Achieve Target Blood Pressure Research Articles

Control of arterial hypertension in the context of metabolically-associated disease: challenges and opportunities in Ukraine

Abstract Background/Introduction Arterial hypertension is a prevalent, but modifiable cardiovascular (CV) risk factor. Effective control of blood pressure (BP) is associated with decreased rates of CV morbidity and mortality, as was convincingly demonstrated in randomized clinical trials. There is a substantial gap between BP control in clinical trials and real clinical practice due to multiple factors – e.g. lack of awareness, low medication compliance, side effects of medications, and insufficient availability of medical care – to name the few. The association between poor BP control and metabolically associated disease (MAD) like diabetes and obesity is widely acknowledged and considered the key challenge in effective management of arterial hypertension. Purpose To determine patterns of awareness and control of arterial hypertension in the context of MAD in Ukrainian outpatient patient sample. Methods We enrolled 309 subjects (108 with MAD and 201 without MAD). MAD was defined as the presence of type 2 diabetes and/or overweight/obesity. All subjects were consented for the structured interview and triple sitting BP measurement with an automated device. Results MAD-positive and MAD-negative groups were comparable by age (54.4±1.34 vs 51.8±1.2 years, p=0.29), systolic BP (141.3±2.0 vs 137.4±1.6 mm Hg, p=0.082), diastolic BP (85.2±1.2 vs 82.5±0.9 mm Hg, p=0.13). Presence of MAD was associated with increased odds of having BP>139/89 mm Hg (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.04-2.67, p=0.035), better awareness on hypertension (OR 2.65, CI 1.64-4.28, p=0.0001), and less prevalent normotension (OR 0.51, CI 0.31-0.84, p=0.008). Among MAD-positive patients without history of HTN, 50% actually had elevated office BP, although it did not reach statistical significance as compared to MAD-negative subjects (OR 1.32 CI 0.68-2.56, p=0.42, see Picture 1). Less MAD-positive patients did not take any antihypertensive drugs (37.0% vs 56.7%, difference -19.7%, CI -8.03 to -30.51%, p=0.001), and more of them were taking 3 antihypertensive drugs (17.6% vs 7.5%, difference 10.1% CI 2.58-18.85. p=0.007). Only 53.7% of MAD-positive subjects and 39.8% of MAD-negative subjects claimed they were taking BP-lowering medications on a regular basis (p=0.02). There was no difference in achievement of BP control between MAD-positive and MAD-negative groups (39.2 vs 38.7% for subjects who were aware of HTN, 31.9 vs 31.3% of all hypertensive individuals, p=NS for both). More MAD-positive than MAD-negative subjects admitted they consume alcohol several times per week or daily (22.2 vs 12.4%, p=0.025). Conclusions MAD disease is associated with more prevalent HTN and better awareness on elevated BP. MAD requires more intensive BP-lowering therapy to achieve target BP, but the compliance to medications is suboptimal.Patterns of awareness and BP control

Cardioprotective efficacy of combined therapy with azilsartan, indapamide, and nitrendipine in patients with essential hypertension

Abstract Objective To conduct a comparative assessment of the six-month cardioprotective efficacy of combined therapy using azilsartan with indapamide and nitrendipine in patients with essential hypertension (EH). Materials and Methods The study included 101 male and female patients with grade I–II arterial hypertension (AH) according to the classification (ESC/ESH, 2018), who were undergoing outpatient treatment at the Republican Specialized Scientific-Practical Medical Center of Cardiology. The mean age of the patients was 53.1±11.2 years, and the mean duration of AH was 8.5±7.2 years. Initially and after 6 months of therapy, echocardiography was performed to determine the left ventricular myocardial mass index (LVMMI) and left ventricular (LV) echo geometry types. Echocardiography (ECHO) was performed using the "En VisorC" ultrasound system (Philips, Netherlands). Statistical significance was considered for all analyses with p <0.05. Results All patients were divided into 2 groups: Group 1 - patients on combined antihypertensive therapy (AHT) with azilsartan and indapamide (n=50) and Group 2 - patients on therapy with azilsartan and nitrendipine (n=51). The mean daily dose of azilsartan was 49.3±6.0 mg, nitrendipine was 10.88±4.3 mg, and indapamide was 1.69±0.5 mg. In Group 1, the LVMMI initially was 127.4±32.9 g/m2, and after treatment, it was 110.3±29.0 g/m2 (p<0.001); in Group 2, it was 138.7±31.9 g/m2 and 116.6±30.3 g/m2, respectively (p<0.001). The degree of LVMMI reduction in Group 1 was -13.3±15.6% compared to Group 2, which was -14.4±17.9% (p>0.05). During therapy with azilsartan, indapamide, and nitrendipine, the reduction of LVMMI in EH patients was associated with a decrease in the concentric type of left ventricular hypertrophy (LVH) in both therapy groups: in both groups, a significant increase in the LV diastolic filling pattern index/LVMMI was observed, which was 0.51±0.07 ml/g before treatment and 0.57±0.14 ml/g after treatment in Group 1 (p<0.001), and 0.50±0.11 ml/g before treatment and 0.54±0.12 ml/g after treatment in Group 2 (p<0.02). Significant regression of LVH with 6-month combined therapy in both groups was accompanied by an improvement in LV echo geometry. Initially, there were 12 patients (11.9%) with unchanged LV echo geometry, concentric remodeling was detected in 9 patients (8.91%), eccentric LVH in 30 patients (29.7%), and concentric LVH in 50 patients (49.5%). In the dynamics, the number of patients with normal LV echo geometry increased to 41 patients (40.6%), with concentric LVH decreased to 34 patients (33.6%), with concentric remodeling decreased to 7 patients (7%), and with eccentric LVH decreased to 19 patients (18.8%) (χ2=21.635, p<0.001). Conclusion Achieving target blood pressure levels provided high cardioprotective efficacy of combined therapy with azilsartan, indapamide, and nitrendipine with improvement in LV echo geometry in both groups.

