managing hypertension in heart failure patients in a

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Managing Hypertension In Heart Failure Patients In ATeaching Hospital In GhanaA Charles, M v, O Isaac

Citation

A Charles, M v, O Isaac. Managing Hypertension In Heart Failure Patients In A Teaching Hospital In Ghana. The InternetJournal of Cardiovascular Research. 2008 Volume 7 Number 1.

Abstract

The study was carried to establish hypertension as the major cause of heart failure in patients seen at the medicine directorateof a teaching hospital in Kumasi. The study also determined the efficiency of the pharmacotherapeutical management ofhypertension in these patients. It was retrospective covering a 3-year period i.e. 2004 to 2006. It involved 307 heart failurepatients consisting of 54.7% males and 45.3 females aged between 13 to 100 years with the age range of 53-60 years formingthe majority. The median age of the patients was 54.6 years with a standard deviation of 18.12. The study was non-randomizedand hence all heart failure patients who fell within these periods were used. Hypertension was found to be main cause of heartfailure affecting 61.7% (n=189) out of the 307 patients who were admitted for heart failure. The patients had a mean systolicblood pressure of 148.2mmHg (SD.38.49) with the majority (28.7%) having systolic blood pressure in the range of140-165mmHg. Their mean diastolic blood pressure was 92.60mmHg (SD. 22.32) with the majority (52.4%) having diastolicblood pressure in the range of 90-110mmHg. For asymptomatic heart failure patients with hypertension a thiazide diuretic wasfound be effective especially for elderly patients over 65 years. 23.8% of the patients in this study received the calcium-channelblocker, nifedipine to treat hypertension in heart failure, however, the newer calcium antagonists, felodipine and amlodipinewere more effective in treating arterial hypertension in heart failure. 13.3% of the patients in this study received the β-blocker,carvedilol. Maximizing the dose of β-blockers and ACE-inhibitors, which extend survival in heart failure, was found be moreeffective than adding calcium-channel blockers to control hypertension. 41.7% of the patients in the study received low dose ofthe ACE-inhibitor, lisinopril (2.5mg-5mg) to treat symptomatic heart failure due to systolic left ventricular dysfunction, however,maximizing the dosage to 10mg-20mg was found to achieve a decrease in blood pressure as well as improved survival of thepatients. The centrally acting drug, methyldopa was administered to 18% of the patients. A dosage of 250-1000 twice daily wasfound to effectively control their blood pressure. Although most of the patients were discharged with a decreased blood pressurelevels the recommended target blood pressure levels of <140/90 or 130/80mmHg could not be achieved. This was due to thefact that most of the patients became asymptomatic and therefore were discharged to be reviewed at the cardiac clinic.

INTRODUCTION

Hypertension has been associated with an increased risk ofheart failure in several epidemiological studies. In theFramingham heart study, hypertension was reported as thecause of heart failure either alone or in association with otherfactors in over 70% of cases, on the basis on non-invasiveassessment(1). Hypertension predisposes to the developmentof heart failure via a number of pathological mechanisms,including left ventricular hypertrophy. Left ventricularhypertrophy is associated with left ventricular systolic anddiastolic dysfunction and an increased risk of myocardialinfarction and it predisposes to both atrial and ventriculararrhythmias. Electrocardiographic left ventricularhypertrophy is strongly correlated with the development ofheart failure, as it is associated with a 14-fold increase in therisk of heart failure in those aged 65 years or under(16).

There have been worrying reports recently both inepidemiology and clinical outcomes of hypertension inrecent studies. Hypertension has been reported to account forup to 30% of hospital admissions for heart failure in WestAfrica(3) and the prognosis of hypertensive heart failureamong black Africans has also been found to be poor(4).Amoah and Kallen found the main cause of heart failure inAccra, Ghana to be hypertension(5). Owusu, I., in Kumasialso found the main cause of heart failure to behypertension(6).

