Intensive Hypertension Control Research Articles

PS-P12-5: CHALLENGES FOR REGISTERED PATIENTS RECEIVING HYPERTENSION CARE FROM PRIMARY HEALTH CENTERS IN BANGLADESH

Introduction: One in every five adults in Bangladesh suffers from Hypertension. There is a high prevalence of undetected hypertensive patients. Among the detected cases, the control rate of hypertension is poor. Since 2018, the National Heart Foundation of Bangladesh has undertaken an intensive hypertension control program along with the Non-Communicable Disease Control (NCDC) program, the Government of Bangladesh at primary health care settings. This control program implements a number of proven strategies which are a standard simplified treatment protocol, community-based care and task sharing, regular supply of medication, and patient-centered care. Irregular follow up visit and non-adherent to medication fail to control hypertension and increase premature death among patients. Objectives: To identify the challenges and barriers to the adherence of antihypertensive medication. Design and method: A cross sectional study where total number of 6498 registered hypertensive patients of four Upazila Health Complexes (UHC)s in Sylhet district, northeast part of Bangladesh is selected from April 2019 to August 2020 for this study purpose. These patients are identified since they missed all of their three consecutive monthly follow-up visits at their respective UHCs.. A digital android based application is used as the monitoring tool in the program through which patients are identified as overdue. Data were collected by a questionnaire through an interview over telephone. Result: Among 6498 registered hypertensive patients, 3548 patients were contacted. Among those 47% mentioned the distance to the UHCs and long waiting time as challenging factors for receiving antihypertensive medications monthly from their assigned facilities. Due to poor treatment compliance, a number of patients (2.9%) did not return. Moreover, 3.3% of the respondents switched to private practitioners and 0.2% moved to the secondary or tertiary hospital. 0.6% of the respondents could not receive the antihypertensive medication from UHC due to their physical illness and 0.3% migrated to another location. The interviewer found 0.4% overdue patients dead. 12.9% did not receive the call and 8.6% did not mention any reason. 23.5% of the overdue patients gave wrong phone number during their registration. Conclusion: This study revealed a number of challenges mentioned by the respondents receiving hypertension care from primary health centers. Addressing these challenges might be effective to improve the hypertension care. Hypertension treatment at community level from the nearest health facility should be included to overcome the barriers.

An economic evaluation of intensive hypertension control in CKD patients: a cost-effectiveness study

BackgroundStudies have suggested that intensive hypertension control in patients with a high risk of cardiovascular disease (CVD) is both effective and economically feasible. The purpose of this study is to conduct an economic evaluation of intensive hypertension control targeting chronic kidney disease (CKD) patients using the representative data in Korea.MethodsWe used a Markov decision model to compare both cost and effectiveness of intensive hypertension control versus standard hypertension control in hypertensive CKD patients. Model parameters were estimated with the data from the National Health Insurance Service (NHIS)-National Sample Cohort, as well as latest literature. One-way sensitivity analysis was conducted to test the effect of variation in key parameters on the model outcome.ResultsFor CKD patients with hypertension, intensive hypertension control would cost more but increase utilities, compared to standard hypertension control. The incremental cost-effectiveness ratio (ICER) for intensive hypertension control in CKD patients was projected at 18,126 USDs per quality-adjusted life year (QALY) compared to standard hypertension control. The results of sensitivity analysis suggest that the results are overall robust.ConclusionsThis study finds that intensive hypertension control in CKD patients in Korea is economically sound. This information is expected to be useful for clinicians in managing hypertension of CKD patients and policymakers when making decisions.

Association between blood pressure levels and cognitive impairment in older women: a prospective analysis of the Women's Health Initiative Memory Study

