Primary Hypertension In Adults Research Articles

Impact of sociodemographic patient factors on prescriber adherence to antihypertensive prescription guidelines: a cross-sectional study using data from The Irish Longitudinal Study on Ageing

Abstract Introduction Uncontrolled hypertension causes significant morbidity and mortality worldwide. Several international prescribing guidelines have been created to address this. However, prescriber adherence to these guidelines may be influenced by sociodemographic patient factors such as socio-economic status, gender and age. Aim To examine the effects of gender and other patient factors, including age, geographical location, educational attainment, duration of disease, socio-economic status, smoking status, and previous history of cardiovascular diseases on prescriber adherence to hypertension prescription guidelines. Achievement of blood pressure goals (<140/90 mmHg) with adherence to prescription guidelines was also assessed. Methods This study is a secondary analysis of cross-sectional data from the first wave (2009-2011) of The Irish Longitudinal Study on Ageing (TILDA), which included 8,175 Irish adults ≥50 years of age. Participants were included in the present study if they reported a previous doctor diagnosis of hypertension. Antihypertensive medication regimens were compared and categorised according to the 2011 National Institute for Health and Clinical Excellence (NICE)[1] prescription guidelines, which included the use of angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers, and thiazide diuretics in the treatment of hypertension. In this study, the antihypertensive medication regimens of participants were categorised based on age categories (<55, ≥55, and all age groups), and compared to the 2011 NICE Guidelines which differentiate treatment in those ≥55, and <55 years of age. The effects of patient sociodemographic factors on prescriber adherence to the guidelines, and the effects of guideline adherence on blood pressure control, (defined as blood pressure<140/90 mmHg), were determined using multinomial logistic regression models. The mlogit, RRR code in STATA 17 SE was used to report relative risks (RRs). Results A total of 2,992 participants were included, of whom 54.9% were women. The mean age of participants was 65.69 years (±9.23). Male gender, older age and lower socioeconomic status among participants were associated with increased prescriber guideline adherence. Prescribers were less likely to adhere to guidelines in female patients ≥55 years (RR 0.75 [0.62 to 0.91]), and female patients across all age groups (RR 0.80 [0.67 to 0.95]). Better blood pressure control was seen with medication regimens adherent to prescription guidelines with a mean of 140.38 (±18.98)/83.09 (±11.02) mmHg compared to a mean of 141.66 (±19.86)/84.77 (±11.71) mmHg in those non-adherent to guidelines. Conclusion This study highlights the effects of patient gender on prescriber adherence to antihypertensive prescription guidelines. A study strength is the use of a large, nationally representative cohort that used a standardised protocol of data collection within the Irish population. A potential limitation is the inclusion of self-reported data, including doctor diagnosis of hypertension. The results of this study may emphasise a larger issue of the systemic undertreatment of women within healthcare; however, these results should be interpreted in the context of 2011 guidelines, which have since been superseded by 2019 NICE guidelines. Further research may seek to determine possible reasons for such differences in hypertensive care. Reference 1. Linden B. NICE guidance on primary hypertension National Institute for Health and Clinical Excellence (2011) Hypertension: Clinical Management of Primary Hypertension in Adults. NICE Clinical Guideline 127. British journal of cardiac nursing. 2011;6:582-584.

First-line drugs for hypertension

Review of: Wright JM, Musini VM, Gill R. First-line drugs for hypertension (Review). Cochrane Database Syst Rev 2018;4:10.1002/14651858.CD001841.pub3. Commentary by: Dr Elizabeth Adeyeye and Dr Teck Khong, Clinical Pharmacology, St...

Eplerenone for hypertension.

