Long-term Treatment Of Hypertension Research Articles

Ten-year follow-up of very-high risk hypertensive patients undergoing renal sympathetic denervation.

Renal denervation (RDN) has been proven to be effective in lowering blood pressure (BP) in patients, but previous studies have had short follow-ups and have not examined the effects of RDN on major cardiovascular outcomes. This study aimed to demonstrate the effectiveness and safety of RDN in the long-term treatment of hypertension and to determine if it has an effect on cardiovascular outcomes. All patients with resistant hypertension who underwent RDN between 2011 and 2015 at Tianjin First Central Hospital were included in the study. Patients were followed up at 1,5 and 10 years and the longest follow-up was 12 years. Data were collected on office BP, home BP, ambulatory BP monitoring (ABPM), renal function, antihypertensive drug regimen, major adverse events (including acute myocardial infarction, stroke, cardiovascular death and all cause death) and safety events. A total of 60 participants with mean age 50.37 ± 15.19 years (43.33% female individuals) completed long-term follow-up investigations with a mean of 10.02 ± 1.72 years post-RDN. Baseline office SBP and DBP were 179.08 ± 22.05 and 101.17 ± 16.57 mmHg under a mean number of 4.22 ± 1.09 defined daily doses (DDD), with a reduction of -35.93/-14.76 mmHg as compared with baseline estimates ( P < 0.0001). Compared with baseline, ambulatory SBP and DBP after 10-years follow-up were reduced by 14.31 ± 10.18 ( P < 0.001) and 9 ± 4.35 ( P < 0.001) mmHg, respectively. In comparison to baseline, participants were taking fewer antihypertensive medications ( P < 0.001), and their mean heart rate had decreased ( P < 0.001). Changes in renal function, as assessed by estimated glomerular filtration rate (eGFR) and creatinine, were within the expected rate of age-related decline. No major adverse events related to the RDN procedure were observed in long-term consequences. All-cause mortality and cardiovascular mortality rates were 10 and 8.34%, respectively, for the 10-year period. The BP-lowering effect of RDN was safely sustained for at least 10 years post-procedure. More importantly, to the best of my knowledge, this is the first study to explore cardiovascular and all-cause mortality at 10 years after RDN.

Antihypertensive therapy in the elderly

Arterial hypertension is the most common modifiable risk factor for cerebrovascular and cardiovascular morbidity and mortality in old age. The prevention of cognitive brain disorders is also atherapeutic goal of long-term treatment of hypertension. Older patients also have ahigher risk of developing cardiovascular diseases and therefore benefit from arelatively moderate reduction in blood pressure. With respect to the high prevalence of hypertension in old age and the increasing incidence with time, the therapy of hypertension is becoming increasingly more important to achieve an improved prognosis for patients along with areduction of costs. The accurate blood pressure measurement for elderly patients includes repeated measurements while standing and sitting. Additionally, the measurements should also be conducted by the patient or by afamily member. The most accurate method for assessing the daily blood pressure level, e.g. practice hypertension, non-dipping and intermittent hypertension, is the 24-h blood pressure measurement by ambulatory blood pressure monitoring (ABPM). General measures and lifestyle interventions are effective for reducing blood pressure of elderly patients with hypertension and alow salt diet is scientifically proven to be superior. The same drugs used for young people are also recommended for older patients and most give preference to diuretics, renin-angiotensin-aldosterone system (RAAS) inhibitors and calcium antagonists. The target blood pressure in elderly patients is repeatedly the focus of scientific discussions. The current recommendations are presented in the text and the characteristics which must be particularly considered in the therapy of elderly patients are presented in detail.

Nurse Management of Hypertension in Rural Western Kenya: Implementation Research to Optimize Delivery

