Blood Pressure-lowering Medication Research Articles

Determination of Patient Characteristics and Role of Physician Intervention for Uncontrolled Hypertension: A Risk for Coronary Artery Disease

Objective: Our research was designed to evaluate the association of uncontrolled hypertension with coronary artery disease and analyze the role of intervention in preventing CAD mortality ratio.
 Methodology: This case controlled single-center study was conducted in department of Medicine, Peoples University of Medical and Health Sciences Nawabshah Pakistan from January 2020 to September 2021. In this study, BP screening was done among the adult population aged 50 years or over. All the recruited patients of coronary artery disease were divided into two main groups for a clinical trial; case (identified cases of uncontrolled hypertension) and the control group (without history of cardiovascular disorders and used medication for hypertension). For evaluating physician intervention, both groups were divided into two main groups for treatments; the standard Bp control (having <140 mm Hg SBP level) and the intensive blood pressure control (whose SPB <120 mm Hg). we used BP-lowering medication which adjusted the systolic blood pressure around 135–139 mm Hg in the standard group and less than 120 in intensive group.
 Results: Overall the female prevalence was comparatively high (63.2%) than males (37%). No significant differences were found in the baseline characteristics of participants. In 42% of cases, we found coronary artery calcification. Univariate logistic analysis of our study demonstrates the association of CAD with age, smoking, and BMI. We also found a positive association of CAD with higher CRP, and uncontrolled hypertension.
 Conclusion: Our study observed a significant association between uncontrolled hypertension and coronary artery disease. The results of our study concluded that interventions in terms of BP control might be affected due to pre-existing cardiovascular diseases. However, intensive BP treatment would help to reduce the mortality ratio of CAD patients.

Incorporation of Retinal Arteriolosclerosis into Risk Stratification of Blood Pressure Category According to the 2017 ACC/AHA Blood Pressure Guideline

Aim: We investigated whether retinal arteriolosclerosis (RA) could be used for cardiovascular disease (CVD) risk stratification of individuals categorized according to the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) Blood Pressure (BP) guideline. Methods: We studied 291,522 participants without a history of CVD and not taking any BP-lowering medications from the JMDC Claims Database. RA was defined as Keith–Wagener–Barker system grade ≥ 1. Each participant was classified into one of the six groups: (1) normal or elevated BP without RA, (2) normal or elevated BP with RA, (3) stage 1 hypertension without RA, (4) stage 1 hypertension with RA, (5) stage 2 hypertension without RA, and (6) stage 2 hypertension with RA. Results: Median (interquartile range) age was 46 (40–53) years, and 141,397 (48.5%) of the participants were men. During a mean follow-up of 1,223±830 days, 527 myocardial infarction (MI), 5,718 angina pectoris, 2,890 stroke, and 5,375 heart failure (HF) events occurred. Multivariable Cox regression analyses revealed that the risk of CVD increased with BP category, and this association was pronounced by the presence of RA. Compared with normal or elevated BP without RA, the hazard ratios (HRs) for MI (HR 1.17, 95% CI 0.93–1.47) were higher in stage 1 hypertension without RA. The HRs for MI further increased in stage 1 hypertension with RA (1.86 [1.17–2.95]). This association was present in stroke and HF. Conclusion: Incorporation of the assessment for RA may facilitate the CVD risk stratification of people classified based on the 2017 ACC/AHA BP guideline, particularly for those categorized in stage 1 hypertension.

Long-term trends in blood pressure and hypertension in Russia: an analysis of data from 14 health surveys conducted in 1975\u20132017

