Inadequate Blood Pressure Control Research Articles

Effects of baroreflex activation therapy on cardiac function and morphology.

Arterial hypertension (aHTN) plays a fundamental role in the pathogenesis and prognosis of heart failure with preserved ejection fraction (HFpEF). The risk of heart failure increases with therapy-resistant arterial hypertension (trHTN), defined as inadequate blood pressure (BP) control ≥140/90mmHg despite taking ≥3 antihypertensive medications including a diuretic. This study investigates the effects of the BP lowering baroreflex activation therapy (BAT) on cardiac function and morphology in patients with trHTN with and without HFpEF. Sixty-four consecutive patients who had been diagnosed with trHTN and received BAT implantation between 2012 and 2016 were prospectively observed. Office BP, electrocardiographic and echocardiographic data were collected before and after BAT implantation. Mean patients' age was 59.1years, 46.9% were male, and mean body mass index (BMI) was 33.2kg/m2. The prevalence of diabetes mellitus was 38.8%, atrial fibrillation was 12.2%, and chronic kidney disease (CKD) stage ≥3 was 40.8%. Twenty-eight patients had trHTN with HFpEF, and 21 patients had trHTN without HFpEF. Patients with HFpEF were significantly older (64.7 vs. 51.6years, P<0.0001), had a lower BMI (30.0 vs. 37.2kg/m2, P<0.0001), and suffered more often from CKD-stage ≥3 (64 vs. 20%, P=0.0032). After BAT implantation, mean office BP dropped in patients with and without HFpEF (from 169±5/86±4 to 143±4/77±3mmHg [P=0.0019 for systolic BP and 0.0403 for diastolic BP] and from 170±5/95±4 to 149±6/88±5mmHg [P=0.0019 for systolic BP and 0.0763 for diastolic BP]), while a significant reduction of the intake of calcium-antagonists, α2-agonists and direct vasodilators, as well as a decrease in average dosage of ACE-inhibitors and α2-agonists could be seen. Within the study population, a decrease in heart rate from 74 ± 2 to 67 ± 2 min-1 (P=0.0062) and lengthening of QRS-time from 96±3 to 106±4ms (P=0.0027) and QTc-duration from 422±5 to 432±5ms (P=0.0184) were detectable. The PQ duration was virtually unchanged. In patients without HF, no significant changes of echocardiographic parameters could be seen. In patients with HFpEF, posterior wall diameter decreased significantly from 14.0±0.5 to 12.7±0.3mm (P=0.0125), left ventricular mass (LVM) declined from 278.1±15.8 to 243.9±13.4g (P=0.0203), and e' lateral increased from 8.2±0.4 to 9.0±0.4cm/s (P=0.0471). BAT reduced systolic and diastolic BP and was associated with morphological and functional improvement of HFpEF.

The Global Burden of Resistant Hypertension and Potential Treatment Options.

Resistant hypertension (RH) is defined as systolic blood pressure (SBP) or diastolic blood pressure (DBP) that remains .140 mmHg or .90 mmHg, respectively, despite an appropriate lifestyle and the use of optimal or maximally tolerated doses of a three-drug combination, including a diuretic. This definition encompasses the category of controlled RH, defined as the presence of blood pressure (BP) effectively controlled by four or more antihypertensive agents, as well as refractory hypertension, referred to as uncontrolled BP despite five or more drugs of different classes, including a diuretic. To confirm RH presence, various causes of pseudo-resistant hypertension (such as improper BP measurement techniques and poor medication adherence) and secondary hypertension must be ruled out. Inadequate BP control should be confirmed by out-of-office BP measurement. RH affects about 5% of the hypertensive population and is associated with increased cardiovascular morbidity and mortality. Once RH presence is confirmed, patient evaluation includes identification of contributing factors such as lifestyle issues or interfering drugs/substances and assessment of hypertension-mediated organ damage. Management of RH comprises lifestyle interventions and optimisation of current medication therapy. Additional drugs should be introduced sequentially if BP remains uncontrolled and renal denervation can be considered as an additional treatment option. However, achieving optimal BP control remains challenging in this setting. This review aims to provide an overview of RH, including its epidemiology, pathophysiology, diagnostic work-up, as well as the latest therapeutic developments.

Lipid Toxicity in the Cardiovascular-Kidney-Metabolic Syndrome (CKMS).

