Pressure Control In Patients Research Articles

Blood pressure control in patients with chronic kidney disease.

Chronic kidney disease (CKD) is defined as either kidney damage or an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m2 for more than 3 months. Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. CKD is classified as stage 1 to 5 on the basis of eGFR. Cardiovascular disease (CVD) carries a reciprocal risk of loss of kidney function in patients with chronic kidney disease (CKD) and with the development of kidney disease. CVD is a major cause of morbidity and mortality in patients with CKD. Blood pressure control in patients with CKD aims to prevent CVD and provide renoprotection. The renin-angiotensin system (RAS) is involved in every stage of the progression of CKD and is, therefore, a critical link in the pathologic relationship between hypertension and renal disease. The first-line agents for controlling blood pressure are inhibitors of the RAS: angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers. These agents have been shown to have renoprotective effects in addition to their ability to control blood pressure. In CKD, the target blood pressure is less than 130/80 mm Hg, or 125/75 mm Hg, if amount of urinary protein is more than 1 g/day. To achieve the target blood pressure, other classes of antihypertensive agents, such as diuretics and calcium channel blockers, should be administered in addition to angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers.

Effectiveness of Nicardipine for Blood Pressure Control in Patients with Subarachnoid Hemorrhage

ObjectiveThe purpose of the study is to determine the effectiveness and safety of nicardipine infusion for controlling blood pressure in patients with subarachnoid hemorrhage (SAH).MethodsWe prospectively evaluated 52 patients with SAH and treated with nicardipine infusion for blood pressure control in a 29 months period. The mean blood pressure of pre-injection, bolus injection and continuous injection period were compared. This study evaluated the effectiveness of nicardipine for each Fisher grade, for different dose of continuous nicardipine infusion, and for the subgroups of systolic blood pressure.ResultsThe blood pressure measurement showed that the mean systolic blood pressure / diastolic blood pressure (SBP/DBP) in continuous injection period (120.9/63.0 mmHg) was significantly lower than pre-injection period (145.6/80.3 mmHg) and bolus injection period (134.2/71.3 mmHg), and these were statistically significant (p < 0.001). In each subgroups of Fisher grade and different dose, SBP/DBP also decreased after the use of nicardipine. These were statistically significant (p < 0.05), but there was no significant difference in effectiveness between subgroups (p > 0.05). Furthermore, controlling blood pressure was more effective when injecting higher dose of nicardipine in higher SBP group rather than injecting lower dose in lower SBP group, and it also was statistically significant (p < 0.05). During the infusion, hypotension and cardiogenic problems were transiently combined in five cases. However, patients recovered without any complications.ConclusionNicardipine is an effective and safe agent for controlling acutely elevated blood pressure after SAH. A more systemic study with larger patients population will provide significant results and will bring solid evidence on effectiveness of nicardipine in SAH.

Abstract P182: Comparing Blood Pressure Control in Diabetic Versus Nondiabetic Veterans Following Percutaneous Coronary Intervention

