Adequate BP Control Research Articles

Clinical Effects of Torasemide Prolonged Release in Mild‐to‐Moderate Hypertension: A Randomized Noninferiority Trial Versus Torasemide Immediate Release

The efficacy of a new torasemide prolonged release (PR) formulation to torasemide immediate release (IR) was compared in a randomized noninferiority double-blind trial. Patients with newly diagnosed mild-to-moderate hypertension or unresponsive or poor tolerability to previous antihypertensive monotherapy received 5 mg/day of torasemide-PR (n = 219) or torasemide-IR (n = 223) for 12 weeks (uptitration to 10 mg/day if no response at 4 or 8 weeks). Mean diastolic blood pressure (DBP) reduction in the torasemide-PR group (11.6 +/- 7.1 mmHg, 95% confidence interval [CI] 10.6-12.5) versus torasemide-IR (11.3 +/- 7.5 mmHg, 95% CI 10.2-12.3) met the noninferiority criterion of a nonsided 97.5% CI lower than the preestablished margin of 2 mmHg. A significantly higher percentage of patients in the torasemide-PR group achieved adequate BP control after 8 and 12 weeks. Ambulatory 24-h BP monitoring (ABPM) measurements in a subset of 100 patients showed greater daytime SBP reductions in the torasemide-PR group (128.4 +/- 9.9 mmHg vs. 133.5 +/- 10.4 mmHg, P < 0.05). Safety and tolerability of both formulations were similar.

Los ciclos de mejora de calidad en la atención al paciente hipertenso: Ciclo-Risk Study

Fundamentos: Con frecuencia encontramos deficiencias en el manejo de los factores de riesgo en las personas hipertensas. El objetivo del estudio fue evaluar el efecto de una intervencion de mejora de calidad en la atencion a los factores de riesgo cardiovascular en personas hipertensas. Metodos: Estudio de mejora de calidad. Dos centros de salud y catorce medicos de familia. Un centro (siete medicos) se selecciono para recibir una intervencion de mejora de calidad y otro como grupo control. Se incluyo a 482 personas hipertensas en el grupo de estudio [64% mujeres, edad media 61,4 anos (DS:6.8)] y 360 en el grupo control (63% mujeres, edad media 60,7 (DS:7.4)). La intervencion consistio en una auditoria de historias clinicas con feedback, sesiones de entrenamiento y discusion de guias clinicas. Previamente a la intervencion y un ano despues de la misma se evaluaron criterios de proceso de atencion a personas hipertensas, presion arterial, peso, lipidos, tabaco, riesgo cardiovascular y farmacos antihipertensivos. Resultados: La mejora media en el proceso despues de la intervencion fue de 5,3 puntos porcentuales (CI95%:3,7-6,9). La presion arterial sistolica descendio 3,5 mmHg (IC95%:1,6-5,3) y la presion arterial diastolica 2,5 mmHg (IC95%:1,3-3,8). El control adecuado de la presion arterial se incremento en el grupo de intervencion (29,1% a 40,9%; p<0.01) y no hubo cambios en el grupo control. El riesgo cardiovascular descendio en el grupo de intervencion (15,86 a 14,34%, P<0.01) y en el grupo control no vario. El riesgo absoluto descendio 2,07(IC95%:1,21-2,93) y el relativo 0,25 puntos porcentuales (IC95%:0,14-0,35). Conclusiones: La intervencion fue efectiva en la mejora de calidad de atencion al proceso asistencial al haber descendido la presion arterial y el riesgo cardiovascular, tanto absoluto como relativo.

Establishing Sound Goals for Hypertension Management

There is a clear need to reduce the prevalence of hypertension and, therefore, cardiovascular risk, among Americans. Many are unaware they have elevated BP, less than half who have been diagnosed with hypertension are treated, and only a third of those treated reach recommended goals. While hypertension affects American men and women of many ethnicities, prevalences are notably increased among blacks and Hispanics. Merely adopting positive lifestyle changes that include more exercise, a healthy, low-sodium diet for weight reduction, and smoking cessation can significantly improve both systolic and diastolic BP When pharmacologic treatment is needed, several classes ofantihypertensive agents with differing mechanisms of action are available for use as monotherapy or in various combinations to help patients reach their BP goals. Often three or more antihypertensive drugs are necessary for adequate BP control; however, the antihypertensive regimen must be tailored to the individual patient. It is more meaningful to assess and understand the individual patient with hypertension in order to set realistic BP goals than to expect all patients to reach the same goal with a uniform therapeutic plan.

Does Knowledge Matter?

