Antihypertensive Prescription Research Articles

Testing interventions to reduce clinical inertia in the treatment of hypertension: rationale and design of a pragmatic randomized controlled trial

Clinical inertia, or failure to intensify treatment when indicated, leads to suboptimal blood pressure control. Interventions to overcome inertia and increase antihypertensive prescribing have been modestly successful in part because their effectiveness varies based on characteristics of the provider, the patient, or the provider-patient interaction. Understanding for whom each intervention is most effective could help target interventions and thus increase their impact. This three-arm, randomized trial tests the effectiveness of 2 interventions to reduce clinical inertia in hypertension prescribing compared to usual care. Forty five primary care providers (PCPs) caring for patients with hypertension in need of treatment intensification completed baseline surveys that assessed behavioral traits and were randomized to one of three arms: 1) Pharmacist e-consult, in which a clinical pharmacist provided patient-specific recommendations for hypertension medication management to PCPs in advance of upcoming visits, 2) Social norming dashboards that displayed PCP's hypertension control rates compared to those of their peers, or 3) Usual care (no intervention). The primary outcome was the rate of intensification of hypertension treatment. We will compare this outcome between study arms and then evaluate the association between characteristics of providers, patients, their clinical interactions, and intervention responsiveness. Forty-five primary care providers were enrolled and randomized: 16 providers and 173 patients in the social norming dashboards arm, 15 providers and 143 patients in the pharmacist e-consult arm, and 14 providers and 150 patients in the usual care arm. On average, the mean patient age was 64 years, 47% were female, and 73% were white. Baseline demographic and clinical characteristics of patients were similar across arms, with the exception of more Hispanic patients in the usual care arm and fewest in the pharmacist e-consult arm. This study can help identify interventions to reduce inertia in hypertension care and potentially identify the characteristics of patients, providers, or patient-provider interactions to understand for whom each intervention would be most beneficial. Clinicaltrials.gov (NCT, Registered: NCT04603560).

Efficacy and safety aspects of renal denervation in treatment of arterial hypertension: a systematic review and meta-analysis

Abstract Introduction Current guidelines for the management of arterial hypertension 2018 of European Society for Cardiology (ESC) do not recommend use of renal denervation (RDN) (as device-based therapy) for treatment of hypertension except as part of clinical studies. However, in the meantime several randomized sham-controlled clinical trials were designed using second generation radiofrequency (RF) (SPYRAL HTN-OFF MED, SPYRAL HTN-ON MED), ultrasound (RADIANCE-HTN SOLO, RADIANCE-HTN TRIO) or alcohol-mediated renal denervation (TARGET BP-OFF) devices. We aimed to perform a comprehensive meta-analysis from all published and unpublished randomized, sham-controlled clinical trials which explored the effects of renal denervation on blood pressure across different devices. Methods We searched MEDLINE and Embase via OVID@ for eligible trials. Of note, we also included unpublished data from the SPYRAL-ON Extension and TARGET BP OFF trials. Pooling the data from all studies, we explored the efficacy (ambulatory and office systolic and diastolic BP) and safety (all cause death, vascular complication, renal artery stenosis >70%, hypertensive crisis) of RDN. Results Analysis included 9 eligible trials (i.e. SYMPLICITY HTN-3, ReSET, SPYRAL HTN OFF MED, Desch et al., RADIANCE-HTN SOLO, RADIANCE-HTN TRIO, RADIANCE, TARGET BP OFF, SPYRAL HTN ON MED extension) comprising 2,091 patients (Table 1). RDN reduced ambulatory systolic (-3.10 mmHg, 95% CI -4.22, -1.97, p<0.00001) and office systolic (-5.15 mmHg, 95% CI -6.65, -3.66, p<0.00001) BP and ambulatory diastolic (-1.58 mmHg, 95% CI -2.54, -0.63, p=0.001) and office diastolic (-2.74 mmHg, 95% CI -3.65, -1.83, p<0.00001) BP compared with sham groups. There was no difference concerning ambulatory SBP reduction between trials with ON medication design (-2.94 mmHg, p<0.0001) and those with OFF medication design (-3.37 mmHg, p<0.0001) (p for interaction 0.69). Similarly, office SBP reduction was comparable between trials with (-4.38 mmHg, p<0.0001) and without concomitant antihypertensive drugs prescription (-6.27 mmHg, p<0.00001) (p for interaction 0.22). The rate of vascular complications (OR 1.21, 95% CI 0.28, 5.25, p=0.80), renal artery stenosis (OR 1.50, 95% CI 0.06, 36.97, p=0.80), hypertensive crisis (OR 1.39, 95% CI 0.50, 3.92, p=0.53) and all cause death (OR 0.52, 95% CI 0.10, 2.83, p=0.45) was not different between treatment and sham groups. Conclusions RDN is associated with clinically significant reductions in ambulatory and office SBP as compared with sham in the presence and absence of antihypertensive medication. The procedure use was not associated with an excess in safety events compared with sham group.

