4 Артериальная гипертензия основные принципы диагностики и лечения.pptx

Editor's Notes

• #7: Двукратное измерение АД утром (в течение часа после пробуждения, до завтрака) и вечером (до ужина или не менее чем через 2 ч после ужина) в течение 7 последовательных дней. Анализируются (усредняются) данные последних 5 дней.
• #66: SLIDE INFORMATION SOURCE: Facts about the DASH eating plan. Bethesda, Md: National Heart, Lung, and Blood Institute 1998. NIH publication no. 03-4082. In a multicenter randomized trial of 412 participants, the DASH diet resulted in significantly lower systolic and diastolic blood pressure at high and intermediate levels of sodium intake (approximately 3500 mg and 2500 mg per day). A combination of the DASH diet and a sodium intake of approximately 1500 mg daily lowered mean systolic blood pressure by 11.5 mm Hg compared to a control diet with a sodium intake comparable to the average intake in the U.S. (3500 mg) (1). The DASH diet is most effective when combined with low sodium intake (approximately 1500 mg per day). (1). Sacks FM, et al. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. N Eng J Med 2001; 344: 3-10.
• #76: BMJ. 2008 May 17;336(7653):1121-3. doi: 10.1136/bmj.39548.738368.BE. Epub 2008 May 14. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. Blood Pressure Lowering Treatment Trialists' Collaboration1, Turnbull F, Neal B, Ninomiya T, Algert C, Arima H, Barzi F, Bulpitt C, Chalmers J, Fagard R, Gleason A, Heritier S, Li N, Perkovic V, Woodward M, MacMahon S. Collaborators (73) Author information Abstract OBJECTIVE: To quantify the relative risk reductions achieved with different regimens to lower blood pressure in younger and older adults. DESIGN: Meta-analyses and meta-regression analyses used to compare the effects on the primary outcome between two age groups (<65 v > or =65 years). Evidence for an interaction between age and the effects of treatment sought by fitting age as a continuous variable and estimating overall effects across trials. MAIN OUTCOME MEASURES: PRIMARY OUTCOME: total major cardiovascular events. RESULTS: 31 trials, with 190 606 participants, were included. The meta-analyses showed no clear difference between age groups in the effects of lowering blood pressure or any difference between the effects of the drug classes on major cardiovascular events (all P> or =0.24). Neither was there any significant interaction between age and treatment when age was fitted as a continuous variable (all P>0.09). The meta-regressions also showed no difference in effects between the two age groups for the outcome of major cardiovascular events (<65 v > or =65; P=0.38). CONCLUSIONS: Reduction of blood pressure produces benefits in younger (<65 years) and older (> or =65 years) adults, with no strong evidence that protection against major vascular events afforded by different drug classes varies substantially with age. Comment in Review: blood pressure-lowering drugs prevent cardiovascular events equally well in younger and older patients. [ACP J Club. 2008] Should you consider your patient's age when choosing an antihypertensive? [J Fam Pract. 2008] Reducing blood pressure in people of different ages. [BMJ. 2008] Review: BP-lowering drugs prevent cardiovascular events equally well in younger and older patients. [Evid Based Med. 2008] PMID: 18480116 [PubMed - indexed for MEDLINE] PMCID: PMC2386598 Free PMC Article Share on FacebookShare on TwitterShare on Google+
• #77: Effects of more or less-intense blood pressure reduction on different outcomes in various groups of hypertensives. Hazard ratios (circles) and confidence intervals (horizontal lines) for different types of outcome (listed on the left) are indicated for groups of hypertensive patients in whom mean SBP achieved lower (felodipine treatment) or higher values (placebo treatment). Patients were grouped by older or younger age; higher or lower SBP at randomization; presence of either cardiovascular disease (CVD) or diabetes (DM), presence of neither CVD nor DM; male or female gender. Eur Heart J. 2011 Jun;32(12):1500-8. doi: 10.1093/eurheartj/ehr039. Epub 2011 Feb 22. Is a systolic blood pressure target <140 mmHg indicated in all hypertensives? Subgroup analyses of findings from the randomized FEVER trial. Zhang Y1, Zhang X, Liu L, Zanchetti A; FEVER Study Group. Author information Abstract AIMS: Major guidelines recommend lowering systolic blood pressure (SBP) to <140 mmHg in all hypertensives, but evidence is missing whether this is beneficial in (i) uncomplicated hypertensives, (ii) grade 1 hypertensives, and (iii) elderly hypertensives. Providing this missing evidence is important to justify efforts and costs of aggressive therapy in all hypertensives. METHODS AND RESULTS: Felodipine Event Reduction (FEVER) was a double-blind, randomized trial on 9711 Chinese hypertensives, in whom cardiovascular outcomes were significantly reduced by more intense therapy (low-dose hydrochlorothiazide and low-dose felodipine) achieving a mean of 138 mmHg SBP compared with less-intense therapy (low-dose hydrochlorothiazide and placebo) achieving a mean of 142 mmHg.FEVER included older and younger patients, and patients with and without diabetes or cardiovascular disease. In the analyses here reported, Cox regression models assessed outcome differences between more and less-intense treatments in groups of patients with different baseline characteristics. Significant reductions in stroke were found in uncomplicated hypertensives (-39%, P = 0.002), in hypertensives with randomization SBP <153 mmHg (-29%, P = 0.03), and in elderly hypertensives (-44%, P < 0.001), when their SBP was lowered by more intense treatment. Significant reductions (between -29 and -47%, P = 0.02 to <0.001) were also found in all cardiovascular events and all deaths. Achieving mean SBP values <140 mmHg by adding a small dose of a generic drug prevented 2.1 (uncomplicated hypertensives) and 5.2 (elderly) cardiovascular events every 100 patients treated for 3.3 years. CONCLUSIONS: These analyses provide strong support, missing so far, to guidelines recommending goal SBP <140 mmHg in uncomplicated hypertensives, individuals with moderately elevated BP and elderly hypertensives. TRIAL REGISTRATION: ClinicalTrials.gov NCT01136863. PMID: 21345850 [PubMed - indexed for MEDLINE] Free full text
• #87: При оценке предшествующей терапии было выявлено, что в группе женщин с неконтролируемой АГ достоверно реже назначали лишь один класс антигипертензивных препаратов – диуретики. Даже при учете частоты применения препаратов отдельных классов, а также общего числа назначаемых препаратов с адекватным контролем АД было связано только назначение диуретиков – ОШ составило 2,25 (1,63–3,10).
