Improve BP Control Research Articles

Semaglutide for the treatment of resistant hypertension

Abstract Background Treatment options for resistant hypertension (RH) are often limited by medication intolerance and adverse effects. Novel approaches to treatment are required. The disease of obesity affects 70% of patients with RH. Purpose To determine if a weight centric approach using semaglutide improved BP control in patients with RH. Methods Individual participant data from three randomised placebo-controlled trials (STEP 1, 3 and 4) examining the effect of semaglutide 2.4mg on body weight over 68 weeks were included. Participants on >4 anti-hypertensive medications or those with systolic BP (SBP) >130mmHg at baseline and 3 anti-hypertensive medications including a diuretic were considered to have RH. Firstly, the change in SBP comparing those on semaglutide to placebo was analysed with baseline systolic BP as a covariate in an ANCOVA model. Then, the RH group was subdivided into those with SBP above or below 130mmHg at baseline and BP response to semaglutide assessed. Analyses were performed using R Software version 4.0.3. Results In the pooled analysis of 3136 trial participants, 111 met the criteria for RH. Compared to placebo, participants on semaglutide had a SBP reduction of -4.93mmHg, adjusted for SBP baseline to -3.16mmHg (95%CI -8.69 to 2.37). For those with RH and a baseline SBP > 130mmHg on semaglutide, the SBP change was -10.94mmHg. This change was 4.54mmHg for those with a SBP < 130mmHg. The diastolic BP changes were -3.62 and 2.79mmHg respectively (Figure 1). At trial completion, 36% of those on semaglutide did not meet the criteria for RH. Conclusions The effect of semaglutide on BP for patients with RH is modest. A greater BP reduction is evident for those with a higher baseline SBP. Targeting excess body weight with semaglutide is a viable treatment option for patients with RH and uncontrolled BP.

Abstract MP11: Evaluation of a Remote Patient Monitoring Hypertension Program with Telehealth Pharmacist Management in Nephrology Clinic Patients

Introduction: Remote patient monitoring (RPM) and physician-pharmacist collaborative models have potential in improving hypertension control. Herein, we report the effectiveness of a community based, self-measured blood pressure (SMBP) RPM program on BP control and healthcare utilization in a largely rural health system. Methods: A multidisciplinary team developed a self-measured blood pressure (SMBP) RPM program in central and northeast PA using a virtual platform with bluetooth-connected BP devices targeting patients with BP ≥140/90 mmHg seen in nephrology clinics. From 3/2022 to 9/2022, high BP notifications were transmitted to nephrologists. After 9/2022, BP notifications were transmitted first to pharmacists, who co-managed BP through collaborative practice agreements via telehealth. We captured pharmacist interventions by reviewing electronic health record documentation. Changes in SMBP over time and the effect of pharmacist interventions were analyzed using mixed effects models. All-cause hospitalizations and emergency room (ER) visits were compared in 6-month pre/post-enrollment periods. Results: A total of 205 patients (mean age 62.3y, clinic BP 146/84, 3.1 BP classes, 48% female, 53% CKD) were enrolled into the program and had ≥ 6 months follow-up data. SMBP control <140/90 improved from 30% during week 1 to 67% at 6 months and 74% at 12 months. Overall, systolic SMBP improved over the first 6 months with stronger effect on patients with higher baseline BP (baseline BP ≥150/100 mmHg: -3.3 mmHg/month (95% CI: -3.5, -3.1); baseline 140-149/90-99: -2.4 (95% CI: -2.6, -2.1) mmHg/month; baseline <140/90: -0.6 (-0.9, -0.4) mmHg/month). Pharmacist telehealth encounters were documented in 65% of patients; 46% had a BP medication adjustment; 37% had new BP medication classes, including 9% mineralocorticoid receptor antagonist. Pharmacist medication intervention was associated with greater decline in systolic BP over time (-1.3 mmHg/month; 95% CI: -1.6, -1.1). Comparing the 6 months pre vs. post-enrollment, patients experienced a reduction in hospitalizations (6.0% vs. 0%; Exact Mcnemar p=0.0005) and no difference in ER visits (14.9% vs. 12.9%; p=0.6). Conclusion: Participation in a nephrologist-pharmacist SMBP RPM program was associated with improvement in BP control and reduced hospitalizations. Future efforts are underway to refine delivery of this program for the largest impact on improving BP control.

