Better Control Of Hypertension Research Articles

Area Deprivation and Risk of Death and CKD Progression: Long-Term Cohort Study in Patients under Unrestricted Nephrology Care

Background: Area deprivation index (ADI) associates with prognosis in non-dialysis CKD. However, no study has evaluated this association in CKD patients under unrestricted nephrology care. Methods: We performed a long-term prospective study to assess the role of deprivation in CKD progression and mortality in stage 1–4 CKD patients under regular nephrology care, living in Naples (Italy). We used ADI calculated at census block levels, standardized to mean values of whole population in Naples, and linked to patients by georeference method. After 12 months of “goal-oriented” nephrology treatment, we compared the risk of death or composite renal outcomes (end-stage kidney disease or doubling of serum creatinine) in the tertiles of standardized ADI. Estimated glomerular filtration rate (eGFR) decline was evaluated by mixed effects model for repeated eGFR measurements. Results: We enrolled 715 consecutive patients (age: 64 ± 15 years; 59.1% males; eGFR: 49 ± 22 mL/min/1.73 m²). Most (75.2%) were at the lowest national ADI quintile. At referral, demographic, clinical, and therapeutic features were similar across ADI tertiles; after 12 months, treatment intensification allowed better control of hypertension, proteinuria, hypercholesterolaemia, and anaemia with no difference across ADI tertiles. During the subsequent long-term follow-up (10.5 years [interquartile range 8.2–12.6]), 166 renal events and 249 deaths were registered. ADI independently associated with all-cause death (p for trend = 0.020) and non-cardiovascular (CV) mortality (p for trend = 0.045), while CV mortality did not differ (p for trend = 0.252). Risk of composite renal outcomes was similar across ADI tertiles (p for trend = 0.467). The same held true for eGFR decline (p for trend = 0.675). Conclusions: In CKD patients under regular nephrology care, ADI is not associated with CKD progression, while it is associated with all-cause death due to an excess of non-CV mortality.

AVALIAÇÃO DO PERFIL FARMACOTERAPÊUTICO DE GRUPO HIPERDIA EM UNIDADE DE SAÚDE DA FAMÍLIA

Um dos fatores mais importantes para o controle da Hipertensão e Diabetes é a adesão ao tratamento farmacológico. Esse trabalho é uma pesquisa transversal com abordagem quantitativa realizada na Unidade de Saúde da Família Casarão do Cordeiro em Recife, PE, de maio a julho de 2019. De acordo com os resultados, 72,5% dos usuários do Hiperdia eram mulheres e a maioria possuia idade superior a 50 anos. Hipertensão foi a condição de maior prevalência entre os participantes. Um índice elevado de pessoas faziam uso de cinco ou mais medicamentos. Cerca de 90% declararam saber que diabetes e hipertensão são doenças crônicas e podem ser controladas com dieta e medicamento, porém a maioria desconhecia quais órgãos podem ser afetados. Apenas 17,7% demonstraram seguir corretamente o tratamento. Cerca de 57% dos participantes estavam com a pressão arterial (PA) alterada, o que pode ter relação direta com a baixa adesão ao tratamento. Dessa forma, fi ca evidente a importância do desenvolvimento de ações interdisciplinares de educação em saúde para o manejo e melhor controle da hipertensão e diabetes em tais pacientes.

P0160HOW TO MANAGE INTRADIALYTIC HYPERTENSION?

Abstract Background and Aims Hypertension in subjects on long term dialysis is frequent. Intradialytic hypertension affects up to 20% of hemodialysis patients and occurs more frequently in patients who are older, have lower dry weights, are prescribed more antihypertensive medications. Elevated BP detected by home or ambulatory BP monitoring is clearly associated with shorter survival. Method We realized a cross sectional study in two hemodialysis center patients during october 2019. We compared two groups of patients: group 1 with HTA (HTA+) and the second without (HTA-). Prevalence of hypertension intra dialysis (increase in systolic BP > 15mmHg during dialysis) was determined by blood pressure recordings every thirty minutes during hemodialysis. We collect information about prescription patients (bolus dose of IV nicardipine or administration of captopril orally) after HTA inicident. We collected and analyzed datas of 1476 hemodialysis sessions for 123 patients. Results The mean age of your patients was 46 ± 26,3 years with a female predominance. The mean duration of hemodialysis was 9,8 years. The initial nephropathy was hypertensive in 14,6%. 44,7% (n=55) patients used at least one antihypertensive treatment (HTA+ group), in 72,7% calcic inhibitor. Hypertension crisis in HTA+ group was higher than HTA- group, respectively 37,9% and 4,7% (p=0,0002). Concerning HTA+ group, in 9,35% of cases patients receveid IV bolus of nicardipine, 7,9% captopril and 17,9% of cases have not receveid any antihypertensive medication. In HTA- group they receveid IV nicardipine on only 2,5% cases and no drugs in half of all cases. Patients who were older and receive erythropoietin-stimulating agents were more likely to exhibit an increase in SPB despite similar amounts of ultrafiltration in each groups. It appears HTA- group had better control of hypertension crisis in 77,5% versus 65,5% in HTA+ group, at 20minutes of crisis (p= 0,004). Administration of captopril in the both group allowed better control of hypertension 90% (HTA+ group) and 84,2%(HTA- group). Hypertension crisis was more controlled in group with high ultrafiltration rate with administration of captopril . Conclusion Use of ACE inhibitors during dialysis to manage hypertension crisis appears a great solution and confirm hypothesis of activation of the renin–angiotensin–aldosterone system. Treatment of intradialytic hypertension may include careful attention to dry weight, avoidance of dialyzable antihypertensive medications, limiting the use of high calcium dialysate, achieving adequate sodium solute removal during hemodialysis, and using medications which inhibit the rennin-angiotensin-aldosterone system or which lower endothelin 1.