BackgroundHypertension is recognized as an important contributor to high cardiovascular mortality in Russia. A comprehensive analysis of data from Russian studies that measured blood pressure in population-based samples has not been previously undertaken. This study aims to identify trends and patterns in mean blood pressure and the prevalence of hypertension in Russia over the most recent 40 years.MethodsWe obtained anonymized individual records of blood pressure measurements from 14 surveys conducted in Russia in 1975–2017 relating to a total of 137,687 individuals. For comparative purposes we obtained equivalent data from 4 surveys in the USA and England for 23,864 individuals. A meta-regression on aggregated data adjusted for education was undertaken to estimate time trends in mean systolic and diastolic blood pressure, the prevalence of elevated blood pressure (> 140/90 mmHg), and hypertension (defined as elevated blood pressure and/or the use of blood pressure-lowering) medication. A meta-analysis of pooled individual-level data was used to assess male-female differences in blood pressure and hypertension.ResultsDuring the period 1975–2017 mean blood pressure, the prevalence of elevated blood pressure and hypertension remained stable among Russian men. Among Russian women, mean systolic blood pressure decreased at an annual rate of 0.25 mmHg (p < 0.1) at age 35–54 years and by 0.8 mmHg (p < 0.01) at ages 55 and over. The prevalence of elevated blood pressure also decreased by 0.8% per year (p < 0.01), but the prevalence of hypertension remained stable. Mean blood pressure and prevalence of hypertension were higher in Russia compared to the USA and England at all ages and for both sexes.ConclusionsIn contrast to the generally observed downward trend in elevated blood pressure in many other countries, levels in Russia have changed little over the past 40 years, although there are some positive trends among women. Improved strategies to bring down the high levels of mean blood pressure and hypertension in Russia compared to countries such as England and the USA are important to further reduce the high burden of CVD in Russia.

Abstract 9893: Polypills for Primary Prevention of Cardiovascular Disease: A Systematic Review and Meta-Analysis of Clinical Trials

Background: Single pills with fixed-dose combinations (FDC) of lipid and blood pressure lowering medications have been proposed for the treatment of cardiovascular disease. Although polypills have proven to be effective in secondary prevention of major cardiovascular events, there is a lack of evidence regarding polypill use in primary prevention in intermediate and high-risk patients. This systematic review and meta-analysis was conducted to evaluate the effect of polypills on primary prevention of cardiovascular (CV) events using data from clinical trials. Methods: We searched Pubmed, Web of Science, EBSCO, and SCOPUS through May 2021. Two authors independently screened articles for fulfillment of inclusion criteria. The RevMan (version 5.4) software was used to calculate the pooled risk ratios (RRs) and mean differences (MDs), along with their associated confidence intervals (95% CI). Results: Eight trials with a total of 20653 patients were included. There was a significant reduction in total fatal and non-fatal CV events among the polypill group [RR (95% CI) = 0.71 (0.63, 0.80); P &lt; 0.001]. Moreover, this reduction was present for both the intermediate [RR (95% CI) = 0.76 (0.65, 0.89); P &lt; 0.001] and high-risk [RR (95% CI) = 0.63 (0.52, 0.76); P &lt; 0.001] group of patients. Subgroup analysis based on the follow up duration revealed this benefit was only evident in the five-year follow up duration group [RR (95% CI) = 0.70 (0.62, 0.79); P&lt; 0.001] and was absent in the one-year or less interval group [RR (95% CI) = 0.77 (0.47, 1.29); P= 0.330]. Furthermore, there was a significant reduction in 10-year predicted cardiovascular risk in the polypill group [MD (95% CI) = -3.74 (-5.96, -1.51); P&lt; 0.001] compared to controls. Conclusion: A polypill strategy decreases the incidence of fatal and non-fatal CV events in patients with intermediate and high cardiovascular risk and may be an effective component in the care of these patients.

The relationship of socioeconomic factors to the use of preventative cardiovascular disease medications: A prospective Australian cohort study

