HTN Patients Research Articles

Adherence to antihypertensive treatment and associated factors among patients on follow up at University of Gondar Hospital, Northwest Ethiopia

BackgroundHypertension is an overwhelming global challenge with high morbidity and mortality rates. The prevalence of HTN is estimated to be 6% in Ethiopia and 30% in Addis Ababa. Poor adherence is associated with bad outcome of the disease and wastage of healthcare resources. In Ethiopia, particularly in the study area little is known about treatment adherence and associated factors. Therefore this study aimed to assess adherence to antihypertensive therapy and associated factors among HTN patients on follow up at University of Gondar Referral Hospital.MethodInstitution based cross sectional study was conducted. Systematic sampling technique was used to select 384 participants. A structured standard questionnaire was used after some modifications. Morisky Medication Adherence Scale was used for labeling patients as adherent or non-adherent. Data were entered and analyzed using SPSS version 16.ResultsMore than half (64.6 %) of the study participants were found to be adherent to their treatment. Sex (AOR = 0.48, 95%CI = 0.28, 0.82), knowledge about HTN and its treatment (AOR = 6.21, 95%CI = 3.22, 11.97), distance from the hospital (AOR = 2.02, 95% CI =1.19-3.43) and co morbidity (AOR = 2.5, 95%CI = 1.01, 6.21) variables were found significantly associated with treatment adherence.ConclusionOnly 64.6% of the study subjects were found to be adherent to their treatment. Factors such as sex, distance from the hospital, number of co morbidities, Knowledge about HTN and its treatment were associated with adherence behavior of patients. Early diagnosis and management of co morbidities, adherence counseling and patient education about the disease and its treatment are important to improve adherence status of patients.

J-007 ANTI-HYPERTENSIVE MEDICATIONS TRENDS AND RISK OF STROKE AMONG HYPERTENSIVE PATIENTS IN TAIWAN

Background To evaluate the trend of anti-hypertensive medications and also examine the risk of stroke among these HTN patients from 2001 to 2005 in Taiwan. Methods Based on the National Health Insurance (NHI) database, we randomly selected 10% hypertension outpatients from the NHI claim database on 2001 and then follow their anti-HTN medications and occurrence of stroke for a 4-year follow-up period. Results In 2001, there are 1931436 patients with ICD-9 coding of hypertension, we selected 194547 subjects as study population, after excluded those visited less than 3 times or without anti-HTN subjects, there are 135660 subjects in the finally analyses. The prevalence of stroke among hypertension patients was slightly decreased from 12.0 to 11.3% since 2001 to 2005 (for male from 20.1 to 19.8 and for females from 17.7 to 16.7%). There are 27.6% patients with only one anti-HTN medication and 37.0% patients with 3 or more medications for HTN. Among these anti-HTN patients, 68.2% used CCB, 55.1% for beta-blocker, and 42.5% with ACEI and 31% with diuretics. Among these patients, 9395 (4402 males and 5128 females) had both information on 2001 and 2004. The prevalence of stoke was 7.3% in 2001 and increased to 13.6% in 2004. Using Cox proportion hazard model, gender (male) and age were important factors to predict the occurrence of stroke. Comparing with beta-blocker, diuretics had higher relative risk for stoke but the risk was attenuate after adjusted for other confounders (HR = 1.3, 95% CI 0.7–2.6). Conclusions From this study, we could found that the occurrence of stroke among hypertensive patients was increased during this period. There was no significant protective effect for stroke among hypertensive patients using different anti-HTN medications. Further studies may be indicated to evaluate the cost-effectiveness of different medications on hypertensive-related disorders.

