Specialist Hypertension Clinic Research Articles

Prediction of adverse outcome by ophthalmic artery Doppler and angiogenic markers in pregnancies with new onset hypertension

ObjectivesTo compare the ophthalmic artery Doppler peak systolic velocity ratio (OA PSV-ratio) and soluble fms-like tyrosine kinase-1/placental growth factor ratio (sFlt-1/PlGF ratio) in predicting adverse maternal and perinatal outcomes in women presenting with new onset hypertension. Study designProspective cohort study in a specialist hypertension clinic, within a tertiary referral centre. Main outcome measuresComparison between the OA PSV-ratio and sFlt-1/PlGF ratio in predicting delivery within one week from presentation and adverse maternal and perinatal outcomes e.g. severe hypertension, neonatal unit admission, small for gestational age. ResultsWomen who delivered within one week, compared to those who did not, had a higher OA PSV-ratio (0.82 vs 0.71, p < 0.01) and sFlt-1/PlGF ratio (93.3 vs 40.5, p = 0.08). Independent predictors of the OA PSV-ratio included mean arterial pressure and maternal weight and predictors of the sFlt-1/PlGF ratio included diastolic blood pressure and use of antihypertensive medications. Prediction of adverse outcomes with both ratios were similar and only modest e.g. AUROC for predicting delivery within one week for OA PSV-ratio was 0.57 (95% CI 0.47–0.67) and for sFlt-1/PlGF ratio was 0.61 (95% CI 0.52–0.70) (p = 0.53). ConclusionsIn women presenting with new onset hypertension, the OA PSV-ratio and sFlt-1/PlGF ratio have similar and modest performance in predicting adverse outcomes.

Retrospective Audit of Patient Characteristics and Outcomes Following Review in a Specialist Hypertension Clinic

Retrospective Audit of Patient Characteristics and Outcomes Following Review in a Specialist Hypertension Clinic

REASONS OF NON-COMPLIANCE TO OFFICE VISITS IN HYPERTENSIVE PATIENTS: RESULTS FROM THE REGISTRY OF SPECIALIZED HYPERTENSION CLINICS

Objective: Hypertensive patients’ compliance to the clinic’s follow up visits was found to be associated with a better blood pressure control and a better compliance to antihypertensive medications. The aim was to detect reasons of non-compliance to office visits in hypertensive patients included in the registry of the specialized hypertension clinics Design and method: Patients were enrolled from the registry of the specialized hypertension clinics of 9 university hospitals. Those who attended less than 3 office visits were considered non-compliant and were contacted through the phone. A simple questionnaire was prepared, and it included pre-specified questions about the reasons of dropping out the office visits. They were also asked about compliance to their antihypertensive medications and salt restriction, and whether they experienced any drug side effects. Results: There were 3014 patients eligible for inclusion in this study but only 689 patients (34.6%) completed the questionnaire. The reasons of non-compliance to the follow up visits in the specialized hypertension clinics were either that patients preferred to follow up elsewhere (n = 546, 79.2%) mostly in pharmacies, 129 patients (18.7%) claimed that the healthcare service was unsatisfactory, 118 patients (17.1%) were asymptomatic and they thought that absence of symptoms meant a well-controlled blood pressure, 136 patients (19.7%) said that the clinic was far from their homes, and 74 patients (10.7%) said that they were referred to the clinic for other comorbidities. Despite non-compliance to office visits, 455 patients (66.0%) were compliant to their antihypertensive medications and 264 (38.3%) patients were compliant to salt restriction. Patients’ reasons for non-compliance to medications were because of side effects (n = 14, 6.9%), financial restrains (n = 13, 6.4%), or because their BP was controlled (n = 20, 9.9%). About 42% of patients used herbs, mainly hibiscus, as adjuvant to their antihypertensive medications. Conclusions: Reasons for non-compliance to office visits were either patient-related or healthcare-related. To improve patients’ compliance, physicians need to allocate more time to educate their patients about hypertension, patients need to follow their doctors’ instructions as regard medications, salt restriction and scheduled office visits, and governments need to provide better and cheaper healthcare services.