Abstract 13673: Effects of Bariatric Surgery on Blood Pressure Management in Type 2 Diabetes: Analysis From a Thirteen-Year Cohort Study

Introduction: Bariatric surgery (BS) is an effective intervention for both weight loss and improved metabolic health in those with Type 2 diabetes (T2D), yet there is limited data on its long-term effect on blood pressure (BP) control. Aim: This prospective cohort study aims to evaluate the long-term effect of BS on BP and metabolic health in T2D patients in a tertiary centre in North-West England. Methods: Patients who underwent BS (gastric bypass/sleeve gastrectomy) between 2009 - 2012 at a single tertiary surgical centre in North-West England were followed for up to 13 years. Preoperative and follow-up data including BP readings, HbA1c, BMI and antihypertensive medication use was obtained from electronic patient records at regular intervals to ascertain longitudinal outcomes in BP, BMI and HbA1c. Results: 119 patients were included in the study. Optimal metabolic health state was achieved at 12 months post-surgery for BMI (-14.78kg/m 2 (95%CI: 13.37-16.20, p<0.001)), systolic BP (sBP) (-15.02mmHg 95%CI: 8.23-21.81mmHg, p<0.001)), diastolic BP (dBP) (-8.1mmHg, 95%CI: 4.26-11.91, p<0.001)) and HbA1c (-24.41mmol/mol, 95%CI: 18.25-30.58, p<0.001). A sustained reduction in both sBP and dBP was maintained for up to 5 years, mirroring a reduction in concurrent use of antihypertensive medications (164 prescriptions v 66 at 5 years). However, at latest follow-up, there was an observed increase in antihypertensive prescription (95 v 66) yet there was no statistically significant change in mean BP. Furthermore, the number of patients with clinically diagnosed hypertension (BP 140/90 or more was lowest at 5 years (n=53 v 86 pre-op) before rising at the latest follow-up (n=57). Conclusions: Our study demonstrates that BS has a sustained benefit on BP as reflected by both absolute measurements and reduction in antihypertensive medication use. It remains an effective strategy not only for weight loss but also for the comprehensive management of metabolic comorbidities in T2D patients as evidenced by reductions in antihypertensive use, HbA1c, BMI and BP. However, more research is needed to explore the longer-term effects of these benefits at ≥ 10 years given the increases in antihypertensive use, BMI and HbA1c after this period.

White coat effect in patients with hypertension

The article is devoted to various aspects of white coat effect (WCE) in patients with hypertension (HTN). WCE is due to the patient’s anxious response to office blood pressure (BP) measurement and is characterized by a BP increase. In patients with HTN, WCE is detected with a high frequency. Pronounced WCE in hypertensive patients is associated with worsening the HTN course and the prognosis of all-cause and cardiovascular mortality. In addition, BP increase in these patients during a doctor’s visit may lead to additional prescription of antihypertensive drugs, increasing costs and side effects. To identify WCE, a large number of methods are used, which can be divided into following groups: I – data from clinical and daytime ambulatory blood pressure measurement, II – clinical and home BP assessment, III – only ambulatory BP measurement, IV – clinical and laboratory BP data, and V – only clinical BP measurement. There are following WCE in patients with HTN: female sex, age, never smoking, as well as anxiety, introversion, etc. WCE is due to the patient’s anxiety state during office BP measurement and a conditioned reflex BP increase associated both with the physician presence and medical background. Severe WCE in some groups of patients with HTN may be associated with a worse prognosis compared with other hypertensive patients as follows: in individuals with a significant difference between clinical and ambulatory blood pressure levels or between the first and third BP office data, with a combination of resistant HTN and WCE, with WCE increasing from visit to visit, etc.

From guidelines to current practices: Suboptimal hypertension management in France

In France, the prevalence of hypertension is higher than 30%. Although treatment guidelines have been well established over the last twenty years, the national blood pressure control rate is below the average of high-income countries. This observational study aimed to describe the antihypertensive prescription behaviours of primary care physicians (PCPs) in France and to assess their compliance with current French guidelines, focusing on three specific prescription issues and their potential repercussions on blood pressure control: treatment initiation, treatment renewal or change and type of triple therapy. Prescription data were retrieved using the IQVIA longitudinal patient database (LPD), which delivers real-world data insights from French primary care electronic medical records (EMR). The average number of prescribed therapeutic agents was 1.9 per patient, with 39.3% monotherapy prescriptions. Treatment initiation represented 7.2% of all antihypertensive prescriptions. At treatment initiation, 22.5% of patients were prescribed dual therapy. The proportion of treatment renewal in the same therapeutic class was 74.3% while the proportion of treatment change was 18.5%. Of these, only 6.3% of patients received an additional therapy. Lastly, 35.7% of triple therapies were consistent with the recommended combinations. In conclusion, this study provides evidence of therapeutic gaps in hypertension management in France. The low blood control rate may be attributed to PCPs' therapeutic inertia and lack of knowledge of treatment guidelines. All stakeholders should commit to rapid corrective action in order to provide patients with the best care.

Factors Associated with Antihypertensive Therapy Prescription in Youth Delaware Medicaid Recipients with Primary Hypertension Diagnosis.

