HYPERTENSION BURDEN AND SPOTLIGHT ON ESC-ESH GUIDELINES

Ambrosio G, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual congress.

In the last 2 years, cardiovascular mortality has sharply decreased. Hypertension remains a CV risk factor, but less important. Hypertension has little impact on quality of life. Hypertension heart disease is a problem of elderly people. Impact of hypertensive heart disease in quality of life has remained stable in many years but once again gets raised; hence it is the main cause of disability in the patients. Hypertension heart disease gets increased in male population highly as compared to female as per global burden of cardiovascular diseases and risk factors 1990-2019 data.

2018 ESC/ESH Guidelines for the management of Arterial Hypertension recommended that the first objective of treatment should be to lower BP to <140/90 mmHg in all patients and, provided that the treatment is well tolerated, treated BP values should be targeted to 130/80 mmHg or lower in most patients. In patients <65 years it is recommended that SBP should be lowered to a BP range of 120–129 mmHg in most patients. Based on these new data, this task force recommends that (1) lifestyle advice should be accompanied by BP lowering drug treatment in patients with grade 1 hypertension at low-moderate CV risk, (2) the most effective strategy to reduce risk is to prevent the development of high CV risk situation with early intervention, (3) when BP lowering drugs are used the first objective should be to lower BP to <140/90 mmHg in all patients, (4) provided that treatment is well tolerated, treated BP values should be targeted to 130/80 mmHg or lower in most patients. In older patients (<65 years) SBP should be targeted to between 130 and 140 mmHg and DBP to <80 mmHg, (5) treated SBP should not be targeted to <120 mmHg.

According to the guideline it was recommended that among all antihypertensive drugs, Angiotensin-converting enzyme inhibitors (ACEi), Angiotensin receptor blockers (ARBs), beta-blockers, Calcium channel blockers (CCBs), and diuretics (thiazides and thiazide-like drugs such as chlorthalidone and indapamide) have demonstrated effective reduction of BP and CV events in RCTs, and thus are indicated as the basis of antihypertensive treatment strategies. Combination treatment is recommended for most hypertensive patients as initial therapy. Preferred combinations should comprise a RAS blocker (either an ACE inhibitor or an ARB) with a CCB or diuretic. Other combinations of the five major classes can be used.

 It was concluded that ACEi or ARBs are the pillars of hypertension management.

 

 

 

IS IT IMPORTANT TO TAKE HEART RATE INTO CONSIDERATION WHILE TREATING HYPERTENSIVE PATIENTS?

Mancia G, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress. The author suggested that heart rate (HR) has an influence on clinical outcomes. An 18-year follow-up study revealed increased mortality rates w.r.t HR in hypertensive men compared to normotensive men.

As per 2018 ESC/ESH guidelines, HR is an independent risk factor for CV events & organ damage in hypertension. It is listed as CV risk factor but not included in the total CV risk quantification. Guidelines mention a cutoff HR value of 80 bpm above which risk may be elevated and HR lowering must be considered & it is recommended to measure HR after BP measurement at each visit. Following are the evidences:

  • Higher HR reduces arterial distensibility.
  • Tachycardia reflects in sympathetic nerve activation.
  • Various conditions in which sympathetic nerve activation leading to increased mortality have been shown in figure.
  • Removal of sympathetic influences has demonstrated a significant increase in arterial distensibility.

Although trial results are not entirely consistent, protection at higher baseline HR is indicated as higher HR is linked to increased risk of CV death or hospitalization due to HF. In Ontarget trial, lower HR is associated with lower CV events, improved renal end-points & lower risk of cognitive decline. Beta-blockers may be considered in hypertensive patients with HR > 80 bpm.

In conclusion, heart rate dose play a significant role in management of hypertension.

 

 

 

BLOOD PRESSURE-LOWERING, ANTIHYPERTENSIVE TREATMENT AND INCIDENT DIABETES

Nazarzadeh M, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual congress. The impact of blood pressure lowering and particular antihypertensives on the risk of new-onset type 2 diabetes was analysed, influencing the strengths of both genetic data and individual-level data from randomised trials of blood pressure-lowering therapies.

