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Foy AJ, Filippone EJ, Schaefer E, Nudy M, Ruzieh M, Dyer AM, Chinchilli VM, Naccarelli GV. Association Between Baseline Diastolic Blood Pressure and the Efficacy of Intensive vs Standard Blood Pressure-Lowering Therapy. JAMA Netw Open 2021; 4:e2128980. [PMID: 34668944 PMCID: PMC8529404 DOI: 10.1001/jamanetworkopen.2021.28980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Low diastolic blood pressure (DBP) has been found to be associated with increased adverse cardiovascular events; however, it is unknown whether intensifying blood pressure therapy in patients with an already low DBP to achieve a lower systolic blood pressure (SBP) target is safe or effective. OBJECTIVE To evaluate whether there is an association of baseline DBP and intensification of blood pressure-lowering therapy with the outcomes of all-cause death and cardiovascular events. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed patients who were randomized to intensive or standard BP control in the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial and Systolic Blood Pressure Intervention Trial (SPRINT). Data were collected from September 1999 to June 2009 (ACCORD-BP) and from October 2010 to August 2015 (SPRINT). Data were analyzed from December 2020 to June 2021. EXPOSURES Baseline DBP as a continuous variable. MAIN OUTCOMES AND MEASURES All-cause death and a composite cardiovascular end point (CVE) that included cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. RESULTS A total of 14 094 patients (mean [SD] age, 66.2 [8.9] years; 8504 [60.4%] men) were included in this analysis. There were significant nonlinear associations between baseline DBP and all-cause death (eg, baseline DBP 50 vs 80 mm Hg: hazard ratio [HR], 1.48; 95% CI, 1.06-2.08; P = .02) and the composite CVE (eg, baseline DBP 50 vs 80 mm Hg: HR, 1.45; 95% CI, 1.27-3.04; P = .003) observed among all participants. Findings for the interaction between baseline DBP and treatment group assignment for all cause death did not reach statistical significance. For intensive vs standard therapy, the HR of death for a baseline DBP of 50 mm Hg was 1.80 (95% CI, 0.95-3.39; P = .07) and that for a baseline DBP of 80 mm Hg was 0.77 (95% CI, 0.59-1.01; P = .05). Overall, there was no interaction found between baseline DBP and treatment group assignment for the composite CVE. Over the range of baseline DBP values, significant reductions in the composite CVE for patients assigned to intensive vs standard therapy were found for baseline DBP values of 80 mm Hg (HR, 0.78; 95% CI, 0.62-0.98; P = .03) and 90 mm Hg (HR, 0.74; 95% CI, 0.55-0.98; P = .04). CONCLUSIONS AND RELEVANCE This pooled cohort study found no evidence of a significant interaction between baseline DBP and treatment intensity for all-cause death or for a composite CVE. These results are hypothesis generating and merit further study.
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Affiliation(s)
- Andrew J. Foy
- Department of Medicine, Penn State University Heart and Vascular Institute, Hershey, Pennsylvania
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center and College of Medicine, Hershey, Pennsylvania
| | - Edward J. Filippone
- Department of Medicine, Sydney Kimmel Medical Center at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Eric Schaefer
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center and College of Medicine, Hershey, Pennsylvania
| | - Matt Nudy
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center and College of Medicine, Hershey, Pennsylvania
| | | | - Anne-Marie Dyer
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center and College of Medicine, Hershey, Pennsylvania
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center and College of Medicine, Hershey, Pennsylvania
| | - Gerald V. Naccarelli
- Department of Medicine, Penn State University Heart and Vascular Institute, Hershey, Pennsylvania
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Grubbs C, Morris L. This is not the time to modify a HTN regimen. J Fam Pract 2021; 70:293-295. [PMID: 34431775 PMCID: PMC8407227 DOI: 10.12788/jfp.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Intensifying hypertension regimens at discharge increases risk in older patients.
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Senoo Y, Saito H, Ozaki A, Sawano T, Shimada Y, Yamamoto K, Suzuki Y, Tanimoto T. Pharmaceutical company payments to authors of the Japanese guidelines for the management of hypertension. Medicine (Baltimore) 2021; 100:e24816. [PMID: 33761642 PMCID: PMC10545077 DOI: 10.1097/md.0000000000024816] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 12/25/2020] [Accepted: 01/29/2021] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Antihypertensive drugs have been of significant interest to the pharmaceutical industry due to increasing sales opportunities in a global market. The financial relationships between pharmaceutical companies and the Japanese Society of Hypertension (JSH) have a possible influence on clinical practices in Japan. This study examined the distribution of pharmaceutical payments made to the authors of the revised Guidelines for the Management of Hypertension (JSH2019) and the transparency of the Conflict of Interest disclosure that each author made.We retrospectively obtained publicly available data regarding payments made by Japanese pharmaceutical companies to all authors of the JSH2019 in 2016. We also collected data on individual financial disclosure of JSH2019 authors to investigate whether their self-reported financial relationship with companies were compliant to the financial disclosure policy of JSH2019.The total and mean payment values reported by pharmaceutical companies were $4,246,436 and $21,447, respectively. Of the 198 authors, 171 (86.4%) authors received at least 1 payment. Of 74 authors required to disclose their conflict of interest (COI) the authors, one-third failed to follow the COI policy covering the clinical guidelines.Major pharmaceutical companies selling antihypertensive drug products in the Japanese market had a significant financial connection with the JSH2019 authors. Financial relationships between pharmaceutical companies and authors or Japanese medical societies are raising significant concerns about the credibility of clinical guidelines and the potentially biases and undue influences that they may cause, especially with respect to adverse prescription patterns.
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Affiliation(s)
- Yuki Senoo
- Medical Governance Research Institute, Shinagawa, Tokyo
| | - Hiroaki Saito
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Miyagi
| | - Akihiko Ozaki
- Medical Governance Research Institute, Shinagawa, Tokyo
- Department of Breast Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki, Fukushima
| | - Toyoaki Sawano
- Department of Surgery, Sendai City Medical Center, Sendai, Miyagi
| | - Yuki Shimada
- Department of Neurosurgery, Minamisoma Municipal General Hospital, Minamisoma, Fukushima
| | - Kana Yamamoto
- Medical Governance Research Institute, Shinagawa, Tokyo
| | - Yosuke Suzuki
- Medical Governance Research Institute, Shinagawa, Tokyo
- Department of Obstetrics and Gynecology, Tone Chuo Hospital, Gunma, Japan
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Böhm M, Kario K, Kandzari DE, Mahfoud F, Weber MA, Schmieder RE, Tsioufis K, Pocock S, Konstantinidis D, Choi JW, East C, Lee DP, Ma A, Ewen S, Cohen DL, Wilensky R, Devireddy CM, Lea J, Schmid A, Weil J, Agdirlioglu T, Reedus D, Jefferson BK, Reyes D, D'Souza R, Sharp ASP, Sharif F, Fahy M, DeBruin V, Cohen SA, Brar S, Townsend RR. Efficacy of catheter-based renal denervation in the absence of antihypertensive medications (SPYRAL HTN-OFF MED Pivotal): a multicentre, randomised, sham-controlled trial. Lancet 2020; 395:1444-1451. [PMID: 32234534 DOI: 10.1016/s0140-6736(20)30554-7] [Citation(s) in RCA: 288] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Catheter-based renal denervation has significantly reduced blood pressure in previous studies. Following a positive pilot trial, the SPYRAL HTN-OFF MED (SPYRAL Pivotal) trial was designed to assess the efficacy of renal denervation in the absence of antihypertensive medications. METHODS In this international, prospective, single-blinded, sham-controlled trial, done at 44 study sites in Australia, Austria, Canada, Germany, Greece, Ireland, Japan, the UK, and the USA, hypertensive patients with office systolic blood pressure of 150 mm Hg to less than 180 mm Hg were randomly assigned 1:1 to either a renal denervation or sham procedure. The primary efficacy endpoint was baseline-adjusted change in 24-h systolic blood pressure and the secondary efficacy endpoint was baseline-adjusted change in office systolic blood pressure from baseline to 3 months after the procedure. We used a Bayesian design with an informative prior, so the primary analysis combines evidence from the pilot and Pivotal trials. The primary efficacy and safety analyses were done in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT02439749. FINDINGS From June 25, 2015, to Oct 15, 2019, 331 patients were randomly assigned to either renal denervation (n=166) or a sham procedure (n=165). The primary and secondary efficacy endpoints were met, with posterior probability of superiority more than 0·999 for both. The treatment difference between the two groups for 24-h systolic blood pressure was -3·9 mm Hg (Bayesian 95% credible interval -6·2 to -1·6) and for office systolic blood pressure the difference was -6·5 mm Hg (-9·6 to -3·5). No major device-related or procedural-related safety events occurred up to 3 months. INTERPRETATION SPYRAL Pivotal showed the superiority of catheter-based renal denervation compared with a sham procedure to safely lower blood pressure in the absence of antihypertensive medications. FUNDING Medtronic.
