LITHUANIAN UNIVERSITY OF HEALTH SCIENCES FACULTY OF MEDICINE INSTITUTE OF PHYSIOLOGY AND PHARMACOLOGY

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

FACULTY OF MEDICINE

INSTITUTE OF PHYSIOLOGY AND PHARMACOLOGY

SIVAJI KIRUSHANTHAN

Health-related quality of life among patients treated with ACE

inhibitors and other drugs involved in hypertension treatment

Final Master’s Thesis

Supervised by Mantas Malinauskas, PhD

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1. SUMMARY

Author: Sivaji Kirushanthan.

Research title: Health-related quality of life among patients treated with ACE inhibitors and other drugs involved in hypertension treatment.

Research aim: The aim of the study is to describe the relationship between medication-related factors and HRQoL among hypertensive individuals.

Objective:

1.To describe the relationship between antihypertensive drugs and HRQoL in patients of different age groups.

2.To describe the relationship between antihypertensive drugs and HRQoL in patients according to gender.

3.To describe the relationship between the treatment of ACE inhibitors and other groups of antihypertensive medication on HRQoL in hypertensive patients.

4.To describe the relationship in HRQoL between the control group and patients treated with antihypertensive medication.

Methodology: The participating patients were asked to complete the SF-36 questionnaire, and the names of the antihypertensive medication were asked personally from each hypertensive patient or nurses. The study group consisted of 105 patients for which, SF-36 questionnaires were collected from hospitalized hypertensive patients (65 patients) and control group-normotensive patients (40 patients) in Kauno klinikos Lithuania. All these hospitalized hypertensive patients (65 patients) were treated by antihypertensive medications. All these patients were identified in the following time period between, 2018/ 05/ 01 - 2018/ 12/ 31. The collected data were aggregated and evaluated statistically using SPSS software to find correlations between various parameters.

Results: The most common hypertension was related to elderly patients (≥ 45 years old) compared to younger patients (< 45 years old), It’s more associated to male patients compared to female patients. We found significant differences when we compared between hypertensive patients and control group patients on HRQoL, including the general health, daily activities, physical and emotional health, physical or emotional health interfered the normal social activities. Our study has found a significant difference when we compared ACE inhibitors (mono) and ACE inhibitors (combines) on walking 100 meters (daily activities). We found significant differences when we

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compared ACE inhibitors (mono) and beta blockers (mono) on patient’s nervousness (feeling of the patient).

Conclusion:

1. In our studied population, we found that patients over 45 years old who have a higher incidence of hypertension and take antihypertensive drugs, are associated with impairment in their HRQoL.

2. Our study has found that males have a higher incidence of hypertension compared to female subjects; no significant difference was found between gender and their HRQoL.

3. There has been improvement in the daily activities of patients taking ACE inhibitors alone compared to patients taking ACE inhibitors in combinations. However, the nervousness of the patient was worsened in the patients taking ACE inhibitor alone, compared to the patients taking beta blockers only.

4. Our study also found that patients treated with antihypertensive medication had significantly poor HRQoL compared to the control group-normotensive patients.

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2. ACKNOWLEDGMENT

I would like to thank Mr.Mantas Malinauskas (Ph.D.) for his guidance throughout the research as well as doctors and resident doctors for their help in collecting questionnaires in Kauno klinikos.

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3. CONFLICTS OF INTEREST

There is no conflict of interest reported by the author.

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5. ABBREVIATIONS

ACE- Angiotensin-converting enzyme

ACE inhibitor / ACEIs- Angiotensin-converting enzyme inhibitors ARBs- Angiotensin receptor blockers

AT-I - Angiotensin I AT-II - Angiotensin II BBs - betta blockers BMI- Body mass index

CCBs- Calcium channel blockers CKD- Chronic kidney disease CNS- Central nervous system CVD- Cardiovascular disease DM- Diabetic Mellitus

HPB- Health-promoting a behavior HPL- Health-promoting a lifestyle HRQoL- Health-related quality of life HTN- Hypertension

RAAS- Renin angiotensin aldosterone system

SF-36- Medical outcome study short form-36; MOS- ‘SF-36’ VAD- Vascular dementia

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6. INTRODUCTION

One of the most common chronic diseases prevalent in elderly people is hypertension (HTN), which is a high-risk factor for chronic kidney disease, cardiovascular disease, stroke, and diabetes mellitus [1,2,3].

Many factors are responsible in patient’s adherence to antihypertensive medication, including the doctor and patient relationship, the patient’s general health and their other comorbidities, psychological factors and social functioning, growth of health care system, the wide number of medications used in the treatment of patients and their interaction. The antihypertensive treatment is lifelong in hypertensive patients and may itself worsen Health-related quality of life (HRQoL) in the long run [3].

It’s thought that improper treatment of hypertensive patients with antihypertensive medications is found to have a high incidence in side effect and poor quality of life [4,5]. HRQoL is affected by the adverse effect of antihypertensive medication, thus it affects the patient’s emotions, physical health, mental health perceptions, psychological state (anxiety, depression), level of independence, personal beliefs and social functioning [6,7].

According to HRQoL and treatment adherence to hypertension (HTN), antihypertensive medications can significantly control high blood pressure while improving patient’s quality of life and reducing the high-risk factors resulting from hypertension [2]. Hypertension and/ or inappropriate treatment of hypertension can be reducing HRQoL compared to the person with normal blood pressure [8,6]. Mostly this HRQoL is worsening in hypertensive elderly people due to their uncontrolled high blood pressure resistance to their inappropriate single/ combination of antihypertensive treatment [8]. Appropriate treatment is associated with higher adherence to antihypertensive drugs and its improved HRQoL [3].

The aim of the present study is to investigate the changes of HRQoL among the hypertensive patients treated by the ACE inhibitors and other drugs involved in hypertension treatment.

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7. AIM AND OBJECTIVES

AIM: The aim of the study is to describe the relationship between medication-related factors and HRQoL among hypertensive individuals.

OBJECTIVES:

1. To describe the relationship between antihypertensive drugs and HRQoL in patients of different age groups.

2. To describe the relationship between antihypertensive drugs and HRQoL in patients according to gender.

3. To describe the relationship between the treatment of ACE inhibitors and other groups of antihypertensive medication on HRQoL in hypertensive patients.

4. To describe the relationship in HRQoL between the control group and patients treated with antihypertensive medication.

