Blood Pressure Management In Patients Research Articles

Reducing cardiovascular disease risk in type 2 diabetes: is the focus on glycaemia warranted?

Cardiovascular disease remains a major source of morbidity and mortality in type 2 diabetes mellitus. This article examines the recent evidence from trials and related meta-analyses on the effects of glycaemic control on cardiovascular disease (and, to a lesser extent, microvascular outcomes) in diabetes, and compares this with evidence accrued from blood pressure and statin trials. On the basis of such evidence, as well as pragmatic considerations, it is clear that clinicians should place stronger emphasis on lipid and blood pressure management to lessen cardiovascular risks. At the same time, cardiovascular disease benefits of glycaemia reduction appear less pronounced, with patient characteristics critically influencing risk to benefit ratio. Recent guidelines now reflect recent observations on glycaemic control (with relaxed targets in specific patient groups), whereas future guidelines should encourage physicians to prioritize lipid-lowering and blood pressure management in patients with diabetes.

Effectiveness and Safety of Nicardipine and Labetalol Infusion for Blood Pressure Management in Patients with Intracerebral and Subarachnoid Hemorrhage

Nicardipine and labetalol are two commonly used antihypertensives for treating elevated blood pressures in the setting of intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). There are no studies comparing these two agents as continuous infusions. A retrospective chart review was conducted of patients admitted between November 2009 and January 2011 with ICH and SAH to compare effectiveness and safety between both agents. Percent time spent at goal was set as the primary outcome. The secondary outcomes included blood pressure variability, time to goal, incidence of bradycardia, tachycardia, and hypotension. A total of 81 patients were available for analysis, 10 initiated on labetalol (LAB), 57 on nicardipine (NIC), and 14 required the combination of these agents (COMB) to reach goal. We found no difference between NIC, LAB, and the COMB groups in the median percent time at goal [88 % (61-98); 93 % (51-99); 66 % (25-95), (p = NS)]. Median percentage of blood pressure variability, hypotension, and bradycardia were also comparable between groups, however, more tachycardia was observed in the COMB group versus both LAB and NIC groups (45 vs. 0 vs. 3 %; p < 0.001). Mean time to goal SBP in 24 patients who had BP readings available at 1st h of initiation was 32 ± 34 min in the NIC group and 53 ± 42 min in the LAB group (p = 0.03). Both agents appear equally effective and safe for blood pressure control in SAH and ICH during the initial admission hours. A prospective study is needed to validate these findings.

Thiazide and Thiazide-like Diuretics: An Opportunity to Reduce Blood Pressure in Patients with Advanced Kidney Disease

Thiazide and thiazide-like diuretics have been widely used as blood pressure-lowering agents for more than 5 decades. However, their use in patients with advanced chronic kidney disease has been limited and often discouraged. The exact mechanism of how thiazide and thiazide-like diuretics lower blood pressures is still in question. Emerging evidence suggests that thiazides and thiazide-like diuretics are effective as blood pressure-lowering drugs in patients with advanced chronic kidney disease. Review of the literature suggests that physicians should not discard thiazide and thiazide-like diuretics as options for blood pressure management in patients with chronic advanced kidney disease.

Blood Pressure Management in Patients With Chronic Kidney Disease at a Teaching Hospital Ambulatory Clinic

Blood Pressure Management in Patients With Chronic Kidney Disease at a Teaching Hospital Ambulatory Clinic

122 Blood pressure management in patients with chronic heart failure

122 Blood pressure management in patients with chronic heart failure

Urinary Protein as a Marker for Systolic Blood Pressure Reduction in Patients with Type 2 Diabetes Mellitus Participating in an In-Hospital Diabetes Education Program

Increased blood pressure (BP) and urinary protein (UP)/microalbuminuria are risk factors for cardiovascular disease in patients with diabetes. Although the management of BP in patients with diabetes should involve a multidisciplinary therapy, there are no reports in which modulators have been identified in an in-hospital diabetes education program. The aim of the present study was to investigate the change in BP levels in patients with type 2 diabetes mellitus (T2DM) during a short-term (2-week) in-hospital education program on lifestyle modifications. A total of 167 patients with T2DM (101 men, 66 women; mean age, 61.1 years; glycated hemoglobin, 9.2%) were divided into 2 groups on the basis of their urinary albumin levels: 1 group without UP (urinary albumin level < 30 mg/day) and 1 group with UP (urinary albumin level ≥ 30 mg/day). We defined efficacy in reducing BP as a 20-mm Hg reduction in systolic BP (SBP) and a 10-mm Hg reduction in diastolic BP, and compared the changes between the 2 groups. Although the group with UP had higher SBP levels than the group without UP at baseline, this difference disappeared at the end of the program. Adjusted multivariate logistic regression analysis showed that UP at baseline was associated with a reduction in SBP (odds ratio, 3.361; 95% confidence interval, 1.29–8.79; P = 0.013). The data suggest that UP may be a marker related to the management of SBP through lifestyle modifications in patients with T2DM.