• #89: Clin Drug Investig. 2007;27(11):735-53. Updated meta-analytical approach to the efficacy of antihypertensive drugs in reducing blood pressure. Baguet JP, Legallicier B, Auquier P, Robitail S. Source Cardiology and Hypertension Unit, Grenoble University Hospital, Grenoble, France. JPBAGUET@chu-grenoble.fr Abstract BACKGROUND AND OBJECTIVE: Despite advances in the treatment of hypertension, control rates continue to be suboptimal in both Europe and the US. Strategies that improve hypertension control are therefore urgently needed. This study aimed to assess the relative efficacies of various antihypertensive drugs commonly used in France in reducing systolic and diastolic blood pressure (SBP and DBP) by using a meta-analytical approach. This update of a previously published meta-analytical approach extends the number of drugs evaluated from 13 to 19. METHODS: A total of 80 randomised, controlled trials published between 1973 and 2007 involving 10 818 patients were selected for inclusion in the meta-analytical approach. Data were examined for 19 drugs, and 16 drugs were included in the analysis: hydrochlorothiazide, indapamide sustained-release (SR), atenolol, amlodipine, lercanidipine, manidipine, enalapril, ramipril, trandolapril, candesartan cilexetil, irbesartan, losartan, olmesartan medoxomil, telmisartan, valsartan and aliskiren. Weighted average reductions in SBP and DBP over a period of 8-12 weeks were calculated for each drug from information on both the mean and the variability in BP reduction. No trials evaluating furosemide, spironolactone or cicletanine satisfied the inclusion criteria for this analysis. RESULTS: The average weighted reductions in SBP over 8-12 weeks were most marked with diuretics, and in particular indapamide SR 1.5 mg/day (mean change from baseline -22.2mm Hg), which reduced SBP to a greater extent than any of the other drugs evaluated (at any dosage considered). Average weighted reductions in DBP were generally similar with all classes of antihypertensives and ranged from -11.4mm Hg with the beta-adrenoceptor blocker atenolol and calcium channel antagonists to -10.3mm Hg with the angiotensin II type 1 receptor antagonists. CONCLUSION: This new analysis supports the results of the earlier investigation, in that indapamide SR 1.5 mg/day appeared to be the most effective drug for producing significant reductions in SBP within 8-12 weeks, which is an essential element in optimising cardiovascular prevention among hypertensive patients. The clinical application of these results should take into consideration all the limitations discussed in this analysis.
• #94: РАС играет ключевую роль в различных физиологических процессах таких как поддержание АД, электролитов, жидкости и, соответственно, объема крови. The RAS plays a key role in the regulation of several physiologic functions such as systemic BP, electrolyte and fluid balance, and blood volume.25 Angiotensinogen, produced primarily in the liver, is transformed to angiotensin I by renin. Angiotensin I is cleaved into angiotensin II by both ACE and non-ACE pathways. ACE acts by cleaving the C-terminal dipeptide from biologically inactive angiotensin I and bradykinin, thus affecting the RAS and kallikrein-kinin systems.25 Angiotensin I is converted to the physiologically active octapeptide angiotensin II by ACE.26 ACE catalyzes the breakdown of bradykinin to inactive peptides. The physiologic functions of RAS are mediated via angiotensin II, a very potent vasoactive substance.26 ACE regulates the balance between the vasoconstrictive and salt-retentive properties of angiotensin II and the vasodilatory and natriuretic properties of bradykinin.25 When angiotensin II binds with the angiotensin type 1 (AT1) receptor, it causes vasoconstriction, cell growth, sodium and fluid retention, and sympathetic activation—all of which play a part in hypertension and its sequelae.27
• #102: The renin-angiotensin system (RAS) is a hormonal system comprising substrate enzyme interactions that result in the formation of the active peptide angiotensin II (Ang II). Ang II, in turn, has a dramatic effect on both blood pressure (BP) and cardiovascular (CV) function and structure. It is also believed to play a role in the end-organ damage seen with hypertension, congestive heart failure (CHF), and vascular disease. Two subtypes of Ang II receptors have been identified: AT1 and AT2. As demonstrated in the above figure, stimulation of the AT1 receptor leads to cellular responses that initiate the elevation of intracellular free calcium as well as the retention of sodium and water and inotrophy. Immediate effects of AT1 stimulation include vasoconstriction. Long-term effects include cardiac hypertrophy, vascular hypertrophy, glomerulorsclerosis, increased cardiac contractility, vascoconstriction, renal salt retention, and aldosterone/arginine vasopressin release. The AT2 receptor is less well understood but appears to have opposing effects to the AT1 receptor, including antiproliferative effects, apoptosis, endothelial cell growth, vasodilation (which may be mediated by nitric oxide [NO]), and stimulation of renal bradykinin and NO.1 AT2 receptor antagonists (AIIRAs) may have an advantage over ACE inhibitors (ACEIs) in that they more completely inhibit the RAS by blocking the AT1 receptor, leading to reduced BP as well as reduced urinary protein and glomerulorsclerosis. By blocking only AT1 and leaving AT2 unopposed, it is believed that these agents may provide further end-organ protection as well as reduce the morbidity and mortality associated with myocardial infarction (MI) and other conditions that occur as a result of structural alterations in the heart.
• #104: инфаркта миокарда (ОШ 1.01; 95% ДИ 0.95-1.07; р = 0.75), сердечно-сосудистой (ОШ 1.03; 95% ДИ 0.98-1.08; р = 0.23) и общей смертности (ОШ 1.03; 95% ДИ 0.97-1.10; р = 0.20). Важно отметить только, что риск инсульта у тех, кто лечиться АРА ниже, чем при использовании ИАПФ (ОШ 0.92; 95% ДИ 0.85-0.99; р = 0.037) [Reboldi, G., ; Angeli, F. ; Cavallini, C. ; Gentile, G. ; Mancia, G.; Verdecchia, P. Comparison between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the risk of myocardial infarction, stroke and death: a meta-analysis Journal of Hypertension. 2008. 26(7):1282-1289].
