Hypertension Awareness and Control Among Young Adults in the National Longitudinal Study of Adolescent Health

BACKGROUND

Young adults are less likely than older adults to be aware they have hypertension or to be treated for hypertension.

OBJECTIVE

To describe rates of hypertension awareness and control in a cohort of young adults and understand the impact of health insurance, utilization of preventive care, and self-perception of health on rates of hypertension awareness and control in this age group.

DESIGN AND PARTICIPANTS

Cross-sectional study of 13,512 young adults participating in Wave IV of the National Longitudinal Study of Adolescent Health in 2007–2008.

MAIN MEASURES

We defined hypertension as an average of two measured systolic blood pressures (SBP) ≥ 140 mmHg, diastolic blood pressures (DBP) ≥ 90 mmHg, or self-report of hypertension. We defined hypertension awareness as reporting having been told by a health care provider that one had high blood pressure, and assessed awareness among those with uncontrolled hypertension. We considered those aware of having hypertension controlled if their average measured SBP was < 140 mmHg and DBP was < 90 mmHg.

KEY RESULTS

Of the 3,303 young adults with hypertension, 2,531 (76 %) were uncontrolled, and 1,893 (75 %) of those with uncontrolled hypertension were unaware they had hypertension. After adjustment for age, sex, race/ethnicity, weight status, income, education, alcohol and tobacco use, young adults with uncontrolled hypertension who had (vs. didn’t have) routine preventive care in the past 2 years were 2.4 times more likely (95 % confidence interval [CI] 1.68–3.55) to be aware, but young adults who believed they were in excellent (vs. less than excellent) health were 64 % less likely to be aware they had hypertension (OR 0.36, 95 % CI 0.23–0.57). Neither preventive care utilization nor self-rated health was associated with blood pressure control.

CONCLUSIONS

In this nationally representative group of young adults, rates of hypertension awareness and control were low. Efforts to increase detection of hypertension must address young adults’ access to preventive care and perception of their need for care.     

Association of Body Mass Index, Diabetes, Hypertension, and Blood Pressure Levels with Risk of Permanent Atrial Fibrillation

BACKGROUND

After an initial episode of atrial fibrillation (AF), AF may recur and become permanent. AF progression is associated with higher morbidity and mortality. Understanding the risk factors for permanent AF could help identify people who would benefit most from interventions.

OBJECTIVE

To determine whether body mass index (BMI), diabetes, hypertension, and blood pressure levels are associated with permanent AF among people whose initial AF episode terminated.

DESIGN

Population-based inception cohort study.

PARTICIPANTS

Enrollees in Group Health, an integrated health care system, aged 30–84 with newly diagnosed AF in 2001–2004, whose initial AF terminated within 6 months and who had at least 6 months of subsequent follow-up (N?=?1,385).

MAIN MEASURES

Clinical characteristics were determined from medical records. Permanent AF was determined from medical records and ECG and administrative databases. Permanent AF was defined as AF present on two separate occasions 6–36 months apart, without any documented sinus rhythm between the two occasions. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs).

KEY RESULTS

Five-year cumulative incidence of permanent AF was 24 %. Compared with normal BMI (18.5–24.9 kg/m²), BMI levels of 25.0–29.9 (overweight), 30.0–34.9 (obese 1), 35.0–39.9 (obese 2), and ≥ 40.0 kg/m² (obese 3) were associated with HRs of permanent AF of 1.26 (95 % CI: 0.92, 1.72); 1.35 (0.96, 1.91); 1.50 (0.97, 2.33); and 1.79 (1.13, 2.84), adjusted for age, sex, diabetes, hypertension, blood pressure, coronary heart disease, valvular heart disease, heart failure, and prior stroke. Diabetes, hypertension, and blood pressure were not associated with permanent AF.

CONCLUSIONS

For people whose initial AF episode terminates, benefits of having lower BMI may include a lower risk of permanent AF. Risk of permanent AF was similar for people with and without diabetes or hypertension and across blood pressure levels.     

