Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. Non-pharmacological treatment of hypertension in primary health care: a 2-year open randomized controlled trial of lifestyle intervention against hypertension in eastern Finland Improving hypertension care in a large group-model MCO. Trial of antihypertensive interventions and management. Design, methods, and selected baseline results. The 2001 Canadian recommendations for the management of hypertension: Part two--Therapy. Pharmacist intervention program to enhance hypertension control: a randomised controlled trial Non-pharmacological methods reduce drug use in the treatment of hypertension. A two-year trial in general practice. Medical treatment of hypertension in Switzerland. The 2009 Swiss Hypertension Survey (SWISSHYPE). Community-Based Interventions to Promote Blood Pressure Control in a Developing Country The effectiveness of daily SMS reminders in pharmaceutical care of older adults on improving patients’ adherence to antihypertensive medication (SPPA): study protocol for a randomized controlled trial Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. Predictors of adherence to antihypertensive medication in northern United Arab Emirates. Choices, persistence and adherence to antihypertensive agents: evidence from RAMQ data. Success and predictors of blood pressure control in diverse North American settings: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT): Practical Implications Improving Medication Adherence in Patients with Hypertension: A Randomized Trial. South African hypertension guideline 2011.
OBJECTIVE Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries ( LMICs ) . Mobile health technologies may improve noncommunicable disease outcomes , but LMICs lack re sources to provide these services . We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure ( BP ) monitoring as a strategy for improving systolic BPs ( SBPs ) and other outcomes of hypertensive patients in two LMICs . SUBJECTS AND METHODS This was a r and omized trial with a 6-week follow-up . Participants with high SBPs ( ≥140 mm Hg if nondiabetic and ≥130 mm Hg if diabetic ) were enrolled from clinics in Honduras and Mexico . Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States , plus a home BP monitor . At baseline , control patients received BP results , hypertension information , and usual healthcare . The primary outcome , SBP , was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs . Secondary outcomes included perceived health status and medication-related problems . RESULTS Of the 200 patients recruited , 181 ( 90 % ) completed follow-up , and 117 of 181 had low literacy or high hypertension information needs . The median annual income was $ 2,900 USD , and average educational attainment was 6.5 years . At follow-up intervention patients ' SBPs decreased 4.2 mm Hg relative to controls ( 95 % confidence interval -9.1 , 0.7 ; p=0.09 ) . In the subgroup with high information needs , intervention patients ' average SBPs decreased 8.8 mm Hg ( -14.2 , -3.4 , p=0.002 ) . Compared with controls , intervention patients at follow-up reported fewer depressive symptoms ( p=0.004 ) , fewer medication problems ( p<0.0001 ) , better general health ( p<0.0001 ) , and greater satisfaction with care ( p≤0.004 ) . CONCLUSIONS Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs . A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support Objective To assess whether lifestyle counselling is effective in non-pharmacological treatment of hypertension in primary health care . Design Open r and omized controlled trial . Setting Ten municipal primary health care centres in eastern Finl and . Patients Seven hundred and fifteen subjects aged 25–74 years with systolic blood pressure 140–179 mmHg and /or diastolic blood pressure 90–109 mmHg or antihypertensive drug treatment . Interventions Systematic health counselling given by local public health nurses for 2 years . Main outcome measures Blood pressure , lipids and lifestyle data were collected annually . Results Among participants with no antihypertensive drug treatment , the net reductions after 1 year both in systolic blood pressure [ −2.6 mmHg ; 95 % confidence interval ( CI ) , −4.7 to −0.5 mmHg ] and in diastolic blood pressure ( −2.7 mmHg ; 95 % CI , −4.0 to −1.4 mmHg ) were significant in favour of the intervention group . This difference in blood pressure change was maintained during the second year . In participants with antihypertensive drug treatment , no significant difference in blood pressure reduction was seen between the groups during the study . Conclusions A relatively modest , but systematic counselling in primary health care can , at least among untreated hypertensive subjects , produce reductions in blood pressure levels that are modest for the individual , but very important from the public health point of view The effectiveness of a quality improvement program for hypertension management practice s and patient health outcomes in a group-model managed care organization was evaluated . Health-system pharmacists analyzed medical and pharmacy cl aims data to identify hypertensive patients . Chart review was conducted on a r and om sample of these patients to vali date a hypertension diagnosis and to obtain blood pressure ( BP ) control rates and prevalence of cardiovascular risk factors and comorbid conditions . The interventions consisted of educating health care providers and recommending appropriate pharmacotherapy for compelling indications . Patient outcomes were compared