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\def\citeauthor{~Haseena~Tabassum,
              ~Bushra~Unisa,
              ~Heena~Fatima,
              ~Sumayya~Nouras}
\def\citetitle{\textbf{Observational Study on Prescribing Patterns of Antihypertensive Agent and Evaluation of Comorbidities in Hypertensive Patients}}
\def\copyrightstmt{This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial- ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.}
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\def\RunningAuthor{Haseena Tabassum et al.}
\firstPage{115}
\articleType{Original Article}
\receivedDate{25 Apr 2022}
\acceptedDate{14 May 2022}
\revisedDate{10 May 2022}
\journalVolume{2}
\journalIssue{3}
\journalDoi{fjphs.v2i3.270}
\copyrightYear{2022}
\eISSN{2583-116X}
\journalDoi{fjphs.v2i3.270}
\def\authorCount{4}
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\def\journalTitle{Future Journal of Pharmaceuticals and Health Sciences}

\title{\textbf{Observational Study on Prescribing Patterns of Antihypertensive Agent and Evaluation of Comorbidities in Hypertensive Patients}}
\author{Haseena~Tabassum\textsuperscript{*}\textsuperscript{1},  
            Bushra~Unisa\textsuperscript{2}\textsuperscript{\href{https://orcid.org/0000-0003-0570-8107}{\XeTeXLinkBox{\includegraphics[height=7pt]{orcid-logo-pharmascope.pdf}}}},  
            Heena~Fatima\textsuperscript{2}, 
            Sumayya~Nouras\textsuperscript{2}~\\[5pt]{\textsuperscript{1}Department of Clinical Pharmacy Practice, MRM College of Pharmacy, Chinthapallyguda (V), Ibrahimpatnam (M)-501510, Ranga Reddy District, Telangana State, India}~\\{\textsuperscript{2}Department of Pharmacy Practice, MRM College of Pharmacy, Chinthapallyguda (V), Ibrahimpatnam (M)-501510, Ranga Reddy District, Telangana State, India}}

\begin{abstract}
Appraise the prescribing patterns of anti hypertensive agents in the treatment of hypertension and related co-morbid conditions. To assess the prescribing patterns of medications in hypertensive patients. To study the demographics of patients associated with hypertension. To compare the differences in the prescribing patterns of antihypertensive drugs, with co morbidity conditions. Review on medication outcomes in hypertensive patients. To evaluate the rationality outcomes in hypertensive patients. To obtain the mean arterial blood pressure of an individual patient. The age group 40-69 has more affected females followed by males at age group 60-79. Blood pressure increases with age, presence of the co-morbid condition, body weight, and lifestyle modification. The cause of hypertension may be known in some individuals whereas in most of the patients the cause is unknown. The individuals must be made aware of hypertension and directions about management with drugs and non-pharmacological implementation. The presence of hypertension for years may lead to further complications which if managed and monitored regularly can reduce risk. During the study period, 92 individuals were stage 1 (36.8) hypertensive followed by stage 2 (29.6\%), elevated (15.2\%), and normal (9.6\%). The most commonly prescribed drugs in the study were Telmisartan (22.8\%), Amlodipine (2.8\%), Furosemide (2.4), Nifedipine (1.4), Captopril (1.4\%), Metoprolol (0.8\%), and Torsemide (0.8\%) followed by losartan, Olmesartan, propranolol, ramipril, terlipressin, atenolol, valsartan, carvedilol, mannitol, vasopressin, and bisoprolol. Based on JNC 8 guideline the rationality of drugs obtained was 74.8\%.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Antihypertensive Agents,\newline Patients,\newline Prescribing Patterns,\newline Comorbidities
\end{keywords}
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\makeatletter{\raggedright{\Large$^\ast$}Corresponding Author\par Name:\ Haseena~Tabassum~\\ Phone:\ +91 8074894849~\\  Email:\ tabassumfatima253@gmail.com
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\section{Introduction}
Antihypertensive Hypertension is stated as ``the persistently elevated arterial blood pressure (BP)''. Blood pressure is quantified as systolic and diastolic pressure measured in mm Hg. The systolic blood pressure represents the pressure due to ventricular contraction during systole whereas, diastolic pressure represents the pressure of ventricular relaxation in diastole. Although elevated blood pressure is regarded as essential for adequate perfusion of essential organs during the early and middle 1900s, it is now considered as one of the most significant risk factors for cardiovascular diseases \unskip~\cite{1432392:25097021}. Outcome trials have shown that drug therapy significantly reduces the risk of cardiovascular events. The vital goal of treating hypertension is to decrease hypertension-associated morbidity and mortality. A goal BP of less than 140/90 mm Hg is suitable for general anticipation of cardiovascular events and cardiovascular deaths. 

However, achieving Blood Pressure of less than 130/80 mm Hg goal is recommended in patients with co-morbid conditions like Diabetes, significant chronic kidney disease, known coronary artery disease (ischemic stroke, transient ischemic attack, peripheral artery disease, abdominal aortic aneurism), patients with left ventricular dysfunction (Systolic Heart Failure) must have a goal Blood Pressure of less than 120/80 mm Hg. 