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8. LITERATURE REVIEW

8.1.1. Health-Related Quality of Life (HRQoL) on hypertension

HRQoL studies about a person’s physical, psychological, emotional and social functioning [9,10,11]. The poor quality of life related to hypertension and/or who have been treated to hypertension with antihypertensive medications [12]. Daily activities and work limitation in hypertensive patients due to the decreased physical or emotional functioning, feelings of nervousness, depression, and fatigue, limiting and severity of body pain, worse perception of personal health and poor social functioning [13].

Health-promoting behaviors (HPB) is more important for self-initiating independently and daily activities. Hypertensive patients have slight alterations in HPB and lower HRQoL than other normotensive people [9]. The poor social support and stress impacts the HRQoL in hypertensive older adult patients [10].

The lower health-promoting lifestyle (HPL) in hypertension patients due to the sedentary lifestyle, low income, physical and mental disorders, and social isolation. The majority of hypertensive elderly people feel lonely and depressive. This kind of lower health-promoting lifestyle (HPL) might progress to lower probability of health-promoting behavior (HPB) and impact on health-related quality of life [11].

Chronic renal disease related hypertension impacts on physical functioning compared to the psychological/ cognitive functioning, with ranges in women being poorer than in men. HRQoL is affected in patients with long-term history of hypertension, a higher number of antihypertensive medication usage, higher mean arterial pressure and chronic renal insufficiency [13].

Cardiovascular disease (CVD) impacts on HRQoL in hypertensive patients including heart failure, peripheral vascular disease, risk of diabetic mellitus and coronary disease. Elderly hypertensive patients and/ or female gender with CVD have poor HRQoL than other CVD patients [14,13]. HRQoL is worsening in elderly hypertensive patients than younger hypertensive patients [13]. Heart failure (HF) patients have poor physical and mental HRQoL as compared to patients with another cardiovascular disease/ coronary artery disease [15].

The poor health-related quality of life is greater related to coronary artery disease in hypertensive patients, including poor social support, depression, anxiety and personality-related impairments. Fatigue is a common symptom of coronary artery disease or heart failure or depression. Fatigue is related to poor physical functioning, major mental distress and increasing the risk of

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mortality [16]. Physical and mental functioning is higher for hypertensive male patients than female patients [17]. Heart failure female patients live longer than male patients do, but they may have lifelong worse HRQoL and also complain more about psychological and physical disability [18].

8.1.2. Physical functioning of HRQoL related to hypertension:

Physical functioning is explained as the capacity to perform a range of activities in day to day life. Physical health constitutes of physical functioning, role-physical limitation and body pain in hypertensive patients [19]. Physical functioning is worse in congestive heart failure patients than in patients with coronary artery disease [13,14].

Hypertensive patients who were not breastfed in childhood had severe body pain than those who were breastfed in childhood. Hypertensive patients with higher body mass index (BMI) have a better quality of life including role-physical, physical and mental health; than those who had lower BMI [20].

8.1.3. Psychological or emotional functioning of HRQoL related to hypertension

Psychological functioning or cognitive functioning ranges between severe unpleasant feelings to a sense of positive well-being [19]. The cognitive function is evaluated in HRQoL studies of hypertension with a number of factors including executive function, speed of processing or attention and the specific domains of memory. Hypertension is one of the high risk factors for cerebrovascular damage, resulting in psychological/ cognitive impairment by progressing to hypoperfusion, white matter injury, ischemic and hemorrhagic stroke [21].

8.1.4. Social functioning of HRQoL related to hypertension

Social functioning is explained as the quantitative and qualitative features of social relationships and interactions [19]. Psychological stresses are related to social activities including family or friends or neighbours, which may change the HRQoL among hypertensive patients. The poor contribution from the family or friends or neighbors reflects a lower quality of physical function, social function and emotional function compared to those with better connection with family or friends or neighbours. The hypertensive patients, who have better connection with family was shown to have a higher compliance with antihypertensive medications, lower depression and better quality of life [20].

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8.1.5. Hypertension definition

Arterial hypertension means there is increased blood pressure in the arteries. This needs stronger cardiac work than normal to pump blood through the blood vessels. High blood pressure may be defined by two measurements, which are systolic and diastolic. Hypertension(HTN) is defined by systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg in more than two outpatient office visits [22,23]. Hypertensive patients have a higher risk of stroke, cardiovascular disease (heart failure, coronary artery disease, peripheral artery disease), chronic renal disease, cognitive decline, and early life mortality [24]. Hypertension is highly related to cardiovascular mortality in Lithuania. The number of hypertensive patients are very high in Lithuania [24, 25].

Hypertension can be divided into primary (essential) or secondary hypertension. Primary hypertension can be in middle/ old age group people due to the genetic and environmental factors [26]. Genetic factors that are related to hypertension consists of family history and race (most in Black people). Environmental factors could be older age, obesity, lack of exercise, alcohol and smoking and high salt intake [23]. Secondary hypertension can occur in an early age group in people mostly younger than 40 years old due to either unknown causes, contraceptive pills, renal disorders, endocrine disorders, diabetes mellitus, hyperlipidemia or medication [26,23]. In Kaunas Lithuania, hypertensive male patients have a higher risk of association with alcohol consumption and overweight [25].

Most of the hypertensive patients have no specific signs or symptoms unless prolonged or severe hypertension [25]. Some of the hypertensive patients may have headache, irritability, fatigue, facial paralysis, blurred vision, nose bleeding, neck pain and failure to thrive [27].

Geriatric hypertensive patients have age-related high arterial stiffness. Arterial stiffness is due to lack of vascular smooth muscle cells hypertrophy and contractility, collagen deposition in the vascular wall, fibrosis, calcification, loss of baroreceptor sensitivity, increased stimulation of sympathetic nervous system, increased α-adrenergic receptor binding, loss of nitric oxide production due to endothelial dysfunction, decreased excretion of sodium, high resistance to insulin resulting in central obesity and low renin activity in plasma [28].

8.1.6. Hypertension physiology and pathophysiology:

Increase in blood pressure is defined as the body’s response to external stressors to maintain adequate blood pressure for supplying the brain and heart’s demands. Renin-angiotensin system and

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autonomic nervous system has a role to increasing the blood pressure by regulating compensatory mechanisms [23].

Sympathetic and parasympathetic nervous systems controls the function of the cardiovascular system. These systems are maintaining the cardiac contractility, vascular resistance, heart rate, blood volume level and blood pressure [29].

