Pharmacological Antihypertensive Treatment Research Articles

Antihypertensive Prescriptions for Newly Treated Patients Before and After the Main Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Results and Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Guidelines

Main results of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial were published in December 2002. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, published in May 2003, recommended thiazide-type diuretics as initial pharmacological treatment alone or in combination with another drug in most patients with hypertension. To assess changes from before to after these publications, we compared antihypertensive medication prescriptions filled by patients who initiated pharmacological antihypertensive treatment in a large managed care organization during 3 time periods: (1) July 1, 2001, to June 30, 2002 (before these publications; n=1354); (2) July 1, 2003, to June 30, 2004 (to assess short-term changes; n=1542); and (3) July 1, 2004, to June 30, 2005 (to assess extended changes; n=1865). The percentage of patients initiating antihypertensive treatment with a thiazide-type diuretic increased from 30.6% to 39.4% (P<0.001) between 2001-2002 and 2003-2004, and the increase was maintained at 36.5% in 2004-2005 (P<0.001 compared with 2001-2002 and P=0.33 compared with 2003-2004). Among patients without diabetes mellitus, renal disease, a history of myocardial infarction, or heart failure, the percentage initiating pharmacological antihypertensive treatment with a thiazide-type diuretic increased from 33.1% in 2001-2002 to 43.4% in 2003-2004 (P<0.001) and remained increased (41.0%) in 2004-2005 (P<0.001 and P=0.23 compared with 2001-2002 and 2003-2004, respectively). Despite a sustained increase in the use of thiazide-type diuretics, this study indicates that an opportunity exists to increase adherence to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines.

Estudio del riesgo coronario y de ictus en pacientes hipertensos mayores de 54 años atendidos en Atención Primaria

Quantification of stroke risk is not always performed in hypertensive patients in Primary Care. This was an epidemiological study in hypertensive patients aged 55 years and older attending primary care centres in Spain. The D'Agostino Stroke Risk Scale, using data from the Framingham Study, was used for assessment of stroke risk. We analysed 4,945 patients (mean age, 66.8 years; 50.9% females). Mean blood pressure (BP) values were 145/86 mmHg in men and 143.7/84.7 mmHg in women (p < 0.001). The majority of patients (80.5%) showed high BP values that were above the values recommended in the guidelines, despite most of them (89.6%) receiving pharmacological antihypertensive treatment. 41% of patients were diabetics. The 10-year global risk of stroke was 22.5%, and was higher in men (28.6% vs. 16.8%; P < 0.001). The risk of stroke increased with age, being more marked in women. Several risk factors showed a statistically significant association with the risk of stroke. From higher to lower significance, these risk factors were: age, left ventricular hypertrophy (LVH), cardiovascular disease, systolic BP, auricular fibrillation, diabetes, cigarette smoking, control of BP, gender, and antihypertensive treatment. The 10-year coronary risk was higher in men (24.2% vs. 16.0%; p < 0.001) and was significantly related to the 10-year risk of stroke (r = 0.626). The risk of stroke in the Spanish hypertensive population is high, and is significantly higher in men, although it shows a larger age-related increase in women. Linear regression analysis showed a moderate, but statistically significant, correlation between coronary risk and risk of stroke. Apart from all the variables included in the Framingham Stroke Risk Model, gender, control of BP, and antihypertensive treatment accounted significantly and independently as calculated risk factors for incidence of stroke.

Blood pressure drug therapy and electrolyte disturbances

Antihypertensive pharmacologic treatment may be associated with diverse disturbances of electrolyte homeostasis. These drug-induced disorders are relatively common, typically including hyponatraemia, hypokalaemia, hyperkalaemia, hypomagnesaemia, hypophosphataemia and hypercalcaemia. Diuretics, beta-blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are particularly likely to cause these complications. Recognised risk factors include high-dosage regimens (especially diuretics), old age, diabetes and impairment of renal function. Strategies to prevent these adverse drug reactions involve careful consideration of risk factors and clinical and laboratory evaluation in the course of treatment.

