Association Between Improvement in Cardiovascular Risk Profile and Changes in Sickness Absence: Results of the ICARIA Study.

INTRODUCTION AND OBJECTIVES: The purpose of this study was to investigate whether changes in cardiovascular risk (CVR) are associated with the length and cost of sickness absence. METHODS: A prospective cohort of 179 186 participants was evaluated. Each participant's CVR (SCORE) was assessed on 2 consecutive medical examinations, approximately 1 year apart (365 ± 90 days). Cardiovascular risk was categorized as < 4% or ≥ 4%, and participants were divided into 4 groups according to changes in their risk between the 2 assessments. After the second CVR estimate, a 1-year follow-up was carried out to assess sickness absence. Differences between the 4 groups in terms of the total count of sickness absence days during the follow-up period were tested using Poisson regression models. RESULTS: After adjustment for covariates, participants who showed an improvement in CVR had a lower count of sickness absence days compared with both those who showed a worsening in risk and those who remained stable at ≥ 4% (RR, 0.91; 95%CI, 0.84-0.98). In comparison with participants whose CVR did not improve, more of the participants whose risk did improve had quit smoking (+17.2%; P < .001), and had controlled their blood pressure (+26.0%, P < .001), total cholesterol (+9.3%; P < .001), low-density lipoprotein cholesterol (+14.9%; P < .001), and triglyceride levels (+14.6%; P < .001). CONCLUSIONS: Our results suggest that an improvement in CVR profile is accompanied by a decrease in sickness absence during a 1-year follow-up.

Ambulatory and home blood pressure monitoring in people with chronic kidney disease. Time to abandon clinic blood pressure measurements?

PURPOSE OF REVIEW: There is currently much interest in the usefulness of out-of-office blood pressure (BP) for the diagnosis and the management of hypertension in patients with chronic kidney disease (CKD). This is not to suggest that office BP should be disregarded and we will take the opportunity to stress how it could be improved. RECENT FINDINGS: Arterial hypertension constitutes a very relevant cardiovascular and renal risk factor in patients with CKD. To assess this risk, the best tool is ambulatory BP monitoring (ABPM), as it allows the detection of masked hypertension, masked untreated hypertension (MUCH) and nondipping pattern, conditions known to be associated with target organ damage that further contributes to increased risk to the patient. Home BP monitoring (HBPM) cannot fully substitute for ABPM because of the absence of BP data during the night. Despite this, there are good reasons to use HBPM systematically in patients with CKD during long-term follow-up. SUMMARY: In the individual patient office, BP may significantly differ from out-of-office measurements. This shortcoming can be attenuated by repeated measurement at every visit, but even if office BP is considered normal, it is still highly desirable to obtain out-of-office data.

European Society of Hypertension practice guidelines for ambulatory blood pressure monitoring.

Given the increasing use of ambulatory blood pressure monitoring (ABPM) in both clinical practice and hypertension research, a group of scientists, participating in the European Society of Hypertension Working Group on blood pressure monitoring and cardiovascular variability, in year 2013 published a comprehensive position paper dealing with all aspects of the technique, based on the available scientific evidence for ABPM. The present work represents an updated schematic summary of the most important aspects related to the use of ABPM in daily practice, and is aimed at providing recommendations for proper use of this technique in a clinical setting by both specialists and practicing physicians. The present article details the requirements and the methodological issues to be addressed for using ABPM in clinical practice, The clinical indications for ABPM suggested by the available studies, among which white-coat phenomena, masked hypertension, and nocturnal hypertension, are outlined in detail, and the place of home measurement of blood pressure in relation to ABPM is discussed. The role of ABPM in pharmacological, epidemiological, and clinical research is also briefly mentioned. Finally, the implementation of ABPM in practice is considered in relation to the situation of different countries with regard to the reimbursement and the availability of ABPM in primary care practices, hospital clinics, and pharmacies.

Spanish Society of Nephrology document on KDIGO guidelines for the assessment and treatment of chronic kidney disease.