Reasons behind high rate of non-compliance to scheduled office visits in hypertensive patients: results from the Egyptian registry of specialized hypertension clinics

BackgroundHypertensive patients’ compliance to the clinic’s follow-up visits is associated with a better blood pressure control. The aim of this study was to detect the reasons of non-compliance to office visits in Egyptian hypertensive patients.ResultsThis is an observational, prospective, cross-sectional research study where patients were enrolled from the registry of the specialized hypertension clinics of 9 university hospitals. Those who attended less than 3 office visits, throughout the registry period, were considered non-compliant and were contacted through the phone. A simple questionnaire was prepared, which included questions about the reasons of non-compliance to follow up. There were 3014 patients eligible for inclusion in this study but only 649 patients (21.5%) completed the questionnaire. Patients claimed that the reasons of non-compliance to the follow up visits in the specialized hypertension clinics were as follows: 444 patients (68.4%) preferred to follow up elsewhere mostly in pharmacies, 53 patients (8.2%) claimed that the healthcare service was unsatisfactory, 94 patients (14.5%) were asymptomatic, and 110 patients (16.9%) said that the clinic was far from their homes. Despite non-compliance to office visits, 366 patients (59.2%) were compliant to their antihypertensive medications and 312 (48.1%) patients were compliant to salt restriction. About 34% of patients used herbs, mainly hibiscus, as adjuvant to their antihypertensive medications.ConclusionsReasons for non-compliance to office visits in hypertensive patients were either patient-related, or healthcare-related. To improve patients’ compliance, physicians need to educate their patients about hypertension, patients need to follow their doctors’ instructions as regard medications, salt restriction and scheduled office visits, and governments need to provide better and cheaper healthcare services.

Ophthalmic artery peak systolic velocity ratio distinguishes pre-eclampsia from chronic and gestational hypertension: Aprospective cohort study.

To examine whether the ophthalmic artery peak systolic velocity ratio (OA PSV-ratio) is higher in women with pre-eclampsia compared with gestational hypertension (GH) and chronic hypertension (CH), after controlling for confounding variables. Prospective cohort. Specialist hypertension clinic in a tertiary referral centre. Singleton pregnancies presenting between 32+0 and 36+6 weeks of gestation with pre-eclampsia (n=50), GH (n=54) and CH (n=56). Paired measurements of maternal mean arterial pressure (MAP) and OA PSV-ratio were performed by trained sonographers. Multiple linear regression was fitted to the OA PSV-ratio, including maternal characteristics and medical history, GH, pre-eclampsia and MAP and use of antihypertensive medication. Whether pre-eclampsia is independently associated with higher OA PSV-ratio. MAP was significantly higher in both GH (p=0.0015) and pre-eclampsia (p=0.008) than in CH pregnancies. There was no significant difference between pre-eclampsia and GH (0.670). The OA PSV-ratio was significantly higher in pre-eclampsia than CH (p=0.0008) and GH (p=0.015). There was no significant difference between the OA PSV-ratio in CH and GH (p=0.352). Multiple linear regression modelling showed that the OA PSV-ratio was influenced by maternal weight (p=0.005), maternal age (p=0.014), antihypertensive medications (p=0.007) and MAP (p<0.0001). After controlling for these variables, the OA PSV-ratio was still significantly higher in those with pre-eclampsia (p=0.0002). The OA PSV-ratio is influenced by maternal weight, age, antihypertensive medications and MAP. Pre-eclampsia is an independent predictor of OA PSV-ratio, which therefore may be a useful point-of-care test when assessing women presenting with hypertension.