with baseline hypertension data . After interventions were implemented , medical and pharmacy cl aims identified 30,721 hypertensive patients and chart review s were performed on a r and om sample of 417 patients . Pharmacy cl aims revealed a total of 193,311 antihypertensive prescriptions . Approximately 47 % of all hypertensive patients were managed with monotherapy , while 24 % received dual therapy , and 11 % were taking three or more antihypertensive medications per day . Of the patients on monotherapy , 93 % received an angiotensin-converting-enzyme inhibitor ( 27.3 % ) , diuretic ( 26.6 % ) , beta-blocker ( 23.4 % ) , or calcium channel blocker ( 15.4 % ) . The overall level of BP control significantly improved from 37.2 % at baseline to 49.2 % at follow-up ( p = 0.0007 ) . BP control in the follow-up evaluation was 22.2 % in diabetic patients . For treatment of patients with comorbid disease states , provider practice patterns were evaluated at baseline and follow-up . Improving the quality of hypertension management increased BP control from 37.2 % to 49.2 % . Continued efforts to improve hypertension management , particularly in patients with concomitant diabetes and in elderly patients with isolated systolic hypertension , are needed The Trial of Antihypertensive Interventions and Management was a multicenter r and omized , placebo-controlled  trial design ed to assess the effectiveness of various combinations of pharmacologic and dietary interventions in the treatment of mild hypertension ( diastolic blood pressure 90 - 100 mmHg ) . The primary outcome was blood pressure change between baseline and 6 months . The study consisted of a 3 X 3 factorial design wherein participants were r and omly allocated to  nine drug-diet treatment groups . Drugs included placebo , diuretic , and beta-blocker . Diets were usual , weight loss , and low sodium/high potassium . The basic strategy was to address clinical questions of interest by comparing mean blood pressure changes of selected drug-diet combinations . This paper describes the study including experimental design , sample size considerations , statistical analysis , organizational structure , and baseline findings OBJECTIVE To provide up date d , evidence -based recommendations for the therapy of hypertension in adults . OPTIONS For patients with hypertension , a number of antihypertensive agents may control blood pressure . R and omized trials evaluating first-line therapy with thiazides , beta-adrenergic antagonists , angiotensin-converting enzyme inhibitors , calcium channel blockers , alpha-blockers , central ly acting agents or angiotensin II receptor antagonists were review ed . OUTCOMES The health outcomes that were considered were changes in blood pressure , cardiovascular morbidity , and cardiovascular and /or all-cause mortality rates . Economic outcomes were not considered due to insufficient evidence . EVIDENCE MEDLINE was search ed for the period March 1999 to October 2001 to identify studies not included in the 2000 revision of the Canadian Recommendations for the Management of Hypertension . Reference lists were scanned , experts were polled , and the personal files of the subgroup members and authors were used to identify other published studies . All relevant articles were review ed and appraised , using prespecified levels of evidence , by content experts and method ological experts . VALUES A high value was placed on the avoidance of cardiovascular morbidity and mortality . BENEFITS , HARMS AND COSTS Various antihypertensive agents reduce the blood pressure of patients with sustained hypertension . In certain setting s , and for specific classes of drugs , blood-pressure lowering has been associated with reduced cardiovascular morbidity and /or mortality . RECOMMENDATIONS The present document contains detailed recommendations pertaining to treatment thresholds , target blood pressures , and choice of agents in various setting s in patients with hypertension . The main changes from the 2000 Recommendations are the addition of a section on the treatment of hypertension in patients with diabetes mellitus , the amalgamation of the previous sections on treatment of hypertension in the young and old into one section , increased emphasis on the role of combination therapies over repeated trials of single agents and expansion of the section on the treatment of hypertension after stroke . Implicit in the recommendations for therapy is the principle that treatment for an individual patient should take into consideration global cardiovascular risk , the presence and /or absence of target organ damage , and comorbidities . VALIDATION All recommendations were grade d according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group . Individuals with potential conflicts of interest relative to any specific recommendation were excluded from voting on that recommendation . Only those recommendations achieving high levels of consensus are reported here . These guidelines will continue to be up date d annually Objective Studies have demonstrated that hypertension remains inadequately managed throughout the world , with lack of adherence to BP-lowering medication being a major factor . The aim of the present study was to evaluate if a pharmaceutical care program could improve antihypertensive medication adherence and blood pressure control . Setting This study was conducted in a secondary care hypertension/dyslipidemia outpatient clinic in the university teaching hospital of Cova da Beira Hospital Centre , Covilhã , located in the Eastern Central Region of Portugal . Method This report evaluates the pharmacist ’s interventions during a prospect i ve r and omised controlled trial , from July 2009 to June 2010 . Patients with diagnosis of essential hypertension attending the clinic for routine follow-up were r and omly allocated either to a control group ( no pharmaceutical care ) or to an intervention group ( quarterly follow-up by a hospital pharmacist during a 9-month period ) . The pharmacist interventions , aim ed to increase medication adherence and blood pressure control , involved educational interventions and counselling tips directed to the patient . Main outcome measure Systolic blood pressure , diastolic blood pressure and blood pressure control ( according to JNC 7 guidelines ) assessed at the baseline visit and at the end of pharmaceutical care were the main outcome measures . Blood pressure measurements were performed by blinded nurses . Medication adherence was also evaluated , using a vali date d question naire at baseline and at the end of investigation . Results A total of 197 hypertensive patients were r and omly assigned to the study ( 99 in the control group and 98 in the intervention group ) . Although there were no significant differences ( P > 0.05 ) in both groups concerning mean age , gender , body mass index , and antihypertensive pharmacotherapy , blood pressure control was higher in the intervention group ( P = 0.005 ) at the end of the study . Significant lower systolic blood pressure ( −6.8 mmHg , P = 0.006 ) and diastolic blood pressure ( −2.9 mmHg , P = 0.020 ) levels were observed in the intervention group . Medication adherence was also significantly higher in the intervention group at the end of the study ( 74.5 % vs. 57.6 % , P = 0.012 ) . Conclusion Pharmacist intervention can significantly improve medication adherence and blood pressure control in patients treated with antihypertensive agents In a primary -care based study , 122 patients who were taking antihypertensive drugs took part in a two-year trial that aim ed at establishing the feasibility of non-pharmacological methods in the treatment of hypertension in general practice . The patients could choose from among 14 non-pharmacological methods of blood pressure reduction . Increased physical exercise ; weight reduction , low-sodium and low-fat diet , relaxation training , and home-monitoring of blood pressure were the most popular methods . The use of anti-hypertensive drugs  was reduced by 55 % in the participants , with the defined daily dose ( DDD ) being lowered from 1.18 to 0.55 ( P less than 0.001 ) . At the end of the study , 46 % of the participants were free from anti-hypertensive drugs . Significant reductions occurred in body mass index ( 27.1 to 26.4 kg/m2 , P = 0.001 ) and serum cholesterol ( 6.89 to 6.48 mmol/l , P less than 0.001 ) . According to some measures used , the study group 's experience of " quality of life " was not reduced OBJECTIVES Despite a broad and efficient pharmacological antihypertensive armamentarium , blood pressure ( BP ) control is suboptimal and heterogeneous throughout Europe . Recent representative data from Switzerl and are limited . The goal of the present survey was therefore to assess the actual control rate of high BP in Switzerl and in accordance with current guidelines . The influence of risk factors , target organ damage and medication on BP levels and control was also evaluated . METHODS A cross-sectional visit-based survey of ambulatory hypertensive patients was performed in 2009 in Switzerl and . 281 r and omly selected physicians provided data on 5 consecutive hypertensive patients attending their practice s for BP follow-up . Data were anonymously collected on demographics , comorbidities and current medication , and BP was recorded . Subsequent modification of pharmacological antihypertensive therapy was assessed . RESULTS Data from 1376 patients were available . Mean age was 65 ± 12 years , 53.9 % were male subjects . 26.4 % had complicated hypertension . Overall , BP control ( < 140/90 mm Hg for uncomplicated and < 130/80 mm Hg for complicated hypertension ) was achieved in 48.9 % . Compared to patients with complicated hypertension , BP control was better in patients with uncomplicated hypertension ( 59.4 % vs. 19.2 % , p < 0.001 ) . As a monotherapy the most prescribed drug class were angiotensin receptor blockers ( ARB , 41 % ) , followed by angiotensin converting enzyme ( ACE ) inhibitors ( 21.5 % ) , betablockers ( 20.8 % ) and calcium channel blockers ( CCB , 10.8 % ) . The most prescribed drug combinations were ARB + diuretic ( 30.1 % ) and ACE inhibitors + diuretic ( 15.3 % ) . 46 % were receiving a fixed drug combination . In only 32.7 % of patients with uncontrolled hypertension was a change in drug therapy made . CONCLUSION This representative survey on treated adult hypertensive patients shows that , compared to earlier reports , the control rate of hypertension has improved in Switzerl and for uncomplicated but not for complicated , particularly diabetes-associated hypertension . ARBs and ACE inhibitors are the most prescribed antihypertensive drugs for monotherapy , whereas diuretics and ARBs were the most used for combination therapy Context Physician education and community-based interventions to educate people with hypertension may improve hypertension care in re source -poor setting s. Contribution Among 1341 patients living in 12 communities in Pakistan that were r and omly assigned to general practitioner education , home