aged Chinese-Canadian participants partook in a telephone interview. Participants were asked to name three facilitators and three barriers that influenced their ability to follow the DASHNa-CC intervention. Telephone transcripts were then analyzed and coded using computer software and categorized into personal, familial, community, and societal facilitators or barriers. Results: Personal factors included health problems, motivation, effects of healthy diet, health-related careers, and dietary habits. Family factors included family structure, support from family members, and critical health events involving family members or relatives. Community factors consisted of educational materials, friends, primary care physicians, and online social networks. Societal factors included accessibility to grocery stores and restaurants. Conclusions: Aged Chinese-Canadian immigrants experience unique facilitators of and barriers to healthy eating, which may warrant further attention from healthcare professionals when educating patients in a culturally-sensitive manner.

Diagnosing hypertension in Indigenous Canadians (DREAM-GLOBAL): A randomized controlled trial to compare the effectiveness of short message service messaging for management of hypertension: Main results

Hypertension, the leading cause of cardiovascular morbidity and mortality, affects more than 1 billion people globally. The rise in mobile health in particular the use of mobile phones and short message service (SMS) to support disease management provides an opportunity to improve hypertension awareness, treatment, and control, in remote and vulnerable patient populations. The primary objective of this randomized controlled study was to assess the effect of active (with hypertension specific management SMS) or passive (health behaviors SMS alone) on the difference in blood pressure (BP) reduction between the active and passive SMS groups in hypertensive Canadian First Nations people from six rural and remote communities. Pragmatic features of the study included shifting of BP measures to non-medical health workers. Despite an overall reduction in BP over the study, there was no difference in the BP change between groups from baseline to final for systolic 0.8 (95% CI -4.2 to 5.8 mm Hg) or diastolic -1.0 (95% CI -3.7 to 1.8 mm Hg, P = 0.5) BP. Achieved BP control was 37.5% (25.6%-49.4%, 95% CI) in the active group and 32.8% (20.6%-44.8%, 95% CI) in the passive group (difference in proportions -4.74% (-21.7% to 12.2%, 95% CI, P = 0.6). The study looked at changes in health services delivery, mobile health technologies, and patient engagement to support better management of hypertension in Canadian First Nations communities. The active hypertension specific SMS did not lead to improvements in BP control.

Psychosocial Stressors at Work and Ambulatory Blood Pressure

PURPOSE OF REVIEW

Psychosocial stressors at work from the demand-latitude and effort-reward imbalance models are adverse exposures affecting about 20-25% of workers in industrialized countries. This review aims to summarize evidence on the effect of these stressors on blood pressure (BP).

RECENT FINDINGS

Three systematic reviews have recently documented the effect of these psychosocial stressors at work on BP. Among exposed workers, statistically significant BP increases ranging from 1.5 to 11 mmHg have been observed in prospective studies using ambulatory BP (ABP). Recent studies using ABP have shown a deleterious effect of these psychosocial stressors at work on masked hypertension as well as on blood pressure control in pharmacologically treated patients. Evidence on the effect of these psychosocial stressors on BP supports the relevance to tackle these upstream factors for primary prevention and to reduce the burden of poor BP control. There is a need for increased public health and clinical awareness of the occupational etiology of high BP, hypertension, and poor BP control.

Antihypertensive effect of the mineralocorticoid receptor antagonist eplerenone: a pooled analysis of patient-level data from comparative trials using regulatory-approved doses

Purpose

Several options are available for the treatment of hypertension; however, many treated patients are still not below blood pressure (BP) target. Eplerenone, a selective mineralocorticoid receptor antagonist, is an approved treatment option for the management of patients with hypertension in a number of countries. This patient-level pooled analysis was conducted to document the efficacy and safety/tolerability of eplerenone at the dosages approved for use in hypertension in comparison to placebo or other approved antihypertensive agents.

Methods

Seventeen Phase III studies conducted in patients with mild-to-moderate hypertension in the Eplerenone Hypertension Clinical Program were reviewed; eleven met the selection criteria. The primary endpoint was change from baseline in seated diastolic BP and seated systolic BP measured at the end of the study.

