ABSTRACT in the vessels. Each time the heart beats,

ABSTRACT

Hypertension is the most prevalent ailment in primary care with its management being a daily affair. The use of antihypertensive drugs has demonstrated their efficacy in blood pressure reduction. However, the efficient choice of an antihypertensive drug with which treatment should be initiated at precise blood pressure threshold and maintained at target level was not discerned. Consequently, the Eighth Joint National Committee provides an evidence-based tool. All patients with hypertension with/without diabetes mellitus and/or chronic kidney failure admitted in general medicine and the dialysis unit of a Father Muller Medical Hospital, for period-4 months, were enrolled in this prospective, observational study. The rationality of antihypertensive drug chosen and target blood pressure was noted 125 patients enrolled in the study, 90 males and 35 females. Average age observed was between 51-60 years, with the length of stay 14.39 (SD±1. 52) and 9.3 (SD±0. 46) days in the respective unit. The total number of drug administered was 1085 drugs with 337 being antihypertensive drugs alone. The most frequent choice of an antihypertensive drug was clonidine and amlodipine. Cent percent adherence was observed in hypertension lone patients followed by 82.35% adherence in hypertension with diabetes mellitus and least adherence in hypertension with chronic kidney disease patients. Total 86 drugs prescribed were adherent to the guidelines (25.52%). Rationality of drug based on hypertension stages depicts, 25.6% were rational and 73.6% observed non-rational with a demise of a single patient. A suboptimal adherence of physician to the eight joint national committee guidelines was observed.

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Keywords: Hypertension, JNC-8 Adherence, and Rationality.

 

 

 

 

 

INTRODUCTION

Hypertension as stated by the World Health Organization, is known as “high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure. Blood is carried from the heart to all parts of the body in the vessels. Each time the heart beats, it pumps blood into the vessels. The force of blood pushing against the wall of blood vessels (arteries) as the heart pumps it creates blood pressure (BP). The higher the pressure the harder the heart has to pump”. 1

 

Table No.1: Hypertension Classified by   JNC-8.

Category

Systolic Diastolic Pressure (mm Hg)

Normal

?120 and ?80

Pre-hypertension

120-139 or 80-89

High blood pressure/Hypertension
Stage 1 Hypertension

 
140-159 or 90-99

Stage 2 Hypertension

?160 or ?100

 

Hypertension is the most prevalent ailment in primary care with its management being a daily affair.2 Hypertension having an asymptomatic nature has gained an alias as “silent killer”.3 India is going through a demographic transition as a developing country with every increase in the population trends. This momentous upliftment in life expectancy may cause a non-communicable disease to eclipse infectious disease in implicating a stain in the health budget of our country.4 The lifetime expectancy of encountering hypertension is gauged at 90%, with the prevalence in urban and rural India being 25% and 10%.5

 

Hypertension is the most prevalent ailment in primary care with its management being a daily affair.2 Hypertension having an asymptomatic nature has gained an alias as “silent killer”.3 India is going through a demographic transition as a developing country with every increase in the population trends. This momentous upliftment in life expectancy may cause a non-communicable disease to eclipse infectious disease in implicating a stain in the health budget of our country.4 The lifetime expectancy of encountering hypertension is gauged at 90%, with the prevalence in urban and rural India being 25% and 10%.5

Hypertension and Diabetes Mellitus (DM) are known to coexist in several patients 6, with diabetes mellitus being a leading cause and hypertension being the secondary, but independent risk factor/cause in End-Stage Renal Disease (ESRD). The sequentially chronic renal disease can cause or be a consequence of hypertension.7 A majority of renal disease patients have hypertension also, thus leading to declining in renal function. Therefore, prevention strategies in ESRD should include the prevention, treatment, and control of blood pressure.8

According to the WHO, DM prevalence in adults worldwide was accounted for 4.0% in 1995 and predicted to rise to 5.4% by the year 2025, so that the adulated population would rise from 135 million in 1995 to 300 million in the year 2025. The risk of cardiovascular disease increases by a factor of two to three in DM patients with every level of systolic blood pressure.9 In Patient with DM along with hypertension, reduction in blood pressure poses an early benefit in results and better cost-effectiveness than maintaining a tight control over blood glucose levels.10

 

Up until 1950, there was no effective treatment available in the management of hypertension, with the development of antihypertensive and their efficacy in reducing blood pressure in the past 3 decades has highlighted antihypertensive as a therapeutic success.11 However, the efficient choice of an antihypertensive drug with which treatment should be initiated at precise blood pressure threshold and maintained at target level was not discerned.12 Consequently the Eighth Joint National Committee on the prevention, detection, evaluation and treatment of high blood pressure provides an evidence-based tool for physician in the clinical approach of hypertension management 13 The Joint National Committee is considered as the “golden standard” in the management of hypertension,14 JNC-8 the 2014 guidelines have been based on rigorous scientific evidence and includes nine recommendations, based on reviewed studies of hypertensive patients aged 18 and elder.15 The 2014 Guidelines recommend the use of four types of medication-Calcium Channel Blockers (CCBs), Angiotensin-Converting Enzyme Inhibitors (ACEIs), Angiotensin Receptor Blockers (ARBs), and diuretics-on the basis of Randomized Control Trial (RCT) evidence, with speci?c recommendations according to race, Chronic Kidney Disease (CKD), or diabetic status.16

 

The present study aims to assess the physicians prescribing pattern of anti-hypertensive drugs and depict their adherence to JNC-8 guidelines. The compliance to such guideline provides a means through which an effective monitoring practice allows an optimum management in the individual patient’s treatment regimen.

