Antihypertensive Prescription Research Articles

Non-Adherence to Antihypertensive Guidelines in Patients with Asymptomatic Carotid Stenosis

ImportanceHypertension and carotid stenosis are both risk factors for stroke, but the presence of carotid stenosis might dampen enthusiasm for tight control of hypertension because of concerns for hypoperfusion. ObjectiveTo determine the extent to which there are opportunities to potentially improve pharmacotherapy for hypertension in patients known to have asymptomatic high-grade carotid stenosis. DesignWe examined anti-hypertensive medication prescription and adherence to evidence-based hypertension treatment guidelines in a cross-sectional analysis of baseline data of patients enrolled in a clinical trial. SettingThe Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) is a multicenter prospective randomized open blinded end-point clinical trial of intensive medical management with or without revascularization by endarterectomy or stenting for asymptomatic high-grade carotid stenosis. Participants1479 participants (38.6% female; mean age 69.8 years) from 132 clinical centers enrolled in the CREST-2 trial as of April 6, 2020 who were taking ≥1 antihypertensive drug at baseline. ExposuresPharmacotherapy for hypertension. Main outcomeAdherence to evidence-based guidelines for treating hypertension. ResultsOf 1458 participants with complete data, 26% were on one, 31% on 2, and 43% on ≥3 antihypertensive medications at trial entry. Thirty-two percent of participants were prescribed thiazide; 74%, angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB); 38%, calcium channel blocker (CCB); 56%, a beta blocker; 11%, loop diuretic; and 27%, other. Of those prescribed a single antihypertensive medication, the proportion prescribed thiazide was 5%; ACEI or ARB, 55%, and CCB, 11%. The prevalence of guideline-adherent regimens was 34% (95% CI, 31-36%). Conclusions and relevanceIn a diverse cohort with severe carotid disease and hypertension, non-adherence to hypertension guidelines was common. All preferred classes of antihypertensive drug were under-prescribed. Using staged iterative guideline-based care for hypertension, CREST-2 will characterize drug tolerance and stroke rates under these conditions. Trial registrationClinicalTrials.gov Number NCT02089217.

Multi-morbidity and blood pressure trajectories in hypertensive patients: A multiple landmark cohort study.

Our knowledge of how to better manage elevated blood pressure (BP) in the presence of comorbidities is limited, in part due to exclusion or underrepresentation of patients with multiple chronic conditions from major clinical trials. We aimed to investigate the burden and types of comorbidities in patients with hypertension and to assess how such comorbidities and other variables affect BP levels over time. In this multiple landmark cohort study, we used linked electronic health records from the United Kingdom Clinical Practice Research Datalink (CPRD) to compare systolic blood pressure (SBP) levels in 295,487 patients (51% women) aged 61.5 (SD = 13.1) years with first recorded diagnosis of hypertension between 2000 and 2014, by type and numbers of major comorbidities, from at least 5 years before and up to 10 years after hypertension diagnosis. Time-updated multivariable linear regression analyses showed that the presence of more comorbidities was associated with lower SBP during follow-up. In hypertensive patients without comorbidities, mean SBP at diagnosis and at 10 years were 162.3 mm Hg (95% confidence interval [CI] 162.0 to 162.6) and 140.5 mm Hg (95% CI 140.4 to 140.6), respectively; in hypertensive patients with ≥5 comorbidities, these were 157.3 mm Hg (95% CI 156.9 to 157.6) and 136.8 mm Hg (95% 136.4 to 137.3), respectively. This inverse association between numbers of comorbidities and SBP was not specific to particular types of comorbidities, although associations were stronger in those with preexisting cardiovascular disease. Retrospective analysis of recorded SBP showed that the difference in mean SBP 5 years before diagnosis between those without and with ≥5 comorbidities was -9 mm Hg (95% CI -9.7 to -8.3), suggesting that mean recorded SBP already differed according to the presence of comorbidity before baseline. Within 1 year after the diagnosis, SBP substantially declined, but subsequent SBP changes across comorbidity status were modest, with no evidence of a more rapid decline in those with more or specific types of comorbidities. We identified factors, such as prescriptions of antihypertensive drugs and frequency of healthcare visits, that can explain SBP differences according to numbers or types of comorbidities, but these factors only partly explained the recorded SBP differences. Nevertheless, some limitations have to be considered including the possibility that diagnosis of some conditions may not have been recorded, varying degrees of missing data inherent in analytical datasets extracted from routine health records, and greater measurement errors in clinical measurements taken in routine practices than those taken in well-controlled clinical study settings. BP levels at which patients were diagnosed with hypertension varied substantially according to the presence of comorbidities and were lowest in patients with multi-morbidity. Our findings suggest that this early selection bias of hypertension diagnosis at different BP levels was a key determinant of long-term differences in BP by comorbidity status. The lack of a more rapid decline in SBP in those with multi-morbidity provides some reassurance for BP treatment in these high-risk individuals.