Cardiovascular disease (CVD) events are highly preventable through appropriate treatment and disproportionally affect socioeconomically disadvantaged individuals. This study quantified the relationship of socioeconomic factors to dispensing and persistent use of lipid- and blood pressure-lowering medication following hospital admission for a major CVD event (myocardial infarction, ischaemic stroke/transient ischaemic attack). Data from 8285 people with such events aged ≥45 years from the Australian 45 and Up Study with linked medication data were used to estimate relative risks (RRs) for combined lipid- and blood pressure-lowering dispensing at three-months following hospital discharge and for 12-month persistent use, in relation to education, income, and level of medication subsidisation. Overall, 56% were dispensed guideline-recommended medications at three months and 37% persistently used them across 12 months. After adjusting for demographic factors, type of CVD and history of CVD hospitalisation, RRs for lowest (no educational qualifications) compared to highest education level (university degree) were 1.14 (95% CI: 1.06, 1.22) for medication dispensing and 1.15 (1.02, 1.29) for persistent medication use; 1.14 (1.06, 1.22) and 1.17 (1.04, 1.32) respectively for lowest (<$20,000) versus highest (≥$70,000) household pre-tax income; and 1.25 (1.17, 1.33) and 1.28 (1.15, 1.43) respectively for those receiving highest versus lowest subsidisation. There was little to no evidence of a relationship of income and education to medication use after adjustment for medication subsidisation. While preventive medication use is sub-optimal, subsidisation is substantially associated with increased use and accounts for most of the relationship with socioeconomic position, suggesting subsidy schemes are working in the intended direction.

Blood pressure lowering and risk of new-onset type 2 diabetes: an individual participant data meta-analysis

SummaryBackgroundBlood pressure lowering is an established strategy for preventing microvascular and macrovascular complications of diabetes, but its role in the prevention of diabetes itself is unclear. We aimed to examine this question using individual participant data from major randomised controlled trials.MethodsWe performed a one-stage individual participant data meta-analysis, in which data were pooled to investigate the effect of blood pressure lowering per se on the risk of new-onset type 2 diabetes. An individual participant data network meta-analysis was used to investigate the differential effects of five major classes of antihypertensive drugs on the risk of new-onset type 2 diabetes. Overall, data from 22 studies conducted between 1973 and 2008, were obtained by the Blood Pressure Lowering Treatment Trialists’ Collaboration (Oxford University, Oxford, UK). We included all primary and secondary prevention trials that used a specific class or classes of antihypertensive drugs versus placebo or other classes of blood pressure lowering medications that had at least 1000 persons-years of follow-up in each randomly allocated arm. Participants with a known diagnosis of diabetes at baseline and trials conducted in patients with prevalent diabetes were excluded. For the one-stage individual participant data meta-analysis we used stratified Cox proportional hazards model and for the individual participant data network meta-analysis we used logistic regression models to calculate the relative risk (RR) for drug class comparisons.Findings145 939 participants (88 500 [60·6%] men and 57 429 [39·4%] women) from 19 randomised controlled trials were included in the one-stage individual participant data meta-analysis. 22 trials were included in the individual participant data network meta-analysis. After a median follow-up of 4·5 years (IQR 2·0), 9883 participants were diagnosed with new-onset type 2 diabetes. Systolic blood pressure reduction by 5 mm Hg reduced the risk of type 2 diabetes across all trials by 11% (hazard ratio 0·89 [95% CI 0·84–0·95]). Investigation of the effects of five major classes of antihypertensive drugs showed that in comparison to placebo, angiotensin-converting enzyme inhibitors (RR 0·84 [95% 0·76–0·93]) and angiotensin II receptor blockers (RR 0·84 [0·76–0·92]) reduced the risk of new-onset type 2 diabetes; however, the use of β blockers (RR 1·48 [1·27–1·72]) and thiazide diuretics (RR 1·20 [1·07–1·35]) increased this risk, and no material effect was found for calcium channel blockers (RR 1·02 [0·92–1·13]).InterpretationBlood pressure lowering is an effective strategy for the prevention of new-onset type 2 diabetes. Established pharmacological interventions, however, have qualitatively and quantitively different effects on diabetes, likely due to their differing off-target effects, with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers having the most favourable outcomes. This evidence supports the indication for selected classes of antihypertensive drugs for the prevention of diabetes, which could further refine the selection of drug choice according to an individual's clinical risk of diabetes.FundingBritish Heart Foundation, National Institute for Health Research, and Oxford Martin School.

