Therapeutic inertia is an impediment to achieving the Healthy People 2010 blood pressure control goals

Therapeutic inertia (TI), defined as the providers' failure to increase therapy when treatment goals are unmet, contributes to the high prevalence of uncontrolled hypertension (> or =140/90 mm Hg), but the quantitative impact is unknown. To address this gap, a retrospective cohort study was conducted on 7253 hypertensives that had > or =4 visits and > or =1 elevated blood pressure (BP) in 2003. A 1-year TI score was calculated for each patient as the difference between expected and observed medication change rates with higher scores reflecting greater TI. Antihypertensive therapy was increased on 13.1% of visits with uncontrolled BP. Systolic BP decreased in patients in the lowest quintile of the TI score but increased in those in the highest quintile (-6.8+/-0.5 versus +1.8+/-0.6 mm Hg; P<0.001). Individuals in the lowest TI quintile were &33 times more likely to have their BP controlled at the last visit than those in highest quintile (odds ratio, 32.7; 95% CI, 25.1 to 42.6; P<0.0001). By multivariable analysis, TI accounted for &19% of the variance in BP control. If TI scores were decreased &50%, that is, increasing medication dosages on &30% of visits, BP control would increase from the observed 45.1% to a projected 65.9% in 1 year. This study confirms the high rate of TI in uncontrolled hypertensive subjects. TI has a major impact on BP control in hypertensive subjects receiving regular care. Reducing TI is critical in attaining the Healthy People 2010 goal of controlling hypertension in 50% of all patients.     

A practical approach to persistent elevation of blood pressure in the hypertension clinic

Patients seen with persistent elevation of office blood pressure (BP) in the hypertension clinic are common and pose a significant challenge to the hypertension specialist. These are usually patients sent to the clinic because of difficulty in achieving BP goals. In this clinical setting there is usually data available from home self measurement and ambulatory BP readings. We propose a scheme to encourage specialists to consciously consider the causes of persistent elevation of office BP. The scheme relies initially on consideration that the measured office readings are falsely elevated due to pseudohypertension, small cuff size or other equipment problems. If this is not the case then the measured office BP is truly elevated. If so, a further distinction can be made in this group into those with (1). transient office BP elevation and normal home and/or ambulatory readings and (2). elevated office and out of office readings. The first subgroup is usually called white-coat hypertension but may also be seen with transient increases in BP due to talking or other factors. The second subgroup probably is the majority of patients with persistent high office BP and reflects sustained hypertension and its own list of causes including secondary hypertension. The nature and intensity of evaluation for secondary hypertension varies depending on the clinical presentation of the patient. We recommend an explicit consideration of reasons for persistent high office BP in the hypertension clinic.     

A multidisciplinary program for achieving lipid goals in chronic hemodialysis patients

Background  

There is little information on how target lipid levels can be achieved in end stage renal disease (ESRD) patients in a systematic, multidisciplinary fashion.     

Abnormal blood pressure response to exercise in normoalbuminuric insulin dependent diabetic patients.

Eight male normoproteinuric Type I (insulin dependent) diabetic patients and eight age- and sex-matched non-diabetic control subjects were studied for their response to exercise. Systolic blood pressure showed an exaggerated response to exercise in the diabetic group (median 123, range 98-151 mmHg, pre-exercise vs. 187, 163-217 mmHg, immediately post exercise P less than 0.01) compared to the control group (median 112 (100-145) pre-exercise, 153 (138-178) post exercise). Resting noradrenaline levels were lower in the diabetic (D) compared with the control (C) group (D: 1.66, 0.55-3.92 nmol/l vs. C: 2.96, 2.04-4.49 nmol/l, P less than 0.02). Levels rose during exercise by 79% (25-307%) and 43% (4-90%) respectively (NS). Resting urinary sodium was raised in the diabetic group and fell during exercise (P less than 0.05) (D: 146, 74-244 mumol/min, C: 108.5 (83.4-151.0) pre-exercise vs. D: 73, 48-264 mumol/min, C: 81.7 (23.0-92.0) post exercise). Resting atrial natriuretic peptide levels were lower in the diabetic group (D: 10.1, 4.3-16.9 pmol/l vs. C: 16.0, 9.5-22.9 pmol/l, P less than 0.02) and levels rose significantly in both groups during exercise (D: 25.9, 5.2-38.9 pmol/l vs. C: 28.6, 17.3-47.2 pmol/l, P less than 0.05). We conclude that exercise provokes an exaggerated rise in systolic blood pressure and decrease in urinary sodium excretion in normoalbuminuric diabetic patients. These findings may reflect increased sensitivity to the renin-angiotensin-aldosterone system. Reduced atrial natriuretic peptide levels may stimulate sodium retention and increased blood pressure in early diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)     