Eplerenone is an aldosterone receptor blocker that is chemically derived from spironolactone. In Canada, it is indicated for use as adjunctive therapy to reduce mortality for heart failure patients with New York Heart Association (NYHA) class II systolic chronic heart failure and left ventricular systolic dysfunction. It is also used as adjunctive therapy for patients with heart failure following myocardial infarction. Additionally, it is indicated for the treatment of mild and moderate essential hypertension for patients who cannot be treated adequately with other agents. It is important to determine the clinical impact of all antihypertensive medications, including aldosterone antagonists, to support their continued use in essential hypertension. No previous systematic reviews have evaluated the effect of eplerenone on cardiovascular morbidity, mortality, and magnitude of blood pressure lowering in patients with hypertension. To assess the effects of eplerenone monotherapy versus placebo for primary hypertension in adults. Outcomes of interest were all-cause mortality, cardiovascular events (fatal or non-fatal myocardial infarction), cerebrovascular events (fatal or non fatal strokes), adverse events or withdrawals due to adverse events, and systolic and diastolic blood pressure. We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers up to 3 March 2016. We handsearched references from retrieved studies to identify any studies missed in the initial search. We also searched for unpublished data by contacting the corresponding authors of the included studies and pharmaceutical companies involved in conducting studies on eplerenone monotherapy in primary hypertension. The search had no language restrictions. We selected randomized placebo-controlled trials studying adult patients with primary hypertension. We excluded studies in people with secondary or gestational hypertension and studies where participants were receiving multiple antihypertensives. Three review authors independently reviewed the search results for studies meeting our criteria. Three review authors independently extracted data and assessed trial quality using a standardized data extraction form. A fourth independent review author resolved discrepancies or disagreements. We performed data extraction and synthesis using a standardized format on Covidence. We conducted data analysis using Review Manager 5. A total of 1437 adult patients participated in the five randomized parallel group studies, with treatment durations ranging from 8 to 16 weeks. The daily doses of eplerenone ranged from 25 mg to 400 mg daily. Meta-analysis of these studies showed a reduction in systolic blood pressure of 9.21 mmHg (95% CI -11.08 to -7.34; I2 = 58%) and a reduction of diastolic pressure of 4.18 mmHg (95% CI -5.03 to -3.33; I2 = 0%) (moderate quality evidence).There may be a dose response effect for eplerenone in the reduction in systolic blood pressure at doses of 400 mg/day. However, this finding is uncertain, as it is based on a single included study with low quality evidence. Overall there does not appear to be a clinically important dose response in lowering systolic or diastolic blood pressure at eplerenone doses of 50 mg to 400 mg daily. There did not appear to be any differences in the number of patients who withdrew due to adverse events or the number of patients with at least one adverse event in the eplerenone group compared to placebo. However, only three of the five included studies reported adverse events. Most of the included studies were of moderate quality, as we judged multiple domains as being at unclear risk in the 'Risk of bias' assessment. Eplerenone 50 to 200 mg/day lowers blood pressure in people with primary hypertension by 9.21 mmHg systolic and 4.18 mmHg diastolic compared to placebo, with no difference of effect between doses of 50 mg/day to 200 mg/day. A dose of 25 mg/day did not produce a statistically significant reduction in systolic or diastolic blood pressure and there is insufficient evidence for doses above 200 mg/day. There is currently no available evidence to determine the effect of eplerenone on clinically meaningful outcomes such as mortality or morbidity in hypertensive patients. The evidence available on side effects is insufficient and of low quality, which makes it impossible to draw conclusions about potential harm associated with eplerenone treatment in hypertensive patients.

Hypertension: diagnosis, assessment and management.

Hypertension is a serious and common condition, the prevalence of which is set to rise given the increase in the ageing population, sedentary lifestyles and obesity. This article reviews the management of primary hypertension in adults, with reference to the National Institute for Health and Care Excellence guidelines. Diagnosis using clinic, ambulatory and home blood pressure (BP) monitoring, risk factors , BP targets, lifestyle advice, drug treatment and patient education are also discussed.

KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Management of Blood Pressure in CKD

In response to the 2012 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for blood pressure management in patients with chronic kidney disease not on dialysis, the National Kidney Foundation organized a group of US experts in hypertension and transplant nephrology to review the recommendations and comment on their relevancy in the context of current US clinical practice and concerns. The overriding message was the dearth of clinical trial evidence to provide strong evidence-based recommendations. For patients with CKD with normal to mildly increased albuminuria, goal blood pressure has been relaxed to ≤140/90 mm Hg for both diabetic and nondiabetic patients. In contrast, KDIGO continues to recommend goal blood pressure ≤130/80 mm Hg for patients with chronic kidney disease with moderately or severely increased albuminuria and for all renal transplant recipients regardless of the presence of proteinuria, without supporting data. The expert panel thought the KDIGO recommendations were generally reasonable but lacking in sufficient evidence support and that additional studies are greatly needed.

Is It Possible to Manage Hypertension and Evaluate Therapy Without Ambulatory Blood Pressure Monitoring?

In the management of patients with hypertension, blood pressure (BP) has been traditionally measured in the physician's office. The contribution of ambulatory BP monitoring (ABPM) to the management of hypertensive patients has been increasingly recognized through clinical and epidemiological research. Ambulatory BP monitoring can enhance the ability to detect white-coat or masked hypertension, determine the absence of nocturnal dipping status, and evaluate BP control in patients on antihypertensive therapy. Recently, the United Kingdom National Clinical Guideline Centre published guidelines for the clinical management of primary hypertension in adults, recommending the routine use of ABPM to make the initial diagnosis of hypertension. While the advantages of ABPM are apparent from a clinical perspective, its use should be considered in relation to the cost of the equipment, data evaluation, and staff training as well as the possible inconvenience to the patient. In this review, we summarize the clinical importance of ABPM and discuss the current guidelines for establishing the diagnosis of hypertension.

New NICE Guideline on the Treatment of Hypertension

The British guidelines on the management of primary hypertension, developed by the National Institute for Clinical Excellence (NICE), have just been published in August 2011. There are several significant changes in the diagnosis and the treatment for primary hypertension in adults. Ambulatory blood pressure measurement should be regarded as the new gold standard in the diagnosis. Home blood pressure monitoring is also useful for the diagnosis and monitoring of hypertension. Because of the results of the Anglo-Scandinavian Cardiac Outcomes Trial study, calcium channel blockers (CCB) and blockers of the renin-angiotensin system have surpassed diuretics and beta-blockers as first line options. Patients younger than 55 should receive an ACE inhibitor, or an angiotensin receptor blocker if the former is not tolerated. Older patients should be started on a CCB. A thiazide diuretic can be used as an adjunct to the first line treatment. Chorthalidone and indapamide are preferred as they showed favorable outcomes in large clinical trials. Treatment with these three drug classes should be sufficient in the majority of patients, but if triple therapy is still insufficient, referral to a hypertension specialist is recommended. Further diuretic therapy with spironolactone can be used as the fourth line treatment. Some aspects of the new guideline are controversial, such as the practical difficulties of using ambulatory blood pressure monitoring in family practice, and the arbitrary blood pressure cutoff levels. Many doctors also believe that control of blood pressure is best achieved using a wider range of drugs to suit the individual patient.