Designing Health Center Self-Measured Blood Pressure Program Models to Improve Hypertension Control

Summary: With the aim of achieving higher, equitable hypertension control rates, 350 nationwide federally qualified health centers implemented self-measured blood pressure programs (SMBP) over a three-year grant initiative. Various SMBP program designs with systematic processes, team-based care models, and culturally sensitive approaches with improved BP control are highlighted.

Participants' views of ultra-low dose combination therapy for high blood pressure: a mixed-methods study from the QUARTET trial.

Single-pill combination therapy containing four quarter-dose medications for high blood pressure improves BP control compared to monotherapy, however patient-reported acceptance of the quadpill as a treatment strategy remains undescribed. We collected within-trial feedback and interviewed participants from the quadruple ultra-low-dose treatment for hypertension (QUARTET) trial to characterise patient attitudes to this intervention. All trial participants were asked about ease and preference for the quadpill and provided an opportunity to give further comments on the trial at 12 weeks (trial primary endpoint) and 52 weeks extended follow-up. Separately, we used purposive and quota sampling for the semi-structured telephone interviews, with the resultant verbatim transcripts analysed using an inductive thematic analysis approach. Themes were re-evaluated after each successive interview, and at suspected data saturation, an additional interview conducted for confirmation. At 12 weeks follow-up, 502 of 591 (85%) participants responded to acceptability questions, and 359 of 417 (86%) responded at week 52. Most reported the trial capsule easy or very easy to take. From eight sites, 16 participants were interviewed between 5 August 2020 and 19 November 2020. All described a positive experience, preferred once-daily morning dosing and found routine facilitated adherence. Participants valued individual responsibility for adherence, and involvement of the general practitioner in blood-pressure management. Most reported capsule size did not deter adherence but desired a smaller capsule. Participants described a preference for minimising number and dosage of medications, reduced capsule size, and once-daily morning dosing. These findings suggest a preference for single-pill combination therapy for blood pressure lowering.

Study of various dietary interventions in patients with hypertension and metabolic syndrome

Obesity is an independent risk factor оf cardiovascular diseases (CVD), type 2 diabetes mellitus and arterial hypertension (HT). Optimization of CVD control methods is one of the most relevant and urgent problems for Russia. Many studies have shown that body weight correlates with blood pressure, and this relationship is due to complex pathogenetic mechanisms. Therefore, therapeutic approaches in a patient with obesity, metabolic syndrome and HT require consideration of all pathophysiologic changes associated with these diseases. Non-pharmacological treatments such as lifestyle changes including weight loss, following dietary guidelines and increasing physical activity can directly affect of BP levels and improve BP control. A wide range of nutritional interventions are effective in treating obesity and comorbidities, and clinicians must consider all options and provide personalized interventions. The Mediterranean diet, vegetarian diets, DASH-diet, Nordic diet, and low-carbohydrate diets have all been associated with improved metabolic health with or without changes in body weight. Recent evidence reinforce more the role of dietary fiber supplementation to the daily diet in patients with HT and metabolic syndrome, although no evidence of significant benefit has been found. Taking into account national dietary characteristics, we have proposed a study in which we plan to study the effect of the Russian diet with fiber supplementation on metabolic parameters in patients with HT. It is planned to evaluate the effect of diet therapy on indicators of metabolic disorders of intestinal metabolites.

Post-Intervention Acceptability of a Multicomponent Intervention for Hypertension Management in Primary Care Clinics by Health Care Providers and Patients: A Qualitative Study of a Cluster RCT in Singapore.