Higher neighborhood deprivation is associated with hypertension diagnosis in youth. In this study, we assess if there is an association between neighborhood deprivation and antihypertensive therapy prescription among insured youth with a primary hypertension diagnosis. Using a retrospective cross-sectional design, we assessed the proportion of youth with a diagnosis of primary hypertension prescribed antihypertensive therapy. We evaluated the proportion of youth prescribed antihypertensive therapy and compared prescribing patterns by area deprivation index (ADI), age, sex, obesity diagnosis, race, ethnicity, and duration of Medicaid coverage. Of the 65,452 non-pregnant Delaware Medicaid recipients, 8-18 years of age, 1,145 (1.7%) had an International classification of diseases (ICD)-9/ICD-10 diagnosis of primary hypertension; 165 of the 1,145 (14%) were prescribed antihypertensive therapy. Factors associated with a greater odds of prescription by multivariable logistic regression were age, obesity diagnosis, and duration of Medicaid full benefit coverage. Odds of antihypertensive therapy prescription did not vary by race, ethnicity, or ADI. Antihypertensive therapy prescription rates are poor despite national guideline recommendations. Among youth receiving Delaware Medicaid between 2014 and 2019, prescription proportions were highest among youth of older age, with an obesity diagnosis, and among youth with longer duration of Medicaid benefit coverage. Although high area deprivation has been shown to be associated with the diagnosis of hypertension, high vs. low area deprivation was not associated with greater antihypertensive therapy prescription among youth with primary hypertension. Our finding of a mismatch between hypertension diagnosis and antihypertensive therapy prescription highlights a potential disparity in antihypertensive therapy prescription in youth.

Optimizing Antihypertensive Management for Hypertensive Patients With Secondary Complications: A Systematic Review and Meta-Analysis in PrimaryCareSettings.

Despite significant pharmacological advancements, hypertension management remains challenging, with varying quality of primary care. Digital tools and other non-pharmacological interventions hold promise in addressing this challenge. Consequently, a thorough examination of these interventions is recommended. This meta-analysis focuses on clinician-oriented strategies aimed at improving hypertension management, to assess the most effective approaches for improving antihypertensive prescribing and blood pressure control for secondary prevention. This was done through a systematic review of randomized controlled trials published in PubMed and Embase since the beginning of 2010 that aimed to enhance antihypertensive medication prescription in primary care settings for hypertensive patients with secondary complicationswhile reporting changes in blood pressure or target achievement. We screened6305 records. Four studies met the inclusion criteria, with reported interventions including physician education and the implementation of electronic decision support systems. All studies showed that the control group had a statistically significant lower systolic blood pressure, but the effect on diastolic blood pressure was not statistically significant. The overall mean difference was 2.12 mmHg (95% CI = 0.98; 3.26, P-value = 0.0003) for systolic blood pressure in favor of the control group and 1.22 mmHg (95% CI = -0.48; 3.26, P-value = 0.16) for diastolic blood pressure, which was not statistically significant. Despite considerable efforts to control hypertension, it remains a significant obstacle to optimal cardiovascular risk reduction.This review is also limited by a scarcity of studies.

Abstract P354: Leveraging Electronic Health Records For Quality Improvement Among Patients With Markedly Elevated Blood Pressure

Introduction: Electronic health records (EHR) can improve quality of care for patients with markedly elevated blood pressure (BP). This study aimed to develop EHR-based computable algorithms to identify barriers to BP control and enhance triage and patient management. Methods: We conducted a retrospective analysis using EHR data from Yale New Haven Health System (YNHHS) employees and their dependents. Patients with markedly elevated BP had ≥2 outpatient BP readings ≥160/100 mmHg within a 180-day period. We assessed 3-month follow-up visits after BP elevation, along with the proportions of patients prescribed antihypertensives, filled prescriptions, and self-reported adherence using EHR data sources. Results: The study included 46,361 adult patients, with a mean age of 45.7 (14.5) years; 65% were female, 59% were White, and 17% were Black. Among them, 1,437 (3.3%) had markedly elevated BP, and 880 (1.9%) had consecutive markedly elevated BP readings. Among patients with markedly elevated BP, 626 (43.6%) had follow-up visits with relevant specialties within 3 months after the BP elevation. Moreover, 970 (67.5%) patients had antihypertensive prescriptions, of whom 927 (95.6%) filled their prescriptions, and among those who filled prescriptions, 806 (87.2%) reported taking the medications. Black patients were more likely to receive antihypertensive prescriptions but less likely to fill them or report taking medications (Figure). Conclusion: This study demonstrates the potential of EHR data and computable algorithms to enhance patient triage, interventions, and resource allocation for effective BP reduction among YNHHS employees.

Abstract P195: Association Of Unmet Social Needs With Antihypertensive Medication Prescription And Dietitian Referral: Interim Analysis Of The Study Of The Epidemiology Of Pediatric Hypertension Registry (SUPERHERO)

HTN is a significant public health concern with increasing prevalence in youth. Optimizing BP control with both lifestyle counseling and antihypertensive medications improves health outcomes. However, adequate BP control remains difficult in majority of patients, in part due to a lack of understanding of how social determinants of health affect dietitian referral and initiation of antihypertensive therapy. We performed a cross-sectional analysis of baseline EHR data from the SUPERHERO Registry in youth who received initial care from sub-specialists for HTN disorders defined by ICD-10 codes from 1/1/2015-12/31/2022. We excluded those with pregnancy, kidney transplantation, and dialysis. We examined the association of individual-level social drivers (transportation, finances, food access housing) with the likelihood of antihypertensive medication prescription and dietitian referral at initial visit in youth with HTN disorders using unadjusted generalized linear models. Of our large cohort of 11,580, only 47 youth had at least one unmet social need (0.4%). Participants with at least one unmet social need were 1.81 times more likely to be prescribed antihypertensive medication (95% CL 0.94- 3.48; p= 0.08) and 6.73 times more likely to be referred to a dietitian (95% CL 3.7-12.25). We found that children with at least one unmet social need were more likely to be referred to a dietitian at the initial visit than those without an unmet social need. The small number of participants with unmet social needs might reflect poor screening or documentation practices. It is imperative that screening for unmet social needs is incorporated into clinical practice in youth with HTN disorders.

