The effectiveness of Dietary Approaches to Stop Hypertension (DASH) counselling on estimated 10-year cardiovascular risk among patients with newly diagnosed grade 1 hypertension: A randomised clinical trial.

BACKGROUND: The Dietary Approaches to Stop Hypertension (DASH) has been shown to lower blood pressure in the West. However, the real-life impact of DASH on reducing cardiovascular (CV) risk in routine clinical setting has not been studied. METHODS: A parallel-group, open-labelled, physician-blinded, randomised controlled trial was conducted in January-June 2013 and followed up for 6- and 12-months in primary care settings in Hong Kong. Patients newly diagnosed with grade 1 hypertension (aged 40-70years) who had no concomitant medical conditions requiring dietary modifications were consecutively recruited. Subjects were randomised to standard education (usual care) (n=275), or usual care plus dietitian-delivered DASH-based dietary counselling in a single one-to-one session (intervention) (n=281). Primary outcomes were the changes in estimated 10-year CV risk. RESULTS: Outcome data were available for 504 (90.6%) and 485 (87.2%) patients at 6 and 12months, respectively. There was no difference in the reduction of 10-year CV risk between the two groups at 6months (-0.13%, 95% confidence interval [95% CI] -0.50% to 0.23%, p=0.477) and 12months (-0.08%, 95% CI -0.33% to 0.18%, p=0.568). Multivariate regression analyses showed that male subjects, younger patients, current smokers, subjects with lower educational level, and those who dined out for main meals for ≥4 times in a typical week were significantly associated with no improvements in CV risk. CONCLUSIONS: The findings may not support automatic referral of newly diagnosed grade 1 hypertensive patients for further one-to-one dietitian counselling on top of primary care physician's usual care. Patients with those risk factors identified should receive more clinical attention to reduce their CV risk. CLINICAL TRIAL REGISTRATION: ChiCTR-TRC-13003014 (http://www.chictr.org.cn/enindex.aspx).

The adoption of the Reference Framework for diabetes care among primary care physicians in primary care settings: A cross-sectional study.

The prevalence of diabetes mellitus has been increasing both globally and locally. Primary care physicians (PCPs) are in a privileged position to provide first contact and continuing care for diabetic patients. A territory-wide Reference Framework for Diabetes Care for Adults has been released by the Hong Kong Primary Care Office in 2010, with the aim to further enhance evidence-based and high quality care for diabetes in the primary care setting through wide adoption of the Reference Framework.A valid questionnaire survey was conducted among PCPs to evaluate the levels of, and the factors associated with, their adoption of the Reference Framework.A total of 414 completed surveys were received with the response rate of 13.0%. The average adoption score was 3.29 (SD 0.51) out of 4. Approximately 70% of PCPs highly adopted the Reference Framework in their routine practice. Binary logistic regression analysis showed that the PCPs perceptions on the inclusion of sufficient local information (adjusted odds ratio [aOR] = 4.748, 95%CI 1.597-14.115, P = 0.005) and reduction of professional autonomy of PCPs (aOR = 1.859, 95%CI 1.013-3.411, P = 0.045) were more likely to influence their adoption level of the Reference Framework for diabetes care in daily practices.The overall level of guideline adoption was found to be relatively high among PCPs for adult diabetes in primary care settings. The adoption barriers identified in this study should be addressed in the continuous updating of the Reference Framework. Strategies need to be considered to enhance the guideline adoption and implementation capacity.

Dietary counselling has no effect on cardiovascular risk factors among Chinese Grade 1 hypertensive patients: a randomized controlled trial.

