High blood pressure is a common wellness job impacting the immature, middle-age and the aged worldwide. Worldwide high blood pressure is estimated to do 7.1 million premature deceases and 4.5 % of the disease load [ 64 million disability-adjusted life old ages ( DALYS ) ] 1. The incidence increases with come oning age, as about, 55 % of the whole population will be hypertensive by age 60 and 65 % over age 70 2. High blood pressure is the most prevailing hazard factor for the development of cardiovascular and kidney diseases 3,4 and histories for 35 % of atherosclerotic cardiovascular disease 4,5. It is besides a hazard factor for the development of bosom failure, both because it leads to the development of left ventricular hypertrophy, and because it is a hazard factor for the development of coronary bosom disease. The comparative hazard of bosom failure among patients with high blood pressure, compared to that of the general population has been estimated to be 1.4 6.
There are indicants that high blood pressure can frequently be associated with a neglecting bosom in many aged patients. In bosom failure, forecast is by and large poorer for hypertensive than for normotensive persons 7,8. For these patients, the systolic blood force per unit area is more strongly related with cardiovascular complications, particularly bosom failure, than is diastolic blood force per unit area 9. In systolic disfunction, the primary abnormalcy is impaired cardiac contractility but in diastolic disfunction, there is a restriction to diastolic filling and hence in forward end product due to increased ventricular stiffness. Therefore, intervention of high blood pressure in patients with bosom failure must take into history the type of bosom failure that is present 10.
The desired curative ends in the direction of high blood pressure are frequently achieved utilizing a combination of patient and household instruction and support, other nonpharmacological and pharmacological therapies, surgical processs and device therapy 11. The benefits of antihypertensive drugs in take downing blood force per unit area or forestalling cardiovascular morbidity and mortality in aged outpatient have been documented 2. Antihypertensive therapy reduces the hazard of shot, congestive bosom failure, and coronary bosom disease by 35 % , 42 % , and 28 % , severally 4,12. High blood pressure in bosom failure ensuing from systolic disfunction is frequently managed utilizing angiotonin change overing enzyme ( ACE ) inhibitors ( such as Capoten, Vasotec, fosinopril, Prinival, quinapril and Altace ) or angiotensin II receptor blockers ( ARBs, such as irbesartan, losartan and Diovan ) and i??-adrenergic receptor blockers ( such as carvedilol, Lopressor or bisoprolol ) . i??-blockers are non recommended for patients who are hemodynamically unstable, or those who have rest dyspnoea with marks of congestion. Low dose aldosterone adversaries ( Aldactone ) can be used for this type of patients and diagnostic patients who have suffered a recent myocardial infarction. Low dose water pills, normally loop water pills such as bumetanide, ethacrynic acid, Lasix and torsemide, are besides needed to extinguish unstable overload in many patients. Digoxin is recommended when symptoms persist despite ACE inhibitors and i??-receptor blockers. But bosom failure secondary to diastolic disfunction can be treated with ACE inhibitors, water pills or i??-blockers without ARB or verapamil 11,13.
Earlier surveies have shown that Ca channel blockers ( CCBs ) may be effectual in the direction of high blood pressure with diastolic bosom failure but non systolic bosom failure 13,14. CCBs have vasodilatory every bit good as negative inotropic effects. They act by direct relaxation through suppression of smooth musculus L-type Ca current, indirect relaxation through release of azotic oxide from vascular endothelium and deceleration of coronary artery disease through consequence on localised accretion of collagen, elastin and Ca and monocyte infiltration and smooth musculus proliferation and migration 2. The first coevals CCBs ( including Procardia, Cardizem, and Calan ) universally produce hemodynamic and clinical impairment in patients with systolic bosom failure because of direct negative inotropic effects, farther activation of hurtful neurohormonal responses and increase in blood volume which may increase afterload and are non recommended for patients with systolic bosom failure 13,14. For aged outpatients, any hurtful effects ensuing from disposal of CCBs may non be instantly related to the drug but may be seen as extension of the medical job that led to the prescription of the CCBs. Anecdotal grounds indicates that many doctors in our wellness attention systems recommend CCBs to elderly hypertensive patients without sing the type of bosom failure in the aged patients being treated..
Given the high prevalence of high blood pressure among older people and the widespread usage of CCBs 15,16, rating of the inappropriate usage in the aged is of import. The possible public wellness impact of this issue is considerable, given that it may be possible to modify a individual ‘s antihypertensive regimen. There has non been old research in this country in Benin City. Our primary aim was to measure the rational prescription of CCBs in hypertensive aged patients by doctors with the hope of supplying a model for an interventional programme to guarantee the safety of these patients on antihypertensive therapy.