The new Kidney Disease: Improving Global Outcomes (KDIGO) international guidelines on chronic kidney disease (CKD) and the management of blood pressure (BP) in CKD patients are an update of the corresponding 2002 and 2004 KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines. The documents aim to provide updated guidelines on the assessment, management and treatment of patients with CKD. The first guidelines retain the 2002 definition of CKD but present an improved prognosis classification. Furthermore, concepts about prognosis of CKD, recommendations for management of patients, and criteria for referral to the nephrologist have been updated. The second guideline retains the <130/80 mm Hg-goal for management of BP in patients with CKD presenting increased albuminuria or proteinuria (albumin-to-creatinine ratio 30-300 mg/g, and >300 mg/g, respectively) but recommends a less-strict goal of <140/90 mm Hg in patients with normoalbuminuria. The development of the guidelines followed a predetermined process in which the evidence available was reviewed and assessed. Recommendations on management and treatment are based on the systematic review of relevant studies. The GRADE system (Grading of Recommendations Assessment, Development and Evaluation) was used to assess the quality of evidence and issue the grade of recommendation. Areas of uncertainty are also discussed for the different aspects addressed.

Influence of high cardiovascular risk in asymptomatic people on the duration and cost of sick leave: results of the ICARIA study.

AIMS: We investigated the potential influence of a moderate-to-high cardiovascular (CV) risk (CVR) (defined as a Systematic COronary Risk Evaluation model, or SCORE ≥ 4%), in the absence of an established CV disease, on the duration and cost of CV and non-CV sick leave (SL) resulting from common and occupational accidents or diseases. METHODS AND RESULTS: We conducted a prospective cohort study on 690 135 workers with a 1-year follow-up and examined CV- and non-CV-related SL episodes. To obtain baseline values, CVR factors were initially assessed at the beginning of the year during routine medical examination. The CVR was calculated with the SCORE charts for all subjects. Moderate-to-high CVR was defined as SCORE ≥ 4%. A baseline SCORE ≥ 4% was associated with a higher risk for long-term CV and non-CV SL, as revealed by follow-up assessment. This translated into an increased cost, estimated at €5 801 464.18 per year. Furthermore, pharmacological treatment for hypertension or hyperlipidaemia was significantly associated with longer SL duration. CONCLUSION: Moderate-to-high CVR in asymptomatic subjects was significantly associated with the duration and cost of CV and non-CV SL. These results constitute the first body of evidence that the SCORE charts can be used to identify people with a non-established CV disease, which might ultimately translate into more lost workdays and therefore increased cost for society.

Review of blood pressure control rates and outcomes.

Despite the high prevalence of hypertension and documented benefits of blood pressure (BP) control, >40% of patients with hypertension are not controlled. A majority of uncontrolled hypertensive patients receive two or more antihypertensive drugs. The current review examined the relationship between antihypertensive combination drug therapy, achievement of goal BP, and cardiovascular (CV) outcomes. Articles were selected from a PubMed search using a prespecified search strategy. Randomized, controlled clinical trials of adult human subjects published in English between January 1991 and January 2013 were included. From 2319 identified articles, 28 met inclusion criteria and contained a total of 226,877 subjects. There were seven placebo-controlled studies and 21 treatment comparator and combination therapy studies. The studies included in this review reported a positive association between the degree of BP lowering, number of medications, and CV outcomes. As combination therapy became available, it was increasingly utilized in clinical trials and enabled an increased proportion of patients to achieve a prespecified BP target. Adverse events with monotherapy and combination therapy were as anticipated for the specific classes of antihypertensive therapy. Although many patients reach BP goal, combination antihypertensive therapy is often needed to reach BP goal. Effective BP lowering has been shown to result in improvements in CV outcomes.

European Society of Hypertension position paper on ambulatory blood pressure monitoring.

Ambulatory blood pressure monitoring (ABPM) is being used increasingly in both clinical practice and hypertension research. Although there are many guidelines that emphasize the indications for ABPM, there is no comprehensive guideline dealing with all aspects of the technique. It was agreed at a consensus meeting on ABPM in Milan in 2011 that the 34 attendees should prepare a comprehensive position paper on the scientific evidence for ABPM.This position paper considers the historical background, the advantages and limitations of ABPM, the threshold levels for practice, and the cost-effectiveness of the technique. It examines the need for selecting an appropriate device, the accuracy of devices, the additional information and indices that ABPM devices may provide, and the software requirements.At a practical level, the paper details the requirements for using ABPM in clinical practice, editing considerations, the number of measurements required, and the circumstances, such as obesity and arrhythmias, when particular care needs to be taken when using ABPM.The clinical indications for ABPM, among which white-coat phenomena, masked hypertension, and nocturnal hypertension appear to be prominent, are outlined in detail along with special considerations that apply in certain clinical circumstances, such as childhood, the elderly and pregnancy, and in cardiovascular illness, examples being stroke and chronic renal disease, and the place of home measurement of blood pressure in relation to ABPM is appraised.The role of ABPM in research circumstances, such as pharmacological trials and in the prediction of outcome in epidemiological studies is examined and finally the implementation of ABPM in practice is considered in relation to the issue of reimbursement in different countries, the provision of the technique by primary care practices, hospital clinics and pharmacies, and the growing role of registries of ABPM in many countries.

