[Secondary hypertension: diagnosis and treatment]. / Ipertensione arteriosa secondaria: diagnosi e trattamento.

Hypertension does not recognize obvious pathogenic causes in the majority of patients (essential hypertension). However, a secondary underlying cause of hypertension can be recognized in 5-10% of unselected hypertensive patients, and this prevalence may increase to more than 20% in patients with hypertension that is difficult to control or frankly resistant to treatment. In children, secondary hypertension is most often due to aortic coarctation, distal thoracic or abdominal aortic stenosis, or specific gene mutations. In adults or elderly individuals, secondary hypertension is most often due to atherosclerotic renal artery stenosis, primary hyperaldosteronism, and Cushing's disease or syndrome. Parenchymal nephropathy and hyperparathyroidism can cause hypertension at all ages, while pheochromocytoma and paraganglioma tend to occur more often in adolescents or young adults. In general, secondary hypertension should be suspected in subjects with: (a) onset of hypertension under 30 years of age especially if in the absence of hypertensive family history or other risk factors for hypertension; (b) treatment-resistant hypertension; c) severe hypertension (>180/110 mmHg), malignancy, or hypertensive emergencies; d) rapid rise in blood pressure values in previously well controlled patients. Any clinical signs suspicious or suggestive of hypertension from endocrine causes, a "reverse dipping" or "non-dipping'" profile at 24 h ambulatory blood pressure monitoring not justified by other factors, signs of obvious organ damage may be helpful clues for diagnosis. Finally, patients snoring or with clear sleep apnea should also be considered for possible secondary hypertension.

Association between intensive blood pressure lowering and stroke-free survival among patients with and without Diabetes.

This study pooled data from SPRINT (Systolic Blood Pressure Intervention Trial) and ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes Blood Pressure) trial to estimate the treatment effect of intensive BP on stroke prevention, and investigate whether stroke risk score impacted treatment effect. Of all the potential manifestations of the hypertension, the most severe outcomes were stroke or death. A composite endpoint of time to death or stroke (stroke-free survival [SFS]), whichever occurred first, was defined as the outcome of interest. Participants without prevalent stroke were stratified into stroke risk tertiles based on the predicted revised Framingham Stroke Risk Score. The stratified Cox model was used to calculate the hazard ratio (HR) for the intensive BP treatment. 834 (5.92%) patients had SFS events over a median follow-up of 3.68 years. A reduction in the risk for SFS was observed among the intensive BP group as compared with the standard BP group (HR: 0.76, 95% CI: 0.65, 0.89; risk difference: 0.98([0.20, 1.76]). Further analyses demonstrated the significant benefit of intensive BP treatment on SFS only among participants having a high stroke risk (risk tertile 1: 0.76 [0.52, 1.11], number needed to treat [NNT] = 861; risk tertile 2: 0.87[0.65, 1.16], NNT = 91; risk tertile 3: 0.69[0.56, 0.86], NNT = 50). Intensive BP treatment lowered the risk of SFS, particularly for those at high risk of stroke.

Emergency Department Blood Pressure Treatment and Outcomes in Adults Presenting with Severe Hypertension.

Background: Patients who present to the emergency department (ED) with severe hypertension defined as a systolic blood pressure (SBP) ≥180 millimeters of mercury (mm Hg) or diastolic (DBP) ≥120 (mm Hg) without evidence of acute end-organ damage are often deemed high risk and treated acutely in the ED. However, there is a dearth of evidence from large studies with long-term follow-up for the assessment of major adverse cardiovascular events (MACE). We conducted the largest study to date of patients presenting with severe hypertension to identify predictors of MACE and examine whether blood pressure at discharge is associated with heightened risk. Methods: We enrolled ED patients with a SBP of 180-220 mm Hg but without signs of end-organ damage and followed them for one year. The primary outcome was MACE within one year of discharge. Secondarily, we performed a propensity-matched analysis to test whether SBP ≤160 mm Hg at discharge was associated with reduced MACE at 30 days. Results: A total of 12,044 patients were enrolled. The prevalence of MACE within one year was 1,865 (15.5%). Older age, male gender, history of cardiovascular disease, cerebrovascular disease, diabetes, smoking, presentation with chest pain, altered mental status, dyspnea, treatment with intravenous and oral hydralazine, and oral metoprolol were independent predictors for one-year MACE. Additionally, discharge with an SBP ≤160 mm Hg was not associated with 30-day MACE-free survival after propensity matching (hazard ratio 0.99, 95% confidence interval 0.78-1.25, P = 0.92). Conclusion: One-year MACE was relatively common in our cohort of ED patients with severe hypertension without acute end-organ damage. However, discharge blood pressure was not associated with 30-day or one-year MACE, suggesting that BP reduction in and of itself is not beneficial in such patients.