Background: Blood pressure control in patients with coronary artery disease (CAD) or diabetes is essential to decrease morbidity and mortality. The US Joint National Committee VII (JNC-7) recommends systolic blood pressure (SBP) &lt;130 and diastolic blood pressure (DBP) &lt;80. These values can be attained using beta-blockers, angiotensin antagonists, calcium channel blockers, diuretics and nitrates. Methods: We conducted a retrospective cohort study focusing on the attainment of the JNC-7 guidelines, comparing 331 diabetic to 524 non-diabetic patients who underwent percutaneous coronary intervention (PCI) between September 2004 and December 2009 at the Jesse Brown Veterans Hospital in Chicago, IL. Results: Among the diabetic population, the mean SBP decreased 135 to 131mmHg (p = 0.0014) and mean DBP decreased 72 to 70mmHg (p= 0.0014). In non-diabetics, the mean SBP decreased 133 to 128mmHg (p&lt;0.0001) and mean DBP decreased 73 to 71mmHg (p&lt;0.0007). The percent of diabetics at JNC-7 SBP goal increased from 41 to 50% (136 to 166 of 331) (p= 0.0041), however the percent change at DBP goal was not significant. In non-diabetics, percent at goal for SBP increased 45 to 57% (236 to 299 of 524) (p&lt;0.0001) and for DBP increased 69 to 76% (362 to 398 of 524) (p=0.0075). At six months, among diabetics, the medication usage increased for beta-blockers, from 80 to 92% (265 to 305 of 331) (p&lt;0.0001) and for nitrates from 32 to 37% (106 to 122 of 302) (p=0.0465). Among non-diabetics, use of beta-blockers increased from 68 to 87% (356 to 456 of 524) (p&lt;0.0001) and nitrates from 20 to 25% (105 to 131 of 524) (p=0.0054). Use of angiotensin antagonists also increased from 52 to 71% (272 to 372 if 524) (p&lt;0.0001) among non-diabetics. Conclusions: There were improvements in blood pressure among both populations at six months post-PCI. Both groups attained JNC-7 SBP goals; only non-diabetics achieved DBP goal. Medication use increased for both groups with beta-blockers and nitrates. Angiotensin antagonists only increased significantly among non-diabetics. This demonstrates that post-intervention, tighter control of blood pressure is attempted however levels are not yet optimal.

The Correlates and Course of Depression in Patients with Lacunar Stroke: Results from the Secondary Prevention of Small Subcortical Strokes (SPS3) Study

Background: Little is known about post-stroke depression in patients with lacunar stroke due to cerebral small vessel disease. Our objectives were to describe the prevalence of depression, its correlates and to examine the course of depression over time in a cohort of patients with lacunar stroke, the majority of whom had mild functional disability. Methods: Depression was determined in participants in the international Secondary Prevention of Small Subcortical Strokes (SPS3) trial which is testing antiplatelet therapies and targets of blood pressure control in patients with lacunar strokes and assessing stroke recurrence and cognitive decline. Depression was evaluated using the Patient Health Questionnaire. Multivariable logistic regression models were fitted to examine the relationship between the covariates of interest and depression. Generalized estimating equations were used to examine the likelihood of depression over time, while accounting for the multiple measurements within each subject. Results: The prevalence of depression in 2,477 participants at approximately 4 months after stroke was 19%. Older age (OR 0.97; 95% CI 0.96–0.99), male gender (OR 0.62; 95% CI 0.48–0.80) and less cognitive impairment (OR 0.99; 95% CI 0.98–1.00) were independently associated with a lower risk of depression. Functional disability (OR 1.8; 95% CI 1.3–2.4), living with a spouse/family (OR 1.6; 95% CI 1.1–2.3) and risk factors for stroke (OR 1.2; 95% CI 1.0–1.3) were each independently associated with a higher risk of depression. Longitudinal modeling indicated that the likelihood of depression decreased by 1.12 times (95% CI 1.06–1.17) for each 1-year increase in time. Conclusions: One fifth of those in the SPS3 trial cohort reported depression that is sustained over time. Although this is lower than the prevalence reported for stroke in general, these results underscore the importance of early screening for post-stroke depression, treatment and follow-up to minimize the negative consequences associated with depression.

Influence of Left Ventricular Function on Blood Pressure Control in Patients with Coronary Heart Disease

Influence of Left Ventricular Function on Blood Pressure Control in Patients with Coronary Heart Disease

COXIBs, CINODs and H2S-Releasing NSAIDs: Current Perspectives in the Development of Safer Non Steroidal Anti-Inflammatory Drugs

