Hypertension Blood Pressure Control Research Articles

Hypertension: What's Sex Got to do With It?

Hypertension is a complex and multifaceted disease, and there are well established sex differences in many aspects of blood pressure (BP) control. The intent of this review is to highlight recent work examining sex differences in the molecular mechanisms of BP control in hypertension to assess whether the "one-size-fits-all" approach to BP control is appropriate with regard to sex.

AB0430 What is the role of ambulatory blood pressure monitoring in sle?

BackgroundPatients with systemic lupus erythematosus (SLE) are at increased risk for the development of atherosclerotic cardiovascular disease (CVD). Hypertension (HT) which is frequently seen in SLE is a major risk...

Impact of antihypertensive medication adherence on blood pressure control in hypertension: the COMFORT study

It has not been fully elucidated whether antihypertensive medication adherence affects blood pressure (BP) control in hypertension cases. To investigate the association of adherence to antihypertensive drug regimens and BP control using data from the Combination Pill of Losartan Potassium and Hydrochlorothiazide for Improvement of Medication Compliance Trial (COMFORT) study. An observational analysis from a randomized controlled trial. A total of 203 hypertensive subjects were randomly assigned to a daily regimen of a combination pill (losartan 50 mg/hydrochlorothiazide 12.5 mg) or two pills, an angiotensin II receptor blocker and a thiazide diuretic. Medication adherence calculated based on pill counts and BPs was evaluated at 1, 3 and 6 months after randomization. The subjects were divided into three groups according to their adherence, i.e. relatively low-adherence (<90%; n = 19), moderate-adherence (90-99%; n = 71) and high-adherence (100%; n = 113) groups. Clinical characteristics of the subjects including BP, sex, randomized treatments and past medical history did not differ significantly among the three groups. Achieved follow-up BPs over the 6-month treatment period, which were adjusted for age, sex, baseline BP and randomized treatment, were significantly higher in the low-adherence group (135/78 mmHg) compared with the high-adherence (130/74 mmHg; P = 0.02/0.02) and the moderate-adherence (128/74 mmHg; P = 0.003/0.02) groups. Low adherence to an antihypertensive-drug regimen was associated with poor BP control.

Quality and Efficiency in Small Practices Transitioning to Patient Centered Medical Homes: A Randomized Trial

There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition. Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices. Randomized Controlled Trial. Eighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices. Modeled on 2008 NCQA PPC®-PCMH™, intervention practices received 18 months of tailored practice redesign support; 2 years of revised payment, including up to $2.50 per member per month (PMPM) for achieving quality targets and up to $2.50 PMPM for PPC-PCMH recognition; and 18 months of embedded care management support. Controls received yearly participation payments. Eleven clinical quality indicators from the 2009 HEDIS process and health outcomes measures derived from patient claims data; Ten efficiency indicators based on Thomson Reuter efficiency indexes and Emergency Department (ED) Visit Ratios; and a panel of costs of care measures. Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control -2 percentage points, p =0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control -0.4 percentage points, p =0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention -0.7 percentage points, control + 0.5 percentage points, p = 0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures. In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.

Optimizing blood pressure control in hypertension: The need to use ABPM

Hypertension is the most prevalent, treatable cause of cardiovascular (CV) disease. Patients with hypertension and one or more comorbidities increasingly form a significant part of the primary care practitioner's caseload. The emphasis on intensive blood pressure (BP) lowering has softened, encouraging any degree of BP lowering, since any fall in BP is beneficial for reducing CV risk. Consistency of BP control during long-term therapy (i.e. low visit-to-visit variability) and decreasing BP variability over 24-h may be as, if not more, important than degree of BP lowering per se. Fluctuations in BP between visits as well as within a 24-h period have been associated with increased CV risk. Ambulatory BP monitoring (ABPM) is a crucial element of the clinician's armamentarium not only for assessing the “true” BP load and fluctuations under real-life conditions but for identification of various abnormal BP patterns that may require attention, including white- coat hypertension, masked hypertension, non-dipping and the morning BP surge. ABPM provides accurate assessment of treatment effectiveness over 24-h and may lead to better tailoring of therapy. This article reviews the benefits of ABPM and discusses the importance of selecting long-acting antihypertensive agents for optimizing BP control.