Renin‐angiotensin-aldosterone system inhibitors and mortality risk in elderly patients with atrial fibrillation. Insights from the nationwide START registry

BackgroundArterial hypertension is the most common cardiovascular comorbidity in atrial fibrillation (AF). Few studies investigated management strategies of hypertension in AF. Materials and methodsWe included 5769 AF patients on oral anticoagulants from the nationwide ongoing Italian START registry. We investigated the prescription of antihypertensive drugs and mortality risk. Subgroup analyses according to sex and major cardiovascular comorbidities were performed. ResultsMean age was 80.8 years, 46.1% were women; 80.3% of patients were hypertensive. Furosemide (30.1%) was the most frequent diuretic followed by hydrochlorothiazide (15.4%) and potassium canrenoate (7.9%). 61.1% received β-blockers: 34.2% bisoprolol, 6.2% atenolol. Additionally, 36.9% were on angiotensin converting enzyme inhibitors (ACE-I): ramipril (20.9%), enalapril (5.3%) and perindopril (2.8%); 31.7% were on angiotensin receptors blockers (ARBs): valsartan (7.6%) and irbesartan (6.4%). Amlodipine and lercanidipine were prescribed in 14.0% and 2.3%, respectively. ACE-I (p < 0.001), α-blockers (p = 0.020) and Dihydropyridines calcium channel blockers (p = 0.004) were more common in men, while ARBs (p = 0.008), thiazide diuretics (p < 0.001) and β-blockers (p < 0.001) in women.During 22.61 ± 17.1 months, 512 patients died. Multivariable Cox regression analysis showed that ACE-I (Hazard ratio [HR] 0.758, 95% Confidence Interval [95%CI] 0.612–0.940, p = 0.012) and ARBs (HR 0.623, 95%CI 0.487–0.796, p < 0.001) inversely associated with mortality. ACE-I/ARBs inversely associated with mortality in both sexes and in patients with diabetes. This associastion was evident for ACE-I in patients with previous cardiovascular disease, and for ARBs in HF. ConclusionA lower mortality risk was found in AF patients on ACE-I/ARBs. Different prescription patterns of antihypertensive drugs between men and women do exist.

Korea hypertension fact sheet 2022: analysis of nationwide population-based data with a special focus on hypertension in the elderly

BackgroundThe Korean Society of Hypertension has published the Korea Hypertension Fact Sheet 2022 to provide an overview of the magnitude and management status of hypertension and their recent trends.MethodsThe Fact Sheets were based on the analyses of Korean adults aged 20 years or older of the 1998–2020 Korea National Health and Nutrition Examination Survey and the 2002–2020 National Health Insurance Big Data.ResultsAs of 2020, 29.4% of the adult population aged 20 or older in Korea, about 12.6 million people, have high blood pressure, of which 5.0 million (40%) are 65 years of age or older and 1.2 million (10%) are 80 years of age or older. Among those with hypertension, the awareness rate is 69%, the treatment rate is 65%, and the control rate is 47%. The number of people diagnosed with hypertension increased from 3.0 million in 2002 to 10.5 million in 2020. During the same period, the number of people using antihypertensive medication increased from 2.5 million to 9.9 million, and the number of people adherent to treatment increased from 0.6 million to 7.4 million. Among those treated for hypertension in 2020, 74% used angiotensin blockers, 61% used calcium channel blockers, 24% used diuretics, and 15% used beta blockers. Combination therapy with at least two classes of antihypertensive medication consisted of 60% of all antihypertensive prescriptions. The number of people with hypertension aged 65 or older is increasing very rapidly compared to those aged 20–64. Awareness and treatment rates of hypertension improved rapidly, especially in those aged 65 or older, but the rate of improvement slowed since 2012.ConclusionsIn Korea, the level of hypertension management is improving, but the absolute number of people with hypertension, especially elderly hypertension, is increasing due to the rapid aging of the population. It is necessary to develop more efficient and target-specific policies to control blood pressure and prevent cardiovascular disease.

