Reasons for Switching Antihypertensive Medication in General Practice: A Cross-Sectional Czech Nationwide Survey

To improve blood pressure (BP) control of their patients, physicians either adjust or switch antihypertensive medication. Currently, there is only limited information available on why physicians decide to switch antihypertensive medications.A questionnaire-based survey was performed between November 2011 and March 2012 in the Czech Republic. General practitioners were asked to fill in questionnaires about their hypertensive patients whose antihypertensive medication they were planning to change. These questionnaires recorded data about patient demographic information, cardiovascular risk factors, BP values, and reasons for switching antihypertensive medication.Two hundred eight-six general practitioners surveyed a total of 4341 hypertensive patients. The mean age of the patients was 59.8 years, 68.9% of patients were overweight or obese. Uncontrolled office systolic and diastolic BP >140/90 mm Hg was present in 89.6% and 81.5% of patients, respectively, despite the fact that 49.4% of patients used a combination of 2 or more antihypertensive drugs. The most common reasons for switching medication were insufficient BP control (73.7%), followed by aiming for a better 24-hour effect (38.4%) and increased cardiovascular risk of the patients (37.7%).The major reason for switching antihypertensive treatment in general practice was insufficient BP control. Switching medication because of adverse drug effects is less frequent than reported a decade ago.     

A summary of the effects of antihypertensive medications on measured blood pressure

BACKGROUND: Epidemiologic analysis of family data on blood pressure (BP) is often compromised by the effects of antihypertensive medications. A review of numerous clinical trials that investigated the effects of BP-lowering medications is summarized here. METHODS: Published clinical trials, including 137 clinical trials with monodrug therapies and 28 clinical trials of combination drug therapies with a total of 11,739 participants, were reviewed from PubMed. Six major classes/groups of antihypertensive medications were categorized by ethnicity, including angiotensin-converting enzyme (ACE) inhibitors, alpha1-blockers, cardioselective beta-blockers (beta1-blockers), calcium channel blockers, thiazide and thiazide-like diuretics, and loop diuretics. RESULTS: Using sitting or supine BP, for ethnic groups combined, monodrug therapy with ACE inhibitors showed a weighted average effect of lowering the systolic and diastolic BP by 12.5/9.5 mm Hg; alpha1-blockers by 15.5/11.7 mm Hg; beta1-blockers by 14.8/12.2 mm Hg; calcium channel blockers by 15.3/10.5 mm Hg; thiazide diuretics by 15.3/9.8 mm Hg; and loop diuretics by 15.8/8.2 mm Hg. However, ACE inhibitors, alpha1-blockers, and beta1-blockers were less effective in African Americans than in non-African Americans, whereas calcium channel blockers, thiazide diuretics, and loop diuretics were more effective in African Americans than in non-African Americans. For two-drug combination therapy with ethnic groups combined, the BP-lowering effect of the second medication, when compared to its effect as monodrug therapy, was 84% and 65% for systolic and diastolic BP, respectively. CONCLUSIONS: The BP-lowering effects reported here may be used to impute the pretreatment BP levels, which can improve the information content and hence the power of epidemiologic analysis in studies where use of antihypertensive medications is a confounding factor in the BP measurements.     

Office and ambulatory blood pressure control in hypertensive patients treated with different two-drug and three-drug combinations

There is scarce information regarding ambulatory blood pressure (BP) achieved in daily practice with a wide range of antihypertensive drug combinations. We looked for differences in office and ambulatory BP among major drug combinations of two and three antihypertensive agents from a different drugs class. A total of 17187 patients treated with six types of two-drug combinations and 9724 treated with six types of three-drug combinations from the Spanish ABPM Registry were analyzed. We compared achieved office and ambulatory BP, as well as office (< 140/90 mmHg) and ambulatory (24-hour BP < 130/80; day BP < 135/85, and night BP < 120/70 mmHg) BP control among groups. The combination of renin-angiotensin system (RAS) blockers with diuretics and the triple combination of RAS blockers with diuretics and calcium channel blockers (CCB) were associated with lower values of 24-hour, daytime and nighttime BP, as well as more pronounced nocturnal BP dip. Compared with such combinations (reference), other double combinations had lower rates of ambulatory BP control. Moreover, triple combinations containing alpha blockers also had lower rates of ambulatory BP control. We conclude that even with similar office BP control, differences exist among antihypertensive two-drug and three-drug combinations with respect to ambulatory BP control achieved during treatment, with RAS blockers/diuretics and RAS blockers/CCBs/diuretics obtaining better control rates. This can help physicians choose among drug combinations in order to obtain further ambulatory BP reductions.     