AIMS: To evaluate the effectiveness of Dietary Approaches to Stop Hypertension (DASH) by one-off dietary counselling on reducing cardiovascular risk factors among Chinese Grade 1 hypertensive patients in primary care. METHODS AND RESULTS: A parallel-group, randomized controlled trial (ChiCTR-TRC-13003014) was conducted among patients (40-70 years old) newly diagnosed with Grade 1 hypertension in primary care settings in Hong Kong. Subjects were randomized to usual care (standard education, control) (n = 275), or usual care plus DASH-based dietary counselling (intervention) (n = 281). The study endpoints included blood pressure (BP), lipid profile, and body mass index (BMI) at 6- and 12-months. Outcome data were available for 504 (90.6%) and 485 (87.2%) patients at 6 and 12 months, respectively. Blood pressure levels reduced in both groups at follow-ups. However, the intervention group did not show a significantly greater reduction in either systolic BP (-0.7 mmHg, 95%CI -3.0-1.5 at 6-month; -0.1 mmHg, 95%CI -2.4-2.2 at 12-month) or diastolic BP (-1.0 mmHg, 95%CI -2.7-0.7 at 6-month; -1.1 mmHg, 95%CI -2.9-0.6 at 12-month), when compared with the control group. The improvements in lipid profile and BMI were observed among all subjects, yet no significant differences were detected between intervention and control groups. CONCLUSION: The DASH diet by one-off dietitian counselling which resembled the common primary care practice might confer no added long-term benefits on top of physician's usual care in optimizing cardiovascular risk factors. Physicians may still practice standard usual care, yet further explorations on different DASH delivery models are warranted to inform best clinical practice.

Factors associated with grade 1 hypertension: implications for hypertension care based on the Dietary Approaches to Stop Hypertension (DASH) in primary care settings.

BACKGROUND: A Reference Framework for Hypertension Care was recently developed by Hong Kong government to emphasise the importance of primary care for subjects with high blood pressure (BP). The Dietary Approaches to Stop Hypertension (DASH) interventional regime was recommended for patients aged 40-70 years with grade 1 hypertension (having systolic BP of 140-159 mmHg and/or diastolic BP of 90-99 mmHg). This study explored factors associated with grade 1 hypertension among subjects screened in primary care settings. METHODS: The study sample consisted of community dwellers (N = 10,693) enrolled in a primary care programme in which participants overall had similar characteristics when compared to the Hong Kong population census. Invitation phone calls were given by trained researchers to a randomly selected subjects (N = 2,673, [50% of total subjects aged 40-70 years]) between January and June 2013. BP and body mass index (BMI) were measured by trained clinical professionals according to a standard protocol. Interviewer-administered survey questionnaires were used to collect self-report information on socio-demographics, family history, and lifestyle characteristics. Multiple logistic regression analysis was performed to explore factors associated with grade 1 hypertension. Adjusted odds ratios (aORs) were estimated with 95% confidence intervals (CI). RESULTS: A total of 679 out of 2,673 subjects agreed to participate in the screening and completed the baseline assessment (100% completion rate), among which, 320 subjects (47.1%, [320/679]) were grade 1 hypertensive. Unhealthy diet (aOR = 2.19, 95%CI 1.04-4.62), irregular meals (aOR = 1.47, 95%CI 1.11-1.95), BMI >27.5 kg/m(2) (aOR = 1.87, 95%CI 1.53-2.27), duration of cigarette smoking (aOR = 1.83 per year), increased daily cigarette consumption (aOR =1.59 per pack [20 cigarettes per pack]), duration of alcohol drinking (aOR = 1.65 per year), and higher frequency of weekly binge drinking (aOR = 1.87 per occasion) were independently associated with grade 1 hypertension. The increase in the number of risk factors combined significantly correlated with higher predicted probability of grade 1 hypertension. CONCLUSIONS: Dietary-intake factors were significantly associated with grade 1 hypertension, echoing the recommendation in the Reference Framework on incorporating dietary-related intervention based on the DASH approach for hypertension care in primary care settings. The association between aggregate risk factors and grade 1 hypertension should also be taken into consideration in long-term preventive strategy.

The incidence of cancer deaths among hypertensive patients in a large Chinese population: a cohort study.

Current evidence is mixed regarding the association between antihypertensive prescriptions and cancer mortality. We evaluated this association in a large Chinese hypertensive population. We followed for five years all patients who were prescribed their first-ever antihypertensive agents between 2001 and 2005 in a public healthcare sector of Hong Kong. The association between antihypertensive drug class and cancer mortality was evaluated by Cox proportional hazard models with propensity score matching. Age, gender, socioeconomic status, service settings, district of residence, proportion of days covered reflecting medication adherence, and the number of comorbidities were adjusted. From 217,910 eligible patients, 9500 (4.4%) died from cancer within five years after their first-ever antihypertensive prescription. Most cancer deaths occurred in the digestive (38.9%) and respiratory system (30.4%); the breast (6.2%); and the lympho-hematopoietic tissues (5.3%). The proportion of patients who died from cancer was the highest in the calcium channel blocker (CCB) group (6.5%), followed by thiazide diuretics (4.4%), angiotensin converting enzyme inhibitors (4.2%) and ß-blockers (2.6%). When compared with ß-blockers, patients prescribed CCBs (Adjusted Hazard Ratio [AHR]=1.406, 95% C.I. 1.334-1.482, p<0.001) were more likely to die from cancer. Thiazide users were also more likely to suffer from cancer deaths (AHR=1.364, 95% C.I. 1.255-1.483, p<0.001), but became insignificant in stratified analysis. The association between cancer mortality and use of CCB, and perhaps thaizide, may alert physicians to the need for more meticulous and comprehensive care of these patients in clinical practice. We recommend prospective studies to evaluate cause-and-effect relationships of these associations.