BackgroundHypertension is the leading global risk factor for mortality. Hypertension treatment and control rates are low worldwide, and insufficient human resource capacity is among the contributing factors. Thus, a critical component of hypertension management is to develop novel and effective solutions to the human resources challenge. One potential solution is task redistribution and nurse management of hypertension in these settings. ObjectivesThe aim of this study is to investigate whether nurses can effectively reduce blood pressure in hypertensive patients in rural western Kenya and, by extension, throughout sub-Saharan Africa. MethodsAn initial phase of qualitative inquiry will assess facilitators and barriers of nurse management of hypertension. In addition, we will perform usability and feasibility testing of a novel, electronic tablet-based integrated decision-support and record-keeping tool for the nurses. An impact evaluation of a pilot program for nurse-based management of hypertension will be performed. Finally, a needs-based workforce estimation model will be used to estimate the nurse workforce requirements for stable, long-term treatment of hypertension throughout western Kenya. FindingsThe primary outcome measure of the impact evaluation will be the change in systolic blood pressure of hypertensive individuals assigned to nurse-based management after 1 year of follow-up. The workforce estimation modeling output will be the full-time equivalents of nurses. ConclusionsThis study will provide evidence regarding the effectiveness of strategies to optimize task redistribution and nurse-based management of hypertension that can be applicable to noncommunicable disease management in low- and middle-income countries.

Chinese classical formulas for treatment of essential hypertension

Essential hypertension is one of the most prevalent and important public health concerns in both westernized and developing countries. Recent studies have demonstrated that successful long-term treatment of hypertension has a significant impact on morbidity and mortality from cardiovascular diseases (CVDs) and stroke. Chinese classical formulas, which are important components of traditional Chinese medicine (TCM), have been increasingly accepted by patients with CVDs worldwide. According to TCM theory and syndrome differentiation, hypertension could be categorized into 3 patterns including fire syndrome, fluid retention syndrome, and deficiency syndrome. Chinese classical formulas, including Chaihu Jia Longgu Muli tang, Tianma Gouteng yin, Zhen Gan Xifeng tang, Banxia Baizhu Tianma tang, Liu Wei Dihuang wan, etc, play an important role in the treatment of essential hypertension, which could be further research priorities.

Long-Term Antihypertensive Treatment Fails to Improve E/e′ Despite Regression of Left Ventricular Mass

Antihypertensive treatment can improve tissue Doppler indices of left ventricular diastolic function in the short term, but little is known about the longer-term effect of different antihypertensive treatments on progression of left ventricular diastolic function and left ventricular hypertrophy. We hypothesized that long-term treatment of hypertension will lead to improvements in left ventricular hypertrophy and diastolic function. We collected detailed cardiovascular phenotypic data on 1006 participants from a substudy of the Anglo-Scandinavian Cardiac Outcomes Trial. Patients randomized to either an amlodipine±perindopril-based or an atenolol±bendroflumethiazide-based regimen underwent conventional and tissue Doppler echocardiography at time of control of blood pressure after randomization (≈1.5 years; phase 1) and after a further 2 years of antihypertensive treatment (phase 2). There were no prerandomization data. Five hundred thirty-six patients had complete data collection at both phases. Left ventricular mass index regressed from phase 1 to 2 with no significant difference between treatment groups (amlodipine: 119.5–116.8; atenolol: 122.9–117.5; P &lt;0.001 for both). Conversely, tissue Doppler diastolic indices did not change in the amlodipine±perindopril-based regimen (E/e′, 7.5–7.6 cm/s; P =not significant), but deteriorated in the atenolol±bendroflumethiazide-based regimen (E/e′, 8.0–8.5 cm/s; P &lt;0.01). Despite regression of left ventricular hypertrophy, there was no associated improvement in diastolic function. In fact, long-term treatment with atenolol±bendroflumethiazide resulted in a progressive deterioration in E/e′. This may be a factor contributing to the previously described worse clinical outcome in patients treated with atenolol±bendroflumethiazide compared with amlodipine±perindopril.

Long-Term Blood Pressure Control: What Can We Do?

There are unique problems associated with the long-term control of blood pressure (BP) in patients with hypertension. Many of these problems warrant specific discussion for the primary care physician. Up to one-third of high-risk patients are estimated to have uncontrolled hypertension. Although long-term control is essential to avoid complications of cardiovascular disease, such as myocardial infarction, stroke, heart failure, and kidney disease, it can become troublesome because of challenges with patient compliance and adherence to medication regimens. This may be due to low tolerability profiles, complicated regimens, or prohibitive costs. Trials have shown that a combination approach may reduce side effects with complementary therapies such as a calcium channel blocker (CCB)/angiotensin receptor blocker (ARB) combination. Combination therapy can be used in any patient group not responsive to monotherapy, or who remain 20 mm Hg higher than their BP goal. This method may achieve the goal of reaching target BP sooner as a first-line approach and, in a fixed-dose combination, may be a more economic choice as well as a simpler regimen for the patient. Together with supportive measures, CCB/ARB combinations are a compelling alternative for the long-term treatment of hypertension.