An individual-level data of 145,939 participants was merged from 19 randomised clinical trials. A stratified Cox proportional hazard models was used, with fixed therapy impacts, and participants as the unit of evaluation. Evaluations were accompanimented with Mendelian randomisation studies by naturally randomised genetic variants correlated with systolic blood pressure and genetic variants encoding the therapeutic targets of each drug class.

9,883 participants were detected with new-onset diabetes following a median of 4.4 years follow-up in clinical trials. Blood pressure-lowering therapy showed reduction in the risk of diabetes by 11% (hazard ratio [HR] per 5-mm Hg reduction in systolic blood pressure 0.89 [95% confidence interval [CI] 0.84 to 0.95]). Correspondingly, each 5-mm Hg genetically-affected lower systolic blood pressure was correlated with an 11% lower risk of diabetes in the Mendelian randomisation study (odds ratio [OR] 0.88 [95% CI 0.84 to 0.92]). Evidence from genetic data and trials were also uniform in which angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) decreased the risk of diabetes, and beta-blockers elevated the risk. There was no confirmation of an impact for calcium channel blockers and findings for thiazide diuretics were uncertain; although genetic evaluation exhibited a decrease in risk, the mainly indirect assessment from network analysis of trials recommended an increased risk than placebo.

Reduction in the blood pressure decreases the risk of new-onset diabetes. But, this protective impact was not consistent between different antihypertensive classes. Although ACEIs and ARBs showed reduction in the risk of new-onset diabetes, the opposite was noticed with beta-blockers and possibly with thiazide diuretics. Consideration of diabetes risk may aid inform clinical decision-making in analysing which class of drug to use to treat increased blood pressure.

 

 

THE ISH 2020 GLOBAL HYPERTENSION PRACTICE GUIDELINES – ESSENTIAL TREATMENT STANDARDS

Poulter NR, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress. Essential standards of the blood pressure (BP) targets reported that: (1) it was important to reduce blood pressure by ≥20/10 mmHg, (2) ideally BP should be less than 140/90 mmHg, (3) as per data, aim for BP control is within 3 months. Essential targets for drug treatment choices (I) reported to use best drugs available based on deal characteristics like: treatment should be evidence based in relation to morbidity/mortality prevention, use a once-daily regimen which provides 24-hour BP control, treatment should be affordable and/or cost-effective relative to other agents, treatment should be well-tolerated, and evidence of benefits of use of the medication in population to which it is to be applied. Essential targets for drug treatment choices (2) like: Use free combinations if single pill combinations (SPCs) are not available or unaffordable, use thiazide diuretics if thiazide-like diuretics are not available, use alternative to DHP-CCBs if these are not available or not tolerated (i.e. Non-DHP-CCBs: diltiazem or verapamil), and consider β-blockers at any treatment step when there is a indication for their use, e.g. heart failure, angina, post-MI, atrial or younger women with, or planning pregnancy.

Hence, according to ISH 2020 global hypertension practice guidelines it is necessary to follow essential targets for drug treatment choices.

 

 

 

THE ISH 2020 GLOBAL HYPERTENSION PRACTICE GUIDELINES – HYPERTENSION GUIDELINES AT A GLANCE

Unger T, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress.

The ISH Guidelines Committee extracted evidence-based content from recently published thoroughly reviewed guidelines and modified essential and optimal standards of care in a realistic format that is easy to use by physicians, nurses, and community health workers, as necessary, not just in low-resource settings but also in high-resource settings. The term “optimal care” refers to an evidence-based standard of care outlined in recent recommendations, while “important standards” acknowledge that optimal standards are not always feasible. As a result, essential requirements apply to the bare minimum of treatment.

Young and elderly people both suffer from isolated systolic hypertension, which is characterised as an elevated SBP (140mmHg) and a low DBP (<90mmHg). Isolated systolic hypertension is the most common form of essential hypertension in young people, including infants, teenagers, and young adults. It is more common in the elderly, and it is caused by the stiffening of the broad arteries combined with an increase in pulse pressure (difference between SBP and DBP).

Hence, to minimise hypertension-related cardiovascular morbidity and mortality, every effort should be made to achieve essential quality of treatment.