Abstract P231: Patient-Centered Care of Stage I and II Hypertension in Underserved Communities

Background: Inadequate BP control leads to excess cardiovascular disease risk (CVD), especially in underserved communities. Patient-centered care tools including home monitoring of BP are key components in BP control and CVD risk reduction. We compared two communication methods to modify CVD risk in hypertensive patients. We also tested whether either strategy is more effective in stage I or II hypertension. Methods: 388 asymptomatic subjects (59% white, 37% AA) with Framingham risk score >10% from one urban and one rural center completed our trial. 37% had StageI HTN (SBP 140-159 mmHg), and 24% StageII HTN (SBP≥160 mmHg). Subjects were randomized to nurse management (NM) with 4 visits/year, or nurse management plus Telemedicine (T). T group reported weight, BP, steps/day at least weekly via internet (average 6.3 reports/month). Periodic summaries were sent to patients and to their care providers Results: BP decreased substantially in both groups, with a significant difference in BP reduction between NM and T in patients with stageI HTN (P=0.037-see graph). T had a lower 8 month average BP compared to NM (T: 134.6 ± 15.0, NM: 140.4±16.9 mmHg, P<0.02). StageII HTN patients had significant reduction in BP with no difference between NM and T (P=.900). Risk score was reduced by 2.6±6.8% (P< 0.001), with no difference between NM and T (P=0.750) Conclusion: Telemedicine improved BP control in patients with StageI HTN more than with StageII HTN. It appears that SBP ≥160 is more likely to be immediately treated by care providers than SBP in the (140-159) range. StageI patients, therefore, had greater benefit from Telemedicine as it stimulated a more effective intervention by their care providers.

Assessment of arterial stiffness from ambulatory blood pressure monitoring in children with diabetes mellitus type-1 (DMT1)

Pulse pressure (PP) and ambulatory arterial stiffness index (AASI) can be calculated from ambulatory blood pressure (BP) monitoring (ABPM) and have been suggested as markers of arterial stiffness and predictors of cardiovascular mortality. We retrospectively evaluated PP and AASI from ABPM records in 84 children (43 boys) with diabetes mellitus type-1 (DMT1) compared with 27 non-diabetic normotensive children. Based on office BP and ABPM, patients with DMT1 were divided into three groups: 24/84 (29%) had hypertension (DM HTN), 33/84 (39%) were normotensive (DM NT) and 27/84 (32%) had white-coat hypertension (DM WCH). DM WCH and DM HTN patients had significantly higher PP when compared with DM NT and NT patients alone (47.62 ± 7.31 and 47.43 ± 8.68 versus 41.45 ± 4.44 and 42.18 ± 5.97, respectively, P=0.0002). Similarly, AASI was significantly elevated in both DM WCH and DM HTN patients when compared with NT patients (0.35 ± 0.14 and 0.36 ± 0.15 versus 0.23 ± 0.15, respectively, P=0.007). In conclusion, children with DMT1 and hypertension, including WCH, had significantly higher PP and AASI levels when compared with normotensive patients. This suggests that these children may be at an increased risk for developing cardiovascular complications later on in life.

C-C2-02: The High Five for Kids Study: An Intervention to Improve Primary Care to Prevent Childhood Obesity

