Evaluating the Impact of a Blood Pressure Remote Telemonitoring Program (BP Connect)

Analysis of Recent Papers in Hypertension Jan Basile, MD, Senior Editor

Background There are limited data on the effects of blood pressure (BP) control and lipid lowering in secondary prevention of coronary artery disease (CAD) patients. We report a secondary analysis of the effects of BP control and lipid management in participants of the HIJ-CREATE, a prospective randomized trial. Methods HIJ-CREATE was a multicenter, prospective, randomized, controlled trial that compared the effects of candesartan-based therapy with those of non-ARB-based standard therapy on major adverse cardiac events (MACE; a composite of cardiovascular death, non-fatal myocardial infarction, unstable angina, heart failure, stroke, and other cardiovascular events requiring hospitalization) in 2,049 hypertensive patients with angiographically documented CAD. In both groups, titration of antihypertensive agents was performed to reach the target BP of <130/85 mmHg. The primary endpoint was the time to first MACE. Incidence of endpoint events in addition to biochemistry tests and office BP was determined during the scheduled 6, 12, 24, 36, 48, and 60-month visits. Achieved systolic BP and LDL-Cholesterol (LDL-C) level were defined as the mean values of these measurements in patients who did not develop MACEs and as the mean values of them prior to MACEs in those who developed MACEs during follow-up. Results During a median follow-up of 4.2 years (follow-up rate of 99.6%), the primary outcome occurred in 304 patients (30.3%). Among HIJ-CREATE participants, 905 (44.2%) were prescribed statins on enrollment. Kaplan–Meier curves for the primary outcome revealed that there was no relationship between statin therapy and MACEs in hypertensive patients with CAD. The original HIJ-CREATE population was divided into 9 groups based on equal tertiles based on mean achieved BP and LDL-C during follow-up. For the analysis of subgroups, estimates of relative risk and the associated 95% CIs were generated with a Cox proportional-hazards model (Figure 1). The relation between LDL cholesterol level and hazard ratios for MACEs was nonlinear, with a significant increase of MACEs only in the patients with inadequate controlled LDL-C level even in the patients with tightly controlled BP. Conclusions The results of the post-hoc analysis of the HIJ-CREATE suggest that clinicians should pay careful attention to conduct comprehensive management of lipid lowering even in the contemporary BP lowering for the secondary prevention in hypertensive patients with CAD. Figure 1 Funding Acknowledgement Type of funding source: None

Introduction: Hypertension prevalence among end-stage renal disease (ESRD) patients range from 76% to 90%. Increasing the duration of dialysis time, either by longer session hours or increased sessions, aiming at reducing the dry weight to achieve euvolemia, may be beneficial for individuals who failed to achieve target BP or ideal volume status during standard HD prescription hours. Objective: We aimed to study the effect of increasing hemodialysis session time on blood pressure control. Methods: This observational study was conducted on 50 hypertensive prevalent HD patients on thrice-weekly maintenance HD. Patients were divided into 2 groups: (A) 25 patients who received longer hemodialysis session (4.5 hours) and (B) 25 patients HD who received the usual 4 hours session. They were followed up for a period of 6 months to assess changes of pre-dialysis blood pressure to monitor response. Results: Ultrafiltration volume declined significantly with longer HD sessions compared to conventional sessions (p-value < 0.001 versus 0.523). Longer HD session time group was associated with highly significant decline in mean SBP, (p-value < 0.001). Moreover, longer HD session time group was associated with highly statistically significant decline in mean DBP, (p-value < 0.001). The decline in mean perdialysis SBP & DBP was -17.27 & -9 mmHg respectively and the rate of decline of postdialysis SBP & DBP was -6.45 & -12.38 mmHg respectively at 6th month compared to values in 1st month of follow up period. Conclusion: Longer HD session duration is associated with better improvement in UF volume, mean SBP & DBP, pre-dialysis SBP & DBP and post-dialysis SBP & DBP as well.

