Search

Background: For patients on dialysis with poor quality of life and prognosis, dialysis withdrawal and subsequent transition to palliative care is recommended. This study aims to understand multi-stakeholder perspectives regarding dialysis withdrawal and identify their information needs and support for decision-making regarding withdrawing from dialysis and end-of-life care. Methods: Participants were recruited through purposive sampling from eight dialysis centers and two public hospitals in Singapore. Semi-structured in-depth interviews were conducted with 10 patients on dialysis, 8 family caregivers, and 16 renal healthcare providers. They were held in-person at dialysis clinics with patients and caregivers, and virtually via video-conferencing with healthcare providers. Interviews were audio-recorded, transcribed, and thematically analyzed. The Ottawa Decision Support Framework's decisional-needs manual was used as a guide for data collection and analysis, with two independent team members coding the data. Results: Four themes reflecting perceptions and support for decision-making were identified: a) poor knowledge and fatalistic perceptions; b) inadequate resources and support for decision-making; c) complexity of decision-making, unclear timing, and unpreparedness; and d) internal emotions of decisional conflict and regret. Participants displayed limited awareness of dialysis withdrawal and palliative care, often perceiving dialysis withdrawal as medical abandonment. Patient preferences regarding decision-making ranged from autonomous control to physician or family-delegated choices. Cultural factors contributed to hesitancy and reluctance to discuss end-of-life matters, resulting in a lack of conversations between patients and providers, as well as between patients and their caregivers. Conclusions: Decision-making for dialysis withdrawal is complicated, exacerbated by a lack of awareness and conversations on end-of-life care among patients, caregivers, and providers. These findings emphasize the need for a culturally-sensitive tool that informs and prepares patients and their caregivers to navigate decisions about dialysis withdrawal and the transition to palliative care. Such a tool could bridge information gaps and stimulate meaningful conversations, fostering informed and culturally aligned decisions during this critical juncture of care. [ABSTRACT FROM AUTHOR]

The prevalence of hypertension varies by country and region, but it remains a leading yet modifiable risk factor of cardiovascular disease. There are many factors that contribute to the burden of hypertension in Asia, a region with diverse ethnicity. It has been shown that sociodemographic variability is related to ethnic differences, thereby emphasizing the importance of hypertension screening and educating at-risk or vulnerable groups. In this review, we describe the ethnic differences in genetic variants, dietary choice, and lifestyle habits, as well as its association with sociodemographic differences, hypertension awareness, and treatment control. [ABSTRACT FROM AUTHOR]

Unlike other international guidelines but in accord with the earlier Japanese Society of Hypertension (JSH) guidelines, the 2019 JSH guidelines ("JSH 2019") continue to emphasize the importance of out-of-office blood pressure (BP) measurements obtained with a home BP device. Another unique characteristic of JSH 2019 is that it sets clinical questions about the management of hypertension that are based on systematic reviews of updated evidence. JSH 2019 states that individuals with office BP < 140/90 mm Hg do not have normal BP. The final decisions regarding the diagnosis and treatment of hypertension should be performed based on out-of-office BP values together with office BP measurements. For hypertensive adults with comorbidities, the office BP goal is usually <130/80 mm Hg and the home BP goal is <125/75 mm Hg. Recommendations of JSH 2019 would be valuable for not only Japanese hypertensive patients but also Asian hypertensive patients, who share the same features including higher incidence of stroke compared with that of myocardial infarction and a steeper blood pressure-vascular event relationship. [ABSTRACT FROM AUTHOR]

Epidemiologic studies have consistently demonstrated an increased risk of cardiovascular disease during colder temperatures. Hemodynamic changes associated with cold temperature and an increase in thrombogenicity may both account for the increase in cardiovascular risk and mortality. Studies using both in-office and out-of-office BP measurements have consistently shown an elevation in BP during the colder seasons. The large difference in BP between cold and warm months may increase the incidence of hypertension and reduce the hypertension control rate, potentially resulting in increased cardiovascular risk, especially among those at risk of cardiovascular disease. The current trends in global warming and climate change may have a profound impact on the epidemiology of hypertension and cardiovascular disease, as changes in the climate may significantly affect both BP variability and cardiovascular disease, especially in those with high cardiovascular risk and the elderly. Furthermore, climate change could have a significant influence on hypertension in Asia, considering the unique characteristics of hypertensive patients in Asia. As an increase in ambient temperature decreases the mean daytime average and morning surge in BP, but increases the nocturnal BP, it is difficult to predict how environmental changes will affect the epidemiology and prognosis of hypertension in the Asian-Pacific region. However, these seasonal variations in BP could be minimized by adjusting the housing conditions and using anticipation medicine. In this review, we discuss the impact of seasonal variation in the ambient temperature on hypertension and cardiovascular disease and discuss how this may impact the epidemiology of hypertension and cardiovascular disease. [ABSTRACT FROM AUTHOR]