Hypertension is a major public health challenge, globally. Recently, we reported findings from cluster randomized trial in 8 primary care clinics in Singapore and showed that a multicomponent "SingHypertension" intervention comprising 1) motivational conversation by trained nurses, 2) telephone-based follow-ups, 3) standardized algorithm with single-pill combination (SPC) antihypertensive medications, and 4) subsidy on SPC antihypertensive drugs was effective on improving BP control. This paper presents the acceptability of SingHypertension multicomponent intervention among the key stakeholders. We conducted post-implementation interviews of 38 stakeholders, including 18 patients and 20 healthcare providers (HCPs) in 4 primary care clinics randomized to the multicomponent "SingHypertension" intervention in Singapore. We used Theoretical Framework for Acceptability (TFA) framework with a focus on affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy to assess stakeholders' acceptability of the intervention. SingHypertension multicomponent intervention had high perceived effectiveness and a good fit with the value system and ethics of patients and HCPs. Physicians appreciated the guidance from standardized training in hypertension management. Although workload was increased, the nurses felt rewarded for their positive interactions with the patients during motivational conversation sessions and the telephone follow-ups. Most patients reported high self-efficacy levels, improved lifestyles, and adherence to antihypertensive medications. The limited choice of SPC medication, lack of subsidy beyond the trial duration, and shortage of nurses were significant challenges to wide-scale implementation. All HCPs and patients supported scaling up the intervention across primary care clinics. SingHypertension multicomponent intervention is acceptable to the key stakeholders in Singapore. Taken together with the effectiveness of the intervention, our findings make a compelling case for scaling-up SingHypertension in primary care clinics in Singapore and possibly other countries with similar healthcare infrastructure.

CURATE.AI-assisted dose titration for anti-hypertensive personalized therapy: study protocol for a multi-arm, randomized, pilot feasibility trial using CURATE.AI (CURATE.AI ADAPT trial).

Artificial intelligence-driven small data platforms such as CURATE.AI hold potential for personalized hypertension care by assisting physicians in identifying personalized anti-hypertensive doses for titration. This trial aims to assess the feasibility of a larger randomized controlled trial (RCT), evaluating the efficacy of CURATE.AI-assisted dose titration intervention. We will also collect preliminary efficacy and safety data and explore stakeholder feedback in the early design process. In this open-label, randomized, pilot feasibility trial, we aim to recruit 45 participants with primary hypertension. Participants will be randomized in 1:1:1 ratio into control (no intervention), home blood pressure monitoring (active control; HBPM), or CURATE.AI arms (intervention; HBPM and CURATE.AI-assisted dose titration). The home treatments include 1 month of two-drug anti-hypertensive regimens. Primary endpoints assess the logistical (e.g. dose adherence) and scientific (e.g. percentage of participants for which CURATE.AI profiles can be generated) feasibility, and define the progression criteria for the RCT in a 'traffic light system'. Secondary endpoints assess preliminary efficacy [e.g. mean change in office blood pressures (BPs)] and safety (e.g. hospitalization events) associated with each treatment protocol. Participants with both baseline and post-treatment BP measurements will form the intent-to-treat analysis. Following their involvement with the CURATE.AI intervention, feedback from CURATE.AI participants and healthcare providers will be collected via exit survey and interviews. Findings from this study will inform about potential refinements of the current treatment protocols before proceeding with a larger RCT, or potential expansion to collect additional information. Positive results may suggest the potential efficacy of CURATE.AI to improve BP control. NCT05376683.

Abstract 140: Implementation Of The World Health Organization Hearts Package Lowers Blood Pressure And Improves Hypertension Control In Rural Bangladesh: A Quasi Experimental Trial

Background: The World Health Organization (WHO) promotes the HEARTS technical package for improving hypertension control worldwide, but its effectiveness has not been evaluated. Methods: We conducted a quasi-experimental trial in primary healthcare facilities, Upazila Health Complexes (UHC), in rural Bangladesh. We enrolled a total of 3935 patients (mean age 52.3y, 70.5% female) with uncontrolled hypertension (blood pressure [BP] ≥140/90 mmHg): 1950 patients from 7 UHCs implementing HEARTS and 1985 patients from 7 matched usual care UHCs. The HEARTS package intervention components were 1) simplified treatment protocol, 2) reliable medication supply, 3) team-based care, 4) standardized follow-up, and 5) a mobile app to record BPs and medications. The primary outcome was systolic BP at 6 months measured at the patients' home; secondary outcomes were diastolic BP, hypertension control rate (<140/90 mmHg), and loss to follow-up. We ran multivariable mixed-effect linear and Poisson models. Results: At baseline, mean systolic BP was 158.4 mmHg in the intervention arm and 158.8 mmHg in the usual care arm. Follow-up was 95.5%. Compared to usual care, the intervention significantly lowered systolic and diastolic BP (Figure) and improved BP control (62.0% vs. 49.7%, p<0.001). Loss-to-follow-up was lower in the intervention arm (8.8% vs. 39.3%, p<0.001). Conclusions: The WHO HEARTS package implemented in rural Bangladesh significantly lowered BP and improved hypertension control. These results support use of the WHO HEARTS package to control hypertension in Bangladesh and provide a strong rationale for its implementation in other low and middle-income countries.