Results

A total of 2,698 patients were included in this per-protocol analysis. In patients treated for at least 6 weeks with a stable dose of eplerenone, doses of 50 mg daily and 100 mg daily were associated with greater reductions of seated systolic BP and seated diastolic BP compared with placebo (P<0.001) and active-controlled studies (P< 0.033). In the analysis of covariance model testing of the contribution of four factors (age, body mass index [BMI], history of cardiovascular disease, and diabetes) on the BP lowering effects of eplerenone, only BMI and age were associated with small though statistically significant changes in BP (<0.2 mmHg). Eplerenone was well tolerated; headache was the most common adverse event for patients in any group. Severe hyperkalemia (serum potassium level >6.0 mmol/L) occurred in up to 0.4% in the eplerenone groups, 0.4% in the placebo group, and 0.1% in the active-control group.

Conclusion

This patient-level pooled analysis provides robust evidence that eplerenone, at 50 mg or 100 mg daily, was effective in lowering BP in patients with mild-to-moderate hypertension and was well tolerated.

Prevalence, management and control of hypertension in older adults on admission to hospital

Introduction

The aim of this study was to explore the prevalence and management of hypertension among older adults on admission to hospital and to assess the choice of antihypertensive pharmacotherapy in light of relevant comorbid conditions using the national treatment guideline.

Materials and methods

A retrospective cross sectional study of 503 patients aged 65 years or older admitted to a large metropolitan teaching hospital in Sydney Australia was conducted. The main outcome measures were prevalence of hypertension, blood pressure (BP) control, antihypertensive medication use and the appropriateness of antihypertensive medications.

Results

Sixty-nine percent (n = 347) of the study population had a documented diagnosis of hypertension and of these, approximately one third were at target BP levels on admission to hospital. Some concerns regarding choice of antihypertensive noted with 51% of those with comorbid diabetes and 30% of those with comorbid heart failure receiving a potentially inappropriate antihypertensive agent.

Conclusions

Despite the use of antihypertensive pharmacotherapy, many older adults do not have optimal BP control and are not reaching target BP levels. New strategies to improve blood pressure control in older populations especially targeting women, those with a past history of myocardial infarction and those on multiple antihypertensive medications are needed.

Lowering blood pressure in primary care in Vienna (LOW-BP-VIENNA) : A cluster-randomized trial

Background

In Austria only 41% of patients with treated hypertension (HTN) have their blood pressure (BP) controlled. This study investigated a strategy to improve BP control in primary care.

Methods

General practitioners (GPs) were randomized to interventional care vs. standard care and included patients with uncontrolled office BP > 140/90 mm Hg. In interventional care, antihypertensive therapy was up-titrated using a single pill combination (olmesartan, amlodipine and/or hydrochlorothiazde) in 4‑week intervals. In standard care, physicians were encouraged to treat according to the 2013 European Society of Cardiology guidelines for the management of arterial hypertension. The primary endpoint was the proportion of patients with controlled office BP < 140/90 mm Hg at 6 months. The main secondary endpoint was the improvement in 24 h ambulatory BP (ABPM, Clinicaltrials.gov NCT02377661).

Results

Between 2015–2017, 20 GPs contributed to patient recruitment. The trial was discontinued due to slow recruitment after inclusion of 139 eligible patients, 54 of whom were included in the interventional group. A significantly larger proportion of patients in interventional vs. standard care achieved the office BP target (67% ± 26% vs. 39% ± 29%, respectively, mean difference −27.9%, 95% confidence interval CI −54.0%; −1.7%, p = 0.038). The proportion of patients with controlled 24 h ABPM (<130/80 mm Hg) was similar between groups (49% ± 33% vs. 40% ± 34%, respectively, mean difference −8.8%, 95% CI −40.7%; 23.1%, p = 0.57). At baseline, pretreated patients received an average of 1.5 ± 0.8 vs. 1.7 ± 0.9 antihypertensive prescriptions. At 6 months, the respective BP reductions were achieved with 1.2 ± 0.5 prescriptions in interventional vs. 2.0 ± 1.0 in standard care (p < 0.01).

Conclusion

In both groups statistically and clinically significant BP reductions were observed after 6 months. In the interventional care group, a larger proportion of patients achieved the office BP target compared to standard care. The 24 h ambulatory blood pressure levels were controlled in 44% of patients at 6 months, without significant differences between groups. The respective BP reductions were achieved with a significantly lower medication burden in interventional care.

Electronic supplementary material

The online version of this article (10.1007/s00508-018-1374-4) contains supplementary material, which is available to authorized users.

The impact of lifestyle intervention on atrial fibrillation

PURPOSE OF REVIEW

Atrial fibrillation is the most common sustained cardiac arrhythmia, attributable to several factors that may be amenable through lifestyle modification. There is emerging evidence to suggest that the successful management of several cardiovascular risk factors [obesity, hypertension (HTN), diabetes mellitus, and obstructive sleep apnea (OSA)] can lead to fewer complications and atrial fibrillation prevention. However, the long-term sustainability and reproducibility of these effects have yet to be explored in larger studies. This review explores recent findings for exercise and lifestyle modifications to promote alternative strategies to interventional therapy for atrial fibrillation management.

