Standardized Hypertension Treatment Research Articles

Methods for the assessment of microcirculation in patients with hypertension

Background: Skin microcirculation is considered an easily accessible vascular bed, which can potentially be representative and helpful in evaluating, understanding the mechanisms of microvascular function and detection of its dysfunction. Many studies claim that functional changes in cutaneous circulation precede the development of arterial hypertension (HT). Identifying them at an early stage can enhance patients’ prognosis. There are methods which can be applied for these purposes. We aimed to describe available methods of skin microcirculation assessment, in the context of HT. Material and methods: The PubMed database was searched till March 2022. Research articles used in the systematic review were experimental articles, reviews and abstracts from conference materials that reported the methods of the microcirculation assessment. From 1131 records, 47 articles were included in the final review. Results: This review identified that the microcirculation examined with various methods was dysfunctional in HT patients. Standard HT treatment usually helped to achieve a partial reversal of those changes. Even though some of the methods described are non-invasive and relatively affordable, still, none of them is the standard for HT diagnosis. Conclusion: Each of the methods has its advantages and disadvantages. Photoplethysmography appears to be promising. The method is non-invasive, cheap, does not require experience, and might be synchronized with mobile devices. It is possible that the simplification of the device calibration process and the development of a method allowing for the correct interpretation of the result, regardless of e.g., the patient's skin color, could influence its wider use in the group of HT patients.

Maximizing Brain Health After Hemorrhagic Stroke: Bugher Foundation Centers of Excellence.

Maximizing Brain Health After Hemorrhagic Stroke: Bugher Foundation Centers of Excellence.

Blood pressure-lowering effect of repeated Waon therapy in non-smokers with hypertension.

Waon therapy (WT) has been used as a thermal therapy in chronic heart failure patients. However, its effect in patients with hypertension is unclear. This study aimed to reveal the hypotensive effect of WT in patients with hypertension. WT was performed on 31 patients with hypertension (63.9 ± 11.9 years, male: 17) on standard hypertension treatment focusing on lifestyle modification and medication. Systolic and diastolic blood pressures were measured before and after WT using an upper arm automated sphygmomanometer. We investigated the effect of single and repeated (1 time/d, >5 times) WT sessions on blood pressure and further compared its effect between current smoking (n = 11, 55.4 ± 6.4 years, 8.5 ± 2.4 times) and non-smoking (n = 11, 66.9 ± 8.5 years, 12.2 ± 5.9 times) groups. A total of 370 sessions of WT were conducted. Systolic and diastolic blood pressures significantly decreased after a single WT session (systolic blood pressure: 118.5 ± 10.1 to 115.1 ± 9.0 mm Hg, P < .001; diastolic blood pressure: 70.5 ± 6.4 to 65.9 ± 5.3 mm Hg, P < .001). The blood pressure decrease following repeated WT was not significant when all participants were considered (systolic blood pressure: 122.3 ± 15.2 to 116.9 ± 19.6 mm Hg; diastolic blood pressure: 73.8 ± 16.7 to 68.2 ± 13.2 mm Hg); however, it was significant in the non-smoking group (systolic blood pressure: 124.2 ± 11.3 to 108.8 ± 13.4 mm Hg, P < .001; diastolic blood pressure: 73.6 ± 4.9 to 62.1 ± 7.6 mm Hg, P < .001). Repeated WT (at least 5 sessions) decreased blood pressure in patients with hypertension, especially in non-smokers. WT is a simple method to reduce blood pressure in non-smoking patients with hypertension.

