Inequities in hypertension: we can do better … but how?

British Journal of General Practice | Vol. 73, Issue 736, November 2023

Hypertension is the most commonly reported long-term condition in the UK, estimated to affect one in three adults; however, it is underdiagnosed, and it is often suboptimally managed when diagnosed. This is despite well-established evidence that lifestyle modification and therapeutic treatment are highly effective in reducing fatal and non-fatal events, and morbidity.

In this issue of the BJGP, two articles explore some of the obstacles to effective management of hypertension:

• Rison, S. et al. Inequities in hypertension management: observational cross-sectional study in North East London using electronic health records
• Xu, W. et al. Team-based continuity of care for patients with hypertension: a retrospective primary care cohort study in Hong Kong
• See also: Inequities in hypertension: we can do better … but how? [Editorial]

Diagnosing hypertension in primary care: the importance of night-time blood pressure assessment

British Journal of General Practice 2023; 73 (726): e16-e23. DOI: https://doi.org/10.3399/BJGP.2022.0160

Ambulatory blood-pressure monitoring (ABPM) has become less frequent in primary care since the COVID-19 pandemic, with home blood-pressure monitoring (HBPM) often the preferred alternative; however, HBPM cannot measure night-time blood pressure (BP), and patients whose night-time BP does not dip, or rises (reverse dipping), have poorer cardiovascular outcomes.

This retrospective cohort study investigated the importance of measuring night-time BP when assessing individuals for hypertension. The authors conclude that not measuring night-time BP puts all groups, other than dippers, at risk of failure to identify hypertension. As a result of this study, it is recommended that GPs should offer ABPM to all patients aged over 60 years as a minimum when assessing for hypertension.

Full paper: Diagnosing hypertension in primary care: a retrospective cohort study to investigate the importance of night-time blood pressure assessment

Implementation of non-pharmacological interventions for the treatment of hypertension in primary care

Dhungana et al. | Implementation of non-pharmacological interventions for the treatment of hypertension in primary care: a narrative review of effectiveness, cost-effectiveness, barriers, and facilitators | BMC Primary. Care 23, 298 (2022). https://doi.org/10.1186/s12875-022-01884-8

The current guidelines for the prevention, detection, evaluation, and management of hypertension recommend six types of non-pharmacological interventions: alcohol reduction, salt intake reduction, increased potassium intake, physical activity, weight loss, and heart-healthy diets. However, the non-pharmacological interventions are still not widely used in primary care. This paper reviews and summarises the evidence on the effectiveness, cost-effectiveness, barriers, and facilitators of non-pharmacological interventions for the treatment of hypertension in primary care.

Full paper: Implementation of non-pharmacological interventions for the treatment of hypertension in primary care: a narrative review of effectiveness, cost-effectiveness, barriers, and facilitators

Reducing the disease burden for hypertension

Reducing the disease burden for hypertension – how an integrated approach is improving patient care | via UCLPartners

In this video case study GP Dr Vaishali Ashar, and Health and Wellbeing Coach, Darshana Lithagra, discuss transforming care for their patients by implementing the UCLPartners Proactive Care frameworks. They discuss the process and give a patient example of how it can work in practice, demonstrating how an integrated approach can improve patient care.

Lifestyle advice for hypertension or diabetes: trend analysis from 2002 to 2017 in England

British Journal of General Practice | Vol. 72, Issue 717 | DOI: https://doi.org/10.3399/BJGP.2021.0493

Guidelines recommend that GPs give patients lifestyle advice to manage hypertension and diabetes. Increasing evidence shows that this is an effective and practical treatment for these conditions, but it is unclear whether GPs offer this support. the aim of this research was to investigate trends in the percentage of patients with hypertension/diabetes receiving lifestyle advice versus medication.

The study showed only a minority of patients with diabetes or hypertension report receiving lifestyle advice or have this recorded in their medical records. Interventions beyond guidelines are needed to increase the delivery of behavioural interventions to treat these conditions.

Full detail: Lifestyle advice for hypertension or diabetes: trend analysis from 2002 to 2017 in England

First line drug treatment for hypertension and reductions in blood pressure according to age and ethnicity

Objective To study whether treatment recommendations based on age and ethnicity according to United Kingdom (UK) clinical guidelines for hypertension translate to blood pressure reductions in current routine clinical care.

Design Observational cohort study.

Setting UK primary care, from 1 January 2007 to 31 December 2017.

Participants New users of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB), calcium channel blockers (CCB), and thiazides.

