Association of blood pressure with sodium-related knowledge and behaviors in adults with hypertension.

 

Increased sodium consumption can increase ones chances of developing hypertension. The purpose of this study was to evaluate a test group of 664 patients with hypertension to see if they were aware of this fact, and if they regularly checked the amount of sodium that was in their food. The vast majority of the patients (91.1%) reported that they were aware of the correlation between sodium and hypertension, but only 15% reported that they regularly check the sodium content of the food that they buy.

It is an interesting problem that so many patients are aware of the effects of excessive sodium intake, but so few actually do anything to regulate their sodium intake. It is possible that people just don’t realize they can keep track of the amount of sodium that is in their foods so easily. If that is the case, doctors and pharmacists should make sure that they are not only telling hypertensive patients about the effects of sodium, but also reminding them that they can easily keep track of how much sodium they are getting by looking at the nutrition facts labels of the food they buy.

Westrick SC, Garza KB, Stevenson TL, Oliver WD. Association of blood pressure with sodium-related knowledge and behaviors in adults with hypertension. Journal of American Pharmacists Association. 2014;54;154-158.

Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses

According to the new guidelines for treatment of hypertension, it is recommended to initiate pharmacological treatment in diabetic patients when their blood pressure goes above 140/90. This recommendation is one of many that come from JNC 8, a trusted guideline by pharmacists and doctors all over the world. One issue with the JNC treatment guidelines, however, is that while they give extensive and thorough recommendations about the initiation of antihypertensive therapy, they offer little to no recommendations about when antihypertensives should be continued or stopped after a goal blood pressure has been reached.

 

In this review article that looked at 49 randomized controlled trials, it was determined that further treatment of diabetes patients with anti-hypertensives after they were below goal blood pressure actually increased risk of cardiovascular death as well as correlated to an increase towards all types of mortality. This surprised me because it seems counterintuitive that antihypertensive medications could ever increase the possibility of a cardiovascular death, even in a patient with healthy blood pressure.

 

I think this article may shed some light on the “if it ain’t broke don’t fix it” attitude of many doctors towards maintenance medications. Many doctors will keep their patients on anti-hypertensives or statins even if the patient’s blood pressure or lipid levels are at goal. This attitude, as shown by this review article, could have some negative effects on patient outcomes. What do you think? Should patients be discontinued on medications when they reach their goals? Or is this review finding specific to patients with both hypertension and diabetes?

 

Brunström M. & Carlberg, B. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: Systematic review and meta-analyses. Bmj 2016;352:I717.

Study suggests sildenafil may relieve severe form of edema in swimmers

Swimmers and divers who are prone to pulmonary edema in cold water (which can be deadly), could benefit from a dose of sildenafil, which is more commonly known by its brand name, Viagra®.

We all know that sildenafil can be used to treat erectile dysfunction in men, but it is also used to treat pulmonary arterial hypertension.  It works by dilating blood vessels.  In cold water swimmers and divers, their blood vessels rapidly constrict; this can lead to pooling of blood in the heart and lungs.

Athletes and swimmers with SIPE (swiming-induced pulmonary edema) cough up blood, have trouble breathing, and have low blood oxygen.  The symptoms may go away over 24 hours, but the condition can be fatal.

Researchers put 10 SIPE-susceptible athletes into a pool that mimicked the conditions that trigger SIPE.  They then compared those 10 athletes to 20 other athletes who had no history of SIPE.  The SIPE-susceptible athletes had higher pulmonary arterial pressure and pulmonary artery wedge pressure during the underwater exercise.

When the SIPE susceptible athletes were given sildenafil and performed the same exercises, their pressures were no longer as elevated.

In the words of Moon, one of the researchers, the conclusion of the study is that “It appears that the drug, which dilates the blood vessels, could be creating more capacity in the blood vessels in the arms and legs, reducing the tendency for blood to redistribute to the thorax, and therefore reducing the high pressure in the pulmonary vessels.”

This can be a promising lead on a drug that can make swimming/diving possible for people who are prone to SIPE.