Azilsartan Decreases Renal and Cardiovascular Injury in the Spontaneously Hypertensive Obese Rat

Purpose

Angiotensin II type 1 receptor blockers (ARBs) are widely used in treating hypertension. In the present study, we tested the hypothesis that a novel ARB, azilsartan medoxomil (AZL-M) will prevent renal and cardiovascular injury in the spontaneously hypertensive obese rat (SHROB), a model of cardiometabolic syndrome.

Methods

Male SHROB were treated with vehicle or AZL-M orally for 56 days. Vehicle treated normotensive Wistar-Kyoto (WKY) rats served as controls. The effects of AZL-M on kidney injury, vascular endothelial and heart functions, lipid profile, and glucose tolerance were assessed.

Results

AZL-M demonstrated anti-hypertensive effects along with markedly improved vascular endothelial function in SHROB. In these rats, AZL-M demonstrates strong kidney protective effects with lower albuminuria and nephrinuria along with reduced tubular cast formation and glomerular injury. AZL-M treatment also improved left ventricular heart function, attenuated development of left ventricular hypertrophy, and reduced cardiac fibrosis in SHROB.

Conclusion

Overall, these findings demonstrate kidney and heart protective effects of AZL-M in SHROB, and these effects were associated with its ability to lower blood pressure and improve endothelial function.     

Hypertonie-Update 2014

Background

Hypertension is still one of the most important diseases in Germany. More than 60% of patients over 60 years of age suffer from hypertension. The consequences of uncontrolled hypertension are stroke or ischemic heart disease. Many studies during the last decades investigated therapeutic options to lower hypertension with respect to morbidity and mortality.

Aim

In this review, a summary of recently published guidelines to diagnose and treat hypertension is given.

Material and methods

Several international hypertension societies and groups have revised their guidelines for rational and also resource sparing diagnostics and therapy of arterial hypertension during recent years. The target values and therapeutic approaches in particular were amended.

Results

Target values for treatment of hypertension were changed in current guidelines. The treatment goal for all hypertensive patients is now below 140/90 mmHg. Patients older than 80 years of age might have systolic blood pressure up to 150 mmHg without intensification of therapy. Early combination of blood pressure reducing agents is applicable in many patients. For first line antihypertension therapy special importance is given to angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, calcium antagonists and thiazide diuretics.

Discussion

In the new guidelines there is a special focus on blood pressure values which are not so ambitious as in the early phase of this century. Blood pressure goals are now more moderate. Combination therapy is now generally accepted for many patients in eary stages, to target the correct blood pressure control.     

Physician Underutilization of Effective Medications for Resistant Hypertension at Office Visits in the United States: NAMCS 2006–2010

BACKGROUND

The American Heart Association (AHA) published guidelines for treatment of resistant hypertension in 2008 recommending use of thiazide diuretics (particularly chlorthalidone), aldosterone antagonists, and fixed-dose combination medications, but it is unclear the extent to which these guidelines are being followed.

OBJECTIVE

To describe trends in physician use of recommended medications for resistant hypertension and assess variations in medication use based on geography, physician specialty and patient characteristics.

DESIGN

Cross-sectional analysis using the National Ambulatory Medical Care Survey from 2006 to 2010.

STUDY SAMPLE

We analyzed visits of hypertension patients to family physicians, general internists, and cardiologists. Resistant hypertension was defined as concurrent use of ≥ 4 classes of blood pressure (BP) medications or elevated BP despite the use of ≥ 3 medications. Pregnant patients and visits with diagnosed heart failure or end-stage renal disease were excluded.

MAIN OUTCOME

Use of AHA-recommended medications for management of resistant hypertension.

RESULTS

Of 19,500 patient visits with hypertension, 1,567 or 7.1 % CI (6.6–7.7 %) met criteria for resistant hypertension. Thiazide diuretic use was reported in 58.9 % of visits pre-guidelines vs. 54.8 % post-guidelines (p?=?0.37). Use of aldosterone antagonists was low and also did not change significantly after guideline publication (3.1 % vs. 4.5 %, p?=?0.27). Fixed-dose combinations use was 42.0 % before and 37 % after guideline publication (p?=?0.29). Each 10-year increase in patient age was associated with lower thiazide use (OR 0.87, CI 0.77–0.97), as was presence of comorbid ischemic heart disease (OR 0.62, CI 0.41–0.94). Medication use did not vary by geography or physician specialty.

