Blood Pressure Goals In Patients Research Articles

Comparison of the use of blood pressure telemonitoring versus standard medical care in the achievement of short-term therapeutic goals in blood pressure in patients with uncontrolled hypertension: An open-label clinical trial.

In Mexico less than half of the treated hypertensive patients reach blood pressure (BP) targets. Most hypertensive individuals rely on the standard medical care (SMC) to achieve the BP control goals; however, the efficacy of BP telemonitoring (BPT) to achieve BP targets has been poorly studied. To compare the efficacy of BPT versus SMC to achieve BP goals in patients with uncontrolled hypertension. A two-arm, open-label clinical trial was conducted in patients ≥18 years with uncontrolled hypertension. The participants were randomized to 2 arms (BPT vs SMC) and followed for 12 weeks. For the statistical analysis, the chi-squared test and covariance were used. One hundred and seventy-eight participants were included, BPT (n = 94) and SMC (n = 84), after 12 weeks of follow up, we observed a baseline-adjusted reduction in systolic BP with both BPT (-13.5 [1.3] mmHg) and the SMC (-5.9 [1.4] mmHg; p < 0.001) but a greater decrease with BPT (p < 0.001). Likewise, we found a baseline-adjusted reduction of diastolic BP with BPT (-6.9 [0.9] mmHg) and SMC (-2.7 [0.9] mmHg) (p = 0.007) with a more significant percentage change from baseline with BPT (-6.8% [1.0] vs 2.5% [1.1]; p = 0.007). In the BPT arm, a larger proportion of patients achieved the BP target versus SMC (30.5% vs 12.8%; p = 0.005). BPT showed a greater proportion of patients achieving office BP control goals (<140/90 mmHg), compared to standard medical care.

The Impact of Mean Arterial Pressure and Volume Contraction in With Acute Ischemic Stroke.

Background and PurposeHydration at the time of stroke may impact functional outcomes. We sought to investigate the relationship between blood pressure, hydration status, and stroke severity in patients with acute ischemic stroke (AIS).MethodsWe evaluated hydration status, determined by blood urea nitrogen (BUN)/creatinine ratio, in consecutive patients with AIS from a single comprehensive stroke center. Baseline mean arterial pressure (MAP) was analyzed using a linear spline with a knot at 90 mmHg. Baseline stroke severity was defined based on admission NIH Stroke Scale scores (NIHSSS) and MRI diffusion-weighted imaging.ResultsAmong 108 eligible subjects, 55 (51%) presented in a volume contracted state. In adjusted models, in the total sample, for every 10 mmHg higher MAP up to 90 mmHg, NIHSSS was 2.8 points lower (p = 0.053), without further statistically significant association between MAP above 90 and NIHSSS. This relationship was entirely driven by the individuals in a volume contracted state: MAP was not associated with NIHSSS in individuals who were euvolemic. For individuals in a volume contracted state, each 10 mmHg higher MAP, up to 90 mmHg, was associated with 6.9 points lower NIHSSS (95% CI −11.1, −2.6). MAP values above 90 mmHg were not related to NIHSSS in either dehydrated or euvolemic patients.ConclusionsLower MAP contributes to more severe stroke in patients who are volume contracted, but not those who are euvolemic, suggesting that hydration status and blood pressure may jointly contribute to the outcome. Hydration status should be considered when setting blood pressure goals for patients with AIS.

Impact of pharmacist intervention for blood pressure control in patients with chronic kidney disease: A meta-analysis of randomized clinical trials.