Cardiovascular mortality in hypertensive patients newly prescribed perindopril vs. lisinopril: a 5-year cohort study of 15,622 Chinese subjects.

BACKGROUND: Perindopril and lisinopril are two common ACE inhibitors prescribed for management of hypertension. Few studies have evaluated their comparative effectiveness to reduce mortality. This study compared the all-cause and cardiovascular related mortality among patients newly prescribed ACE inhibitors. METHODS: All adult patients newly prescribed perindopril or lisinopril from 2001 to 2005 in all public clinics or hospitals in Hong Kong were retrospectively evaluated, and followed up until 2010. Patients prescribed the ACE inhibitors for less than a month were excluded. The all-cause mortality and cardiovascular-specific (i.e. coronary heart disease, heart failure and stroke) mortality were compared. Cox proportional hazard regression model was used to assess the mortality, controlling for age, sex, socioeconomic status, patient types, the presence of comorbidities, and medication adherence as measured by the proportion of days covered. An additional model using propensity scores was performed to minimize indication bias. RESULTS: A total of 15,622 patients were included in this study, in which 6910 were perindopril users and 8712 lisinopril users. The all-cause mortality (22.2% vs. 20.0%, p<0.005) and cardiovascular mortality (6.5% vs. 5.6%, p<0.005) were higher among lisinopril users than perindopril users. From regression analyses, lisinopril users were 1.09-fold (95% C.I. 1.01-1.16) and 1.18-fold (95% C.I. 1.02-1.35) more likely to die from any-cause and cardiovascular diseases, respectively. Age-stratified analysis showed that this significant difference was observed only among patients aged >70 years. The additional models controlled for propensity scores yielded comparable results. CONCLUSIONS: The long-term all-cause and cardiovascular related mortality rates of lisinopril users was significantly different from those of perindopril users. These findings showed that intra-class variation on mortality exists among ACE inhibitors among those aged 70 years or older. Future studies should consider a longer, large-scale randomized controlled trial to compare the effectiveness between different medications in the ACEI class, especially among the elderly.

The effectiveness of metoprolol versus atenolol on prevention of all-cause and cardiovascular mortality in a large Chinese population: a cohort study.

BACKGROUND: Existing trials almost exclusively used atenolol to represent the entire ß-blocker class, and it is unknown whether there are intra-class differences. We compared the incidence of all-cause and cardiovascular mortality, blood pressure (BP) control and adherence levels between patients newly prescribed atenolol vs. metoprolol tartrate. METHODS: This cohort study included all public, clinical settings in Hong Kong between 2001 and 2005, followed up till 2010. We compared outcomes between 22,479 new atenolol users and 29,972 new metoprolol tartrate users. Cox proportional hazard regression analysis was used to evaluate the difference in mortality between drugs. Binary logistic regression analyses were used to compare the BP control rates and adherence levels. RESULTS: 7.0% and 13.1% died of any causes among atenolol and metoprolol users, respectively (p<0.005). The incidence of cardiovascular mortality among atenolol users was lower than metoprolol users (1.4% vs. 3.7%, p<0.001). When compared with atenolol users, metoprolol users were 1.13-fold (95% C.I. 1.06-1.20) and 1.56-fold (95% C.I. 1.27-1.90), respectively, more likely to experience all-cause and cardiovascular mortality; less likely to be drug adherent (adjusted relative risk [aRR]: 0.95, 95% C.I. 0.90-0.99, p=0.013); and less likely to achieve optimal overall BP control (aRR 0.94, 95% C.I. 0.90-0.99, p=0.023) and diastolic BP control (aRR 0.86, 95% C.I. 0.77-0.97, p=0.013). CONCLUSIONS: These findings imply an intra-class difference for beta-blockers when used as first-line antihypertensive prescriptions in real-life clinical settings which inform future clinical guidelines. More outcome studies on the effectiveness of different subtypes within other major antihypertensive drug classes are warranted.

