Optimising Primary Care Management of Hypertension: The Valsartan Intensified Primary Care Reduction of Blood Pressure (VIPER-BP) Study

Abstract

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.

Determinants of Achieving Early Blood Pressure Control with Monotherapy in a Primary Care Setting

“…As described in our previous reports describing the rationale and design of the study and the primary results in favor of the study intervention of more intensive primary care management overall, the VIPER‐BP study was a pragmatic, multicenter randomized controlled trial involving a total of 119 general practices Australia‐wide. The study received ethics approval from all relevant bodies including the Alfred Hospital Ethics of Human Research Committee, Melbourne, Australia, in accordance with the Declaration of Helsinki (2008).…”

“…Beyond the application of pharmacotherapy, there is strong evidence, including a Cochrane review of the literature, that more intensive and structured management in the primary care setting will significantly improve BP control rates . We therefore conducted the multicenter, randomized Valsartan Intensified Primary Care Reduction of Blood Pressure (VIPER‐BP) study to test the clinical effectiveness and overall safety of a more intensive and structured approach to optimizing BP control in a group of individuals with persistently high BP levels in primary care. During the randomized component of comparing the VIPER‐BP intervention (n=1038) with an enhanced form of usual care (n=524), the primary endpoint (individual risk‐based BP target) was achieved in 36.2% vs 27.4% of participants, respectively (adjusted relative risk 1.28 in favor of the intervention; P =.001) and the classical BP target of ≤140/90 mm Hg in 63.5% vs 54.0% of participants (adjusted relative risk 1.18 in favor of the intervention; P <.001) .…”

Addressing chronic kidney disease in Far North Queensland: gains and opportunities

“…This is possibly reflected in the less favourable outcomes for blood pressure control, a common problem locally and worldwide. For example, the Valsartan Intensified Primary carE Reduction of Blood Pressure (VIPER‐BP) study, which involved more than 2300 primary care patients around Australia, showed that only 28% of ‘usual care’ patients met ideal blood pressure targets . Remoteness, with its inherent logistic challenges, may be a key factor in this context.…”

Barriers and challenges for primary and secondary prevention of heart disease in sub-Saharan Africa

“…(18) Coordinating management of hypertension through primary healthcare initiatives represents an important, but often, under-estimated component of wider BP control. (19) At the other end of the spectrum (i.e. from treating hypertension as a primary risk factor), in the past, there have been similar issues in determining optimal ways to detect and manage the syndrome of chronic HF (CHF) in the ageing populations of high-income countries.…”