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Target blood pressures in hypertension treatment

Target blood pressures in hypertension treatment

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Treatment strategies are provided in accordance with the level of global cardiovascular risk, from lifestyle modification in the lower risk group to more comprehensive treatment in the higher risk group. Considering the common trend of combination drug regimen, the choice of the first drug is suggested more liberally according to the physician's di...

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... shown in Table 2, except under specific circum- stances, the target BP is generally an SBP of less than 140 mm Hg and a DBP of less than 90 mm Hg [5,17,18]. ...

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... In terms of recognition of the requirement for more active blood pressure (BP) control, the American Heart Association revised the diagnostic guidelines for HTN, reducing the cut-off to 130/80 mmHg. More than two-thirds of patients with hypertension require treatment with two or more antihypertensive drugs to achieve their target BP goals [2,3]. The European Society of Cardiology recommends initial combination therapy for the majority of patients with HTN [4]. ...
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Background This study evaluated the circadian efficacy of a telmisartan 40 mg/S-amlodipine 2.5 mg fixed-dose combination (Telmisartan40/S-Amlodipine2.5) compared to telmisartan 80 mg (Telmisartan80) in patients with essential hypertension who did not respond to 2–4 weeks’ treatment with telmisartan 40 mg. Methods Eligible patients with essential hypertension (clinic mean sitting systolic blood pressure [MSSBP] ≥140 mmHg, or ≥ 130 mmHg in those with diabetes mellitus or chronic kidney disease) were randomly assigned to Telmisartan40/S-Amlodipine2.5 or Telmisartan80 for 8 weeks. All patients underwent ambulatory BP monitoring (ABPM) at baseline and 8 weeks later. Primary endpoints were changes in mean 24-h SBP and DBP on 24-h ABPM from baseline after 8 weeks. Secondary endpoints were changes in daytime, nighttime, and morning SBP and DBP, and clinic MSSBP and MSDBP. Results A total of 316 Korean patients were enrolled, 217 patients were randomized to treatment, and 192 patients completed the study. Compared to Telmisartan80, Telmisartan40/S-Amlodipine2.5 showed significantly better reductions in 24-h mean SBP and DBP after 8 weeks. Telmisartan40/S-Amlodipine2.5 also significantly reduced secondary endpoints compared to Telmisartan80. Among 15 adverse events (7 [Telmisartan40/S-Amlodipine2.5] and 8 [Telmisartan80]), there were five adverse drug reactions; 14 events were mild, and none were identified with significant between-group differences. Conclusions Telmisartan40/S-Amlodipine2.5 was tolerable and more effective than Telmisartan80 in lowering 24-h mean ambulatory BP in patients with essential hypertension not responding adequately to Telmisartan40. Our findings support the fact that the combination of S-amlodipine with telmisartan is more appropriate than increasing the dose of telmisartan monotherapy. Trial registration ClinicalTrials.gov , NCT02231788 . Registered 4 September 2014.
... Most guidelines are based on evidence from multiple randomized clinical trials (RCTs) and recommend that the clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP is not reached, guidelines recommend increasing the dose of the initial drug or adding a second drug from one of the recommended classes [2][3][4][5][6]. ...
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Background Chronic diseases like hypertension need comprehensive lifetime management. This study assessed clinical and patient-reported outcomes and compared them by treatment patterns and adherence at 6 months among uncontrolled hypertensive patients in Korea. Methods This prospective, observational study was conducted at 16 major hospitals where uncontrolled hypertensive patients receiving anti-hypertension medications (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg) were enrolled during 2015 to 2016 and studied for the following 6 months. A review of medical records was performed to collect data on treatment patterns to determine the presence of guideline-based practice (GBP). GBP was defined as: (1) maximize first medication before adding second or (2) add second medication before reaching maximum dose of first medication. Patient self-administered questionnaires were utilized to examine medication adherence, treatment satisfaction and quality of life (QoL). Results A total of 600 patients were included in the study. Overall, 23% of patients were treated based on GBP at 3 months, and the GBP rate increased to 61.4% at 6 months. At baseline and 6 months, 36.7 and 49.2% of patients, respectively, were medication adherent. The proportion of blood pressure-controlled patients reached 65.5% at 6 months. A higher blood pressure control rate was present in patients who were on GBP and also showed adherence than those on GBP, but not adherent, or non-GBP patients (76.8% vs. 70.9% vs. 54.2%, P < 0.001). The same outcomes were found for treatment satisfaction and QoL ( P < 0.05). Conclusions This study demonstrated the importance of physicians’ compliance with GBP and patients’ adherence to hypertensive medications. GBP compliance and medication adherence should be taken into account when setting therapeutic strategies for better outcomes in uncontrolled hypertensive patients.
