Zengwu Wang

Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature

We assessed, in a double-blind, placebo-controlled trial, whether lowering blood pressure (BP) prevents the recurrence of stroke in Chinese patients with cerebrovascular disease. Patients were randomized into two groups: 2825 patients received a placebo and 2840 patients received 2.5 mg of indapamide daily. The primary and secondary outcomes were the recurrence of fatal or nonfatal stroke and major fatal and nonfatal cardiovascular events, respectively. The average systolic/diastolic BP at randomization was 153.8/92.8 mm Hg. At median follow-up (2 years), BP was, on an average, 6.8/3.3 mm Hg lower in patients on active treatment. In total, 143 patients on indapamide and 219 patients on placebo had recurrent strokes (hazard ratio for indapamide, 0.69; 95% confidence interval (CI): 0.54–0.89; P<0.001). In addition, 199 patients on indapamide and 258 patients on placebo had a cardiovascular event (hazard ratio, 0.75; 95% CI: 0.89–0.62; P=0.002). We performed a systematic review of literature that included our new results. Across 10 trials, the odds ratio for the prevention of stroke recurrence by BP lowering was 0.78 (95% CI: 0.68–0.90; P=0.0007). The pooled odds ratio was 0.63 (95% CI: 0.54–0.73; P<0.0001) for trials involving diuretics as a component of therapy and 0.93 (95% CI: 0.87–1.01; P=0.086) for trials in which treatment included renin system inhibitors (P<0.0001 for heterogeneity). The weighted correlation between the odds for stroke recurrence and the reduction in systolic BP was −0.57 (P=0.067). In conclusion, BP lowering by indapamide treatment reduced the recurrence of stroke and the incidence of cardiovascular events in Chinese patients with cerebrovascular disease. Whether prevention of stroke recurrence depends on drug class, degree of BP lowering or both requires further investigation.

Implications of Recently Published Trials of Blood Pressure–Lowering Drugs in Hypertensive or High-Risk Patients

We reviewed 6 recent outcome trials of blood pressure (BP)-lowering drugs in 74,524 randomized hypertensive or high-risk patients. Over interpretation of nonsignificant or marginal probability values in large trials with overlapping end points, exclusion of patients not tolerating or not adhering to experimental treatments, labeling nonsignificant treatment effects as modest, and insufficient information on the quality of the BP measurements or on the BP changes early after randomization raise concern. From a clinical viewpoint, results should not be extrapolated to patients with characteristics dissimilar from those randomized. The benefit beyond BP lowering in cardiovascular prevention is tiny. Dual inhibition of the renin system should only be used in patients at high risk, in whom all drug combinations have been tried and who cannot be controlled by a single renin system inhibitor. Current evidence does not support BP lowering in normotensive patients or the use of renin system inhibitors for prevention of stroke recurrence. Because angiotensin-receptor blockers might offer less protection against myocardial infarction than angiotensin-converting enzyme inhibitors, the latter should remain the preferred renin system inhibitor for cardiovascular prevention in angiotensin-converting enzyme inhibitor-tolerant patients. In 2 trials, in which new-onset diabetes was a predefined end point, 1000 patients had to be treated for 1 year with an angiotensin-receptor blocker instead of placebo to prevent just 2 cases. From a design viewpoint, the time has come to revise the concept of large simple trials and to pursue research questions that serve patient interests more than showing noninferiority or highlight the ancillary qualities of marketable antihypertensive drugs.

Status of Hypertension in China: Results From the China Hypertension Survey, 2012–2015

