Abstract P497: Re-analysis of the Systolic Blood Pressure Intervention Trial (SPRINT): The Renal Consequences of Intensive versus Standard Blood Pressure Lowering

Hypertension ◽  
2017 ◽  
Vol 70 (suppl_1) ◽  
Author(s):  
Leora Branfield Day ◽  
David M Naimark
Keyword(s):  
Blood Pressure ◽  
Lifetime Cost ◽  
Intensive Therapy ◽  
Cost Savings ◽  
Cost Effective ◽  
Pressure Control ◽  
Average Lifetime ◽  
Ckd Progression ◽  
Lifetime Horizon ◽  
Increased Risk

Background: BP management guidelines suggest that persons with CKD should be treated to a SBP ≤ 140 mmHg. SPRINT compared this target to intensive SBP lowering (≤ 120 mmHg) in persons with and without CKD and found a reduced rate of CV events and all-cause mortality (ACM). However intensive therapy was associated with an increased risk of AKI. We extrapolated the results of SPRINT over a lifetime horizon to determine whether in the long-term, the benefit in terms of the primary outcome would be less economically attractive when the risks of more frequent AKI and subsequent CKD progression were considered. Methods: We re-configured the CKD Simulator, a Markov model of CKD progression, AKI events, fatal and non-fatal CV events, and ESRD. We recalibrated the model to be representative of the SPRINT cohort and compared intensive vs. standard blood pressure control among 10 million simulated persons with and without CKD over their lifetimes. Marginal treatment costs were calculated and hazard ratios for AKI, CV events and ACM observed in SPRINT were applied to the monthly probabilities of these events in the intensive SBP arm. Results: Lifetime average, discounted, costs per person associated with intensive vs. standard SBP lowering were predicted to be $35,811 and $30,584, respectively. Quality-adjusted, discounted average lifespans were 196.05 and 190.47 months, respectively. The cost of each quality-adjusted life-year gained by adopting intensive over standard BP lowering would be $11,220, significantly below the accepted cost-effectiveness threshold of $50,000. Intensive SBP control would reduce the lifetime incidence of at least one CV event by 5.5%, but increase the incidence of at least one AKI episode and ESRD by 1.7% and 0.7%, respectively. These differences were associated with average lifetime cost savings per person of $459 for CV events, but losses of $161 and $2,889 for AKI and ESRD. Discussion: Intensive SBP management would be cost-effective and associated with a significant lifetime reduction in CV events. However, there would be an increase in the lifetime risk of AKI and ESRD, contributing to 58% of the total increase in cost of intensive relative to usual SBP control. Intensive SBP lowering should be adopted judiciously in persons at high risk of ESRD.

Abstract 15595: Missed Targets: United States Trends in Hypertension Prevalence, Control, and Treatment 2005-2018

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Rahul Aggarwal ◽  
Nicholas Chiu ◽  
Rishi Wadhera ◽  
Changyu Shen ◽  
Robert W Yeh ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Temporal Trends ◽  
Cost Effective ◽  
Pressure Control ◽  
Healthy People ◽  
Sensitivity Analyses ◽  
Base Case ◽  
Improve Blood Pressure Control ◽  
Hypertension Prevalence ◽  
And Control

Introduction: Hypertension is a major risk factor for cardiovascular disease. The US government, through the Healthy People Initiative 2020, set targets to improve hypertension prevalence and treatment rates in US adults by a relative 10% from 2005 to 2020, and increase control rates by a relative 40%. We examined US progress towards this goal from 2005-2018. Methods: We analyzed data from 38,876 non-pregnant US adults from the NHANES 2005-2018 surveys to determine nationally representative estimates of hypertension prevalence, treatment rates, and control. Temporal trends in hypertension prevalence, treatment, and control were assessed using weighted linear regression after age adjustment to the 2000 US census (per the Healthy People Initiative approach). In the base case, we defined hypertension as blood pressure >140/90 or on an antihypertensive; we used the ACC/AHA definition of blood pressure >130/80 in sensitivity analyses. Results: In 2017-2018, 34.3% (±1.7) of US adults had hypertension, of these 69.7% (±1.5) were on treatment, and 43.7% (±1.6) were controlled. After age-adjustment, no statistically significant changes in hypertension prevalence, treatment rates, or control were observed from 2005-2018 (p for trend 0.91, ,0.98, 0.66, Figure 1). In sensitivity analyses, applying the ACC/AHA definition increased the estimated prevalence of hypertension during the period, but trends in prevalence remained unchanged. Conclusions: There has been no material progress in reducing the prevalence of hypertension or improving rates of treatment and control from 2005 to 2018. As planning is underway for Healthy People Initiative 2030, setting of hypertension targets must be accompanied with investments in cost-effective, scalable programs to improve blood pressure control nationwide, with a focus on high-risk populations.