The 10-year incidence of hypertension across blood pressure categories in a population-based cohort in southwestern Sweden

BackgroundTo explore the determinants of incident hypertension, and especially the impact of baseline blood pressure categories, in a representative Swedish population.MethodsA 10-year longitudinal study of residents aged 30–74. Blood pressures were measured and categorized according to ESH guidelines with optimal blood pressure < 120/80 mmHg, normal 120–129/80–84 mmHg, and high normal 130–139/85–89 mmHg. Incident hypertension was defined as ongoing treatment or three consecutive blood pressure readings ≥ 140/ ≥ 90 mmHg (one or both) at follow-up, while those with ≥ 140 and/or ≥ 90 mmHg at only one or two visits were labelled as unstable. After excluding subjects with hypertension, ongoing blood pressure lowering medication or a previous CVD event at baseline, 1099 remained for further analyses.ResultsSixteen (2.6%) subjects with optimal baseline blood pressure had hypertension at follow up. Corresponding numbers for subjects with normal, high normal and unstable blood pressure were 55 (19.4%), 50 (39.1%) and 46 (74.2%), respectively. Compared with subjects in optimal group those in normal, high normal and unstable blood pressure categories had significantly higher risk to develop manifest hypertension with odds ratios OR and (95% CI) of 7.04 (3.89–12.7), 17.1 (8.88–33.0) and 84.2 (37.4–190), respectively, with adjustment for age, BMI and family history for hypertension. The progression to hypertension was also independently predicted by BMI (p < 0.001), however, not by age.ConclusionsSubjects with high normal or unstable blood pressure should be identified in clinical practice, evaluated for global hypertension risk and offered personalized advice on lifestyle modification for early prevention of manifest hypertension and cardiovascular disease.

Blood pressure response during treadmill exercise testing and the risk for future cardiovascular events and new-onset hypertension

Abstract Background Although there is a diminishing role of exercise stress testing (EST) in the diagnostic assessment of coronary heart disease, the physiologic response to exercise may provide valuable prognostic information. We aimed to investigate the association of repeated blood pressure (BP) measurements during EST with long-term risk of myocardial infarction, stroke or death (MACE), as well as the development of new-onset hypertension. Methods Retrospective analysis of EST performed between the years 2005–2019 in a single center according to Bruce protocol. Included were patients aged 35–75 years without a history of cardiovascular disease (n=14,792; 48% women). BP was documented at rest, submaximal exercise (Bruce stage-2), peak exercise and recovery (2 minutes). Association of BP measures with study outcomes during a median follow-up of 78 months was investigated. Results An increment of 10-mmHg in rest, submaximal, peak and recovery systolic BP was each associated with a significant increase in the hazard ratio (HR) and 95% confidence interval (CI) for MACE: 1.09 (1.04–1.14), 1.06 (1.01–1.10), 1.04 (1.01–1.08), and 1.06 (1.02–1.10), respectively, after adjustment including exercise capacity, medications and resting BP. The association between SBP at submaximal exercise and recovery with MACE had a J-shaped appearance (Figure). Among non-hypertensive patients without BP lowering medications (n=8,529), 13% were diagnosed with new-onset hypertension during follow-up. Excessive systolic BP response to peak exercise (≥190 mmHg in women and ≥210 mmHg in men) was an independent predictor of future hypertension [HR (95% CI)]: 1.87 (1.41–2.48), as were systolic BPs during submaximal exercise [&amp;gt;160 vs. ≤130 mmHg: 2.44 (1.97–3.03)] and recovery [≥140 vs. ≤120 mmHg: 1.65 (1.37–1.98)], showing gradual, incremental association with the risk for developing hypertension. Conclusions BP measurement during exercise and recovery phases of treadmill testing provides incremental prognostic information regarding long-term risk for cardiovascular events and the probability for developing future hypertension. Funding Acknowledgement Type of funding sources: None.