PRIVATE HEALTH SECTOR PREFERENCES IN TREATMENT OF HYPERTENSION IN INDIA: EVIDENCE FROM HYPERTENSION DRUGS MARKET DATA

Objective: In India, there are an estimated 200 million adults with high blood pressure. National and international guidelines recommend calcium channel blockers (CCB), diuretics, angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) for first line treatment of uncomplicated hypertension, while beta-blockers (BB) have been relegated to second-line treatment. As the private sector provides 70% of out-patient care in the country, we assessed private health sector preferences of antihypertensive medications using market data. Design and method: Sales of all antihypertensive formulations in India from 2016–2018 were analysed, using a large nationally representative dataset for the private sector pharmaceuticals market. In addition to analysis at the National level, data for five states was analysed to determine any inter-state variations. Results: The Indian hypertension drug market grew at a compounded annual growth rate of 6.9% from 2016 to 2018 with a total of 21,066 million tablet or capsule sales in 2018. Two-drug single pill combinations (SPCs) had the highest market share in 2018, with 36% of market volumes, followed by CCBs (18%), BBs (16%), ARBs (14%), diuretics (5%), ACEI (3.6%), and three-or-more-drug SPCs (2.8%). Among two-drug SPCs, amlodipine/atenolol (9.8%) was the most preferred, followed by telmisartan/hydrochlorothiazide (4.1%) and amlodipine/telmisartan (3.8%). There were inter-state variations in the market share of antihypertensive drugs. In four states, two-drug SPCs accounted for approximately 40% of all antihypertensives sold (range 38%-42%). This was followed by BBs as the second most preferred drug class in two states (range 18%-19%), while CCBs were preferred in the other two states (range 16%-18%). In the fifth state, CCBs (25%) were most preferred, followed closely by BBs (21%). Amlodipine/atenolol was the most preferred molecule in two states, amlodipine in another two states and telmisartan in the fifth state. Conclusions: Despite changes in standard hypertension treatment guidelines, evidence from pharmacy sales data indicate variable treatment practices in the private health sector in India, with a preference for beta blockers. This study highlights the need to improve hypertension care quality through private sector engagement strategies including sensitisation, regular training programmes and possibly provider incentives for evidence-based practice.

Standardized treatment to improve hypertension control in primary health care: The HEARTS in the Americas Initiative.

Hypertension is the leading risk factor for cardiovascular disease (CVD) worldwide. Despite the availability of effective antihypertensive medications, the control of hypertension at a global level is dismal, and consequently, the CVD burden continues to increase. In response, countries in Latin America and the Caribbean are implementing the HEARTS in the Americas, a community-based program that focuses on increasing hypertension control and CVD secondary prevention through risk factor mitigation. One key pillar is the implementation of a standardized hypertension treatment protocol supported by a small, high-quality formulary. This manuscript describes the methodology used by the HEARTS in the Americas program to implement a population-based standardized hypertension treatment protocol. It is rooted in a seamless transition from existing treatment practices to best practice using pharmacologic protocols built around a core set of ideal antihypertensive medications. In alignment with recent major hypertension guidelines, the HEARTS in the Americas protocols call for the rapid control of blood pressure, through the use of two antihypertensive medications, preferably in the form of a single pill, fixed-dose combination, in the initial treatment of hypertension. To date, the HEARTS in the Americas program has seen the improvement in antihypertensive medication formularies and the establishment of pharmacologic treatment protocols tailored to individual participating countries. This has translated to significant increases in hypertension control rates post-program implementation in these jurisdictions. Thus, the HEARTS in the Americas program could serve as a model, for not only the Americas Region but globally, and ultimately decrease the burden of CVD.

A perspective of private health care providers in the state of Madhya Pradesh on adopting key strategies of the India hypertension control initiative.

The India Hypertension Control Initiative (IHCI) has been implemented in public health facilities. This study assessed the perspective of private physicians (PPs) on adopting the core strategies of the IHCI in Bhopal district of Madhya Pradesh. A semi-structured interview was purposely applied to 30 PPs to obtain their opinions on standardized hypertension treatment protocols, patient-centered services, and easy-to-use information system in their private practices. Verbatim data were recorded and analyzed thematically. Only 11 PPs followed the state hypertension treatment protocol. Among the remaining 19 PPs, the major reasons for not adopting protocol were (1) limited availability of single component hypertension drugs, (2) preferences for fixed dose combinations (FDCs), and (3) fear of either losing patients due to a lack of immediate blood pressure control or causing drug-related adverse effects. None of the interviewed doctors had resources to provide patient-centered care and use a digital health information system. Overall, the interviewed doctors identified that free supply of hypertension treatment protocol drugs, inclusion of FDCs in treatment protocol, increasing number of staff for follow-up visits, and patient education, IT-based solutions for patient records, employee incentives, and need for national data sharing policies are the key actions to accelerate the adoption of IHCI strategies in the private sector. This exploratory qualitative study suggests that engagement of private sector in the IHCI is feasible. Plans to expand the IHCI to the private sector should consider ensuring the wider availability of hypertension treatment protocol drugs and developing a simple user-friendly digital platform for patient monitoring.