SAT-213 Parotid Carcinoma Ex Pleomorphic Adenoma Can Produce Ectopic ACTH Too

Background: Ectopic ACTH syndrome accounts for about 14% of Cushing syndrome cases. Small cell lung cancer is the most common cause. A few case reports described ectopic ACTH syndrome in patients with parotid acinic cell carcinoma. Parotid carcinoma ex pleomorphic adenoma is a malignant transformation within a pleomorphic adenoma, which is mostly adenocarcinoma not otherwise specified, but other subtypes can occur. Clinical Case: A 41-year old man with parotid cancer and hypothyroidism was admitted to the hospital for hypokalemia (2.1 mmol/L, n: 3.5-5 mmol/L). Parotid cancer was diagnosed a year before admission. At that time, he underwent left parotidectomy, and pathology showed carcinoma ex pleomorphic adenoma with areas of acinic cell carcinoma. Despite chemoradiation, he was diagnosed with metastasis in the lungs, for which pembrolizumab was started. Over the two months prior to admission, he gained 20 lb, and developed lower extremity weakness, acne, erectile dysfunction and loss of libido. He was also diagnosed with hypertension and started to have mild hypokalemia. Suspecting hyperaldosteronism, oncology team ordered labs just prior to admission, which showed the hypokalemia of 2.1 mmol/L, hypernatremia (147 mmol/L, n: 133-143 mmol/L), normal aldosterone and renin, and high cortisol (59.12 mcg/dL, n: 3-22 mcg/dL) and ACTH (121 pg/mL, n: 9-50 pg/mL).In the hospital, potassium was slowly improving despite aggressive replacement, and blood pressure was still elevated despite increasing his lisinopril dose. Screening for Cushing syndrome revealed an abnormal 1 mg dexamethasone suppression test (cortisol 51.9 mcg/dL, n: <1.8 mcg/dL), and high 24-hour urinary free cortisol (6495 mcg/24h, n: 3.5-45 mcg/24h) and midnight salivary cortisol (2610 ng/dL and 4250 ng/dL, n: <100 ng/dL). Cortisol was not suppressed after 8 mg dexamethasone (cortisol 47.85 mcg/dL, pretest cortisol 48.73 mcg/dL) pointing toward ectopic ACTH syndrome. Spironolactone was started and titrated up to 100 mg BID with better control of hypertension and normalization of potassium. Ketoconazole was started at 200 mg TID and increased gradually as outpatient to 400 mg TID within three weeks. A repeat 24-hour urinary free cortisol was done five weeks after ketoconazole was started showing significant improvement (110 mcg/24h, n: 3.5-45 mcg/24h). Potassium requirements remarkably decreased from 80 mEq TID to 40 mEq daily. Of note, chest CT done during hospitalization showed new lung lesions despite treatment with pembrolizumab. Conclusion: This is the first case of ectopic ACTH syndrome to be described in a patient with parotid carcinoma ex pleomorphic adenoma, though areas of acinic cell carcinoma within the tumor can be the source of ACTH. Hypercortisolism due to ectopic ACTH secretion is usually of rapid onset, and can present with severe hypokalemia. Steroid synthesis inhibitors seem to be an effective therapy.