Telemedicine and Digital Medicine in the Clinical Management of Hypertension and Hypertension-Related Cardiovascular Diseases: A Position Paper of the Italian Society of Arterial Hypertension (SIIA).

High blood pressure is the leading cause of death and disability globally and an important treatable risk factor for cardiovascular, cerebrovascular and chronic kidney diseases. Digital technology, including mobile health solutions and digital therapy, is expanding rapidly in clinical medicine and has the potential to improve the quality of care and effectiveness of drug treatment by making medical interventions timely, tailored to hypertensive patients' needs and by improving treatment adherence. Thus, the systematic application of digital technologies could support diagnosis and awareness of hypertension and its complications, ultimately leading to improved BP control at the population level. The progressive implementation of digital medicine in the national health systems must be accompanied by the supervision and guidance of health authorities and scientific societies to ensure the correct use of these new technologies with consequent maximization of the potential benefits. The role of scientific societies in relation to the rapid adoption of digital technologies, therefore, should encompass the entire spectrum of activities pertaining to their institutional role: information, training, promotion of research, scientific collaboration and advice, evaluation and validation of technological tools, and collaboration with regulatory and health authorities.

A SPECIFIC 3 MONTHS-PROGRAM TO IMPROVE NON-ADHERENCE IN UNCONTROLLED HYPERTENSION IMPROVES BLOOD PRESSURE CONTROL AND ASSOCIATED ORGAN DAMAGE (ATHAN CLINICAL TRIAL)

Objective: To evaluate whether a specific 3-month(m) action plan to improve therapeutic adherence in patients with uncontrolled hypertension on ◊ 2 drugs results in a decrease in BP and whether this is maintained at 12m. Secondly, to assess if this correlates with an improvement in subclinical organ damage. Design and Method: Prospective, randomized clinical trial where patients attended consecutively in a Hypertension Unit with ambulatory 24h-BP ◊130/80 mmHg despite receiving at least 2 antihypertensive drugs and with therapeutic non-compliance confirmed by the determination of antihypertensive drugs in the urine, were randomized (1:1) to receive a specific 3-month program to improve adherence (INT = intervention) or routine follow-up (C = control). Antihypertensive treatment was not modified, but beyond 3m all patients received usual care. Before randomization, and at 3m and 12m, urinary screening for antihypertensive drugs and albuminuria, and 24h-ambulatory BP monitoring were determined. Results: Forty-six patients were randomized. At 3m, mean (95%CI) baseline-adjusted BP differences (INT vs. C) were -14.7 mmHg (-5.4 to -24.1), p = 0.001 and -10.0 mmHg (-3.9 to -16.2), p<0.001 for 24h-SBP and 24h-DBP, respectively. The INT group maintained the BP decrease at 12m. vs. baseline: mean(95%CI) variation of 24h-SBP = -16.1 mmHg (-22.8 to -9.4), p<0.001 and variation of 24h-DBP = -7.8 (-12.8 to -2.7), p = 0.002. In the INT group, the percentage of non-detected antihypertensive drugs decreased compared to baseline: median [IQR]: 40% [20-85.7], 0% [0-25], and 18.3 % [0-40] at baseline, 3m and 12m respectively; Z = -3.295 (p<0.001) and Z = -3.055 (p = 0.002) for changes at 3m and 12m, respectively. Albuminuria (median [IQR]) decreased in the INT group: 27.1 mg/g [11.2-116.2] and 22.4 mg/g [6.4-91.9] at baseline and 12m, respectively (Z = -2.207, p = 0.027). At 12m, variation of albuminuria correlated with variation of 24h-BP but not with variation of percentage of non-detected antihypertensive drugs. Conclusions: a 3-month specific nursing intervention to improve therapeutic adherence results in improved BP control in patients with inadequate therapeutic compliance. This improvement continues beyond the completion of this program. Decreased BP correlates with a regression of albuminuria.

