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Intermittent blood pressure control: potential consequences for outcome
1Hypertension Unit, University of Ottawa Heart Institute, Ontario. fleenen@ottawaheart.ca
Insights
Intermittent compliance with hypertension medications can lead to uncontrolled blood pressure and increased cardiovascular risk. Drugs with slow onset and long duration of action offer more consistent blood pressure control and fewer risks with missed doses.
Area of Science:
- Cardiology
- Pharmacology
- Hypertension Management
Background:
- Blood pressure (BP) and left ventricular (LV) mass predict cardiovascular risk.
- Achieved BP and LV mass during treatment correlate more strongly with cardiovascular event rates.
- Intermittent medication compliance is a primary cause of uncontrolled hypertension and persistent LV hypertrophy.
Purpose of the Study:
- To evaluate the impact of intermittent compliance with antihypertensive drugs on cardiovascular risk.
- To compare the effects of different drug classes with varying onset and duration of action on BP control and adverse events.
Main Methods:
- Review of existing literature on antihypertensive drug pharmacokinetics and pharmacodynamics.
- Analysis of the relationship between drug properties (onset, duration), compliance patterns, and clinical outcomes.
- Categorization of antihypertensive drug classes based on their suitability for intermittent dosing.
Main Results:
- Drugs with rapid onset and short duration may cause significant BP fluctuations and increase adverse event risk, especially with missed doses.
- Short-acting drugs like dihydropyridines can lead to intermittent BP control and sympathetic activation.
- Diuretics, ACE inhibitors, and ARBs appear to have no identified adverse effects with intermittent compliance.
Conclusions:
- Intermittent BP control is generally not advisable for hypertension management due to increased risks.
- Drugs with slow onset and long duration of action provide more consistent BP control and mitigate risks associated with noncompliance.
- Tailoring antihypertensive therapy based on drug properties and patient compliance is crucial for optimizing cardiovascular outcomes.
Abstract:
Although both blood pressure (BP) and left ventricular (LV) mass at initial evaluation predict future cardiovascular risk, the actual BP and LV mass achieved over years of treatment more clearly relate to cardiovascular event rates. Intermittent compliance or noncompliance is the major reason for uncontrolled hypertension and presumably persistent LV hypertrophy. In general, drugs with rapid onset and short duration of action are not desirable because this profile may lead to large variations in BP lowering effect during actual drug intake and rapid disappearance of the antihypertensive effect with missed doses. In addition, intermittent compliance per se introduces the potential for adverse events. For drugs requiring several dose-titrations (e.g., alpha1-blockers), restarting at full doses may lead to excessive drug action and symptomatic hypotension. For other drugs (e.g., short acting beta-blockers or clonidine-like drugs), sudden discontinuation with intermittent compliance may lead to rebound-enhanced sympathetic responsiveness after one to two days, resulting not only in side effects, but also in adverse events, particularly in patients with (silent) coronary artery disease. The rapid onset, short acting dihydropyridines cause intermittent BP control at each dosing, particularly at higher doses. This intermittent control of BP is even more apparent at dosing intervals that are long relative to the duration of action. Thus, sympathetic activation and potential for adverse events can be anticipated at each dosing unless these drugs are being taken frequently at relatively low doses. For diuretics, angiotensin-converting enzyme inhibitors and angiotensin I receptor blockers, no adverse effects have been identified with intermittent compliance. Intermittent BP control is, in general, not an appropriate approach to the management of hypertension and introduces additional risks depending on the type of antihypertensive drug. In contrast, drugs with slow onset and long duration of action provide a more consistent effect during actual drug intake and a more persistent effect during short periods of noncompliance.