Hypertension prevalence among the male population aged 35-74 years in Novosibirsk

Aim. To study the prevalence and risk factors of hypertension (HTN), structure and effectiveness of treatment coverage, as well as disease control indicators among the male population aged 35-74 years in Novosibirsk.Material and methods. This cross-sectional study of the Novosibirsk population was conducted in 2021-2023 at the Research Institute for Internal and Preventive Medicine — branch of the Federal Research Center Institute of Cytology and Genetics according to the ESSE-RF3 study protocol. A total of 1200 people aged 35-74 years living in Novosibirsk were examined. The analysis included 600 men. The response rate exceeded 70%. HTN was considered detected in systolic blood pressure (BP) ≥140 mm Hg and/or diastolic BP ≥90 mm Hg and/or in patients taking antihypertensive agents. Awareness was estimated as the proportion of individuals who had previously been informed by a physician about HTN. Treatment effectiveness was considered the proportion of individuals who achieved target BP values while taking antihypertensive therapy. Hypertension control was considered the proportion of individuals who achieved target values among all those examined with HTN. Statistical processing was performed using the SPSS software package (version 13.0). Associations were assessed using multiple logistic regression analysis. The critical significance level of the null hypothesis (p) was 0,05.Results. The medians of systolic and diastolic BP among men in No­vo­sibirsk were 136,0 [126,5; 149,5] and 89,0 [82,0; 95,5] mm Hg, respectively. The prevalence of HTN among men aged 35-74 in Novo­sibirsk was 68,9%, while 81,1% of men in Novosibirsk were aware of HTN. Among men with HTN, 54,7% take antihypertensive agents. The effectiveness of treatment among men in Novosibirsk is 32,3%, while 19,6% of men control the disease. The odds of hypertension occurrence in men with hypertriglyceridemia increased by 3,5 times, with abdominal obesity — by 2 times, with an positive family history for cardiovascular diseases — by 1,6 times, and with each year of life increased by 1,1 times.Conclusion. The prevalence of HTN among men in Novosibirsk is higher in comparison with the average Russian level. Significant risk factors for HTN include abdominal obesity, hypertriglyceridemia, and decreased physical activity. While awareness, treatment coverage, and HTN control among men aged 35-74 in Novosibirsk correspond to Russian trends, treatment effectiveness turned out to be slightly lower than in the Russian population.

Choice Between Free Combination of Antihypertensive Agents and Fixed Dosed Combinations in the Treatment of Arterial Hypertension

Most patients with arterial hypertension require more than one antihypertensive drug for blood pressure target achievement. Some patients are recommended for a multi-pill antihypertensive regimen, others — treatment with fixed dosed combinations in one tablet. Analysis of elibrary and PubMed publications in the period mostly from 2014 to 2024 concerning the choice of two-component combined antihypertensive agents containing renin-angiotensin system inhibitor and diuretic or calcium channel blocker, revealed that fixed-dose combinations (FDC) use and taking one tablet once a day improves adherence to treatment and facilitates blood pressure control. Although the cost of FDC containing the renin-angiotensin-aldosterone system inhibitor and a thiazide/thiazide-like diuretic or calcium channel blocker is in most cases higher than the same drugs taken separately, the use of fixed combinations, increasing patient adherence to therapy, has clinical advantage in terms of the effectiveness of lowering blood pressure, which confirms their economic feasibility. On the other hand, the use of free combination therapy in two different tablets, when taken separately during the day, can sometimes provide a more sustained antihypertensive effect over 24 hours. Evidence of the effectiveness of blood pressure control for FDCs is often extrapolated from data on free combinations. In addition, FDCs are characterized by less detection of possible ineffectiveness of one of the components. The range of FDCs and the dosage ratios of the components presented in them is gradually expanding, but the choice among free combinations is still wider. In addition, the list of vital and essential drugs (VED) for 2024 does not contain FDCs for antihypertensive drugs, which excludes the possibility of free receiving them on a preferential basis and gives the opportunity for the manufacturer to set prices for them. Despite the fact that recently the scientific community has recommended the use of FDC antihypertensive drugs as initial therapy due to better compliance with the regimen, and therefore clinical effectiveness and economic feasibility, it cannot be said that there is no space left for free combinations of antihypertensive drugs in the treatment of arterial hypertension. The choice of doctor, frequency of prescription, share of purchases of the FDCs in the Russian Federation, review of their consumption requires further analysis.

Current approach to resistant hypertension

Resistant hypertension is the inability to achieve target blood pressure (<130/80 mmHg) despite using the maximum tolerated doses of three antihypertensive drugs, including a diuretic, or the need for four or more medications. It is linked to aging, obesity, obstructive sleep apnea, and chronic kidney disease, with contributing factors such as high sodium intake and sympathetic nervous system overactivity. Treatment includes optimizing diuretic use, with spironolactone proving highly effective. Lifestyle modifications, including sodium reduction and exercise, are critical. Emerging therapies like renal denervation offer promising long-term blood pressure control.