Effective management of hypertension in heart failure willdecrease stroke by 35-40%, myocardial infarction by20-25% and congestive heart failure by 50%. The goal oftreatment is to reduce cardiovascular and renal morbidityand mortality and vascular dementia by focusing on reducing

Managing Hypertension In Heart Failure Patients In A Teaching Hospital In Ghana

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systolic blood pressure with objective of achieving bloodpressure of <140/90 or <130/80 in heart failure patients withdiabetes or renal disease(7,8).

Aggressive treatment strategies for hypertension in heartfailure must begin with prevention, and hypertensionrepresents a major contributing factor. Some have estimatedthat as many as 90% of persons with heart failure have anantecedent history of hypertension. However, data suggestthat only 1/3 of patients have their blood pressurecontrolled(9). This low control rate is, in part, because ofphysician and patient behaviours that prevent achievementof blood pressure treatment goals. These behaviours include;

Prescribing suboptimal drug doses or failure toescalate antihypertensive dose

Reluctance to prescribe effective drugs due to theirside effects

Poor patient adherence to prescribed drugs

Therefore, to optimally treat heart failure patients withhypertension and achieve target pressure, these barriers mustbe overcome. Educating patients regarding the risks andconsequences of non-adherence, minimizing tolerabilityissues and side-effects and simplifying dosing regimens mayimprove adherence to treatment and resulting outcomes.

Cochrane review updated in 2004 gives the oralantihypertensive drugs that are used in the management ofhypertension in heart failure patients as below;

Figure 1

Table 1: Oral antihypertensive drugs used in themanagement of hypertension in heart failure patients. XR =extended release. Adapted from Chobanian AV, Bakris GL.Black HR, Cushman WC, Green, LA, Izzo, Jr. JL, Jones,DW et al. The Seventh Report of the Joint NationalCommittee on Prevention, Detection, Evaluation andTreatment of High Blood Pressure. The JNC 7 Report.JAMA 2003;289:2560-2572. Used with permission.

Figure 2

Table 2: Antihypertensive medication and co-morbidconditions

In managing hypertension in heart failure, the strategies toadapt are;

minimize polypharmacy

simplify treatment plan

prescribe inexpensive drugs

educate patients about disease and goal therapy

review medications regularly and discontinue whennot needed.


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MATERIALS AND METHODS

STUDY TYPE

The study was a hospital-based retrospective descriptivecarried out at the medicine

directorate, Komfo Anokye Teaching Hospital in Kumasicovering a 3-year period from January 2004 to December2006 involving 307 heart failure patients with hypertension.

SAMPLING METHOD

Heart failure patients aged between 13 and 100 years whowere admitted at the

medicine wards of the hospital were non-randomly used.Documentation of patients in the nurses’ admission anddischarge books at the wards was poor and hence onlypatients who were properly documented within the saidperiods of the study were used.

DATA PROCESSING AND ANALYSIS

The data collected using the Data Collection Forms wereentered separately into

STATA Version 7.0 statistical software for analysis.Descriptive analysis of baseline parameters was providedand numbers and percentages were calculated.

LIMITATION OF STUDY

As a result of the retrospective nature of the study, somevital information on some patients could not be obtained dueto poor documentations in the admission and dischargebooks at the wards. Some names and folder numbersretrieved from the admission and discharge books could notbe traced from the medical records department. These hadthe potential of affecting the results and might have dilutedthe observed results.

RESULTS

307 patients were involved in the study comprising 168males and 139 females who were admitted at the medicalwards of the medicine directorate from January 2004 toDecember 2006.

DEMOGRAPHIC CHARACTERISTICS

Sex Distribution

Males formed 54.7% whiles females formed 45.3% of thepatients in the study.

Figure 3

Table 3: sex distribution of heart failure patients

Figure 4

Figure 1; sex distribution of heart failure patients

Age Distribution

The ages of the patients admitted with heart failure duringthe period under review ranged from 13 to 100 years withthe range 53-60 years forming the majority i.e. 16.62%. Themedian age of the patients was 54.6 years with a standarddeviation (SD) of 18.12.

Figure 5

Table 4; age distribution of heart failure patients


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Figure 6

Figure 2; age distribution of heart failure patients.

SYSTOLIC BLOOD PRESSURE OF PATIENTS

The patients had a mean systolic blood pressure of148.2mmHg.