糖尿病患者的血压管理

严格控制血压可以减少糖尿病患者的大血管和微血管并发症.降压目标值是<130/80 mmHg;若24 h尿白蛋白≥1g,血压应<125/75 mmHg;老年人降压目标值≤140/90 mmHg;舒张压≥65 mmHg.所有的糖尿病患者,无论其血压处于什么水平,都要进行非药物治疗.药物降压首选血管紧张素转换酶抑制剂(ACEI)或血管紧张素Ⅱ受体拮抗荆(ARB),其次为钙离子拮抗剂(CCB);单药不能达标应尽早联合用药,联合治疗方案首选ACEL/ARB+CCB,其次为ACEI/ARB+利尿荆.     

Current understanding of optimal blood pressure goals in dialysis patients

The hemodialysis population is associated with a very low survival rate, with myocardial infarctions and strokes accounting for most of the increased mortality. Recent observational studies demonstrate a paradoxical relationship between increasing blood pressure and increasing mortality. Hypertension treated with antihypertensive medications unequivocally reduces cerebrovascular risk, but demonstration of a survival benefit for cardiovascular mortality has proven more difficult to demonstrate. Increased pulse pressure is caused by inadequate dialysis treatment that increases arterial wall stiffness and afterload, and decreases coronary perfusion. The disproportionate representation of diastolic dysfunction and coronary artery atherosclerosis may explain why increased pulse pressure is associated with higher cardiovascular risk for the dialysis population. Optimum blood pressure control has not been established, due to a lack of prospective studies targeting blood pressure reduction. Opinion-based recommendations are offered, but goals should be individualized based on a complete assessment of prevailing comorbidities and should target normalization of the pulse pressure.     

Single-pill amlodipine/atorvastatin helps patients of diverse ethnicity attain recommended goals for blood pressure and lipids (the Gemini-AALA study)

The Gemini-AALA (Australia, Asia, Latin America, Africa/Middle East) study evaluated the efficacy and safety of single-pill amlodipine/atorvastatin (Caduet) for the treatment of patients of diverse ethnicity with concomitant hypertension and dyslipidaemia. This was a 14-week, open-label study including patients from 27 countries across the Middle East, Asia-Pacific, Africa and Latin America. Eight dosage strengths of single-pill amlodipine/atorvastatin (5/10, 10/10, 5/20, 10/20, 5/40, 10/40, 5/80 and 10/80 mg) were titrated to improve blood pressure and lipid control. Blood pressure and lipid goals were determined according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP ATP III) guidelines, respectively (blood pressure, <140/90 or <130/80 mm Hg; low-density lipoprotein cholesterol (LDL-C), <4.1 to <2.6 mmol l(-1) (<160 to <100 mgdl(-1))). Overall, 1649 patients received study medication. Most patients (91.4%) had >or=1 cardiovascular risk factor (as defined by NCEP ATP III guidelines) in addition to hypertension/dyslipidaemia, and 61.7% had coronary heart disease/risk equivalent. At baseline, mean blood pressure was 146.6/88.3 mm Hg and LDL-C was 3.4 mmol l(-1) (130.2 mgdl(-1)). At week 14, 55.2% of patients reached both blood pressure and lipid goals, 61.3% reached blood pressure goal and 87.1% reached lipid goal (34.0% were at lipid goal at baseline). Mean blood pressure reduction was 20.2/11.4 mm Hg. For patients who were lipid-lowering drug naive at baseline, mean reduction in LDL-C was 41.0%. Treatment-related adverse events led to the discontinuation of 3.6% of patients. Single-pill amlodipine/atorvastatin therapy was well tolerated and effective for the reduction of blood pressure and lipids to recommended goals in patients from diverse ethnic backgrounds.     

2型糖尿病患者血糖、血脂和血压治疗达标后血尿酸下降

对532例2型糖尿病患者施行血糖(HbA1C、空腹血糖)、血脂(总胆同醇、甘油三酯)和血压的目标治疗,不直接对血尿酸水平进行干预.上述指标治疗达标后,血尿酸水平也明显降低(P<0.01),高尿酸血症患者人数明显下降(P相似文献   

The effect of achieving a systolic blood pressure of 140 mmHg. A prospective study of ambulatory measurements in type 2 diabetic patients with nephropathy

