Insufficient Blood Pressure Control Research Articles

Patterns of hypertension management in Italy: results of a pharmacoepidemiological survey on antihypertensive therapy. Scientific Committee of the Italian Pharmacoepidemiological Survey on Antihypertensive Therapy.

To collect statistically significant information on patterns of antihypertensive therapy in medical practice, with particular attention to the drugs used in the pharmacological management of hypertensive patients and the reasons for the limited achievement of therapeutic goals during treatment A survey conducted among general practitioners, specialists, and hypertensive patients. A total of 28,000 physicians were contacted by letter and 3,394 declared their willingness to participate and received a questionnaire. Subsequently, 1,255 questionnaires suitable for analysis (corresponding to 37.0% of adhering physicians) were received. In addition, 4,612 questionnaires completed by patients were pooled and evaluated. The prevalence of hypertension was calculated from a base of 254,192 patients, seen by general practitioners. The prevalence of hypertension, defined as systolic blood pressure > or = 160 mmHg or diastolic blood pressure > or = 95 mmHg, or current treatment, was 19.7%. The average number of hypertensive patients in each general practitioner's file, covering the previous 12 months, was approximately 230. Physicians reported a 66% rate of discontinuation of treatment or switching to another drug. Physicians and patients both considered inadequate blood pressure control and side effects to be the two main reasons for switching antihypertensive therapy, but in opposite order. Furthermore, physicians indicated a prevalence of drug side effects between 10 and 20%, according to class of drug used, whereas 69% of patients reported to have experienced side effects. In the doctors' opinions, there were many reasons for poor patient adherence: complexity of the drug regimen, appearance of side effects, forgetfulness, reduced patient understanding of the need for long-term continuation of treatment, and refusal to accept a chronic pathological condition. The survey showed awareness of the disease among physicians and provides a representation of the experiences of both general practitioners and specialists, in addition to that of their patients. During antihypertensive therapy, a disconcerting degree of discontinuation and switching of drugs occurred. Insufficient blood pressure control and side effects accounted for most of the observed treatment changes. This survey revealed the existence of a gap between the physicians' perception of tolerability and the real experience of patients, a clear need for greater tolerability of treatments, and a need for an enhancement of patient-physician communication.

High prevalence of hypertension and insufficient blood pressure control among Argentinian with type 2 diabetes

High prevalence of hypertension and insufficient blood pressure control among Argentinian with type 2 diabetes

Are angiotensin-converting enzyme inhibitors the best treatment for hypertension in type 2 diabetes?

The influence of hypertension on the clinical course and complications of type 2 diabetes is well established. With a special focus on angiotensin-converting enzyme inhibitors, this paper will review recently published results of prospective studies addressing two important aspects: the degree of blood pressure control, and the choice of antihypertensive regimen, in the prevention of complications in hypertensive type 2 diabetic patients. None of the recent studies have shown worse outcomes in patients treated with angiotensin-converting enzyme inhibitor-based regimens compared with alternative treatments. Some studies have suggested that angiotensin-converting enzyme inhibitor-based antihypertensive regimens may be superior to alternative treatments in reducing the risk of micro- and macrovascular complications, whereas other studies found similar effects for beta-blockers or calcium antagonists. Several trials showed beneficial effects of angiotensin-converting enzyme inhibitors over calcium antagonists, and have raised concerns about the use of dihydropyridine calcium antagonists in these patients. However, it remains to be determined whether there should be more reserved use of calcium antagonists in such patients, in the light of more major trials showing the safety and efficacy of calcium antagonists in preventing cardiovascular and renal endpoints. The degree of reduction of blood pressure rather than the choice of a particular drug may be the most important factor. Studies focusing on renal endpoints suggest that angiotensin-converting enzyme inhibitors have a better antiproteinuric effect than other agents, but this phenomenon is not always reflected by a more beneficial effect of angiotensin-converting enzyme inhibitors on the decline in glomerular filtration rate. In many ways, the question of whether angiotensin-converting enzyme inhibitors are the best class of agent in these patients is academic. Angiotensin-converting enzyme inhibitors are sufficiently safe, and, according to recent evidence, equally or more effective than other classes of agents. Tight blood pressure control is usually achievable only with a combination of agents. On the basis of available evidence, it appears that angiotensin-converting enzyme inhibitors, together with a low-dose cardioselective beta-blocker and a diuretic, should be used in most hypertensive type 2 diabetes patients, with calcium antagonists serving as reserve drugs in case of insufficient blood pressure control.