Hypertension is a major risk factor for stroke (both ischemic and hemorrhage), myocardial infarction, heart failure, chronic kidney disease, and peripheral vascular disease. Most individuals with hypertension don`t suffer from any sign or symptom, the lesser individuals experience symptoms like headache, shortness of breath, epistaxis but these symptoms can`t be specific for all the patients \unskip~\cite{1432392:25097018}.
    
\section{MATERIALS AND METHODS}
\textbf{Study Design}

This is an observational study conducted over 6 months from October 2019 to March 2020 at Thumbay New Life Hospital, Chaderghat in an in-patient department. 

The individuals who met the inclusion criteria are taken into consideration. The patients are included according to their interests and willingness to carry out the study \unskip~\cite{1432392:25097016}.

\textbf{Collection of Data}


  
  \begin{enumerate}
  \item \relax Patients demographics.
  \item \relax Prescription chart.
  \item \relax Nursing notes.
  \item \relax Medical records.
  \item \relax Doctors notes.
  \end{enumerate}
  \textbf{Inclusion Criteria}


  
  \begin{enumerate}
  \item \relax Patients above 20 years of age.
  \item \relax Blood pressure above 120/80.
  \item \relax Inpatients with case notes and laboratory investigations.
  \item \relax Patients with co-morbid conditions.
  \end{enumerate}
  \textbf{Exclusion Criteria}


  
  \begin{enumerate}
  \item \relax Pediatric department.
  \item \relax Patients below 20 years of age.
  \item \relax Pregnant and lactating women.
  \end{enumerate}
  \textbf{Methods and Collection of Data}

The individuals are examined including their-


  
  \begin{enumerate}
  \item \relax Chief complaints
  \item \relax History of present illness
  \item \relax Past disease history
  \item \relax Past medications
  \item \relax Complaints on any allergy to drugs
  \item \relax Interview with patient or caretakers
  \item \relax Patients prescription
  \item \relax Medical records of inpatients.
  \end{enumerate}
  \textbf{Etiology of Hypertension}

In almost patients, hypertension results from an unknown pathophysiologic etiology which is known as Essential/Primary hypertension. This type of hypertension cannot be healed completely, but it can be managed. 

A less percentage of patients have a specific cause of their hypertension which is known as Secondary hypertension. Besides, 90\% of the people have essential hypertension \unskip~\cite{1432392:25097029}. 

Fewer than 10\% of individuals have secondary hypertension either co-morbid diseases or drugs are responsible for increasing Blood Pressure. Some drugs directly or indirectly, can cause hypertension or exacerbate hypertension by increasing Blood Pressure. 

\textbf{CVD Risk Factors Common in Patients with Hypertension}

The persistent presence of a particular co-morbid condition like kidney disorder, thyroid disease, Cushing's syndrome, etc results in worsening hypertension which leads to further complications like stroke, heart attack, aneurism, dementia, metabolic syndrome, etc \unskip~\cite{1432392:25097023}. 

Thus, proper management can reduce the risk and complications associated with hypertension [Table~\ref{tw-ef1b4bd1afa2}].