Abstract 171: Direct versus Calculated LDL Cholesterol and C Reactive Protein in Cardiovascular Disease Risk Assessment in the Framingham Offspring Study

Background: Elevated serum LDL cholesterol (LDL-C) and high sensitivity C reactive protein (hsCRP) levels have been identified as major risk factors for cardiovascular disease (CVD). Our goal was to assess direct versus calculated LDL-C and hsCRP levels as compared to standard risk factors in the prospective Framingham Offspring Study. Methods: Stored frozen plasma samples (-80 degrees C) obtained after an overnight fast from male and female participants free of CVD at cycle 6 of the Framingham Offspring Study were used (n=3,147, mean age 58 years) and 677 or 21.5% developed a CVD endpoint over 16 years. Total cholesterol, triglycerides, HDL cholesterol (HDL-C), direct LDL-C, and hsCRP were measured by standardized automated analysis, and LDL-C was also calculated. Results: For inclusive CVD risk on univariate analysis significant factors in order included the standard risk factors age, hypertension, HDL-C, hypertension treatment, gender, diabetes, smoking, and total cholesterol, as well as the non-standard risk factors non-HDL-C, direct LDL-C, calculated LDL-C, triglycerides (TG), and hsCRP. On multivariate analysis only direct LDL-C and hsCRP were still significant after inclusion of the standard model. Both parameters significantly improved the model C statistic and the net risk reclassification index. The same findings were noted for other CVD risk categories including hard CVD with procedures and hard CVD. Conclusions: Our data indicate that direct LDL-C is superior to calculated LDL-C in CVD risk prediction, and that both direct LDL-C and hsCRP add significant information to CVD risk prediction versus the standard model.

Use of strategies to improve antihypertensive medication adherence within United States outpatient health care practices, DocStyles 2015-2016.

Patients' adherence to antihypertensive medications is key to controlling high blood pressure. Evidence-based strategies to improve adherence exist, but their use, individually and in combination, has not been described. 2015-2016 DocStyles data were analyzed to describe health care professionals' and their practices' use of 10 strategies to improve antihypertensive medication adherence across 3 categories: prescribing, education, and tracking/encouragement. Among 1590 respondents, a mean of using 5 strategies was reported, with individual strategy use ranging from 17.2% (providing patients adherence-related rewards) to 69.4% (prescribing once-daily regimens). Those with higher odds of using ≥7 strategies and strategies across all 3 categories included: (1) nurse practitioners compared to family practitioners/internists and (2) health care professionals in practices with standardized hypertension treatment protocols who routinely recommend home blood pressure monitor use compared to respondents without those characteristics. Despite using an array of evidence-based adherence-promoting strategies, additional opportunities exist for health care professionals to provide adherence support among hypertensive patients.

Controlling hypertension and reducing its associated morbidity and mortality in the Caribbean: implications of race and ethnicity.

Cardiovascular diseases and stroke, especially hypertension, represent a significant global disease burden for both morbidity and mortality, with a disproportionately higher impact in vulnerable low- to middle-income countries. International initiatives such as the Centers for Disease and Prevention and the Pan American Health Organization Standardized Hypertension Treatment Project have been developed to address this burden on the Caribbean and Latin America populations. The disparity in disease burden observed in low- to middle-income countries is explained, in part, by differences in disease risks for different racial and ethnic groups with high blood pressure more prevalent and hypertension-related morbidity significantly higher in men and women of African heritage. In addition to the race and ethnic differences in indicators of socioeconomic status, access to care and health service delivery, the physiologic mechanism of high blood pressure including salt-sensitivity, may also play a significant role in the disparities in hypertension and hypertension-related outcomes. This article focuses on potential racial and ethnic differences in influences on the pathophysiology of hypertension in the Caribbean region of the world. The identification of such differences may be used in the development of population hypertension control strategies and treatment approach that address the excess disease burden in these populations. The consideration of strategies, such as salt reduction and hypertension awareness and treatment, are particularly relevant to the high-risk Caribbean region.