Patients with uncontrolled hypertension or concomitant hypertension and benign prostatic hyperplasia

At optimal doses, individual antihypertensive agents lower blood pressure (BP) by an average of 10 mmHg. Many patients with hypertension, including those with stage 3 hypertension, target organ damage, or those at high risk for cardiovascular events and/or adverse effects of high-dose monotherapy, are likely to require combination antihypertensive drug treatment to achieve the recommended systolic/diastolic BP (< 140/90 mmHg). Two studies, a placebo-controlled, double-blind trial (n = 70) and a community-based, open-label trial (n = 491) investigated the antihypertensive efficacy of doxazosin, a long-acting selective alpha1-adrenoceptor blocker, as add-on therapy for uncontrolled hypertension with other antihypertensive medications and in patients with concomitant benign prostatic hyperplasia (BPH) and treated but inadequately controlled hypertension, respectively. The addition of doxazosin to baseline antihypertensive medication(s) significantly lowered BP and had a significantly positive effect on the serum lipid profile. In patients with concomitant BPH, doxazosin significantly improved all BPH symptom scores, regardless of initial symptom severity. Add-on doxazosin sufficiently reduced systolic/diastolic BP such that many patients whose hypertension was previously uncontrolled by other antihypertensive medications were able to reach goal BP (< 140/90 mmHg). Doxazosin as add-on therapy was well tolerated. In conclusion, doxazosin as add-on therapy improves BP control in hypertensive patients not at goal BP and improves lower urinary tract symptoms in patients with concomitant BPH.     

Perioperative Blood Pressure Variability in the Treated Hypertensive Patients

Perioperative blood pressure (BP) management is important to prevent cardiovascular complication, especially for hypertensive patients. In the present study, we investigated perioperative BP variability and contributing factors in hypertensive patients. Subjects were 28 treated hypertensive patients who underwent total or subtotal gastrectomy. Ambulatory BP monitoring was carried out before and after (16 days in average) the surgery. Angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and diuretics were withdrawn on the previous day, while other drugs were administered until the day of surgery. BP, body weight, blood chemistry, as well as the use of intravenous vasopressor or vasodepressor agents during the perioperative period were investigated. The 24-hour BP before surgery was 124 ± 19/70 ± 12 mm Hg, and the number of antihypertensive drugs was 1.8. In 22 patients, intravenous vasopressor agents were used during surgery, while another patient received intravenous vasodepressor agents after surgery. The 24-hour BP significantly decreased after surgery (?8.2 ± 14.7/?2.6 ± 7.3 mm Hg). Body weight, serum Na, and hematocrit also decreased. There were nine patients whose 24-hour systolic BP decreased by more than 10 mm Hg and for two patients more than 20 mm Hg. The decrease in BP correlated with the change in serum Na. Forty-three percent of the patients who took ACE inhibitors/ARBs showed BP reduction greater than 10 mm Hg, while 25% of the patients without these drugs showed such BP reduction. Our findings suggest that 24-hour BP decreases after gastrectomy. Patients taking ACE inhibitors or ARBs may need careful monitoring to prevent excessive BP fall.     

Drug treatment of high blood pressure in the community--experience in eastern Finland

The effects of antihypertensive drug therapy were assessed in 8,459 patients (2,801 men and 5,658 women) from the hypertension register of the North Karelia Project in 1978-1979. Fifty-two per cent of the men and 56% of the women were taking one drug only. The most common drugs used were diuretics and beta-blockers. Women were on diuretics more often than men, but beta-blockers were more common in men. The effect of the treatment was assessed in terms of the BP means and percentage of patients whose DBP was below 100 mmHg. BP was controlled better in women than men. The best BP control was obtained in groups of patients who were on a single drug. Adequate BP control was achieved in 71% of men and 83% of women on diuretics, in 75% of men and 83% of women on beta-blockers, in 85% of both sexes on fixed combinations of a diuretic + reserpine + vasodilator, and 79% of men and 89% of women on a diuretic + reserpine. Fixed combinations containing only low doses of each drug are a good alternative for some patients.     

