Improve Blood Pressure Control Rates Research Articles

Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster Randomized Trial.

Disparities in hypertension control are well documented but underaddressed. RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) was a 2-arm, cluster randomized trial comparing the effect on blood pressure (BP) control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of 2 multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline. A total of 1820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women; 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%-62.0%]; SCP: 56.7% [95% CI, 51.9%-61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months. Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%-73.9%] versus 50.8% [95% CI, 42.6%-59.0%]; P=0.04), as did patients in rural areas (67.3% [95% CI, 49.8%-84.8%] versus 47.8% [95% CI, 32.4%-63.2%]; P=0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: -13.8 mm Hg [95% CI, -15.2 to -12.5]; SCP: -14.6 mm Hg [95% CI, -15.9 to -13.2]) and diastolic BP (CC/SC: -6.9 mm Hg [95% CI, -7.8 to -6.1]; SCP: -5.5 mm Hg [95% CI, -6.4 to -4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (-1.4 mm Hg [95% CI, -2.6 to -0.2). Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02-0.22]). Adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness care.

PS-C33-7: TRUE RESISTANT HYPERTENSION IN A TERTIARY HYPERTENSION CLINIC IN SAUDI ARABIA

Objective: Resistant hypertension(RH), defined as office blood pressure (BP) above goal despite the use of more than three anti-hypertensives (one ideally being a diuretic) or BP that requires more than four agents to achieve control, has received more attention with increased efforts to improve BP control rates and the emergence of device-based therapies. Based on this definition of RH, the prevalence rates vary around 15–30% worldwide. However, there is paucity of data on RH, particularly true RH in the Middle-East. The aim of this study was to explore the prevalence, clinical characteristics and choice of anti-hypertensives in a Saudi RH population. Design & Methods: We analysed retrospectively clinic and ambulatory BP monitory (ABPM) data in Saudi patients between January 2016 to June 2018. Office HTN was defined as greater than 140 systolic or greater than 90 diastolic, mm Hg. HTN was confirmed using one of the following ABPM cut-offs; 24-hr greater than 130/80 or daytime greater than 135/85, mm Hg. Results were analysed using JMP version 13, p less than 0.05 considered significant. Results: The mean age of the population(n = 540) was 54 ± 15 years, 40% female. The overall prevalence of RH was 47% in our cohort, of which 35% was true RH. The patients with RH were older; 62 ± 13 vs. 50.5 ± 14 years with no significant gender difference. RH was associated with diabetes (OR = 6.2, CI%, 3–12); CAD(OR = 3.3, CI%, 2–5); history of coronary revascularization(CABG/PCI) (OR = 3, CI%, 2–5); CKD(OR = 5.7, CI%, 3–12) and heart failure(OR = 1.9, CI%, 1–3). The average number of anti-hypertensives was 4.2 ± 1 in RH compared with 1.1 ± 1 in control group. Only a third of the patients were prescribed spironolactone in the RH group with some 10% on an alpha blocker. Conclusions: To the best of our knowledge, this is the first study in the Middle-East to establish the prevalence of true RH using ABPM. With a high prevalence rate, our cohort of RH is complex with high number of co-morbidities, sub optimal prescription rates of spironolactone or alpha-blockers, representing a therapeutic challenge.

Abstract 12066: Older Age and Higher Number of Comorbidities Are Associated With Therapeutic Inertia for Blood Pressure Control

Introduction: Therapeutic inertia, defined as failure to initiate or escalate dose of blood pressure (BP) lowering medications when BP goals are not achieved, remains a major barrier to improving BP control rates. This study examines factors associated with therapeutic inertia for hypertensive ambulatory patients receiving care in university-affiliated primary care clinics. Methods: This retrospective cohort study included 8,451 hypertensive adults age > 65 years with > 1 primary care follow-up visit within one year between January 1, 2017 and January 31, 2021. Sociodemographic and clinical data, including comorbidities of diabetes, obesity, and cardiovascular disease, were extracted from the electronic health record. Generalized linear mixed models with a binomial distribution were used to calculate adjusted odds of therapeutic inertia during a clinic visit when BP was elevated by age group (65-74, ≥ 75 years) and number of comorbidities (0, 1, 2, 3-4, > 5), after adjustment for covariates. An interaction term of age group * number of comorbidities in the adjusted model was statistically significant (P<0.001), so marginal effects were used to calculate adjusted probabilities of therapeutic inertia at a clinic visit by age group and by number of comorbidities. Results: Mean age was 75 ± 8 years old, 42% were male, and race was 72% White, 17% Black, and 11% other. Across 28,585 clinic visits when BP was elevated, mean SBP and DBP were 152 ± 13 and 78 ± 11 mmHg, respectively, and therapeutic inertia occurred in 75% (21,325) of visits. Figure 1 shows that mean adjusted probability of therapeutic inertia among adults with 0 to > 5 comorbidities ranged from 64 ± 15 % to 81 ± 12% with age 65-74 years, respectively, and 70 ± 15% to 82 ± 11% with age ≥ 75 years. Conclusions: Therapeutic inertia is common among older hypertensive adults with multiple comorbidities, and interventions are needed to address lack of medication escalation when BP remains uncontrolled.

