M. Pappaccogli

Adherence to antihypertensive therapy and therapeutic dosage of antihypertensive drugs

Adherence to antihypertensive therapy is critical to achieving adequate blood pressure control. About half of hypertensive patients do not take their drugs as directed and the physicians often underestimate this issue. Non-adherence has important public health economic implications (numbers of visits, diagnostic procedures, prescribed drugs) and, moreover, it results in increased morbidity and mortality rates. Poor adherence can have several patients and therapy related causes. Currently, multiple different direct and indirect methods to measure therapeutic adherence are available, but, in clinical practice, there is no cost-effective and simple one. Therapeutic drug monitoring (TDM), characterized by drug (or metabolites) concentration measurement in body fluids (blood or urine), is a cost-effective direct method to assess therapeutic adherence. Despite some limitations, TDM may decrease health costs, by reducing the number of visits and by identifying those patients who would undergo unnecessary invasive procedures. Moreover, TDM can be a new alternative method to identify patients with true resistant hypertension, improving the achievement of blood pressure control In this minor revision, we would assess poor therapeutic adherence in hypertensive population, analyzing the different direct and direct available methods, with emphasis on TDM.

NURSE-OBP: A NURSING STANDARDISED METHOD FOR MEASURING BLOOD PRESSURE

Objective: Objective. The role of the nurse in both diagnostic and therapeutic management of hypertensive patient is becoming more and more important; nevertheless until now there is not a nursing standardised method of blood pressure (BP) measurement. The aim of this study was to standardise a nursing method for measuring blood pressure (Nurse-OBP) and to compare it with the Ambulatory Office Blood Pressure. Figure. No caption available. Design and method: Design and Method. 118 treated non-diabetic hypertensive adults afferent to our Hypertension Unit were included in the study. All underwent an AOBP measurement with Omron HEM-907XL and the Nurse-OBP measurement, designed to be methodologically identical to the classical AOBP proposed by Meyers and colleagues but which takes place with the nurse staying in the same patients room during the BP measurement. All subjects were randomized into two groups, different according to the order in which the two method of measurement were performed to avoid eventual reduction of white coat effect mostly deriving from changes in patient behaviour, and finally, during the medical examination all underwent a traditional OBP measurement. All patients signed an informed consent and the study was approved by local ethical committee (CEI 652). Pearsons correlation coefficient was used to evaluate agreement between AOBP and Nurse-OBP measurements Results: Results. Mean Nurse-OBP values (132 ± 19.4/73.3 ± 12.9) were significantly lower than OBP ones (141.3 ± 18.8/84.7 ± 10.7). When AOBP and Nurse-OBP were compared, no statistically significant differences between the two methods were found. The Bland - Altman analysis showed how the presence of the nurse could cause a minimum rise of BP values, (mean SBP and DBP difference respectively of 3.57 ± 12.23 mmHg and 2.25 ± 7.26 mmHg), but clinically non significant; therefore the two modalities, AOBP and Nurse-OBP, can be considered as comparable. Furthermore no differences in terms of Nurse-OBP values were found when the two groups were compared. Conclusions: Conclusions. Our study proposes a standardised nursing method for measuring BP absolutely comparable to AOBP technique, that could have practical implications mostly when it is not possible to have a dedicated room where performing AOBP.

Therapeutic drug monitoring guided definition of adherence profiles in resistant hypertension and identification of predictors of poor adherence

Arterial hypertension is an important cardiovascular risk factor. A substantial proportion of patients show resistance to antihypertensive treatment but poor adherence to medication regimens is also a significant cause of treatment failure. In this context, therapeutic drug monitoring (TDM) could be useful. The objective of this study was to assess adherence to treatment in patients with resistant hypertension by TDM and to identify parameters that predict nonadherence.

[PP.25.08] THERAPEUTIC DRUG MONITORING IN RESISTANT HYPERTENSIVES PREVIOUSLY TREATED WITH INVASIVE APPROACHES

Objective: Renal denervation (RDN) and baroreflex activation therapy (BAT) are invasive therapeutic approaches for resistant hypertension (RH), indicated when antihypertensive drug therapy is inefficacious. Several reports have found an unsatisfactory response to these approaches; one of the factors called upon to account for the failure of these devices is the lack of therapeutic adherence. The aim of this study was to retrospectively evaluate the therapeutic adherence, using an objective assessment as the therapeutic drug monitoring (TDM), in a group of patients who have undergone invasive approach in previous years, either RDN or BAT, and correlate it with the answer to the invasive procedure. Design and method: We retrospectively analysed 12 patients with RH (9 females). Before performing invasive procedure, all patients were considered adherent according to the physician intuition and the answers given to the Morisky questionnaire. Serum TDM, by Ultra High Performance Liquid Cromatography (UHPLC) method, was done during a routine follow up visit, after at least one year from the last invasive approach. A clinical response to invasive approaches was considered as a reduction in 24 h Ambulatory Blood Pressure Monitoring (ABPM) systolic blood pressure (SBP) of at least 10 mmHg at 12 months from the procedure. Patients were considered adherents (AD) if all the prescribed drugs were found or only one was not found; patients were considered non-adherents (NAD) if none of the prescribed drugs were found. Results: 4 patients were AD and 8 NAD. In the whole sample a clinical response was found in 41% of the patients. Among AD the clinical response rate was 75%, whilst among NAD the clinical response rate dropped to 25%. No significant clinical and social differences were found between NAD and AD, but NAD had significant higher office SBP and 24 h ABPM SBP than AD (p < 0.05). Conclusions: Lack of therapeutic adherence is associated to a limited clinical efficacy of invasive approaches in apparent RH. Our data underlines the importance of adherence therapeutic evaluation before and after performing invasive procedures, whose effectiveness can be undermined by poor therapeutic adherence.

