Clinical Management Of Hypertensive Patients Research Articles

PPG-Based Blood Pressure Monitoring by Pulse Wave Analysis: Calibration Parameters are Stable for Three Months.

The current non-invasive gold standard for the measurement of blood pressure (BP) is the oscillometric cuff at the upper arm, despite its known limitations. In particular, its poor adequacy with continuous monitoring and its measurement incommodity call for the development of simpler and more convenient solutions. Among these, solutions based on pulse wave analysis (PWA) and photoplethysmography (PPG) are of particular interest, due to their low-cost, strong patient compliance, and applicability in and out of clinical settings. In that context, we have recently disclosed a PPG-based PWA algorithm (oBPM™) dedicated to the continuous monitoring of BP in patients undergoing induction of general anesthesia. As is standard with PPG-based BP monitoring techniques, an initial calibration procedure with a reference device is required to allow the estimation of absolute values of BP (in mmHg). However, due to their sensitivity to peripheral effects such as vasomotion, the applicability of PPG-based techniques is often limited by the constant need of re-calibration procedures, sometimes in matters of minutes. In the present study, we evaluated the long-term stability of the calibration for our algorithm by performing PPG measurements at irregular time intervals over a period of 3 months in 13 healthy volunteers. For each measurement, diastolic BP (DBP) was assessed by an oscillometric device and estimated by the oBPM™ algorithm. We found the calibration to remain stable over the entire 3-month period, with estimation errors remaining stable over time and complying with the ISO 81060-2:2018 standard. In addition, we verified - in 11 of our 13 subjects - the sensitivity of the oBPM™ algorithm to changes in DBP. This was done in a protocol involving static leg extension exercises. Excellent trending ability (average per-subject concordance rate of 97.7 ± 5.2 %, and correlation coefficient of 0.98 ± 0.02, p <; 0.001) was found between cuff-derived DBP changes and our estimates. These findings provide a strong added value to the practical usability of the proposed PPG-based PWA approach to BP monitoring, particularly for the clinical management of hypertensive patients in and out of clinics, for whom a simple and comfortable continuous alternative to the oscillometric cuff would be strongly preferred.

Herramienta para mejorar la eficiencia en el manejo clínico de pacientes hipertensos

ObjectiveTo create a tool to evaluate the efficiency of the clinical management of hypertensive patients in Primary Care. Material and methodsA web-based questionnaire was designed for Primary Care centres to self-evaluate the management of hypertension in five specific areas: information systems, diagnostic and analytical tests, organisational aspects, use of resources, and continuous training programmes for patients and healthcare professionals. A committee of experts previously defined these questions and their ideal responses or “control”, based on the scientific literature or, if there were no published references, by consensus of the committee. A descriptive analysis was performed on the data, and an adherence score was created that ranged from 0 (no adherence) to 1 (total adherence). ResultsA total of 35 Primary Care centres entered their data into the website for the clinical management of hypertensive patients. The highest adherence to the ideal algorithm was observed in the area “Diagnostic and analytical tests” (0.69±0.10), and the lowest in “Continuous training programmes for patients and professionals” (0.42±0.21). ConclusionsThe efficiency of clinical management in hypertensive patients can be analysed using the website tool created for this purpose. Its use allows an internal audit to detect the areas that need improvement, and also serves to make comparative evaluations in the different areas of management over time.

Monotherapy and Dual Combination Therapies Based on Olmesartan: A Comprehensive Strategy to Improve Blood Pressure Control.

Olmesartan medoxomil is an antihypertensive drug of the class of angiotensin II type 1 (AT1) receptor antagonists (or blockers), characterized by tight and prolonged binding to AT1 receptor compared to other molecules within the same class. These characteristics produce effective and sustained blood pressure reductions in hypertensive patients at different cardiovascular risk profile with a good tolerability profile. After a brief description of the pharmacological characteristics of olmesartan, we will provide a thorough overview of the clinical studies that investigated its efficacy and safety in the clinical management of hypertensive patients both in monotherapy and in dual combination therapies with either thiazide diuretics or calcium channel blockers. These studies demonstrated that olmesartan-based antihypertensive strategy may indeed provide sustained BP control over the 24-h period in a wide proportion of hypertensive patients, thus contributing to a substantial progress in hypertension management. Finally, since growing evidence suggest that olmesartan may also exert potential favourable effects at vascular level, thereby antagonizing the vascular inflammatory process involved in the development and progression of atherosclerosis, the main clinical studies addressing this issue will be also discussed.

