Blood Pressure Control In People Research Articles

The short and long-term efficacy of nurse-led interventions for improving blood pressure control in people with hypertension in primary care settings: a systematic review and meta-analysis

BackgroundPrevious systematic reviews suggest that nurse-led interventions improve short-term blood pressure (BP) control for people with hypertension. However, the long-term effects, adverse events, and appropriate target BP level are unclear. This study aimed to evaluate the long-term efficacy and safety of nurse-led interventions.MethodsWe conducted a systematic review and meta-analysis. We searched the Cochrane Central Register of Controlled Trials, PubMed, and CINAHL, as well as three Japanese article databases, as relevant randomized controlled trials from the oldest possible to March 2021. This search was conducted on 17 April 2021. We did an update search on 17 October 2023. We included studies on adults aged 18 years or older with hypertension. The treatments of interest were community-based nurse-led BP control interventions in addition to primary physician-provided care as usual. The comparator was usual care only. Primary outcomes were long-term achievement of BP control goals and serious adverse events (range: 27 weeks to 3 years). Secondary outcomes were short-term achievement of BP control goals and serious adverse events (range: 4 to 26 weeks), change of systolic and diastolic BP from baseline, medication adherence, incidence of hypertensive complications, and total mortality.ResultsWe included 35 studies. Nurse-led interventions improved long-term BP control (RR 1.10, 95%CI 1.03 to 1.18). However, no significant differences were found in the short-term effects of nurse-led intervention compared to usual care about BP targets. Little information on serious adverse events was available. There was no difference in mortality at both terms between the two groups. Establishing the appropriate target BP from the extant trials was impossible.ConclusionsNurse-led interventions may be more effective than usual care for achieving BP control at long-term follow-up. It is important to continue lifestyle modification for people with hypertension. We must pay attention to adverse events, and more studies examining appropriate BP targets are needed. Nurse-led care represents an important complement to primary physician-led usual care.

The Australian Health Care Homes trial: quality of care and patient outcomes. A propensity score-matched cohort study.

To assess the impact of the Health Care Homes (HCH) primary health care initiative on quality of care and patient outcomes. Quasi-experimental, matched cohort study; analysis of general practice data extracts and linked administrative data from ten Australian primary health networks, 1 October 2017 - 30 June 2021. People with chronic health conditions (practice data extracts: 9811; linked administrative data: 10 682) enrolled in the HCH 1 October 2017 - 30 June 2019; comparison groups of patients receiving usual care (1:1 propensity score-matched). Participants were involved in shared care planning, provided enhanced access to team care, and encouraged to seek chronic condition care at the HCH practice where they were enrolled. Participating practices received bundled payments based on clinical risk tier. Access to care, processes of care, diabetes-related outcomes, hospital service use, risk of death. During the first twelve months after enrolment, the mean numbers of general practitioner encounters (rate ratio, 1.14; 95% confidence interval [CI], 1.11-1.17) and Medicare Benefits Schedule claims for allied health services (rate ratio, 1.28; 95% CI, 1.24-1.33) were higher for the HCH than the usual care group. Annual influenza vaccinations (relative risk, 1.20; 95% CI, 1.17-1.22) and measurements of blood pressure (relative risk, 1.09; 95% CI, 1.08-1.11), blood lipids (relative risk, 1.19; 95% CI, 1.16-1.21), glycated haemoglobin (relative risk, 1.06; 95% CI, 1.03-1.08), and kidney function (relative risk, 1.13; 95% CI, 1.11-1.15) were more likely in the HCH than the usual care group during the twelve months after enrolment. Similar rate ratios and relative risks applied in the second year. The numbers of emergency department presentations (rate ratio, 1.09; 95% CI, 1.02-1.18) and emergency admissions (rate ratio, 1.13; 95% CI, 1.04-1.22) were higher for the HCH group during the first year; other differences in hospital use were not statistically significant. Differences in glycaemic and blood pressure control in people with diabetes in the second year were not statistically significant. By 30 June 2021, 689 people in the HCH group (6.5%) and 646 in the usual care group (6.1%) had died (hazard ratio, 1.07; 95% CI, 0.96-1.20). The HCH program was associated with greater access to care and improved processes of care for people with chronic diseases, but not changes in diabetes-related outcomes, most measures of hospital use, or risk of death.

