blood pressure control
Association Between Blood Pressure Control and Risk of Recurrent Intracerebral HemorrhageBlood Pressure Control and Recurrent Intracerebral HemorrhageBlood Pressure Control and Recurrent Intracerebral Hemorrhage
Importance Intracerebral hemorrhage (ICH) is the most severe form of stroke. Survivors are at high risk of recurrence, death, and worsening functional disability.
Objective To investigate the association between blood pressure (BP) after index ICH and risk of recurrent ICH.
Design, Setting, and Participants Single-site, tertiary care referral center observational study of 1145 of 2197 consecutive patients with ICH presenting from July 1994 to December 2013. A total of 1145 patients with ICH survived at least 90 days and were followed up through December 2013 (median follow-up of 36.8 months [minimum, 9.8 months]).
Exposures Blood pressure measurements at 3, 6, 9, and 12 months, and every 6 months thereafter, obtained from medical personnel (inpatient hospital or outpatient clinic medical or nursing staff) or via patient self-report. Exposure was characterized in 3 ways: (1) recorded systolic and diastolic measurements; (2) classification as adequate or inadequate BP control based on American Heart Association/American Stroke Association recommendations; and (3) stage of hypertension based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 7 criteria.
Main Outcomes and Measures Recurrent ICH and its location within the brain (lobar vs nonlobar).
Results There were 102 recurrent ICH events among 505 survivors of lobar ICH and 44 recurrent ICH events among 640 survivors of nonlobar ICH. During follow-up adequate BP control was achieved on at least 1 measurement by 625 patients (54.6% of total [range, 49.2%-58.7%]) and consistently (ie, at all available time points) by 495 patients (43.2% of total [range, 34.5%-51.0%]). The event rate for lobar ICH was 84 per 1000 person-years among patients with inadequate BP control compared with 49 per 1000 person-years among patients with adequate BP control. For nonlobar ICH the event rate was 52 per 1000 person-years with inadequate BP control compared with 27 per 1000 person-years for patients with adequate BP control. In analyses modeling BP control as a time-varying variable, inadequate BP control was associated with higher risk of recurrence of both lobar ICH (hazard ratio [HR], 3.53 [95% CI, 1.65-7.54]) and nonlobar ICH (HR, 4.23 [95% CI, 1.02-17.52]). Systolic BP during follow-up was associated with increased risk of both lobar ICH recurrence (HR, 1.33 per 10-mm Hg increase [95% CI, 1.02-1.76]) and nonlobar ICH recurrence (HR, 1.54 [95% CI, 1.03-2.30]). Diastolic BP was associated with increased risk of nonlobar ICH recurrence (HR, 1.21 per 10-mm Hg increase [95% CI, 1.01-1.47]) but not with lobar ICH recurrence (HR, 1.36 [95% CI, 0.90-2.10]).
Conclusions and Relevance In this observational single-center cohort study of ICH survivors, reported BP measurements suggesting inadequate BP control during follow-up were associated with higher risk of both lobar and nonlobar ICH recurrence. These data suggest that randomized clinical trials are needed to address the benefits and risks of stricter BP control in ICH survivors.
Losartan plus hydrochlorothiazide improves BP control in diabetics with hypertension
Combination therapy using losartan plus hydrochlorothiazide improves blood pressure control in patients with type 2 diabetes mellitus (T2DM) complicated with hypertension, according to a Japanese study.
The 24-week study recruited 43 Japanese patients with T2DM complicated with treatment-resistant hypertension. Prior to the study, participants were given 12 weeks of continuous treatment with the maximum dosage of angiotensin II receptor blockers (ARBs) as recommended in Japan, but their blood pressure did not reach the target level of systolic ≤130mm Hg and diastolic ≤80mm Hg. [Hypertens Res 2009;32:3-107]
Study participants were assessed for changes in blood pressure and metabolism after switching their treatment plan from maximum dose ARB to a combination of losartan 50 mg/day and hydrochlorothiazide 12.5 mg/day. At the end of the study, participants had significantly lower systolic and diastolic blood pressure. The results also showed that combination therapy did not have any effect on lipid metabolism, serum uric acid and potassium levels. However, HbA1c levels were higher and urinary albumin-creatinine ratios lower, said the researchers. [Intern Med 2014;53:1283-9]
The study found that mean systolic blood pressure dropped from 147±11mmHg at baseline to 133±13 mmHg at the end of the study, while mean diastolic blood pressure fell from 79±8 mmHg to 72±10 mmHg. This significant reduction could be due to the fact that patients with diabetes have enhanced renal tubular reabsorption, leading to the formation of sodium-sensitive hypertension. Diuretics promote sodium excretion, thus increasing the antihypertensive effects of other drugs.
Another explanation for the improved antihypertensive effect is that hydrochlorothiazide probably enhances the antihypertensive effects of ARBs by reducing circulating blood volume and increasing plasma renin activity. As ARBs work by inhibiting the actions of angiotensin II, their effectiveness increases in parallel with plasma renin activity. [J Pharmacol Exp Ther 1990;252:726-32]
Most patients with diabetes complicated by hypertension require multidrug therapy to achieve target blood pressure. Combining a diuretic with ARB and regularly monitoring kidney function, electrolytes and glucose metabolism is a potentially effective option for patients who fail first-line therapy using ARBs. This is particularly apparent in diabetic Japanese patients with treatment-resistant hypertension, summarized the researchers.
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