Opportunities for improving the quality of hypertension care in a managed care setting.

Hypertension management practices and patient health outcomes in a managed care setting were evaluated. Health-system pharmacists analyzed plan medical and pharmacy claims data for September 1, 1998, to August 31, 1999, to identify hypertensive enrollees (n = 23,316). Reviews of pharmacy claims and medical charts of a sample of hypertensive patients (n = 374) determined blood pressure control status, prevalence of cardiovascular risk factors, and comorbidities. The majority of patients treated for hypertension (66%) did not achieve blood pressure control. Analysis revealed a high prevalence of cardiovascular risk factors among hypertensive patients, with 92.2% of study patients having two or more risk factors. Reviews of 132,512 pharmacy claims revealed that one half of all prescribed therapies were for monotherapy, and 21% of hypertensive patients were prescribed combination therapy with two different agents. Data from a large managed care organization revealed that more than half of all hypertensive patients had inadequate blood pressure control. A quality improvement program for hypertension care that can improve patient health outcomes must educate patients and health care providers about the implications of the disease, identify patients with compelling comorbidities, evaluate pharmacologic regimens, and recommend therapeutic changes when necessary.     

Relationship of blood pressure control to adherence with antihypertensive monotherapy in 13 managed care organizations

OBJECTIVE: This study was conducted to evaluate the relationship between medication compliance and blood pressure (BP) control among members of 13 managed care organizations with essential hypertension (HTN) who received antihypertensive monotherapy for at least 3 pharmacy claims prior to the blood pressure measurement. METHODS: This was a retrospective review of medical and pharmacy claims over a 4-year period (1999-2002) from 13 U.S. health plans. Data were collected by trained health professionals from randomly selected patient medical records per Health Plan Employer Data and Information Set (HEDIS) technical specifications. Patients were selected if they (1) had received monotherapy or fixed-dose combination therapy (administered in one tablet or capsule) during the time BP was measured (thus those with no BP drug therapy were excluded); (2) had received 3 or more antihypertensive pharmacy claims for the antihypertensive drug therapy prior to BP measurement; and (3) had one or more antihypertensive pharmacy claims after BP was measured. Control of BP was defined according to guidelines of the Sixth Report of the Joint National Committee (JNC 6) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (<140/90 mm Hg, or <130/85 mm Hg for patients with diabetes). Medication adherence was measured using the medication possession ratio (MPR), and MPR was used to classify patients into 3 adherence levels: high (80%-100%), medium (50%-79%), and low (<50%). The relationship between medication adherence and BP control was assessed using a logistic regression model. RESULTS: There were 1,017,181 patients with a diagnosis of HTN in medical claims data from which 10,734 (10.6%) were randomly selected for chart review. There were 1,032 patients (9.6%) in the sample who had a diagnosis of HTN but who were excluded because they had no HTN drug therapy. Of the total 9,894 patients (92.2%) who were excluded from the sample, 3,029 patients (28.2%) met all other inclusion criteria but were receiving more than one HTN drug. Of the 840 patients on HTN monotherapy, the mean age was 59 12.2 years; 422 (50%) were women, 16% had diabetes, and 43% had dyslipidemia. The monotherapy HTN drug was an angiotensin-converting enzyme inhibitor (27% of patients), calcium channel blocker (22%), beta-blocker (20%), or diuretic (11%). Of the 840 patients, 629 (74.8%) were determined to have high medication adherence, 165 (19.6%) had medium adherence, and 46 (5.5%) had low adherence. Approximately 270 (43%) of high adherence patients achieved BP control compared with 56 (34%) and 15 (33%) patients with medium and low adherence, respectively. High-adherence patients were 45% more likely to achieve BP control than those with medium or low compliance after controlling for age, gender, and comorbidities (odds ratio=1.45; P =0.026). CONCLUSION: These results demonstrate that 75% of these health plan members with a diagnosis of essential HTN who were selected for receipt of at least 4 pharmacy claims for HTN monotherapy exhibited high medication adherence. However, only 43% of high-adherence patients attained their target (JNC 6) blood pressure goal compared with 33% to 34% of patients with medium or low adherence to antihypertensive monotherapy.     