Recent studies of Cardiovascular-Kidney-Metabolic Syndrome (CKMS) indicate that elevated concentrations of derivatives of phospholipids (ceramide, sphingosine), oxidized LDL, and lipoproteins (a, b) are toxic to kidney and heart function. Energy production for renal proximal tubule resorption of critical fuels and electrolytes is required for homeostasis. Cardiac energy for ventricular contraction/relaxation is preferentially supplied by long chain fatty acids. Metabolism of long chain fatty acids is accomplished within the cardiomyocyte cytoplasm and mitochondria by means of the glycolytic, tricarboxylic acid, and electron transport cycles. Toxic lipids and excessive lipid concentrations may inhibit cardiac function. Cardiac contraction requires calcium movement from the sarcoplasmic reticulum from a high to a low concentration at relatively low energy cost. Cardiac relaxation involves calcium return to the sarcoplasmic reticulum from a lower to a higher concentration and requires more energy consumption. Diastolic cardiac dysfunction occurs when cardiomyocyte energy conversion is inadequate. Diastolic dysfunction from diminished ATP availability occurs in the presence of inadequate blood pressure, glycemia, or lipid control and may lead to heart failure. Similar disruption of renal proximal tubular resorption of fuels/electrolytes has been found to be associated with phospholipid (sphingolipid) accumulation. Elevated concentrations of tissue oxidized low-density lipoprotein cholesterols are associated with loss of filtration efficiency at the level of the renal glomerular podocyte. Macroscopically excessive deposits of epicardial and intra-nephric adipose are associated with vascular pathology, fibrosis, and inhibition of essential functions in both heart and kidney. Chronic triglyceride accumulation is associated with fibrosis of the liver, cardiac and renal structures. Successful liver, kidney, or cardiac allograft of these vital organs does not eliminate the risk of lipid toxicity. Lipid lowering therapy may assist in protecting vital organ function before and after allograft transplantation.

Efficacy and safety of a single-pill versus free combination of perindopril/indapamide/amlodipine: a multicenter, randomized, double-blind study in Chinese patients with hypertension.

In China, the prevalence of hypertension is high and the use of combination antihypertensive therapy is low, which contributes to inadequate blood pressure (BP) control. The availability of simplified treatments combining complementary BP-lowering agents may help more patients achieve their goals. This Phase III, multicenter, randomized, double-blind, noninferiority study included Chinese adults with mild-to-moderate hypertension. Following a 1-month run-in on perindopril/indapamide bi-therapy, patients with uncontrolled systolic/diastolic BP (≥140/90 mmHg) were randomized to perindopril 5 mg/indapamide 1.25 mg/amlodipine 5 mg (Per/Ind/Aml) single-pill combination (SPC) or perindopril 4 mg/indapamide 1.25 mg plus amlodipine 5 mg (Per/Ind + Aml) for 6 months. Uptitration was permitted from month 2 onwards. The primary efficacy objective was the noninferiority of Per/Ind/Aml in lowering office systolic BP at 2 months. The secondary objectives included the effectiveness of SPC on diastolic BP, uptitration efficacy, and office BP control (systolic/diastolic <140/90 mmHg). A subgroup of patients participated in 24-h ambulatory BP monitoring (ABPM). A total of 532 patients were randomized: Per/Ind/Aml ( n = 262) and Per/Ind + Aml ( n = 269). Overall, the mean (±SD) age was 55.7 ± 8.8 years, 60.7% were male, and the mean office systolic/diastolic BP at baseline on Per/Ind was 150.4/97.2 mmHg. Systolic BP decreased in both groups at 2 months from baseline: -14.99 ± 14.46 mmHg Per/Ind/Aml versus -14.49 ± 12.87 mmHg Per/Ind +Aml. A predefined noninferiority margin of 4 mmHg was observed ( P < 0.001). The effectiveness of the Per/Ind/Aml SPC was also demonstrated for all secondary endpoints. ABPM demonstrated sustained BP control over 24 h. Both treatments were well tolerated. Per/Ind/Aml is an effective substitute for Per/Ind + Aml, providing at least equivalent BP control over 24 h in a single pill, with comparable safety.

Adherence to pharmacological therapy in patients with hypertension: protocol of a qualitative study by focus groups

IntroductionNon-adherence to antihypertensive medication significantly contributes to inadequate blood pressure control. Regarding non-pharmacological interventions to improve medication adherence, the question remains of which interventions yield the highest efficacy.Understanding the complementary...

ATP2B1 gene polymorphisms associated with resistant hypertension in the Japanese population.

Single-nucleotide polymorphisms (SNP) of ATP2B1 gene are associated with essential hypertension but their association with resistant hypertension (RHT) remains unexplored. The authors examined the relationship between ATP2B1 SNPs and RHT by genotyping 12 SNPs in ATP2B1 gene of 1124 Japanese individuals with lifestyle-related diseases. Patients with RHT had inadequate blood pressure (BP) control using three antihypertensive drugs or used ≥4 antihypertensive drugs. Patients with controlled hypertension had BP controlled using ≤3 antihypertensive drugs. The association between each SNP and RHT was analyzed by logistic regression. The final cohort had 888 (79.0%) and 43 (3.8%) patients with controlled hypertension and RHT, respectively. Compared with patients homozygous for the minor allele of each SNP in ATP2B1, a significantly higher number of patients carrying the major allele at 10 SNPs exhibited RHT (most significant at rs1401982: 5.8% vs. 0.8%, p=.014; least significant at rs11105378: 5.7% vs. 0.9%, p=.035; most nonsignificant at rs12817819: 5.1% vs. 10%, p=.413). After multivariate adjustment for age, sex, systolic BP, and other confounders, the association remained significant for rs2681472 and rs1401982 (OR: 7.60, p<.05 and OR: 7.62, p=.049, respectively). Additionally, rs2681472 and rs1401982 were in linkage disequilibrium with rs11105378. This study identified two ATP2B1 SNPs associated with RHT in the Japanese population. rs1401982 was most closely associated with RHT, and major allele carriers of rs1401982 required significantly more antihypertensive medications. Analysis of ATP2B1 SNPs in patients with hypertension can help in early prediction of RHT and identification of high-risk patients who are more likely to require more antihypertensive medications.