\begin{table*}[!htbp]
\caption{\boldmath {Secondary Causes of Hypertension} }
\label{tw-ef1b4bd1afa2}
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\tbltoprule \rowcolor{kwdboxcolor}Diseases & Drugs\\
\tblmidrule 
$\bullet$~Chronic Kidney Disease~\newline $\bullet$~Cushing`S Syndrome~\newline $\bullet$~Obstructive Sle~\newline $\bullet$~Ep Apnea~\newline $\bullet$~Parathyroid Disease~\newline $\bullet$~Thyroid Disease~\newline $\bullet$~Congenitaladrenal Hyperplasia &
  $\bullet$~Adrenal Steroids~\newline $\bullet$~Amphetamines~\newline $\bullet$~Calcineurin Inhibitors~\newline $\bullet$~Decongestants~\newline $\bullet$~Oral Contraceptives~\newline $\bullet$~Nonsteroidal Inflammatory Drugs~\newline $\bullet$~Food Substances-Sodium, Ethanol\\
\tblbottomrule 
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\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Modifiable Risk Factor and Relatively Fixed Risk Factors} }
\label{tw-707fa81a9ca1}
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\tbltoprule \rowcolor{kwdboxcolor}Modifiable Risk Factor & Relatively Fixed Risk Factors\\
\tblmidrule 
$\bullet$~Current cigarette smoking, second-hand smoking~\newline $\bullet$~Diabetes Mellitus~\newline $\bullet$~Dyslipidemia/Hypercholesterolemia~\newline $\bullet$~Overweight/Obesity~\newline $\bullet$~Physical Inactivity &
  $\bullet$~Chronic Kidney Disease~\newline $\bullet$~Family History~\newline $\bullet$~Increased Age~\newline $\bullet$~Low Educational Status~\newline $\bullet$~Obstructive Sleep Apnea~\newline $\bullet$~Psychosocial Stress\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Prevalence of Hypertension based on SBP and DBP} }
\label{tw-401bbf0e4c3f}
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\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.2116\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.1884\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack  & \cAlignHack 9SBP & \cAlignHack  & \cAlignHack DBP & \cAlignHack \\
\rowcolor{kwdboxcolor}\cAlignHack Age Groups & \cAlignHack Men & \cAlignHack Women & \cAlignHack Men & \cAlignHack Women\\
\tblmidrule 
\cAlignHack 20-44 &
  \cAlignHack 30\% &
  \cAlignHack 19\% &
  \cAlignHack 11\% &
  \cAlignHack 10\%\\
\cAlignHack 45-54 &
  \cAlignHack 50\% &
  \cAlignHack 44\% &
  \cAlignHack 33\% &
  \cAlignHack 27\%\\
\cAlignHack 55-64 &
  \cAlignHack 70\% &
  \cAlignHack 63\% &
  \cAlignHack 53\% &
  \cAlignHack 52\%\\
\cAlignHack 65-74 &
  \cAlignHack 77\% &
  \cAlignHack 75\% &
  \cAlignHack 64\% &
  \cAlignHack 63\%\\
\cAlignHack 75+ &
  \cAlignHack 79\% &
  \cAlignHack 85\% &
  \cAlignHack 71\% &
  \cAlignHack 78\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Non-Pharmacological Interventions for Prevention and Treatment of Hypertension} }
\label{tw-3010fe76772b}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1851\linewidth-2\tabcolsep}p{\dimexpr.26310000000000002\linewidth-2\tabcolsep}p{\dimexpr.16339999999999996\linewidth-2\tabcolsep}p{\dimexpr.18840000000000003\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack  & \cAlignHack Non-pharmacological interventions & \cAlignHack Dose & \cAlignHack Appropriate \mbox{}\protect\newline Impact on \mbox{}\protect\newline Htn  & \cAlignHack Systolic Blood Pressure \mbox{}\protect\newline Normotension\\
\tblmidrule 
\cAlignHack Weight Loss &
  \cAlignHack Weight/Body Fat &
  \cAlignHack - &
  \cAlignHack -5 mm Hg &
  \cAlignHack -2/3 mm Hg\\
\cAlignHack Healthy Diet &
  \cAlignHack Dash Dietary Pattern &
  \cAlignHack Diet Rich In Fruit, Vegetables, Whole Grain, And Low-Fatdairy Products &
  \cAlignHack -11 mmHg &
  \cAlignHack -3mm Hg \\
\cAlignHack Reduce Intake of Dietary Sodium &
  \cAlignHack Dietary Sodium &
  \cAlignHack {\textless}1500 mg/d &
  \cAlignHack -5/6 mm Hg &
  \cAlignHack -2/3 mm Hg\\
\cAlignHack Enhance Intake of Dietary Potassium &
  \cAlignHack Dietary Potassium &
  \cAlignHack 3500-5000 mg/d &
  \cAlignHack -4/5 mm Hg &
  \cAlignHack -2 mm Hg\\
\cAlignHack Physical Activity &
  \cAlignHack Aerobic &
  \cAlignHack 90-150 min/week &
  \cAlignHack -5/8 mm Hg &
  \cAlignHack -2/4 mm Hg\\
\cAlignHack  &
  \cAlignHack Dynamic Resistance &
  \cAlignHack 90-150 min/week &
  \cAlignHack -4 mm Hg &
  \cAlignHack -2 mm Hg\\
\cAlignHack Moderate in Alcohol Intake &
  \cAlignHack Alcohol Consumption &
  \cAlignHack Men-{\textless}2 drinks/d \mbox{}\protect\newline Women-{\textless}1 drink/d &
  \cAlignHack -4mm Hg &
  \cAlignHack -3 mm Hg\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Blood Pressure Threshold for Goals of Pharmacologic Therapy in Patient`S with Hypertension According to Clinical Conditions} }
\label{tw-c96092461ec7}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3757000000000001\linewidth-2\tabcolsep}p{\dimexpr.3466\linewidth-2\tabcolsep}p{\dimexpr.27770000000000003\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Clinical Condition`S & \cAlignHack Bp Threshold Mm Hg & \cAlignHack Bp Goal Mm Hg\\
\tblmidrule 
\cAlignHack Clinical CVD/ 10year ASCVD risk {\textgreater}10\% &
  \cAlignHack {\textgreater}130/80 &
  \cAlignHack {\textless}130/80\\
\cAlignHack No clinical CVD &
  \cAlignHack {\textgreater}140/90 &
  \cAlignHack {\textless}130/80\\
\cAlignHack Older Person ({\textgreater}65years of age) &
  \cAlignHack {\textgreater}130(SBP) &
  \cAlignHack {\textless}130(SBP)\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Specific Comorbidities} }
\label{tw-570110c0c3ad}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.34870000000000005\linewidth-2\tabcolsep}p{\dimexpr.3486\linewidth-2\tabcolsep}p{\dimexpr.30269999999999996\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Disorders & \cAlignHack Bp Threshold Mm Hg & \cAlignHack Bp Goal Mm Hg\\
\tblmidrule 
\cAlignHack Diabetes Mellitus &
  \cAlignHack {\textgreater}130/80 &
  \cAlignHack {\textless}130/80\\
\cAlignHack Chronic Kidney Disease &
  \cAlignHack {\textgreater}130/80 &
  \cAlignHack {\textless}130/80\\
\cAlignHack CKD Post Renal Transplant &
  \cAlignHack {\textgreater}130/80 &
  \cAlignHack {\textless}130/80\\
\cAlignHack Heart Failure &
  \cAlignHack {\textgreater}130/80 &
  \cAlignHack {\textless}130/80\\
\cAlignHack Stable Ischemic Heart Disease &
  \cAlignHack {\textgreater}130/80 &
  \cAlignHack {\textless}130/80\\
\cAlignHack Secondary Stroke Prevention &
  \cAlignHack {\textgreater}140/90 &
  \cAlignHack {\textless}130/80\\
\cAlignHack Peripheral Arterial Disease &
  \cAlignHack {\textgreater}130/80 &
  \cAlignHack {\textless}130/80\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textbf{Cardiovascular Disease Risk Factors}