Antihypertensive medication needs and blood pressure control with weight loss in the Diabetes Remission Clinical Trial (DiRECT)

Aims/hypothesisOur aim was to evaluate the safety and efficacy of a planned therapeutic withdrawal of all antihypertensive and diuretic medications, on commencing a formula low-energy diet replacement, targeting remission of type 2 diabetes.MethodsPost hoc analysis of changes in BP, antihypertensive medication prescriptions and symptoms during the initial total diet replacement phase was performed in the intervention arm of the Diabetes Remission Clinical Trial (n = 143) and in the subset (n = 69) who discontinued antihypertensive medications at the start of total diet replacement. The Counterweight-Plus total diet replacement provided about 3470 kJ/day (830 kcal) with automatic reductions in all nutrients, including sodium, to achieve marked negative energy balance and rapid weight loss over 12–20 weeks, with regular BP monitoring and an antihypertensive reintroduction protocol based on current clinical guidelines.ResultsOf 143 intervention group participants who commenced total diet replacement, 78 (55%) were on treatment for hypertension at baseline. The overall mean BP fell significantly from the start of total diet replacement (week 1) and was significantly lower at week 20, after total diet replacement finished, and also at 12 and 24 months. Of the 78 participants previously on treatment for hypertension, 65 (83%) stopped all antihypertensive and diuretic medications as per protocol, and four (5%) stopped some drugs. These 69 participants experienced no immediate (within the first week) change in BP, but their mean BP fell significantly from 9 weeks. No excessive rises in BP were recorded in individuals, but antihypertensive medications were reintroduced during total diet replacement to manage raised BP for 19/69 (27.5%) participants, mostly within the first 3–7 weeks, despite some weight loss. Reintroduction of antihypertensive medications was necessary for 5/19 participants previously on one drug, and for 14/19 previously on two or more drugs. Of the 69 who stopped antihypertensives, 19 (28%) remained off medications at 24 months. Among the 53 participants who achieved sustained remissions of diabetes at 24 months (with a mean weight loss of 11.4 kg), 31 had been previously treated for hypertension. Twenty-seven stopped medication at baseline, and 15/27 required reintroduction of antihypertensive medications. Mild to moderate dizziness, suggesting some postural hypotension, was reported during total diet replacement by 51 participants, 15 of whom had recorded dizziness at baseline prior to starting total diet replacement, with nine of these on antihypertensive or diuretic medications.Conclusions/interpretationReplacing antihypertensive medications with a 3470 kJ/day (830 kcal) diet to induce weight loss reduces BP substantially and may increase mild dizziness. It is safe to stop antihypertensives, but BP should be monitored regularly, particularly for those taking two or more antihypertensives, as over two-thirds will require reintroduction of some medications. Long-term support to maintain weight loss is vital.Trial registrationISRCTN registry, number 03267836.Graphical abstract

MO183TELEMEDICINE AS A MODALITY OF HEALTH CARE DELIVERY FOR PATIENTS WITH SEVERE CHRONIC KIDNEY DISEASE DURING COVID-19 PANDEMIC

Background and AimsTelemedicine is a new modality of care delivery. Over the last months, it has been used to deliver health care to outpatients with chronic kidney disease (CKD) during COVID-19 pandemic. However, experience of telemedicine in patients with severe CKD is scarce and there are not reassuring data about its efficacy in improving patients’ outcome. To evaluate the efficacy and the outcome profile of telemedicine in people with severe CKD, we reviewed all data of outpatients with severe kidney impairment who underwent nephrological evaluation during the first wave of this pandemic. In particular, outcomes of the ambulatory activity (urgent-start dialysis, late referral and modalities of dialysis initiation) were compared to 2019 ambulatory activity.MethodOutpatients with severe chronic kidney disease included in the ambulatory program called “Pre-Dialysis Program were enrolled in a retrospective study. We reviewed all electronic charts of patients who underwent nephrological follow-up from 9th March to June 21st, 2020 (15 weeks in total) at the University Hospital of Modena, Italy. Extension of the observation period to 30th September 2020 allowed us to determine the long-term effects of telemedicine on the rate of urgent-star dialysis, late referral, and modalities of dialysis initiation.ResultsDuring 15 weeks of follow-up, 186 nephrological visits were performed (Table) They were subdivided into telemedicine visits (56.5%) and in-person visits (43.5%). Overall, mean age of patients was 71.7±13.1 years with a prevalence of male (60.2%). Patients who received telemedicine visits had a statistically significant lower sCr (3.7±1.2 vs 4.5±1.5 mg/dl; P=0.0001) and higher eGFR level (14.7±6.02 vs 12.16±5.8 ml/min; P=0.002) than patients followed in the ambulatory setting. A high prevalence of patients with CKD stage 5 was monitored by in-person visits (P=0.0001). Patients followed by telemedicine had a clinical profile including a lower weight (P=0.007) and better control of metabolic acidosis (P=0.039) than the counterpart.Changes in domiciliary therapy occurred more frequently in patients monitored in the ambulatory setting (P=0.036). Statistically significant differences were encountered in the prescription of diuretics (P=0.002), sodium bicarbonate (P=0.043), antihypertensive drugs (P=0.001) and uric acid-lowering agents (P=0.046). During the 15-week period in 2019, 214 visits were performed (+13% compared to 2020). The vast majority of these visits were conducted in the hospital setting (210 out of 214; 98.2%). The severity of CKD was similar between patients, without statistically significant difference in the rate of patients in CKD stage III (P=0.7), stage IV (0.388) and stage V (P=0.593).Implementation of telemedicine to in-person visits during COVID-19 pandemic did not change the outcomes of patients. Short-term follow-up showed a similar rate in urgent-start dialysis (P=0.361), late referral (P=1), and HD (P=0.875) or PD initiation (P=0.661). Similar results were seen also at the end of the extended follow-up.ConclusionImplementation of telemedicine has been fundamental to maintain a high level of care in CKD patients during the COVID-19 pandemic. Telemedicine services in combination with in-person visits have contributed to the delivery of clinical monitoring in a group of patients with severe and progressive CKD. No differences have been identified in terms of rate of unplanned dialysis, late referral, and modality of dialysis initiation.