Blood pressure during sleep: antihypertensive medication

To investigate whether excessive reduction of blood pressure (BP) by antihypertensive medications correlates with myocardial infarction, especially during sleep in elderly patients, we used telemetry and cuvette dye-dilution methods to assess the direct BP and the hemodynamics of 68 inpatients with essential hypertension during wakefulness and sleep. There were 25 patients greater than or equal to 60 years old (OH-group) and 43 were less than or equal to 59 years old (YH-group). Of the OH-group, 36% showed high BP during the day, with marked decreases (minimum BP less than 110/70 mm Hg) during sleep. Average cardiac index (CI) of the OH-group was low during wakefulness and extremely low during slow-wave sleep. Changes of mean BP in the OH-group correlated with changes in total peripheral vascular resistance index (TPRI) during sleep, but this correlation was not observed in the YH-group. The antihypertensive effects on nocturnal BP of the various medications was: central adrenergic inhibitors less than or equal to beta blockers with intrinsic sympathomimetic activity less than or equal to alpha (alpha beta) blockers less than or equal to angiotensin-converting enzyme inhibitors less than or equal to calcium antagonists. Because BP and CI were found to be very low and TPRI seems to play an important role in BP regulation in sleeping elderly patients, excessive antihypertensive medication may be harmful to this subgroup. However, because the effects on nocturnal BP differ among various antihypertensive treatments, further research is required on the relation between antihypertensive medication and the hemodynamics of sleeping elderly hypertensive patients.     

Resistant hypertension: comparing hemodynamic management to specialist care

Although resistant hypertension affects a minority of all hypertensives, this group continues to experience disproportionately high cardiovascular event rates despite newer antihypertensive agents. Hypertension represents an imbalance of hemodynamic forces within the circulation, usually characterized by elevated systemic vascular resistance. We studied the utility of serial hemodynamic parameters in the selection and titration of antihypertensive medication in resistant hypertensive patients using highly reproducible noninvasive measurements by thoracic bioimpedance. Resistant hypertension patients (n=104) were randomized to drug selection based either on serial hemodynamic (HD) measurements and a predefined algorithm or on drug selection directed by a hypertension specialist (SC) in a 3-month intensive treatment program. Blood pressure was lowered by intensified drug therapy in both treatment groups (169+/-3/87+/-2 to 139+/-2/72+/-1 mm Hg HD versus 173+/-3/91+/-2 to 147+/-2/79+/-1 mm Hg SC, P<0.01 for systolic and diastolic BP), using similar numbers and intensity of antihypertensive medications. Blood pressures were reduced further for those treated according to hemodynamic measurements, resulting in improved control rates (56% HD versus 33% SC controlled to 相似文献   

Clinical characteristics influencing the effectiveness of metformin on Japanese type 2 diabetes receiving sulfonylureas

In this study, we described the effectiveness of metformin on Japanese type 2 diabetes patients receiving sulfonylureas and the clinical characteristics of the patients whose glycemic control were significantly improved with metformin administration. Our results showed that the reduction of glycohemoglobin (HbA1C), serum concentration of total cholesterol, and diastolic blood pressure was statistically significant through the administration of metformin. The clinical characteristics of the patients who responded to metformin therapy exhibited lower systolic blood pressure in addition to higher HbA1C value just before administration of metformin when compared with DeltaHbA1C (HbA1C 6 months after administration of metformin--HbA1C before administration of metformin). Moreover, effectiveness of metformin was weakened, in comparison with non-hypertensive patients, even though the blood pressure of hypertensive patients was reduced to normal range by medication with antihypertensive drugs. But average reduction of HbA1C level of hypertensive patients without antihypertensive medications was smaller than those of patients with high blood pressure with such medication. These results suggested that high blood pressure and hypertension phenotype itself were suppressive factors of metformin but antihypertensive therapy itself enhanced the effectiveness of metformin regardless of the improvement of blood pressure.     

Time trends in high blood pressure control and the use of antihypertensive medications in older adults: the Cardiovascular Health Study