Blood pressure goal attainment according to JNC 7 guidelines and utilization of antihypertensive drug therapy in MCO patients with type 1 or type 2 diabetes

OBJECTIVE: Controlling hypertension (HTN) in patients with diabetes mellitus (DM) can reduce complications such as nephropathy, cerebrovascular disease, and cardiovascular disease. As part of a quality improvement project with a managed care organization (MCO), we evaluated blood pressure (BP) control relative to the type of drug therapy for patients with type 1 or type 2 DM who were identified from pharmacy claims for antihyperglycemic drug therapy. METHODS: Pharmacy claims for antihyperglycemic drugs, including insulin, were used to identify a random sample of commercial members in an MCO comprising 30 health plans across the United States. Retrospective medical record review was conducted in October 2003 to collect data from 4,814 patient charts. BP goal attainment according to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines was determined for each patient from the most recent BP reading documented in the medical chart. RESULTS: The distribution by type of DM was 21.0% (n = 1,011) for type 1, 75.7% (n = 3,644) for type 2, and 3.3% (n = 159) for cases not documented in the medical chart. Excluding 590 charts (12.3%) without BP values, there were 1,328 of 4,224 DM patients (31.4%) at JNC 7 BP goal (< 130/80 mm Hg). Of the 1,328 patients at JNC 7 BP goal, 577 (43.4%) were at JNC 7 BP goal with no drug therapy. Excluding the 577 patients who did not require drug therapy to reach JNC 7 goal, 751 (20.6%) of the remaining 3,647 patients who required antihypertensive drug therapy were at JNC 7 BP goal, and 788 (21.6%) received no antihypertensive drug therapy. For the population of 4,224 DM patients with a BP value recorded in the chart, application of the lower BP goals in the JNC 7 guidelines reduced the proportion with controlled BP to 31.4% (1,328/4,224) from 42.6% (1,799/4,224) according to the former JNC 6 guidelines (P < 0.01). The proportion of DM patients with HTN was 59.6% (n = 2,870), and 28.4% (n = 814) of these patients were not taking either an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB). There were 704 patients with albuminuria or nephropathy (14.6%), of which 35.4% (n = 249) were not taking either an ACEI or an ARB, preferred therapy in these patients. CONCLUSION: In this population of MCO members with DM for whom a BP value was recorded in the medical chart, 13.7% met JNC 7 BP goal with no antihypertensive drug therapy. For the patients with DM who received antihypertensive drug therapy and had a BP value recorded in the medical chart, only 26.3% were at JNC 7 BP goal. The application of JNC 7 guidelines significantly reduced the proportion of DM patients at target BP goal from 42.6%% to 31.4%     

Primary care provider perceptions of an integrated community pharmacy hypertension management program

BackgroundTrained community pharmacists provided hypertension (HTN) management services in collaboration with a patient-centered medical home (PCMH).ObjectiveTo explore primary care provider (PCP) perceptions of a HTN management program in which patients at the PCMH with elevated blood pressure could choose to receive follow-up care with a trained community pharmacist at a chain community pharmacy.MethodsWe conducted informal interviews with 8 PCPs with a range of level of involvement with the collaborative HTN management program to inform the development of a 13-question online survey that was distributed to PCPs at 10 participating Michigan Medicine PCMH clinics. The primary outcome was the percent of PCPs who reported that the program improved their patient’s blood pressure. Secondary outcomes included awareness of the program, alternative follow-up strategies, PCP satisfaction, and barriers to using the program.ResultsA total of 39 PCPs (30.0%) responded to the survey. More than one-half (n = 21 of 39, 53.9%) of respondents reported that at least 1 of their patients had seen a trained community pharmacist for HTN management services. Almost all of these PCPs (n = 19 of 21, 90.5%) reported being satisfied with the program, and 80.9% (n = 17 of 21) agreed that it helped patients improve their blood pressure control. The most common barriers identified were patients preferring to follow up directly with their PCP (n = 18 of 39, 46.2%), PCPs being more comfortable with patients having a visit with an embedded ambulatory care pharmacist (n = 16 of 39, 41.0%), and a lack of written materials to share with patients about the program (n = 15 of 39, 38.5%).ConclusionPCPs who used the integrated community pharmacy HTN management program were satisfied with the program and thought that it resulted in improved blood pressure control. PCPs may benefit from written information to share with their patients as well as education to increase their awareness of the program and its beneficial effect on patient blood pressure.     