 

 

 

TWO-DRUG FIXED-DOSE COMBINATION AS INITIAL ANTIHYPERTENSIVE TREATMENT STRATEGY CONFERS HIGHER MEDICATION ADHERENCE COMPARED TO MONOTHERAPY

Rea F, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress. To boost the poor adherence to the medication regimen that characterises the hypertensive community, recent European guidelines suggest starting treatment with two medications in a single tablet in most hypertensive patients. However, there is no evidence that this is the case. The study’s aim was to compare adherence to antihypertensive drug therapy amongst newly treated patients who were given either monotherapy or a fixed-dose combination of two medications as their first treatment.

The target group was Lombardy citizens (Italy) between the ages of 40 and 80 who were National Health Service beneficiaries. 63,448 patients were monitored for a year after receiving their first prescription for antihypertensive drugs in 2016. Adherence to drug treatment was assessed using the “proportion of days covered” (PDC) criterion, which is the average of the number of days the drug was available from a prescription to the number of days it was used for follow-up. Patients with a PDC of more than 75% is considered adherent to drug therapy. To estimate the risk (HR) or tendency to treatment adherence in relation to the initial condition, log-binomial regression models were used. To estimate the risk (HR) or susceptibility to treatment adherence in relation to the initial therapeutic approach, log-binomial regression models were used. Baseline demographic and clinical covariates were taken into account.

For the first year of drug therapy, 47% of patients had a high level of commitment to medication. Patients who were initially treated with a fixed dose combination have a greater tendency to stick to antihypertensive care than those who were initially treated with monotherapy (HR 1.19, 95% CI 1.17-1.22, p<0.0001). This was true across the board, for all genders, ages below and above 65, various health statuses, and no or recent cardiovascular events. That was also evident of the various initial fixed-dose combinations, with the majority of them promoting greater adherence than the monotherapies.

Patients who were initially administered a fixed-dose combination of two antihypertensive drugs had better adherence to antihypertensive care than those who started with a single medication in a real-world environment. This lends credence to the original fixed-dose-combination approach as a way of increasing adherence and improving blood pressure regulation.

 

 

 

NEW STROKE RISK SCORE FOR PATIENTS WITH CORONARY ARTERY DISEASE

Minushkina L, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress. The study evaluated the possible correlation of clinical factors with the occurrence of strokes in patients following acute coronary syndrome (ACS).

1843 ACS patients from the 4 PCI centers were incorporated in ORACLE II (ObseRvation after Acute Coronary syndrome for development of treatment options) observational multicenter study between 2014-2017 years. 1149 (61.9%) were men with mean age 64.9 years. The primary end-point was all-cause death. Ischemic stroke was one of the secondary end-points. A data about unfavourable outcomes was gathered on 25, 90, 180 and 360 days following hospital discharge. Blood pressure (BP) was controlled on the day of discharge and at all follow-up visits. Visit-to-visit BP variability was indicated as the CV (%) of mean BP over all visits in the follow-up.

42 stokes were fixed in the follow-up (2.3%). 25 strokes were fatal. Patients with stroke were older in the follow up (70.9± 11.88 and 64.7±12.72, p=0.01), showed higher blood pressure visit to visit variability (CV 25.3±4.25 and 12.7±3.67%, p=0.019). These patients more commonly showed arterial hypertension (100% and 88%, p=0.017) and lower rate of accomplishment of target blood pressure (35.7% and 62.7%). Patients with stroke showed higher rate of atrial fibrillation (38.1% and 16.9%), heart failure (83.3% and 49.6%), peripheral atherosclerosis (47.6% and 25.4%), CKD (64.3% and 36.7%), IGT (17.1% vs 7.1%). Stroke patients were less likely to acquire anticoagulant therapy (2.0% vs 5.8%, p=0,003) and were less likely to acquire PCI in index hospitalization (31.1% vs 50.5%, p=0.01). These patients also showed lower level of HDL (1.00±0.266 vs 1.18± 0.503, p=0.039). A simple stroke risk score was made as per the results of linear regression analysis: BP CV low as compared to 12% (-1), atrial fibrillation (+3), heart failure (+2), IGT (+2), CKD (+1), HDL more than 1 mmol/l (-1), PCI (-1), anticoagulants therapy (-3). Score greater than 4 is correlated with high store risk. Area under the ROC curve was 0.780 for this risk score.

The risk of ischemic stroke was correlated with glomerular filtration rate, percutaneous coronary intervention, heart failure, atrial fibrillation, blood pressure variability, high density lipoprotein levels, and anticoagulant therapy.