Effect of Diet-Mediated Immune Optimization on Antihypertensive Drug Treatment Requirement

Background: Claiming over 92 million adjusted life years per annum globally, systemic arterial hypertension is at the forefront of noncommunicable diseases and mandates urgent attention to the etiopathogenic mechanism rather than depending on suppressive drug therapies. Good diet, adequate sleep, and moderate-intensity exercise are immune optimizers as well as life-style modifiers and may have substantial impact on antihypertensive drug treatment requirements for blood pressure control in essential hypertension (EH). Objective: We appraised the impact of diet-mediated immune optimization on antihypertensive drug treatment requirement. Materials and Methods: This was a longitudinal study and part of an open clinical trial of a personalized food avoidance dietary to stop hypertension approved by the University of Nigeria Teaching Hospital Ethics Committee. Drug treatment parameters assessed were antihypertensive drug prescription, adherence, actual treatment (AdhRx), and antihypertensive drug treatment requirement (ADTR) scores. ADTR score was determined by adding or subtracting 0.1 to AdhRx score for every mmHg that average systolic automated office blood pressure or average systolic home blood pressure get higher or lower than 120 and 100 mmHg, respectively. Results: There was no significant reduction of AdhRx and ADTR scores of study participants with good dietary compliance to a personalized food avoidance dietary approach to stop hypertension, although mean of the scores were lower than that of those with bad dietary compliance (P &gt; 0.05). Conclusion: We conclude that AdhRx and ADTR scores may serve as valid tools to assess the impact of diet-mediated immune optimization which addresses etiopathogenic dysfunction in EH.

Antihypertensive medication class and diastolic orthostatic hypertension in older Caribbean adult patients.

In the Caribbean there is limited data on orthostatic hypertension (OHT) in elderly hypertensive patients with atherosclerotic disease who are at risk for cardiovascular events. The authors examined the association of antihypertensive classes of drugs with diastolic OHT in patients 60year and older with hypertension and hyperlipidemia attending public primary care facilities. These relationships were evaluated in a cross-sectional study of hypertensive hyperlipidemic older patients (n=400) to determine orthostatic changes in blood pressure based on seated to standing measurements. OHT was defined as an increase in systolic blood pressure of ≥20mm Hg and/or increase in diastolic blood pressure of ≥10mm Hg upon orthostasis at 3min. Patients were categorized based on their orthostatic blood pressure response: orthostatic normotensive (n=200) and blood pressure dysregulated (n=200) of which 168 were diastolic OHT. Multivariable logistic regression models were used to examine associations of antihypertensive classes and diastolic OHT. Renin-angiotensin-aldosterone-system (RAAS) blockers were the most commonly prescribed (79.3%), followed by diuretics (DIUs) (61.6%), dihydropyridine calcium channel blockers (dCCBs) (53.8%), and beta-blockers (BBs) (19.3%). Most normotensive (76.0%) and diastolic OHT (75.0%) patients were prescribed two or more antihypertensive medications. Pharmaceutical prescription of triple combination RAAS blockers+dCCBs+DIUs (OR, 0.55; 95% CI, 0.31-0.99) or RAAS blockers+dCCBs+BBs (OR, 0.23; 95% CI, 0.06-0.92) showed a protective effect of diastolic OHT in analyses adjusted for age, sex, sitting diastolic blood pressure, and comorbidities. Our study suggests prescription of triple combination antihypertensive drugs of RAAS blockers+dCCBs+DIUs or RAAS blockers+dCCBs+BBs may reduce the likelihood of diastolic OHT.

#3605 TREATMENT OF HYPERTENSION IN AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE PATIENTS: A COMPARISON OF POLISH AND JAPANESE MEDICATION PATTERNS

Abstract Background and Aims Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disease and fourth case of kidney failure worldwide. Treatment options for ADPKD include therapy with vasopressin (ADH) receptor 2 antagonist, nephroprotection, and eventually renal replacement therapy. The earliest and most prevalent systemic complication of ADPKD is hypertension. The pathogenesis of hypertension in ADPKD is multifactorial, including endothelial dysfunction and activation of renin-angiotensin-aldosterone system (RAAS). Antihypertensive therapy with angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) is expected to decrease the left ventricular hypertrophy and proteinuria in ADPKD patients, according to HALT-PKD study. Data about preferences of second choice therapy and safety of other medications is lacking. Diuretics are commonly prescribed drugs in essential hypertension but carry risk of provoking ADH stimulation that may be potentially harmful in ADPKD because ADH stimulates cyst proliferation. We analyzed real-life data on antihypertensive prescriptions to determine and compare trends in treatment of hypertension in ADPKD patients in Poland and Japan. Method Patterns of antihypertensive prescriptions of ACEi, ARB, and diuretics were analyzed in patients from Poland (n = 131, median age 40 years; data 2014-2019) and Japan (n = 180, median age 44 years, data 2005-2017) diagnosed with ADPKD. The number of different medications used in combination was counted. For diuretics, even if multiple diuretics were used, they were counted as a single item. Furthermore, combination drug products were decomposed into their individual components, which were counted as either antihypertensive drugs or diuretics, respectively. Results The patterns of the number of prescriptions of antihypertensive drugs were similar in the two countries, see Figure 1. In Polish patients, the commonest pattern was no antihypertensive drugs (45.0%), followed by one (28.2%), two (16.8%), three (9.2%), and four (0.8%) prescriptions. In Japanese patients, the corresponding figures were: no antihypertensive drugs (41.1%), followed by one (32.2%), two (20.6%), three (4.4%), and four (1.7%) prescriptions in decreasing order. ACEi and ARBs were used for more than half of the patients, both Polish and Japanese. The utilization of ACEi/ARB in Polish individuals as a first-choice medication was 78.4% (75.0% in men, 81.0% in women) while in Japan 65.5% (66.7% in men, 63.2% in women). When patients were prescribed 3 or more antihypertensive drugs, ACEi/ARB was chosen in 100%, in both countries. Regarding diuretics, 15.3% of Polish patients and 6.7% of Japanese patients used them. Among patients who had one antihypertensive drug, 7.6% of Polish and 2.2% of Japanese patients also used diuretics. 44.2% of Polish and 38.9% of Japanese did not use either antihypertensive drugs or diuretics. Conclusion The patterns of number of prescriptions of antihypertensive drugs were similar among ADPKD patients in Poland and Japan while the use of diuretics was more common in Polish than in Japanese patients. In both countries, ACEi/ARB was the most frequent choice, which is in concordance with current recommendations. Unexpectedly, anti-RAAS were as frequently prescribed in women than in men, suggesting that the teratogenicity risk of the drugs did not limit access to the benefits of the treatment in both sexes.