To examine predictors of intentional and unintentional nonadherence to antihypertensive medication regimens and their relationships to blood pressure outcomes. Although poor adherence to medical regimens is a major concern in the care of patients with high blood pressure (HBP), our understanding of the complex behavior related to adherence is limited. Moreover, few studies have been devoted to understanding adherence issues in ethnic minority groups, such as the interplay between cultural beliefs and HBP medication-taking behaviors. A cross-sectional analysis was performed to assess the factors affecting nonadherence to antihypertensive medication regimens. The data used in this analysis came from an ongoing HBP intervention trial involving middle-aged (40-64 years) Korean Americans with HBP. A total of 445 Korean Americans with HBP was enrolled in the trial at baseline. Of these, 208 participants who were on antihypertensive medication were included in the analysis. Using multivariate logistic regression, we examined theoretically selected variables to assess their relationships to intentional and unintentional nonadherence in this sample. Approximately 53.8% of the subjects endorsed 1 or more types of nonadherent behaviors. After controlling for demographic variables, multivariate analysis revealed that a greater number of side effects from the medication (adjusted odds ratio [OR], 1.19; 95% confidence interval [CI], 1.07 to 1.33) and a lower level of HBP knowledge (adjusted OR, 0.89; 95% CI, 0.79 to 0.99) were significantly associated with intentional nonadherence. Unintentional nonadherence was less strongly associated with the study variables examined in the analysis. Our findings indicate that intentional nonadherence to antihypertensive medication that stems from incomplete knowledge of HBP treatment is prevalent among middle-aged Korean Americans with HBP. The results highlight the strong need for an intervention that focuses on increasing patient knowledge about HBP, including the benefits and side effects of antihypertensive medication. This type of focused intervention may help reduce intentional nonadherence to antihypertensive medications and ultimately result in achieving adequate BP control in this high-risk group.

Efficacy and Tolerability of Olmesartan Medoxomil in Patients??with Mild to Moderate Essential Hypertension

Achieving target BP is important to control the increased cardiovascular risk associated with uncontrolled hypertension. However, failure to respond to therapy is common with all classes of antihypertensive agents. Angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) possess many of the positive features of angiotensin-converting enzyme inhibitors, with fewer adverse effects. However, many patients fail to respond adequately to low-dose monotherapy. This study examined whether olmesartan medoxomil dose titration and olmesartan medoxomil/hydrochlorothiazide combination therapy were therapeutically equivalent in patients with mild to moderate essential hypertension who had shown an inadequate response to low-dose olmesartan medoxomil monotherapy. This was a prospective, parallel group, partially randomised, double-blind study set in 463 centres in nine European countries. 2306 male and female adult patients aged 18-75 years with mild to moderate essential hypertension (sitting diastolic BP [DBP] > or =90mm Hg and <110mm Hg) were enrolled. All enrolled patients received open-label olmesartan medoxomil 20mg once daily for 8 weeks. At the end of this period, patients whose BP had not normalised (sitting DBP > or =90mm Hg) were randomised to receive olmesartan medoxomil monotherapy (40mg once daily, n = 302) or olmesartan medoxomil (20mg once daily)/hydrochlorothiazide (12.5mg once daily) combination therapy (n = 325) for 4 weeks. The main outcome measure was change in mean sitting DBP during randomised treatment. After 8 weeks of open-label treatment with olmesartan medoxomil 20 mg/day, 76% of patients showed a DBP response (sitting DBP <90mm Hg or reduction of > or =10mm Hg). During the randomised phase of the study, both treatments were associated with further improvements in sitting SBP/DBP: a reduction of 5.3/5.1mm Hg with olmesartan medoxomil 40 mg/day, and a reduction of 10.8/7.9mm Hg with olmesartan medoxomil/hydrochlorothiazide combination therapy. Final mean BPs of 145.3/90.9mm Hg (olmesartan medoxomil 40 mg/day) and 140.7/88.7mm Hg (olmesartan medoxomil 20mg + hydrochlorothiazide) were achieved, compared with a mean BP of 160.8/100.5mm Hg at baseline. The two treatments were not therapeutically equivalent. Sitting DBP showed a response and was normalised (<90mm Hg) in 62% and 47% of olmesartan medoxomil monotherapy patients, respectively. In the combination therapy group, these endpoints were achieved by 71% (response) and 59% (normalisation) of patients. Treatment with olmesartan medoxomil 40 mg/day was associated with a lower frequency of adverse events than olmesartan medoxomil/hydrochlorothiazide combination therapy (21.5% vs 28.3%, respectively). For patients who did not achieve adequate BP control after initial treatment with olmesartan medoxomil 20 mg/day, olmesartan medoxomil dose titration (to 40 mg/day) or addition of hydrochlorothiazide (12.5 mg/day) elicited a sitting DBP response in the majority of patients who had failed to respond to low-dose monotherapy, and normalisation of sitting DBP in approximately 50% of patients. Both these strategies represent effective and well tolerated treatment options in patients who show an inadequate response to low-dose monotherapy with olmesartan medoxomil.