The sympathetic ganglionic and postganglionic fibers innervates the juxtaglomerular cells in the kidneys and aids in the release of renin. The release in renin helps in the conversion of angiotensin I to angiotensin II. Angiotensin II is constricting the afferent and efferent renal arterioles resulting in an increased fluid reabsorption. Angiotensin II increases the release of aldosterone from the adrenal cortex. Aldosterone also increases the reabsorption of water and sodium level in the kidney via distal tubules and collecting ducts. Thus, its effect increases the blood pressure [30].

Uncontrolled hypertension is related to inappropriate treatment or intolerance to antihypertensive medications. This could be in elderly people, people with lack of social and family support, people with the mental or cognitive or psychological disease, high cost of antihypertensive medications and complicated drug regimens [31].

8.2.1. Health-related quality of life in the management of hypertension

Antihypertensive management has an influence on HRQoL, including mobility, self-care, pain or discomfort, usual daily activities and anxiety or depression [32].

Nonadherence of antihypertensive management affects the HRQoL which is due to improper following of dietary and lifestyle advices, harmful habits (smoking, alcohol use), inappropriate medication-taking, behavior and improper follow-up visits [17, 21]. There are a number of factors that are influencing the adherence of antihypertensive drugs including long-term history of hypertension, patients with hearing, visual or cognitive impairments, poor knowledge about hypertension, fear of taking drugs, complexity of drug regimen, lifelong usage of drug regimen, frequent changes in regimen, severe adverse effects, lack of doctor-patient relationship, lack of social support and cost of treatment [21,32].

Antihypertensive drugs can cause a few side effects such as headache, anxiety, depression, dizziness and palpitation, reduced amount of time spent on work or other activities; not working as carefully as usual and accomplished less than what they would like [11]. A side effect of antihypertensive medications can impact the quality of life [32].

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8.2.2. Physical functioning of HRQoL in the management of hypertension

Hypertensive patients can be associated with chronic diabetic peripheral neuropathic pain (DPNP). This body pain may affects the patient’s sleep, impact on cognitive function, decrease the mood or depression or anxiety and lower daily activities, which results in worse HRQoL [33].

Hypertension is commonly related with elderly people than adults or children. Hypertension is associated with the high incidence of cardiovascular disease in elderly people, which can lower the quality of life. Impairments of physical and psychological functioning is more associated with elderly hypertensive patients. Elderly people can have poor adherence to antihypertensive medications, therefore worsening of HRQoL including the physical, emotional and social wellbeing. Elderly hypertensive patients treated with appropriate drugs of choice can improve the HRQoL [39,51]. Hypertension has a high risk of dementia, falls or fractures and physical disability in elderly hypertensive patients [12].

8.2.3. Psychological/ emotional functioning of HRQoL in the management of hypertension

Depression can be related to several risk factors including the higher number of antihypertensive medication use, lack of physical activity, poor eating habits, higher BMI and smoking habits. Symptoms of depression can be sleeping disorders, social isolation, hopelessness, apathy, and failure of attention [34]. The psychological function is more affected with intensive antihypertensive therapy compared to moderate antihypertensive treatment [35].

Hypertensive patients may become anxious about their antihypertensive medication and inadequate blood pressure control due to the lower number of follow ups with doctors. Hypertension- associated HRQoL and emotional health are improving with appropriate drug-drug combination therapy [17].

A side effect of antihypertensive medication is increase in anxiety/ fear, which may lead to the patients stop taking antihypertensive medications. The high anxiety may relate to the risk of intolerance to antihypertensive drugs. Fear or anxiety has been related to hypertension and adverse cardiovascular health behaviors. The anxiety-related sensations is related to antihypertensive drugs nonadherence [36].

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8.2.4. Social functioning of HRQoL in the management of hypertension

Depression is related to poor health outcomes and worse quality of life in older hypertensive patients. Depression is related to a low level of social support and nonadherence of antihypertensive drugs in older hypertensive patients. Poor social functioning is seen among elderly hypertensive patients as a result of mortality and morbidity of friends and family members or isolation resulting from depression. Low level of social support decreases the adherence of antihypertensive treatment in elderly hypertensive patients [37].

8.3. HRQoL in the management of hypertension by ACE inhibitors 8.3.1.ACE inhibitors actions

ACE inhibitors are used in the treatment of patients as mono or combined forms, who have been diagnosed with acute hypertension, chronic hypertension, acute myocardial infarction, heart failure, cardiac attacks, diabetic nephropathy, strokes and chronic kidney disease [38].

The mechanism of ACE inhibitors can be explained by its action on RAAS. ACE inhibitors are blocking the ACE enzymes activity, which reduces the angiotensin II (responsible for the constriction of blood vessels) converted from Angiotensin I in the blood. These medications cause vasodilation and decrease the blood pressure by lowering angiotensin II, Aldosterone and vasopressin in the blood [40].

ACE inhibitors affects the sympathetic adrenergic activity resulting in the decrease of angiotensin II in the blood. This group of medications increases vasodilation due to the increased production of prostacyclin and nitric oxide in the blood vessels and also decreasing the breakdown of bradykinin, which may result in increased levels of bradykinin in the blood. ACE inhibitors reduces the production of aldosterone, resulting in increased excretion of sodium and water in urine. Reduction of cardiac workload is due to decreased blood volume, cardiac preload and afterload [41].

Inhibiting activity of RAAS feedback is decreased due to a lower level of Angiotensin II in the blood, may result in increase in the production of renin from both kidneys, , thereby ACE independently partially increase the production of Angiotensin II from Angiotensin I, which is termed as ACE Escape (ACE inhibitors are not functioning here) [42].

There are a few side effect for ACE inhibitors namely hypotension, hyperkalemia, fever, dry cough, rash, taste impairment, dizziness, headache, drowsiness, weakness, chest pain and sun

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sensitivity [43,13]. Angioedema is the most life-threatening adverse reaction due to the high level of bradykinin [44,45].

ACE inhibitors are avoided in patients with renal artery stenosis and pregnancy. This group of drugs are used in cautions in patients with impaired renal or hepatic function, patients with hypovolemia or hypotension, patients who have undergone hemo-dialysis and previous history of angioedema [44,37,38, 45]. ACE inhibitors with a combination of angiotensin II receptor blockers are more effective in blocking the Angiotensin II (Ang II) [46,42]. ACEIs with potassium‐sparing diuretic reduces the adverse effects of decreased potassium levels that occurs with taking ACE inhibitors alone [47].