Marked Underestimation of Blood Pressure Control With Conventional vs. Ambulatory Measurements in an Urban, Developing Community of African Ancestry

As groups of African descent may have higher nocturnal blood pressure (BP) for a given day BP than other ethnic groups, we ascertained whether this translates into differences in conventional (CBP) and 24-h ambulatory (ABP) BP control at a community level. Ambulatory 24-h, day and night BP (model 90207; SpaceLabs, Issaquah, WA) and CBP (mean of five values) control rates were determined in 689 randomly selected participants (>16 years) of African ancestry in South Africa. Target organ effects were determined from urinary microalbumin-to-creatinine ratios (ACR) and aortic pulse wave velocity (PWV, applanation tonometry). Of the participants 45.7% were hypertensive and 22.6% were receiving antihypertensive medication. More participants had uncontrolled BP at night (34.0%) than during the day (22.6%, P < 0.0001). Uncontrolled CBP was noted in 37.2% of participants, while a much lower proportion had uncontrolled ABP (24.1%) (P < 0.0001). Marked differences in the proportion of hypertensive participants with uncontrolled CBP and ABP were noted (treated: CBP = 62.2%, ABP = 33.3%, P < 0.0001; all: CBP = 81.3%, ABP = 44.4%, P < 0.0001). These differences were accounted for by a high prevalence of isolated increases in CBP (white-coat effects) (treated = 35.9%; all = 39.4%). Indeed, after censoring data from participants with white-coat effects, similar CBP and ABP control rates were noted. Participants with white-coat effects had similar ACR and PWV values as participants with normal ABP and CBP. In communities of African descent, despite worse BP control at night than during the day, a high prevalence of white-coat effects translates into a striking underestimation of BP control in hypertensives when employing CBP rather than ABP measurements.

Blood pressure control and antihypertensive pharmacotherapy patterns in a hypertensive population of Eastern Central Region of Portugal

BackgroundInterventions to improve blood pressure control in hypertension have had limited success in clinical practice despite evidence of cardiovascular disease prevention in randomised controlled trials.The objectives of this study were to evaluate blood pressure control and antihypertensive pharmacotherapy patterns in a population of Eastern Central Region of Portugal, attending a hospital outpatient clinic (ambulatory setting) for routine follow-up.MethodsMedical data of all patients that attended at least two medical appointments of hypertension/dyslipidemia in a university hospital over a one and a half year period (from January 2008 to June 2009) were retrospectively analysed. Demographic variables, clinical data and blood pressure values of hypertensive patients included in the study, as well as prescribing metrics were examined on a descriptive basis and expressed as the mean ± SD, frequency and percentages. Student's test and Mann-Whitney rank sum test were used to compare continuous variables and χ2 test and Fisher exact probability test were used to test for differences between categorical variables.ResultsIn all, 37% of hypertensive patients (n = 76) had their blood pressure controlled according to international guidelines. About 45.5% of patients with a target blood pressure <140/90 mmHg (n = 156) were controlled, whereas in patients with diabetes or chronic kidney disease (n = 49) the corresponding figure was only 10.2% (P < 0.001). Among patients initiating hypertension/dyslipidemia consultation within the study period 32.1% had stage 2 hypertension in the first appointment, but this figure decreased to 3.6% in the last consultation (P = 0.012). Thiazide-type diuretics were the most prescribed antihypertensive drugs (67%) followed by angiotensin receptor blockers (60%) and beta-blockers (43%). About 95.9% patients with comorbid diabetes were treated with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker.ConclusionsClinically important blood pressure decreases can be achieved soon after hypertension medical appointment initiation. However, many hypertensive patients prescribed with antihypertensive therapy fail to achieve blood pressure control in clinical practice, this control being worse among patients with diabetes or chronic kidney disease. As pharmacotherapy patterns seem to coincide with international guidelines, further research is needed to identify the causes of poor blood pressure control.

The 10 keys to healthy aging: findings from an innovative prevention program in the community.