The question I will pose is:  Is it better to take drugs as a preventative measure, or to take them after symptoms have developed?

 

 

Richard E. Moon, Stefanie D. Martina, Dionne F. Peacher, Jennifer F. Potter, Tracy E. Wester, Anne D. Cherry, Michael J. Natoli, Claire E. Otteni, Dawn N. Kernagis, William D. White, and John J. Freiberger. Swimming-Induced Pulmonary Edema: Pathophysiology and Risk Reduction With Sildenafil. Circulation: Journal of the American Heart Association, February 2016 DOI:10.1161/CIRCULATIONAHA.115.019464

Barriers to Effective Management of Hypertension in Older Populations

The leading cause of preventible death, not only in our own country, but worldwide, is hypertension. There is substantial evidence from robust trials for management of hypertension in older adults. The prevalence of hypertension seems to  increase with age, and therefore management of hypertension among older individuals through pharmacotherapy is essential to reach optimal health care for older populations. I study was conducted through the Journal of Pharmaceutical Policy and Practice to determine how exactly the prevalence of hypertension changes with age. The study also explored evidence regarding current pharmacological management in older adults for hypertension. The evidence from this study was then used to identify barriers that prevent older adults from receiving the best quality of care in the management of their hypertension.

The study found that the number of individuals struggling with hypertension increases significantly with age. At the age of 65 years or younger, 30% of the population has hypertension. But the age of 80 and over, this percentage of individuals with hypertension increased to 70% of the population. With the increase of the prevalence of hypertension with age, there is good evidence for the use of a number of medications to control blood pressures in older population.  However, despite good evidence for pharmacological management of hypertension in older adults, the quality of care available for treatment of hypertension in older adults is suboptimal. System, physician, and patient related barriers prevented older adults from reaching optimal blood pressure control.

J of Pharm Policy and Pract Journal of Pharmaceutical Policy and Practice 8.1 (2015): n. pag. Web.

Link to article

This study showed me the importance of open dialogue between patients and pharmacists. A pharmacist could easily prevent the patient-related barrier to the optimal treatment of hypertension in older adults. A pharmacist must make sure that each of his or her patients knows exactly how to adhere to his or her medication regimen. A pharmacist must also be able to advocate for his or her patients by expressing any concerns that they may have to the physician. Communication and a strong patient-pharmacist relationship are key to fixing the under treatment of hypertension in the older population.

New Drug to Prevent Heart Failure

In the event of a myocardial infarction or another related episode concerning one’s cardiovascular health, it is common for an angiotensin converting enzyme inhibitor to be prescribed in addition to a beta adrenergic blocker, and a diuretic or aldosterone antagonist. In place of an ACE inhibitor an angiotensin II receptor blocker (ARB) may be prescribed. However, a new class of drug is being studied that may become an additional team player in the fight against cardiovascular disease.

Sacubitril is a prodrug which is converted to LBQ657 by esterases in the body. This metabolite is a neprilysin inhibitor. Neprilysin is an endopeptidase that can degrade peptides that are responsible for regulating actions in the blood vessels. This can lead to vasoconstriction and increased sodium retention. Thus, sacubitril would work to reduce vasoconstriction and sodium retention.

So far the formulation of this drug has been only in a form coupled with valsartan; it has not been administered as the single drug, sacubitril. It was administered to 8,400 patients with symptomatic heart failure and a left ventricle ejection of 40% or lower. The patients involved had been treated with an ACE inhibitor and a beta adrenergic blocker for at least 4 weeks. Many of the patients were also taking a diuretic. The rate of cardiovascular deaths for those taking sacubitril was 13.3% which was considered significantly lower than that of those taking the ACE inhibitor, enalapril, which was 16.5%.

Thus there is reason to believe that sacubitril, and other drugs from this class of neprilysin inhibitors, may account for a new model of first line drug therapy in the treatment of cardiovascular disease.

Reference

Hussar D, Abdelsayed M. Sacubitril/valsartan, ivabradine hydrochloride, alirocumab, and evolocumab. Journ Am Pharm Assoc. 2015; 55(6): 674-78.