Heart rate variability and incident type 2 diabetes mellitus

Abstract Background Hyperglycemia and autonomic dysfunction are bidirectionally related. The implications from former cross-sectional studies regarding the association of autonomic dysfunction and diabetes are limited due to the potential reverse causation. We aimed to investigate the association of longitudinal evolution of heart rate variability (HRV) with incident type 2 diabetes mellitus (T2D) among the general population. Methods Using data from the prospective population-based cohort study, 7630 participants with available repeated assessments of HRV, who were free of T2D and atrial fibrillation, were included. Measurements of HRV were analyzed from standard 10-s electrocardiograms records, including heart rate and two time-domain HRV markers: the heart-rate corrected standard deviation of the normal-to-normal RR intervals (SDNNc) and heart-rate corrected root mean square of successive RR-interval differences (RMSSDc). Joint models with the Bayes approach were performed to assess the associations between longitudinal evolutions of heart rate and different HRV metrics with incident T2D during follow-up. Models were adjusted for age, sex, body mass index, smoking status, systolic blood pressure, total and high-density lipoprotein cholesterol, use of blood pressure-lowering or lipid-lowering medication, and prevalent cardiovascular disease. Spearmen correlation was used to examine the associations between HRV metrics and glycemic traits (fasting blood glucose, insulin, and homeostatic model assessment of insulin resistance (HOMA-IR) and beta-cell function (HOMA-β)) at baseline. Results During a median follow-up time of 8.6 years, 871 individuals developed T2D. Based on joint models, one standard deviation (SD) increment of heart rate (hazard ratio [HR], 1.21; 95% CI, 1.09–1.34), log(SDNNc) (HR, 1.10; 95% CI, 0.94–1.27), and log(RMSSDc) (HR, 1.15; 95% CI, 1.02–1.31) was associated with the risk of developing T2D in fully-adjusted models. Subgroup analyses suggested stronger associations among men. The HRs of incident T2D per SD increment were 1.25 (1.09, 1.43) for men and 1.16 (0.99, 1.35) for women for heart rate, 1.23 (1.01, 1.51) for men and 0.97 (0.78, 1.20) for women for log(SDNNc), and 1.24 (1.05, 1.48) for men and 1.09 (0.89, 1.31) for women for log(RMSSDc). Results did not change after excluding participants who were prediabetes at baseline or after exclusion of underweight participants. Spearmen correlation indicated that heart rate was significantly associated with baseline glycemic traits, while RMSSDc was only related to fasting blood glucose. Conclusion Our study suggests that both higher heart rate and heart rate variability are associated with an increased risk of T2D development, especially among men. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Erasmus MC and Erasmus University Rotterdam; Netherlands Organization for Scientific Research; Netherlands Organization for Health Research and Development (ZonMw); Research Institute for Diseases in the Elderly; Netherlands Genomics Initiative; Netherlands Ministry of Education, Culture and Science; Netherlands Ministry of Health, Welfare and Sports; European Commission; and Municipality of Rotterdam. We would like to thank the China Scholarship Council for the scholarship to K.W. Forest plot

A COMPARATIVE EXPECTED VALUE ANALYSIS STUDY TO DETERMINE IF THE ECONOMIC BENEFITS OF THE MOST COMMONLY PRESCRIBED PRESCRIPTION AND NON-PRESCRIPTION DRUGS IN THE UNITED STATES PROVIDE ECONOMIC VALUE

It was found that anti-biotics, aspirin, bisphosphonates, blood pressure lowering medications, statins, medications treating depression, diabetes, sexual dysfunction and the poly-pill provided economic value, while medications to treat Alzheimer’s, cancer, multiple sclerosis and Clopidogrel were not found to have provided economic value. The current evidence is insufficient to determine if weight loss medication provides economic value or not

Eating before bed and new-onset hypertension in a Japanese population: the Iki city epidemiological study of atherosclerosis and chronic kidney disease.

The aim of this study was to determine the relationship between eating before bed and the development of hypertension in a general Japanese population. We conducted a population-based retrospective cohort study using annual health check-up data collected from the residents of Iki City, Nagasaki Prefecture, Japan. In total, 2930 participants without hypertension at baseline (mean age 57.0 years, male 42.8%) were included in the present analysis. Eating before bed was defined as eating within 2 h of bedtime. The outcome of this study was incident hypertension (blood pressure ≥140/90 mmHg or initiation of blood pressure-lowering medications). Multivariable-adjusted hazard ratios and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models. During an average follow-up of 4.5 years, 909 participants developed hypertension. The incidence (per 1000 person-years) of hypertension in the group of individuals who ate before bed was 82.8, whereas that in the group of individuals who did not eat before bed was 65.8. The association was significant even after adjusting for other risk factors, including age, sex, current smoking status, current alcohol intake, regular exercise, obesity, elevated blood pressure, diabetes mellitus, and dyslipidemia, with a hazard ratio of 1.23 (95% CI: 1.05-1.44) for the group of individuals who ate before bed compared with the group of individuals who did not eat before bed (P = 0.01 for trend). Eating before bed was correlated with a future risk of developing hypertension in the general Japanese population.