Prevention of cardiovascular disease guided by total risk estimations--challenges and opportunities for practical implementation: highlights of a CardioVascular Clinical Trialists (CVCT) Workshop of the ESC Working Group on CardioVascular Pharmacology and Drug Therapy.

This paper presents a summary of the potential practical and economic barriers to implementation of primary prevention of cardiovascular disease guided by total cardiovascular risk estimations in the general population. It also reviews various possible solutions to overcome these barriers. The report is based on discussion among experts in the area at a special CardioVascular Clinical Trialists workshop organized by the European Society of Cardiology Working Group on Cardiovascular Pharmacology and Drug Therapy that took place in September 2009. It includes a review of the evidence in favour of the "treat-to-target" paradigm, as well as potential difficulties with this approach, including the multiple pathological processes present in high-risk patients that may not be adequately addressed by this strategy. The risk-guided therapy approach requires careful definitions of cardiovascular risk and consideration of clinical endpoints as well as the differences between trial and "real-world" populations. Cost-effectiveness presents another issue in scenarios of finite healthcare resources, as does the difficulty of documenting guideline uptake and effectiveness in the primary care setting, where early modification of risk factors may be more beneficial than later attempts to manage established disease. The key to guideline implementation is to improve the quality of risk assessment and demonstrate the association between risk factors, intervention, and reduced event rates. In the future, this may be made possible by means of automated data entry and various other measures. In conclusion, opportunities exist to increase guideline implementation in the primary care setting, with potential benefits for both the general population and healthcare resources.

Telmisartan for the management of patients at high cardiovascular risk.

BACKGROUND: Cardiovascular disease (CVD) places a significant burden on healthcare providers. High blood pressure (BP) is the single most prevalent risk factor for CVD worldwide and is responsible for more deaths than any other risk factor. 'Cardiovascular (CV) high-risk patients' make up the broad cross-section of patients in the middle of the risk spectrum for CVD progression that is referred to as the CV continuum and includes those with atherothrombotic disease, those with target organ damage associated with type 2 diabetes and those with multiple risk factors. Angiotensin II is involved in CVD progression at every stage of the CV continuum, making the renin-angiotensin system a rational target for pharmacologic intervention. Angiotensin II receptor blockers (ARBs) offer a better tolerated alternative to angiotensin converting enzyme inhibitors, with greater long-term adherence. The ARB telmisartan recently received an indication for CV prevention. SCOPE: A PubMed literature search was conducted to identify evidence on the use of telmisartan for preventing CV events. FINDINGS: Telmisartan has a favourable safety and tolerability profile, and has demonstrated efficacious and long-lasting 24-hour BP reductions, whether as monotherapy or in combination with hydrochlorothiazide or amlodipine. In the largest CV prevention trial program undertaken with an ARB (the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial; ONTARGET), telmisartan 80 mg/day alone was as effective as ramipril in reducing the composite primary endpoint of CV mortality, non-fatal myocardial infarction, non-fatal stroke and hospitalization for heart failure in CV high-risk patients. However, patients were significantly more likely to adhere to treatment with telmisartan than ramipril due to its better tolerability. CONCLUSION: To date, telmisartan is the only ARB indicated to reduce CV morbidity in a broad CV high-risk population.

Public health value of fixed-dose combinations in hypertension.

It is well documented that reducing blood pressure (BP) in hypertensive individuals reduces the risk of cardiovascular (CV) events. Despite this, many patients with hypertension remain untreated or inadequately treated, and fail to reach the recommended BP goals. Suboptimal BP control, whilst arising from multiple causes, is often due to poor patient compliance and/or persistence, and results in a significant health and economic burden on society. The use of fixed-dose combinations (FDCs) for the treatment of hypertension has the potential to increase patient compliance and persistence. When compared with antihypertensive monotherapies, FDCs may also offer equivalent or better efficacy, and the same or improved tolerability. As a result, FDCs have the potential to reduce both the CV event rates and the non-drug healthcare costs associated with hypertension. When FDCs are adopted for the treatment of hypertension, issues relating to copayment, formulary restrictions and therapeutic reference pricing must be addressed.

Left ventricular hypertrophy and clinical outcomes in hypertensive patients.

