Choice of optimal antihypertensive therapy in patients with diabetes mellitus type 2

Aim of the study: to develop personalized approaches to combined antihypertensive therapy in patients with type 2 diabetes mellitus and arterial hypertension, depending on the parameters of the daily blood pressure profile and heart rate variability.Material and methods. We examined 322 patients with type 2 diabetes and arterial hypertension who had not previously received antihypertensive drugs on a regular basis. At the first stage, patients were prescribed Perindopril 10 mg per day and Indapamide retard 1,5 mg per day. In the absence of reaching target blood pressure (BP) levels after 28 days, a third antihypertensive drug was added — Amlodipine 5 mg per day, followed by titration to 10 mg 1 r per day (group I) or a b-blocker — Carvedilol at a dose of 12,5 mg 2 r per day, also followed by titration up to 25 mg 2 r per day (group II). Daily monitoring of BP and ECG was carried out, the average daily heart rate (HR), circadian index (CI), as well as heart rate variability were determined.Results and its discussion. Patients with type 2 diabetes have a high variability of blood pressure throughout the day, high pulse blood pressure, as well as a rigid circadian profile of heart rate. The appointment of a standard two-component antihypertensive therapy, including Perindopril 10 mg and Indapamide retard 1,5 mg per day, allows reaching the target blood pressure only in 46% of patients. The addition of amlodipine or carvedilol significantly increases the effectiveness of therapy, allowing more than 80% of patients to achieve the target blood pressure. At the same time, the use of amlodipine leads to a greater extent to a decrease in pulse pressure, and the inclusion of carvedilol improves the circadian profile of blood pressure and heart rate, and has a positive effect on heart rate variability.

Oral Nifedipine versus Intravenous Labetalol for Acute Blood Pressure Control in Severe Hypertension of Pregnancy: A Study at Faridpur Medical College Hospital

The first line antihypertensive treatment for severe hypertension of pregnancy includes labetalol, hydralazine, or nifedipine. Rapid but safe blood pressure control allows the definitive treatment, the delivery of baby to be carried out with minimal delay and good maternal and fetal outcomes. This non-randomized clinical trial was performed in Faridpur Medical College Hospital to compare the effectiveness and tolerability of oral nifedipine and intravenous labetalol in the acute control of severe hypertension of pregnancy. Total 50 admitted pregnant women with a viable fetus (>_ 24 weeks of gestation) having severe hypertension were allocated into two groups, Group A: 25 patients receiving oral nifedipine (10 mg), Group B: 25 patients receiving injectable labetalol (with incremental doses: 20, 40, 80mg). Up to 5 doses were tried for each drug at 15 minutes interval until target blood pressure (<_150/100 mmHg) was achieved. Baseline characteristics like mean age, mean weight, heart rate, systolic and diastolic pressures were similar in both labetalol and nifedipine groups. The average time required to achieve target blood pressure was 30.33 ± 10.44 minutes for labetalol and 25.63 ± 10.12 minutes for nifedipine (p=0.9129). Feto-maternal outcomes and adverse drug related effects were similar among the two groups. Both intravenous labetalol and oral nifedipine were found to be equally effective and well tolerated. Nifedipine may be preferable as it is a simple, flat dose schedule and an oral regimen. Faridpur Med. Coll. J. 2021;16(1):25-29