Abstract 16782: Depression and Its Relationship With Uncontrolled Hypertension: A Single Urban Center Experience

Introduction: Depression and hypertension (HTN) contribute to cardiovascular risks with studies showing that depression increases the risk of developing HTN. However, the impact of depression on blood pressure control in patients with HTN remains unclear. The study aimed to investigate the incidence of depression in patients with uncontrolled HTN. Methods: A matched-pair analysis was conducted on 9,046 patients with diagnosis of HTN at a single-center Internal Medicine clinic between 2019 and 2022. Demographic variables, co-morbidities, blood pressure and PHQ 9 scores were recorded. Uncontrolled HTN was defined as BP ≥140/90 mmHg, and PHQ-9 scores ≥ 4 indicated depression. Age- and gender-matched patients with controlled HTN were included for comparison. Results: Among 9,046 patients with HTN, 1,886 (20.4%) had uncontrolled HTN. Patients with uncontrolled HTN were older (57.43 ±17.02 vs 46.68 ± 18.6, p=0.000) and more likely to be black (34.1 % vs 29.1%, p&lt;0.000) compared to those with controlled HTN. In the matched-pair analysis (3,660 patients), no significant difference in incidence of depression was observed in patients between uncontrolled and controlled HTN (389 vs 377, p=0.626). Patients with uncontrolled HTN had a higher prevalence of congestive heart failure (150 vs 113, p=0.018) and chronic kidney disease (211 vs 167, p=0.017). Conclusions: This single-center matched-pair analysis suggest that depression is not associated with inadequate blood pressure control, despite its role in increasing the risk of developing HTN in prior studies. Optimal blood pressure control plays a crucial role in preventing development of co-morbid conditions as seen in our study. A holistic approach to HTN management and factors beyond depression should be considered. Further research is warranted to gain a deeper understanding of the relationship between depression, HTN, and cardiovascular outcomes, enabling more targeted interventions and improved patient care.

THU529 Challenges In The Management Of Biochemically Silent Paraganglioma

Abstract Disclosure: S. Dewan: None. A. Farooqi: None. J. Jun: None. Biochemically silent Pheochromocytoma and Paraganglioma (PPGL) are rare neuro-endocrine tumors because of which there is low quality evidence and insufficient guidelines for their management. 74-year-old Female was referred to our Endocrine clinic for incidentally discovered Retroperitoneal mass on MRI. On evaluation patient reported having concerns of escalating anxiety, difficult to control HTN and episodic flushing after physical activity in the last one year. A CT abdomen and pelvis with contrast was ordered which showed 1.7 x 1.8 cm mass anterior to the L5 vertebral body just caudal to the aortic bifurcation. The biochemical work up including 24-hour urine Metanephrines (104 ug/24 hr; n 52-341), Normetanephrines (479 ug/24 hr; n 88-444), Total Metanephrines (583 ug/24 hr; n 88-444), 3 Methoxytyramine (166 mcg/24 hr; n &amp;lt;242) was inconclusive. For further evaluation PET CT DOTATATE scan was ordered which showed the lesion to be DOTATAE somatostatin analogue avid, consistent with somatostatin receptor positive neuroendocrine tumor. Patient was scheduled for surgery in 2 weeks and was started on Terazosin in addition to her anti HTN medications Amlodipine, Losartan and HCTZ. The surgery had to be rescheduled due to inadequate blood pressure control. Her amlodipine and Terazosin dosage were gradually increased while the procedure was rescheduled. Eventually she underwent Laparotomy exploration and resection of the lesion. Patient tolerated the procedure well and had no major intra or post operative fluctuations in her blood pressure, heart rate or blood glucose. According to the Endocrine Surgery team, the tumor could not be sufficiently removed since it was immovable during surgery and could not be delineated from the spine. The post-operative CT scan showed nodular lesion at aortic bifurcation slightly increased in soft tissue component from prior CT scan. After discussions with surgery and oncology team, patient opted for imaging surveillance for now and will consider genetic counseling and/or radiation therapy if the tumor increases in size. Untreated PPGL carries a high risk of cardiovascular morbidity and mortality, and some may also be malignant with a propensity to cause mass effects and metastasis. Currently, there are scarce evidence-based studies comparing treatment options in biochemically silent PPGL, and there is no consensus for the most appropriate peri-operative management of biochemically silent PPGL. This case adds to the literature on how a combination of calcium channel blocker and alpha blocker can be used to achieve peri-operative blood pressure and heart rate control with no major side effects. It also demonstrates the importance of functional imaging, especially in clinically or radiologically suspected PPGL, even with a normal biochemical work up. We suggest multi-disciplinary evaluation and individualized management to ensure positive outcomes. Presentation: Thursday, June 15, 2023