Improving adequacy improves haemodialysis outcome.

Our goal of maintenance dialysis for the coming millennium is optimal rather than just adequate dialysis. Delivering a large amount of dialysis expressed in terms of urea Kt/V is a necessary but insufficient measure to improve clinical outcome. Cardiovascular morbidity and mortality remain very high in haemodialysis. This is due in great part to the insufficient control of extra cellular volume and blood pressure. Ours, as well as published data, indicate that up to now, only increasing dialysis time either by prolonging the session or increasing its frequency has proven value in overcoming this critical issue.

Prognostic value of nighttime blood pressure in the elderly: a prospective study of 24-hour blood pressure.

Although it has been suggested in several reports that 24-h ambulatory blood pressure (BP) is a better predictor than casual BP measured in a clinician's office of the incidence of cardiovascular (CV) events, little information is available concerning the prognostic value of nighttime BP in the elderly population. Therefore, to evaluate the clinical implications of the nighttime BP in the elderly, we prospectively followed-up 324 elderly individuals (mean age, 77.2 +/- 7.0 years) who had undergone ambulatory BP monitoring at an annual health examination over a mean follow-up period of 51.5 +/- 22.0 months, and the relationship between BP and CV events was analyzed using Cox's proportional hazard model. For the analysis, 310 participants, excluding 14 subjects who were withdrawn due to non-CV events, were classed into two groups, one consisting of 134 individuals who were undergoing treatment with an anti-hypertensive drug (medicated group) and another consisting of 176 who were not medicated (nonmedicated group). New cardiovascular events developed in 43 cases in the medicated group and in 14 cases in the non-medicated group during the follow-up period. In the medicated group, a linear relationship was observed between BP and the event rates. The hazard ratio for CV events adjusted for age, sex, and other cardiovascular risks was 1.28 (95% confidence interval [CI], 1.05 to 1.54, p< 0.05) for a 10 mmHg increase of 24-h systolic BP. Corresponding values in 24-h diastolic BP, nighttime systolic BP, and nighttime diastolic BP were 1.71 (1.19 to 2.46, p< 0.01), 1.34 (1.13 to 1.58, p< 0.01), and 1.67 (1.20 to 2.31, p< 0.01), respectively. In the non-medicated group, the event rate was least in the subgroup in the second-lowest quartile for nighttime systolic BP, with a slight non-significant increase in the subgroup of the lowest quartile. It was shown that insufficient control of nighttime BP in the elderly with hypertension is associated with the development of CV complications.

Quality of Life in Hypertensive Patients Treated with Either Carvedilol or Enalapril

An important aspect of antihypertensive drug treatment is quality of life (QL) which should at least not be negatively affected. In this study, the QL during treatment with carvedilol (C), a beta-blocker with vasodilating properties due to alpha-1-receptor blockade, was compared to that of enalapril (E) in patients who had responded to the treatment. Patients with mild to moderate hypertension (diastolic blood pressure 95-115 mmHg) were randomised to receive either E(n = 119) of C(n = 129) in a double-blind multicenter study. The starting doses were 12.5 (C) and 10 (E) mg with doubling of the dose if necessary at 3-week intervals. If insufficient blood pressure (BP) control was found at 50 mg C or 40 mg E, 12.5 mg of hydrochlorothiazide was added. After having reached the goal BP the patients entered a 5-months maintenance period. General well-being was evaluated by the "Göteborg Quality of Life Questionnaire". Equally many patients in the respective treatment groups responded at the different dose levels. Diastolic BP after 5 months in the maintenance period was similar on C and E, respectively. For most items, QL was not affected by the treatments. An increased incidence of cough was perceived in the E group (p < 0.001). None of the C treated patients reported frequent cough at the end of the study compared with 12% of E treated patients. C and E had similar BP lowering effects. Neither treatment seemed to affect the patients QL adversely. Cough, although seldom leading to withdrawal from the therapy, may be more common than is commonly recognised during treatment with ACE-inhibitors.