Traditional nonsteroidal anti-inflammatory drugs, tNSAIDs, are effective medication for prevention of ischemic events and treatment of pain, fever and inflammation. However their use associates with a significant risk to develop gastrointestinal and cardiovascular complications. Low doses of acetyl salicylic acid (ASA) and effective doses of tNSAIDs associate with a 2-6 fold increase in the risk of gastrointestinal bleeding. ASA and tNSAIDs inhibit cyclooxygenases (COXs). The COX exists at least in two isoforms, COX-1 and COX-2. Selective inhibitors of COX-2, the coxibs, spares the gastrointestinal tract while exert anti-inflammatory and analgesic effects. However, coxibs increase the risk of thrombo-embolic events. Nitric oxide (NO) and hydrogen sulfide (H₂S), are potent vasodilatory agents that maintain mucosal integrity in the gastrointestinal tract. Hybrid molecules generated by coupling a NO or H₂S releasing moiety to ASA or tNSAIDs has resulted into new classes of NSAIDs. These agents, the NO-releasing NSAIDs, or CINOD, and the H₂S releasing NSAIDs are currently investigated as a potential alternative to tNSAIDs and coxibs. Naproxcinod has been the first, and so far the only, CINOD investigated in clinical trials. These studies have shown a slightly improvement in gastrointestinal tolerability in comparison to naproxen in surrogate endpoints (number of gastric and duodenal ulcers) and a significant reduction in the risk of destabilization of blood pressure control in patients with osteoarthosis taking anti-hypertensive medications in comparison to either naproxen and rofecoxib. The lack of outcome studies, however, has precluded the approval of naproxcinod by the Food and Drug Administration leading to a voluntary withdrawn of an application to the EMEA in May 2011. NSAIDs that releases H₂S as a mechanism supporting an intrinsic gastrointestinal and cardiovascular safety are being investigated in preclinical models. Either naproxen and diclofenac hybrids have been reported to cause less gastrointestinal injury than parent NSAIDs. These novel chemical entities exert a variety of beneficial effects in rodent models of cardiovascular and metabolic disorders through a mechanism that might involve the release of H₂S and/or by exerting anti-oxidant effects. The beneficial role these mechanisms in clinical settings await a proof-of-concept study.

Trends in blood pressure control in patients with type 2 diabetes – Data from the Swedish National Diabetes Register (NDR)

We assessed blood pressure (BP) trends in patients with type 2 diabetes from a national diabetes register using three cross-sectional samples (aged 30–85 years) in 2005, 2007 and 2009, and in patients from 2005 followed individually until 2009. The prevalence of hypertension was 87% among all 180 369 patients in 2009, although lower in subgroups with ages 30–39, 40–49 and 50–59 years: 40%, 60% and 77%. In the three cross-sectional surveys, mean BP decreased (141/77–136/76 mmHg), uncontrolled BP≥ 140/90 mmHg decreased (58–46%), and antihypertensive drug treatment (AHT) increased (73–81%). Comparatively in 79 185 patients followed individually for 5 years, mean BP decreased (141/77–137/75 mmHg), uncontrolled BP ≥140/90 mmHg decreased (58–47%) and AHT increased (73–82%). Independent predictors of BP decrease were BMI decrease (stronger) and increase in AHT. AHT occurred among 81% of all patients in 2009. In 57 645 patients on AHT followed individually, mean BP decreased (143/77–138/75 mmHg) and uncontrolled BP ≥140/90 mmHg decreased (63–50%). Among 5164 patients with nephropathy on AHT followed individually, BP <130/80 mmHg increased (12–21%). In conclusion, BP control improved from 2005 to 2009, relative to BMI decrease and AHT increase, although still about half had BP ≥140/90 mmHg.