J Am Pharm Assoc. 2016; 55(6): 674-678

Hypertension and Precision Medication

Hypertension is one of the most common disease states amongst US adults today. About 80 million US adults are currently dealing with high blood pressure, and amongst these 80 million patients, 48% are taking more than one medication and 40% are still seeing no response to their drug therapy. In order to combat this issue, precision medicine and epigenetics have the potential to yield more effective drug treatment for hypertension control by identifying personalized targets for prevention and treatment.

The Precision Medicine Initiative that was introduced in 2011 by the US National Research Council is intended to produce new approaches for detecting, measuring, and analyzing biomedical information. Current work in precision medicine focuses mainly on genome sequences, however, this alone does not account for environmental and lifestyle factors that contribute to complex diseases like hypertension. Epigenomics, on the other hand, does pick up on environmental and lifestyle factors it is therefore important to include this study when assessing for more complex pathologies.

The mechanism behind hypertension and responses in blood pressure to different antihypertensives varies between different groups of patients. Blood pressure is not an easily identifiable phenotype because of specific environmental exposures. It is predicted that in the future, precision medicine that also incorporates epigenomics will lead to the development  of new drug targets for the treatment of hypertension. Translating these findings into a clinical setting will require a cooperated and coordinated effort.

JAMA. 2016;315(4):343-344.

Link to article

Precision medicine and epigenomics, in my opinion, is leading to a more  efficient community of medicine. This increase in efficiency is going to lead to an overall more positive medication experience for all patients. Despite some of the negative perceptions of genetic sequencing, I believe that is important for the future of medicine to lead more and more individuals towards personalized medication. This will result in less drug therapy problems and faster responses to drug therapy. It is exciting to see personalized medication make its way to more common disease states.

 

Prevalence of Excess Sodium Intake in The United States

This article addresses a problem that is facing the United States and is contributing to many health concerns- sodium intake. The National Health and Nutrition Examination Survey found that out of 14,728 people, 89% of adults and over 90% of children had sodium intake over the recommended daily amount, which is 2,300 mg. In addition, for patients with hypertension, 86% of them exceeded the daily dietary sodium intake. Hypertension is a major risk factor for developing cardiovascular disease and is prevalent in about 29% of the United States. Increased sodium consumption can increase blood pressure, and thus cause hypertension, and by reducing sodium intake, people will also reduce their blood pressure and risk for developing cardiac problems down the road. When analyzing why the sodium intake is so high in America, there were some major food sources identified such as breads, deli meats, pizza, soup, meatloaf, and tomato sauce. In order to help combat this problem, the CDC is recommending an decrease in consumption of these foods, an increase in consumption of fruits and vegetables, and is implementing guidelines and recommendations for food manufacturers and restaurants to reduce the sodium content added to their foods.

MMWR Morb Mortal Wkly Rep. 2016; 64(52):1393-1397.

I believe this article is addressing a major problem in our country because “fast food” is heavily relied on for our on-the-go society. These foods are fried, battered, and have high sodium and caloric contents. This high reliance on and intake of sodium is contributing to the growing problem of obesity and heart disease in America. Specifically, this is contributing to the epidemic of hypertension that we see in pharmacies, and in my pharmacy alone, the vast majority of the “fast mover” medications are related to hypertension. I make sure my diet is low in sodium and other food additives, but not everyone has the time or resources to do this. How can we help fix our country’s dependence on sodium-rich foods so that we can target the source of a disease state that affects so many people and requires them to go on so many medications?

Interactive effects of physical fitness and body mass index on the risk of hypertension

A cohort study with Sweden was conducted over a long duration of time. They measured the aerobic capacity, muscular strength, and body mass index during military consignment evaluations in Sweden from 1969 to 1997. This accounts for 97% of 18 year old men in Sweden during that duration of time. The researchers performed follow-up evaluations of these patients in 2012 to measure their degree of hypertension. The study measures the correlation between aerobic capacity, muscular strength, and body mass index in late adolescence and the degree of hypertension in adulthood. The results showed that high body mass index and low aerobic capacity combined posed the highest risk of developing hypertension later in life. In patients with normal body mass index, a low aerobic capacity still posed a significant risk of developing hypertension. All statistics were adjusted for socioeconomic status and family history.