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Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg (Saar), Germany.
| | - Kazuomi Kario
- Jichi Medical University School of Medicine, Tochigi, Japan
| | | | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg (Saar), Germany; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | | | - Konstantinos Tsioufis
- National and Kapodistrian University of Athens, Hippocratio Hospital, Athens, Greece
| | - Stuart Pocock
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - James W Choi
- Baylor Scott and White Heart and Vascular Hospital, Dallas, TX, USA
| | - Cara East
- Baylor Scott and White Heart and Vascular Hospital, Dallas, TX, USA
| | - David P Lee
- Stanford Hospital and Clinics, Stanford, CA, USA
| | - Adrian Ma
- Stanford Hospital and Clinics, Stanford, CA, USA
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg (Saar), Germany
| | - Debbie L Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Wilensky
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Janice Lea
- Emory University School of Medicine, Atlanta, GA, USA
| | - Axel Schmid
- Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | | | | | - David Reyes
- TriStar Centennial Medical Center, Nashville, TN, USA
| | | | - Andrew S P Sharp
- University Hospital of Wales, Cardiff, UK; University of Exeter, Exeter, UK
| | - Faisal Sharif
- Galway University Hospitals and National University of Ireland Galway, Galway, Ireland
| | | | | | - Sidney A Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Medtronic, Santa Rosa, CA, USA
| | | | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Unda Villafuerte F, Llobera Cànaves J, Lorente Montalvo P, Moreno Sancho ML, Oliver Oliver B, Bassante Flores P, Estela Mantolan A, Pou Bordoy J, Rodríguez Ruiz T, Requena Hernández A, Leiva A, Torrent Quetglas M, Coll Benejam JM, D’Agosto Forteza P, Rigo Carratalà F. Effectiveness of a multifactorial intervention, consisting of self-management of antihypertensive medication, self-measurement of blood pressure, hypocaloric and low sodium diet, and physical exercise, in patients with uncontrolled hypertension taking 2 or more antihypertensive drugs: The MEDICHY study. Medicine (Baltimore) 2020; 99:e19769. [PMID: 32332617 PMCID: PMC7220514 DOI: 10.1097/md.0000000000019769] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION High blood pressure is the leading modifiable risk factor for cardiovascular disease, and is associated with high morbidity and mortality and with significant health care costs for individuals and society. However, fewer than half of the patients with hypertension receiving pharmacological treatment have adequate blood pressure control. The main reasons for this are therapeutic inertia, lack of adherence to treatment, and unhealthy lifestyle (i.e., excess dietary fat and salt, sedentary lifestyle, and overweight). Cardiovascular risk and mortality are greater in hypertensive patients who are receiving treatment but have suboptimal control of blood pressure. METHODS/DESIGN This is a multicentre, parallel, 2-arm, single-blind (outcome assessor), controled, cluster-randomized clinical trial. General practitioners and nurses will be randomly allocated to the intervention group (self-management of antihypertensive medication, self-measurement of blood pressure, hypocaloric and low sodium diet, and physical exercise) or the control group (regular clinical practice). A total of 424 patients in primary care centers who use 2 or more antihypertensive drugs and blood pressure of at least 130/80 during 24-hambulatory blood pressure monitoring will be recruited. The primary outcome is systolic blood pressure at 12 months. The secondary outcomes are blood pressure control (<140/90 mm Hg); quality of life (EuroQol 5D); direct health care costs; adherence to use of antihypertensive medication; and cardiovascular risk (REGICOR and SCORE scales). DISCUSSION This trial will be conducted in the primary care setting and will evaluate the impact of a multifactorial intervention consisting of self-management of blood pressure, antihypertensive medications, and lifestyle modifications (hypocaloric and low sodium diet and physical exercise).
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Affiliation(s)
| | - Joan Llobera Cànaves
- Primary Care Research Unit of Mallorca, Balearic Health Services (IB-Salut)
- Institut d’investigació Sanitària Illes Balears
| | | | | | | | | | | | | | - Tomás Rodríguez Ruiz
- Primary Care Research Unit of Menorca, Balearic Health Services (IB-Salut), Menorca, Balearic Islands, Spain
| | | | - Alfonso Leiva
- Primary Care Research Unit of Mallorca, Balearic Health Services (IB-Salut)
- Institut d’investigació Sanitària Illes Balears
| | - Matíes Torrent Quetglas
- Institut d’investigació Sanitària Illes Balears
- Primary Care Research Unit of Menorca, Balearic Health Services (IB-Salut), Menorca, Balearic Islands, Spain
| | - José María Coll Benejam
- Institut d’investigació Sanitària Illes Balears
- Menorca Primary care management, Menorca, Balearic Health Services (IB-Salut)
| | | | - Fernando Rigo Carratalà
- Institut d’investigació Sanitària Illes Balears
- San Agustín Healthcare Centre, Institut d’investigació Sanitària Illes Balears
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Ndichu ET, Ohiri K, Sekoni O, Makinde O, Schulman K. Evaluating the quality of antihypertensive drugs in Lagos State, Nigeria. PLoS One 2019; 14:e0211567. [PMID: 30759124 PMCID: PMC6373917 DOI: 10.1371/journal.pone.0211567] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/14/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND As the burden of noncommunicable diseases grows, access to safe medical therapy is increasing in importance. The aim of this study was to develop a method for evaluating the quality of antihypertensive drugs and to examine whether this prevalence varies by socioeconomic variables. METHODS We conducted a cross-sectional survey of registered pharmacies in 6 local government areas (LGAs) in Lagos State, Nigeria. In each LGA, we sampled 17 pharmacies from a list of all registered pharmacies derived from the Pharmacists Council of Nigeria. We assessed drug quality based on (1) the level of active pharmaceutical ingredients (APIs), which identified falsely labeled drug samples; and (2) the amount of impurities, which revealed substandard drug samples in accordance with the international pharmacopoeia guidelines. Good-quality drugs met specifications for both API and impurity. RESULTS Of the 102 drug samples collected, 30 (29.3%) were falsely labeled, 76 (74.5%) were substandard,78 (76.5%) were of poor quality and 24 (23.5%) were of good quality.Among the falsely labeled drugs, 2 samples met standards set for purity while 28 did not. Among the 76 substandard drug samples, 28 were also falsely labeled. Of the falsely labeled drugs, 17 (56.7%) came from LGAs with low socioeconomic status, and 40 (52.6%) of the substandard drug samples came from LGAs with high socioeconomic status. Most of the good-quality drug samples, 14 (58.3%), were from LGAs with low socioeconomic status. Eighteen (60%) of the falsely labeled samples, 37 (48.7%) of the substandard samples, and 15 (62.5%) of the good-quality drug samples were from manufacturers based in Asia. The average price was 375.67 Nigerian naira (NGN) for falsely labeled drugs, 383.33 NGN for substandard drugs, and 375.67 NGN for good-quality drugs. The prevalence of falsely labeled and substandard drug samples did not differ by LGA-level socioeconomic status (P = .39) or region of manufacturer (P = .24); however, there was a trend for a difference by price (P = .06). CONCLUSION The prevalence of falsely labeled and substandard drug samples was high in Lagos. Treatment of noncommunicable diseases in this setting will require efforts to monitor and assure drug quality.
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Affiliation(s)
| | - Kelechi Ohiri
- Health Strategy and Delivery Foundation, Lagos, Nigeria
| | | | | | - Kevin Schulman
- Clinical Excellence Research Center, Department of Medicine, Stanford University, Stanford, California, United States of America
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Kalkman DN, Brouwer TF, Spiering W, Peters RJG, van den Born BJH. [Limits to the treatment of hypertension]. Ned Tijdschr Geneeskd 2018; 162:D2807. [PMID: 30379497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
According to the 2011 Dutch guideline on Cardiovascular risk management 1 in 5 hypertensive patients are eligible for blood pressure lowering treatment. The Dutch guideline recommends striving for a systolic blood pressure (SBP) of < 140 mmHg in adult patients who have no cardiovascular disease or diabetes mellitus, while the recent American guideline now recommends an SBP target value of < 130 mmHg for all adult patients. An important reason for using a stricter SBP target value are the results of randomised studies and meta-analyses that looked at the effect of intensive antihypertensive therapy on the risk of mortality and cardiovascular disease. Based on the literature, there appears to be sufficient evidence that intensive antihypertensive therapy (SBP target value of < 130 mmHg) is useful in patients with cardiovascular disease and in patients with high cardiovascular risk. Currently, there is insufficient evidence that intensive antihypertensive therapy is useful in patients who have diabetes mellitus or who are over 80 years old.