ACE inhibitors with other antihypertensive combination therapy have been related to high risk of drug duplication, drug-drug interactions and other side effects that reduces other physical functions such as decreased alertness, aerobic endurance, flexibility, agility or dynamic balance, muscle strength and vision[48].

There is moderate evidence that the usage of ACE inhibitor, reduces mortality and heart failure or cardiovascular disorders, mild evidence that it reduces stroke and coronary heart disease. Functional status has been improved by treating the hypertensive elderly patients to a combination of ACE inhibitors and other antihypertensive medication compared to ACE inhibiting monotherapy. This combination of medications is improving the physiological reserve, agility/ dynamic balance, lower or upper body strength and flexibility and cardiorespiratory endurance [11].

8.3.2. HRQoL in the management of hypertension by ACE inhibitors

ACE inhibitors with exercise training have a more positive effect on physical functioning and prevention of physical disability in elderly hypertensive patients. ACE inhibitors have a lesser impact in the decline of muscle strength, muscle mass and walking speed in older hypertensive patients. It’s possible that ACE inhibitors with exercise training have more effect on muscle function and improved quality of life [11].

The combination of ACE inhibitors and ARB medications are recommended for hypertensive patients with chronic kidney disease. Advanced stage of kidney disease has been related to the poor HRQoL and other clinical outcomes including physical functioning which can worsen the hospitalization rates. The combined ACE inhibitors and ARB drugs can improve the physical

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functioning and renal outcomes in hypertensive patients at risk of cardiovascular, hyperkalemia and acute kidney failure [49].

Angiotensin genes are related to depression, psychotic or cognitive and mood disorders. The angiotensin I (AT-I) receptor inhibitors are related to antidepressant and anxiolytic-like effects. ACE inhibitors/ AT-I receptor blockers reduces neuroinflammation by lowering action of angiotensin II. AT-I receptor blockers / ACE inhibitors has improved cognitive or mental disorder, depression and anxiety related- HRQoL and positive wellbeing [50].

The combination of exercise training and ACE inhibitors or other antihypertensive medications has improved the quality of life in older hypertensive patients. The improved functional status is related to increased lower and upper body strength and flexibility, the agility and dynamic balance and the cardiorespiratory endurance. ACE inhibitors increases the functional movements and daily activities such as climbing stairs, leaning, kneeling, standing up, walking, personal care (bathing or dressing them self), lifting or carrying groceries and other house work. This group of drugs can stop prolonged physical disability and improve HRQoL [51].

Hypertensive patients with intermittent claudication have impairment functional movement and poor quality of life. ACE inhibitors increases the peripheral blood supply, endothelial function and the effect of muscle metabolism, which results in reduced pain, increase walking distances and improved quality of life. ACE inhibitors can improve physical functioning or functional ability in hypertensive elderly patients [52].

The combination of ACE inhibitors or ARB medication has improved depression and quality of life compared to other antihypertensive drugs [53].

8.4. HRQoL in the management of hypertension by Angiotensin II receptor blockers (ARBs)

This group of medications commonly used in the treatment of hypertension, diabetic nephropathy, heart failure, stroke, left ventricular hypertrophy and migraines [54,55,56].

Angiotensin II stimulates AT-I and AT-II receptors in RAAS. AT-II receptor can be regulated by AT-I receptors. AT-I receptors have been found in endothelial/ smooth muscle cells of vessels, capillaries, adrenergic nerve synapses and adrenal gland. ARBs medications are inhibiting AT-I receptors. It decreases the fluid retention, increases vasodilation, decreases the production of aldosterone level and reduces vasopressin secretion into blood. It leads to the decrease of blood

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pressure in hypertensive patients/ other CV complicated patients. ARB does not change the bradykinin levels in blood [57,56].

Most common adverse effects of ARBs are hypotension, hyperkalemia, dizziness, headache, back pain, rash, diarrhea, and insomnia [38]. This drug should be used in caution in patients with impaired renal function and high serum potassium level [47]. ARBs are combined with ACE inhibitors in severely hypertensive patients or other CV risk hypertensive patients. This groups of combination drugs are most effective in the inhibition of angiotensin II, reducing the blood pressure and also lowering the CV risk [58,42,46].

Depression has been listed as a risk factor for cerebrovascular disorders (CVDs), including coronary artery disease (CAD), chronic heart failure (CHF) and hypertension. Depression can reduce the quality of life. ARB can improve functional and psychological HRQoL [59].

ARBs have anti- atherogenic actions that prevent end-organ failure and multi-organ protection including prevention of cognitive impairment and osteoporosis and also independently reduces the blood pressure. This group of the drugs can improve cardiovascular disorders as well as physical and mental quality of life [60].

There is more improvement in the HRQoL in hypertensive patients in adherence to CCB + ARB combinations compared to ARB + thiazide diuretic combinations; and more improvement in adherence to CCB + ARB +betablocker combinations compared to CCB + ARB + thiazide diuretic combinations [61].

8.5. HRQoL in the management of hypertension by other antihypertensive drugs 8.5.1. HRQoL in the management of hypertension by adrenergic receptors antagonist Alpha-adrenergic blocking agents are inhibiting the Alpha-adrenergic receptors, which is effective in decreasing the sympathetic tone of blood vessels, resulting in reduced peripheral vascular resistance [62].

Beta-adrenergic blocking agents are used in the treatment of hypertension, angina pectoris, myocardial infarction, migraine, hyperthyroidism, glaucoma, stable angina, heart failure and supraventricular cardiac arrhythmias. According to the inhibiting effect on receptors, the beta-adrenergic blocking agents are divided into two groups, including non-selective which inhibits both beta 1 and beta 2 receptors and selective which inhibits beta 1 receptors alone. These drugs reduces the

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cardiac output and workload, decreases the blood pressure, reduces the oxygen demand and increases the heart rate. Beta‐adrenoceptor antagonists have an effect on lowering both systolic and diastolic blood pressure [63,64,65].

The more common adverse effects that occur with Beta-adrenergic blocking agents are bronchoconstriction, arrhythmias, sexual and metabolic disturbance, tremor, tachycardia/bradycardia and CNS effects including hallucination, memory loss, depression, nightmares, emotional changes, blurred vision, dizziness, weakness, fatigue [66].

ACEIs, ARBs in combination with beta blockers are more effective in lowering the blood pressure. Combination of alpha blockers and beta blockers can have more effect in reducing the blood pressure and also safe in hypertensive patients less than 70 years old [67].