The effect of resveratrol on hypertension: A clinical trial.

The aim of this clinical trial was to investigate the effects of Evelor, a micronized formulation of resveratrol (RESV; 3,5,4′-trihydroxy-trans-stilbene), in patients with primary hypertension. RESV is a stilbenoid and phytoalexin produced by several plants in response to injury or attack by pathogens, such as bacteria and fungi. Patients included in the clinical trial were split into the following two groups, based on the severity of their disease: Group A (n=46), stage I hypertension [systolic blood pressure (SBP), 140–159 mmHg; diastolic blood pressure (DBP), 90–99 mmHg] and Group B (n=51), stage II hypertension (SBP, 160–179 mmHg; DBP, 100–109 mmHg). Each group was divided into two subgroups: A1 and B1, patients treated with standard antihypertensive therapy (A1, 10 mg Dapril; B1, 20 mg Dapril), and A2 and B2, patients treated with antihypertensive therapy (Dapril) plus Evelor. The present study aimed to determine the effects of Evelor, in addition to the standard hypertension treatment, and its effect on the hepatic enzymes serum glutamate-pyruvate transaminase (SGPT) and gamma-glutamyl transferase (gamma-GT). Following the trial, which lasted two years (October 2010 to October 2012), the mean blood pressure of both groups lay within the normal range, indicating that blood pressure was efficiently controlled. The results of the present study demonstrate that the addition of RESV to standard antihypertensive therapy is sufficient to reduce blood pressure to normal levels, without the need for additional antihypertensive drugs. In addition, statistical analysis of the results identified a significant reduction in plasma concentration levels of SGPT (P<0.001) and gamma-GT (P<0.001) with the addition of RESV, indicating that RESV prevents liver damage.

SSA 04-4 CURRENT STATUS IN MANAGEMENT OF HYPERTENSION IN LATIN AMERICA

Latin America has 23 countries ranging from Mexico, Central America, South America and the Caribbean, of these 19 countries are considered by the WHO as countries with high and very high risk, one of the similarities of our countries is poor access to services health and medicine, resulting from poor government investment in health as the amount used in this sector occupies only the best 3% of the national budget and gross domestic product. Thus we know that the prevalence of hypertension varies widely from country to country and from city to city, presenting in Guatemala a prevalence of 40%, while in other countries in the area ranges between 25 and 35%, most complicated problem is that within the same country as the population this prevalence can vary greatly and have a different impact between populations Therefore we know that the impact of cardiovascular disease within the range of non-communicable diseases occupies at least 30% and of these about 70% occupied countries of low and moderate income. In Latin American countries the rates of detection, diagnosis and control of hypertensive disease are not uy encouraging and have a common denominator, the educated, so it is not the same be diagnosed in the rural area or urban area, and of course this impacts the way it understands the disease. In the best Detection reached 60% of the population (31–69%), Treatment 31% (14–48%) and most frightening is that control rates on average were 12% (7 - 18%), and although we have no reliable statistics on the vast majority of countries, we could say that control rate should be less than 10% in most cases. In recognition of the need to meet the challenge of improving the prevention and control of hypertension in the Americas and worldwide, the Centers for Disease Control and Prevention (CDC) and the Pan American Health Organization (PAHO), in collaboration with other stakeholders, have launched the Standardized Hypertension Treatment and Prevention (SHTP) Project. The SHTP Project's goal is to improve CVD prevention and management, using hypertension as the entry point, by developing and implementing an approach for standardizing the management of hypertension and strengthening health systems at the primary care level. The SHTP Project design aims to be feasible and flexible for worldwide applicability and can be adapted to improve control of other NCDs. Rationale for Strengthening Healthcare Delivery About the Systems for Hypertension Control, Strengthening of health systems can help address challenges to hypertension control by addressing a number of barriers to effective and sustained hypertension like a Patient barriers, Provider Barriers and Health System Barries to medication availabilities and affordabilities To effectively reduce the burden of hypertension within a care delivery system, it is essential to develop and implement a multipronged strategy based on strong political will. This strategy should create an environment where hypertension control is a priority and specific stakeholders, as well as leaders and champions, are identified with clearly defined roles and responsibilities. Involved parties should include patients, clinicians, pharmacists, and social service workers, as well as others to comprise a multidisciplinary team. Concrete targets and goals and an accountability mechanism should be established at all levels with a plan to conduct monitoring and evaluation. Financial resources, including funding sources and procurement mechanisms, should be considered and mobilized. Furthermore, a formative assessment should be conducted prior to implementation to inform the needs for the program's success. We are currently working on developing 20 x 20 LASH, 25 x 25 WHF and many others in order to achieve a reduction of the impact of cardiovascular disease and its risk factors, hypertension continues to grow and the prevalence is ever-increasing, Latin America occupies the highest prevalence rates and the worst controls, and if we do nothing about it, stop being silent murderer a chronicle of a death foretold