health visits by trained lay workers , both , or neither , patients in communities assigned to both interventions had the greatest improvements in systolic blood pressure ( 10.8 mm Hg ) after 2 years . Improvements were similar in all other groups ( about 5 mm Hg ) . Caution Twenty-two percent of patients were lost to follow-up . Implication Home visits by trained lay workers plus physician education deserves further study as a way to improve hypertension control in re source -poor setting s. The Editors Cardiovascular disease has , in just a few decades , become the leading cause of death in adults worldwide , accounting for 1 in 5 deaths . Hypertension confers the highest attributable risk for death and disease associated with cardiovascular disease ( 1 , 2 ) . Despite the demonstrated benefits of effective drug treatment ( 3 , 4 ) and the existence of many clinical practice guidelines ( 5 ) , hypertension prevention , treatment , and control rates remain suboptimal worldwide ( 6 ) . The situation is particularly acute in developing countries , such as Pakistan , India , and China , where hypertension has reached epidemic proportionsaffecting more than 20 % of the adult population (7)yet control rates are less than 6 % ( 8) . Poor health literacy and unhealthy lifestyles , compounded by lack of awareness of hypertension ( 7 ) , are part of the cause . In addition , the health systems in these countries are often dysfunctional : More than 80 % of the expenditure for chronic disease care is out-of-pocket ; private care general practitioners ( GPs ) , who primarily treat acute conditions , are the front-line service providers ; and national programs for preventing and controlling hypertension are inadequate . Serious deficiencies in management of hypertension also have been identified in the knowledge and practice of health care providers . ( 9 ) However , evidence for public health interventions to improve hypertension control rates through patient or physician education in Indo-Asian countries is lacking . We conducted the COBRA-1 ( Control of Blood Pressure and Risk Attenuation-1 ) trial in Karachi , Pakistan , to test the effectiveness of 2 community-based strategies : family-based home health education ( HHE ) , delivered by trained community health workers , to improve population -level health literacy and behaviors , and hypertension management training for GPs . We tested the effect of these interventions , alone and in combination , on blood pressure in adults with hypertension . We hypothesized that HHE would be more effective than no education , that the specially trained GPs would provide more effective care than that usually received in Karachi , and that the combined interventions would provide additional benefit . Methods Study Design and Setting We performed a cluster r and omized , controlled trial with a 22 factorial design to determine the effect of  family-based HHE and special training for GPs  on blood pressure in adults 40 years or older with hypertension . We used a cluster approach because our objective was to assess the effectiveness of both HHE and GP training as health system interventions at a population level , and an individual approach would be prone to contamination of interventions and biased outcomes ( 10 ) . The Aga Khan University Ethics Review Committee granted ethical approval . The sampling frame is described elsewhere ( 11 ) . In brief , we used a multistage r and om sampling technique to select 12 of 4200 low- to middle-income , geographic census-based clusters ( mean household monthly income , $ 70 ; about 250 households in each cluster ) in Karachi , the most populous city in Pakistan ( about 16 million inhabitants ) . We ensured at least a 10-km distance between clusters to minimize the risk for contamination by the intervention . Participants Persons 40 years or older who resided in the 12 clusters and had known hypertension or consistently elevated blood pressure on 2 separate visits ( mean of 2 of past 3 measurements of systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg ) were eligible for inclusion . We excluded pregnant women , persons who could not give informed consent , and bed-bound persons . R and omization and Intervention We used computer-generated codes to r and omly assign 3 clusters each to the following groups : HHE alone , GP alone , HHE and GP combined , and no intervention . Home Health Education We trained 6 community health workers ( 1 for each cluster ) over 6 weeks in methods for using behavior-changing communication strategies to convey st and ardized health education messages to all households in clusters assigned to receive HHE . The education status of the workers we employed was consistent with the requirements of the government-sponsored Lady Health Workers Programme of Pakistan ( 8 or preferably 10 years of schooling ) ( 12 ) . Salary scales and assigned workload were similarly consistent . The health messages included information on the deleterious effects of hypertension and nonpharmacologic interventions for preventing and controlling hypertension and cardiovascular disease , as well as advice on the importance of engaging in moderate physical activity ; maintaining normal body weight ; reducing salt intake ; consuming a diet rich in fruit , vegetables , and low-fat dairy products ; reducing intake of saturated and total fat ( including suggestions on sample recipes for culturally acceptable and economically feasible food products ) ; and smoking cessation ( Appendix 1 ) . The importance of