This research survey was carried out in two government-funded third wellness attention installations ( University of Benin Teaching Hospital, UBTH and Central Hospital, Benin City ) besides offering secondary attention, and two private community wellness attention installations ( Mount Gilead Hospital and St Philomena Hospital in Benin City ) . While UBTH is a 650-bed federal authorities funded infirmary, Central Hospital is a 450-bed Edo State Government funded infirmary. Mount Gilead Hospital is a 40-bed private clinic and St Philomena is a 100-bed Catholic Church-owned infirmary. We consistently selected these infirmaries to stand for the different classs of countries of pattern in Benin City with an estimated population of 1.2 million ( 2006 national population censors ) viz. third infirmary, secondary infirmary, and community pattern clinics. The survey population consisted of all 651 medical physicians ( house officers, medical officer/registrar and advisers ) working in the assorted wellness attention installations mentioned above from June 2009 to August 2009 when the survey was conducted. All the medical physicians who disagreed to take part in the survey and all dental medical practicians were excluded from the survey.
Prior to this survey, appropriate permission was sought and obtained from the assorted caputs in the aforesaid wellness attention installations before the questionnaires were distributed to the physicians. A one-page questionnaire consisting of a combination of open-ended or closed 23 inquiries was designed by the writers. The inquiries focused on sociodemographic features ( including old ages of professional experience, making, topographic point of pattern, position, class of specialisation and specific countries of specialisation ) of the respondents ( doctors ) , old intervention information of the aged patients with the doctors including diagnostic probes, drugs frequently prescribed by the doctors for the patients, usage of Ca channel blockers ( CCBs ) in the patients with or without bosom failure and information provided to the patients prescribed CCBs. The questionnaire was pre-tested, modified as appropriate and the dependability of the information was determined utilizing Cronbach ‘s alpha. Pre-test dependability coefficients for the informations evaluated ranged from 0.78 to 0.91.
Based on the population of 651 physicians in the infirmaries selected for this survey, a sample size of 135 was calculated utilizing appropriate statistical method at 95 % assurance interval, 50 % as the proportion physicians in the mark population probably to order CCBs unsuitably ( since the proportion was non antecedently reported ) and 0.075 as the grade of truth 17,18. The questionnaire was distributed to a random sample of 161 medical physicians in their offices in the assorted wellness installations and at assorted times during the survey period ( June to August 2009 ) for self-administration. This took the population of physicians in each infirmary into consideration. Response was made voluntary and all questionnaires completed within a hebdomad were retrieved for calculation and analysis.
The primary result of this survey was to observe the proportion of doctors who unsuitably prescribe CCBs to aged patients. For this intent, any doctor who acknowledged prescribing or will order CCB to an aged hypertensive patient with systolic bosom failure with or without measuring the bosom position and/or reding them on the possibility of acknowledging the unsafe consequence on bosom while taking the CCB was considered to hold prescribed CCBs unsuitably. We besides determined the proportion of prescribers who ( 1 ) prescribe CCBs in aged patients with high blood pressure ; ( 2 ) confirm or except bosom failure in aged patients before ordering CCBs ; ( 3 ) know that CCBs are merely effectual in high blood pressure with diastolic bosom failure and that CCBs can farther deject a failing bosom ; ( 4 ) prescribe CCBs in hypertensive aged patients with diastolic bosom failure ; and ( 5 ) advice the aged patients they prescribe CCBs for, on how they can easy acknowledge unsafe consequence on bosom while taking the drugs and what the patients need to make if jobs are noticed.
The informations collected were entered into Microsoft Excel ( Microsoft Inc, USA ) and dual checked for truth. Using Epi Info version 3.5.1 ( Centers for Disease Control and Prevention, CDC, Atlanta, USA ) , relative informations were analyzed utilizing Chi-square trial or Fisher ‘s exact trial for 2×2 comparings. Descriptive statistics ( frequence and per centums ) was used for the presentation of the information. The association between the dependent variables ( inappropriate prescription of CCBs ) and the independent variables ( making, old ages of experience, and country of specialization ) was determined utilizing logistic arrested development analysis. At 95 % assurance interval, 2-tailed p-values less than 0.05 were considered to be statistically important.
