Optimal Management Of Hypertension Research Articles

Assessment of Rational Prescribing of Antihypertensive Drug combinations in Lagos University Teaching Hospital

Purpose: The study aimed to assess prescribing trends of antihypertensives and proportion of prescriptions containing irrational combinations of antihypertensives and co-prescribed drugs. Methods: Five hundred and fifty four prescriptions, containing antihypertensives, were collected prospectively over a period of twelve months, from the internal medicine clinic of the Lagos University Teaching Hospital, and evaluated. Results: The average number of drugs prescribed per encounter was 2.9. Encounters with injections were 0.5%. The percentage of drugs prescribed by generic name was 31.6%. All the drugs prescribed were from the National Essential Drugs List. Calcium antagonists were the most frequently used group of drugs (41.3%), followed by Diuretics (33.0%) and Angiotensin-Converting Enzyme inhibitors (ACEIs) (22.4%). Nifedipine (31.9%), Methyldopa (22.4%) and Propranolol (20.2%) were the most frequently used individual drugs. Beta-blockers with Calcium antagonists (13.3%), Methyldopa with Diuretics (10.6%), Calcium antagonists with ACEIs (10.3%) were the most frequently prescribed drug combinations. Irrational drug combinations with NSAIDs were observed in 21.8% of the prescriptions. Also beta-blockers were prescribed in 22% of prescriptions for hypertensive / diabetic patients. Conclusion: There is need to educate prescribers on appropriate therapeutic combinations that would provide optimal management of hypertension and associated clinical conditions. KEY WORDS: Antithypertensive, rational, drug combination. Nig. Jnl Health & Biomed. Sciences Vol.3(1) 2004: 8-11

Managing hypertension in African-American patients.

Epidemiologic evidence indicates that African Americans are at greater risk for hypertension compared with other ethnic groups in the United States. The prevalence of hypertension is estimated to be approximately 37% for this group, compared with 20%-25% for non-Hispanic whites. Hypertension seems to follow a more malignant course in African Americans, possibly as a result of the higher prevalence of concomitant cardiovascular risk factors in this population. Compared with white persons with hypertension, these patients are at increased risk for left ventricular hypertrophy, heart failure, and end-stage renal disease. Data suggest that ethnicity may influence the response to certain types of antihypertensive medication. Additional data indicate that more aggressive use of combination therapy may improve clinical outcomes among high-risk hypertensive patients. Based on these findings, recommendations are made for the optimal clinical management of hypertension in African-American patients.

Blood pressure response of eplerenone according to baseline characteristics

The heterogeneity of the hypertensive population has a direct bearing on optimal hypertension management. Certain drug classes are noted to be more or less effective in patients with particular profiles1. Thus, new agents require evaluation in a variety of patient profiles to ascertain their potential widespread usefulness. This analysis evaluates the blood pressure response of eplerenone (EPL), the first selective aldosterone blocker, according to the following characteristics: age, gender, race, body mass index (BMI), diabetes status, and aldosterone/active renin ratio. Demographic data from 2 controlled trials comparing EPL 50 to 100 mg administered once or twice daily to placebo (PBO) in patients with mild-to-moderate hypertension were summarized to evaluate differences in blood pressure response. Sub-groups analyzed are depicted below: There were no significant interactions in change in BP between treat-ment and baseline demographic characteristics. In conclusion, the antihypertensive efficacy of eplerenone was demonstrated regardless of age, gender, race, BMI, diabetes status, or baseline aldosterone/renin ratio, mak-ing this agent an attractive treatment option for many different hypertensive patient profiles (see Table). 1JNC VI. Arch Intern Med 1997;157:2413–46. Mean Blood Pressure Reduction by Demographic Group Mean Blood Pressure Reduction by Demographic Group

Disease management and pharmacoeconomics as tools for mass prevention of hypertensive complications.

Hypertension has been identified as a major predictor of cardiovascular disease, which is a worldwide cause of morbidity and premature mortality. Optimal management of hypertension involves finding a balance among the benefits, risks, and costs of disease treatment and prevention of hypertensive sequelae. Cost-effectiveness analysis helps to clarify the trade-offs between the costs and benefits of treatment and also to evaluate the effects on quality of therapy. Disease management programs that incorporate pharmacoeconomic analysis and computerized methods of targeting patients at high risk of hypertensive sequelae are useful and cost-effective tools. Critical to these cost-effectiveness analyses and disease management programs are the expected benefits attributable to blood pressure reduction. The utility of these programs in helping to determine which patients will benefit from intensive intervention depends to a great extent on the assumptions made and the quality of the data used for the analyses--that is, the degree to which the data are evidence based.