SummaryBackgroundWhether blood pressure (BP), and at what level of controlled BP, reduces risk of cognitive impairment remains uncertain. We investigated the association of BP and hypertension treatment status with mild cognitive impairment and dementia in older women.MethodsWe prospectively analysed a sample of 7207 community-dwelling women aged 65–79 years participating in the Women’s Health Initiative Memory Study (WHIMS). Participants were recruited between May 28, 1996, and Dec 13, 1999, at 39 US clinical centres, and they were followed up until Dec 31, 2019. Cognitive function was assessed annually. Mild cognitive impairment and probable dementia were defined through a centralised adjudication process. BP was measured by trained and certified staff at baseline. Pulse pressure (PP) was calculated as systolic BP (SBP) minus diastolic BP. Hypertension was defined using the American Heart Association 2017 Guideline for High BP in Adults. Outcomes were (1) mild cognitive impairment, (2) probable dementia, and (3) cognitive loss (the combined endpoint of either mild cognitive impairment or probable dementia, or both). We estimated hazard ratios (HRs) to assess the association between hypertension, SBP, and PP with the risk of study outcomes using Cox proportional hazards regression models, with adjustment for key covariates.FindingsDuring a median follow-up of 9 years (IQR 6–15), 1132 (15·7%) participants were classified as mild cognitive impairment, 739 (10·3%) as probable dementia, and 1533 (21·3%) as cognitive loss. The incidence rates per 1000 person-years were 15·3 cases (95% CI 14·4–16·2) for mild cognitive impairment, 9·7 cases (9·0–10·4) for probable dementia, and 20·3 (19·3–21·3) for cognitive loss. Elevated SBP and PP were significantly associated with increased risk of mild cognitive impairment and cognitive loss (test for trends across SBP and PP strata, p<0·01). Individuals with hypertension, but with controlled SBP of less than 120 mm Hg did not have a significantly increased risk of mild cognitive impairment (HR 1·33, 95% CI 0·98–1·82, p=0·071), and of cognitive loss (1·09, 0·82–1·44, p=0·57) compared with normotension. Individuals on anti-hypertensive treatment with PP of less than 50 mm Hg did not have a significantly higher risk of mild cognitive impairment (1·26, 0·98–1·62, p=0·07) and of cognitive loss (1·17, 0·94–1·46, p=0·16). There were no significant associations between hypertension, SBP, or PP and probable dementia.InterpretationResults of our study show significant associations of hypertension and elevated SBP and PP levels with risk of mild cognitive impairment and the combined endpoint of either mild cognitive impairment or probable dementia, suggesting that intensive control of hypertension, SBP, and PP can preserve cognitive health in older women.FundingNational Heart, Lung, and Blood Institute, National Institutes of Health, and US Department of Health and Human Services.

PCV10 Cost-Effectiveness of Intensive VS. Moderate Hypertension Treatment in US Adults Age 65 and Older at High Risk of Atherosclerotic Cardiovascular Disease

Many hypertension management guidelines are available from different organizations, with no consensus on whether an intensive or moderate systolic blood pressure (SBP) management for high-risk adults aged ≥65 is better. This study aimed to assess the long-term economic value of intensive hypertension control compared with moderate control in the US elderly to guide the decision-making of hypertension treatment strategies. We developed a Markov model with a one-year time cycle to simulate the progression of stroke, coronary heart disease, and mortality over a lifetime window. We used the 2017 National Center for Health Statistics data to generate a national representative simulation sample of older adults aged ≥65. We extracted costs from the Healthcare Cost and Utilization Project Statistical Briefs and recent publications. We defined having SBP <130 mmHg as SBP control, and SBP <140 mmHg as moderate SBP control. Sensitivity analyses were conducted to assess how uncertainties of key model parameters influenced the simulation results. An incremental cost-effectiveness ratios (ICER) of ≤$50,000 per quality-adjusted life years (QALY) gained was considered as cost-effective. The mean survival time of moderate and intensive SBP control were 7.80 (95% CI 7.71-7.89) and 9.63 (95% CI 9.52-9.74) years, respectively. The incremental costs, QALYs, and life years of intensive control compared with moderate SBP control were $7,399 (95% CI $7,076- $7,722), 0.88 (95% CI 0.76-1.00), and 1.83 (95% CI 1.58-2.08) years. Comparing with moderate SBP control, intensive SBP control was cost-effective, with an ICER of $8,405/QALY (95% CI $7,960-$8,924/QALY). Sensitivity analyses showed that low medication adherence and high medication cost had moderate and high negative impacts on the cost-effectiveness of intensive SBP control, respectively. Among adults aged ≥65, aiming for an intensive SBP goal of <130 mmHg is a cost-effective strategy.

Intensive control of hypertension and risk of Alzheimer's dementia in older adults with depression.

