Atrial Fibrillation and Hypertension: “Quo Vadis”

Hypertension is one of the most well-established risk factors for atrial fibrillation. Long-standing untreated hypertension leads to structural remodeling and electrophysiologic alterations causing an atrial myopathy that forms a vulnerable substrate for the development and maintenance of atrial fibrillation. Hypertension-induced hemodynamic, inflammatory, hormonal, and autonomic changes all appear to be important contributing factors. Furthermore, hypertension is also associated with several atrial fibrillation-related comorbidities. As such, hypertension may represent an important target for therapy in atrial fibrillation. Clinicians should be aware of pitfalls of the blood pressure measurement in atrial fibrillation. While the auscultatory method is preferred, the use of automated devices appears to be an acceptable method in the ambulatory setting. There are pathophysiologic bases and emerging clinical evidence suggesting the benefit of renin-angiotensin system inhibition in risk reduction of atrial fibrillation development particularly in patients with left ventricular hypertrophy or left ventricular dysfunction. A better understanding of hypertension’s pathophysiologic link to atrial fibrillation may lead to the development of novel therapies for the primary prevention of atrial fibrillation. Finally, future studies are needed to address optimal blood pressure goal to minimize the risk of atrial fibrillation-related complications.

Hypertension Control and Guideline-Recommended Target Blood Pressure Goal Achievement at an Early Stage of Hypertension in the UAE

(1) Background: The present study aimed to assess the changes in blood pressure (BP) within the first 6 months of treatment initiation in a newly treated hypertensive cohort and to identify the factors that are associated with achieving the target BP recommended by the American (ACC/AHA, 2017), European (ESC/ESH, 2018), United Kingdom (NICE, 2019), and International Society of Hypertension (ISH, 2020) guidelines. (2) Methods: We analyzed 5308 incident hypertensive outpatients across Abu Dhabi, United Arab Emirates (UAE), in 2017; each patient was followed up for 6 months. Hypertension was defined as a BP of 130/80 mmHg according to the ACC/AHA guidelines and 140/90 mmHg according to the ESC/ESH, NICE, and ISH guidelines. Multiple logistic regression was used to identify factors associated with achieving the guideline-recommended BP targets. (3) Results: At baseline, the mean BP was 133.9 ± 72.9 mmHg and 132.7 ± 72.5 mmHg at 6 months. The guideline-recommended BP targets were 39.5%, 43%, 65.6%, and 40.8%, according to the ACC/AHA, ESC/ESH, NICE, and ISH guidelines, respectively. A BMI of <25 kg/m2 was associated with better BP control according to the ACC/AHA (odds ratio (OR) = 1.26; 95% confidence interval (CI) = 1.07–1.49), ESC/ESH (OR = 1.27; 95% CI = 1.08–1.50), and ISH guidelines (OR = 1.22; 95% CI = 1.03–1.44). Hypertension treated in secondary care settings was more likely to achieve the BP targets recommended by the ACC/AHA (1.31 times), ESC/ESH (1.32 times), NICE (1.41 times), and ISH (1.34 times) guidelines. (4) Conclusions: BP goal achievement was suboptimal. BP control efforts should prioritize improving cardiometabolic goals and lifestyle modifications.

Pharmacist Hypertension Management Quality Review at an Ambulatory Care Clinic

Background: A reduction of 10 mm Hg in systolic blood pressure (SBP) significantly decreases the risk of major cardiovascular disease events. Pharmacists’ management of blood pressure may assist with this reduction. Objective: Assess the impact of pharmacist management of hypertension via a collaborative practice agreement with physicians in an ambulatory care clinic. Methods: The first phase of this study was a retrospective chart review of physician/nurse hypertension visits from October 2019 to August 2020. The second prospective phase consisted of pharmacist managed hypertension visits from December 2020 to January 2021. The primary outcome was the change in SBP from the beginning to the end of the study period in the prospective group. Secondary outcomes included the proportion of patients achieving their blood pressure goal and the proportion of patients adherent to all antihypertensive medications at their follow-up visits in both groups. This study was institutional review board approved. Results: Forty-seven patients were included and analyzed (24 in the retrospective group and 23 in the prospective group). Patients in the prospective group had an average SBP lowering of 10.83 mm Hg ( P = .0035). Thirteen patients (56.5%) met their blood pressure goal of <130/80 mm Hg in the prospective group, compared to 5 patients (20.8%) in the retrospective group ( P = .012). One adverse event occurred during this study. Limitations included small sample size and short duration of study. Conclusion: Patients had an average SBP lowering of >10 mm Hg. More patients reached a goal blood pressure of <130/80 mm Hg when managed by pharmacists.

Atenolol And Nifedipine Combination Is Better Than Monotherapy: A New Era In Novel Drug Delivery For Hypertension

Hypertension is considered a major health problems globally affect millions of patient.Various study confirms that single drug treatment usually is not adequate to achieve blood pressure goal in most hypertensive patients.In this regard,consideration is given to combination therapy, which offers the potential advantages towards minimizing hypertension in a rapid manner and produces lower adverse effects.SLTs (Sublingual tablets) provides immediate action to enhanced absorption and bioavailability rate. Sublingual tablets are absorbed within the mucus membrane and directly reach in blood systemic circulation. The objective of this ongoing research focused on theatenolol (ATN)and nifedipine (NIF) combined drug deliveryin emergency condition of hypertension. Direct compression technique is used to formulate SLTsby taking different types and concentrations of superdisintegrantsCroscarmellose sodium (CCS) and Crospovidone (CP). Sublimating agents like camphor (CM) and thymol (TY)) also added for better result. FTIR and DSC analysis confirms the ccompatibility results between drug and superdisintegrants.Formulated tablets are evaluated for different parameters and found satisfactory. Formulation F6 considered as the best formulation. The disintegration shows 13 sec and dissolution profile shows 97.36% drug release at 10 min. Formulation F6 shows better pharmacokinetic activity and antihypertensive activity in compare to pure drug and marketed formulation.A combination of ATN and NIF produces rapid disintegration and dissolution property during an emergency and is a lifesaving approach in hypertension treatment.