Increased lipoprotein (a) as an additional factor in the failure to achieve target blood pressure levels and lipid spectrum optimal parameters in patients with arterial hypertension and multifocal atherosclerosis

Aim. To establish the frequency of achieving target of blood pressure (BP) levels and lipid spectrum parameters (LS) in patients with arterial hypertension (AH) and multifocal atherosclerotic lesion (MFAL) with normal and elevated levels of lipoprotein (a) (Lp(a)) in real clinical practice.Material and methods. The study included 110 patients with AH and MFAL, median age was 59.0 (51.0; 64.3) years. Depending on the level of Lp(a), all patients were divided into 2 groups: group 1 — 72 patients (65.5%), Lp(a) level was ≤50 mg/dl (13.2 (3.7; 21.1)), group 2 — 38 patients (34.5%) Lp(a) level was >50 mg/dl (89.5 (62.5; 110.0)). The diagnosis of MFAL included damage to two or more arterial basins according to carotid artery, abdominal aorta and lower extremities arteries duplex scan. Patients of both groups received antihypertensive, lipid-lowering, and antiplatelet therapy.Results. Patients in groups 1 and 2 showed similar blood pressure levels and frequency of antihypertensive therapy use. In both groups, the majority of patients were on a free combination of antihypertensive drugs, only a third of patients used a fixed combination. In most cases, patients of both groups did not reach the target blood pressure levels (63.9% — group 1, 55.3% — group 2), despite the fact that the average blood pressure figures were relatively low (132;83 mmHg in each group). Drug control was also unsatisfactory in both groups, regardless of the level of Lp(a). However, all drug indicators were significantly worse in group 2, despite comparable lipid-lowering therapy, which more often included statin monotherapy. Combination therapy with lipid-lowering drugs was used in patients of groups 1 and 2 only in 20.8% and 10.5%, respectively. Parameters of low-grade inflammation high-sensitivity C-reactive protein and interleukin-6 did not differ between the groups and did not exceed the reference values.Conclusion. An increased level of Lp(a) may be accompanied by drug disorders and increased BP in patients with MFAL. Due to the lack of effective Lp(a) reducing therapy, the prevention of cardiovascular events in such patients should focus on BP and lipid spectrum correction. The use of fixed combinations, including antihypertensive and lipid-lowering drugs, can lead to improved adherence to therapy, increased BP and LS control.

Do clinical decision support tools improve quality of care outcomes in the primary prevention of cardiovascular disease: A systematic review and meta-analysis

AimTo assess the effectiveness of Clinical Decision Support Tools (CDSTs) in enhancing the quality of care outcomes in primary cardiovascular disease (CVD) prevention. MethodsA systematic review was undertaken in accordance with PRISMA guidelines, and included searches in Ovid Medline, Ovid Embase, CINAHL, and Scopus. Eligible studies were randomized controlled trials of CDSTs comprising digital notifications in electronic health systems (EHS/EHR) in various primary healthcare settings, published post-2013, in patients with CVD risks and without established CVD. Two reviewers independently assessed risk of bias using the Cochrane RoB-2 tool. Attainment of clinical targets was analysed using a Restricted Maximum Likelihood random effects meta-analysis. Other relevant outcomes were narratively synthesised due to heterogeneity of studies and outcome metrics. ResultsMeta-analysis revealed CDSTs showed improvement in systolic (Mean Standardised Difference (MSD)=0.39, 95 %CI=-0.31, -1.10) and diastolic blood pressure target achievement (MSD=0.34, 95 %CI=-0.24, -0.92), but had no significant impact on lipid (MSD=0.01; 95 %CI=-0.10, 0.11) or glucose target attainment (MSD=-0.19, 95 %CI=-0.66, 0.28). The CDSTs with active prompts increased statin initiation and improved patients’ adherence to clinical appointments but had minimal effect on other medications and on enhancing adherence to medication. ConclusionCDSTs were found to be effective in improving blood pressure clinical target attainments. However, the presence of multi-layered barriers affecting the uptake, longer-term use and active engagement from both clinicians and patients may hinder the full potential for achieving other quality of care outcomes. Lay SummaryThe study aimed to evaluate how Clinical Decision Support Tools (CDSTs) impact the quality of care for primary cardiovascular disease (CVD) management. CDSTs are tools designed to support healthcare professionals in delivering the best possible care to patients by providing timely and relevant information at the point of care (ie. digital notifications in electronic health systems). Although CDST are designed to improve the quality of healthcare outcomes, the current evidence of their effectiveness is inconsistent. Therefore, we conducted a systematic review with meta-analysis, to quantify the effectiveness of CDSTs. The eligibility criteria targeted patients with CVD risk factors, but without diagnosed CVD. The meta-analysis found that CDSTs showed improvement in systolic and diastolic blood pressure target achievement but did not significantly impact lipid or glucose target attainment. Specifically, CDSTs showed effectiveness in increasing statin prescribing but not antihypertensives or antidiabetics prescribing. Interventions with CDSTs aimed at increasing screening programmes were effective for patients with kidney diseases and high-risk patients, but not for patients with diabetes or teenage patients with hypertension. Alerts were effective in improving patients' adherence to clinical appointments but not in medication adherence. This study suggests CDSTs are effective in enhancing a limited number of quality of care outcomes in primary CVD prevention, but there is need for future research to explore the mechanisms and context of multiple barriers that may hinder the full potential for cardiovascular health outcomes to be achieved.