2 Denver VA Medical Center Background and Aims: Among coronary artery disease (CAD) patients, control of hypertension reduces rates of myocardial infarction and mortality. Yet, BP control among CAD patients remains sub-optimal in clinical practice. Few prior studies have had the longitudinal data necessary to assess the role of treatment intensification and medication adherence in achieving optimal control. Methods: In this retrospective cohort study, we evaluated baseline and 1-year BP control rates among 15,102 HTN patients with an incident diagnosis of CAD between January 1, 2003 and December 31, 2006. Among those patients with sub-optimal baseline BP control, we assessed the contribution of treatment intensification and medication adherence to achieving 1-year BP control. Sub-optimal BP control was defined as systolic BP =140 mmHg and/or diastolic BP =90 mmHg (for those with diabetes or renal disease, sub-optimal control was defined as SBP =130mmHg and/or DBP =80mmHg). Treatment intensification was defined as an increase in BP medication dosage, the addition of another BP medication, and/or a switch of medication that resulted in a higher bioequivalent dose. Medication adherence was calculated using the proportion of days covered by medication prescription, and defined as a PDC > 80%. Logistic regression was used to determine the contribution of treatment intensification and medication adherence on achieving 1-year BP control, adjusting for baseline patient variables. Results: At the time of CAD diagnosis, 9,513 (65%) had sub- optimal BP control. At 1 year, 3,628(38%) of these subjects achieved BP control. Treatment intensification occurred more often among those patients who achieved 1-year BP control than those who did not (54% vs. 42%, p-value <0.0001). Medication adherence was similar between patients who achieved 1-year BP control and those who did not (87% vs.86%, p-value 0.10) during the year post-CAD. In adjusted analyses, treatment intensification was significantly associated with 1 year BP control (OR 1.42 95%CI 1.39, 1.45). In contrast, medication adherence was not significantly associated with 1 year BP control (OR 1.02, 95%CI 0.87, 1.16). Conclusions: Treatment intensification, but not medication adherence, was significantly associated with 1-year BP control among a newly diagnosed CAD population. Interventions to improve treatment intensification may improve BP control and patient outcomes.

PS1-06: The Impact of Treatment Intensification and Medication Adherence in Achieving Blood Pressure Control Among Coronary Artery Disease Patients

Background and Aims: Among coronary artery disease (CAD) patients, control of hypertension reduces rates of myocardial infarction and mortality. Yet, BP control among CAD patients remains sub-optimal in clinical practice. Few prior studies have had the longitudinal data necessary to assess the role of treatment intensification and medication adherence in achieving optimal control. Methods: In this retrospective cohort study, we evaluated baseline and 1-year BP control rates among 15,102 HTN patients with an incident diagnosis of CAD between January 1, 2003 and December 31, 2006. Among those patients with sub-optimal baseline BP control, we assessed the contribution of treatment intensification and medication adherence to achieving 1-year BP control. Sub-optimal BP control was defined as systolic BP =140 mmHg and/or diastolic BP =90 mmHg (for those with diabetes or renal disease, sub-optimal control was defined as SBP =130mmHg and/or DBP =80mmHg). Treatment intensification was defined as an increase in BP medication dosage, the addition of another BP medication, and/or a switch of medication that resulted in a higher bioequivalent dose. Medication adherence was calculated using the proportion of days covered by medication prescription, and defined as a PDC > 80%. Logistic regression was used to determine the contribution of treatment intensification and medication adherence on achieving 1-year BP control, adjusting for baseline patient variables. Results: At the time of CAD diagnosis, 9,513 (65%) had suboptimal BP control. At 1 year, 3,628(38%) of these subjects achieved BP control. Treatment intensification occurred more often among those patients who achieved 1-year BP control than those who did not (54% vs. 42%, p-value <0.0001). Medication adherence was similar between patients who achieved 1-year BP control and those who did not (87% vs. 86%, p-value 0.10) during the year post-CAD. In adjusted analyses, treatment intensification was significantly associated with 1 year BP control (OR 1.42 95% CI 1.39, 1.45). In contrast, medication adherence was not significantly associated with 1 year BP control (OR 1.02, 95% CI 0.87, 1.16). Conclusions: Treatment intensification, but not medication adherence, was significantly associated with 1-year BP control among a newly diagnosed CAD population. Interventions to improve treatment intensification may improve BP control and patient outcomes.