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Affiliation(s)
- Deborah N Kalkman
- Amsterdam UMC, Universiteit van Amsterdam, Hartcentrum, afd. Klinische en Experimentele Cardiologie, Amsterdam Cardiovascular Sciences
| | - Tom F Brouwer
- Amsterdam UMC, Universiteit van Amsterdam, Hartcentrum, afd. Klinische en Experimentele Cardiologie, Amsterdam Cardiovascular Sciences
| | | | - Ron J G Peters
- Amsterdam UMC, Universiteit van Amsterdam, Hartcentrum, afd. Klinische en Experimentele Cardiologie, Amsterdam Cardiovascular Sciences
| | - B J H van den Born
- Amsterdam UMC, Universiteit van Amsterdam, Hartcentrum, afd. Vasculaire Geneeskunde
- Contact: B.J.H. van den Born
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Margolis KL, Asche SE, Dehmer SP, Bergdall AR, Green BB, Sperl-Hillen JM, Nyboer RA, Pawloski PA, Maciosek MV, Trower NK, O’Connor PJ. Long-term Outcomes of the Effects of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Among Adults With Uncontrolled Hypertension: Follow-up of a Cluster Randomized Clinical Trial. JAMA Netw Open 2018; 1:e181617. [PMID: 30646139 PMCID: PMC6324502 DOI: 10.1001/jamanetworkopen.2018.1617] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Hypertension is a leading cause of cardiovascular disease. The results were previously reported of a trial of home blood pressure (BP) telemonitoring and pharmacist management intervention in which the interventions stopped after 12 months. There were significantly greater reductions in systolic BP (SBP) in the intervention group than in the usual care group at 6, 12, and 18 months (-10.7, -9.7, and -6.6 mm Hg, respectively). OBJECTIVES To examine the durability of the intervention effect on BP through 54 months of follow-up and to compare BP measurements performed in the research clinic and in routine clinical care. DESIGN, SETTING, AND PARTICIPANTS Follow-up of a cluster randomized clinical trial among 16 primary care clinics and 450 patients with uncontrolled hypertension in a large health system from March 2009 to November 2015. INTERVENTIONS A home BP telemonitoring intervention with pharmacist management or usual care. MAIN OUTCOMES AND MEASURES Change from baseline to 54 months in SBP and diastolic BP (DBP) measured as the mean of 3 measurements obtained at each research clinic visit. RESULTS Among 450 patients, 228 (mean [SD] age, 62.0 [11.7] years; 54.8% male) were randomized to the telemonitoring intervention and 222 (mean [SD] age, 60.2 [12.2] years; 55.9% male) to usual care. Research clinic BP measurements were obtained from 326 of 450 (72.4%) study patients at the 54-month follow-up visit, including 162 (mean [SD] age, 62.0 [11.1] years; 54.9% male) randomized to the telemonitoring intervention and 164 (mean [SD] age, 60.0 [11.2] years; 57.3% male) to usual care. Routine clinical care BP measurements were obtained from 439 of 450 (97.6%) study patients at 6248 visits during the follow-up period. Based on research clinic measurements, baseline mean SBP was 148 mm Hg in both groups. In the intervention group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 126.7, 125.7, 126.9, and 130.6 mm Hg, respectively. In the usual care group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 136.9, 134.8, 133.0, and 132.6 mm Hg, respectively. The differential reduction by study group in SBP from baseline to 54 months was -2.5 mm Hg (95% CI, -6.3 to 1.2 mm Hg; P = .18). The DBP followed a similar pattern, with a differential reduction by study group from baseline to 54 months of -1.0 mm Hg (95% CI, -3.2 to 1.2 mm Hg; P = .37). The SBP and DBP results from routine clinical measurements suggested significantly lower BP in the intervention group for up to 24 months. CONCLUSIONS AND RELEVANCE This intensive intervention had sustained effects for up to 24 months (12 months after the intervention ended). Long-term maintenance of BP control is likely to require continued monitoring and resumption of the intervention if BP increases. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00781365.
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Affiliation(s)
- Karen L. Margolis
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Stephen E. Asche
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Steven P. Dehmer
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Anna R. Bergdall
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | | | | | - Rachel A. Nyboer
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Pamala A. Pawloski
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | | | - Nicole K. Trower
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
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Elinoff JM, Agarwal R, Barnett CF, Benza RL, Cuttica MJ, Gharib AM, Gray MP, Hassoun PM, Hemnes AR, Humbert M, Kolb TM, Lahm T, Leopold JA, Mathai SC, McLaughlin VV, Preston IR, Rosenzweig EB, Shlobin OA, Steen VD, Zamanian RT, Solomon MA. Challenges in Pulmonary Hypertension: Controversies in Treating the Tip of the Iceberg. A Joint National Institutes of Health Clinical Center and Pulmonary Hypertension Association Symposium Report. Am J Respir Crit Care Med 2018; 198:166-174. [PMID: 29425462 PMCID: PMC6058980 DOI: 10.1164/rccm.201710-2093pp] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/09/2018] [Indexed: 01/13/2023] Open
Affiliation(s)
| | - Richa Agarwal
- Division of Cardiovascular Disease, Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | | | - Raymond L. Benza
- Division of Cardiovascular Disease, Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Michael J. Cuttica
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ahmed M. Gharib
- National Institute of Diabetes, Digestive, and Kidney Diseases, and
| | | | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marc Humbert
- Service de Pneumologie, Hôpital Bicêtre (Assistance Publique–Hôpitaux de Paris), Institut National de la Santé et de la Recherche Médicale U999, University Paris–Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Tim Lahm
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Jane A. Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Vallerie V. McLaughlin
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ioana R. Preston
- Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | | | - Oksana A. Shlobin
- Pulmonary Vascular Disease Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Virginia D. Steen
- Rheumatology Division, Department of Medicine, Georgetown University, Washington, DC; and
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Kakio T, Nagase H, Takaoka T, Yoshida N, Hirakawa J, Macha S, Hiroshima T, Ikeda Y, Tsuboi H, Kimura K. Survey to Identify Substandard and Falsified Tablets in Several Asian Countries with Pharmacopeial Quality Control Tests and Principal Component Analysis of Handheld Raman Spectroscopy. Am J Trop Med Hyg 2018; 98:1643-1652. [PMID: 29611498 PMCID: PMC6086158 DOI: 10.4269/ajtmh.17-0553] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 01/19/2018] [Indexed: 11/07/2022] Open
Abstract
The World Health Organization has warned that substandard and falsified medical products (SFs) can harm patients and fail to treat the diseases for which they were intended, and they affect every region of the world, leading to loss of confidence in medicines, health-care providers, and health systems. Therefore, development of analytical procedures to detect SFs is extremely important. In this study, we investigated the quality of pharmaceutical tablets containing the antihypertensive candesartan cilexetil, collected in China, Indonesia, Japan, and Myanmar, using the Japanese pharmacopeial analytical procedures for quality control, together with principal component analysis (PCA) of Raman spectrum obtained with handheld Raman spectrometer. Some samples showed delayed dissolution and failed to meet the pharmacopeial specification, whereas others failed the assay test. These products appeared to be substandard. Principal component analysis showed that all Raman spectra could be explained in terms of two components: the amount of the active pharmaceutical ingredient and the kinds of excipients. Principal component analysis score plot indicated one substandard, and the falsified tablets have similar principal components in Raman spectra, in contrast to authentic products. The locations of samples within the PCA score plot varied according to the source country, suggesting that manufacturers in different countries use different excipients. Our results indicate that the handheld Raman device will be useful for detection of SFs in the field. Principal component analysis of that Raman data clarify the difference in chemical properties between good quality products and SFs that circulate in the Asian market.