... According to the Korean guidelines issued to primary healthcare institutions, basic target BP was < 140/90 mmHg based on CBP, but different standards were applied in people aged ≥80 years (< 150/90 mmHg), diabetic patients (< 140/85 mmHg), and patients with chronic kidney disease as indicated by proteinuria (urine albumin level ≥ 30 mg/d or ≥ 30 mg/g [albuminuria], urine protein level ≥ 150 mg/d or ≥ 150 mg/g [proteinuria]) (< 130/80 mmHg) [23]. ...
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Background Although recent hypertension guidelines recommend home blood pressure (HBP) monitoring, its effect in clinical practice is not well known. This study aimed to identify current HBP measurement status and obstacles and their efficacy on blood pressure (BP) control. Methods Sixty-three intervention and 61 control centers with 2483 (mean age: 58.0 years, 56.0% male) drug-naïve stage 2 hypertensive patients or patients requiring second anti-hypertensive medications were included. The intervention group was instructed to measure HBP twice a day for 7 days from the scheduled visit at 4, 8, and 12 weeks. Results At the end of 12 weeks, 842 (68.7%) and 807 (64.15%) patients of the control and intervention groups, respectively, achieved a target BP. The odds ratio (OR) for improving BP control of HBP was 0.836 (95% confidence interval [CI]: 0.694–1.007). Among intervention group, clinic BP of the subgroup those measured their HBP at least once well controlled compared to subgroup those not measured their HBP at all (OR 1.602, 95% CI: 1.182–2.172). Only 19.17% ( n = 476) had a home sphygmomanometer, and among those, 26.89% measured their BP at least once a week and 34.87% did not measure the BP at all. The obstacles of HBP measurement were lack of awareness of its importance (40.83%), lack of confidence on how to measure BP and maintain the measurement (37.04%), and difficulty in selecting an appropriate device (14.41%). Conclusions HBP measurement alone did not improve BP control, but better compliance with the HBP measurement resulted in improved BP control. Trial registration ClinicalTrials, NCT03254914 , Registered 21 August 2017.
... Patients already under pharmacological treatment for hypertension and high blood cholesterol were initially screened. The need for pharmacological treatment was determined based on the guidelines of the 2013 Korean Society of Hypertension [16] and the Korean Society of Lipid and Atherosclerosis [17]. ...
Article
Background: The efficacy of fixed-dose combinations (FDCs) in improving adherence and risk factor control for cardiovascular disease has not been reported consistently. Here, we compared adherence and efficacy between an olmesartan/rosuvastatin FDC and the usual regimen. Methods: In this 6-month, open-label, randomized, active-control study, we screened 154 patients; of these, 150 were randomly assigned to receive either olmesartan/rosuvastatin FDC or the usual regimen with separate angiotensin receptor blockers and statins. In total, 135 patients completed the study (median age: 68 years; male: 68.9%). The primary outcome was patients' adherence; the secondary outcomes were changes in blood pressure (BP) and lipid parameters. Results: During follow-up, adherence in both groups was high and similar between the groups (98.9% and 98.3% in the FDC and usual regimen groups, respectively, p = 0.328). Changes in systolic (-8 and -5 mmHg, respectively, p = 0.084) and diastolic BP (-5 and -2 mmHg, p = 0.092) did not differ significantly, although they were numerically greater in the FDC group. Changes in low-density lipoprotein cholesterol (LDL-C) were greater in the FDC group (-13 and -4 mg/dL, respectively, p = 0.019), whereas changes in other lipid parameters were similar between the groups. The test drugs were well tolerated, showing no difference in safety between the groups. Conclusions: Patients' adherence was excellent and similar in the groups, whereas the reduction in the LDL-C level was greater in the FDC group. We provide comprehensive information on the adherence and efficacy of an FDC compared to the usual regimen in Korean patients with high cardiovascular risk.