HYPERTENSION PHENOTYPES, TARGET ORGAN DAMAGE AND STIFF ARTERIES AND SEVERITY OF COVID-19

Objective: Since the Coronavirus Disease 2019 (COVID-19) pandemic began, conflicting reports have emerged regarding its association with hypertension (HTN) in various populations worldwide. However, there is paucity of data regarding the association between the severity of COVID-19 and HTN phenotypes and HTN mediated organ damage (HMOD). Design and method: In a cohort of patients (n = 501, mean age 53.5 ± 14.6) attending a specialist hypertension clinic at King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia, we identified patients diagnosed with COVID-19 between January and November, 2020. We compared HTN phenotypes and HMOD in patients admitted with severe COVID-19 infection to those with mild disease and without disease. Data were analysed using JMP version 13 Pro (SAS for Windows). Results: Twenty-seven patients developed COVID-19 (5.38%), 8 of whom were admitted (29.6%), with one fatality (3.8%). Patients admitted with COVID-19 were more likely to have refractory HTN (43% vs. 15% vs. 8.9%, p &lt; 0.01), body mass index &gt; 30 (85.7% vs. 46% vs. 47%, p &lt; 0.05), left ventricular hypertrophy (28.6% vs. 7.7% vs. 6.5%, p &lt; 0.01), high hs-CRP (7.8 ± 1.1 vs. 2.1 ± 2 vs. 5 ± 1.5, p &lt; 0.01) and greater central systolic pressure (132 ± 5 vs. 122 ± 7 vs. 110 ± 13, p &lt; 0.01) with no difference in age and gender. Conclusions: In hypertensive patients, severe COVID-19 is associated with severe uncontrolled hypertension with HMOD and stiff arteries. While this is a small single center study, it does highlight aspects of COVID-19 in hypertensive patients which warrant further investigation.

CLINICAL CHARACTERISTICS OF YOUNG ADULTS WITH HYPERTENSION REFERRED TO A SPECIALIST HYPERTENSION CLINIC

Objective: Objective: Compared to older adults, young adults (18–39 years) with hypertension have poorer awareness of their conditions, are less likely to be treated and much less likely to have their blood pressure (BP) controlled as a result. The objective of this study was to identify the clinical characteristics of the young hypertensives, the extent of treatment and its success in achieving guideline BP targets. Design and method: Design: A pragmatic observational study of patients referred with hypertension to our clinic. Method: Consent for inclusion in the study was be requested from all patients attending the specialist hypertension clinic at St James Hospital from June to September 2019. Clinical details will be recorded to characterise the groups of interest. Details to be recorded from the patients first and most recent visit including demographics, referral information, co-morbidities, investigations and treatments. The study was approved by the local research ethics committee (Tallaght hospital, Dublin). T-tests and Chi-squared tests were applied as appropriate. Results: Results: 236 patients were recruited for the study of which 63 (26.7%) were young adults. The mean age of the young group was 32.1 years and the BMI was 30.3 kg/m2. 75% were either obese or overweight, both in line with the rest of the study cohort. 76% had a family history of hypertension. The young group were more likely to have controlled BP at a cut-off of 140/90mmHg (69.5 v 50.3%;p = 0.014) but this group were taking less anti-hypertensive medications compared to those forty years or older (1.41 drugs v 2.28;p &lt; 0.001). While the young group were more likely to have controlled BP according to the new AHA guidelines (27.1% v 13.3%;p = 0.025; cut-off 130/80mmHg), the figures were similar for both groups when the ESH guidance was used due to a higher cut-off for those over 65 years (27.1 v 28.5%). Conclusions: Conclusions: This study suggests that younger patients with hypertension require less anti-hypertensive treatment to achieve BP control. It did not identify subgroups of patients within the young group, however, the group is notable for the extent of overweight and obese patients referred to the clinic.

Registry of the Egyptian specialized hypertension clinics: Sex-related differences in clinical characteristics and hypertension management among low socioeconomic hypertensive patients.

