Resistant hypertension: diagnosis, evaluation, and treatment a clinical consensus statement from the Thai hypertension society.

Resistant hypertension (RH) includes hypertensive patients with uncontrolled blood pressure (BP) while receiving ≥3 BP-lowering medications or with controlled BP while receiving ≥4 BP-lowering medications. The exact prevalence of RH is challenging to quantify. However, a reasonable estimate of true RH is around 5% of the hypertensive population. Patients with RH have higher cardiovascular risk as compared with hypertensive patients in general. Standardized office BP measurement, confirmation of medical adherence, search for drug- or substance-induced BP elevation, and ambulatory or home BP monitoring are mandatory to exclude pseudoresistance. Appropriate further investigations, guided by clinical data, should be pursued to exclude possible secondary causes of hypertension. The management of RH includes the intensification of lifestyle interventions and the modification of antihypertensive drug regimens. The essential aspects of lifestyle modification include sodium restriction, body weight control, regular exercise, and healthy sleep. Step-by-step adjustment of the BP-lowering drugs based on the available evidence is proposed. The suitable choice of diuretics according to patients' renal function is presented. Sacubitril/valsartan can be carefully substituted for the prior renin-angiotensin system blockers, especially in those with heart failure with preserved ejection fraction. If BP remains uncontrolled, device therapy such as renal nerve denervation should be considered. Since device-based treatment is an invasive and costly procedure, it should be used only after careful and appropriate case selection. In real-world practice, the management of RH should be individualized depending on each patient's characteristics.

May Measurement Month 2021: an analysis of blood pressure screening results from Thailand.

Blood pressure (BP) measurement is the mainstay for diagnosing and treating hypertension. Blood pressure screening in the May Measurement Month (MMM) project is helpful for the early detection of hypertension, which is usually asymptomatic. This study aimed to investigate the epidemiology of hypertension from data in the MMM21 project in Thailand. A cross-sectional study was conducted according to the MMM clinical study protocol for MMM21 in all regions of Thailand from August to November 2021. We included adults aged ≥18 years. Baseline characteristics, history of hypertension diagnosis, and treatment were collected through the questionnaires followed by three standardized BP measurements, 1 min apart. We included 10 940 participants with a mean age of 41.3 (SD ± 13.5) years. Only 6% never had their BP measured before. Of all participants, 30.2% had hypertension, and among this hypertensive population, 50.3% were aware, and 46.2% were taking antihypertensive medications. Of participants with hypertension, 31.6% had controlled BP (<140/90 mmHg), and BP control was 68.5% among those taking antihypertensive medication. The proportion of participants who had diabetes, were on aspirin, and were on statin were 6, 7.2, and 11.4%, respectively. Almost all participants (93.7%) had received at least one COVID-19 vaccination, and 8.0% reported a previous COVID-19 positive test. Most of the participants (97.4%) received hypertension care at no cost. Hypertension awareness and overall BP control rate were relatively low, while most subjects had previously had their BP checked. The widespread use of BP measurement may improve the diagnosis and treatment of hypertension to improve the care of those with hypertension in Thailand.

2022 Renal denervation therapy for the treatment of hypertension: a statement from the Thai Hypertension Society.

Hypertension remains a significant risk factor for major cardiovascular events worldwide. Poor adherence to treatment is extremely common in clinical practice, leading to uncontrolled hypertension. However, some patients with resistant hypertension still have uncontrolled blood pressure despite good medical compliance. A specific group of patients also develop adverse reactions to many blood pressure-lowering medications. These scenarios indicate that innovative strategies to lower blood pressure in challenging cases of hypertension are needed. The blood pressure-lowering efficacy of catheter-based renal denervation therapy to decrease sympathetic tone has been confirmed in many publications in recent years. Apart from both the invasiveness and the expensiveness of this technology, appropriate case selection to undergo this procedure is still developing. The utilization of renal denervation therapy for hypertension treatment in Thailand has lasted for 10 years with a good response in most cases. Currently, only certain interventionists at a few medical schools in Thailand can perform this procedure. However, more physicians are now interested in applying this technology to their patients. The Thai Hypertension Society Committee has reviewed updated information to provide principles for the appropriate utilization of renal denervation therapy. The blood pressure-lowering mechanism, efficacy, suitable patient selection, pre- and postprocedural assessment and procedural safety of renal denervation are included in this statement.

