BP+ benefits in a nutshell

Hypertension and pharmacy

Hypertension remains a vital, modifiable risk factor in the prevention of cardiovascular disease. However, many patients do not achieve their therapeutic goals for numerous reasons which can include poor disease insight and non adherence. 

Pharmacists can be key players in controlling hypertension, given their medication knowledge and patient counselling skills, yet they remain an under-utilised resource in the management of chronic disease states. 

The role of the pharmacist in hypertension encompasses medication management, disease state education and patient counselling and is most successful when integrated into the patient's care team (Di Palo and Kish, 2018).

Central Blood Pressure

 Central blood pressure is a novel predictor of cardiovascular risk that can be measured in the clinical setting using currently available technology.

Studies show that systolic aortic blood pressure has been shown to be a superior predictor of cardiovascular risk as compared to brachial blood pressure.

As more studies emerge demonstrating the value of central blood pressure as a therapeutic target, it is possible that targeting central blood pressure may become an important part of the armamentarium to lower cardiovascular risk (Ochoa et al., 2018).

Central Blood pressure and medication management

Central blood pressure (BP) is an acknowledged contributor to end-organ damage and independent determinant of prognosis (Kosmala et al., 2016).

Hypertension management guided by central BP, resulting in significant withdrawal of medication to maintain appropriate BP control, had no adverse effect on LV systolic or diastolic function. Clinical trials registration: Australia New Zealand Clinical Trial Registry Number ACTRN12608 000041358.

Hypertensive patients whose brachial blood pressure were controlled have significantly higher central aortic systolic pressure (CASP) than normal subjects. 

CONCLUSIONS: Central blood pressure is more reflective of actual blood pressure and vessel function. Enhanced control of CASP in hypertensive patients contributes to improving vessel compliance (Li et al., 2015).

Arm cuff blood pressure (BP) may overestimate cardiovascular risk. Central aortic BP predicts mortality and could be a better method for patient management. Guidance of hypertension management with central BP results in a significantly different therapeutic pathway than conventional cuff BP, with less use of medication to achieve BP control and no adverse effects on left ventricular mass, aortic stiffness, or quality of life (Sharman et al., 2013).

Dangers of overly aggressive Blood Pressure Control

A personalised approach to BP drug management is suggested, considering individual risks, benefits, and preferences when choosing therapeutic targets, recognising that a goal of 130/80 mmHg should always be considered (US guidelines). Additionally, we recommend an intense focus on lifestyle changes and medication adherence (Rahman and McEvoy, 2018).

 Arterial stiffness and Cardiovascular Risk

Increasing evidence indicates that remarkable differences in cardiovascular risk between ethnic groups cannot be fully explained by traditional risk factors such as hypertension, diabetes or dyslipidemia measured in midlife. Therefore, the underlying pathophysiology leading to this "excess risk" in ethnic minority groups is still poorly understood, and one way to address this issue is to shift the focus from "risk" to examine target organs, particularly blood vessels and their arterial properties more directly. In fact, structural and functional changes of the vascular system may be identifiable at very early stages of life when traditional factors are not yet developed. 

Arterial stiffening, measured as aortic pulse wave velocity, and wave reflection parameters, especially augmentation index, seem to be an important pathophysiological mechanism for the development of cardiovascular disease and predict mortality independent of other risk factors (Faconti et al., 2016).

Pulsatile arterial haemodynamics

Due to the cyclic function of the human heart, pressure and flow in the circulation are pulsatile rather than continuous. 

Addressing pulsatile haemodynamics starts with the most convenient measurement, brachial pulse pressure, which is widely available, related to development and treatment of heart failure (HF), but often confounded in patients with established HF. The next level of analysis consists of central (rather than brachial) pressures and, more importantly, of wave reflections (Weber and Chirinos, 2018).

The true additive value of measuring arterial ageing with a given apparatus had to be translated into the predictive value of arterial stiffness as an intermediate end point, i.e., the higher the arterial stiffness the higher the number of cardiovascular (CV) events (Laurent et al., 2016).

Study: Differential effects of angiotensin II receptor blocker and losartan/hydrochlorothiazide combination on central blood pressure and augmentation index.

Central systolic blood pressure (CSBP) may be a better predictor of cardiovascular risk than clinic brachial (B)SBP. 

The effects of dose increment from medium dose of angiotensin II receptor blockers (ARBs) to the maximum dose of ARBs (maximum) and changing from medium dose of ARBs to losartan 50 mg/hydrochlorothiazide 12.5 mg combination (combination) were compared in hypertensive patients in whom monotherapy with a medium ARB dose did not achieve goal home SBP (135 mmHg). 