Alpha-adrenergic blocking drugs shows some evidence in the decline of cognitive or psychotic function including worsening of memory or language and executive function [68]. Cognitive or psychotic function and behavior changes are not affected in moderate hypertensive elderly patients, who have been treated with beta-blockers [69].

The quality of life is worsened in older and female hypertensive patients due to frequent syncopal spells/ frequent presyncope. Beta‐adrenergic blockers have not improved the quality of life in syncope. The adverse effects of beta‐blockers decreases the quality of life. Metoprolol improves the quality of life in hypertensive patients with frequent vasovagal syncope, this effect may depend on the patient’s age [70].

8.5.2. HRQoL in the management of hypertension by calcium channel blockers (CCBs) The calcium channel blockers are used in the treatment of hypertensive patients with angina or diabetes or chronic kidney disease and elderly hypertensive patients with a high risk of stroke, heart failure, left ventricular hypertrophy, angina pectoris or chest pain [71,72,74]. CCBs inhibits the L- type calcium channels, resulting in decreased amount of calcium ions in the cytosol. Cardiac and vascular smooth muscle cells are relaxing due to the inhibitory effects of the drug in the L – type calcium channels. CCBs are used in maintaining the dilation of the myocardium, peripheral artery and coronary artery [73,74,72].

The common side effects of this drugs are constipation, dizziness, headache, fatigue, peripheral edema, gingival hyperplasia or hypertrophy, hypotension, flushing, tachycardia or bradycardia and palpitation [75, 76,66].

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Calcium channel blockers can also induce gingival hyperplasia. This adverse effect of CCBs may have an unwanted effect on the quality of life as well as increasing the oral bacterial load by generating plaque retention sites [77].

CCBs has improved the physical function and body pain in hypertensive elderly patients, resulting in great improvements in hypertension-related symptoms and overall HRQoL. These improvements benefits the functional movements such as climbing stairs, walking and standing up, which in turn increases the ability to carry out everyday activities such as shopping, personal care, and housework and decreases the physical disability [78].

8.5.3. HRQoL in the management of hypertension by Diuretics

Thiazide and thiazide-like diuretics acts by inhibiting the Na+/Cl− ion channels on the ascending loop of Henle and the distal convoluted tubule, resulting in decreased reabsorption of Na+, increased excretion of Na+ and Cl−, loss of K+ and Mg2+, reduced urinary calcium excretion and decreased peripheral vascular resistance [79,80,81]. Loop Diuretics inhibits the co-transport of Na+/K+/2Cl− ions channels in the ascending loop of Henle, resulting in increased urinary excretion of Na+, Cl-, Ca2+, Mg2+, and K+ ions. Potassium-sparing diuretics inhibits the Na+ reabsorption and K+ excretion on the collecting tubule, resulting in retention of K+ ions and urine excretion of Na+ ions [80,84].

Most common adverse effects of diuretics are volume depletion, hypotension, drowsiness,

paresthesia, hypercalcemia, hyperglycemia, hyponatremia, hypokalemia, hypochloremia,

hypomagnesemia, sexual dysfunction and metabolic alkalosis [81,80,66]. The diuretics drugs can improve symptoms/ signs including dyspnea, edema, pulmonary congestion fatigue, confusion, pain, anorexia, depression, anxiety also decreasing the number of hospitalization and reducing the mortality rate related to the hypertension/ heart failure , resulting in better HRQoL for patients with advanced heart failure [82, 85].

Diuretic drugs used in the management of hypertension impacts on the quality of life by

altering urinary frequency, erectile disorder, muscle cramps and fatigue [61].

The hypertensive patients with restricted salt and fluid in diet, avoids higher demand for diuretics drugs and also improves HRQoL [83]. The inadequate symptoms relief with diuretics drugs has been related to longer hospitalization, increased mortality rate and decreased quality of life [84].

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8.6. Most common drugs in the management of hypertension and cardiovascular disease in Lithuania

 Antihypertensive drugs: methyldopa, clonidine, moxonidine, prazosin, doxazosin [86].

 ACE inhibitors: captopril, enalapril, lisinopril, perindopril, ramipril, quinapril, fosinopil, trandolapril, spirapril, zofenopril [86].

 Combination of ACE inhibitors: enalapril or ramipril or quinapril or fosinopril with hydrochlorothiazide (HCT), perindopril with indapamide, lisinopril or perindopril with amlodipine, trandolapril with verapamil [86].

 Angiotensin II receptor blockers (ARB): losartan, eprosartan, valsartan, irbesartan, candesartan, telmisartan, olmesartanmedoxomil [86].

 Combination of ARB: losartan or eprosartan or valsartan or telmisartan with HCT, olmesartanmedoxomil with HCT or amlodipine, valsartan with amlodipine [86].

 Beta-blocking agents (BBs): propranolol, metoprolol, atenolol, betaxolol, bisoprolol, nebivolol, carvedilol [86].

 Combination of BBs: bisoprolol or nebivolol with HCT [86].

 Calcium channel blockers (CCBs): amlodipine, felodipine, nifedipine, nitrendipine, lacidipine, lercanidipine, verapamil, diltiazem [86].

 Diuretics: hydrochlorothiazide (HCT), indapamide, furosemide, torasemide, spironolactone [86].

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9. RESEARCH METHODOLOGY AND METHODS

Patients selection and amount

Our study was approved by the Ethics committee of the hospital of LSMU, Kaunas, Lithuania (No. BEC- MF- 361). The SF- 36 questionnaire which is used in the collection of data in our study has also been used in previous other’s research studies [87,88,89]. The SF-36 questionnaires consist of several various questions, which were in Lithuanian language. The SF-36 questionnaires were collected from hospitalized patients in Kauno klinikos Lithuania, and a total of 105 SF-36 questionnaires were used in our study.

The patients who were studied, were hospitalized in various department of Kauno klinikos such as Cardiology, Nephrology, Neurology, Gastroenterology, and Pulmonology. Out of 105 patients, 65 patients (age 32- 87 years) were diagnosed with hypertension, 40 patients (age 16- 81 years) had no-hypertension (control group patients). All these hospitalized hypertensive patients (65 patients) were treated with antihypertensive medications. All these patients were identified in between the following time period, 2018/ 05/ 01 - 2018/ 12/ 31.

Participating patients were asked to complete the SF-36 questionnaire, and the names of the antihypertensive medication were asked personally from each hypertensive patient or nurses. Majority of the patients who were evaluated for this study, used one of the following antihypertensive drugs such as ACE inhibitors(mono), ACE inhibitors(combined), Beta blockers(mono), ARBs(combined) were included and a very few patients were excluded who were under Diuretics(mono), ARBs(mono), CCBs (mono) and CCBs+ Diuretics combination.

