Use Of Blood Pressure Lowering Drugs Research Articles

Cardiovascular risk prediction in a New Zealand cohort of patients with known cardiovascular disease - a regional individual patient-level data linkage study

Abstract Background National health databases have been underutilised in the development of cardiovascular disease (CVD) risk prediction equations for people with known CVD, yet can inform population level practice and policy—including identification of health equity gaps, high-risk groups, and high-risk localities. With the recent introduction of novel and expensive preventive cardiovascular drugs, stratifying risk in patients with prior CVD could be required to inform cost-effective use of these medications in the future. Purpose We sought to develop 5-year CVD risk equations in adults with known history of CVD in Aotearoa New Zealand, using data from administrative health databases and characterize distribution of risk according to sex. Methods All people above 18 years of age with a history of CVD hospitalization, living in the Auckland and Northland regions of Aotearoa New Zealand (approximately one-third of the national population) on 1 January 2014 were included. Participants were followed for 5 years (31 December 2018) or until death or the outcome of interest, being any fatal or non-fatal CVD hospitalization (ischemic heart disease, heart failure, ischemic stroke, or peripheral artery disease) during follow-up. Sex-specific 5-year CVD risk prediction equations were developed using multivariable Fine and Gray models taking competing risk of non-cardiovascular death into account. Predictor variables included were age; ethnicity; deprivation level; time since most recent CVD hospitalization, history of smoking, heart failure, atrial fibrillation, chronic renal disease, and diabetes mellitus; use of anti-thrombotic, blood pressure-lowering, and lipid-lowering drugs; and blood levels of glycosylated hemoglobin (HbA1c), non-HDL cholesterol, and creatinine. Results The cohort comprised 42,130 men (median age: 68 years [interquartile range (IQR): 59–76]) and 31,717 women (median age: 70 years [IQR: 60–78]) with 12,875 and 8,734 observed events during follow-up, respectively. Sex-specific 5-year CVD risk prediction equations with excellent calibration (accuracy) were developed (Figure 1). Increasing age; high deprivation level; more recent CVD hospitalization; history of smoking, heart failure, atrial fibrillation, chronic renal disease, diabetes mellitus; use of blood-pressure lowering drugs; and high blood levels of HbA1c, non-HDL cholesterol, or creatinine were predictors of elevated risk. There was a wide range of predicted 5-year risk, with 15% of men and 24% of women having a predicted risk below 15%, and 24% and 20%, respectively, having a predicted risk of 40% or above (Figure 2). Conclusion This study demonstrates that it is possible to develop accurate CVD risk prediction equations from administrative health databases for patients with known CVD. Marked heterogeneity in 5-year risk of a subsequent CVD event emphasise that the current ‘one size fits all’ approach to secondary prevention of CVD requires review.Figure 1Figure 2

#6463 IMPLEMENTATION OF CLINICAL ALARM SYSTEM IS ASSOCIATED WITH REDUCTION OF THE RISK OF INTRADIALYTIC HYPOTENSION

Abstract Background and Aims Intradialytic hypotension (IDH) plays an essential role in hemodialysis. IDH prevalence can be up to 8% to 40% [1], according to research. Furthermore, research shows that IDH positively correlates with severe complications such as non-occlusive mesenteric ischemia[2], critical limb ischemia[3] and tissue ischemia, which leads to irreversible damage, even increasing the chance of infection. Many causes and risk factors result in IDH, such as excessive weight gain during dialysis, cardiovascular dysfunction, and improper use of blood pressure-lowering drugs[1]. Therefore, it still relies on experienced medical professionals to monitor patients’ blood pressure to beware of the risk of developing IDH. However, this increases the workload on medical professionals and does not provide standard or more objective early warning indicators of hypotension for new medical professionals. Method Selection of experimental and control group: In this study, we included 81 subjects that received hemodialysis in Tainan City Municipal Annan Hospital from January 2021 to August 2022. The control group was retrospective data collected from January 2021 to August 2021. Then, from January 2022 to August 2022, we implemented our IDH predicting system and took subjects’ data from this interval as the experimental group to compare the incidence of IDH with the control group. IDH prediction system monitoring interface: After integrating with the hemodialysis dataset, our prediction system will predict patients’ systolic pressure and the likelihood of IDH in the next 30 minutes. As soon as the system detects that the patient will encounter hypotension, it sends warning signals, blood pressure and IDH incidence probability predictions to the monitoring interface to alert medical professionals. Furthermore, our system also supports multi-bed monitoring, which can significantly increase the efficiency of monitoring during hemodialysis. Results After implementing the IDH prediction system, the outcome yielded an IDH incidence of 6.12% in August 2022. Compared to the control group, when the IDH system was not yet implemented, which yielded an IDH incidence of 9.34%, it showed a reduction of 34.5% in IDH cases. Furthermore, the average reduction in IDH rate each month was 12%. Conclusion The present study demonstrated that implementing the IDH predicting model may efficiently reduce the incidence of IDH. However, along with the IDH warning multi-bed monitoring interface, medical professionals must develop a standard procedure to deploy when noticing the warning signals. As a result, this may further reduce the incidence of IDH during hemodialysis sessions.