#5507 ANTIHYPERTENSIVE PRESCRIBING PATTERNS IN CKD: FINDINGS FROM THE SALFORD KIDNEY STUDY

Abstract Background and Aims Hypertension is the second leading cause of chronic kidney disease (CKD) following diabetes and occurs in most patients with CKD. Finding an optimal treatment regime for hypertension remains challenging due to the complex bidirectional cause-and-effect relationship between hypertension and CKD, and hypertensive CKD patients may require treatment with multiple antihypertensive drugs. Database studies and practice guidelines have continued to demonstrate international variability in antihypertensive treatment practices. We analysed data from the Salford Kidney Study (SKS) database in relation to antihypertensive prescribing patterns amongst study patients. Method The SKS is an ongoing prospective study recruiting patients with CKD since the year 2002. Data including patient demographics, comorbidities, physical parameters, concurrent medications, and biochemical results are collected at baseline (study enrolment). All patients are followed up annually until they reach their endpoints [reaching end-stage kidney disease (ESKD), death, or discharge from follow-up] individually, with updates in their medical records including a list of medications. We have used Cox regression analysis and Kaplan Meier charts to investigate the associations between Renin-Angiotensin-Aldosterone System inhibitor (RAASi) use and the number of antihypertensive agents (binary groups of ≤3 or &amp;gt;3), and clinical outcomes (ESKD and all-cause mortality). Results A total of 3230 patients recruited between October 2002 and December 2019 were included in this analysis. At baseline, the median age of the cohort was 67 years with a predominance of males (62%) and those of white ethnicity (96%). 90% had a history of hypertension and 32% were diabetic. The median blood pressure was 138/75 mmHg. Previous myocardial infarction was recorded in 15%, congestive cardiac failure in 17% and cerebrovascular disease in 7.7% of the patients. The median estimated glomerular filtration rate (eGFR) was 30 ml/min/1.73 m2 and the median urine protein creatinine ratio (uPCR) was 33 mg/mmol. RAASi agents (ACEi &amp; ARB) (56%) were the most common antihypertensive medications to be prescribed, followed by diuretics (50%), calcium channel blockers (45%), and beta blockers (34%). The proportion of patients prescribed RAASi was associated with greater proteinuria (43 vs 33%, p&amp;lt;0.001). CKD patients with preexisting cardiovascular comorbidities were more likely to be prescribed beta blockers (44 vs 27%, p&amp;lt;0.001), diuretics (58 vs 39%, p&amp;lt;0.001) and mineralocorticoid antagonists (6.4 vs 1.85%, p&amp;lt;0.001). An increasing number of CKD patients were being prescribed ARBs over 24-month follow-up (34 vs 28%, p = 0.02). In a multivariable Cox-regression analysis, RAASi intake was not associated with reaching ESKD (HR 0.91; p = 0.49) but was associated with a significant survival benefit (HR 0.84; p = 0.001) (Figure 1). Use of a higher number of antihypertensive agents (i.e. &amp;gt;3) was associated with both greater mortality (HR 1.28; p = 0.02) and worse dialysis-free survival (HR 1.46; p = 0.007) (Figure 2). Conclusion Antihypertensive prescribing patterns in the SKS were consistent with current guidelines in the U.K. (e.g. NICE guidance 2022), with RAASi being predominantly prescribed as the first-line antihypertensive agent. An overall survival benefit was noted with RAASi use, although there was no signal for reducing progression towards ESRD. Outcomes were poor in patients with resistant hypertension needing multiple antihypertensive agents. Considering existing variations between the U.K. and other international guidelines regarding antihypertensive treatment in CKD, continued research is indicated to bridge the gaps between these recommendations and optimise patient outcomes.