The SF-36 questionnaire is composed of several various questions, related to the patient’s gender, age, whether they were diagnosed with arterial hypertension/ not, question regarding general health status currently and general health status compared to one year ago, questions regarding the daily activities; physical health status and emotional health status; the evaluation of extent and time period of physical health/ emotional health interfered to normal social activities with family, friends, neighbours/ groups; questions regarding body pain intensity and body pain interfered to normal work and some questions related to the patient’s feeling.

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Statistical analyses

The collected data from SF- 36 questionnaires and groups of patient’s antihypertensive medication, were aggregated and evaluated statistically using SPSS software to find the correlations between various parameters. IBM SPSS Statistics software were used for statistical analyses. According to the questionnaires, different parameters were calculated to analyze the data and find out the descriptive statistics, distribution and correlation. Graphs were created based on patient’s age, gender, and a group of various antihypertensive medications.

The questionnaires were divided into four (4) groups, based on the antihypertensive drugs used in the management of hypertension by, the patients (65 patients) namely, Hypertension treated by only ACE inhibitors (ACEIs) , Hypertension treated by only beta-blockers (BBs), Hypertension treated by combination of ACE inhibitors with other antihypertensive medications and Hypertension treated by combination of ARBs with others antihypertensive medication.

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10. RESULTS

Figure 10.1. Distribution of hypertensive patients by age and gender:

Figure 10.1. We can see the distribution by age and gender of these 65 patients, who have been diagnosed with hypertension. Out of 65 subjects were 37 were males and 28 were females, which accounts for 56.9% males and 43.1% females. The above distribution ranges from age groups between 32 years old (young patient) to 87 years old (elderly patient). From the above graph, we can see that, there is a higher prevalence of male gender and older people (aged over 45 years) who has been diagnosed with hypertension.

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Figure 10.2. represents the distribution by age and gender of these 40 normotensive-control group patients. Out of 40 subjects 19 were males and 21 were females, which accounts for 47.5% males and 52.5% females. This distribution based on age groups ranges between 16 years old (young patient) to 81 years old (elderly patient). From the above graph, we can see the higher prevalence of younger females population (< 45 years) have a normal blood pressure, when compared to males.

Figure 10.3. Distribution of antihypertensive medications in the management of hypertension:

Figure 10.3. shows 4 groups of hypertenive patients treated with different groups of antihypertensive medications. It’s show, 18 (27.69%) patients with hypertension were treated with only ACE inhibitors (ACEIs); 22 (33.85%) patients with hypertension were treated with only beta-blockers (BBs); 20 (30.77%) patients with hypertension were treated with ACE inhibitors along with other antihypertensive combination, 5 (7.69%) patients with hypertension were treated with angiotensin receptor blockers (ARBs) along with other antihypertensive combination. Therefore,

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according to the graph, a higher number of hospitalized patients were treated with only beta blockers for hypertension compared to other group of antihypertensive medications in Kauno klinikos.

Figure 10.4. Distribution of antihypertensive medications according to gender in the management of hypertension:

Figure 10.4. According to the graph, we can see the distribution of antihypertensive medications by gender, It shows that 18 (27.69%) (11 males and 7 females) patients with hypertension were treated with only ACE inhibitors; 22 (33.85%) (10 males and 12 females) patients with hypertension were treated with only beta blockers; 20 (30.77%) (13 males and 7 females) patients with hypertension were treated with ACEIs plus other antihypertensive combination and 5 (7.69) (3 males, 2 females) patients with hypertension were treated with angiotensin receptor blockers (ARBs) plus other antihypertensive combination.

Therefore, according to the graph, a higher number of male patients were treated with ACEIs (mono or combines) or ARBs (combines) compared to female patients; and majority of the female patients were treated with only beta blockers compared to male patients.

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HRQoL Age Pearson

correlatio n P- value (<0.05) <65 ≥ 65 Total patients 28 37

General health Great 0 1 0.151 0.229

Very good 6 3

Good 1 6

Not bad 21 20

Bad 0 7

Yes, limited a little 11 10

No, not limited at all 2 5

Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf (daily activities)

Yes, limited a lot 3 13 - 0.081 0.519

Yes, limited a little ₁₆ ₁₄ No, not limited at all 9 10

Lifting or carrying food items (daily activities) Yes, limited a lot 5 14 -0.090 0.475

Yes, limited a little ₁₃ ₁₆ No, not limited at all 10 7

Climbing one stair (daily activities) Yes, limited a lot 2 6 -0.039 0.758

Leaning, kneeling or standing (daily activities) Yes, limited a lot 5 14 -0.179 0.153

Walking 100 meters (daily activities) Yes, limited a lot 1 2 -0.143 0.256

No, not limited at all ₁₇ ₂₃

Bathing or dressing yourself (daily activities) Yes, limited a lot 1 2 0.040 0.751

Spend less time at work or other activities (physical health) Yes 11 19 -0.109 0.386

No 17 18

Difficulty performing the work or other activities (physical health)

Yes 23 24 0.018 0.886

No 5 13

Accomplished less than would like (emotional health) Yes 18 25 -0.076 0.550

No 10 12

Work or other activities didn’t do as carefully as usual

(emotional health) Yes

16 19 0.018 0.884

No 12 18

Physical health or emotional problems interfered with their normal social activities with family, friends, neighbors or groups Not at all 14 9 0.101 0.425 slightly 9 16 Moderately 0 7 Quite a bit 4 5 Extremely 1 0

Intensity of body pain None 4 7 -0.010 0.936

Very mild 12 10

Mild 2 6

Moderate 7 12

Severe 3 2

Very severe 0 0

Very nervous person (feeling of the patient) All of the time 0 1 -0.061 0.629

Most of the time ₄ ₅ A good bit of the

time

10 14

Some of the time 6 8

A little of the time 7 8

None of the time 1 1

Tired (feeling of the patient) All of the time 2 3 -0.228 0.067

Most of the time 7 12

A good bit of the time

9 19

Some of the time ₇ ₂ A little of the time 3 1

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According to table 10.1, we evaluated the correlation between patient’s age and HRQoL, using Pearson correlation. Out of the 65 patients with hypertension we tested (28 were <65 year old & 37 were 65 year old and above), we didn’t find any significant differences between the HRQoL and patient’s age.