Fig.1: 2014 Hypertension Guideline Management Algorithm

 

  The 2014 Hypertension Guideline Management Algorithm SBP indicates Systolic Blood Pressure; DBP, Diastolic Blood Pressure; ACEI, Angiotensin-Converting Enzyme Inhibitor; ARB, Angiotensin Receptor Blocker; and CCB, Calcium Channel Blocker. An ACEIs and ARBs should not be used in combination. If blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual therapeutic plan.17 

 

MATERIALS AND METHODS

A prospective observational study was conducted in the general medicine and dialysis department of Father Muller Medical College Hospital, Mangalore for a period of 4 months from November 2016 to February 2017 after seeking approval from the institutional ethics committee (FMMC/FMIEC/3054/2016). Overall, 125 patients were included in the study. All  hypertension   patients of age 18-60 year admitted in the in-patient general medicine ward and dialysis in and out-patient ward with comorbidities of diabetes mellitus and/or chronic kidney disease were included in this study, whereas patients with incomplete data and those who were transferred to other departments within the span of 24 hours were not incorporated in this study. Patient information was collected and entered in the data collection form generated. Adherence was

assessed by comparing with the eight joint national committee hypertension treatment algorithm (Fig.1). Analysis of rationality was done based on the stage of hypertension the patient presented when admitting to the hospital (Table No.1).

 

Statistical Analysis: Data were entered into the statistical software SPSS (version 20, developed by IBM) and analysis were performed accordingly. Descriptive statistics such as percentages were calculated for categorical variables. Mean and standard deviation was used to compute continuous variables. Graphic representations were generated using Microsoft Excel 2007 for visual interpretation of analyzing data.

 

RESULT

One hundred and twenty five prescriptions were analyzed in the current study, with 69 received from general medicine ward and 56 from dialysis ward. Males 90 (72%) and females 35 (28%) constituted the total patient sample. The patient age distribution was majorly observed to be between 51-60 years (44%) and the least age group was that of 18-28 years (5.6%) with mean age of 31.3 (SD ± 23.8). The average length of stay was 14.39 (SD ±1.52) and 9.3 (SD ±0.46) days in the respective wards.

 

An evaluation of the total number of drugs prescribed to the patient obtained a count of 1085 drugs, with a frequent number of drugs being administered per patient was estimated at approx. 6-10 (37.7%) drugs and least amount being 1-5 (29%) drugs having a mean of 14.9

(SD ± 1.5). Similarly the antihypertensive drugs accounted for 337 drugs out of the total drugs  administered, with a highest count valued at 3-4 (45.6%) drugs followed by 1-2 (44.8%) drugs  and  ? 5 (9.6%)  drugs  with   mean  41.7 (SD±25.7). (Table No.2)

Out  of  the total 125 patients surveyed, 7 (5.6%) patients  had lone hypertension,17 (13.6%)  patients had diabetes mellitus as a co-morbidity, 65 (52%)  patients had chronic kidney failure  as a co-morbidity  and 36 (28.8%) patients  had both as the co-morbidity.(Fig.2)

 

 

 

 

Fig.2: Disease distribution

 

HTN: Hypertension, DM: Diabetes Mellitus, CKD: Chronic Kidney Disease.

 

Table No.2: Demographic data and patient details

Characteristics

Number of  patients

Percentage (%)

1.  Gender

Male

90

72

Female

35

28

2.  Age Distribution

18-28

7

5.6

29-39

15

12

40-50

48

38.4

51-60

55

44

Mean ± Standard deviation

31.3  ± 23.8

3. Total  drugs  prescribed

1-5

24

19.2

6-10

75

60

?11

26

20.8

Mean ± Standard deviation

41.7 ±  28.9

4.  Antihypertensive  drugs  prescribed

1-2

56

44.8

3-4

57

45.6

?5

12

9.6

Mean ± Standard deviation

41.7 ±  25.7

5. Length  of  stay  in  general  medicine  department

1-5

20

29

6-10

26

37.7

11-15

11

15.9

?21

6

8.7

Death

1

1.4

Mean ± Standard deviation

14.9 ± 1.5

6. Length  of  stay in  dialysis  department

Twice  in  a  week

39

69.6

Thrice  in  a  week

17

30.4

Mean ± Standard deviation

9.3  ±  0.5

 

 

 

 

 

 

 