... Combination of CCBs and RAAS inhibitors represents one of the commonly used CTs due to its demonstrated efficacy and favorable safety profile [7,8]. RAAS inhibitors have shown distinct cardio-and renoprotective advantages [8][9][10][11]. ARBs are better tolerated than ACEIs, which are typically associated with dry cough and angioedema [12][13][14][15]. is preference is reflected in the rapid growth in the use of CCBs and ARBs that are the most commonly prescribed agents in both Japan and China [1,6]. Currently, more than 60% of the Japanese HTN patients are treated by a CCB, an ARB, or both [16]. ...
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Background: Hypertension (HTN) is the leading risk factor for cardiovascular mortality globally. The WHO estimates a 60% increase in Asian HTN patients between 2000 and 2025. Numerous studies have compared safety and efficacy between antihypertensive classes, but in-class comparisons of angiotensin II receptor blockers (ARBs) in combination therapy (CT) (fixed-dose combination or dual combination) with a calcium channel blocker (CCB) are lacking in Asia. Objective: To compare the efficacy and safety of the various ARB-amlodipine CTs and amlodipine (AML) monotherapy for treatment of HTN in Asian population. Methods: A systematic literature review sourced Asian randomized controlled trials (RCTs) from PubMed and Cochrane Libraries to inform a network meta-analysis (NMA). We considered the ARB-AML CT. The primary efficacy and safety endpoints were short-term (8-12 weeks) treatment response and treatment-emergent adverse events (TEAEs), respectively. AML monotherapy was used as a comparator to allow for indirect treatment effect estimation in the absence of direct RCTs evidence comparing the different ARB-AML CTs. Results: The analysis included 1198 Asian HTN patients from seven studies involving six ARB-AML CTs: azilsartan (AZL), candesartan (CAN), fimasartan (FIM), losartan (LOS), olmesartan (OLM), and telmisartan (TEL). Compared to AML monotherapy, CT of AZL-AML had five times greater odds of prompting a treatment response (OR 5.2, 95% CI: 2.5, 11.2), while CAN-AML had 3.9 (95% CI: 2.5, 6.4), FIM-AML had 3.4 (95% CI: 1.4, 8.5), TEL-AML had 3.3 (95% CI: 1.6, 7.1), OLM-AML had 2.7 (95% CI: 1.6, 5.0), and LOS-AML had 2.0 (95% CI: 0.6, 7.3). All ARB-AML CTs had safety profiles comparable to AML monotherapy except TEL-AML, which had significantly lower odds of TEAEs (0.26 (95% CI: 0.087, 0.70)). Conclusion: This study suggests that all ARB-AML CTs compared favorably to AML monotherapy regarding short-term treatment response in uncomplicated HTN patients of Asian origin. AZL-AML prompted the most favorable treatment response. Safety profiles among the ARB-AML CTs were largely comparable. Due to the limited study size and small number of trials (direct evidence), our findings should best be interpreted as an exploratory effort importance to inform future research direction.
... Korean Society of Hypertension guidelines 11 home BP ≥135/85 mm Hg). However, even when home BP is controlled to below 135/85 mm Hg, further reductions in BP might contribute to achieving optimal clinical outcomes. ...
Article
Hypertension is present in almost one‐quarter of women and one‐third of men in Korea. Although mortality rates from stroke and myocardial infarction (MI) appear to be decreasing, stroke is a more common cause of cardiovascular death than MI. This may be due to better control of hypertension, but national control rates have remained stable for more than a decade (at about 45%). Korean Society of Hypertension guidelines have recommended the use of home blood pressure monitoring (HBPM) since 2007, but a recent survey suggests that physicians have concerns about the accuracy of HBPM devices. Nevertheless, use of HBPM is indispensable to monitoring and achieving blood pressure (BP) control. Current diagnostic and treatment thresholds and recommendations are based on Asian consensus document guidance. Use of dual combination antihypertensive therapy is slightly more common than use of monotherapy in Korea, while triple combination therapy is used less often. Angiotensin receptor blockers and calcium channel blockers are the most popular choices for antihypertensive therapy and are the most widely used combination. HBPM plays an important role in evaluating and monitoring BP, particularly in Asians. Individualized cardiovascular risk assessment and better BP control are required to prevent cardiovascular diseases, but there is a need for local evidence relating to optimal BP thresholds and targets.
