American Society of Hypertension
he American Society of Hypertension (ASH) 27th Annual Scientific Meeting, held May 19-22, 2012, in New York City, was a scientific forum for clinical investigators and health care professionals treating hypertension to present research findings and advances in treatment. The presenters addressed emerging trends in research and new developments in the approach to treating patients with hypertension and its consequences. Cardiology Review highlights 4 studies presented at the ASH meeting.
“Clinical Inertia” Common for Hypertension Patients
linical inertia, the failure of the physician to adjust antihypertensive medication regimens within 30 days of a visit in which documented hypertension remained uncontrolled, is common, particularly among those at highest risk for poor outcomes, according to new data presented by Jeffrey Harman, PhD, of the University of Florida in Gainesville.
The study of large, multispecialty group practices showed that 59.4% of patients with hypertension experienced clinical inertia. More than half of the patients experienced
clinical inertia at least once during the study and 45% had uncontrolled hypertension at the end of the study.
The patients who were most likely to experience clinical inertia were older, obese, and Hispanic and had higher blood pressure at the start of the study, said Dr Harman.
“The patients who really need aggressive treatment are the ones who seem to be least likely to be getting it,” he noted. The importance of the problem was highlighted by the finding that patients who experienced inertia were more than 2.5 times as likely to have uncontrolled hypertension at the final office visit during the study. Dr Harman noted that the investigators were unable to assess whether the patients were already taking maximum doses of prescribed medications.
The data suggest that none of the physician characteristics assessed in the study— age, gender, specialty, years in practice, and patient volume—was associated with
clinical inertia, which suggests that it is a potential problem for all clinicians.
Dr Harman said that possible solutions to clinical inertia were increased physician education and building pop-up warnings or alerts into electronic medical records to remind physicians about the need to bring blood pressure under control.
This study was funded by Novartis.Harman J, et al. Clinician and patient characteristics associated with clinical inertiain blood pressure control. ASH 2012; Abstract PO-16.
Resistant Hypertension Associated With Greater Risks
but Lower Mortality
atients with resistant hypertension have significantly higher risks of myocardial infarction (MI), heart failure, stroke, and end-stage renal disease but still
had a 19% lower risk of death through 3 years of follow-up, according to the
results of a study presented by John Sim, MD, of Kaiser Permanente Los Angeles
Medical Center. The reason for the finding of a U-shaped curve is unclear, Dr Sim
said, but the researchers are planning to examine whether greater health care utilization
among the resistant patients could explain the lower death rate. Medication
effects could also provide an explanation because patients with resistant hypertension were more likely to be taking diuretics, ß-blockers, ACE
inhibitors, and angiotensin receptor blockers.
Of 2.4 million adult members in the Kaiser health plan during the study period, 20.7% had hypertension. Resistant hypertension was defined as uncontrolled blood pressure (>140/90 mm Hg) despite the use of 3 antihypertensive medications or the use of 4 antihypertensive medications regardless of blood pressure levels. The study compared clinical outcomes between resistant and nonresistant hypertensives treated within the Kaiser Permanente health system, which has a closed pharmacy system, uniform care aided by a guideline based on Joint National Committee recommendations, low clinical inertia, and a high level of retention in the program.
After adjusting for older age and higher rates of obesity, chronic kidney disease, ischemic heart disease, congestive heart failure, cerebrovascular disease, and diabetes among the patients with resistant hypertension, there was 10% to 36% greater risk of heart failure, stroke, MI, and end-stage renal disease, but a 19% lower risk of dying during followup.
The study’s limitations included the use of single blood pressure values and a lack of information that would have allowed adjustment for pseudoresistant hypertension. The authors stressed the need for further research to better understand the findings.
Dr Sim reported receiving grant/research support from Novartis, sanofi-aventis, and Genzyme. Sim J, et al. Comparative outcomes in resistant hypertension (RH) versus non-RH: Kaiser Permanente Southern California cohort. ASH 2012; Abstract OR-9.
New Diabetes Drug Lowers Blood
ulaglutide, an investigational glucagon-like peptide (GLP-1) agonist, significantly reduced systolic blood pressure in patients with type 2 diabetes mellitus who were taking oral antihyperglycemic medications. Keith Ferdinand, MD, of Tulane University in New Orleans, LA, presented data from a phase 2 trial of 775 adult patients showing that after 16 once-weekly injections of dulaglutide 1.5 mg, 24-hour ambulatory systolic blood pressure was an average of 2.8 mm Hg lower versus placebo (P <0.001), a difference that was sustained at the end of the 26-week treatment period (2.7 mm Hg; P = 0.002).
The study is the first large randomized trial to use ambulatory monitoring to assess the long-term effects of a GLP-1 agonist on blood pressure and heart rate. Patients had a mean age of 56 years and all had type 2 diabetes mellitus, a glycated hemoglobin level of 7% to 9.5%, were on a stable regimen of at least 1 oral antihyperglycemic medication, and had a mean clinic blood pressure greater than 90/60 mm Hg and less than140/90 mm Hg. Hypertensives had to be taking no more than 3 antihypertension medications.
A lower 0.75-mg dose of dulaglutide resulted in nonsignificant reductions of 1.1 and 1.7 mm Hg. There were slight (but nonsignificant) increases in heart rate with the higher dose. Dr Ferdinand said he and his colleagues did not believe at this point that the increases are clinically significant. Dulaglutide was well tolerated, with serious adverse event rates of 3.2% with placebo and 3.1% with the lower dulaglutide dose and 4.85% with the higher dose.
Four of the study’s coauthors are employed by Eli Lilly, which is developing dulaglutide.
Ferdinand K, et al. Long-term effects of dulaglutide, a novel GLP-1 agonist, on ambulatory blood pressure and heart rate in patients with type 2 diabetes. ASH 2012; Abstract LB-OR-04.
Women May Need Lower Ambulatory
Blood Pressure Cutoffs
Spanish study suggests that the ambulatory blood pressure monitoring (ABPM) cutoff for the diagnosis of hypertension should be lower in women than in men. Ramon Hermida, PhD, of the University of Vigo in Spain, presented data showing that in a randomized trial of antihypertensive treatment, the ABPM cutoffs associated with an
increased risk of cardiovascular events in men were 135/85 mm Hg for daytime and 120/70 mm Hg for nighttime, which is consistent with current guidelines. However, the cutoffs associated with cardiovascular risk in women were 125/80 mm Hg for daytime and 110/65 mm Hg for nighttime, said Dr.Hermida. Thus, to equal the cardiovascular risk of a man with an awake systolic pressure of 135 mm Hg, a woman only needs to achieve a systolic pressure of 125 mm Hg.
For blood pressure readings of 125/75 mm Hg for daytime and 110/70 mm Hg for nighttime and higher, the risk for cardiovascular events increased more rapidly for women than for men. The findings suggest that the ABPM threshold for starting hypertension treatment should be lower in women even though the current guidelines have the same cutoff figures for both sexes, Dr Hermida noted.
The study included 1718 men and 1626 women with hypertension (mean age, 52.6 years) randomized to take all prescribed antihypertensives after waking up in the morning
or at least 1 of the medications at bedtime. Forty-eight-hour ABPM was performed at baseline and at least annually for every patient in the study. The occurrence of cardiovascular disease events, including cardiovascular mortality, myocardial infarction, coronary revascularization, stroke, and heart failure, was tracked through a median of 5.6 years.
Hermida R, et al. Gender differences in ambulatory blood pressure thresholds for diagnosis of hypertension based on cardiovascular outcomes. ASH 2012; Abstract FP-4.