Resistant hypertension is a well recognized clinical entity, which has been inadequately researched to date.
A multivariable Cox model was developed to identify baseline predictors of developing ...resistant hypertension among 3666 previously untreated Anglo-Scandinavian Cardiac Outcome Trial (ASCOT) patients and construct a risk score to identify those at high risk. Secondary analyses included evaluations among all 19 257 randomized patients.
One-third (1258) of previously untreated, and one-half (9333) of all randomized patients (incidence rates 75.2 and 129.7 per 1000 person-years, respectively) developed resistant hypertension during a median follow-up of 5.3 and 4.8 years, respectively. Increasing strata of baseline SBP (151-160, 161-170, 171-180, and >180 mmHg) were associated with increased risk of developing resistant hypertension hazard ratio 1.24 (95% confidence interval, CI 0.81-1.88), 1.50 (1.03-2.20), 2.15 (1.47-3.16), and 4.43 (3.04-6.45), respectively. Diabetes, left ventricular hypertrophy, male sex, and raised BMI, fasting glucose, and alcohol intake were other significant determinants of resistant hypertension. Randomization to amlodipine ± perindopril vs. atenolol ± thiazide 0.57 (0.50-0.60), previous use of aspirin 0.78 (0.62-0.98), and randomization to atorvastatin vs. placebo 0.87 (0.76-1.00) significantly reduced the risk of resistant hypertension. Secondary analysis results were similar. The risk score developed allows accurate risk allocation (Harrell's C-statistic 0.71), with excellent calibration (Hosmer-Lemeshow χ statistics, P = 0.99). A 12-fold (8.4-17.4) increased risk among those in the highest vs. lowest risk deciles was apparent.
Baseline SBP and choice of subsequent antihypertensive therapy were the two most important determinants of resistant hypertension in the ASCOT population. Individuals at high risk of developing resistant hypertension can be easily identified using an integer-based risk score.
Visit-to-visit systolic blood pressure variability (BPV) is an important predictor of cardiovascular (CV) outcomes. The long-term effect of a period of blood pressure (BP) control, but with ...differential BPV, is uncertain. Morbidity and mortality follow-up of UK participants in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure-Lowering Arm has been extended for up to 21 years to determine the CV impact of mean systolic blood pressure (SBP) control and BPV during the trial, and amongst those allocated to amlodipine- and atenolol-based treatment.
Eight thousand five hundred and eighty hypertensive participants (4305 assigned to amlodipine ± perindopril-based and 4275 to atenolol ± diuretic-based treatment during the in-trial period (median 5.5 years) were followed for up to 21 years (median 17.4 years), using linked hospital and mortality records. A subgroup of participants (n = 2156) was followed up 6 years after the trial closure with a self-administered questionnaire and a clinic visit. In-trial mean SBP and standard deviation of visit-to-visit SBP as a measure of BPV, were measured using >100 000 BP measurements. Cox proportional hazard models were used to estimate the risk hazard ratios (HRs), associated with (i) mean with SBP and BPV during the in-trial period, for the CV endpoints occurring after the end of the trial and (ii) randomly assigned treatment to events following randomization, for the first occurrence of pre-specified CV outcomes.
Using BP data from the in-trial period, in the post-trial period, although mean SBP was a predictor of CV outcomes {HR per 10 mmHg, 1.14 95% confidence interval (CI) 1.10-1.17, P < .001}, systolic BPV independent of mean SBP was a strong predictor of CV events HR per 5 mmHg 1.22 (95% CI 1.18-1.26), P < .001 and predicted events even in participants with well-controlled BP. During 21-year follow-up, those on amlodipine-based compared with atenolol-based in-trial treatment had significantly reduced risk of stroke HR 0.82 (95% CI 0.72-0.93), P = .003, total CV events HR 0.93 (95% CI 0.88-0.98), P = .008, total coronary events HR 0.92 (95% CI 0.86-0.99), P = .024, and atrial fibrillation HR 0.91 (95% CI 0.83-0.99), P = .030, with weaker evidence of a difference in CV mortality HR 0.91 (95% CI 0.82-1.01), P = .073. There was no significant difference in the incidence of non-fatal myocardial infarction and fatal coronary heart disease, heart failure, and all-cause mortality.
Systolic BPV is a strong predictor of CV outcome, even in those with controlled SBP. The long-term benefits of amlodipine-based treatment compared with atenolol-based treatment in reducing CV events appear to be primarily mediated by an effect on systolic BPV during the trial period.