Elevated Blood Pressure, Antihypertensive Medications and Bone Health in the Population: Revisiting Old Hypotheses and Exploring Future Research Directions

Blood pressure and bone metabolism appear to share commonalities in their physiologic regulation. Specific antihypertensive drug classes may also influence bone mineral density. However, current evidence from existing observational studies and randomized trials is insufficient to definitely suggest likely causal associations between blood pressure levels and use of blood-pressure lowering drugs on bone health outcomes, particularly on the risks of osteoporosis and fractures. Nevertheless, the availability and access to relevant large-scale biomedical data sources as well as developments in study designs and analytical approaches are providing opportunities to examine the nature of the association between blood pressure and bone health more reliably and in greater detail than has ever been possible. It is unlikely that a single source of data or study design can provide a definitive answer. However, with appropriate considerations of the strengths and limitations of the different data sources and analytical approaches, we should be able to advance our understanding of the role of raised blood pressure and its drug treatment on bone health outcomes. As elevated blood pressure and use of blood pressure-lowering drugs are highly prevalent, even small effects of these exposures on bone health outcomes could be important at a population level.

Blood pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attack.

Stroke is an important cause of death and disability worldwide. Since high blood pressure is an important risk factor for stroke and stroke recurrence, drugs that lower blood pressure might play an important role in secondary stroke prevention. To investigate whether blood pressure-lowering drugs (BPLDs) started at least 48 hours after the index event are effective for the prevention of recurrent stroke, major vascular events, and dementia in people with stroke or transient ischaemic attack (TIA). Secondary objectives were to identify subgroups of people in which BPLDs are effective, and to investigate the optimum systolic blood pressure target after stroke or TIA for preventing recurrent stroke, major vascular events, and dementia. In August 2017, we searched the Trials Registers of the Cochrane Stroke Group and the Cochrane Hypertension Group, the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 8), MEDLINE Ovid (1946 to August 2017), Embase Ovid (1974 to August 2017), ClinicalTrials.gov, the ISRCTN Registry, Stroke Trials Registry, Trials Central, and the World Health Organization (WHO) International Clinical Trials Registry Platform Portal. Randomised controlled trials (RCTs) of BPLDs started at least 48 hours after stroke or TIA. Two review authors independently screened all titles and abstracts, selected eligible trials, extracted the data, assessed risk of bias, and used GRADE to assess the quality of the evidence. If necessary, we contacted the principal investigators or corresponding authors for additional data. We included 11 studies involving a total of 38,742 participants: eight studies compared BPLDs versus placebo or no treatment (35,110 participants), and three studies compared different systolic blood pressure targets (3632 participants). The risk of bias varied greatly between included studies. The pooled risk ratios (RRs) of BPLDs were 0.81 (95% confidence interval (CI) 0.70 to 0.93; 8 RCTs; 35,110 participants; moderate-quality evidence), 0.90 (95% CI 0.78 to 1.04; 4 RCTs; 28,630 participants; high-quality evidence) for major vascular event, and 0.88 (95% CI 0.73 to 1.06; 2 RCTs; 6671 participants; high-quality evidence) for dementia. We mainly observed a reduced risk of recurrent stroke in the subgroup of participants using an angiotensin-converting enzyme (ACE) inhibitor or a diuretic (I2 statistic for subgroup differences 72.1%; P = 0.006). The pooled RRs of intensive blood pressure-lowering were 0.80 (95% CI 0.63 to 1.00) for recurrent stroke and 0.58 (95% CI 0.23 to 1.46) for major vascular event. Our results support the use of BPLDs in people with stroke or TIA for reducing the risk of recurrent stroke. Current evidence is primarily derived from trials studying an ACE inhibitor or a diuretic. No definite conclusions can be drawn from current evidence regarding an optimal systolic blood pressure target after stroke or TIA.

Screening for elevated albuminuria and subsequently hypertension identifies subjects in which treatment may be warranted to prevent renal function decline.