To develop and evaluate a novel, comprehensive prevention program for older adults designed to assess and improve adherence to preventive health care goals. In McKeesport, Pennsylvania, 389 men and women aged 65 and older were enrolled. We assessed adherence to 10 preventive health goals, provided education and counseling, and reevaluated after 12 months. At baseline, adherence varied. After 12 months, proportions of participants meeting goals were improved for several areas. Overall, improvements were seen for the proportion of participants meeting goals for low-density lipoprotein (LDL) cholesterol (+43%), blood pressure control in hypertensives (+17%), blood glucose control in diabetics (+50%), and colon cancer screening (+13%). Among those without prior vaccination, influenza vaccine increased by 25% and pneumonia vaccine by 20%. This comprehensive prevention program had short-term benefits for improving adherence to established prevention guidelines in older adults. This low-cost effective program could be disseminated nationwide.

The cardiovascular effects of upper-limb aerobic exercise in hypertensive patients

Aerobic exercise is broadly recommended as a helpful adjunct to obtain blood pressure control in hypertension. Several hypertensive patients, however, are limited by musculoskeletal complaints or vascular occlusive disease from lower-limb exercise such as jogging or cycling. In the present randomized-controlled study, we evaluate whether an aerobic arm-cycling program provides a measurable cardiovascular benefit. Twenty-four probands were randomly assigned to sedentary activity or a heart rate controlled 12 week exercise program, consisting of arm-cycling at target lactate concentrations of 2.0 +/- 0.5 mmol/l. Endothelial function was assessed by flow-mediated dilation of the brachial artery. Augmentation index and large/small artery compliance (C(1) and C(2)) were measured by computerized pulse-wave analysis of the radial artery. The exercise program led to a significant reduction in systolic (134.0 +/- 20.0 to 127.0 +/- 16.4 mmHg; P = 0.03) and diastolic blood pressure (73.0 +/- 21.6 to 67.1 +/- 8.2 mmHg; P = 0.02) accompanied by a significant improvement in C(2) (3.5 +/- 1.6 to 4.8 +/- 2.0 ml/mmHg x 100; P = 0.004). Flow-mediated dilation, augmentation index, and C(2) were not significantly affected (P > 0.05). Physical performance as derived from lactate and heart rate curves of lower-limb stress tests was unchanged, whereas maximal workload in an upper-limb ergometry significantly increased (P = 0.005). Blood pressure and vascular parameters remained unchanged in the control group. Regular arm aerobic exercise leads to a marked reduction in systolic and diastolic blood pressures and an improvement in small artery compliance. Arm-cycling is a reasonable option for hypertensive patients who want to support blood pressure control by sports despite having coxarthrosis, gonarthrosis, or intermittent claudication.

Getting to Goal Blood Pressure: Why Reserpine Deserves a Second Look

Getting to Goal Blood Pressure: Why Reserpine Deserves a Second Look

Beta-blockers do not impair the cardiovascular benefits of endurance training in hypertensives

Aerobic physical exercise is broadly recommended as a helpful adjunct to obtain blood pressure control in hypertension. Beta-blockade interacts with heart rate, sympathetic tone, maximal workload and local lactate production. In the present randomized-controlled study, we compared the cardiovascular effects of an endurance training programme in elderly hypertensives with or without beta-blockers and developed a first approach to determine a lactate-based training heart rate in presence of beta-blockade. Fifty-two patients (23 with beta-blocker, 29 without beta-blocker) > or =60 years with systolic 24-h ambulatory blood pressure (ABP) > or =140 mm Hg and/or antihypertensive treatment were randomly assigned to sedentary activity or a heart-rate controlled 12-week treadmill exercise programme (lactate 2.0 mmol/l). In the exercise group, the training significantly decreased systolic and diastolic 24-h ABP, blood pressure on exertion (100 W) and increased endothelium-dependent vasodilation (flow-mediated vasodilation, FMD) and physical performance both in the presence and absence of beta-blockade (P<0.05 each). The extent of ABP reduction did not significantly differ in the presence or absence of beta-blockade (Delta systolic ABP 10.6+/-10.5 vs 10.6+/-8.8 mm Hg, Delta diastolic ABP 5.7+/-8.6 vs 5.8+/-4.0 mm Hg). Mean training heart rate was significantly lower in the patients on beta-blockers (97.2+/-7.7 vs 118.3+/-7.5/min, P<0.001). Lactate-based aerobic endurance training evokes comparable cardiovascular benefits in the presence and absence of beta-blockade including a marked improvement of endothelial function. In the present study, target training heart rate with beta-blockers is about 18% lower than without.