New perspectives for hypertension management: progress in methodological and technological developments.

Hypertension is the most common and preventable risk factor for cardiovascular disease (CVD), accounting for 20% of deaths worldwide. However, 2/3 of people with hypertension are undiagnosed, untreated, or under treated. A multi-pronged approach is needed to improve hypertension management. Elevated blood pressure (BP) in childhood is a predictor of hypertension and CVD in adulthood; therefore, screening and education programmes should start early and continue throughout the lifespan. Home BP monitoring can be used to engage patients and improve BP control rates. Progress in imaging technology allows for the detection of preclinical disease, which may help identify patients who are at greatest risk of CV events. There is a need to optimize the use of current BP control strategies including lifestyle modifications, antihypertensive agents, and devices. Reducing the complexity of pharmacological therapy using single-pill combinations can improve patient adherence and BP control and may reduce physician inertia. Other strategies that can improve patient adherence include education and reassurance to address misconceptions, engaging patients in management decisions, and using digital tools. Strategies to improve physician therapeutic inertia, such as reminders, education, physician-peer visits, and task-sharing may improve BP control rates. Digital health technologies, such as telemonitoring, wearables, and other mobile health platforms, are becoming frequently adopted tools in hypertension management, particularly those that have undergone regulatory approval. Finally, to fight the consequences of hypertension on a global scale, healthcare system approaches to cardiovascular risk factor management are needed. Government policies should promote routine BP screening, salt-, sugar-, and alcohol reduction programmes, encourage physical activity, and target obesity control.

Effect of Lifestyle Coaching or Enhanced Pharmacotherapy on Blood Pressure Control Among Black Adults With Persistent Uncontrolled Hypertension

Greater difficulty in controlling blood pressure (BP) and adverse lifestyle practices such as higher salt intake or less physical activity may account for some of the differences between BP control rates in Black vs White adults, thereby exposing Black adults to a higher risk of vascular events. To determine whether a lifestyle coaching intervention or an enhanced pharmacotherapy protocol is more effective than usual care in improving BP control rates in Black adults treated within an integrated health care delivery system. Shake, Rattle & Roll, a cluster randomized clinical trial, was conducted from June 5, 2013, to June 11, 2018, in a large integrated health care delivery system. Enrollment was completed during a 12-month period and interventions were implemented for 12 months. Follow-up lasted 48 months after enrollment. Panels of Black adult members of the health care delivery system with BP of at least 140/90 mm Hg from 98 adult primary care physicians were randomly assigned at the primary care physician level to usual care (UC group [n = 1129]), enhanced pharmacotherapy monitoring (EP group [n = 346]) of current BP management protocol, or diet and lifestyle coaching consisting of photographs, stories, and recipes, for example, that are appropriate for Black adults (LC group [n = 286]) focused on the Dietary Approaches to Stop Hypertension (DASH) diet. Data were analyzed from June 1, 2016, to March 25, 2022. The UC group received care per customary protocol. The EP group was contacted by a research nurse and/or a clinical pharmacist to discuss barriers to hypertension control, and drug therapy emphasized the use of thiazide diuretic intensification and addition of spironolactone as needed. The LC group received as many as 16 telephone sessions with a lifestyle coach and an emphasis on implementing reduction of sodium intake and the DASH diet. Intention-to-treat analysis of BP control rates at end of the 12-month intervention. Among the 1761 participants, the mean (SD) age was 61 (13) years, and 1214 (68.9%) were women. At the end of the 12-month intervention period, there was no significant difference in BP control rate among study groups (UC, 61.8% [95% CI, 58.8%-64.9%]; EP, 64.5% [95% CI, 59.0%-69.4%]; LC, 67.8% [95% CI, 62.1%-73.2%]; LC vs EP, P = .07). However, greater BP control was present in the LC group vs UC at 24 months (UC, 61.2% [95% CI, 57.3%-64.7%]; EP, 67.6% [95% CI, 61.9%-72.8%]; LC, 72.4% [95% CI, 66.9%-78.1%]; LC vs UC, P = .001), and 48 months (UC, 64.5% [95% CI, 61.6%-67.2%]; EP, 66.5% [95% CI, 61.3%-71.3%]; LC, 73.1% [95% CI, 67.6%-77.9%]; LC vs UC, P = .006) after enrollment. The contribution of BP medication adherence to explain group differences was inconclusive. In this cluster randomized clinical trial including Black adults with persistent uncontrolled hypertension, a 12-month LC intervention was more effective at controlling BP than UC at 24 and 48 months after enrollment. Further research is needed to explore the potential implementation of this intervention into clinical practice. ClinicalTrials.gov Identifier: NCT01892592.