Observational studies have stated that cardiovascular disease risk factors frequently occur in combination \unskip~\cite{1432392:25097017}, with more than 3 risk factors present in 17\% of patients [Table~\ref{tw-707fa81a9ca1}].

\textbf{Prevalence of Hypertension}

The prevalence of hypertension based on age groups and respective Blood Pressure \unskip~\cite{1432392:25097027}  values includes in Table~\ref{tw-401bbf0e4c3f}.

\textbf{Pharmacological Management}

Generally, the goal of treating hypertension is to manage hypertension-related morbidity and mortality \unskip~\cite{1432392:25097019}. Managing risk remains the vital objective of hypertension therapy and the standard choice of drug therapy to be made for every particular co-morbid condition to reduce the risk. During the treatment, the goal BP of less than 120/90 mm Hg is considered for the general prevention of cardiovascular events and cardiovascular disease [Table~\ref{tw-3010fe76772b}]. For individuals with hypertension, attaining the SBP goal almost assures achievement of the DBP goal. When coupled with the fact that SBP is a better predictor of cardiovascular risk than DBP, SBP can be used as the primary clinical marker control in individuals with hypertension. 

However, lifestyle modification cannot be only considered, for patients with hypertension and additional cardiovascular risk factors \unskip~\cite{1432392:25097022}. The management with drug therapy depends on the blood pressure values and also occurs of any other disorder [Table~\ref{tw-c96092461ec7}]. 

The management of comorbid conditions is initiated through the following Joint National Committee Guidelines 8 which specifically provides the management of hypertension with comorbid diseases [Table~\ref{tw-570110c0c3ad}].

The non-pharmacological interventions such as weight loss for obese patients, healthy diet which includes ``Dash Diet'', reducing sodium intake, enhancing potassium intake, regular physical activity practice, and limiting alcohol consumption reduces the risk for cardiovascular morbidity and mortality \unskip~\cite{1432392:25097026}.

\textbf{Common Co-Morbid Conditions with Hypertension Diabetes}

The contribution of hypertension in raising the microvascular and macrovascular risk in individuals with Diabetes has been confirmed in the United Kingdom Prospective Diabetes Study (UKPDS) and Hypertension Optimization Treatment trials. The recommendation for the management of blood pressure in patients with diabetes is less than130/80 mm Hg. The category of drugs included is ACE and ARB which are considered during the initial therapy management \unskip~\cite{1432392:25097024}. The national kidney foundation also recommends that the goal of blood pressure be considered is less than 130/80 mm Hg, as well as recommending diuretics as second-line drugs in individuals with diabetic kidney disease. Frequent monitoring of blood pressure is essential for patients with diabetes to reduce further risk and complications.

\textbf{Heart Failure}

Approximately two-thirds of heart failure patients have current hypertension or a history of hypertension. Hypertension can directly contribute to the development of heart failure or the presence of coronary artery disease contributes indirectly to heart failure \unskip~\cite{1432392:25097020}. The management of heart failure along with hypertension includes ACE inhibitors, Beta-blockers, and Diuretics, if the proper recovery is not achieved then additional drugs are included such as ARB, aldosterone antagonist, or a second-generation CCB such as amlodipine.

\textbf{Diastolic Heart Failure}

Hypertension complications can lead to diastolic heart failure. The individuals with heart failure and preserved ejection fraction have a history of hypertension with years which may worsen and lead to diastolic heart failure \unskip~\cite{1432392:25097025}.

\textbf{Peripheral Artery Disease}

Hypertension is a risk factor for individuals with peripheral artery disease and can lead to further complications like acute myocardial infarction, stroke, and heart failure. The goal blood pressure in individuals with PAD is 130/80to prevent further complications \unskip~\cite{1432392:25097030}.

\textbf{Chronic Kidney Disease}

The individual with hypertension is also affected by CKD, the abnormal filtration rate affects the blood pressure, and hence directly or indirectly it raises blood pressure. The proper management of hypertension in patients with CKD can reduce further risk. A goal BP of 130/80 is considered for CKD patients and management includes ACE inhibitors and ARB blockers \unskip~\cite{1432392:25097028}.
    
