Reach Target Blood Pressure Research Articles

Addressing chronic kidney disease in Far North Queensland: gains and opportunities

To determine whether people seen by the Far North Queensland Specialist Medical Outreach Service (SMOS) with chronic kidney disease (CKD) and proteinuria were treated according to established guidelines. Audit of SMOS clinical reports from 18th May to 27th July 2012. Clinical markers were compared with the Caring for Australians with Renal Impairment and National Heart Foundation management guidelines. Reports covering primary health care centres located in remote communities of Cape York Peninsula and Torres Strait, Far North Queensland. The proportion of people with CKD and proteinuria on appropriate renoprotective treatment with an angiotensin-converting enzyme inhibitor (ACE-inhibitor) or angiotensin-2 receptor blocker (ARB). The proportion of people with CKD and proteinuria reaching blood pressure targets as per National Heart Foundation guidelines. The proportion of people with stage 4 CKD appropriately referred to a specialist renal service. One hundred and eighty-six clinical reports were reviewed; 48 people had markers of CKD. Forty-five of the 48 (94%) had been prescribed an ACE-inhibitor or ARB according to management guidelines. Nineteen of the 48 (40%) had blood pressures within the target range. Four of six people with late-stage CKD (stage 4 or 5) had been referred to a specialist renal service. This audit confirms the high rate of CKD in the people of Far North Queensland, although this is a highly selected sample. It shows appropriate prescribing of renoprotective treatment in most cases. However, it also highlights the need for a more vigorous approach to blood pressure control.

Tratamiento de los factores de riesgo vascular y objetivos terapéuticos

Global cardiovascular risk assessment is recommended for every individual patient. Among other risk factors and clinical conditions, management of diabetes, hypertension and smoking will be reviewed here. Goals in diabetes control should be individualized for every patient. Treatment includes diet modification, physical exercise and pharmacological treatment including insulins and oral antidiabetic drugs. When treating hypertension the main benefit depends on the reduction of blood pressure achieved. Both lifestyle modifications and drugs may contribute to reach blood pressure targets. Smoking cessation therapies have shown to reduce quit rates. They are based on behavioral support and pharmacological aids if necessary. First-line smoking cessation therapies help to control smoker physical addiction and are: nicotine replacement therapy (NRT), bupropion and varenicline.

The proportion of isolated systolic hypertension is lower in Korean elderly hypertensives

Background: This study aimed to find characteristics of hypertension subtypes and predictive factors associated with failure of reaching target blood pressure (BP) in Korean elderly hypertensives. Methods: This prospective, multi-center, observational study evaluated 2439 hypertensive elderly patients (≥60 years), between December 2008 and November 2011. The inadequately treated and drug-naïve patients were categorized in three hypertension subtypes (isolated systolic hypertension [ISH], combined systolic/diastolic hypertension [SDH], and isolated diastolic hypertension [IDH]). At six month, patients were assessed for achieving target BP. The study compared the clinical characteristics of patients who did not achieve target BP with those who achieved. Results: In Korean elderly hypertensives, ISH was the most frequent subtype of uncontrolled hypertension (53.2%, 1297/2439). In total drug-naïve patients, SDH was predominant hypertension subtype (59.6%, 260/436), while in patients aged 60-69 years, SDH was prevalent in 64.1% patients and ISH in 34.4%. At six month, 1395 (66.2%, 1395/2107) patients achieved target BP. Predictive factors associated with failure of reaching target BP were old age and awareness of hypertension. Predictive factors for failure of reaching target BP were awareness of hypertension, ISH and microalbuminuria for drug naïve patients and old age for inadequately treated patients. Conclusions: The proportion of ISH in Korean elderly hypertensives was lower than that published by earlier studies in the US. Old age and awareness of hypertension were predictive factors for failure of reaching target BP in Korean elderly hypertensives. These results would help in adjusting antihypertensive treatment strategies in Korean elderly hypertensives.