RECENT FINDINGS

Several studies have highlighted the impact of established modifiable risk factors on atrial fibrillation burden and the potential for effective risk management in a clinical setting. Higher SBP, HTN, pulse pressure, and antihypertensive treatment have been linked to alterations in left atrial diameter and dysfunction. Effective treatment of HTN has been shown to reduce all-cause mortality, cardiovascular mortality, and the overall risk of developing atrial fibrillation. Given the impact of obesity on the development of atrial fibrillation, diet has been identified as a modifiable risk factor for stroke. Maintenance of proper glycemic control through structured exercise training for prediabetes and continuous positive airway pressure utilization for OSA, have also been correlated with reductions in atrial fibrillation recurrence.

SUMMARY

Early intervention of modifiable cardiometabolic factors leads to lifestyle and behavioral change, which has significant potential to evolve atrial fibrillation management in the coming years.

Validated registry of pre-dialysis chronic kidney disease: description of a large cohort

Introduction:

Chronic diseases account for the majority of deaths in Brazil. These include hypertension (SAH) and diabetes mellitus (DM), which are the main causes of chronic kidney disease (CKD).

Objective:

This study aimed to validate the data of an electronic health record and to point out characteristics of the profile of these users in relation to clinical quality indicators for a pre-dialytic CKD.

Methods:

Retrospective cohort, August/2010 to December/2014. Included users > 18 years, with at least two queries. Variables analyzed: sociodemographic, underlying disease, main medications and main clinical indicators of control. A descriptive analysis was performed and the percentage of users was evaluated in the goals at admission and at the end of the study.

Results:

Exported, converted and validated data of 1,977 users with average follow-up time of 21 months. Of these, 51.4% were men, 58% were > 64 years of age and 81.6% were overweight. The main medications in use were diuretics (82.9%), BRAT (62%), Statin (60.7%) and ACE inhibitors (49.9%). The percentage of users with a decline in the glomerular filtration rate was 33.7%. Regarding glycated hemoglobin, users with CKD and DM, 36% were within the initial goal and 52.1% of the final. Blood pressure was at the target for admission at 34.3% and 49.8% at the end of follow-up.

Conclusion:

Validated data are of vital importance for health managers to monitor users. The population of this study is predominantly elderly, obese, requiring multi-professional care to slow the progression of the disease and decrease morbidity and mortality.

Recognition and control of hypertension, diabetes, and dyslipidemia in patients with rheumatoid arthritis

Absolute cardiovascular risk of an individual with rheumatoid arthritis (RA) is greater when compared to the general population, and several factors have proven to be important for the development of coronary artery disease (CAD) in these patients, including factors related to the underlying disease, such as the systemic inflammatory response, drugs used in its treatment, and a higher prevalence of traditional risk factors for CAD. Our aim is to describe the recognition and control frequencies of systemic arterial hypertension (SAH), dyslipidemia, and diabetes mellitus (DM) in RA patients. Patients with RA answered a questionnaire focused on their general knowledge of the risk factors for CAD, as well as on the recognition of the risk factors that they possess. The patient's information, collected from a structured medical record, was reviewed to evaluate the control of risk factors. Hundred and thirty-four patients were included in the study. One patient was excluded due to the impossibility of reviewing her medical records. Therefore, 133 patients remained in the study. Patients had a mean (SD) age of 57.3 (12.9) years. SAH was diagnosed in 88 subjects, with a recognition frequency of 89.8%, and 63.3% had desirable blood pressure control. Seventy-two patients were diagnosed with dyslipidemia; 68.1% recognized that they had dyslipidemia and 69.4% achieved desirable LDL-c control. Twenty-two patients had DM; 90.9% admitted being diabetic and 40.9% had desirable glycemic control. The frequencies of the CAD risk factor recognition and control were high in comparison to those described for the general population.