Exposure to air pollutants and mortality in hypertensive patients according to demography: a 10 year case-crossover study.

This study evaluated whether short term exposures to NO2, O3, particulate matter <10 mm in diameter (PM10) were associated with higher risk of mortality. A total of 223,287 hypertensive patients attended public health-care services and newly prescribed at least 1 antihypertensive agent were followed-up for up to 5 years. A time-stratified, bi-directional case-crossover design was adopted. For all-cause mortality, significant positive associations were observed for NO2 and PM10 at lag 0-3 days per 10 µg/m(3) increase in concentration (excess risks 1.187%-2.501%). Significant positive associations were found for O3 at lag 1 and 2 days and the excess risks were 1.654% and 1.207%, respectively. We found similarly positive associations between these pollutants and respiratory disease mortality. These results were significant among those aged ≥65 years and in cold seasons only. Older hypertensive patients are susceptible to all-cause and respiratory disease-specific deaths from these air pollutants in cold weather.

Comparative effectiveness of dipeptidyl peptidase-4 (DPP-4) inhibitors and human glucagon-like peptide-1 (GLP-1) analogue as add-on therapies to sulphonylurea among diabetes patients in the Asia-Pacific region: a systematic review.

The prevalence of diabetes mellitus is rising globally, and it induces a substantial public health burden to the healthcare systems. Its optimal control is one of the most significant challenges faced by physicians and policy-makers. Whereas some of the established oral hypoglycaemic drug classes like biguanide, sulphonylureas, thiazolidinediones have been extensively used, the newer agents like dipeptidyl peptidase-4 (DPP-4) inhibitors and the human glucagon-like peptide-1 (GLP-1) analogues have recently emerged as suitable options due to their similar efficacy and favorable side effect profiles. These agents are widely recognized alternatives to the traditional oral hypoglycaemic agents or insulin, especially in conditions where they are contraindicated or unacceptable to patients. Many studies which evaluated their clinical effects, either alone or as add-on agents, were conducted in Western countries. There exist few reviews on their effectiveness in the Asia-Pacific region. The purpose of this systematic review is to address the comparative effectiveness of these new classes of medications as add-on therapies to sulphonylurea drugs among diabetic patients in the Asia-Pacific countries. We conducted a thorough literature search of the MEDLINE and EMBASE from the inception of these databases to August 2013, supplemented by an additional manual search using reference lists from research studies, meta-analyses and review articles as retrieved by the electronic databases. A total of nine randomized controlled trials were identified and described in this article. It was found that DPP-4 inhibitors and GLP-1 analogues were in general effective as add-on therapies to existing sulphonylurea therapies, achieving HbA1c reductions by a magnitude of 0.59-0.90% and 0.77-1.62%, respectively. Few adverse events including hypoglycaemic attacks were reported. Therefore, these two new drug classes represent novel therapies with great potential to be major therapeutic options. Future larger-scale research should be conducted among other Asia-Pacific region to evaluate their efficacy in other ethnic groups.

Effectiveness of a pharmacist-led drug counseling on enhancing antihypertensive adherence and blood pressure control: a randomized controlled trial.

Adherence to antihypertensive medications represents a crucial success factor for optimal blood pressure (BP) control in clinical practice. This study evaluated whether an additional pharmacist-led medication counseling could achieve better optimal BP control and enhance compliance. In a designated family clinic in a region with similar resident characteristics to Hong Kong, patients taking ≥ one antihypertensive agent with suboptimal compliance were randomly allocated to a brief 3-minute drug advice (control; n = 161) or pharmacist counseling (intervention; n = 113). The two groups were compared by repeated measure ANOVA at 3-months and 6-months with BP control and medication compliance as outcome variables, respectively. The proportions of patients having optimal compliance increased from 0% to 41.1% at 3 months and 61.9% at 6 months (P < 0.001). The proportion of patients having optimal BP control improved from 64.1% at baseline to 74.0% at 3 months and 74.5% at 6 months (P = 0.023). There were no significant differences between the two groups in the changes of BP control and compliance levels. This study implied that even a brief 3-minute drug advice might lead to improved BP levels among patients on antihypertensive medications in general practice, but did not demonstrate additional effects by pharmacist counseling.