Hypertension in the elderly

TREATMENT OF ELDERLY HYPERTENSIVES: Treatment of hypertension in the elderly is nowadays an accepted and highly effective medical intervention following the positive reports on the benefits of lowering elevated arterial pressure in elderly patients. Most of the intervention studies an antihypertensive treatment in elderly patients have used diuretics or beta-blockers or the two in combination as the therapy by which blood pressure was lowered. However, from a theoretical point of view, novel therapies such as calcium antagonists could offer advantages that would translate into an even greater reduction in cardiovascular morbidity and mortality than has been obtained with the traditional antihypertensive therapies used so far. DATA ON CALCIUM ANTAGONISTS IN THE ELDERLY: Some of the studies in elderly hypertensives that are currently in progress are using calcium antagonists as one of the main therapies, e.g. the Swedish Trial in Old patients with hypertension (STOP-Hypertension)-2 study and the Systolic hypertension in Europe (Syst-Eur) study. Another source of information is a large database on nicardipine, a dihydropyridine-derived calcium antagonist, used in the treatment of elderly hypertensives.

Relationship between dose in vivo of ethylene oxide and exposure to ethene studied in exposed workers

1. In vivo doses of ethylene oxide, arising from ethene exposure, in plastic industry workers were estimated through hemoglobin adducts. The ethene exposure was assessed through person-worn monitors. The metabolic conversion of ethene to ethylene oxide was estimated from the exposure dose/in vivo dose ratio. 2. Two studies were done: In the first study hemoglobin adducts were determined in samples collected on one occasion in exposed groups and exposure doses were estimated by using exposure data from the hygienic surveillance program. The second study applies a newly developed study design with repeated blood sampling in a few persons combined with a complete personal exposure monitoring during the study period. This makes it possible to relate adduct formation with individual short-time exposure doses, which in theory should overcome the problems with exposure history dependence of the adduct level in a single blood sample. The results of the second study shows that it is possible, through the proposed method, to utilize occupational exposure situations for this kind of studies even if the exposure pattern is irregular and highly variable. Both studies show a metabolic conversion of ethene to ethylene oxide of only 0.5%, which is unexpectedly low. 3. The cancer risk associated with the ethene exposure in the highly exposed group (3.6 p.p.m. 40 h/week) is estimated by applying the radiation-dose-equivalence approach. The result of this evaluation leads to a risk corresponding to a radiation dose of 4 mSv/year which is about a factor 3 below the current dose limit for radiological work recommended by ICRP.

Structure of the human kappa-casein gene

The human kappa-casein-encoding gene, Kca, was cloned and sequenced. The structural gene consists of five exons ranging from 33 to 496 nucleotides (nt) separated by introns ranging from 1146 to 2942 nt, and extends over 8821 nt. All intron/exon splice junctions conform to the GT/AG rule. The gene organization is similar to that of the bovine gene. The 5'-flanking region contains an A + T-rich sequence; TTTAATT, close to where the TATA motif is found in most other genes, a CAAT box, and an AP-1 consensus sequence. In addition, one Alu repetitive element was found in the second intron.

The optimal blood pressure reduction

OPTIMAL BLOOD PRESSURE REDUCTION: The optimal blood pressure reduction when treating arterial hypertension is obviously the one which causes the maximum achievable prevention of hypertension-associated cardiovascular morbidity and mortality. This goal has not yet been reached by present approaches to antihypertensive treatment. Several large intervention trials in hypertension have shown that treated hypertensive patients still have an increased risk of cardiovascular morbidity and mortality in spite of receiving antihypertensive treatment. One possible explanation for this is that treated blood pressure is rarely, if ever, reduced to strictly normotensive levels. Another explanation, favored by proponents of the J-curve argument, is that excessive lowering of blood pressure may increase cardiovascular risks. DATA AVAILABLE FROM INTERVENTION TRIALS: So far, two prospective intervention trials have addressed this problem, the Swedish BBB (Treat Blood Pressure Better) study, for which results have been published, and the much larger Hypertension Optimal Treatment (HOT) study, which is still under way. Moreover, new epidemiological data from the Framingham Heart Study and the study of 50-year-old men in Gothenburg suggest that active intervention against arterial hypertension may change the pattern of blood pressure distribution in the population towards lower levels, also in untreated subjects, suggesting an additional and unexpected benefit from antihypertensive treatment.

