Verapamil-sustained release-based treatment strategy is equivalent to atenolol-based treatment strategy at reducing cardiovascular events in patients with prior myocardial infarction: an INternational VErapamil SR-Trandolapril (INVEST) substudy

BACKGROUND

In patients with prior myocardial infarction (MI), beta-blockers reduce mortality by 23% to 40%. However, despite this favorable effect, adverse effects limit compliance to this medication. The purpose of the study was to compare a beta-blocker-based strategy with a heart rate-lowering calcium antagonists-based strategy in patients with prior MI.

METHODS

We evaluated 7,218 patients with prior MI enrolled in the INternational VErapamil SR-Trandolapril (INVEST) substudy randomized to verapamil-sustained release (SR)- or atenolol-based strategies. Primary outcome was time to first occurrence of death (all-cause), nonfatal MI, or nonfatal stroke. Secondary outcomes included death, total MI (fatal and nonfatal), and total stroke (fatal and nonfatal) considered separately.

RESULTS

During the 2.8 +/- 1.0 years of follow-up, patients assigned to the verapamil-SR-based and atenolol-based strategies had comparable blood pressure control, and the incidence of the primary outcome was equivalent. There was no difference between the 2 strategies for the outcomes of either death or total MI. However, more patients reported excellent/good well-being (82.3% vs 78.0%, P = .02) at 24 months with a trend toward less incidence of angina pectoris (12.0% vs 14.3%, adjusted P = .07), nonfatal stroke (1.4% vs 2.0%; P = .06), and total stroke (2.0% vs 2.5%, P = .18) in the verapamil-SR-based strategy group.

CONCLUSIONS

In hypertensive patients with prior MI, a verapamil-SR-based strategy was equivalent to a beta-blocker-based strategy for blood pressure control and prevention of cardiovascular events, with greater subjective feeling of well-being and a trend toward lower incidence of angina pectoris and stroke in the verapamil-SR-based group.

Protein biochip array technology for cytokine profiling predicts etanercept responsiveness in rheumatoid arthritis

In rheumatoid arthritis (RA) there are currently no useful indicators to predict a clinical response to tumour necrosis factor-alpha (TNF-alpha) blockade. The purpose of this study was to determine the role of peripheral blood cytokine profiling in differentiating between a good versus poor response to etanercept in RA. Peripheral blood samples were collected at baseline and at 3 months from 33 patients with active disease who were treated twice weekly by etanercept therapy. Responders are defined by the presence of three of four American College of Rheumatology criteria: > or =20% decrease in C-reactive protein (CRP), visual analogue score of disease activity, erythrocyte sedimentation rate and improvement of the disease activity score (28; four values) by > or =1.2 obtained at 3 months. Twelve cytokines were measured from serum collected on days 0 and 90 by proteomic array (protein biochip array, Investigator Evidence, Randox France), including interleukin (IL)-6, TNF-alpha, IL-1a, IL-1b, IL-2, IL-8, interferon-gamma, IL-4, IL-10, monocyte chemoattractant protein (MCP)-1, epidermal growth factor (EGF) and vascular endothelium growth factor. Our results showed that high serum levels of MCP-1 and EGF were associated with a response to etanercept. In addition, the increase of two combined parameters CRP and EGF was predictive of a response to etanercept treatment at 3 months (sensitivity: 87.5% and specificity: 75%, accuracy: 84.4%). These findings suggest that cytokine profiling by proteomic analysis before treatment initiation may help to identify a responder patient to TNF-alpha blocking agents in RA.

Managing hypertension: state of the science

Hypertension management is both routine and a challenge. Updated guidelines emphasize the need to achieve increasingly stringent blood pressure goals to reduce cardiovascular morbidity and mortality; however, the blood pressure of many patients who have been diagnosed with hypertension is not well controlled. Treating prehypertension nonpharmacologically may preempt the progression to hypertension, whereas early and aggressive management of hypertension with antihypertensive agents reduces short- and long-term cardiovascular risk. Treatment decisions should follow current guidelines while evaluating recently published clinical studies. When choosing between agents from different therapeutic classes or combining agents, physicians should consider current and targeted blood pressure levels, the patient's demographic profile, the presence or absence of compelling cardiovascular and metabolic indications, other comorbidities, and concurrent medication(s).