Abstract P330: Next-Gen Hypertension Control: Integrating Clinical Pharmacists And Cutting-Edge EPIC Electronic Medical Record For Quality And Result Driven Approaches at Federally Qualified Health Centers

Hypertension management in Federally Qualified Health Centers (FQHCs) requires innovative and comprehensive strategies beyond traditional methods. This study explores a collaborative approach by integrating clinical pharmacists into the healthcare team and utilizing the EPIC Electronic Medical Record (EMR) system. The model addresses medical and non-medical health determinants, offering comprehensive treatment for underserved communities regardless of their ability to pay. We hypothesized that integrating clinical pharmacists would improve and sustain blood pressure control, resulting in more patients achieving their target health outcomes. As part of multidisciplinary teams, clinical pharmacists identify, track, and analyze patient data, manage medication therapies under collaborative practice agreements, and coordinate with other healthcare providers to ensure continuous care. By leveraging EPIC EMR’s data management and patient monitoring capabilities, clinical pharmacists use real-time data to tailor medication regimens, ensure timely interventions, and conduct follow-ups every 2 to 4 weeks via telemedicine or in-clinic visits until patients reach their goals. This approach enhances patient engagement and medication adherence, which is crucial for adequate blood pressure control and cost management. It also supports personalized care addressing medical needs, lifestyle, and socioeconomic factors affecting patient health. The study, initiated in January 2024, involves adult patients with hypertension at one of the largest FQHC in Houston, TX. Key performance indicators include the percentage of patients achieving target blood pressure levels, medication adherence rates, and the frequency of follow-up visits. Preliminary data from quarter 1, 2024, shows that out of 327 patients, 58% have had at least 2 consultations with a clinical pharmacist. Out of those patients, 46% reached blood pressure control below 140/90 mmHg, while 27% showed improvement toward their goal. This quality and result-driven approach elevates hypertension management standards, reduces health disparities, and enhances healthcare delivery within FQHCs. Clinical pharmacists have proven to be indispensable members of the healthcare team. This session aims to provide practical insights and strategies for healthcare professionals to implement similar models, paving the way for the future of hypertension care.

Single-Pill Combination Therapy of Amlodipine, Telmisartan, and Chlorthalidone in the Management of Hypertension: A Systematic Review of Randomized Controlled Trials.

Hypertension is a major cause of cardiovascular disease and death worldwide. Low-dose combination therapy is a promising approach for managing hypertension due to its safety and efficacy. This systematic review evaluates the safety and efficacy of a single-pill, low-dose combination of amlodipine, telmisartan, and chlorthalidone for essential hypertension based on evidence from randomized controlled trials (RCTs). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched the Cochrane, Scopus, PubMed, and Web of Science databases until July 01, 2024, using the following search string: (telmisartan) AND (amlodipine) AND (chlorthalidone) AND (randomized OR randomly). The quality of the RCTs was assessed using the revised Cochrane risk of bias tool. The primary endpoint was the mean change in sitting systolic blood pressure (BP), with secondary endpoints including BP target achievement rates, BP response rates, and serious treatment-related adverse events. Overall, three RCTs met the inclusion criteria and exhibited a low risk of bias. The doses in the combination pill ranged from 2.5 to 5 mg of amlodipine, 20 to 80 mg of telmisartan, and 4.167 to 25 mg of chlorthalidone. Control groups varied, including usual care, amlodipine 10 mg, and dual therapy of telmisartan and amlodipine. Results showed significant reductions in mean sitting systolic and diastolic BP, improved BP control and response rates, and a generally safe profile with no significant differences in serious adverse events. Despite encouraging data, results should be interpreted with caution due to heterogeneity in doses and control groups. Further research should address the long-term effects and explore predictors of response to this therapy.

Характеристика факторів серцево-судинного ризику в пацієнтів з артеріальною гіпертензією, які приймають подвійну комбінацію антигіпертензивних препаратів: результати дослідження ФАКТОР-дуо

The aim – to study the characteristics of cardiovascular risk factors, the structure and effectiveness of treatment in hypertensive patients (pts) on the background of a dual combination of antihypertensive drugs, to evaluate the efficacy and tolerability of calcium channel blockers (CCB) (amlodipine and lercanidipine) when added to the combination of renin-angiotensin-aldosterone system (RAAS) inhibitor with a diuretic.Materials and methods. A multicenter study with 1616 hypertensive pts who received dual combination antihypertensive therapy. Cardiovascular risk factors were studied (smoking status, alcohol consumption, physical activity, family history of cardiovascular disease), concomitant cardiovascular diseases, carbohydrate metabolism disorders, and body mass index were determined, and current antihypertensive therapy and its effectiveness were evaluated based on office blood pressure (BP) measurements. Amlodipine 5-10 mg/day or lercanidipine 10–20 mg/day was added to the combination of RAAS blocker with a diuretic in the case of office BP ≥ 140/90 mm Hg. 1198 hypertensive pts received triple combined therapy. The effectiveness and tolerability of the treatment were evaluated after 4 weeks according to data from office BP measurements and home BP monitoring (HBPM). Lercanidipine was taken by 76 % of pts and amlodipine was taken by 24 % of pts.Results and discussion. Hypertensive pts were characterized by a significant prevalence of obesity (38.6 %), smoking (27.9 %), and insufficient physical activity (31.2 %). A significantly higher percentage of smoking and alcohol consumption was registered among men, while a lower level of physical activity was registered among women. Concomitant type 2 diabetes was present in almost a quarter of pts, stroke/TIA in 8.7 %, and myocardial infarction/revascularization in 8.3 %. At the same time, 53.2 % of the pts received statin therapy, and 64.7 % received antiplatelet drugs.Conclusions. The addition of CCB contributed to office BP target achievement in 69.1 % of pts, and optimal BP according to HBPM data in 54.3 % of pts. Lercanidipine and amlodipine have demonstrated comparable antihypertensive efficacy. Lercanidipine demonstrated a better tolerability profile compared to amlodipine: the incidence of side effects was significantly lower, respectively, 3.6 vs. 12.3 %; edema of the lower legs occurred in 6.5 times more often under amlodipine treatment than lercanidipine.