Abstract P2148: Beyond Traditional Pharmacology: A Critical Appraisal Of Enhanced External Counterpulsation (EECP) As A Promising Alternative Treatment For Hypertension

Introduction: Hypertension is a significant global public health concern and a leading cause of cardiovascular disease. Despite the availability of numerous pharmacological therapies, many hypertensive patients experience inadequate blood pressure control, medication side effects, or resistance. Thus, non-pharmacological interventions such as Enhanced External Counter pulsation (EECP) have garnered interest as a promising alternative treatment for hypertension.This systematic review aims to evaluate the existing clinical evidence on the efficacy, safety, and underlying mechanisms of EECP as a non-invasive therapy for hypertension. Eligible studies included randomized controlled trials, non-randomized controlled trials, and observational studies. Material and Methods: A comprehensive search of the MEDLINE database was done from March 2002 to March 2023 to identify studies evaluating the use of “EECP in hypertensive patients”. Initially, 31 articles were screened for eligibility, and subsequently, 9 articles met the inclusion criteria, &amp; were thereby included in the review. The inclusion criteria being relevance to the research question, thereby excluding the rest. Results: The review finds that EECP therapy can have beneficial effects on blood pressure control, endothelial function, arterial stiffness, and inflammation in patients with hypertension. The underlying mechanisms of EECP involve enhancing arterial blood flow, improving endothelial function, and reducing peripheral vascular resistance. Although the evidence base for EECP is limited, the available studies suggest that this therapy is safe and well-tolerated, with few adverse effects reported. Conclusions: EECP represents a promising alternative treatment option for hypertension beyond traditional pharmacotherapy. However, further high-quality studies are needed to confirm its efficacy and to identify optimal treatment protocols for different patient populations. Nevertheless, the current evidence suggests that EECP is a valuable addition to the armamentarium of hypertension management strategies.

Antihypertensive medication nonadherence and target organ damage in children with chronic kidney disease.

Nonadherence is common in children with chronic kidney disease (CKD). This may contribute to inadequate blood pressure control and adverse outcomes. This study examined associations between antihypertensive medication nonadherence, ambulatory blood pressure monitoring (ABPM) parameters, kidney function, and cardiac structure among children with CKD. We performed secondary analyses of data from the CKD in Children (CKiD) study, including participants with treated hypertension who underwent ABPM, laboratory testing, and echocardiography biannually. Nonadherence was defined by self-report of any missed antihypertensive medication 7days prior to the study visit. Linear regression and mixed-effects models were used to assess the association of nonadherence with baseline and time-updated ABPM profiles, estimated glomerular filtration rate (eGFR), urine protein to creatinine ratio (UPCR), and left ventricular mass index (LVMI). Five-hundred and eight participants met inclusion criteria, followed for a median of 2.9years; 212 (42%) were female, with median age 13years (IQR 10-16), median baseline eGFR 49 (33-64) ml/min/1.73m2 and median UPCR 0.4 (0.1-1.0) g/g. Nonadherence occurred in 71 (14%) participants. Baseline nonadherence was not significantly associated with baseline 24-h ABPM parameters (for example, mean 24-h SBP [β - 0.1, 95% CI - 2.7, 2.5]), eGFR (β 1.0, 95% CI - 0.9, 1.2), UCPR (β 1.1, 95% CI - 0.8, 1.5), or LVMI (β 0.6, 95% CI - 1.6, 2.9). Similarly, there were no associations between baseline nonadherence and time-updated outcome measures. Self-reported antihypertensive medication nonadherence occurred in 1 in 7 children with CKD. We found no associations between nonadherence and kidney function or cardiac structure over time. A higher resolution version of the Graphical abstract is available as Supplementary information.

Leveraging Electronic Health Record Technology and Team Care to Address Medication Adherence: Protocol for a Cluster Randomized Controlled Trial.

Low medication adherence is a common cause of high blood pressure but is often unrecognized in clinical practice. Electronic data linkages between electronic health records (EHRs) and pharmacies offer the opportunity to identify low medication adherence, which can be used for interventions at the point of care. We developed a multicomponent intervention that uses linked EHR and pharmacy data to automatically identify patients with elevated blood pressure and low medication adherence. The intervention then combines team-based care with EHR-based workflows to address medication nonadherence. This study aims to describe the design of the Leveraging EHR Technology and Team Care to Address Medication Adherence (TEAMLET) trial, which tests the effectiveness of a multicomponent intervention that leverages EHR-based data and team-based care on medication adherence among patients with hypertension. TEAMLET is a pragmatic, cluster randomized controlled trial in which 10 primary care practices will be randomized 1:1 to the multicomponent intervention or usual care. We will include all patients with hypertension and low medication adherence who are seen at enrolled practices. The primary outcome is medication adherence, as measured by the proportion of days covered, and the secondary outcome is clinic systolic blood pressure. We will also assess intervention implementation, including adoption, acceptability, fidelity, cost, and sustainability. As of May 2023, we have randomized 10 primary care practices into the study, with 5 practices assigned to each arm of the trial. The enrollment for the study commenced on October 5, 2022, and the trial is currently ongoing. We anticipate patient recruitment to go through the fall of 2023 and the primary outcomes to be assessed in the fall of 2024. The TEAMLET trial will evaluate the effectiveness of a multicomponent intervention that leverages EHR-based data and team-based care on medication adherence. If successful, the intervention could offer a scalable approach to address inadequate blood pressure control among millions of patients with hypertension. ClinicalTrials.gov NCT05349422; https://clinicaltrials.gov/ct2/show/NCT05349422. DERR1-10.2196/47930.