Blood pressure reduction, persistence and costs in the evaluation of antihypertensive drug treatment – a review

BackgroundBlood pressure lowering drugs are usually evaluated in short term trials determining the absolute blood pressure reduction during trough and the duration of the antihypertensive effect after single or multiple dosing. A lack of persistence with treatment has however been shown to be linked to a worse cardiovascular prognosis. This review explores the blood pressure reduction and persistence with treatment of antihypertensive drugs and the cost consequences of poor persistence with pharmaceutical interventions in arterial hypertension.MethodsWe have searched the literature for data on blood pressure lowering effects of different antihypertensive drug classes and agents, on persistence with treatment, and on related costs. Persistence was measured as patients' medication possession rate. Results are presented in the form of a systematic review.ResultsAngiotensin II receptor blocker (ARBs) have a competitive blood pressure lowering efficacy compared with ACE-inhibitors (ACEi) and calcium channel blockers (CCBs), beta-blockers (BBs) and diuretics. 8 studies describing the persistence with treatment were identified. Patients were more persistent on ARBs than on ACEi and CCBs, BBs and diuretics. Thus the product of blood pressure lowering and persistence was higher on ARBs than on any other drug class. Although the price per tablet of more recently developed drugs (ACEi, ARBs) is higher than that of older ones (diuretics and BBs), the newer drugs result in a more favourable cost to effect ratio when direct drug costs and indirect costs are also considered.ConclusionTo evaluate drugs for the treatment of hypertension several key variables including the blood pressure lowering effect, side effects, compliance/persistence with treatment, as well as drug costs and direct and indirect costs of medical care have to be considered. ARBs, while nominally more expensive when drug costs are considered only, provide substantial cost savings and may prevent cardiovascular morbidity and mortality based on the more complete antihypertensive coverage. This makes ARBs an attractive choice for long term treatment of hypertension.

Tablet of captopril with a cross-linked system of alginate

Captopril has a short biological half life (1-3h) and has been used for long-term treatment of hypertension. The properties of captopril such as freely water-soluble and instability in intestinal environment lead to the difficulty of developing captopril as a sustained-release preparation. . In this study, sustained-release of captopril was prepared with a matrix system using sodium alginat as a polymeric forming-matrix. The ratio of sodium alginat and captopril was 1:2. Matrix system was obtained by forming alginate cross-linked with a various concentration of calcium acetate. Xanthan gum was used to help cross-linked reaction. Tablet was prepared by wet granulation and the dissolution test was performed in HCl 0.01 N, paddle method, 100 rpm, for 12 h. Although release profile of captopril from all formula developed were different, the release of captopril sustained up 12 h. Formula containing 30 % of xanthan gum and 40 % of sodium alginate showed the best release profile of captopril and the hardness of tablets do not influence to the release of captopril. Tablet of captopril with a crosslinked system of alginate sustained the release of captopril until 12 h . Key words : captopril, sustained-release, sodium alginat, calcium acetat.

Effect of Regular Phosphodiesterase Type 5 Inhibition in Hypertension

There are no published controlled clinical trials of regular phosphodiesterase type 5 inhibitor therapy as a long-term treatment of hypertension. In a randomized, double-blind, 2-way crossover study, 25 otherwise untreated hypertensive subjects were administered 50 mg of sildenafil or matched placebo 3 times daily for 16 days, and the effects on ambulatory blood pressure (BP), clinic BP, arterial wave reflection, carotid-femoral pulse wave velocity, and brachial artery flow-mediated dilatation were assessed. Three subjects were withdrawn because of adverse effects, and the data from the remaining 22 subjects were analyzed. Sildenafil reduced ambulatory BP (mean [SE] change from baseline for average daytime BP: systolic -8 [2] mm Hg versus 2 [2] mm Hg with placebo, P<0.01; diastolic -6 [1] mm Hg versus 0 [1] mm Hg, P<0.01) and clinic BP (change from baseline to 1 hour after drug administration on day 16: systolic -5 [2] mm Hg versus 4 [2] mm Hg, P<0.01; diastolic -5 [1] mm Hg versus 2 [2] mm Hg, P<0.01). Compared with baseline, sildenafil, but not placebo, reduced arterial wave reflection both acutely and after chronic treatment, but the chronic change in arterial wave reflection was not statistically different from the chronic change with placebo. Sildenafil did not affect pulse wave velocity or flow-mediated dilatation. The main adverse effects of sildenafil, which were generally transient and rated as mild or moderate in severity, were dyspepsia, headache, and myalgia. In conclusion, regular sildenafil constitutes effective antihypertensive therapy. Further studies are warranted to evaluate the role of longer-acting phosphodiesterase type 5 inhibitors as antihypertensive agents in clinical practice.