achieving blood pressure targets and adhering to medication and physician follow-up was emphasized . The first HHE session , lasting 90 minutes , was held at a time when all members of the household could be present . Follow-up reinforcement visits of 30 minutes were made every 3 months . Appendix 1 . Training Manual for Community Health Workers General Practitioner Education We invited all GPs in the 6 study areas assigned to this intervention to receive training , with the aim of training at least two thirds of the GPs in each area . We considered this proportion to be feasible both for future uptake of the strategy and for assessing the effectiveness of training . Training was a 1-day session that focused on st and ard treatment algorithms for the stepped-care management of hypertension , which were based on the seventh report of the Joint National Committee ( 3 ) and the Fourth Working Party of the British Hypertension Society guidelines ( 4 ) and modified for the Indo-Asian population ( Appendix 2 ) . The course included components on nonpharmacologic ( diet , exercise , weight loss , and smoking cessation ) and pharmacologic interventions , prescription of low-cost and appropriate generic drugs , preferential use of single-dose drug regimens , scheduled follow-up visits guided by blood pressure , the stepped-care approach for titrating drugs to achieve target blood pressure , and satisfactory consultation sessions for patients , with explanations of treatment and use of appropriate communication strategies . For managing persons with known hypertension , GPs were advised to review medication and blood pressure ; simplify regimens ; and aim to return to a regimen that was in line , as reasonably as possible , with that recommended for those with newly diagnosed hypertension . The recommended target blood pressure was < 140/90 mm Hg for all patients . Although this diverges from recent guidelines for special subgroups ( such as diabetic persons or those with end-organ damage ) , we reasoned that we needed to keep the intervention , guidelines , and targets simple for both patients and practitioners in a setting where blood pressure control rates are less than 3 % ( 7 ) . The training sessions for GPs used a case-based curriculum and were interactive . We provided a certificate of training at the end of the course . Appendix 2 . Training Manual for General Practitioner All study participants were advised to consult a local GP . If participants in the clusters r and omly assigned to a trained GP group did not already have a preferred GP , we gave them a list of trained GPs in their cluster from which to choose . However , it remained the participant 's choice whether they attended a physician on the list . We did not provide for medications or fee-for-health care services . Participants were blinded to intervention status ( training of GP ) . Neither the patients nor the GPs received reimbursement for participation . Screening and Recruitment All households in each cluster were visited , and we obtained informed consent for screening from all adults 40 years and older , whose blood pressure was then measured 3 times with a calibrated automated device ( Omron HEM-737 IntelliSense ; Omron Healthcare , Vernon Hills , Illinois ) in the sitting position after 5 minutes of rest . Those with known hypertension were invited to participate . Those with elevated blood pressure who were not receiving antihypertensive medication were visited again for remeasurement of blood pressure 1 to 4 weeks after the initial visit . If mean blood pressure remained elevated , these persons were also invited to participate . A routine physical examination was performed , and the following information was collected : smoking status , food frequency , and physical activity by question naire , the latter by using the international physical activity question naire ; blood pressure , measured as described above ; anthropometric characteristics ( height , weight , and waist and hip circumferences ) ; and fasting blood glucose level ( Synchron Cx-7/Delta , Beckman Coulter , Fullerton , California ) and lipid profile ( Hitachi-912 , Roche , Basel , Switzerl and ) ( 11 ) . Follow-up Procedures Trained outcomes assessors ( who were not part of and had no relationship with the community health worker team ) evaluated Background Despite a variety of efficient and cost-effective antihypertensive medication , hypertension remains a serious health and economic burden . High consumption of cardiovascular drugs in the Slovak Republic does result neither in better hypertension control nor in significant decrease in cardiovascular mortality . At the same time , Slovakia has alarmingly low patients ’ adherence to medication intake . Studies have shown the efficiency of short messaging service ( SMS ) reminders to improve patients ’ adherence and health outcomes at low costs . Since SMS is popular among Slovaks , this approach may be feasible also in Slovakia . The primary objective is to assess if daily SMS reminders of antihypertensive medication intake provided by pharmacists in addition to the st and ard pharmaceutical care increase the proportion of adherent older hypertensive ambulatory patients . Methods The SPPA trial is a pragmatic r and omized parallel group ( 1:1 ) trial in 300 older hypertensive patients carried out in community pharmacies in Slovakia . Trial pharmacies will be selected from all main regions of Slovakia . Trial intervention comprises daily personalized SMS reminders of medication intake embedded