“Polypills” Are Broadly Effective for Primary Cardiovascular Disease Prevention in Patients with Excess Risk

“Polypills” — fixed-dose pills that contain two or more blood pressure–lowering medications plus a statin, with or without aspirin — have improved

Abstract P130: The Use Of A Digital Telehealth Platform To Understand The Prevalence And Control Of Hypertension In The Indian Population - A Proof Of Concept Study

Introduction: Despite the enormous burden of cardiovascular disease (CVD) in India, there is still lack of awareness about the importance of guideline-based risk factor (RF) management. Objective: Understand the feasibility &amp; utilization pattern of an open-to-public digital health (mHealth) platform designed to assess CVD risk and RFs, and provide appropriate education and guidance. Methods: Data was collected over 1 month through the mHealth platform that was open to all adults aged 25-80 years. It was accessible at no cost via all web browsers on smart phones, computers &amp; tablets with internet connectivity and in 2 languages. Platform utilization was higher in males - 93.7% (251/268) respondents. Therefore, the study population comprised 251 males (age 45.4 + 11.7 yrs). Females were not included due to the small sample size; the corresponding results will be published once adequate sample is reached. Results: Hypertension (HTN) was the most commonly reported RF - 152 (60.5%) of subjects. Of these, 128 (84.2%) reported taking &gt;=1 BP lowering medications. However, BP control was poor with only 26.6% (34/128) of those on BP medications and 4.2% (1/24) of those not on medications reporting BP &lt;130/80 mm Hg. Out of 99 subjects without history of HTN, 21.2% and 28.3% met criteria for diagnosis of HTN and high normal BP, respectively. 151 (99.3%) of subjects had at least 1 other CVD RF - 50% hyperlipidemia, 47.4% diabetes mellitus, 16.4% prediabetes, 57.2% sedentary lifestyle, 24.3% active smoking, 61.2% obesity. Conclusion: The use of a mHealth tool for HTN is feasible and reveals a large unmet need. Next Steps Assessing use of this tool to improve HTN control through lifestyle changes and compliance.

Lowering Nighttime Blood Pressure With Bedtime Dosing of Antihypertensive Medications: Controversies in Hypertension - Con Side of the Argument.

Lowering Nighttime Blood Pressure With Bedtime Dosing of Antihypertensive Medications: Controversies in Hypertension - Con Side of the Argument.

267Cardiovascular preventive pharmacotherapy stratified by cardiovascular risk in a complete New Zealand primary prevention population

Abstract Background Many countries, including Aotearoa/New Zealand, have guidelines recommending cardiovascular disease (CVD) management based on predicted risk. We conducted the first study to examine CVD preventive pharmacotherapy, stratified by CVD risk, within a complete national primary prevention population. Methods Anonymised individual-level linkage of New Zealand administrative health and non-health data identified 2,250,201 individuals without atherosclerotic CVD, alive and aged 30-74 years on 31/03/2013. We identified individuals with ≥1 dispensing by community pharmacies of blood pressure lowering (BPL) and/or lipid lowering (LL) medications at baseline (1/10/2012-31/3/2013) and in 6-month periods between 1/04/2013-31/03/2016. Individuals were stratified by 5-year CVD risk. Results One quarter of individuals had ≥5% 5-year risk (current New Zealand guideline threshold for considering preventive medications) and 5% met the ≥15% risk threshold for recommended dual therapy. Baseline dual therapy varied according to 5-year risk: 1% with &amp;lt;5%, 15% with 5-9%, 31% with 10-14% and 47% with ≥15% risk. Among those dispensed baseline dual therapy, 83%-89% across risk strata were still treated after three years. Initiation of dual therapy during follow-up occurred among only 13% of high-risk individuals; people without diabetes and those aged ≥65 years were more likely to remain untreated. There were few differences in treatment maintenance across clinical/demographic sub-groups. Conclusions CVD primary preventive pharmacotherapy was strongly associated with CVD risk and, once commenced, was generally continued. However, only half of high-risk individuals received recommended dual therapy and treatment initiation was modest. Key messages Individually-linked administrative datasets can identify clinically-relevant quality improvement opportunities for an entire national population.