Four weeks after treatment with a medium ARB dose monotherapy, those whose home SBP level was above 135 mmHg were randomised to receive the maximum ARB dose (n = 101) or the combination (n = 99) once daily for 8 weeks. Both regimens significantly decreased BSBP and CSBP, while a decrease in BSBP and CSBP was greater with combination.The maximum significantly decreased augmentation index (AIx), while the combination did not. The rate of a decrease in reflection to decrease in CSBP was greater in the maximum than in the combination. 

In the elderly subgroup, the combination more effectively lowered BSBP than the maximum, and only the combination decreased CSBP. However, in the young subgroup, the maximum decreased AIx more than combination, while both regimens lowered CSBP and BSBP to a similar extent. It is explained in part that the maximum may affect pulse wave reflection more predominantly than the combination, especially in young subjects. A weak effect on pulse wave reflection and, thus, on CSBP, of the combination may be overcome by the potent antihypertensive effect of this regimen (Metoki et al., 2015).

Long term medication adherence

Health care providers should acknowledge the impact of multiple long-term medicines on patient's daily lives and should make an effort to diminish patients' medication-related burden by improving patient-provider relationships and by providing adequate treatment information incorporating patients' individual circumstances. This may facilitate the integration of long-term medicine use in patients' daily lives (van der Laan et al., 2018).

Pulse Rate Variability and Atrial Fibrillation (AF)

Many patients with atrial fibrillation (AF) present with stroke as their first clinical manifestation and since improved AF screening methods are thus required, we investigated whether pulse rate variability parameters predict future AF and cerebrovascular events.

Conclusion: Elevated RMSSD or IrrIx values indicative of the presence of AF predict future AF and cerebrovascular events; more so with increasing pulse irregularity and even among those without prior AF diagnosis (Sluyter et al., 2018).

Reference: 

DI PALO, K. E. & KISH, T. 2018. The role of the pharmacist in hypertension management. Curr Opin Cardiol,33,382-387.

FACONTI, L., NANINO, E., MILLS, C. E. & CRUICKSHANK, K. J. 2016. Do arterial stiffness and wave reflection underlie cardiovascular risk in ethnic minorities? JRSM Cardiovasc Dis,5,2048004016661679.

KOSMALA, W., MARWICK, T. H., STANTON, T., ABHAYARATNA, W. P., STOWASSER, M. & SHARMAN, J. E. 2016. Guiding Hypertension Management Using Central Blood Pressure: Effect of Medication Withdrawal on Left Ventricular Function. Am J Hypertens,29,319-25.

LAURENT, S., MARAIS, L. & BOUTOUYRIE, P. 2016. The Noninvasive Assessment of Vascular Aging. Can J Cardiol,32,669-79.

LI, M., LIU, Y., LI, M. & JIANG, H. 2015. [The Application of Noninvasive Central Blood Pressure Detection in Blood Pressure Management and Vessel Function Assessment of Hypertension]. Zhongguo Yi Liao Qi Xie Za Zhi,39,219-21.

METOKI, H., OBARA, T., ASAYAMA, K., SATOH, M., HOSAKA, M., ELNAGAR, N., MIYAWAKI, Y., KOJIMA, I., OHKUBO, T. & IMAI, Y. 2015. Differential effects of angiotensin II receptor blocker and losartan/hydrochlorothiazide combination on central blood pressure and augmentation index. Clin Exp Hypertens,37,294-302.

OCHOA, A., PATARROYO-APONTE, G. & RAHMAN, M. 2018. The Role of Central Blood Pressure Monitoring in the Management of Hypertension. Curr Cardiol Rep,20,41.

RAHMAN, F. & MCEVOY, J. W. 2018. Dangers of Overly Aggressive Blood Pressure Control. Curr Cardiol Rep,20,108.

SHARMAN, J. E., MARWICK, T. H., GILROY, D., OTAHAL, P., ABHAYARATNA, W. P. & STOWASSER, M. 2013. Randomized trial of guiding hypertension management using central aortic blood pressure compared with best-practice care: principal findings of the BP GUIDE study. Hypertension,62,1138-45.

SLUYTER, J. D., CAMARGO, C. A., JR., LOWE, A. & SCRAGG, R. K. R. 2018. Pulse rate variability predicts atrial fibrillation and cerebrovascular events in a large, population-based cohort. Int J Cardiol.

VAN DER LAAN, D. M., ELDERS, P. J. M., BOONS, C., NIJPELS, G., KRSKA, J. & HUGTENBURG, J. G. 2018. The impact of cardiovascular medication use on patients' daily lives: a cross-sectional study. Int J Clin Pharm,40,412-420.

WEBER, T. & CHIRINOS, J. A. 2018. Pulsatile arterial haemodynamics in heart failure. Eur Heart J.