CONCLUSION

Use of AHA-recommended medications for resistant hypertension remains low after publication of guidelines. Healthcare systems should encourage more frequent prescribing of these medications to improve care in this high-risk population.     

Awareness,Treatment and Control of Hypertension Among Filipino Immigrants

BACKGROUND

Filipino Americans have high rates of hypertension, yet little research has examined hypertension awareness, treatment, and control in this group.

OBJECTIVE

In a community-based sample of hypertensive Filipino American immigrants, we identify 1) rates of hypertension awareness, treatment, and control; and 2) factors associated with awareness, treatment, and control.

DESIGN

Cross-sectional analysis of survey data from health screenings collected from 2006 to 2010.

PARTICIPANTS

A total of 566 hypertensive Filipino immigrants in New York City, New York and Jersey City, New Jersey.

MAIN MEASURES

Hypertension awareness, treatment, and control. Participants were included in analysis if they were hypertensive, based on: a past physician diagnosis, antihypertensive medication use, and/or high blood pressure (BP) screening measurements. Demographic variables included sex, age, time in the United States, location of residence, and English spoken language fluency. Health-related variables included self-reported health, insurance status, diabetes diagnosis, high cholesterol diagnosis, clinical measures (body mass index [BMI], glucose, and cholesterol), exercise frequency, smoking status, cardiac event history, family history of cardiac event, and family history of hypertension.

RESULTS

Among the hypertensive individuals, awareness, treatment, and control rates were suboptimal; 72.1 % were aware of their status, 56.5 % were on medication, and only 21.7 % had controlled BP. Factors related to awareness included older age, worse self-reported health, family history of hypertension, and a diagnosis of high cholesterol or diabetes; factors related to treatment included older age, longer time lived in the United States, and being a non-smoker; having health insurance was found to be the main predictor of hypertension control. Many individuals had other cardiovascular disease (CVD) risk factors; 60.4 % had a BMI ≥25, 12.0 % had at-risk glucose measurements and 12.8 % had cholesterol ≥ 240.

CONCLUSIONS

Hypertensive Filipinos exhibit poor hypertension management, warranting increased efforts to improve awareness, treatment and control. Culturally tailored public health strategies must be prioritized to reduce CVD risk factors among at-risk minority populations.     

Cerebral hemodynamic changes in obstructive sleep apnea syndrome after continuous positive airway pressure treatment

Background

Patients with obstructive sleep apnea syndrome (OSAS) are at increased risk for cerebrovascular diseases. The underlying mechanisms remain obscure. It may occur through a reduction in cerebral vascular reactivity. Continuous positive airway pressure (CPAP) is effective in reducing the occurrence of apneas. We hypothesized that treatment with CPAP improves cerebral vascular reactivity.

Methods

This is a prospective study with OSAS patients. The apnea test (ApT) was calculated as an increase of mean artery velocity during apnea: [Artery velocity in apnea minus Resting artery velocity]/Resting artery velocity expressed as percentage. After 2 years of CPAP treatment, the test was repeated.

Results

Seventy-six patients represented the study pool. After 2 years of treatment with CPAP, we were able to conduct a reassessment in 65 patients. Of the 65 patients who finished the clinical study, 56 were men, and 9 were women, with an average age of 48.1?±?10.4 years. There was an improvement in the ApT after CPAP treatment (30.8?±?12.1 vs 39.8?±?15.1; p:0.000). The values of cerebral blood flow velocities, diastolic blood pressure in apnea, and basal heart rate decreased.

Conclusions

Cerebral vascular reactivity in OSAS patients measured by ApT improved after 2 years of CPAP.     

Glucocorticoid treatment impairs microvascular function in healthy men in association with its adverse effects on glucose metabolism and blood pressure: a randomised controlled trial

Aims/hypothesis

Glucocorticoids (GCs) are widely used anti-inflammatory agents that frequently induce side effects, including insulin resistance, diabetes and hypertension. Here, we investigated the contribution of microvascular dysfunction to the development of these adverse effects in healthy men.