Figure 7

Table 5: the frequency of the systolic blood pressures of thepatients

Figure 8

Table 6: mean systolic blood pressure

DIASTOLIC BLOOD PRESSURE OF PATIENTS

Figure 9

Table 7: Frequency of diastolic blood pressures of thepatients.

Figure 10

Table 8: Mean diastolic blood pressure

Figure 11

Figure 3: systolic blood pressure distribution of patients

Figure 12

Figure 4: diastolic blood pressure of the patients beforetreatment

Drugs distribution

Figure 13

Table 9: drugs used and their frequency


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Figure 14

Figure 5: pattern of drugs used in managing hypertensiveheart failure

DISCUSSION

The ages of the patients admitted with heart failure duringthe period under review ranged from 13 to 100 years withthe range 53-60 years forming the majority i.e.16.62%. Themedian age of the patients was 54.6 years with a standarddeviation (SD) of 18.12. This correlates with the median ageof 56.15 (18.5) reported by Owusu in his study of the causesof heart failure in Kumasi(6). A similar mean age of 53(12.1) years was reported by Isezuo et al among Gambiansand Nigerians with heart failure(4). However, Amoah andKallen reported a low mean age of 42.3 (0.9) years in theirstudy at the National Cardiothoracic Centre in Accra(5).This may be due to the many congenital heart cases reportedat the centre and also being a national referral point, thecentre sees a lot of patients of all ages.

Males constituted 54.7% and females made up 45.3% ofheart failure patients in the study representing a ratio of1.2:1.0. Amoah and Kallen also reported a similar ratio of1.2:1.0 of male to female affected with the disease at theNational Cardiothoracic Centre in Accra(5). This confirmsavailable data(7,8) that heart failure affects more males thanfemales. This is probably due to the fact that the incidence ofhypertension is more prevalent in males than females andhypertension is a major cause of heart failure in the sub-region. The main causes of heart failure in this study werehypertension (61.7%). Data available shows that the maincause of heart failure in Africa is hypertension(7,8). Thiswas reported as such by Owusu, in Kumasi(6) and Amoahand Kallen in Accra(5). Given the importance ofhypertension, it is alarming that the awareness, treatment,and control rates of hypertension in Africa are as low as20%, 10% and 1%, respectively(7,8). Owusu reported thatthe detection and control of hypertension remains achallenge even in developed countries, with as many as 70%of hypertensive patients with uncontrolled high blood

pressure(6). 28.7% of the patients recorded a systolic bloodpressure in the range of 140-165mmHg whiles the meansystolic pressure recorded was 148.2mmHg. 22.3% of thepatients recorded a diastolic blood pressure of 92.6mmHgwith as many as 52.4% recording a diastolic blood pressurein the range of 90-110mmHg. These results exceeded targetblood pressure goals of <140/90 or 130/80mmHg asrecommended by guidelines for the management ofhypertension in heart failure (9). Physicians are oftensatisfied with decreasing blood pressure, even if bloodpressure target is not achieved. The notion that reachingtarget diastolic blood pressure goals is satisfactory althoughsystolic blood pressure remains high must be discarded. Thisis because for patients over 50 years, the systolic bloodpressure has been shown to be more important to controlthan the diastolic blood pressure (10) in managing bloodpressure in heart failure patients.

TREATMENT

Almost all the patients (98.7%) in this study receivedfrusemide, a loop diuretic in accordance with the updatedtreatment guidelines for heart failure since all the patientswere symptomatic. The frusemide was to manage fluidoverload and to relieve the patients of symptoms likebreathlessness. Strong clinical consensus(19) indicates thatdiuretics should be used to treat volume overload. A meta-analysis of several small trials also suggests that the use ofdiuretics reduce the risk of death and worsening heartfailure(19). The dose should be carefully tailored to theindividual patient to control fluid overload. All the patientshad fluid overload either as pulmonary oedema, peripheraloedema or both. For asymptomatic heart failure patients withhypertension the initial recommended medication wouldhave been a thiazide diuretic especially for elderly patientsover 65 years.