WHEN HYPERTENSION IS RESISTANT WE THINK IT OVER!

Objective: Hypertension is defined as resistant when the treatment strategy fails to lower office SBP and DBP values to &lt;140 mmHg and/or &lt;90 mmHg, respectively, and the inadequate control of blood pressure is confirmed by ABPM or HBPM in patients whose adherent to therapy. We report a case of resistant hypertension of a 64-year-old woman who referred to our Center in August 2021 for uncontrolled BP (160/94 mmHg) despite anti-hypertensive treatment with ramipril/hydrochlorothiazide 5/25 mg, atenolol 50 mg, ramipril 5 mg and lacidipine 4 mg daily and mild hypokalaemia (3.3 mmol/L). Design and method: Clinical history revealed dyslipidemia in treatment with simvastatin 20 mg/daily, osteoporosis in treatment with calcium and vitamin D supplements, parathyroid nodules in follow-up,family history of CAD. Laboratory tests confirmed hypokalaemia (3.1 mmol/L). Blood glucose, creatinine,lipids thyroid function were normal; no proteinuria was observed. The echocardiogram showed left ventricular hypertrophy with EF 60% and grade-1 diastolic dysfunction. Results: After wash-out of anti-hypertensive drugs, the screening tests revealed high aldosterone plasma levels (1166 pg/mL) and low renin level (1.6 microu/mL) with an ARR of 729. Other adrenal hormone levels were within normal limits. The saline infusion test confirmed the hyper-aldosteronism and an abdominal CT scan revealed a left adrenal neoformation of 17 x 15 mm in seize (Figure 1A). The patient underwent adrenal venous sampling which did not show lateralization and patients refuse to repeat the procedure. Anti-hypertensive therapy with spironolactone, eplerenone, canrenone and amiloride was stopped due to diarrhoea and rectal tenesmus (colonscopy excluded microscopic colitis). A 131I-norcholesterol adrenal scintigraphy with dexamethasone suppression documented early uptake only in the left adrenal gland (Figure 1B). After surgical evaluation, the patient underwent a video-laparoscopic left adrenalectomy and the histological examination revealed an adrenal cortical adenoma. The post-operative course was complicated by a syncopal episode due to hypotension (80/50 mmHg) with head injury for which antihypertensive therapy was revised and at the discharged she takes valsartan 80 mg, verapamil 40 mg twice. Conclusions: Primary aldosteronism intolerant to potassium-sparing diuretics and aldosterone antagonists is a rare condition and the establishment of a multidisciplinary team can improve its management.

Current practice toward the use of antihypertensive agents in the management of hypertension – A cross-sectional study among Indian physicians

Objective: The objective of this study was to assess current practices and usage patterns of antihypertensive medications in managing hypertension (HTN) in India. Materials and Methods: A cross-sectional, observational digital study was conducted among health-care practitioners (HCPs) across India (November 2022–March 2023). Results: A total of 792 HCPs (cardiologists, consulting, and general physicians) participated in this study. According to 63.38% of HCPs, 20–50 essential HTN patients seek consultation weekly. The majority of patients were in the age range of 40–60 years (84.09%). A total of 67.55% of HCPs mentioned that systolic blood pressure (BP) ranged between 140 and 160 mmHg. Type 2 diabetes mellitus was the most common comorbidity among hypertensive patients (84.09%). In total, 53.79% and 37.37% of HCPs preferred angiotensin receptor blockers (ARBs)/angiotensin-converting enzyme and calcium channel blockers (CCBs) as the first choice of antihypertensive agents. The majority of HCPs (&gt;69%) preferred prescribing a triple-drug fixed-dose combination (FDC) of CCBs + ARB + diuretics in hypertensive patients with coronary artery disease (CAD) and resistant HTN. The majority (89.90%) of HCPs preferred prescribing FDC of CCBs over monotherapy. Amlodipine (&gt;55%) followed by cilnidipine (&gt;32%) were preferred CCBs for young and older hypertensive patients. In patients with essential HTN without any CVD, amlodipine (72.85%) was the preferred CCB. Vascular selectivity (59.09%) and longer half-life (54.55%) were important factors for prescribing CCBs. Resistant HTN, inadequate BP control with monotherapy, and the presence of CAD were all (62.63%) important considerations for FDC with CCBs. The underutilization of CCBs in managing HTN (63.88%) was highlighted. Conclusion: Overall responses provide a comprehensive overview of the prevailing perception and the usage patterns of antihypertensive agents employed by HCPs in India.