Potential Benefits of Rho-kinase Inhibition in Arterial Hypertension

Arterial hypertension is a major health problem, accounting for 12 % of the global death rate. A large proportion of patients treated for high blood pressure do not reach target blood pressure values. The question arises if new antihypertensive drugs could improve present hypertension treatment. Rho-kinases (ROCKs) are ubiquitously expressed serine/threonine kinases and involved in a variety of cell functions. They contribute to the pathogenesis of human and experimental hypertension. Pharmacological ROCK inhibition has been shown to effectively lower blood pressure in patients and experimental animals. Progress has been made towards the understanding on how non-selective ROCK inhibitors lower arterial pressure and efforts are currently undertaken to develop ROCK inhibitors to improve their specificity and isoenzyme selectivity. If introduction of ROCK inhibitors for the treatment of high blood pressure can significantly advance currently available options of antihypertensive pharmacotherapy awaits further experimental and clinical research.

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Which is the Optimal Antihypertensive Combination in Different Diseases, a Renin- Angiotensin-aldosterone System Inhibitor with a Diuretic or with a Calcium Channel Blocker?

Successful treatment of hypertension often requires the association of drugs from different classes. Combination therapy takes advantage of complementary mechanisms of action, in order to reach target blood pressure (BP) earlier and to minimize the side effects of medications. In the last decade, several randomized trials have demonstrated the efficacy of combining a renin-angiotensin-aldosterone system (RAAS) inhibitor with a calcium channel blocker (CCB) or with a diuretic in different populations. The ACCOMPLISH trial was the only large clinical trial that directly compared the two combination strategies. In hypertensive individuals at high cardiovascular risk, benazepril plus amlodipine was superior to benazepril plus hydrochlorothiazide in reducing the primary composite endpoint of cardiovascular events plus death from cardiovascular causes. Small randomized trials have evaluated the two combination therapies in surrogate endpoints, such as microalbuminuria, with contrasting results. Current European and American guidelines recommend combination therapy as first-line when BP is at least 20/10 mmHg above treatment goals. However, the choice of the best combination therapy is still debated: the National Institute for Health and Clinical Excellence guidelines recommend a RAAS inhibitor plus a CCB, while the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines underline the pivotal role of thiazide diuretics. The combination of a RAAS inhibitor with a CCB demonstrated the best efficacy in reducing cardiovascular endpoint. However, the combination of a RAAS inhibitor with a diuretic has shown beneficial results in particular subgroup of patients, such as patients with heart failure or with African American origin. This review will focus on the rationale and current evidences about combination therapy in the management of arterial hypertension.

Effects of CPAP on &amp;quot;vascular&amp;quot; risk factors in patients with obstructive sleep apnea and arterial hypertension

BackgroundThe aim of this study was to assess the effects of continuous positive airway pressure (CPAP) on arterial stiffness, central blood pressure, and reflected pulse wave characteristics in patients with severe obstructive sleep apnea (OSA) and stage 2–3 arterial hypertension.MethodsForty-four patients with hypertension and severe OSA (apnea/hypopnea index > 30) received stepped dose titration of antihypertensive treatment, consisting of valsartan 160 mg + amlodipine 5–10 mg + hydrochlorothiazide 25 mg. CPAP therapy was added after 3 weeks of continuous antihypertensive treatment with BP < 140/90 mmHg or after adjusting triple treatment in patients with resistant arterial hypertension. The patients were randomized to effective CPAP (4–15 mm H2O) or placebo CPAP (pressure 4 mm H2O) for three weeks, then crossed over to the alternative treatment in a single-blind manner. Office blood pressure (BP), ambulatory BP monitoring, ambulatory arterial stiffness index (AASI), aortic BP, carotid-femoral pulse wave velocity (cfPWV), and systolic wave augmentation index were measured using a Sphygmocor® device at baseline, after antihypertensive treatment, placebo CPAP, and effective CPAP.ResultsBaseline cfPWV was above the normal range in 94% of patients. After reaching target BP, the cfPWV decreased by 1.9 ± 1.0 msec (P = 0.007). Effective CPAP achieved a further cfPWV reduction of 0.7 msec (P = 0.03). Increased arterial stiffness (pulse wave velocity > 12 msec) persisted in 35% of patients on antihypertensive treatment and effective CPAP, in 56% of patients on antihypertensive treatment alone, and in 53% of patients on placebo CPAP. Only the combination of antihypertensive treatment with effective CPAP achieved a significant reduction in augmentation index and AASI, along with a further reduction in aortic and brachial BP.ConclusionEffective CPAP for 3 weeks resulted in a significant additional decrease in office BP, ambulatory BP monitoring, central BP, and augmentation index, together with an improvement in arterial stiffness parameters, ie, cfPWV and AASI, in a group of hypertensive patients with OSA.