• #106: Рисунок 12. Рисунок 12. Достижение целевых значений АД при двойной антигипертензивной терапии [25] The proportions of patients reaching target BP was Достижение целевых значений АД при двойной антигипертензивной терапии БРА – блокаторы рецептров ан II, ИАПФ – ингибитора ангиотензин превращающего фермента, АК – антагонисты кальция ГХТ – гидрохлоротиазид Р – достоверность различий с группой лиц получавших комбинацию БРА+ГХТ 35% on ARBs + HCTZ compared to 30% on ACEIs + HCTZ (p=0.006), 32% on ARBs + CCBs (p=0.03), and 28% on ACEIs + CCBs (p=0.001). Search for in Advanced Search « PreviousNext »Clinical Therapeutics Volume 33, Issue 9 , Pages 1190-1203, September 2011 Retrospective Analysis of Real-World Efficacy of Angiotensin Receptor Blockers Versus Other Classes of Antihypertensive Agents in Blood Pressure Management Robert Petrella, MD, PhD Affiliations Faculty of Medicine and Dentistry University of Western Ontario, London, Ontario, Canada Lawson Health Research Institute, London, Ontario, Canada Address for correspondence: Robert Petrella, MD, PhD, Beryl & Richard Ivey Research Chair, University of Western Ontario, London, Ontario, Canada, N6C5J1 , Paul Michailidis, MSc Affiliations Lawson Health Research Institute, London, Ontario, Canada Accepted 10 August 2011. published online 02 September 2011. Abstract Full Text PDF Images References Abstract  Background Efficacy of blood pressure (BP) lowering may differ between clinical trials and what is observed in clinical practice. These differences may contribute to poor BP control rates among those at risk. Objective We conducted an observational study to determine the BP-lowering efficacy of angiotensin receptor blocker (ARB) versus non–ARB-based antihypertensive treatments in a large Canadian primary care database. Methods We analyzed the South Western Ontario database of 170,000 adults (aged >18 years) with hypertension persisting with antihypertensive medication for ≥9 months. Routine standard of care office BP was measured using approved manual aneroid or automated devices. BP <140 mm Hg and/or <90 mm Hg ≤9 months after treatment initiation, persistence (presence of initial antihypertensive prescription at the first, second, third, and fourth year anniversary) with antihypertensive therapy, and the presence of a cardiovascular (CV) event (ie, myocardial infarction) were studied. Results After 9 months of monotherapy, 28% (978 of 3490) of patients on ARBs achieved target BP versus 27% (839 of 3110) on angiotensin-converting enzyme inhibitors (ACEIs) (P > 0.05), 26% (265 of 1020) on calcium channel blockers (CCBs) (P > 0.05), 21% (221 of 1050) on β-blockers (P = 0.002), and 19% (276 of 1450) on diuretics (P = 0.001). Attainment rates were significantly higher with irbesartan (38%; 332 of 873) versus losartan (32%; 335 of 1047; P = 0.01), valsartan (19%; 186 of 977; P = 0.001), and candesartan (25%; 148 of 593; P = 0.001). BP goal attainment rates were significantly higher when ARB was compared with non–ARB-based dual therapy (39%; 1007 of 2584 vs 31%; 1109 of 3576; P = 0.004); irbesartan + hydrochlorothiazide (HCTZ) was significantly higher than losartan + HCTZ (36%; 500 of 1390 vs 20%; 252 of 1261; P = 0.001). For patients receiving dual or tri-therapy, 48% (667 of 1390) of patients receiving irbesartan reached target BP versus 41% to 42% for losartan (517 of 1261), valsartan (194 of 462), and candesartan (168 of 401) (P = 0.001 for each). After 4 years, persistence rates were not statistically different among ARB, CCB, and diuretic monotherapies, but appeared somewhat higher with ACEIs and β-blockers (78%, 78%, 79%, 91%, and 84%, respectively). Persistence was not significantly different between irbesartan and losartan monotherapy (76% for both; P > 0.05), but was significantly higher with irbesartan + HCTZ versus losartan + HCTZ (96% vs 73%, respectively; P = 0.001). Patients treated with ARBs reported fewer CV events than those receiving ACEIs or CCBs (4.3% vs 7.0% and 11.0%, respectively; P < 0.001). Within the ARB class, the lowest rate was with irbesartan (3.0% vs 4.6%–5.0% for other ARBs; P < 0.02). Conclusions In this real-world setting, hypertensive adults treated with ARBs versus β-blockers or diuretics were more likely to have evidence-based target BP recorded. In addition, patients using ARBs versus ACEIs or CCBs had fewer reports of CV events
• #108: Int J Cardiol. 2010 Oct 29. [Epub ahead of print] Angiotensin receptor blockers for prevention of new-onset type 2 diabetes: A meta-analysis of 59,862 patients. Geng DF, Jin DM, Wu W, Xu Y, Wang JF. Source Department of Cardiology, Sun Yat-sen memorial hospital, Zhongshan University, 510120 Guangzhou, China. Abstract BACKGROUND: Angiotensin receptor blockers (ARBs) have been linked to reduced risk of new-onset diabetes, but the evidence was insufficient. OBJECTIVE AND METHODS: The aim of this study was to evaluate the effect of ARBs on the development of new-onset type 2 diabetes. Randomized controlled trials (RCTs) about ARBs and new-onset diabetes were identified by electronic and manual searches. RESULTS: Eleven RCTs with 79,773 patients (59,862 non-diabetic patients at baseline) were included in this study. Compared with control group, incidence of new-onset diabetes was significantly reduced in ARBs group [OR 0.79, (0.74, 0.84)] and various categories of ARBs subgroup. ARBs were associated with significant reduction in the risk of new-onset diabetes compared with placebo [OR 0.83, (0.78, 0.89)], beta-blocker [OR 0.73, (0.62, 0.87)], calcium channel blocker [OR 0.76, (0.68, 0.85)] and non-ARB [OR 0.57, (0.36, 0.91)]. ARBs were associated with significant reduction in the risk of new-onset diabetes in patients with hypertension [OR 0.74, (0.68, 0.81)], heart failure [OR 0.70, (0.50, 0.96)], impaired glucose tolerance [OR 0.85, (0.78, 0.92)] or cardiocerebrovascular diseases [OR 0.84, (0.72, 0.97)]. Compared with control group, incidence of new-onset diabetes was significantly reduced in ARBs group, irrespective of achieved blood pressure level. ARBs were associated with a lower incidence of new-onset diabetes in Western population [OR 0.81, (0.76, 0.85)] and Japanese population [OR 0.61, (0.48, 0.79)]. CONCLUSION: There is sufficient evidence that ARBs have beneficial effect in preventing new-onset type 2 diabetes. ARBs should be considered in patients with high risk of developing diabetes.