into usual pharmaceutical practice . The primary outcome is a combined adherence endpoint consisting of subjective self-reported medication adherence via the eight-item Morisky Medication Adherence Scale ( MMAS-8 ) and objective pill count rate . Secondary outcomes include : change in the MMAS-8 ; comparison of adherence rates using pill count ; change in systolic blood pressure ; and patient satisfaction . Also , direct treatment costs will be evaluated and a cost-effectiveness analysis will be carried out . Discussion The SPPA trial engages community pharmacists and mobile health ( mHealth ) technologies via evidence -based pharmaceutical care to efficiently and cost-effectively addresses current main healthcare challenges : high prevalence of hypertension ; overconsumption of cardiovascular medicines ; low adherence to medication treatment ; and result ing uncontrolled blood pressure . The results may identify new possibilities and capacities in healthcare with low additional costs and high value to patients .Trial registration Clinical Trials.gov , NCT03105687 . Registered on 07 March 2017 IMPORTANCE Hypertension is the most important preventable cause of morbidity and mortality globally , yet there are relatively few data collected using st and ardized methods . OBJECTIVE To examine hypertension prevalence , awareness , treatment , and control in participants at baseline in the Prospect i ve Urban Rural Epidemiology ( PURE ) study . DESIGN , SETTING , AND PARTICIPANTS A cross-sectional study of 153,996 adults ( complete data for this analysis on 142,042 ) aged 35 to 70 years , recruited between January 2003 and December 2009 . Participants were from 628 communities in 3 high-income countries ( HIC ) , 10 upper-middle-income and low-middle-income countries ( UMIC and LMIC ) , and 4 low-income countries ( LIC ) . MAIN OUTCOMES AND MEASURES Hypertension was defined as individuals with self-reported treated hypertension  or with an average of 2 blood pressure measurements of at least 140/90 mm Hg using an automated digital device . Awareness was based on self-reports , treatment was based on the regular use of blood pressure-lowering medications , and control was defined as individuals with blood pressure lower than 140/90 mm Hg . RESULTS Among the 142,042 participants , 57,840 ( 40.8 % ; 95 % CI , 40.5%-41.0 % ) had hypertension and 26,877 ( 46.5 % ; 95 % CI , 46.1%-46.9 % ) were aware of the diagnosis . Of those who were aware of the diagnosis , the majority ( 23,510 [ 87.5 % ; 95 % CI , 87.1%-87.9 % ] of those who were aware ) were receiving pharmacological treatments , but only a minority of those receiving treatment were controlled ( 7634 [ 32.5 % ; 95 % CI , 31.9%-33.1 % ] ) . Overall , 30.8 % , 95 % CI , 30.2%-31.4 % of treated patients were taking 2 or more types of blood pressure-lowering medications . The percentages aware ( 49.0 % [ 95 % CI , 47.8%-50.3 % ] in HICs , 52.5 % [ 95 % CI , 51.8%-53.2 % ] in UMICs , 43.6 % [ 95 % CI , 42.9%-44.2 % ] in LMICs , and 40.8 % [ 95 % CI , 39.9%-41.8 % ] in LICs ) and treated ( 46.7 % [ 95 % CI , 45.5%-47.9 % ] in HICs , 48.3 % , [ 95 % CI , 47.6%-49.1 % ] in UMICs , 36.9 % , [ 95 % CI , 36.3%-37.6 % ] in LMICs , and 31.7 % [ 95 % CI , 30.8%-32.6 % ] in LICs ) were lower in LICs compared with all other countries for awareness ( P < .001 ) and treatment ( P < .001 ) . Awareness , treatment , and control of hypertension were higher in urban communities compared with rural ones in LICs ( urban vs rural , P < .001 ) and LMICs ( urban vs rural , P < .001 ) , but similar for other countries . Low education was associated with lower rates of awareness , treatment , and control in LICs , but not in other countries . CONCLUSIONS AND RELEVANCE Among a multinational study population , 46.5 % of participants with hypertension were aware of the diagnosis , with blood pressure control among 32.5 % of those being treated . These findings suggest substantial room for improvement in hypertension diagnosis and treatment This study aim ed to assess the predictors of non-adherence to antihypertensive medications in northern United Arab Emirates . In a cross-sectional , multicentre study in Ajman Emirate , 250 patients with hypertension were r and omly selected from outpatient clinics . Participants answered an interview question naire about sociodemographic and clinical data and completed the Morisky medication adherence scale . Non-adherence to antihypertensive medication was reported by 45.6 % of patients . Sociodemographic predictors of non-adherence were sex and number of children . Therapy-related predictors of adherence were hospital admissions , number and cost of medications , medication perceived effectiveness and use of traditional remedies . Patient-related predictors of non-adherence were forgetfulness , method of identifying medication and poor awareness of hypertension complications . Health-care-related predictors were regular follow up at clinics , education and counselling , frequency of changing medication by physicians and awareness of physicians ' instructions BACKGROUND Most treatment recommendations for hypertension are based on criteria that consider efficacy , safety and cost . Given the need for long-term use of antihypertensive agents , treatment compliance should also be taken into consideration in the selection process . OBJECTIVE The purpose of the present study was to estimate persistence and adherence to  antihypertensive agents in a real-life setting . METHODS Persistence and adherence to treatment were estimated using