Educational intervention performed by nurses for blood pressure control: a systematic review with meta-analysis.

to assess the effect of an educational intervention performed by nurses for blood pressure control in people with arterial hypertension, when compared to usual care. a systematic review with meta-analysis of randomized clinical trials, conducted in six databases. The studies included were those in which an educational intervention was performed by nurses on people with arterial hypertension. The risk of bias was assessed by means of the Risk of Bias Tool, the meta-analysis was performed in the Review Manager software and certainty of the evidence was calculated in the Grading of Recommendations Assessment, Development and Evaluation system. a total of 1,692 studies were found, which were peer-reviewed, including eight of them in the meta-analysis. The meta-analysis was calculated for the "systolic blood pressure" and diastolic blood pressure" outcomes, in subgroups by time and by intervention performance type. For the in-person educational intervention, performed individually combined with a group activity, the effect estimate was -12.41 mmHg (95% Confidence Interval: from -16.91 to -7.91, p<0,00001) for systolic pressure and -5.40 mmHg (95% Confidence Interval: from -7.98 to -2.82, p<0,00001) for diastolic pressure, with high certainty of evidence. the educational intervention performed by nurses, individually and combined with a group activity, presents a statistically significant clinical effect. PROSPERO registration No.: CRD42021282707.

Blood pressure screening results in adults in Thua Thien Hue province through the program “May Measurement Month” 2022 of the International Society of Hypertension

Background: Hypertension is a common disease in adults, also the leading cause of cardiovascular disease and premature death worldwide. The prevalence of hypertension has increased, especially in low- and middle-income countries. Therefore, hypertension screening is important to provide the basis and evidence for the development of timely intervention policies and programs. The objective of the “May Measurement Month” 2022 program is to investigate the prevalence of hypertension, drug treatment and blood pressure control in people in Thua Thien Hue province and to assess the risk factors surrounding hypertension. Subjects and Methods: This cross–sectional study collected data from volunteer adults (≥ 18 years old) in Thua Thien Hue province from 7/2022 to 8/2022. Sitting blood pressure had been measured in triplicate according to standardized specified methods of the International Society of Hypertension. Results: Average age 54.07 ± 18.17, there were 627 people (23.4%) with hypertension at the time of screening, 245 of which (39.1%) had never been diagnosed with hypertension before screening at the time. 724 people were on treatment with 1 or more types of drug, however, there were 337 people (46.5%) having their blood pressure not controlled. The statistics showed that 84.9% of volunteers were using at least 1 drug to treat hypertension. Related factors of hypertension are age, sex, overweight/obesity status, smoking, medical history of diabetes and medical history of COVID-19. The rate of subjects who had history of COVID-19 was 36.4%, including 31.6% of hypertension patients. Conclusion: The hypertension percentage of Thua Thien Hue population is still high and the rate of blood pressure control is still limited. There is a relationship between hypertension proportion and history of COVID-19. It is necessary to publish timely intervention measures to reduce the rate of hypertension and its risks to people. Key words: Hypertension, screening, control, 2022 MMM program, ISH, COVID-19.

Intervenção educativa realizada por enfermeiros para controle da pressão arterial: revisão sistemática com metanálise

Objetivo: to assess the effect of an educational intervention performed by nurses for blood pressure control in people with arterial hypertension, when compared to usual care. Método: a systematic review with meta-analysis of randomized clinical trials, conducted in six databases. The studies included were those in which an educational intervention was performed by nurses on people with arterial hypertension. The risk of bias was assessed by means of the Risk of Bias Tool, the meta-analysis was performed in the Review Manager software and certainty of the evidence was calculated in the Grading of Recommendations Assessment, Development and Evaluation system. Resultados: a total of 1,692 studies were found, which were peer-reviewed, including eight of them in the meta-analysis. The meta-analysis was calculated for the “systolic blood pressure” and diastolic blood pressure” outcomes, in subgroups by time and by intervention performance type. For the in-person educational intervention, performed individually combined with a group activity, the effect estimate was -12.41 mmHg (95% Confidence Interval: from -16.91 to -7.91, p&lt;0,00001) for systolic pressure and -5.40 mmHg (95% Confidence Interval: from -7.98 to -2.82, p&lt;0,00001) for diastolic pressure, with high certainty of evidence. Conclusión: the educational intervention performed by nurses, individually and combined with a group activity, presents a statistically significant clinical effect. PROSPERO registration No.: CRD42021282707.