• #109: Int J Cardiol. 2010 Oct 29. [Epub ahead of print] Angiotensin receptor blockers for prevention of new-onset type 2 diabetes: A meta-analysis of 59,862 patients. Geng DF, Jin DM, Wu W, Xu Y, Wang JF. Source Department of Cardiology, Sun Yat-sen memorial hospital, Zhongshan University, 510120 Guangzhou, China. Abstract BACKGROUND: Angiotensin receptor blockers (ARBs) have been linked to reduced risk of new-onset diabetes, but the evidence was insufficient. OBJECTIVE AND METHODS: The aim of this study was to evaluate the effect of ARBs on the development of new-onset type 2 diabetes. Randomized controlled trials (RCTs) about ARBs and new-onset diabetes were identified by electronic and manual searches. RESULTS: Eleven RCTs with 79,773 patients (59,862 non-diabetic patients at baseline) were included in this study. Compared with control group, incidence of new-onset diabetes was significantly reduced in ARBs group [OR 0.79, (0.74, 0.84)] and various categories of ARBs subgroup. ARBs were associated with significant reduction in the risk of new-onset diabetes compared with placebo [OR 0.83, (0.78, 0.89)], beta-blocker [OR 0.73, (0.62, 0.87)], calcium channel blocker [OR 0.76, (0.68, 0.85)] and non-ARB [OR 0.57, (0.36, 0.91)]. ARBs were associated with significant reduction in the risk of new-onset diabetes in patients with hypertension [OR 0.74, (0.68, 0.81)], heart failure [OR 0.70, (0.50, 0.96)], impaired glucose tolerance [OR 0.85, (0.78, 0.92)] or cardiocerebrovascular diseases [OR 0.84, (0.72, 0.97)]. Compared with control group, incidence of new-onset diabetes was significantly reduced in ARBs group, irrespective of achieved blood pressure level. ARBs were associated with a lower incidence of new-onset diabetes in Western population [OR 0.81, (0.76, 0.85)] and Japanese population [OR 0.61, (0.48, 0.79)]. CONCLUSION: There is sufficient evidence that ARBs have beneficial effect in preventing new-onset type 2 diabetes. ARBs should be considered in patients with high risk of developing diabetes.
• #115: J Clin Hypertens (Greenwich). 2007 Sep;9(9):692-700. Effects of initial antihypertensive drug class on patient persistence and compliance in a usual-care setting in the United States. Patel BV, Remigio-Baker RA, Mehta D, Thiebaud P, Frech-Tamas F, Preblick R. Source MedImpact Healthcare Systems, Inc, San Diego, CA 92131, USA. bimal.patel@medimpact.com Abstract Antihypertensive treatment regimen persistence and compliance were measured using a retrospective cohort study of pharmacy claims data. Newly treated patients receiving monotherapy with angiotensin II receptor blockers (ARBs), angiotensin-converting enzyme inhibitors (ACEIs), calcium channel blockers (CCBs), beta-blockers (BBs), or diuretics were followed for 1 year (N=242,882). A higher proportion of ARB patients (51.9%) were persistent in taking prescribed medication compared with those in the ACEI (48.0%), BB (40.3%), CCB (38.3%), and diuretic groups (29.9%). Compared with patients receiving diuretics, those receiving ARBs (hazard ratio [HR], 0.593; P<.0001), ACEIs (HR, 0.640; P<.0001), CCBs (HR, 0.859; P<.0001), and BBs (HR, 0.819; P<.0001) were all less likely to discontinue therapy. Compliance was similar in ACEI and ARB patients, but patients receiving ARBs and ACEIs had better compliance than those receiving BBs, CCBs, or diuretics. The lesser degree of compliance and persistence observed in patients receiving diuretics compared with other antihypertensive medications may have public health as well as cost implications.
• #116: Рисунок 3. Число пациентов с АГ, оставшихся на начальной терапии в течение 4 лет, в зависимости от класса препаратов [12] 19th Scientific Meeting of the European Society of Hypertension (ESH), Milan, June 2009 1. Discontinuation and persistence of antihypertensive drugs among newly diagnosed hypertensive patients in French General Practice. Thales-Cegedim database. X. Girerd. Journal of Hypertension 2009;27suppl 4:S312 -7A-7 􀂾 Patients newly diagnosed with hypertension and subsequently treated with antihypertensive drugs were evaluated for persistence of their initial antihypertensive prescription (ARB, ACE-I, CCB or diuretics) at the first, second, third and fourth year anniversary. 􀂾 One-year persistence ranged from 69.8% (ARB) to 45.3% (diuretics) whereas four-year persistence was 63.2% (ARB); 41.2% (ACE-I); 42.0% (CCB) and 34.2% (diuretics). 􀂾 23.2% (ARB) to 36.9% (diuretics) of the patients who discontinued their first-ever antihypertensive drug before the first year anniversary, failed to restart an antihypertensive drug within 4 years of follow-up. 􀂾 It is important that GPs monitor patients closely in the first year following antihypertensive drug initiation, due to the high early risk of discontinuation, and the low percentage of patients who switch to a different antihypertensive drug class after a drugclass discontinuation.
• #117: Based on univariate analysis, patients who were initiated on irbesartan were significantly more likely to still be on irbesartan monotherapy 12 months after initiation of the drug, compared with patients taking any other single antihypertensive agent, including a different AIIRA. Patients taking diuretics, ACEIs, CCBs, losartan, or beta-blockers were significantly less likely to still be on this monotherapy at 12 months compared with those taking irbesartan, p=0.001. Patients taking other AIIRAs, taken as a whole group, were significantly less likely to still be on this monotherapy at 12 months compared with those taking irbesartan, p=0.009.