Research Roundup

British Journal of Cardiac NursingVol. 7, No. 3 Research RoundupResearch RoundupBelinda LindenBelinda LindenSearch for more papers by this authorBelinda LindenPublished Online:27 Sep 2013https://doi.org/10.12968/bjca.2012.7.3.142AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Reese RL, Freedland KE, Steinmeyer BC, Rich MW, Rackley JW, Carney RM (2011) Depression and rehospitalization following acute myocardial infarction. Circ Cardiovasc Qual Outcomes 4: 626–626 Crossref, Google ScholarMalach M, Imperato PJ (2004) Depression and acute myocardial infarction. Medscape Today http://www.medscape.com/viewarticle/475151 (loginrequired) Google ScholarWard AM, Takahashi O, Stevens R, Heneghan C (2012) Home measurement of blood pressure and cardiovascular disease: systematic review and meta-analysis of prospective studies. J Hypertens doi: 10.1097/HJH.0b013e32834e4aed (online ahead of print) Crossref, Google ScholarNational Institute for Health and Clinical Excellence (2011) Hypertension: Clinical Management of Primary Hypertension in Adults. [CG 127]. NICE, London Google ScholarGrech M, Debono J, Xuereb RG, Fenech A, Grech V (2011) A comparison between dual axis rotational coronary angiography and conventional coronary angiography. Catheter Cardiovasc Interv doi: 10.1002/ ccd.23415 (online ahead of print) Google ScholarKlein AJ, Garcia JA, Hudson PA et al. (2011) Safety and efficacy of dual-axis rotational coronary angiography vs. standard coronary angiography. Catheter Cardiovasc Interv 77: 820–820 Crossref, Google ScholarCollinson P, Goodacre S, Gaze D, Gray A on behalf of the RATPAC team (2012) Very early diagnosis of chest pain by point-of-care testing: comparison of the diagnostic efficiency of a panel of cardiac biomarkers compared with troponin measurement alone in the RATPAC trial. Heart 98: 312–312 Crossref, Google ScholarPatterson C, Bryan L, Duncan M, Collinson J, Padley S (2011) The feasibility of nurse-led assessment in acute chest pain admissions by means of coronary computed tomography. Eur J Cardiovasc Nurs http://dx.doi.org/10.1016/j.ejcnurse.2011.06.002 (onlineahead of print) Google ScholarBrignole M, Botto GL, Mont L et al. (2012) Predictors of clinical efficacy of ‘Ablate and Pace’ therapy in patients with permanent atrial fibrillation. Heart 98: 297–297 Crossref, Google ScholarBishu K, Hamdani N, Mohammed SF et al. (2011) Sildenafil and B-type natriuretic K peptide acutely phosphorylate titin and improve diastolic distensibility in vivo. Circulation 124: 2882–2882 Crossref, Google ScholarNational Heart, Lung and Blood Institute (2011) Evaluating the effectiveness of sildenafil at improving health outcomes and exercise ability in people with diastolic heart failure (The Relax Study) http://clinicaltrials.gov/ct2/show/NCT00763867 (accessed 15 February 2012) Google ScholarBrännström M, Hägglund L, Fürst CJ, Boman K (2011) Unequal care for dying patients in Sweden – A comparative registry study of deaths from heart disease and cancer. Eur J Cardiovasc Nurs http://dx.doi.org/10.1016/j.ejcnurse.2011.06.007 (online aheadof print) Google ScholarClark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL (2012) Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis. Lancet doi:10.1016/S0140-6736(11)61710-8 (onine ahead of print) Crossref, Google ScholarNational Institute for Health and Clinical Excellence (2011) Hypertension: Clinical Management of Primary Hypertension in Adults. [CG 127]. NICE, London Google Scholar FiguresReferencesRelatedDetails 1 March 2012Volume 7Issue 3ISSN (online): 2052-2207 Metrics History Published online 27 September 2013 Published in print 1 March 2012 Information© MA Healthcare LimitedPDF download

NICE clinical guideline 127: Hypertension: Clinical management of primary hypertension in adults

NICE clinical guideline 127: Hypertension: Clinical management of primary hypertension in adults

NICE clinical guideline 127: Hypertension: Clinical management of primary hypertension in adults

NICE clinical guideline 127: Hypertension: Clinical management of primary hypertension in adults

UK Guidelines Call for Routine 24-Hour Ambulatory Blood Pressure Monitoring in All Patients to Make the Diagnosis of Hypertension-Not Ready for Prime Time in the United States

UK Guidelines Call for Routine 24-Hour Ambulatory Blood Pressure Monitoring in All Patients to Make the Diagnosis of Hypertension-Not Ready for Prime Time in the United States

The effectiveness of Hibiscus sabdariffa in the treatment of hypertension: A systematic review