ObjectivesWhat is the prognostic significance of achieving a systolic blood pressure of < 140 mmHg?SettingDiabetic renal policlinic, university hospital of Lund, Sweden.Subjects118 type 2 diabetic patients with micro-macroalbuminuria were followed for four years (range 1–8 years).Method and main outcome measuresThe prognostic significance of office, day- and nighttime measurements of blood pressure (BP) for development of cardiovascular complications was studied.ResultsForty-two percent (n = 49) developed one or more of the following cardiovascular endpoints: 23% (n = 27) death, 9% (n = 10) stroke, 9% (n = 11) myocardial infarction, 9% (n = 11) heart failure, 31% (n = 36) uremia and 17% (n = 20) need for dialysis. Reaching the goal for day- and nighttime systolic BP (SBP) at baseline of < 140 mmHg was associated with lower risk for developing uremia. Reaching the goal for nighttime SBP was associated with a decreased risk for developing myocardial infarction and need for dialysis treatment. None of these associations was found for office SBP.Patients not achieving the goal for nighttime systolic blood pressure of < 140 mmHg had a 12.9 times higher risk of developing myocardial infarction and 3.9 times increased risk of uremia and 2.7 times increased risk for death than patients achieving the goal.ConclusionNighttime blood pressure had better prognostic significance for developing cardiovascular and renal complications than office and daytime blood pressure.     

Lacidipine and blood pressure variability in diabetic hypertensive patients

The aim of our study was to assess the effects of lacidipine, a long-acting calcium antagonist, on 24-hour average blood pressure, blood pressure variability, and baroreflex sensitivity. In 10 mildly to moderately hypertensive patients with type II diabetes mellitus (aged 18 to 65 years), 24-hour ambulatory blood pressure was continuously monitored noninvasively (Portapres device) after a 3-week pretreatment with placebo and a subsequent 4-week once daily lacidipine (4 mg) or placebo treatment (double-blind crossover design). Systolic blood pressure, diastolic blood pressure, and heart rate means were computed each hour for 24 hours (day and night) at the end of each treatment period. Similar assessments were also made for blood pressure and heart rate variability (standard deviation and variation coefficient) and for 24-hour baroreflex sensitivity, which was quantified (1) in the time domain by the slope of the spontaneous sequences characterized by progressive increases or reductions of systolic blood pressure and RR interval and (2) in the frequency domain by the squared ratio of RR interval and systolic blood pressure spectral power approximately 0.1 and 0.3 Hz over the 24 hours. Compared with placebo, lacidipine reduced the 24-hour, daytime, and nighttime systolic and diastolic blood pressure (P<0.05) with no significant change in heart rate. It also reduced 24-hour, daytime, and nighttime standard deviation (-19.6%, -14.4%, and -24.0%, respectively; P<0.05) and their variation coefficient. The 24-hour average slope of all sequences (7.7+/-1.7 ms/mm Hg) seen during placebo was significantly increased by lacidipine (8.7+/-1.8 ms/mm Hg, P<0.01), with a significant increase being obtained also for the 24-hour average alpha coefficient at 0.1 Hz (from 5.7+/-1.5 to 6.4+/-1.3 ms/mm Hg, P<0.01). Thus, in diabetic hypertensive patients, lacidipine reduced not only 24-hour blood pressure means but also blood pressure variability. This reduction was accompanied by an improvement of baroreflex sensitivity. Computer analysis of beat-to-beat 24-hour noninvasive blood pressure monitoring may offer valuable information about the effects of antihypertensive drugs on hemodynamic and autonomic parameters in daily life.     

A practical approach to treating patients with chronic diarrhea

Although diarrhea is a common complaint, its evaluation and treatment can be challenging. Appropriately defining and classifying diarrhea provide the framework for approaching diagnostic and therapeutic options. Diarrhea can be defined based on frequency, consistency, and/or weight, and classified as acute or chronic with specific clinical characteristics and stool appearance. Colonoscopy is the most common diagnostic tool used in the evaluation of patients with chronic diarrhea. Other evaluation strategies include timed stool collections, evaluation of inflammatory markers, and hydrogen breath tests. A focused workup of chronic diarrhea may yield a specific diagnosis, including diarrhea-predominant IBS (dIBS), functional diarrhea, diabetic diarrhea, bile acid-induced diarrhea, and microscopic colitis. Ideally, therapeutic decisions are specifically tailored to target the underlying pathophysiology, including, for example, gluten restriction for celiac disease, rotating antibiotics for small bowel bacterial overgrowth, budesonide therapy for collagenous colitis, and loperamide for treatment of functional diarrhea. It is also important to assess the role of diet and medications in chronic diarrhea. However, if no specific causes are identified following workup, empiric therapy with simple opiate antidiarrheals such as loperamide may be effective. If this proves unsuccessful, the use of more potent agents, including codeine and opium, may be considered.