Hypertension is a major modifiable risk factor for cardiovascular disease (CVD) which is a leading cause of death in developing countries affecting both genders. Gender dissimilarity in clinical characteristics and hypertension (HTN) management among hypertensive patients has been reported in several reports before. The aim was to detect sex differences in clinical characteristics and HTN management among Egyptian hypertensive patients. Data from 4701 hypertensive patients attending 9 university located Specialized Hypertension clinic (SHC) were collected from October 2014 to September 2017. The collected data included demographics, cardiovascular risk profile, hypertension‐related history, anthropometric and blood pressure (BP) measurements, antihypertensive medications used, number of patients attending the follow‐up visits, and HTN control rate. Females represented 58.5% of the recruited patients, they were younger, with higher BMI, lower education level, and employment rate compared with males. Females had lower mean office systolic and diastolic BP than males (144.2 ± 22.6 vs. 146.5 ± 22.0 mmHg and 88.1 ± 13.0 vs. 89.9 ± 12.6 mmHg, respectively) and lower rate of uncontrolled BP (54.8% vs. 61.1% in males P < .001). Antihypertensive drugs were comparable among both sexes except for angiotensin converting enzyme inhibitors which were more prescribed in males. Compliance to antihypertensive medications was better in females (63.6% vs. 60.1% in males, P = .015). To conclude, Egyptian hypertensive females have different clinical characteristics as compared to their counterpart males with better BP control, adherence to antihypertensive medications, lower systolic and diastolic BP, and no major differences in the prescribed antihypertensive distribution.

Referrals to, and characteristics of patients attending a specialist hypertension clinic.

The management of hypertension is suboptimal in Ireland and internationally. The role of a specialist hypertension clinic is not always defined but an analysis of the reasons for referral are likely informative. Also, a description of the clinical characteristics of patients with hypertension will inform requirements for comprehensive hypertension management in the community and secondary care. Patients were recruited at consecutive hypertension clinics at St James Hospital, Dublin from July to September 2019. Reasons for referral, clinical characteristics of patients, their investigations and treatment were analyzed. 236 patients were included in the study. The majority of patients, 83%, were obese or overweight. A family history of hypertension was a frequent finding with 70.8% of patients reporting same. 26.7% of patients were under the age of 40. 78% of referrals were from primary care and the most referrals were to investigate secondary causes of hypertension or because the patient was ≤40 years of age. Calcium channel blockers were the treatment most frequently prescribed (51.7%). Clinic blood pressure for the cohort was 137/81 mmHg and this was replicated by their ambulatory BP. This insight into the contemporary management of hypertension highlights the frequency of obesity and a positive family history in those with hypertension. Most referrals were consistent with international guidance though deviations were evident. Findings suggest a national program for hypertension with greater focus on public health interventions and better resourcing of primary care is required.

Prevalence and clinical correlates of ambulatory blood pressure phenotypes in a Saudi hypertensive population.

International Guidelines recommend ambulatory blood pressure monitoring (ABPM) for the management of hypertension. ABPM phenotypes predict outcomes independent of office blood pressure (BP). The authors explored the prevalence and clinical correlates of ABPM phenotypes and relationship with office BP in Saudi patients (n=428, mean age 53.5±14.6, 55% male) referred to a Specialist Hypertension clinic in Riyadh, Saudi Arabia. ABPM phenotypes included sustained normotension (27%), masked hypertension, MHT(32%), sustained hypertension, SHT(52%), and white coat hypertension(2.6%). MHT was more prevalent using asleep than 24-hours (26.4% vs 12.9%, P<.01) or awake BP (26.4% vs 8.5%, P<.001) and observed in 85% of pre-hypertensive patients. Isolated nocturnal hypertension was more prevalent in MHT vs SHT (70% vs 30%, P<.001). Office BP overestimated control rates compared with ABPM (48% vs 12.9%, P<.001). Our study shows that one in three Saudi patients will be managed inappropriately if office BP alone was relied upon for management of hypertension.

The effectiveness of a specialist Hypertension Clinic in reducing blood pressure: Factors determining blood pressure response.