Hypertension is a common global health problem with significant mortality and morbidity. Hibiscus sabdariffa is a plant known in many countries and is consumed as hot and cold drinks In addition to its use in folk medicine; it has been suggested as treatment for many conditions including hypertension. The objectives of this review were to examine the evidence of effectiveness and safety of hibiscus in the treatment of hypertension. We searched several medical databases (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and the specialized register of the Cochrane Hypertension Group and the general engine Google) to January 2009. We included randomized controlled trials that had examined Hibiscus's effectiveness and safety in the treatment of primary hypertension in adults. Two authors independently selected the trials for the review, extracted the data, and critically appraised the included studies. Four trials, with a total of 390 patients, met our inclusion criteria. Two studies compared Hibiscus sabdariffa to black tea; one study compared it to captopril and one to lisinopril. The studies found that Hibiscus had greater blood pressure reduction than tea but less than the ACE-inhibitors. However, all studies, except one, were short term and of poor quality with a Jadad scoring of <3 and did not meet international standards. The four randomized controlled studies identified in this review do not provide reliable evidence to support recommending Hibiscus sabdariffa for the treatment of primary hypertension in adults.

P03-273 Emotional stress and primary hypertension in adults

Psychological factors in the etiology of hypertension is supported by many epidemiological investigations. However, further studies are warranted because inconsistent results of several experimental and clinical studies. The aim of this study was to estimate the exposure and the resistance to emotional stress in hypertensive patients.The 33 subjects with diagnosed primary hypertension (17 women and 16 men, 47.8±12.6 years ) and 29 healthy volunteers (12 women and 17 men, 30.0±11.0 years ) were examined. The exposure and the resistant to emotional stress in the subjects was assayed based on a questionnaire including items to assess sources of stress, occurrence of emotional stress in life periods (from childhood to nowadays) as well as the resistance to stress in the subjects own sense as good, moderate and weak. All the participants had also measured blood pressure.Most of the subjects (80%) were exposed to emotional stress in both groups. Results of the study showed that the main sources of emotional stress in hypertensive subjects were: job (56%), family (74%) and health (56%) while in the healthy: job (50%) and family (79%). The least 11% of healthy people declared health as the main source of stress. It was found that significantly higher percentage of hypertensive subjects declared weak resistance to stress than healthy (55 vs.17%). Analysis of blood pressure didn't show any significant dependence on stress in both studied groups.Based on the obtained results it is justified to conclude that hypertensive patients were less resistant to emotional stress than healthy people.

Relaxation therapies for the management of primary hypertension in adults: a Cochrane review

The objective of this review was to evaluate the effectiveness of relaxation to lower high blood pressure. We searched electronic bibliographic databases and grey literature to identify randomized controlled trials comparing relaxation therapies with no active treatment or sham therapy, enrolling adult participants with raised systolic blood pressure (SBP) > or = 140 mm Hg or diastolic blood pressure (DBP) > or = 85 mm Hg and follow-up > or = 8 weeks. Twenty-five trials with up to 5 years follow-up, assessing 1198 participants, met our inclusion criteria and were meta-analysed. Overall, relaxation resulted in small, statistically significant reductions in SBP (mean difference: -5.5 mm Hg, 95% CI: -8.2 to -2.8) and DBP (mean difference: -3.5 mm Hg, 95% CI: -5.3 to -1.6) compared to the control. Substantial heterogeneity between trials (I2 > 70%) was not explained by duration of follow-up, type of control, type of relaxation therapy or baseline blood pressure. The 9 trials that reported blinding of outcome assessors found a non-significant net reduction in blood pressure (SBP mean difference: -3.2 mm Hg, 95% CI: -7.7 to 1.4) associated with relaxation, as did the 15 trials comparing relaxation with sham therapy (SBP mean difference: -3.5 mm Hg, 95% CI: -7.1 to 0.2). Adequate randomization was confirmed in only seven trials and concealment of allocation in only one. In view of the poor quality of the included trials and unexplained variation between trials, the evidence in favour of a causal association between relaxation and blood pressure reduction is weak. Some of the apparent benefit of relaxation was probably due to aspects of treatment unrelated to relaxation.