Main outcome measures Change in systolic blood pressure in new users of ACEI/ARB versus CCB, stratified by age (< v ≥55) and ethnicity (black v non-black), from baseline to 12, 26, and 52 week follow-up. Secondary analyses included comparisons of new users of CCB with those of thiazides. A negative outcome (herpes zoster) was used to detect residual confounding and a series of positive outcomes (expected drug effects) was used to determine whether the study design could identify expected associations.

Results During one year of follow-up, 87 440 new users of ACEI/ARB, 67 274 new users of CCB, and 22 040 new users of thiazides were included (median 4 (interquartile range 2-6) blood pressure measurements per user). For non-black people who did not have diabetes and who were younger than 55, CCB use was associated with a larger reduction in systolic blood pressure of 1.69 mm Hg (99% confidence interval −2.52 to −0.86) relative to ACEI/ARB use at 12 weeks, and a reduction of 0.40 mm Hg (−0.98 to 0.18) in those aged 55 and older. In subgroup analyses using six finer age categories of non-black people who did not have diabetes, CCB use versus ACEI/ARB use was associated with a larger reduction in systolic blood pressure only in people aged 75 and older. Among people who did not have diabetes, systolic blood pressure decreased more with CCB use than with ACEI/ARB use in black people (reduction difference 2.15 mm Hg (−6.17 to 1.87)); the corresponding reduction difference was 0.98 mm Hg (−1.49 to −0.47) in non-black people.

Conclusions Similar reductions in blood pressure were found to be associated with new use of CCB as with new use of ACEI/ARB in non-black people who did not have diabetes, both in those who were aged younger than 55 and those aged 55 and older. For black people without diabetes, CCB new use was associated with numerically greater reductions in blood pressure than ACEI/ARB compared with non-black people without diabetes, but the confidence intervals were overlapping for the two groups. These results suggest that the current UK algorithmic approach to first line antihypertensive treatment might not lead to greater reductions in blood pressure. Specific indications could be considered in treatment recommendations.

Reference: BMJ 2020;371:m4080

Use of renin–angiotensin–aldosterone system inhibitors and risk of COVID-19 requiring admission to hospital: a case-population study

Background

Concerns have been raised about the possibility that inhibitors of the renin–angiotensin–aldosterone system (RAAS) could predispose individuals to severe COVID-19; however, epidemiological evidence is lacking. We report the results of a case-population study done in Madrid, Spain, since the outbreak of COVID-19.

Methods

In this case-population study, we consecutively selected patients aged 18 years or older with a PCR-confirmed diagnosis of COVID-19 requiring admission to hospital from seven hospitals in Madrid, who had been admitted between March 1 and March 24, 2020. As a reference group, we randomly sampled ten patients per case, individually matched for age, sex, region (ie, Madrid), and date of admission to hospital (month and day; index date), from Base de datos para la Investigación Farmacoepidemiológica en Atención Primaria (BIFAP), a Spanish primary health-care database, in its last available year (2018). We extracted information on comorbidities and prescriptions up to the month before index date (ie, current use) from electronic clinical records of both cases and controls. The outcome of interest was admission to hospital of patients with COVID-19. To minimise confounding by indication, the main analysis focused on assessing the association between COVID-19 requiring admission to hospital and use of RAAS inhibitors compared with use of other antihypertensive drugs. We calculated odds ratios (ORs) and 95% CIs, adjusted for age, sex, and cardiovascular comorbidities and risk factors, using conditional logistic regression. The protocol of the study was registered in the EU electronic Register of Post-Authorisation Studies, EUPAS34437.

Findings

We collected data for 1139 cases and 11 390 population controls. Among cases, 444 (39·0%) were female and the mean age was 69·1 years (SD 15·4), and despite being matched on sex and age, a significantly higher proportion of cases had pre-existing cardiovascular disease (OR 1·98, 95% CI 1·62–2·41) and risk factors (1·46, 1·23–1·73) than did controls. Compared with users of other antihypertensive drugs, users of RAAS inhibitors had an adjusted OR for COVID-19 requiring admission to hospital of 0·94 (95% CI 0·77–1·15). No increased risk was observed with either angiotensin-converting enzyme inhibitors (adjusted OR 0·80, 0·64–1·00) or angiotensin-receptor blockers (1·10, 0·88–1·37). Sex, age, and background cardiovascular risk did not modify the adjusted OR between use of RAAS inhibitors and COVID-19 requiring admission to hospital, whereas a decreased risk of COVID-19 requiring admission to hospital was found among patients with diabetes who were users of RAAS inhibitors (adjusted OR 0·53, 95% CI 0·34–0·80). The adjusted ORs were similar across severity degrees of COVID-19.

Interpretation

RAAS inhibitors do not increase the risk of COVID-19 requiring admission to hospital, including fatal cases and those admitted to intensive care units, and should not be discontinued to prevent a severe case of COVID-19.