Effect of Board Certification on Antihypertensive Treatment Intensification in Patients With Diabetes Mellitus

Regular recertification is mandatory to maintain board certification status in all specialties. However, the evidence that physicians' performance decreases with time since initial certification is limited. We therefore carried out a study to determine whether the frequency of antihypertensive treatment intensification for diabetic patients changes with time since their physicians' last board certification. In this retrospective cohort study, we analyzed treatment of 8127 hypertensive patients with diabetes mellitus treated by 301 internists at primary care practices affiliated with 2 large academic hospitals. Patient visits with documented blood pressure > or = 130/85 mm Hg between January 1, 2000, and August 31, 2005, were studied. The association between the number of years since the physician's last board certification and the probability of pharmacological antihypertensive treatment intensification at a given visit was analyzed. Frequency of treatment intensification decreased from 26.7% for physicians who were board certified the previous year to 6.9% for physicians who were board certified 31 years before the visit. Treatment intensification rate was 22.5% for physicians certified < or = 10 years ago versus 16.9% for physicians last certified > 10 years ago (P<0.0001). Multivariable analysis adjusted for patient and visit characteristics and physician age showed that for every decade since the physician's last board certification, the probability of treatment intensification decreased by 21.3% (P=0.0097). Physician intensification of pharmacological therapy for blood pressure levels above the recommended treatment goals decreases with time since the last board certification. This finding supports the current policy of mandatory recertification.

Traitement pharmacologique de l’HTA en hémodialyse

A fraction of the dialyzed patients remains hypertensive despite achievement of the « dry weight » and will eventually require a pharmacological antihypertensive treatment. There is only scarce randomized intervention trials available in those patients so it is difficult to estimate whether the cardiovascular benefit of the treatment is related to blood pressure lowering per se or to class or drug specific properties. This paper reviews the different class of antihypertensive drugs focusing on their advantages and disadvantages in dialysis patients. On a practical ground, prescription will be driven by pharmacokinetics considerations and mostly according to specific indications pertinent to cardiovascular complications associated with hypertension.

What effect on blood pressure can we expect from continuous positive airway pressure treatment in obstructive sleep apnoea?

What effect on blood pressure can we expect from continuous positive airway pressure treatment in obstructive sleep apnoea?

Conducta del médico de atención primaria ante el mal control de la presión arterial

To investigate the behaviour of primary care (PC) physicians on inadequate hypertension control. Cross-sectional and multicentric study. PC clinics in the whole of Spain. Patients > or =18 years old who followed pharmacological antihypertensive treatment since at least 3 months before, selected by a consecutive sampling. Blood pressure measured by family doctors. The therapeutic diagram used before and after the visit was registered, and in those cases in which some kind of modification was adopted, the reasons why. 12,754 hypertensive patients were included. The average age was 63.3+/-10.9 years (57.3% women). A 65% lived in urban areas and the 35% in semi-urban o rural areas. The 63.9% (95% confidence interval, 63.1%-64.8%) showed a bad control of hypertension. The majority of the patients followed a therapeutic regimen of monotherapy (56%) being the ACE inhibitors the most prescribed drug (34.8%), followed by the calcium antagonist (21.3%), and angiotensin II antagonists (17.4%). The percentage of patients with inadequate control of the blood pressure, in which the therapeutic behaviour was modified was 18.3% (95% confidence interval, 17.5%-19.1%) (a change of drug in 47%, association in 34.7% and an increase in the dose in 18.3%). The main reasons for which the therapeutic behaviour was modified was because no drug efficacy (63.7%) and the presence of adverse events (5.5%). The price of the therapy originated 1.2% of the modifications. PC physicians behaviour was conservative in uncontrolled hypertension cases. Amongst the doctors who modified their behaviour, by inadequate blood pressure control, the change of drug was the decision most adopted.