Visual Analytics Dashboard Promises to Improve Hypertension Guideline Implementation.

BACKGROUNDPrimary care management of hypertension under new guidelines incorporates assessment of cardiovascular disease risk and commonly requires review of electronic health record (EHR) data. Visual analytics can streamline the review of complex data and may lessen the burden clinicians face using the EHR. This study sought to assess the utility of a visual analytics dashboard in addition to EHR in managing hypertension in a primary care setting.METHODSPrimary care physicians within an urban, academic internal medicine clinic were tasked with performing 2 simulated patient encounters for hypertension management: the first using standard EHR, and the second using EHR paired with a visual dashboard. The dashboard included graphical blood pressure trends with guideline-directed targets, calculated atherosclerotic cardiovascular disease risk score, and relevant medications. Guideline-appropriate antihypertensive prescribing, correct target blood pressure goal, and total encounter time were assessed.RESULTSWe evaluated 70 case simulations. Use of the dashboard with the EHR compared with use of the EHR alone was associated with greater adherence to prescribing guidelines (95% vs. 62%, P < 0.001) and more correct identification of blood pressure target (95% vs. 57%, P < 0.01). Total encounter time fell an average of 121 seconds (95% confidence interval 69–157 seconds, P < 0.001) in encounters that used the dashboard combined with the EHR.CONCLUSIONSThe integration of a hypertension-specific visual analytics dashboard with EHR demonstrates the potential to reduce time and improve hypertension guideline implementation. Further widespread testing in clinical practice is warranted.

Retrospective analysis of clinical decision support system use in patients with hypertension and atrial fibrillation (INTELLECT)

Aim. To evaluate the relationship between the clinical decision support system use (CDSS) and adherence to clinical guidelines.Materials and methods. Medical records of 300 patients with atrial fibrillation and hypertension from the electronic medical database of the Almazov National Medical Research Center were analyzed. Demographic and clinical data, as well as information on anticoagulant, antiarrhythmic and antihypertensive prescriptions were analyzed. The primary endpoint was adherence of prescribed treatment to current clinical guidelines for each of the three therapies. Firstly, a group of independent clinical experts assessed primary endpoint for retrospective prescriptions. Secondly, new prescriptions were simulated by another group of clinical experts using CDSS and blinded to previous therapy. Primary endpoint at the second step was analysed by independent experts. We compared adherence to relevant clinical guidelines with and without use of CDSS. Additionally, we analyzed predictors of failing to meet the current recommendations in the retrospective records.Results. Out of 300 patients, only 291 (97%) had all characteristics and were included in the analysis. In 26 patients (18%), all three treatment strategies were in accordance with current clinical guidelines. Anticoagulant therapy was adherent to the guidelines in 92% of cases. Experts who used CDSS were 15% (95% confidence interval [CI], 10-21%) more likely to prescribe novel oral anticoagulants and 14% (95% CI, 10-19%) less likely to prescribe warfarin compared to baseline. Antiarrhythmic therapy was adherent to the guidelines in 69% of cases. When the CDSS platform was applied, experts were 14% (95% CI 4-19%) more likely to prefer antiarrhythmic drug (AAD) monotherapy and 32% (95% CI 26-37%) more often prescribed radiofrequency ablation (RFA) of left atrium. At baseline, antihypertensive therapy combinations were adherent clinical guidelines in 28% of cases. The use of the CDSS platform by experts was significantly associated with an increase in the frequency of prescribing dual and triple antihypertensive therapy.Conclusion. CDSS use is associated with improved adherence to current clinical guidelines. Prospective randomized trials are needed to evaluate the CDSS effectiveness in the prevention of cardiovascular events.

Persistence of uncontrolled hypertension post-cardiac rehabilitation in stable coronary patients.