Hypertension (HTN) and chronic kidney disease (CKD) are recognized as silent killers because they are asymptomatic conditions that contribute to the burden of multiple comorbidities. The achievement of a blood pressure (BP) goal can dramatically reduce the risks of CKD. In this study, we aimed to assess the effectiveness of pharmacist intervention on BP control in patients with CKD and evaluate the usefulness of home-based BP telemonitoring. The terms "chronic kidney disease," "pharmacist," "BP" and "randomized controlled trial (RCT)" were used five databases to search for information regarding pharmacist intervention on BP control in patients with CKD. The inclusion criteria were as follows: (a) studies for adult patients with uncontrolled HTN and (b) studies with adequate data for meta-analysis. The primary outcome was an evaluation of achievement of BP goal in patients with CKD. The secondary outcome was usefulness of home-based BP telemonitoring by pharmacists in patients with CKD. Six RCTs were identified and included in the meta-analysis with a total of 2573 patients (mean age 66.0years and 63.9% male). Pharmacist interventions resulted in significantly better BP control vs usual care (OR=1.53, 95% CI=1.15-2.04, P<.01). Pharmacist interventions using home-based BP telemonitoring were significantly superior to control/usual care (OR=2.03, 95% CI=1.49-2.77, P<.01), whereas pharmacist interventions without home-based BP telemonitoring did not significantly improve BP control compared to that with control/usual care (OR=1.30, 95% CI=0.97-1.75, P=.08). Home-based BP telemonitoring supported team-based care for HTN in these studies. In addition, patient self-monitoring with telemedicine devices might enhance patients' abilities to manage their condition by pharmacist instruction. The findings of this meta-analysis showed that pharmacist interventions with home-based BP telemonitoring improve BP control among adult patients with CKD.

Blood pressure management in emergency department patients with spontaneous intracerebral hemorrhage.

Despite the well documented importance of blood pressure management in patients with spontaneous intracerebral hemorrhage (sICH), little is known about whether emergency departments (EDs) are able to achieve close monitoring and precise management. Our study characterizes ED monitoring and management of blood pressure in sICH patients. This is a retrospective study of adults with sICH and elevated intracranial pressure. Patients who were admitted from any referring ED to our CCRU from 1 August 2013 to 30 September 2015 were included. We graphically assessed the association between average minutes between blood pressure measurements and average minutes between administration of antihypertensives. We also performed logistic regression to evaluate factors associated with close blood pressure monitoring and the achievement of goal blood pressure in patients with sICH who presented with hypertension. Of 115 patients, 73 presented to the ED with SBP above 160 mmHg. Length of stay in the ED was significantly associated with a longer period between blood pressure measurements. Longer periods between blood pressure measurements were a significant determinant of failure to achieve blood pressure goal in sICH patients. Longer periods between blood pressure measurements were significantly associated with longer periods between administration of antihypertensives. Our study suggests that blood pressure monitoring is related to the frequency of blood pressure interventions and achievement of adequate blood pressure control in patients with sICH. There is significant variability in EDs' achievement of the recommended close blood pressure monitoring and management in patients with sICH.

Target Blood Pressure Goals in Patients with Chronic Kidney Disease: Where Do We Stand in this Era of Evidence based Medicine?

Target Blood Pressure Goals in Patients with Chronic Kidney Disease: Where Do We Stand in this Era of Evidence based Medicine?

Management of Resistant Hypertension Based on Recommendations from Different Guidelines and the Systolic Blood Pressure Intervention Trial

The long-term management of patients with resistant hypertension has been made even more difficult by a “moving target” goal blood pressure (BP). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines defined resistant hypertension as the failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic. The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) guidelines laid out more lenient target BP goals, without addressing the definition of resistant hypertension directly. The present scenario is a state of confusion, with providers selectively adopting recommendations from different guidelines. The Systolic Blood Pressure Intervention Trial (SPRINT) trial contributed to the confusion with further evidence supporting the strict control of hypertension. In addition, the failure of another trial on renal denervation in the US has essentially put an end to six long years of experimentation with catheter ablation in patients with resistant hypertension. Other therapies are still experimental. Adding a new dimension of medical management, spironolactone has made a comeback in resistant hypertension, with reports of better responsiveness when added to existing anti-hypertensive therapy. The present review discusses the current state and management options for patients with resistant hypertension considering the new evidence. Newer advances in pharmacological and device therapy are also discussed to improve understanding and quality in the management of resistant hypertension.