Effects of pet ownership on arterial hypertension and cardiovascular disease

Preventing high blood pressure and reducing cardiovascular risk are the cornerstones of preventing and treating cardiovascular disease. Non-traditional cardiovascular risk reduction The potential applicability of methods, such as pet ownership, has attracted increasing attention. Studies have shown that pet ownership can reduce the risk of death from any cause, especially cardiovascular disease, and pet ownership can reduce the risk of high blood pressure and improve blood pressure control in people with diagnosed hypertension. This article focuses on the direct and indirect influencing factors of pet ownership on cardiovascular diseases, briefly reviews the research on the relationship between pet ownership and human coronary artery disease (CAD) in the past decade, and briefly describes the research methods, analysis models, main conclusions, and limitations. The aim is to prove whether pet ownership, especially dog ownership, is associated with a reduced risk of coronary artery disease and ultimately draw positive conclusions that provide new ideas for treating this type of disease in the future.

The Effectiveness of a Nurse-led Team-Based Hypertension Management among People with Uncontrolled Hypertension in a Community Hospital, Thailand

Introduction: Uncontrolled blood pressure of people with hypertension remains a major public health issue. The purpose of this research was to evaluate the effectiveness of a Nurse-led Team-based Hypertension Management Program (NTHMP) among people with uncontrolled hypertension.Methods: This quasi-experimental one-group pre-posttest design research was done to evaluate the effectiveness of a NTHMP in a community hospital in Thailand. The sample was thirty people with uncontrolled hypertension who received outpatient care in a community hospital in Thailand. They participated in three months NTHMP which included 1) team-approached health education, 2) medication administration support, 3) motivation interviewing on behavioral adjustment and 4) home blood pressure monitoring for three months. Outcomes of the program; systolic blood pressure, diastolic blood pressure, hospital admissions with signs of hypertensive urgency were analyzed by using frequency, percentage, mean, standard deviation, and repeated measured ANOVA.Results: The results indicated that people with uncontrolled HT had lower systolic blood pressures and diastolic blood pressure compared with baseline levels (p&lt;0.001), and no hospital admissions.Conclusion: This program provided evidence for nurses to manage blood pressure control in people with hypertension within a collaboration with multidisciplinary team members in the community hospital.

Protocol design and preliminary evaluation of the REAL-Health Triple Aim, an open-cohort CVD-care optimisation initiative

IntroductionEffective treatment of cardiovascular disease (CVD) in primary care could be improved. We aim to assess the efficacy of a scalable treatment optimisation programme in unselected community populations in South East England, with the triple aim of improved blood pressure control in people with hypertension, increased high-intensity statin use in people with CVD and reduced gastrointestinal bleeding in patients on antithrombotic medication.MethodThis observational study comprises an open cohort of approximately 200,000 adults at high cardiovascular risk registered with general practitioners in five South East England Clinical Commissioning Groups (CCGs). An intervention programme is planned in four of these CCGs with a further non-intervention CCG acting as a control group. The intervention will consist of: clinical guidelines and educational outreach; virtual patient-reviews software; peer-performance “dashboards” and, where available, financial incentives.The study will examine 3 primary outcomes: 1. Diagnosed hypertension with a blood pressure <140/90mmHg; 2. Diagnosed CVD on a high-intensity statin; 3. A cardiovascular indication for antithrombotic therapy with one or more factors for increased risk of gastrointestinal bleeding (e.g. age ≥65) on gastroprotection. A further 17 secondary outcomes related to these three aims will be assessed.AnalysisWe will use an interrupted time series analysis over 18 months, representing the pre-implementation, implementation and the post-implementation phases with comparison to the control CCG and applicable national Quality and Outcomes Framework and national prescribing statistics (e.g. OpenPrescribing). Secondary outcomes include an equity impact analysis with results stratified by age, gender, ethnic group and index of deprivation.Preliminary dataWe present preliminary data on Key Performance Indicators (KPIs) collected from 191 GP practices including [percentage achievement on 01/09/2019, on 01/09/2020]: 1. Patients with hypertension and most recent blood pressure ≤140/90mmHg [68.7%, 60.6%]. 2. Patients eligible for treatment with a high-intensity statin on such treatment [53.8%, 55.8%]. 3. Patients on antithrombotics with ≥1 risk factors for gastrointestinal bleeding on gastroprotection [59.0%, 60.1%]. We also present our virtual patient-review software tool and outcome visualisation dashboard.ConclusionThe REAL-Health Triple Aim initiative is a large-scale primary care cardiovascular risk reduction initiative which was launched almost contemporaneously with the United Kingdom's first SARS-CoV-2 related lockdown. Preliminary data justify the need for the Triple Aim initiative and give us an insight on the impact of the pandemic on its implementation.FUNDunding AcknowledgementType of funding sources: Other. Main funding source(s): Barts CharityBritish Heart Foundation