Nondipping Blood Pressure: Predictive or Reactive Failure of Renal Sodium Handling?

Physiology ◽  
2021 ◽  
Vol 36 (1) ◽  
pp. 21-34 ◽  
Author(s):  
Jessica R. Ivy ◽  
Matthew A. Bailey
Keyword(s):  
Blood Pressure ◽  
Pressure Control ◽  
Sodium Reabsorption ◽  
Nocturnal Sleep ◽  
Sodium Homeostasis ◽  
Increased Risk ◽  
Health And Disease ◽  
Renal Sodium Handling ◽  
Sodium Handling

Blood pressure follows a daily rhythm, dipping during nocturnal sleep in humans. Attenuation of this dip (nondipping) is associated with increased risk of cardiovascular disease. Renal control of sodium homeostasis is essential for long-term blood pressure control. Sodium reabsorption and excretion have rhythms that rely on predictive/circadian as well as reactive adaptations. We explore how these rhythms might contribute to blood pressure rhythm in health and disease.

scholarly journals Management of Presumed Acute Kidney Injury during Hypertensive Therapy: Stay Calm and Carry on?

2020 ◽  
Vol 51 (2) ◽  
pp. 108-115
Author(s):  
Teresa K. Chen ◽  
Chirag R. Parikh
Keyword(s):  
Blood Pressure ◽  
Acute Kidney Injury ◽  
Serum Creatinine ◽  
Blood Pressure Control ◽  
Kidney Injury ◽  
Pressure Control ◽  
Intensive Treatment ◽  
Urinary Biomarkers ◽  
Increased Risk ◽  
Intensive Blood Pressure

Background: Recent studies have demonstrated that intensive blood pressure control is associated with improved cardiovascular outcomes. Acute kidney injury (AKI), however, was more common in the intensive treatment group prompting concern in the nephrology community. Summary: Clinical trials on hypertension control have traditionally defined AKI by changes in serum creatinine. However, serum creatinine has several inherent limitations as a marker of kidney injury, with various factors influencing its production, secretion, and elimination. Urinary biomarkers of kidney injury and repair have the potential to provide insight on the presence and phenotype of kidney injury. In both the Systolic Blood Pressure Intervention Trial and the Action to Control Cardiovascular Risk in Diabetes study, urinary biomarkers have suggested that the increased risk of AKI associated with intensive treatment was due to hemodynamic changes rather than structural kidney injury. As such, clinicians who encounter rises in serum creatinine during intensification of hypertension therapy should “stay calm and carry on.” Alternative explanations for serum creatinine elevation should be considered and addressed if appropriate. When the rise in serum creatinine is limited, particularly if albuminuria is stable or improving, intensive blood pressure control should be continued for its potential long-term benefits. Key Messages: Increases in serum creatinine during intensification of blood pressure control may not necessarily reflect kidney injury. Clinicians should evaluate for other contributing factors before stopping therapy. Urinary biomarkers may address limitations of serum creatinine as a marker of kidney injury.

Atrial fibrillation and hypertension

ESC CardioMed ◽  
2018 ◽  
pp. 2227-2229
Author(s):  
Hung-Fat Tse ◽  
Jo-Jo Hai
Keyword(s):  
Oxidative Stress ◽  
Risk Factors ◽  
Atrial Fibrillation ◽  
Blood Pressure ◽  
Pressure Control ◽  
Hypertensive Patients ◽  
Good Blood Pressure Control ◽  
Increased Risk ◽  
Independent Risk Factors ◽  
Stress Activation

Hypertension is one of the most important independent risk factors for atrial fibrillation (AF). Conversely, AF is associated with an increased risk of stroke in hypertensive patients. While the pathophysiology linking the two conditions is not completely understood, it is likely attributed to interplay between mechanical stress, activation of the renin–angiotensin–aldosterone system, oxidative stress, and inflammatory response in hypertension to cause atrial electroanatomical remodelling, and thus AF. Management of hypertensive patients with AF encompasses lenient rate control, thromboprophylaxis, and good blood pressure control.

scholarly journals The potential of real-time analytics to improve care for mechanically ventilated patients in the intensive care unit: an early economic evaluation

2020 ◽  
Vol 18 (1) ◽  
Author(s):  
Lytske Bakker ◽  
Katerina Vaporidi ◽  
Jos Aarts ◽  
William Redekop
Keyword(s):  
Intensive Care ◽  
Cost Effectiveness ◽  
Real Time ◽  
Cost Savings ◽  
Cost Effective ◽  
Potential Cost ◽  
Lifetime Horizon ◽  
Scenario Analyses ◽  
Life Years ◽  
The Impact