Methods

In a randomised, placebo-controlled, dose–response intervention study, 32 healthy normoglycaemic men (age: 21?±?2 years; BMI: 21.9?±?1.7 kg/m²) were allocated to receive prednisolone 30 mg once daily (n?=?12), prednisolone 7.5 mg once daily (n?=?12) or placebo (n?=?8) for 2 weeks using block randomisation. A central office performed the treatment allocation, and medication was dispersed by the hospital pharmacy that was also blinded. Treatment allocation was kept in concealed envelopes. Participants, study personnel conducting the measures and assessing the outcome were blinded to group assignment. The study was conducted at a university hospital. Primary endpoint was prednisolone-induced changes in microvascular function, which was assessed by capillary microscopy. Insulin sensitivity was determined by hyperinsulinaemic–euglycaemic clamp and postprandial glycaemic excursions by standardised meal tests.

Results

Compared with placebo, prednisolone 7.5 mg and 30 mg decreased insulin-stimulated capillary recruitment by 9?±?4% and 17?±?3%, respectively (p?<?0.01). In addition, prednisolone 7.5 mg and 30 mg reduced insulin sensitivity (M value) by ?11.4?±?4.5 μmol kg^?1 min^?1 and ?25.1?±?4.1 μmol kg^?1 min^?1 (p?<?0.001) and increased postprandial glucose levels by 11?±?5% and 27?±?9% (p?<?0.001), respectively. Only high-dose prednisolone increased systolic blood pressure (6?±?1.2 mmHg, p?=?0.006). Prednisolone-induced changes in insulin-stimulated capillary recruitment were associated with insulin sensitivity (r?=?+0.76; p?<?0.001), postprandial glucose concentrations (r?=??0.52; p?<?0.03) and systolic blood pressure (r?=??0.62; p?<?0.001). Prednisolone increased resistin concentrations, which were negatively related to insulin-stimulated capillary recruitment (r?=??0.40; p?=?0.03). No effects were noted on adiponectin and leptin concentrations. Prednisolone treatment was well tolerated; none of the participants left the study.

Conclusions/interpretation

Prednisolone-induced impairment of insulin-stimulated capillary recruitment was paralleled by insulin resistance, increased postprandial glucose levels, hypertension and increased circulating resistin concentrations in healthy men. We propose that GC-induced impairments of microvascular function may contribute to the adverse effects of GC treatment on glucose metabolism and blood pressure.

Trial registration

isrctn.org ISRTCN 78149983

Funding

The study was funded by the Dutch Top Institute Pharma T1-106.     

Effects of diabetes and hypertension on macrophage infiltration and matrix expansion in the rat kidney

Background

In experimental models of diabetes mellitus, aggravation of renal injury by concomitant hypertension has been described. Inflammatory mechanisms contribute to renal damage in both diseases. We investigated whether hypertension and diabetes mellitus act synergistically to induce macrophage infiltration and matrix expansion in the kidney.

Methods

Insulin-dependent diabetes mellitus was induced by streptozotocin injections to hypertensive mRen2-transgenic rats (TGR) and normotensive Sprague-Dawley control rats. Quantitative immunohistochemical examination of kidney tissue sections was used to measure macrophage infiltration and matrix expansion. The expression of MCP-1, Osteopontin, RANTES, ICAM-1 and VCAM-1 was evaluated by real-time RT-PCR. The localization of MCP-1 was studied by immunohistochemistry.

Results

Macrophage infiltration was present in the kidney of normotensive diabetic rats. Hypertensive rats exhibited a more marked infiltration of macrophages, regardless of whether diabetes was present or not. Gene expression of ICAM-1, VCAM-1 and RANTES was unaltered whereas Osteopontin and MCP-1 were induced by hypertension. Immunoreactive MCP-1 was slightly increased in diabetic rat kidney podocytes, and more markedly increased in hypertensive animals. Glomerular matrix accumulation was induced by diabetes and hypertension to a similar degree, and was highest in hypertensive, diabetic animals.