In stable coronary heart disease, uncontrolled risk factors are strongly associated with incident myocardial infarction. We analysed the management of hypertension in 746 stable coronary patients recruited between 2005 and 2015 in a single-centre prospective study. Risk factors and pharmacological treatments were documented prior to and immediately after cardiac rehabilitation, and 1 year later. One year post-cardiac rehabilitation, all cardiovascular risk factors were significantly better controlled with the notable exception of hypertension: blood pressure (BP) <140/90 mmHg in 60% of the total population vs 49% (N = 450) of hypertensive patients (20% or 10%, according to the ACC/AHA 2017 or ESH/ESC guidelines, respectively). Of those who had achieved normotension by the end of cardiac rehabilitation, 42% had uncontrolled hypertension again 1 year later; in addition, body weight had increased, while physical activity and antihypertensive drug use had dropped (differences between controlled or uncontrolled hypertension at 1 year post-cardiac rehabilitation, NS). Three factors were correlated with BP elevations: discontinuation of betablockade: +7.9 mmHg; age >65 years: +6.2 mmHg; diabetes mellitus: +7.6 mmHg. Only 48% hypertensive patients were on guideline-recommended antihypertensive polytherapy. Although 28% were still hypertensive post-cardiac rehabilitation, and hypertension remained uncontrolled in 70% 1 year later, 61% antihypertensive prescriptions were not adjusted post-cardiac rehabilitation. One year post-cardiac rehabilitation, hypertension was the only cardiovascular risk factor that had not improved. This can be attributed to three main reasons, all associated with BP elevations: precipitous reduction in betablockade, physicians' inertia when faced with uncontrolled hypertension and lack of adherence to international guidelines.

Antihypertensive prescribing patterns and hypertension control in females of childbearing age.

The use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) to treat hypertension (HTN) during pregnancy presents well-established risks to a developing fetus. A cross-sectional study was conducted to evaluate the current state of antihypertensive prescribing and contraceptive use in females of childbearing age within a large safety-net health system. The retrospective cross-sectional study focused on females aged 18-49 years with a documented diagnosis of HTN. The proportion of patients prescribed an ACE inhibitor or ARB and using a documented form of contraception was calculated. Documented forms of contraception included oral contraceptives, intrauterine devices, injections, implants, and surgical intervention. A total of 4,187 patients were identified from the HTN registry; after application of exclusion criteria 3,045 patients were included in the study population. The mean age was 39 years (range, 18-49 years). The most frequently prescribed classes of antihypertensive medications were ACE inhibitors and ARBs (one or the other was used by 1,146 patients [37.6%]), followed by thiazide diuretics (n = 710, 23.3%) and calcium channel blockers (n = 599, 19.7%). Of the 1,146 patients prescribed an ACE inhibitor or ARB, 553 (48%) were using a documented form of contraception. Rates of ACE inhibitor or ARB prescribing to females of childbearing age were high despite the teratogenic risks, and fewer than half of patients had documented protection from pregnancy. Provider and patient education and potential creation of best practice alerts in the electronic medical record regarding the risks of using ACE inhibitors and ARBs in females of childbearing age are warranted.

EPIDEMIOLOGICAL PREVALENCE ESTIMATES OF HYPERTENSION OF 856,878 ADULTS IN GLASGOW

Objective: Systematic reviews estimate the prevalence of hypertension in high income countries to be 28.5%, with 55.6% of hypertensives on treatment and 28.4% of those on treatment having controlled hypertension. We used these estimates to determine the proportion of untreated hypertensives in the Greater Glasgow and Clyde population and to evaluate if the estimated proportion of untreated hypertension translated into increased CV mortality. Design and method: Dispensed prescription and mortality data were obtained on 856,878 adults who attended either primary care or secondary care in the NHS Greater Glasgow and Clyde area between 2010 and 2016. Age-specific hypertension prevalence were obtained from the Scottish Public Health Observatory (2018) and for high income countries from Mills et al (Circulation 2016). Individuals were considered to be on hypertension treatment if they had at least 6 months of 2011 covered by their antihypertensive prescriptions. Cardiovascular deaths from 2012–2016 were obtained from mortality records through record linkage. Generalised estimating equations (GEE) were used to assess the relationship between proportion of untreated hypertension and CV mortality. Results: The estimated number of hypertensives was 308,208 (35.9%) and the numbers treated and untreated were 181,662 (58.9%) and 126,546 (41.1%) respectively. Age-stratified analyses showed the highest proportion of untreated hypertensives was in the 30–40-year (72%) and 40–50 year (58%) age groups while the lowest proportion was the 70–80 year group (28%). Stratification by SIMD showed SIMD 1 (least deprived group) had the lowest proportion of untreated hypertensives (34%) while the most deprived groups 4 and 5 had 49% and 43% respectively. Cardiovascular mortality rates increased with each decade of life -0.95/1000 among 30–40 years old group and rising to 233/1000 in the 80+ age group. These results were maintained even after adjusting for age and SIMD using GEE. Conclusions: Estimating prevalence of untreated hypertension in the Greater Glasgow and Clyde region do not show correlation with five-year cardiovascular mortality. This discrepancy indicates more accurate estimation of hypertension prevalence and treatment using home BP is required for formulating effective health policies on hypertension.