Table 10.2. Distribution of HRQoL by gender:

HRQoL Gender Pearson

correlatio n P- value (<0.05) male female Total patients 37 28

Very good 8 1

Good 3 4

Not bad 21 20

Bad 5 2

Yes, limited a lot ₈ ₈ _-0.055 _0.664 Yes, limited a little 18 12

Yes, limited a little ₁₅ ₁₀ No, not limited at all 20 12

Yes, limited a little ₁₄ ₁₅ No, not limited at all 12 5

Bathing or dressing themself (daily activities) Yes, limited a lot 2 1 -0.109 0.388

Spend less time at work or other activities (physical health) Yes 16 14 -0.067 0.595

No 21 14

Yes 26 21 -0.052 0.679

No 11 7

Accomplished less than would like (emotional health) Yes 27 16 0.166 0.187

No 10 12

18 17 -0.120 0.342

No 19 11

Physical health or emotional problems interfered with their normal social activities with family, friends, neighbors or groups Not at all 15 8 0.054 0.672 slightly 12 13 Moderately 4 3 Quite a bit 6 3 Extremely 0 1

Intensity of body pain None 6 5 0.086 0.496

Very mild 14 8

Mild 5 3

Moderate 10 9

Severe 2 3

Very severe 0 0

Very nervous person (feeling of the patient) All of the time 0 1 0.033 0.792

Most of the time ₆ ₃ A good bit of the

time

14 10

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Tired (feeling of the patient) All of the time 1 4 -0.058 0.644

15 13

A little of the time ₂ ₂ None of the time 0 0

According to table 10.2, we evaluated the correlation between gender and HRQoL, using Pearson correlation. Out of the 65 patients with hypertension we tested (37 were males & 28 were females), we didn’t find any significant differences between HRQoL and gender.

Table 10.3. Distribution of HRQoL by hypertensive patients and control group-normotensive patients:

HRQoL patients Pearson

correlatio n P- value (<0.05) hyperte nsion No-hypertens ion Total patients 65 40

General health Great 1 10 -0.421 0.000

Very good 9 12

Good 7 2

Not bad 41 14

Bad 7 2

Yes, limited a lot ₁₆ ₇ _0.268 _0.006 Yes, limited a little 30 7

Lifting or carrying food items (daily activities) Yes, limited a lot ₁₉ ₇ _0.268 _0.006 Yes, limited a little 29 10

Climbing one stair (daily activities) Yes, limited a lot 8 4 0.197 0.044 Yes, limited a little 25 6

Leaning, kneeling or standing (daily activities) Yes, limited a lot 19 5 0.276 0.004 Yes, limited a little ₂₉ ₁₄

Walking 100 meters (daily activities) Yes, limited a lot 3 3 0.128 0.192

Yes, limited a little ₂₂ ₅ No, not limited at all 40 32

Spend less time at work or other activities (physical health) Yes 30 11 0.186 0.058

No 35 29

Yes 47 19 0.249 0.010

No 18 21

Accomplished less than would like (emotional health) Yes 43 12 0.352 0.000

No 22 28

35 15 0.159 0.105

No 30 25

Physical health or emotional problems interfered with their normal social activities with family, friends, neighbors or groups Not at all 23 27 -0.242 0.013 slightly 25 8 Moderately 7 1 Quite a bit 9 4 Extremely 1 0

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31 Very mild 22 5 Mild 8 1 Moderate 19 10 Severe 5 4 Very severe 0 2

24 14

Tired (feeling of the patient) All of the time 5 6 0.182 0.064

28 12

According to table 10.3, we evaluated the correlation between hypertensive patients (65) and control group-normotensive patients (40) on HRQoL, using Pearson correlation. The correlation between hypertensive patients and control group-normotensive patients on general health, shows a weak negative correlation (-0.421) with statistical significance (p=0.000). The correlation between hypertensive patients and control group-normotensive patients on moderate activities, shows a weak positive correlation (+0.268) with statistical significance (p=0.006). The correlation between hypertensive patients and control group-normotensive patients on lifting or carrying the food items, shows a weak positive correlation(+0.268) with statistical significance (p=0.006). The correlation between hypertensive patients and control group-normotensive patients on climbing one stair, shows weak positive correlation (+0.197) with statistical significance (p=0.044). The correlation between hypertensive patients and control group-normotensive patients on leaning or kneeling or standing, shows a weak positive correlation (+0.276) with statistical significance (p=0.004). The correlation between hypertensive patients and control group-normotensive patients on difficulty of performing the work or other activities, shows a weak negative correlation (+0.249) with statistical significance (p=0.010). The correlation between hypertensive patients and control group-normotensive patients on accomplished less than would like, shows a weak positive correlation (+0.352) with statistical significance (p=0.000). The correlation between hypertensive patients and control group-normotensive patients on physical health or emotional health interfered with their normal social activities, shows a weak negative correlation (-0.242) with statistical significance (p=0.013). No more significant differences between hypertensive patients and control group-normotensive patients on HRQoL methods were found.

Table 10.4. Distribution of HRQoL by antihypertensive medications (ACEIs mono, ACEIs combines):

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According to table 10.4, we evaluated the correlation between management of hypertension in patients who take only ACE inhibitors (18 patients) and those who combine ACE inhibitors with other

HRQoL Antihypertensive medications Pearson correlatio n P- value (<0.05) ACEIs, mono ACEIs, combines Total patients 18 20

Very good 4 2

Good 3 2

Not bad 9 14

Bad 2 2

Yes, limited a lot ₂ ₆ _0.027 _0.874 Yes, limited a little 12 5

Climbing one stair (daily activities) Yes, limited a lot 3 1 0.123 0.460

Yes, limited a little ₆ ₈ No, not limited at all 9 11

Leaning, kneeling or standing (daily activities) Yes, limited a lot 4 5 0.101 0.545

Yes, limited a little ₁₀ ₇ No, not limited at all 4 8

Walking 100 meters (daily activities) Yes, limited a lot 1 0 -0.346 0.033 Yes, limited a little 2 12

No 8 10

Yes 12 16 -0.151 0.365

No 6 4

Accomplished less than would like (emotional health) Yes 11 15 -0.149 0.371

No 7 5

9 14 -0.204 0.219

No 9 6

Physical health or emotional problems interfered with their normal social activities with family, friends, neighbors or groups Not at all 7 7 -0.005 0.976 slightly 5 8 Moderately 3 1 Quite a bit 3 4 Extremely 0 0

Intensity of body pain None 2 4 -0.144 0.387

Very mild 6 8

Mild 4 3

Moderate 5 4

Severe 1 1

Very severe 0 0

Very nervous person (feeling of the patient) All of the time 0 0 0.308 0.060

Most of the time ₈ ₁ A good bit of the

time

4 8

Some of the time ₂ ₅ A little of the time 4 6

Tired (feeling of the patient) All of the time ₁ ₂ _-0.148 _0.376 Most of the time 6 5

6 10

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antihypertensive drugs (20 patients) on HRQoL, using Pearson correlation. The correlation between this groups of medications on walking 100 meters, shows a weak negative correlation (- 0.346) with statistical significance (p=0.033). The above calculations shows an improvement in daily activities (walking 100 meters) in patients taking ACEIs (mono) compared to those take ACEIs (combined). No more significant differences between these group of medications on HRQoL were found.