Relaxation therapies for the management of primary hypertension in adults

Lifestyle interventions are often recommended as initial treatment for mild hypertension, but the efficacy of relaxation therapies is unclear. To evaluate the effects of relaxation therapies on cardiovascular outcomes and blood pressure in people with elevated blood pressure. We searched the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, ISI Proceedings, ClinicalTrials.gov, Current Controlled Trials and reference lists of systematic reviews, meta-analyses and randomised controlled trials (RCTs) included in the review. RCTs of a parallel design comparing relaxation therapies with no active treatment, or sham therapy; follow-up >/=8 weeks; participants over 18 years, with raised systolic blood pressure (SBP) >/=140 mmHg or diastolic blood pressure (DBP) >/=85 mmHg); SBP and DBP reported at end of follow-up. participants were pregnant; participants received antihypertensive medication which changed during the trial. Two reviewers independently extracted data and assessed trial quality. Disagreements were resolved by discussion or a third reviewer. Random effects meta-analyses and sensitivity analyses were conducted. 29 RCTs, with eight weeks to five years follow-up, met our inclusion criteria; four were excluded from the primary meta-analysis because of inadequate outcome data. The remaining 25 trials assessed 1,198 participants, but adequate randomisation was confirmed in only seven trials and concealment of allocation in only one. Only one trial reported deaths, heart attacks and strokes (one of each). Meta-analysis indicated that relaxation resulted in small, statistically significant reductions in SBP (mean difference: -5.5 mmHg, 95% CI: -8.2 to -2.8, I2 =72%) and DBP (mean difference: -3.5 mmHg, 95% CI: -5.3 to -1.6, I2 =75%) compared to control. The substantial heterogeneity between trials was not explained by duration of follow-up, type of control, type of relaxation therapy or baseline blood pressure. The nine trials that reported blinding of outcome assessors found a non-significant net reduction in blood pressure (SBP mean difference: -3.2 mmHg, 95% CI: -7.7 to 1.4, I(2) =69%) associated with relaxation. The 15 trials comparing relaxation with sham therapy likewise found a non-significant reduction in blood pressure (SBP mean difference: -3.5 mmHg, 95% CI: -7.1 to 0.2, I(2) =63%). In view of the poor quality of included trials and unexplained variation between trials, the evidence in favour of causal association between relaxation and blood pressure reduction is weak. Some of the apparent benefit of relaxation was probably due to aspects of treatment unrelated to relaxation.

Combined calcium, magnesium and potassium supplementation for the management of primary hypertension in adults

Previous research suggests that increasing dietary intakes of calcium, potassium or magnesium separately may reduce BP to a small degree over the short term. It is unclear whether increasing intakes of a combination of these minerals produces a larger reduction in BP. To evaluate the effects of combined mineral supplementation as a treatment for primary hypertension in adults. We searched the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, ISI Proceedings, ClinicalTrials.gov, Current Controlled Trials, CAB abstracts, and reference lists of systematic reviews, meta-analyses and randomised controlled trials (RCTs) included in the review. The search was unrestricted by language or publication status. Inclusion criteria were: 1) RCTs of a parallel or crossover design comparing oral supplements comprising a combination of potassium, and/or calcium, and/or magnesium with placebo, no treatment, or usual care; 2) treatment and follow-up >=8 weeks; 3) participants over 18 years old, with raised systolic blood pressure (SBP) >=140 mmHg or diastolic blood pressure (DBP) >=85 mmHg with no known primary cause; 4) SBP and DBP reported at end of follow-up. We excluded trials where participants were pregnant, or received antihypertensive medication which changed during the study. Two reviewers independently extracted data and assessed trial quality. Disagreements were resolved by discussion or a third reviewer. Random effects meta-analyses and sensitivity analyses were conducted. We included three RCTs (n=277) with between 24 and 28 weeks follow-up. Three combinations of minerals were investigated: potassium & magnesium, calcium & magnesium, and calcium & potassium. One trial investigated combinations of calcium & magnesium and of calcium & potassium, and for each found a statistically non-significant increase in both SBP and DBP. All three trials investigated the combination of potassium & magnesium. None of the trials provided data on mortality or morbidity. The combination of potassium & magnesium compared to control resulted in statistically non-significant reductions in both SBP (mean difference = -4.6 mmHg, 95% CI: -9.9 to 0.7) and DBP (mean difference = -3.8 mmHg, 95% CI: -9.5 to 1.8), although the results were heterogeneous (I(2)=68% and 85% for SBP and DBP respectively).A sensitivity analysis using alternative reported values which accounted for missing data had very little effect on DBP but resulted in a larger, statistically significant reduction in SBP (mean difference = -5.8 mmHg, 95% CI: -10.5 to -1.0). The quality of the trials was not well reported. We found no robust evidence that supplements of any combination of potassium, magnesium or calcium reduce mortality, morbidity or BP in adults. More trials are needed to investigate whether the combination of potassium & magnesium is effective.