Intensive control of hypertension has been reported to decrease risk of cognitive decline. However, the effect of this in older adults with hypertension and comorbid depression is not well understood. We aim to identify whether intensive control of systolic blood pressure (BP) is associated with reduced risk of Alzheimer's dementia (AD) in a clinical population. Using data from the National Alzheimer's Coordinating Center, we conducted survival analyses in older adults with normal cognition at baseline and treated hypertension. We also examined those with comorbid depression, to determine if intensive control of systolic BP (≤120 mmHg) was associated with reduced risk of AD. In all older adults with treated hypertension (n = 4505), 298 (6.6%) developed AD during a median follow-up duration of 4.2 years. In the comorbid depression subgroup (n = 1327), 152 (11.5%) developed AD. Intensive control of systolic BP was not significantly associated with reduced risk of AD in the overall sample (HR 1.13, 95%, 0.79-1.64). However, in the comorbid depression subgroup, intensive control of systolic BP (≤120 mmHg) was associated with increased risk of AD (HR 1.49, 95%, 1.03-2.15) compared to standard control (121-139 mmHg). In a clinical population of older adults with hypertension and comorbid depression, we found that an intensive systolic BP target of ≤120 mmHg was associated with increased risk of AD. While these findings are preliminary, they suggest that a more cautious approach to hypertension treatment may be warranted in this vulnerable subgroup.

Cost-effectiveness analysis of intensive hypertension control in China

China has the largest population of adults with hypertension in the world. Recent clinical trials have shown that intensive hypertension control can help patients achieve lower blood pressure and reduce the incidence of major cardiovascular disease (CVD) events, but this level of hypertension control also incurs additional costs to patients and society and may result in a substantial increase in adverse events. The objective of this study is to assess the cost-effectiveness of intensive hypertension control to inform health policymakers and health care delivery systems in China in their decision-making regarding hypertension treatment strategies. We developed a Markov based simulation model of hypertension to assess the impact of intensive and standard hypertension control strategies for the Chinese population who are diagnosed with hypertension. Model parameters were estimated based on the best available data and the literature. We projected that intensive hypertension control would avert about 2.2 million coronary heart disease events and 4.4 million stroke events for all hypertensive patients in China in 10 years compared to standard hypertension control. The incremental cost-effectiveness ratio (ICER) for intensive hypertension control was estimated at 7876 CNY per quality-adjusted life year (QALY) compared to standard hypertension control. Intensive hypertension control would be more cost-effective than standard hypertension control in China. Our findings indicated that China should consider expanding intensive hypertension control among hypertensive patients given its great potential in preventing CVD.

BP in Dialysis: Results of a Pilot Study.

The optimal BP target for patients receiving hemodialysis is unknown. We randomized 126 hypertensive patients on hemodialysis to a standardized predialysis systolic BP of 110-140 mmHg (intensive arm) or 155-165 mmHg (standard arm). The primary objectives were to assess feasibility and safety and inform the design of a full-scale trial. A secondary objective was to assess changes in left ventricular mass. Median follow-up was 365 days. In the standard arm, the 2-week moving average systolic BP did not change significantly during the intervention period, but in the intensive arm, systolic BP decreased from 160 mmHg at baseline to 143 mmHg at 4.5 months. From months 4-12, the mean separation in systolic BP between arms was 12.9 mmHg. Four deaths occurred in the intensive arm and one death occurred in the standard arm. The incidence rate ratios for the intensive compared with the standard arm (95% confidence intervals) were 1.18 (0.40 to 3.33), 1.61 (0.87 to 2.97), and 3.09 (0.96 to 8.78) for major adverse cardiovascular events, hospitalizations, and vascular access thrombosis, respectively. The intensive and standard arms had similar median changes (95% confidence intervals) in left ventricular mass of -0.84 (-17.1 to 10.0) g and 1.4 (-11.6 to 10.4) g, respectively. Although we identified a possible safety signal, the small size and short duration of the trial prevent definitive conclusions. Considering the high risk for major adverse cardiovascular events in patients receiving hemodialysis, a full-scale trial is needed to assess potential benefits of intensive hypertension control in this population.