Diagnosis and Management of Ischemic Nephropathy

Analysis of the Third National Health and Nutrition Examination Survey (1988 to 1994) suggests that chronic kidney disease (CKD) is a major public health problem (1). Approximately 11% of the US population has CKD. Roughly half have a GFR <60 ml/min per 1.73 m2 with or without kidney damage (stages 3 to 4), and half have exclusively kidney damage as manifested by microalbuminuria (stages 1 to 2) (2). It is widely recognized that the prevalence of stage 5 CKD is also increasing at a rapid rate, and it is estimated that the number of patients who have ESRD may reach 2.24 million by 2030 (3). Evidence to establish reduced GFR as an independent risk factor for cardiovascular disease (CVD) mortality has emerged. Analysis of data from several population-based epidemiologic studies (4,5) demonstrates poorer outcomes regarding stroke, myocardial infarction, and congestive heart failure (CHF) in patients with even mild compromise of kidney function. The morbidity of this group of patients constitutes an economic burden both directly in terms of resource utilization and indirectly through loss of productivity and impaired quality of life (2). Atherosclerotic renovascular disease (ARVD) can result in renovascular hypertension. However, ARVD is an increasingly recognized cause of CKD (6,7). In this article, we focus mainly on ARVD or renal artery stenosis (RAS) secondary to atherosclerosis as a cause of ischemic nephropathy. ARVD is a disease of aging, and several studies have shown its strong association with extrarenal atherosclerotic disease (8–10). Patients with ARVD seem to be at a much greater risk for cardiovascular death than for progressing to renal replacement therapy (11). Whether renal revascularization can benefit renal and cardiovascular outcomes has not been established. Atherosclerosis is the cause of approximately 90% of RAS in adults who are older …

A clinical classification of hypertension

A clinical classification of hypertension

Calcium Channel Blockers and Renal Protection

Calcium channel blockers have been widely used in clinical practice because of their antihypertensive capacity. Prevention of renal damage is a very important aim of antihypertensive therapy. This is particularly so taking into account the high prevalence of chronic kidney disease (CKD) in the general population. Recent data have shown that CKD is related to the absence of adequate BP control and also to the clustering of other cardiovascular risk factors seen in the metabolic syndrome. The knowledge of the capacities of the different antihypertensive drugs or their combinations to simultaneously control BP while protecting the kidney and avoiding the facilitation of metabolic alterations is warranted. Recent data from the Intervention as a Goal in Hypertension Treatment trial, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, and African American Study of Kidney Disease and Hypertension (AASK) allow the conclusion that in hypertensive patients with preserved renal function or with CKD, calcium channel blockers are effective antihypertensive drugs to be considered alone or in combination with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker.

Stroke prevention 2003: are we any closer to adequate blood pressure control?

Background: Hypertension (HTN) remains the strongest modifiable risk factor for stroke. The objective of this study was to assess the utility of a Stroke Screening Tool (SST) for detection of HTN at Community Education Fairs (CEF). Methods: Three RNs gave the SST to volunteer participants (VP) at CEF in Southeastern Wisconsin from 2002–2003. SST included assessment of BP and past medical and family history (HX). BP was divided into groups according to the JNC 7 guidelines. Demographic data, BP, frequency, and means were reported. Results: One hundred thirty-one VP with mean age of 52.5 ± 1.4 (mean ± SE) were included. Seventy-five percent were females, 20% were African Americans, and 63% had a self-reported history of HTN (SRHH). Using SST, 39% fulfilled the JNC-7 HTN criteria. The probability of detecting HTN was 64%. Mean systolic blood pressure (SBP) of VP with SRHH was significantly higher (143.2 ± 2.6 v 129.2 ± 1.9) than VP without SRHH. No difference in diastolic BP was found. Of VP with SBP > 160 mm Hg, 69% had SRHH and 31% did not report HX of HTN. Those with SRHH, 63% had SBP > 140 mm Hg. In VP without SRHH, 25% had HTN. Conclusion: HTN and PMH screening in CEF remains a useful method to assess stroke risk factors. However, this study suggests that VP with HX of HTN are poorly treated despite educational efforts. Prevention programs should emphasize current BP guidelines and the importance of adequate BP control.