 

 

COMPARATIVE EFFECTIVENESS OF HYDROCHLOROTHIAZIDE VERSUS CHLORTHALIDONE ON CARDIAC, RENAL AND ELECTROLYTE EVENTS BY eGFR STAGE

Edwards C, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress.

As a first-line blood pressure-lowering treatment, thiazide diuretics are advised. Chlorthalidone, not Hydrochlorothiazide, was used in previous trials showing cardiovascular gain (such as ALLHAT and SHEP). Despite this, hydrochlorothiazide is often administered and available in a variety of combinations. As the approximate glomerular filtration rate (eGFR) decreases, little is known about the relative efficacy of the two medications. The aim of the study was to compare hydrochlorothiazide to chlorthalidone in terms of cardiac, kidney, and electrolyte-related adverse events.

In Ontario, Canada, a population-based, retrospective cohort study of adults over the age of 66 with a diagnosis of hypertension was conducted (2009-2016). In an attempt to treat research, Fine and Grey sub-distribution hazards models were used to look at the relationship between matched hydrochlorothiazide vs. chlorthalidone pairs and outcome events. A cardiac incident, kidney event (egfr decline>30%), electrolyte disorder (hypo- or hyperkalemia, hyponatremia), or all-cause mortality were the study’s outcomes. Using an interaction phrase, the impact of eGFR groups (>60, 45-59, and 45 ml/min/1.73m2) on outcomes was investigated.

A total of 9,786 users of hydrochlorothiazide were compared 4:1 to 2,936 users of chlorthalidone (mean age 73.6, 55% female, 41.6% diabetes). The baseline eGFR distributions for >60, 45-59, and 45 ml/min were 73.4, 17.4, and 9.2 percent, respectively. When compared to chlorthalidone, hydrochlorothiazide was linked to a lower risk of eGFR decline (HR 0.78 95 percent CI 0.70-0.88), CV events (HR 0.83 95 percent CI 0.76-0.92), hypokalemia (HR 0.54 95 percent CI 0.48-0.60), and all-cause mortality (HR 0.79 95 percent CI 0.63-0.98).

Hydrochlorothiazide use was linked to a lower risk of eGFR reduction, CV events, hypokalemia, and all-cause mortality in people with an eGFR greater than 60 ml/min. At lower eGFR levels, these differential effects were not observed.

 

 

 

SINGLE PILL COMBINATIONS IN HYPERTENSION: AN OPPORTUNITY FOR MULTIPLE MODES OF ACTION

Kjeldsen SE, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress.

Sympathetic nervous system (SNS) overactivity is a key driver in pathophysiology of essential HTN in young & middle aged people. Thus highlighting the role of beta-blockers in the management of hypertension. Increased heart rate is a marker of SNS overactivity in HTN & increased risk of incident AF, HF & CV mortality. Hear rate above 84 bpm nearly double the risk of AF & new onset HF in HTN patients. It also increase CV mortality & all-cause mortality.

VALUE Study demonstrated the prognostic impact of in-treatment heart rate. Regimen with valsartan & amlodipine showed non-inferiority in clinical outcomes & proportion of patients with first event. Overall, beta-blockers with CCB make a strong FDC targeting SNS, RASS & arterial blood vessels.  Bisoprolol reduces hear rate & lowers BP while amlodipine has significant vasodilating effects. It also has 19.6 fold higher affinity for beta-1 receptor compared to beta-2 receptors & brings about 34% reduction in all-cause mortality.

Modern beta-1 selective blockade with bisoprolol is a choice of treatment for HTN patients with fast heart rate (and other clinical situations) according to the 2018 ESC/ESH Hypertension Guidelines.

The long-acting calcium-antagonist amlodipine as ideal companion to beta-1 selective bisoprolol in single-pill combination. Clinical studies with fixed combination bisoprolol & amlodipine show benefits in BP control & drug adherence. 

Single-pill combination therapy leads to improved medication adherence & persistence compared to free-equivalent combination therapy. It may lead to better BP control in patients with hypertension.

 

 

 

SYMPATHETIC OVERDRIVE IN HYPERTENSION: A RATIONALE FOR BETA BLOCKER RECOMMENDATION IN THE GUIDELINES?

Schlaich M, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress.