In the overview of the current study the most substantial prescribed antihypertensive drug was amlodipine in 55 prescriptions with 1.95 units being consumed. The most popular type of therapy prescribed was triple combination therapy 35 (28%) prescriptions of calcium channel blocker + ? blocker + ?2 agonist (4%) and calcium channel blocker + ?2 agonist + diuretics (6.4%). Succeeded by monotherapy 31 (24.8%) prescriptions, most dominant choice- calcium channel blockers 18 (14.4%) and angiotensin receptor blocker 5 (4%) prescriptions, double. Likewise, double combination therapy 31 (24.8%) prescriptions, a popular therapy with- calcium channel blockers + ?2 agonist 7 (5.6%), calcium channel blockers + diuretics 5 (4%) and calcium channel blockers + angiotensin receptor blockers 5 (4%). The least opted therapy was multiple drug combination therapy 8 (6.4%) prescriptions. (Fig.3)

 

Fig.3: Antihypertensive drug prescribed to patients in mono and combination therapy

 

 

 

 

Fig.4: Antihypertensive drug class prescribed in hypertension with its comorbidities

HTN: Hypertension, DM: Diabetes Mellitus, CKD: Chronic Kidney Disease, ACEI: Angiotensin Converting Enzyme Inhibitor, ARB: Angiotensin Receptor Blocker, CCB: Calcium Channel Blocker.

 

When contemplating the predominant class of drug prescribed in the co-morbidities studied, calcium channel blocker was found to be the principal drug of choice, followed by angiotensin receptor blockers in hypertension lone patients, similarly by ? blocker in patients with diabetes mellitus as co-morbidity, ?2 agonist in patients with chronic kidney disease as co-morbidity and angiotensin receptor blockers in patients with both as co-morbidity. (Fig.4)

 

Fig.5: Prescribed antihypertensive drugs adherence to JNC-8 guidelines

 

Among the patients with hypertension alone, cent percent adherence 15 (100%). Least adherence was found in hypertension with diabetes mellitus and chronic kidney disease 19 (7.7%). Therefore out of the total number of antihypertensive drugs administered (337drugs) only 86 (25.52%) drugs were in adherence to the eight joint national committee of hypertension which the patient presented on the initial examination when admitted to the hospital. The analysis concluded the following results, 11 patients were categorized as normal, 20 as pre-hypertension, 36 as stage I hypertension and 58 as stage II hypertension with a demise of a single individual. The rationality of antihypertensive drugs in patients was calculated at the estimate of 32 (25.6%), compared to which 92 (73.6%) patients were deemed non-rational. (Fig.6)

 

DISCUSSION

Hypertension is a predominant medical condition worldwide and is the principal cause of stroke, it is also a primary risk factor for coronary artery disease and its complications. The ultimate goal of treating hypertension is to prevent and decline the probability of hypertension associated morbidity and mortality. The Eight Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure is the most prominent evidence-based clinical guideline for the management of  hypertension.

 

In the overview of this study, prevalence of hypertension was found to be higher in males 90(%) as compared to females 35(%), This was similar to the findings of Kothari N and Ganguly B, (2015) where it was higher in male 474(52.7%) than that in female 425(47.3%).13 The  patients age distribution in our study was majorly observed to be between 51-60 years (44%) and the least age group was that of 18-28 years (5.6%) with mean age of 31.25(SD±23.78), which is contradictory to the study carried out by Tadvi AY, Bandi JR (2016) in which out of 73 hypertensive participants, 12 (16.4%) participants were in the age group 20 to 25 years, 16 (21.9%) participants were in the age group 26 to 30 years, 24 (32.9%) participants were in the age group 31 to 35 years and 21 (28.8%) participants were in the age group 36 to 40 years.18  The average length of stay was 14.39 (SD±1.52) and 9.3 (SD±0.46) days in the respective wards.

 

As per the present study, the total number of drugs prescribed to the patient obtained a count of 1085 drugs, with a frequent number of drugs being administered per patient was estimated at approx. 6-10 (60%) drugs and least amount being 1-5(19.2%) drugs having a mean of 41.66 (SD±28.9). Similarly the antihypertensive drugs accounted for 337 drugs out of  the total drugs administered, with a highest count valued at 3-4 (45.6%) drugs followed by 1-2 (44.8%) drugs  and ? 5 (9.6%) drugs with mean 41.7(SD±25.7). This is in par with the findings of Shah J, et al., (2013) in which a total of 63 antihypertensive medication was prescribed for 50 patients, which was composed of 38 patients (76%) who received 1 drug followed by 11 patients (22%) and 1 patient (2%) who received 2 and 3 drugs of different antihypertensive class respectively.19 Out of the total 125 patients surveyed in our study, 7 (24.6%) patients had alone hypertension, 17 (13%) patients had diabetes mellitus as a co-morbidity, 65 (10.1%) patients had chronic kidney failure as a co-morbidity and 36 (28.8%) patients had both as the co-morbidity. This contradicts the study done by Mohan M, (2016) where out of 325 patients (71.42%) had DM with HTN and 130 patients (28.57%) had respiratory disorders with HTN 20.

 

In the overview of the current study, the most substantial prescribed antihypertensive drug was 

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