A Comparison of Web Sites Used to Manage and Present Home Blood Pressure Readings

Home blood pressure (HBP) monitoring is now recommended as a routine component of blood pressure management in patients with known or suspected hypertension. Over the last few years, a large number of Web sites, commonly termed Personal Health Records, have been developed so that patients can manage and present HBP readings. The objective of this report is to describe and compare these Web sites. A list of 33 desirable Web site features, organized into 4 categories, was developed. Between June and August of 2009, a total of 60 Web sites was identified, of which 20 were free or free to try. Each of the 20 Web sites displayed HBP readings in tabular and graphical formats, most offered an option to print results in tabular (70%) and graphical (70%) form, and many (47%) could download HBP data from Microsoft HealthVault. In contrast, none of the Web sites directly linked with common electronic medical records. Overall, Web sites offered between 41% and 77% of the 33 features considered desirable. In conclusion, there is considerable variation in available features on Web sites used to manage HBP data. Information presented in this report should be useful to physicians and patients in selecting a Web site for managing and presenting HBP readings and ultimately improving blood pressure control.

Role of Vasopressor Administration in Patients with Acute Neurologic Injury

Pharmacologic blood pressure elevation is often utilized to prevent or treat ischemia in patients with acute neurologic injury, and routinely requires administration of vasopressor agents. Depending on the indication, vasopressor agents may be administered to treat hypotension or to induce hypertension. Although numerous guideline statements exist regarding the management of blood pressure in these patients, most recommendations are based largely on Class III evidence. Further, there are few randomized controlled trials comparing vasopressor agents in these patients and selection is often guided by expert consensus. We discuss the clinical evidence regarding vasopressor administration for blood pressure management in patients with acute neurologic injury. The effect of various vasopressors on cerebral hemodynamics is also discussed. Although high-quality clinical data are scarce, the available evidence suggests that norepinephrine should be considered as the vasopressor of choice when blood pressure elevation is indicated in patients with acute neurologic injury.

Aliskiren and valsartan in stage 2 hypertension: subgroup analysis of a randomized, double-blind study

Patients with stage 2 hypertension require large absolute reductions in blood pressure (BP) to achieve recommended BP goals. Combination therapy with the direct renin inhibitor, aliskiren, and the angiotensin receptor blocker, valsartan, has been shown to produce greater BP reductions than either agent alone in a double-blind study in 1797 hypertensive patients. This post-hoc analysis evaluated the BP-lowering efficacy of aliskiren in combination with valsartan in a subset of patients (n=581) with stage 2 hypertension (baseline mean sitting systolic BP [msSBP] > or =160 mmHg). Patients were randomized to receive aliskiren/valsartan 150/160 mg, aliskiren 150 mg, valsartan 160 mg, or placebo once daily for 4 weeks followed by 4 weeks at double the initial dose. Mean changes from baseline in msSBP and mean sitting diastolic BP were assessed at week-8 endpoint (intent-to-treat population). Aliskiren/valsartan 300/320 mg reduced BP from baseline by 22.5/11.4 mmHg at week-8 endpoint. BP reductions with combination therapy were significantly greater than with aliskiren 300 mg (17.3/8.9 mmHg, P<0.05), valsartan 320 mg (15.5/8.3 mmHg, P<0.01), or with placebo (7.9/3.7 mmHg, P<0.0001). BP control rates (<140/90 mmHg) were also significantly higher (P<0.05) with aliskiren/valsartan 300/320 mg (29.8%) compared with either aliskiren 300 mg (19.0%) or valsartan 320 mg (13.8%) monotherapy, or placebo (8.9%). All treatments were generally well tolerated. Combination therapy with aliskiren and valsartan provided significantly greater BP reductions over aliskiren or valsartan monotherapy and is an appropriate option for management of BP in patients with stage 2 hypertension.