Relationship of aortic pulse wave velocity and baroreceptor reflex sensitivity to blood pressure control in patients with repaired coarctation of the aorta

Increased aortic stiffness and reduced baroreceptor reflex sensitivity have been described independently after coarctation of the aorta (CoA) repair. This study sought to determine the relationship between these variables and blood pressure control in adolescents after early CoA repair. Spontaneous baroreceptor reflex sensitivity (sBRS) and aortic pulse wave velocity (PWV) were measured in 29 adolescents after CoA repair and compared with 20 age-matched controls. Patients treated for hypertension or having residual aortic narrowing were excluded. Ambulatory blood pressure (ABP), heart rate variability, and cardiac output were also recorded. After ABP measurement, CoA subjects were classified as normotensive or hypertensive. Nine patients (31%) were hypertensive according to standard definitions, and this subgroup had higher aortic PWV than the normotensive subgroup (P = .004). There was a significant positive correlation between ABP and PWV seen in the whole CoA group (r(2) = 0.5, P < .01). The normotensive subgroup had increased sBRS compared with controls (P = .02). This difference was not seen between the hypertensive subgroup and controls. There was a significant inverse relationship between sBRS and aortic PWV in the whole CoA group (r(2) = 0.25, P = .01). The normotensive subgroup had a significant reduction in stroke index compared with controls (P = .02), which was not seen in the hypertensive subgroup (P = .96). Adolescents with hypertension after CoA repair have increased aortic PWV and a relative reduction in sBRS compared with normotensive CoA patients. Thus, failure of the baroreceptor reflex to compensate for increasing arterial stiffness may herald the onset of hypertension in these patients.

ADDITION OF SPIRONOLACTONE IN PATIENTS WITH RESISTANT ARTERIAL HYPERTENSION (ASPIRANT) - STUDY PROTOCOL

There is currently limited data on which drug should be used to improve blood pressure control in patients with resistant hypertension. Recent observational trials reported spironolactone as having good effects. This study is designed to assess the effect of the addition of 25 mg of spironolactone on blood pressure (BP) in patients with resistant arterial hypertension. Patients with office systolic BP > 140 mmHg or diastolic BP > 90 mmHg despite treatment with at least 3 antihypertensive drugs including a diuretic, are enrolled in this double-blind, placebo-controlled, multicentre trial. Patients are randomly assigned to receive spironolactone or a placebo at a ratio of 1:1 by the method of simple randomisation. Our primary endpoints are to show a statistically significant difference in the fall of mean day-time systolic and diastolic BP by ambulatory blood pressure monitoring (ABPM), between the spironolactone and placebo groups, after 8 weeks of treatment. Secondary outcomes are changes of serum potassium, natrium, creatinine, body weight, casual blood pressure in office, difference in the fall of mean night-time and 24-hour ABPM BP and treatment response depending on different baseline levels of aldosterone and aldosterone/PRA ratio. If spironolactone proves effective, it might become the standard of treatment in patients with resistant arterial hypertension.

Effect of Renal Sympathetic Denervation on Glucose Metabolism in Patients With Resistant Hypertension

Background— Hypertension is associated with impaired glucose metabolism and insulin resistance. Chronic activation of the sympathetic nervous system may contribute to either condition. We investigated the effect of catheter-based renal sympathetic denervation on glucose metabolism and blood pressure control in patients with resistant hypertension. Methods and Results— We enrolled 50 patients with therapy-resistant hypertension. Thirty-seven patients underwent bilateral catheter-based renal denervation, and 13 patients were assigned to a control group. Systolic and diastolic blood pressures, fasting glucose, insulin, C peptide, hemoglobin A 1c , calculated insulin sensitivity (homeostasis model assessment–insulin resistance), and glucose levels during oral glucose tolerance test were measured before and 1 and 3 months after treatment. Mean office blood pressure at baseline was 178/96±3/2 mm Hg. At 1 and 3 months, office blood pressure was reduced by −28/−10 mm Hg ( P &lt;0.001) and −32/−12 mm Hg ( P &lt;0.001), respectively, in the treatment group, without changes in concurrent antihypertensive treatment. Three months after renal denervation, fasting glucose was reduced from 118±3.4 to 108±3.8 mg/dL ( P =0.039). Insulin levels were decreased from 20.8±3.0 to 9.3±2.5 μIU/mL ( P =0.006) and C-peptide levels from 5.3±0.6 to 3.0±0.9 ng/mL ( P =0.002). After 3 months, homeostasis model assessment–insulin resistance decreased from 6.0±0.9 to 2.4±0.8 ( P =0.001). Additionally, mean 2-hour glucose levels during oral glucose tolerance test were reduced significantly by 27 mg/dL ( P =0.012). There were no significant changes in blood pressure or metabolic markers in the control group. Conclusions— Renal denervation improves glucose metabolism and insulin sensitivity in addition to a significantly reducing blood pressure. However, this improvement appeared to be unrelated to changes in drug treatment. This novel procedure may therefore provide protection in patients with resistant hypertension and metabolic disorders at high cardiovascular risk. Clinical Trial Registration— URL: http://www.ClinicalTrials.gov . Unique identifiers: NCT00664638 and NCT00888433.