2D SPECKLE STRAIN IMAGING IDENTIFIES DEPRESSED LEFT ATRIAL FUNCTION IN HYPERTENSIVE PATIENTS WITH DIASTOLIC DYSFUNCTION: 3C.07

Background: Assessment of LA deformation obtained by 2D Speckle Strain Imaging (2DSI) has been recently proposed as an alternative method of exploring LA function. The aim of this study was to analyze LA function with 2DSI in hypertensive patients and normal controls. Methods: 39 HTN with grade 1–2 diastolic dysfunction (76 ± 14years; 72%women) and 66 healthy volunteers (NLS; 44 ± 16; 55%women) underwent standard echocardiography with complete evaluation of diastolic function and atrial 2DSI. LA volume was calculated by the area-length method. The ratio of E/e' (filling pressure) to LA 2DSI (strain) was used as an index of LA stiffness. Results: HTN patients were older and more often women as compared to NLS (both p < 0.05). In analysis of covariance with means adjusted for differences in age and gender among groups, HTN showed lower E/A ratio, paired with higher E/e' and LA volume (all p < 0.01). HTN also showed a reduction in LA 2DSI (23.8 ± 8.2% vs 43.0 ± 11.1%; p < 0.001) paired with a marked increase in LA stiffness (0.52 ± 0.09 vs 0.21 ± 0.11%; p < 0.001).As shown in Figure, LA 2DSI was negatively associated with LA volume (p < 0.001; r = -0.51) with no significant association found with other indices of left ventricular diastolic function (including e' and E/A ratio). In a subgroup analysis of 14 randomly selected HTN and 14 age and gender matched controls, both LA 2SDI and LA stiffness were significantly impaired in HTN as compared to NLS also after further correction for differences among groups in LA volume and E/e' ratio. Conclusion: LA function by 2DSI is significantly reduced in HTN with diastolic dysfunction as compared to normal controls. Lower atrial strain is related to higher LA stiffness and LA dilation but is independent of other indices of left ventricular diastolic function.

SAFETY AND TOLERABILITY OF COMBINATION OLMESARTAN MEDOXOMIL (OM)+AMLODIPINE BESYLATE (AML)+HYDROCHLOROTHIAZIDE (HCTZ) IN PATIENTS WITH HYPERTENSION: THE TRINITY STUDY: PP.5.166

Since hypertension is an asymptomatic disease, patient adherence to therapy is often influenced by a treatment's tolerability and adverse-event (AE) profile. The efficacy and safety of OM 40 mg+AML 10 mg+HCTZ 25 mg compared with its corresponding dual components (OM/AML, OM/HCTZ, or AML+HCTZ) was evaluated in 2492 moderate to severe HTN patients in a phase 3, multicenter, parallel-group study consisting of a 12-wk double-blind treatment period followed by a 40-wk open-label treatment period. Patients were stratified by age, race, and diabetic status and received dual-combination therapy for 2 wks. A subset of treatment-naive patients received placebo (n=36) prior to switching to dual-combination therapy, which continued for all patients from wks 2 to 4. OM+AML+HCTZ was initiated in a subset of patients from each of the 3 dual-combination groups at wk 4 and continued until wk 12.The primary safety cohort (n=2302) for the assessment of AEs was defined as patients who took at least 1 dose of study medication at or beyond wk 4. At baseline for all randomized patients, mean age was 55.1 y, with 52.9% male, 66.8% Caucasian, 19% >/=65 y, and 15.5% diabetic; mean SeBP was 168.5/100.9 mmHg. Across all groups, treatment-emergent AEs (TEAEs) (>/=3%) included dizziness (7.0%), headache (6.5%), peripheral edema (6.0%), fatigue (5.4%), and upper respiratory tract infection (3.2%). Similar TEAE incidences were seen across all 4 treatment groups, and most TEAEs and drug-related TEAEs were mild or moderate in severity. Slightly more discontinuations due to TEAEs occurred in the OM+AML+HCTZ group due to the greater pharmacodynamic effects. Overall, OM+AML+HCTZ was safe and well tolerated by most patients.

Oxidant–antioxidant Status and Lipid Profile in the Hypertensive Patients.