PP.05.26

Objective: Tight blood pressure control with a mean office blood pressure of 144/82 mmHg in patients with hypertension and type 2 diabetes achieves a clinically important reduction in hypertension related complications such as stroke (UKPDS). Further blood pressure reduction to an office blood pressure of 135/75 mmHg reduced cardiovascular mortality by 18% compared to placebo (140/75 mmHg) in the ADVANCE trial. The objective of the present registry study was to investigate the role of ambulatory-24-h-blood pressure measurement (ABPM) for the clinical management of hypertensive patients with type 2 diabetes in the general physician[Combining Acute Accent]s (GP) office. Design and method: 919 ABPM recordings of type 2 diabetic patients (age 64.4 + 12.3 years) with treated hypertension were obtained at 306 GPs using validated recorders. Hypertension management based on ABPM recordings of the 306 GPs was compared to a central, blinded and independent analysis of ABPM recordings in accordance with the recent ESH guidelines. Results: Mean office blood pressure was 151.7 ± 19.6/87.5 ± 11.5 mmHg. Mean ABPM daytime values were 141.3 ± 15.2/81.8 ± 10.2 mmHg and night-time values were 131.1 ± 18.3/72.6 ± 11.1 mmHg. The predominant form of hypertension based on ABPM was systolic/diastolic hypertension (58%) followed by isolated systolic hypertension (21%). Control rate of hypertension based on ABPM was estimated to be 64% by GPs. In contrast a control rate of 14% was calculated based on a central analysis according to ESH-ABPM guidelines. The GPs assessed the 10-year cardiovascular risk to be “very high” as to the definition of the ESH in 11% of their patients, while the estimated 10-year risk was “very high” in 892 patients (97%) based on the central, independent analysis. Despite 784 patients were deemed uncontrolled, antihypertensive therapy remained unchanged in 322 patients (41%). Conclusions: Blood pressure control was grossly overestimated in patients with hypertension and type-2 diabetes. This resulted in an underestimation of the total cardiovascular risk and a lack of efforts to control blood pressure more tightly. Whether a lack of therapeutic decision making of GPs was caused by inertia or a lack of knowledge of ABPM normal values remains to be determined.

Attitudes and preferences for the clinical management of hypertension and hypertension-related cardiac disease in general practice: results of the Italian Hypertension and Heart Survey.

The aim of this study was to evaluate attitudes and preferences for the clinical management of hypertensive patients with cardiac organ disease, including left ventricular hypertrophy (LVH) and coronary artery disease (CAD), in Italy. A predefined 15-item questionnaire was anonymously administered to a large community sample of general practitioners (GPs) and specialised physicians between November 2012 and June 2013. Estimated prevalence of hypertension-related clinical conditions was stratified into four groups (10-20%, 20-40%, 40-50%, >50%); preferences were reported as percentage among valid answers to the survey questionnaire. A total of 1319 physicians (672 males, age 55.0 ± 7.1 years, age of medical activity 27.1 ± 7.6 years), among whom 1264 GPs and 55 specialised physicians, was included. LVH was reported to be the most frequent marker of organ damage by the majority of physicians (73.5%). LV diastolic dysfunction was reported to be relatively frequent (>40%) by more than half of the specialised physicians (58.2%) and less frequent (10-20%) by GPs (49.8%); LV systolic dysfunction, atrial fibrillation and CAD were considered to be less frequent (10-20%) by the majority of physicians (61.3, 71.6 and 53.3%, respectively). Echocardiography was the preferred diagnostic tool used to estimate LVH (76.6%). Tight blood pressure control (130/80 mm Hg) was considered to be the most appropriate by the majority of physicians, both in hypertensive patients with LVH and in those with CAD. With the well-known limitations of a cross-sectional survey, this study provides information on attitudes and preferences for the clinical management of outpatients with hypertension and high CV risk profile in general practice in Italy.

Blood pressure effects of glucagon-like peptide 1 analogues and sodium glucose transporter 2 inhibitors.