• #130: 1160 3766 30,8 1647 3766 43,7 959 3766 25,5
• #131: NICE Clinical Guideline 34. Management of hypertension in adults in primary care (partial update of NICE clinical guideline 18). June 2006
• #139: GLB.IRB.08.01.01 080108a_Irbe
• #140: Новый мета-анализ баз данных 12 исследований показал (рисунок ), что использование готовых комбинированных форм увеличивает приверженность к терапии соблюдение режима дозирования на 8 % 3 -13,26 более высокое у ранее не леченных и на 13,37% 8 -18,35 более высокое у пациентов ранее леченных , , чем на терапии теми же компонентами в свободной комбинации в два раза большую вероятность удержания на лечении 2.1; 95% CI, 1.1–4.1).и более низкую стоимость ведения пациентов на $1357 (95% confidence interval [CI], $778–$1935) lower in favor of SPC than FEC groups.     Single-Pill vs Free-Equivalent Combination Therapies for Hypertension: A Meta-Analysis of Health Care Costs and Adherence Beth Sherrill, MS;1 Michael Halpern, MD, PhD, MPH;2 Shahnaz Khan, MPH;1 Jie Zhang, MSPH;1 Sumeet Panjabi, PhD3 From RTI Health Solutions, Research Triangle Park, NC;1 RTI International, Washington, DC;2 and Daiichi Sankyo Inc, Parsippany, NJ3 This meta-analysis compares health care resource use costs, adherence, and persistence between groups of patients taking antihypertensives as single-pill combinations (SPCs) vs free-equivalent components (FEC) based on a structured review of published studies. The search yielded 12 retrospective database studies included in analyses. The mean difference in combined total annual allcause and hypertension-related health care costs was $1357 (95% confidence interval [CI], $778–$1935) lower in favor of SPC than FEC groups. Adherence, measured as the mean difference in medication possession ratio, was estimated to be 8% higher for patients naive to prior antihypertensives and 14% higher for nonnaive SPC patients compared with corresponding FEC patients. Persistence in the SPC groups was twice as likely as the FEC groups (pooled risk ratio, 2.1; 95% CI, 1.1–4.1). Improved adherence and persistence may have contributed to the lower costs in the SPC groups via improved clinical outcomes. J Clin Hypertens (Greenwich). 2011;13:898–909. 2011
• #147: Among all of the patients, 59% initiated on free combinations and monotherapy and 68% begun on single-pill combinations were controlled to goal after 396 days. The percentage of hypertensives controlled at 1 year was significantly higher in whites than blacks, for monotherapy (BP control 65% versus 53%; P˂0.001), free combinations (67% versus 51%; P˂0.001), and single-pill combinations (73% versus 63%; P˂0.001). For all of the patients, the median time to 50% BP control for the single-pill combination group was 195 days (95% confidence interval [CI],185-203), 269 (95% CI, 254-285) for free-dose combinations, and 280 days (95% CI, 273-287) for monotherapy with overall P˂0.001. This retrospective study used electronic record data from 180 clinical sites in the Outpatient Quality Improvement Network in the United States. From 1 414 020 adults seen at practices in the Outpatient Quality Improvement Network between January 2004 and June 2009, 106 621 were eligible for analysis based on inclusion and exclusion criteria. The majority of patients completed the year on their initial treatment category (monotherapy [57%], free combinations [91%], and single-pill combinations [86.2%]). Patients initiated on monotherapy received 1 antihypertensive pill and medication category. Patients initiated on free combinations were given 2 pills in different medication categories. Patients initiated on single-pill combinations received 1 pill with 2 different antihypertensive medication categories. The single-pill combination group was 3 to 5 years younger; had a higher body mass index; a higher proportion of females, patients with stage 2 hypertension, and BP ≥20/10 mm Hg above goal; and fewer Veterans Affairs patients than other initial therapy groups. Hypertensive patients begun on single-pill combinations were 53%, and on free combination 34%, more likely than those started on monotherapy to attain BP control in the first year. Other covariables independently associated with better BP control included female sex, higher baseline diastolic BP, cardiovascular disease, depression, and number of visits yearly. None of these other covariables was as strongly related to BP control as initial therapy. Covariables independently associated with worse BP control included higher baseline body mass index and systolic BP, chronic kidney disease and diabetes mellitus, greater therapeutic inertia, and higher mean dose equivalents, unique BP medication categories, and number of BP pills. Hypertensive patients initiated on single-pill combinations had higher untreated BP values and were more likely to have stage 2 hypertension than those started on monotherapy, which is consistent with clinical guidelines for initial therapy in patients ≥20/10 mm Hg from goal. Despite starting with higher untreated BP, patients who began treatment with single-pill combinations were more likely to achieve BP control than those started on free combinations or monotherapy BP. These data suggest that beginning more patients on combination therapy, especially single-pill combinations, which composed only 8.6% of the total, could improve hypertension control.  Greater use of single-pill combinations as initial therapy improves hypertension control and cardiovascular outcomes in the first year of treatment. Patients were included if they were ≥18 years old, untreated, and uncontrolled for ≥6 months before initial therapy, and had ≥1 year of follow-up data.
• #148: Among all of the patients, 59% initiated on free combinations and monotherapy and 68% begun on single-pill combinations were controlled to goal after 396 days. The percentage of hypertensives controlled at 1 year was significantly higher in whites than blacks, for monotherapy (BP control 65% versus 53%; P˂0.001), free combinations (67% versus 51%; P˂0.001), and single-pill combinations (73% versus 63%; P˂0.001). For all of the patients, the median time to 50% BP control for the single-pill combination group was 195 days (95% confidence interval [CI],185-203), 269 (95% CI, 254-285) for free-dose combinations, and 280 days (95% CI, 273-287) for monotherapy with overall P˂0.001. This retrospective study used electronic record data from 180 clinical sites in the Outpatient Quality Improvement Network in the United States. From 1 414 020 adults seen at practices in the Outpatient Quality Improvement Network between January 2004 and June 2009, 106 621 were eligible for analysis based on inclusion and exclusion criteria. The majority of patients completed the year on their initial treatment category (monotherapy [57%], free combinations [91%], and single-pill combinations [86.2%]). Patients initiated on monotherapy received 1 antihypertensive pill and medication category. Patients initiated on free combinations were given 2 pills in different medication categories. Patients initiated on single-pill combinations received 1 pill with 2 different antihypertensive medication categories. The single-pill combination group was 3 to 5 years younger; had a higher body mass index; a higher proportion of females, patients with stage 2 hypertension, and BP ≥20/10 mm Hg above goal; and fewer Veterans Affairs patients than other initial therapy groups. Hypertensive patients begun on single-pill combinations were 53%, and on free combination 34%, more likely than those started on monotherapy to attain BP control in the first year. Other covariables independently associated with better BP control included female sex, higher baseline diastolic BP, cardiovascular disease, depression, and number of visits yearly. None of these other covariables was as strongly related to BP control as initial therapy. Covariables independently associated with worse BP control included higher baseline body mass index and systolic BP, chronic kidney disease and diabetes mellitus, greater therapeutic inertia, and higher mean dose equivalents, unique BP medication categories, and number of BP pills. Hypertensive patients initiated on single-pill combinations had higher untreated BP values and were more likely to have stage 2 hypertension than those started on monotherapy, which is consistent with clinical guidelines for initial therapy in patients ≥20/10 mm Hg from goal. Despite starting with higher untreated BP, patients who began treatment with single-pill combinations were more likely to achieve BP control than those started on free combinations or monotherapy BP. These data suggest that beginning more patients on combination therapy, especially single-pill combinations, which composed only 8.6% of the total, could improve hypertension control.  Greater use of single-pill combinations as initial therapy improves hypertension control and cardiovascular outcomes in the first year of treatment. Patients were included if they were ≥18 years old, untreated, and uncontrolled for ≥6 months before initial therapy, and had ≥1 year of follow-up data.