American Heart Association's 2024 Impact Goal: Every Person Deserves the Opportunity for a Full, Healthy Life.

American Heart Association's 2024 Impact Goal: Every Person Deserves the Opportunity for a Full, Healthy Life.

Питательные вещества и пищевые добавки для лечения высокого нормального артериального давления: консенсусный документ на основе доказательств

Эссенциальная гипертензия по-прежнему представляет собой наиболее распространенный фактор риска сердечно-сосудистой системы, отвечающий за большую часть глобального бремени заболеваний во всем мире. Антигипертензивная терапия, направленная на снижение уровня артериального давления (АД) в рекомендованных терапевтических целях, доказала снижение риска развития сердечно-сосудистых, цереброваскулярных и почечных осложнений. Несмотря на эти доказательства, общий уровень контроля АД остается достаточно низким в большинстве европейских и западных стран, а также в развивающихся странах, что способствует увеличению расходов на лечение и инвалидность, связанных с гипертензией. По этим причинам превентивные стратегии, направленные на улучшение уровня контроля АД у больных артериальной гипертензией (АГ), которые принимают медикаментозную терапию, и снижение АД при его высоком нормальном уровне у бессимптомных здоровых лиц могут способствовать уменьшению бремени заболеваний, связанных с гипертензией. С этой точки зрения было показано, что использование определенных питательных веществ и пищевых добавок может обеспечить благоприятные эффекты в лечении и контроле АГ, вне приема фармакологических препаратов и нефармакологических вмешательств. Их применение может эффективно и безопасно снижать уровень АД до целевых показателей и предотвращать прогрессирование заболевания с высокого нормального уровня АД к гипертензии 1-й степени. В этом консенсусном документе представлены систематический обзор и критический анализ имеющихся в настоящее время доказательств в пользу использования питательных веществ и пищевых добавок у лиц с высоким нормальным уровнем АД при различных степенях сердечно-сосудистого риска.

Factors associated with suboptimal blood pressure control in a multi-ethnic population in Amsterdam

Abstract Background Among patients using antihypertensives, blood pressure (BP) control is generally low and appears to vary between ethnicities. We aimed to identify factors associated with suboptimal BP control in a multi-ethnic population. Methods Cross-sectional data of the Healthy Life in an Urban Setting (HELIUS) study were used, including participants aged 18-70 years, with Dutch, African Surinamese (AS), South-Asian Surinamese (SAS), Ghanaian, Turkish or Moroccan ethnicity living in Amsterdam, the Netherlands. Suboptimal BP control was defined as BP ≥ 140/90 mmHg among participants using antihypertensives. Logistic regression analysis was performed to identify sociodemographic, lifestyle, health and psychosocial factors associated with suboptimal BP control for the total population and for each ethnic group. Results A total of 3,571 participants (500 Dutch, 1052 AS, 656 SAS, 637 Ghanaian, 433 Turkish, 293 Moroccan) were included in the analysis, of whom 53.3% had suboptimal BP control. Female sex (OR 0.50, 95%CI 0.43-0.59), being married (0.83, 0.72-0.96), current smoking (0.78, 0.65-0.94), obesity (1.67, 1.35-2.06), cardiovascular disease (CVD) history (0.56, 0.46-0.68), non-adherence to antihypertensives (1.26, 1.00-1.58), and family history of hypertension (1.19, 1.02-1.38) were associated with suboptimal BP control. Among ethnic subgroups, female sex was associated with lower odds of suboptimal BP control in all ethnic groups, as was current smoking (Turkish) and CVD history (Dutch, SAS, AS), whereas obesity (Dutch, AS, Turkish), older age (Turkish) and non-adherence to antihypertensives (Dutch) were associated with higher odds of suboptimal BP control. Conclusions Our analysis identifies several factors that are independently associated with suboptimal BP control, with only small variation between ethnic groups, suggesting that focussing on well-known determinants of suboptimal BP control is worthwhile to improve BP control rates in a multi-ethnic population. Key messages Several factors are associated with suboptimal blood pressure control in a multi-ethnic population, with only small variation between ethnic groups. These findings suggest that focussing on well-known determinants of suboptimal BP control is worthwhile to improve BP control rates in a multi-ethnic population.