Conclusion

Diabetes mellitus caused a mild, and angiotensin-dependent hypertension a more marked infiltration of macrophages in the kidney. Combination of both diseases led to additive effects on matrix expansion but not on inflammation. Hypertension appears to be a much stronger stimulus for inflammation of the kidney than STZ diabetes, at least in mRen2-transgenic rats.     

Effects of treatment with oral appliance on 24-h blood pressure in patients with obstructive sleep apnea and hypertension: a randomized clinical trial

Background

Continuous positive airway pressure treatment has been shown to lower blood pressure (BP) in patients with obstructive sleep apnea (OSA). The aims of the present pilot study were to evaluate the potential effects of oral appliance (OA) therapy on BP, to assess various outcome BP measures, and to inform sample size calculation.

Methods

Seventy-two patients with OSA and hypertension were randomly assigned to intervention with either an OA with mandibular advancement (active group) or an OA without advancement (control group). Before and after 3 months of treatment, the patients underwent nocturnal somnographic registration and 24-h ambulatory BP monitoring.

Results

Among the various BP measures, the largest trend toward effect of OA treatment was seen in 24-h mean systolic BP with a 1.8 mmHg stronger BP reduction in the active group compared with controls. A stronger trend toward effect was seen in a subgroup with baseline ambulatory daytime mean systolic BP >135/85 mmHg where the mean systolic BP fell, on average, 2.6 mmHg. Additional exclusion of patients with baseline apnea hypopnea index (AHI) ≤15 gave a significant reduction in mean systolic BP of 4.4 mmHg (P?=?0.044) in the active group compared with controls.

Conclusions

In patients with OSA and hypertension, OA treatment had a modest trend toward effect on reducing BP. A stronger trend toward treatment effect was seen after excluding patients with normal baseline ambulatory BP. Additional exclusion of patients with baseline AHI ≤15 showed a significant treatment effect. Data to inform sample size for an adequately powered randomized study are provided.     

The effect of different doses of vitamin D3 on markers of vascular health in patients with type 2 diabetes: a randomised controlled trial

Aims/hypothesis

Low 25-hydroxyvitamin D levels predict future cardiovascular events and are common in patients with type 2 diabetes. We compared the effect of 100,000 and 200,000 IU doses of vitamin D₃ on endothelial function, blood pressure and markers of glycaemic control in patients with type 2 diabetes.

Methods

This was a randomised, parallel group, placebo-controlled trial. Patients with type 2 diabetes and baseline 25-hydroxyvitamin D levels <100 nmol/l were enrolled from community and hospital-based diabetes clinics. Participants were assessed in a university department of clinical pharmacology and received a single oral dose of placebo or vitamin D₃ (100,000 IU or 200,000 IU) at baseline, randomly allocated via numbered bottles prepared offsite; participants and investigators were both blinded to treatment allocation. Endothelial function, office blood pressure, B-type natriuretic peptide, insulin resistance and glycosylated haemoglobin were measured at baseline, and at 8 and 16 weeks.

Results

We randomised 61 participants to the three groups (placebo 22, 100,000 IU vitamin D₃ 19, 200,000 IU vitamin D₃ 20). There was no significant difference in the primary outcome of endothelial function at 8 weeks (placebo 5.2%, n?=?22; 100,000 IU 4.3%, n?=?19; 200,000 IU 4.9%, n?=?17) or at 16 weeks. Insulin resistance and glycosylated haemoglobin did not improve with either dose of vitamin D₃. On covariate analysis, systolic blood pressure was significantly lower in both treatment arms than in the placebo group at 8 weeks (placebo 146.4 mmHg, 100,000 IU 141.4 mmHg [p?=?0.04 vs placebo], 200,000 IU 136.8 mmHg [p?=?0.03 vs placebo]). B-type natriuretic peptide levels were significantly lower in the 200,000 IU group by 16 weeks (placebo 34 pg/ml, 200,000 IU 21 pg/ml, p?=?0.02). No significant excess of adverse effects was noted in the treatment arms.

Conclusions/interpretation

High-dose vitamin D₃ improved systolic blood pressure and B-type natriuretic peptide levels, but not endothelial function, insulin resistance or glycosylated haemoglobin in patients with type 2 diabetes.