A Randomized Trial of the Effect of Community Pharmacist and Nurse Care on Improving Blood Pressure Management in Patients With Diabetes Mellitus

Blood pressure (BP) control in patients with diabetes mellitus is difficult to achieve and current patterns are suboptimal. Given increasing problems with access to primary care physicians, community pharmacists and nurses are well positioned to identify and observe these patients. This study aimed to determine the efficacy of a community-based multidisciplinary intervention on BP control in patients with diabetes mellitus. We performed a randomized controlled trial in 14 community pharmacies in Edmonton, Alberta, Canada, of patients with diabetes who had BPs higher than 130/80 mm Hg on 2 consecutive visits 2 weeks apart. Care from a pharmacist and nurse team included a wallet card with recorded BP measures, cardiovascular risk reduction education and counseling, a hypertension education pamphlet, referral to the patient's primary care physician for further assessment or management, a 1-page local opinion leader-endorsed evidence summary sent to the physician reinforcing the guideline recommendations for the treatment of hypertension and diabetes, and 4 follow-up visits throughout 6 months. Control-arm patients received a BP wallet card, a pamphlet on diabetes, general diabetes advice, and usual care by their physician. The primary outcome measure was the difference in change in systolic BP between the 2 groups at 6 months. A total of 227 eligible patients were randomized to intervention and control arms between May 5, 2005, and September 1, 2006. The mean (SD) patient age was 64.9 (12.1) years, 59.9% were male, and the mean (SD) baseline systolic/diastolic BP was 141.2 (13.9)/77.3 (8.9) mm Hg at baseline. The intervention group had an adjusted mean (SE) greater reduction in systolic BP at 6 months of 5.6 (2.1) mm Hg compared with controls (P = .008). In the subgroup of patients with a systolic BP greater than 160 mm Hg at baseline, BP was reduced by an adjusted mean (SE) of 24.1 (1.9) mm Hg more in intervention patients than in controls (P < .001). Even in patients who have diabetes and hypertension that are relatively well controlled, a pharmacist and nurse team-based intervention resulted in a clinically important improvement in BP. Trial Registration clinicaltrials.gov Identifier: NCT00374270.

Ethnic Disparities in Blood Pressure Management in Patients With Hypertension After the Introduction of Pay for Performance

Little is known about the impact of pay-for-performance incentives on health care disparities. We examined ethnic disparities in the management of hypertension among patients with and without cardiovascular comorbidities after the implementation of a major pay-for-performance incentive scheme in UK primary care. We undertook a population-based, cross-sectional survey of medication prescriptions and blood pressure control among patients with hypertension using electronic medical records from 16 family practices in southwest London. Black patients with hypertension were significantly less likely to achieve an established treatment target for blood pressure control than white or South Asian patients (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-0.99). The prevalence of cardiovascular comorbidities was higher among South Asian patients with hypertension than among their white or black counterparts (41.3% vs 28.5% vs 28.8%). The presence of 2 or more cardiovascular comorbidities was associated with significantly improved blood pressure control among white patients but not among black or South Asian patients (mean systolic blood pressure, -9.4 mm Hg, -0.6 mm Hg, and -1.8 mm Hg, respectively). South Asian patients with poorly controlled hypertension were prescribed fewer antihypertensive medications than their black or white peers (adjusted odds ratio, 0.66; 95% confidence interval, 0.46-0.96). Ethnic disparities in the management of hypertension have persisted in the United Kingdom despite major investment in quality improvement initiatives, including pay for performance. These disparities are particularly marked among patients with multiple cardiovascular conditions.

Using a Multidisciplinary Team and Clinical Redesign to Improve Blood Pressure Control in Patients With Diabetes

Optimal blood pressure (BP) control in patients with diabetes poses a challenge in primary care clinics because of the complexity of the disease and competing patient care demands. We used a multidisciplinary team to standardize and improve hypertension care for patients with diabetes by implementing a visual and action-oriented high BP prompt, collaborative practice agreement, medication intensification protocol, and home BP monitoring machine loan program. Prospective, pre-/poststudy. General medicine clinic affiliated with a large academic healthcare system. Two hundred sixty-three patients with type 2 diabetes mellitus. Hypertension control (ie, BP < 135/80 mm Hg) in patients with diabetes improved from 53.6% to 69.3% (P < .001) after implementing a standardized BP assessment and treatment process. There was also a significant decrease of 4 mm Hg in both the mean systolic and diastolic BPs after the intervention. The improvement in BP control was associated with an increase in the average number of antihypertensive medications from 1.56 to 1.93. The use of a process-oriented clinical redesign and a multidisciplinary team approach resulted in improved BP management in patients with diabetes in a primary care setting.