Long-term renal preservation in essential hypertension. Angiotensin converting enzyme inhibition is superior to beta-blockade

Antihypertensive treatment is known to slow down the decline in glomerular filtration rate (GFR) with time. Angiotensin converting enzyme (ACE) inhibition has been shown to be more effective in this regard than conventional antihypertensive therapy. In a recent prospective, randomized, double blind trial in 257 patients with essential hypertension, the loss of GFR, determined with 51Cr-EDTA clearance, was significantly less with an ACE inhibitor (cilazapril) than with a beta-adrenoceptor blocker (atenolol) during the first year of treatment. However, after 2 years, the two therapies were equally effective in this regard, thereby creating doubts about the long-term superiority of ACE inhibition in this regard. In order to elucidate whether the superior renal preservation with the ACE inhibitor was a transient effect, GFR was measured after 1 more year of treatment, i.e., after 36 months. At that time, the decline in GFR was significantly smaller in the ACE inhibitor group as compared to the beta-adrenoceptor blocker group (-3.0 [-5.5, -1.0; 95% CI] v -7.0 [-9.0, -4.5; 95% CI] mL/min x 1.73 m2; P = .026). This demonstrates that in the treatment of essential hypertension ACE inhibition preserves GFR significantly better than beta-adrenoceptor blockade during long-term therapy.

The Nordic Comparative Study on Sectorized Psychiatry. III. Accessibility of psychiatric services, degree of urbanization and treated incidence

As part of a Nordic Comparative Study on Sectorized Psychiatry, accessibility of psychiatric services and degree of urbanization in seven catchment areas were related to treated incidence. One-year treated incidence cohorts were used. Accessibility was assessed according to referral practice, existence of a round the clock emergency service and geographical location of the services. Accessibility was surprisingly weakly associated with treated incidence. Easy access to the psychiatric services was not related to a high treated incidence of less severe psychiatric problems at the expense of patients suffering from severe illness. Geographical distance to the services did not predict the demand for services. A positive correlation was found between the degree of urbanization and treated incidence of psychoses but not of other diagnostic groups.

The Swedish Trial in old patients with hypertension-2 (STOP-hypertension-2): a progress report

OBJECTIVE

The Swedish Trial in Old Patients with Hypertension-2 (STOP-Hypertension-2) was designed by a project group of the Swedish Hypertension Society to test whether the "newer" treatment alternatives (ACE inhibitors and calcium antagonists) are as good as, better or less good than, the "older" ones (beta-blockers and diuretics) in terms of preventing cardiovascular morbidity and mortality in elderly hypertensives. The aim of the present paper is to report on the progress of the study.

DESIGN

Prospective, open trial with blinded end-point committee and centralized randomization (PROBE design). STOP-Hypertension-2 may be regarded as a scientific follow-up of the previously published Swedish Trial in Old Patients with Hypertension (STOP-Hypertensioon-1) (6) using the same study organization.

SUBJECTS

By the end of 1994 when recruitment was stopped, 6628 hypertensive men (34%) and women (66%) aged 70-84 (mean age 76) had been included at 312 Swedish health centres (out of approximately 850). In the whole cohort 11% are diabetics and 9% smokers. The mean total cholesterol value is 6.5 mmol/L.

RESULTS

In the whole study cohort, blood pressure was lowered from 194/98 mmHg to 167/85 mmHg after one year. At the end of 1995, 319 fatal events (all-cause mortality) had been reported, corresponding to a mortality rate of 21.3 per 1000 person-years.

CONCLUSION

In STOP-Hypertension-2, 6628 elderly hypertensive have been randomized to three different treatment regimes: beta-blocker+diuretics (the active treatment arm in STOP-Hypertension-1), ACE inhibitors, or calcium antagonists. Their average lowering of blood pressure was 27/13 mmHg and end-points have occurred at the expected rate. Thus, it should be possible to terminate STOP-Hypertension-2 within two to three years.