Changes in the usage of antihypertensive drugs: implications and prospects

In their paper [1], Cheung and colleagues describe changes in antihypertensive drug usage over 8 years at a university hospital in Hong Kong. The quantitative analysis of usage frequency is supplemented by estimates of the percentage of patients with blood pressure at target levels. Their findings prompt a number of questions, about patterns of drug usage in different populations worldwide, the possible influences on these patterns and how these might change over the next few years. Of course, such detailed information is not available everywhere, so some comparisons are likely to remain speculative. In this particular case there are apparently no specific Hong Kong or Chinese national guidelines which are applicable, unlike the USA or Europe [2–4]: it would indeed be very interesting to establish how far such guidelines do actually modify prescribing practice in countries where they are supposed to be applicable. Regardless of that, Cheung's paper can serve as a focus for several current issues of interest and debate.

A randomized controlled trial of stress reduction in African Americans treated for hypertension for over one year

Psychosocial stress has been implicated in the disproportionately higher rates of hypertension among African Americans. This randomized controlled trial compared the effects of two stress reduction techniques and a health education control program on hypertension during a period of 1 year in African-American men and women (N = 150, mean age 49 +/- 10 years, mean blood pressure (BP) = 142/95 mm Hg) at an urban community health center. Interventions included 20 min twice a day of Transcendental Meditation (TM) or progressive muscle relaxation (PMR), or participation in conventional health education (HE) classes. All subjects continued usual medical care. Outcomes assessed were systolic BP and diastolic BP at 3, 6, 9, and 12 months after treatment, analyzed by repeated measures ANCOVA. The TM group showed decreases in systolic BP/diastolic BP of -3.1/-5.7 mm Hg compared to -0.5/-2.9 mm Hg for PMR or HE, (P = .12 to .17 for systolic BP, P = .01 for diastolic BP). In addition the TM group demonstrated reduced use of antihypertensive medication relative to increases for PMR (P = .001) and HE (P = .09) groups. Group analysis by gender showed that women practicing TM had decreased BP (-7.3/-6.9 mm Hg) significantly more than women practicing PMR (0.7/-2.7 mm Hg) or HE (-.07/-3.0 mm Hg) (P .01 to .03). The change in men praticing TM (0.2 /-4.7 mm Hg) was greater than men practicing HE (-0.9/-2.0 mm Hg) for diastolic BP only (P = .09,) and not different from PMR men (-2.0/-3.1). A selected stress reduction approach, the Transcendental Meditation program, may be useful as an adjunct in the long-term treatment of hypertension in African Americans.

More evidence on blocking the renin-angiotensin-aldosterone system in cardiovascular disease and the long-term treatment of hypertension: data from recent clinical trials (CHARM, EUROPA, ValHEFT, HOPE-TOO and SYST-EUR2).

More evidence on blocking the renin–angiotensin–aldosterone system in cardiovascular disease and the long-term treatment of hypertension: data from recent clinical trials (CHARM, EUROPA, ValHEFT, HOPE-TOO and SYST-EUR2)

The Effect of Intensified Diet Counseling on the Diet of Hypertensive Subjects in Primary Health Care: A 2-Year Open Randomized Controlled Trial of Lifestyle Intervention against Hypertension in Eastern Finland