Effectiveness of an intervention to improve screening and treatment management of hypertension at the Commune Health Stations, Cao Bang province in 2021 – 2022

The study aimed to evaluate the effectiveness of interventions in screening and treatment management of hypertension at commune health stations (CHSs) in Cao Bang province in 2021- 2022. All 161 CHSs in Cao Bang province were selected for the study. The intervention package was developed based on the needs of CHSs in Cao Bang, including i) conducting advocacy workshops to support and remove barriers that affect activities on screening and treatment management of hypertension at CHSs; ii) providing capacity building for commune health workers, village health worker through hand-on training and supportive supervision; iii) providing CHSs with essential equipment; and iv) using software to support the management of data on hypertension screening and treatment management. Data were collected through self administered questionnaires filled by CHSs, and extracted from the management software. The effectiveness of the intervention was analyzed based on a comparison of pre and post-intervention outcomes. Results showed that the rate of CHSs implementing screening for hypertension increased from 27.3% to 95.0%. The rate of CHSs conducting treatment management also increased from 69.6% to 96.9%. The proportion of people screened for hypertension increased from 31.8% to 86.0%. The average number of hypertensive people who received treatment management at CHSs increased from 3.0 to 54.2 people. Additionally, the rate of patients achieving target blood pressure increased by 10.4% (64.4% compared to 54.0%). The results showed that the intervention package was effective and suitable for CHSs, and it should be replicated in other provinces.

Exploring patient-, provider-, and health facility-level determinants of blood pressure among patients with hypertension: A multicenter study in Ghana.

Optimal blood pressure (BP) control is essential in averting cardiovascular disease and associated complications, yet multiple factors influence the achievement of BP targets. We explored patient-, provider-, and health facility-level factors of systolic and diastolic BP and controlled BP status among patients with hypertension in Ghana. Using a cross-sectional design, we recruited 15 health facilities, and from each facility, we recruited four healthcare providers involved in managing hypertension and 15 patients diagnosed with hypertension. The primary outcome of interest was systolic and diastolic BP; the secondary outcome was BP control (<140/90 mmHg) in compliance with Ghana's national standard treatment guidelines. We used mixed-effects regression models to explore the patient- and facility-level predictors of the outcomes. Two hundred twenty-four patients and 67 healthcare providers were sampled across 15 health facilities. The mean (SD) age of providers and patients was 32 (7) and 61 (13) years, respectively. Most (182 [81%]) of the patient participants were female, and almost half (109 [49%]) had controlled BP. At the patient level, traveling for 30 minutes to one hour to the health facility was associated with higher diastolic BP (Coeff.:3.75, 95% CI: 0.12, 7.38) and lower odds of BP control (OR: 0.51, 95% CI: 0.28, 0.92) compared to traveling for less than 30 minutes. Receiving hypertension care at government health facilities than at private health facilities was associated with lower systolic BP (Coeff.: -13.89; 95% CI: -23.99, -3.79). A higher patient-to-physician or physician-assistant ratio was associated with elevated systolic BP (Coeff.: 21.34; 95% CI: 8.94, 33.74) and lower odds of controlled BP (OR: 0.19, 95% CI: 0.05, 0.72). Along with addressing the patient-level factors influencing BP outcomes in Ghana, there is a need for public health and policy interventions addressing the inaccessibility of hypertension services, the shortage of clinical care providers, and the underperformance of private health facilities.

Efficacy of combined antihypertensive therapy in patients with type 2 diabetes mellitus and non-alcoholic fatty liver disease with various polymorphisms of the CYP2C9 gene