Characteristics and blood pressure management in patients with and without diabetes in primary care in rural Victoria

Aims/hypothesis This study tested whether diabetic hypertensive patients receive more intensive BP management than hypertensive patients without diabetes. Methods A 12 month retrospective review of BP management was undertaken among 2460 hypertensive patients (335 with diabetes), aged 40–79 years from randomly selected general practices in rural Australia. Results Prevalent diagnosed cardiovascular disease (CVD) was commoner among diabetic than non-diabetic patients (27.2% vs. 16.0%, OR 1.82 (1.39–2.39)). The proportion with a BP < 130/80 mm Hg was low (22.9% vs. 18.6%, p = .069, respectively). BP was monitored more closely among diabetic patients (e.g. quarterly BP measurements in 18.2% vs. 10.5% respectively, p < .001), was treated with more anti-hypertensive agents (1.5 ± 1.0 vs. 1.0 ± 1.0, p < 001) and was more likely to be associated with other CVD medications. Achievement of non-diabetic BP targets was associated with living in the regional centre (vs. smaller rural town: 1.21 (1.02–1.43)) and CVD (1.54 (1.21–1.95)), but not the presence of diabetes (0.94 (0.73–1.19)). Conclusions In this population, hypertension is more aggressively monitored and treated among diabetic than non-diabetic patients, but largely due to their CVD and not to the level recommended in guidelines. Commencing anti-hypertensive treatment earlier (e.g. at diagnosis) and recommending more agents (e.g. in combination) may be needed to improve BP control among diabetic patients on a population basis.

Blood pressure management in patients with acute stroke: Pathophysiology and treatment strategies

Hypertension is one of the key risk factors for development of various forms of vascular disease including ischemic and hemorrlmgic stroke, coronary artery disease, and peripheral vascular disease. Blood pressure (BP) elevation and its treatment have implications for both primary ~md secondary prevention [1] and in the acute management of cardiovascular diseases. In acute myocardial infarction, administration of antihypertensive drugs, especially ~3-blockers and angiotensin-com~erting enzyme (ACE) inhibitors, are incorporated into the treatment algorithms [2-41. In patients with cerebrovascular events, best management strategies remain somewhat tmcertain. Contributing to this uncertainty are the heterogeneity of these conditions, complex interaction between systemic and cerebral circulation, differential involvement of vascular distributions, and limited data from clinical trials.

Blood pressure management in patients with intracerebral and subarachnoid hemorrhage

Derangements in blood pressure (BP) have been associated with the pathophysiology of both subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH). Although there are few high-quality studies regarding optimal BP management in these conditions, mounting data support a critical role for BP in modulating the extent of acute brain injury in these patients. We undertook this review of the literature to identify the best current data regarding BP management in SAH and ICH.

Acute Chemotherapy-Induced Cardiovascular Changes in Patients With Testicular Cancer: Are There Implications for Blood Pressure Management in Patients Receiving Chemotherapy?

Acute Chemotherapy-Induced Cardiovascular Changes in Patients With Testicular Cancer: Are There Implications for Blood Pressure Management in Patients Receiving Chemotherapy?

Clinical Decision-Making in Blood Pressure Management of Patients with Diabetes Mellitus: An Oklahoma Physicians Resource/Research Network (OKPRN) Study

Outcomes can be improved when the blood pressure (BP) is kept below 130/80 in patients with diabetes mellitus. However, physicians and patients achieve this target less than 50% of the time. The purpose of this study was to determine the reasons for this apparent quality deficit from the perspective of a small random sample of family physicians. Nine family physicians completed interviews about encounters with diabetic patients with BP >or=130/80 for whom no change in management was recorded. Four investigators analyzed the transcribed interviews to identify and categorize reasons for failure to intervene. Ninety-eight (62%) of 159 patients had BP >or=130/80 at the index visit. No change in management was recorded in 73 (74%). Physicians gave 175 reasons for nonintervention in 3 broad categories, physician-related, patient-related, and information/measurement-related reasons, and 10 subcategories. In most cases they gave more than one reason (mean 2.4) per case. The most frequent subcategories were limited treatment options (47/73; 64%), inadequate information on which to intervene (43/73; 59%), and patient nonadherence (27/73; 37%). Competing demands were mentioned in 10 cases (13.7%). Physicians differed with regard to the kinds of reasons given. Physicians have a variety of clinical reasons for not responding to elevated BP in diabetic patients. Some might be addressed with better technology (eg, more reliable BP measurements) or health care system reforms (eg, less expensive medications). Others (eg, patient nonadherence) are more challenging. Methods for measuring quality must be robust enough to account for legitimate clinical reasons for not achieving BP targets. Physician-based interventions will need to take into account different physician personalities and practice styles.