Albuminuria and hypertension are independently associated with circulating antipericyte autoantibodies in type 2 diabetic patients

Aims To determine whether albuminuria, hypertension, or HbA 1c are independently associated with antipericyte autoantibodies (APAAs) in type 2 diabetes mellitus. Methods Two hundred ninety-nine subjects with different degrees of retinopathy according to the Early Treatment Diabetic Retinopathy Study Scale participated in this study. Albuminuria was defined as an albumin/creatinine ratio above the normal cutoff limit, that is, 2.0 g/mol for men and 2.8 g/mol for women. Hypertension was defined as a diastolic blood pressure more than 90 mm Hg, a systolic blood pressure more than 140 mm Hg, or pharmacological antihypertensive treatment. Serum APAAs were detected by immunofluorescence on tissue-cultured bovine retinal pericytes. Association analysis was performed using univariate and multivariate statistical tools. Results In type 2 diabetes, APAAs were independently associated with albuminuria (OR = 0.56; P < .04), hypertension (OR = 2.21; P < .01), as well as with proliferative retinopathy (OR = 0.39; P < .01). Conclusions The increased prevalence of APAA in patients with hypertension may suggest that these antibodies are related to tissue damage and repair and that the decline in frequency with albuminuria may serve as a marker for more advanced angiopathy. Future longitudinal studies are needed to determine whether the frequency of APAA is associated with the progression of angiopathy, and to determine the biological activity and antigens recognized by the antibody.

Antihypertensive Pharmacological Treatment Evaluation with Ambulatory Blood Pressure Monitoring

Antihypertensive Pharmacological Treatment Evaluation with Ambulatory Blood Pressure Monitoring

Left ventricular hypertrophy and its regression in essential arterial hypertension: A tissue Doppler imaging study

The mitral annulus velocities of Doppler transmitral flow and pulsed-wave tissue Doppler imaging (TDI) were sampled by echocardiography for the assessment of left ventricular (LV) diastolic function in 118 never-treated essential hypertensive patients with normal systolic function and compared with those of 59 normotensive healthy subjects matched for age and sex. A selected group (n = 26) of the hypertensive study population was observed after 1 year of pharmacologic antihypertensive treatment to determine the behavior of TDI parameters in relation to eventual regression of LV hypertrophy (LVH). We found that the TDI early myocardial diastolic wave (E(m)) was significantly lower both in concentric and eccentric LVH. In addition, TDI late myocardial diastolic wave (A(m)) was significantly higher in concentric remodeling and concentric and eccentric hypertrophy. The TDI E(m)/A(m) ratio was significantly lower in all geometric remodeling subgroups. The E/A ratio Doppler transmitral flow velocity measured showed that of the 118 patients, only 32 (25%) could really be discriminated from normal, whereas individual analysis for TDI E(m)/A(m) at the mitral annulus septal level showed that of 118 patients 108 (91%) could be discriminated from normal P < .001). The LV mass was significantly less after 1 year of treatment (LVH regression), and TDI parameters showed a trend toward normalization, in particular of TDI E(m)/A(m) at the annular septal level. Pulsed-wave TDI analysis could enable not only the early assessment of whether a patient is still in an adaptive or compensatory phase before transition to irreversible damage (pathologic phase) but also the detection of precocious LV global diastolic dysfunction. With regard to this, more extensive randomized studies are needed to evaluate the effect of different pharmacologic treatments (calcium antagonists, beta-blockers, angiotensin I and II inhibitors) on TDI parameters.

Effects of hygienic-dietary recommendations on ambulatory blood pressure in untreated patients with grade 1 hypertension

P-20 Key Words: Mild Hypertension, Hygienic-Dietary Intervention, BP Control

Impact of clinical inertia on the estimation of blood pressure control in treated patients with essential hypertension

P-9 Key Words: Clinical Inertia, BP Control, Diabetes

Sympathetic deactivation as a goal of nonpharmacologic and pharmacologic antihypertensive treatment: rationale and options.

Several unanswered questions remain about the effects of nonpharmacologic or pharmacologic treatment on sympathetic function. These include 1) the effects of an association between no drug and drug treatment, 2) the effects of a combination drug treatment, and 3) the relationship between the intervention-induced sympathetic modulation and the concomitant effects on target-organ damage. Answers to these questions will allow for more precise definition of the clinical relevance of the therapeutic-induced sympathoinhibition in terms of cardiovascular protection.

Cost of treating hypertension in the elderly.