Trial registration

ISRCTN50587697 (www.controlled-trials.com)

Funding

Diabetes UK, grant number 06/0003429. M. D. Witham is funded by a Scottish Government NES/CSO Clinician Scientist Award.     

Noninvasive assessment of subclinical atherosclerosis in normotensive gravidae with gestational diabetes

Aim

Carotid artery intima-media thickness (CIMT), hyperhomocysteinemia, microalbuminuria, and nitric oxide reflect subclinical atherosclerosis and predict the risk of future cardiovascular events. We aimed to evaluate the presence of subclinical atherosclerosis and endothelial dysfunction in normotensive patients with gestational diabetes mellitus (GDM) noninvasively.

Patients and methods

We enrolled 41 normotensive patients with GDM and 44 healthy gravidae in the study. Serum homocysteine and nitric oxide levels, urinary albumin excretion (microalbuminuria), and CIMT were evaluated along with lipid parameters and anthropometric measurements.

Results

Patients with GDM had significantly higher levels of serum homocysteine, urinary albumin excretion, and increased CIMT (p?Conclusion Independent of elevated blood pressure, subclinical atherosclerosis and endothelial dysfunction exist in normotensive patients with GDM. Further studies with a large number of participants are required to clarify these data.     

Use of an Electronic Health Record Clinical Decision Support Tool to Improve Antibiotic Prescribing for Acute Respiratory Infections: The ABX-TRIP Study

BACKGROUND

Antibiotics are often inappropriately prescribed for acute respiratory infections (ARIs).

OBJECTIVE

To assess the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs.

DESIGN

A two-phase, 27-month demonstration project.

SETTING

Nine primary care practices in PPRNet, a practice-based research network whose members use a common electronic health record (EHR).

PARTICIPANTS

Thirty-nine providers were included in the project.

INTERVENTION

A CDSS was designed as an EHR progress note template. To facilitate CDSS implementation, each practice participated in two to three site visits, sent representatives to two project meetings, and received quarterly performance reports on antibiotic prescribing for ARIs.

MAIN OUTCOME MEASURES

1) Use of antibiotics for inappropriate indications. 2) Use of broad spectrum antibiotics when inappropriate. 3) Use of antibiotics for sinusitis and bronchitis.

KEY RESULTS

The CDSS was used 38,592 times during the 27-month intervention; its use was sustained for the study duration. Use of antibiotics for encounters at which diagnoses for which antibiotics are rarely appropriate did not significantly change through the course of the study (estimated 27-month change, 1.57 % [95 % CI, ?5.35 %, 8.49 %] in adults and ?1.89 % [95 % CI, ?9.03 %, 5.26 %] in children). However, use of broad spectrum antibiotics for ARI encounters improved significantly (estimated 27 month change, ?16.30 %, [95 % CI, ?24.81 %, ?7.79 %] in adults and ?16.30 [95%CI, ?23.29 %, ?9.31 %] in children). Prescribing for bronchitis did not change significantly, but use of broad spectrum antibiotics for sinusitis declined.

CONCLUSIONS

This multi-method intervention appears to have had a sustained impact on reducing the use of broad spectrum antibiotics for ARIs. This intervention shows promise for promoting judicious antibiotic use in primary care.     

Lower BMI is a predictor of obstructive sleep apnea in elderly Thai hypertensive patients

Purpose

The prevalence of both hypertension and obstructive sleep apnea (OSA) are increased in patients with age greater than 60 years. We studied the clinical differences of OSA in hypertensive patients with age greater or less than 60 years. In addition, rate of OSA-induced hypertension in Thai population is limited.

Methods

We retrospectively reviewed medical records of patients treated at the hypertension/sleep clinic at Srinagarind Hospital, Khon Kaen University, between 2010 and 2011. The inclusion criteria used were hypertensive patients who had at least one symptom of OSA and had been tested for the sleep study. Rate and clinical features of OSA were studied and categorized by age of 69 years. Factors associated with likelihood of having OSA in hypertensive patients age over 60 years were identified by multiple logistic regression analysis.