Hyperinsulinemia rather than insulin resistance itself induces blood pressure elevation in high fat diet-fed rats

ABSTRACT Objective To investigate if insulin resistance per se or the accompanying hyperinsulinemia induced hypertension and its underlying mechanisms. Methods Sprague-Dawley rats were randomized into normal diet-fed group (ND group) and high-fat diet-fed group (HFD group). Then, the HFD group was further randomly divided into the control group (HFD_C group), the PIO group (treated with pioglitazone), the STZ_DM group (to induce diabetes with streptozotocin) and the DM+Ins group (streptozotocin injection followed by insulin treatment). Insulin sensitivity, plasma insulin, endothelin-1, norepinephrine, aldosterone, angiotensinⅡ and 24-h urinary sodium excretion (USE) levels of the groups were measured and analyzed. A multiple stepwise regression analysis method was applied to exam our hypothesis. Results Compared to HFD_C group, the groups with lower plasma insulin, the PIO group and STZ_DM group, showed higher USE and lower blood pressure. The groups with higher plasma insulin (but same level of insulin resistance), the HFD_C group and DM+Ins group, showed lower USE and higher blood pressure. The 24-h urinary sodium excretion was the most important contributor to the significant changes of blood pressure with an R2 of 25.2% in this animal experiment. Conclusions It is the compensatory hyperinsulinemia rather than insulin resistance per se that causes blood pressure elevation. The urinary sodium excretion is the key mediator among the multiple mechanisms. Therapies targeting hyperinsulinemia and restricting salt intake may favor a better control of hypertension associated with insulin resistance.

Os efeitos do exercício físico em pacientes submetidos à hemodiálise: uma revisão sistemática

INTRODUÇÃO: Pacientes portadores de doença renal crônica submetidos à hemodiálise são sedentários devido a dor, fadiga muscular e baixo condicionamento físico. Estudos recentes demonstram os efeitos benéficos de programas de exercícios físicos para estes pacientes durante a hemodiálise resultando em melhor controle da hipertensão arterial, da capacidade funcional, da função cardíaca, da força muscular e, assim, da qualidade de vida. OBJETIVOS: Analisar pesquisas que mostram se o exercício físico produz ou não desfechos clínicos benéficos para indivíduos em hemodiálise. METODOLOGIA: Este artigo constitui-se de uma revisão sistemática composta por ensaios clínicos randomizados publicados entre 2014 e 2019 que relacionassem hemodiálise, exercício físico e qualidade de vida e que apresentassem escore de PEDro superior a 5. Foram excluídos os estudos que estavam em desconformidade com o tema proposto, artigos duplicados entre as bases de dados e intenções de pesquisa. As palavras-chave utilizadas para a busca seguiram a descrição dos termos DECS e MESH, sendo elas: Hemodiálise, exercício físico e qualidade de vida. Essas palavras estavam presentes em qualquer seção do artigo. RESULTADOS: Foram selecionados 15 estudos segundo os critérios de elegibilidade. Os artigos analisados obtiveram um total de 1057 participantes de ambos os sexos com idades entre 18 e 80 anos. Esses foram submetidos a exercícios aeróbicos, anaeróbicos e respiratórios, apresentaram desfechos clínicos benéficos nas três modalidades de exercício físico. CONCLUSÃO: Programas de exercício físico durante a hemodiálise otimizam o ganho da massa, força e resistência muscular, aptidão física, qualidade do sono, autopercepção de saúde, capacidade funcional e consequentemente a qualidade de vida.

Adherence to a Health Literacy and Healthy Lifestyle with Improved Blood Pressure Control in Iran.

Introduction and AimHigh blood pressure is the leading and most important modifiable risk factor for cardiovascular disease. Health literacy and lifestyle are two paramount key factors behind better control of hypertension. This study was conducted to examine the current situation of health literacy and health-promoting lifestyle and its association with blood pressure control among people affected by hypertension in the population over age 30 of Northwest Iran.Patients and MethodsThis was a cross-sectional study conducted in October and December 2018 on the over 30-year-old population among subjects suffering from hypertension (n= 210). A self-reported questionnaire was used for assessing health literacy dimensions and lifestyle.ResultsIn hierarchical linear analysis, the HL explained 33.9% of the variance in healthy lifestyle. Among HL dimensions, the ability to access health information and decision-making were significantly associated with healthy lifestyle. The health literacy dimensions contributed to an additional significant increase in 4.7% of the variance explained in hypertension, furthermore, the health-promoting lifestyle items were explained an additional 14.8% of the hypertension variance. In total, lifestyle and health literacy dimensions were able to explain 21.7% of the variance in hypertension.ConclusionOur study encourages efforts to monitor health literacy in people with hypertension and investigate associations with involvement with health-promoting lifestyle.