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Affiliation(s)
- Tomoko Kakio
- Analytical Development, Pharmaceutical Sciences, Takeda Pharmaceutical Company, Ltd., Osaka, Japan
- Drug Management and Policy, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hitomi Nagase
- Drug Management and Policy, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Takashi Takaoka
- Drug Management and Policy, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Naoko Yoshida
- Drug Management and Policy, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Junichi Hirakawa
- Chemical Analysis Business, Thermo Fisher Scientific K.K., Yokohama, Japan
| | - Susan Macha
- Global Product Protection, Takeda Pharmaceuticals U.S.A., Inc., Deerfield, Illinois
| | - Takashi Hiroshima
- Analytical Development, Pharmaceutical Sciences, Takeda Pharmaceutical Company, Ltd., Osaka, Japan
| | - Yukihiro Ikeda
- Analytical Development, Pharmaceutical Sciences, Takeda Pharmaceutical Company, Ltd., Osaka, Japan
| | - Hirohito Tsuboi
- Drug Management and Policy, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kazuko Kimura
- Drug Management and Policy, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
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Talwar A, Garcia JGN, Tsai H, Moreno M, Lahm T, Zamanian RT, Machado R, Kawut SM, Selej M, Mathai S, D'Anna LH, Sahni S, Rodriquez EJ, Channick R, Fagan K, Gray M, Armstrong J, Rodriguez Lopez J, de Jesus Perez V. Health Disparities in Patients with Pulmonary Arterial Hypertension: A Blueprint for Action. An Official American Thoracic Society Statement. Am J Respir Crit Care Med 2017; 196:e32-e47. [PMID: 29028375 DOI: 10.1164/rccm.201709-1821st] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Health disparities have a major impact in the quality of life and clinical care received by minorities in the United States. Pulmonary arterial hypertension (PAH) is a rare cardiopulmonary disorder that affects children and adults and that, if untreated, results in premature death. The impact of health disparities in the diagnosis, treatment, and clinical outcome of patients with PAH has not been systematically investigated. OBJECTIVES The specific goals of this research statement were to conduct a critical review of the literature concerning health disparities in PAH, identify major research gaps and prioritize direction for future research. METHODS Literature searches from multiple reference databases were performed using medical subject headings and text words for pulmonary hypertension and health disparities. Members of the committee discussed the evidence and provided recommendations for future research. RESULTS Few studies were found discussing the impact of health disparities in PAH. Using recent research statements focused on health disparities, the group identified six major study topics that would help address the contribution of health disparities to PAH. Representative studies in each topic were discussed and specific recommendations were made by the group concerning the most urgent questions to address in future research studies. CONCLUSIONS At present, there are few studies that address health disparities in PAH. Given the potential adverse impact of health disparities, we recommend that research efforts be undertaken to address the topics discussed in the document. Awareness of health disparities will likely improve advocacy efforts, public health policy and the quality of care of vulnerable populations with PAH.
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13
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Affiliation(s)
- Daniel Levy
- Journal of the American Society of Hypertension
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14
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Khan MA, Badshah A, Shahid M. PHARMACEUTICAL EVALUATION AND TOXICOLOGICAL QUANTIFICATION OF HEAVY METALS AND ADULTERATED ALLOPATHIC CONTENTS IN RAW AND FINISHED DOSAGE FORM OF ANTIHYPERTENSIVE HERBAL PRODUCTS. Afr J Tradit Complement Altern Med 2016; 13:54-60. [PMID: 28480360 PMCID: PMC5412202 DOI: 10.21010/ajtcam.v13i6.9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Herbal products of questionable quality create major concern for human population since their production is often not controlled and regulated. MATERIAL AND METHODS Antihypertensive herbal products were subjected to pharmaceutical quality control parameters specified in Pharmacopoeias, toxic quantification of heavy metals by flame atomic absorption spectrophotometer and adulterated allopathic contents were quantified using advanced HPLC techniques. RESULTS A lot of variations in pharmaceutical parameters like moisture contents and LOD% values were observed. Also deviations to a greater extent in weight variation, (P1, P2, P6, P12, P16, P17, P19, and P20), and hardness of the tablets of products (P1, P3, P8 and P11) were found. Friability of tablets of the Products (P3, P9 and P11) was found failed. Heavy metals i-e Fe (1597.20ppm, 1648ppm) in P5, P9, Pb (61.32ppm, 16.59 ppm) in P5, Cr (96.91ppm,108.48 ppm) in P4, P14, Cd (39.53ppm, 32.31 ppm) in P11, P12, Cu (28.22ppm, 21.04 ppm) in P15, P17, Zn (80.31ppm,76.27 ppm) in P15, P16, Ni (45.46ppm,22.18ppm) in P9, P13 in toxic concentrations were detected. Adulterated allopathic contents of Amlpdopine in higher quantities, administered according to manufacturer dose were found in P12 (20.30 mg/day), Verapamil in P2 (93.50 mg/day), Nifedipine (38.65 mg/day) in P6. Products P4, P5 and P7 were found to have a combination of Amlodipine and Hydrochlorothiazide and higher concentrations were found in P5 (10.72 mg/day, 24.75 mg/day). CONCLUSION The antihypertensive herbal products contained different kind of adulterants. Our findings suggest that effective regulatory measures should be put in place to address this problem. This will help to decrease the toxic effects of these remedies and increase the commercialization, internationalization and harmonization of antihypertensive herbal products.
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Affiliation(s)
- Muhammad Asif Khan
- Department of Pharmacy, University of Peshawar, Peshawar, 25120, Pakistan
| | - Amir Badshah
- Department of Pharmacy, University of Peshawar, Peshawar, 25120, Pakistan
| | - Muhammad Shahid
- Department of Pharmacy, University of Peshawar, Peshawar, 25120, Pakistan
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Affiliation(s)
- Sonia Y Angell
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kevin M De Cock
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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16
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Stolarczyk EU, Groman A, Łuniewski W. Development and validation of the GC method for the quantitative determination of semi-volatile solvents in the pharmaceutical substance bosentan. Acta Pol Pharm 2014; 71:1107-1113. [PMID: 25745788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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17
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New blood pressure treatment guidelines challenged. Disagreement over key points leaves patients and doctors scratching their heads. Duke Med Health News 2014; 20:4-5. [PMID: 25195208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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18
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Lyerly MJ, Albright KC, Boehme AK, Bavarsad Shahripour R, Houston JT, Rawal PV, Kapoor N, Alvi M, Sisson A, Alexandrov AW, Alexandrov AV. Safety of protocol violations in acute stroke tPA administration. J Stroke Cerebrovasc Dis 2013; 23:855-60. [PMID: 23954609 DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/06/2013] [Accepted: 07/08/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intravenous (IV) tissue plasminogen activator remains the only approved therapy for acute ischemic stroke (AIS) in the United States; however, less than 10% of patients receive treatment. This is partially because of the large number of contraindications, narrow treatment window, and physician reluctance to deviate from these criteria. METHODS We retrospectively analyzed consecutive patients who received IV thrombolysis at our stroke center for National Institute of Neurological Disorders and Stroke (NINDS) protocol violations and rates of symptomatic intracerebral hemorrhage (sICH). Other outcome variables included systemic hemorrhage, modified Rankin Scale at discharge, and discharge disposition. RESULTS A total of 212 patients were identified in our stroke registry between 2009 and 2011 and included in the analysis. Protocol violations occurred in 76 patients (36%). The most common violations were thrombolysis beyond 3 hours (26%), aggressive blood pressure management (15%), elevated prothrombin time (PT) or partial thromboplastin time (PTT) (6.6%), minor or resolving deficits (4.2%), unclear time of onset (3.9%), and stroke within 3 months (3%). There were no significant differences in any of the safety outcomes or discharge disposition between patients with or without protocol violations. Controlling for age, National Institutes of Health Stroke Scale on admission, and glucose on admission, there was no significant increase in sICH (odds ratio: 3.8; 95% confidence interval: .37-38.72) in the patients who had protocol violations. CONCLUSIONS Despite more than one third of patients receiving thrombolysis with protocol violations, overall rates of hemorrhage remained low and did not differ from those who did not have violations. Our data support the need to expand access to thrombolysis in AIS patients.
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Affiliation(s)
- Michael J Lyerly
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.
| | - Karen C Albright
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), University of Alabama at Birmingham, Birmingham, Alabama; Center for Excellence in Comparative Effectiveness Research for Eliminating Disparities, Minority Health and Health Disparities Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amelia K Boehme
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Reza Bavarsad Shahripour
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - James T Houston
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pawan V Rawal
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Niren Kapoor
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Muhammad Alvi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - April Sisson
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anne W Alexandrov
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrei V Alexandrov
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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19
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Hindlet P, Rosenbaum D, Colpin C, Jublanc C, Farinotti R, Bruckert E, Girerd X. [Influence of hospitalisation on drug prescription in arterial hypertension and chronic conditions]. Ann Cardiol Angeiol (Paris) 2012; 61:224-8. [PMID: 22766264 DOI: 10.1016/j.ancard.2012.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 06/14/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the influence of hospitalization on drug prescription in chronic conditions. METHODS Admission and discharge prescriptions from 92 patients consecutively admitted in a specialized department of the Assistance Publique-Hôpitaux de Paris hospital were recorded in a prospective two-month study. A Qualitative Therapeutical Score (QTS) was calculated as an estimation of qualitative modifications in the prescription. RESULTS Patients admitted for an hospital stay of over 24h have more lines of prescription than patients admitted for an hospitalization shorter than 24h (5.7±4.2/d vs 2.9±2.5/d, P<0.01). For all the patients enrolled, the hospital stay is not associated with any change in the global number of treatments. However, in patients treated with antihyperstensive drug, the number of drug intakes decreases (2.6±1.5/d vs 1.9±1.4/d, P<0.05) as a consequence of an increase in the prescription of fixed-dose combinations. In patients with cardiovascular diseases, the QTS is higher and qualitative modifications are more often found in patients admitted for an hospital stay of over 24h than for those admitted for a an hospitalization shorter than 24h (0.57 vs 0.11; P<0.01 and 31% vs 11%; P<0.05 respectively). Antihypertensive drugs are the most represented drugs within these qualitative modifications. CONCLUSION In patients with drug treatments for arterial hypertension or chronic conditions, hospitalization is not associated with quantitative but with qualitative modifications, especially for an over 24h hospital stay.