Of the 161 questionnaire administered, 150 were punctually completed by the doctors, giving a response rate of 93.2 % . The distribution of these doctors and their sociodemographic charactaeristics are given in Table 1. Majority of them were medical officers/registrar ( 75.1 % ) , had less than 11 old ages of professional experience ( 68.7 % ) and 56 % had postgraduate preparation, but none had a PhD. Five of the respondents form portion of the 12 specializers in cardiology in the infirmaries who accepted to take part in the survey. Majority of the respondents ( 79.3 % ) were in the countries of community, household and internal medical specialty field.
All the respondents acknowledged handling between 4 and 350 ( 107.7i‚±63.7 ) aged outpatients each month from an estimated entire outpatient population of 277.6i‚±142.5. Majority of them ( 98.7 % ) reported of all time handling high blood pressure in an norm of 48.5i‚±42.3 ( 2-250 ) aged outpatients per month. Among the aged outpatients, an estimated 36.9 % were hypertensive. Most of the participants ( 86 % ) reported transporting out ECG ( 86 % ) , echo ( 98 % ) or chest x-ray ( 98 % ) scrutiny before ordering drugs. Blood sugar and organic structure electrolyte analysis were besides routinely done for the aged outpatients by 97 % of the respondents.
The mean BP for which antihypertensive drugs were recommended was 145i‚±6.4 mmHg ( systolic ) and 91.17i‚±3.03 mmHg ( diastolic ) . CCBs ( viz. Procardia, amlodipine and felodipine ) were frequently prescribed by 118 ( 78.7 % ) physicians for the aged while angiotensive change overing enzyme inhibitors ( ACEIs ) including Altace, Prinival, Capoten and Vasotec were frequently prescribed by 70 ( 46.7 % ) . Diuretics including thiazides, moduretics and frusemide were often prescribed by 95 ( 63.3 % ) of the physicians while merely a little proportion of them ( 8.7 % ) prescribed soluble acetylsalicylic acid, methyldopa and Tenormin.
Calcium channel blockers ( CCBs ) use in the aged
Over 75 % of the respondents recommend CCBs ( amlodipine, Procardia and felodipine ) to aged hypertensive patients as their antihypertensive therapy with some of the respondents ( 63.3 % ) including water pills in their prescription to these patients. Some of the respondents ( 52 % ) on a regular basis prescribe CCBs to elderly hypertensive outpatients. Although 54.7 % of the doctors believe that it is appropriate to order CCBs in bosom failure, 34.3 % of them describing prescribing of CCBs in systolic bosom failure which was inappropriate. The CCBs reported being prescribed for aged outpatients with bosom failure were amlodipine, nifedipine and felodipine ( Table 2 ) .
Although most of the doctors ( 88.7 % ) reported reding the aged patients prescribed CCBs, information frequently provided was based on attachment, infirmary regular visits, diet limitations, exercising, patients ‘ monitoring, lifestyle alteration ( 59.3 % ) , side effects and inauspicious events ( 70.7 % ) . Some of them ( 4.7 % ) counseled on what the patients should make if serious side effects or inauspicious events such as bradycardia, palpitations, thorax strivings, giddiness and fatigues occur.
Forecasters of inappropriate prescribing of CCBs
The relationship between inappropriate prescribing and some forecaster variables are given in Table 3. The major forecasters of the irrational prescribing of CCBs in systolic bosom failure are country of specialisation ( OD=1.0759 ) , topographic point of work ( OD=1.0799 ) and position ( 1.1982 ) ( Table 3 ) . From our limited information, it does look that doctors in subjects other than cardiology and anesthesiology were less likely to order CCBs unsuitably while those working in private infirmaries and advisers in different subjects were more likely to order CCBs unsuitably ( Table 3 ) . Area of specialisation ( OD=0.9641 ) , position ( OD=1.0804 ) and old ages of professional experience ( OD-1.9393 ) were the major determiners of who will or will non supply proper reding on possible of serious inauspicious effects of CCBs on the bosom. Physicians rehearsing in the subject of haematology, cardiology, community wellness and surgery were more likely non to advocate decently when compared to other countries of specialisation. Besides the advisers and those with more than 10 old ages of professional experience were less likely to advocate the patients prescribed CCBS suitably ( Table 3 ) .