\section{RESULTS AND DISCUSSION}
Hypertension is persistently elevated arterial blood pressure. The epidemiological data shows that 31\% of the population has hypertension and among males and females, females are more prevalent according to our study [Table~\ref{tw-8219764973d6}  \& Figure~\ref{f-db0c1892686b}]. The prevalence of females is higher due to improper therapy, lack of awareness, an unhealthy lifestyle. The age group 40-69 has more affected females followed by males at age group 60-79. Blood pressure increases with age, presence of the co-morbid condition, body weight, and lifestyle modification [Table~\ref{tw-0339f405ea95}  \& Figure~\ref{f-4fe60b37af92}]. The cause of hypertension may be known in some individuals whereas in most of the patients the cause is unknown. During the study period, 92 individuals were stage 1(36.8) hypertensive followed by stage 2(29.6\%), elevated (15.2\%), and normal (9.6\%).


\begin{table*}[!htbp]
\caption{\boldmath {Categorization Based on Age and Gender} }
\label{tw-8219764973d6}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.33\linewidth-2\tabcolsep}p{\dimexpr.3217\linewidth-2\tabcolsep}p{\dimexpr.3483\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Count of Age & \cAlignHack Number of Males & \cAlignHack Number of Females\\
\tblmidrule 
\cAlignHack 20-29 &
  \cAlignHack 1 &
  \cAlignHack 2\\
\cAlignHack 30-39 &
  \cAlignHack 8 &
  \cAlignHack 9\\
\cAlignHack 40-49 &
  \cAlignHack 19 &
  \cAlignHack 22\\
\cAlignHack 50-59 &
  \cAlignHack 17 &
  \cAlignHack 32\\
\cAlignHack 60-69 &
  \cAlignHack 35 &
  \cAlignHack 40\\
\cAlignHack 70-79 &
  \cAlignHack 25 &
  \cAlignHack 18\\
\cAlignHack 80-89 &
  \cAlignHack 11 &
  \cAlignHack 10\\
\cAlignHack 90-99 &
  \cAlignHack 0 &
  \cAlignHack 1\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Stages of Blood Pressure {\textendash} Systolic and Diastolic blood pressure} }
\label{tw-0339f405ea95}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.33\linewidth-2\tabcolsep}p{\dimexpr.3155\linewidth-2\tabcolsep}p{\dimexpr.3545\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Stages of Blood Pressure & \cAlignHack Systolic Blood Pressure & \cAlignHack Diastolic Blood Pressure\\
\tblmidrule 
\cAlignHack Normal &
  \cAlignHack 24 &
  \cAlignHack 28\\
\cAlignHack Elevated &
  \cAlignHack 38 &
  \cAlignHack 75\\
\cAlignHack Stage-1  &
  \cAlignHack 92  &
  \cAlignHack 94 \\
\cAlignHack Stage-2  &
  \cAlignHack 74  &
  \cAlignHack 52 \\
\cAlignHack Hypertension Crisis  &
  \cAlignHack 22  &
  \cAlignHack 1 \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Antihypertensive Drugs Category} }
\label{tw-894470469836}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.34449999999999996\linewidth-2\tabcolsep}p{\dimexpr.2968\linewidth-2\tabcolsep}p{\dimexpr.35870000000000005\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Antihypertensive Drugs Category & \cAlignHack Number of Patient`S & \cAlignHack Percentage \\
\tblmidrule 
\cAlignHack ARB`S &
  \cAlignHack 71 &
  \cAlignHack 28.4\%\\
\cAlignHack Diuretic`s &
  \cAlignHack 11 &
  \cAlignHack 4.4\%\\
\cAlignHack BB`S &
  \cAlignHack 8 &
  \cAlignHack 3.2\%\\
\cAlignHack CCB`S &
  \cAlignHack 6 &
  \cAlignHack 2.4\%\\
\cAlignHack ACE'S &
  \cAlignHack 4 &
  \cAlignHack 1.6\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Total Social History of Hypertensive Patients} }
\label{tw-aeff1e010c2f}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.34660000000000004\linewidth-2\tabcolsep}p{\dimexpr.31339999999999996\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Social history & \cAlignHack Number of patients & \cAlignHack Percentage\\
\tblmidrule 
\cAlignHack Alcoholic  &
  \cAlignHack 66  &
  \cAlignHack 26.4\% \\
\cAlignHack Smokers &
  \cAlignHack 37 &
  \cAlignHack 14\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Antihypertensive Dual Therapy Category} }
\label{tw-87dc25a047e6}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3964\linewidth-2\tabcolsep}p{\dimexpr.28229999999999997\linewidth-2\tabcolsep}p{\dimexpr.3213\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Antihypertension Dual Therapy & Number of Patient`S & Percentage\\
\tblmidrule 
CCB`S+ARB`S  &
  22  &
  8.8\% \\
ARB`S+BB`S  &
  20  &
  8\% \\
Diuretic+ARB`S &
  17 &
  6.8\%\\
CCB`S+BB`S &
  16 &
  6.4\%\\
ACEI`S+ARB`S &
  16 &
  6.4\%\\