2022 Thai Hypertension Society guidelines on home blood pressure monitoring.

In 2021, the Universal Health Coverage Payment Scheme of Thailand approved home blood pressure monitoring (HBPM) devices for reimbursement. National utilization of HBPM devices will begin in 2022. This article provides the recommendations for HBPM from the Thai Hypertension Society. In this report, the authors review the benefits of HBPM and recommend confirming the diagnosis of hypertension by HBPM. Devices for HBPM should be the automated and validated upper arm cuff devices. HBPM should be ideally done for seven consecutive days before each clinic visit and take at least two readings (1 min apart) in the morning and before going to bed. The average blood pressure (BP) of 125-134/75-84 mmHg is classified as high normal BP and hypertension is BP of 135/85 mmHg or more. Target BP levels depend on the age of the patients; that is, < 125/75 mmHg for patients aged 18-65 years old, and <135/85 mmHg for patients over 65 years of age.

Long-term outcome of renal nerve denervation (RDN) for resistant hypertension.

We aimed to determine the long-term outcome of renal denervation (RDN). All patients with resistant hypertension who underwent RDN between 2012 and 2018 at Siriraj Hospital were included in the study. Patients were followed up at 3, 6, and 12 months and then annually up to 9 years. Effectiveness of the RDN outcome was defined by either (1) a reduction in office systolic BP ≥ 10 mmHg, (2) a reduction in the number of antihypertensive drugs taken, or (3) both outcomes being achieved. In total, 18 RDN procedures were performed during the study period. The mean and longest follow-up periods were 52 months and 104 months, respectively. Heterogeneous BP responses after RDN for resistant hypertension were observed. Effectiveness of the RDN outcome was achieved in 88% of the patients at 1 year and in >80% of the patients during the entire follow-up at each time point up to 9 years.

Clinical risk factors and predictive score for the non-dipper profile in hypertensive patients: a case-control study.

BACKGROUND: Night-time BP, especially non-dipper, is a stronger predictor of adverse cardiovascular outcomes. Ambulatory blood pressure monitoring (ABPM) is a gold standard for the detection of non-dippers but it often is unavailable and expensive. This study aims to determine clinical risk factors that predict non-dipper. METHODS: An exploratory traditional case-control study, exclusive sampling of control was conducted from January 2013 to September 2018 to explore clinical risk factors associated with non-dippers in hypertensive patients. Subgroup analysis was performed in each treated and untreated hypertensive patient. The parsimonious predictive score for non-dippers was constructed. RESULTS: The study included 208 hypertensive patients receiving 24 h ABPM. There were 104 dippers and 104 non-dippers. Significant clinical risk factors associated with non-dippers were the age of > 65 years, average office diastolic blood pressure (DBP), and fasting plasma glucose of > 5.6 mmol/L. Results of subgroup analysis showed that dyslipidemia, history of coronary artery disease, use of angiotensin-converting enzyme inhibitors (ACEIs) and direct vasodilators, average office DBP, and serum uric acid were associated with non-dippers in treated hypertensive patients, however, there were no risk factors associated with non-dippers in the untreated group. The predictive score for non-dippers in treated group included average office DBP, dyslipidemia, serum uric acid, male, calcium channel blockers and ACEIs use. The area under Receiver Operating Characteristic (AuROC) was 0.723. A cut-off point which was > 0.0701 and prevalence of non-dippers of 46%, this score had a sensitivity of 77.4%, specificity of 65.6%, positive predictive value (PPV) of 66.1%, and negative predictive value (NPV) of 79.6%. For untreated group, age, hemoglobin and body mass index were included in the predictive model. AuROC was 0.74. There was a sensitivity of 51.9%, specificity of 91.2%, PPV of 82.4%, and NPV of 70.5% at the cut-off point of > 0.357, and prevalence of 44%. CONCLUSION: There were several significant clinical risk factors associated with non-dippers in treated hypertensive patients. The predictive score might be useful for the detection of non-dippers; however, it cannot replace ABPM.

An Implementation Framework for Telemedicine to Address Noncommunicable Diseases in Thailand.

To maintain the continuity of noncommunicable disease (NCD) services and ascertain the health outcomes of patients with NCDs during the COVID-19 (coronavirus disease 2019) outbreak in Thailand, various telemedicine services have been developed. To achieve this determination, the implementation framework has been constructed based on recommendations from multidisciplinary experts (Thai NCD Collaboration Group). Within the framework, all key elements are illustrated with their priority and expected collaborations. Ultimately, active collaborations from multi-stakeholders are vitally important to ensure that telemedicine services for NCDs will finally become practical, successful, and sustainable.

Differences in ambulatory blood pressure profiles between Japanese and Thai patients with hypertension /suspected hypertension.