The Effect of COVID-19 on Blood Pressure Control in Hypertension Patients– A Literature Review

COVID-19 is caused by Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2). First identifiedin Wuhan, China, in December 2019, and declared an International Public Health Emergency in January2020, the WHO declared a pandemic in March 2020. Hypertension, a disease that has long been a problemfor most people in Indonesia and around the world . COVID-19 can affect blood pressure control for peoplewith hypertension due to obstruction of the RAAS system. This research was conducted to find out whateffect COVID-19 has on blood pressure control in people with hypertension. In the condition of COVID-19patients with comorbid hypertension, SARS-CoV-2 which attacks ACE2 can eliminate the role of ACE2 inthe RAAS system. Inhibition of ACE2 can also cause buildup of angiotensin II which has a vasoconstrictiveeffect. This results in the absence of homeostasis in the blood pressure control system and makes bloodpressure conditions that continue to be at high pressure.

Usefulness of Exercise for Home Blood Pressure Control in People with Diabetes: A Study Protocol for a Crossover Randomized Controlled Trial.

BackgroundThe coexistence of hypertension and diabetes mellitus significantly increases the risk of macrovascular complications in patients with diabetes. Home blood pressure is important because it is more strongly associated with target organ damage and total mortality than clinic blood pressure measurements. Regular moderate aerobic exercise has antihypertensive effects. This study aims to examine the effect of aerobic exercise therapy on blood pressure at home in patients with diabetes.Patients and MethodsIn this crossover randomized controlled trial, 110 patients with type 2 diabetes will be randomly assigned to two groups: an exercise preceding group and an exercise lagging group. During the exercise period, patients will be instructed to walk either 30 minutes twice each day or 60 minutes once each day for at least 3 days per week. During the non-exercise period, patients will be permitted to perform physical activity associated with activities of daily life. Patients will be followed up for 56 days. The primary outcome will be the mean nocturnal blood pressure from day 24 to 28 during the exercise period compared to that during the non-exercise period. The secondary outcome will include variation in nocturnal blood pressure, mean blood pressure values and variation of morning and evening blood pressure from day 24 to 28 in the exercise period compared to the non-exercise period, body weight, body mass index and bioelectrical impedance analysis. Biochemical tests such as hemoglobin A1c level, blood glucose level, serum lipid profile, renal function, uric acid levels and liver function tests will also be measured.DiscussionThis randomized controlled trial will provide critical information regarding the effectiveness of moderate exercise on nocturnal blood pressure reduction. If successful, the results of this randomized controlled trial may increase exercise motivation in people with diabetes and may lead to improvement or prevention of target organ damage and overall mortality.Trial RegistrationTrial registration: University Hospital Medical Information Network, UMIN 000035973. Protocol version number: R000040969. Registration date: February 22, 2019. Recruitment began: June 19, 2019. The date of completion of recruitment: July 3, 2020. URL: http://www.umin.ac.jp.

Combined training is the most effective training modality to improve aerobic capacity and blood pressure control in people requiring haemodialysis for end-stage renal disease: systematic review and network meta-analysis.