Diuretic+Diuretic &
  3 &
  1.2\%\\
BB`S+BB`S &
  3  &
  1.2\%\\
Diuretic+CCB`S &
  2 &
  0.8\%\\
Diuretic+ACEI`S &
  2 &
  0.8\%\\
ACEI`S+BB`S &
  2 &
  0.8\%\\
Nitrates+ACEI`S &
  1 &
  0.4\%\\
Diuretic+Alpha Bocker &
  1 &
  0.4\%\\
CCB`S+ACEI`S &
  1 &
  0.4\%\\
CCB`S+CCB`S &
  1 &
  0.4\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Antihypertensive Triple Therapy Category} }
\label{tw-83c2986cb3c5}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.52290000000000006\linewidth-2\tabcolsep}p{\dimexpr.1889\linewidth-2\tabcolsep}p{\dimexpr.28820000000000004\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Antihypertensive triple therapy category & \cAlignHack Number of Patient`s & \cAlignHack Percentage\\
\tblmidrule 
\cAlignHack CCB`+BB`S+ARB`S &
  \cAlignHack 20 &
  \cAlignHack 8\%\\
\cAlignHack ARB`S+CCB`S+Diuretics &
  \cAlignHack 3 &
  \cAlignHack 1.2\%\\
\cAlignHack ARB`S+Diuretics+Nitrates &
  \cAlignHack 3 &
  \cAlignHack 1.2\%\\
\cAlignHack Diuretic+ARB`S+BB`S &
  \cAlignHack 2 &
  \cAlignHack 0.8\%\\
\cAlignHack Alpha Bocker+ACI`S+Diuretic &
  \cAlignHack 2 &
  \cAlignHack 0.8\%\\
\cAlignHack BB`S+NITRATES+Diuretics &
  \cAlignHack 1 &
  \cAlignHack 0.4\%\\
\cAlignHack Diuretics+BB`S+ACEI`S &
  \cAlignHack 1 &
  \cAlignHack 0.4\%\\
\cAlignHack CCB`ALPHA BLOCKER+ARB`S &
  \cAlignHack 1 &
  \cAlignHack 0.4\%\\
\cAlignHack Diuretic+CCB`S+Alpha Bocker &
  \cAlignHack 1 &
  \cAlignHack 0.4\%\\
\cAlignHack Alpha Bocker+ARB`S+Diuretics &
  \cAlignHack 1 &
  \cAlignHack 0.4\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Statistical Data on Blood Pressure} }
\label{tw-6b0b12533381}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.2099\linewidth-2\tabcolsep}p{\dimexpr.1818\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.1552\linewidth-2\tabcolsep}p{\dimexpr.2531\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Stages & \cAlignHack SBP & \cAlignHack DBP & \cAlignHack \ensuremath{\Sigma }D & \cAlignHack \ensuremath{\Sigma }D2\\
\tblmidrule 
\cAlignHack Normal &
  \cAlignHack 24 &
  \cAlignHack 28 &
  \cAlignHack 4 &
  \cAlignHack 16\\
\cAlignHack Elevated &
  \cAlignHack 38 &
  \cAlignHack 75 &
  \cAlignHack 37 &
  \cAlignHack 1369\\
\cAlignHack Stage-1 &
  \cAlignHack 92 &
  \cAlignHack 94 &
  \cAlignHack 2 &
  \cAlignHack 4\\
\cAlignHack Stage-2 &
  \cAlignHack 74 &
  \cAlignHack 52 &
  \cAlignHack 22 &
  \cAlignHack 484\\
\cAlignHack Htn Crisis &
  \cAlignHack 22 &
  \cAlignHack 1 &
  \cAlignHack 21 &
  \cAlignHack 441\\
\cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \ensuremath{\Sigma }D=86 &
  \cAlignHack \ensuremath{\Sigma }D2=2314\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Statistical Test on Therapies} }
\label{tw-5149fbd57d9e}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.2199\linewidth-2\tabcolsep}p{\dimexpr.1801\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Age group & \cAlignHack Mono therapy & \cAlignHack Dual therapy & \cAlignHack Triple therapy & \cAlignHack Row total\\
\tblmidrule 
\cAlignHack 20-29 &
  \cAlignHack 2 &
  \cAlignHack 1 &
  \cAlignHack 0 &
  \cAlignHack 3\\
\cAlignHack 30-39 &
  \cAlignHack 6 &
  \cAlignHack 12 &
  \cAlignHack 1 &
  \cAlignHack 19\\
\cAlignHack 40-49 &
  \cAlignHack 13 &
  \cAlignHack 25 &
  \cAlignHack 3 &
  \cAlignHack 41\\
\cAlignHack 50-59 &
  \cAlignHack 16 &
  \cAlignHack 28 &
  \cAlignHack 5 &
  \cAlignHack 49\\
\cAlignHack 60-69 &
  \cAlignHack 21 &
  \cAlignHack 46 &
  \cAlignHack 7 &
  \cAlignHack 74\\
\cAlignHack 70-79 &
  \cAlignHack 10 &
  \cAlignHack 23 &
  \cAlignHack 10 &
  \cAlignHack 43\\
\cAlignHack 80-89 &
  \cAlignHack 2 &
  \cAlignHack 14 &
  \cAlignHack 4 &
  \cAlignHack 20\\
\cAlignHack 90-99 &
  \cAlignHack 0 &
  \cAlignHack 1 &
  \cAlignHack 0 &
  \cAlignHack 1\\
\cAlignHack Column \mbox{}\protect\newline Total (\ensuremath{\Sigma }X) &
  \cAlignHack \ensuremath{\Sigma }X1=70 &
  \cAlignHack \ensuremath{\Sigma }X2=150 &
  \cAlignHack \ensuremath{\Sigma }X3=30 &
  \cAlignHack \ensuremath{\Sigma }X=250\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {List Out Sources of Variance} }
\label{tw-b9beaad0adc4}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.21\linewidth-2\tabcolsep}p{\dimexpr.2232\linewidth-2\tabcolsep}p{\dimexpr.1668\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Source of variance & Degree of freedom & Sum of squares & Mean squares & F\\