Mass clinical survey as a possible population strategy for the better control of hypertension in Japan

Mass clinical survey as a possible population strategy for the better control of hypertension in Japan

Renal artery Chronic Total occlusion Angioplasty in a Patient with Bilateral Renal Artery Occlusion and Hypertensive Emergency

Atherosclerotic bilateral renal artery chronic total occlusions (CTOs) as a cause of hypertensive emergency is rare, and other causes such as vasculitis should be ruled out before definitive diagnosis. Successful CTO intervention in such a scenario has only been sparsely reported. A 53-year-old-male smoker with severe resistant hypertension required multiple emergency admissions for flash pulmonary edema and aggressive blood pressure control. He was found to have deranged renal parameters with a serum creatinine of 2.4 mg/dL and an estimated glomerular filtration rate of 25 mL/min. His complete blood picture, metabolic panel, and inflammatory markers were within normal limits. Renal Doppler ultrasonography revealed bilateral severe renal artery stenosis and a contracted left kidney. Renal angiography showed total occlusion of both renal arteries with well-collateralized right kidney. He underwent right renal artery CTO angioplasty with stenting. Left renal artery occlusion was managed conservatively because of the contracted kidney size and poor function. He is doing well for the last 30 months with good hypertension control, well-perfusing and preserved right kidney volume, stable renal function, and significantly fewer medications from baseline. Renal artery stenting is lifesaving in patients with bilateral renal artery occlusion and should be expeditiously performed, particularly in patients with and hypertensive emergency or recurrent unexplained heart failure. Kidney size, function, presence of collateralization, and viable renal parenchymal tissue guide in planning the intervention.

Asian management of hypertension: Current status, home blood pressure, and specific concerns in Korea.

Hypertension is present in almost one-quarter of women and one-third of men in Korea. Although mortality rates from stroke and myocardial infarction (MI) appear to be decreasing, stroke is a more common cause of cardiovascular death than MI. This may be due to better control of hypertension, but national control rates have remained stable for more than a decade (at about 45%). Korean Society of Hypertension guidelines have recommended the use of home blood pressure monitoring (HBPM) since 2007, but a recent survey suggests that physicians have concerns about the accuracy of HBPM devices. Nevertheless, use of HBPM is indispensable to monitoring and achieving blood pressure (BP) control. Current diagnostic and treatment thresholds and recommendations are based on Asian consensus document guidance. Use of dual combination antihypertensive therapy is slightly more common than use of monotherapy in Korea, while triple combination therapy is used less often. Angiotensin receptor blockers and calcium channel blockers are the most popular choices for antihypertensive therapy and are the most widely used combination. HBPM plays an important role in evaluating and monitoring BP, particularly in Asians. Individualized cardiovascular risk assessment and better BP control are required to prevent cardiovascular diseases, but there is a need for local evidence relating to optimal BP thresholds and targets.

Registry of the Egyptian specialized hypertension clinics: patient risk profiles and geographical differences.

Data regarding the prevalence and characteristics of cardiovascular (CV) risk factors among Egyptian hypertensive patients are limited. Nationwide Specialized Hypertension Clinics (SHCs) were initiated for screening, investigating, and treating hypertensive patients. This study aimed to determine the clinical characteristics and the CV risk profile of hypertensive Egyptians attending SHCs. Data from 4701 hypertensive patients were collected from the SHCs of nine university hospitals representing the different geographical regions of Egypt. Data collection started in October 2014 and ended in September 2017. Data included blood pressure (BP) measurements, clinical data, socio-demographic characteristics, anthropometric measurements, and cardiovascular risk profiles. The patients' mean age was 51.8 ± 11.5 years, 58.7% were older than 50 years, and 58.5% were females. The mean office systolic and diastolic BP values were 145.2 ± 22.4 and 88.7 ± 12.9 mmHg, respectively. Regarding CV risk factors, 58.6% were obese, 23.4% were smokers, and 25.1% had diabetes mellitus. Obesity was more prevalent in females than males (65.7% vs. 53.0%, p < 0.001, respectively), while dyslipidaemia and smoking were significantly more common in male patients. The highest levels of BP and the highest global risk were observed in the inhabitants of the Delta region, despite their younger age. In conclusion, this study revealed a high prevalence of modifiable CV risk factors among a cohort of Egyptian hypertensive patients attending SHCs. The pattern of the risk factors across the different geographic regions may be attributed to rapid urbanization. Governmental and community-based approaches are needed for better control of hypertension and its associated CV risk factors.