THE EFFECT OF TEXT MESSAGES BY CELL PHONE IN THE CONTROL OF HYPERTENSION: A RANDOMIZED CLINICAL TRIAL

Objective: To compare the effects of texting by cell phone plus standard usual guidance for hypertension versus standard usual guidance alone, on blood pressure control, among hypertensive patients undergoing outpatient treatment. Design and method: Randomized controlled clinical trial, composed of two groups: Intervention Group, who received SMS text messages twice a week for 10 weeks; and Comparison Group, who received the usual care. Both groups received an educational pamphlet about the hypertension. The primary outcome was BP control by office blood pressure measurement (OBPM; <140/90 mmHg) or by daytime Ambulatory Blood Pressure Monitoring (ABPM; <135/85 mmHg). Adherence to treatment was assessed indirectly using the 4 item Morisky Medication Adherence Scale and, directly, by assessing antihypertensive drugs in the urine, using a high-performance liquid chromatography technique associated with mass spectrometry. The significance level was 5%. Results: In the study, 178 patients were randomized, (90 in the Intervention Group and 88 in the Comparison Group). The sample was 60 (10) years old, women (63.8%), non-white (58.9%) and married (54.6%). The hypertensive patients were classified as having high cardiovascular risk (77.3%). The result of the intervention effect showed that there was no difference between the Intervention Group and Comparison Group (RR = 1.05; 95%CI = 0.75-1.47, and RR = 1.23; 95%CI = 0.87-1.74, respectively) in the control of OBPM, or by the daytime ABPM. However, in the Intervention Group and Comparison Group, respectively, there was a mean reduction in BP (-8.6 and -7.3 mmHg in systolic OBPM and -2.19 mmHg and -2.09 mmHg in systolic daytime ABPM); and increase in the BP control by the OBPM (19.8% to 36.0% and 19.7% to 38.2%) and daytime ABPM (38.6% to 42.5% and 41.3% to 52.2%); and in the assessment of adherence indirectly (45.3% to 69.4% and 57.1% to 59.2%). In the assessment of adherence directly, there was little difference between the groups and the two moments evaluated. Conclusions: The effect of texting by cell phone was similar to usual treatment for hypertension on BP control. On the other hand, both groups improved BP control and increased adherence to treatment.

Blood pressure control and its associated factors in patients with hypertension and type 2 diabetes

In this retrospective study, the medical records of hypertensive patients with type 2 diabetes attending two major hospitals were reviewed to find the factors associated with poor blood pressure control in patients who have diabetes as a comorbid disease with hypertension. Binary regression analysis was conducted to find the factors independently associated with BP control. A total of 522 participants were included in the study. Most of the participants had uncontrolled hypertension (63.4%) and uncontrolled type 2 diabetes (51.3%). Regression results revealed that having retinopathy (OR=1.468 (95% CI: 1.020-2.113), p<0.05), and not receiving dipeptidyl-peptidase 4 (DPP4) inhibitors were independently associated with uncontrolled BP (OR=0.633 (95%CI 0.423-0.946), p<0.05). Therefore, greater efforts should be exerted to improve BP control in hypertensive patients with type 2 diabetes, particularly in those suffering from retinopathy.

Cost-effectiveness analysis of initial treatment with single-pill combination antihypertensive medications.

Hypertension guidelines recommend initiating treatment with single pill combination (SPC) antihypertensive medications, but SPCs are used by only one-third of treated hypertensive US adults. This analysis estimated the cost-effectiveness of initial treatment with SPC dual antihypertensive medications compared with usual care monotherapy in hypertensive US adults.The validated BP Control Model-Cardiovascular Disease (CVD) Policy Model simulated initial SPC dual therapy (two half-standard doses in a single pill) compared with initial usual care monotherapy (half-standard dose when baseline systolic BP < 20 mmHg above goal and one standard dose when ≥20 mmHg above goal). Secondary analyses examined equivalent dose monotherapy (one standard dose) and equivalent dose dual therapy as separate pills (two half-standard doses). The primary outcomes were direct healthcare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) over 10 years from a US healthcare sector perspective.At 10 years, initial dual drug SPC was projected to yield 0.028 (95%UI 0.008 to 0.051) more QALYs at no greater cost ($73, 95%UI -$1 983 to $1 629) than usual care monotherapy. In secondary analysis, SPC dual therapy was cost-effective vs. equivalent dose monotherapy (ICER $8 000/QALY gained) and equivalent dose dual therapy as separate pills (ICER $57 000/QALY gained). At average drug prices, initiating antihypertensive treatment with SPC dual therapy is more effective at no greater cost than usual care initial monotherapy and has the potential to improve BP control rates and reduce the burden of CVD in the US.