Impact of Self-Monitoring of Blood Pressure on Processes of Hypertension Care and Long-Term Blood Pressure Control.

BackgroundSelf‐monitoring of blood pressure (SMBP) improves blood pressure (BP) outcomes at 12‐months, but information is lacking on how SMBP affects hypertension care processes and longer‐term BP outcomes.Methods and ResultsWe pooled individual participant data from 4 randomized clinical trials of SMBP in the United Kingdom (combined n=2590) with varying intensities of support. Multivariable random effects regression was used to estimate the probability of antihypertensive intensification at 12 months for usual care versus SMBP. Using these data, we simulated 5‐year BP control rates using a validated mathematical model. Trial participants were mostly older adults (mean age 66.6 years, SD 9.5), male (53.9%), and predominantly white (95.6%); mean baseline BP was 151.8/85.0 mm Hg. Compared with usual care, the likelihood of antihypertensive intensification increased with both SMBP with feedback to patient or provider alone (odds ratio 1.8, 95% CI 1.2–2.6) and with telemonitoring or self‐management (3.3, 2.5–4.2). Over 5 years, we estimated 33.4% BP control (<140/90 mm Hg) with usual care (95% uncertainty interval 27.7%–39.4%). One year of SMBP with feedback to patient or provider alone achieved 33.9% (28.3%–40.3%) BP control and SMBP with telemonitoring or self‐management 39.0% (33.1%–45.2%) over 5 years. If SMBP interventions and associated BP control processes were extended to 5 years, BP control increased to 52.4% (45.4%–59.8 %) and 72.1% (66.5%–77.6%), respectively.ConclusionsOne year of SMBP plus telemonitoring or self‐management increases the likelihood of antihypertensive intensification and could improve BP control rates at 5 years; continuing SMBP for 5 years could further improve BP control.

Sustainability of blood pressure reduction in black barbershops.

The prevalence of hypertension (HTN) among non-Hispanic blacks increased from 41 to 55% with the release of the new 2017 ACC/AHA guidelines - the highest among any racial group. Non-Hispanic black men have less physician interaction and lower blood pressure (BP) treatment and control rates when compared with their female counterparts, necessitating community outreach. Here, we review the Los Angeles Barbershop Blood Pressure Study (LABBPS) which demonstrated a community-based approach involving pharmacists, physicians, and barbers could improve BP control rates among black men. LABBPS was a cluster-randomized trial that evaluated both the efficacy and sustainability of a pharmacist-led HTN management program in which barbers promoted follow-up with pharmacists who prescribed antihypertensive therapy under collaborative practice agreements with intervention participant's primary care providers. After 6 months researchers observed a 21 mmHg greater fall in SBP among intervention group participants when compared with the control group participants who received 'usual care.' The 6-month extension phase of the study showed that the impressive BP reduction achieved was sustained with less pharmacist contact. Multidisciplinary, community-based approaches to HTN management can be effective and are necessary to tackle the current disparity seen in BP control rates. The model developed in LABBPS represents one such approach.

Nutrients and Nutraceuticals for the Management of High Normal Blood Pressure: An Evidence-Based Consensus Document.