PS-C36-1: CLINICAL INERTIA IN THE HYPERTENSIVE PATIENTS TREATED BY HYPERTENSION SPECIALISTS

Background: Only about 30% of hypertensive patients in Japan is reported to have properly controlled blood pressure (BP). The clinical inertia (Inertia) seems to be one of the factors behind the inadequate BP control. Purpose: We investigate the achievement rate of the BP lowering target in 2020 for outpatients in the division of hypertension, and confirm the prevalence of inertia as a possible factor for the failure to achieve their BP targets. Methods: Subjects were 517 outpatients (mean age 68.6 ± 13.2 years, 54% of women) who regularly visited the division of hypertension from March to September 2020 and took antihypertensive drugs prescribed by hypertension specialists. We calculated the average of office BP (OBP) in the two visits during the same period, and the average of home BP (HBP) for the three days before each two visits. In addition, we investigated the antihypertensive drugs taken during that period and complications such as diabetes and chronic kidney disease, and collected blood chemistry and urine test data. From these data, as of December 2021, the attending doctors determined whether each patient achieved the BP target according to the Japanese Society of Hypertension 2019 (JSH2019), and chose one reason from the options in the patients who failed to achieve target BP. Results: The target for OBP in all subjects was &lt; 130/80 (48%), &lt; 140/90 (140 group, 15%), &lt; 140/90 mandatory, and &lt; 130/80 if tolerable (37%). The percentage of those who achieved each OBP target was 48% (OBP achievers, N = 246). As a result of investigating the reason for the OBP non-achievement (N = 273) by the attending doctors, 20% answered “judged to be the optimal BP level (Optimal)”, 20% answered “due to the white coat effect ”, and then “Inertia” was the next highest at 14%. Regarding the achievement rate of HBP for OBP achievers, 36% did not measure HBP, 38% achieved &lt; 135/85 or &lt; 130/80 (HBP 135), and 26% (N = 65) did not achieve it. Among the HBP 135 other than the 140 group (N = 66), the unachieved rate of &lt; 125/75 was 58% (N = 38). The reasons for non-achievement of HBP (N = 103 in total), “Optimal” was the most common answer (42%), followed by “Inertia” (27%). Conclusion: Inertia existed as a factor explaining insufficient BP control even in the patients treated by hypertension specialists. From now on, in order to increase the rate of achieving the BP target, we should make an effort to overcome inertia.

S-48-4: PHYSICAL FRAILTY IN HYPERTENSION MANAGEMENT

The significance of hypertension management in older individual is greatly influenced by factors other than chronological age, as they have diverse physical, mental, and social backgrounds. Particularly, differences in physical function, between independence, frailty and dependence, have a great impact on antihypertensive therapy in the older population. Recent clinical trials support the significance of active antihypertensive therapy in the independent elderly, and inadequate blood pressure control in the older patients is one of the challenges in the practice of hypertension. On the other hand, there is a lack of evidence to positively support the significance of antihypertensive therapy for the older people who require nursing care, and some observational studies suggest that antihypertensive therapy is actually detrimental. Physical frailty between independence and the need for nursing care, is suggested to be the tipping point at which the significance of antihypertensive therapy changes, and observational studies have shown that the relationship between blood pressure and prognosis changes with the degree of frailty. In the practice of hypertension treatment in the older patients, it is important to understand such changes in the significance of antihypertensive therapy according to physical function. There are still issues to be addressed in practicing antihypertensive therapy with an awareness of the concept of frailty. For example, the Guidelines for the treatment of hypertension recommend that antihypertensive therapy for older patients with frailty be determined on an individual basis, but it is currently not easy to understand the basis to support such a decision. It is important to elucidate the factors that influence the association between blood pressure control and prognosis in frail hypertensive patients. Conversely, given the association between the significance of antihypertensive therapy and physical function, the preservation of physical function is a key to maintain the significance of antihypertensive therapy. In particular, as it is important to maintain or improve physical function in frail older patients, a future challenge is required to clarify what kind of assessment and antihypertensive treatment is optimal for this purpose. The future challenges to improve the management of hypertension in frail patients in the perspectives of geriatric medicine will also be presented.

PS-C10-9: EFFECTIVENESS OF AMLODIPINE ON 24-HOUR AMBULATORY BLOOD PRESSURE IN ADULT PATIENTS WITH MILD-MODERATE ESSENTIAL HYPERTENSION: A MULTICENTRE OBSERVATIONAL, REAL-WORLD STUDY