Hypertension, knowledge, attitudes, and practices of primary care physicians in Ulaanbaatar, Mongolia

We examined the knowledge, attitudes, and practices of primary care doctors in Ulaanbaatar, Mongolia using a recently developed World Hypertension League survey. The survey was administered as part of a quality assurance initiative to enhance hypertension control. A total of 577 surveys were distributed and 467 were completed (81% response rate). The respondents had an average age of 35 years and 90.1% were female. Knowledge of hypertension epidemiology was low (13.5% of questions answered correctly); 31% of clinical practice questions had correct answers and confidence in performing specific tasks to improve hypertension control had 63.2% "desirable/correct" answers. Primary care doctors mostly had a positive attitude toward hypertension management (76.5% desirable/correct answers) and highly prioritized hypertension management activities (85.7% desirable/correct answers). Some important highlights included the majority (> 80%) overestimating hypertension awareness, treatment, and control rates; 78.2% used aneroid blood pressure manometers; 15% systematically screened adults for hypertension in their clinics; 21.8% reported 2 or more drugs were required to control hypertension in most people; and 16.1% reported most people could be controlled by lifestyle changes alone. 55% of respondents were not comfortable prescribing more than 1 or 2 antihypertensive drugs in a patient and the percentage of desirable/correct responses to treating various high-risk patients was low. Most (53%-74%) supported task shifting to nonphysician health care providers except for drug prescribing, which only 13.9% supported. A hypertension clinical education program is currently being designed based on the specific needs identified in the survey.

Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: a pooled analysis of 1018 population-based measurement studies with 88.6 million participants

BACKGROUND

Change in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure (representing the combined effects of public health interventions and secular trends) and changes in its high-blood-pressure tail (representing successful clinical interventions to control blood pressure in the hypertensive population). Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure.

METHODS

We pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and prevalence of raised blood pressure by sex and 10-year age group from 20-29 years to 70-79 years in each study, taking into account complex survey design and survey sample weights, where relevant. We used a linear mixed effect model to quantify the association between (probit-transformed) prevalence of raised blood pressure and age-group- and sex-specific mean blood pressure. We calculated the contributions of change in mean SBP and DBP, and of change in the prevalence-mean association, to the change in prevalence of raised blood pressure.

RESULTS

In 2005-16, at the same level of population mean SBP and DBP, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, and men and women in the high-income Asia Pacific and high-income Western regions would have the lowest. In most region-sex-age groups where the prevalence of raised blood pressure declined, one half or more of the decline was due to the decline in mean blood pressure. Where prevalence of raised blood pressure has increased, the change was entirely driven by increasing mean blood pressure, offset partly by the change in the prevalence-mean association.

CONCLUSIONS

Change in mean blood pressure is the main driver of the worldwide change in the prevalence of raised blood pressure, but change in the high-blood-pressure tail of the distribution has also contributed to the change in prevalence, especially in older age groups.

Prevalence, awareness, treatment, control, and risk factors of hypertension among adults: a cross-sectional study in Iran

OBJECTIVES

Hypertension (HTN) is an important risk factor for cardiovascular disease. Considering the importance of this disease for public health, this study was designed in order to determine the prevalence, awareness, treatment, control, and risk factors of HTN in the Iranian adult population.

METHODS

This cross-sectional study was conducted among 2,107 residents of Isfahan, Iran. Samples were selected through multi-stage random cluster sampling in 2015-2016. The outcome variable was HTN, determined by measuring blood pressure in the right arm via a digital arm blood pressure monitor. Awareness, treatment, and control of HTN were assessed by a validated and reliable researcher-developed questionnaire. Other demographic and clinical variables were assessed via a demographic questionnaire.

RESULTS

The overall prevalence of HTN was 17.3% (18.9 and 15.5% in men and women, respectively). The prevalence of HTN increased in both genders with age. The prevalence of awareness of HTN among people with HTN was 69.2%, of whom 92.4 and 59.9% were taking medication for HTN and had controlled HTN, respectively. Logistic regression identified age, body mass index, having diabetes and hyperlipidemia, and a positive family history of HTN as determinants of awareness of HTN.

CONCLUSIONS

The results showed that HTN was highly prevalent in the community, especially in men and in middle-aged and older adults. Approximately 30.8% of patients were unaware of their disease, and there was less awareness among younger adults. Despite the high frequency of taking medication to treat HTN, it was uncontrolled in more than 40.1% of patients. Health policy-makers should therefore consider appropriate preventive and therapeutic strategies for these high-risk groups.

Six-year time-trend analysis of dyslipidemia among adults in Newfoundland and Labrador: findings from the laboratory information system between 2009 and 2014

Background

Dyslipidemia, an increased level of total cholesterol (TC), triglycerides (TG), low-density-lipoprotein cholesterol (LDL-C) and decreased level of high-density-lipoprotein cholesterol (HDL-C), is one of the most important risk factors for cardiovascular disease. We examined the six-year trend of dyslipidemia in Newfoundland and Labrador (NL), a Canadian province with a historically high prevalence of dyslipidemia.