Variation in hypertension clinical practice guidelines: a global comparison

Background Hypertension is the largest single contributor to the global burden of disease, affecting an estimated 1.39 billion people worldwide. Clinical practice guidelines (CPGs) can aid in the effective management of this common condition, however, inconsistencies exist between CPGs, and the extent of this is unknown. Understanding the differences in CPG recommendations across income settings may provide an important means of understanding some of the global variations in clinical outcomes related to hypertension. Aims This study aims to analyse the variation between hypertension CPGs globally. It aims to assess the variation in three areas: diagnostic threshold and staging, treatment and target blood pressure (BP) recommendations in hypertension. Methods A search was conducted on the MEDLINE repository to identify national and international hypertension CPGs from 2010 to May 2020. An additional country-specific grey-literature search was conducted for all countries and territories of the world as identified by the World Bank. Data describing the diagnosis, staging, treatment and target blood pressure were extracted from CPGs, and variations between CPGs for these domains were analysed. Results Forty-eight CPGs from across all World Bank income settings were selected for analysis. Ninety-six per cent of guidelines defined hypertension as a clinic-based BP of ≥140/90 mmHg, and 87% of guidelines recommended a target BP of < 140/90 mmHg. In the pharmacological treatment of hypertension, eight different first-step, 17 different second-step and six different third-step drug recommendations were observed. Low-income countries preferentially recommended diuretics (63%) in the first-step treatment, whilst high-income countries offered more choice between antihypertensive classes. Forty-four per cent of guidelines, of which 71% were from higher-income contexts recommended initiating treatment with dual-drug therapy at BP 160/100 mmHg or higher. Conclusion This study found that CPGs remained largely consistent in the definition, staging and target BP recommendations for hypertension. Extensive variation was observed in treatment recommendations, particularly for second-line therapy. Variation existed between income settings; low-income countries prescribed cheaper drugs, offered less clinician choice in medications and initiated dual therapy at later stages than higher-income countries. Future research exploring the underlying drivers of this variation may improve outcomes for hypertensive patients across clinical contexts.

Optimal target blood pressure in critically ill adult patients with vasodilatory shock: a protocol for a systematic review and meta-analysis

IntroductionThe optimal target of mean arterial pressure (MAP) for better outcomes in patients with vasodilatory shock remains a matter of debate. Although catecholamines are generally used to maintain target blood pressure in hypotensive patients with vasodilatory shock, the adverse effects of catecholamines must also be considered. We will perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the certainty of evidence determining the optimal target of MAP control for patients with vasodilatory shock in critically ill settings.Methods and analysisThis study protocol was registered in the University Hospital Medical Information Network Clinical Trials Registry. We will include only RCTs that evaluated the two different comparators for target MAP to be maintained for clinical outcomes of all-cause mortality: organ dysfunction and adverse events in critically ill adult patients with vasodilatory shock. We will search the electronic bibliographic databases of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials in November 2020. Two reviewers will independently screen titles and abstracts, perform full article reviews and extract study data. We will report study characteristics and assess methodological quality using the Cochrane Risk-of-Bias 2 tool. If pooling is appropriate, we will calculate relative risks with 95% CIs for all outcome measures. Clinical and methodological subgroup and sensitivity analyses will be performed to explore heterogeneity. Overall certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach.Ethics and disseminationThis study will not involve primary data collection, and formal ethics approval will therefore not be required. We aim to publish this systematic review in a peer-reviewed journal.Trial registration numberUMIN000042624.

The place of fixed antihypertensive drugs in modern therapy of arterial hypertension

The article provides information on modern approaches to the treatment of arterial hypertension. The historical information about therapy with combined antihypertensive drugs is given. Based on data from multicenter clinical trials, the article provides evidence of the benefits of dual and triple fixed drug combinations. Combinations of 1-adrenoreceptor antagonist bisoprolol and the dihydropyridine-type calcium channel blocker amlodipine are considered. The article highlights the advantages of each of the drugs, as well as their combination. It shows the benefits of a fixed combination of low and medium doses compared to high-dose monotherapy, such as efficacy in achieving target blood pressure, preventing cardiovascular events, increasing adherence to treatment, safety and development of side effects. It provides the evidence base for the effectiveness of a triple fixed combination of renin-angiotensin-aldosterone system blockers with calcium channel blockers and diuretics in achieving target blood pressure compared to a double fixed combination of members of these drug classes, which is due to additive effects. The safety and tolerability profiles were found to be more effective with triple therapy compared with dual therapy, which is also supported by studies.