Hypertension accounts for the greatest burden of disease worldwide, yet hypertension awareness and control rates are suboptimal, especially within low- and middle-income countries. Guidelines can ...enable consistency of care and improve health outcomes. A small body of studies investigating clinicians' perceptions and implementation of hypertension guidelines exists, mostly focussed on higher income settings. This study aims to explore how hypertension guidelines are used by clinicians across different resource settings, and the factors influencing their use.
A qualitative approach was employed using convenience sampling and in-depth semi-structured interviews. Seventeen medical doctors were interviewed over video or telephone call from March to August 2020. Two clinicians worked in low-income countries, ten in middle-income countries, and five in high-income countries. Interviews were recorded, transcribed, and coded inductively. Reflexive thematic analysis was used.
Themes were generated at three levels at which clinicians perceived influencing factors to be operating: healthcare worker, healthcare worker interactions with patients, and the wider health system. Within each level, influencing factors were described as barriers to and facilitators of guideline use. Variation in factors occurred across income settings. At the healthcare worker level, usability of guidelines, trust in guidelines, attitudes and views about guidelines' purpose, and relevance to patient populations were identified as themes. Influencing factors at the health system level were accessibility of equipment and medications, workforce, and access to healthcare settings. Influences at the patient level were clinician perceived patient motivation and health literacy, and access to, and cost of treatment, although these represented doctors' perceptions rather than patient perceived factors.
This study adds a high level global view to previous studies investigating clinician perspectives on hypertension guideline use. Guidelines should be evidence-based, regularly updated and attention should be given to increasing applicability to LMICs and a range of healthcare professionals.
The lowering of cholesterol concentrations in individuals at high risk of cardiovascular disease improves outcome. No study, however, has assessed benefits of cholesterol lowering in the primary ...prevention of coronary heart disease (CHD) in hypertensive patients who are not conventionally deemed dyslipidaemic.
Of 19 342 hypertensive patients (aged 40–79 years with at least three other cardiovascular risk factors) randomised to one of two antihypertensive regimens in the Anglo-Scandinavian Cardiac Outcomes Trial, 10 305 with non-fasting total cholesterol concentrations 6·5 mmol/L or less were randomly assigned additional atorvastatin 10 mg or placebo. These patients formed the lipid-lowering arm of the study. We planned follow-up for an average of 5 years, the primary endpoint being non-fatal myocardial infarction and fatal CHD. Data were analysed by intention to treat.
Treatment was stopped after a median follow-up of 3·3 years. By that time, 100 primary events had occurred in the atorvastatin group compared with 154 events in the placebo group (hazard ratio 0·64 95% CI 0·50–0·83, p=0·0005). This benefit emerged in the first year of follow-up. There was no significant heterogeneity among prespecified subgroups. Fatal and non-fatal stroke (89 atorvastatin
vs 121 placebo, 0·73 0·56–0·96, p=0·024), total cardiovascular events (389
vs 486, 0·79 0·69–0·90, p=0·0005), and total coronary events (178
vs 247, 0·71 0·59–0·86, p=0·0005) were also significantly lowered. There were 185 deaths in the atorvastatin group and 212 in the placebo group (0·87 0·71–1·06, p=0·16). Atorvastatin lowered total serum cholesterol by about 1·3 mmol/L compared with placebo at 12 months, and by 1·1 mmol/L after 3 years of follow-up.
The reductions in major cardiovascular events with atorvastatin are large, given the short follow-up time. These findings may have implications for future lipid-lowering guidelines.