Hypertension and frailty in older adults

The association between hypertension and frailty syndrome in older adults remains unclear. There is scarce information about the prevalence of hypertension among frail elderly patients or on its relationship with frailty. Up to one quarter of frail elderly patients present without comorbidity or disability, yet frailty is a leading cause of death. The knowledge and better control of frailty risk factors could influence prognosis. The present study evaluated: (1) the prevalence of hypertension in robust, prefrail, and frail elderly; and (2) factors that might be associated with frailty including hypertension. A cross-sectional study was conducted in 619 older adults at a university-based outpatient center. Study protocol included sociodemographic data, measures of blood pressure and body mass index, frailty screening according to the internationally validated FRAIL (fatigue, resistance, ambulation, illnesses, and loss of weight) scale, number of comorbidities, drug use assessment, physical activity, cognitive status, and activities of daily living. Ordinal logistic regression was used to evaluate factors associated with frailty. Prevalence of hypertension and frailty was 67.3% and 14.8%, respectively, in the total sample. Hypertension was more prevalent in the prefrail (72.5%) and frail (83%) groups than among controls (51.7%). Hypertension, physical activity, number of prescribed drugs, and cognitive performance were significantly associated with frailty status. Hypertension presented an odds ratio of 1.77 towards frailty (95% confidence interval, 1.21-2.60; P = .002). Hypertension was more prevalent in frail elderly patients and was significantly associated with frailty. Intensive control of hypertension could influence the trajectory of frailty, and this hypothesis should be explored in future prospective clinical trials.

Cognitive Associates of Current and More Intensive Control of Hypertension: Findings From the Hispanic Community Health Study/Study of Latinos.

Hypertension control in Hispanics/Latinos lag behind general US trends by 10-15%. Intensive systolic blood pressure (SBP) management <120 mm Hg may significantly reduce morbidity/mortality risk in adults with hypertension; less is known about cognition. We investigated cross-sectional associations of cognition with observed hypertension control at currently recommended (SBP < 140 mm Hg) and more intensive (SBP < 120 mm Hg) levels using baseline data from the Hispanic Community Health Study/Study of Latinos. From this multicenter cohort study, we focused on 1,735 Hispanic/Latino men and women ages 45-74 years with hypertension and verified antihypertensive use. Verbal fluency, information processing speed, learning, and memory were tested in Spanish or English. Separate linear regressions revealed that being on 1 vs. >1 antihypertensive medication was not associated with cognition; however, individuals with SBP controlled to currently recommended levels outperformed individuals with uncontrolled SBP on verbal fluency [Beta = 1.44 (0.52), P < 0.01] and information processing speed [Beta = 3.01 (0.89), P < 0.001] in age-adjusted regression analyses; only information processing speed remained significant (P < 0.05) after additional adjustments including acculturation, health insurance, and other cardiovascular disease risk factors. When regrouping individuals based on more intensive SBP control, individuals with levels <120 mm Hg outperformed individuals with higher SBP on verbal fluency regardless of adjustments (P < 0.01). More intensive rather than currently recommended levels of control associated with higher verbal fluency performance regardless of adjustments (P < 0.05). Individual cognitive test scores related to distinct SBP management with more intensive management appearing more robust against confounders. While cognitive associations with hypertension in Hispanics/Latinos may be multifactorial, different levels of SBP control should be considered in future prospective intervention studies.

Clinical trials of intensive versus less intensive control of hypertension: HOPE or HYPE?

The recently published Heart Outcomes Prevention Evaluation trial (HOPE-3) demonstrated no benefit of lowering blood pressure with candesartan and hydrochlorothiazide in persons at intermediate cardiovascular risk and with adequate blood pressure control as determined by the enrolling physician. The results of Systolic Blood Pressure Intervention Trial (SPRINT) and HOPE-3 highlight the importance of considering differences in study design and patient population when interpreting the results of clinical trials.

Left ventricular dyssynchrony in hypertensive patients with normal systolic function: tissue synchronization imaging study