We investigated whether initial population screening for elevated albuminuria with subsequent screening for hypertension in case albuminuria is elevated may be of help to identify subjects at risk for accelerated decline in kidney function. We included subjects who participate in the PREVEND observational, general population-based cohort study and had two or more glomerular filtration rate (eGFR) measurements available during follow-up. Elevated albuminuria was defined as an albumin concentration ≥20 mg/L in a first morning urine sample confirmed by an albumin excretion ≥30 mg/day in two 24-h urines. Hypertension was defined as systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg or use of blood pressure-lowering drugs. eGFR was estimated with the CKD-EPI creatinine-cystatin C equation. Overall, 6471 subjects were included with a median of 4 [95% confidence interval (CI) 2-5] eGFR measurements during a follow-up of 11.3 (95% CI 4.0-13.7) years. Decline in eGFR was greater in the subgroups with elevated albuminuria. This held true, not only in subjects with known hypertension (-1.84 ± 2.27 versus -1.16 ± 1.45 mL/min/1.73 m 2 per year, P < 0.05), but also in subjects with newly diagnosed hypertension (-1.59 ± 1.55 versus -1.14 ± 1.38 mL/min/1.73 m 2 per year, P < 0.05) and in subjects with normal blood pressure (-1.18 ± 1.85 versus -0.81 ± 1.02 mL/min/1.73 m 2 per year in subjects, P < 0.05). This effect was most pronounced in the population ≥55 years of age and male subjects. In addition, subjects with elevated albuminuria had higher blood pressure than subjects with normoalbuminuria, and in subjects with elevated albuminuria as yet undiagnosed hypertension was twice as prevalent as diagnosed hypertension. Initial screening for elevated albuminuria followed by screening for hypertension may help to detect subjects with increased risk for a steeper decline in kidney function.

Treatment quality indicators predict short-term outcomes in patients with diabetes: a prospective cohort study using the GIANTT database

ObjectiveTo assess whether quality indicators for treatment of cardiovascular and renal risk factors are associated with short-term outcomes in patients with diabetes.DesignA prospective cohort study using linear regression adjusting for...

Prevention of hypertension in patients with pre-hypertension: protocol for the PREVER-prevention trial

BackgroundBlood pressure (BP) within pre-hypertensive levels confers higher cardiovascular risk and is an intermediate stage for full hypertension, which develops in an annual rate of 7 out of 100 individuals with 40 to 50 years of age. Non-drug interventions to prevent hypertension have had low effectiveness. In individuals with previous cardiovascular disease or diabetes, the use of BP-lowering agents reduces the incidence of major cardiovascular events. In the absence of higher baseline risk, the use of BP agents reduces the incidence of hypertension. The PREVER-prevention trial aims to investigate the efficacy, safety and feasibility of a population-based intervention to prevent the incidence of hypertension and the development of target-organ damage.MethodsThis is a randomized, double-blind, placebo-controlled clinical trial, with participants aged 30 to 70 years, with pre-hypertension. The trial arms will be chlorthalidone 12.5 mg plus amiloride 2.5 mg or identical placebo. The primary outcomes will be the incidence of hypertension, adverse events and development or worsening of microalbuminuria and of left ventricular hypertrophy in the EKG. The secondary outcomes will be fatal or non-fatal cardiovascular events: myocardial infarction, stroke, heart failure, evidence of new sub-clinical atherosclerosis, and sudden death. The study will last 18 months. The sample size was calculated on the basis of an incidence of hypertension of 14% in the control group, a size effect of 40%, power of 85% and P alpha of 5%, resulting in 625 participants per group. The project was approved by the Ethics committee of each participating institution.DiscussionThe early use of blood pressure-lowering drugs, particularly diuretics, which act on the main mechanism of blood pressure rising with age, may prevent cardiovascular events and the incidence of hypertension in individuals with hypertension. If this intervention shows to be effective and safe in a population-based perspective, it could be the basis for an innovative public health program to prevent hypertension in Brazil.Trial RegistrationClinical Trials NCT00970931.

Large improvements in major cardiovascular risk factors in the population of northern Sweden: the MONICA study 1986-2009

the incidence of cardiovascular disease has declined rapidly in Sweden since the 1980s. We explored changes in major cardiovascular risk factors in northern Sweden between 1986 and 2009. since 1986, six population surveys have been carried out in northern Sweden using procedures of the World Health Organization MONICA project. The population age range was 25-64 years in 1986 and 1990, and 25-74 years from 1994. Trends were analysed using generalized linear models. a total of 10586 subjects were included in the surveys. Blood pressure decreased by 4.9/3.9 mmHg in women and 1.8/1.5 mmHg in men aged 25-64 years between 1986 and 2009. In men and women aged 65-74 years, the decrease was 12.6/6.1 mmHg between 1994 and 2009. From 1994, the use of blood pressure-lowering drugs increased, particularly among the older subgroup. The prevalence of smoking halved between 1986 and 2009; 11% of women and 9% of men were smokers in 2009. Cholesterol levels decreased by 0.9 mmol L(-1) in the younger age group (25-64 years), and the use of lipid-lowering agents increased from 1994. Among subjects aged 25-64 years, one in five was obese in 2009, which was twice as many as in 1986, and body mass index (BMI) increased by 1.5 kg m(-2) , corresponding to an increase in weight of 4 kg. There was no further increase in BMI from 2004. The prevalence of diabetes did not change between 1986 and 2009. The proportion that received a university education increased markedly in all age groups, especially in women, during the study period. significant improvements were observed in major cardiovascular risk factors in northern Sweden between 1986 and 2009.