Major antihypertensive intervention trials conducted outside the United States

Five antihypertensive trials launched outside of the United States have been designed to address one of two vital issues. The first is whether or not there is an optimal level of blood pressure that clinicians should aim for to minimize the risk of cardiovascular disease. This has been addressed by the Swedish Behandla Blodtryck Battre (BBB) Trial and the international Hypertension Optimal Treatment (HOT) Study. The BBB Trial revealed interesting trends, but no definitive conclusions. The ongoing HOT Study will have to be completed before this particular issue can be adequately addressed. However, preliminary analysis of a subgroup study has revealed that the HOT treatment regimens are as effective in the elderly as in younger patients. The second important issue, which is the question of whether traditional antihypertensive agents are more effective than the newer agents in reducing cardiovascular risk, is the current focus of three ongoing studies. Investigators in the Captopril Prevention Project (CAPPP) are comparing captopril to beta-blocker and diuretic regimens. The purpose of the Nordic Diltiazem Study (NORDIL) is to determine if diltiazem is more effective than conventional therapy in reducing cardiovascular risk. The Swedish Trial in Old Patients with Hypertension-2 (STOP-Hypertension-2) has been designed to compare therapy with beta-blockers and diuretics to therapy with calcium antagonists and angiotension converting enzyme inhibitors. All ongoing trials should be completed in the next few years and are expected to yield valuable information that will improve current strategies for the treatment of hypertension.

Fosinopril versus enalapril in the treatment of hypertension: a double-blind study in 195 patients

The new angiotensin-converting enzyme (ACE) inhibitor fosinopril was compared with the ACE inhibitor enalapril in a multicenter (n = 11), multinational (Denmark, Finland, Iceland, Norway, and Sweden), double-blind, randomized, parallel-group 24-week study in 195 patients with mild to moderate essential hypertension [supine diastolic blood pressure, (SDBP) > or = 95 to < or = 110 mm Hg]. After discontinuing all previous antihypertensive medication, patients were entered into a placebo lead-in period of 4-6 weeks, followed by 24 weeks of randomized treatment with the active compounds administered with a double-dummy technique. The dose of fosinopril was 20 mg, which could be increased to 40 mg after 8 weeks (average 25.6 mg); that of enalapril was 10 mg, which could be increased to 20 mg after 8 weeks (average 12.9 mg). Hydrochlorothiazide 12.5 mg could be added after 16 weeks and was administered to 27% of the patients in the fosinopril group and to 30% in the enalapril group. All drugs were administered once daily. Supine systolic BP (SSBP) decreased from 157 to 143 mm Hg in the fosinopril group (p < 0.01), and from 159 to 147 mm Hg in the enalapril group (p < 0.01). SSDP decreased from 100 to 89 mm Hg in the fosinopril group (p < 0.01) and from 100 to 92 mm Hg in the enalapril group (p < 0.01). Throughout the study period, fosinopril reduced SSBP and SDBP numerically more than did enalapril, by 0-3 mm Hg. Adverse events (AE) caused withdrawal of study medication in 8 patients in the fosinopril group and in 14 patients in the enalapril group (NS). The number of reported AE was not statistically different in the two groups. Inhibition of the ACE was assessed in a subgroup of patients (n = 26, 13 in each group). Fosinopril caused a greater inhibition of ACE at the doses used in the present study, which was statistically significant. Both fosinopril and enalapril caused statistically significant reductions in BP of a similar magnitude, and both agents were well tolerated. However, fosinopril was consistently numerically slightly more effective than enalapril in reducing BP. There were fewer withdrawals due to AE (NS) in the fosinopril group, and the overall recorded AE were fewer in the fosinopril group (NS).