Improved Blood Pressure Control to Reduce Cardiovascular Disease Morbidity and Mortality: The Standardized Hypertension Treatment and Prevention Project.

Hypertension is the leading remediable risk factor for cardiovascular disease, affecting more than 1 billion people worldwide, and is responsible for more than 10 million preventable deaths globally each year. While hypertension can be successfully diagnosed and treated, only one in seven persons with hypertension have controlled blood pressure. To meet the challenge of improving the control of hypertension, particularly in low- and middle-income countries, the authors developed the Standardized Hypertension Treatment and Prevention Project, which involves a health systems-strengthening approach that advocates for standardized hypertension management using evidence-based interventions. These interventions include the use of standardized treatment protocols, a core set of medications along with improved procurement mechanisms to increase the availability and affordability of these medications, registries for cohort monitoring and evaluation, patient empowerment, team-based care (task shifting), and community engagement. With political will and strong partnerships, this approach provides the groundwork to reduce high blood pressure and cardiovascular disease-related morbidity and mortality.

A practice-based randomized controlled trial to improve medication adherence among Latinos with hypertension: study protocol for a randomized controlled trial.

BackgroundLatinos experience disproportionately higher rates of uncontrolled hypertension as compared to Blacks and Whites. While poor adherence is a major contributor to disparities in blood pressure control, data in Latino patients are scant. More importantly, translation of interventions to improve medication adherence in community-based primary care practices, where the majority of Latino patients receive their care is non-existent.MethodsUsing a randomized controlled design, this study evaluates the effectiveness of a culturally tailored, practice-based intervention compared to usual care on medication adherence, among 148 Latino patients with uncontrolled hypertension who are non-adherent to their antihypertensive medications. Bilingual medical assistants trained as Health Coaches deliver the intervention using an electronic medical record system-embedded adherence script. Patients randomized to the intervention group receive patient-centered counseling with a Health Coach to develop individualized self-monitoring strategies to overcome barriers and improve adherence behaviors. Health Coach sessions are held biweekly for the first 3 months (6 sessions total) and then monthly for the remaining 3 months (3 sessions total). Patients randomized to the usual care group receive standard hypertension treatment recommendations as determined by their primary care providers. The primary outcome is the rate of medication adherence at 6 months. The secondary outcome is reduction in systolic and diastolic blood pressure at 6 months.DiscussionIf successful, findings from this study will provide salient information on the translation of culturallytailored, evidence-based interventions targeted at medication adherence and blood pressure control into practice-based settings for this high-risk population.Trial registrationNCT01643473 on 16 July 2012.

Improving Control Rates of HTN in the Caribbean

It is estimated that about two-thirds of patients with hypertension (HTN) are located in the developing world, such as the Caribbean. Despite effective medications and other tools for the management of HTN, the prevalence of poorly controlled HTN remains high. Thus, additional measures are needed to improve the control of HTN, particularly in the developing world. This article discusses the standardization of the Global Standardized Hypertension Treatment Project and the Caribbean Public Health Agency.