Since noninvasive central blood pressure (BP) measuring devices are readily available, central BP has gained growing attention regarding its clinical application in the management of hypertension. The disagreement between central and peripheral BP has long been recognized. Some previous studies showed that noninvasive central BP may be better than the conventional brachial BP in association with target organ damages and long-term cardiovascular outcomes. Recent studies further suggest that the central BP strategy for confirming a diagnosis of hypertension may be more cost-effective than the conventional strategy, and guidance of hypertension management with central BP may result in less use of medications to achieve BP control. Despite the use of central BP being promising, more randomized controlled studies comparing central BP-guided therapeutic strategies with conventional care for cardiovascular events reduction are required because noninvasive central and brachial BP measures are conveniently available. In this brief review, the rationale supporting the utility of central BP in clinical practice and relating challenges are summarized. [ABSTRACT FROM AUTHOR]

Hypertension is an important public health concern. The prevalence keeps increasing, and it is a risk factor for several adverse health outcomes including a decline in cognitive function. Recent data also show that the prevalence of hypertension and age-related dementia is rising in Asian countries, including in the oldest old group. This study aims to discuss possible treatments for high blood pressure in the elderly and propose an optimal target for BP relative to cognitive outcomes. This review discusses several studies on related blood pressure treatments that remain controversial and the consequences if the treatment target is too low or aggressive. Longitudinal, cross-sectional, and RCT studies were included in this review. An optimum systolic blood pressure of 120-130 mm Hg is recommended, especially in nondiabetic hypertensive patients with significant risk factors. In the oldest old group of patients, hypertension might have a protective effect. The use of calcium channel blockers (CCB) and angiotensin receptor blocker (ARB) is independently associated with a decreased risk of dementia in older people. However, personalized care for patients with hypertension, especially for patients who are frail or very old, is encouraged. [ABSTRACT FROM AUTHOR]

Hypertension professionals from Asia have been meeting together for the last decade to discuss how to improve the management of hypertension. Based on these education and research activities, the Hypertension, brain, cardiovascular and renal Outcome Prevention and Evidence in Asia (HOPE Asia) Network was officially established in June 2018 and includes experts from 12 countries/regions across Asia. Among the numerous research and review papers published by members of the HOPE Asia Network since 2017, publications in three key areas provide important guidance on the management of hypertension in Asia. This article highlights key consensus documents, which relate to the Asian characteristics of hypertension, home blood pressure monitoring (HBPM), and ambulatory blood pressure monitoring (ABPM). Hypertension and hypertension-related diseases are common in Asia, and their characteristics differ from those in other populations. It is essential that these are taken into consideration to provide the best opportunity for achieving "perfect 24-hour blood pressure control", guided by out-of-office (home and ambulatory) blood pressure monitoring. These region-specific consensus documents should contribute to optimizing individual and population-based hypertension management strategies in Asian country. In addition, the HOPE Asia Network model provides a good example of the local interpretation, modification, and dissemination of international best practice to benefit specific populations. [ABSTRACT FROM AUTHOR]

The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was set up to improve the management of hypertension in Asia with the ultimate goal of achieving "zero" cardiovascular events. Asia is a diverse continent, and the prevalence of hypertension has increased over the last 30 years. There are a number of Asia-specific features of hypertension and hypertension-related cardiovascular complications, which means that a region-specific approach is needed. White-coat hypertension will become more of an issue over time as Asian populations age, and masked hypertension is more prevalent in Asian than in Western countries. Identifying and treating masked hypertension is important to reduce cardiovascular risk. Abnormal patterns of blood pressure (BP) variability common in Asia include exaggerated early morning BP surge and nocturnal hypertension. These are also important cardiovascular risk factors that need to be managed. Home blood pressure monitoring (HBPM) is an important tool for detecting white-coat and masked hypertension, and monitoring BP variability, and practices in Asia are variable. Use of HBPM is important given the Asia-specific features of hypertension, and strategies are needed to improve and standardize HBPM usage. Development of HBPM devices capable of measuring nocturnal BP along with other information and communication technology-based strategies are key developments in the widespread implementation of anticipation medicine strategies to detect and prevent cardiovascular events in patients with hypertension. Region-wide differences in hypertension prevalence, control, and management practices in Asia highlight the importance of information sharing to facilitate best practices. [ABSTRACT FROM AUTHOR]