Trends in using of antihypertensive medication among US CKD adults, NHANES 2001-2018.

Blood pressure (BP) control rates among adult patients taking antihypertensive medications in the United States have not improved over the last decade. Many CKD adults require more than one class of antihypertensive agent to reach the BP target recommended by the guidelines. However, no study has quantified the proportion of adult CKD patients taking antihypertensive medication who are on monotherapy or combination therapy. National Health and Nutrition Examination Survey data during 2001-2018 was used, including adults with CKD taking antihypertensive medication (age ≥ 20 years, n = 4,453). BP control rates were investigated under the BP targets recommended by the 2021 KDIGO, the 2012 KDIGO, and the 2017 ACC/AHA guidelines. The percentages of uncontrolled BP among US adults with CKD taking antihypertensive medication were 81.4% in 2001-2006 and 78.2% in 2013-2018. The proportion of monotherapy of antihypertensive regimen were 38.6, 33.3, and 34.6% from 2001 to 2006, 2007-2012, and 2013-2018, with no obvious difference. Similarly, there was no significant change in percentages of dual-therapy, triple-therapy, and quadruple-therapy. Although proportion of CKD adults not treated with ACEi/ARB decreased from 43.5% in 2001-2006 to 32.7% in 2013-2018, treatment of ACEi/ARB among patients with ACR > 300 mg/g had no significant change. The BP control rates among US adult CKD patients taking antihypertensive medications have not improved from 2001 to 2018. Mono-therapy accounted for about one third of adult CKD patients taking antihypertensive medication and not changed. Increasing antihypertensive medication combination therapy may help improve BP control in CKD adults in the United States.

Validation of spot urine in estimating 24-h urinary sodium, potassium and sodium-to-potassium ratio during three different sodium diets in healthy adults

Purpose To evaluate the validity of spot urine assay methods in estimating the 24-h urinary sodium, potassium and sodium-to-potassium ratio during three different sodium diets. Materials and methods Twelve healthy volunteers were asked to adhere to 3 dietary sodium targets (3.3–5.0g/day,<3.3 g/day and >5.0 g/day) for three consecutive weeks and to measure salt excretion daily in spot urine samples using a self-monitoring device. On day 7 of each week, 24-h urine was collected to compare measured with estimated 24-h salt excretion (by the Kawasaki, Tanaka and INTERSALT equations). Results Correlation coefficients relating measured and estimated 24-h sodium excretion were low and not significant for Kawasaki and INTERSALT and moderate for the Tanaka equation (τ 0.56–0.64,p<.05). Bland–Altman plots showed considerable differences between estimated and measured sodium excretion across all salt diets. Over 40% of the participants showed an absolute difference between measured and estimated 24-h sodium of more than 1000 mg/day. The correlation coefficients between 24-h and spot Na/K ratio were 0.67, 0.94 and 0.85(p<.05), and mean differences were 0.59, 0.06 and 0.48 for the intermediate, low and high sodium diets, respectively. Conclusion These findings do not support estimation of individual 24-h salt excretion from spot urine by the Kawasaki, Tanaka, or INTERSALT formula.