INTERACTION OF COMORBID HYPERTENSION AND SEX ON OCCURRENCE OF MILD COGNITIVE IMPAIRMENT IN OUTPATIENTS WITH DIABETES MELLITUS: A 6-YEAR FOLLOW-UP STUDY

Objective: Hypertension and diabetes are known as a risk factor for impaired cognitive function among general population. And there are some sex-differences in prevalence/incidence of dementia and/or MCI and its related risk factors. We therefore examined the interaction of sex and hypertension comorbidity on MCI occurrence in diabetic patients. Design and method: Six-year follow-up study was conducted. A total of 308 without MCI out of 461 outpatients with diabetes mellitus assessed MMSE in 2014 were included. Blood pressure (BP) was evaluated twice after 5-muinite rest in the baseline survey. Comorbidity of hypertension was defined by prescription of antihypertensives. The follow-up assessment of MMSE were performed in 2019. A total of 155 patients were consequently used for the analysis (follow-up rate: 50.3%; 105 men and 50 women; age[years]: mean 63.9, SD 11.7, range 31-84). Participants were divided into four categories, men without hypertension(Mw/oHTN, reference), men with hypertension(MwHTN), women without hypertension(Ww/oHTN), women with hypertension(WwHTN) by baseline assessment. The odds ratios(ORs) and 95% confidence intervals(CIs) of MCI occurrence at the follow-up survey by sex and HTN category were calculated by multivariate logistic regression analyses after stratification by age. Results: Among 155 patients, 43 MCI was observed (case/n: 7/53 in Mw/oHTN, 18/52 in MwHTN, 9/23 Ww/oHTN, 9/27 WwHTN) at all ages during follow-up. After stratified by age, in patient aged under 65, age-adjusted ORs[95%CIs] of MCI were 9.85[1.08-89.49] for MwHTN, 13.33[1.10-162.10] for Ww/oHTN, 15.94[1.30-195.50] for Ww/oHTN. These results remained after adjusting SBP, BMI, HbA1c at baseline. Any significant increase on MCI occurrence by sex and HTN comorbidity was not observed in elderly diabetic patients. Limitations: We could not identify whether hypertension or diabetes occurred first. Due to the low follow-up rate, especially in higher BP levels, the sample size and the number of events were insufficient to consider all possible confounders. Strength: MMSE and other measures were assessed by well-trained researchers or research nurses with strict protocols. Conclusions: Comorbid hypertension in men with diabetes may cause MCI in adulthood. Further research focusing on risk factors for MCI in women with diabetes is needed.

QUALITY OF TREATMENT OF ARTERIAL HYPERTENSION IN COMBATANTS TAKING INTO ACCOUNT THE PRESENT COMORBID PATHOLOGY

Objective: Assessment of compliance of treatment of arterial hypertension (AH) in participants of modern armed conflicts with the requirements of evidence-based medicine, taking into account their comorbid pathology. Design and method: The design of the study was passive retrospective one-time (cross-sectional). The medical charts of inpatient patients of 213 male combatants, aged 27-59 years, average age 45.0 ± 6.8 years, who underwent treatment during 2018-2021, were analyzed by the method of random sampling. Results: It was established that all combatants with hypertension were prescribed antihypertensive drugs: angiotensin-converting enzyme inhibitors (54% of patients), calcium channel blockers (26%), angiotensin receptor blockers (25%) (that is, not all patients used angiotensin-converting enzyme inhibitors or angiotensin receptor blockers), beta blockers (24%) and diuretics (16%). In combatants suffering from hypertension with comorbid coronary heart disease (CHD), beta blockers were prescribed in 26%, calcium channel blockers in 28%, statins in only 45% of patients, without monitoring the achievement of target levels of low-density lipoprotein cholesterol density; antiplatelet therapy was prescribed for 70% of patients, which does not meet the requirements of modern medical and technological documents and needs correction. An insufficient prescription of antihypertensive drugs from the groups of beta blockers (26% of patients) and calcium channel blockers (28%) was established in military personnel with hypertension - participants in modern armed conflicts with comorbid coronary artery disease. Inadequate prescribing of statins (only in 45% of patients) and antiplatelet therapy (70%) to patients with hypertension with comorbid coronary heart disease and lack of strict control of low-density lipoprotein cholesterol levels were revealed. Conclusions: It is necessary to increase the awareness of military doctors about the need for cardiovascular risk stratification in all patients with hypertension and patients with hypertension with comorbid coronary heart disease of combatants, regarding modern requirements for the treatment of patients with hypertension with concomitant pathology, on issues of safety and feasibility of prescribing statins and antiplatelet therapy to combatants with hypertension and concomitant coronary heart disease to reduce the risk of developing cardiovascular complications and improve the prognosis with this comorbidity.

&lt;i&gt;NOS2&lt;/i&gt;, &lt;i&gt;NOS3&lt;/i&gt;, &lt;i&gt;SONE&lt;/i&gt; gene transcripts levels in peripheral blood leukocytes and their relationship with markers of endothelial dysfunction in hypertension