The prevalence of left ventricular hypertrophy (LVH) rises with severity of hypertension (HT), age, and obesity. Its prevalence ranges from 20% in mildly hypertensive patients to almost 100% in those with severe or complicated HT. However, the diagnosis of LVH is not straightforward, and the definitions and criteria used in clinical studies lack consistency. While many factors play a role in the onset and progression of LVH, blood pressure (BP) is recognized as a central factor. Twenty-four-hour BP measurements are more closely related to LVH than conventional BP readings taken in the clinician's office. Increased renin-angiotensin system (RAS) activity also plays an important role in the development of LVH, and various studies show a correlation between plasma renin activity and left ventricular mass (LVM). LVH is a recognized marker of HT-related target organ damage, and a strong and independent risk factor for adverse cardiovascular (CV) outcomes. CV risk increases with increasing LVM, and decreases with regression of LVH in response to antihypertensive treatment. Therefore the detection, prevention, and reversal of LVH are important goals in HT management. Most antihypertensive drugs can attenuate BP and LVH. However, each drug class may induce LVH regression to a different extent and these extents seldom correlate with the degree of BP reduction achieved. Data from the few large comparative studies in this area suggest that certain classes of antihypertensive drugs and/or their combinations are more effective than others. In particular, calcium channel blockers and drugs that target the RAS, such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), appear to have a specific effect on LVH, independent of BP reduction. Guidelines, therefore, have recommended these drug classes for the treatment of hypertensive patients with LVH.

Advantages of new cardiovascular risk-assessment strategies in high-risk patients with hypertension.

BACKGROUND: Accurate assessment of cardiovascular disease (CVD) risk in patients with hypertension is important when planning appropriate treatment of modifiable risk factors. The causes of CVD are multifactorial, and hypertension seldom exists as an isolated risk factor. Classic models of risk assessment are more accurate than a simple counting of risk factors, but they are not generalizable to all populations. In addition, the risk associated with hypertension is graded, continuous, and independent of other risk factors, and this is not reflected in classic models of risk assessment. OBJECTIVE: This article is intended to review both classic and newer models of CVD risk assessment. METHODS: MEDLINE was searched for articles published between 1990 and 2005 that contained the terms cardiovascular disease, hypertension, or risk assessment. Articles describing major clinical trials, new data about cardiovascular risk, or global risk stratification were selected for review. RESULTS: Some patients at high long-term risk for CVD events (eg, patients aged <50 years with multiple risk factors) may go untreated because they do not meet the absolute risk-intervention threshold of 20% risk over 10 years with the classic model. Recognition of the limitations of classic risk-assessment models led to new guidelines, particularly those of the European Society of Hypertension-European Society of Cardiology. These guidelines view hypertension as one of many risk and disease factors that require treatment to decrease risk. These newer guidelines include a more comprehensive range of risk factors and more finely graded blood pressure ranges to stratify patients by degree of risk. Whether they accurately predict CVD risk in most populations is not known. Evidence from the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) study, which stratified patients by several risk and disease factors, highlights the predictive value of some newer CVD risk assessments. CONCLUSION: Modern risk assessments, which include blood pressure along with a wide array of modifiable risk factors, may be more accurate than classic models for CVD risk prediction.

An update of irbesartan and renin-angiotensin system blockade in diabetic nephropathy.

Type 2 diabetes is a chief cause of pathologies such as cardiovascular disease, nephropathy and retinopathy, and its prevalence is increasing worldwide. Development of renal disease can be slowed by tight glycaemic control and treatment of associated hypertension with angiotensin-converting enzyme inhibition, as The Diabetes Control and Complications Trial and the UK Prospective Diabetes Study have demonstrated. Recent clinical trials have supported the use of angiotensin II receptor antagonists in the treatment of diabetic nephropathy, resulting in the approval of new therapeutic indications in the US and Europe. The main goal of this review is to demonstrate how results from the Programme for Irbesartan Mortality and Morbidity Evaluation and other recent studies, based on the effects of renin-angiotensin system blockade, can be appropriate in clinical practice, thus displaying benefits of irbesartan therapy at any stage of renal disease in diabetics.

On the importance of estimating renal function for cardiovascular risk assessment.

Microalbuminuria has been shown to predict an increased probability of suffering a cardiovascular event or death. It has also been shown to be decreased by antihypertensive therapy and in particular by drugs counteracting the effects of angiotensin II. In this issue of Journal of Hypertension data, from the LIFE study, are reported indicating for the first time that a decrease in urinary albumin excretion rate is accompanied by a significant decrease in cardiovascular events. This evidence is of great relevance because it constitutes the first evidence showing that regression of an intermediate end-point, microalbuminuria, ensures a better cardiovascular prognosis.