Hypertension is a common disease among the elderly, a population that will continue to grow over the next decade. Untreated hypertension can lead to cardiovascular events and mortality. Given the seriousness of this disease and the increase in the number of elderly with hypertension, this review focuses on the cost of treating hypertension in the elderly as described in recent publications. We found a limited number of articles related to the treatment of hypertension in the elderly. One publication provided insightful information pertaining to expenditures in the United States for hypertension in 1998. This article was the first to examine age distribution among persons 65 years and older. It has been shown that antihypertensive pharmacologic treatment significantly reduces the incidence of cardiovascular events. Without any other medical conditions, thiazide-like diuretics are recommended for the treatment of hypertension in the elderly due to their beneficial effects, low risk for side effects, and low cost. In general, it was found that the elderly have higher expenditures per capita for hypertension and per hypertensive condition.

Do we undertreat hypertensive smokers? A comparison between smoking and non-smoking hypertensives

The acute effect of smoking is a rise in blood pressure and heart rate. Nevertheless, in several epidemiologic studies, smokers tend to have a slightly lower office blood pressure than non-smokers. We studied the 24 h ambulatory blood pressure consecutively in hypertensive smokers (> or = 10 cigarettes per day, n = 26) and hypertensive non-smokers (n = 26) to test the hypothesis that smoking is associated with a rise in ambulatory blood pressure. There was no difference between smokers and non-smokers in office blood pressure (153.8 +/- 22.2/98.5 +/- 10.6 vs 149.0 +/- 16.1/96.9 +/- 11.6 mmHg). However, we found a statistically significant higher daytime systolic and diastolic blood pressure in smokers (153.7 +/- 16.2/96.1 +/- 9.5 vs 145.0 +/- 12.1/90.1 +/- 10.0 mmHg) than in non-smokers. Differences were also found for office-daytime differences and when studying patients on pharmacological antihypertensive treatment separately. Daytime heart rate was also significantly higher in smokers (86.6 +/- 9.4 vs 76.0 +/- 10.9). We conclude that smokers tend to be undertreated in that they have a higher daytime blood pressure than do non-smokers, a difference that is not recognized by measuring office blood pressure alone. We therefore recommend 24h ambulatory blood pressure measurement in smokers with essential hypertension.

Validation of self diagnosis of high blood pressure in a sample of the Spanish EPIC cohort: overall agreement and predictive values

STUDY OBJECTIVEHigh blood pressure is a variable related to several chronic conditions whose repeated measurement in large cohort studies is often not feasible having to rely on the self reporting...

La hipertensión en los ancianos y resultados globales en salud con distintas terapias farmacológicas

To describe the benefits of treatment for hypertension in the elderly, the most efficient drugs, those most widely used in clinical practice to reduce morbi-mortality taken from the literature. Systematic review. Review study in Medline and the Cochrane Collaboration database. The antihypertensive pharmacological treatment is described (diuretics high and low dosage, calcium channel blockers, ACE inhibitor, and beta-blockers) administered to elderly people and their outcomes in morbi-mortality. Reduction in coronary and cerebral morbidity and general, cardiovascular and cerebrovascular mortality. There is evidence to suggest that treatment for hypertension is helpful in the elderly, although efficiency is doubtful in patients over 80 years old. For persons aged over 65 general mortality is RR = 0.84 (0.75-0.94) and coronary morbidity RR = 0.80 (0.70-0.92). For persons aged over 80 general mortality is RR = 1 (0.86-1.17) and cardiovascular mortality is RR = 0.94 (0.75-1.18). Not all pharmacological groups produce the same results in mortality and morbidity. Diuretics (low dosage) offer better results than the remaining treatments reducing cardiovascular mortality as well cerebrovascular morbidity. Treatment with drugs in hypertense elderly people is beneficial in terms of mortality and morbidity. Treatment with low dose diuretics, with or without potassium savers, is the elective treatment for hypertension in elderly patients.

Limited echocardiography for hypertensive left ventricular hypertrophy.