ObjectiveThe objective of our study was to assess left ventricular (LV) dyssynchrony in hypertensive patients with normal systolic function using tissue synchronization imaging (TSI).BackgroundLV systolic and diastolic dyssynchrony are not uncommon in patients with hypertension. Dyssynchrony is associated with increasing incidence of heart failure, cardiovascular morbidity, and mortality.Patients and methodsA total of 71 individuals were enrolled in this study. They were divided into two groups.Group A included 51 hypertensive patients with good LV systolic function (ejection fraction≥ 50%) and narrow QRS on the ECG (<120 ms). We excluded individuals with any of the following: acute coronary syndrome, diabetes mellitus, atrial fibrillation, significant valvular heart disease, chronic renal failure, pulmonary hypertension, or myocardial or pericardial disease.Group B included 20 age-matched and sex-matched healthy volunteers and represented the control group.All participants underwent standard two-dimensional echocardiography and TSI.ResultsThe hypertensive group had significantly higher septal wall and posterior wall thickness than the control group. In addition, the LV mass was significantly higher in hypertensive patients than in controls (P < 0.05). The delay between the septal and lateral walls was significantly higher in hypertensive patients than in controls (67.882 ± 53.536 in HTN vs. 44.400 ± 39.495 in controls) (P < 0.05). The severity of dyssynchrony is significantly related to the LV mass, septal wall thickness, posterior wall thickness, and left ventricular end-diastolic dimension.ConclusionPatients with systemic hypertension and normal systolic function may demonstrate LV dyssynchrony by TSI. The severity of dyssynchrony is significantly related to LV mass, septal wall thickness, posterior wall thickness, and left ventricular end-diastolic dimension. Systolic dyssynchrony may identify hypertensive patients at risk for the development of congestive heart failure, and who may benefit from more intensive hypertension control at an earlier stage in their disease process.

EFFECT OF ANTI-HYPERTENSIVE THERAPY ON LEFT ATRIAL FUNCTION IN PATIENTS WITH HYPERTENSIVE HEART DISEASE

Prior studies suggest that hypertension is associated with LA dysfunction, even in the presence of normal LA size; whether or not LA function can improve with BP lowering therapy is unknown. We studied a subset of 174 patients (55p women) from the Exforge Intensive Control of Hypertension to

Essential hypertension and risk of nephropathy: a reappraisal

Treating mild-to-moderate essential hypertension in nondiabetic African Americans fails to halt nephropathy progression, whereas hypertension control slows nephropathy progression in European Americans. The pathogenesis of these disparate renal syndromes is reviewed. The nonmuscle myosin heavy chain 9 gene (MYH9) is associated with a spectrum of kidney diseases in African Americans, including idiopathic focal global glomerulosclerosis historically attributed to hypertension, idiopathic focal segmental glomerulosclerosis, and the collapsing variant of focal segmental glomerulosclerosis [HIV-associated nephropathy (HIVAN)]. Risk variants in MYH9 likely contribute to the failure of hypertension control to slow progressive kidney disease in nondiabetic African Americans. Early and intensive hypertension control fails to halt progression of 'hypertensive nephropathy' in African Americans. Genetic analyses in patients with essential hypertension and nephropathy attributed to hypertension, focal segmental glomerulosclerosis and HIVAN reveal that MYH9 gene polymorphisms are associated with a spectrum of kidney diseases in this ethnic group. Mild to moderate hypertension may cause nephropathy in European Americans with intrarenal vascular disease improved by the treatment of hypertension, hyperlipidemia and smoking cessation.

EXCEED: Exforge®-intensive control of hypertension to evaluate efficacy in diastolic dysfunction: study rationale, design, and participant characteristics

Both diastolic dysfunction and increased vascular stiffness represent important measures of target-organ damage in hypertension. Whether intensive blood pressure (BP) control can further improve these measures remains unknown. EXCEED is a prospective, randomized open-label blinded endpoint trial (PROBE) design, aiming to test the hypothesis that more aggressive BP lowering would result in greater improvement in diastolic function among patients with stage II hypertension, evidence of diastolic dysfunction and preserved systolic function (EF > or = 50%). Patients were randomized to one of two treatment strategies, targeting systolic blood pressure (SBP) <140 mmHg or <130 mmHg using a combination of amlodipine/valsartan with additional antihypertensive medications as needed to achieve the prescribed targets. Diastolic function was assessed using Doppler tissue imaging of early diastolic velocity of lateral mitral annulus (E'), while vascular stiffness was assessed using radial augmentation index (RAI) derived from radial artery tonometry. The study primary endpoint will be the change in lateral E' velocity between baseline and 24 weeks. Two hundred and twenty eight patients (50% female) with mean age of (59.6+/-9.7) years and mean BP of (162+/-14/92+/-13 mmHg) were randomized equally to either treatment strategies. Left ventricular hypertrophy was present among <4% of the enrolled patients. Inspite diastolic function was impaired, baseline lateral E' velocity (7.6+/-1.2 cm/s) was not related to baseline SBP while baseline RAI was weakly related (r = 0.2, p <0.01) to SBP even after adjustment to age, gender and heart rate. EXCEED will determine whether intensive BP lowering will further improve diastolic dysfunction and vascular stiffness among patients with uncontrolled hypertension.