PCV92 - The Cost-Utility of Catheter-Based Renal Denervation as Compared to Current Standard of Care for Resistant Hypertension in Belgium

Hypertension affects 41% of male and 31% of female adults in Belgium; 13% of these are believed to be refractory to standard hypertension treatment, defined as uncontrolled hypertension under ≥ 3 different classes of antihypertensive drugs. Surgical renal denervation has been used in the past, but due to significant side effects it was abandoned. Catheter-based renal denervation (RDN) is a novel, minimally invasive therapy for treatment-resistant hypertension. The results of the Symplicity HTN-2 randomised trial (Esler, 2010) were used to conduct cost-effectiveness and cost-utility analyses comparing RDN to current standard of care (SoC) for treatment of refractory hypertension in Belgium. Background

Characteristics of Resistant Hypertension in a Large, Ethnically Diverse Hypertension Population of an Integrated Health System

ObjectiveTo evaluate the prevalence of and characterize resistant hypertension in a large representative population with successful hypertension management and reliable health information. Patient and MethodsWe performed a cross-sectional study using clinical encounter, laboratory, and administrative information from the Kaiser Permanente Southern California health system between January 1, 2006, and December 31, 2007. From individuals older than 17 years with hypertension, resistant hypertension was identified and prevalence was determined. Multivariable logistic regression was used to calculate odds ratios (ORs), with adjustments for demographic characteristics, clinical variables, and medication use. ResultsOf 470,386 hypertensive individuals, 60,327 (12.8%) were identified as having resistant disease, representing 15.3% of those taking medications. Overall, 37,061 patients (7.9%) had uncontrolled hypertension while taking 3 or more medicines. The ORs (95% CIs) for resistant hypertension were greater for black race (1.68 [1.62-1.75]), older age (1.11 [1.10-1.11] for every 5-year increase), male sex (1.06 [1.03-1.10]), and obesity (1.46 [1.42-1.51]). Medication adherence rates were higher in those with resistant hypertension (93% vs 89.8%; P<.001). Chronic kidney disease (OR, 1.84; 95% CI, 1.78-1.90), diabetes mellitus (OR, 1.58; 95% CI, 1.53-1.63), and cardiovascular disease (OR, 1.34; 95% CI, 1.30-1.39) were also associated with higher risk of resistant hypertension. ConclusionIn a more standardized hypertension treatment environment, we observed a rate of resistant hypertension comparable with that of previous studies using more fragmented data sources. Past observations have been limited due to nonrepresentative populations, reliability of the data, heterogeneity of the treatment environments, and less than ideal control rates. This cohort, which was established using an electronic medical record–based approach, has the potential to provide a better understanding of resistant hypertension and outcomes.

Irbesartan is projected to be cost and life saving in a Spanish setting for treatment of patients with type 2 diabetes, hypertension, and microalbuminuria

The purpose of this study was to project the cumulative incidence of end-stage renal disease (ESRD), life expectancy, and costs in a Spanish setting of treating patients with diabetes, hypertension, and microalbuminuria with either standard hypertension treatment alone or standard hypertension treatment plus irbesartan 300 mg daily. A peer-reviewed, published Markov model that simulated progression from microalbuminuria to nephropathy, doubling of serum creatinine, ESRD, and all-cause mortality in patients with hypertension, type 2 diabetes, and microalbuminuria was adapted to a Spanish setting. Two strategies were compared: (1) irbesartan versus (2) standard hypertension care with comparable blood pressure control; both began in diabetic hypertensive subjects with microalbuminuria. Cumulative incidence of ESRD, costs, and life expectancy were projected for a hypothetical cohort of 1000 subjects. Future costs and life expectancy were discounted at 3% yearly. A 25-year time horizon and third party payer perspective were used. When compared to standard blood pressure control, irbesartan was projected to reduce the cumulative incidence of ESRD from (mean +/- standard deviation) 24 +/- 1% to 9 +/- 2%, save 11,082 +/- 2,996 euro, and add 1.40 +/- 0.27 life years per treated patient. The superiority of irbesartan over standard care was robust under a wide range of plausible assumptions. Treating patients with hypertension, microalbuminuria, and type 2 diabetes with irbesartan was projected to reduce the incidence of ESRD, extend life, and reduce costs.