Barriers to hypertension care and control in young urban black men

Barriers to high blood pressure (HBP) care and control have been reported in the literature for > 30 years. Few reports on barriers, however, have focused on the young black man with HBP, the age/sex/race group with the highest rates of early severe and complicated HBP and the lowest rates of awareness, treatment, and control. In a randomized clinical trial of comprehensive care for hypertensive young urban black men, factors potentially associated with care and control were assessed at baseline for the 309 enrolled men. A majority of the men encountered a variety of barriers including economic, social, and lifestyle obstacles to adequate BP care and control, including no current HBP care (49%), risk of alcoholism (62%), use of illicit drugs (45%), social isolation (47%), unemployment (40%), and lack of health insurance (51%). Having health insurance (odds ratio = 7.20, P = .00) and a negative urine drug screen (odds ratio = .56, P = .04) were significant predictors of being in HBP care. Low alcoholism risk and employment were identified as significant predictors of compliance with HBP medication-taking behavior. Men currently using illicit drugs were 2.64 times less likely to have controlled BP compared with their counterparts who did not use illicit drugs, and men currently taking HBP medication were 63 times more likely have controlled BP compared with men not taking HBP medication. Comprehensive interventions are needed to address socioeconomic and lifestyle issues as well as other barriers to care and treatment, if HBP care is to be salient and effective in this high risk group.

Detection and treatment of hypertension in patients with non-insulin-dependent diabetes mellitus:: Does the `rule of halves' apply to a diabetic population?

The extent to which hypertension is detected and adequately treated in the general population is often described by the `rule of halves', but corresponding figures for patients with non-insulin-dependent diabetes mellitus (NIDDM), based on current American Diabetes Association (ADA) criteria, have not been previously reported. This study looked at the detection and management of hypertension among 2331 consecutive patients with NIDDM attending for annual complications assessment. Hypertension was defined according to ADA criteria, i.e. systolic blood pressure (sBP) >140 mmHg and/or diastolic blood pressure (dBP) >90 mmHg. A total of 69% of patients were hypertensive, with proportionately more women in the hypertensive group (48 versus 39%, P<0.002). Among those with hypertension, 59% were taking antihypertensive drugs but only 31% of treated hypertensives were adequately controlled. Thus, hypertension affects roughly two-thirds of patients with NIDDM and compared with treatment strategies reported in the literature for the non-diabetic population (summarised in the `rule of halves'), proportionately more hypertensive patients with NIDDM are treated with BP-lowering drugs (59%) but proportionately less (31%) have adequate BP control.

Monotherapy with the calcium channel antagonist nisoldipine for systemic hypertension and comparison with diuretic drugs

A comparative, double-blind, placebo-controlled, double-dummy, randomized, crossover trial was performed in 32 hypertensive patients (initial blood pressure [BP] 165 105 ± sol3 2 mm Hg ), most of them obese women, to evaluate the antihypertensive efficacy and tolerability of the new calcium channel blocking drug nisoldipine, 10 mg once or twice daily, over 6 weeks compared with the diuretic hydrochlorothiazide-amiloride (hydrochlorothiazide, 25 mg, in combination with amiloride, 2.5 mg once or twice daily). Adequate 24-hour control of BP (supine diastolic BP less than 90 mm Hg) was achieved in 15 of 32 patients (47%) with monotherapy by 1 agent and in 23 of 32 patients (72%) when including those who responded to either agent. Both nisoldipine and the diuretic had a flat dose-response curve. The larger dose of diuretic yielded lower systolic and exercise BP values (erect and supine) than high-dose nisoldipine (p < 0.05), with less headache (p < 0.05). In the other 9 patients who did not respond, the combination of nisoldipine 10 mg plus hydrochlorothiazide (25 mg)-amiloride (2.5 mg) was administered and yielded a response in 8 patients (overall response including monotherapy 96%). Ten patients were given nisoldipine for an additional period of 6 months, and they required an average dose of 33 mg/day for BP control. In both the 6-week and 6-month studies, nisoldipine monotherapy caused frequent subjective adverse effects. In contrast, in the 6-week study the combination of low-dose nisoldipine and low-dose diuretic gave good BP control with no adverse effects.

Adequate Control of BP is Achieved on Nitrendipine Monotherapy

Adequate Control of BP is Achieved on Nitrendipine Monotherapy

Propranolol given twice daily in hypertension.

Abstract.Two small series of hypertensive patients are accounted for. They were treated with propranolol orally twice daily instead of the common administration of 3–4 doses a day. In the first series of 10 patients on a 2‐dose regimen the maintenance of blood pressure control was tested by repeated BP measurements. No significant changes of BP were recorded during a 10‐hour observation period after the morning dose. Sublingual application of nitroglycerine in order to test the degree of adrenergic β‐receptor blockade did not show a significant increase of the pulse rate at the end of the observation period. The second series consisted of 39 previously untreated patients with mild to moderate hypertension. Propranolol given twice daily gave adequate BP control (&lt;170/&lt;100) in 32 patients, while 7 had to be given additional hydralazine. In 6 of the latter the maximum propranolol dose did not exceed 400 mg daily. The side‐effects were few and their frequency did not seem to be influenced by the 2‐dose regimen.