Ethnic differences in the profiles of hypertension and cardiovascular risk have been reported between Asians and Westerners. However, blood pressure (BP) profiles and the risk factors for cardiovascular disease might differ even among different Asian populations because of the diversity of cultures, foods, and environments. We retrospectively examined differences in 24-h BP profiles between 1051 Japanese (mean age, 62.5 ± 12.4 years; medicated hypertension, 75.7%) and 804 Thai (mean age, 56.9 ± 18.5 years; medicated hypertension, 65.6%) by using the Japanese and Thai ambulatory BP monitoring (ABPM) databases, in order to check the BP control status in treated hypertensives and to inform the clinical diagnosis of hypertension. The two populations had similar office systolic BP (SBP) (142.7 ± 20.0 vs 142.3 ± 20.6 mm Hg, p = .679). However, the Japanese population had higher 24-hr average and daytime SBP, and the Thai population had higher nighttime SBP even after adjusting for cardiovascular risk factors (all p < .05). Greater morning BP surge was observed in Japanese (31.2 vs 22.8 mm Hg, p < .001). Regarding nocturnal BP dipping status, the prevalence of riser status (higher nighttime than daytime SBP) was higher in the Thai population (30.5% vs 10.9%). These findings suggest that a substantial difference in 24-hr BP profiles exists between even neighboring countries in Asia.

Hypertensive emergencies remain a clinical problem and are associated with high mortality.

OBJECTIVE: We suspect that hypertensive emergencies remain a clinical problem and data on their long-term prognosis are lacking. This study was conducted in order to determine the frequency, management, and outcome of hypertensive emergencies in this era, in which hypertension treatment is more effective than in the past. MATERIAL AND METHOD: We reviewed the medical records of patients with hypertensive emergencies admitted to the medical wards of Siriraj Hospital in 2003 and collected data on their characteristic, management, investigations, and follow-ups through 31 December 2007. RESULTS: There were 184 patients included. Hypertension has been previously diagnosed in 89% of cases. Nearly half also had diabetes mellitus and around a quarter had chronic kidney failure. Mean +/- SD of blood pressure at presentation was 205.96 +/- 21.36/114.60 +/- 20.59 mmHg. Cardiac complications and stroke accounted for 71% and 23% of all target organ damage, respectively. Intravenous nitroglycerine and furosemide were most frequently prescribed. Additional investigations to search for the causes of hypertension were performed in only 55 cases. The average hospital stay was 9.8 days. The in-hospital mortality rate was 15%. Some 26% of patients were lost to follow-up and another 20% died later. Only 19% of patients had regular follow-ups until the end of 2007 and remained on an average of 2.4 antihypertensive drugs. CONCLUSION: Hypertensive emergencies are usually found in patients with a history of hypertension and diabetes mellitus or kidney failure. Recommended investigations usually failed to identify the cause of hypertension. The mortality rate of these patients was extremely high while their adherence to treatment was extremely poor.

Blood pressure determination by traditionally trained personnel is less reliable and tends to underestimate the severity of moderate to severe hypertension.

OBJECTIVE: Blood pressure determined by nurses has been observed to be unreliable. This study was conducted to compare the reliability of blood pressure measurements performed by traditionally trained nurses with those performed by a well-trained nurse and by an automatic device. METHODS: Hypertensive patients in an outpatient clinic were studied. Each individual was subjected to three blood pressure measurements: the first one was performed by the traditionally trained nurse on duty at the time of study (TT nurse BP), the second one by a specifically trained nurse (ST nurse BP), both using sphygmomanometer; and the third one was done using Omron HEM-907 (digital BP). RESULTS: A total of 907 participants were enrolled. More than 99% of both systolic and diastolic TT nurse BP ended with zero, demonstrating that they had terminal digit preference. ST nurse BP was in better agreement with digital blood pressure measurement than with TT nurse BP. The number of differences of < or =5 mmHg between ST nurse BP and digital blood pressure measurement was approximately 60% for both systolic and diastolic blood pressure. Overall, traditionally trained nurses overestimated, rather than underestimated, blood pressure. However, systolic blood pressure underestimation was extremely prominent in participants with moderate to severe hypertension. Systolic blood pressure underestimation of >5 mmHg was as high as 57.5% by traditionally trained nurses versus 33.8% by the automatic device, indicating that traditionally trained nurses tended to underestimate blood pressure in participants with more severe hypertension.

Hyperthyroidism induces glucose intolerance by lowering both insulin secretion and peripheral insulin sensitivity.