Abstract Background Mechanical ventilation services are an important driver of the high costs of intensive care. An optimal interaction between a patient and a ventilator is therefore paramount. Suboptimal interaction is present when patients repeatedly demand, but do not receive, breathing support from a mechanical ventilator (> 30 times in 3 min), also known as an ineffective effort event (IEEV). IEEVs are associated with increased hospital mortality prolonged intensive care stay, and prolonged time on ventilation and thus development of real-time analytics that identify IEEVs is essential. To assist decision-making about further development we estimate the potential cost-effectiveness of real-time analytics that identify ineffective effort events. Methods We developed a cost-effectiveness model combining a decision tree and Markov model for long-term outcomes with data on current care from a Greek hospital and literature. A lifetime horizon and a healthcare payer perspective were used. Uncertainty about the results was assessed using sensitivity and scenario analyses to examine the impact of varying parameters like the intensive care costs per day and the effectiveness of treatment of IEEVs. Results Use of the analytics could lead to reduced mortality (3% absolute reduction), increased quality adjusted life years (0.21 per patient) and cost-savings (€264 per patient) compared to current care. Moreover, cost-savings for hospitals and health improvements can be incurred even if the treatment’s effectiveness is reduced from 30 to 10%. The estimated savings increase to €1,155 per patient in countries where costs of an intensive care day are high (e.g. the Netherlands). There is considerable headroom for development and the analytics generate savings when the price of the analytics per bed per year is below €7,307. Furthermore, even when the treatment’s effectiveness is 10%, the probability that the analytics are cost-effective exceeds 90%. Conclusions Implementing real-time analytics to identify ineffective effort events can lead to health and financial benefits. Therefore, it will be worthwhile to continue assessment of the effectiveness of the analytics in clinical practice and validate our findings. Eventually, their adoption in settings where costs of an intensive care day are high and ineffective efforts are frequent could yield a high return on investment.

scholarly journals Cost-effectiveness Analysis of Ribociclib plus Letrozole versus Palbociclib plus Letrozole in the United Kingdom

10.36469/9725 ◽  
2019 ◽  
Vol 6 (2) ◽  
pp. 20-31 ◽  
Author(s):  
Gaurav Suri ◽  
David Chandiwana ◽  
Adam Lee ◽  
Rohit Mistry
Keyword(s):  
Breast Cancer ◽  
Cost Effectiveness ◽  
Advanced Breast Cancer ◽  
Cost Savings ◽  
Cost Effective ◽  
Advanced Breast ◽  
Lifetime Horizon ◽  
Menopausal Women ◽  
Post Menopausal ◽  
The Cost

Objective: To evaluate the cost-effectiveness of ribociclib plus letrozole versus palbociclib plus letrozole in post-menopausal women with hormone receptor positive (HR+) and human epidermal growth receptor 2 negative (HER2-) advanced breast cancer from a UK payer perspective. Methods: A cohort-based partitioned survival model was developed to evaluate the cost-effectiveness of ribociclib plus letrozole versus palbociclib plus letrozole in post-menopausal women with HR+/HER2- advanced breast cancer over a lifetime horizon. The analysis was carried out from a National Health Services and Personal Social Services perspective, and results are presented in incremental costs per quality adjusted life years. Clinical data from three randomized controlled trials (MONALEESA-2, PALOMA-1 and PALOMA-2 studies) were used, and supplemented with available real world evidence. Costs categories comprised of drug acquisition, medical management, and treatment of adverse events. Healthcare resource utilization data were identified from literature and unit costs sourced from secondary sources. Utility values were derived from MONALEESA-2 study and were supported with values identified from literature. Both deterministic and probabilistic analyses were carried out to assess uncertainty. Results: In the base case, treatment with ribociclib plus letrozole increased mean progression free survival (PFS) by 4.1 months and overall survival by 5.0 months compared to palbociclib plus letrozole. Further, treatment with ribociclib plus letrozole resulted in cost-savings of £8464 and incremental QALYs of 0.261, demonstrating that treatment with ribociclib plus letrozole is dominant to treatment with palbociclib plus letrozole. The probabilistic analysis also yielded mean cost-savings of £7914 and mean QALY gain of 0.273. At willingness-to-pay threshold of £30 000 per QALY, treatment with ribociclib plus letrozole had a 92% probability of being cost-effective compared to palbociclib and letrozole. Conclusions: The results of the analysis demonstrate that ribociclib plus letrozole treatment is both cost-saving and a cost-effective option amongst the available cyclin dependent kinase 4/6 inhibitors for the treatment of post-menopausal women with advanced breast cancer. The biggest driver of the cost savings were the lower acquisition costs of ribociclib.