• #149: Пациенты с быстрым ответом на лечение характеризовались достоверно меньшей частотой кардиальных осложнений, инсульта и смерти на протяжении оставшейся части исследования. В качестве критериев быстрого ответа использовался уровень АД через 1 месяц наблюдения. К группе быстрого ответа были отнесены пациенты без предшествующего лечения, у которых систолическое АД снизилось ≥10 мм рт. ст., и пациенты, ранее получавшие лечение, с АД ниже начального уровня через 1 месяц. Пациенты, не удовлетворяющие этим критериям, считались поздно ответившими на лечение. Таким образом, адекватный и быстрый контроль АД имеет значительные преимущества для снижения риска развития сердечно-сосудистых осложнений у больных АГ высокого риска.
• #150: Among all of the patients, 59% initiated on free combinations and monotherapy and 68% begun on single-pill combinations were controlled to goal after 396 days. The percentage of hypertensives controlled at 1 year was significantly higher in whites than blacks, for monotherapy (BP control 65% versus 53%; P˂0.001), free combinations (67% versus 51%; P˂0.001), and single-pill combinations (73% versus 63%; P˂0.001). For all of the patients, the median time to 50% BP control for the single-pill combination group was 195 days (95% confidence interval [CI],185-203), 269 (95% CI, 254-285) for free-dose combinations, and 280 days (95% CI, 273-287) for monotherapy with overall P˂0.001. This retrospective study used electronic record data from 180 clinical sites in the Outpatient Quality Improvement Network in the United States. From 1 414 020 adults seen at practices in the Outpatient Quality Improvement Network between January 2004 and June 2009, 106 621 were eligible for analysis based on inclusion and exclusion criteria. The majority of patients completed the year on their initial treatment category (monotherapy [57%], free combinations [91%], and single-pill combinations [86.2%]). Patients initiated on monotherapy received 1 antihypertensive pill and medication category. Patients initiated on free combinations were given 2 pills in different medication categories. Patients initiated on single-pill combinations received 1 pill with 2 different antihypertensive medication categories. The single-pill combination group was 3 to 5 years younger; had a higher body mass index; a higher proportion of females, patients with stage 2 hypertension, and BP ≥20/10 mm Hg above goal; and fewer Veterans Affairs patients than other initial therapy groups. Hypertensive patients begun on single-pill combinations were 53%, and on free combination 34%, more likely than those started on monotherapy to attain BP control in the first year. Other covariables independently associated with better BP control included female sex, higher baseline diastolic BP, cardiovascular disease, depression, and number of visits yearly. None of these other covariables was as strongly related to BP control as initial therapy. Covariables independently associated with worse BP control included higher baseline body mass index and systolic BP, chronic kidney disease and diabetes mellitus, greater therapeutic inertia, and higher mean dose equivalents, unique BP medication categories, and number of BP pills. Hypertensive patients initiated on single-pill combinations had higher untreated BP values and were more likely to have stage 2 hypertension than those started on monotherapy, which is consistent with clinical guidelines for initial therapy in patients ≥20/10 mm Hg from goal. Despite starting with higher untreated BP, patients who began treatment with single-pill combinations were more likely to achieve BP control than those started on free combinations or monotherapy BP. These data suggest that beginning more patients on combination therapy, especially single-pill combinations, which composed only 8.6% of the total, could improve hypertension control.  Greater use of single-pill combinations as initial therapy improves hypertension control and cardiovascular outcomes in the first year of treatment. Patients were included if they were ≥18 years old, untreated, and uncontrolled for ≥6 months before initial therapy, and had ≥1 year of follow-up data.
• #151: Hypertension. 2012 Jun;59(6):1124-31. doi: 10.1161/HYPERTENSIONAHA.112.194167. Epub 2012 May 7. Initial monotherapy and combination therapy and hypertension control the first year. Egan BM, Bandyopadhyay D, Shaftman SR, Wagner CS, Zhao Y, Yu-Isenberg KS. Source Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA. eganbm@musc.edu Abstract Initial antihypertensive therapy with single-pill combinations produced more rapid blood pressure control than initial monotherapy in clinical trials. Other studies reported better cardiovascular outcomes in patients achieving lower blood pressure during the first treatment year. We assessed the effectiveness of initial antihypertensive monotherapy, free combinations, and single-pill combinations in controlling untreated, uncontrolled hypertensives during their first treatment year. Electronic record data were obtained from 180 practice sites; 106 621 hypertensive patients seen from January 2004 to June 2009 had uncontrolled blood pressure, were untreated for ≥ 6 months before therapy, and had ≥ 1 one-year follow-up blood pressure data. Control was determined by the first follow-up visit with blood pressure <140/<90 mm Hg for patients without diabetes mellitus or chronic kidney disease and <130/<80 mm Hg for patients with either or both conditions. Multivariable hazards regression ratios (HRs) and 95% CIs for time to control were calculated, adjusting for age, sex, baseline blood pressure, body mass index, diabetes mellitus, chronic kidney disease, cardiovascular disease, initial therapy, final blood pressure medication number, and therapeutic inertia. Patients on initial single-pill combinations (N = 9194) were more likely to have stage 2 hypertension than those on free combinations (N = 18 328) or monotherapy (N = 79 099; all P<0.001). Initial therapy with single-pill combinations (HR, 1.53 [95% CI, 1.47-1.58]) provided better hypertension control in the first year than free combinations (HR, 1.34; [95% CI, 1.31-1.37]) or monotherapy (reference) with benefits in black and white patients. Greater use of single-pill combinations as initial therapy may improve hypertension control and cardiovascular outcomes in the first treatment year.