Review: self monitoring interventions modestly reduce diastolic blood pressure (BP) but do not improve BP control in hypertension

Fahey T, Schroeder K, Ebrahim S. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev 2005;(1):CD005182. Q How effective are various models of...

Potential mechanisms of impaired endothelial function in arterial hypertension and hypercholesterolemia.

This review focuses on the role of impaired endothelial function for the development of atherosclerosis in human arterial hypertension and hypercholesterolemia in vivo. Potential mechanisms underlying impaired endothelial function and decreased bioavailability of nitric oxide under these clinical conditions are discussed. It further addresses therapeutic strategies aimed at improving the bioavailability of nitric oxide in these patients. The overall conclusion is that the bioavailability of nitric oxide is probably impaired, not by a single defect, but by various mechanisms affecting nitric oxide synthesis as well as nitric oxide breakdown. In both diseases increased superoxide anion production and oxidative stress represent a major mechanism. Decreased bioavailability of nitric oxide not only impairs endothelium-dependent vasodilation, but also activates other mechanisms that play an important role in the pathogenesis of atherosclerosis. Thus, therapeutic strategies should aim to restore bioavailability of nitric oxide, which has been demonstrated for lipid-lowering therapy in hypercholesterolemia and blood pressure control in hypertension. In addition, antioxidative strategies will represent a major therapeutic tool against atherosclerotic diseases in the future. Statins and blockers of the renin-angiotensin system seem to have such antioxidative effects independent from their effects on lipid profiles or blood pressure control.

Overall cardiovascular risk still ignored in general practice care of hypertension.

Recent guidelines for the management of arterial hypertension have emphasized the importance of total cardiovascular risk for setting the blood pressure (BP) goal to be achieved and the intensity with which it should be pursued. To assess the degree of BP control in hypertensives receiving long-term antihypertensive treatment according to the presence of major cardiovascular risk factors or diseases and the level of individual total cardiovascular risk, a large sample of general practitioners throughout Italy had to evaluate a random sample of their hypertensive patients. A clinical history was collected for each patient and BP was measured three times using a reliable automatic instrument. To stratify the cardiovascular risk we used the criteria suggested by the 1999 WHO-ISH guidelines. Among the 1204 patients recruited (mean age 64.2 +/- 11.4 years, 663 females), only 399 patients (33.1%) had a BP lower than 140/90 mmHg. Except for male sex and previous myocardial infarction, the concomitant presence of major cardiovascular risk factors or diseases was never associated to a better control of hypertension. BP control was unrelated to individual overall cardiovascular risk: BP was < 140/90 mmHg respectively in 44.0, 37.7, 33.5 and 42.1% (P for trend = 0.54) of people aged less than 65 years with low, medium, high and very high risk and in 27.7, 25.9 and 27.1% (P for trend = 0.91) of people aged more than 65 years at medium, high and very high risk. BP control in Italian hypertensives is still unsatisfactory, even in patients at high and very high cardiovascular risk.

Hypertension in developing nations in sub-Saharan Africa.

There is a rapid development of the 'second wave epidemic' of cardiovascular disease that is now flowing through developing countries and the former socialist republics. It is now evident from WHO data that coronary heart disease and cerebrovascular disease are increasing so rapidly that they will rank No. 1 and No. 5 respectively as causes of global burden by the year 2020. In spite of the current low prevalence of hypertensive subjects in some countries, the total number of hypertensive subjects in the developing world is high, and a cost-analysis of possible antihypertensive drug treatment indicates that developing countries cannot afford the same treatment as developed countries. Control of hypertension in the USA is only 20% (blood pressure <140/90 mm Hg). In Africa only 5-10% have a blood pressure control of hypertension of <140/90 mm Hg. There are varying responses to antihypertensive therapy in black hypertensive patients. Black patients respond well to thiazide diuretics, calcium channel blockers vasodilators like alpha-blockers, hydralazine, reserpine and poorly to beta-blockers, angiotensin-converting enzyme inhibitors and All receptor antagonists unless they are combined with a diuretic. A comprehensive cardiovascular disease (CVD) programme in Africa is necessary. There are social, economic, cultural factors which impair control of hypertension in developing countries. Hypertension control is ideally suited to the initial component on an integrated CVD control programme which has to be implemented. Primary prevention, through a population-based lifestyle linked programme, as well as cost-effective methods of detection and management are synergistically linked. The existing health care infrastructure needs to be orientated to meet the emerging challenge of CVD, while empowering the community through health education.

