Caution Before Universally Recommending SGLT2i or GLP-1RAs in Inpatient Cardiac Care Setting
SGLT2i and GLP-1RA have clear outcomes benefits in high CV risk patients with diabetes, but the drugs are currently underutilized. However, the side effect profile of these medications must be carefully considered before initiation of these drugs in the hospital. Initiation of drug at the conclusion of hospital stay or at discharge may be safest and most effective approach at this time.
Risk of Acute Kidney Injury in Real-World Use of Dapagliflozin
A study compared the occurrence of acute kidney injury in new users of Dapagliflozin & of comparator GLDs. Comparators incorporated GLDs besides SGLT2 inhibitors or monotherapy of insulin, metformin, or sulfonylureas. Study exhibited that a reduced risk of AKI was correlated with Dapagliflozin than other GLDs and adjusted with findings from Dapagliflozin clinical trials.
SGLT2is and GLP-1RAs—What Are the Benefits?
SGLT2 inhibitors & GLP1RAs should be considered in T2D patients with ASCVD or at high risk regardless of A1c. Empagliflozin, Semaglutide, Liraglutide, Canagliflozin reduced the rate of CV death, non-fatal MI or stroke . Dapagliflozin, Lixisenatide, was not associated with a significant difference in CV events. Substantial evidence exists supporting their safety & efficacy.
Rivaroxaban Plus Aspirin: Mortality in Chronic CAD or PAD
Patients with stable CAD or PAD plus baseline high-risk features experienced greater mortality benefit with rivaroxaban plus aspirin therapy.The authors concluded that combination of rivaroxaban plus aspirin compared to aspirin alone reduced overall and cardiovascular mortality for patients with chronic CAD or PAD. They also concluded that mortality benefits are greater for patients .
Do we need beta blockers in hypertension
BBs are less effective in reducing stroke compared to other drugs, while they are as equivalent as other drugs in preventing major CV events. BBs have shown to be particularly useful in treatment of hypertension in specific situations: Symptomatic angina; Heart rate control; Post myocardial infarction; HFrEF; Younger hypertensive women planning pregnancy or a childbearing potential.
Increasing disease burden imposed by hypertension in india
In India, crude prevalence of hypertension was found to be 25.3%. Age, diabetes, hypercholesteremia, extra salt intake, BMI, and alcohol consumption are contributing factors. Hypertension & diabetes co-exists in about 20.6% of Indian population. Hypertensives are 11 times more likely to be affected by CHD, contributing to 20% of global burden of HTN in India.
Sympathetic nervous system: Key regulator of multiple targets
SNS regulates cardiovascular and metabolic functions. Autonomic dysfunction is linked to HTN, BP variability, heart rate, blood flow and HRV. The various ways to modify vago-sympathetic activity and favourably change in BP and metabolic profile are: Lifestyle and weight loss; CPAP; New glucose-lowering drugs; Renal denervation; Central Sympatholytic agents - targeting BP and insulin resistance.
Association of COVID-19, hypertensive hospitalized patients with mortality
The cross-sectional, observational, retrospective multicentre study states that hypertension is considered to be an independent risk factor for all-cause mortality in COVID-19 patients. HTN was found to be significantly predictive of all-cause mortality with multivariate analysis results and the analysis adjusted for gender, age, and Charlson Comorbidity Index scores.
ISH hypertension guidelines: Secondary and Resistant Hypertension
Essential Secondary HTN can be screened through history+clinical clues+basic blood biochemistry + dipstick urine analysis. Optimal Secondary HTN can be screened through additional biochemistry tests or imaging based on information from history, physical examination and basic clinical investigations and/or if feasible, it is advised to refer to a specialist centre.
ISH hypertension guidelines: Essential treatment standards
BP may rise even after lifestyle modifications in patients with hypertension. The risk may be high in patients with Grade I hypertension, 140-159/90-99 mmHg. In this case, treatment has to be initiated immediately. While in low risk patients, dietary and lifestyle changes can help control BP. If BP is still uncontrollable, patients can be rationed on drug treatment based on risk status.
ISH hypertension guidelines: Optimal standards for hypertension treatment
Following steps are recommended:1: Dual low dose combination of ACE inhibitor or ARB (A) and Dihydropyridine CCB (C).2: Dual full dose combination as monotherapy in low-risk Grade I HTN patients a combination of A+ Thiazide like diuretic (D) and a combination of C+D in black patients.3: A+C+D triplet combination.4: A triple combination with spironolactone or another drug.
ISH hypertension guidelines: Lifestyle modification
Healthy lifestyle choices can prevent or delay onset of high BP & can reduce CV risk and are recommended as 1st line of anti-hypertensive treatment. Dietary changes, reduced salt intake, drinking healthy drinks, avoiding obesity and engagement of regular moderate-intensity aerobic & resistance exercises for 30 mins for 5-7 days a week, and reducing stress can help manage hypertension.
Triple Single-Pill Combination: What do the guidelines tell us?
The recipe for successful treatment of a hypertensive patient is appropriate treatment, therapy adherence and inertia-free physician. Triple single-pill combination facilitates BP control in difficult to manage hypertension and provides optimal CV protection. Combination therapy leads to quicker BP control, less variability, safe and well-tolerated, and better adherence.
20 Years Follow up of ASCOT-LEGACY
The ASCOT-Legacy Study was conducted in the UK for 21 yrs and included 8580 hypertensive patients. Patients received either atenolol+/-diuretic or amlodipine+/-perindopril-based treatments. Patients on amlodipine-based treatment had reduced risk of atrial fibrillation, stroke, total coronary and CV events compared to those on atenolol-based treatment.
Treatment adherence & resistance in patients with hypertension.
Non-adherence is a common and an important contributor to Hypertension associated morbidity. Different people have different reason for non-adherence. Adherence can change over time as circumstances/beliefs/behaviors change so it becomes important to reassess regularly. Adherence in resistant patients should be the 1st point to be considered before treatment or investigations are initiated.
Effect of Sotagliflozin: SOLOIST-WHF Trial
Sotagliflozin is an SGLT2 inhibitor, but also inhibits SGLT1, which primarily exists in the gut and appears to delay glucose absorption. The SOLOIST-WHF trial showed that sotagliflozin has salutary effects on CV outcomes among patients with T2DM and HF. Patient-centric outcomes such as days alive and out of the hospital were also improved with sotagliflozin compared with placebo.
Individualization of treatment for hypertensive patients with elevated heart rate
By the time patient treatment plans are approached positively, poor adherence/persistence shows 50% reduction in its effectiveness. SPC is recommended as 1st line treatment. Also among RAAS blockers, ACEi should be preferred over ARBs as 1st line of treatment. In patients with elevated BP and HR, SPC including BB+ACEi shows a rationale and effective treatment strategy.
The 2018 ESC/ESH and 2020 ISH core treatment Strategy: Importance of SPC
SPC medicines play a significant role in improving adherence and clinical outcomes of patients requiring multiple drugs for BP control. FDC medicines improve patient adherence to medication, improving BP control. Low dose SPCs are recommended as 1st line therapy by the latest guidelines for most patients, as it improves adherence, simplifies treatment, improves persistence with medications.