\tblmidrule 
Between varities \mbox{}\protect\newline (column) &
  c-1=8-1=7 &
  B-D \mbox{}\protect\newline =3537.5-2604.1 \mbox{}\protect\newline =933.4 &
  MSC=B-D/c-1 \mbox{}\protect\newline =933.4/8-1 \mbox{}\protect\newline =933.4/7 \mbox{}\protect\newline =33.3 &
  MSC/MSE \mbox{}\protect\newline =33.3/261.6 \mbox{}\protect\newline =0.12\\
Between treatments \mbox{}\protect\newline (rows) &
  r-1=3-2=1 &
  C-D \mbox{}\protect\newline =4059.1-2604.1 \mbox{}\protect\newline =1455 &
  MSE=C-D/r-1 \mbox{}\protect\newline =1455/2 \mbox{}\protect\newline =727.5 &
  MSE/residual \mbox{}\protect\newline =727.5/261.6 \mbox{}\protect\newline =2.78\\
Residuals &
  (c-1)(r-1) \mbox{}\protect\newline =7x2 \mbox{}\protect\newline =14 &
  [A-D-(B-D)+(C-D)] \mbox{}\protect\newline =5746-2604.1-[933.4]+[1455] \mbox{}\protect\newline =5746-2604.1+521.6 \mbox{}\protect\newline =3141.9+521.6 \mbox{}\protect\newline =366.5 &
  [A-D-(B-D)+(C D)]/(c-1)(r-1) \mbox{}\protect\newline =3663.5/14 \mbox{}\protect\newline =261.6 &
  \\
Total &
  Cr-1 \mbox{}\protect\newline =24-1 \mbox{}\protect\newline =23 &
  A-D \mbox{}\protect\newline =5746-2601.1 \mbox{}\protect\newline =3141.9 &
   &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/b3a3ccdd-6efa-43f5-8a95-0b5a3dc6245d-upicture1.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/b3a3ccdd-6efa-43f5-8a95-0b5a3dc6245d-upicture1.png}{\includegraphics{images/b3a3ccdd-6efa-43f5-8a95-0b5a3dc6245d-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Hypertensive History of Patient`s}}
\label{f-db0c1892686b}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/085c5217-fe8c-4d4d-abca-dc4432b71537-upicture2.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/085c5217-fe8c-4d4d-abca-dc4432b71537-upicture2.png}{\includegraphics{images/085c5217-fe8c-4d4d-abca-dc4432b71537-upicture2.png}}{}
\makeatother 
\caption{\boldmath {Stages of Blood Pressure {\textendash} Systolic and Diastolic Blood Pressure}}
\label{f-4fe60b37af92}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/26de3c1c-c181-4b0f-8f94-36891492fa8b-upicture3.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/26de3c1c-c181-4b0f-8f94-36891492fa8b-upicture3.png}{\includegraphics{images/26de3c1c-c181-4b0f-8f94-36891492fa8b-upicture3.png}}{}
\makeatother 
\caption{\boldmath {Social History of Hypertensive Drugs}}
\label{f-a16353860e10}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/d93dfc8e-52b6-4270-b33b-b15b2fd1e29b-upicture4.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/d93dfc8e-52b6-4270-b33b-b15b2fd1e29b-upicture4.png}{\includegraphics{images/d93dfc8e-52b6-4270-b33b-b15b2fd1e29b-upicture4.png}}{}
\makeatother 
\caption{\boldmath {List of Monotherapy of Drugs}}
\label{f-20bfa0f5ee50}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/9f75cd41-db07-4aa1-a0cd-62471f4d51dc-upicture5.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/9f75cd41-db07-4aa1-a0cd-62471f4d51dc-upicture5.png}{\includegraphics{images/9f75cd41-db07-4aa1-a0cd-62471f4d51dc-upicture5.png}}{}
\makeatother 
\caption{\boldmath {Antihypertensive Therapies}}
\label{f-794b6e436226}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/3ebeca50-fd2b-4bd5-8c64-048d27b17e96-upicture6.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/3ebeca50-fd2b-4bd5-8c64-048d27b17e96-upicture6.png}{\includegraphics{images/3ebeca50-fd2b-4bd5-8c64-048d27b17e96-upicture6.png}}{}
\makeatother 
\caption{\boldmath {Single Co-Morbidity}}
\label{f-9a547286e06f}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/7e84f04a-3471-4ec5-be49-f6c0d87ae4a5-upicture7.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/7e84f04a-3471-4ec5-be49-f6c0d87ae4a5-upicture7.png}{\includegraphics{images/7e84f04a-3471-4ec5-be49-f6c0d87ae4a5-upicture7.png}}{}
\makeatother 
\caption{\boldmath {Dual Co-Morbidities}}
\label{f-8f3a931e1126}
\end{figure}
\egroup
The individuals must be made aware of hypertension and directions about management with drugs and non-pharmacological implementation. The presence of hypertension for years may lead to further complications which if managed and monitored regularly can reduce risk. The elderly patients {\textgreater}65years of age are diagnosed as hypertensive according to JNC 8 guidelines due to multiple pathologies leading to polypharmacy, consumption of over-the-counter medications. 