Preserving Target-organ Function with Candesartan Cilexetil in Patients with Hypertension

Epidemiological evidence suggests that reducing blood pressure alone in hypertensive patients delays the onset of cardiovascular events without necessarily preventing the progression of chronic target-organ disease, such as end-stage renal failure and heart failure. Successful clinical management of hypertensive patients will therefore not be possible unless therapies are aimed both at the effective control of blood pressure and at the preservation of target-organ function. The new angiotensin II type 1 (AT 1 ) receptor blocker candesartan cilexetil has been shown to be effective in reducing target-organ damage in animal models of hypertension, even at doses that do not produce significant reductions in blood pressure. Protective effects of candesartan cilexetil towards the heart and kidney have also been demonstrated in the clinical studies that have been conducted to date. Thus, candesartan cilexetil has been shown to induce regression of left ventricular hypertrophy within 8-12 weeks of treatment and to improve renal haemodynamics, both acutely and after 6 weeks of treatment in hypertensive patients. Furthermore, in hypertensive patients with co-existent non-insulin-dependent diabetes mellitus and microalbuminuria, 12 weeks of treatment with candesartan cilexetil, 8-16 mg, significantly reduced urinary albumin excretion. Clinical evidence is therefore accumulating that the antihypertensive efficacy and tolerability profile already established for candesartan cilexetil is combined with the renal and cardioprotective effects necessary for optimal management of hypertension.

Economic factors in the initiation of antihypertensive therapy.

Optimal management of hypertension involves finding a balance among its benefits, risks and costs. Cost-effectiveness analysis helps to clarify not only the trade-offs between the costs and benefits of treatment, but also the trade-offs between the risks and benefits, and the costs and quality of therapy. Existing analyses of hypertension treatment suggest a consistent set of strategies by which cost-effectiveness may be improved. These include strategies to increase the effectiveness of therapy, such as excluding false-positive diagnoses of hypertension, and according higher priority to treating patients with sustained elevations of diastolic blood pressure above 100mm Hg. A complementary set of strategies involve reducing the costs of therapy by prescribing lower-cost first-step regimens, making use of the minimum effective dose for particular medicines and attempting step-down therapy for suitable patients. Consideration of economic factors in initiating hypertension treatment is consistent with sound clinical practice.

Hypertension. Relationship with other risk factors.

Elevated blood pressure is a major contributor to cardiovascular disease in general and to coronary heart disease in particular, now its most common sequela. The risk is proportional to the degree of blood pressure elevation, at all ages and in either sex, whether the increased pressure is labile or fixed, diastolic or systolic in character. The effect of blood pressure on cardiovascular disease incidence is independent of the influence of other predisposing co-factors, but the hazard is greatly influenced by them. Elevated pressures are often accompanied by hyperlipidaemia, hyperuricaemia, overweight, hyperglycaemia, elevated fibrinogen values and ECG abnormalities. The risk associated with any degree of elevation of pressure varies greatly, depending on the number and level of these often associated risk factors, and on whether or not there is the indication of target organ involvement. The excess cardiovascular risk in hypertensive persons tends to be concentrated in those with an increased LDL/HDL cholesterol ratio, impaired glucose tolerance, cigarette smokers and those with accompanying ECG abnormalities. Hypertension is best conceptualised as a component of a multivariate cardiovascular risk profile which provides a sound basis for determining urgency for drug treatment. Optimal preventive management of hypertension requires multifactorial correction of all disordered components of the cardiovascular risk profile before occurrence of target organ involvement.

Management of coronary artery disease in patients with hypertensive left ventricular hypertrophy

An appreciation of the cardiac effects of antihypertensive drugs and important pharmacologic advances in the past 10 years have permitted a more rational approach to the management of the patient with both coronary artery disease and hypertensive left ventricular hypertrophy. Since this is a particularly high-risk group of patients, early detection and optimal management of ischemic symptoms and hypertension are necessary. Beta-blocking agents are ideal agents (in the absence of heart failure) since their efficacy has been proved in both coronary artery disease and hypertension. Similarly, calcium slow-channel blocking agents have both antianginal and antihypertensive properties. When arterial pressure reduction is needed quickly, caution is required in the choice of an agent since adverse reflexive cardiac effects may occur, particularly with pure arteriolar dilators. If a diuretic is required, serum potassium levels should be carefully monitored since both coronary artery disease and left ventricular hypertrophy already increase the risk of life-threatening dysrhythmias. The decrease in mortality from coronary heart disease seen in the past 10 years is likely to be further improved by specific attention to management of such high-risk groups as those with associated hypertensive left ventricular hypertrophy.

INTRACRANIAL PRESSURE IN REYE'S SYNDROME

During the past 3 years the intracranial pressure(ICP)of 17 children with Reye's Syndrome(RS)has been monitored. The epidural monitor was placed in patients whose level of coma was III or deeper(Sherard Stages I-VI). The cerebrospinal fluid pressure or ICP was measured on 15 patients on admission to the hospital. The pressure was 200mm H2O or less in 7 patients and 300mm H2O or less in 13 patients. In survivors maximum ICP was recorded at 8-24 hours after admission and correlated with the level of coma. An ICP of 400-800 mm H2O was associated with coma level of IV or deeper. In one child the ICP was greater than 1300mm H2O. In 8 patients abrupt increases in ICP to 700mm HpO or greater occurred and preceded any clinical evidence of increasing ICP. These episodes lasted 20-30 minutes, and were treated with hyperventilation and/or mannitol. In 4 patients these episodes were repetitive, being separated by intervals of 2-12 hours. Most of our patients were admitted to the hospital during the early hours of their illness and were in Stage II or III coma. During this phase, the level of consciousness does not appear to be directly related to the ICP, however if the level of coma deepens during the next 24 hours after admission the ICP correlates with the stage of coma. Continuous ICP monitoring is essential for the optimal management of intracranial hypertension associated with RS and serves as an objective criteria for the administration of hyperosmolar agents in patients with coma Stage III or deeper.