Background. The difficulty of achieving target blood pressure (BP) levels in patients with arterial hypertension (AH) is often due to their type 2 diabetes mellitus (T2DM) and non-alcoholic fatty liver disease (NAFLD). In turn, taking into account the individual genetic characteristics of the body helps to personalize treatment and make it more effective. Aim. To compare the antihypertensive efficacy of a fixed combination of amlodipine and olmesartan medoxomil (Aml/Ol-M) in patients with hypertension and T2DM, with and without NAFLD, depending on the polymorphism of the CYP2C9 gene. Materials and methods. The study included 139 patients with uncontrolled hypertension and concomitant T2DM; after diagnosis of NAFLD, they were randomized into 2 groups: without NAFLD (group 1, n=70), with NAFLD (group 2, n = 69). After discontinuation of previous ineffective antihypertensive therapy, they were prescribed a combination of Aml/Ol-M in doses of 5-10/20-40 mg/day. At baseline, 4, 8, 12 and 24 weeks, their office BP levels were determined; Also, at the initial visit and after 24 weeks of treatment, the main indicators of 24-hour blood pressure monitoring (ABPM) were measured. Patients who did not reach the blood pressure target within 12 weeks of therapy were excluded from the study. Those who continued to participate in the amplifierThe Rotor Gene-Q allele discrimination method revealed the following distribution of polymorphic variants of the CYP2C9 gene: *1/*1 was found in 52 and 47, *1/*2 – in 6 and 5, *1/*3 – in 5 and 6 subjects, for groups 1 and 2, respectively. Results. The initial levels of office BP values were significantly higher in patients of group 2 and amounted to 153,5 mm Hg for systolic and 93 mm Hg for diastolic blood pressure, compared with 145 mm Hg and 88 mm Hg those included in group 1. After 12 weeks of therapy, the achievement of target blood pressure was registered in 63 (90 %) patients of group 1 and in 58 (84,1 %) of group 2. After 24 weeks of observation, in both groups a beneficial effect of the studied combination of drugs on all indicators of ABPM was noted, but a more pronounced improvement was noted in patients with NAFLD. Along with this, significant improvements in daily blood pressure profiles were registered in both groups 1 and 2: an increase in the number of patients with the “dipper” profile and a decrease in the number of patients with the pathological “non-dipper” profile. The antihypertensive effectiveness of Aml/Ol-M has been demonstrated for all isolated allelic variants of the CYP2C9 gene. Conclusions. A 24-week study with the use of Aml/Ol-M demonstrated a high incidence of achieving office BP target values in patients with hypertension and T2DM, with and without NAFLD. However, a more pronounced decrease in ABPM levels was found in patients with NAFLD. Carriage of any of the identified polymorphic gene variantsCYP2C9 had no effect on the clinical effects of the studied combination.

When Hypertension Gets On One’s Nerves: Has The Time Come For Renal Denervation?

For centuries, hypertension (HTN) has been a major cause of cardiovascular morbidity and mortality. Even now in 2024, despite all the advances in its understanding, adequate diagnosis and treatment of HTN globally is still sorely lacking. In a 2022 publication it is estimated that as much as 54% of hypertensive patients worldwide are undiagnosed. 42% of the hypertensive patients are both diagnosed and treated, yet only 21% of all hypertensive patients have blood pressure (BP) under control(1). Obviously, on a global scale there are way too many factors and variables that need to be addressed. Yet as practicing clinical physicians we are left to do what we can for the patients we encounter. Assuming there is a program in place to ensure compliance and follow-up, it is estimated that 82% of patients can achieve target BP(2). By simple calculation however, that also means nearly 20% of compliant patients will still not achieve target BP levels despite adequate medical treatment. And amongst those who do, around 20% would be on 3 or 4 anti hypertensive agents(3). This then begs the question… what else can we do for these difficult-to control patients? Renal denervation (RDN) was heralded into the limelight by the SYMPLICITY HTN-1(4) trial which showed RDN provided significant benefit to ambulatory BP readings on follow-up. At that time, RDN seemed poised to achieve a breakthrough in the management of HTN by offering difficult to-control patients another alternative to an ever-increasing number of medications. The RDN train however got derailed when several sham-controlled trials revealed little to no benefit with RDN treated patients compared to control(5,6,7,8). It was not until the second generation RDN technology came around and until RDN technique became much more refined that RDN plus medical therapy was proven to be clearly superior to medical therapy alone. The overall consensus now is that RDN can now provide the same benefits as adding another anti-hypertensive agent(9). And because of this, something that was heretofore unforeseen also occurred. RDN has somehow slowly moved past recommendation guidelines, and has become a therapy of choice for several patient subsets. In more developed countries, a good number of patients who have undergone RDN are those who asked for it. These patients are those who find it difficult to be compliant with medications, patients who are younger, of male gender, have higher ambulatory BP readings, those with concomitant heart failure and those who have numerous side effects from medical treatment for HTN(10). In some countries therefore, it is gradually becoming as mainstream as adding another medicine. As with any new technology, in our local Philippine setting the main barrier is cost. In patients in whom this is not an issue however, it seems the RDN floodgates are about to be opened. And if RDN trends in other countries are any indication, it is only a matter of time before RDN becomes standard therapy for the Philippine hypertensive patient. This consensus statement on RDN therapy by the 2023 Philippine Working Group published by Oliva et al (this issue) highlights what RDN is all about, its indications as well as the subsets of patients that are candidates for RDN. By its mere publication, it serves other purposes. It helps increase awareness about RDN’s availability, and lends more steam to the local RDN locomotive. Next stop? Better and more consistent BP control for the Filipino hypertensive patient!