Différences de prise en charge de l’HTA entre la métropole et les DOM-ROM

BackgroundHigh blood pressure (HBP) is the most common chronic disease worldwide. In France, its prevalence varies by region. It is high in most Overseas Departments and Regions (DOM-ROM), at 38.2% in Réunion (1), 44% in Mayotte (2), 28% in the French Antilles, 18% in French Guiana, 25% in French Polynesia (3) and 28% in Saint-Martin (4). PurposeTo determinate the differences within the same healthcare system between hypertension in Metropolitan France compared to Overseas France Departments and Regions (DOM-ROM). ResultsSex-based differences. In contrast to Metropolitan France, in Overseas France the prevalence of HBP is higher in women, although women show better rates of care (screening and rates of patients “normalised” under medical treatment). The main explanation for this is the higher prevalence of obesity in women. Obesity multiplies the risk of developing hypertension by 2.5 Obesity in Guadeloupe affects 14% of men compared to 31% of women. Socio-economic particularities of hypertension in Overseas France. The numerous epidemiological surveys carried out in the French Antilles have demonstrated the major role of socio-economic conditions in the occurrence of hypertension, alongside the usual risk factors such as sedentary lifestyle, salt consumption and obesity (7). In the absence of socio-economic disparity, there is no significant disparity in the prevalence of hypertension specially in men. ConclusionsThere are differences between France Overseas Regions and Territories (DOM-ROMs) and Metropolitan France in terms of the prevalence, knowledge, treatment and control of hypertension, and these vary according to sex. For men, the prevalence and treatment of hypertension differ very little when considering a population of workers or employees in both regions. On the other hand, for women, the prevalence of hypertension is higher in the French Antilles-Guiana. This difference is not fully explained by the higher prevalence of obesity observed among female employees in the French Antilles-Guiana. For these patients, we also observe better knowledge and better control of hypertension. Care for men in socio-economically disadvantaged situations of precarity must be improved in terms of screening and adherence to treatment.

Differences within the same healthcare system between hypertension in Metropolitan France compared to Overseas France Departments and Regions (DOM-ROM)

High blood pressure (HBP) is the most common chronic disease worldwide. In France, its prevalence varies by region. It is high in most Overseas Departments and Regions (DOM-ROM), at 38.2% in Réunion (1), 44% in Mayotte (2), 28% in the French Antilles, 18% in French Guiana, 25% in French Polynesia (3) and 28% in Saint-Martin (4). To determinate the differences within the same healthcare system between hypertension in Metropolitan France compared to Overseas France Departments and Regions (DOM-ROM) Sex-based differences: in contrast to Metropolitan France, in Overseas France the prevalence of HBP is higher in women, although women show better rates of care (screening and rates of patients “normalised” under medical treatment). The main explanation for this is the higher prevalence of obesity in women. Obesity multiplies the risk of developing hypertension by 2.5. Obesity in Guadeloupe affects 14% of men compared to 31% of women. Socio-economic particularities of hypertension in Overseas France: the numerous epidemiological surveys carried out in the French Antilles have demonstrated the major role of socio-economic conditions in the occurrence of hypertension, alongside the usual risk factors such as sedentary lifestyle, salt consumption and obesity (7). In the absence of socio-economic disparity, there is no significant disparity in the prevalence of hypertension specially in men. There are differences between France Overseas Regions and Territories (DOM-ROMs) and Metropolitan France in terms of the prevalence, knowledge, treatment and control of hypertension, and these vary according to sex. For men, the prevalence and treatment of hypertension differ very little when considering a population of workers or employees in both regions. On the other hand, for women, the prevalence of hypertension is higher in the French Antilles-Guiana. This difference is not fully explained by the higher prevalence of obesity observed among female employees in the French Antilles-Guiana. For these patients, we also observe better knowledge and better control of hypertension. Care for men in socio-economically disadvantaged situations of precarity must be improved in terms of screening and adherence to treatment.

Awareness about Life-style Modication in Hypertensive Patients Residing in Natore District, Bangladesh