The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) compared in >30 000 high-risk hypertensive patients the effects on coronary heart disease of 3 treatment strategies: (1) based on the diuretic chlorthalidone, (2) the calcium-channel blocker (CCB) amlodipine, and (3) the angiotensin converting-enzyme (ACE) inhibitor lisinopril, respectively.1 Sponsored by the National Heart, Lung, and Blood Institute, ALLHAT stands out because no differences occurred in the incidence of the primary end point that consisted of the combination of fatal coronary heart disease and acute myocardial infarction.1 Not surprisingly, the attention of the ALLHAT consortium shifted to secondary end points, such as stroke, or to loosely defined2 components of secondary end points, such as heart failure. At the end of the line, the ALLHAT investigators based their main conclusions on events that, at the initiation of the trial, they regarded as “soft data that will at best confirm or supplement the primary endpoint.”3 More importantly, what was not identical in the 3 treatment groups was the on-treatment blood pressure despite vigorous attempts to titrate and combine the study medications to achieve a blood pressure of <140 mm Hg systolic and 90 mm Hg diastolic.1 These salient features of ALLHAT should be kept in mind whenever one attempts to interpret the findings of this landmark trial. In this issue of Hypertension , Leenen et al4 published a post hoc analysis, in which they made a direct comparison of cardiovascular and other outcomes among the 18 102 ALLHAT participants randomly assigned to amlodipine or lisinopril. In line with previous reports,1 the incidence of the primary coronary end point and total and cardiovascular mortality were similar in both groups. However, the patients randomly assigned to lisinopril experienced higher risks of stroke, combined cardiovascular disease, gastrointestinal bleeding, …

Hypertension Optimal Treatment (HOT) trial

Introduction Hypertension prevalence among ESRD patients range from 76% to 90%. Sodium &amp; volume overload is among the main mechanisms. Increasing the duration of dialysis time, either by longer session hours or increased sessions, aiming at reducing the dry weight to achieve euvolemia, may be beneficial for individuals who failed to achieve target BP or ideal volume status during standard HD prescription hours. We aim to study the effect of increasing hemodialysis session time on blood pressure control. Methods This observational study was conducted on 50 adult clinically stable hypertensive prevalent HD patients on thrice weekly maintenance HD. Patients with secondary causes of hypertension and Patients with decompensated medical conditions were excluded from our study. Patients were divided into 2 groups: (A) 25 patients who received longer session hemodialysis session (4.5 hour) and (B) 25 patients HD who received the usual 4 hours session. Revision of antihypertensive medications&amp; dosages, dry weight was reassessed regularly, and they were instructed to restrict their salt intake as much as possible aiming at BP &amp;lt; 140/90 mmHg. they were followed up for a period of 6 months assess changes of pre-dialysis blood pressure to monitor response. Results Patients in both groups were age matched, with male sex predominance (64%in groupA&amp;56% in groupB). Patients in both groups underwent their HD sessions mostly through AVF (68% and 92% for group A and B respectively). Ultrafiltration volume declined significantly with longer HD sessions compared to conventional sessions (pvalue &amp;lt;0.001 vs 0.523). Longer HD session time session was associated with highly significant decline in mean SBP, (p-value &amp;lt;0.001). Longer HD session time session was associated with highly statistically significant decline in mean DBP, (p-value &amp;lt;0.001). The decline in mean perdialysis SBP &amp; DBP was -17.27 &amp;-9 mmHg, respectively and the rate of decline of postdialysis SBP &amp; DBP was -6.45 &amp; -12.38 mmHg, respectively at 6th month compared to values in 1st month of follow up period. Conclusion Longer HD session duration is associated with better improvement in UF volume, mean SBP&amp;DBP, pre-dialysis SBP&amp;DBP and post-dialysis SBP&amp;DBP as well.