Perindopril for the treatment of hypertension

INTRODUCTION: Treatment of hypertension is fundamental for the prevention of cardiovascular events and mortality. This review focuses on the specific benefits of the ACE inhibitor perindopril. AREAS COVERED: A systematic literature search is undertaken for supporting the pharmacological proprieties and clinical efficacy of perindopril in the treatment of hypertension. Good tissue penetration, strong affinity for ACE and a long duration of action support the dose-dependent blood pressure lowering efficacy. Perindopril in combination with amlodipine significantly reduced total and cardiovascular mortality as compared to atenolol/diuretic in large-scale clinical trials of hypertensive patients. A greater reduction in blood pressure variability, central blood pressure and specific vascular protective proprieties of perindopril (improvement in arterial stiffness and endothelial function) might explain these results. Cardiovascular prevention with perindopril, in combination with indapamide, has been also shown in the elderly and patients with diabetes, cardio- and cerebrovascular diseases. EXPERT OPINION: Perindopril is effective and safe for blood pressure control with a dose-dependent effect. Combination therapy with indapamide or amlodipine reduces cardiovascular events and mortality in hypertensive patients. Pharmacological proprieties and results of clinical trials support the choice of perindopril as an appropriate treatment for hypertensive patients.     

Utilization and cost of sildenafil in a large managed care organization with a quantity limit on sildenafil

OBJECTIVE: Erectile dysfunction (ED) affects approximately 30 million men in the United States. The objectives of this study were to (1) assess the cost and utilization of sildenafil citrate (Viagra), an oral therapeutic agent for ED, in a large managed care organization (MCO) with a quantity limit of 6 units per 30-day supply and (2) describe the incidence of comorbid conditions and the severity of cardiovascular disease in adult male users of sildenafil. METHODS: Pharmacy claims for sildenafil were identified from an administrative database of claims with dates of service in calendar year 2001 for male members aged 18 years or older. Medical claims for MCO members who had sildenafil claims were used to identify comorbid diseases and categorize patients by degree of cardiovascular risk. High risk was defined as having at least 1 medical claim with a diagnosis of diabetes mellitus, ischemic heart disease, abdominal aortic aneurysm, or peripheral arterial disease, and medium risk was defined as not having any diagnosis in the high-risk category but at least 1 cardiovascular risk factor that included smoking, hypertension, hypercholesterolemia, family history of premature coronary heart disease, or being aged 45 years or older. RESULTS: There were 67,914 pharmacy claims for sildenafil during 2001 for 20,281 MCO members, an average of 3.3 pharmacy claims per patient. The prevalence of sildenafil use was 54.1 per 1,000 male MCO members aged 18 years or older. The total allowed charges for sildenafil pharmacy claims in 2001 were 3.56 million US dollars, of which patients paid 26.6% in average cost-share, and the net MCO cost per member per month (PMPM) was 0.18 US dollars. A total of 1,681 patients (8.3%) exceeded their quantity restrictions for sildenafil tablets in 2001, of which 1,362 (81.0%) paid cash and 319 (19.0%, or 1.6% of all sildenafil users) appealed and received approval from the MCO for additional sildenafil tablets beyond the restriction of 6 tablets per month. Medical claims were available for 15,644 sildenafil patients (77.1%), and 12,720 sildenafil users (81.3% of those with medical claims) were judged to be at high or medium cardiovascular risk. CONCLUSIONS: A quantity limit of 6 tablets of sildenafil per 30-day period was associated with a drug cost to users and the MCO of 0.25 US dollars PMPM. Sildenafil users paid an average cost-share of 26.6%, resulting in a net drug cost of 0.18 US dollars PMPM to the MCO.     