... Quality of the survey was controlled by trained personnel using calibrated equipment and strictly adhering to standardized protocols. 5) Blood pressure measurement, hypertension, and hypertension control BP was measured using a standard mercury sphygmomanometer (Baumanometer Wall Unit 33(0850); Baum Co., Inc., Copiague, NY, USA). Participants sat in a comfortable position after they had rested for at least 5 minutes and had not smoked within 30 minutes of the measurement. ...
... First, central obesity, rather than high BMI, may be more closely associated with high BP. 5 Stratification by waist circumference (according to National Cholesterol Education Program Adult Treatment Panel III metabolic syndrome criteria 22) ) indicated contrasting results, where wider waist circumference was associated with poorer systolic and diastolic BP control rates in both sex, although without statistical significance. While BMI is a widely utilized and practically obtained index, waist circumference may better characterize obesity and metabolic health in association with BP control. ...
... 7) Differential misclassification bias also cannot be ruled out; in single-center studies from a domestic tertiary hospital, white coat hypertension occurred more frequently in patients with low BMI. 5 The slight decline of the combined BP control rate in the oldest group may be construed by survival bias. Our older participants might have been those who survived through high BP and are still relatively healthy, thus selectively surveyed. ...
Article
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Background and objectives: Discrepancy in blood pressure (BP) control rate may be owed to different risk factors associated with elevated systolic and diastolic BP (SBP and DBP). Methods: In a nationally representative survey of Korean population with BP measurements, a total of 5,100 participants with hypertension was included in the analyses. Three separate types of control rates were calculated: SBP, DBP, and (combined) S&DBP among all participants with hypertension and participants with treated hypertension, separately. Control rates were compared across sex and age groups. Multivariable logistic regression was used to identify demographic factors associated with SBP, DBP, and S&DBP control rates, separately. Results: In total, SBP, DBP, and S&DBP control rates were 63.0%, 63.7%, and 42.5% among all hypertension patients, and 77.5%, 87.4%, and 71.6% among treated hypertension patients. Men aged 40-49 years with hypertension and 30-39 years treated for hypertension had the highest SBP control rate (74.6% and 96.2%), which decreased by older age. Inversely, DBP control rate progressively increased with older age. SBP control rate among women with hypertension was the highest in 40-49 years (67.0%) but without linear trend by age group. Interestingly, both combined and DBP control rates were noticeably low among women aged 50-59 years. Women with body mass index ≥25 were at higher odds of having controlled SBP. Lower DBP control rate was observed in men with lower education level, higher household income, and heavy drinkers. Conclusions: Separate examination of control rates demonstrated different sex- and age-differential trends, which would have been overlooked in combined control rates.
... Pharmacological treatment of hypertension in Korea includes the use of angiotensin II receptor blockers, angiotensin-converting enzyme inhibitors, alpha blockers, beta blockers, calcium antagonists, and diuretics. These classes of antihypertensive agents are often effective, but side effects such as persistent dry cough (angiotensin-converting enzyme inhibitors), tachycardia (calcium antagonists), adverse lipid metabolism (beta blockers and diuretics), and potential worsening of heart failure (alpha blockers) often limit their use [14]. Angiotensin II receptor blockers are generally considered to have a placebo-like safety profile with fewer specific adverse events (cough) compared with angiotensin-converting enzyme inhibitors [15]. ...
... However, greater decreases in blood pressure have been associated with a greater reduction in risk of stroke in Asian patients compared with white patients, specifically in patients with diabetes or other associated comorbidities [34]. As such, a target SBP of < 140 mmHg is recommended for Korean patients at risk of stroke or coronary artery disease and in patients with diabetes or chronic kidney disease [14]. ...