Background Although the systolic blood pressure (SBP) time in target range (TTR) shows great potential in predicting clinical outcomes in hypertensive patients, its role in reducing the incidence of acute kidney injury (AKI) requires further validation. The aim of this study was to investigate the associations between SBP TTR and AKI events. Methods This is a post-hoc analysis of the Systolic Blood Pressure Intervention Trial (SPRINT). Participants aged 50 or older were randomly assigned to intensive (&amp;lt;120 mm Hg) or standard (&amp;lt;140 mm Hg) SBP treatment arms. SBP TTR was defined as 110–130 mm Hg for the intensive arm and 120–140 mm Hg for the standard arm over 3 months. The primary outcome was incident AKI. The secondary outcome was the severity of AKI, based on modified KDIGO criteria. Competing risk models were used to estimate the relationship between SBP TTR and AKI. Results Of 8985 eligible participants, 258 experienced AKI, resulting in an incidence rate of 7.62 (95% CI, 6.72–8.61) per 1,000 person-years. Each 1-SD increase in SBP TTR was associated with a 15% reduction in AKI risk (adjusted HR, 0.85; 95% CI, 0.75-0.97; P=0.012), particularly for severe AKI stages (HR, 0.71; 95% CI, 0.58-0.87; P&amp;lt;0.001). Compared to participants with lower TTR (0 to &amp;lt;59%), those with higher TTR (59 to 100%) had a lower risk of AKI events (HR: 0.67, 95% CI: 0.51–0.88, P &amp;lt; 0.001). Furthermore, after categorizing by treatment arm, HRs (95% CIs) comparing the standard/lower group against intensive/lower, standard/higher, and intensive/higher were 1.71 (1.23–2.38; P = 0.001), 0.67 (0.44–1.01; P = 0.057), and 1.15 (0.78–1.71; P = 0.470), respectively. Conclusions Maintaining a higher SBP TTR significantly reduces the risk of AKI in hypertensive patients, underscoring the importance of sustained blood pressure management.

Introduction: Most epidemiological studies have shown that the prevalence of high blood pressure (BP) has significantly increased among children and adolescents in various countries of the world. Objectives: To assess the blood pressure levels and prevalence of high blood pressure among adolescents (14–19 years) and identify the risk factors associated with high blood pressure. Methods: This is a cross-sectional study on 262 teenager population (115 male, 147 female) in peripheral area, Bintan Island, Riau Archipelago, Indonesia. Each participant was conducted measurement of arterial blood pressure, weight, height, and body mass index (BMI). Information regarding risk factors of hypertension was conducted by questionnaire. Results: Mean SBP and mean DBP were 119.5 (SD 18.8) and 75.1 (SD 10.9) mm Hg respectively (124.53 (SD 20.6) & 77.12 (SD 11.3) in males, 115.56 (SD 16.4) and 73.52 (SD 10.4) in females). Mean age was 16.62 (SD 1.1). Mean blood pressure (MBP) showed significant correlation with age. From 262 participants, 35 participants (13.3%) had hypertension, 14 participants (5.3%) had obese (RR = 5.12; 95% CI 3.78–6.92). MBP showed significant correlation with BMI. Other risk factors such as family history of hypertension, salt intake, exercise, smoke, stress, alcohol consumption, illness, and medication history showed insignificant correlation with MBP. Conclusion: Prevalence of hypertension among adolescences in peripheral area is higher than national prevalence. The major risk factors for hypertension among adolescents are BMI.