Determinants of daily insulin use in Type 1 diabetes

Objective Insulin need for a given degree of glucose control varies markedly among individuals. We examined which factors determine daily insulin use in patients with Type 1 diabetes. Methods A cross-sectional study was performed in 416 patients. Clinical parameters, medication use, physical activity, smoking, alcohol consumption, and laboratory parameters were determined. Results Body mass index and waist circumference were positively related to daily insulin use (2.3 U/kg/m 2, 95% CI=1.9–2.7 and 0.8 U/cm, 95% CI=0.6–0.9, adjusted for age and sex). Age, female sex, and duration of diabetes were inversely related to daily insulin dose. There was an increase of 3.6 U of insulin per mmol/l triglycerides (95% CI=1.04–6.2) and a decrease of 5.9 U of insulin per mmol/l high-density lipoprotein cholesterol (95% CI=−10.0 to −1.8), adjusted for age, sex, and weight. For blood pressure-lowering drugs, the strongest relation was found for thiazide diuretics (difference of 7.1 U insulin/day, 95% CI=0.2–14.2, adjusted for age, sex, and weight). The use of an insulin pump and physical activity were related to lower daily insulin need: −8.7 U/day (95% CI=−11.8 to −5.5) and −1.7 U/day per activity score unit (95% CI=−3.2 to −0.2), respectively, adjusted for age, sex, and weight. Smoking was related to an increased need of 5.3 U/day (95% CI=1.5–9.0), adjusted for age, sex, and weight. Conclusions Our results show that components of the metabolic syndrome are positively related to daily insulin use. Also, decreased physical activity, smoking, and the use of blood pressure-lowering drugs, which influence insulin sensitivity, are associated with an increased insulin need. These findings suggest that the presence of insulin resistance in Type 1 diabetes or “double diabetes” plays a key role in determining daily insulin need.

Improved hypertension management using an electronic medical record with online physician prompts

Hypertension (HTN) is a significant cardiovascular risk factor occurring in an estimated 50 million Americans. However, only 50 - 70% of patients with HTN have had the diagnosis of HTN established by their physician while the others remain undiagnosed. In addition, only 50% of patients with HTN are treated with blood pressure (BP) lowering medication and only 20 - 30% are adequately controlled below the goal of 140/90 mmHg. Despite the substantial benefits associated with the treatment of HTN, there remains a significant “treatment gap” in the United States. New and innovative ways to narrow this gap are necessary. In 1998, we developed a comprehensive electronic medical record (EMR) which interfaces with the physician during each outpatient visit and provides real-time feedback about patient care management including the diagnosis and treatment of hypertension. The purpose of this study was to determine whether this interactive EMR increases the rate of establishing the diagnosis of HTN, increases the number of patients being treated for HTN, and improves the rate of successful BP lowering. During a 12 month period, consecutive outpatients (n=1076) were seen for routine follow-up, and patient care documentation relied solely on the EMR. We prospectively evaluated the BP management of these patients using quality indicators that included: documentation of the diagnosis of HTN, use of BP lowering drugs, and successful BP lowering below the goal of 140/90 mmHg. We compared the EMR patients to a control group of patients (n=723) with patient care documentation relying solely on traditional “pen and paper” charts (PAP). Patient characteristics were similar between the EMR and PAP groups including the prevalence of HTN (73% vs. 70%, p = NS). However, patients in the EMR group were more likely to have an established and documented diagnosis of HTN (90% vs. 76%, p < 0.0001). EMR patients diagnosed with HTN were also more likely to be on BP lowering medication (96% vs. 89%, p < 0.0001) and EMR patients received, on average, a greater number of anti-hypertensives (2.16 ± .03 vs. 1.44 ± .04, p < 0.001) indicating a more aggressive upward drug titration in patients not yet at goal. As a result, the EMR patients were also more likely to achieve successful BP lowering below the goal of 140/90 mmHg (60% vs. 36%, p < 0.0001). In conclusion, the EMR with real-time feedback at the point of service improves the physician's ability to diagnose HTN, start drug therapy, titrate drug upward, and achieve successful BP control.