PS-C33-11: FACTORS RELATED TO DETERIORATED KIDNEY FUNCTION IN RESISTANT HYPERTENSION PATIENTS

Objectives: To determine the factors associated with renal function deterioration in resistant hypertension (RH) patients Methods: The study included 152 patients aged 28 to 79 years with RH. They underwent measurement of office and ambulatory blood pressure monitoring (ABPM). Blood level of potassium, sodium, glucose, creatinine, uric acid, citrulline, C-reactive protein (CRP), matrix metalloproteinase-12 (MMP-12), aldosterone-renin ratio and 24-h excretion of metanephrine and 24-h urinary albumin excretion rate (AER) were determined. Glomerular filtration rate (GFR) was estimated by the CKD-EPI formula. Results: Chronic kidney disease (CKD) was diagnosed in 32.3% of patients with RH (gr.1 pts), gr.2 pts - those without CKD. Spearman's correlation analysis showed a negative relationship between GFR and office diastolic BP (DBP) and 24 hours mean DBP (r = -0.233; r = -0.373; P &lt; 0.01, respectively). Significant negative correlation was revealed between GFR and daytime systolic BP variability (r = -0.275; P &lt; 0.01). GFR was inversely related to AER (r = -0.412; P &lt; 0.01), uric acid (r = -0.311; P &lt; 0.05), CRP (r = -0.314; P &lt; 0.05), MMP-12 (r = -0.385; P &lt; 0.01), citrulline (r = -0.375; P &lt; 0.01), sodium (r = -0.284; P &lt; 0.05), aldosterone and urinary metanephrine level (r = -0.225; P &lt; 0.05 and r = - 0.210; P &lt; 0.05). In gr.1pts. level of CRP, MM-12 and citrulline was significantly (P &lt; 0.01) higher than in the gr.2 pts. Factors independently and most closely related to reduced GFR in RH patients are 24 hours mean DBP (β; = -0.449, P &lt; 0.001), CRP (β; = -0.354, P &lt; 0.01), MMP-12 (β; = -0.248; P &lt; 0.01) and citrulline (β; = -0.232; P &lt; 0.05). Conclusions: Revealed associations, in addition to elevated blood pressure, indicate the possible pathogenic role of low-grade systemic inflammation biomarkers in the renal function deterioration in RH patients. Targeting low-grade systemic inflammation may improve BP control in resistant hypertension patients with CKD.

S-26-1: LESSONS LEARNED ABOUT HYPERTENSION FROM RENAL DENERVATION CLINICAL TRIALS

Renal denervation is being studied in clinical trials at a time when the community management of hypertension has fallen behind expectations. A major issue is poor adherence to medications. The DENER HTN trial of denervation used urine/plasma medication monitoring to confirm patient drug taking, but discovered that despite rigorous instructions to patients only 50% were taking drugs as prescribed, and 20% were taking no drugs at all. Similarly, the Spyral On Meds trial reported that only about 50% of patients took their medications consistently during the trial. But clinicians are also part of the problem: despite unrestricted access to drugs, long term follow-up of non-denervated patients in RDN trials has failed to achieve acceptable levels of BP control. On a positive note, the TRIO RDN trial in patients with uncontrolled hypertension despite multi-drug regimens observed that substitution by a single-pill 3-drug combination was remarkably effective in many patients. Guidelines recommend out-of-office BP measurements, and home BP is now used by many patients and is helpful in diagnosing hypertension. But HBP may be a two-edged sword. In the REQUIRE RDN trial, where patients routinely measured HBPs, an early significant BP-reduction advantage to RDN over sham progressively disappeared as some patients with lower BPs (mainly RDN patients) started reducing medications, and those with higher BPs (mainly sham) increased medications. Ambulatory BP monitoring is also recommended. Its data are reproducible over time for cohorts, but the Spyral Off-Meds trial demonstrated large fluctuations of BP, both upwards and downwards, in individuals in the control group, thus questioning the value of single ABPM procedures for diagnosing hypertension in clinical practice. Surveys of hypertensive patients attitudes regarding RDN in Japan and the United States have demonstrated a likely acceptance if it is needed to improve BP control. Interestingly, this occurred in patients who in many cases were not adherent to medications; but yet were concerned at the possible serious medical consequences of poorly controlled BP, thus illustrating a challenging clinical paradox. An important lesson from these observations in RDN studies is that there are limits to what can be achieved with conventional drug therapy in many people with hypertension, and that the clinical use of RDN may not just be appropriate for patients with true resistant hypertension, but might be of particular value in those who despite the well-intentioned prescription of medications remain with unacceptably high blood pressures.

RAG-SACA-3: ROLE OF PRIMARY CARE PHYSICIAN TO MANAGE HYPERTENSION IN A LOW-RESOURCE SETTING

Hypertension is a primary care clinical condition that is therefore best detected, managed, and followed at a primary care level by a primary care team led by a physician. However, the delivery of primary care services is not unique in all countries, especially in low- or lower-middle-income countries where primary care physicians used to manage hypertension in low-resource settings (LRS). This presentation will focus on the concept of LRS, a list of potential roles played by a primary care physician, and possible challenges usually face. Usually, the settings where health care systems do not meet the minimum standards set by the World Health Organization or any other quasigovernmental organization are considered LRS. However, there is no explicit definition for LRS. The major roles of a primary care physician in LRS are identification of an individual at high risk for HTN, proper screening, diagnosis with a proper communication strategy to inform about the diagnosis, cost-effective rational treatment with counseling, and finally follow-up. The primary care physician is at the heart of a team-based HTN care in an LRS and will provide supportive supervision to the team to ensure the best outcome: (i) increased patient enrollment, (ii) increased patient treatment rate, (iii) improve BP control rate, (iv) high treatment compliance (v) reduction of drug stock-outs. In LRS, without team-based care and shifting of tasks, it will be very difficult to ensure proper management. In general, a primary care physician will play a leadership role in a resource-poor setting to successfully implement an HTN management program.