Essential hypertension still represents the most common cardiovascular risk factor, which is responsible for the vast majority of global burden of disease, worldwide. Antihypertensive treatment aimed at lowering blood pressure (BP) levels to the recommended therapeutic targets has demonstrated to reduce risk of developing major cardiovascular, cerebrovascular and renal complications. Despite these evidence, overall rates of BP control are dramatically low in most European and Western countries, as well as in the so called developing countries, thus contributing to the increasingly amount of hypertension-related costs and disabilities. For these reasons, preventive strategies aimed at improving BP control rates in treated hypertensive patients and reducing high-normal BP levels in asymptomatic otherwise healthy individuals may contribute to reduce the burden of disease related to hypertension. In this view, an extensive use of nutrients and nutraceuticals has demonstrated to provide favorable effects in hypertension management and control, beyond the adoption of pharmacological and non-pharmacological interventions. These interventions can effectively and safely reduce BP levels to targets and prevent disease progression form high-normal BP levels towards stage 1 hypertension. The present consensus document will systematically describe and critically analyze the currently available evidence in favor of the use of nutrients and nutraceuticals in those individuals with high-normal BP levels at different cardiovascular risk profile.

Shake Rattle & Roll – Design and rationale for a pragmatic trial to improve blood pressure control among blacks with persistent hypertension

BackgroundIn Kaiser Permanente Northern California (KPNC), members had similar access to care and a very high overall rate of hypertension control. However, blacks had poorer blood pressure (BP) control than whites. The Shake Rattle & Roll (SRR) trial aimed to improve BP control rates in blacks and to reduce disparities in hypertension control. MethodsSRR was a cluster randomized controlled trial conducted at an urban medical center. All 98 adult primary care physicians (PCP) and their panels of hypertensive black patients were randomized, stratified by panel size, to one of three arms: 1) Usual Care (n = 33 PCPs, N = 1129 patients); 2) Enhanced Monitoring arm with an emphasis on improving pharmacotherapy protocol adherence (n = 34 PCPs, N = 349 patients); or 3) Lifestyle arm with a culturally tailored diet and lifestyle coaching intervention focusing on the Dietary Approaches to Stop Hypertension eating plan (n = 31 PCPs, N = 286 patients). The intervention period was for 12-months post-enrollment. Follow-up was planned for one and three years post-intervention completion. Primary outcome measure was the proportion of participants with controlled BP, defined as <140/90 mmHg, at 12-months post-enrollment. Secondary outcome included adverse cardiovascular events. An intention-to-treat analysis was carried out as the primary analysis. ConclusionSRR was a uniquely designed trial that included components from both pragmatic and explanatory methods. The pragmatic aspects allow for a more cost-effective way to conduct a clinical trial and easier implementation of successful interventions into clinical practice. However, there were also challenges of having mixed methodology with regards to trial conduction and analysis.

The 2017 American College of Cardiology/American Heart Association hypertension guideline and opportunities for community pharmacists

ObjectivesTo initiate a call to action for community pharmacists to maximize the opportunities to improve the management of hypertension (HTN) in light of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) HTN guideline. SummaryIn November 2017, the ACC and the AHA, along with 9 other professional organizations, released a comprehensive guideline on the prevention, detection, evaluation, and management of high blood pressure (BP). Major changes included the reclassification of BP and redefinition of HTN to 130/80 mm Hg or above, significantly increasing the number of individuals with HTN. The 2017 ACC/AHA HTN guideline also emphasized out-of-office BP readings and recommended team-based care models that include pharmacists and other health professionals as one strategy to improve BP control rates and provide appropriate follow-up and monitoring. Community pharmacists are highly accessible health professionals that now have an even greater opportunity to improve the monitoring and management of patients with HTN. Monitoring of BP in pharmacies could be greatly improved if BP kiosks were replaced by automated BP monitors operated by appropriately trained personnel that would initiate a face-to-face consultation with a community pharmacist. Physicians and other prescribers should also refer patients directly to their community pharmacists to receive assistance in selecting a home BP monitor. Given recent expansion of collaborative practice legislation and prescriptive authority, health information exchanges, and reimbursement models, community pharmacists have a renewed opportunity to collaborate with medical practices and health systems to improve BP control. In addition, greater collaboration among pharmacists practicing in primary care and community pharmacy could improve care coordination. ConclusionCommunity pharmacists have a significant opportunity to collaborate with patients, physicians, and the health care community at large to improve the monitoring and management of HTN and ensure that the 2017 ACC/AHA HTN guideline is successfully implemented.