周産期の医薬品使用の安全性に関する研究

We have been conducting research with the aim of generating evidence for the safety of perinatal drugs. As a result of reviewing the records of inquiries to the Drug Information Office of our hospital, we found a large discrepancy between the description of perinatal drugs in package inserts in Japan and the description of the Pregnancy Risk Category according to the U.S. Food and Drug Administration. In the Japan Environment and Children's Study (JECS), we determined the proportion of drug and supplement use among 97464 pregnant women. We clarified that prescriptions of antihypertensive drugs for pregnant women increased during the second half of pregnancy, while prescriptions of anti-epileptic and anti-anxiety drugs decreased after pregnancy using a claims database. A survey of pharmacists and pharmacy students revealed a lack of awareness of effective folic acid intake to reduce the risk of neural tube defects in infants. The percentage of pre-pregnancy folic acid supplementation among pregnant women participating in the Babies and their Parents' Longitudinal Observation in Suzuki Memorial Hospital on Intrauterine Period (BOSHI) study, the JECS, and the Tohoku Medical Megabank (TMM) Birth and Three-Generation (BirThree) cohort study was 6.3-18.0%. As a result of close examination of the records of inquiries to the Drug Information Office of our hospital, and of cases in which our lactation plan sheet was applied, it was found that there were discrepancies between the information on the drug package insert and the information on Medications & Mother's Milk, etc. in Japan. The results obtained have been clinically applied in daily practice and we are continuing our research while taking measures.

Korea hypertension fact sheet 2020: analysis of nationwide population-based data

BackgroundThe Korean Society of Hypertension has published the Korea Hypertension Fact Sheet 2020 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 2007–2018 Korea National Health and Nutrition Examination Survey (KNHANES) and the 2002–2018 National Health Insurance Big Data (NHI-BD).ResultsCurrently, the population average of systolic/diastolic blood pressure was 118/76 mmHg in Korean adults aged 20 years or older showing little change in the recent decade. However, the number of people with hypertension increased steadily, exceeding 12.0 million. Indeed, the number of people diagnosed with hypertension increased from 3.0 million in 2002 to 9.7 million in 2018. During the same period, the number of people using antihypertensive medication increased from 2.5 million to 9.0 million, and the number of people adherent to treatment increased from 0.6 million to 6.5 million. Hypertension awareness, treatment, and control rates increased rapidly until 2007, but showed plateaued thereafter. In 2018, the awareness, treatment, and control rates of hypertension among all adults were 67, 63, and 47%, respectively. However, the awareness and treatment rates were only 17 and 14% among adults aged 20 to 39 years old with hypertension. Among patients treated for hypertension, 61% of them were also using glucose-lowering or lipid-lowering drugs. Among antihypertensive prescriptions, 41% of the patients received monotherapy, 43% received dual therapy, and 16% received triple or more therapy. The most commonly prescribed antihypertensive medication was angiotensin receptor blockers, followed by calcium channel blockers and diuretics.ConclusionTo achieve further improvement in management of hypertension, we need to encourage awareness and treatment in young adults. It is required to develop tailored prevention and management strategies that are appropriate for and inclusive of various demographics.

Antihypertensive Prescribing for Uncomplicated, Incident Hypertension: Opportunities for Cost Savings

BackgroundA range of first-line similarly effective medications ranging in price are recommended for treating uncomplicated hypertension. Considering drug costs alone, thiazides and thiazide-like diuretics are the most cost-efficient option. We determined incident prescribing of thiazides for newly diagnosed hypertension as first-line treatment in Alberta, factors that predicted receiving thiazides vs more costly medications, and how much could be saved if more patients were prescribed thiazides. MethodsUsing a retrospective cohort design, factors predicting receiving thiazides vs other agents were determined using mixed effects logistic regression. Cost savings were simulated by shifting patients from other antihypertensive medications to thiazides and calculating the difference. ResultsWithin our cohort of 89,548 adults, only 12% received thiazides as first-line treatment whereas 44% received angiotensin converting enzyme inhibitors, 17% received angiotensin receptor blockers, 16% received calcium channel blockers, and 10% received β-blockers. Antihypertensive medications were typically prescribed by office-based, general practitioners (88%). Being male and receiving a prescription from a physician with ≥ 20 years of practice and a high clinical workload were associated with increased odds of receiving nonthiazides. In the extreme case that all patients received thiazides as their first prescription, spending would have been reduced by a maximum of 95% (CAD$1.8 million). ConclusionsOnly 12% of Albertan adults with incident, uncomplicated hypertension were prescribed thiazides as first-line treatment. With the opportunity for drug cost savings, future research should evaluate the risk of adverse events and side effects across the drug classes and whether the costs associated with managing those risks could offset the savings achieved through increased thiazide use.