Do aerobic, resistance and combined exercise training improve aerobic capacity, arterial blood pressure and haemodialysis efficiency in people requiring haemodialysis for end-stage renal disease? Is one exercise training modality better than the others for improving these outcomes? Systematic review with network meta-analysis of randomised trials. Adults requiring haemodialysis for end-stage renal disease. Aerobic training, resistance training, combined training and control (no exercise or placebo). Aerobic capacity, arterial blood pressure at rest, and haemodialysis efficiency. Thirty-three trials involving 1254 participants were included. Direct meta-analyses were conducted first. Aerobic capacity improved significantly more with aerobic training (3.35 ml/kg/min, 95% CI 1.79 to 4.91) and combined training (5.00 ml/kg/min, 95% CI 3.50 to 6.50) than with control. Only combined training significantly reduced systolic (-9 mmHg, 95% CI-13 to-4) and diastolic (-5 mmHg, 95% CI-6 to-3) blood pressure compared to control. Only aerobic training was superior to control for haemodialysis efficiency (Kt/V 0.11, 95% CI 0.02 to 0.20). However, when network meta-analysis was conducted, there were some important different findings. Both aerobic training and combined training again elicited greater improvements in aerobic capacity than control. For systolic blood pressure, combined training was superior to control. For diastolic blood pressure, combined training was superior to aerobic training and control. No modality was superior to control for haemodialysis efficiency. Combined training was ranked as the most effective treatment for aerobic capacity and arterial blood pressure. Combined training was the most effective modality to increase aerobic capacity and blood pressure control in people who require haemodialysis. This finding helps to fill the gap created by the lack of head-to-head comparisons of different modalities of exercise in people with end-stage renal disease. PROSPERO CRD42015020531.

The Stroke Prevention Programme: a programme of research to inform optimal stroke prevention in primary care

BackgroundThe management of cardiovascular (CV) risk factors in community populations is suboptimal. The aim of this programme was to explore the role of three approaches [use of a ‘polypill’; self-management of hypertension; and more intensive targets for blood pressure (BP) lowering after stroke] to improve prevention of CV disease (CVD) in the community.Research questions(1) Is it more cost-effective to titrate treatments to target levels of cholesterol and BP or to use fixed doses of statins and BP-lowering agents (polypill strategy)? (2) Will telemonitoring and self-management improve BP control in people on treatment for hypertension or with a history of stroke/transient ischaemic attack (TIA) in primary care and are they cost-effective? (3) In people with a history of stroke/TIA, can intensive BP-lowering targets be achieved in a primary care setting and what impact will this have on health outcomes and cost-effectiveness?DesignMixed methods, comprising three randomised controlled trials (RCTs); five cost-effectiveness analyses; qualitative studies; analysis of electronic general practice data; a screening study; a systematic review; and a questionnaire study.SettingUK general practices, predominantly from the West Midlands and the east of England.ParticipantsAdults registered with participating general practices. Inclusion criteria varied from study to study.InterventionsA polypill – a fixed-dose combination pill containing three antihypertensive medicines and simvastatin – compared with current practice and with optimal implementation of national guidelines; self-monitoring of BP with self-titration of medication, compared with usual care; and an intensive target for systolic BP of &lt; 130 mmHg or a 10 mmHg reduction if baseline BP is &lt; 140 mmHg, compared with a target of &lt; 140 mmHg.ResultsFor patients known to be at high risk of CVD, treatment as per guidelines was the most cost-effective strategy. For people with unknown CV risk aged ≥ 50 years, offering a polypill is cost-effective [incremental cost-effectiveness ratio (ICER) of £8115 per quality-adjusted life-year (QALY)] compared with a strategy of screening and treating according to national guidelines. Both results were sensitive to the cost of the polypill. Self-management in people with uncontrolled hypertension led to a 5.4 mmHg [95% confidence interval (CI) 2.4 to 8.5 mmHg] reduction in systolic BP at 1 year, compared with usual care. It was cost-effective for men (ICER of £1624 per QALY) and women (ICER of £4923 per QALY). In people with stroke and other high-risk groups, self-management led to a 9.2 mmHg (95% CI 5.7 to 12.7 mmHg) reduction in systolic BP at 1 year compared with usual care and dominated (lower cost and better outcome) usual care. Aiming for the more intensive BP target after stroke led to a 2.9 mmHg (95% CI 0.2 to 5.7 mmHg) greater reduction in BP and dominated the 140 mmHg target.ConclusionsPotential for a polypill needs to be further explored in RCTs. Self-management should be offered to people with poorly controlled BP. Management of BP in the post-stroke population should focus on achieving a &lt; 140 mmHg target.Trial registrationCurrent Controlled Trials ISRCTN17585681, ISRCTN87171227 and ISRCTN29062286.FundingThe National Institute for Health Research (NIHR) Programme Grants for Applied Research programme. Additional funding was provided by the NIHR National School for Primary Care Research, the NIHR Career Development Fellowship and the Department of Health Policy Research Programme.