Current Strategies to Achieve Further Cardiac and Renal Protection through Enhanced Renin-Angiotensin-Aldosterone System Inhibition

An incomplete inhibition of the renin angiotensin aldosterone system (RAAS) may be responsible for the residual organ damage and event rate that still occur in spite of an apparent blood pressure control in patients with hypertension, diabetes, chronic kidney disease and heart failure treated with angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB). Additional antiproteinuric effect in diabetic and non diabetic chronic kidney disease, and reduction in hospitalizations in patients with heart failure already receiving a single RAAS antagonist, has been achieved by incremental inhibition of the RAAS with dual therapy or uptitration of an individual agent above conventional dosages. However, the synergistic increase in plasma renin activity (PRA) and the angiotensin II escape could reduce the expected benefit obtained with dual therapy. Results from ONTARGET showing a lack of additional outcome benefit over monotherapy, with a concomitant increase risk of hyperkalemia, renal impairment, and hypotension, discourage the use of the ACEI/ARB combination in patients at high risk of cardiovascular events. This occured despite a lower albumin excretion in dual versus single RAAS blockade, indicating that an incremental antiproteinuric effect is not automatically translated into clinical outcome benefits. The efficacy and safety of ACEI/ARB combination versus monotherapy in patients with overt proteinuria is currently evaluated by LIRICO and VA NEPHRON-D clinical trials. The long lasting direct renin inhibitor aliskiren, acting at the first and rate limiting step of the RAAS cascade, prevents the reactive increase in PRA when combined with ACEIs, ARBs or diuretics. The ASPIRE HIGHER programme, involving more than 35,000 patients with hypertension, heart failure, kidney disease and diabetes, is currently evaluating the efficacy and safety of aliskiren on top of standard therapy. The clinical benefit of adding mineralocorticoid receptor blockers (MRBs) in the control of resistant hypertension, proteinuric kidney diseases, and prevention of mortality in patients with heart failure on top of conventional treatment, evidences the pathogenic role of inadequately suppressed aldosterone as a cause of suboptimal response to conventional RAAS inhibition. The present review will focus on the pathophysiological ground, and the evidence provided by clinical trials assessing the efficacy and safety of recent strategies for the prevention of cardiovascular events and target organ damage progression via enhanced RAAS inhibition.

Better HbA1c and Blood Pressure Control in Patients with Diabetes Mellitus Treated at a Primary Health Care Level 10 Years After Initiation of a Diabetes Quality Improvement Program