Characterisation of the complex of plasminogen activator inhibitor type 1 with tissue-type plasminogen activator by mass spectrometry and size-exclusion chromatography

Glycosylated human plasminogen activator inhibitor type 1 (PAI-1), produced in Chinese hamster ovary (CHO) cells, showed a variety of compounds with different molecular weights when subjected to electrospray mass spectrometry (ES-MS), owing to the heterogeneity of the carbohydrate chains. However, non-glycosylated human PAI-1, produced in E. coli, gave rise to a prominent species with a molecular weight of 42,774, consistent with the amino-acid sequence. A non-glycosylated mutant of the proteinase domain (B-chain) of tissue-type plasminogen activator (tPA) produced in C 127 cells, had a molecular weight of 28,168. Full-length, glycosylated, tPA showed a large heterogeneity in molecular mass. For a mass study, a tPA-PAI-1 complex was formed, composed of non-glycosylated PAI-1 and non-glycosylated B-chain. This complex was remarkably stable at room temperature in buffer with a neutral pH. The mass spectrum of the complex provided two main species, a peptide with a mass of 3803 and a dominating species of 67,133. These masses are consistent with a complex where PAI-1 is cleaved at the P1-P1' position. A trace of a species with a molecular mass of 70,942 was also found, corresponding to the complete, non-dissociated complex with PAI-1. Separation of the cleaved peptide, corresponding to the hydrophobic C-terminal 33 amino-acid residues of PAI-1, from the complex, was achieved by size-exclusion chromatography in the presence of 30% acetonitrile. Thus, in the complex between tPA and PAI-1, the proteins are held together by a tight covalent bond, but the C-terminal cleaved peptide of PAI-1 is only bound to the complex by hydrophobic forces. To assess whether this is specific to the tPA B-chain alone, experiments with the complex of full-length, glycosylated tPA and glycosylated PAI-1 were also performed, and it was possible to demonstrate the release of the C-terminal PAI-1 peptide by chromatography, mass spectrometry, as well as by SDS-PAGE.

Reproductive history and cigarette smoking as risk factors for thyroid cancer in women: a population-based case-control study

A population-based case-control study was conducted in Northern Norway and Central Sweden to investigate hormonal and reproductive factors and cigarette smoking as determinants of papillary and follicular thyroid carcinoma in women. Information on 191 histologically confirmed cases and 341 age-matched controls was included. No clear association was found with regard to the number of live births, number of pregnancies, a history of incomplete pregnancies, or the use of oral contraceptives or hormonal replacement therapy. However, an early first childbirth (before 20 years of age, or less than 5 years after menarche) was associated with an increased risk of thyroid cancer. There was an increased risk of thyroid cancer among women with a history of artificial menopause compared to those with a spontaneous menopause [odds ratio (OR), 2.52; 95% confidence interval (CI), 0.96-6.62], which was more pronounced for the papillary carcinoma and after adjustment for age at menopause and use of replacement therapy. Cigarette smokers had a decreased risk of borderline statistical significance compared to nonsmokers (OR, 0.69; 95% CI, 0.47-1.01), particularly among premenopausal women (OR, 0.60; 95% CI, 0.38-0.96). This negative association persisted after adjustment for parity, hormonal treatments, and education. Women who started smoking before the age of 15 experienced a marked reduction in risk (OR, 0.38%; 95% CI, 0.18-0.80¿). Moreover, there was a suggestion of a dose-response effect with the amount of cigarettes smoked daily and with duration of the habit. Both the increased risk of artificial menopause and the negative association with smoking are compatible with a relation between levels of estrogens and thyroid cancer among women.

Remikiren (Ro 42-5892)--an orally active renin inhibitor in essential hypertension. Effects on blood pressure and the renin-angiotensin-aldosterone system

Remikiren (Ro 42-5892) is a new orally active renin inhibitor with high potency and specificity in vitro. In the present study, the drug was given in a short-term study in patients with essential hypertension, either as monotherapy or with added hydrochlorothiazide. Following a wash-out period of at least 3 weeks and then 8 days of single-blind placebo, 29 patients with essential hypertension were given remikiren 600 mg orally for 8 days. After 4 days of remikiren, hydrochlorothiazide 12.5 mg or 25 mg or placebo was added in double-blind fashion for the last 4 days. There were no significant changes in blood pressure in patients given remikiren alone. In patients given additional hydrochlorothiazide for 4 days, a marked reduction in blood pressure was observed. Remikiren effectively inhibited the plasma renin activity 24 h post-dose, whereas angiotensin II was reduced only during the first hours after drug administration. It is concluded that remikiren is orally effective. Its antihypertensive effect during short-term administration was not significant, but when given with a diuretic, a marked potentiation occurred. Further studies are needed to establish the long-term effects of remikiren alone and in combination therapy.