BACKGROUND: Control of high blood pressure (BP) in older adults is an important part of public health efforts at prevention. OBJECTIVE: To assess recent time trends in the awareness, treatment, and control of high BP and in the use of medications to treat high BP. METHODS: In the Cardiovascular Health Study, 5888 adults 65 years and older were recruited from 4 US centers. At baseline, participants underwent an extensive examination that included the measurement of BP, use of medications, and other risk factors. Participants were followed up with annual visits that assessed BP and medication use from baseline in 1989-1990 through the examination in 1998-1999. The primary outcome measures were control of BP to levels lower than than 140/90 mm Hg and the prevalence of use of various classes of antihypertensive medications. RESULTS: The awareness, treatment, and control of high BP improved during the 1990s. The proportions aware and treated were higher among blacks than whites, though control prevalences were similar. For both groups combined, the control of high BP to lower than 140/90 mm Hg increased from 37% at baseline to 49% in 1999. The 51% whose BP was not controlled generally had isolated mild to moderate elevations in systolic BP. Among treated persons, the improvement in control was achieved in part by a mean increase of 0.2 antihypertensive medications per person over the course of 9 years. Improved control was also achieved by increasing the proportion of the entire Cardiovascular Health Study population that was treated for hypertension, from 34.5% in 1990 to 51.1% in 1999. Time trends in antihypertensive drug use were pronounced. Among those without coronary disease, the use of low-dose diuretics and beta-blockers decreased, while the use of newer agents, such as calcium channel blockers, angiotensin-converting enzyme inhibitors, and alpha-blockers increased. CONCLUSIONS: While control of high BP improved in the 1990s, about half the participants with hypertension had uncontrolled BP, primarily mild to moderate elevations in systolic BP. Low-dose diuretics and beta-blockers--the preferred agents since 1993 according to the recommendations of the Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure--remained underused. More widespread use of these agents will be an important intervention to prevent the devastating complications of hypertension, including stroke, myocardial infarction, and heart failure.     

Drugs and short losses of consciousness in the elderly. A case/control study

To study the possible role of multiple medications and different types of drugs prescribed to the elderly as a risk factor for short-term loss of consciousness, we compared the drug consumption by 188 patients (65 and over) hospitalized for short-term loss of consciousness to that by 188 controls (65 and over) taken from the general population. The two groups were age- and sex-matched. We took into consideration the evolution of drug consumption due to the time-lag between the two studies. There was no significant difference between the mean number of drugs taken per group. Beta-blocker and anti-angina drug usage was significantly increased in the patient group. For diuretics, tranquilizers and anti-depressants, a large difference was noted but it was not significant. Use of vasodilators, hypnotic drugs and antihypertensive agents was similar in both groups. We discuss the possible lack of statistical potency for several drugs and the fact that it is sometimes difficult to distinguish between the respective roles of certain medications and the underlying disease in the etiology of the loss of consciousness.     

北京农村老年高血压患者降压药物使用及血压控制情况调查

目的了解北京农村地区老年高血压患者降压药物使用及高血压控制情况。方法对北京大兴区长子营地区1240例60岁以上正在治疗的高血压患者降压药物使用及血压控制情况进行调查。降压药分为三类:推荐制剂、传统制剂、中药制剂。推荐制剂:包括血管紧张素转换酶抑制剂(ACEI)、血管紧张素Ⅱ受体拮抗剂(ARB)、β受体阻滞剂(βRB)、钙通道阻滞剂(CCB)和噻嗪类利尿剂(HCTZ);传统制剂:包括降压0号、复方降压片、复方利血平等;中药制剂:包括罗布麻片、珍菊降压片、牛黄降压丸等。降压药物使用后血压≤140/90 mmHg为血压达标。结果 1240例调查对象中710例(57.2%)使用推荐制剂,499例(40.2%)使用传统制剂,9例(0.7%)使用中药制剂,22例(1.7%)使用推荐制剂+传统制剂;血压达标率分别为43.1%、40.7%、33.3%和54.5%;总体达标率为42.3%。使用推荐制剂患者中选用单种及两种或三种降压药联合治疗的患者分别占66.9%、31.0%和2.1%,血压达标率分别为34.1%、60.0%和80.0%。使用单种推荐制剂的患者中使用CCB、ACEI/ARB,βRB和HCTZ比例分别为62.1%、29.9%、6.3%和5.6%。使用两种推荐制剂联合治疗的患者中CCB+ACEI/ARB占83.2%,HCTZ+其他推荐制剂患者仅为2.3%。结论北京局部农村地区老年高血压治疗药物使用尚不够规范,推荐制剂使用不足60%;推荐制剂组达标率高于传统制剂组和中药制剂组。40%以上的患者使用传统制剂和中药制剂,有必要进一步探讨其降压效果和是否减少心脑血管疾病发生的循证医学证据。     

Resistant hypertension, secondary hypertension, and hypertensive crises: diagnostic evaluation and treatment