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Affiliation(s)
- P Hindlet
- Service de pharmacie, groupe hospitalier Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 75013 Paris, France.
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20
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Kobalava ZD, Kotovskaia IV. [Achievements and problems of modern trials of antihypertensive drugs]. Kardiologiia 2011; 51:91-99. [PMID: 21626808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Most important value of lowering of substantially elevated arterial pressure (AP) for improvement of outcomes in patients with arterial hypertension (AH) was convincingly confirmed by large truly placebo controlled randomized clinical trials (RCT) with the use of mainly diuretics, and/or beta-adrenoblockers in the 60-80ths. Later comparative RCT confirmed equal antihypertensive efficacy of 5 main drug classes relative to AP level in brachial artery. In this review we discuss merit of auxiliary class-specific properties of antihypertensive agents potentially affecting prognosis besides AP lowering. We also discuss problems related to decline of significance of quantitative criteria of AH and consideration of AP level in general context of cardiovascular risk; problems of external validity of RCT; extrapolation of RCT results obtained in patients with complicated AH and very high cardiovascular risk on young patients with uncomplicated AH; significance of hard and surrogate end points.
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Abstract
Angiotensin II receptor blockers (ARBs) are antihypertensive agents with considerable evidence of efficacy and safety for the reduction of cardiovascular (CV) disease risk in numerous patient populations across the CV continuum. There are several agents within this class, all of which have contributed to various degrees, to this evidence base. The evidence with ARBs continues to accumulate, with ongoing trials investigating their role in additional patient populations, potentially expanding their efficacy across a broad spectrum of CV disease states. Cardiovascular disease (CVD) is a leading cause of death around the world, accounting for approximately 29.2% of total global deaths. Of all the deaths attributed to CVD, approximately 43% are due to ischemic heart disease, 33% to cerebrovascular disease, and 23% to hypertensive and other heart conditions. CVD has been represented as a "CV continuum". This continuum concept can be used to describe CVD in general or in specific vascular beds (eg, coronary artery disease or cerebrovascular disease). This review article will discuss the results of the landmark ARB candesartan clinical trials published over the past decade. The evidence presented spans the entire CV continuum, including the effects of ARBs in at-risk patients, stroke, myocardial infarction (MI), and heart failure (HF), as well as a brief discussion of ongoing trials.
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22
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Sweileh WM, Sawalha AF, Zyoud SH, Al-Jabi SW, Tameem EJ. Patterns of anti-hypertensive therapy in diabetic patients with and without reduced renal function. Saudi J Kidney Dis Transpl 2010; 21:652-9. [PMID: 20587868 DOI: pmid/20587868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Renal function deterioration is a common complication in patients with diabetes mellitus and hypertension. Appropriate use of anti-hypertensive agents and tight control of blood pressure (BP) can minimize and delay such complications. This study was performed in order to investigate the utilization patterns of anti-hypertensive agents and to evaluate BP control among diabetic-hypertensive patients with and without reduced renal function. In a retrospective cohort study, all diabetic-hypertensive patients attending The Al-Watani Medical Governmental Center from August 01, 2006 until August 01, 2007 were enrolled in the study. Patients with congestive heart failure and/or end-stage renal disease were excluded from the study. The proportion of use of five different anti-hypertensive drug classes were compared for all patients receiving 1, 2, 3, or 4 drugs, and separately among patients with and without reduced renal function. Over 60% of patients were receiving angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blocker (ARB), followed by diuretics (40.8%), calcium channel blockers (25.1%) and (beta-blockers (12.5%). The majority of patients (> 55%) were either on mono or no drug therapy. Patients on monotherapy were mostly receiving ACEI/ARB (60%). In patients with reduced renal function, use of diuretics, but not ACEI/ARB or CCB, was higher and 41.8% of the patients were on monotherapy compared to 46.6% in patients with normal renal function. The proportion of patients achieving good BP control was 20% with mono-therapy and 28% with combination therapy. Our study suggests that the pattern of anti-hypertensive therapy was generally consistent with inter-national guidelines. Areas of improvement include increasing use of ACEI/ARB and diuretics, decreasing the number of untreated patients, and increasing the proportion of patients with well controlled BP in this population.
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Affiliation(s)
- Waleed M Sweileh
- College of Pharmacy, Clinical Pharmacy Graduate Program, Nablus, Palestine.
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23
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Campo C, Segura J, Roldán C, Alcázar JM, Rodicio JL, Ruilope LM. Doxazosin GITS versus hydrochlorothiazide as add‐on therapy in patients with uncontrolled hypertension. Blood Press 2009; 2:16-21. [PMID: 14761072 DOI: 10.1080/08038020310016369] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The objective of this prospective, randomized, open-label, parallel-arm comparative study, with a 4-month follow-up, was to assess the antihypertensive efficacy, tolerability and metabolic safety of doxazosin GITS (gastrointestinal therapeutic system) 4-8 mg/day vs hydrochlorothiazide (HCTZ) 12.5-25 mg/day as add-on therapy in patients not controlled with monotherapy with other drugs. Ninety-eight patients completed the study (mean age 57.4 +/- 15 years, 53% female). Mean systolic/diastolic blood pressure reduction was 8.2/4.5 mmHg in the HCTZ group and 8.9/5.0 mmHg in the doxazosin GITS group, and a strict blood pressure control was achieved in 79% and 83% of the patients, respectively. The incidence rates of adverse events were low and similar in both groups. However, metabolic differences were seen between the groups, doxazosin GITS vs HCTZ, respectively: total cholesterol (mg/dl) 210 +/- 53 vs 231 +/- 62 (p < 0.05), low-density lipoprotein (LDL) cholesterol (mg/dl) 139 +/- 40 vs 161 +/- 57 (p < 0.01), high-density lipoprotein (HDL) cholesterol (mg/dl) 58 +/- 16 vs 48 +/- 13 (p < 0.01), HDL/total cholesterol ratio 27.6 +/- 8 vs 21.2 +/- 7 (p < 0.001), plasma uric acid (mg/dl) 5.3 +/- 2.6 vs 6.8 +/- 3.1 (p < 0.05) and serum potassium (mEq/l) 4.1 +/- 1.3 vs. 3.7 +/- 1.2 (p < 0.01). In conclusion, doxazosin GITS has a tolerability and efficacy profile similar to low doses of thiazide diuretics, with a better evolution of metabolic and electrolyte parameters. Therefore, in patients not controlled with monotherapy, doxazosin GITS can be considered an alternative to the addition of thiazide diuretics.
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Affiliation(s)
- Carlos Campo
- Hypertension Unit, Hospital Universitario 12 de Octubre, Madrid ES-28041, Spain.
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24
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Yamamoto S, Kawashima T, Kunitake T, Koide S, Fujimoto H. The effects of replacing dihydropyridine calcium‐channel blockers with angiotensin II receptor blocker on the quality of life of hypertensive patients. Blood Press 2009; 2:22-8. [PMID: 14761073 DOI: 10.1080/08038020310016378] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Hypertension is a major risk factor for cardiovascular events and the goal of treating hypertension is to prevent complications due to these events. However, some other properties, including few side-effects and improvement of the quality of life (QOL), are desirable in a drug as well as its antihypertensive effect. Dehydropydine calcium-channel blockers (DCCBs) are the most frequently used antihypertensive agents in Japan. The antihypertensive effect of DCCBs is satisfactory, but side-effects, e.g. nocturia, flushing and palpitations, are a problem. The aim was to evaluate the effects of a change of treatment from DCCBs on the QOL of hypertensive patients. An open study was performed to evaluate the effects of switching treatment from DCCBs to angiotensin II receptor blocker (ARB) therapy on the QOL of hypertensive patients. The ARBs have been reported to be effective and well-tolerated antihypertensive drugs. Candesartan cilexetil was selected because it is the most frequently used ARB in Japan. One hundred patients with mild to moderate hypertension, being treated with DCCBs, were randomly selected to receive candesartan cilexetil (8-12 mg once a day). The patients were followed for 3 months, while blood pressure (BP), side-effects and QOL were monitored. BP was equally well controlled before and after the change of antihypertensive therapy. The candesartan cilexetil-treated patients exhibited improvement of several aspects of QOL, including general symptoms, physical symptoms and well-being, work and satisfaction and sleep scale. Emotional state and cognitive function also improved. Patients aged 65 years or younger achieved significant improvement of sexual function. Changing treatment from DCCBs to ARB therapy achieved equal BP control with a lower drug dose. Moreover, the change to cadesartan cilexetil had a positive impact on the QOL.