Funding

Instituto de Salud Carlos III.

Reference: The Lancet, VOLUME 395, ISSUE 10238, P1705-1714, MAY 30, 2020

Hypertension, renin–angiotensin–aldosterone system inhibition, and COVID-19

Few could have imagined that hypertension and its treatment with inhibitors of the renin–angiotensin–aldosterone system (RAAS) would become a hot topic during the global COVID-19 pandemic. Two factors have contributed to this: first, the observation that hypertension is one of the most common comorbidities associated with severe cases of COVID-19 in patients who have been admitted to hospital and their risk of death; and second, that like the severe acute respiratory syndrome coronavirus (SARS-CoV), SARS-CoV-2 infects cells via specific binding to angiotensin-converting enzyme 2 (ACE2), which is ubiquitously expressed in the lung and other tissues.  These factors have fuelled speculation that use of RAAS inhibitors, particularly ACE inhibitors or angiotensin-receptor blockers, could lead to increased expression of ACE2 in the respiratory tract, thereby increasing the risk of both becoming infected and developing severe life-threatening complications due to COVID-19. The fact that no evidence supports any aspect of this speculation mattered little as the hypothesis gained traction, initially via social media and subsequently via the medical press. Anxiety among patients and physicians has been profound because ACE inhibitors and angiotensin-receptor blockers are the foundation of drug treatment for hypertension, heart disease, and chronic kidney disease, and are among the most widely prescribed drugs globally. Patients have subsequently been withdrawing and substituting these treatments, prompting international cardiovascular and hypertension specialist societies to issue statements of reassurance, while acknowledging the lack of high-quality data to refute the increasing alarm.

Full article: The Lancet,  VOLUME 395, ISSUE 10238, P1671-1673, MAY 30, 2020

Effect of Antihypertensive Medication Reduction vs Usual Care on Short-term Blood Pressure Control in Patients With Hypertension Aged 80 Years and Older

Question  Among older adults taking multiple antihypertensive medications, is a strategy of antihypertensive medication reduction noninferior to usual care with regard to short-term blood pressure control?

Findings  In this randomized clinical trial that included 569 patients aged 80 years and older, the proportion with systolic blood pressure lower than 150 mm Hg at 12 weeks was 86.4% in the intervention group and 87.7% in the control group (adjusted relative risk, 0.98), a difference that met the noninferiority margin of a relative risk of 0.90.

Meaning  The findings suggest antihypertensive medication reduction can be achieved without substantial change in blood pressure control in some older patients with hypertension.

Reference: JAMA. 2020;323(20):2039-2051. 

Efficacy of catheter-based renal denervation in the absence of antihypertensive medications (SPYRAL HTN-OFF MED Pivotal)

Background

Catheter-based renal denervation has significantly reduced blood pressure in previous studies. Following a positive pilot trial, the SPYRAL HTN-OFF MED (SPYRAL Pivotal) trial was designed to assess the efficacy of renal denervation in the absence of antihypertensive medications.

Methods

In this international, prospective, single-blinded, sham-controlled trial, done at 44 study sites in Australia, Austria, Canada, Germany, Greece, Ireland, Japan, the UK, and the USA, hypertensive patients with office systolic blood pressure of 150 mm Hg to less than 180 mm Hg were randomly assigned 1:1 to either a renal denervation or sham procedure. The primary efficacy endpoint was baseline-adjusted change in 24-h systolic blood pressure and the secondary efficacy endpoint was baseline-adjusted change in office systolic blood pressure from baseline to 3 months after the procedure. We used a Bayesian design with an informative prior, so the primary analysis combines evidence from the pilot and Pivotal trials. The primary efficacy and safety analyses were done in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT02439749.

Findings

From June 25, 2015, to Oct 15, 2019, 331 patients were randomly assigned to either renal denervation (n=166) or a sham procedure (n=165). The primary and secondary efficacy endpoints were met, with posterior probability of superiority more than 0·999 for both. The treatment difference between the two groups for 24-h systolic blood pressure was −3·9 mm Hg (Bayesian 95% credible interval −6·2 to −1·6) and for office systolic blood pressure the difference was −6·5 mm Hg (−9·6 to −3·5). No major device-related or procedural-related safety events occurred up to 3 months.

Interpretation

SPYRAL Pivotal showed the superiority of catheter-based renal denervation compared with a sham procedure to safely lower blood pressure in the absence of antihypertensive medications.

Funding

Medtronic.

Reference: The Lancet, VOLUME 395, ISSUE 10234, P1444-1451, MAY 02, 2020