The growing number of obese patients with a high risk of developing hypertension and type 2 diabetes mellitus requires several drugs to treat all the associated morbidities. Ideally, one drug would help to tackle several health problems at the same time. We review available information on the blood pressure-reducing effects of the new antidiabetic drug classes, glucagon-like peptide 1 analogues and sodium glucose transporter 2 inhibitors. Blood pressure reduction with glucagon-like peptide 1 analogues or sodium glucose transporter 2 inhibitors ranges between 1 and 7 mmHg, both systolic and diastolic. As these drugs have not been sufficiently investigated in studies with office or ambulatory blood pressure as the primary efficacy measure or in prespecified hypertensive patient populations, their true efficacy in reducing blood pressure remains unclear. These studies are needed because the blood pressure-lowering effects of metabolic drugs may help to improve the clinical management of hypertensive patients with type 2 diabetes mellitus. Obese patients with type 2 diabetes mellitus and difficult to control arterial hypertension represent a clinically important patient group at high cardiovascular risk that may profit from combined cardiovascular and metabolic actions of a drug.

National Survey on Excellence Centers and Reference Centers for Hypertension Diagnosis and Treatment: Geographical Distribution, Medical Facilities and Diagnostic Opportunities

Blood pressure (BP) control is poorly achieved in Western Countries, including Italy. Several interventions have been proposed at national and local level to improve BP control rate. This survey of the Italian Society of Hypertension (SIIA) is aimed at analysing the number and the distribution of reference centers and excellence centers for the diagnosis and treatment of arterial hypertension (hypertension centers) in Italy. In October 2011, a specifically designed survey questionnaire was developed by SIIA National Committee, both to evaluate geographical distribution of the reference hypertensive population and to assess general requirements (days of activity, number of active physicians, medical facilities, diagnostic opportunities, use of electronic support), deemed necessary to identify an outpatient clinic as hypertension center in Italy. This questionnaire was locally distributed by regional coordinators of the Society and all collected data were centrally analysed by two independent study coordinators. From October 2011 to September 2012, 89 centers with clinical expertise in the diagnosis and treatment of hypertension provided data on their own activity. Among these, 45 (50.5%) centers are located in the North, 20 (22.5%) in the Center and 24 (27.0%) in the South of Italy. Approximately 50% of the hypertensive outpatients who are referred from general practitioners to hypertension centers are living in the province and about one third in the region. More than half of the centers is active for 3-5days per week, and approximately 40% of the centers have 3-5 active physicians. Beyond outpatient visits for hypertension, these centers are able to organize day hospital (25%), day service (29%), or hospital admission (29%) for advanced diagnostic evaluation or therapeutic interventions. All centers collect data from clinic and 24-hour ambulatory BP measurements, and almost all (95%) centers are able to perform a standard 12-lead electrocardiogram. In addition, the majority of the centers are able to perform advanced diagnostic examinations, including echocardiography (74%) or carotid Doppler ultrasound (71%) analysis. Finally, 78% of the centers use an electronic case report form, specifically designed for the clinical management of hypertensive patients. Although with some limitations related to the study methodology applied for data collection, the survey illustrates a quite unbalanced distribution of the hypertension centers, the majority of which are located in the North of Italy, with a medium-high standard of quality of care. This analysis may provide useful elements for a rational and effective use of existing resources, in order to improve BP control in our Country.

Response to Home Blood Pressure Measurements Will or Will Not Replace 24-Hour Ambulatory Blood Pressure Measurement

We have read with interest the letter by O'Brien1 contributing to the debate on the respective role of home blood pressure (BP; HBP) monitoring (HBPM) and ambulatory BP (ABP) monitoring (ABPM) in the clinical management of hypertensive patients.2,3 We largely agree with O'Brien’s1 observations, although with a slightly different perspective. First, we agree that isolated HBP measurements are of limited clinical value. Indeed, only the average of repeated HBP readings carries diagnostic and prognostic information, which may be partly comparable to that provided by 24-hour ABPM,4 with most outcome studies being based …

Atrial Fibrillation And Coronary Heart Disease:Fatal Attraction.

In this manuscript, the profile and clinical management of hypertensive patients with chronic ischemic heart disease and atrial fibrillation (AF) is examined and whether high heart rate is associated with a different profile is determined. CINHTIA was a cross-sectional and multicenter survey aimed to define the clinical profile of hypertensive patients with chronic ischemic heart disease daily attended in Spain. Blood pressure, LDL-cholesterol and diabetes control rates were established according to ESHESC 2003, NCEP-ATP III and ADA 2005 guidelines, respectively. Out of the 2024 patients, 338 (16.7%) exhibited AF. The group of patients with AF was older and with higher prevalence of diabetes, organ damage and cardiovascular disease. Blood pressure (41.8% vs 34.5%, p=0.014) and diabetes (28.5% vs 20.9%,p=0.044) were worse controlled in patients with AF, with a trend to a lower control of LDL-cholesterol (31.2% vs 26.8%, p=0.093). When distributing patients with AF according to heart rate, except for smoking, left ventricular hypertrophy and peripheral arterial disease that were more frequent in those with higher heart rate, no significant differences were found in other risk factors or organ damage between groups. Blood pressure, glycemia and LDL-cholesterol were worse controlled in the subgroup with highest heart rate. In clinical practice, hypertensive patients with chronic ischemic heart disease and AF have a bad prognosis not only due to a worse clinical profile, but also due to lower risk factors control rates. In contrast with patients at sinus rhythm, higher heart rate was less related with a worse clinical profile in subjects with AF.