A report from the American Society of Hypertension 28th Annual Scientific Meeting and Exposition (May 15-18, 2013 - San Francisco, California, U.S.A.)

A wide selection of antihypertensive drugs are currently available for managing hypertension, with distinct advantages and disadvantages in selected patient populations. However, many patients require combination approaches for effective control of blood pressure, and new drugs are required for reaching target blood pressure values in difficult-to-treat subjects. Indeed, initial use of combination therapies more effectively lowered blood pressure, resulting in a further decreased risk of stroke compared to antihypertensive monotherapy (Yu, J. et al., Abst PO-13). Nevertheless, novel drugs and new fixed-drug combinations are being developed, as reported in the following report from this year's American Society of Hypertension meeting. As exemplified by a comparison of newer versus older antihypertensive drugs in Sub-Saharan African countries that demonstrated the superiority of valsartan/amlodipine versus bisoprolol/hydrochlorothiazide (M'Buyamba-Kabangu, J.R. et al., Abst PO-86), newer drugs are beating the efficacy of older agents, and drugs currently in development may eventually demonstrate greater benefits that drugs considered new today. Research continues, as the morbidity and mortality associated with hypertension is better recognized as a threat in aging populations worldwide.

Efficacy of Telmisartan Plus Amlodipine in Nonresponders to CCB Monotherapy

Hypertensive patients unable to reach blood pressure (BP) targets with antihypertensive monotherapy may be switched to a combination of two medications with complementary modes of action for improved treatment response. This post hoc analysis pools data from 2812 patients, 1891 of whom were not at goal (diastolic BP [DBP] <90 mm Hg) with amlodipine 5 mg (A5) monotherapy who subsequently switched to telmisartan 40 or 80 mg (T80)/A5 single-pill combination (SPC) or amlodipine 10 mg (A10) monotherapy, and considers an additional 921 patients, 616 of whom were not at goal with A10 monotherapy who switched to telmisartan/amlodipine SPC. Patients switched to telmisartan/amlodipine SPC achieved significantly greater BP reductions compared with continued monotherapy (P < 0.0001) with reductions of −15.2/−10.9 mm Hg seen with T80/A5 after 8 weeks in patients switched from A5. BP goal (<140/90 mm Hg), systolic BP goal (<140 mm Hg), and DBP goal (<90 mm Hg) were reached by significantly more patients with telmisartan/amlodipine than with monotherapy (P < 0.0001 for all comparisons; 56.1%, 69.7%, and 66.9%, resp., in patients who switched from A5 to T80/A5). Early use of such combination therapy should be considered to quickly reach BP targets, particularly in patients with added risk.

Resistant Hypertension in Nondialysis Chronic Kidney Disease

Resistant hypertension (RH) is defined as blood pressure (BP) that remains above the target of less than 140/90 mmHg in the general population and 130/80 mmHg in people with diabetes mellitus or chronic kidney disease (CKD) in spite of the use of at least three full-dose antihypertensive drugs including a diuretic or as BP that reaches the target by means of four or more drugs. In CKD, RH is a common condition due to a combination of factors including sodium retention, increased activity of the renin-angiotensin system, and enhanced activity of the sympathetic nervous system. Before defining the hypertensive patient as resistant it is mandatory to exclude the so-called “pseudoresistance.” This condition, which refers to the apparent failure to reach BP target in spite of an appropriate antihypertensive treatment, is mainly caused by white coat hypertension that is prevalent (30%) in CKD patients. Recently we have demonstrated that “true” RH represents an independent risk factor for renal and cardiovascular outcomes in CKD patients.