Published online April 2,2003 http://image.thelancet.com/extras/03art3046web.pdf
OBJECTIVE:--This study aims to establish the benefits of lowering cholesterol in diabetic patients with well-controlled hypertension and average/below-average cholesterol concentrations, but without ...established coronary disease. RESEARCH DESIGN AND METHODS--In the lipid-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-LLA), 10,305 hypertensive patients with no history of coronary heart disease (CHD) but at least three cardiovascular risk factors were randomly assigned to receive 10 mg atorvastatin or placebo. Effects on total cardiovascular outcomes in 2,532 patients who had type 2 diabetes at randomization were compared. RESULTS:--During a median follow-up of 3.3 years, concentrations of total and LDL cholesterol among diabetic participants included in ASCOT-LLA were approximately1 mmol/l lower in those allocated atorvastatin compared with placebo. There were 116 (9.2%) major cardiovascular events or procedures in the atorvastatin group and 151 (11.9%) events in the placebo group (hazard ratio 0.77, 95% CI 0.61-0.98; P = 0.036). For the individual components of this composite end point, the number of events occurring in the diabetes subgroup was small. Therefore, although fewer coronary events (0.84, 0.55-1.29; P = 0.14) and strokes (0.67, 0.41-1.09; P = 0.66) were observed among the patients allocated atorvastatin, these reductions were not statistically significant. CONCLUSIONS:--Atorvastatin significantly reduced the risk of major cardiovascular events and procedures among diabetic patients with well-controlled hypertension and without a history of CHD or markedly elevated cholesterol concentrations. The proportional reduction in risk was similar to that among participants who did not have diagnosed diabetes. Allocation to atorvastatin prevented approximately9 diabetic participants from suffering a first major cardiovascular event or procedure for every 1,000 treated for 1 year.
Observational data suggest a potential for subclinical cardiac damage from intensive blood glucose or blood pressure (BP) control, particularly in adults with very low blood glucose and BP levels. ...However, this has not been tested in a randomized trial.
The Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Research Controlled Evaluation (ADVANCE) study was a factorial, randomized trial designed to test the effects of intensive blood glucose (hemoglobin A1c ≤6.5% versus usual care) and intensive BP (combination of perindopril-indapamide versus placebo) control on vascular events in adults with diabetes. Using mixed effects tobit models, we determined the effect of the randomized interventions on change in subclinical cardiac injury (high sensitivity cardiac troponin T hs-cTnT) and strain (N-terminal b-type pro natriuretic peptide NT-proBNP), 1 year after randomization.
Among the 682 participants, mean age was 66.1 (SD, 6.5) years; 40% were women. Mean baseline hemoglobin A1c was 7.4% (SD, 1.5) and systolic/diastolic BP was 147 (SD,21)/81 (SD,11) mmHg. After 1 year, intensive versus standard glucose control did not significantly change hs-cTnT (1.5%; 95%CI:-4.9,8.2) or NT-proBNP (−10.3%; 95%CI: −20.2%,0.9%). Intensive versus standard BP control also did not affect hs-cTnT (−2.9%; 95%CI: −8.9,3.6), but did significantly lower NT-proBNP by 21.6% (95%CI:-30.2%,-11.9%). Changes in systolic BP at 1 year (versus baseline) were strongly associated with NT-proBNP (P = 0.004), but not hs-cTnT (P = 0.95).
In adults with diabetes, intensive BP control reduced NT-proBNP without increasing hs-cTnT, supporting the benefits and safety of intensive BP control in adults with diabetes.
This trial is registered at clinicaltrials.gov, number: NCT00145925.
•Intensive glucose control did not lower subclinical cardiac injury or strain.•Intensive blood pressure control lowered subclinical cardiac strain.•Intensive blood pressure control did not increase subclinical cardiac injury.•Intensive BP control is important and safe for adults with type 2 diabetes.
To promote the primary prevention of hypertension and cardiovascular disease by changes in the diet and lifestyle of the whole population To increase the detection and treatment of undiagnosed ...hypertension by routine screening and increase awareness of hypertension among the public To ensure that patients taking antihypertensive drugs are controlled to optimal blood pressure levels To reduce the risk of cardiovascular disease of treated hypertensive patients by non-pharmacological measures, and by appropriate use of statin and aspirin treatment To increase the identification and treatment of patients with mild hypertension who are at high risk of cardiovascular disease-for example, elderly patients, patients with ischaemic heart disease, people with diabetes, people with target organ damage, or people with multiple risk factors To promote continued adherence to drug treatment, by optimising the choice and use of drugs, minimising side effects, and increasing information and choice for patients. Blood pressure measurement by standard mercury sphygmomanometer or semiautomated device Use a properly maintained, calibrated, and validated device Measure sitting blood pressure routinely: standing blood pressure should be recorded at least at the initial estimation in elderly or diabetic patients Remove tight clothing, support arm at heart level, ensure arm relaxed and avoid talking during the measurement procedure Use cuff of appropriate size (see box 3 in the full guidelines, 3 http://www.bhsoc.org/ ) Lower mercury column slowly (2 mm per second) Read blood pressure to the nearest 2 mm Hg Measure diastolic blood pressure as disappearance of sounds (phase V) Take the mean of at least two readings, more recordings are needed if marked differences between initial measurements are found Do not treat on the basis of an isolated reading For full details of methods see http://www.bhsoc.org/ and reference 8 Absolute risk of cardiovascular disease estimation The treatment of hypertension and the primary prevention of cardiovascular disease should be informed by assessment of total risk of cardiovascular disease.\n The minimum acceptable level of control (audit standard) recommended is < 150/ < 90 mm Hg In people with diabetes mellitus, initiate antihypertensive drug treatment if systolic blood pressure is sustained âper thousand¥ 140 mm Hg or diastolic blood pressure is sustained âper thousand¥ 90 mm Hg In hypertensive people with diabetes, chronic renal disease, or established cardiovascular disease optimal blood pressure goals are systolic blood pressure < 130 mm Hg and diastolic blood pressure < 80 mm Hg.