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Affiliation(s)
- Shigeki Yamamoto
- Department of Internal Medicine, Mitsubishikagaku Hospital, 13-1 Higashiouji, Yahatanishi-ku, Kitakyushu 806-0037, Japan.
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25
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Generic heart drugs as good as brand names. "You get what you pay for" doesn't apply to prescription drugs. Harv Heart Lett 2009; 19:3. [PMID: 19575519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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De Braekeleer K, Corthout J. Lisinopril and lisinopril/hydrochlorothiazide preparations on the Belgian market: a comparative study. J Pharm Belg 2008; 63:78-83. [PMID: 18972864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Preparations containing lisinopril and the combination lisinopril/hydrochlorothiazide, and formulated as tablets were evaluated with different tests, including in vitro dissolution, assay and content uniformity, and determination of related compounds. The analytical methods were previously validated according to international guidelines. All examined products complied with the postulated requirements.
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Iriarte G, Ferreirós N, Ibarrondo I, Alonso RM, Itxaso Maguregui M, Jiménez RM. Biovalidation of an SPE-HPLC-UV-fluorescence method for the determination of Valsartan and its metabolite valeryl-4-hydroxy-valsartan in human plasma. J Sep Sci 2007; 30:2231-40. [PMID: 17694512 DOI: 10.1002/jssc.200700033] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A simple and fast method for the simultaneous determination of the antihypertensive drug Valsartan and its metabolite in human plasma has been validated. The proposed method deals with SPE, followed by an HPLC separation coupled with fluorimetric and photometric detection. The optimization of the SPE-HPLC method was achieved by an experimental design. The separation was performed on an RP C18 Atlantis 100 mmx3.9 mm column. The mobile phase consisted of a mixture of ACN 0.025% TFA and phosphate buffer (5 mM, pH = 2.5) 0.025% TFA and was delivered in gradient mode at a flow rate of 1.30 mL/min. The eluent was monitored with a fluorescence detector at 234 and 378 nm excitation and emission wavelengths, respectively, and at 254 nm using a photometric detector. The full analytical validation was performed according to the Food and Drug Administration (FDA) 'guidance for industry: bioanalytical method validation' and the recoveries obtained for Valsartan and its metabolite ranged from 94.6 to 108.8%. The validated method was successfully applied to 12 plasma samples obtained from patients under antihypertensive treatment with Valsartan.
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Affiliation(s)
- Gorka Iriarte
- Kimika Analitikoaren Saila, Zientzia eta Teknologia Fakultatea, Euskal Herriko Unibertsitatea/UPV, Bilbo, Basque Country, Spain
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Abstract
In the Trial of Preventing Hypertension (TROPHY), volunteers with "high normal blood pressure" were randomized to 4 years of placebo (n = 381) or 2 years of 16 mg/d of candesartan (n = 391) followed by 2 years of placebo. At 2 years, there was a 26.8% absolute and a 66.3% relative risk reduction (P < 0.0001) of hypertension in the candesartan group. At study end, the former candesartan group had a 9.8% absolute and a 15.6% relative risk reduction (P < 0.007) of hypertension. The treatment was well tolerated. The Seventh Joint National Committee (JNC 7) changed the nomenclature from "high normal blood pressure" to "prehypertension" and widened the range to 120 to 139 and/or 80 to 89 mm Hg. Our results support the term "prehypertension" only for the 130 to 139 and/or 85 to 89 mm Hg group; in 4 years two thirds of the placebo group developed hypertension. We suggest stratifying the JNC classification into "prehypertension" (130-139 and/or 85-89 mm Hg) and "high normal blood pressure" (120-129 and/or 80-84 mm Hg). By the present JNC definition, only one quarter of adult men have normal blood pressure. Removing the disease label from another 28% would appropriately focus attention on high-risk prehypertension.
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Affiliation(s)
- Stevo Julius
- Internal Medicine and Physiology, Division of Cardiovascular Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Lobby M, 3rd Floor, Ann Arbor, MI 48106, USA.
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Moser M, Oparil S, Cushman W, Papademetriou V. The ALLHAT Study Revisited: Do Newer Data From This Trial and Others Indicate Changes in Treatment Guidelines? J Clin Hypertens (Greenwich) 2007; 9:372-80. [PMID: 17485973 PMCID: PMC8109886 DOI: 10.1111/j.1524-6175.2007.06433.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Following a hypertension symposium in Washington, DC, in November 2006, a panel was convened to discuss new data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) and to revisit the significance of this trial in the management of hypertension. Based on these data and information from other trials, the expert panel also addressed the questions, "Is it time for a new Joint National Committee report?" and "Should the 2003 hypertension treatment recommendations be updated or are they still valid?" The panel was moderated by Marvin Moser, MD, Clinical Professor of Medicine, Yale University School of Medicine, New Haven, CT. On the panel were Suzanne Oparil, MD, Professor of Medicine at the University of Alabama in Birmingham, and President of the American Society of Hypertension (ASH); William Cushman, MD, Professor of Preventive Medicine and Medicine at the University of Tennessee in Memphis and attending physician at the Washington, DC, VA Medical Center; and Vasilios Papademetriou, MD, Professor of Medicine at Georgetown University in Washington, DC, and attending physician at the Washington, DC, VA Medical Center. This expert panel discussion was supported by Pfizer Inc and each author received an honorarium from Pfizer Inc for time and effort spent participating in the discussion and reviewing the transcript for important intellectual content prior to publication. The authors maintained full control of the discussion and the resulting content of this article; Pfizer had no input in the choice of topic, speakers, or content.
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Abstract
Angiotensin converting enzyme (ACE)-inhibitory drugs have been used as therapeutic tools in the clinical management of hypertension and associated cardiovascular disorders. Food-derived ACE-inhibitory peptides have lower potency than similar acting drugs but the peptides usually have no adverse side effects and there is virtually no risk of overdosing that is associated with drugs. This review summarizes several patents that have reported the development of technologies for the production of potent food protein-derived hydrolysates and peptides, which can be used to formulate antihypertensive functional foods and nutraceuticals. A common process to all the patents is the use of proteases to split large inactive proteins into smaller bioactive peptides. Ultrafiltration may be combined with liquid chromatography methods to separate the peptides according to size alone or a combination of size and charge density, respectively. Efficacy of the protein hydrolysates or peptide fractions is evaluated first in an in vitro system and may then be confirmed by measuring their hypotensive ability in an appropriate animal model such as the spontaneously hypertensive rats. Finally, protein hydrolysates or peptide fractions that have hypotensive ability may then be used to formulate foods, beverages or pills that can be taken as therapeutic tools against hypertension.
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Affiliation(s)
- Rotimi E Aluko
- Department of Human Nutritional Sciences and the Richardson Centre for Functional Foods and Nutraceuticals, University of Manitoba, Winnipeg, Manitoba, R3T 2N2, Canada.
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Abstract
Hypertension control rates remain alarmingly low worldwide despite the extensive evidence for decreased rates of cardiovascular, cerebrovascular, and renal events in response to blood pressure (BP) lowering to recommended targets. Several classes of antihypertensive drugs are available, which in combination can produce major decreases in BP, with minimal side effects. Moreover, most patients only have mild hypertension and, in general, can be controlled to < 140/90 mm Hg by proper combinations of two antihypertensive drugs. Although patient-related factors clearly contribute to poor control of hypertension, physician-related factors, particularly "passive" therapeutic inertia, are as responsible if not more so. Recent studies clearly indicate that monitoring performance of individual physicians and providing feedback on the care delivered by them can move treatment of hypertension to BP control rates in the 60% to 70% range. If health care organizations would implement this approach, enormous benefits could be expected for the prevention of cardiovascular and cerebrovascular disease.
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Affiliation(s)
- Marcel Ruzicka
- Hypertension Unit, University of Ottawa Heart Institute, 40 Ruskin Street, Room H360, Ottawa, Ontario, Canada K1Y 4W7.
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Rao RN, Nagaraju D, Jena N, Kumaraswamy G. Development and validation of a reversed-phase HPLC method for monitoring of synthetic reactions during the manufacture of a key intermediate of an anti-hypertensive drug. J Sep Sci 2006; 29:2303-9. [PMID: 17120814 DOI: 10.1002/jssc.200600170] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A reversed-phase high-performance liquid-chromatographic method for monitoring of reactions involved in process development of a key intermediate of antihypertensive drugs, e.g, doxazosin mesylate, prazosin, alfuzosin, terazosin, etc., has been developed and validated. The HPLC profiles of impurities of 4-amino-2-chloro-6,7-dimethoxyquinazoline were used as fingerprints to follow the synthetic procedures in the manufacturing unit. The separation was accomplished on an Inertsil ODS-3 column with isocratic elution using acetonitrile-ammonium acetate (10 mM; pH 4.0; 50:50 v/v) as mobile phase and a photodiode array detector set at 240 nm at ambient temperature. The method was validated with respect to accuracy, precision, linearity, and limits of detection and quantification. The method could detect the impurities at a level of 0.01 to 0.20 microg/mL and it was found to be suitable not only for monitoring of reactions but also for quality assurance of 4-amino-2-chloro-6,7-dimethoxyquinazoline.