Background. Diet is an essential part of the nonpharmacological management of hypertension. The aim of this study was to investigate in a primary health care setting the effect of intensified diet counseling on the diet of hypertensive subjects. Methods. A total of 715 free-living subjects, ages 25–74 years, with systolic blood pressure 140–179 mm Hg and/or diastolic blood pressure 90–109 mm Hg and/or drug treatment for hypertension participated in an open randomized trial with a 2-year follow-up at health centers in eastern Finland. The intervention group ( n = 360) was advised to reduce their total fat, saturated fat, and salt intake and to increase monounsaturated and polyunsaturated fat intake as well as to reduce weight and to use alcohol in moderation if at all. The usual care group ( n = 355) continued with their usual primary health care. The subjects filled out a 4-day food record, and 24-h urine samples were collected at baseline and at 1- and 2-year examinations. Results. The 2-year net changes (change in intervention minus change occurring in usual care group) in total fat intake [−2.7 E% (95% CI −4.0, −1.6; P < 0.0005)], in saturated fatty acid intake [−1.7 E% (95% CI −2.3, −1.1; P < 0.0005)], and in body weight [−1.4 kg (95% CI −2.0, −0.8; P < 0.0005)] were significant. Furthermore, the 2-year net change in daily sodium intake was significant, −9 mmol (95% CI −17, −2; P = 0.021), but the 24-h urinary sodium excretion showed no difference between the study groups. Conclusion. The intensified diet counseling in primary health care resulted in dietary changes interpreted as being of benefit in the long-term treatment of hypertension and prevention of atherosclerotic vascular diseases.

Use of calcium antagonists in hypertension

Calcium antagonists represent an important group of drugs for treatment of hypertension; they are effective in the whole range of severity of the disease. Dihydropyridine derivatives are most frequently used. Dihydropyridines can also be used in association with other antihypertensive drugs. Nevertheless, phenylalkylamines and benzothiazepines are contraindicated in association with beta-blocker drugs. Calcium antagonists with slow starting effect and long duration of action are the choice to be used in long-term antihypertensive treatment. This group of drugs is specially indicated in elderly patients, in hypertensive patients with diabetes mellitus and in patients with coronary heart disease. Phenylalkylamine and benzothiazepine derivatives are also used in patients with supraventricular arrhythmias. Calcium antagonists, with long duration of action due to a long half life, have the advantage to maintain antihypertensive effect for longer periods, even when patients have minor failure in antihypertensive treatment compliance. Calcium antagonists as a group of agents are as safe as diuretics, ACE-inhibitors or beta-blocking drugs in the long-term treatment of hypertension and are well tolerated.

Update on the use of calcium antagonists on hypertension.

Calcium antagonists represent an important group of drugs for the treatment of hypertension; they are effective in the whole range of severity of the disease. Dihy- dropyridine derivatives are most frequently used, and can be used in association with other antihypertensive drugs; meanwhile phenylalkylamines and benzothiazepines are contraindicated in association with beta-blocker drugs. Calcium antagonists with slow starting effect and long duration of action are the choice for use in long-term antihypertensive treatment. This group of drugs is specially indicated in elderly patients, in those with diabetes mellitus and in patients with coronary heart disease. Phenylalkylamines and benzothiazepine derivatives are also used in patients with supraventricular arrhythmias. This group of agents is as safe as diuretics, angiotensin-converting enzyme-inhibitors and beta-blocking drugs in the long-term treatment of hypertension.

Antihypertensive action and blockade of alpha1-adrenoceptors by DL-017, a quinazoline derivative.

3-[[4-(2-Methoxyphenyl)piperazin-1-yl]methyl]-5-(methylthio)-2,3-dihydroimidazo[1,2-c]quinazoline (DL-017), a quinazoline derivative, exhibits alpha 1 -adrenoceptor antagonistic and type I antiarrhythmic effects on mammalian cardiac tissues. In the current study, the effects of DL-017 on the hemodynamic profile in anesthetized, spontaneously hypertensive rats were evaluated. Intravenous administration of DL-017 induced dose-dependent reductions of heart rate and blood pressure, which persisted over 2 h. DL-017 exerted a maximal antihypertensive effect at 0.1 mg/kg, which was similar to that of 0.1 mg/kg of prazosin. DL-017 was able to block the pressor response to phenylephrine but not to angiotensin II. Regional cerebral blood flow of the right parietal cortex decreased by 14 +/- 4% 10 min after bolus injection and then rapidly returned to control levels while the arterial pressure was still low. These results indicate that blockade of the alpha 1 -adrenoceptor by DL-017 contributes to reduction of arterial pressure. The antihypertensive effect without reflex tachycardia and loss of autoregulation of cerebral blood flow makes DL-017 suitable for chronic long-term treatment of hypertension.