Raised blood pressure (BP) remains the single most important modifiable risk factor contributing to cardiovascular and all-cause mortality in Australia and worldwide. May Measurement Month , a global ...BP measurement and screening campaign initiated by the International Society of Hypertension and carried out in Australia since its inception in 2017, aimed at obtaining standardized BP measurements from members of the community to increase awareness of high BP and its associated risks.
Adults participants (≥18 years) were recruited through opportunistic sampling across Australia during the month of May in 2017, 2018 and 2019. Trained volunteers recorded BP readings in a standardized manner and collected data on demographic, lifestyle factors and comorbidities. Hypertension was defined as SBP of at least 140 mmHg, or DBP of at least 90 mmHg, or taking antihypertensive medication. Data were collated centrally and analysis was carried out using regression models to evaluate the associations between BP and participant characteristics.
A total of 10 046 participants were screened, of whom 3097 (31.0%) had hypertension, only 48.5% were aware of their condition and 44.4% were taking antihypertensive medication. Of those taking antihypertensive medication, 53.2% were controlled to less than 140/90 mmHg, whereas the remaining 46.8% of participants had BP of at least 140/90 mmHg suggestive of inadequately treated hypertension.
Consecutive data obtained over a 3-year period in Australia demonstrated stagnating awareness, treatment and control rates with the latter two being substantially lower than global rates and those in other high-income countries. Concerted efforts from all stakeholders will be required to help overcome the unacceptably poor rates of BP treatment and control in Australia.
The objective of the PERSONAL-CovidBP (Personalised Electronic Record Supported Optimisation When Alone for Patients With Hypertension: Pilot Study for Remote Medical Management of Hypertension ...During the COVID-19 Pandemic) trial was to assess the efficacy and safety of smartphone-enabled remote precision dosing of amlodipine to control blood pressure (BP) in participants with primary hypertension during the COVID-19 pandemic.
This was an open-label, remote, dose titration trial using daily home self-monitoring of BP, drug dose, and side effects with linked smartphone app and telemonitoring. Participants aged ≥18 years with uncontrolled hypertension (5-7 day baseline mean ≥135 mm Hg systolic BP or ≥85 mm Hg diastolic BP) received personalized amlodipine dose titration using novel (1, 2, 3, 4, 6, 7, 8, 9 mg) and standard (5 and 10 mg) doses daily over 14 weeks. The primary outcome of the trial was mean change in systolic BP from baseline to end of treatment. A total of 205 participants were enrolled and mean BP fell from 142/87 (systolic BP/diastolic BP) to 131/81 mm Hg (a reduction of 11 (95% CI, 10-12)/7 (95% CI, 6-7) mm Hg,
<0.001). The majority of participants achieved BP control on novel doses (84%); of those participants, 35% were controlled by 1 mg daily. The majority (88%) controlled on novel doses had no peripheral edema. Adherence to BP recording and reported adherence to medication was 84% and 94%, respectively. Patient retention was 96% (196/205). Treatment was well tolerated with no withdrawals from adverse events.
Personalized dose titration with amlodipine was safe, well tolerated, and efficacious in treating primary hypertension. The majority of participants achieved BP control on novel doses, and with personalization of dose there were no trial discontinuations due to drug intolerance. App-assisted remote clinician dose titration may better balance BP control and adverse effects and help optimize long-term care.
URL: clinicaltrials.gov. Identifier: NCT04559074.
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