Hypertension is highly prevalent in the United States and worldwide. In the United States, 1 in 3 adults (≈73 million people) have hypertension. The financial and human costs of hypertension are substantial. The estimated costs attributable to hypertension in the United States alone in 2010 were $70 billion direct costs for medical treatments and $24 billion indirect costs because of lost productivity.1 Awareness and treatment of hypertension have improved considerably during the past several decades: >80% of all people with hypertension are aware of the condition and 75% are using antihypertensive medications.2,3 However, despite enormous effort and treatment-related expenditures, only 53% of those with documented hypertension have their blood pressure controlled.3 Older age (Figure 1), left ventricular hypertrophy, and obesity are important risk factors for uncontrolled or drug-resistant hypertension.4 Importantly, the foregoing are also risk factors for increased aortic stiffness.5 Figure 1. Hypertension prevalence and control rates as a function of age in the National Health and Nutrition Examination Survey 2003 to 2004. Data derived from Wong et al.44 During the past 2 decades, measures of aortic stiffness have emerged as important risk factors for progression of blood pressure and incident cardiovascular disease. Carotid femoral pulse wave velocity (CFPWV), a measure of aortic wall stiffness, increases markedly with age, particularly after midlife. For example, Framingham Heart Study investigators have shown that the prevalence of CFPWV ≥12 m/s increases from a few percentage before 50 years of age to ≥60% after 70 years of age (Figure 2A). Importantly, elevated CFPWV is associated with high risk for incident hypertension (Figure 2B) and cardiovascular disease (Figure 2C). Figure 2C should be interpreted within the context that a normal value (<95th percentile) for CFPWV in a healthy Framingham Heart Study reference sample <50 years of age was 8.1 …

Patients with resistant hypertension (RH) are at greater risk for stroke, renal insufficiency, and cardiovascular disease (CVD) events than are those for whom blood pressure (BP) is responsive to and well controlled by therapeutic interventions. Although all chronotherapy trials have compared the effects on BP regulation of full daily doses of medications when ingested in the morning versus at bedtime, prescription of the same medications in divided doses twice daily (BID) is frequent. Here, we investigated the influence of hypertension treatment-time regimen on the circadian BP pattern, degree of BP control, and relevant clinical and laboratory medicine parameters of RH patients evaluated by 48-h ambulatory BP monitoring (ABPM). This cross-sectional study evaluated 2899 such patients (1701 men/1198 women), 64.2 ± 11.8 (mean ± SD) yrs of age, enrolled in the Hygia Project. Among the participants, 1084 were ingesting all hypertension medications upon awakening (upon-awakening regimen), 1436 patients were ingesting the full daily dose of ≥1 of them at bedtime (bedtime regimen), and 379 were ingesting split doses of ≥1 medications BID upon awakening and at bedtime (BID regimen). Patients of the bedtime regimen compared with the other two treatment-time regimens had lower likelihood of microalbuminuria and chronic kidney disease; significantly lower albumin/creatinine ratio, glucose, total cholesterol, and low-density lipoprotein (LDL) cholesterol; plus higher estimated glomerular filtration rate and high-density lipoprotein (HDL) cholesterol. The bedtime regimen was also significantly associated with lower asleep systolic (SBP) and diastolic (DBP) BP means than the upon-awakening and BID regimens. The sleep-time relative SBP and DBP decline was significantly attenuated by the upon-awakening and BID regimens (p < .001), resulting in significantly higher prevalence of non-dipping in these two treatment-time regimen groups (80.5% and 77.3%, respectively) than in the bedtime regimen (54.4%; p < .001 between groups). Additionally, the prevalence of the riser BP pattern, associated with highest CVD risk, was much greater, 31.0% and 29.8%, respectively, among patients of the upon-awakening and BID-treatment regimens, compared with the bedtime regimen (17.6%; p < .001 between groups). Patients of the bedtime regimen also showed significantly higher prevalence of properly controlled ambulatory BP (p < .001) as a result of a greater proportion of them showing complete control of asleep SBP and DBP means. Our findings demonstrate significantly lower asleep SBP and DBP means and attenuated prevalence of blunted nighttime BP decline, i.e., lower prevalence of CVD risk markers, in RH patients ingesting the full daily dose of ≥1 hypertension medications at bedtime than in those ingesting all of them upon awakening or ≥1 of them as split doses BID. In RH, ingesting the same medications BID neither improves ambulatory BP control nor reduces the prevalence of non-dipping, and cannot be considered chronotherapy. Collectively, findings of this study indicate that a bedtime hypertension medication regimen, in conjunction with proper patient evaluation by ABPM to corroborate the diagnosis of true RH and avoid treatment-induced nocturnal hypotension, should be the therapeutic scheme of choice for patients who, by conventional cuff methods (and in the absence of ABPM) and the morning-treatment regimen, have been mistakenly judged to be resistant to therapy. (Author correspondence: rhermida@uvigo.es)