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Affiliation(s)
- Ramisetti Nageswara Rao
- Analytical Chemistry Division, Discovery Laboratory, Indian Institute of Chemical Technology, Hyderabad, India.
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Affiliation(s)
- John Brian Copley
- Department of Nephrology and Hypertension, Cleveland Clinic Florida, Weston, FL 33331, USA.
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SA Hypertension Guidelines set minimum standards for medical aid schemes. Cardiovasc J S Afr 2006; 17:218-9. [PMID: 17001432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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Abstract
Compared with isolated clinic measurements, ambulatory blood pressure monitoring (ABPM) provides an insight into blood pressure (BP) changes in everyday life and an estimate of the overall BP load exerted on the cardiovascular system over 24 hours. Cross-sectional evidence suggests a direct and significant relationship between ambulatory BP and organ damage. There is also longitudinal evidence for a superior predictive value of 24-hour BP in relation to the risk for cardiovascular morbidity and mortality as opposed to clinic BP. The usefulness of ABPM in pharmacologic studies aimed at evaluating the 24-hour antihypertensive efficacy of different drugs and drug combinations is now acknowledged. Among the mathematical indices available to explore 24-hour BP coverage by treatment, the ABPM-derived smoothness index provides a superior measure of the homogeneity of BP control compared with trough:peak ratios. The main applications of clinical practice should be in identifying patients with isolated office hypertension and those who are nonresponders to treatment, in assessing coverage of the 24-hour BP profile in high-risk patients and in diagnosing suspected treatment-related hypotension.
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Affiliation(s)
- Giuseppe Mancia
- Department of Clinical Medicine, Prevention and Applied Biotechnologies, and Clinica Medica, University of Milano-Bicocca, St Gerardo Hospital, Via Donizetti 106, 20052 MONZA, Milano, Italy.
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Abstract
Hypertension affects 65 million people in the US, and is a major cause of morbidity and mortality, but less than one-third of patients with hypertension are treated to goal blood pressure. Multiple factors have been cited, and include suboptimal adherence to treatment and lifestyle modifications, limited access to healthcare services, and the failure of health professionals to treat hypertension aggressively. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends a goal blood pressure of <140/90mm Hg for most patients and <130/80mm Hg for those with diabetes mellitus or chronic kidney disease. The 'ideal' antihypertensive agent would have a number of characteristics: (i) effective in lowering blood pressure to recommended goals; (ii) high efficacy as monotherapy; (iii) rapid onset of effect; (iv) convenient once-daily dose administration to maximise compliance; (v) sustained efficacy over 24 hours; (vi) response increases with higher doses (clear dose-response effect); and (vii) optimum tolerability profile. Although the ideal agent does not yet exist and will vary from patient to patient, drug development and new formulations have provided more options for clinicians and patients and certain drug classes appear to show promise because they possess many beneficial characteristics. Hypertension treatment needs to be tailored to individual patients' age, race, socioeconomic situation, concomitant conditions and family history. Physicians and other clinical providers have an important role to play in hypertension management, particularly by combining culturally sensitive patient care with aggressive treatment. Regular follow-up that is directed at achieving goal blood pressure, while monitoring the patient for possible drug-related adverse effects, will help ensure and support adherence to treatment regimens. By supporting the integration of lifestyle changes into this plan, the clinician can further influence and have a positive impact on a patient's overall cardiovascular profile.
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Affiliation(s)
- Lisa Mustone Alexander
- George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA.
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Post W, Moser M, Kaplan N. A Conversation With Drs. Kaplan and Moser About Conflicting Data, Confusing Results, and Some Recent Treatment Recommendations for the Management of Hypertension. J Clin Hypertens (Greenwich) 2005; 7:606-11. [PMID: 16227763 PMCID: PMC8109592 DOI: 10.1111/j.1524-6175.2005.04704.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Following a hypertension symposium in Baltimore, MD, on June 1, 2005, Dr. Wendy Post from the Johns Hopkins University School of Medicine, Baltimore, MD, had the opportunity to interview two of the outstanding hypertension experts in the United States on several controversial issues in hypertension management. Dr. Norman Kaplan is Clinical Professor of Medicine at the Southwestern Health Science Center in Dallas, TX, and Dr. Marvin Moser is Clinical Professor of Medicine at the Yale University School of Medicine, New Haven, CT. Both have been leaders in the field of hypertension treatment and education for more than 40 years. Dr. Kaplan's book Clinical Hypertension has been a standard textbook since 1973 and is now in its ninth edition. Dr. Marvin Moser was the Senior Medical Consultant to the National High Blood Pressure Education Program from 1974 to 2002 and was Chairman of the first Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure and a member of the six subsequent committees. His book Clinical Management of Hypertension is in its seventh edition. Drs. Moser and Kaplan were corecipients of the 2004 International Society of Hypertension Award for Outstanding Contributions to Hypertension Treatment and Education and have lectured extensively throughout the United States and overseas.
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Moser M, Victor R, Handler J. Secondary Hypertension—Whom and How Do You Study? What Type of Therapy Is Appropriate? J Clin Hypertens (Greenwich) 2005; 7:224-30. [PMID: 15860962 PMCID: PMC8109336 DOI: 10.1111/j.1524-6175.2005.04317.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Following a hypertension symposium in Los Angeles, CA on October 20, 2004, a roundtable was convened to discuss secondary or treatable forms of high blood pressure, when and whom should be studied, and treatment methods. Dr. Marvin Moser, Clinical Professor of Medicine at Yale University School of Medicine, New Haven, CT, moderated the panel discussion. Participants included Dr. Ron Victor, from the Southwestern Medical Center, Dallas, TX and Dr. Joel Handler of the Orange County Kaiser Permanente Hypertension Clinic, Anaheim, CA.
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Affiliation(s)
- Marvin Moser
- Yale University School of Medicine, New Haven, CT, USA
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Abstract
Any meaningful discussion about the present value of old drugs requires appropriate comparisons with new drugs. While there is noisy propaganda claiming the superiority of new drugs, the evidence supporting these claims is often scanty and poor. Therefore, the database utilizable to evaluate old and new drugs is incomplete and fragile. There are several reasons, including the poor dossiers presented for the approval of new drugs, the lack of comparisons aimed at showing superiority of new drugs, the bias frequently involved in clinical trials and the conflict of interests. This brief discussion reviews these questions and gives some examples by comparing diuretics and new antihypertensive agents, ticlopidine and clopidogrel, and atypical and classical antipsychotic agents.
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Affiliation(s)
- Silvio Garattini
- Mario Negri Institute for Pharmacological Research, Milan, Italy.
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Abstract
Hypertension is a leading cause of morbidity and mortality worldwide and its control rates remain poor. In 2003, several official organizations presented new guidelines for hypertension management. These guidelines were developed using an evidence-based interpretation of the available information. Recommendations on hypertension prevention, diagnosis, patients' evaluation, decision to treat, antihypertensive drug selection and goals of treatment are included. There is considerable agreement among the new guidelines and only a few points of disagreement, that are of minor significance. Emphasis has been placed on the simplicity of recommendations in order for them to be easily applied by primary care physicians. This review focuses on the key messages of the 2003 guidelines and the areas of agreement and disagreement among them.
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Affiliation(s)
- George S Stergiou
- Third University Department of Medicine, Sotiria Hospital, 152, Mesogion Avenue, Athens 11527, Greece.
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Persson M, Carlberg B, Tavelin B, Lindholm LH. Doctors' estimation of cardiovascular risk and willingness to give drug treatment in hypertension: fair risk assessment but defensive treatment policy. J Hypertens 2004; 22:65-71. [PMID: 15106796 DOI: 10.1097/00004872-200401000-00014] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE We studied the differences between recommendations given in the 1999 World Health Organization-International Society of Hypertension (WHO/ISH) Guidelines and doctors' risk estimation and willingness to give antihypertensive drugs. METHODS A population-based sample, the WHO Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (WHO MONICA) (n = 5997), was classified according to the 1999 WHO/ISH Hypertension Guidelines risk stratification scheme. A total of 54 subjects were randomly drawn from the 12 different risk categories. Written case stories were constructed based on risk-factor levels for each selected subject. SETTING AND PARTICIPANTS Doctors (n = 139), comprising general practitioners (GPs, n = 110) and specialists in internal medicine or cardiology (specialists, n = 29), in northern Sweden assessed 12 cases each. MAIN OUTCOME MEASURES Factors used in risk assessment, estimation of cardiovascular risk, and willingness to give antihypertensive drugs. RESULTS In a multivariate logistic regression model including all doctors, most major risk factors were significantly associated with a higher estimated risk and willingness to give drug treatment. Estimated risk was lower than the risk classified by 1999 WHO/ISH Hypertension Guidelines, and there was no difference between GPs and specialists in this respect. The use of antihypertensive drugs was much lower than advocated by the guidelines, but specialists were more inclined to give antihypertensive drug treatment than GPs. CONCLUSIONS Doctors estimated the cardiovascular risk as being less severe than the recommendation given in the 1999 WHO/ISH Hypertension Guidelines. Moreover, their willingness to prescribe antihypertensive drugs was also lower than that advocated by the guidelines. The control of hypertension is poor in the community today, and this seems to be the way the profession wants to have it.
