Objective To determine the effectiveness of intensive structured care to optimise blood pressure control based on individual absolute risk targets in primary care.

There is greater potential to achieve blood pressure targets in primary care with practice nurse-mediated hypertension management.

Objective:To examine protocol adherence to structured intensive management in the Valsartan Intensified Primary carE Reduction of Blood Pressure (VIPER-BP) study involving 119 primary care clinics and 1562 randomized participants.Methods:Prospective criteria for assessing adherence to treatment prescription, uptitration, and visit attendance at 6, 10, 14, and 18 weeks postrandomization were applied to 1038 intervention participants. Protocol adherence scores of 1–5 (least to most adherent) were compared to blood pressure (BP) control during 26 weeks of follow-up.Results:Mean age was 59.3 ± 12.0 years, 963 (62%) were men, and 1045 (67%) had longstanding hypertension. Clinic attendance dropped from 91 (week 6) to 83% (week 26) and pharmacological instructions were followed for 93% (baseline) to 61% at week 14 (uptitration failures commonly representing protocol deviations). Overall, 26-week BP levels and BP target attainment ranged from 132 ± 14/79 ± 9 and 51% to 141 ± 15/83 ± 11 mmHg and 19% in those participants subject to the highest (n = 270, 26%) versus least (n = 148, 14%) per protocol adherence, respectively; adjusted relative risk (RR) 1.22 per unit protocol adherence score, 95% confidence interval (CI) 1.15–1.31; for achieving BP target (P < 0.001). Participants with a per protocol score of 4 or 5 (512/1038, 49.3%) were 1.54-fold (95% CI 1.31–1.81; P < 0.001) more likely to achieve their individual BP target compared with usual care. Clinics equipped with a practice nurse significantly influenced protocol adherence (adjusted RR 1.20, 95% CI 1.06–1.37; P = 0.004) and individual BP control (RR 1.21, 95% CI 1.04–1.41; P = 0.015).Conclusion:There is considerable potential for structured care management to improve BP control in primary care, especially when optimally applied.

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Background: Intra-arterial Doppler is a novel technique which enables accurate assessment of blood flow haemodynamics. We evaluated the feasibility of using intra-arterial Doppler for insights into the pulmonary artery flow velocity profile in patients with pulmonary arterial hypertension (PAH), and determined the changes in the flow velocity profile following pulmonary vasodilator therapy.Methods: Intra-arterial Doppler was performed in the pulmonary arteries of seven subjects with PAH before and after six months of Bosentan therapy. The following Doppler derived parameters were measured: acceleration time (AcT), systolic ejection time (ET), ratio of acceleration time to systolic ejection time (AcT/ET), systolic velocity time integral (sVTI), diastolic velocity time integral (dVTI) and total velocity time integral (tVTI). Relationships between Doppler parameters and clinical response to Bosentan therapy were analysed.Results: At baseline, all PAH patients displayed a Doppler flow velocity profile consisting of a sharp rise to peak velocity followed by mid-to-late systolic notching. In one patient, systolic notching disappeared following Bosentan therapy. Only clinical responders (n = 3) demonstrated a significant increase in tVTI (583 ± 132 versus 897 ± 138, p = 0.023), and an increase in dVTI (62 ± 28 versus 195 ± 40, p = 0.044). No significant change was observed in VTI amongst non-responders.Conclusion: Intra-arterial Doppler is feasible in the quantitative characterisation of pulmonary artery flow velocity profile. An increase in pulmonary blood flow, particularly diastolic flow, was associated with a clinical response to Bosentan therapy. This technique may provide additional insights into the haemodynamics of the pulmonary circulation in pathophysiological states.