Should we CLICK on chlorthalidone for treatment-resistant hypertension in chronic kidney disease?

Treatment-resistant hypertension is common among patients with advanced chronic kidney disease (CKD). In people with preserved kidney function, spironolactone is an evidence-based treatment. However, the risk for hyperkalemia limits its use in people with more advanced CKD. In the Chlorthalidone in Chronic Kidney Disease (CLICK) trial, 160 patients with stage 4 CKD and poorly controlled hypertension as confirmed by 24-hour ambulatory blood pressure (ABP) monitoring were randomly assigned to either placebo or chlorthalidone 12.5mg daily in a 1:1 ratio stratified by prior loop diuretic use. The primary endpoint was the change in 24-hour systolic ABP from baseline to 12 weeks. The trial showed a treatment-induced reduction of 24-hour systolic ABP by 10.5mmHg. Of the 160 patients randomized, 113 (71%) had resistant hypertension, of which 90 (80%) were on loop diuretics and the mean number of antihypertensive medications prescribed was 4.1 (standard deviation 1.1). In this subgroup of patients with treatment-resistant hypertension, the adjusted change from baseline to 12weeks in the between-group difference in 24-hour systolic ABP was -13.9mmHg (95% CI -19.4 to -8.4; P<.0001). Furthermore, compared with placebo, the urine albumin:creatinine ratio in the chlorthalidone group at 12weeks was 54% lower (95% CI -65 to -40). Following randomization, hypokalemia, reversible increases in serum creatinine, hyperglycemia, dizziness, orthostatic hypotension and hyperuricemia occurred more frequently in the chlorthalidone group. Chlorthalidone has the potential to improve BP control among patients with advanced CKD and treatment-resistant hypertension. However, caution is advised when treating patients, especially when they are on loop diuretics.

Clinical characteristics and management of hemodialysis patients with pre-dialysis hypertension: a multicenter observational study

Background Hypertension is a leading preventable risk factor for cardiovascular disease in hemodialysis patients. Pre-dialysis systolic blood pressure (SBP) more than 160 mmHg was thought to be associated with increased risk of cardiovascular events and all-cause mortality. The present study was performed to explore the clinical characteristics and management of hemodialysis patients with pre-dialysis SBP ≥ 160 mmHg. Methods A total of 1233 patients undergoing hemodialysis from nine hemodialysis centers were enrolled. Pre-dialysis and home BP were measured and clinical data were collected. The characteristics of patients with pre-dialysis SBP ≥ 160 mmHg were explored. Clinical parameters between hypertensive and non-hypertensive patients were compared. The partial correlation analyses performed to identify the associations between BP and clinical parameters. Results There were 24.6% of the hemodialysis patients had pre-dialysis SBP ≥ 160 mmHg and the average SBP was 173.8 ± 10.9 mmHg. Only 21.4% of the patients achieved dry weight after dialysis and up to 30.2% of patients were not given combination therapies of antihypertensive drugs. Compared to patients with pre-hemodialysis SBP < 160 mmHg, patients with pre-dialysis SBP ≥ 160 mmHg had lower target-reaching rate of Kt/v and higher incidences of intradialytic hypotension and muscle spasm. Most patients (96%) with pre-dialysis SBP ≥ 160 mmHg had home SBP≥ 135 mmHg. Patients with home SBP ≥ 160 mmHg had higher left ventricular weight index and lower hemoglobin levels when compared to their counterparts with home SBP <160 mmHg. Conclusions Pre-dialysis SBP ≥ 160 mmHg is common in clinical practice and most of the patients could diagnosed to be hypertensive according to their home SBP. Patients with pre-dialysis SBP ≥ 160 mmHg are more likely to be subjected to dialysis insufficiency and intradialytic complications. Achieving dry weight and sufficient pharmacologic interventions should be strengthened to improve BP control in the hemodialysis population.