Factors associated with inadequate blood pressure control in patients of primary care

Objective: To identify the association between socioeconomic, personal and health care factors, with inadequate blood pressure control. Method: Cross sectional, descriptive study, of 392 hypertensive individuals, randomly and proportionally selected from among 23 registered in the Basic Health of a city in Southern Brazil. Data were collected from homes between December 2011 and March 2012, using a semistructured questionnaire. Results: Almost half of the respondents had inadequate blood pressure control, which was associated with age less than 60 years; Non adherence to pharmacotherapy; failure to attend scheduled appointments, and; use of three or more antihypertensive drugs. Conclusion: Among the actions to improve blood pressure control in people with hypertension, the health care team needs to create strategies that encourage attendance at appointments, scheduled and simplify the treatment regimen. Such activities should focus particularly on the elderly.

What Are Optimal Blood Pressure Targets for Patients with Hypertension and Chronic Kidney Disease?

To maximize the risk benefit ratio of blood pressure control in people with chronic kidney diseases (CKD), a number of guidelines provide recommendations on optimal blood pressure (BP) targets in CKD. This review examines these guidelines, their supporting evidence base, and generalizability and limitations of current standards of care. Over the years, the BP targets are liberalized. They now focus on the usual BP target of <140/90 mmHg. In the elderly, where guidelines call for a target of <150/90 mmHg in the general population, the recommendations provide room for the clinician to tailor therapy. Among those with albuminuria of >300 mg/g creatinine, low-quality evidence suggests targeting BP to <130/90 mmHg. Individualization of BP lowering is a key based on comorbid conditions, response to treatment, and level of kidney function. Consideration of out of clinic BP monitoring either implemented by home BP recordings or ambulatory BP measurements may enhance BP control.

Reduction in sodium intake is independently associated with improved blood pressure control in people with chronic kidney disease in primary care.

Decreasing sodium intake has been associated with improvements in blood pressure (BP) and proteinuria, two important risk factors for CVD and chronic kidney disease (CKD) progression. We aimed to investigate the role of sodium intake by examining the effect of changes in sodium intake over 1 year on BP and proteinuria in people with early stage CKD. From thirty-two general practices, 1607 patients with previous estimated glomerular filtration rate of 59-30 ml/min per 1.73 m² and mean age of 72.9 (sd 9.0) years were recruited. Clinical assessment, urine and serum biochemistry testing were performed at baseline and after 1 year. Sodium intake was estimated from early morning urine specimens using an equation validated for this study population. We found that compared with people who increased their sodium intake from ≤ 100 to >100 mmol/d over 1 year, people who decreased their intake from >100 to ≤ 100 mmol/d evidenced a greater decrease in all BP variables (Δmean arterial pressure (ΔMAP) = -7.44 (SD 10.1) v. -0.23 (SD 10.4) mmHg; P<0.001) as well as in pulse wave velocity (ΔPWV = -0.47 (SD 1.3) v. 0.08 (SD 1.88) m/s; P<0.05). Albuminuria improved only in albuminuric patients who decreased their sodium intake. BP improved in people who maintained low sodium intake at both times and in those with persistent high intake, but the number of anti-hypertensive increased only in the higher sodium intake group, and PWV improved only in participants with lower sodium intake. Decreasing sodium intake was an independent determinant of ΔMAP. Although more evidence is needed, our results support the benefits of reducing and maintaining sodium intake below 100 mmol/d (2.3-2.4 g/d) in people with early stages of CKD.

