Supporting the Development of Evidence-Informed Policy Options: An Economic Evaluation of Hypertension Management in Ghana.

OBJECTIVES: Universal healthcare coverage in low- and middle-income countries requires challenging resource allocation decisions. Health technology assessment is one important tool to support such decision making. The International Decision Support Initiative worked with the Ghanaian Ministry of Health to strengthen health technology assessment capacity building, identifying hypertension as a priority topic area for a relevant case study. METHODS: Based on guidance from a national technical working group of researchers and policy makers, an economic evaluation and budget impact analysis were undertaken for the main antihypertensive medicines used for uncomplicated, essential hypertension. The analysis aimed to address specific policy questions relevant to the National Health Insurance Scheme. RESULTS: The evaluation found that first-line management of essential hypertension with diuretics has an incremental cost per disability-adjusted life-year avoided of GH¢ 276 ($179 in 2017, 4% of gross national income per capita) compared with no treatment. Calcium channel blockers were more effective than diuretics but at a higher incremental cost: GH¢ 11 061 per disability-adjusted life-year avoided ($7189 in 2017; 160% of gross national income per capita). Diuretics provide better health outcomes at a lower cost than angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or beta-blockers. Budget impact analysis highlighted the potential for cost saving through enhanced price negotiation and increased use of better-value drugs. We also illustrate how savings could be reinvested to improve population health. CONCLUSIONS: Economic evaluation enabled decision makers to assess hypertension medicines in a Ghanaian context and estimate the impact of using such evidence to change policy. This study contributes to addressing challenges associated with the drive for universal healthcare coverage in the context of constrained budgets.

Early and Quantitative Assessment of Myocardial Deformation in Essential Hypertension Patients by Using Cardiovascular Magnetic Resonance Feature Tracking.

The aims of the study were to identify subclinical global systolic function abnormalities and evaluate influencing factors associated with left ventricular (LV) strain parameters in hypertensive subjects using cardiovascular magnetic resonance imaging feature tracking (CMR-FT). The study enrolled 57 patients with essential hypertension (mean age: 43.04 ± 10.90 years; 35 males) and 26 healthy volunteers (mean age: 38.69 ± 10.44 years; 11 males) who underwent clinical evaluation and CMR examination. Compared with controls, hypertensive patients had significantly impaired myocardial strain values while ejection fraction (EF) did not differ. After multivariate regression analyses adjustment for confounders, the global radial strains (GRS) was independently associated with the mean arterial pressure (MAP) and left ventricular mass index (LVMI) (ß = -0.219, p = 0.009 and ß = -0.224, p = 0.015, respectively; Adjusted R2 = 0.4); the global circumferential strains (GCS) was also independently associated with the MAP and LVMI (ß = 0.084, p = 0.002 and ß = 0.073, p = 0.01, respectively; Adjusted R2 = 0.439); the global longitudinal strains (GLS) was independently associated with the Age and MAP (ß = 0.065, p = 0.021 and ß = 0.077, p = 0.009, respectively; Adjusted R2 = 0.289). Myocardial strain can early detect the myocardial damage and may be an appropriate target for preventive strategies before abnormalities of EF.

Fibrinogen-erythrocyte binding and hemorheology measurements in the assessment of essential arterial hypertension patients.

Some studies have reported a positive association between plasma fibrinogen levels, erythrocyte aggregation and essential arterial hypertension (EAH). The aim of this study was to understand how the interaction between fibrinogen and its erythrocyte membrane receptor is altered in EAH. EAH patients (n = 31) and healthy blood donors (n = 65) were enrolled in the study. EAH patients were therapeutically controlled for the disease, presenting a systolic blood pressure between 108 and 180 mmHg and a diastolic blood pressure between 66 and 123 mmHg. Clinical evaluation included blood pressure monitoring, electrocardiography, echocardiography and blood cell count. The hemorheological parameters were also analyzed. Fibrinogen-erythrocyte binding force and frequency were evaluated quantitatively, at the single-molecule level, using atomic force microscopy (AFM). Changes in erythrocyte elasticity were also evaluated. Force spectroscopy data showed that the average fibrinogen-erythrocyte binding forces increase from 40.4 ± 3.0 pN in healthy donors to 73.8 ± 8.1 pN in patients with EAH, despite a lower binding frequency for patients compared to the control group (7.9 ± 1.6% vs. 27.6 ± 4.2%, respectively). Elasticity studies revealed an increase of erythrocyte stiffness in the patients. The stronger fibrinogen binding to erythrocytes from EAH patients and alteration in cell elasticity may lead to changes in the whole blood flow. The patients' altered hemorheological parameters may also contribute to these blood flow perturbations. The transient bridging of two erythrocytes, by the simultaneous binding of fibrinogen to both of them, promoting erythrocyte aggregation, could represent an important cardiovascular risk factor.