• #155: Hermida RC, Ayala DE, Fontao MJ, Mojón A, Fernández JR. Chronotherapy with valsartan/amlodipine fixed combination: improved blood pressure control of essential hypertension with bedtime dosing. Chronobiol Int. 2010 Jul;27(6):1287-303.   Source Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain. rhermida@uvigo.es Abstract Administration of valsartan at bedtime as opposed to upon wakening improves the sleep-time relative blood pressure (BP) decline towards a more normal dipper pattern without loss of 24-h efficacy. Amlodipine, however, has been shown to be effective in reducing BP throughout the day and night, independent of dosing time. A large proportion of hypertensive subjects cannot be properly controlled with a single medication. However, no study has yet investigated the potential differing effects of combination therapy depending of the time-of-day of administration. Accordingly, the authors investigated the administration-time-dependent BP-lowering efficacy of valsartan/amlodipine combination. The authors studied 203 hypertensive subjects (92 men/111 women), 56.7 +/- 12.5 yrs of age, randomized to receive valsartan (160 mg/day) and amlodipine (5 mg/day) in one of the following four therapeutic schemes: both medications on awakening, both at bedtime, either one administered on awakening and the other at bedtime. BP was measured by ambulatory monitoring for 48 consecutive hours before and after 12 wks of treatment. Physical activity was simultaneously monitored every min by wrist actigraphy to accurately determine the beginning and end of daytime activity and nocturnal sleep. BP-lowering efficacy (quantified in terms of reduction of the 48-h mean of systolic/diastolic BP) was highest when both hypertension medications were ingested at bedtime, as compared to any one of the three other tested therapeutic schemes (17.4/13.4 mm Hg reduction with both medications on awakening; 15.1/9.6 mm Hg with valsartan on awakening and amlodipine at bedtime; 18.2/12.3 mm Hg with valsartan at bedtime and amlodipine on awakening; 24.7/13.5 mm Hg with both medications at bedtime; p < .018 between groups). The sleep-time relative BP decline was significantly increased towards a more normal dipper pattern only when both medications were jointly ingested at bedtime (p < .001). Bedtime dosing of the combination of the two medications also resulted in the largest percentage of controlled subjects among all the assessed therapeutic schemes (p = .003 between groups). In subjects requiring combination therapy to achieve proper BP control, the association of amlodipine and valsartan efficiently reduces BP for the entire 24 h independent of dosing time. However, the greater proportion of controlled patients, improved efficacy on lowering asleep BP mean, and increased sleep-time relative BP decline suggest valsartan/amlodipine combination therapy should be preferably administered at bedtime.
• #169: Higher pulse pressure and pulse wave velocity are associated with higher risk of incident CKD. Forest plots of multivariate–adjusted relative risks (RRs) for the association of each SD of (A) pulse pressure and (B) pulse wave velocity with incident CKD (11) Tomiyama H, Tanaka H, Hashimoto H, Matsumoto C, Odaira M, Yamada J, Yoshida M, Shiina K, Nagata M, Yamashina A: Arterial stiffness and declines in individuals with normal renal function/early chronic kidney disease. Atherosclerosis 212: 345–350, 2010 [PubMed: 20594557]
• #170: Send to Korean Circ J. 2018 Jan;48(1):36-47. doi: 10.4070/kcj.2017.0036. The J-curve between Diastolic Blood Pressure and Risk of All-cause and Cardiovascular Death. Kimm H1, Mok Y1,2, Lee SJ1, Lee S3, Back JH3, Jee SH1,4. Author information Abstract BACKGROUND AND OBJECTIVES: The J-curve phenomenon between diastolic blood pressure (DBP) and mortality has been reported repeatedly in treated patients. However, the baseline risk of low DBP has not been fully explored. This study was to examine the relationship between DBP and risk of mortality from all-cause, atherosclerotic vascular diseases (ASCVD), and ischemic heart disease (IHD) using a prospective cohort of general population. METHODS: We analyzed 1,234,435 participants of the Korean Cancer Prevention Study cohort (789,255 men, 30-95 years of age) who had a medical evaluation from 1992 to 1995 using Cox proportional hazards models. RESULTS: A total of 22.5 million person-years were followed up (mean age 46.6 years, deaths 193,903 cases). The hazard ratios of mortality from all-cause and ASCVD, among those with DBP <60 mmHg compared to 70-79 mmHg were 1.23 (95% confidence interval [CI], 1.16-1.30) and 1.37 (95% CI, 1.20-1.57), respectively, after adjustment for multivariable including systolic blood pressure. Increased risks of all-cause death in the lowest DBP category group were maintained in men or women, 30-59 or ≥60 years of age, smoker or non-smoker and diabetes mellitus (DM) or non-DM subgroups. The risk in DBP 60-69 mmHg groups increased in several subgroups. However, the risk for ASCVD death in 30-59 years and DM group, and risk for IHD death in most subgroups except for elderly (≥60 years) decreased. CONCLUSION: A J-curve relationship between low DBP and all-cause death was found consistently. The baseline risk in the general population may be considered for risk assessment, particularly in case of interventions that lower DBP below 60 mmHg. Copyright © 2018. The Korean Society of Cardiology KEYWORDS: Blood pressure; Diastolic blood pressure; Hypertension; Mortality; Myocardial ischemia Comment in J-curve Phenomenon Might Be Inherent: How to Know If It Is Treatment Induced? [Korean Circ J. 2018] PMID: 29322696 PMCID: PMC5764869 DOI: 10.4070/kcj.2017.0036 Free PMC Article