Clinical pharmacy specialist implementation of lisinopril therapy in patients with coronary artery disease and diabetes mellitus

STUDY OBJECTIVE: As the results of the Heart Outcomes Prevention Evaluation trial suggested that patients with both coronary artery disease (CAD) and diabetes mellitus would benefit from angiotensin-converting enzyme (ACE) inhibitor therapy, our objective was to increase the percentage of patients with both of these conditions receiving the goal dosage (20 mg/day) or highest tolerated dosage of the ACE inhibitor lisinopril through intervention of a clinical pharmacy service. STUDY DESIGN: Prospective study with historic comparison (control group). SETTING: Clinical Pharmacy Cardiac Risk Service. PATIENTS: Hospitalized patients with CAD and type 2 diabetes mellitus. MEASUREMENTS AND MAIN RESULTS: At hospital discharge, lisinopril 5 mg/day was started in eligible patients; the drug was titrated to a goal dosage of 20 mg/day or the highest tolerated dosage. Potassium level, serum creatinine level, and blood pressure were monitored at baseline, at each dosage titration, and 2 weeks after the goal or highest tolerated dosage was reached. The group receiving usual care (control group) consisted of 95 patients; the treatment group had 101 patients. At baseline, 19 patients (20%) in the control group were receiving the goal dosage of lisinopril, 34 (36%) were taking a suboptimal dosage, 16 (17%) were excluded from treatment, and 26 (27%) were eligible but were not receiving lisinopril therapy. After 9 months, ACE inhibitor dosages had changed minimally in the control group. In the treatment group, at baseline, 37 patients (36%) were at their goal dosage and therefore titration was not necessary; 15 (15%) were receiving a suboptimal dosage, 35 (35%) were excluded from treatment, and 14 (14%) were eligible but not receiving therapy. After the titration period, 55 (54%) treatment group patients were at the goal dosage, 11 (11%) were taking a suboptimal dosage, and 35 (35%) were not candidates for ACE inhibitor therapy. The most common reasons for exclusion were renal insufficiency, cough, and baseline hypotension. Changes in potassium level, serum creatinine level, and blood pressure were not significant during the study. CONCLUSION: The clinical pharmacy service more than doubled the number of patients with CAD and diabetes who achieved the goal dosage of an ACE inhibitor, a drug class that has been shown to decrease morbidity and mortality in this patient population.     

ACE inhibitors versus diuretics: ALLHAT versus ANBP2

The ALLHAT (The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial) trial enrolled hypertensive patients with at least one additional risk factor for coronary heart disease (CHD) to a comparison of the diuretic chlorthalidone, the calcium channel blocker, amlodipine, and the angiotensin-converting enzyme (ACE) inhibitor, lisinopril. Throughout the study, chlorthalidone decreased the systolic blood pressure to a slightly, but significantly greater extent (0.8-3.1 mmHg) than amlodipine or lisinopril. No significance differences were reported for amlodipine versus chlorthalidone or lisinopril versus chlorthalidone on the primary outcome of combined incidence of fatal CHD and nonfatal myocardial infarction. The findings of ALLHAT support the use of thiazide-type diuretics as first choice pharmacological therapy in at risk patients with hypertension. ANBP2 (The Second Australian National Blood Pressure Study) was also a comparison between diuretics (hydrochlorothiazide) and ACE inhibitors (enalapril) but was performed in older hypertensives that had few previous cardiovascular events. Diastolic blood pressure reduction was similar in both groups at all times. The risk of the primary outcome of all cardiovascular events or death from any cause was 11% lower in the ACE group than the diuretic group and the benefit was predominantly in men. Thus, ANBP2 suggests that in relatively healthy elderly hypertensive patients, ACE inhibitors should be preferred to diuretics.     