Objective. The aim of the study was to evaluate the level of expression of the NOS2, NOS3, SONE genes in peripheral blood leukocytes (PBL) of patients with hypertension (HTN) and to study the relationship between the level of transcripts of these genes and the content of nitric oxide metabolites and markers of endothelial dysfunction.Design and methods. The study included healthy people (25 people) and patients with HTN (stages I–II) before prescribing antihypertensive drugs (15 people) and taking cardioselective β-adrenergic receptor blockers for more than a year (metoprolol (25 mg per day) or bisoprolol (5–10 mg per day)) (20 people). The level of gene transcripts was assessed by real-time polymerase chain reaction (PCR). The level of nitric oxide metabolites was determined by the colorimetric method using the Griess reagent. The content of asymmetric dimethylarginine (ADMA), soluble forms of vascular cell adhesion molecule (sVCAM), and intercellular adhesion molecule (sICAM) in blood plasma was determined by ELISA. The content of malondialdehyde (MDA) in blood plasma was determined spectrophotometrically by color reaction with thiobarbituric acid. Statistical processing of the results was carried out using the Statgraphics Centurion XVI software package (version 16.1.11).Results. The level of nitric oxide metabolites in the blood plasma of HTN patients without antihypertensive therapy was 2,1 times higher than in healthy individuals (p = 0,001) and 1,7 times higher than in patients with HTN taking metoprolol or bisoprolol (p = 0,002). The relative content of mRNA of the NOS3 gene in PBL of individuals included in the study did not differ (p &gt; 0,05). The level of NOS2 gene transcripts in PBL of HTN patients before the prescription of antihypertensive drugs exceeded that in healthy individuals (p = 0,0009) and in HTN patients taking metoprolol or bisoprolol (p = 0,0002). The number of SONE transcripts in the PBL of HTN patients was higher than in people with normal blood pressure (p &lt; 0,00001 when comparing patients before the prescription of antihypertensive therapy and individuals from the control group; p = 0,04 when comparing patients with HTN taking antihypertensive drugs and normotensive subjects). The content of MDA, ADMA, sVCAM was higher in the plasma of HTN patients without antihypertensive therapy compared with people from the control group (p = 0,005, 0,003, 0,039, respectively) and patients taking metoprolol or bisoprolol (p = 0,0006, 0,019, 0,016, respectively). The content of nitric oxide metabolites positively correlated with NOS2, SONE, VCAM1 mRNA level in PBL, the content of MDA and ADMA in blood plasma (p &lt; 0,05). A positive correlation was found between the concentration of MDA and ADMA in plasma (p = 0,03).Conclusions. An increase in the level of nitric oxide metabolites in HTN is associated with an increase in the transcriptional activity of the NOS2 gene, a disturbance of the redox balance of the body, and the development of endothelial dysfunction. The SONE gene is probably involved in the modulation of nitric oxide levels in HTN not only as an antisense transcript that destabilizes the mRNA of the NOS3 gene in vascular endothelial cells, but also indirectly, namely, through the regulation of homeostasis of immune system cells through autophagy.

Drug Utilization Of Anti-Diabetic And Anti-Hypertension Drugs At Tertiary Care Teaching Hospital, Bangalore, India

Background: Hypertension is extremely prevalent in patients with diabetes. Limited data exist on utilization patterns of antihypertensive in this population are consistent with evidence-based practice guidelines.&#x0D; Objective: The present study is aimed to evaluate utilization patterns of antihypertensive agents among hypertensive diabetic patients.&#x0D; Methodology: The study was conducted in the patient pharmacy department of Bangalore.&#x0D; A prospective observational study was conducted for a period of 6 months in at Tertiary Care Teaching Hospital, Bangalore, India. We included 150 hypertensive diabetic patients with or without other comorbid conditions and patients aged below 18 years and pregnant women were excluded. All the prescribed medications along with other medications and relevant information will be noted in a customized data collection. The study patients will be followed daily until their discharge. The Micromedex, Medscape, articles and relevant references books will be used as tools to review the collected data. The prescribed medication will be checked for their existence in the hospital and also the reelevating calculation. Check for any error in prescription such as doses, frequency and route of administration and analysis.&#x0D; Result: Out of 150 patients, 50% were male and 50% were female. Maximum patients belonged to age group of 51-60 years. Chronic Kidney Disease (18%) the was the most common associated disease with hypertension and diabetes mellitus. More than half of the patients had received one antihypertensive drug (60%), followed by two (28%), three (10%) and four (2%) antihypertensive drugs. Amlodipine (CCB) was the most commonly prescribed antihypertensive drug (64%).&#x0D; Conclusion: Amlodipine and furosemide were the most frequently prescribed antihypertensive drugs. Prescription of antihypertensive drugs for some patients with compelling indications were not in congruent with JNC 8 guidelines. This study highlights some therapeutic rationality in this health center. However, targeted education of the prescription-givers and dissemination of treatment guideline could facilitate rational use of drugs and adherence to treatment guide lines.

An Overview of the Use of Antihypertensive Drugs at the Outpatient Pharmacy of Tarakan "X" Hospital in 2022

Hypertension is a global health problem often encountered, and the appropriate use of antihypertensive drugs is very important for optimal blood pressure control. Therefore, it is necessary to research the description of the use of antihypertensive drugs in various health facilities. The purpose of this study was to describe the prescription of antihypertensive drugs in patients at "X" hospital in the outpatient department. The research data obtained were digital data from prescription services from January-December 2022. This study used retrospective data by accessing computer service data at the "X" hospital outpatient pharmacy to track the history of past hypertensive patients’ treatment. The sampling technique used is total sampling. The results showed that the most prescribed antihypertensive drugs were amlodipine, with 13,203 prescription items. Bisoprolol with 10,704 prescription items, and candesartan with 9,885 prescription items. The frequency of prescribing the antihypertensive drug class the most was calcium channel blockers, as much as 13,784 (23.41%), while for the drug class which was the least prescribed, namely alpha-2 agonists, there were 68 drugs (0.12%). Based on the study results, it can be concluded that the most widely prescribed antihypertensive drugs at the outpatient pharmacy at "X" hospital are amlodipine, bisoprolol, and candesartan.