Shop-to-Stop Hypertension: A multicenter cluster-randomized controlled trial protocol to improve screening and text message follow-up of adults with high blood pressure at health kiosks in hardware retail stores

High blood pressure (BP) is the leading preventable risk factor for death, but only one in three patients achieve target BP control. A key contributor to this problem is poor population awareness of high BP, as the majority of patients are asymptomatic. The Shop-To-Stop Hypertension study is a multicenter, cluster-randomized controlled trial to identify, refer and follow adults in need of hypertension care, whilst raising population-wide awareness. In participants with high BP measured by SiSU Health Stations located in major hardware chain stores across New South Wales, Australia, we will determine whether text message-based nudges will encourage repeat BP checks and visits to their doctor. Based on pilot data, we anticipate 65,340 participants will be screened over 12 months, of which 18% will have high BP. Thirty hardware stores will be randomized (1:1) to: (i) Intervention: participants detected with high BP (≥140/≥90 mmHg) will receive text message-based nudges to return for a repeat SiSU Health Station BP check and to visit their general practitioner (GP) to check and manage their BP; (ii) Control: participants with high BP will not receive text messages. The primary outcome is the difference in the proportion of participants with high BP having a repeat BP check at hardware Health Stations in the intervention vs. control group at 12 months. This novel setting for screening utilises a novel ‘citizen science’ approach inviting the general public to perform their own BP screening at health kiosks and foster behavioral change. This will allow screening in a low-stress environment.

Combination therapy for hypertension management: insights from the Indian experts

Cardiovascular diseases (CVDs) pose a significant global health challenge, with India bearing a disproportionate burden of CVD-related morbidity and mortality. Hypertension (HTN) is a major risk factor for CVDs, affecting nearly 30% of the Indian population. Achieving target blood pressure (BP) levels is crucial for reducing cardiovascular risk, necessitating aggressive antihypertensive therapy. Combination therapy has emerged as a cornerstone in HTN management, especially in high-risk patients. This review delves into the literature and perspectives of Indian cardiologists on combination therapy for HTN management. Despite the efficacy of contemporary antihypertensive medications, a substantial proportion of patients fail to reach target BP levels with monotherapy. Combination therapy offers synergistic effects, addressing multiple pathways involved in HTN pathogenesis. Recent guidelines recommend initiating treatment with two-drug combinations, transitioning to three-drug combinations in resistant cases. Combination therapy not only enhances BP control but also reduces the risk of cardiovascular events and mortality compared to monotherapy. Optimal management of HTN requires personalized approaches, considering individual patient profiles and comorbidities such as coronary artery disease (CAD), diabetes mellitus (DM), dyslipidemia, and heart failure (HF). In such cases, combination therapy plays a pivotal role in mitigating cardiovascular risks. ARB/CCB combination therapy, particularly telmisartan/amlodipine, demonstrates significant efficacy and tolerability across various patient populations, including those with metabolic risk factors and renal impairment. Expert recommendations highlight the importance of individualized therapy, patient education, early diagnosis, and initiation with dual therapy in India. Strategies to improve medication adherence and compliance, such as single-pill double or triple combinations, are emphasized. Moreover, awareness of newer treatment options and contactless diagnostic instruments is crucial for optimizing HTN management. In conclusion, combination therapy stands as a cornerstone in HTN management, offering enhanced efficacy, tolerability, and cardiovascular protection. Tailored approaches guided by expert recommendations are essential to address the growing burden of HTN and reduce the socioeconomic impact of CVDs in India.

RESULTS OF BLOOD PRESSURE SCREENING IN PEOPLE 18 YEARS AND OLDER IN NGHE AN: A CROSS-SECTIONAL STUDY IN 5 YEARS FROM 2016-2020

Aim: Determine the rate of hypertension, the proportion of hypertensive people taking medication, the proportion of people taking antihypertensive medication to achieve the target and the proportion of people who were measured the blood pressure in the last 12 months. Subjects and methods: People at the age of 18 years and older, including both sexes, including people with blood pressure. The total number of people having screening test accounts for 12303 people. All patients were allowed to have a rest at least 5 minutes before the measurement, then they have their blood pressure measured in a sitting position, measured 3 times with one-minute observation interval. The measuring room is airy and has an ambient temperature of 300 C. The person doing the measurement is a final-year student and the nurses are thoroughly trained in how to measure and record data. Results: The overall prevalence of hypertension in the study population was 31.4%. The rate of grade I hypertension accounts for 82.1%. The rate of isolated systolic hypertension is 43.7%. The rate of people with treated hypertension is 40.8%. Percentage of people with the target blood pressure over the total number of hypertensive people is 29.7%. Percentage of hypertensive people taking medication with the target blood pressure is 72.9%. The proportion of people who were not measured the blood pressure in the last 12 months is up to 60.4%. Conclusion: nearly 1/3 of the population aged 18 years and older has hypertension. The proportion of people using medication to treat hypertension is low (40.8%). The rate of achieving target blood pressure among people with hypertension is still low.

COMPARATIVE EFFECTIVENESS OF FREE AND FIXED COMBINED ANTIHYPERTENSIVE THERAPY IN ACHIEVING TARGET BLOOD PRESSURE VALUES IN UNCONTROLLED ARTERIAL HYPERTENSION