COMPARISON OF A PHARMACIST-PHYSICIAN COLLABORATIVE CARE MODEL TO STANDARD CARE ON THE TIME TO REACH GOAL BLOOD PRESSURE FOR PATIENTS PRESENTING WITH URGENT HYPERTENSION

Background: Delayed intensification of blood pressure (BP) management is associated with an increased risk of cardiovascular disease. Pharmacist-physician collaborative care models (PPCMs) improve BP control rates and reduce mean BP, but it is unknown if PPCMs affect time to BP goal when compared to

Management of Blood Pressure Control: At the Cutting Edge

Prof Williams opened the symposium by discussing the current state of blood pressure (BP) control in Europe and the key barriers to improving BP control rates. Prof Weiss presented the ‘Low BP in Vienna’ initiative that has been initiated in Austria in order to improve BP control. Prof Mourad discussed the ongoing campaign to improve BP control rates in France, and Prof Volpe presented a case study of an elderly patient with hypertension and chronic kidney disease (CKD). Prof Parati concluded the symposium by commenting on the improvements in technology with respect to BP control. The meeting objectives were to review the current achievement of BP goals in Europe since 2008; to evaluate the 70% BP goal initiatives in France and Italy; to use practical examples to assess the use of single-pill fixed-dose combinations (FDCs); and to assess the impact of technological advances on BP control.

Hypertension Care: It’s Time to Act

The satellite symposium was held in two separate sessions – the first a traditional symposium format, and the second as an interactive panel discussion in which the faculty answered questions from the delegates. The symposium objectives included consideration of the impact of suboptimal blood pressure (BP) control on the high levels of cardiovascular (CV) events in Europe; evaluation of the importance of patient adherence in improving management of BP; consideration of the management of treatment-resistant patients; discussion of a new initiative to drive improved management of hypertension; and how angiotensin receptor blocker (ARB)-based treatments and single-pill combinations may be used to treat hypertensive patients. Professor Burnier discussed the difficulties associated with achieving good BP control in the primary care setting and highlighted the utility of single-pill fixed-dose combinations (FDCs) for improving adherence and BP normalisation. Professor Ruilope discussed the clinical work-up and management of patients with treatment-resistant hypertension, while Professors Schmieder and Weiss outlined some initiatives taking place that aim to improve BP control rates. Finally, Professor Volpe described an ARB-based treatment platform which shows how patients can be effectively treated with single-pill combination therapy.

Apparent and true resistant hypertension: definition, prevalence and outcomes

Resistant hypertension, defined as blood pressure (BP) remaining above goal despite the use of > or =3 antihypertensive medications at maximally tolerated doses (one ideally being a diuretic) or BP that requires > or =4 agents to achieve control, has received more attention with increased efforts to improve BP control rates and the emergence of device-based therapies for hypertension. This classically defined resistant group consists of patients with true resistant hypertension, controlled resistant hypertension and pseudo-resistant hypertension. In studies where pseudo-resistant hypertension cannot be excluded (for example, 24-h ambulatory BP not obtained), the term apparent resistant hypertension has been used to identify 'apparent' lack of control on > or =3 medications. Large, well-designed studies have recently reported the prevalence of resistant hypertension. Pooling prevalence data from these studies and others within North America and Europe with a combined sample size of >600,000 hypertensive participants, the prevalence of resistant hypertension is 14.8% of treated hypertensive patients and 12.5% of all hypertensives. However, the prevalence of true resistant hypertension, defined as uncontrolled both by office and 24-h ambulatory BP monitoring with confirmed medication adherence, may be more meaningful in terms of identifying risk and estimating benefit from newer therapies like renal denervation. Rates of cardiovascular events and mortality follow mean 24-h ambulatory BPs in patients with resistant hypertension, and true resistant hypertension represents the highest risk. The prevalence of true resistant hypertension has not been directly measured in large trials; however, combined data from smaller studies suggest that true resistant hypertension is present in half of the patients with resistant hypertension who are uncontrolled in the office. Our pooled analysis shows prevalence rates of 10.1% and 7.9% for uncontrolled resistant hypertension among individuals treated for hypertension and all hypertensive individuals, respectively.