ObjectivesWe retrospectively assessed both blood pressure response to management in a specialist Hypertension Clinic and the predictors of response.DesignRetrospective data audit.SettingHypertension Clinic at Guy’s and St Thomas’ Hospitals, London, UK.ParticipantsOne hundred and twenty-two sequential patients attending the clinic between January 2017 and October 2018. Patients were excluded if they had previously been seen in the clinic, failed to attend their initial appointment or did not return after their initial appointment.Outcome measureChange in blood pressure readings between first and last recorded appointments.ResultsSystolic blood pressure decreased from 149 ± 20 mmHg to 140 ± 17 mmHg, and diastolic blood pressure from 92 ± 13 to 86 ± 1 mmHg, between the first and last recorded appointments (P < 0.05 for each). Those patients who reached target blood pressure were significantly younger than those who did not (age 45 ± 14 versus 52 ± 17 years, P = 0.0171); however, the degree of blood pressure reduction was independent of age, and younger subjects had a baseline blood pressure significantly lower than older subjects. Sex, body mass index and lifestyle interventions had an important effect on blood pressure reduction; however, these were not associated with attainment of target blood pressure.ConclusionSpecialist hypertension input is effective in helping patients to achieve target blood pressure, especially so in younger as compared to older hypertensive patients, but this appears to be related to the fact that blood pressure in younger patients is already closer to target at baseline. Blood pressure reduction is greater in women, those with higher body mass index and those who receive lifestyle interventions.

Registry of the Egyptian specialized hypertension clinics: patient risk profiles and geographical differences.

Data regarding the prevalence and characteristics of cardiovascular (CV) risk factors among Egyptian hypertensive patients are limited. Nationwide Specialized Hypertension Clinics (SHCs) were initiated for screening, investigating, and treating hypertensive patients. This study aimed to determine the clinical characteristics and the CV risk profile of hypertensive Egyptians attending SHCs. Data from 4701 hypertensive patients were collected from the SHCs of nine university hospitals representing the different geographical regions of Egypt. Data collection started in October 2014 and ended in September 2017. Data included blood pressure (BP) measurements, clinical data, socio-demographic characteristics, anthropometric measurements, and cardiovascular risk profiles. The patients' mean age was 51.8 ± 11.5 years, 58.7% were older than 50 years, and 58.5% were females. The mean office systolic and diastolic BP values were 145.2 ± 22.4 and 88.7 ± 12.9 mmHg, respectively. Regarding CV risk factors, 58.6% were obese, 23.4% were smokers, and 25.1% had diabetes mellitus. Obesity was more prevalent in females than males (65.7% vs. 53.0%, p < 0.001, respectively), while dyslipidaemia and smoking were significantly more common in male patients. The highest levels of BP and the highest global risk were observed in the inhabitants of the Delta region, despite their younger age. In conclusion, this study revealed a high prevalence of modifiable CV risk factors among a cohort of Egyptian hypertensive patients attending SHCs. The pattern of the risk factors across the different geographic regions may be attributed to rapid urbanization. Governmental and community-based approaches are needed for better control of hypertension and its associated CV risk factors.

PREVALENCE OF CARDIOVASCULAR RISK FACTORS AMONG HYPERTENSIVE EGYPTIANS, DATA FROM THE EGYPTIAN SPECIALIZED HYPERTENSION CLINICS

Objective:Data regarding the prevalence and characteristics of cardiovascular (CV) risk factors among Egyptian hypertensive patients are limited. Nationwide Specialized Hypertension Clinics (SHC) were initiated for screening, investigating, and treating hypertensive patients. This study aimed to det