Objective: Aim of our study was to assess the achievement of target blood pressure in uncontrolled hypertensive patients with high and very high-risk, resistant to double AHT, depending on the treatment regimen - free and fixed combinations of three antihypertensive drugs. Design and method: The study included 143 patients II-III AH stage, who were on double AHT, who are not reached the target blood pressure level. The average age of patients was 55.8±9.35 years, including men n=70 (49%), women n=73 (51%). All patients underwent a physical examination with three measurements of office blood pressure using the Korotkoff method. Patients were randomized into 2 groups: group 1- triple antihypertensive therapy with a free combination of indapamide, amlodipine, and perindopril (n=71), and 2 nd group- a fixed combination therapy (n=72). Statistics were carried out between the stages before treatment and 6 months. Results: Research results. Against the background of triple AHT, target blood pressure levels were achieved in both groups: in group 1, initial SBP/DBP before treatment was 171.29±16.6 mmHg/99.64±9.03 mmHg, in dynamics 128.38±8.5 mmHg/80.89±6.38 mmHg. (p=0.0001); in group 2: initially SBP/DBP before treatment 170.76±17.75 mmHg/100.63±8.39 mmHg, 6 months of therapy 121.95±6.7 mmHg st./77.23±5.59 mmHg (p=0.0001). The results showed a significant decrease in SBP (p=0.0001) and DBP (p=0.0001) in group 2 compared to group 1. At the same time, the primary target level in group 1 was achieved in 83.3%, in group 2 in 94.4% of patients (χ2 = 7.471; p = 0.006). The target blood pressure level &lt;130/80 according to SBP was achieved by 42% and 67% of patients, respectively, for groups 1 and 2 (χ2=11.61; p=0.0001); for DBP – 10% and 33.3%, respectively, for groups 1 and 2 (χ2=9.011; p=0.003). Conclusions: Obtained results showed the high antihypertensive effectiveness of 6-month AHT with a triple fixed combination therapy compared to free, achieving the primary target blood pressure level and the main target blood pressure level in a significantly larger number of patients with hypertension on a triple fixed combination of antihypertensive drugs.

OBSTRUCTIVE SLEEP APNEA AND TARGET BP VALUE IN NON-OBESE HYPERTENSIVE PATIENTS

Objective: To assess obstructive sleep apnea impact on the target blood pressure (BP) value achievement in non-obese hypertensive patients. Design and method: In this prospective cross-sectional study were included 305 patients (mean age 60.0 years old [48.0; 67.0], 203 men) with different stages and grades of arterial hypertension (AH). All patients have been receiving antihypertension therapy, prescribed by their cardiologist, for at least 3 weeks before inclusion in the study. During the study, office systolic and dyastolic blood pressure (SBP and DBP resp.) were assessed (oscillometric method, Omron, Japan) and home sleep respiratory monitoring (SomnoChek, Weinmann, Germany) was done in all patients. Results: Two groups were formed: non-target BP group (BP&gt;140/90 mm Hg, n=164) and target BP group (BP&lt;140/90 mm Hg, n=141). Comparative data analysis included such indicators as: age, body mass index (BMI), apnea/hypopnea index (AHI), desaturation index (DI) and minimum oxygen saturation (min SaO2), revealed only differences between age (61.0 years old [50.0; 68.0] versus 57.0 years old [47.0; 66.0] resp., p=0.03) and BMI (32.5 kg/m2 [29.7; 38.1] vs. 31.6 kg/m2 [27.8; 35.5] resp., p=0.02). The analysis of non-obese patients’ data (BMI &lt;30 kg/m2, n=100) didn’t reveal differences by age, but a higher value of AHI and DI were determined in patients with non-target BP, as well as higher BMI; similar differences were not found in obese patients (BMI&gt;30 kg/m2, n=205) (Table 1). In two-factor logistic regression analysis (included AHI and BMI) AHI was the only predictor of non-target BP in patients without obesity, while BMI had no predictive value (Table 2). Conclusions: Even mild or moderate obstructive sleep apnea may be an important negative factor in achieving BP targets in non-obese patients, unlike the other clinical cases with AH.

FOLLOW-UP OF SURVIVAL PATIENTS WITH RESISTANT ARTERIAL HYPERTENSION

Objective: Resistant arterial hypertension (RAH) contributes to high mortality worldwide. Aim of the study: to assess 7-year follow-up survival and development of a composite end point (CEP) in patients with RAH. Design and method: The analysis includes 50 patients with RAH who were discharged from hospital. After 7 years discharge from the hospital, the patients underwent office BP measurement. Adverse events or death were reported as the composite endpoint (CEP). The average age of patients as of 2016 was 57.89 ± 11.81 y.o. 16% had type 2 diabetes (n=8). Results: After 7 years, in 32% (n=16) developed CEP, and 10% (n=5) of them died. The BMI increased from 30.87 ± 6.30 to 33.80 ± 6.90 kg/m2 (p&lt;0.05). 20% had smoke (n=10), but 8% (n=4) (quit smoking after developing CEP). After 7 years, 48.88% of patients (n=22) controlled office blood pressure below 140/90 mmHg and 51.11% did not (n=23). Among patients who reached the target office BP (130.73 ± 6.61/81.59 ± 4.13 mmHg), there was a decrease in the number of drugs from 3.76 ± 0.19 to 2.85 ± 0.14, p&lt;0.05. 45% (n=10) from the group took fixed combinations. Among patients who did not reach target office BP (148.04 ± 7.49/92.17 ± 4.66 mmHg), there was also a decrease in the number of drugs from 3.52 ± 0.18 to 2.50 ± 0.13, p&lt;0.05 – patients decision. After regression analysis the main factors that were associated with the occurrence of CEP in patients with RAH were: the presence of diabetes (β= 5,237, p= 0,032) smoking (β=4,326, p= 0,037), increased body weight (β =3,423, p=0,024), failure to achieve target blood pressure levels (β =4,152, p=0,041) Conclusions: Mortality among patients with RAH were 10% during 7 years. The total composite endpoint were 32%. Did not reach the target office BP in patients with RAH the factors for the development of combined end point was diabetes mellitus, smoking and weight gain.