Case study: pearls in hypertension pharmacotherapy

BACKGROUND

Research and therapy only has relevance when applied to an actual patient.

OBJECTIVE

To review a case study of a patient with hypertension and diabetes.

SUMMARY

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) of 2004 recommends that a diagnostic workup include an assessment of risk factors and comorbidities using history, physical exam, and laboratory parameters. The presence of comorbidities influences drug selection. Patient evaluation should also include identification of possible causes of hypertension, such as renal arterial stenosis, and an assessment for the presence of target organ damage. Treatment is always influenced by the presence or absence of comorbidities. Lifestyle modifications are crucial to enhancing the success of pharmacologic therapy and should be ongoing. If lifestyle modifications do not work, the clinician must consider drugs. Study data and JNC 7 recommend beta-blockers for hypertension in patients with compelling indications, e.g., high risk for cardiovascular disease and diabetes.

CONCLUSION

JNC 7 emphasizes that evaluation for hypertension includes the assessment for the presence of compelling indications, e.g., diabetes, hyperlipidemia, and high coronary risk. These comorbidities may inform and direct pharmacologic choices.

Overview of physiology, vascular biology, and mechanisms of hypertension

BACKGROUND

Our understanding of the process leading to hypertension is allowing us to adopt principles of therapy that may be more beneficial for patients.

OBJECTIVE

To review the physiology, vasular biology, and mechanisms of hypertension.

SUMMARY

Hypertension, particularly in high-risk patients, is a result of loss of balance and the absence of the ability to vasodilate normally. The interaction between the endothelial cell and the smooth muscle cell is very important in this process. The endothelium is a group of cells that produce compounds that are important in regulating vascular homeostasis by elaborating factors such as angiotensin II, nitric oxide (NO), endothelin, and prostaglandins. Specifically, NO is found in endothelial cells responsible for smooth muscle relaxation. Gaseous NO diffuses across the endothelial cell and into the underlying smooth muscle cell, where it stimulates the pathway of guanylate cyclase to produce vasorelaxation. Normal endothelium maintains vascular tone and blood viscosity, prevents abnormal blood clotting and bleeding, limits inflammation of the vasculature, and suppresses smooth muscle cell proliferation. Abnormal endothelium causes increased inflammation and hypertrophy of the smooth muscle cells, promotes thrombosis and vasoconstriction, and creates a situation ripe for establishment and rapid growth of atherosclerotic plaques. Endothelial dysfunction also predicts poor outcome in patients with non-insulin-dependent diabetes mellitus and may worsen insulin resistance, increase vascular reactivity, and encourage macrovascular disease.

CONCLUSION

Understanding endothelial vasculature will be imperative as researchers develop newer compounds that may enhance NO formation within the vasculature.

Cardioprotection: The Role of β‐Blocker Therapy

Randomized controlled clinical trials document that beta blockers reduce cardiovascular morbidity and mortality, particularly sudden death, in patients with hypertension, heart failure, and post-myocardial infarction. The benefits of beta blockers extend across the boundaries of age, gender, and ethnicity, and include diabetic patients with heart failure and/or previous myocardial infarction. Unfortunately, beta blockers remain underutilized in many high-risk patients who would likely benefit from their use. This paper reviews the protective role of beta blockade in the primary and secondary prevention of cardiovascular events and examines some of the potential barriers to appropriate beta blocker use in patients with compelling indications.

Lipoprotein particles, insulin, adiponectin, C-reactive protein and risk of coronary heart disease among men with metabolic syndrome