Hypertension is a very common modifiable risk factor for cardiovascular morbidity and mortality. Patients with hypertension represent a diverse group. In addition to those with primary hypertension, there are patients whose hypertension is attributable to secondary causes, those with resistant hypertension, and patients who present with a hypertensive crisis. Secondary causes of hypertension account for less than 10% of cases of elevated blood pressure (BP), and screening for these causes is warranted if clinically indicated. Patients with resistant hypertension, whose BP remains uncontrolled in spite of use of 3 or more antihypertensive agents, are at increased cardiovascular risk compared with the general hypertensive population. After potentially correctible causes of uncontrolled BP (pseudoresistance, secondary causes, and intake of interfering substances) are eliminated, patients with true resistant hypertension are managed by encouraging therapeutic lifestyle changes and optimizing the antihypertensive regimen, whereby the clinician ensures that the medications are prescribed at optimal doses using drugs with complementary mechanisms of action, while adding an appropriate diuretic if there are no contraindications. Mineralocorticoid receptor antagonists are formidable add-on agents to the antihypertensive regimen, usually as a fourth drug, and are effective in reducing BP even in patients without biochemical evidence of aldosterone excess. In the setting of a hypertensive crisis, the BP has to be reduced within hours in the case of a hypertensive emergency (elevated BP with evidence of target organ damage) using parenteral agents, and within a few days if there is hypertensive urgency, using oral antihypertensive agents.     

Blood Pressure and Serum Potassium Levels in Hypertensive Patients Receiving or Not Receiving Antihypertensive Treatment

Objective. Serum potassium has a fundamental role in blood pressure (BP) regulation, and there is evidence highlighting the importance of potassium homeostasis in hypertension. The aim of this study was to determine the relationship between serum potassium levels and office BP in untreated essential hypertensives and the effect of antihypertensive medication on serum potassium levels. Setting and Participants. In a retrospective analysis, we collected data for consecutive patients first visiting our Hypertension Clinic from 1999–2004. From this population, we first selected patients who were not taking any antihypertensive medication. Patients who had conditions that could affect potassium metabolism, such as history of arrhythmias treated with digitalis, diabetes mellitus under insulin treatment, and hypo- and hyperthyroidism, were excluded from the study. From the remaining patients, those who had impaired renal function (serum creatinine ≥1.6 mg/dL for men and ≥1.4 mg/dl for women) and patients with secondary forms of hypertension were also excluded. The final population consisted of 817 subjects. Multivariate linear regression analysis was applied, and models were created associating serum potassium with systolic BP, diastolic BP, mean BP, or pulse pressure. The population for the second part of the study consisted of patients first visiting our Hypertension Clinic who were on one antihypertensive agent. This second group included 757 patients, 218 of whom were on β-blockers, 42 on diuretics, 187 on angiotensin-converting enzyme (ACE) inhibitors, 287 on calcium channel blockers (CCBs), and 28 on angiotensin receptor blockers (ARBs). Results. After adjusting for age, gender, and body mass index, significant negative correlations were found between serum potassium levels and systolic BP (R?=??0.093, p?=?0.007), diastolic BP (R?=??0.078, p?=?0.03), mean BP (R?=??0.122, p?=?0.002), and pulse pressure (R?=??0.071, p?=?0.044). The levels of potassium were found to be significantly lower among patients receiving diuretics than those receiving one of the other four drug categories of antihypertensive (p < 0.05 for β-blockers, ACE inhibitors, and CCBs; p < 0.001 for ARBs). In addition, hypokalemia was found to be significantly more prevalent in the group using diuretics than the other groups. Conclusions. The observed reverse relation between serum potassium and BP supports a close pathophysiological connection between serum potassium and essential hypertension. Moreover, diuretic therapy is a significant cause of hypokalemia and requires systematic monitoring.     

Escalating antihypertensive medications in end-stage renal disease patients does not improve blood pressure control

The authors examined the efficacy of antihypertensive medication use in end-stage renal disease (ESRD). They compared achieved blood pressures (BPs) in a cross-sectional study of 106 ESRD patients whose medications had not been changed for at least 2 months. Group 1 (n=36) included patients who took 0 or 1 medication; group 2 (n=56), 2 or 3 medications; and group 3 (n=14), ≥4 medications. The population's mean age was 55.1 years, 87% were African American, and 57% were men weighing 76.9 kg who were on 229 minutes of hemodialysis with an edKt/V of 1.35; there was no difference between the 3 groups. The authors found a difference in the mean BPs: 139/72 mm Hg in group 1, 154/82 mm Hg in group 2, and 165/91 mm Hg in group 3 ( P =.01 for systolic, P =.002 for diastolic), with a mean arterial pressure difference of 94.4, 106.4, and 115.4 mm Hg ( P =.002). The authors conclude that in this group of primarily African American patients, the control of hypertension in ESRD is not achieved by escalating the number of antihypertensive medications .
J Clin Hypertens (Greenwich). 2008;10:215–218 .     