Deutsche BKK, a German health insurance company, initiated in 1997 a diabetes quality improvement programme. Changes in HbA (1c) and blood pressure (BP) from 1997 to 2006 are presented. Between 1997 to 2006 n=15 096 patients with diagnosed type 1 (6.7%) or type 2 (91.4%) diabetes were recruited by 351 primary care physicians. HbA (1c), BP, serum creatinine, microalbuminuria and presence of diabetic complications (nephropathy, retinopathy, neuropathy) were documented once per year. Physicians received an extra payment of Euro 25 as an incentive for each enrolled and examined participant. Systolic BP decreased by 10.5 ± 0.9 mmHg (baseline 149 ± 21.5), diastolic BP by 4.0 ± 0.46 mmHg (baseline 82.8 ± 10.6), HbA (1c) by 0.55 ± 0.069% (baseline 7.62 ± 1.63) and more patients achieved acceptable HbA (1c) <7% (42.5 vs. 59.9%) and BP <140/90 mmHg (84.9 vs. 94.6%). HbA (1c) and BP of patients with diabetes mellitus improved while participating in a yearly structured screening programme, performed by primary care physicians in a health insurance initiated quality improvement programme. The intense monitoring derives from extra remuneration of the physicians and the patients' involvement in the quality assurance process. The pre-requisite for remuneration is that the data sheet must be signed by both patient and physician.

Pharmacist intervention program to enhance hypertension control: a randomised controlled trial

Objective Studies have demonstrated that hypertension remains inadequately managed throughout the world, with lack of adherence to BP-lowering medication being a major factor. The aim of the present study was to evaluate if a pharmaceutical care program could improve antihypertensive medication adherence and blood pressure control. Setting This study was conducted in a secondary care hypertension/dyslipidemia outpatient clinic in the university teaching hospital of Cova da Beira Hospital Centre, Covilhã, located in the Eastern Central Region of Portugal. Method This report evaluates the pharmacist’s interventions during a prospective randomised controlled trial, from July 2009 to June 2010. Patients with diagnosis of essential hypertension attending the clinic for routine follow-up were randomly allocated either to a control group (no pharmaceutical care) or to an intervention group (quarterly follow-up by a hospital pharmacist during a 9-month period). The pharmacist interventions, aimed to increase medication adherence and blood pressure control, involved educational interventions and counselling tips directed to the patient. Main outcome measure Systolic blood pressure, diastolic blood pressure and blood pressure control (according to JNC 7 guidelines) assessed at the baseline visit and at the end of pharmaceutical care were the main outcome measures. Blood pressure measurements were performed by blinded nurses. Medication adherence was also evaluated, using a validated questionnaire at baseline and at the end of investigation. Results A total of 197 hypertensive patients were randomly assigned to the study (99 in the control group and 98 in the intervention group). Although there were no significant differences (P > 0.05) in both groups concerning mean age, gender, body mass index, and antihypertensive pharmacotherapy, blood pressure control was higher in the intervention group (P = 0.005) at the end of the study. Significant lower systolic blood pressure (−6.8 mmHg, P = 0.006) and diastolic blood pressure (−2.9 mmHg, P = 0.020) levels were observed in the intervention group. Medication adherence was also significantly higher in the intervention group at the end of the study (74.5% vs. 57.6%, P = 0.012).Conclusion Pharmacist intervention can significantly improve medication adherence and blood pressure control in patients treated with antihypertensive agents.

Efficacy of a Pharmacist-Managed Intervention for Improved Blood Pressure Control in Patients with Elevated Cardiovascular Disease Risk: Subgroup Analysis of the HAPPY RCT

Efficacy of a Pharmacist-Managed Intervention for Improved Blood Pressure Control in Patients with Elevated Cardiovascular Disease Risk: Subgroup Analysis of the HAPPY RCT

Feasibility of a structured group education session to improve self-management of blood pressure in people with chronic kidney disease: an open randomised pilot trial

ObjectivesWe aimed to test, at pilot level, a structured group educational intervention to improve self-management of blood pressure in people with chronic kidney disease (CKD). The current paper explores patient...