As many as 23.8% of the patients in this study received thecalcium-channel blocker,

Nifedipine, to treat arterial hypertension in heart failure.However, the antihypertensive and lipid-lowering treatmentto prevent heart attack trial (ALLHAT)(15) and a recentmeta-analyses(18) suggested that hypertensive heart failurepatients treated with calcium-channel blockers are at risk forworsening heart failure. The updated guidelines recommendthe use of the newer calcium antagonists i.e. felodipine andamlodipine to treat arterial hypertension in heart failure.

13.3% of the patients in this study received the β-blocker,carvedilol. Owusu, also found that only 17% of heart failure


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patients in his study received the β-blocker, carvedilol(5).However, maximizing the doses of β-blockers and ACE-inhibitors, which extend survival in heart failure, is preferredto adding calcium-channel blockers to controlhypertension(16,17). Although 41.7% of the patients in thestudy received the ACE-inhibitor, lisinopril, dosage was lowdose from 2.5mg-5mg to treat symptomatic heart failure dueto systolic left ventricular dysfunction, maximizing thedosage to 10mg-20mg would have achieved a decrease inblood pressure as well as improved survival of the patients.A meta-analysis of 32 trials completed before 1995 thatinvolved 7105 patients with heart failure concluded thatACE-inhibitors reduced the total mortality rate by 23% andthe combined end point of death from or hospitalization forheart failure by 35%(17). Furthermore, long-term follow-upof these studies suggests that these benefits are sustainedover many years.

The centrally acting drug methyldopa (i.e. Aldomet) wasused in 18% of the patients to treat hypertension. A dosageof 250-1000 twice daily is recommended to lower bloodpressure levels.

Although most of the patients were discharged with adecreased blood pressure the recommended target bloodpressure levels of <140/90 or 130/80mmHg could not beachieved. This was due to the fact that most of the patientsbecame asymptomatic and therefore, were discharged to bereviewed at the cardiac clinic.

CONCLUSION

Of all the diagnosis made in heart failure, hypertension is themost common cause. However, data suggest that only 1/3 ofthe patients have their blood pressure controlled. This ismainly due to physicians prescribing suboptimal drug dosesor failure to escalate antihypertensive dose. The goal oftreatment is to reduce cardiovascular and renal morbidityand mortality and vascular dementia by focusing on reducingsystolic blood pressure with goal being <140/90 or<130/80mmHg with hypertensive heart failure with diabetesor renal disease. Initial recommended medication is athiazide diuretic. After thiazide diuretics, the choice of anti-hypertensive medications is based on other co-morbidconditions. The newer calcium-channel antagonists,felodipine and amlodipine are recommended to treathypertension in heart failure. Maximizing the doses of ACE-inhibitors and β-blockers will be sufficient to controlhypertension in heart failure. Educating physicians andpatients regarding the importance of treating to goal is a

crucial step in overcoming barriers that prevent bloodpressure goal achievement. Again the simplification ofdosing may provide adherence benefits over a twice-orthree-time daily drug. Overall, physicians must be confidentthat aggressive treatment will not result in an adversebenefit-to-ratio for the patient.

References

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clinical study. Afr J Med. Sci 1997 Dec; 6(4): 185-192.17. Task Force report. (2001). Guidelines for the diagnosisand treatment of chronic heart failure, European Society ofCardiology. Eur Heart J (2001) 22, 1527-1560.18. Turnbull, F. (2003). Effects of different blood-pressure-lowering regimes on major cardiovascular events: results of

protectively- designed overviews of randomized trials.Lancet. 2003;362:1527-35[PMID:14615107]19. Faris, R; Flather, M; Purcell, H; Henein, M; Poole-Wilson, P; Coats, A.(2002). Current Evidence Supportingthe Role of Diuretics in Heart Failure; a meta analysis ofrandomized controlled trials. Ht J Cardiol. 2002; 82:149-58[PMID: 12932605]


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Author Information

Anane CharlesPhD Cand Clinical Pharmacist, Cardiology and Critical Care, KATH

Mensah vHead, Clinical Pharmacy, KATH

Owusu Isaac, MDCardiologist Consultant, KATH

managing hypertension in heart failure patients in a

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