Lifestyle Educational Program Strongly Increases Compliance to Nonpharmacologic Intervention in Hypertensive Patients: A 2‐Year Follow‐Up Study

J Clin Hypertens (Greenwich). 2012;14:767–772. ©2012 Wiley Periodicals, Inc. The authors investigated the efficacy of a lifestyle educational program, organized in small group meetings, in improving the outcome of a nonpharmacologic intervention. One hundred and eighty‐eight hypertensive patients with stable blood pressure (BP) levels and drug therapy in the previous 6 months were randomly divided into educational care (EC) and usual care (UC) groups. They were followed at 3‐month intervals up to 2 years. In addition to the visits in an outpatient clinic, patients in the EC program participated in small group meetings in order to improve their knowledge of the disease and reinforce their motivation for treatment. At baseline, EC and UC groups were similar for age, sex, body mass index (BMI), blood pressure (BP) levels, and pharmacologic treatment. Patients in the EC group had significantly reduced total energy, total and saturated fats, and sodium intake. Physical activity was significantly increased in the EC group as well. At the end of the 1‐year follow‐up, BMI (P<.001), visceral fat (P<.001), and BP (P<.001) were significantly lower in the EC group compared with the UC group. Pharmacologic treatment during the study was similar for all classes of drugs apart from diuretics whose dose was higher in the UC group at the end of the study.     

Failure of antihypertensive therapy with diuretic,beta-blocking and calcium channel-blocking drugs to consistently reverse left ventricular diastolic filling abnormalities

The present protocol was designed to determine whether antihypertensive therapy with hydrochlorothiazide, propranolol or diltiazem, 3 agents with different mechanisms of action and potentially different effects on myocardial function, reverses left ventricular filling abnormalities. Twelve patients with essential hypertension and no evidence of associated cardiovascular disease, either clinically or with noninvasive testing, were evaluated while taking no medication and after 2 months of treatment with these agents. All 3 drugs produced equivalent control of blood pressure (BP), reducing sitting systolic BP by a mean of 20 to 24 mm Hg and diastolic BP by 14 to 16 mm Hg. LV ejection fraction and end-diastolic volume were normal in all but 1 subject (who was excluded from the analyses of LV diastolic filling) and were not altered by drug therapy. The peak LV filling rate and the first-third filling fraction were reduced in the patients with hypertension, but neither of these indexes nor the time to peak filling rate were significantly improved for the group as a whole by any of these medications. Nine of 10 patients whose BP was controlled by diltiazem had increases in their first-third filling fraction, but this change did not reach statistical significance. Our findings suggest that abnormalities of LV diastolic filling are not consistently affected by short-term therapy in patients with chronic, previously treated systemic hypertension.     

Abstract, closing summary, and table of contents for Laragh’s 25 lessons in pathophysiology and 12 clinical pearls for treating hypertension

These 25 lessons 1) review the roles of plasma renin levels for causing malignant and most essential hypertension and their related vascular injuries (heart attack, heart failure, kidney failure and stroke); 2) review how antihypertensive anti-R drugs that block renin activity (beta blockers, the first converting enzyme inhibitor from venom, and the first angiotensin receptor blocker) were used to reveal plasma renin involvement in the hypertension of medium and high renin patients and to show; 3) that the 30% with low renin essential hypertension do not respond to R drugs, are not prone to heart attack or stroke, and BP is corrected instead by the natriuretic anti-V drugs (diuretics, spironolactone, CCB, alpha blockers); 4) thus, all hypertensives can be divided into R patients who have too much renin vasoconstriction or V patients who instead have predominant sodium-volume mediation. Furthermore, all antihypertensive drug classes can be divided into R drugs that block the renin factor, or V drugs that reduce body sodium volume; 5) these findings document our conception of two biochemically and physiologically different final factors that sustain all BP in which the sodium-volume factor continuously sustains cardiac output and flow while plasma renin-angiotensin sets total peripheral resistance (TPR), which, within the Poiseuille Equation (BP = cardiac output [CO] × TPR) describes our [Na⁺-volume × renin-angiotensin vasoconstriction] model that supports all normotension or hypertension; 6) in this light, we designed a visit-by-visit method for treating untreated hypertensives using the ambient plasma renin level and BP responses to guide primary drug therapy against either the V or R factor; and 7) for also correcting nonresponders receiving multiple drugs where renin testing correctly guides addition or subtraction of drugs depending on whether the test indicates unresponsiveness due to a reactive sodium-volume excess, or to lack of effectiveness of an R drug in a V patient or of a V drug in an R patient, or from large reactive increases in renin that override the R drug, calling for strengthening the R and/or removing V drugs. This objective, biochemically based method results in effective longterm BP control of nearly all patients using fewer, but the correct drug(s) for each individual.     