Non-pharmacological methods in the treatment of resistant hypertension

Arterial hypertension is the most common chronic cardiovascular disease affecting about 25% of the adult population. Meta-analyses have demonstrated a linear relationship between blood pressure and the risk of cardiovascular events. Resistant hypertension defined as failure to reach blood pressure targets despite treatment with three antihypertensive drugs including a diuretic represents a serious clinical problem. It has been estimated that it affects between 8.9% and 12.8% of all treated hypertensive subjects. In resistant hypertension the optimal blood pressure is illusive despite very well tailored therapy. Management of resistant hypertension is exactly the field where blood pressure-controlling non-pharmacological methods fit best. The present article aims at throwing light on these methods' principles of action, on who the target patient groups are and the respective results. Two methods are especially reviewed here: the carotid baroreflex stimulation and the transcatheter renal sympathetic denervation. Current results from the use of renal denervation suggest stable efficiency of the method, the results becoming significant 6 months after the procedure is applied and sustained for two years in the follow-up. As much as 90% of the treated patients respond to the procedure. The transcatheter renal denervation is associated with only 2.61% of procedural complications. The baroreflex carotid stimulation, too, is known to produce a stable effect on blood pressure: the effect become obvious at 12 months in 88% of the treated subjects. The neurologic complications associated with the procedure are reported to occur in 4.4% of cases. The present review article clearly demonstrates that non-pharmacological methods for treatment of resistant hypertension show great promise despite some open questions concerning their long term effects and procedural safety.

Clinical analysis of factors predisposing the recurrence of primary intracerebral hemorrhage in patients taking anti-hypertensive drugs: A prospective cohort study

ObjectiveThe study examined differences in the recurrence rate of primary intracerebral hemorrhage (P-ICH) according to anti-hypertensive drug (AHD) use by patients with hypertension. MethodsThis prospective, longitudinal cohort study was performed on 2384 patients diagnosed with supratentorial P-ICH and hypertension in the stroke unit of a single-center. During follow-up (mean, 44.9±31.5 months), investigators interviewed subjects or caregivers by telephone or examined patients every 3–6 months. Target blood pressure was <140/90mmHg in the P-ICH cohort with hypertension. ResultsOf 1317 P-ICH patients defined to be taking AHDs, P-ICH recurrence occurred in 129 (9.8%). 1211 patients (92.0%) reached target blood pressure. In multivariate regression analysis, advanced age (≥70 years), poor functional outcome after first P-ICH, lobar location of P-ICH, previous history of cerebral ischemia, diuretic monotherapy and α- or β-blocker monotherapy were associated with risk of recurrence. ConclusionsAlthough hypertension is the most important factor for preventing P-ICH recurrence, we found that, even in the presence of optimal anti-hypertensive medication, recurrent P-ICH attack can occur. Therefore, management of other risk factors of recurrent P-ICH, such as modification of lifestyle, must be considered in treating the P-ICH patients.

Hematocrit Predicts Long-Term Mortality in a Nonlinear and Sex-Specific Manner in Hypertensive Adults

Hematocrit has been inconsistently reported to be a risk marker of cardiovascular morbidity and mortality. The Glasgow Blood Pressure Clinic Study cohort included 10951 hypertensive patients, who had hematocrit measured at their initial clinic visit and followed for ≤35 years. Cox proportional hazards models were used to estimate hazard ratios for all-cause, cardiovascular, ischemic heart disease, stroke, and noncardiovascular mortality. There were 3484 deaths over a follow-up period of 173245 person-years. Hematocrit was higher in men (median, 0.44; interquartile range, 0.42-0.47) than in women (median, 0.41; interquartile range, 0.38-0.43). The lowest risk for all-cause mortality was seen in quartile 2 for men (range, 0.421-0.440) and women (range, 0.381-0.400). Compared with quartile 2, the adjusted hazard ratios for quartiles 1, 3, and 4 were, respectively, 1.11 (range, 0.97-1.28), 1.19 (range, 1.04-1.37), and 1.22 (range, 1.06-1.39) in men and 1.17 (range, 1.01-1.36), 0.97 (range, 0.83-1.13), and 1.19 (range, 1.04-1.37) in women. Men showed a J-shaped pattern for cardiovascular mortality and a linear pattern for noncardiovascular mortality in cause-specific analysis, whereas in women a U-shaped pattern was observed for noncardiovascular mortality only. Higher baseline hematocrit was associated with higher on-treatment blood pressure during follow-up. Baseline hematocrit did not affect the time to reach target blood pressure. The increased risk of death attributed to higher hematocrit was seen in men and women irrespective of their achievement of target blood pressure, indicating that the risk is independent of the effect of hematocrit on blood pressure. Hypertensive patients with hematocrit levels outside of the sex-specific reference ranges identified in this study should be targeted for more aggressive blood pressure and cardiovascular risk reduction treatment.