Echocardiographic assessment of left ventricular (LV) mass has provided the best noninvasive information to permit diagnostic, therapeutic, and prognostic assessment of hypertensive heart disease1 2 3 4 5 6 7 (Table 1⇓). Reversal of hypertension-induced LV hypertrophy (LVH) occurs with all pharmacological (and some nonpharmacological) antihypertensive treatment, although few data are yet available to demonstrate that such reversal is associated with a reduced risk of LVH. However, one recent report suggested that patients who had changes of reversal of LVH (by electrocardiography [ECG]) were at substantially reduced risk compared with those who did not demonstrate diminished LVH.9 However, the cost of echocardiography has limited its utility in patients with hypertension. A less time-consuming and less-expensive LVH screening echocardiogram would be of great value; such a procedure is referred to as a limited echocardiogram.10 View this table: Table 1. Summary of Epidemiological Studies Relating Echocardiographic Left Ventricular Mass With Long-term Prognosis Echocardiography has been used as a standard procedure for the calculation of LV muscle mass for more than 25 years.11 Primary measurements of LV dimensions are made according to American Society of Echocardiography standards using the leading edge method of interface recognition and by identifying end diastole and end systole at the QRS onset and nadir of posterior systolic motion of the interventricular septum.12 13 14 Adequate M-mode images for calculation of LV mass can be obtained in approximately 90% of patients in an experienced echo laboratory.15 16 17 Assessment of the degree of LVH should include measurements of the posterior wall and septal thickness and calculation of LV mass index. However, even in patients with good-quality studies, there is significant intrareader and interreader variability of LV mass.15 For instance, in the Treatment of Mild Hypertension Study, the variance between the two readers was 23.8% (49.2g), and …

Prevalence and control of arterial hypertension in the south-east of Spain: a radical but still insufficient improvement.

Stroke mortality rates in Spain are one of the highest in all of Europe. At the same time, the Murcia region (south-east Spain) shows, for both genders, the highest age-adjusted stroke mortality rates in all of Spain. The earliest available hypertension figure estimations for this area go back to 1981, when a high prevalence combined with an almost nonexistent control was detected. One decade later, updated prevalence estimations of hypertension are presented jointly with their degree of control and their association with other risk factors based on the results of a prevalence survey in a random population sample (n = 3,091). Arterial blood pressure was measured following the MONICA protocol, maintaining a tight quality control on between and within-observer variability. As hypertensive was considered any person with systolic blood pressure (SBP) > or = 140 mmHg or with diastolic blood pressure (DBP) > or = 90 mmHg or with antihypertensive pharmacological treatment. Detected prevalence rises to 32.3% (CI 95%: 29.1%-35.5%) among males and to 23.7% (CI 95%: 21.4%-26%) among females, maintaining its level regarding figures observed back in 1981. However, its control has been increased, especially among hypertensive women [from less than 5% in 1981 to 35% (95% CI: 32%-37.8%) at present]. Hypertension is strongly associated to hipercholesterolemia, overweight, obesity and diabetes (p < 0.01). On the contrary, it shows an opposite association with current smoking, higher educational level and leisure time physical activity (p < 0.01). The highest educational level was associated with better hypertension treatment and control. In summary, while hypertension prevalence is stabilized in our population, its control has improved in a measurable but still insufficient way. These results are in accordance with a decreasing trend in stroke mortality registered in the Murcia Region along the last decade.

6 Hyperlipidaemia and hypertension

Hyperlipidaemia and hypertension are commonly found in the population and are independent risk factors for cardiovascular complications. The combined presence of hypertension and hypercholesterolaemia increases considerably the risk for cardiovascular complications. These high-risk patients have to be identified early and treated appropriately in order to avoid complications. The goal of antihypertensive therapy is to reduce the average levels of diastolic pressure to below 90 mm Hg and the systolic pressure to below 140 mm Hg. The goals set for lipid levels in these patients are total cholesterol less than or equal to 200 mg/dl, LDL cholesterol less than or equal to 135 mg/dl and triglycerides less than or equal to 200 mg/dl. The first step in the treatment of patients with both hyperlipidaemia and hypertension is to seek underlying causes and to take appropriate therapeutic measures for both diseases. Non-pharmacological treatment of these high-risk patients includes weight reduction, appropriate dietary measures including alcohol and salt restriction, cessation of smoking and increasing physical activity. If pharmacological antihypertensive treatment is needed, drugs without adverse effects on lipid and lipoprotein levels should be preferred. If, in addition to dietary measures, drug treatment is necessary to reduce high cholesterol levels, bile acid sequestrants are the drug of first choice at present. If long-term safety can be established for HMG CoA reductase inhibitors, these drugs will represent a major advance in the therapy of hypercholesterolaemia.