ACCURACY OF SEQUENTIAL BLOOD PRESSURE MEASUREMENTS IN COMPARISON TO AMBULATORY BLOOD PRESSURE MEASUREMENTS

Objective: Accurate blood pressure measurement is crucial for diagnosis and follow up hypertension. Office blood pressure may be misleading in certain situations. Our study aimed to compare the accuracy and degree of agreement of automated sequential blood pressure with office blood pressure and ambulatory blood pressure readings Design and method: This was a cross sectional observational study that included patients who were known to be hypertensive and coming to check up their blood pressure. The study was conducted in Kasr El-Aini Specialized hypertension clinic. Full medical history, clinical examination, electrocardiogram, fundus examination and essential labs (e.g. urine analysis, fasting blood sugar, serum potassium, creatinine, lipid profile and hemoglobin) were done for each patient. Office blood pressure was recorded by using digital sphygmomanometer device (Omrone-6 automated device), automated sequential blood pressure by using the Mobile-O- Graph, PWA device over half an hour. The ambulatory blood pressure readings were taken within 24 hours from the previous measurements. All measurements were taken according to the European society guidelines for the management of hypertension. Results: 64 patients were included. Their age ranged between 20 and 85 years (mean ± SD of age 50.0 ± 15.0 years). There were 51.1% female. The office blood pressure readings were significantly higher than the automated sequential blood pressure (142.7 ± 15.5 versus 137.8 ± 16.7 mmHg, P < 0.0001) for systolic blood pressure and (88.5 ± 12.3 versus 86.1 ± 13.8 mmHg, P < 0.0001) for diastolic blood pressure. And higher than the day time ambulatory blood pressure readings (142.7 ± 15.5 versus 135.8 ± 15.7 mmHg, P < 0.0001) for systolic blood pressure and (88.5 ± 12.3 versus 82.1 ± 13.7 mmHg, P < 0.0001) for diastolic blood pressure. The automated sequential blood pressure has a strong positive correlation with day time ambulatory blood pressure(r = 0.74, P < 0.0001). There is a moderate degree of agreement between sequential systolic blood pressure and day time systolic ambulatory blood pressure (kappa = 0.59, P < 0.001). Conclusions: Automated sequential blood pressure measurement is significantly lower than office blood pressure measured by semi-automated electronic devices, and provides a reading which has significant correlation with the day time ambulatory blood pressure.

Masked uncontrolled hypertension: Prevalence and predictors.

BackgroundThere are limited data on ‘masked uncontrolled hypertension’ (MUCH) in patients with treated and apparently well-controlled BP is unknown.ObjectivesTo define the prevalence and predictors of MUCH among hypertensive patients with controlled office blood pressure.MethodsOne hundred ninety-nine hypertensive patients presented to the specialized hypertension clinics at two University Hospitals. All patients had controlled office blood pressure (less than 140/90 mmHg). Patients were assessed regarding history, clinical examination, and laboratory data. All patients underwent ambulatory blood pressure monitoring (ABPM) for 24 h, within a week after the index office visit. MUCH was diagnosed if average 24-h ABPM was elevated (systolic BP ≥ 130 mmHg and/or diastolic BP ≥ 80 mmHg) despite controlled clinic BP.ResultsSixty-six patients (33.2%) had MUCH according to 24-h ABPM criteria (mean age 53.5 ± 9.3 years, 60.6% men). MUCH was mostly caused by the poor control of nocturnal BP; with the percentage of patients in whom MUCH was solely attributable to an elevated nocturnal BP almost double that due to daytime BP elevation (57.3% vs. 27.1%, P < 0.001). The most common predictors of MUCH were smoking, DM and positive family history of DM.ConclusionThe prevalence of masked suboptimal BP control is high. Office BP monitoring alone is thus inadequate to ascertain optimal BP control because many patients have an elevated nocturnal BP. ABPM is needed to confirm proper BP control, especially in patients with high cardiovascular risk profile. Smoking, DM and positive family history of DM were the most common predictors of MUCH.