Emerging drug combinations to optimize renovascular protection and blood pressure goals

Hypertension and renal disease are closely related. In fact, there is an inverse linear relationship between renal function and prevalence of hypertension. Hypertensive patients with renal dysfunction exhibit a poor clinical profile, which markedly increases their risk for cardiovascular outcomes. This review considers the available evidence on the best therapeutic approach for optimizing renovascular protection in the hypertensive population. To effectively reduce or at least slow the establishment and progression of renal disease in the hypertensive population it is critical to reach blood pressure targets. Many studies have shown that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prevent or at least delay the development of microalbuminuria in patients with hypertension and type 2 diabetes, reduce the incidence of overt diabetic nephropathy, and are also beneficial in patients with nondiabetic renal disease. Therefore, renin-angiotensin system (RAS) inhibition plays a key role in the prevention of renal outcomes. As the majority of patients with hypertension will need at least two antihypertensive agents to achieve blood pressure goals, the use of RAS inhibitors is a mandatory part of antihypertensive therapy. The question of which antihypertensive agent is the best choice for combining with RAS blockers should be considered. Many studies have shown that diuretics and calcium channel blockers are the best choice. However, more studies are needed to clarify the subgroups of patients who will benefit more from a combination with a diuretic or from a combination with a calcium channel blocker. To date, RAS inhibitors recommended in this context are angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Aliskiren, the first oral direct renin inhibitor available, has shown promising results.

GP's Adherence to Guidelines for Cardiovascular Disease among Elderly: A Quality Development Study

Background. Evidence-based guidelines should in most cases be followed also in the treatment of elderly. Older people are often suboptimally treated with the recommended drugs. Objectives. To describe how well general practitioners adhere to current guidelines in the treatment of elderly with cardiovascular disease and evaluate local education as a tool for improvement. Method. Data was collected from the medical records of patients aged ≥65, who visited a primary health care center in Sweden 2006 and had one or more of the following diagnoses: hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation, or prior stroke. Local education was organized and included feed-back to the patient's doctor and discussion about regional guidelines. Repeated measurements were performed in 2008. Results and Conclusion. The adherence to guidelines was low. Approximately one-third of the patients with hypertension reached target blood pressure, stroke patients more often. More patients with heart failure were treated with angiotensin converting enzyme inhibitor than in other European countries, but still only 60%. Half of the patients with chronic atrial fibrillation were treated with Warfarin, although more than two-thirds had a CHADS2 score indicating the need. Educational efforts appeared to increase the adherence and hence should be encouraged.

Overcoming barriers in the management of hypertension: the experience of the cardiovascular health program in chilean primary health care centers.

Objective. To assess the blood pressure control and cardiovascular risk factors (CVRFs) in a population of hypertensive patients with access to care under a government-financed program, the Cardiovascular Health Program (CHP). Design. A cross-sectional and multicenter study. Setting. 52 primary care centers, metropolitan area of Santiago, Chile. Participants. 1,194 patients were selected by a systematic random sampling from a universe of 316,654 hypertensive patients. Key Measurements. Demographic information, blood pressure (BP) measurements, and CVRF were extracted from medical records of patients followed for a 12-month period. Results. 59.7% of patients reached target BP <140/90 mmHg. More women were captured in the sampling (2.1 : 1), achieving better BP control than men. Diabetic patients (26.4%) had worse BP control than nondiabetics. Antihypertensive medications were used in 91.5%, with multidrug therapy more frequent in patients with higher BP and more difficult control. Conclusions. The success in improving the BP control to values <140/90 mmHg from 45.3% to 59.7% underscores the contribution of this program in the Chilean primary care cardiovascular preventive strategies. However, fewer hypertensive men than women were captured by this program, and it is of concern the underperforming of BP control observed in diabetics.