Effects of low-dose aspirin on clinic and ambulatory blood pressure in treated hypertensive patients

Nonsteroidal antiinflammatory drugs may affect blood pressure (BP) control in hypertensive patients receiving drug treatment, but data on the effects of low-dose aspirin are scanty. This study assessed the effects of chronic treatment with low doses of aspirin (100 mg/day) on clinic and ambulatory systolic (SBP) and diastolic (DBP) BP in hypertensives on chronic, stable antihyper- tensive therapy. The study was conducted in the framework of the Primary Prevention Project (PPP), a randomized, controlled factorial trial on the preventive effect of aspirin or vitamin E in people with one or more cardiovascular risk factors. Fifteen Italian hypertension units studied 142 hypertensive patients (76 men, 66 women; mean age 59 ± 5.9 years) treated with different antihypertensive drugs: 71 patients were randomized to aspirin and 71 served as controls. All patients underwent a clinic BP evaluation with an automatic sphygmomanometer and a 24-h ambulatory BP monitoring, at baseline and after 3 months of aspirin treatment. At the end of the study the changes in clinic SBP and DBP were not statistically different in treated and untreated subjects. Ambulatory SBP and DBP after 3 months of aspirin treatment were similar to baseline: ΔSBP −0.5 mmHg (95% confidence intervals [CI] from −1.9 to +2.9 mm Hg) and ΔDBP −1.1 mm Hg (95% CI from −2.5 to +0.3 mm Hg). The pattern was similar in the control group. No interaction was found between aspirin and the most used antihypertensive drug classes (angiotensin converting enzyme inhibitors and calcium antagonists). Despite the relatively small sample size our results seem to exclude any significant influence of low-dose aspirin on BP control in hypertensives under treatment.

Ambulatory blood pressure monitoring assessment of blood pressure control in hypertension associated with chronic renal failure

Ambulatory blood pressure monitoring assessment of blood pressure control in hypertension associated with chronic renal failure

Blood pressure control in hypertensives—a model for the study of life events

Life events were elicited during an average recall period of 8.5 months among 235 hypertensive patients whose blood pressure was under control just prior to the beginning of the recall period. At the end of the recall period, the 41 patients no longer under control reported a significantly higher proportion both of unfavourable and unexpected life changes compared with the 194 patients whose blood pressure was still under control. The differences persisted after allowing for potentially confounding variables. The patients were not aware of their blood pressure status at the time of the life events interview.

A survey of blood pressure in the state of Maryland

To provide baseline data for a state program to coordinate hypertension resources, a blood pressure (BP) survey was undertaken in Maryland in 1978. A statewide probability sample of households was chosen; each adult member was eligible for interview and measurement of BP. A total of 6,425 adults were interviewed for an overall response rate of 79.5%. Using a definition of diastolic blood pressure (DBP) of 95 mm Hg or higher or use of antihypertensive medication, 15.1% of state residents were estimated to be hypertensive. Of these, 85.8% were estimated to be aware of their condition, 77.6% of them were treated, and 67.6% had their BP controlled to a normal level by medication. Data are also presented using DBP 90 mm Hg or higher. A comparison of data from the Hypertension Detection and Follow-up Program (HDFP) home screen in 1973–1974 and comparable information from this survey showed lower rates of awareness, treatment, and BP control in hypertensives at HDFP home screen. Results of this survey will be compared with those of a second statewide survey conducted four years later to assess changes in rates of hypertension awareness, treatment, and control.

Peer review in diabetes and hypertension: the relationship between care process and patient outcome.

To assess the effect of physician performance on patient outcomes, we examined the relationship between performance of essential care items and several patient outcomes in hypertension and diabetes. A group of internists in private practice selected the criteria and allowed their records to be reviewed to ascertain their adherence to these criteria and their patients' outcome status. Among all physicians and patients, adherence to criteria was not associated with a composite measure of control status or with blood sugar level in diabetes, or with blood pressure control in hypertension. Peer review groups should recognize the limitations in measuring care process and patient outcomes, and that adequacy of physician performance does not necessarily predict how well the patient will do.