Validity of self-reported blood pressure control in people with hypertension attending a primary care center

The aim of this study was to estimate the validity of self-reported blood pressure control and medication use in people with hypertension, with and without diabetes. In a sample of 161 patients with hypertension in a family health team in Ontario, we applied questions from the 2009 Survey on Living with Chronic Disease in Canada Hypertension Component and compared responses against objectively measured and chart-abstracted clinical indicators. Objective blood pressure control was defined as a blood pressure of less than 130/80 mmHg and less than 140/90 mmHg for individuals with and without diabetes, respectively. Self-reported blood pressure control showed reasonable sensitivity (83±11 and 78±10%) but low specificity (30±19 and 58±21%) in people with and those without diabetes, respectively. In the subgroup with diabetes, specificity improved to 88±11% when blood pressure control was defined on the basis of a 140/90 mmHg target. Self-reported and chart-abstracted numbers of prescribed antihypertensive medications showed fair agreement (κ=0.7); 9 and 14% of patients overestimated and underestimated the number of prescribed medications, respectively. Although most individuals with controlled hypertension reported having controlled blood pressure, a large proportion of individuals with uncontrolled hypertension also reported that their blood pressure was controlled. This level of misclassification suggests that in a family medicine clinic population and in health survey contexts, a self-reported measure of blood pressure control may not be useful for assessing hypertension control.

An assessment of discriminatory power of office blood pressure measurements in predicting optimal ambulatory blood pressure control in people with type 2 diabetes.

IntroductionAmbulatory blood pressure (BP) measurements (ABPM) predict health outcomes better than office BP, and are recommended for assessing BP control, particularly in high-risk patients. We assessed the performance of office BP in predicting optimal ambulatory BP control in sub-Saharan Africans with type 2 diabetes (T2DM).MethodsParticipants were a random sample of 51 T2DM patients (25 men) drug-treated for hypertension, receiving care in a referral diabetes clinic in Yaounde, Cameroon. A quality control group included 46 non-diabetic individuals with hypertension. Targets for BP control were systolic (and diastolic) BP.ResultsMean age of diabetic participants was 60 years (standard deviation: 10) and median duration of diabetes was 6 years (min-max: 0-29). Correlation coefficients between each office-based variable and the 24-h ABPM equivalent (diabetic vs. non-diabetic participants) were 0.571 and 0.601 for systolic (SBP), 0.520 and 0.539 for diastolic (DBP), 0.631 and 0.549 for pulse pressure (PP), and 0.522 and 0.583 for mean arterial pressure (MAP). The c-statistic for the prediction of optimal ambulatory control from office-BP in diabetic participants was 0.717 for SBP, 0.494 for DBP, 0.712 for PP, 0.582 for MAP, and 0.721 for either SBP + DBP or PP + MAP. Equivalents in diabetes-free participants were 0.805, 0.763, 0.695, 0.801 and 0.813.ConclusionOffice DBP was ineffective in discriminating optimal ambulatory BP control in diabetic patients, and did not improve predictions based on office SBP alone. Targeting ABPM to those T2DM patients who are already at optimal office-based SBP would likely be more cost effective in this setting.

Suboptimal blood pressure control in chronic kidney disease stage 3: baseline data from a cohort study in primary care

BackgroundPoorly controlled hypertension is independently associated with mortality, cardiovascular risk and disease progression in chronic kidney disease (CKD). In the UK, CKD stage 3 is principally managed in primary care, including blood pressure (BP) management. Controlling BP is key to improving outcomes in CKD. This study aimed to investigate associations of BP control in people with CKD stage 3.Methods1,741 patients with CKD 3 recruited from 32 general practices for the Renal Risk in Derby Study underwent medical history, clinical assessment and biochemistry testing. BP control was assessed by three standards: National Institute for Health and Clinical Excellence (NICE), National Kidney Foundation Kidney Disease Outcome Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Descriptive statistics were used to compare characteristics of people achieving and not achieving BP control. Univariate and multivariate logistic regression was used to identify factors associated with BP control.ResultsThe prevalence of hypertension was 88%. Among people with hypertension, 829/1426 (58.1%) achieved NICE BP targets, 512/1426 (35.9%) KDOQI targets and 859/1426 (60.2%) KDIGO targets. Smaller proportions of people with diabetes and/or albuminuria achieved hypertension targets. 615/1426 (43.1%) were only taking one antihypertensive agent. On multivariable analysis, BP control (NICE and KDIGO) was negatively associated with age (NICE odds ratio (OR) 0.27; 95% confidence interval (95% CI) 0.17-0.43) 70–79 compared to <60), diabetes (OR 0.32; 95% CI 0.25-0.43)), and albuminuria (OR 0.56; 95% CI 0.42-0.74)). For the KDOQI target, there was also association with males (OR 0.76; 95% CI 0.60-0.96)) but not diabetes (target not diabetes specific). Older people were less likely to achieve systolic targets (NICE target OR 0.17 (95% CI 0.09,0.32) p < 0.001) and more likely to achieve diastolic targets (OR 2.35 (95% CI 1.11,4.96) p < 0.001) for people >80 compared to < 60).ConclusionsSuboptimal BP control was common in CKD patients with hypertension in this study, particularly those at highest risk of adverse outcomes due to diabetes and or albuminuria. This study suggests there is scope for improving BP control in people with CKD by using more antihypertensive agents in combination while considering issues of adherence and potential side effects.