Background: Hypertension is associated with an elevation of ROS and frequently also with an impairment of endogenous antioxidant mechanisms. Increased level of serum cholesterol, TG, VLDL has been observed in patients with hypertension. It has been shown that oxidized lipoprotein inactivates NO and aggravates hypertension. This study intends to know the association of oxidative stress and lipid profile with hypertensive patients of the Western Nepal.Methods: Our study group comprised of 32 confirmed cases of HTN. Inclusion criteria included the patients with blood pressure ≥140/90mm of Hg. Patients with secondary hypertension, past history of stroke, coronary artery disease (CAD), myocardial infarction, and peripheral vascular disease and diabetes mellitus were excluded. Serum lipid profile, plasma thiobarbituric acid reactive substances (PTBARS), plasma total antioxidant activity (TAA) and urinary thiobarbituric acid reactive substances (UTBARS) were estimated in these patients by standard procedures and the values were compared with 30 age, sex and socioeconomically matched normal healthy control subjects.Results: TBARS levels and Lipid profile were significantly raised in HTN patients, but TAA and urinary TBARS levels were comparable to normal subjects. BMI and W/H ratio in patients were comparable to control. Smoking and alcohol did not influence lipid profile, TBARS and TAA.Conclusion: Lipid profile and TBARS were significantly raised in HTN patients compare to controls. Thus, monitoring lipid level and maintaining oxidative balance in hypertensive patients would be helpful in preventing the diseases associated with hypertension. Key words: Hypertension; Lipid profile; Oxidative stress; Antioxidant; Nepal.doi: doi: 10.3126/jnhrc.v6i2.2185Journal of Nepal Health Research Council Vol. 6, No. 2, 2008 October Page : 63-68

Hemodialysis vascular access: Variable thrombus-free survival in three subpopulations of black patients

Hemodialysis vascular access-related problems account for most hospitalizations in chronic hemodialysis patients. Although some co- morbid risk factors for early fistula failures have been described, a great deal of unknown exists as to why access survival is favorable in some patients. In this longitudinal study, fistulae patency and thrombosis episodes were monitored from placement date in three groups of end-stage renal disease (ESRD) patients who have been on dialysis for > or =90 days. Thirty-six patients (29 male; 80%) with a mean age of 42+/-2 years were monitored. The groups consisted of eight patients with biopsy-confirmed focal segmental glomeruloscierosis (FSGS), 13 with acquired immunodeficiency syndrome-related nephropathy (human immunodeficiency virus [HIV]), and 15 with hypertensive ESRD (hypertensive nephrosclerosis [HTN]) who served as controls. Diabetics and patients aged > or =64 years were excluded. Twenty-five of 36 (69%) fistulae were prosthetic (AVG), while 11 (31%) were native (AVF). The FSGS group was more likely to have an AVG (87.5%), while 54% of the HIV group had an AVG. The thrombosis event rate was significantly greater among the FSGS patients (3/patient-year) than the HIV (0.15/patient- year) and HTN (0.5/patient-year) patients (P < 0.0001 and P < 0.002, respectively). The mean thrombosis-free duration for both AVG and AVF among the HIV and HTN groups were 318.5+/-17 days and 311.7+/-22.5 days, respectively. These were significantly greater than in the FSGS group (26.5+/-7 days; P < 0.0001). The cumulative 1-year patency rate for AVG among the HIV and HTN groups was 85% and 65%, respectively, while that of the FSGS group was 0%. Kaplan-Meier hazard analysis showed that all groups were at risk of access thrombosis as time progressed, but the FSGS group had the highest risk of access thrombosis, which began from the date of placement and increased exponentially with time. The increased thrombosis rate among the patients in the FSGS group correlated with their weight (R = 0.8, P = 0.003) and pre-ESRD 24-hour urinary protein excretion (R = 0.9, P = 0.001). The HIV status appeared to confer enhanced hemodialysis access survival. This may be related to the high rate of native fistulae placement and favorable vascular reactivity to shear stress. Accelerated atherosclerosis and small caliber vessels may be responsible for the poor fistulae outcome among the FSGS group. More studies will be necessary to further explore these findings. (Am J Kidney Dis 1998 Feb;31(2):250-6)