The Nordic comparative study on sectorized psychiatry. Part IV. The influence of patient social characteristics on treated incidence

As part of a Nordic comparative study on sectorized psychiatry, sociodemographic characteristics (gender, age and marital status) were studied in relation to treated incidence in eight diagnostic subgroups. One-year incidence cohorts in seven sectorized psychiatric services were used. Women with a neurosis diagnosis had a significantly higher relative probability of contact with all services. Men with a dependence diagnosis had a significantly higher relative probability of contact with four of the seven services. Older people had a significantly higher relative risk for affective psychosis in six of the seven centres, and younger individuals had a significantly higher relative risk for personality disorders in six of the seven centres. Unmarried people showed a higher relative risk for functional psychosis and personality disorders in five of the seven services.

The case for a greater blood pressure fall

Several large intervention trials in hypertension have shown that treated hypertensive patients are at increased risk of cardiovascular morbidity and mortality in spite of being treated. One possible explanation for this is the fact that the treated blood pressure rarely if ever is brought down to strictly normotensive levels. Against this view is the J-curve argument that suggests that too vigorous lowering of blood pressure may increase cardiovascular risks. Two prospective intervention trials have addressed this problem, the BBB Study, which has been published, and the much larger HOT Study which is still ongoing. Some of the findings in these two trials will be discussed with an emphasis on giving an up-date of the HOT Study.

Estrogen and progestagen modify the hemodynamic response to mental stress in young women

OBJECTIVE

To evaluate separately the effects of estrogen and progestagen on the cardiovascular response to a standardized mental stress test.

METHODS

Seven women were studied during the early follicular phase (day 1-4) of three different menstrual cycles after randomized oral administration of either 6 mg estradiol valerate or 15 mg norethisterone acetate or placebo. Heart rate and blood pressure were recorded at rest for 2 hours after administration and throughout the stress test. Forearm plethysmography was recorded at rest and during stress.

RESULTS

Estrogen had no effect on heart rate or blood pressure at rest. After estrogen administration the increases in heart rate (delta 14 bpm/10 bpm; p < 0.01) and diastolic blood pressure (delta 14 mmHg/9 mmHg: p = 0.06) from baseline to stress were augmented compared to those observed after placebo administration. Heart rate, systolic and diastolic blood pressures reached higher levels during stress after estrogen administration compared to placebo (delta 5 bpm, and delta 7 mmHg and delta 5 mmHg respectively; p < 0.05). Estrogen administration also caused a prolongation of the diastolic blood pressure response to stress. Progestagen compared to placebo induced an increase in heart rate already at rest (delta 4 bpm; p < 0.01), and heart rate was maintained on a higher level throughout the stress test (p < 0.05). Blood pressure at rest and pressor responses to stress were not significantly changed after progestagen administration.

CONCLUSIONS

The results indicate that estrogen is responsible for the enhanced cardiovascular responses to stress, whereas progestagen provokes a parallel upward shift of basal heart rate which is independent of level of activation.

Psychiatric morbidity in primary public health care: a Nordic multicentre investigation. Part I: method and prevalence of psychiatric morbidity

The prevalence of mental illness in five different Scandinavian primary care populations was investigated in this study. Patients consecutively consulting their general practitioner a particular week-day were included in the study. Initially the SCL-25 was applied and next the high scores and a sample of the low scores were interviewed by the PSE. In the analysis the screening procedure was first validated. The internal validity of the SCL was tested by means of Rasch latent structure analysis and the external validity tested by ROC/QROC analysis. Based on this, a short 8-item version of the SCL was developed. The prevalence of mental illness in all centres was 0.26 with a minimum of 0.14 in Nacka and a maximum of 0.34 in Turku.