Background: Although the prevalence of hypertension (HTN) continues to increase in developing countries, including China, recent data are lacking. A nationwide survey was conducted from October 2012 to December 2015 to assess the prevalence of HTN in China. Methods: A stratified multistage random sampling method was used to obtain a nationally representative sample of 451 755 residents ≥18 years of age from 31 provinces in mainland China from October 2012 to December 2015. Blood pressure (BP) was measured after resting for 5 minutes by trained staff using a validated oscillometric BP monitor. HTN was defined as systolic BP (SBP) ≥140 mm Hg/or diastolic BP (DBP) ≥90 mm Hg or use of antihypertensive medication within 2 weeks. Pre-HTN was defined as SBP 120 to 139 mm Hg and DBP 80 to 89 mm Hg without antihypertensive medication. HTN control was defined as SBP <140 mm Hg and DBP<90 mm Hg. In addition, the prevalence of HTN (SBP ≥130 or DBP ≥80 mm Hg) and control rate (SBP <130 and DBP <80 mm Hg) of HTN were also estimated according to the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline. Results: Overall, 23.2% (≈244.5 million) of the Chinese adult population ≥18 years of age had HTN, and another 41.3% (≈435.3 million) had pre-HTN according to the Chinese guideline. There were no significant differences of HTN prevalence between urban and rural residents (23.4% versus 23.1%, P=0.819). Among individuals with HTN, 46.9% were aware of their condition, 40.7% were taking prescribed antihypertensive medications, and 15.3% had controlled HTN. Calcium channel blockers were the most commonly used antihypertensive medication (46.5%) as monotherapy, and 31.7% of treated hypertensive patients used ≥2 medications. The prevalence of HTN based on the 2017 American College of Cardiology/American Heart Association guideline was twice as high as that based on 2010 Chinese guideline (46.4%), whereas the control rate fell to 3.0%. Conclusions: In China, there is a high prevalence of HTN and pre-HTN, and awareness, treatment, and control of HTN were low. Management of medical therapy for HTN needs to improve.

Short-term hypertension management in community is associated with long-term risk of stroke and total death in China: A community controlled trial

Background:It is not fully clear whether the effect of short-term management in community can reduce the long-term risk of stroke Objectives:To evaluate whether short-term hypertension management is associated with long-term incidence of stroke and total death in community health centers in China. Design:Community controlled trail. Participants:Six community health centers (4 active, 2 control) in China, patients with hypertension. Control arm:Patients were treated with normally therapy method. Active arm:Patients were treated oriented by the Guideline for hypertension management. Randomization:Two centers (Hebei and Zhejiang) from the Hypertension Control in Community (HCC) Project, which was conducted from 2005 to 2008, were randomly selected for this study. Four thousand hypertensive patients from these centers, who were under management for one year in the baseline, were followed up in 2013. The electronic health record system (2005–2008) was used to identify 2000 hypertensive patients, who were not included in HCC but lived in comparable community health center in the same province, as the control group. All baseline and follow-up data were collected using standardized questionnaires for stroke outcomes. Main outcome measures:Stroke. Results:Of the 6000 participants, 3787 (63.1%) were eligible for analysis. At the time of follow-up, the average BP was kept in the lower level than that in baseline, and the control rate was 59.3%. After propensity-score matching, 110 strokes (2.0% vs 4.6%) and 141 deaths (1.4% vs 3.8%) were noted in the matched intervention and control groups (1078 pairs), respectively. Patients in the intervention group were less likely to experience a stroke or die than those in the control group (hazard ratio [HR] = 0.40, 95% confidence interval [CI]: 0.26–0.62, P < 0.01; HR = 0.50, 95% CI: 0.35–0.72, P < 0.01). The sensitivity analysis showed similar results. Conclusions:Short-term management of hypertension had a positive effect on the long-term risk reduction of death and stroke in hypertensive patients.

Effects of long-term psychological intervention on blood pressure and health-related quality of life in patients with hypertension among the Chinese working population

The aim of this study was to analyze the effects of psychological intervention on blood pressure, health-related quality-of-life (HRQOL), and stroke prevalence in patients with hypertension among the Chinese working population. Cluster sampling was conducted in September 2013 at the Shaanxi Jinduicheng Molybdenum Group General Hospital (intervention group) and the Shaanxi Province Hancheng Mining Bureau General Hospital (control group). The intervention group received regular psychological intervention for 2 years, including cognitive, emotional, and behavioral interventions. HRQOL was measured with the Spanish Hypertension Quality of Life Questionnaire (MINICHAL). We analyzed the data from a total of 409 subjects. After 2 years of psychological intervention, systolic blood pressure (SBP) and diastolic blood pressure (DBP) in the non-anxiety subgroup, and the anxiety subgroup were lower than baseline levels and lower than those in the control group. Post intervention, the mental state, somatic symptoms, and total MINICHAL scores were significantly below baseline levels, and the stroke morbidity was lower than that in the control group. Post intervention, SBP, DBP, and the MINICHAL scores in the intervention group were lower than those in the control group. SBP, DBP, and the MINICHAL scores were lower in the intervention group after 1 and 2 years of psychological intervention, as compared with the control group. Long-term psychological intervention can thus be used as an adjunctive therapy for patients with hypertension among the Chinese working population to improve their blood pressure, HRQOL and stroke prevalence.