Control de las cifras de presión arterial en diabéticos tipo 2 tratados con insulina: Blood pressure control in diabetics type 2 treated with insulin

ObjectiveTo know the blood pressure (BP) control in patients with type 2 diabetes treated with insulin after two years of follow-up. Setting: 9 health centers of Primary Care. DesignProspective, longitudinal, multicentric study performed in Primary Care settings. 121 patients with type 2 diabetes who needed initiation or modification of insulin therapy were included. During the 2 years of follow-up, 5 visits (inclusion, and 6,12,18, and 24 months) were performed. The compliance was studied by means of count of insulin. BP was measured in two occasions and mean BP and degree of BP control was evaluated. Good control was defined when SBP was <140 mmHg, and DBP was <90 mmHg, respectively. Results103 patients (85.1%) (mean age 66.4 years, SD 11.6) concluded the study, of which 45 were men (43.69%). SBP and DBP were respectively 140.2 (SD 14.2) and 86.1 (SD 9.2) mmHg at the initial visit, 140.3 (SD 14) and 86.8 (SD 8.6) mmHg at 1 year and 141.3 (SD 14.5) and 86.9 (SD 8.3) at 2 years (p= NS between initial-final visit). 37.8% (CI 95%: 28.4-47.2), 53.4% (CI 95%: 43.8-63) and 38.8% (CI 95%: 29.43-48.17) for visits (initial, 12 and 24 months, respectively) (p= NS initial-final) had BP controlled. ConclusionsBlood pressure control in patients with type 2 diabetes treated with insulin is very low, without changes after 2 years of follow-up.

Effects of high dose olmesartan medoxomil plus hydrochlorothiazide on blood pressure control in patients with grade 2 and grade 3 hypertension

High dose (40 mg) olmesartan medoxomil (OM) blocks the angiotensin II receptor, significantly reducing blood pressure (BP). Adding hydrochlorothiazide (HCTZ) to OM increases efficacy, but has not been evaluated in patients inadequately controlled by OM 40 mg. Patients with grade 2 and grade 3 hypertension with inadequately controlled BP (seated diastolic blood pressure [SeDBP] 90-115 mm Hg and seated systolic blood pressure [SeSBP] 140-180 mm Hg, plus ambulatory BP criteria) after 8 weeks of OM 40 mg open-label treatment were randomized to 8 weeks of double-blind treatment with OM/HCTZ 40/25 (n=140), 40/12.5 (n=278), 20/12.5 mg (n=280) or OM 40 mg (n=274). Treatment with OM/HCTZ 40/25 mg and 40/12.5 mg significantly reduced SeDBP (-5.3 and -3.4 mm Hg, respectively), and SeSBP (-7.4 and -5.2 mm Hg, respectively), vs OM 40 mg monotherapy (P<0.0001 for each) in patients inadequately controlled on OM 40 mg alone. OM/HCTZ 40/12.5 mg reduced SeSBP significantly more than OM/HCTZ 20/12.5 mg (-2.6 mm Hg, P=0.0255), and also produced a further reduction in SeDBP vs the lower dose. All treatments were well tolerated, with similar low proportions of patients reporting treatment-emergent adverse events in all treatment groups. In conclusion, adding HCTZ to OM 40 mg significantly improves BP reductions and target BP rates in harder-to-treat patients and a clear dose-response was observed for efficacy.

Physician Characteristics as Predictors of Blood Pressure Control in Patients Enrolled in the Hypertension Improvement Project (HIP)

The authors sought to examine the relationship between physician characteristics and patient blood pressure (BP) in participants enrolled in the Hypertension Improvement Project (HIP). In this cross-sectional study using baseline data of HIP participants, the authors used multiple linear regression to examine how patient BP was related to physician characteristics, including experience, practice patterns, and clinic load. Patients had significantly lower systolic BP (SBP) (-0.2 mm Hg for every 1% increase, P=.008) and diastolic BP (DBP) (-0.1 mm Hg for every 1% increase, P=.0007) when seen by physicians with a higher percentage of patients with hypertension. Patients had significantly higher SBP (0.8 mm Hg for every 1% increase, P=.002) when seen by physicians with a higher number of total clinic visits per day. Patients had significantly lower DBP (-4.4 mm Hg decrease, P=.0002) when seen by physicians with inpatient duties. Physician's volume of patients with hypertension was related to better BP control. However, two indicators of a busy practice had conflicting relationships with BP control. Given the increasing time demands on physicians, future research should examine how physicians with a busy practice are able to successfully address BP in their patients.