Marc Fisher MD Kennedy Lees MD Section Editors: Hypertension is the most important modifiable risk factor for stroke.1,2 It is estimated that 25% or more of strokes may be attributable to hypertension. Because many patients with stroke have mild hypertension or prehypertension, we have shifted our focus and now think of stroke on a continuum of risk based on blood pressure (BP) level rather than on a threshold effect.3 Because high BP may not exist in isolation, a wider definition of hypertension has been proposed that also takes into account the absolute risk of cardiovascular events and associated metabolic factors or early disease markers.3 Lowering BP reduces the risk of stroke. Epidemiological studies have shown that for each 10 mm Hg lower systolic blood pressure (SBP), there is a decrease in risk of stroke of approximately one third in persons aged 60 to 79 years. This association is continuous down to levels of at least 115/75 mm Hg and is consistent across sexes, regions, stroke subtypes, and for fatal and nonfatal events.4 Lowering diastolic blood pressure (DBP) was once the main target to achieve stroke and other cardiovascular event reduction, but SBP has now become the target.3 As recently shown, even the elderly with sustained SBP elevation may gain from BP reduction in relation to less fatal or nonfatal stroke, death, and heart failure.5 Although the role of longer-term BP control to improve outcomes in patients with stroke is undisputed, BP management immediately after a stroke remains controversial. In an effort to resolve this controversy, several pilot clinical trials have been initiated. In this review, we discuss the results of some of these trials and available evidence-based guidelines for BP control in the settings of acute ischemic and hemorrhagic stroke (excluding subarachnoid hemorrhage) and …

The Impact of APOL1 on Chronic Kidney Disease and Hypertension.

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Objective: To investigate multiple blood pressure measurements and interarm differences in a pregnant population. Method: Pregnant women attending routine antenatal ultrasound scans in gestational weeks 11-13 or week 20 had three consecutive blood pressure measurements on each arm conducted according to international guidelines. Mean and mean difference between the 1st measurement (BP-A) and 2nd + 3rd measurements combined (BP-B) as well as between right and left arm, respectively, were calculated and compared by paired t-test. Bland-Altman plots illustrate means and mean-differences of systolic and diastolic pressure between BP-A and BP-B. Results: One-hundred women were included. Mean systolic, diastolic and arterial blood pressure for BP-A were 112.1 mmHg, 70.6 mmHg and 84.4 mmHg, respectively, while mean BP-B were 109.8 mmHg, 69.2 mmHg and 82.8 mmHg. Mean differences in systolic, diastolic and mean arterial pressure (MAP) between BP-A and BP-B were 2.5 mmHg (P&lt;0.001, 95% Confidence interval (CI) 1.7;3.2), 1.5 mmHg (P&lt;0.001, 95% CI 1.0;2.0) and 1.8 mmHg (P&lt;0.001, 95% CI 1.4;2.2). Mean interarm differences in systolic, diastolic and MAP were 3.1 mmHg (P&lt;0.001, 95% CI 1.9;4.3), 0.75 mmHg (P=0.019, 95%CI 0.1;1.4) and 2.4 mmHg (P=0.01, 95% CI 0.6;4.2). Conclusion: In pregnancy, the first blood pressure measurement of three consecutive is significantly higher than the following two. Blood pressure on the right arm is significantly higher compared to the left arm. International guidelines on blood pressure measurements should apply to pregnant women.

Treating the Black Hypertensive in 2010: Achieve Lower Targets While Awaiting More Definitive Evidence