The consequences of this probe showed that most of the aged outpatients who have a history of high blood pressure are really likely to be prescribed CCBs ( chiefly Procardia and amlodipine ) without governing out systolic disfunction in the patients. Nifedipine and amlodipine green goods hemodynamic and clinical impairment in patients with systolic bosom failure because of direct negative inotropic effects, farther activation of hurtful neurohormonal responses and increase in blood volume which may increase afterload 13,14. Older people taking CCBs are besides significantly more likely to see cognitive diminution than those other agents 15. However, ACE inhibitors benefit all patients with systolic bosom failure by barricading the transition of angiotonin I to angiotensin II ( powerful vasoconstrictive ) and exciting the release of aldosterone and AVP. They besides facilitate cardinal and peripheral activity of the sympathetic nervous system therefore cut downing both preload and afterload 11. With equal cognition of these facts, the doctors would non be ordering CCBs for the aged patients with systolic bosom failure as in this survey. Equally many as 54.7 % of the doctors were non cognizant of this inappropriate usage of drugs in aged patients as they did non see anything incorrect with the usage of CCBs in aged patients with bosom failure. This determination was a presentation of hapless cognition of the usage of CCBs in the aged by the doctors studied and complements the intensifying job of inauspicious drug events ensuing from inappropriate ordering 19,20.
Since intervention of high blood pressure in patients with bosom failure must take into history the type of bosom failure that is present 10,21, appropriate diagnosing of aged patients is a precedence at all times. The research lab workup for bosom failure frequently include the finding of chest X ray, electrolytes, uranalysis, electrocardiography ( ECG ) and echocardiography ( ECHO ) as reported to be a usual process by many of the prescribers surveyed. However, some other utile processs such as blood urea N, cardiac enzymes ( CK-MB, troponin ) , complete blood cell count, creatinine clearance, liver map trials, Mg, thyroid-stimulating endocrine, electric resistance cardiography, atrial natriuretic peptide ( ANP ) and encephalon natriuretic peptide ( BNP ) 22 were non reported to hold been done. In fact, most of these ulterior probes are barely done for hypertensive patients in the scenes.
Effective patient guidance can significantly cut down patient nonadherence, intervention failure, and wasted wellness resources 23,24. By and large, patients having antihypertensive medicines are normally counseled on attachment, infirmary regular visits, diet limitations, exercising, patients ‘ monitoring, lifestyle alteration and side effects/adverse events as reported to hold been the pattern by some of the participants in this survey. Since CCBs have the possible to bring forth bradycardia, palpitations, thorax strivings, giddiness and fatigues and other hurtful effects in patients with bosom failure, every patient being given CCBs ought to be counselled on what they should make when serious side effects occur and to avoid pseudoephedrine, antihistamines, “ natural ” or herbal merchandises with adrenergic ingredients such as ephedrine or mom huang 11. Although guidance of patients on drugs is a major duty of the druggist, many doctors working in private clinics and infirmaries in Nigeria dispense medicines to quite a figure of patients without the engagement of druggists, doing it indispensable for such doctors to advocate their patients on their medicines. Unfortunately, merely a really little fraction of the doctors ( 4.7 % ) reported the demand to advocate their patients on what the patients should make should serious side effects or inauspicious events occur go forthing them to the druggists who dispense their drugs to advocate them suitably. However, there are indicants that the proportion of patients that may have reding from a druggist can be every bit low as 33-42 % 24,25. In add-on, an earlier survey on pharmacists-patients communicating in the survey country showed that druggists barely provided information to patients in countries such as contraindications, interactions, monitoring, and side effects/adverse events of drugs and the patient besides barely asked inquiries in relation to side effects/adverse events 26. If this is considered in line with the fact that ambulatory aged patients on CCBs may see some of the inauspicious events of their medicines as portion of their medical status, it becomes evident that many of the aged patients are being exposed to the danger of inappropriate prescribing.
Continuing instruction programmes for doctors have the potency of bettering the cognition of the doctors and hence their health care pattern 27. With an estimated norm of 107.7i‚±63.7 aged outpatients being treated by each of the participants in this survey and about 36.9 % of them being hypertensive, a big figure of aged people in the population may be affected from the inappropriate usage of CCBs in the population. There is strong need hence to form awareness programme for all the doctors in the full population to better their prescribing patterns, and prevent inauspicious effects of CCB medicines and evitable deceases.
Irrational prescribing of CCBs for aged patients is common in the four infirmaries studied. There appears to be a direct relationship of this incorrect usage of drugs with the old ages of experience of the doctors. The more the figure of old ages of professional experience the less likeliness of making the right thing. This calls for effectual go oning educational intercession that will better the cognition of doctors in Benin City in rational prescribing of drugs for the aged.