data from the Regie de l'assurance maladie du Quebec . RESULTS Data from a r and om sample of 4561 subjects with a diagnosis of hypertension covered by the Regie de l'assurance maladie du Quebec drug plan and using one of the antihypertensive agents reimbursed by the drug plan for the first time between January 2000 and December 2001 were analyzed . The persistence rate observed after a two-year period with diuretics was significantly lower ( 52.8 % ) than with any other classes of antihypertensive agent ( P<0.01 ) . Persistence rates for beta-blockers , calcium channel blockers , angiotensin-II receptor blockers and angiotensin-I converting enzyme inhibitors were 69.3 % , 64.3 % , 60.9 % and 58.9 % , respectively . After two years , the proportion of patients who were 80 % adherent to their treatment was 64.9 % for angiotensin-I converting enzyme inhibitors , 65.0 % for angiotensin-II receptor blockers , 64.2 % for calcium channel blockers , 60.3 % for beta-blockers and 50.9 % for diuretics . The proportion of patients who were 80 % adherent to their treatment was significantly lower for diuretics than with any other antihypertensive agents ( P<0.01 ) . CONCLUSION Persistence and adherence to treatment are essential to treatment success . Results of the present study indicate that , in a real-life setting , patients are significantly less compliant to diuretics than to any other antihypertensive agents CONTEXT Blood pressure control ( < 140/90 mm Hg ) rates for hypertension fall far short of the US national goal of 50 % or more . Achievable control rates in varied practice setting s and geographic regions and factors that predict improved blood pressure control are not well identified . OBJECTIVE To determine the success and predictors of blood pressure control in a large hypertension trial involving a multiethnic population in diverse practice setting s. DESIGN The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial is a r and omized , double-blind , active-controlled clinical trial with a mean follow-up of 4.9 years . Participant enrollment began in February 1994 and follow-up was completed in March 2002 . SETTING A total of 623 centers in the United States , Canada , and the Caribbean . PARTICIPANTS A total of 33,357 participants ( aged > or = 55 years ) with hypertension and at least one other coronary heart disease risk factor . INTERVENTIONS Participants were r and omly assigned to receive ( double-blind ) chlorthalidone , 12.5 - 25 mg/d ( n=15,255 ) , amlodipine 2.5 - 10 mg/d ( n=9048 ) , or lisinopril 10 - 40 mg/d ( n=9054 ) after other medication was discontinued . Doses were increased within these ranges and additional drugs from other classes were added as needed to achieve blood pressure control ( < 140/90 mm Hg ) . MAIN OUTCOME MEASURES The outcome measures for this report are systolic and diastolic blood pressure , the proportion of participants achieving blood pressure control ( < 140/90 mm Hg ) , and the number of drugs required to achieve control in all three groups combined . RESULTS Mean age was 67 years , 47 % were women , 35 % black , 36 % diabetic ; 90 % were on antihypertensive drug treatment at entry . At the first of two pre-r and omization visits , blood pressure was < 140/90 mm Hg in only 27.4 % of participants . After 5 years of follow-up , the percent controlled improved to 66 % . Systolic blood pressure was < 140 mm Hg in 67 % of participants , diastolic blood pressure was < 90 mm Hg in 92 % , the mean number of drugs prescribed was 2.0+/-1.0 , and the percent on > or = 2 drugs was 63 % . Blood pressure control varied by geographic regions , practice setting s , and demographic and clinical characteristics of participants . CONCLUSIONS These data demonstrate that blood pressure may be controlled in two thirds of a multiethnic hypertensive population in diverse practice setting s. Systolic blood pressure is more difficult to control than diastolic blood pressure , and at least two antihypertensive medications are required for most patients to achieve blood pressure control . It is likely that the majority of people with hypertension could achieve a blood pressure < 140/90 mm Hg with the antihypertensive medications available today The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ( ALLHAT ) , sponsored by the National Heart , Lung , and Blood Institute ( NHLBI ) , is the largest outcome trial of antihypertensive treatment ever carried out and the only large blood pressure ( BP ) trial to be carried out in a US population in the past decade.1 The rationale for ALLHAT , which was design ed in the early 1990s , was the urgent need to determine which of the several classes of antihypertensive drugs that had been developed and released for clinical use was most effective in preventing coronary heart disease ( CHD ) , defined as fatal CHD and nonfatal myocardial infa rct ion.2 The only r and omized trials that had previously compared representatives of the antihypertensive drug classes , the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents3 and the Treatment of Mild Hypertension Study (TOMHS),4 showed BP reductions with all classes but were not powered to evaluate CHD outcomes . Further , prior outcome trials had shown that the reduction in CHD event rates with antihypertensive treatment was less than expected based on epidemiologic data .5 Adverse effects of study drugs , particularly diuretics , including hypokalemia , hypomagnesemia , hyperuricemia , hyperlipidemia , insulin resistance , and ventricular ectopic activity , had been