EPIDEMIOLOGY OF HYPERTENSION IN AN URBAN AREA DEPENDING OF A TERTIARY HOSPITAL

Objective: Electronic Health Recordings are useful tools for monitoring chronic diseases. However, there are potential issues regarding the veracity of the information. Our objective was to know the epidemiological data for hypertension in our health department using the EHR and our own data from a specialised Hypertension Unit. Design and method: Information regarding the status of hypertension in the dependence area of a tertiary hospital of Valencia (Spain) was reviewed, as well as those obtained from the corresponding specialized Hypertension Clinic. Results: The total population ascribed to the tertiary hospital was 341.340 inhabitants. The structure of our Health Department and its demographic characteristics are shown in Figure 1.Of those, one of the many different diagnostics related to hypertension was present in 139.899, which means a prevalence of almost 41%. The main codified diagnosis was “Essential Hypertension” (almost 47.5%), follow by “non-specified hypertension” (35.5%), “benign hypertension” (14%) and “malign hypertension” (1.5%). There were other 25 different diagnosis, which had very low prevalence (less than 1%) and mainly related with hypertensive kidney/heart organ damage. From April 2014 to June 2017, 2296 subjects were attended in the Hypertension Unit. The majority of individuals had only one (28.2%) or two visits (34.6%). There were 495 (21.6%) with three, 236 (10.4) with four, 75 (3.27%) with five, 24 (1%) with six, 14 (0.6%) with seven and 10 patients with 10 visits. Roughly, around 37% patients had criteria to be follow in a specialized unit. The average age of those, was 60 year, 46% women, 87% dyslipidemics, 52% with obesity, 37% diabetics, 23% current smokers, 20% in secondary prevention, 10% with resistant hypertension, 20% with microalbuminuria and 12% with LVH. Conclusions: In order to be useful, EHR integrating primary and specialized care should be implemented to better reflect the grade of control and the associated organ damage.

Abstract P361: Prevalence &amp; Predictors of Orthostatic Hypotension at a Tertiary Care Hypertension Clinic With New Diagnostic Thresholds

Background: Orthostatic hypotension (OH), defined as a decrease of blood pressure (BP) of 20/10 mm Hg (systolic/diastolic) on change in posture from supine to standing is seldom assessed in routine practice because of logistical constraints. A recent study reported a sit-to-stand decrease of 15/7 mm Hg as also having good diagnostic yield. We measured the prevalence &amp; risk factors associated with OH with the new threshold of sit-to- stand of either ≥ 15 mm Hg in systolic (SBP) or ≥ 7 mm Hg in diastolic BP (DBP). Methods: We reviewed medical charts of patients being followed at Renal Hypertension Center, a referral centre for difficult to control hypertension. Sitting BP is measured after 5 minutes of resting, as an average of 5 measurements with an automated device. Standing BP is measured three times at one minute intervals and averaged. OH was determined on the basis of the difference in either average SBP or DBP. Demographic characteristics, comorbidities, medication details, laboratory values and BP measurements were extracted. Results: Data from 219 patients was extracted (see table). The overall difference in SBP (sitting - standing)was 0.94 and DBP was 2.1 mm Hg. 190 patients (87%) did not have OH, whereas 29 (13%) had OH using either SBP or DBP thresholds. The difference in SBP and DBP was 17 mm and 6 mm Hg in those with OH, versus 1.6 and 3 mm Hg amongst those without OH respectively. Higher SBP was significantly associated with OH; age, gender, diabetes, number and hypertension drug class were not. Conclusion: Amongst referred patients to a specialist hypertension clinic, the prevalence of OH using a threshold of 15/7 mm Hg was 13%. The new diagnostic threshold allows for easy assessment of OH.

Detecting non-adherence by urine analysis in patients with uncontrolled hypertension: rates, reasons and reactions.