Objective: For better control of hypertension, behavior (knowledge, attitude and practice) of hypertensive patients about life-style change is essential. This study was done to determine the level of knowledge, attitude and practice of hypertensive patients regarding life-style change needed to control of hypertension.&#x0D; Methods: The present cross-sectional study was conducted in Natore General Hospital, Natore over a period of 4 months from September to December, 2015. A total of 50 adult hypertensive patients suffering from the disease for at least six months were included in the study. Of them 20 were selected from patients attending at the Outpatient Department of Medicine, Natore General Hospital and 30 were selected by snowballing. Data were collected using a semi-structured questionnaire and the levels of knowledge and practice status were measured on Likert Scale (0-4). Score ‘1’ was assigned for each correct answer and score ‘0’ for each wrong answer, except for two knowledge-related questions where highest score was ‘2’ and the lowest was ‘0’. As there were more than one question in assessing respondents’ perception and practice, combined scores were used to measure the intended behaviour.&#x0D; Results: The result showed that about two-thirds (66%) of the respondents lie between 4th and 5th decades of life with mean age being 48.4 years (range: 17 – 80 ears). Male to female ratio was roughly 1:1. Majority (96%) of the respondents was married. Primary level educated formed about one-third (32%) of the respondents followed by HSC (20%), graduation (18%) and illiterate (16%). Nearly half (46%) of the respondents was poor. Seventy percent of the respondents’ blood pressure was beyond control at the time of interview with mean systolic and diastolic blood pressures being 140 and 92 mmHg respectively. More than half (54%) of the respondents’ duration of hypertension was &lt; 5 years with median duration being 3 years. Over one-quarter (28%) was adequately aware and two-thirds (68%) were partially aware of lifestyle modification and most (88%) of the respondents’ source of information was doctor. Although majority (84%) was informed of life-style change from their doctors, only 28.6% of them considered those advices to be adequate to bring about effective change in their life-style. Majority (92%) held the view that additional salt to be avoided followed by smoking cessation or tobacco chewing (88%), diet control (84%) and having regular exercise (82%). A substantial proportion (72%) also put emphasis to weight reduction. In terms of practice, over two-thirds (70%) adopted change in their life-style to control blood pressure. Of them 20(57.1%) were practicing diet control, another 20(57.1%) avoiding added salt with meals and 10(28.5%) quitted smoking for reducing the chance of having heart attack or stroke in future. Ten (20%) respondents were used to smoking at the time of interview. Of them 7(70%) intended to give up the habit. Half (52%) of the respondents took exercise but the rate of performing regular exercise (5 days in a week) was only 19.3%. Those who were not used to taking exercise, 16.7% of them told that they did not have spare time to have exercise, about 30% told that the role of exercise on blood pressure control was not known to them, another 30% tried but failed to continue and 20.8% were reluctant to take exercise. More than half (56%) of the respondents’ level of knowledge was satisfactory, followed by 30% more or less satisfactory and 14% poor. However, about one-third (32%) of the respondents’ practice level was satisfactory, 34% more or less satisfactory, 24% poor, 8% very poor and only 2% highly satisfactory.&#x0D; Conclusion: The knowledge level of hypertensive patients about their life-style change is far below the desired level. The practice level is even low meaning that not all the respondents having knowledge about life-style modification translated the same into practice This indicates that there lies a gap between perception &amp; practice which act as a barrier to motivation.&#x0D; Ibrahim Card Med J 2017; 7 (1&amp;2): 23-30

Use of body composition measurements to guide the assessment of dry weight in anuric dialysis patients: improvements in blood pressure control

PurposeFluid management using a body composition monitor (BCM) based on bioimpedance spectroscopy has been found to be beneficial for maintenance hemodialysis (MHD) patients. Our purpose was to provide a management procedure for the adjustment of post-dialysis overhydration (OHpost) and to evaluate whether this approach could improve blood pressure. MethodsPost-dialysis fluid status was assessed weekly using the BCM. The reference value of OHpost and the flow procedure for post-dialysis target weight (PDTW) adjustment were established via measurements of OHpost in 60 normotensive MHD patients. In the interventional study, we adjusted the PDTW of hypertensive patients to the optimal OHpost range, with a 0.2–0.5 kg change in PDTW per week. ResultsThis observational study included 130 anuric MHD patients, of whom 60 were in the pre-dialysis systolic blood pressure (sBPpre) < 140 mmHg group. On multivariate logistic regression analysis, we found that only OHpost was significantly associated with sBPpre ≥ 140 mmHg (odds ratio = 2.293, p = 0.000). Patients in the OHpost < −1.8 L group were mainly male and younger, and had higher post-dialysis diastolic blood pressure, ultrafiltration volume, levels of nutrition markers (serum albumin and creatinine), body mass index, and lean tissue index (LTI). On multiple stepwise regression analysis, only the change in LTI was found to be an independent predictor of OHpost [R2 0.208, β = −0.196, 95% CI (−0.296, −0.095), p < 0.001]. The reference value of OHpost was found to deviate by − 2.5–0.5 L from that of normotensive patients. At the end of the study, the systolic blood pressure of 38 patients was less than 140 mmHg after PDTW adjustment. The changes in OHpost from the initial to last adjustment were significant (t = 5.431, p < 0.001), with a substantial decrease in the sBPpre (t = 11.208, p < 0.001). ConclusionsAssessment of OHpost and LTI using a BCM with a patient-specific optimal PDTW adjustment flow can lead to significantly better control of hypertension in anuric MHD patients.

Enhanced hypertension care through private clinics in Pakistan: a cluster randomised trial.