The choice of anti-hypertensive used for the management was ARB followed by diuretics, beta-blockers, calcium channel blockers, and ARB`S.

\textbf{Blood Pressure Categorization}

The individuals must be made aware of hypertension and directions about management with drugs and non-pharmacological implementation. The presence of hypertension for years may lead to further complications which if managed and monitored regularly can reduce risk. The elderly patients {\textgreater}65years of age are diagnosed as hypertensive according to JNC 8 guidelines due to multiple pathologies leading to polypharmacy, consumption of over-the-counter medications. 

The choice of anti-hypertensive used for the management was ARB followed by diuretics, beta-blockers, calcium channel blockers, and ARB`S.

\textbf{Antihypertensive Drugs Category}

The individuals must be made aware of hypertension and directions about management with drugs and non-pharmacological implementation. The presence of hypertension for years may lead to further complications which if managed and monitored regularly can reduce risk [Table~\ref{tw-894470469836}]. The elderly patients {\textgreater}65years of age are diagnosed as hypertensive according to JNC 8 guidelines due to multiple pathologies leading to polypharmacy, consumption of over-the-counter medications [Table~\ref{tw-aeff1e010c2f}  \& Figure~\ref{f-a16353860e10}]. The choice of anti-hypertensive used for the management was ARB followed by diuretics, beta-blockers, calcium channel blockers, and ARB`S.

\textbf{Antihypertensive Monotherapy}

The risk of co-morbid conditions is enhanced due to social habits, improper lifestyle, irregular drug management, and loss of physical activity. The co-morbid conditions observed were CVA, CAD, CKD, DM, AKI, PAD, etc which were managed with combinational drug therapy with two or more drugs [Figure~\ref{f-20bfa0f5ee50}]. The preferred fixed two-drug combination was CCB+ARB and ARB+BB, followed by triple-drug combination CCB+BB+ARB, and this practice positively impacted the overall blood pressure control. The prevalence of two co-morbid conditions was higher with the presence of hypertension with diabetes, CAD, CKD, CVA followed by rare conditions with orthopedic, gastroenterology, neurology, and pulmonologist disorder.

\textbf{Antihypertensive Triple Therapy Category}

The most commonly prescribed drugs in the study were Telmisartan (22.8\%), Amlodipine (2.8\%), Furosemide (2.4), Nifedipine (1.4), Captopril (1.4\%), Metoprolol (0.8\%), and Torsemide (0.8\%) followed by losartan, Olmesartan, propranolol, ramipril, terlipressin, atenolol, valsartan, carvedilol, mannitol, vasopressin, and bisoprolol [Table~\ref{tw-87dc25a047e6}, Table~\ref{tw-83c2986cb3c5}  and Figure~\ref{f-794b6e436226}]. Based on JNC 8 guideline the rationality of drugs obtained was 74.8\%. Single CO-Morbidity [Figure~\ref{f-9a547286e06f}]. Dual Co-Morbidities [Figure~\ref{f-8f3a931e1126}], Statistical Data on Blood Pressure [Table~\ref{tw-6b0b12533381}], Statistical Test on Therapies  [Table~\ref{tw-5149fbd57d9e}], List out Sources of Variance [Table~\ref{tw-b9beaad0adc4}].

Hence t calculated value is greater than the t critical value and the P-value is less than, the difference between the two means is significant. The null hypothesis is rejected.
    
\section{Conclusion}
Our study which includes 300 samples provides the prevalence of hypertension higher in women. The most common choice of therapy followed was monotherapy involving Telmisartan (22.8\%0). The management of hypertension was followed by monotherapy, dual therapy, and multiple therapies. The individuals with single co-morbidity were managed with monotherapy and the patients with two or more disorders are followed with a dual triple and multiple therapies. However, blood pressure control was obtained in some individuals, and in some blood pressure was still elevated after drug management due to the presence of co-morbid conditions and poor lifestyle modifications.
    
\section{Acknowledgement}
It would be of great bliss to put on accord the sincere gratefulness to our respected principal, DR. T. Shyam, who allowed us to carry out the studies presented in this thesis at the Department of Clinical Pharmacy, MRM College of Pharmacy, Ibrahimpatnam, Hyderabad, India.

\textbf{Funding Support} \textbf{\space }

The authors declare that they have no funding support for this study. 

\textbf{Conflict of Interest} \textbf{\space }

The authors declare that there is no conflict of interest.
    

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