Out with the Old and In with the New - Understanding Barriers and Facilitators in Obtaining “New” Blood Pressure Goal for Patients with Ischemic Stroke (P5.3-001)

Out with the Old and In with the New - Understanding Barriers and Facilitators in Obtaining “New” Blood Pressure Goal for Patients with Ischemic Stroke (P5.3-001)

Acute Blood Pressure Management in Neurocritically Ill Patients.

Optimal blood pressure (BP) management is controversial in neurocritically ill patients due to conflicting concerns of worsening ischemia with decreased BP versus cerebral edema and increased intracranial pressure with elevated BP. In addition, high-quality evidence is lacking regarding optimal BP goals in patients with most of these conditions. This review summarizes guideline recommendations and examines the literature for BP management in patients with ischemic stroke, intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, traumatic brain injury, and spinal cord injury.

Hypertension artérielle du sujet âgé

After 80 years old, antihypertensive treatment significantly reduces cardiovascular events. In the elderly, blood pressure target depends on patients' frailty. After 80 years, French guidelines propose to aim a SBP<150 mmHg without orthostatic hypotension and without exceeding the prescription of more than three antihypertensive drugs. The target may be more ambitious for robust elderly patients. The new 2018 European guidelines set: a stricter target for robust elderly patient aged 80 years or older (SBP between 130 and 139 mmHg and DBP between 70 and 79 mmHg); this objective is less strict for frail elderly (with several comorbidities, with loss of autonomy, elderly living in nursing home or with orthostatic hypotension). A recent randomized controlled trial shows a significant reduction in mortality and cardiovascular events by achieving a low blood pressure goal in patients over the age of 75 years old. Five major drug classes can be used: thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and beta-blockers. Beta-blockers are less efficient to prevent stroke and are indicated in second line. However, beta-blockers represent first choice of treatment in cases of heart failure, coronary artery disease or atrial fibrillation. Appropriate follow-up and monitoring enable assessment of safety (recording BP while standing, ionogram, creatinine).

Blood Pressure Goals in Patients with Coronary Artery Disease

Blood Pressure Goals in Patients with Coronary Artery Disease

Blood Pressure Goals in Patients with CKD: A Review of Evidence and Guidelines.

Hypertension affects the vast majority of patients with CKD and increases the risk of cardiovascular disease, ESKD, and death. Over the past decade, a number of hypertension guidelines have been published with varying recommendations for BP goals in patients with CKD. Most recently, the American College of Cardiology/American Heart Association 2017 hypertension guidelines set a BP goal of <130/80 mm Hg for patients with CKD and others at elevated cardiovascular risk. These guidelines were heavily influenced by the landmark Systolic Blood Pressure Intervention Trial (SPRINT), which documented that an intensive BP goal to a systolic BP <120 mm Hg decreased the risk of cardiovascular disease and mortality in nondiabetic adults at high cardiovascular risk, many of whom had CKD; the intensive BP goal did not retard CKD progression. It is noteworthy that SPRINT measured BP with automated devices (5-minute wait period, average of three readings) often without observers, a technique that potentially results in BP values that are lower than what is typically measured in the office. Still, results from SPRINT along with long-term follow-up data from the Modification of Diet in Renal Disease and the African American Study of Kidney Disease and Hypertension suggest that a BP goal <130/80 mm Hg will reduce mortality in patients with CKD. Unfortunately, data are more limited in patients with diabetes or stage 4-5 CKD. Increased adverse events, including electrolyte abnormalities and decreased eGFR, necessitate careful laboratory monitoring. In conclusion, a BP goal of <130/80 is a reasonable, evidence-based BP goal in patients with CKD. Implementation of this intensive BP target will require increased attention to measuring BP accurately, assessing patient preferences and concurrent medical conditions, and monitoring for adverse effects of therapy.

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

Blood Pressure Control and Other Quality of Care Metrics for Patients with Obesity and Diabetes: A Population-Based Cohort Study.