Sympathetic nervous system is a key mechanism in BP control as its elevation can lead to hypertension via increased heart rate, increases stroke volume leading to increased cardiac output, increased peripheral vasoconstriction, RAAS activation & water retention. About 70 % of hypertensives are overweight or obese due to increased muscle sympathetic nerve activity & metabolic changes. Hear rate is another clinical marker of increased cardiac sympathetic activity associated with cardiac risk. Sympathetic overdrive is a key driver of elevated heart rate leading to increased risk of CV mortality & is crucial reason for sudden cardiac death. Beta-blockers can be used in patients with heart rate >80 bpm. Controlled BP with low heart rate can result in 53% reduction in incidence of endpoints. Slowing heart rate retard atherosclerosis & reduces sudden death while improving LV dysfunction & CHF.

Although beta-adrenergic blockers differ & there is no class-effect of them in HTN, current guidelines often lead to under-utilization of beta-blockers. Beta-blocker improve LVF in post-MI patients with ejection fraction ≤40%. According to 2018 ESC/ESH guidelines beta-blockers should be considered at any-treatment step in patients with HF, angina, post-MI, AF or younger women with/or planning pregnancy.

Beta-blockers can be used in management of hypertension with careful consideration of patients’ characteristics.

 

 

 

PATTERNS OF PHARMACOTHERAPY OF HYPERTENSION IN INDIA

Agarwala R, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual congress.

It is known that world population of hypertension (HTN) is about 1.13 billion and 23% of world population lives in India with 200 million people suffering from HTN. Indians consume high levels of salt due to food they prefer. It was reported that 42% of Awareness observed in urban part of India and 25% in rural part of India, 38% of patients treated in urban part of India and 20% in rural part of India, and 20% of patients have controlled BP in urban part of India and 20% in rural part of India, respectively.

Specific features for Asians are: masked HTN is more, BP variability is more, early morning surge and nocturnal rise is more, region wide differences in prevalence, HBPM practices are variable and higher BP at lower BMI than Europe. The benefit of pharmacotherapy will be greater in this population than any other population. In a cross-sectional study it was reported that almost 28% patients not on daily treatment and 18% discontinued their treatment. The reason the patients said that their BP went back to normal and there is fear of side effects or addiction. In the India hypertension control initiative study, 51% patients returned for follow-up. On follow-up they showed 60% of BP control. It was also reported that control in primary health centre is about 48% than 23% secondary care facility.  Amlodipine, atenolol and HCT are widely used in India. 40% of Indian patients use Single pill combination. A real world study reported that amlodipine is a good candidate for BP control.

In conclusion, awareness and control of hypertension in India is low at present. Methods to increase awareness and improve compliance can help reduce CVD in India. Cost effective and protocol based approach that is applicable to Indian socio-economic circumstances will be the way to go.

 

 

 

IS THE PREVALENCE OF ARRHYTHMIAS REALLY HIGHER IN HYPERTENSION OR IS IT ONLY A COINCIDENCE?

Manolis AJ, presented a session on prevalence of arrhythmias in hypertension at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual congress. According to 2019 survey, the majority of proportion of CV death is because of ischemic heart disease (49.2%) followed by ischemic stroke (17.7%) and intracerebral haemorrhage (15.5%). The hypertension with diabetes mellitus causes endothelial dysfunction accelerated hypertension mediated organ damage (HMOD) and also clinical organ damage. The preferred therapies are monotherapy or combination therapy of RAS and CCBs. Hypertension increases volume and pressure overload generated increase in afterload induced neurohumoral activation and mechanical stress leads to vasoconstriction and LV hypertrophy resp. It generated hypertensive heart disease such as arrhythmia, HF or CAD. Achieved SBP ≤130 mmHg is associated with a lower risk of new-onset AF in hypertensive patients with electrocardiographic left ventricular hypertrophy (ECG-LVH). Uncontrolled HTN showed significant reduction in the survival rate of patients which increased the risk of AF. In the Swedish primary care database of 45,530 patients exhibited higher risk for AF if the SBP >140 mmHg as compared SBP 130 mmHg. Losartan significantly reduces the risk of new-onset AF by 33%. In the VALUE trial, Valsartan significantly decrease the risk first persistent AF by 32% as compared to amlodipine. As per UK based general practice research database, hypertensive patients receiving long-term monotherapy with ACEi, ARBs, or beta-blockers were less likely to develop AF than those who received only CCBs.