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Background This was a phase 3, randomized, double-blind, placebo-controlled study. Methods Adult Korean patients with essential hypertension and a baseline mean sitting clinic systolic blood pressure (scSBP) ≥150 and ≤180 mmHg were randomized to 6-week treatment with placebo (n = 65), azilsartan medoxomil (AZL-M) 40 mg (n = 132), or AZL-M 80 mg (n = 131). The primary endpoint was the change from baseline to week 6 in trough scSBP. Results The least-squares mean (standard error) change from baseline in trough scSBP in the placebo, AZL-M 40-mg, and 80-mg groups at week 6 were − 8.8 (2.00), − 22.1 (1.41), and − 23.7 (1.40) mmHg, respectively (p < 0.001 for AZL-M 40 and 80 mg vs placebo). No clinically meaningful heterogeneity in efficacy was observed between subgroups (age, sex, diabetes status) and the overall population. Treatments were well tolerated and adverse events were similar between groups. Conclusions Results of this study confirm a positive benefit-risk profile of AZL-M for essential hypertension in Korean adults. Trial registration Clinicaltrial.gov; identifier number: NCT02203916. Registered July 28, 2014 (retrospectively registered) Electronic supplementary material The online version of this article (10.1186/s40885-018-0086-4) contains supplementary material, which is available to authorized users.
... [14] Guidelines have recommended both combination therapies of ARB with an HCTZ and an ARB with a CCB to achieve target BP. [15,16] In addition, FDC regimens have been well investigated to improve drug compliance in hypertension. [17] Which ARB-based fixed combination therapy is useful for hypertension uncontrolled by ARB monotherapy remains unclear. ...
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Background: To determine whether the effectiveness and safety of fixed-dose combinations (FDCs) of amlodipine orotate/valsartan (AML/VAL) 5/160 mg are noninferior to those of valsartan/hydrochlorothiazide (VAL/HCTZ) 160/12.5 mg in hypertensive patients with inadequate response to valsartan 160 mg monotherapy. Methods: This 8-week, active-controlled, parallel-group, fixed-dose, multicenter, double-blind randomized controlled, and noninferiority trial was conducted at 17 cardiovascular centers in the Republic of Korea. Eligible patients had mean sitting diastolic blood pressure (msDBP) ≥90 mm Hg despite monotherapy with valsartan 160 mg for 4 weeks. Patients were randomly assigned to treatment with AML/VAL 5/160 mg FDC (AML/VAL) group or VAL/HCTZ 160/12.5 mg FDC (VAL/HCTZ) group once daily for 8 weeks. A total of 238 patients were enrolled (AML/VAL group, n = 121; VAL/HCTZ group, n = 117), of whom 228 completed the study. Results: At 8 weeks after randomization, msDBP was significantly decreased in both groups (-9.44 ± 0.69 mm Hg in the AML/VAL group and -7.47 ± 0.71 mm Hg in the VAL/HCTZ group, both P < .001 vs baseline). Between group difference was -1.96 ± 1.00 mm Hg, indicating that AML/VAL 5/160 mg FDC was not inferior to VAL/HCTZ 160/12.5 mg FDC at primary efficacy endpoint. Control rate of BP defined as the percentage of patients achieving mean sitting SBP (msSBP) <140 mm Hg or msDBP <90 mm Hg (target BP) from baseline to week 8 was significantly higher in the AML/VAL group than that in the VAL/HCTZ group (84.3% [n = 102] in the AML/VAL group vs 71.3% [n = 82] in the VAL/HCTZ group, P = .016). At 8 weeks after randomization, mean uric acid level was significantly increased in the VAL/HCTZ group compared to that at baseline (0.64 ± 0.08 mg/dL; P < .001). However, it was slightly decreased from baseline in the AML/VAL group (-0.12 ± 0.08 mg/dL; P = .085). The intergroup difference was significant (P < .001). Conclusion: The effectiveness and safety AML/VAL 5/160 mg FDC are noninferior to those of VAL/HCTZ 160/12.5 mg FDC in patients with hypertension inadequately controlled by valsartan 160 mg monotherapy.
... This article concentrates on UK guidance 3 and experience, but will also consider a worldwide perspective. [4][5][6][7][8][9][10] The multitude of learned society guidelines is further expanded with the consideration of comorbidities such as renal disease, 11 diabetes 12 and coronary artery disease. 13 However, as a common disease with a global burden, pragmatically, 'there are situ- ations where the most simple and empirical care for hypertension' may be most appropriate. ...