Managing hypertension in older people: current concepts.

Hypertension management in older people is challenging due to pathophysiological changes brought about by ageing, associated comorbidities, frailty and polypharmacy and often has a poor evidence base. This article gives an overview of these factors and related available evidence with particular attention to clinical issues and consensus guidance.

Renal sympathetic denervation 2024 in Austria: recommendations from the Austrian Society of Hypertension : Endorsed by the Austrian Society of Nephrology and the Working Group of Interventional Cardiology of the Austrian Society of Cardiology.

Renal sympathetic denervation (RDN) is an interventional supplement to medical treatment in patients with arterial hypertension. While the first sham-controlled trial, SYMPLICITY HTN­3 was neutral, with improved procedural details, patient selection and follow-up, recent randomized sham-controlled trials of second-generation devices show a consistent blood pressure lowering effect of RDN, as compared to sham controls. These new data and the recent U.S. Food and Drug Administration (FDA) premarket approval of two RDN devices are the basis for the present recommendations update.This joint position paper from the Austrian Society of Hypertension, together with the Austrian Society of Nephrology and the Working Group of Interventional Cardiology from the Austrian Society of Cardiology includes an overview about the available evidence on RDN and gives specific recommendations for the work-up, patient selection, pretreatment, procedural management and follow-up in patients undergoing RDN in Austria. Specifically, RDN may be used in clinical routine care, together with lifestyle measures and antihypertensive drugs, in patients with resistant hypertension (i.e. uncontrolled blood pressure on 3 antihypertensive drugs) and in those with uncontrolled hypertension, after adequate work-up, if institutional, patient-related and procedural conditions are fulfilled.

Early Addition of Selexipag to Double Therapy for Pulmonary Arterial Hypertension.

Importance: A subgroup analysis of a randomized clinical trial established the efficacy of selexipag plus background therapy (monotherapy or double oral therapy [DOT]) vs placebo plus background therapy and found that the addition of selexipag within 6 months had an added benefit. However, the timing of selexipag addition to DOT and the incremental benefit in clinical practice is not well studied. Objective: To compare triple oral therapy (TOT) consisting of selexipag, endothelin receptor antagonist (ERA), and phosphodiesterase type 5 inhibitor (PDE5i) vs DOT consisting of ERA and PDE5i. Design, Setting, and Participants: This comparative effectiveness study was conducted using data from the US Komodo claims database to emulate a randomized trial. Patients aged 18 years or older with pulmonary arterial hypertension (PAH) treated with ERA plus PDE5i with records from July 2015 through June 2022 were duplicated to TOT and DOT and artificially censored when observed treatment deviated from assigned treatment. Hypothetical randomization was emulated using inverse probability of treatment weighting, and the study accounted for censoring-induced selection bias using inverse probability of censoring weighting. A pooled logistic model estimated the per-protocol difference between treatment groups. Data were analyzed from November 2022 through July 2023. Interventions: TOT (addition of selexipag within 3, 6, and 12 months of initiating DOT) vs DOT. Main Outcomes and Measures: Adjusted risk of all-cause hospitalization, PAH-related hospitalization, and PAH-related disease progression over a 2-year follow-up. Results: A total of 2966 patients with PAH (mean [SD] age, 54.3 [14.0] years; 2125 female [71.6%]) met eligibility criteria. Adding selexipag within 6 months of ongoing DOT was associated with a reduction in risk for all-cause hospitalization (adjusted hazard ratio [aHR], 0.82; 95% CI, 0.72-0.94), PAH-related hospitalization (aHR, 0.81; 95% CI, 0.70-0.95), and PAH-related progression (aHR, 0.82; 95% CI, 0.70-0.95) vs DOT alone. There were no associations if selexipag was initiated within 12 months for all-cause hospitalization, PAH-related hospitalization, or PAH-related disease progression. The association remained with a greater decrease in risk for disease progression vs DOT for selexipag initiation within 3 months (aHR, 0.74; 95% CI, 0.61-0.90). Conclusions and Relevance: This study found that early selexipag addition to ERA plus PDE5i was associated with a reduction in risk of hospitalization and disease progression. These findings suggest that delays in selexipag initiation likely contribute to suboptimal patient and health system outcomes.

[Access to medicines for the treatment of systemic arterial hypertension and type 2 diabetes mellitus in the Brazilian population: data from the 2019 Brazilian National Health Survey]. / Acesso a medicamentos para o tratamento de hipertensão arterial sistêmica e diabetes mellitus tipo 2 na população brasileira: dados da Pesquisa Nacional de Saúde de 2019.

