Biochemical Nonadherence Screening Improves BP (p 1042)
Nonadherence to antihypertensive treatment is difficult to diagnose and treat. Our previous studies showed that liquid chromatography tandem mass spectrometry–based analysis provides an objective confirmation of the presence/absence of prescribed antihypertensive medications in bodily fluids and as such is diagnostically useful. In this issue of Hypertension, we also show that the biochemical analysis of urine/serum is associated with improvement in blood pressure control in hypertensive patients who are nonadherent to blood pressure–lowering therapy. The magnitude of blood pressure reduction on follow-up appointments was very powerful and similar to that normally achieved by 2 antihypertensive medications. This encouraging clinical effect is most likely explained by the improvement in adherence to antihypertensive treatment—the drop in blood pressure correlated with a biochemically confirmed improvement in adherence. Most importantly, a majority of initially nonadherent hypertensive patients responded to the initial biochemical analysis with an improvement in adherence and >50% of them converted to full adherence. The test helps clinicians to discuss nonadherence with their patients, explore their understanding of hypertension, and tailor interventions to improve nonadherence (eg, through reduction in polypharmacy and provision of pill boxes). Collectively, these data show that liquid chromatography tandem mass spectrometry–based analysis has a therapeutic potential in management of hypertension.
DASH Diet, Sodium, and Blood Pressure Over Time (p 923)
Although both sodium reduction and the Dietary Approaches to Stop Hypertension (DASH) diet are known to lower blood pressure, the amounts of time needed for either dietary intervention to achieve its full effects are unknown. In this study, we used weekly blood pressure measurements of the DASH-Sodium trial to answer this important question. Our study reports that in adults with pre-hypertension or Stage 1 hypertension, the blood pressure-lowering effects of the DASH diet occur within 1 week of initiation, and these effects are maintained up to 12 weeks. This suggests that continued consumption of the DASH diet sustains its blood pressure–lowering effects without wearing off. Meanwhile, sodium reduction progressively lowers blood pressure over 4 weeks with the possibility that even greater blood pressure reductions occur after 4 weeks. These findings suggest that sodium reduction beyond 4 weeks may be needed to experience the full effect from sodium restriction. These findings are useful for physicians counseling their patients on the adoption of lifestyle interventions. Whereas early effects can occur, full effects, especially for sodium reduction, may not occur within a month. Similarly, researchers studying the effects of sodium reduction and other interventions on blood pressure might want to extend interventions beyond 4 weeks if a trial is to document the greatest possible effect. Still, reductions in blood pressure before 4 weeks can be detected and can be substantial, but the magnitude of effect is smaller than what could occur with a longer intervention.
Blood Pressure Variability in Atrial Fibrillation (p 862)
Systolic blood pressure visit-to-visit variability (SBP-VVV) is a well-known predictor of major adverse clinical events in hypertensive subjects, as well as in the general population. Several studies have shown that a progressively increasing SBP-VVV is associated with a gradually higher risk for cardiac events, cerebrovascular events, and cardiovascular and all-cause death. In the context of atrial fibrillation, the role of hypertension in determining a higher risk for both thromboembolic and bleeding events is well established, but the role of SBP-VVV in determining outcomes in atrial fibrillation patients is unknown. In the current study, we demonstrate that an increased blood pressure variability is associated with a worse quality of anticoagulation control, underpinning a possible link between an overall low patients’ adherence to medications and physicians’ recommendations. Second, and perhaps more importantly, we show for the first time that a progressively higher SBP-VVV is independently associated with a proportionally increased risk for stroke, major bleeding, and death. When considering a composite clinical outcome of stroke/major bleeding/cardiovascular death, we confirm that patients with the largest variability (third and fourth quartiles of SBP-VVV) had an increasingly higher risk of adverse outcomes. Educational and therapeutic interventions to reduce SBP-VVV, as well as to improve oral anticoagulation control, are needed among atrial fibrillation patients to help reduce major adverse clinical outcomes.
- © 2017 American Heart Association, Inc.