Relationship of Annual Health Checkups with the Subject's Subsequent Behavior of Cardiovascular Risk Management in a Real-World Setting in Japan: A Retrospective Cohort Study on Changes in Antihypertensive Drug Prescription and Blood Pressure from 2015 to 2017.

BackgroundIn Japan, workers receive a health checkup annually, and based on the results, a follow-up health guidance or intervention is provided when deemed necessary. However, it remains unclear whether the current real-world health checkup and guidance programs in Japan successfully lead to behavioral changes or improvement of clinical outcomes in individuals who require cardiovascular (CV) risk management.ObjectiveThis study aimed to explore the association between health checkup and the subsequent behavior change in CV risk management in subjects with uncontrolled blood pressure (BP) without antihypertensive drug prescription, who can have increased risk of CV events.Patients and MethodsThis was a retrospective cohort study that used health-checkup and claims data from a Japanese healthcare database managed by MinaCare Co., Ltd. Of those aged 20–74 years with available data on systolic and diastolic BP from 2015 to 2017, data from individuals with uncontrolled BP who were not prescribed antihypertensive drugs within 6 months before their baseline health checkup in 2015 were extracted and analyzed. The primary outcome measures were changes in antihypertensive drug prescription and BP control status based on health-checkup results from the baseline year (2015) to 2017. CV risk-management behavior was also assessed using body mass index (BMI) and smoking status, as these are the major modifiable CV risk factors.ResultsAmong 39,242 subjects with uncontrolled BP without antihypertensive drug prescription at baseline, 88.9% remained without prescription in 2016. Of the subjects without prescription, 62.9% continued to have uncontrolled BP. Both statuses of the major modifiable CV risk factors remained unchanged in 2016: 92.1% of obese subjects (BMI ≥ 25 kg/m2) at baseline remained obese, and 93.8% of smokers at baseline aged ≥ 40 years continued to smoke. Logistic regression analysis revealed that age 60–69 years (vs. 40–49 years), hypertension (HT) stage II (vs. stage I), HT stage III (vs. stage I), and BMI ≥ 25.0 kg/m2 (vs. < 25.0 kg/m2) were factors associated with uncontrolled BP in 2016 (subsequent year), regardless of antihypertensive drug prescription.ConclusionsUntreated HT for years increases the risk of CV events. These results suggest that current health-checkup and guidance programs are inadequately effective for behavioral change. Further practices for committing to lifestyle modifications and seeking medical advice based on their health-checkup results need to be undertaken to improve health behavior.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40801-020-00224-5.

Association of Blood Pressure Variability and Diuretics With Cardiovascular Events in Patients With Chronic Kidney Disease Stages 1-5.

Visit-to-visit blood pressure variability (BPV) is associated with cardiovascular events in the general population. Data are scarce in chronic kidney disease. We hypothesized that BPV would be associated with cardiovascular outcomes, death, and end-stage kidney disease (ESKD) and that diuretics would modify these associations in patients with chronic kidney disease. We studied US Veterans with nondialysis chronic kidney disease stages 1-5 and hypertension on nondiuretic antihypertensive monotherapy. At the time of second antihypertensive agent prescription, we propensity-matched for exposure to a loop or thiazide diuretic versus any other antihypertensive. BPV was defined as the coefficient of variation of systolic blood pressure over 6 months after second agent prescription. Cox proportional hazards regression measured associations of BPV with a primary cardiovascular event composite (fatal or nonfatal myocardial infarction or ischemic stroke; heart failure hospitalization). Secondary outcomes included all-cause death, each primary outcome component, end-stage kidney disease, and cardiovascular death. There were 31 394 participants in each group. BPV was associated with composite cardiovascular events, hazard ratio (95% CI) at second, third, fourth, and fifth versus first quintile: 1.79 (1.53-2.11), 2.32 (1.99-2.71), 2.60 (2.24-3.02), and 3.12 (2.68-3.62). Diuretics attenuated associations between the fourth and fifth BPV quintiles with composite events (Pinteraction=0.03 and 0.04, respectively). BPV was associated with all secondary outcomes except end-stage kidney disease, with no diuretic interactions. BPV was associated with cardiovascular events and death but not end-stage kidney disease in patients with chronic kidney disease, with attenuated associations with cardiovascular events in the diuretic-treated group at high BPV quintiles. Future studies should investigate whether other antihypertensive classes modify these risks.

Impact of national valsartan recalls on Veterans' outcomes.