Guideline-Driven Management of Hypertension

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

Abstract MP53: Intensive Blood Pressure Reduction and Secondary Stroke Risk: A Posthoc Analysis of the Sps3 Trial

Introduction: The SPRINT trial demonstrated cardiovascular benefit for a target systolic blood pressure (SBP) <120 mm Hg, but the effect on primary stroke was neutral. The Secondary Prevention of Small Subcortical Strokes (SPS3) trial did not reduce secondary stroke with a target SBP <130 mm Hg. No trial has investigated the effect of the more intensive SPRINT target of <120 mm Hg on secondary stroke risk. Methods: We performed a secondary analysis of SPS3 and included patients with at least 10 SBP readings. The primary predictor is mean SBP from day 30 (to avoid confounding from the initial study intervention) to 2 years. The primary outcome is recurrent ischemic stroke from day 30 to 2 years. We fit Cox models to our outcomes to derive hazard ratios for recurrent stroke events. Results: We included 2,859 patients, of which 121 (4.2%) had ischemic stroke during follow-up. There were 321 patients with SBP <120 (mean=115.5 mm Hg) and 2,538 with SBP ≥120 (mean=134.6 mm Hg), with a respective recurrent stroke rate of 1.9% versus 4.5% (p=0.026). In the Cox model, the hazard ratio for stroke with mean SBP <120 mm Hg was 0.40 (95% CI, 0.18-0.92) (Figure 1) and after adjustment for potential confounders (age, sex, race, education, smoking, prior stroke, prior myocardial infarction) the hazard ratio was 0.39 (95% CI, 0.16-0.96). Conclusion: In patients with lacunar stroke, achieving the SPRINT intensive blood pressure goal of <120 mm Hg was associated with a lower risk of recurrent stroke. While the current study is underpowered and has bias, these preliminary results suggest that the SPRINT definition of intensive blood pressure reduction could be beneficial for secondary stroke prevention.

Adherence to prescription guidelines and achievement of treatment goals among persons with coronary heart disease in Tromsø 7

Background Adherence to clinical practice guidelines for coronary heart disease (CHD) reduces morbidity, mortality and treatment costs. We aimed to describe and compare adherence to prescription guidelines for persons with CHD, and explore its association with treatment goal achievement. Method We included all participants reporting myocardial infarction, angina, percutaneous coronary intervention and/or coronary artery bypass surgery in the seventh wave of the Tromsø Study (2015–2016, n = 1483). Medication use and treatment goal measures (blood pressure, low-density lipoprotein (LDL)-cholesterol and HbA1c) were compared to clinical practice guidelines on secondary CHD prevention. Propensity score matched logistic regression was used to assess the association between the use of antihypertensive drugs and achievement of treatment goal for blood pressure, and the use of lipid-lowering drugs (LLDs) and achievement of treatment goal for LDL-cholesterol. Results The prevalence of pharmacological CHD treatment was 76% for LLDs, 72% for antihypertensive drugs and 66% for acetylsalicylic acid. The blood pressure goal (< 140/90 mmHg, < 140/80 mmHg if diabetic) was achieved by 58% and the LDL-cholesterol goal (< 1.8 mmol/l or < 70 mg/dL) by 9%. There was a strong association between using LLDs and achieving the treatment goal for LDL-cholesterol (OR 14.0, 95% CI 3.6–54.7), but not between using antihypertensive drugs and blood pressure goal achievement (OR 1.4, 95% CI 0.7–2.7). Conclusion Treatment goal achievement of LDL-cholesterol and blood pressure was low, despite the relatively high use of LLDs and antihypertensive drugs. Further research is needed to find the proper actions to increase achievement of the treatment goals.

Effects of Intensive Systolic Blood Pressure Control on All-Cause Hospitalizations

Intensive blood pressure control decreases the rate of cardiovascular events by >25% compared with standard blood pressure control. We sought to determine whether the decrease in cardiovascular events seen with intensive blood pressure control is associated with an increased rate of other causes of hospitalization. This is a post hoc analysis of SPRINT (Systolic Blood Pressure Intervention Trial) in 9361 adult participants with hypertension and elevated cardiovascular risk. Participants were randomly assigned to an intensive or standard systolic blood pressure goal (<120 or <140 mm Hg, respectively). The primary outcome was hospitalization rates per 100 person-years for hospitalizations not associated with SPRINT primary events. After excluding hospitalizations linked to SPRINT primary events, there were 4678 participants with a rate of 19.70 hospitalizations per 100 person-years, compared with 4683 participants with a rate of 19.65 ( P =0.37). Equivalence testing shows that these hospitalization rates were statistically equivalent at the P =0.05 level. Of those with hospitalizations, >1 hospitalization was seen in 38.8% of intensive arm participants and 41.9% of standard arm participants ( P =0.08). The mean cumulative count of nonprimary event hospitalizations was comparable between the two arms. The most common causes of hospitalization were cardiovascular (23.6%) followed by injuries, including bone and joint therapeutic procedures (15.7%), infections (12.0%), and nervous systems disorders (10.7%). No categories of hospitalization were statistically more common in the intensive arm compared with the standard arm. Thus, the decrease in cardiovascular events seen with intensive blood pressure control is not associated with an increased rate of other causes of hospitalization. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01206062.