Arterial hypertension accelerates LV hypertrophy which enhances fibrosis and calcification leads to SA node dysfunction and conduction disturbances such as atrioventricular (AV) block, bundle branch block (BBB) increases the risk of bradyarrhythmias. The 12-lead ECG, clinical analysis should be done for the diagnostic examination of non-sustained ventricular arrhythmias. The ECG is helpful for the diagnosis of LV systolic function which assess the underlying heart diseases. And if underlying disease is suspected, blood pressure treatment shall be initiated with ACEi, ARB or beta blockers. There is no need of antiarrhythmic drug (AAD) for ventricular premature beats (VPBs) suppression.

 

 

 

A PERSPECTIVE OF PRIVATE HEALTH CARE PROVIDERS IN MADHYA PRADESH ON ADOPTING KEY STRATEGIES OF THE INDIA HYPERTENSION CONTROL INITIATIVE

Krishna A, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress. The exploratory study was performed to understand the key strategies of India Hypertension Control Initiative (IHCI) adopted by private healthcare providers in Madhya Pradesh, India. The key strategies to be adopted were standardized treatment protocols, patient-centred care services & information system. 30 private physicians (PPs) were selected for the study.

11 PPs followed the protocol while 19 PPs did not follow the protocol. None of them had patient-centred care services & information system. The key challenges faced by the physicians in following standardized treatment protocols were fear of losing patients, limited availability of single component drugs & preference for FDCs. Shortage of manpower, poor administrative process for providing free drugs & concern about drug quality hindered the development of patient-centred care services. Various barriers to patient data sharing & shortage of manpower influenced the inability to incorporate information system.

In order to facilitate adoption of IHCI strategies, it is important to include FDCs, incentives for healthcare workers & provision of government vouchers for free protocol drugs.  National data sharing policy for private sector & digital health records may help enhance the adoption process.

 

 

 

USE OF DOUBLE FIXED-DOSE COMBINATION OF OLMESARTAN AND AMLODOPINE VERSUS FIXED-DOSE COMBINATION OF LISINIPRIL AND AMLODOPINE IN UNCONTROLLED HYPERTENSIVE PATIENTS

Koval S, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress. In obese patients with uncontrolled moderate-to-severe arterial hypertension (AH), this study compared the efficacy of a double fixed-dose combination of Olmesartan (O) and Amlodopine (A) versus a fixed-dose combination of Lisinopril (L) and amlodipine (A).

A total of 60 hypertensive patients with abdominal obesity were studied. Patients in the first subgroup (n = 30) received a fixed-dose combination of O and A (20 mg/5 mg; 40 mg/10 mg), while those in the second subgroup (n=30) received L and A (10 mg/5 mg; 20 mg/5 mg; 20 mg/10 mg). The tests were done at the beginning and again after 6 months.

The first subgroup had a higher frequency of BP target levels after treatment than the second (75% versus 53%, p<0.05). According to 24-hour BP tracking, the fixed-doses combination of O/A significantly reduced 24-hour systolic and diastolic BP, as well as systolic BP (night) and diastolic BP (night) compared to the fixed-doses combination L/A. In contrast to fixed combination L/A, adherence to double fixed-dose combination O/A was also higher (85% versus 61%, p<0.05). In this group of patients, it was discovered that lower fixed-dose combinations of O/A (20 mg/5 mg) were used more frequently than L/A (20% versus 10%, p<0.05). At the same time, in a significantly lower number of patients receiving a fixed dose combination of O/A compared to patients on L/A (60% versus 81%, p0.05), the maximum doses of these drugs were needed to reach target BP levels.

In obese patients with uncontrolled moderate-to-severe AH, the analysis revealed that O/A was more effective than L/A at lowering offi ce BP and 24-hour ambulatory BP. In patients with AH and abdominal obesity, achieving target BP levels was possible with a lower fixed-dose combination of O/A than with L/A.