Results

During the study period, 49 patients met the criteria. Of those, 42 patients (85.71 %) had an apnea–hypopnea index (AHI) of more than 5/h. The average AHI was 22.22?±?13.86 times/h. The common symptoms of OSA were snoring (100 %), daytime sleepiness (28.57 %), unexplained nocturia (28.57 %), and gastroesophageal reflux disease (28.57 %). The numbers of patients with age less than 60 years and more than 60 years were 20 and 22 cases, respectively. Most patients (88.10 %) had well-controlled blood pressure level. Only BMI was significantly associated with OSA-induced hypertension in patients aged over or equal to 60 years. The adjusted odds ratio was 0.743 (0.560, 0.985).

Conclusions

OSA is very common in Thai hypertensive patients aged 40–70 years who have at least one symptom of OSA. Lower BMI is a predictor of obstructive sleep apnea in elderly Thai hypertensive patients     

Studien-Update Hypertonie und Diabetes

Background

Most patients with diabetes also suffer from high blood pressure, and the treatment of arterial hypertension is often an integral part of their treatment. In the present article, the details of several studies on hypertension and diabetes published in 2015 are presented, summarized, and discussed.

PATHWAY studies

The PATHWAY 2 study showed in patients with therapy-resistant hypertension and current treatment with a combination of ACE inhibitors (ACE: angiotensin-converting enzyme) or AT₁ receptor blockers (AT1 receptor: angiotensin-II receptor, subtype 1) plus calcium channel blocker plus a thiazide diuretic that, as an adjunct, the aldosterone antagonist spironolactone is superior to the α?blocker doxazosin or the β?blocker bisoprolol. In a further study of the PATHWAY project, the PATHWAY 3 study demonstrated that the combination of amiloride and low-dose HCT (hydochlorothiazide) leads to improved glucose tolerance and blood pressure control compared to the monotherapies.

SPRINT trial

In the SPRINT (“systolic blood pressure intervention trial”), it was documented for the first time that patients with increased cardiovascular risk benefit from tighter systolic blood pressure control of around 120 mmHg. However, intensive treatment was associated with an increased rate of adverse effects, including serious adverse effects.

ACCORDION study

Preliminary results of the ACCORDION study, a follow-up study of the ACCORD (Action to Control Cardiovascular Risk in Diabetes) study, confirmed the results of ACCORD that in patients with diabetes intense blood pressure lowering reduced the primary endpoint only in a statistically nonsignificant manner. However, the blood pressure data of the patients were influenced by glycemic control.

     

Salt supplementation blunts the blood pressure response to telmisartan with or without hydrochlorothiazide in hypertensive patients with type 2 diabetes

Aims/hypothesis

We assessed the effects of sodium chloride (NaCl) supplementation on the blood pressure response to treatment with telmisartan with or without hydrochlorothiazide in hypertensive patients with type 2 diabetes and habitually high (HDS, sodium excretion >200 mmol/24 h on two out of three consecutive occasions) or low (LDS, sodium excretion <100 mmol/24 h on two out of three consecutive occasions) salt intake.

Methods

Patients received 4 weeks of telmisartan followed by 4 weeks of telmisartan plus hydrochlorothiazide. In a double-blind randomised fashion, patients received sodium chloride (NaCl, 100 mmol/24 h) or placebo capsules in addition to their habitual salt intake during the last 2 weeks of telmisartan and telmisartan plus hydrochlorothiazide therapy. The protocol was repeated with NaCl and placebo capsules administered in reverse order to allow each participant to act as his or her own control. At 0, 4, 8, 14, 18 and 22 weeks, 24 h ambulatory blood pressure (ABP) and 24 h urine collections were performed.

Results

No statistically significant differences were seen in the ABP response in the LDS vs HDS groups to any of the interventions (p?=?0.58). NaCl supplementation reduced the effect of telmisartan with or without hydrochlorothiazide on systolic BP by approximately 50% (?5.8 mmHg during NaCl supplementation vs ?11.3 mmHg during placebo, mean difference 5.6 mmHg [95% CI 1.7–9.4 mmHg], p?=?0.005), irrespective of habitual salt intake. By contrast, addition of hydrochlorothiazide increased the antihypertensive effect of telmisartan on systolic BP by approximately 35% (p?=?0.048) in both groups of patients.