BackgroundHypertension in Pakistan affects 33% of people aged ≥45 years, and in urban areas around 70% of basic health care occurs in private facilities.AimTo assess whether enhanced care at urban private clinics resulted in better control of hypertension, cardiovascular disease (CVD) risk factors, and treatment adherence.Design & settingA two-arm cluster randomised controlled trial was conducted at 26 private clinics (in three districts of Punjab) between January 2015–September 2016. Both arms had enhanced screening and diagnosis of hypertension and related conditions, and patient recording processes. Intervention facilities also had a clinical care guide, additional drugs for hypertension, a patient lifestyle education flipchart, associated training, and mobile phone follow-up.MethodClinics were randomised in a 1:1 ratio (sealed envelope lottery method). A total of 574 intervention and 564 control patients in 13 clusters in each arm were recruited (male and female, aged ≥25 years, systolic blood pressure [SBP] >140 mmHg, and/or diastolic blood pressure [DBP] >90 mmHg). The primary outcome was change in SBP from baseline to 9-month follow-up.Staff and patients were not blinded, but outcome assessors were blinded.ResultsNine-month primary outcomes were available for 522/574 (90.9%) intervention and 484/564 (85.8%) control participants (all clusters). The unadjusted cluster-level analysis results were as follows: mean intervention outcome was -25.2 mmHg (95% confidence intervals [CI] = -29.9 to-20.6); mean control outcome was -9.4 mmHg (95% CI = 21.2 to 2.2); and mean control–intervention difference was 15.8 (95% CI = 3.6 to 28.0; P = 0.01).ConclusionThe findings and separate process evaluation support the scaling of an integrated CVD–hypertension care intervention in urban private clinics in areas lacking public primary care in Pakistan.

The prevalence of arterial hypertension depending on selected demographic factors among adult residents of eastern Poland district

Background. Identification and analysis of risk factors are important aspects of planning the long-term actions to prevent, early diagnose and properly treat hypertension. The aim of this study was to examine the prevalence of hypertension and to determine the relationship between the prevalence of hypertension and selected sociodemographic factors among adult residents of a typical eastern Poland district. Material and methods. The study involved 1225 residents of the Janow Lubelski district aged between 36 and 65 years. The research methodology included a questionnaire survey. Blood pressure, body weight and height were measured, the BMI was calculated. Statistical analysis was performed. Results. 26.8% of subjects are treated for hypertension. 32.9% of hypertensive subjects are treated properly and women have better control of hypertension than man (41.3% vs. 19.7%). Among subjects without treatment for hypertension, 37.5% of them have abnormally high blood pressure and it is more common in men (58.9% vs. 43.4%). The prevalence of hypertension increased with age. The percentages are from 8.6% for subjects aged 36–40 to 45.7% for subjects aged 61–65. Higher prevalence of hypertension is observed in men below the age of 50 compared to women. There is the significant rising prevalence of hypertension in women above the age of 50. The relationship between the prevalence of hypertension and the educational background is demonstrated. Among subjects with elementary education, the prevalence of hypertension is higher (45.5%) as compared to subjects with higher education (18.2%). Area of residence and marital status have no effects on the prevalence of hypertension. Conclusions. The prevalence of hypertension was lower compared to other epidemiological studies. Improvements in hypertension control have been observed for many years. The educational background has an important influence on the prevalence of hypertension. Further studies are required to establish the influence of an area of residence and marital status on the prevalence of hypertension.

Cerebrovascular and hypertensive diseases as multiple causes of death in Brazil from 2004 to 2013.

The proportion of deaths attributed to hypertensive diseases (HYPDs) was only 50% of that registered for cerebrovascular diseases (CBVDs) in 2013 in Brazil. This article aims to evaluate mortality related to HYPDs and CBVDs as multiple causes of death, in Brazil from 2004 to 2013. Analysis of historical series of secondary data obtained from Brazilian official registries. Data about the deaths were obtained from the Mortality Information System of the Brazilian Ministry of Health, available on the DATASUS website. CBVDs and HYPDs were evaluated according to their mentions as the underlying cause of death or entry in any line of the death certificates (DCs), according to their International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes. When CBVDs were the underlying causes of death, HYPDs were mentioned in 40.9% of the DCs. When HYPDs were the underlying causes of death, CBVDs were mentioned in only 5.0%. When CBVDs were mentioned without HYPDs, they were selected as the underlying cause of death 74.4% of the time. When HYPDs were mentioned in DCs without CBVDs, HYPDs were selected 30.0% of the time. In 2004, the frequency of any mention of HYPDs relative to the frequency of HYPDs cited as underlying causes increased fourfold and was followed by a plateau until 2013. In contrast, the frequency of any mention of CBVDs relative to the frequency of CBVDs as underlying causes decreased in the same period. Because this study was based on DC records, it was limited by the way these documents were completed, which may have included lack of record of the causes related to the sequence that culminated in death. When deaths related to HYPDs were evaluated as multiple causes of death, they were mentioned up to four times more often than when they were selected as underlying causes of death. This reinforces the need for better control of hypertension to prevent deaths.