Objective: Inadequate 24-hour blood pressure control could cause complications, especially in high-risk hypertensive individuals. Hence, it is recommended that the targeted blood pressure levels be maintained round the clock. This prospective, observational study assessed the 24-hour ambulatory blood pressure (ABP) control with 8-week amlodipine therapy 5/10 mg/day in patients with hypertension. Methods: Adult patients (62 m, 42 f) with mild-to-moderate essential hypertension received oral amlodipine 5 mg/day (n = 68) or 10 mg/day (n = 36) for 8 weeks. The study was approved by the independent ethics committee and informed consent was obtained from all participants. Primary outcome was change at 8 weeks from baseline in mean 24-hr ABP (systolic and diastolic), and secondary outcomes were change from baseline in mean morning, daytime, night-time, and last 6-hr dosing interval ABP. A repeat measures analysis of covariance (ANCOVA) was done for changes in ABP over 8 weeks, with age, gender, BMI and associated comorbidities as covariates. Nocturnal dippers were assessed as those greater than or equal to 10% reduction in ABP at 8 weeks. Sub-groups were created based on age, duration of hypertension, occupation, baseline BMI and amlodipine dose. Safety was evaluated based on clinical adverse events and 12-lead electrocardiogram. Results: Of the 104 patients from 2 study centers, 49 completed 8-weeks therapy and were included for per-protocol analysis. Significant reductions in the mean 24-hr blood pressure were seen for both SBP and DBP (figure 1). The mean 24-hr. reduction was -10.82 and -6.25 mmHg with 5 mg amlodipine and -19.81 and -11.19 mmHg with 10 mg amlodipine for SBP and DBP respectively (p &lt; 0.0001). The mean morning, daytime, night-time, and last 6-hr reductions in SBP were -14.06, -18.63, -20.42, and -13.51 respectively (p &lt; 0.0001), and DBP reductions were -7.78, -10.27, -11.07, and -6.44 respectively (p &lt; 0.0001). Significant reduction in ABP was seen in all sub-groups (p &lt; 0.0001). Greater reduction in SBP and DBP were observed in patients with stage-2 hypertension. At baseline, there were 30 (61.2%) non-dippers which decreased to 18 (36.7%) at 8 weeks. At the end of the study, 40% of non-dippers were converted to dippers by Amlodipine, whereas none of the dippers were converted to non-dippers. No adverse effects were reported. Conclusion: Amlodipine significantly reduces the 24-hr. mean morning, daytime, night-time, and last 6-hr. ABP and converted non dippers to dippers in adult patients with mild to moderate essential hypertension. The Study highlights the consistent effects of amlodipine on both quantity and quality of 24 hours BP control which is important for associated CV risk reduction.

PS-R01-8: BLOOD PRESSURE CONTROL WAS IMPROVED BY A CHANGE IN THE TIMING OF ANTIHYPERTENSIVE MEDICATION IN A PATIENT WITH NOCTURNAL HYPERTENSION

A 75-year-old-man was referred to our outpatient clinic due to inadequate blood pressure control despite antihypertensive drug treatment. He had dyslipidemia, type 2 diabetes mellitus, and a history of carotid artery stenosis, bilateral central retinal artery occlusion, and lower extremity artery disease. He took losartan potassium 50 mg, hydrochlorothiazide 12.5 mg, cilnidipine 10 mg, and nifedipine CR 40 mg in the morning. Home blood pressure monitoring was performed by using a cuff oscillometric device that could be set to measure blood pressure automatically during sleep. The patient was instructed to measure his morning blood pressure twice after waking, evening blood pressure twice before bedtime, and night-time systolic blood pressure (2:00, 3:00, 4:00, and 5:00 AM) for 7 consecutive days. Mean values were 161 mmHg for morning systolic blood pressure, 134 mmHg for evening systolic blood pressure, and 141 mmHg for night-time systolic blood pressure. After the home blood pressure monitoring, the timing of administration of nifedipine CR 40 mg was shifted from morning dosing to bedtime dosing. One month later, home blood pressure monitoring was performed again using the same schedule as before. Mean values were decreased from 161 mmHg to 135 mmHg for morning systolic blood pressure and from 141 mmHg to 127 mmHg for nigh-time systolic blood pressure. Blood pressure control was improved only by altering the timing of the administration of one antihypertensive drug from morning dosing to bedtime dosing without increasing the dosage of antihypertensive drug or adding a new antihypertensive drug class.

Risk of resistant hypertension associated with insomnia in patients with obstructive sleep apnea

ObjectivesPatients with obstructive sleep apnea (OSA) have a high prevalence of hypertension but vary in blood pressure (BP) control, which may be partially explained by comorbid insomnia. We investigated the association of insomnia symptoms with uncontrolled BP and resistant hypertension (RH) in OSA patients. MethodsBetween 2018 and 2021, hypertensive patients with OSA were enrolled. Information on demographic characteristics, insomnia symptoms, class of antihypertensive medications, BP control and sleep study data were collected. Controlled BP was defined as systolic BP < 140 mm Hg and diastolic BP < 90 mm Hg (BP standard); uncontrolled BP as above BP standard with use of 1–2 classes of antihypertensive medication; and RH as above BP standard with the use of ≥3 classes of antihypertensive medication (including a diuretic). Multinomial logistic regression models were fit to determine the association between insomnia symptoms and uncontrolled BP or RH (versus controlled BP) after multivariable adjustment. ResultsAmong the analytic sample (n = 326), 64.1% of participants had uncontrolled BP and 15.6% had RH. OSA severity was associated with a higher odds of RH (OR, 2.92; 95% CI, 1.71–4.99). After adjustment for confounders including demographic characteristics, sedative hypnotics usage, sleepiness, OSA severity and quality of life, participants experiencing insomnia symptoms had a 3.0 times higher odds of RH. Insomnia was not associated with uncontrolled BP. ConclusionsExperiencing insomnia was associated with increased odds of RH in OSA patients. These results suggest that comorbid insomnia may contribute to inadequate BP control in OSA patients.