This study aimed to measure access to medicines for the treatment of systemic arterial hypertension and type 2 diabetes mellitus in Brazil according to the mode of acquisition, as well as to analyze the factors associated with this access, based on data from the 2019 Brazilian National Survey of Health (PNS, acronym in Portuguese). Socioeconomic data and data related to the use of medicines by people aged 15 and over were analyzed in relation to access via the Brazilian Popular Pharmacy Program (PFPB, acronym in Portuguese) and via public services. The majority of Brazilians who took part in the PNS reported using medication to control hypertension in the previous 15 days (91.5%) and using oral medication for diabetes (95.2%) and/or insulin (70%). Most participants obtained oral medication for hypertension and type 2 diabetes mellitus via PFPB (45.2% and 53.6%, respectively), and the factors that most negatively influenced this access were older age, lower income, lower schooling, very poor self-rated health and not having private health insurance. Access to insulin, on the other hand, was most often via the public health service (69.7%), and the factors that most negatively influenced this access were black/mixed-race skin color, lower income, very poor self-rated health and not having private health insurance. Generally, the importance of the PFPB as a policy to increase access to essential medicines in Brazil was highlighted, considering the free supply of antihypertensive and antidiabetic drugs.

Este estudo objetivou mensurar o acesso aos medicamentos para o tratamento da hipertensão arterial sistêmica e diabetes mellitus tipo 2 no Brasil segundo a via de obtenção, bem como analisar os fatores associados a esse acesso, de acordo com os dados da Pesquisa Nacional de Saúde (PNS) de 2019. Foram analisados dados socioeconômicos e relacionados ao uso de medicamentos de pessoas de 15 anos ou mais, em relação ao acesso via Programa Farmácia Popular do Brasil (PFPB) e via serviço público. A maior parte dos brasileiros que participaram da PNS referiu fazer uso do medicamento para controle da hipertensão, nos últimos 15 dias (91,5%), assim como a maior parte referiu fazer uso de medicamento oral para diabetes (95,2%) e/ou uso da insulina (70%).Os medicamentos orais para hipertensão arterial sistêmica e diabetes mellitus tipo 2 foram obtidos majoritariamente via PFPB, sendo respectivamente (45,2% e 53,6%), e os fatores que mais influenciaram negativamente esse acesso foram maior faixa etária, menor renda, menor escolaridade, não ter plano de saúde e referir uma autoavaliação de saúde muito ruim. O acesso à insulina, por sua vez, se deu com maior frequência via serviço público de saúde (69,7%), e os fatores que mais influenciaram negativamente esse acesso foram raça preta/parda, menor renda, não ter plano de saúde e referir uma autoavaliação de saúde muito ruim. De forma geral, foi evidenciada a importância do PFPB como política de ampliação de acesso a medicamentos essenciais no Brasil, considerando a gratuidade dos anti-hipertensivos e antidiabéticos.

Este estudio tuvo como objetivo medir el acceso a los medicamentos para el tratamiento de la hipertensión arterial sistémica y de la diabetes mellitus tipo 2 en Brasil según la vía de obtención, además de analizar los factores asociados a este acceso, según datos de la Encuesta Nacional de Salud (PNS) de 2019. Se analizaron datos socioeconómicos y relacionados con el uso de medicamentos de personas de 15 años o más, con relación al acceso por medio del Programa Farmacia Popular de Brasil (PFPB) y por medio del servicio público. La mayor parte de los brasileños que participaron en la PNS refirió utilizar medicamentos para controlar la hipertensión, en los últimos 15 días (91,5%), así como la mayoría refirió el uso de medicamentos orales para la diabetes (95,2%) o uso de insulina (70%). Los medicamentos orales para hipertensión arterial sistémica y diabetes mellitus tipo 2 se obtuvieron en su mayoría por medio del PFPB, respectivamente (45,2% y 53,6%), y los factores que influyeron de forma más negativa en este acceso fueron mayor rango de edad, menores ingresos, menor escolaridad, no tener seguro de salud y reportar una autoevaluación de salud muy mala. El acceso a la insulina, a su vez, se produjo con mayor frecuencia por medio del servicio público de salud (69,7%), y los factores que influyeron de forma más negativa en este acceso fueron la raza negra/morena, menores ingresos, no tener plan de salud y reportar una autoevaluación de salud muy mala. En general, se destacó la importancia de la PFPB como política de ampliación del acceso a medicamentos esenciales en Brasil, considerando la gratuidad de los antihipertensivos y antidiabéticos.