Assessing the prognostic relevance of blood pressure variability: discrepant information from different indices

Assessing the prognostic relevance of blood pressure variability: discrepant information from different indices

Blood Pressure Goal Attainment: Meeting the Challenge of the JNC 7's Blood Pressure Goals and the Role of Renin‐Angiotensin‐Aldosterone System Blockade

This roundtable discussion, held in December 2003, was convened to discuss the impact of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure's (JNC 7) challenging blood pressure goal objectives for the clinical management of hypertensive patients. The discussion was moderated by Michael Weber, MD, of the State University of New York Downstate College of Medicine in New York City. Participants included leading experts in the field Joseph Izzo, Jr., MD, of the School of Medicine and Biomedical Sciences at the State University of New York at Buffalo; Suzanne Oparil, MD, of the Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham; and Jan Basile, MD, of the Ralph H. Johnson VA Medical Center and Department of General Internal Medicine/Geriatrics, Medical University of South Carolina in Charleston. The primary intention of this roundtable is to educate physicians about the importance of achieving the blood pressure goals agreed upon by the JNC 7 Committee and to present practical ways for the attainment of such goals in clinical practice.

The REassessment of Antihypertensive Chronic Therapy (REACT) Study

Aim: The principal aim of the REACT study (REassessment of Antihypertensive Chronic Therapy) was to achieve a comprehensive assessment of hypertension management in Italy from both the physician and patient points of view. Blood pressure control, global risk factors, target organ damage stratification, use of diagnostic examinations, prescribing practices and physician/patient satisfaction with the planned therapeutic regimen, as well as an assessment of patient quality of life were evaluated. A total of 1482 hypertensive patients and their physicians participated in this study. Experimental Design: REACT was a multicentre, non-intervention, cross-sectional, observational study of the management of hypertension in Italy. Hypertensive patients were selected from specialised clinics from the following sub-specialties: cardiology, internal medicine, geriatrics, diabetology and nephrology. Patient Population: Between 10 and 20 patients were enrolled in each of the 131 participating centres. Eligible patients had to have been diagnosed with primary hypertension for at least 1 year and been on stable antihypertensive therapy for at least 1 year. Enrolment began in March 2003 and concluded in March 2004. Conclusions: Hypertension management in Italy remains inadequate. This conclusion is based on poor control of blood pressure and cardiovascular risk factors, persistence of target organ damage, inadequate use of diagnostic tests and examinations, and a deficient therapeutic approach. Since this study was performed in patients with antihypertensive treatment established for at least 1 year and followed by expert specialist physicians, these findings are worrisome and indicate the need for more stringent and effective recommendations for the clinical management of hypertensive patients.

Sleep apnoea and hypertension.

This review article provides an update on two major issues. First, the most recent evidence supporting the occurrence of an association between obstructive sleep apnoea syndrome, or more generally sleep-disordered breathing, and arterial hypertension in humans is summarized and discussed. This includes an evaluation of both cross-sectional and longitudinal studies. Second, new insights into the mechanisms responsible for the appearance of chronic hypertension in individuals suffering from recurrent nocturnal apnoeic episodes are provided, based both on experimental studies in animals and on clinical studies in humans. The relevance of these data for the clinical management of hypertensive patients with sleep-disordered breathing, and the possibility of obtaining a reduction in blood pressure through the application of nasal continuous positive air pressure, is also addressed.