MANAGEMENT OF HYPERTENSION ACCORDING TO HEMODYNAMIC MODULATORS BY IMPEDANCE CARDIOGRAPHY IS NOT SUPERIOR TO STANDARD CLINICAL CARE IN TREATING NAÏVE HYPERTENSIVE PATIENTS

Objective: Different hemodynamic profiles have been shown to underlie the process of incident hypertension. Aim of our study was to test the hypothesis that the choice of antihypertensive drugs according to the individual hemodynamic profile of patients might achieve a better control of hypertension than standard clinical care. Design and method: Longitudinal study in 64 consecutive, treatment-naïve hypertensive patients referred to a Hypertension Unit for study. Standard clinical and laboratory examinations were performed, including ABPM. Impedance cardiography by the HOTMAN® System was used for noninvasive assessment of hemodynamic modulators and evaluation of the hemodynamic status of the patients. 30 patients (46.9%) were randomly assigned to the standard group and treated according to standard clinical care (S-group), while the treatment of the other 34 patients (53.1%) was derived from their hemodynamic profile (H-group). All the patients had a follow-up visit after six months. Results: No significant differences were found at baseline between the two groups in anthropomorphic variables or office systolic, diastolic BP or 24-h-ABPM: 146/87 and 138/91 mmHg (S-group) vs. 143/85 and 136/88 mmHg (H-group). At follow-up, both groups showed a significant decrease in office and ambulatory BP without significant differences between groups: 128/77 and 123/80 mmHg in the S-group vs. 128/78 and 124/80 mmHg in the H-group. The number of antihypertensive drugs needed was slightly but not significantly higher in the S-group compared to the H-group (1.27 vs. 1.06, p = 0.17). Use of diuretics was significantly higher in the H-group (23/3; OR: 18.8, p < 0.001), while ACEI (11/3; OR: 4.2, p = 007), ARB (17/6; OR: 3.2, p = 0.001) and CCB (7/2; OR: 4.0, p = 0.045) were significantly more often used in the S-group. Interestingly, the prevalence of the most frequent hemodynamic abnormality in the H-group, intravascular hypervolemia, did not change compared to baseline. Conclusions: Our study shows that management of debuting hypertensive patients guided by the measurement of hemodynamic modulators was not superior to standard clinical care in controlling hypertension. Future studies are required to test if higher doses and more intensive treatment are needed to achieve targets in hemodynamic abnormalities.

In Hospital Stroke Mortality: Rates and Determinants in Southwestern Saudi Arabia.

Objectives: The present study analyzed in-hospital first-time stroke mortality in southwestern Saudi Arabia over one-year to assess the in-hospital stroke case fatality rate, mortality rate and explore the factors associated with in-hospital stroke mortality. Study Design: Hospital based follow-up study. Methods: First-time stroke patients admitted to all hospitals in Asser region over one-year period (January through December 2016) were included in the study. Data about personal characteristics, pre-stroke history and clinical criteria, on admission clinical criteria, in-hospital complications and survival status were collected. The last reported Aseer region population was used to calculate age and sex stroke mortality rate per 100,000 population/year. Hazard ratios (HR) and concomitant 95% confidence intervals (95% CI) were computed using multivariate Cox regression survival analysis. Kaplan-Meier curve survival analysis for stroke patients were plotted. Results: A total of 121 in-hospital deaths out of 1249 first-time stroke patients giving an overall case fatality rate (CFR) of 9.7%. Non-significant difference with gender and age were observed in CFR. Overall, in-hospital stroke mortality rate was 5.58 per 100,000/year. Males and elders showed a significantly higher mortality rates. Multivariable Cox regression analyses revealed pre-stroke smoking (HR = 2.36), pre-stroke hypertension (HR = 1.77), post-stroke disturbed consciousness (HR = 6.86), poor mobility (HR = 2.60) and developing pulmonary embolism (HR = 2.63) as significant predictors of in-hospital stroke mortality. Conclusions: In Southwestern Saudi Arabia, the in-hospital stroke mortality rate is higher in men and increases with aging. The prognosis of acute stroke could be improved by smoking cessation, better control of hypertension and prevention of in hospital complication particularly pulmonary embolism.