Poor adherence with pharmacotherapy is well recognised as one of the main barriers to achieving satisfactory blood pressure control, although accurately measuring patient adherence has historically been very challenging. Urine analysis by high-performance liquid chromatography-tandem mass spectrometry has recently become routinely available as a method of screening for non-adherence. In addition to measuring rates of adherence in hypertensive patients, this study aimed to investigate the reasons for non-adherence given by patients and how patients react when they are informed of their results. This was a retrospective observational study looking at results from the routine use of this assay in a specialist hypertension clinic in Birmingham, UK, in patients with uncontrolled hypertension and those under consideration for renal denervation. Out of the 131 patients analysed, only 67 (51%) were taking all their medications as prescribed. Forty-three patients (33%) were taking some of their medications, whilst 21 patients (16%) were completely non-adherent. The most common reasons cited for non-adherence were adverse effects of medication and forgetfulness. Adherence rates for thiazide/thiazide-like diuretics and spironolactone were lower than for other classes of antihypertensive drug. Despite the objective nature and high sensitivity of the test, 36% of non-adherent patients disputed the results. A minority of patients did not attend follow-up. Further research investigating the implications of a 'non-adherence' result on the patient-clinician relationship is required.

Management of resistant hypertension: expert consensus statement from the French Society of Hypertension, an affiliate of the French Society of Cardiology.

To improve the management of resistant hypertension, the French Society of Hypertension, an affiliate of the French Society of Cardiology, has published a set of eleven recommendations. The primary objective is to provide the most up-to-date information based on the strongest scientific rationale and that is easily applicable to daily clinical practice. Resistant hypertension is defined as uncontrolled blood pressure on office measurements and confirmed by out-of-office measurements despite a therapeutic strategy comprising appropriate lifestyle and dietary measures and the concurrent use of three antihypertensive agents including a thiazide diuretic, a renin-angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, for at least 4 weeks, at optimal doses. Treatment compliance must be closely monitored, as must factors that are likely to affect treatment resistance (excessive dietary salt intake, alcohol, depression, drug interactions and vasopressor drugs). If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for potential target organ damage and secondary causes of hypertension. The recommended treatment regimen is a combination therapy comprising four treatment classes, including spironolactone (12.5-25 mg per day). In the event of a contraindication or a non-response to spironolactone, or if adverse effects occur, a β-blocker, an α-blocker, or a centrally acting antihypertensive drug should be prescribed. Because renal denervation is still undergoing assessment for the treatment of hypertension, this technique should only be prescribed by a specialist hypertension clinic.

Twelve month follow-up audit of Nigerian hypertensives on back titration

Introduction: An audit of a hypertension service in Jos, Nigeria revealed the possibility of back titration of antihypertensive therapy without untoward effect. The impact was reduction of disease economic burden. Consequently a deliberate policy of back- titration was adopted in those who have remained well controlled for >12 months. Objective: To see how low dosages could go without compromising control. Methods: All consenting hypertensive clients in this specialist hypertension clinic who had been controlled for 12 months or longer on regular follow-up(between July and September 2011); with no heart failure, renal failure, stroke or myocardial infarction (<6 months) were enrolled. Drugs were sequentially back-titrated starting with 1 drug in those on multiple drugs. Follow up continued in the usual manner, and if controlled by the next visit a further dose lowering was advised until loss of control when dose was promptly returned to the lowest maintaining control. Results: There were 41 patients initially. 2 did not follow up after the first back-titration visit leaving 39 as the subject of this analysis; 14 of whom were males. Their ages ranged from 40 to 91 years and they had been consistently controlled (BP <140/90 mmHg) for between 12 to 95 months. 18 remained normal at various stages of back-titration; in 5 (3F, 2M) all drugs had been completely withdrawn. In 21, control was lost in the course of backtitration and promptly recovered by returning to previous dose that controlled BP. Those who were successfully back-titrated to no drug were mostly on one drug at low doses. Conclusion: After a minimum of 12 months of sustained BP control, it is possible to back-titrate drug dosages in about 50% of this hypertensive cohort, a quarter of whom went completely without drugs for 1 year. The exact mechanism is unknown, but the benefit is in the psychological relief of lower pill burden and reduced cost of treatment. This observation should be extended to other cohorts to prove its applicability; advisedly only under expert care.