Methods

A serial cross-sectional study on all of the laboratory lipid tests available from 2009 to 2014 was performed. Dyslipidemia for every lipid component was defined using the Canadian Guidelines for the Diagnosis and Treatment of Dyslipidemia. The annual dyslipidemia rates for each component of serum lipid was examined. A fixed and random effect model was applied to adjust for confounding variables (sex and age) and random effects (residual variation in dyslipidemia over the years and redundancies caused by individuals being tested multiple times during the study period).

Results

Between 2009 and 2014, a total of 875,208 records (mean age: 56.9 ± 14.1, 47.6% males) containing a lipid profile were identified. The prevalence of HDL-C and LDL-C dyslipidemia significantly decreased during this period (HDL-C: 35.8% in 2009 [95% CI 35.5-36.1], to 29.0% in 2014 [95% CI: 28.8-29.2], P = 0.03, and LDL-C: 35.2% in 2009 [95% CI: 34.9-35.4] to 32.1% in 2014 [95% CI: 31.9-32.3], P = 0.02). A stratification by sex, revealed no significant trend for any lipid element in females; however, in men, the previously observed trends were intensified and a new decreasing trend in dyslipidemia of TC was appeared (TC: 34.1% [95% CI 33.7-34.5] to 32.3% [95%CI: 32.0-32.6], p < 0.02, HDL-C: 33.8% (95%CI: 33.3-34.2) to 24.0% (95% CI: 23.7-24.3)], P < 0.01, LDL-C: 32.9% (95%CI:32.5-33.3) to 28.6 (95%CI: 28.3-28.9), P < 0.001). Adjustment for confounding factors and removing the residual noise by modeling the random effects did not change the significance.

Conclusion

This study demonstrates a significant downward trend in the prevalence of LDL-C, HDL-C, and TC dyslipidemia, exclusively in men. These trends could be the result of males being the primary target for cardiovascular risk management.

Shifting Trend of Transient Ischemic Attack Admission and Prognosis in Canada

BACKGROUND

Stroke is often preceded by transient symptoms. Although global stroke rates have been shown to be declining, previous studies have reported inconsistent temporal trends of transient ischemic attacks (TIA). The objective of the current study is to report the temporal trends of TIA admissions and outcomes in Canada over the last 11 years.

METHODS

We conducted a complete population cohort study using a national administrative database to study the temporal trend of age- and sex-adjusted TIA admission rates in Canada from 2003 to 2013. We also determined the rates of TIA and stroke diagnoses in the emergency department in the province of Ontario during the same period. We used multivariable analyses to study discharge location after acute hospitalization as well as 90-day stroke and/or TIA readmission rates.

RESULTS

Of 425,799 admissions to an acute care hospital for all stroke and TIA, 71,443 (16.8%) were TIA. The age- and sex-standardized rates of TIA admission decreased significantly during the study period from 30.0 to 20.6 per 100,000 (p<0.0001). In Ontario, decreasing TIA admissions is mirrored by decreasing rates of TIA directly discharged from the emergency department (55.1 to 46.8 per 100,000, p = 0.002). The odds of 90-day readmission rates for stroke or TIA are also decreasing (adjusted odds ratio, 0.97; 95% confidence interval, 0.96-0.99).

CONCLUSIONS

We show that TIA admission rates have declined in the past 11 years in Canada, reflecting improved vascular risk reduction and stroke care. Future studies to confirm our findings on improved stroke or TIA recurrence rates are necessary.

Resistant Hypertension in Adults With Type 1 or 2 Diabetes: A Structured Diagnostic Approach

People with diabetes often have difficulty reaching their blood pressure targets and are labelled as having resistant hypertension. Clinicians often move quickly to screen such people for secondary causes of hypertension; however, such causes are rare, and resistant hypertension usually has other explanations that are significantly more common. By using a structured approach to resistant hypertension, clinicians can assist patients to reach their target blood pressure levels. Step 1 is to determine out-of-office blood pressure measurements using home or ambulatory blood pressure monitors. Step 2 is to determine the level of adherence to prescribed medications. Step 3 is to identify interfering substances. Step 4 is to check that the prescribed medications are synergistic and optimally dosed. Finally, if all other steps fail to get patients to their blood pressure targets, we consider possible secondary causes of hypertension. This approach is particularly useful in helping people with diabetes to reach their blood pressure targets.