 

 

 

EFFECTS OF FIXED DOSE COMBINATION AZILSARTAN MEDOXOMIL/CHLORTALIDONE ON THE CENTRAL BP IN HYPERTENSIVE PATIENTS WITH HFpEF

Gudieva K, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress. The aim of this study was to estimate how a fixed azilsartan medoxomil/chlortalidone (AZL-M/CLD) combination affected central BP in patients with arterial hypertension (AH) and heart failure with preserved ejection fraction (HFpEF). In patients with AH and HFpEF, this 12-week study compared the effects of a fixed-dose combination of AZL-M/CLD (n=30) versus non-fixed-dose combinations of angiotensin-converting-enzyme inhibitors/ angiotensin II receptor blocker (ARB) (iACE/ARB) and thiazide/thiazide-like diuretics (n=30) on central blood pressure (cBP), arterial stiffness, and pulse wave velocity (PWV). Patients with an EF of less than 50%, significant valvular disease, acute coronary syndrome (ACS), permanent atrial fibrillation (AF), neoplasm, eGFR of less than 30 ml/min/1.73 m2, and a BMI of more than 40 kg/m2 were excluded. During weeks 4 to 12, the initial doses should be titrated to reach BP targets: in one group to 40/25 mg, and in the control group to the full daily dose.

The study group’s average age was 67 ± 11 years (M±SD), with 36% (10/30) males, SBP/DBP 140 ± 12/84 ± 9 mmHg (M± SD), DM 30% (9/30), obesity 61.2% (18/30), paroxysmal AF 20% (6/30), CKD 57% (16/30), and eGFR 63 [44.1;72.8]. SBP/DBP was 141 ± 11/82 10 mmHg (MSD) in the control group, with 40%  (12/30) males, DM 30% (9/30), obesity 55% (16/30), paroxysmal AF 26% (7/30), CKD 61% (18/30), and eGFR 65 [46.3;76.1]. During the research, the study group’s pBP dropped from 140 ± 12/84 9 mmHg to 120 ± 15/7112 mmHg (p< 0.05); cBP dropped from 131 ± 15/84 ± 10 to 117 ± 14/78 9 mmHg (p <0.05); and PWV dropped from 11.7 (9.4;13.4) to 10.1 (8.7;12.3) m/s (p <0.05). pBP decreased from 141 ± 11/82 ± 11 mmHg to 128 ± 16/79 ± 9 mmHg (p <0.05), cBP from 132 ± 14/85 9 to 127 ± 16/82 13 mmHg (p <0.05), and PWV from 11.5(9.5; 13.6) to 10.2 (9.2.;12.8) m/s (p <0.05) in the control group. The t-test revealed significant differences in peripheral BP, cBP, and PWV between the two groups (p = 0.004, p<0.01, and p<0,05, respectively).

The levels of pBP in the control group decreased from 141 ± 11/82 ± 11 mmHg to 128 ± 16/79 ± 9 mmHg (p < 0.05), cBP from 132 ± 14/85 ± 9 to 127 ± 16/82 ± 13 mmHg (p < 0.05), PWV from 11.5(9.5; 13.6) to 10.2 (9.2.;12.8) m/s p < 0.05. The t-test indicated significant differences between this two groups in peripheral BP, cBP and PWV (p = 0.004, p<0.01, p<0,05 respectively).

In patients with AH and HFpEF treated with AZL-M/CLD, there is a significant antihypertensive effect as well as a decrease in arterial stiffness.

 

 

 

HOW MANY ADDITIONAL PHYSICIANS ARE NEEDED FOR HYPERTENSION TREATMENT IN INDIA?

Marklund M, presented a study in a session at the European Society of Hypertension (ESH) and International Society of Hypertension (ISH) 2021 Joint Meeting: Virtual Congress.

The study estimated the number of additional physicians needed to treat all individuals with hypertension in India. Existing data and corresponding uncertainties from the Global Burden of Disease Study and two national-representative surveys (including >1.3 adults) were incorporated to estimate the number of adults (>18 years) with hypertension in India.

195 million adults in India were estimated to have hypertension in 2014, requiring over 2.3 billion visits per year assuming monthly visits (i.e., current practice) and nearly 600 million visits per year assuming 3 visits per patient per year. With the current practice of monthly visits, 3.8 million new physicians would be required if they would have the same proportion of hypertensive patients as the available physicians (e.g., 10%), or 384,921 new physicians if they only were to see hypertensive patients (Table). 33,529 new physicians would be required even if they only were to see hypertensive patients.

Adequate monitoring and treatment of individuals with hypertension in India need a substantial number of new physicians & other approach, e.g. task-sharing, will be required to achieve nationwide hypertension control.