OBJECTIVE: The objectives of this study were to examine the effects of hyperthyroidism on glucose tolerance, insulin secretion, and insulin sensitivity. MATERIAL AND METHOD: Thirty-eight patients with hyperthyroidism and twenty-six healthy volunteers with matching age and body mass index were included. Patients with conditions known to affect glucose metabolism were excluded. An oral glucose tolerance test was performed after the diagnosis of hyperthyroidism and again when they achieved euthyroid state. Areas under the glucose and insulin curves were used to assess plasma glucose and insulin responses, respectively. Beta-cell function was determined by the corrected insulin response (CIR) and homostatic model assessment model 2 (HOMA2-%B). Peripheral insulin sensitivity was determined by the insulin activity (IA) and HOMA2-%S. RESULT: The prevalence of glucose intolerance in hyperthyroid state was 39.4% [impaired glucose tolerance (IGT) 31.5% and diabetes mellitus (DM) 7.9%]. This was significantly higher than that of 30.7% [IGT 19.2% and DM 11.5%] in healthy volunteers (p < 0.05). Glucose intolerance was associated with higher systolic blood pressure, higher mean arterial pressure, lower CIR, and higher T4 levels but not with the levels of T3. IA and HOMA2-%S significantly improved when achieving a euthyroid state despite the increase in body mass index. CONCLUSION: In conclusion, glucose intolerance is common in hyperthyroidism. Both impaired insulin secretion and decreased peripheral insulin sensitivity are the factors contributing to the development of abnormal glucose tolerance in the hyperthyroid state.

Aldosterone and not plasminogen activator inhibitor-1 is a critical mediator of early angiotensin II/NG-nitro-L-arginine methyl ester-induced myocardial injury.

BACKGROUND: Angiotensin II (Ang II) increases levels of aldosterone and plasminogen activator inhibitor-1 (PAI-1). Both aldosterone and PAI-1 seem to promote cardiovascular (CV) injury. Our objective was to determine the roles of PAI-1 and aldosterone in the development of myocardial and renal damage in a model with high Ang II and low nitric oxide (NO) availability, a pattern seen in patients with heart failure, diabetes mellitus, and arteriosclerosis. METHODS AND RESULTS: Mice on a moderately high sodium diet were treated with the NO synthase inhibitor NG-nitro-l-arginine methyl ester (L-NAME) for 14 days plus Ang II during days 8 through 14. The roles of aldosterone and PAI-1 in the development of CV injury were assessed using the mineralocorticoid receptor antagonist spironolactone (0, 1.5, 15, and 50 mg x 100 g(-1) x day(-1)) and PAI-1-deficient mice (PAI-1-/-). Ang II/L-NAME-treated mice showed glomerular ischemia, proteinuria, and necrosis of myocytes and vascular smooth muscle cells with an associated mixed inflammatory response, deposition of loose collagen, and neovascularization. Compared with saline-drinking mice, Ang II/L-NAME-treated mice had significantly increased heart to body weight (HW/BW) ratios, cardiac and renal damage assessed by histological examination, PAI-1 immunoreactivity, and proteinuria. Spironolactone treatment decreased PAI-1 immunoreactivity and reduced in a dose-dependent fashion cardiac and renal damage. PAI-1-/- animals had a similar degree of CV injury as PAI-1+/+ animals. CONCLUSIONS: Mineralocorticoid receptor antagonism, but not PAI-1 deficiency, protected mice from developing Ang II/L-NAME-mediated myocardial and vascular injury and proteinuria, suggesting that aldosterone, but not PAI-1, plays a key role in the development of early Ang II/L-NAME-induced cardiovascular injury.

Cardiac damage prevention by eplerenone: comparison with low sodium diet or potassium loading.

To determine the extent to which dietary sodium modulates aldosterone-induced cardiovascular damage, and to determine whether increased dietary potassium can prevent this damage, we used the Nomega-nitro-L-arginine methyl ester (L-NAME)/angiotensin II (Ang II) rat model of cardiac injury. This model is dependent on the presence of aldosterone for the occurrence of myocardial damage. Two sets of experiments were performed. In the first set, the following groups were studied: (1) 1% NaCl to drink (control group); (2) L-NAME/Ang II with water to drink (low salt group); (3) L-NAME/Ang II/1% NaCl (high salt group); (4) L-NAME/Ang II/1% NaCl/eplerenone (eplerenone group). Systolic blood pressure increased similarly in all groups compared with controls. Compared with the controls, the high salt group, but not the low salt or eplerenone groups, developed significant myocardial damage. In the second set of experiments three groups of animals were studied: (1) L-NAME/Ang II/1%NaCl (high salt group) (2) L-NAME/Ang II/1%NaCl/eplerenone (eplerenone group), and (3) L-NAME/Ang II/1%NaCl with an extra 1% KCl in food (high dietary potassium group). Eplerenone, but not dietary potassium supplementation, prevented the development of cardiac damage. Thus, mineralocorticoid receptor antagonist treatment and low sodium diet were effective in preventing cardiac damage, which suggests that a minimal level of aldosterone and a moderately high sodium diet are both required for the development of the cardiovascular damage in the L-NAME/Ang II model. The inability of potassium supplementation to reduce myocardial damage suggests that eplerenone's protective effect is not due to its potassium-sparing ability, but is rather related to some other feature of its selective aldosterone antagonism.