Abstract, closing summary, and table of contents for Laragh's 25 lessons in pathophysiology and 12 clinical pearls for treating hypertension.

These 25 lessons 1) review the roles of plasma renin levels for causing malignant and most essential hypertension and their related vascular injuries (heart attack, heart failure, kidney failure and stroke); 2) review how antihypertensive anti-R drugs that block renin activity (beta blockers, the first converting enzyme inhibitor from venom, and the first angiotensin receptor blocker) were used to reveal plasma renin involvement in the hypertension of medium and high renin patients and to show; 3) that the 30% with low renin essential hypertension do not respond to R drugs, are not prone to heart attack or stroke, and BP is corrected instead by the natriuretic anti-V drugs (diuretics, spironolactone, CCB, alpha blockers); 4) thus, all hypertensives can be divided into R patients who have too much renin vasoconstriction or V patients who instead have predominant sodium-volume mediation. Furthermore, all antihypertensive drug classes can be divided into R drugs that block the renin factor, or V drugs that reduce body sodium volume; 5) these findings document our conception of two biochemically and physiologically different final factors that sustain all BP in which the sodium-volume factor continuously sustains cardiac output and flow while plasma renin-angiotensin sets total peripheral resistance (TPR), which, within the Poiseuille Equation (BP = cardiac output [CO] x TPR) describes our [Na+-volume x renin-angiotensin vasoconstriction] model that supports all normotension or hypertension; 6) in this light, we designed a visit-by-visit method for treating untreated hypertensives using the ambient plasma renin level and BP responses to guide primary drug therapy against either the V or R factor; and 7) for also correcting nonresponders receiving multiple drugs where renin testing correctly guides addition or subtraction of drugs depending on whether the test indicates unresponsiveness due to a reactive sodium-volume excess, or to lack of effectiveness of an R drug in a V patient or of a V drug in an R patient, or from large reactive increases in renin that override the R drug, calling for strengthening the R and/or removing V drugs. This objective, biochemically based method results in effective longterm BP control of nearly all patients using fewer, but the correct drug(s) for each individual.     

Prevalence of high-risk cardiovascular conditions and the status of hypertension management among hypertensive adults 65 years and older in the United States: analysis of a primary care electronic medical records database

This study compared the prevalence of high-risk cardiovascular (CV) conditions, antihypertensive medication treatment patterns, and demographic and clinical characteristics associated with blood pressure (BP) goal attainment between elderly (65 years and older) and nonelderly (younger than 65 years) adults with hypertension. Retrospective cohort study was conducted using an electronic medical record database among patients receiving at least 1 antihypertensive medication. CV risk profiles were assessed by International Classification of Diseases, 9th Revision diagnosis codes. Treatment patterns were assessed by the number of antihypertensive medications prescribed. BP goal attainment was determined by the mean of the last 2 BP readings during 1 year of follow-up. Logistic regression estimated the odds of achieving BP goal. There were 61,355 nonelderly (mean age, 51.8 years) and 47,796 elderly (mean age, 73.2 years) patients in the study. Elderly patients had statistically significant higher levels of isolated systolic hypertension and complicated hypertension. Elderly patients had statistically significant higher levels of prescribing patterns characterized by multiple antihypertensive medications but statistically significant lower levels of BP goal attainment. Age 65 years and older, African American race, body mass index ≥30, and the presence of complicated hypertension were found to be statistically significant factors contributing to a lower likelihood of BP goal attainment. Despite aggressive antihypertensive treatment, elderly patients are less likely to achieve BP goals.