Effects of demographics on the antihypertensive efficacy of triple therapy with amlodipine, valsartan, and hydrochlorothiazide for moderate to severe hypertension

Objective:To compare the antihypertensive efficacy and safety of once-daily triple therapy with amlodipine (Aml) 10 mg, valsartan (Val) 320 mg, and hydrochlorothiazide (HCTZ) 25 mg versus dual-therapy combinations of these components in patients with moderate to severe hypertension.Research design:Subgroup analysis of a multinational, randomized, double-blind, parallel-group, active-controlled trial.Methods:After antihypertensive washout and a placebo run-in of up to 4 weeks, 2271 patients were randomly allocated in a 1:1:1:1 ratio to receive Aml/Val/HCTZ triple therapy or dual therapy with Val/HCTZ, Aml/Val, or Aml/HCTZ for 8 weeks. Forced titration to the full dose was done over the first 2 weeks of treatment. Efficacy and safety parameters were determined by age group (<65 vs. ≥65 years), gender, race (White vs. Black), ethnicity (Hispanic/Latino vs. non-Hispanic/Latino), and body mass index (BMI, <30 vs. ≥30 kg/m2).Main outcome measures:Change from baseline to endpoint in mean sitting systolic blood pressure (MSSBP) and mean sitting diastolic blood pressure (MSDBP); blood pressure (BP) control rate <140/90 mmHg.Results:Triple therapy was numerically superior and, for the majority of comparisons, statistically superior to each dual therapy in reducing MSSBP and MSDBP and in improving BP control rates in all subgroups. Across subgroups, triple therapy reduced MSSBP by 5.7–10.7 mmHg more than Val/HCTZ, 3.4–8.3 mmHg more than Aml/Val, and 4.4–9.4 mmHg more than Aml/HCTZ. Triple therapy was well tolerated across all subgroups. Limitations of our analysis included the lack of stratification of patients by subgroup at randomization and the small sample size of some subgroups (e.g., Blacks, elderly).Conclusions:Triple therapy with Aml/Val/HCTZ is effective and well tolerated in patients with moderate to severe hypertension regardless of age, gender, race, ethnicity, or BMI.Trial registration number:NCT00327587.

Abstract 16936: Vitamin D Supplementation Lowers Blood Pressure and Improves Control Rates in a Predominantly African American Hypertensive Cohort

Background: Vitamin D deficiency, highly prevalent in African Americans, has been associated with elevated blood pressure (BP) and hypertension in epidemiological studies. However, vitamin D supplementation has not been shown to consistently lower BP. Methods: Six hundred forty eight hypertensive patients with vitamin D blood levels and BP above JNC goal levels, with at least one follow-up visit, were followed a median of 10.6 months (5 clinic visits). At baseline, mean age was 56.5 years, mean BP 156/92 mm Hg, (mean of 22.3/8.8 mm Hg above JNC BP goal), mean vitamin D level 17.6 ng/ml; 67.2% were women and 87.7% were African American. Mixed effects general linear models were used to estimate longitudinal BP changes. Cox proportional hazards models were used to estimate the impact of vitamin D supplementation on first attainment of JNC goal BP. Repeated event proportional hazards analysis was utilized to determine the incremental (per 1 category higher of vitamin D supplementation) likelihood of attainment of JNC goal BP during follow-up. Models were adjusted for age, sex, initial BP level, baseline vitamin D level (&lt; 15, &gt; 15 ng/ml), antihypertensive drug therapeutic intensity, and vitamin D supplementation (0 = no vitamin D, 1 = &lt; 2000 IU/d, 2 = &gt; 2000 IU/d); the latter two variables were entered into the models as time-varying covariates. Results: Relative to no vitamin D supplementation, longitudinal SBP change was - 3.9 (p = 0.0089) and - 10.7 mm Hg (p = 0.0003) greater at incrementally higher vitamin D supplementation; DBP change was -2.5 (p = 0.0042) and - 7.0 mm Hg (p &lt; 0.0001) greater. Per 1 category higher vitamin D supplementation, there was no effect on first attainment of goal SBP HR = 1.15, 95% CI 0.94 - 1.39. However, first time DBP control was favorably impacted - HR = 1.28, 95% CI 1.09 - 1.50. Repeated events proportional hazards analysis showed greater BP control per 1 category higher vitamin D supplementation (SBP goal HR = 1.32, 95% CI 1.21 - 1.44; DBP goal HR =1.30, 95% CI 1.20 - 1.41). Conclusion: Vitamin D supplementation appears to lower BP and improve BP control rates independent of the intensity of antihypertensive treatment in a dose-dependent manner. The BP lowering effect is, however, most pronounced at &gt; 2000 IU/d.

Home Blood Pressure Monitoring as an Intervention to Control Hypertension

Home Blood Pressure Monitoring as an Intervention to Control Hypertension