JAMA Intern Med. 2016;176(2):210-216.
I think this research is important because it shows that patients can intervene at a young age to prevent disease states like hypertension later in life. It demonstrates that diseases, even ones that seem to be hereditary like hypertension, are not always inevitable. We can take action now to lower our risk.
I think further research should be done to measure how aerobic capacity, muscular strength, and body mass index affect risk of developing hypertension in women, as well as other ethnicities.

Effects of intensive blood pressure on lowering cardiovascular and renal outcomes

This study analyzed data collected from previous trials involving different blood pressure reduction practices to reduce risk of major cardiovascular and renal events to determine which strategies were most effective. The study looked at data from different trials using more intensive blood pressure reduction, such as stricter target blood pressures or antihypertension medication dosing regimens, versus less strict treatment guidelines. The risk of cardiovascular or renal events looked at were myocardial infarctions, stroke, cardiovascular failure, and end-stage kidney diseases.

The study found that ultimately, the more intensive hypertension treatments are more beneficial than the less intensive ones to all populations, including patients with systolic blood pressure under 140 mmHg. 19 trials with 44989 participants were included in that data analysis, with 2496 major cardiovascular events in a 3-8 year range. The patients that underwent more intensive treatments had a mean blood pressure of 133/76 mmHg, while those with less intensive treatments had a mean blood pressure of 140/81 mmHg. The patients with intensive blood pressure treatments had 14% decreased chance of major cardiovascular events, though didn’t seem to have conclusively less risk of total mortality or end-stage kidney disease.

Management of hypertension is becoming a very important subject within the field of pharmacy, especially since an increasing percentage of the population are struggling with lowering blood pressure. It’s interesting to see a comparison of the efficacy of different antihypertensive practices within different patient populations as we have recently discussed these very guidelines in class. One question that this article raises is why are blood pressure guidelines becoming less stringent, and why are less intensive blood pressure treatments not being used as much in higher-risk patient populations?

Citation:

Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016; 387: 435-43.

http://thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00805-3.pdf

Blood Pressure kiosks for medication therapy management programs

For one month, the total revenue collected by using blood pressure kiosks was generated and measured to identify how valuable kiosks could be in identifying hypertensive patients. Studies currently show that hypertension affects twenty to thirty percent of North American adults, and one-half of this hypertensive population remain uncontrolled. Uncontrolled hypertension leads to many adverse effects, some of which include heart failure, myocardial infarction, and stroke. By implementing blood pressure kiosks, patients may more easily obtain their blood pressure readings, and therefore find help from pharmacists if deemed necessary.

From this study, researchers concluded that on average, 189 hypertensive patients per month would qualify for a drug review and patient consult with a pharmacist. These reviews and consults would qualify for revenue collected. Overall, more than 7.5 million readings from 341 pharmacies were taken on the blood pressure kiosks. Through calculations, researchers determined by pharmacies could collect an average of $12,270 annually in revenue from MTM services provided to patients who discovered their hypertension. It is evident that blood pressure kiosks are very valuable in a pharmaceutical setting.

I found this article interesting because I myself have used a similar kiosk at a local pharmacy. Although I had already known that I was not hypertensive and I was merely just playing with the technology, I did wonder how beneficial the kiosk was to the company that I was in. From this study, I have no doubt implementing a blood pressure kiosk can help pharmacists generate more patients, thereby providing the assistance and improving patient outcomes.

 

Houle SK, Chuck AW, Tsuyuki RT. Blood pressure kiosks for medication therapy management programs: Business opportunity for pharmacists.. J Am Pharm Assoc. 2003;52:188-194.

http://japha.org/article.aspx?articleid=1044014#Methods