Left ventricular hypertrophy in hypertensive patients in Indian primary care: prevalence and effect of treatment with sustained release indapamide

OBJECTIVE: Epidemiologic studies indicate an ethnic determinant of left ventricular hypertrophy (LVH), but its prevalence in hypertensive Asian Indians at diagnosis is not known. The observation that LVH regression reduces cardiovascular risk independent of blood pressure, suggests that initial antihypertensive treatment, which also regresses LVH is a desirable goal. This study investigates the prevalence of LVH and its regression with indapamide sustained release (Natrilix SR) in untreated Indian hypertensive patients managed in the primary care setting. DESIGN AND METHODS: Randomly selected physicians serving a defined population recruited untreated hypertensive patients to determine prevalence of LVH. All patients then received indapamide SR treatment for 6 months. LVH was assessed by echocardiography. All measurements were centralized and interpreted by a single blinded observer. MAIN OUTCOME MEASURES: The primary treatment outcomes were the percentage of patients whose LVH regressed with treatment and the number of patients who achieved a blood pressure below 140/90 mmHg. RESULTS: Of the 86 patients recruited, 21 (24.4%, 95% confidence interval (CI) 15.3-33.8) had LVH. There were 11 cases (26.2%) in men, 10 (22.7%) in women, and 15 (32.6%) in those above 50 years. Treatment regressed LVH in 16 (76.2%, 95%CI, 58.0-94.4) by a mean of 25.4 g/m2 (95%CI, 2.8-47.7, p< 0.05). Blood pressure was controlled in 71 (82.6%, 95%CI, 74.5-90.6) patients. CONCLUSION: Prevalence of LVH in untreated Indian hypertensive patients is similar to that in white western populations. Initial indapamide SR treatment is effective in both controlling blood pressure and regressing LVH in the primary care setting.     

Angiotensin-converting enzyme inhibitor therapy in patients with heart failure enrolled in a managed care organization: effect on costs and probability of hospitalization

STUDY OBJECTIVE: To evaluate the effect of angiotensin-converting enzyme (ACE) inhibitor therapy on risk of hospitalization and resource utilization in patients with heart failure enrolled in a managed care organization. DESIGN: Retrospective medical and pharmacy claims analysis. PATIENTS: One thousand five hundred seventy-three patients with heart failure enrolled in a managed care organization. MEASUREMENTS AND MAIN RESULTS: Medical and pharmacy claims from January 1, 1997-December 31, 1999, from a managed care organization covering approximately 350,000 individuals were analyzed. Patients aged 35 years or older with a diagnostic code for heart failure and 18 months of continuous eligibility were selected. From this group (1573 patients), two cohorts were selected based on exposure to an ACE inhibitor. Dependent variables of interest were all-cause hospitalization and total direct medical costs during the 12-month study period. A logistic regression model and an ordinary least-squares model adjusting for patient demographics, comorbidities, and concomitant drug therapy were used to analyze the risk of all-cause hospitalization and total direct medical costs, respectively. Therapy with an ACE inhibitor for 180 days was associated with a decreased risk of all-cause hospitalization (odds ratio 0.65, p<0.0001) and lower total costs (mean dollars 2397, p<0.001) compared with no ACE inhibitor therapy. CONCLUSION: In patients with a diagnosis of heart failure, exposure to ACE inhibitor therapy is associated with fewer hospitalizations and lower total costs than no ACE inhibitor exposure.     