Magnesium supplementation for the management of primary hypertension in adults

Epidemiological evidence on the effects of magnesium on blood pressure is inconsistent. Metabolic and experimental studies suggest that magnesium may have a role in the regulation of blood pressure. To evaluate the effects of magnesium supplementation as treatment for primary hypertension in adults. We searched the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, ISI Proceedings, ClinicalTrials.gov, Current Controlled Trials, CAB abstracts, and reference lists of systematic reviews, meta-analyses and randomised controlled trials (RCTs) included in the review. Inclusion criteria were: 1) RCTs of a parallel or crossover design comparing oral magnesium supplementation with placebo, no treatment, or usual care; 2) treatment and follow-up >/=8 weeks; 3) participants over 18 years old, with raised systolic blood pressure (SBP) >/=140 mmHg or diastolic blood pressure (DBP) >/=85 mmHg; 4) SBP and DBP reported at end of follow-up. We excluded trials where: participants were pregnant; received antihypertensive medication which changed during the study; or magnesium supplementation was combined with other interventions. Two reviewers independently abstracted data and assessed trial quality. Disagreements were resolved by discussion or a third reviewer. Random effects meta-analyses and sensitivity analyses were conducted. Twelve RCTs (n=545) with eight to 26 weeks follow-up met our inclusion criteria. The results of the individual trials were heterogeneous. Combining all trials, participants receiving magnesium supplements as compared to control did not significantly reduce SBP (mean difference: -1.3 mmHg, 95% CI: -4.0 to 1.5, I(2)=67%), but did statistically significantly reduce DBP (mean difference: -2.2 mmHg, 95% CI: -3.4 to -0.9, I(2)=47%). Sensitivity analyses excluding poor quality trials yielded similar results. Sub-group analyses and meta-regression indicated that heterogeneity between trials could not be explained by dose of magnesium, baseline blood pressure or the proportion of males among the participants. In view of the poor quality of included trials and the heterogeneity between trials, the evidence in favour of a causal association between magnesium supplementation and blood pressure reduction is weak and is probably due to bias. This is because poor quality studies generally tend to over-estimate the effects of treatment. Larger, longer duration and better quality double-blind placebo controlled trials are needed to assess the effect of magnesium supplementation on blood pressure and cardiovascular outcomes.