Ambulatory blood pressure monitoring (ABPM) can measure 24-hour blood pressure (BP), including nocturnal BP and diurnal variations. This feature of ABPM could be of value in Asian populations for preventing cardiovascular events. However, no study has yet investigated regarding the use of ABPM in actual clinical settings in Asian countries/regions. In this study, 11 experts from 11 countries/regions were asked to answer questionnaires regarding the use of ABPM. We found that its use was very limited in primary care settings and almost exclusively available in referral settings. The indications of ABPM in actual clinical settings were largely similar to those of home BP monitoring (HBPM), that is, diagnosis of white-coat or masked hypertension and more accurate BP measurement for borderline clinic BP. Other interesting indications, such as nighttime BP patterns, including non-dipper BP, morning BP surge, and BP variability, were hardly adopted in daily clinical practice. The use of ABPM as treatment guidance for detecting treated but uncontrolled hypertension in the Asian countries/regions didn't seem to be common. The barrier to the use of ABPM was primarily its availability; in referral centers, patient reluctance owing to discomfort or sleep disturbance was the most frequent barrier. ABPM use was significantly more economical when it was reimbursed by public insurance. To facilitate ABPM use, more simplified indications and protocols to minimize discomfort should be sought. For the time being, HBPM could be a reasonable alternative. [ABSTRACT FROM AUTHOR]

Blood pressure variability (BPV) has been shown to be independently associated with cardiovascular (CV) mortality and morbidity. Patients with type 2 diabetes mellitus (T2DM) have also been shown to have increased BPV. We aimed to compare BPV in hypertensive patients with diabetes with those without diabetes. A total of 1443 hypertensive patients measured their blood pressure (BP) twice in the morning and twice before bed at home for a week. Demographic data, history of T2DM, and anti-hypertensive use were captured. Clinic BP was measured twice in the clinic. Control of BP was defined as clinic systolic BP (SBP) <140 mm Hg and home SBP < 135 mm Hg. BPV was based on home SBP measurements. A total of 362(25.1%) hypertensives had diabetes and 47.4% were male. Mean age was 62.3 ± 12.1 years. There was no difference in the mean clinic SBP in both groups (139.9 mm Hg vs 138.4 mm Hg P = .188). However, the mean morning home SBP was significantly higher and control rate lower in hypertensives with diabetes than those without (132.3 ± 15 mm Hg vs 129.7 ± 14.4 mm Hg P = .005, 39.4% vs 47.6% P = .007), respectively. Masked uncontrolled morning hypertension was higher in those with diabetes versus those without (12.8% vs 8.4%, respectively). There was no statistically significant difference in BPV between those with and without diabetes. In summary, clinic SBP was similar in hypertensives with or without diabetes. However, control of BP based on both clinic and home SBP thresholds was poorer in hypertensives with diabetes compared to those without. Masked uncontrolled morning hypertension was higher in those with diabetes than those without. There was no difference in BPV between the two groups. [ABSTRACT FROM AUTHOR]

It is widely accepted that hypertension constitutes a significant cardiovascular risk factor and that treating high blood pressure (BP) effectively reduces cardiovascular risk. An important issue in Asia is not just the high prevalence of hypertension, particularly in some countries, but also the low level of awareness and treatment rates in many regions. The 2017 update of the American College of Cardiology/American Heart Association hypertension guidelines raised the question about which BP threshold should be used to diagnose and treat hypertension. Although there is a theoretical rationale for a stricter BP criterion in Asia given the ethnic-specific features of hypertension in the region, the majority of countries in Asia have retained a diagnostic BP threshold of ≥140/90 mm Hg. Although lowering thresholds might make theoretical sense, this would increase the prevalence of hypertension and also markedly reduce BP control rates. In addition, there are currently no data from robust randomized clinical trials of the benefits of the lower targets in preventing cardiovascular disease and reducing cardiovascular risk, particularly in high-risk patients and especially for Asian populations. There is also no defined home BP treatment target level for an office BP treatment target of 130/80 mm Hg. However, in this regard, in the interim, lifestyle modifications, including reducing body weight and salt intake, should form an important part of hypertension management strategies in Asia, while studies on treating at lower BP threshold level in Asians and getting to lower BP targets will be helpful to inform and optimize the management of hypertension in the region. [ABSTRACT FROM AUTHOR]