• #171: Ann Transl Med. 2018 Jun;6(11):199. doi: 10.21037/atm.2018.04.36. Blood pressure targets for hypertension in patients with type 2 diabetes. Aronow WS1, Shamliyan TA2. Author information Abstract BACKGROUND: Clinical guidelines vary in determining optimal blood pressure targets in adults with diabetes mellitus. METHODS: We systematically searched PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov in March 2018; conducted random effects frequentist meta-analyses of direct aggregate data; and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS: From eligible 14 meta-analyses and 95 publications of randomized controlled trials (RCT), only 6 RCTs directly compared lower versus higher blood pressure targets; remaining RCTs aimed at comparative effectiveness of hypotensive drugs. In adults with diabetes mellitus and elevated systolic blood pressure (SBP), direct evidence (2 RCTs) suggests that intensive target SBP <120-140 mmHg decreases the risk of diabetes-related mortality [relative risk (RR) =0.68; 95% confidence interval (CI), 0.50-0.92], fatal (RR =0.41; 95% CI, 0.20-0.84) or nonfatal stroke (RR =0.60; 95% CI, 0.43-0.83), prevalence of left ventricular hypertrophy and electrocardiogram (ECG) abnormalities, macroalbuminuria, and non-spine bone fractures, with no differences in all-cause or cardiovascular mortality or falls. In adults with diabetes mellitus and elevated diastolic blood pressure (DBP) ≥90 mmHg, direct evidence (2 RCTs) suggests that intensive DBP target ≤80 versus 80-90 mmHg decreases the risk of major cardiovascular events. Published meta-analyses of aggregate data suggested a significant association between lower baseline and attained blood pressure and increased cardiovascular mortality. CONCLUSIONS: We concluded that in adults with diabetes mellitus and arterial hypertension, in order to reduce the risk of stroke, clinicians should target blood pressure at 120-130/80 mmHg, with close monitoring for all drug-related harms. KEYWORDS: Quality of evidence; arterial hypertension; blood pressure targets; cardiovascular morbidity; diabetes mellitus PMID: 30023362 PMCID: PMC6035980 DOI: 10.21037/atm.2018.04.36 Free PMC Article
• #173: Send to Korean Circ J. 2018 Jan;48(1):36-47. doi: 10.4070/kcj.2017.0036. The J-curve between Diastolic Blood Pressure and Risk of All-cause and Cardiovascular Death. Kimm H1, Mok Y1,2, Lee SJ1, Lee S3, Back JH3, Jee SH1,4. Author information Abstract BACKGROUND AND OBJECTIVES: The J-curve phenomenon between diastolic blood pressure (DBP) and mortality has been reported repeatedly in treated patients. However, the baseline risk of low DBP has not been fully explored. This study was to examine the relationship between DBP and risk of mortality from all-cause, atherosclerotic vascular diseases (ASCVD), and ischemic heart disease (IHD) using a prospective cohort of general population. METHODS: We analyzed 1,234,435 participants of the Korean Cancer Prevention Study cohort (789,255 men, 30-95 years of age) who had a medical evaluation from 1992 to 1995 using Cox proportional hazards models. RESULTS: A total of 22.5 million person-years were followed up (mean age 46.6 years, deaths 193,903 cases). The hazard ratios of mortality from all-cause and ASCVD, among those with DBP <60 mmHg compared to 70-79 mmHg were 1.23 (95% confidence interval [CI], 1.16-1.30) and 1.37 (95% CI, 1.20-1.57), respectively, after adjustment for multivariable including systolic blood pressure. Increased risks of all-cause death in the lowest DBP category group were maintained in men or women, 30-59 or ≥60 years of age, smoker or non-smoker and diabetes mellitus (DM) or non-DM subgroups. The risk in DBP 60-69 mmHg groups increased in several subgroups. However, the risk for ASCVD death in 30-59 years and DM group, and risk for IHD death in most subgroups except for elderly (≥60 years) decreased. CONCLUSION: A J-curve relationship between low DBP and all-cause death was found consistently. The baseline risk in the general population may be considered for risk assessment, particularly in case of interventions that lower DBP below 60 mmHg. Copyright © 2018. The Korean Society of Cardiology KEYWORDS: Blood pressure; Diastolic blood pressure; Hypertension; Mortality; Myocardial ischemia Comment in J-curve Phenomenon Might Be Inherent: How to Know If It Is Treatment Induced? [Korean Circ J. 2018] PMID: 29322696 PMCID: PMC5764869 DOI: 10.4070/kcj.2017.0036 Free PMC Article
• #174: Sci Rep. 2018 Aug 15;8(1):12190. doi: 10.1038/s41598-018-30740-y. Effect of medication adherence on long-term all-cause-mortality and hospitalization for cardiovascular disease in 65,067 newly diagnosed type 2 diabetes patients. Kim YY1, Lee JS2,3, Kang HJ1, Park SM4,5. Author information Abstract This study determined the effects of anti-diabetic medication adherence on the long-term all-cause mortality and hospitalization for cerebrovascular disease and myocardial infarction among newly diagnosed patients. The study used retrospective cohort from the National Health Insurance Service. Study participants were 65,076 newly diagnosed type 2 diabetes mellitus patients aged ≥40 years. The medication adherence was evaluated from the proportion of days covered (PDC) between 2006 and 2007. Outcome variables were mortality, newly diagnosed cerebrovascular disease (CVD) and myocardial infarction (MI) in 2008-2017. Cox-proportional hazard regression analysis was performed. After adjusting for sex, age, monthly contribution, insurance type, medical institution type, Charlson comorbidity index score, disability, hypertension, and active ingredients of oral hypoglycemic agents, the adjusted hazard ratio (aHR) for all-cause-mortality of the lowest PDC group (<0.20) was 1.45 (95% confidence interval [CI] = 1.36-1.54) as compared to the highest PDC (≥0.8). The aHR for all-cause-mortality associated with PDC levels of 0.60-0.79, 0.40-0.59, and 0.20-0.39 were 1.19, 1.26, and 1.34, respectively (Ptrend < 0.001). Compared to the highest PDC group, diabetic patients with the lowest PDC had elevated risk for CVD (aHR = 1.41; 95% CI = 1.30-1.52; Ptrend < 0.001). Improving anti-diabetic medication adherence among newly diagnosed type 2 diabetes mellitus patients is essential to the reduce risk for cardiovascular disease and long-term all-cause mortality. PMID: 30111867 PMCID: PMC6093904 DOI: 10.1038/s41598-018-30740-y Free PMC Article Share on FacebookShare on TwitterShare on Google+