Erectile Dysfunction May Improve by Blood Pressure Control in Patients with High-Risk Hypertension

Background: Blood pressure (BP) control induces reductions in target-organ damage and cardiovascular events. Erectile dysfunction (ED) is a multifactorial disease related to cardiovascular disease, but its relationship with BP control has not been extensively studied. Aims: We describe the effect of BP control on ED in patients with high-risk hypertension who were treated with beta-blockers. Study Design: This was a cross-sectional and observational study of male patients with hypertension treated with any beta-blocking agent for ≥ 6 months. Erectile dysfunction was assessed by the International Index of Erectile Function (IIEF). Statistical analysis was performed using a Chi-square test, Fisher's exact test, covariance analysis, and stepwise logistic regressions. Results: A total of 1242 patients were studied; 33.7% had controlled BP. Patients with uncontrolled BP had slightly higher mean age (64.4 years vs 58.6 years) and higher prevalence of diabetes and cardiac and noncardiac comorbidities. Patients with controlled BP had a lower crude and adjusted prevalence of ED. Erectile dysfunction was significantly lower in patients with controlled BP in the 2 older age quartiles (> 59 years). Multivariate analyses, adjusted by age, clinical features, and medical treatments were conducted separately in patients within the 2 younger and older age quartiles. In patients in the 2 younger quartiles, ED was only independently and inversely associated with nebivolol treatment (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.05–0.88). Conversely, BP control (OR, 0.48; 95% CI, 0.26–0.89), diabetes (OR, 2.64; 95% CI, 1.32–5.28), and peripheral artery disease (OR, 3.80; 95% CI, 1.20–12.00) were independently associated with ED in patients in the older 2 age quartiles. Conclusion: In patients with high-risk hypertension treated with beta-blockers, BP control was associated with a lower prevalence of ED, independently of age, cardiovascular disease, and medical treatments. The effect of BP control was higher in older patients.

Effect of adding pharmacists to primary care teams on blood pressure control in patients with type 2 diabetes: a randomized controlled trial.

OBJECTIVETo evaluate the effect of adding pharmacists to primary care teams on the management of hypertension and other cardiovascular risk factors in patients with type 2 diabetes.RESEARCH DESIGN AND METHODSWe conducted a randomized controlled trial with blinded ascertainment of outcomes within primary care clinics in Edmonton, Canada. Pharmacists performed medication assessments and limited history and physical examinations and provided guideline-concordant recommendations to optimize medication management. Follow-up contact was completed as necessary. Control patients received usual care. The primary outcome was a ≥10% decrease in systolic blood pressure at 1 year.RESULTSA total of 260 patients were enrolled, 57% were women, the mean age was 59 years, diabetes duration was 6 years, and blood pressure was 129/74 mmHg. Forty-eight of 131 (37%) intervention patients and 30 of 129 (23%) control patients achieved the primary outcome (odds ratio 1.9 [95% CI 1.1–3.3]; P = 0.02). Among 153 patients with inadequately controlled hypertension at baseline, intervention patients (n = 82) were significantly more likely than control patients (n = 71) to achieve the primary outcome (41 [50%] vs. 20 [28%]; 2.6 [1.3–5.0]; P = 0.007) and recommended blood pressure targets (44 [54%] vs. 21 [30%]; 2.8 [1.4–5.4]; P = 0.003). The 10-year risk of cardiovascular disease, based on changes to the UK Prospective Diabetes Study Risk Engine, were predicted to decrease by 3% for intervention patients and 1% for control patients (P = 0.005).CONCLUSIONSSignificantly more patients with type 2 diabetes achieved better blood pressure control when pharmacists were added to primary care teams, which suggests that pharmacists can make important contributions to the primary care of these patients.