Microalbuminuria as a predictive factor for cardiovascular events

We tested the hypothesis that microalbuminuria screening in a general practice setting would identify high-risk nondiabetic hypertensive patients, and we measured microalbuminuria response to drug treatment. General practitioners were enrolled who had collected medical histories and performed physical examinations and routine laboratory tests in more than 11,000 untreated hypertensive, nondiabetic patients. Microalbuminuria was measured with an albumin-sensitive immunoassay test strip. The patients' mean age was 57 years, 51% were men, and mean duration of hypertension was 69 months. Twenty-five percent of patients had coronary artery disease (CAD), 17% had left ventricular hypertrophy (LVH), 5% had had a stroke, and 6% had peripheral vascular disease (PVD). Microalbuminuria was present in 32% of men and 28% of women. In patients with microalbuminuria, 31% had CAD, 24% had LVH, 6% had had a stroke, and 7% had PVD. In patients without microalbuminuria, all of these rates were significantly lower: 22%, 14%, 4%, and 5%, respectively (p < 0.001). Furthermore, in patients with CAD, LVH, stroke, or PVD, microalbuminuria was significantly greater than in patients who did not have these complications (p < 0.001). A multiple stepwise regression analysis with microalbuminuria as the dependent variable showed microalbuminuria depended on the following factors, in order of importance: systolic blood pressure, retinopathy, CAD, diastolic blood pressure, and LVH (all p < 0.0001). A multiple stepwise regression analysis with each of the concomitant diseases as the dependent variable showed that microalbuminuria was an independent and significant variable for each of the conditions. The patients were assigned to monotherapy with either angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, calcium antagonists, or diuretics. All of the drugs reduced microalbuminuria, although the beta-blocker carvedilol was superior (p < 0.05). We concluded microalbuminuria is an important risk factor that can be influenced by treatment.     

Renal protection and antihypertensive drugs: current status.

The renal protective effect of antihypertensive drugs is linked to 2 mechanisms. First, reduction in blood pressure (BP) is a fundamental prerequisite common to all antihypertensive drugs. The exact definition of the level to which BP should be reduced remains to be established, although there is some evidence that BP should be reduced below 130/85 mm Hg in patients with diabetic and nondiabetic nephropathies and below 125/75 mm Hg in patients with nondiabetic nephropathies and proteinuria >1 g/day. However, available data suggest that tight BP control (BP<140/80 mm Hg) can reduce the risk of cardiovascular complications in hypertensive patients with type 2 diabetes mellitus (non-insulin-dependent diabetes mellitus; NIDDM). Secondly, intrarenal actions on mechanisms such as glomerular hypertension and hypertrophy, proteinuria, mesangial cell proliferation, mesangial matrix production and probably endothelial dysfunction, which can cause and/or worsen renal failure, are relevant for the renal protective action of some drug classes. ACE inhibitors possess such properties and also seem to lower proteinuria more than other antihypertensive drugs, despite a similar BP lowering effect. Calcium antagonists likewise exert beneficial intrarenal effects, but with some differences among subclasses. It remains to be evaluated whether angiotensin II-receptor antagonists can exert intrarenal effects and antiproteinuric actions similar to those of ACE inhibitors. While primary prevention of diabetic nephropathy is still an unsolved problem. there is convincing evidence that in patients with type 1 (insulin-dependent diabetes mellitus; IDDM) or 2 diabetes mellitus and incipient nephropathy ACE inhibitors reduce urinary albumin excretion and slow the progression to overt nephropathy. Similar effects have been reported with some long-acting dihydropyridine calcium antagonists, although less consistently than with ACE inhibitors. In patients with diabetic overt nephropathy, ACE inhibitors and nondihydropyridine calcium antagonists are particularly effective in reducing proteinuria and both drugs can slow the decline in glomerular filtration rate more successfully than other antihypertensive treatment. Available data in patients with nondiabetic nephropathies indicate that ACE inhibitors can be beneficial, principally in patients with significant proteinuria, in slowing the progression of renal failure. However, it is still unclear whether this beneficial effect of ACE inhibitors is particularly evident in patients with mild and/or more advanced renal failure and whether calcium antagonists possess a similar nephroprotective effect. Overall, data from clinical trials thus seem to indicate that ACE inhibitors and possibly calcium antagonists should be preferred in the treatment of patients with diabetic and nondiabetic nephropathies. However, further information is needed to understand renal protection.     

Left ventricular hypertrophy in hypertensive patients in Indian primary care: prevalence and effect of treatment with sustained release indapamide

Objective: Epidemiologic studies indicate an ethnic determinant of left ventricular hypertrophy (LVH), but its prevalence in hypertensive Asian Indians at diagnosis is not known. The observation that LVH regression reduces cardiovascular risk independent of blood pressure, suggests that initial antihypertensive treatment, which also regresses LVH is a desirable goal. This study investigates the prevalence of LVH and its regression with indapamide sustained release (Natrilix SR) in untreated Indian hypertensive patients managed in the primary care setting.