Garlic and Hypertension: Efficacy, Mechanism of Action, and Clinical Implications.

Hypertension is a major risk factor for heart disease and stroke. Garlic has a long history of use in traditional medicine for various conditions, including hypertension. This narrative review examined the scientific evidence on the efficacy of garlic in lowering blood pressure. It explores the historical uses of garlic in different cultures for medicinal purposes and delves into the phytochemical composition of garlic, highlighting key components, like allicin and ajoene, that are believed to contribute to its potential health benefits. Clinical studies that investigated the effects of garlic and garlic-based supplements on blood pressure are presented, with the findings suggesting that garlic consumption may modestly reduce blood pressure, particularly in individuals with mild hypertension. Potential mechanisms of action include increased nitric oxide production, improved endothelial function, and antioxidant properties. While garlic may offer some benefits for blood pressure management, it should not be considered a substitute for conventional antihypertensive medications. Further large-scale, long-term clinical trials are warranted to establish the efficacy of garlic in managing hypertension, including the optimal dosage and formulation.

A Cross-Sectional Survey of Fixed-Dose Combination Antihypertensive Medicine Prescribing in Twenty-Four Countries, Including Qualitative Insights.

Background: Treatment inertia, non-adherence and non-persistence to medical treatment contribute to poor blood pressure (BP) control worldwide. Fixed dose combination (FDC) antihypertensive medicines simplify prescribing patterns and improve adherence. The aim of this study was to identify factors associated with prescribing FDC antihypertensive medicines and to understand if these factors differ among doctors worldwide. Methods: A cross-sectional survey was conducted online from June 2023 to January 2024 to recruit doctors. We collaborated with an international network of researchers and clinicians identified through institutional connections. A passive snowballing recruitment strategy was employed, where network members forwarded the survey link to their clinical colleagues. The survey instrument, developed through a literature review, interviews with academic and clinical researchers, and pilot testing, assessed participants perspectives on prescribing FDC antihypertensive medicines for hypertension. Participants rated their level of agreement (5-point Likert scale) with statements representing six barriers and four facilitators to FDC use. Findings: Data from 191 surveys were available for analysis. 25% (n = 47) of participants worked in high-income countries, 38% (n = 73) in upper-middle income, 25% (n = 48) in lower-middle income, 6% (n = 10) in low-income countries. Forty percent (n = 70) of participants were between 36-45 years of age; two thirds were male. Cost was reported as a barrier to prescribing FDC antihypertensive medicines [51% (n = 87) agreeing or strongly agreeing], followed by doctors' confidence in BP measured in clinic [40%, (n = 70)], access [37%, (n = 67)], appointment duration [35%, (n = 61)], concerns about side-effects [(21%, n = 37)], and non-adherence [12%, (n = 21)]. Facilitators to FDC antihypertensive polypills prescribing were clinician facing, such as access to educational supports [79%, (n = 143)], more BP measurement data [67%, (n = 120)], a clinical nudge in health records [61%, (n = 109)] and patient-facing including improved patient health literacy [49%, (n = 88)]. The levels of agreement and strong agreement across all barriers and facilitators were similar for participants working in higher or lower income countries. Across all countries, participants rated FDC antihypertensive medications highly valuable for managing patients with non-adherence, (82% reported high or very high value), for patients with high pill burden (80%). Interpretation: Cost and access were the most common barriers to prescribing FDCs across high- and low-income countries. While greater educational support for clinicians was perceived as the leading potential facilitator of FDC use, this seems unlikely to be effective without addressing access.

Use of electronic health records to characterize patients with uncontrolled hypertension in two large health system networks.