Table 10.5. Distribution of HRQoL by antihypertensive medications (ACEIs mono, BBs): HRQoL Antihypertensive medications Pearson correlatio n P- value (<0.05) ACEIs, mono BBs Total patients 18 22

Very good 4 1

Good 3 1

Not bad 9 16

Bad 2 3

Yes, limited a lot 2 8 -0.218 0.177

Leaning, kneeling or standing (daily activities) Yes, limited a lot ₄ ₉ _-0.123 _0.449 Yes, limited a little 10 8

Bathing or dressing yourself (daily activities) Yes, limited a lot 1 2 -0.025 0.881

No 8 13

Yes 12 14 0.032 0.846

No 6 8

Accomplished less than would like (emotional health) Yes 11 13 0.021 0.900

No 7 9

9 9 0.091 0.577

No 9 13

Very mild 6 6

Mild 4 1

Moderate 5 8

Severe 1 3

Very severe 0 0

Very nervous person (feeling of the patient) All of the time ₀ ₁ _0.319 _0.045 Most of the time 8 0

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4 8

Tired (feeling of the patient) All of the time ₁ ₂ _-0.128 _0.432 Most of the time 6 7

6 9

None of the time ₀ ₀

According to table 10.5, we evaluated the correlation between the management of hypertension in patients who take only ACE inhibitors (18 patients) and those who take only beta-blockers (22 patients) on HRQoL, using Pearson correlation. The correlation between this group of medications on patient’s nervousness (feeling of the patient) and, shows a weak positive correlation (+0.319) with statistical significance (p=0.045). No more significant differences between these group of medications and the HRQoL were found.

Table 10.6. Distribution of HRQoL by antihypertensive medications (ACEIs combines, ARBs combines): HRQoL Antihypertensive medications Pearson correlatio n P- value (<0.05) ARBs combines ACEIs combines Total patients 5 20

General health Great 0 0 -0.380 0.061

Very good 2 2

Good 1 2

Not bad 2 14

Bad 0 2

Yes, limited a lot ₀ ₆ _0.125 _0.552 Yes, limited a little 3 5

Climbing one stair (daily activities) Yes, limited a lot 0 1 0.070 0.741

Yes, limited a little ₄ ₇ No, not limited at all 0 8

Walking 100 meters (daily activities) Yes, limited a lot 0 0 0.320 0.119

Yes, limited a little ₁ ₁₂ No, not limited at all 4 8

No 4 10

Yes 5 16 -0.218 0.295

No 0 4

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According to table 10.6, we evaluated the correlation between the management of patients with hypertension treated with ARBs combined with other antihypertensive drugs (5 patients) and those treated with ACE inhibitors combined with other antihypertensive drugs (20 patients) on HRQoL, using Pearson correlation. We didn’t find any significant differences between these group of drugs on HRQoL.

No 1 5

3 14 0.086 0.684

No 2 6

Very mild 2 8

Mild 0 3

Moderate 2 4

Severe 0 1

Very severe 0 0

Most of the time ₀ ₁ A good bit of the

time

4 8

Tired (feeling of the patient) All of the time 0 2 0.147 0.482

Most of the time ₁ ₅ A good bit of the

time

3 10

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11. DISCUSSION

From this small sample of patients in the hospital of LSMU, in Kauno klinikos, we evaluated their HRQoL using the SF-36 questionnaire. The aim of the study was to describe the relationship between medication-related factors and HRQoL among hypertensive individuals.

Our review also identified the influencing sociodemographic factors on HRQoL related to antihypertensive medications, who has been treated with hypertension (All these participating hypertensive patients (65 patients) were treated with antihypertensive medications in kauno klinikos). Regarding age and gender among hypertensive patients, our review had similar results to most previous studies that evidenced age and gender incidence. In our studies, we found a higher number of patients, were elderly population (> 45 years old) related to hypertension, which accounts for 98.46 %. Also in our study, more elderly patients have a hypertension and take antihypertensive drugs, are related to poor HRQoL compared to younger patients, and it was also more associated with males compared to females. Also, In a similar study by Baptista LC, et al, more elderly patients who were diagnosed and treated for hypertension with an antihypertensive medication were related to a poor HRQoL [12]. Another similar study by Park NH, et al , shows hypertension is a high risk factor for cardiovascular diseases in elderly people, which can lower the quality of life. Elderly people can have poor adherence to antihypertensive medications, therefore worsening of HRQoL including physical, emotional and social wellbeing [39]. A study by Staniute M, et al, shows there is a greater correlation between coronary artery disease and poor HRQoL in elderly hypertensive patients that includes depression, anxiety and personality-related impairments [16].

In our study, we collected questionnaires from 65 hypertensive patients, of which 37 were male hypertensive patients and 28 female hypertensive patients, which accounts for 56.9% males and 43.1% females. According to the study of Petkeviciene J, et al, people with hypertension in Lithuania were highly associated with alcohol consumption and being overweight, who were also more likely to be male patients compared to females [25].

A study by Soni RK, shows that hypertensive patients had limited their daily activities and work due to the poor physical, emotional and social functioning [13]. Our study also had similar results to most studies that shows evidence of poor HRQoL related to hypertension. We found a significant difference between the patients treated with antihypertensive medication and control group-normotensive patients on their HRQoL, including the general health, daily activities, physical and emotional health and social functioning. Our review found that hypertensive patients had poor HRQoL compared to control group-normotensive patients.

LITHUANIAN UNIVERSITY OF HEALTH SCIENCES FACULTY OF MEDICINE INSTITUTE OF PHYSIOLOGY AND PHARMACOLOGY