Conclusions/interpretation

NaCl supplementation blunts the effectiveness of telmisartan with or without hydrochlorothiazide in hypertensive patients with type 2 diabetes, independently of habitual low or high salt intake.

Trial registration

Australian Clinical Trials Registry ACTRN012606000128594

Funding

This work was supported by a Pfizer Cardiovascular-Lipid Research Grant and an unconditional educational grant from Boehringer Ingelheim. During the period of this work, E. I. Ekinci was supported by grants from the Austin Hospital Medical Research Foundation and the National Health and Medical Research Council.     

Association of Structured Virtual Visits for Hypertension Follow-Up in Primary Care with Blood Pressure Control and Use of Clinical Services

Background

Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. “Virtual visits” are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit.

Objective

To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care.

Design

Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences.

Participants

Primary care patients with hypertension.

Exposure

Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension.

Main measures

Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit.

Key results

Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140–160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, ??2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, ??0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]).

Conclusions

Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.

     

A vascular mechanism for high-sodium-induced insulin resistance in rats

Aims/hypothesis

High sodium (HS) effects on hypertension are well established. Recent evidence implicates a relationship between HS intake and insulin resistance, even in the absence of hypertension. The aim of the current study was to determine whether loss of the vascular actions of insulin may be the driving factor linking HS intake to insulin resistance.

Methods

Sprague Dawley rats were fed a control (0.31% wt/wt NaCl) or HS (8.00% wt/wt NaCl) diet for 4 weeks and subjected to euglycaemic–hyperinsulinaemic clamp (10 mU min^?1 kg^?1) or constant-flow pump-perfused hindlimb studies following an overnight fast. A separate group of HS rats was given quinapril during the dietary intervention and subjected to euglycaemic–hyperinsulinaemic clamp as above.

Results

HS intake had no effect on body weight or fat mass or on fasting glucose, insulin, endothelin-1 or NEFA concentrations. However, HS impaired whole body and skeletal muscle glucose uptake, in addition to a loss of insulin-stimulated microvascular recruitment. These effects were present despite enhanced insulin signalling (Akt) in both liver and skeletal muscle. Constant-flow pump-perfused hindlimb experiments revealed normal insulin-stimulated myocyte glucose uptake in HS-fed rats. Quinapril treatment restored insulin-mediated microvascular recruitment and muscle glucose uptake in vivo.

Conclusions/interpretation

HS-induced insulin resistance is driven by impaired microvascular responsiveness to insulin, and is not due to metabolic or signalling defects within myocytes or liver. These results imply that reducing sodium intake may be important not only for management of hypertension but also for insulin resistance, and highlight the vasculature as a potential therapeutic target in the prevention of insulin resistance.     

The effect of continuous positive airway pressure therapy on blood pressure and arterial stiffness in hypertensive patients with obstructive sleep apnea

Aim

We aimed to evaluate the effect of continuous positive airway pressure (CPAP) therapy on blood pressure (BP) and arterial stiffness in hypertensive patients with obstructive sleep apnea (OSA).

Patients and methods

We studied 38 hypertensive patients who suffered from severe OSA. Ambulatory BP measurement was performed at baseline and after at least 3 months of uninterrupted CPAP therapy. In 19 of these patients, we also measured pulse wave velocity (PWV) at baseline, after the first night of CPAP therapy and at 3 months. Fifteen normotensive subjects without OSA comprised the control group.

Results

CPAP therapy reduced systolic BP from 141.5?±?12.1 to 133.5?±?9.7 mmHg (p?=?0.007) and diastolic BP from 87.8?±?6.8 to 83?±?5.4 mmHg (p?=?0.004). CPAP also reduced the PWV from 8.81?±?1.4 to 8.18?±?1 m/s after the first night of CPAP therapy (p?=?0.003) and to 7.37?±?1 m/s at 3 months (p?=?0.007).

Conclusions

To the best of our knowledge, this is the first study demonstrating that CPAP therapy in hypertensive patients with OSA improves arterial stiffness from the first night and that this favorable effect is maintained for at least 3 months of CPAP use. A reduction in BP was also observed, even though BP control was not always achieved.