Abstract 98: Blood Pressure Control and Risk of Recurrent Lobar Intracerebral Hemorrhage

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Alessandro Biffi ◽  
Christopher D Anderson ◽  
Thomas W Battey ◽  
Alison M Ayres ◽  
Kristin Schwab ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Effect Size ◽  
Apoe Genotype ◽  
Pressure Control ◽  
Recurrence Risk ◽  
Dichotomous Variable ◽  
Increased Risk ◽  
Increase Risk ◽  
Stage 1

Introduction: Elevated blood pressure (BP) is a potent risk factor for risk and recurrence of Intracerebral Hemorrhage (ICH) in non-lobar regions, but its role in lobar ICH remains unclear. Hypothesis: We tested whether: elevated BP after index lobar ICH is associated with lobar ICH recurrence and whether the role of elevated BP is influenced by APOE genotype and microbleeds on MRI. Methods: Eligible subjects were survivors of primary lobar ICH enrolled in a single-center prospective cohort study. The number of MRI-defined lobar microbleeds (MB) and APOE genotype (ε2/ε3/ε4 alleles) were determined at time of index ICH. Survivors were followed prospectively for recurrent ICH. BP measurements were captured at 3, 6, 9, 12 months, and every 6 months thereafter. BP was treated as a time-varying variable, and analyzed in two ways: 1) a dichotomous variable based on AHA/ASA ICH secondary prevention guidelines goal; 2) a categorical variable for JNC7 hypertension stages. Results: Among 505 lobar ICH survivors, there were 102 recurrences during median follow-up of 30 months. Inadequate BP control (based on AHA/ASA guidelines) was associated with increased recurrence risk (Hazard Ratio [HR] 3.53, p=0.001). Effect size correlated with JNC7 stage: pre-hypertension (HR 2.76, p=0.007), hypertension stage 1 (HR 3.90, p=0.012); hypertension stage 2 (HR 5.21, p 2 MB, interaction p = 0.037) to increase risk of lobar ICH recurrence. Conclusions: Elevated BP is associated with increased risk of recurrent lobar ICH, with effect size rising with JNC7 stage. Presence of APOE ε2 / ε4 and > 2 MB on MRI interacts with BP, further increasing risk of recurrence. Further studies are required to determine the clinical implications of these findings.

Abstract P188: Blood Pressure Control And Glaucoma Risk In Older Women

Hypertension ◽  
2021 ◽  
Vol 78 (Suppl_1) ◽  
Author(s):  
Bernhard Haring ◽  
Kathleen Hovey ◽  
Michael La Monte ◽  
Chris Andrews ◽  
Nazmus Saquib ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Antihypertensive Treatment ◽  
Proportional Hazards ◽  
Elderly Women ◽  
Pressure Control ◽  
Cox Proportional Hazards ◽  
Prior History ◽  
Increased Risk ◽  
Elevated Systolic Blood Pressure

Objective: Individuals with elevated systolic blood pressure (BP) or low diastolic BP, whether or not on antihypertensive treatment, may be at higher risk for developing glaucoma. We aimed to investigate BP levels in relation to risk of incident glaucoma in a large cohort of elderly women. Methods: Prospective follow-up of 101,447 postmenopausal women without prior history of glaucoma enrolled in the Women’s Health Initiative Study (WHI). Blood pressure was measured in-clinic at baseline and after 3 years using standardized procedures and average BP was calculated. Antihypertensive medication use was determined by drug inventory at baseline and year 3. Women self-reported incident newly diagnosed glaucoma annually. Hazard ratios (HRs) and 95% confidence intervals (95% CI) were estimated using Cox proportional hazards analyses adjusting for demographic, medical history, and lifestyle covariates. Results: During a mean follow-up of 4.7 years, we documented 7,514 glaucoma cases. Among women not on antihypertensive treatment, those with systolic BP ≥140 mmHg or diastolic BP ≥80 mmHg were not at higher risk of developing glaucoma (HR 0.97, 95% CI 0.88-1.08 and HR 1.00 [0.93-1.08], respectively), compared to women with a systolic BP <120 mmHg or a diastolic BP 60-<80 mmHg. Among women on antihypertensive treatment, neither systolic BP ≥140 mmHg nor diastolic BP ≥80 mmHg was associated with an increased risk of glaucoma (HR 0.91 [0.82-1.01] and HR 0.97 [0.90-1.05], respectively). A diastolic BP <60 mmHg was not associated with a higher risk compared to a diastolic BP 60-<80 mmHg. Conclusions: BP control is not associated with an increased or decreased glaucoma risk in elderly women.

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