There are no population-level estimates in the United States for achievement of blood pressure goals in patients with diabetes and hypertension by obesity weight class. We sought to examine the relationship between the extent of obesity and the achievement of guideline-recommended blood pressure goals and other quality of care metrics among patients with diabetes. We conducted an observational population-based cohort study of electronic health data of three large health systems from 2010-2012 in rural, urban and suburban settings of 51,229 adults with diabetes. Outcomes were achievement of diabetes quality of care metrics: blood pressure, A1c, and LDL control, and A1c and LDL testing. Two blood pressure goals were examined given the recommendation for adults with diabetes of 130/80mmHg from JNC7 and the recommendation of 140/90mmHg from JNC8 in 2014. Patients in obesity classes I, II, and III with diagnosed hypertension were less likely to achieve blood pressure control at both the 140/90mmHg and 130/80mmHg control levels. The patients from obesity class III had the lowest likelihood of achieving control at the 130/80mmHg goal, and control was markedly worse for the 130/80mmHg threshold in all weight classes. There were minimal to no differences by weight class in LDL and A1c control and LDL and A1c testing. Although the cardiovascular risk for patients with obesity and diabetes is greater than for non-obese patients with diabetes, we found that patients with obesity are even further behind in achieving blood pressure control.

Update on Diabetic Nephropathy 2018

UPDATE ON DIABETIC NEPHROPATHY 2018: The prevalance of elevated albuminuria in patients with diabetes is decreasing, while that of reduced eGFR is increasing, probably owing to more stringent blood pressure and blood glucose control.Well validated online score calculators for risk for renal replacement therapy, cardiovascular events and death are available online.Clinical variables remain more suited than histology for predicting end stage renal disease. Extracapillary hypercellularity, segmental sclerosis and exsudative lesions could represent a distinct risk phenotype.SGLT-2-inhibitors and GLP-1 analogues provide significant reductions of micro- and macrovascular end points. SGLT-2-inhibitors can only be prescribed at eGFR > 60 ml/min/1,73 m2, GLP-1 analogues and metformin at eGFR > 30 ml/min/1,73 m2.The ACC/AHA guideline 2017 defines arterial hypertension at blood pressure ≥ 130/80 mmHg, the ESC/ESH guideline 2018 at ≥ 140/90 mmHg. The blood pressure goal for patients with diabetes is < 130/80 mmHg, if well tolerated. ESC/ESH 2018 recommend not lowering blood pressure lower than 120/70 mmHg, in persons aged ≥ 65 years, systolic blood pressure 130 - < 140 mmHg is recommended.

Clinical Factors Affecting the Goal Blood Pressure in Hypertensive Patients of a Rural Polyclinic in Russia

Background:Primary care units in rural areas of the Russian Federation experience difficulties in long-term follow-up of chronic cardiovascular diseases, such as hypertension. Identification of outpatient clinical traits affecting the goal blood pressure (BP) may optimize the choice of treatment pathways.Objective:To identify the patient-related factors affecting the achievement of the goal BP in the course of hypertension treatment at a rural polyclinic.Methods:We analyzed the data on 182 patients with essential hypertension (64.6 ± 11.3 yo; 48.5% men), who were treated in polyclinic settings of a rural settlement in the Saratov Region of the Russian Federation. Outpatient medical records were used as a source of clinical data. Repeat patients with hypertension diagnosis specified in their medical records, visiting a therapeutist or cardiologist on two randomly selected workdays, were enrolled in our study. The first appointment took place during 1-31 July, 2015 (n = 88), while the second visit occurred on 1- 31 July, 2016 (n = 94). Eleven district therapeutists, two general practitioners and the only cardiologist of the polyclinic participated in the study. Discriminant function analysis was used to identify factors affecting the achievement of the goal blood pressure in the patients. Basic demographic and anamnesis data, risk factors, medical treatment type and lifestyle modification measures, if any, which exhibited statistical significance in univariate analysis (p&lt;0.05), were selected for multi-factor discriminant analysis.Results:The goal BP was achieved in 93 patients (51%). The patients with the goal BP differed from those with uncontrolled hypertension in various ways. They were less often women (53.8% vs. 69.7%, p = 0.028), more frequently had prior myocardial infarction (22.6% vs. 10.1%, p = 0.024), more rarely suffered from other forms of stable CAD (55.9% vs. 73%, p = 0.016), as well as took fewer thiazide-like diuretics (9.7% vs 21.3%, p = 0.03). It is worth noting that fewer antihypertensive medications were prescribed to the patients with the goal BP as opposed to those with poor BP control (1.63 ± 0.12 vs. 1.98 ± 0.11, p = 0.018).Resulting discriminant model exhibited high predictive power. The ratio of odds for the model was 5.4 (95% CI: 2.7-10.7), р&lt;0.001. The single factor correlating significantly with the achievement of the goal BP was preceding myocardial infarction (OR 2.6, 95% CI: 1.1 - 6.6, р=0.032), while prescription of two or more antihypertension drugs was associated with poor BP control (OR 0.4, 95% CI: 0.2 - 0.7, р=0.003).Conclusion:In the hypertensive patients with a history of myocardial infarction versus those without it, treated at a rural polyclinic, BP was more likely to be controlled. Administration of multiple antihypertensive drugs was associated with poor BP control.