Prevalence and real-world assessment of central aortic blood pressure in adult patients with essential hypertension uncontrolled on single anti-hypertensive agents.

OBJECTIVE: To assess the prevalence of high central aortic pressure (CAP) in Indian patients with uncontrolled essential hypertension while on anti-hypertensive monotherapy. Also, to determine correlation between brachial blood pressure (BBP) and CAP, and ascertain if it is impacted by anti-hypertensive drug class and patients' age. METHODS: In this real-world, observational, prospective study, patients (30-70 years) with uncontrolled BBP (systolic BP [SBP] ≥140 mmHg or diastolic BP [DBP] ≥90 mmHg) were enrolled. Treatment was adjusted at Visit 1 (baseline), based on BBP and at treating physicians' discretion. Primary endpoint was proportion of patients with uncontrolled central aortic SBP (>125 mmHg) at baseline. Secondary endpoints were comparison of BBP and CAP across drugs classes and age groups at baseline and Visit 2 (End-of-study, ∼8 weeks post-baseline), and proportion of patients with uncontrolled central SBP at end-of-study. RESULTS: Of 2030 patients screened, 1949 patients reported at baseline and 1740 patients completed end-of-study visit. Central SBP was >125 mmHg for 84.3% patients at baseline, and 48% patients at end-of-study. Interestingly, at end-of-study, 6.6% patients still had uncontrolled brachial SBP and controlled central SBP, while 13.6% patients had uncontrolled central SBP and controlled brachial SBP. At both visits, brachial SBP and central SBP showed positive correlation across most drug classes and age groups. At baseline, ACE inhibitors showed better efficacy than other drug classes. At end-of-study, BP control was better with fixed-dose combinations, though free-drug combinations were more frequently prescribed. CONCLUSION: Measurement of CAP along with BBP can be vital in management of hypertension. CTRI REGISTRATION NUMBER: CTRI/2015/10/006302.

Assessment of left atrium and diastolic dysfunction in patients with hypertensive retinopathy: A real-time three-dimensional echocardiography-based study.

The fundoscopic examination of hypertensive patients, which is established hypertension-related target organ damage (TOD), tends to be underutilized in clinical practice. We sought to investigate the relationship between retinal alterations and left atrium (LA) volumes by means of real-time three-dimensional echocardiography (RT3DE). Our population consisted of 88 consecutive essential hypertensive patients (age 59.2 ± 1.2 years, 35 males). All subjects underwent a fundoscopy examination and were distributed into four groups according to the Keith-Wagener-Barker (KWB) classification. The four groups (KWB grades 0-3: including 26, 20, 26, and 16 patients, respectively) did not differ with regard to age, gender, or metabolic profile. There were no significant differences between groups with regard to parameters reflecting LV systolic function and diastolic dysfunction (DD) in two-dimensional echocardiography (2DE). Nevertheless, patients in the higher KWB category had higher values of LA volumes (LA maximal volume index, LA minimal volume index, preatrial contraction volume index, LA total stroke volume index, LA active stroke volume index, p < 0.001) regarding RT3DE. There is also a significant relationship between LA active stroke volume index (ASVI) and duration of hypertension (HT) (r: 0.68, p < 0.001). In the logistic regression analysis, ASVI was independent predictors of LV DD in patients with arterial hypertension (HT). Patients with arterial HT were found to have increased LA volumes and impaired diastolic functions. Assessment of the arterial HT patient by using RT3DE atrial volume analysis may facilitate early recognition of TOD, which is such a crucial determinant of cardiovascular mortality and morbidity.