Assessment of reasons for not intensifying antihypertensive treatment in the Taiwanese population

Despite availability of effective antihypertensives, blood pressure (BP) control is usually inadequate. The Reasons for not Intensifying Antihypertensive Treatment (RIAT) registry evaluated the reasons behind not modifying treatment in an international, cross-sectional study in 16 countries. The Taiwanese cohort of RIAT consisted of 8922 patients with untreated/uncontrolled essential hypertension recruited from 22 centers in the country. At the first visit, physicians selected target BP and antihypertensive treatment, and at the next three visits they measured BP and modified treatment/provided justification for not modifying treatment. Mean target BP selected by physicians was 134.6/84.6 ± 5.1/5.0 mmHg, respectively. Patients' individual risk stratification determined the BP goals. More patients achieved targets according to the physicians' opinion than based on actual BP measurements: visit 2-50.6% vs. 48.6%; visit 3-58.4% vs. 55.2%; and visit 4-61.2% vs. 57.0%. At each visit, treatment remained unchanged for >60% patients not reaching target; the most common reason for this at visit 2 was the assumption that the time was too short to assess new drug therapy and at visits 3 and 4 was the assumption that target was reached/had almost been reached. About 40% Taiwanese hypertensive patients in RIAT did not reach BP targets after an average of 4 months' follow-up. The most common reason for not modifying treatment was the assumption that the target had been reached or had almost been reached.

Review: A Single-Pill Combination of Telmisartan plus Amlodipine for the Treatment of Hypertension

Despite an increased proportion of patients with hypertension achieving recommended blood pressure (BP) targets, BP control remains suboptimal in many patients. A range of combination therapies utilizing medications with differing mechanisms of action have been shown to provide superior BP-lowering efficacy than monotherapy with individual components. Single-pill combinations deliver improved convenience and may help to improve patient compliance. A single-pill combination of the angiotensin receptor blocker (ARB) telmisartan and the calcium channel blocker (CCB) amlodipine has recently been approved in 4 different doses (telmisartan/amlodipine 40 mg/5 mg, 40 mg/10 mg, 80 mg/5 mg, and 80 mg/10 mg) for antihypertensive use in the United States. In an 8-week clinical study (N = 1461), these combinations were superior to monotherapy with telmisartan or with amlodipine with respect to the primary endpoint, change in diastolic BP (DBP) from baseline (mean baseline BP, 153.2 [± 12.1]/101.7 [± 4.3] mm Hg) to study end (placebo-corrected reductions of 10.3, 14.0, 12.0, and 13.9 mm Hg, respectively), as well as in multiple secondary endpoints, including change in systolic BP (SBP), DBP response, SBP response, BP control (< 140/< 90 mm Hg), and DBP control (< 90 mm Hg). The telmisartan plus amlodipine combinations were well tolerated, with the incidence of adverse events similar to placebo; the incidence of peripheral edema was lower with the 40 mg/10 mg and 80 mg/10 mg combinations than with amlodipine 10 mg alone. In another study (N = 858), the highest-dose combination (80 mg/10 mg) demonstrated superior BP-lowering efficacy than same-dose monotherapy with either telmisartan or amlodipine in patients with severe hypertension (SBP ≤ 180 and DBP ≤ 95 mm Hg). Single-pill telmisartan plus amlodipine combination therapy appears to be an effective and well-tolerated treatment as initial therapy for patients likely to require > 1 antihypertensive agent to reach BP targets.

Retrospective Analysis of Real-World Efficacy of Angiotensin Receptor Blockers Versus Other Classes of Antihypertensive Agents in Blood Pressure Management