BACKGROUND: Improving hypertension control is a public health priority. However, consistent identification of uncontrolled hypertension using computable definitions in electronic health records (EHR) across health systems remains uncertain. METHODS: In this retrospective cohort study, we applied two computable definitions to the EHR data to identify patients with controlled and uncontrolled hypertension and to evaluate differences in characteristics, treatment, and clinical outcomes between these patient populations. We included adult patients (≥ 18 years) with hypertension (based on either ICD-10 codes of hypertension or two elevated blood pressure [BP] measurements) receiving ambulatory care within Yale-New Haven Health System (YNHHS; a large US health system) and OneFlorida Clinical Research Consortium (OneFlorida; a Clinical Research Network comprised of 16 health systems) between October 2015 and December 2018. We identified patients with controlled and uncontrolled hypertension based on either a single BP measurement from a randomly selected visit or all BP measurements recorded between hypertension identification and the randomly selected visit). RESULTS: Overall, 253,207 and 182,827 adults at YNHHS and OneFlorida were identified as having hypertension. Of these patients, 83.1% at YNHHS and 76.8% at OneFlorida were identified using ICD-10-CM codes, whereas 16.9% and 23.2%, respectively, were identified using elevated BP measurements (≥ 140/90 mmHg). A total of 24.1% of patients at YNHHS and 21.6% at OneFlorida had both diagnosis code for hypertension and elevated blood pressure measurements. Uncontrolled hypertension was observed among 32.5% and 43.7% of patients at YNHHS and OneFlorida, respectively. Uncontrolled hypertension was disproportionately higher among Black patients when compared with White patients (38.9% versus 31.5% in YNHHS; p < 0.001; 49.7% versus 41.2% in OneFlorida; p < 0.001). Medication prescription for hypertension management was more common in patients with uncontrolled hypertension when compared with those with controlled hypertension (overall treatment rate: 39.3% versus 37.3% in YNHHS; p = 0.04; 42.2% versus 34.8% in OneFlorida; p < 0.001). Patients with controlled and uncontrolled hypertension had similar incidence rates of deaths, CVD events, and healthcare visits at 3, 6, 12, and 24 months. The two computable definitions generated consistent results. CONCLUSIONS: While the current EHR systems are not fully optimized for disease surveillance and stratification, our findings illustrate the potential of leveraging EHR data to conduct digital population surveillance in the realm of hypertension management.

High rate of uncontrolled hypertension among adults receiving integrated HIV and hypertension care with aligned multi-month dispensing in Malawi: results from a cross-sectional survey and retrospective chart review.

INTRODUCTION: People living with HIV have high rates of hypertension. Integrated HIV and hypertension care with aligned multi-month dispensing of medications (MMD) could decrease the burden of care for individuals and health systems. We sought to describe hypertension control and evaluate its association with different durations of MMD among Malawian adults receiving integrated care with aligned dispensing of antiretroviral therapy (ART) and antihypertensive medication. METHODS: We conducted a cross-sectional survey and retrospective chart review of adults (≥18 years) receiving integrated HIV and hypertension care on medications for both conditions for at least 1 year, with aligned MMD at seven clinics in Malawi. Data were collected from July 2021 to April 2022 and included socio-demographics, clinical characteristics, antihypertensive medications and up to the three most recent blood pressure measurements. Bivariate analyses were used to characterize associations with hypertension control. Uncontrolled hypertension was defined as ≥2 measurements ≥140 and/or ≥90 mmHg. Chart reviews were conducted for a random subset of participants with uncontrolled hypertension to describe antihypertensive medication adjustments in the prior year. RESULTS: We surveyed 459 adults receiving integrated care with aligned dispensing (58% female; median age 54 years). Individuals most commonly received a 3-month aligned dispensing of ART and antihypertensive medications (63%), followed by every 6 months (16%) and every 4 months (15%). Hypertension control was assessed in 359 respondents, of whom only 23% had controlled hypertension; 90% of individuals in this group reported high adherence to blood pressure medications (0-1 missed days/week). Control was more common among those with longer aligned medication dispensing intervals (20% among those with 1- to 3-month dispensing vs. 28% with 4-month dispensing vs. 40% with 6-month dispensing, p = 0.011). Chart reviews were conducted for 147 individuals with uncontrolled hypertension. Most had high self-reported adherence to blood pressure medications (89% missing 0-1 days/week); however, only 10% had their antihypertensive medication regimen changed in the prior year. CONCLUSIONS: Uncontrolled hypertension was common among Malawian adults receiving integrated care with aligned MMD and was associated with shorter refill intervals and few antihypertensive medication escalations. Integrated care with aligned MMD is promising, but further work is needed to understand how to optimize hypertension outcomes.

The Evolution of Renal Denervation for the Treatment of Hypertension: Insights from Trials and Prospects for Clinical Practice.

Hypertension affects 1.3 billion adults globally, with severe health implications if left untreated. Despite efforts, research suggests only a fraction achieve adequate control. Renal denervation (RDN) therapy has emerged as a potential solution, particularly for treatment-resistant cases. RDN targets the dysregulated sympathetic nervous system activity frequently encountered in resistant hypertension. Recent FDA approval of advanced RDN catheter systems in 2023 signifies a pivotal advancement in hypertension management. As an adjunctive to pharmacotherapy, RDN holds promise as a therapeutic modality in achieving optimal blood pressure control and attenuating hypertension-related morbidity and mortality. Further research elucidating the nuances of patient selection, procedural standardization, and long-term outcomes is warranted to optimize the clinical utility of RDN in the management of hypertension. This manuscript compiles evidence for the use of RDN and reviews the long-term safety data from recent trials.