Background and Aims:Chemical impurities discovered in angiotensin receptor blocker (ARB) products in late 2018–2019 resulted in recalls of various products and has likely had downstream effects for patients and prescribers. The purpose of this study is to determine how the valsartan recall impacted clinical endpoints and prescribing of antihypertensives.Methods:This was a retrospective, single-center, cohort study including patients receiving recalled valsartan with essential hypertension who were mailed a recall letter on 12 March 2019. Mean blood pressure endpoints were collected 6 months before (pre-recall) and after the recall letter was mailed (post-recall). Antihypertensive medication changes and titrations were also characterized post-recall.Results:A total of 300 patients meeting eligibility criteria were included. There was no statistically significant difference in mean systolic blood pressure (SBP) or diastolic blood pressure (DBP) when pre- and post-recall blood pressures were compared (SBP: 137.2 mmHg versus 135.8 mmHg, p = 0.125; DBP: 78.6 mmHg versus 78.5 mmHg, p = 0.900). In addition, the percentage of patients with controlled blood pressure readings was similar in the pre- and post-recall timeframes (28% versus 27%, p = 0.72). A total of 33 medication changes involving valsartan occurred, with approximately one-third being changed to another ARB (n = 11) or drug class (n = 12). In total, 11 valsartan medication changes were specifically documented to be related to the valsartan recall.Conclusion:The results of this study indicate the valsartan recalls that occurred in 2019 did not significantly impact the clinical outcomes of the studied population.Plain Language SummaryImpact of a medication recall on Veterans’ outcomesBackground:Chemical impurities discovered in a class of blood pressure medications known as angiotensin receptor blockers (ARBs) occurred in late 2018–2019. This resulted in recalls of various products and has likely had downstream effects for patients and prescribers.Objective:The purpose of this study is to determine how the recall of valsartan, which is a medication in the ARB class, impacted clinical endpoints and prescribing of medications for blood pressure.Methods:This was a retrospective, single-center, cohort study including patients receiving recalled valsartan with high blood pressure who were mailed a recall letter on 12 March 2019. Blood pressure endpoints were collected 6 months before (pre-recall) and after the recall letter was mailed (post-recall). Medication changes and titrations were also characterized post-recall.Results:Three hundred patients meeting eligibility criteria were included. There was no difference found in systolic blood pressure (SBP) or diastolic blood pressure (DBP) when pre- and post-recall blood pressures were compared (SBP: 137.2 mmHg versus 135.8 mmHg; DBP: 78.6 mmHg versus 78.5 mmHg). In addition, the percent of patients with controlled blood pressure readings was similar in the pre- and post-recall timeframes (28% versus 27%). A total of 33 medication changes involving valsartan occurred, with approximately one-third being changed to another ARB (n = 11) or drug class (n = 12). Eleven valsartan medication changes were specifically documented to be related to the valsartan recall.Conclusions:The results of this study indicate the valsartan recalls that occurred in 2019 did not significantly impact the clinical outcomes of the studied population.

Pilot Study, Antihypertensive Prescription Analysis of Hypertensive Patients at Community Pharmacy Outlet; Sri Lankan Perspectives

CINEC Academic Journal is a peer reviewed open access multidisciplinary journal published by the CINEC Campus, Malabe, Sri Lanka. CINEC Academic journal publishes papers on all aspects of higher education streams in humanity and education, social sciences, business and management, engineering, information technology, health and medical sciences, maritime sciences and maritime engineering.

N-Terminal Pro-B-Type Natriuretic Peptide and Longitudinal Risk of Hypertension.

Hypertension is a common condition that increases risk for future cardiovascular disease. N-terminal B-type natriuretic peptide (NT-proBNP) is higher in individuals with hypertension, but studies of its association with hypertension risk have been mixed. The REasons for Geographic And Racial Differences in Stroke (REGARDS) study enrolled 30,239 U.S. Black or White adults aged ≥45 years from 2003 to 2007. A subcohort included 4,400 participants who completed a second assessment in 2013-2016. NT-proBNP was measured by immunoassay in 1,323 participants without baseline hypertension, defined as blood pressure ≥140/90 or self-reported antihypertensive prescriptions. Two robust Poisson regression models assessed hypertension risk, yielding incidence rate ratios (IRRs): Model 1 included behavioral and demographic covariates and Model 2 added risk factors. A sensitivity analysis using a less conservative definition of hypertension (blood pressure ≥130/80 or self-reported antihypertensive prescriptions) was conducted. Four hundred and sixty-six participants developed hypertension after mean follow-up of 9.4 years. NT-proBNP was not associated with hypertension (Model 2 IRR per SD log NT-proBNP 1.01, 95% confidence interval 0.92-1.12), with no differences by sex, body mass index, age, or race. Similar findings were seen in lower-threshold sensitivity analysis. NT-proBNP was not associated with incident hypertension in REGARDS; this did not differ by race or sex.