Blood Pressure and Arterial Load After Transcatheter Aortic Valve Replacement for Aortic Stenosis

After aortic valve replacement, left ventricular afterload is often characterized by the residual valve obstruction. Our objective was to determine whether higher systemic arterial afterload-as reflected in blood pressure, pulsatile and resistive load-is associated with adverse clinical outcomes after transcatheter aortic valve replacement (TAVR). Total, pulsatile, and resistive arterial load were measured in 2141 patients with severe aortic stenosis treated with TAVR in the PARTNER I trial (Placement of Aortic Transcatheter Valve) who had systolic blood pressure (SBP) and an echocardiogram obtained 30 days after TAVR. The primary end point was 30-day to 1-year all-cause mortality. Lower SBP at 30 days after TAVR was associated with higher mortality (20.0% for SBP 100-129 mm Hg versus 12.0% for SBP 130-170 mm Hg; P<0.001). This association remained significant after adjustment, was consistent across subgroups, and confirmed in sensitivity analyses. In adjusted models that included SBP, higher total and pulsatile arterial load were associated with increased mortality (P<0.001 for all), but resistive load was not. Patients with low 30-day SBP and high pulsatile load had a 3-fold higher mortality than those with high 30-day SBP and low pulsatile load (26.1% versus 8.1%; hazard ratio, 3.62; 95% confidence interval, 2.36-5.55). Even after relief of valve obstruction in patients with aortic stenosis, there is an independent association between post-TAVR blood pressure, systemic arterial load, and mortality. Blood pressure goals in patients with a history of aortic stenosis may need to be redefined. Increased pulsatile arterial load, rather than blood pressure, may be a target for adjunctive medical therapy to improve outcomes after TAVR. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00530894.

The impact of antihypertensives on kidney disease.

Arterial hypertension and chronic kidney disease (CKD) are intimately related. The control of blood pressure (BP) levels is strongly recommended in patients with CKD in order to protect the kidney against the accompanying elevation in global cardiovascular (CV) risk. Actually, the goal BP in patients with CKD involves attaining values <140/90 mmHg except if albuminuria is present. In this case, it is often recommended to attain values <130/80 mmHg, although some guidelines still recommend <140/90 mmHg. Strict BP control to values of systolic BP around 120 mmHg was recently shown to be safe in CKD according to data from the SPRINT trial, albeit more data confirming this benefit are required. Usually, combination therapy initiated with an angiotensin receptor blocker (ARB) or angiotensin-converting enzyme inhibitor (ACEi) and commonly followed by the addition of a calcium channel blocker and a diuretic is needed. Further studies are required as well as new drugs in particular after the positive data obtained from new oral anti-diabetic drugs.