Association of Depression Onset and Treatment With Blood Pressure Control After Intracerebral Hemorrhage.

Blood pressure (BP) control represents a crucial intervention to improve long-term outcomes following spontaneous intracerebral hemorrhage (ICH). However, fewer than half of ICH survivors achieve target treatment goals. ICH survivors are also at very high risk for poststroke depression, which may contribute to inadequate BP control. We, therefore, sought to determine whether depressive symptoms after ICH are associated with inadequate BP control. We also investigated whether associations between depression after ICH and BP measurements were mediated by treatment with selective serotonin reuptake inhibitors or norepinephrine-serotonin reuptake inhibitors antidepressants. We leveraged data from a single-center longitudinal study of ICH conducted at Massachusetts General Hospital (Boston, MA) between 2006 and 2018. We collected data from semiautomated review of electronic health records, baseline and follow-up interviews, and computed tomography imaging. Information on BP measurements, depression diagnoses, antidepressants medication use, and medical visits were collected longitudinally and analyzed using mixed effects models. Primary outcomes included systolic and diastolic BP measurements during long-term follow-up after ICH. We included 1243 consecutive ICH patients without pre-stroke depression history. Of these, 721 (58%) were diagnosed with incident depression over a median follow-up time of 52.8 months (interquartile range, 42.1-60.5). Depression onset was associated with subsequent increase in systolic (+8.3 mm Hg, SE, 2.4 mm Hg, P=0.012) and diastolic (+4.4 mm Hg, SE, 1.2 mm Hg) BP measurements. Resolution of depressive symptoms was associated with subsequent decrease in systolic (-5.9 mm Hg, SE, 1.4 mm Hg, P=0.031) and diastolic (-3.4 mm Hg, SE, 1.1 mm Hg, P=0.041) BP measurements. We also found associations between higher systolic BP measurements and use of selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor antidepressants, independent of whether depression symptoms were active or not (all P<0.05). ICH survivors displayed increasing BP values after receiving a diagnosis of depression, followed by decreasing values among those experiencing resolution of depressive symptoms. Use of selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor antidepressants was independently associated with higher systolic BP measurements. Clinicians ought to closely monitor BP for ICH survivors being treated for depression, especially using selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor. Future studies will also be required to investigate the mechanisms underlying these associations.

The potential of blood pressure telemonitoring: experience in the UK and Japan.

Hypertension is the most important and modifiable risk factor for cardiovascular disease (CVD) morbidity and mortality worldwide, and a growing issue as the global population with hypertension increases (estimated to be 626 million women and 652 million men in 2019, almost double the number in 1990). In addition, global control rates for hypertension remain poor: 23% for women and 18% for men in 2019 (Lancet. 2021:957). Measures to reduce the number of poorly controlled hypertensive patients are urgently needed. Remarkable advances in healthcare technology have changed healthcare delivery dramatically in the last decade with out-of-office blood pressure (BP) telemonitoring being widely used in clinical research (Hypertension. 2020:1368). We have demonstrated the efficacy of BP telemonitoring and digital intervention for the management of hypertension in the Telemonitoring And Self-Management IN the control of Hypertension (TASMINH) trials (Lancet. 2010:163, JAMA. 2014:799, Lancet. 2018:949), the Home and Online Management and Evaluation of Blood Pressure (HOME BP) trial (BMJ. 2021:m4858), and the HERB Digital Hypertension 1(HERB-DH1) pivotal trial (Eur Heart J. 2021:4111). A recent meta-analysis found that home BP telemonitoring improved office systolic BP (SBP) by 3.99 mmHg and home BP telemonitoring plus additional support (e.g., counselling and medications management) also showed a reduction of office SBP by 2.44 mmHg versus home BP telemonitoring alone (J Hum Hypertens. 2017:427). This evidence suggests that BP telemonitoring is an optimal tool for reducing BP levels and that combining BP telemonitoring and co-interventions would be the most effective approach for the management of hypertension. There are additional benefits from BP telemonitoring system in clinical practice, including assessment of accurate and reliable out-of-office BP data, and ease of BP measurement and recording by patients without the need for manual systems. Furthermore, such systems can reduce nonadherence of antihypertensive medications and clinical inertia, both of which contribute to a treatment-resistant hypertension (J Hypertens. 2017:2346, J Hypertens. 2021:1238). In practical terms, telemonitoring also facilitates optimal BP management for patients living in geographically remote or poorly medically resourced areas (Hypertension. 2021:1927). In this session, through discussion of the evidence base and clinical experience in the UK and Japan, we will examine the prospects of BP telemonitoring systems for the future management of hypertension. We will examine how BP telemonitoring systems are used and affect BP control in both clinical trials and subsequent implementation. In addition, by comparing such work in the UK and Japan, we will assess the potential of BP telemonitoring systems as a solution to the inadequate BP control status worldwide.