Background Efficacy of blood pressure (BP) lowering may differ between clinical trials and what is observed in clinical practice. These differences may contribute to poor BP control rates among those at risk. Objective We conducted an observational study to determine the BP-lowering efficacy of angiotensin receptor blocker (ARB) versus non–ARB-based antihypertensive treatments in a large Canadian primary care database. Methods We analyzed the South Western Ontario database of 170,000 adults (aged >18 years) with hypertension persisting with antihypertensive medication for ≥9 months. Routine standard of care office BP was measured using approved manual aneroid or automated devices. BP <140 mm Hg and/or <90 mm Hg ≤9 months after treatment initiation, persistence (presence of initial antihypertensive prescription at the first, second, third, and fourth year anniversary) with antihypertensive therapy, and the presence of a cardiovascular (CV) event (ie, myocardial infarction) were studied. Results After 9 months of monotherapy, 28% (978 of 3490) of patients on ARBs achieved target BP versus 27% (839 of 3110) on angiotensin-converting enzyme inhibitors (ACEIs) ( P > 0.05), 26% (265 of 1020) on calcium channel blockers (CCBs) ( P > 0.05), 21% (221 of 1050) on β-blockers ( P = 0.002), and 19% (276 of 1450) on diuretics ( P = 0.001). Attainment rates were significantly higher with irbesartan (38%; 332 of 873) versus losartan (32%; 335 of 1047; P = 0.01), valsartan (19%; 186 of 977; P = 0.001), and candesartan (25%; 148 of 593; P = 0.001). BP goal attainment rates were significantly higher when ARB was compared with non–ARB-based dual therapy (39%; 1007 of 2584 vs 31%; 1109 of 3576; P = 0.004); irbesartan + hydrochlorothiazide (HCTZ) was significantly higher than losartan + HCTZ (36%; 500 of 1390 vs 20%; 252 of 1261; P = 0.001). For patients receiving dual or tri-therapy, 48% (667 of 1390) of patients receiving irbesartan reached target BP versus 41% to 42% for losartan (517 of 1261), valsartan (194 of 462), and candesartan (168 of 401) ( P = 0.001 for each). After 4 years, persistence rates were not statistically different among ARB, CCB, and diuretic monotherapies, but appeared somewhat higher with ACEIs and β-blockers (78%, 78%, 79%, 91%, and 84%, respectively). Persistence was not significantly different between irbesartan and losartan monotherapy (76% for both; P > 0.05), but was significantly higher with irbesartan + HCTZ versus losartan + HCTZ (96% vs 73%, respectively; P = 0.001). Patients treated with ARBs reported fewer CV events than those receiving ACEIs or CCBs (4.3% vs 7.0% and 11.0%, respectively; P < 0.001). Within the ARB class, the lowest rate was with irbesartan (3.0% vs 4.6%–5.0% for other ARBs; P < 0.02). Conclusions In this real-world setting, hypertensive adults treated with ARBs versus β-blockers or diuretics were more likely to have evidence-based target BP recorded. In addition, patients using ARBs versus ACEIs or CCBs had fewer reports of CV events.

Blood pressure control rates with an antihypertensive regimen including trandolapril in a canadian usual-care setting

The aim of the study was to assess the effects on blood pressure (BP) levels and control rates in hypertensive subjects receiving trandolapril as monotherapy or as part of an antihypertensive regimen in everyday Canadian clinical practice. The MAVIKtory study was a multicenter, single-arm observational study in 601 primary-care centers in Canada. Diabetic and nondiabetic subjects were included, who were treated with trandolapril for hypertension in accordance with usual practices and national guidelines. Subjects received trandolapril as a new prescription, alone, or in combination with prior therapy. Treatment regimens were at the discretions of the treating physicians. Subjects were followed for 6 months. The primary outcomes measures were the percentage of subjects reaching BP targets set by their physicians after 6 months of therapy, and the percentage of subjects reaching the guidelines targets (systolic blood pressure [SBP]/diastolic blood pressure [DBP] < 140/90 mm Hg) after 6 months as assessed by their physicians. Other outcomes were the percentage of diabetic subjects reaching BP targets, and tolerability. A total of 8787 subjects were enrolled and included in the intention-to-treat population. Starting doses of trandolapril were 1 or 2 mg in the majority of subjects and remained unchanged in 51.9% of the population at 6 months. The target of < 140/90 (< 130/80) mm Hg was reached by 67.3% of the population. The lower mean physician-set target of 133.4/83.3 mm Hg for nondiabetic subjects and 128.6/79.3 mm Hg for diabetic subjects was reached by 52.2%. Mean reductions from baseline to month 6 were 19.4 mm Hg (95% CI: [-19.9 to -19.0]) in SBP, and 10.1 mm Hg (95% CI: [-10.4 to -9.8]) in DBP. Cough was the most commonly reported adverse event, reported in 4.2% of all subjects. Trandolapril demonstrated a favorable safety and effectiveness profile. SBP reductions of approximately 20 mm Hg and control rates > 65% could be achieved over 6 months.