New therapeutic agents for hypertension.

1. Over the last 40 years a range of therapeutic strategies has been introduced for the long term treatment of hypertension. 2. Although safe effective agents are available a significant number of patients are unable or unwilling to take these drugs as long term treatment. 3. Both insufficient efficacy and adverse effects justify the search for new antihypertensive strategies. 4. Recent developments include orally active angiotensin (AT1) receptor antagonists (ARA) which appear to offer the benefits of prevention of angiotensin II effects without the adverse effects of bradykinin potentiation, such as cough, which limit the usefulness of angiotensin converting enzyme (ACE) inhibitors. 5. Imidazoline receptor agonists offer the potential of centrally active antihypertensives without the adverse effects of sedation and dry mouth. Further clinical experience is necessary to confirm whether the clinical efficacy and good tolerability are confirmed with long term use. 6. Both ARA and imidazoline preferring substances offer the bonus of a desirable haemodynamic profile in patients with heart failure and may open new therapeutic avenues in the management of cardiac failure.

Adverse Effects of Direct-Acting Vasodilators

Direct-acting vasodilating agents enter the vascular smooth muscle cell to cause vasodilatation. For long term treatment of hypertension, the use of these drugs as monotherapy is accompanied by activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system. These counteracting mechanisms limit the antihypertensive efficacy of these drugs, and cause adverse effects such as tachycardia and fluid retention. These adverse effects require treatment with beta-blockers and diuretics. However, there is still an important role for intravenous vasodilator therapy in hypertensive emergencies. In the treatment of chronic heart failure, vasodilator therapy has been an important advance. Combination therapy with hydralazine and nitrates is efficacious in improving survival, but ACE inhibitors have an incremental benefit on survival over this combination.

ß-Blockers, Dyslipidemia, and Coronary Artery Disease

Despite the strong association between hypertension and accelerated atherosclerosis, and the known beneficial clinical effects of beta-blockers in patients with coronary artery disease, antihypertensive trials of beta-blockers have shown only modest protection against fatal and nonfatal myocardial infarction. This review explores the explanations put forth for this apparent failure of beta-blockers. It also examines the clinical relevance of the metabolic effects of beta-blockers within the framework of the heterogeneity of this class of drugs. Recent evidence indicates that long-term treatment of hypertension with beta-blockers that do not possess intrinsic sympathomimetic activity reduces the occurrence of cardiac complications of hypertension. There are no data to show a quantified effect on clinical outcome of the lipid and glucose changes associated with beta-blocker therapy. The metabolic influence of these drugs varies considerably within the class and may be of little clinical relevance. Unless it is contraindicated, an appropriate beta-blocker should be considered for the treatment of hypertension in patients who have coronary artery disease or who are at high risk for coronary artery disease.

Fosinopril: a new generation of angiotensin-converting enzyme inhibitors.

Fosinopril, the first agent in a new chemical class of phosphorus-containing angiotensin-converting enzyme (ACE) inhibitors, has unique pharmacologic properties. Fosinopril administration leads to complete inhibition of plasma ACE activity for 12-24 h. In patients with normal renal function, approximately equal amounts of the drug are eliminated via the hepatic and renal routes. With worsening renal function, increasing amounts of fosinopril are eliminated hepatically. This dual elimination allows for the administration of fosinopril using the same starting dosage to any patient, regardless of renal function. Fosinopril may provide end-organ protection against the effects of hypertension and antihypertensive therapy; this drug potentially protects the kidney by increasing renal functional reserve, while maintaining cardiac left ventricular performance. Moreover, despite marked blood reductions, cerebral blood flow is maintained. Controlled trials show that fosinopril in single daily doses of 10-40 mg is efficacious and safe for the long-term treatment of hypertension. At these doses, favorable responses were seen in up to 80% of patients. Fosinopril is equally effective in elderly as well as younger patients and works in black as well as in nonblack patients. The incidence of adverse events does not differ significantly between fosinopril- and placebo-treated patients. Fosinopril represents a clinically useful agent for the treatment of hypertension.