[PP.01.15] ACCURACY OF HOME BLOOD PRESSURE MONITORING IN ARTERIAL HYPERTENSION DIAGNOSIS

Objective: The arterial hypertension diagnosis is based on office blood pressure measurement, and current guidelines suggest the use of out-of-office blood pressure measurement techniques in specific cases, as suspected white-coat or masked hypertension. Home Blood Pressure Monitoring (HBPM) is recommended as a complementary method to Ambulatory Blood Pressure Monitoring (ABPM). However usually HBPM is only used for implementing blood pressure control in treated patients. We tried to identify the accuracy between HBPM and ABPM in untreated patients. (We tried to identify HBPM accuracy between to ABPM in untreated patients.) Design and method: We enrolled 83 consecutive untreated patients who performed ABPM in our Hypertension Unit and completed a short HBPM schedule (two measurements, twice daily, for four days) between November 2011 and June 2015. Patients were instructed about HBPM in accord to current hypertension guidelines and they used validated automated arm devices. We compared the accuracy between the two techniques and the HBPM ability to identify arterial hypertension in comparison with ABPM. Results: Pearsons correlation coefficient between HBPM 4-day average and day-time ABPM values was 0.59 for systolic blood pressure (SBP) and 0.77 for diastolic blood pressure (DBP). Bland-Altman analysis revealed a mean difference of -5.68 mmHg, SD 8.82 mmHg for SBP, and -4.64, SD 6.33 mmHg for DBP. ROC curves described AUC for SBP of 0.75 and for DBP of 0.877. The ABPM identify as hypertensive 54 subjects on 83 (65.1%), the HBPM 29 subjects (34.9%), p-value 0.01609. Conclusions: HBPM has a moderate correlation and a moderate accuracy in the identification of arterial hypertension compared with ABPM. Although HBPM is recommended as alternative method respect to ABPM, in untreated patients it is not reliable for arterial hypertension diagnosis and probably it is not able to identify specific hypertension patterns, in contrast with current guidelines.

[PP.23.13] ANALYSIS OF ELIGIBILITY CRITERIA FOR RENAL SYMPATHETIC DENERVATION

Objective: Resistant hypertension (RH) is a rare condition that affects approximately 10% of hypertensive population, its defined as blood pressure (BP) > 140/90 mmHg despite three full doses antihypertensive drugs including a diuretic. True RH is confirmed when pseudo-hypertension, secondary hypertension or poor adherence are excluded. Percutaneous radio-frequency catheter-based renal sympathetic denervation (DRN) is one of the most used invasive treatments for these patients. The goal of the study is to assess the percentage of eligibility to DRN and analyze the exclusion criteria in a group of resistant hypertensive patients. Design and method: We retrospectively analyzed data of 35 patients (63% female) referred to our Hypertension Unit between June 2011 and June 2014. We considered eligible for DRN subjects with office systolic blood pressure > = 160 mmHg and patients with severe hypertension treated with fewer drugs for poly-intolerances/allergies. Secondary hypertension form and white coat hypertension were excluded. Patients with confirmed true resistant hypertension underwent CT angiography in order to check the renal anatomic criteria of eligibility to the DRN. Results: 35 caucasian patients (63% female) referred to our Hypertension Unit between June 2011 and June 2014 for DRN assessment. At the first evaluation median systolic and diastolic office BP were 179 ± 25 mmHg and 105 ± 20 mmHg; six month later, after appropriate changes in lifestyle and drug therapy, systolic/diastolic office BP was reduced of 18/8 mmHg (p < 0.05). In the most of cases, patients had to BP control with introduction of antialdosteronic (35%). In our sample, 27 patients were considered unsuitable for the DRN for many reason: blood pressure control with optimization of drug therapy (52%), evidence of white coat effect (22%), secondary hypertension (22%), lack of true resistant hypertension (18%), absence of consent to the procedure (29%). Conclusions: A carreful patients selection in Specialistic Center is necessary before DRN; indeed frequently a good BP control is obtained with appropriate drug therapy changes and exclusion of secondary forms.

Evaluation of a short home blood pressure measurement in an outpatient population of hypertensives

ABSTRACT Current guidelines suggest the use of home blood pressure monitoring (HBPM) as a method complementary to ambulatory blood pressure monitoring (ABPM) for the identification of arterial hypertension. A cross-sectional study was conducted to evaluate the accuracy of a short HBPM schedule compared with ABPM, and to evaluate to what extent HBPM can replace ABPM. A total of 310 patients who performed ABPM in our hypertension clinic were enrolled between November 2011 and June 2015. They performed a 4-day HBPM schedule, with two readings in the morning and two readings at night. Results showed a moderate correlation between HBPM and ABPM (r = 0.59 for systolic blood pressure (SBP) and r = 0.72 for diastolic blood pressure (DBP)) and moderate diagnostic agreement (area under curve: 0.791 for SBP and 0.857 for DBP). No significant difference was found between first-day average and those of days 2–4. Diagnostic agreement between the two techniques was moderate, supporting the notion that HBPM cannot replace ABPM in the general population. However, we identified two HBPM thresholds, 123/75 and 144/87 mm Hg, through which subjects who may not require further ABPM can be identified.