Predictors of Hyperkalemia Risk following Hypertension Control with Aldosterone Blockade

Background: Aldosterone antagonists have proven efficacy for management of resistant hypertension and proteinuria reduction; however, they are not widely used due to risk of hyperkalemia. This study assesses the risk factors for hyperkalemia in patients with chronic kidney disease (CKD) and resistant hypertension whose blood pressure (BP) is reduced to a guideline goal. Methods: This is a two-center study conducted in university-based hypertension clinics directed by clinical hypertension specialists. Forty-six patients with resistant hypertension and stages 2 or 3 CKD (mean estimated glomerular filtration rate (eGFR) 56.5 ± 16.2 ml/min/1.73 m²) were evaluated for safety and efficacy of aldosterone blockade added to preexisting BP-lowering regimens. All patients were on three mechanistically complementary antihypertensive agents including a diuretic and a renin-angiotensin system blocker. Patients were evaluated after a median of 45 treatment days. The primary endpoint was change in systolic BP. Secondary endpoints included change in serum potassium, creatinine, eGFR, diastolic BP and tolerability. Results: The mean age of the patients studied was 64.9 ± 10.7 years, all were obese and 86% had type 2 diabetes, with 82% being African-American. Addition of aldosterone antagonism yielded a further mean reduction in systolic BP of 14.7 ± 5.1 mm Hg (p = 0.001). Females with BMI >30 and those with a baseline systolic BP >160 mm Hg were more likely to have a greater BP reduction to aldosterone antagonism. In total, 39% of the patients had a >30% decrease in eGFR when the BP goal was achieved. The mean increase in serum potassium was 0.4 mEq/l above baseline (p = 0.001), with 17.3% manifesting hyperkalemia, i.e. serum potassium >5.5 mEq/l. Predictors of hyperkalemia included a baseline eGFR of ≤45 ml/min/1.73 m² in whom serum potassium was >4.5 mEq/l on appropriately dosed diuretics. Contributing risks in this subgroup included a systolic BP reduction of >15 mm Hg associated with an eGFR fall of >30%. Conclusion: Aldosterone antagonism is effective and safe for achieving a BP goal among people with diabetic nephropathy when added to a triple antihypertensive regimen that includes a blocker of the renin-angiotensin system and an appropriately selected and dosed diuretic. Caution is advised when using aldosterone blockade for BP control in people with advanced stage 3 nephropathy with a serum potassium of >4.5 mEq/l for safety reasons.

Hypertension in dialysis and kidney transplant patients

For the first time, the Canadian Hypertension Education Program has studied the evidence supporting blood pressure control in people requiring renal replacement therapy for end-stage kidney disease, including those on dialysis and with renal transplants. According to the Canadian Organ Replacement Registry's 2008 annual report, there were an estimated 33,832 people with end-stage renal disease in Canada at the end of 2006, an increase of 69.7% since 1997. Of these, 20,465 were on dialysis and 13,367 were living with a functioning kidney transplant. Thus, it is becoming more likely that primary care practitioners will be helping to care for these complex patients. With the lack of large controlled clinical trials, the consensus recommendation based on interpretation of the existing literature is that blood pressure should be lowered to below 140/90 mmHg in hypertensive patients on renal replacement therapy and to below 130/80 mmHg for renal transplant patients with diabetes or chronic kidney disease.