From the Parallel Group Design to the Crossover Design, and From the Group Approach to the Individual Approach

The consequences of heterogeneity in response to antihypertensive drugs for the clinical development programs of new antihypertensive drugs and for the care of the individual hypertensive patient have not previously been sufficiently recognized. They play a role in the inappropriate choice of too-high daily doses of some antihypertensive drugs at the end of extensive international development programs. They are also implicated in the insufficient control of blood pressure observed in the long-term multicenter trials in hypertension, where some patients have been treated for several years with drugs that were not the most appropriate for their disease and which did not adequately control their blood pressure. In addition to the parallel group studies, the use of double-blind two-period or multiple period crossover designs can provide valid data for the dose-finding of new antihypertensive drugs and their comparative evaluation. At the end of the trial, these designs also offer each patient the opportunity to be treated with the right dose of the drug most appropriate for his or her disease.

Do angiotensin converting enzyme inhibitors represent a progress in hypertension care in diabetes mellitus?

Obviously, the introduction of new antihypertensive drugs, as promising they may ever be, will by itself not lead to an improvement of the overall quality of hypertension care in diabetic patients. Rather, the standards of hypertension care in unselected patient populations will depend (on the part of physicians) on systematic attempts to diagnose early and to initiate effective therapy, and (on the part of patients) on adherance to agreed therapeutic procedures [26]. In contrast to the tremendous interest in new pharmaceutical principles in antihypertensive therapy, surprisingly few attempts have been directed towards assessment and improvement of overall quality of hypertension care in diabetic patients. The few available data indicate very infrequent blood pressure measurements in diabetic patients both in general practitioners' offices and in diabetes centres [45, 46], and high percentages of patients with either untreated hypertension [47] or insufficient blood pressure control despite treatment [26, 46]. These problems are most unlikely to be solved by the mere introduction of ACEIs or any other new antihypertensive drug. One may even fear that the emphasis on promoting such new, still incompletely evaluated drugs may detract physicians and patients from the necessity to comply to tedious rules of long-term hypertension care using well established therapeutic principles. On the other hand, one might hope that the present most active marketing campaign for ACEIs will foster the interest for the real problems of hypertension care in diabetes. In this indirect way, the ACEIs may indeed contribute to the urgently needed improvement of hypertension care in diabetic patients.

Computer-assisted Techniques for Evaluation and Treatment of Hypertensive Patients

An integrated approach, progressively implemented in the ARTEMIS system since 1975, is described for the computerized management of hypertensive patients. From a medical point of view, computerized programs can be used to memorize patients' individual records and profiles, to facilitate patient management and follow-up, to store medical knowledge about hypertension and to provide facilities for decision making at the level either of the individual patient or of the population followed up. From a technical point of view, the methodology used integrates data and knowledge management facilities into the same software. Five hypertension clinics are presently using the system in France and more than 22,000 records have been registered. Answer rates to 12 mandatory questions regarding past history and examination at first visit were superior to 95% in 19,601 records created between January 1976 and December 1987. Patient database interrogation can be used to evaluate the sensitivity and specificity of various signs and symptoms for the diagnosis of secondary hypertension, and to predict, for each patient, his/her cardiovascular risk, the risk of drop-out, the risk of insufficient blood pressure control and the probable blood pressure level. It also serves to test the content and validity of the associated expert system which is progressively built up. A prospective evaluation of the performance of the expert system on 80 cases of hypertension showed overall agreement between the specialists and the expert system ranging from 58 to 91% depending on the decision.(ABSTRACT TRUNCATED AT 250 WORDS)

P-7-23 Insufficient blood pressure control as a risk factor for progression of nephropathy in hypertensive type 2 diabetic patients

P-7-23 Insufficient blood pressure control as a risk factor for progression of nephropathy in hypertensive type 2 diabetic patients