Design and methods: Randomly selected physicians serving a defined population recruited untreated hypertensive patients to determine prevalence of LVH. All patients then received indapamide SR treatment for 6months. LVH was assessed by echocardiography. All measurements were centralized and interpreted by a single blinded observer.

Main outcome measures: The primary treatment outcomes were the percentage of patients whose LVH regressed with treatment and the number of patients who achieved a blood pressure below 140/90 mmHg.

Results: Of the 86 patients recruited, 21 (24.4%, 95% confidence interval (CI) 15.3-33.8) had LVH. There were 11 cases (26.2%) in men, 10 (22.7%) in women, and 15 (32.6%) in those above 50years. Treatment regressed LVH in 16 (76.2%, 95%CI, 58.0-94.4) by a mean of 25.4?g/m² (95%CI, 2.8-47.7, p?<?0.05). Blood pressure was controlled in 71 (82.6%, 95%CI, 74.5–90.6) patients.

Conclusion: Prevalence of LVH in untreated Indian hypertensive patients is similar to that in white western populations. Initial indapamide SR treatment is effective in both controlling blood pressure and regressing LVH in the primary care setting.     

Optimization of blood pressure treatment with fixed-combination perindopril/amlodipine in patients with arterial hypertension

Background: Fixed-dose combination treatments using an angiotensin-converting enzyme (ACE) inhibitor, such as perindopril, plus a calcium channel blocker (CCB), such as amlodipine, have been endorsed by guidelines because they improve blood pressure control and cardiovascular outcomes in hypertensive patients, while being well tolerated and well adhered to by patients. Objective: This study aimed to assess the blood pressure-lowering effects of fixed-combination perindopril/amlodipine in patients previously treated with an ACE inhibitor and/or a CCB. Methods: This was a prospective, real-life, open-label, longitudinal, phase IV study conducted in 223 outpatient medical centres across Slovakia. 2132 previously treated patients whose hypertension was insufficiently controlled at baseline or who tolerated treatment poorly were included. Patients were treated for 3 months with fixed-combination perindopril/amlodipine 5?mg/5?mg, 5?mg/10?mg, 10?mg/5?mg and 10?mg/10?mg. The main outcome measure was a reduction in mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) and achievement of blood pressure targets (SBP/DBP <140/90?mmHg or <130/80?mmHg for patients with type 2 diabetes mellitus or high cardiovascular risk). Results: After 3 months of treatment, mean?±?SD SBP/DBP had decreased from 158.5?±?17.5/93.6?±?9.8?mmHg to 132.9?±?10.6/80.7?±?6.2?mmHg (p?相似文献   

Clinical Guidelines for the Treatment of Hypertension in African Americans

African Americans represent a population with the highest prevalence of hypertension in the world, associated with earlier onset, more severity, poorer control rates, and more cardiovascular and renal complications than White Americans. The high prevalence of type 2 diabetes mellitus in African Americans, compared with Whites, compounds the excessive burden of cardiovascular and kidney disease. The Hypertension in African American Working Group of the International Society of Hypertension in Blacks recently developed a consensus document that presented a practical, evidence-based approach aimed at achieving better blood pressure control. It was thought that a new approach, targeted at US Blacks, was needed to achieve better blood pressure control and enhanced target tissue protection. Key elements of the document include (i) emphasis on the importance of therapeutic lifestyle modification such as weight loss, decreased sodium ingestion, increased potassium intake, exercise, and weight loss, to name a few; (ii) recommendation of combination antihypertensive agents because of the high prevalence of individuals with >15 mm Hg above SBP goal and/or 10 mmHg above DBP goal (140/90 unless there is also diabetes and/or kidney disease with >1 g proteinuria daily). Effective combinations include beta-adrenoceptor antagonist/diuretic, ACE inhibitor/diuretic, ACE inhibitor/calcium channel antagonist, and angiotensin receptor antagonist/diuretic; and (iii) the recommendations do not differ from other racial/ethnic groups where specific or compelling indications for the use of specific classes of antihypertensive agents exist.