Potassium supplementation for the management of primary hypertension in adults

Epidemiological evidence on the effects of potassium on blood pressure is inconsistent. To evaluate the effects of potassium supplementation on health outcomes and blood pressure in people with elevated blood pressure. We searched the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, ISI Proceedings, ClinicalTrials.gov, Current Controlled Trials, CAB abstracts, and reference lists of systematic reviews, meta-analyses and randomised controlled trials (RCTs) included in the review. Inclusion criteria were: 1) RCTs of a parallel or crossover design comparing oral potassium supplements with placebo, no treatment, or usual care; 2) treatment and follow-up >=8 weeks; 3) participants over 18 years, with raised systolic blood pressure (SBP) >=140 mmHg or diastolic blood pressure (DBP) >=85 mmHg); 4) SBP and DBP reported at end of follow-up. We excluded trials where: participants were pregnant; received antihypertensive medication which changed during the study; or potassium supplementation was combined with other interventions. Two reviewers independently extracted data and assessed trial quality. Disagreements were resolved by discussion or a third reviewer. Random effects meta-analyses and sensitivity analyses were conducted. Six RCT's (n=483), with eight to 16 weeks follow-up, met our inclusion criteria. Meta-analysis of five trials (n=425) with adequate data indicated that potassium supplementation compared to control resulted in a large but statistically non-significant reductions in SBP (mean difference: -11.2, 95% CI: -25.2 to 2.7) and DBP (mean difference: -5.0, 95% CI: -12.5 to 2.4). The substantial heterogeneity between trials was not explained by potassium dose, quality of trials or baseline blood pressure. Excluding one trial in an African population with very high baseline blood pressure resulted in smaller overall reductions in blood pressure (SBP mean difference: -3.9, 95% CI: -8.6 to 0.8; DBP mean difference: -1.5, 95% CI: -6.2 to 3.1). Further sensitivity analysis restricted to two high quality trials (n=138) also found non-significant reductions in blood pressure (SBP mean difference: -7.1, 95% CI: -19.9 to 5.7; DBP mean difference: -5.5, 95% CI: -14.5 to 3.5). This systematic review found no statistically significant effect of potassium supplementation on blood pressure. Because of the small number of participants in the two high quality trials, the short duration of follow-up, and the unexplained heterogeneity between trials, the evidence about the effect of potassium supplementation on blood pressure is not conclusive. Further high quality RCTs of longer duration are required to clarify whether potassium supplementation can reduce blood pressure and improve health outcomes.

Calcium supplementation for the management of primary hypertension in adults

Metabolic studies suggest calcium may have a role in the regulation of blood pressure. Some epidemiological studies have reported that people with a higher intake of calcium tend to have lower blood pressure. Previous systematic reviews and meta-analyses have reached conflicting conclusions about whether oral calcium supplementation can reduce blood pressure. To evaluate the effects of oral calcium supplementation as a treatment for primary hypertension in adults. We searched the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, ISI Proceedings, ClinicalTrials.gov, Current Controlled Trials, CAB abstracts, and reference lists of systematic reviews, meta-analyses and randomised controlled trials (RCTs) included in the review. Inclusion criteria were: 1) RCTs comparing oral calcium supplementation with placebo, no treatment, or usual care; 2) treatment and follow-up >/=8 weeks; 3) participants over 18 years old, with raised systolic blood pressure (SBP) >/=140 mmHg or diastolic blood pressure (DBP) >/=85 mmHg; 4) SBP and DBP reported at end of follow-up. We excluded trials where: participants were pregnant; received antihypertensive medication which changed during the study; or calcium supplementation was combined with other interventions. Two reviewers independently abstracted data and assessed trial quality. Disagreements were resolved by discussion or a third reviewer. Random effects meta-analyses and sensitivity analyses were conducted. We included 13 RCTs (n=485), with between eight and 15 weeks follow-up. The results of the individual trials were heterogeneous. Combining all trials, participants receiving calcium supplementation as compared to control had a statistically significant reduction in SBP (mean difference: -2.5 mmHg, 95% CI: -4.5 to -0.6, I(2 )= 42%), but not DBP (mean difference: -0.8 mmHg, 95% CI: -2.1 to 0.4, I(2) = 48%). Sub-group analyses indicated that heterogeneity between trials could not be explained by dose of calcium or baseline blood pressure. Heterogeneity was reduced when poor quality trials were excluded. The one trial reporting adequate concealment of allocation and the one trial reporting adequate blinding yielded results consistent with the primary meta-analysis. In view of the poor quality of included trials and the heterogeneity between trials, the evidence in favour of causal association between calcium supplementation and blood pressure reduction is weak and is probably due to bias. This is because poor quality studies generally tend to over-estimate the effects of treatment. Larger, longer duration and better quality double-blind placebo controlled trials are needed to assess the effect of calcium supplementation on blood pressure and cardiovascular outcomes.