Dynamic Cerebral Autoregulation in Patients with Ruptured and Unruptured Aneurysms after Induction of General Anesthesia

Blood pressure management in patients undergoing surgery for clipping of aneurysms is demanding. More information about the ability of cerebral vessels to normally regulate cerebral blood flow may have a direct influence on the intraoperative management. In patients with subarachnoid hemorrhage (SAH) a disturbance of cerebral autoregulation has been reported and it correlated with the severity of the bleeding in these studies. The impairment of autoregulation was demonstrated using static measurements of cerebral pressure autoregulation. However, the dynamic component of the autoregulatory capacity seems to be of importance in the acute setting after SAH. The aim of this study was to evaluate dynamic pressure autoregulation in patients undergoing surgery for intracranial aneurysms. 36 patients with a mean age of 45 years were evaluated, 26 patients with acute SAH, 10 patients with unruptured aneurysms. Cerebral autoregulation in normocapnia was tested using thigh cuffs to alter arterial blood pressure and continuous registration of the blood flow velocities with transcranial Doppler sonography. After the induction of general anesthesia under normocapnia the autoregulatory index (ARI) was calculated (values between 0-9). Patient groups were compared using Wilcoxon- and Spearman's rank test. The two patient groups were comparable with regard to gender, age, PaCO(2), blood flow velocities and blood pressure. In patients with SAH mean ARI was 3.1/3.3 (right/left side) compared to 4.7/4.6 (right/left side) in patients without SAH. The difference was statistically significant (Wilcoxon p = 0.0399). The degree of impairment of the autoregulatory capacity increased significantly (p = 0.006) with the severity of the SAH (Hunt&Hess and Fisher scale). Dynamic pressure autoregulation is impaired in patients after SAH compared to patients without SAH and correlates with the severity of the SAH. We propose that autoregulation should be measured in all patients with SAH or that an impaired autoregulation should be taken into account in patients with SAH undergoing surgery in the acute phase.

Effect of a polyphenoics extracts of Grape Seeds (GSE) on Blood Pressure(BP) in patients with the Metabolic Syndrome (MetS)

Effect of a polyphenoics extracts of Grape Seeds (GSE) on Blood Pressure(BP) in patients with the Metabolic Polyphenolic compounds in grape seeds are potent anti-oxidants which cause a NO mediated endothelium dependent relaxation of blood vessels. The present study was undertaken to determine whether a GSE lowers BP in subjects with the MetS . The GSEs which was manufactured by Polyphenolics Inc. (Madera, CA) contains ~95% phenolic compounds and is low gallate units. 24 subjects with MetS (NCEP III) were randomized into 3 groups (n=8) and given either a placebo, 150 mg/day or 300 mg/day of the extract. A 12 hour ambulatory BP recording was made at the start of the study and after 4 weeks of treatment. Serum lipids, blood glucose, plasma insulin and oxidized LDL were measured at the start and end of the study. Oxidized LDL was measured using an ELISA (Mercodia Inc, Uppsala, Sweden). After 4 weeks subjects receiving both 150 mg and 300 mg of GSEs significantly lowered their BP while those on placebo showed no significant change (p < 0.05, ANOVA). The fasting blood glucose, plasma insulin, serum lipids and plasma oxidized LDL concentrations were unchanged. Insulin resistance as determined by the homeostasis model was elevated in all 3 groups but did not change with treatment. It is suggested that the GSE used in the present study which has been granted GRAS status by the FDA, is a potentially useful nutraceutical compound for the management of BP in patients with Met S.

The challenge of blood pressure control in patients with ischaemic heart disease in Europe

The goal of the paper is to summarize the current status of blood pressure management in patients with ischaemic heart disease. Recently published results from Europe and North America showed that about half of ischaemic heart disease patients have their blood pressure over 140/90 mmHg. Moreover, these data provide further evidence that poor hypertension management is common in a variety of healthcare settings. Although most ischaemic heart disease patients receive blood pressure‐lowering drugs, still a large proportion of them does not reach the recommended treatment goals. During recent years, several attempts were made to improve the control of risk factors (among them blood pressure) in patients with ischaemic heart disease; however, none of them was definitively successful.