Preserving Target-organ Function with Candesartan Cilexetil in Patients with Hypertension

Epidemiological evidence suggests that reducing blood pressure alone in hypertensive patients delays the onset of cardiovascular events without necessarily preventing the progression of chronic target-organ disease, such as end-stage renal failure and heart failure. Successful clinical management of hypertensive patients will therefore not be possible unless therapies are aimed both at the effective control of blood pressure and at the preservation of target-organ function. The new angiotensin II type 1 (AT 1 ) receptor blocker candesartan cilexetil has been shown to be effective in reducing target-organ damage in animal models of hypertension, even at doses that do not produce significant reductions in blood pressure. Protective effects of candesartan cilexetil towards the heart and kidney have also been demonstrated in the clinical studies that have been conducted to date. Thus, candesartan cilexetil has been shown to induce regression of left ventricular hypertrophy within 8-12 weeks of treatment and to improve renal haemodynamics, both acutely and after 6 weeks of treatment in hypertensive patients. Furthermore, in hypertensive patients with co-existent non-insulin-dependent diabetes mellitus and microalbuminuria, 12 weeks of treatment with candesartan cilexetil, 8-16 mg, significantly reduced urinary albumin excretion. Clinical evidence is therefore accumulating that the antihypertensive efficacy and tolerability profile already established for candesartan cilexetil is combined with the renal and cardioprotective effects necessary for optimal management of hypertension.

Early atherosclerosis in human hypertension.

The detection of preclinical atherosclerosis may contribute to better identifying hypertensive subjects at high risk of complications. Three alterations can be diagnosed noninvasively: calcification, thickening, and stiffening of the arterial wall. Their prevalence is increased in asymptomatic hypertensives and their presence may have important prognostic significance, especially with respect to coronary artery disease. They are also ideal targets to test the efficacy of hypertensive therapy on the arterial wall. Finally, the detection of early atherosclerosis may help to improve the clinical management of hypertensive patients.

Echocardiographic Detection of Left Ventricular Hypertrophy: Its Usefulness as a Prognostic Tool in Hypertensive Patients

There is strong evidence that in hypertensive patients, electrocardiographic findings of left ventricular hypertrophy (LVH) are associated with a poor cardiovascular prognosis. In the Framingham study, the presence of defined electrocardiographic evidence of LVH was found to be associated with an increased likelihood of major cardiovascular events, independent of blood pressure level. 1 Kannel WB Gordon T Offutt D Left ventricular hypertrophy by electrocardiogram: prevalence, incidence and mortality in the Framingham study. Ann Intern Med. 1969; 71: 89-105 Crossref PubMed Scopus (692) Google Scholar , 2 Kannel WB The Framingham study. Am J Med. 1983; 75: 4 Abstract Full Text PDF PubMed Scopus (350) Google Scholar Since the detection of such target organ damage is critical for the clinical management of hypertensive patients, an accurate identification of abnormal cardiac anatomy seems particularly important. Although the electrocardiogram (ECG) has been the conventional clinical diagnostic tool for the detection and assessment of acute ischemia, conduction abnormalities, and rhythm disturbances, it has not been highly sensitive in the detection of changes in cardiac mass such as LVH. In a large-scale study by Savage et al 3 Savage DD Drayer JIM Henry WL Mathews Jr, EC Ware JH Gardin JM et al. Echocardiographic assessment of cardiac anatomy and function in hypertensive subjects. Circulation. 1979; 59: 623-632 Crossref PubMed Scopus (342) Google Scholar of patients with mild to moderate hypertension, the ECG and the chest x-ray film each identified approximately 5 percent of the patients as having met the classic criteria for a diagnosis of LVH, whereas echocardiographic criteria for LVH were demonstrated in almost 50 percent. Echocardiography, therefore, might represent the first truly sensitive and widely available noninvasive diagnostic method for critically evaluating early evidence of cardiovascular damage in patients with mild to moderate hypertension. 4 Devereux RB Alonso DR Lutas EM Gottlieb GJ Campo E Sachs I et al. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol. 1986; 57: 450-458 Abstract Full Text PDF PubMed Scopus (5583) Google Scholar This technique may potentially be of value in determining which patients will benefit most from long-term antihypertensive therapy, as well as in evaluating the effect of long-term antihypertensive therapy on left ventricular mass in patients with essential hypertension. So far, only a few long-term follow-up clinical trials have been reported. Therefore, there has not been sufficient time nor clinical experience as yet to evaluate definitively the prognostic significance of echocardiographic evidence for LVH or the use of antihypertensive therapy to reduce LVH, especially in those patients whose ECG and chest roentgenograms are apparently normal. 5 Weber MA Drayer JIM Baird WM Echocardiographic evaluation of left ventricular hypertrophy. J Cardiovasc Pharmacol. 1986; 8: S61-S68 Crossref PubMed Scopus (15) Google Scholar