Blood Pressure Limbo-How Low Can You Go?

Hypertension is one of the leading causes of death worldwide (1). In 2019, 20.3% of all adult female deaths and 18.2% of all adult male deaths were attributed to high systolic blood pressure (SBP) globally (1). Population-based surveys from diverse settings have shown that many adults with high blood pressure (BP) are not appropriately diagnosed (2). This represents a failure of health systems, particularly when it is known that BP-lowering medications significantly reduce cardiovascular disease (CVD) events among hypertensive patients (3). Furthermore, those patients who are diagnosed are nonetheless often undertreated and not at the recommended BP target. Recent guidelines recommend lower BP targets than ever before, resulting in an increasingly urgent need to address the widespread undertreatment of hypertension. For people on BP-lowering medication, the 2017 American College of Cardiology/American Heart Association guidelines for hypertension recommend targeting a BP goal of <130/80 mmHg for all hypertensive patients including patients with diabetes (4). The 2018 European Society of Cardiology guidelines recommend targeting a BP of <130/80 mmHg in most treated patients, as long as such treatment is well tolerated, and targeting an SBP in the range of 120–129 mmHg in patients <65 years of age (5). These more intensive treatment recommendations were informed by randomized clinical trial (RCT) data (6) but also by a wealth of epidemiologic data (7). However, the data informing BP targets for patients with diabetes are somewhat mixed, which contributed to the 2021 American Diabetes Association recommendation to use a CVD risk calculator prior to determining the appropriate BP target for individuals with diabetes. A target of <130/80 mmHg is reserved for patients with a 10-year CVD risk of ≥15%, while a target of <140/90 mmHg is advised for individuals at lower risk (8). These different guideline recommendations reflect the ongoing uncertainty in the balance …

Effect of blood pressure lowering drugs and antibiotics on abdominal aortic aneurysm growth: a systematic review and meta-analysis

ObjectiveThere is currently no medical treatment proven to limit abdominal aortic aneurysm (AAA) progression. The aim of this systematic review and meta-analysis was to pool data from previous randomised controlled...

The Nourish Protocol: A digital health randomized controlled trial to promote the DASH eating pattern among adults with hypertension

IntroductionOver 100 million adults in the United States have hypertension. The DASH (Dietary Approaches to Stop Hypertension) eating pattern is an evidence-based first-line treatment option for hypertension; however, adherence to the DASH eating pattern at a population level remains low. To address this gap, we will implement Nourish, a randomized controlled efficacy trial that will leverage a commercially-available smartphone application and evidence-based behavior change principles to improve adherence to the DASH eating pattern among adults with hypertension. MethodsThe Nourish trial is a two-arm, 12-month randomized control trial that will enroll adults (N = 300) with hypertension, defined as a systolic blood pressure of 120–159 mmHg; a diastolic blood pressure of 80–99 mmHg; and/or adults on blood pressure-lowering medication. Nourish will test the efficacy of a digital health intervention, as compared to the attention control arm, on DASH eating pattern adherence and blood pressure. Intervention components will include skills training, self-monitoring, personalized feedback, and responsive coaching. The primary outcome of the trial is 6-month changes in adherence to the DASH eating pattern, as measured by 24-h dietary recalls. DiscussionMillions of Americans remain in need of effective behavioral interventions to manage and improve their hypertension and its adverse consequences. The ubiquity of smartphones offers a promising approach to disseminate the DASH eating pattern. By leveraging these widely used smartphone applications, combined with evidence-based behavior change principles and the DASH eating plan, Nourish will demonstrate the effectiveness of a digital health intervention to improve DASH adherence, and ultimately, to reduce blood pressure.Trial Number: NCT03875

Targeting Hypertension Screening in Low- and Middle-Income Countries: A Cross-Sectional Analysis of 1.2Million Adults in 56 Countries.