Abstract P176: Impact of Serious Adverse Event Risks on the Cost-effectiveness of Intensive Blood Pressure Goals in Patients Aged ≥75 Years

Background: Compared to the overall Systolic Blood Pressure Intervention Trial (SPRINT) results, patients aged ≥75 years at baseline had a greater reduction in cardiovascular disease (CVD) events and all-cause mortality with an intensive systolic blood pressure (SBP) goal (&lt;120 mmHg) compared to a standard SBP goal (&lt;140 mmHg). Applying an intensive SBP goal in high-risk older patients represents a major shift in clinical practice and may increase concern for medication-related severe adverse events (SAEs). We hypothesized that the benefits of reduced CVD risk would outweigh the increased costs and SAE risk of intensive vs. standard SBP goals in SPRINT-eligible patients aged ≥75 years even when considering variable SAE risks. Methods: A microsimulation health-state transition model of 10,000 patients was created to estimate the CVD events, SAEs, quality-adjusted life years (QALYs), and direct healthcare costs of intensive vs. standard SBP goals. The model assumed patients were adherent to treatment during the median SPRINT follow-up, but that all patients would become non-adherent over 5 years. While adherent, CVD and SAE risks were derived from published SPRINT effect estimates for the ≥75 subgroup. Due to uncertainty in the SAE risk associated with intensive SBP goals in older adults, the intensive arm SAE risk was varied to determine the point at which treatment costs and harms outweighed CVD benefits at accepted willingness-to-pay thresholds. Healthcare costs and health state utilities were derived from national sources and other published estimates. Results: If SAE risk was equal to the observed rates in SPRINT, mean lifetime costs and QALYs were $268,000 and 7.85 for the intensive arm, and $262,000 and 7.60 for the standard arm. The resulting incremental cost-effectiveness ratio (ICER) was about $26,000 per QALY gained. However, as SAE risk in the intensive arm increased by 1.5, 2, and 2.5 times, the ICER increased to $33,000, $43,000, and $55,000 per QALY gained, respectively. Conclusion: Intensive SBP goals may be a cost-effective way to reduce CVD events and improve survival in patients aged ≥75 years, but safety and cost-effectiveness depend on medication-related SAE risk. However, these results are based on summary data and do not account for clustering of risks at the individual patient level. Thus, more precise prediction of risks and benefits is needed to guide selection of older patients for intensive SBP treatment goals.

Hypertension and coronary artery disease: epidemiology, physiology, effects of treatment, and recommendations : A joint scientific statement from the Austrian Society of Cardiology and the Austrian Society of Hypertension.

High blood pressure is amajor modifiable risk factor for all clinical manifestations of coronary artery disease (CAD). In people without known cardiovascular disease, the lowest systolic (down to 90-114mmHg) and the lowest diastolic (down to 60-74mmHg) pressures are associated with the lowest risk for developing CAD. Although diastolic blood pressure is the strongest predictor of CAD in younger and middle-aged people, this relationship becomes inverted and pulse pressure shows the strongest direct relationship with CAD in people above 60years of age.Pathophysiological mechanisms of blood pressure as arisk factor for CAD are complex and include the influence of blood pressure as aphysical force on the development of the atherosclerotic plaque, and the relationship between pulsatile hemodynamics/arterial stiffness and coronary perfusion. Treatment of arterial hypertension has been proven to prevent coronary events in patients without clinical CAD. In patients with established CAD, the effect of blood pressure lowering per se is beneficial, probably more than specific drugs or drug classes. The important exceptions are beta blockers (BBs), which are superior to all other drug classes for use after arecent myocardial infarction. Blood pressure targets in patients with established CAD have created controversy in the light of the so-called J-curve phenomenon, which describes an increase in coronary events at lower diastolic blood pressures. One explanation for this observation is that perfusion of the left ventricle occurs predominantly during diastole, and that coronary autoregulation may be exhausted with low diastolic blood pressure in the setting of left ventricular hypertrophy and atherosclerotic narrowing of the epicardial coronaries. The worst situation is ahigh systolic blood pressure in the presence of alow diastolic blood pressure, both ahallmark of increased aortic stiffness. However, the lowering of systolic blood pressure is clearly beneficial in this setting, even at the price of further lowering diastolic pressure. Primary blood pressure goal in patients with established CAD is below 140/90mmHg. Recent studies suggest that alower systolic blood pressure may be appropriate, whereas caution is advised with diastolic blood pressure below 60mmHg.

New blood pressure goals for patients with increased cardiovascular risk.

New blood pressure goals for patients with increased cardiovascular risk.