Pilot Study, Antihypertensive Prescription Analysis of Hypertensive Patients at Community Pharmacy Outlet; Sri Lankan Perspectives

Prescribing pattern of antihypertensive medicines is much concerned in the context of treating this disease hypertension. The main objective was to determine prescribing patterns of antihypertensive medicines. Hundred prescriptions were collected from one community pharmacy outlet for three days. Prescriptions of hypertensive patients were analysed by using Microsoft Excel. Out of hundred prescriptions, 57% accounted for female and 43% for male. According to the results, antihypertensive drugs were widely prescribed for patients (54%) above 60 years, as expected following 45% of patients within 20-60 years age category. But, only one patient below 20 years of age (1%) was prescribed with anti-hypertensives. Out of all the prescribed anti-hypertensives, 59% accounted for Angiotensin Receptor Blockers (ARBs) &amp; Angiotensin Converting Enzyme Inhibitors (ACEIs) followed by Calcium Channel Blockers (CCB) (16%), Diuretics (13%), β-Blockers (5%) and others (Alpha blockers, Potassium channel blockers, α &amp; β blockers &amp; Alpha-2 adrenergic receptor agonists) (7%) respectively. Losartan was the highly prescribed ACEI and ARBs (85%) followed by HCT (Diuretic) (75%) Diltiazem and Nifedipine (CCB) (36% equally) and Bisoprolol (β-Blocker) (57%) as highly prescribed anti-hypertensives under each category. Study concluded that, ACEIs and ARBs were the highly prescribed drug category following the drug Losartan. 1% from the total prescriptions were accounted for prescribing Nifedipine (CCB) only for the age below 20. But there were antihypertensive drug combinations prescribed for the 20-60 and above 60 age categories rather than prescribing a single antihypertensive. Further recommended to analyse the types of anti-hypertensive combinations among each age category.

Abstract 16061: Antihypertensive Therapy Prescribing Pattern Among Patients With Markedly Elevated Blood Pressure in a Real-world Setting

Introduction: Combination therapy with two or more antihypertensive agents is recommended for management of patients with markedly elevated blood pressure (systolic blood pressure [SBP] ≥160 mmHg or diastolic blood pressure [DBP] ≥100 mmHg) by the 2017 AHA/ACC hypertension guideline. Using electronic health records (EHR) data from a large health system, we characterized real-world antihypertensive drug prescribing patterns and assessed guideline adherence among ambulatory patients with markedly elevated BP. Methods: Our cohort included patients aged 18-85 years with at least 2 outpatient visits in the Yale New Haven Hospital System between January 1 st , 2013 and December 31 st , 2018, resulting in a total of 665,691 patients. We defined the phenotype of markedly elevated BP as two consecutive outpatient visits with SBP ≥160 mmHg or DBP ≥100 mmHg. We described the number and class of antihypertensive drugs (previously taken and newly prescribed) at the second visit with BP ≥160/100 mmHg. Results: We identified 38,098 patients with markedly elevated BP with a mean age of 62.4 (SD: 13.7) years; 47.9% were male; and 67.8%, 20.9%, and 9.3% were White, Black and Hispanic. Among them, 49.3% were not on any antihypertensive drugs at the end of the second visit, 26.2% had one active antihypertensive drug prescription, and 24.5% had two or more agents prescribed (Figure). Among patients with two or more antihypertensive drug prescriptions, the most common drug class combination prescribed was diuretic/ACE inhibitor (10.2%), followed by diuretic/ARB (9.3%), and ACE inhibitor/calcium channel blocker (6.5%). The low prescription of combination therapy was consistent across age, gender, and race subgroups. Conclusions: Prescribing of guideline-recommended combination antihypertensive drugs for patients with markedly elevated BP is suboptimal. Major opportunities exist for improving the guideline adherence of antihypertensive drug prescription in this population.

The outcomes of the postulated interaction between SARS-CoV-2 and the renin-angiotensin system on the clinician's attitudes toward hypertension treatment.

Concern has arisen about the role played in coronavirus disease 2019 (COVID-19) infection by angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). This study was designed to assess the practice behaviors of physicians toward hypertension treatment with ACE-i or ARBs during the COVID-19 pandemic. A self-administered survey questionnaire consisting of 26 questions about current hypertension treatment with ACE-i/ ARBs was applied to cardiologists, internists, and family physicians in central and western Turkey, between 01 and 19 May 2020. A total of 460 physicians were approached, and 220 (47.8%) participated in the study. Of the total respondents, 78.7% reported that they had not changed their antihypertensive medication prescribing pattern, 8.6% of clinicians had changed ACE-i/ ARBs medicine of patients during the COVID-19 pandemic and 12.7% of them were undecided. The median (±interquartile range) score indicating general reliance level of physicians in ACE-i/ARBs therapy was 8 ± 4 (range, 1–10). In multiple comparison analyses, the general reliance level in ACE-i/ARBs, reliance level when starting a new ACEi/ARBs and changing behavior in heart failure patients were significantly different with regard to the specialties (p:0.02, p:0.009, p:0.005 respectively). Although most of the physicians found the publications about ACE-i/ ARBs during the COVID-19 pandemic untrustworthy, there were variable levels of knowledge and reliance among different physicians and specialty groups. In general, the ACE-i/ ARBs prescribing habits were not affected by safety concerns during the COVID-19 pandemic in Turkey.