BackgroundAs screening programs in low‐ and middle‐income countries (LMICs) often do not have the resources to screen the entire population, there is frequently a need to target such efforts to easily identifiable priority groups. This study aimed to determine (1) how hypertension prevalence in LMICs varies by age, sex, body mass index, and smoking status, and (2) the ability of different combinations of these variables to accurately predict hypertension.Methods and ResultsWe analyzed individual‐level, nationally representative data from 1 170 629 participants in 56 LMICs, of whom 220 636 (18.8%) had hypertension. Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or reporting to be taking blood pressure–lowering medication. The shape of the positive association of hypertension with age and body mass index varied across world regions. We used logistic regression and random forest models to compute the area under the receiver operating characteristic curve in each country for different combinations of age, body mass index, sex, and smoking status. The area under the receiver operating characteristic curve for the model with all 4 predictors ranged from 0.64 to 0.85 between countries, with a country‐level mean of 0.76 across LMICs globally. The mean absolute increase in the area under the receiver operating characteristic curve from the model including only age to the model including all 4 predictors was 0.05.ConclusionsAdding body mass index, sex, and smoking status to age led to only a minor increase in the ability to distinguish between adults with and without hypertension compared with using age alone. Hypertension screening programs in LMICs could use age as the primary variable to target their efforts.

Systematic review and quality evaluation of published human ingestion-time trials of blood pressure-lowering medications and their combinations

ABSTRACT The pharmacokinetics (PK) – absorption, distribution, metabolism, and elimination – and pharmacodynamics (PD) of hypertension medications can be significantly affected by circadian rhythms. As a consequence, the time when blood pressure (BP) lowering medications are ingested, with reference to the staging of all involved circadian rhythms modulating PK and PD, can affect their duration of action, magnitude of effect on features of the 24 h BP profile, and safety. We conducted a systematic and comprehensive review of published prospective human trials that investigated individual hypertension medications of all classes and their combinations for ingestion-time differences in BP-lowering, safety, patient adherence, and markers of hypertension-associated target organ pathology of the kidney and heart. The systematic review yielded 155 trials published between 1976 and 2020 – totaling 23,972 hypertensive individuals – that evaluated 37 different single and 14 dual-combination therapies. The vast (83.9%) majority of them reported clinically and statistically significant benefits – including enhanced reduction of asleep BP mean without induced sleep-time hypotension, reduced prevalence of the higher cardiovascular risk non-dipper 24 h BP profile, decreased incidence of adverse effects, improved kidney function, and reduced cardiac pathology – when hypertension medications are ingested at-bedtime/evening rather than upon-waking/morning. Nonetheless, the findings and conclusions of some past conducted trials are inconsistent, often due to disparities and deficiencies of the investigative protocols. Accordingly, we developed a quality assessment method based upon the eight items identified as crucial according to the recently published guidelines of the International Society for Chronobiology and the American Association for Medical Chronobiology and Chronotherapeutics for the design and conduct of human clinical trials on ingestion-time differences of hypertension medications. Among the most frequent deficiencies are: absence or miscalculation of minimum required sample size (83.2%), incorrect choice of primary BP endpoint (53.6%), and inappropriate arbitrary and unrepresentative clock hours chosen for tested treatment times (53.6%). The inability of the very small proportion (16.1%) of trials to verify the advantages of the at-bedtime/evening treatment strategy is likely explained by deficiencies of their study design and conduct. Nonetheless, regardless of the quality score of the 155 trials retrieved by our systematic review, it is most noteworthy that no single published prospective randomized trial reported significantly enhanced BP-lowering, safety, compliance, or other benefits of the unjustified by medical evidence, yet still most recommended, upon-waking/morning hypertension treatment-time scheme.