adduced to account for the disappointing outcomes of earlier trials by off setting the beneficial effects of BP reduction.6,7 To further complicate the picture , benefits beyond BP reduction had been attributed to some antihypertensive drug classes , ie , improved survival and reduced morbidity in persons with heart failure or left ventricular dysfunction treated with angiotensin-converting enzyme ( ACE ) inhibitors8–10 and improved insulin sensitivity and lipid profiles with α-blocker treatment.11 In contrast , another antihypertensive drug class , the dihydropyridine calcium channel blockers ( CCBs ) , had been associated with unfavorable outcomes in patients with acute myocardial infa rct ion or unstable angina.12 There were no data BACKGROUND AND PURPOSE In patients with hypertension , medication adherence is often suboptimal , thereby increasing the risk of ischemic heart disease and stroke . In a r and omized trial , we investigated the effectiveness of a multifaceted pharmacist intervention in a hospital setting to improve medication adherence in hypertensive patients . Motivational interviewing was a key element of the intervention . METHODS Patients ( n = 532 ) were recruited from 3 hospital outpatient clinics and r and omized to usual care or a 6-month pharmacist intervention comprising collaborative care , medication review , and tailored adherence counseling including motivational interviewing and telephone follow-ups . The primary outcome was composite medication possession ratio ( MPR ) to antihypertensive and lipid-lowering agents , at 1-year follow-up , assessed by analyzing pharmacy records . Secondary outcomes at 12 months included persistence to medications , blood pressure , hospital admission , and a combined clinical endpoint of cardiovascular death , stroke , or acute myocardial infa rct ion . RESULTS At 12 months , 20.3 % of the patients in the intervention group ( n = 231 ) were nonadherent ( MPR < 0.80 ) , compared with 30.2 % in the control group ( n = 285 ) ( risk difference -9.8 ; 95 % confidence interval [ CI ] , -17.3 , -2.4 ) and median MPR ( interquartile range ) was 0.93 ( 0.82 - 0.99 ) and 0.91 ( 0.76 - 0.98 ) , respectively , P = .02 . The combined clinical endpoint was reached by 1.3 % in the intervention group and 3.1 % in the control group ( relative risk 0.41 ; 95 % CI , 0.11 - 1.50 ) . No significant differences were found for persistence , blood pressure , or hospital admission . CONCLUSIONS A multifaceted pharmacist intervention in a hospital setting led to a sustained improvement in medication adherence for patients with hypertension . The intervention had no significant impact on blood pressure and secondary clinical outcomes OUTCOMES Extensive data from r and omised controlled trials have shown the benefit of treating hypertension . The target blood pressure ( BP ) for antihypertensive management is systolic < 140 mmHg and diastolic < 90 mmHg with minimal or no drug side-effects ; however , stricter BP control is required for patients with end-organ damage , co-existing risk factors and co-morbidity , e.g. diabetes mellitus . The reduction of BP in the elderly and in those with severe hypertension should be achieved gradually over 1 month . Co-existent risk factors should also be controlled . BENEFITS Benefits of management include reduced risks of stroke , cardiac failure , chronic kidney disease and coronary heart disease . RECOMMENDATIONS The correct BP measurement procedure is described , and evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated . The total cardiovascular disease risk profile should be determined for all patients to inform management strategies . Lifestyle modification and patient education are cornerstones in the management of every patient . Major indications , pre caution s and contra-indications to each recommended antihypertensive drug are listed . Combination therapy should be considered ab initio if the BP is ≥ 20/10 mmHg . First-line drug therapy for uncomplicated hypertension includes low-dose thiazide-like diuretics , calcium channel blockers ( CCBs ) or angiotensin-converting enzyme inhibitors ( ACE-Is ) ( or ARBs - angiotensin II receptor blockers ) . If the target BP is not obtained , a second antihypertensive should be added from the aforementioned list . If the target BP is still not met , the third remaining antihypertensive agent should be used . In black patients  either thiazide-like diuretics or CCBs can be used initially , because response rates are better than with ACE-Is or β-blockers . In treating resistant hypertension , a central ly acting drug , vasodilator , α-blocker , spironolactone or β-locker should be added . This guideline includes management of specific situations , i.e. hypertensive emergency and urgency , severe hypertension with target organ damage , hypertension in diabetes mellitus , resistant hypertension , fixed drug combinations , new trials in hypertension , and interactions of antihypertensive agents with other drugs . VALIDITY The guideline was developed by the Southern African Hypertension Society
Subgroup analyses showed smaller sample s reporting larger effect sizes ; intervention lasting less than 6 months showed larger effect sizes and intention-to-treat analysis showed smaller effect sizes Lifestyle interventions may be of value in preventing and reducing blood pressure in LMICs .
Despite the overwhelming evidence supporting the effectiveness of antihypertensive medication , hypertension remains poorly controlled in low and middle-income countries ( LMICs ) .