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Affiliation(s)
- Mats Persson
- Department of Public Health and Clinical Medicine, University of Umeå, Sweden.
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Abstract
PURPOSE To evaluate the sterility of topical glaucoma medications among chronic glaucoma medication users in the community. SETTING Glaucoma service, Sanz Medical Center, Laniado Hospital, Netanya. Research mode: Cross-sectional laboratory and clinical study. PATIENTS AND METHODS Chronic glaucoma patients were asked to submit their topical glaucoma preparations to the microbiology laboratory at Laniado hospital. Samples taken from the interior of the bottle and the tip were cultured using MacConkey agar, blood agar, and chocolate agar plates. RESULTS Sixty-two bottles of topical glaucoma medications used by 27 patients were tested. Bacterial growth was detected in eight (12.9%) preparations, three of which revealed Pseudomonas aeruginosa, three Staphylococcus epidermidis, one Streptococcus viridans, and one Klebsiella. During the study, acute conjunctivitis was found in one patient, possibly due to the use of infected drops. In another case, two identical medications, which had been used simultaneously for more than 6 weeks by the same patient, were found to be infected. CONCLUSIONS Glaucoma topical preparations are generally found safe in terms of sterility, though bacterial growth may be found in a small percentage. In most cases, the cause of the loss of sterility could not be determined. However, in two preparations, contamination was related to the noncompliance of the patient who continued using the same preparation longer than instructed. It is imperative to increase the awareness of glaucoma patients to the fact that improper use can lead to eye-drop contamination.
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Affiliation(s)
- Yair Porges
- Sanz Medical Center, Laniado Hospital, Netanya, Israel.
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Messerschmidt K. The pressure is on for better blood pressure control. S D J Med 2003; 56:259-60. [PMID: 12901314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
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Diamantopoulos EJ, Andreadis EA, Vassilopoulos CV, Giannakopoulos NS, Papadopoulou P, Tsourous GI, Tsiftsis NH. Adherence to an intensive antihypertensive follow-up programme. J Hum Hypertens 2003; 17:437-9. [PMID: 12764408 DOI: 10.1038/sj.jhh.1001567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Despite the development of hypertension treatment guidelines, blood pressure control in the general population remains inadequate, indicating the need for ongoing re-evaluation of treatment strategies to further improve blood pressure control. Hypertension results from alterations in cardiac output and/or peripheral resistance. The renin-angiotensin-aldosterone system may be responsible, at least in part, for these alterations. Despite pharmacologic intervention with angiotensin-converting enzyme inhibitors and angiotensin type-1 receptor antagonists, aldosterone continues to be produced. Therapeutic modalities for treating hypertension directed toward antagonizing aldosterone might more effectively control blood pressure. Eplerenone, a new selective aldosterone receptor antagonist, recently received approval from the US Food and Drug Administration for the treatment of hypertension, either alone or in combination with other antihypertensive agents. The objective of this review is to summarize the renin-angiotensin-aldosterone system, emphasizing the role for aldosterone antagonism in the management of hypertension, with a focus on eplerenone.
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Affiliation(s)
- Robert E Lamb
- AstraZeneca LP, 725 Chesterbrook Boulevard, Wayne, PA 19087, USA.
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Abstract
OBJECTIVE To determine the readability of ocular medication inserts and whether they are an appropriate source of medication information for patients. MATERIALS AND METHODS The Flesch-Kincaid and SMOG readability formulas were used to calculate the readability of 10 common glaucoma medication inserts (Alphagan, Azopt, Betoptic, Betimolol, Cosopt, Optipranolol, Rescula, Trusopt, Timoptic, and Xalatan) and 6 widely used nonglaucoma medication inserts (Alrex, Lotemax, Ocuflox, Patanol, Pred Forte, and Zaditor). RESULTS The 10 glaucoma medication inserts surveyed required an average overall grade level of 12.9 +/- 0.6 by the Flesch-Kincaid Index and of 13.5 +/- 0.6 by the SMOG formula. The 6 nonglaucoma medication inserts had an overall grade level of 11.1 +/- 0.6 by the Flesch-Kincaid Index and of 11.7 +/- 0.9 by the SMOG formula. All medications reviewed were above the eighth-grade level recommended by the Flesch-Kincaid Index for public materials. CONCLUSIONS Ocular medication inserts are too complex to be an adequate source of medication information for the average American adult. This study highlights the need for improving communication and education regarding patients' medications.
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Affiliation(s)
- Rahul N Khurana
- Department of Ophthalmology, Duke Univeristy Medical Center, Durham, Norht Carolina 27712, USA
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Agodoa L. Lessons from chronic renal diseases in African Americans: treatment implications. Ethn Dis 2003; 13:S118-24. [PMID: 13677426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
End-stage renal disease (ESRD) is a significant public health problem in both developed and developing countries. The magnitude and patterns of renal disease vary among countries, differences that could be due, in part, to regional racial and ethnic composition. The United States is a typical example, with significant racial and ethnic differences in the magnitude and pattern of renal disease. Compared with Caucasians and Asians, African Americans, Native Americans, and Pacific Islanders are disproportionately afflicted with end-stage kidney failure. Whereas diabetes mellitus (primarily type 2) is the predominant cause of renal disease (and ESRD) in the United States, especially in Native Americans, hypertensive kidney disease is a major cause of ESRD in African Americans. Some of the lifestyle and physical characteristics that may be responsible for the increased incidence and prevalence of hypertensive kidney disease in African Americans include: 1) the higher prevalence and severity of hypertension, especially in the early years of life; 2) lower socioeconomic status leading to inadequate health care; 3) a greater propensity toward developing intrinsic renal vascular disease; 4) a greater tendency toward developing target organ damage at "normal" blood pressure levels; 5) illicit drug use; and 6) the use of medication that is less reno-protective to treat their blood pressure.
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Affiliation(s)
- Lawrence Agodoa
- Office of Minority Health Research Coordination, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892-5454, USA.
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Nelson MR, Reid CM, Krum H, McNeil JJ. Factors influencing family physician adherence to hypertension treatment guideline recommendations on the initiation of pharmacotherapy: questionnaire survey. Am J Cardiovasc Drugs 2003; 3:437-41. [PMID: 14728063 DOI: 10.2165/00129784-200303060-00006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Family physicians do not prescribe antihypertensive medication according to current guidelines. This study investigates possible reasons for this. The objectives were to measure the knowledge, attitude and stated practice of family physicians to the initiation of pharmacotherapy for uncomplicated hypertension and to explore the reasons why clinical practice differs from guideline recommendations. STUDY DESIGN A cross-sectional postal survey conducted between June and October 1999. Simple frequency analysis and a chi(2) test comparing family physician characteristics and responses. METHODS A three-phase postal survey was undertaken of a random sample of family physicians. Telephone and facsimile contact was made to non-responders. The survey instrument included respondent characteristics, preference for initiation of antihypertensive drug therapy and their opinion of efficacy, adverse effects and long-term safety, as well as knowledge of guidelines. PARTICIPANTS Family physicians in the state of Victoria, Australia. MAIN OUTCOME MEASURES AND RESULTS Ranked preference of drugs for uncomplicated hypertension. Opinion of drug efficacy, adverse effects, safety and cost. Knowledge of guidelines for first-line antihypertensive drugs. Newer agents are preferred to older agents in the initiation of antihypertensive drug therapy contrary to current guideline recommendations. Newer agents were thought to be more efficacious, have better short- and long-term adverse effect profiles and be more expensive than older agents. Younger doctors most often held these attitudes. Guidelines influenced decision making but were not the most important factor. CONCLUSIONS There is a demonstrable need for governments to invest in the promotion of accurate information on drugs through continuing education of prescribers and facilitating the production of standardized paper and web-based clinical guidelines. A program of targeted investment in clinical trials that examine the justification for more expensive classes of agents should also be considered in appropriate circumstances.
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Affiliation(s)
- Mark R Nelson
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Prahran, Australia.
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