We tested the hypotheses whether nuclear magnetic resonance (NMR) determined lipoprotein particles, insulin and adiponectin, and C-reactive protein (CRP) and white blood cell (WBC) count as markers of inflammation predicted risk of coronary heart disease (CHD) death among 428 men age 35-57 years with metabolic syndrome (MetSyn) in a matched case control study within the multiple risk factor intervention trial. Blood samples collected at entry into the study and stored at -60 degrees C were obtained from central storage for blood analyte analysis. Two hundred and fourteen men with MetSyn who died of CHD were matched with 214 men with MetSyn who did not die of CHD during 18 years of follow-up. Cases were matched to controls on age, study group, number of factors present in the MetSyn, and presence or absence of a nonfatal CVD event during the trial. Mortality follow-up was determined using the National Death Index. Higher levels of high density lipoprotein particles (HDL-P), especially medium-sized HDL-P [hazard ratio (95% confidence interval) 0.45 (0.25-0.83, P<0.01), quartile 1 as compared to quartile 4], were associated with lower risk of CHD death. Low density lipoprotein (LDL) particles were not associated with increased risk of CHD. Elevated LDL cholesterol (LDL-C), smoking and WBC count were, but levels of adiponectin, insulin and CRP were not significantly related to CHD death. In multivariate models adjusting for smoking and LDL-C, medium HDL-P and WBC count remained independent predictors of CHD death. Number of HDL particles, especially medium-sized HDL particles and WBC count were independent predictors of CHD death among men with MetSyn.

Predictors of development of diabetes mellitus in patients with coronary artery disease taking antihypertensive medications (findings from the INternational VErapamil SR-Trandolapril STudy [INVEST])

Knowledge of predictors of diabetes mellitus (DM) development in patients with coronary artery disease (CAD) who use antihypertensive therapy could contribute to decreasing this adverse metabolic consequence. This is particularly relevant because the standard of care, beta blockers combined with diuretics, may contribute to adverse metabolic risk. The INternational VErapamil SR-trandolapril STudy compared a calcium antagonist-based (verapamil SR) and a beta-blocker-based (atenolol) strategy with trandolapril and/or hydrochlorothiazide added to control blood pressure (BP) in patients with CAD. The 16,176 patients without DM at entry were investigated with regard to newly diagnosed DM during follow-up. Newly diagnosed DM was less frequent in the verapamil SR versus atenolol strategy (7.0% vs 8.2%, hazard ratio 0.85, 95% confidence interval 0.76 to 0.95, p <0.01). Characteristics associated with risk for newly diagnosed DM included United States residence, left ventricular hypertrophy, previous stroke/transient ischemic attack, Hispanic ethnicity, coronary revascularization, hypercholesterolemia, greater body mass index, and higher follow-up systolic BP. Addition of trandolapril to verapamil SR decreased DM risk and addition of hydrochlorothiazide to atenolol increased risk. In conclusion, clinical findings associated with more severe vascular disease and Hispanic ethnicity identify a group at high risk for developing DM, whereas lower on-treatment BP and treatment with verapamil SR-trandolapril attenuated this risk.

Indole-3-acetic acid protein conjugates: novel players in auxin homeostasis

Indole-3-acetic acid (IAA) is found in plants in both free and conjugated forms. Within the group of conjugated IAA there is a unique class of proteins and peptides where IAA is attached directly to the polypeptide structure as a prosthetic group. The first gene, IAP1, encoding for a protein with IAA as a prosthetic group, was cloned from bean (Phaseolus vulgaris). It was shown that the expression of IAP1 as a major IAA modified protein in bean seed (PvIAP1) was correlated to a developmental period of rapid growth during seed development. Moreover, this protein underwent rapid degradation during germination. Since further molecular analysis was difficult in bean, the IAP1 gene was transformed into Arabidopsis thaliana and Medicago truncatula. Expression of the bean IAP1 gene in both plant species under the control of its native promoter targeted protein expression to the seeds. In Arabidopsis no IAA was found to be attached to PvIAP1. These results show that there is specificity to protein modification by IAA and suggests that protein conjugation may be catalyzed by species specific enzymes. Furthermore, subcellular localization showed that in Arabidopsis PvIAP1 was predominantly associated with the microsomal fraction. In addition, a related protein and several smaller peptides that are conjugated to IAA were identified in Arabidopsis. Further research on this novel class of proteins from Arabidopsis will both advance our knowledge of IAA proteins and explore aspects of auxin homeostasis that were not fully revealed by studies of free IAA and lower molecular weight conjugates.

Metabolic syndrome: risk factor distribution and 18-year mortality in the multiple risk factor intervention trial

OBJECTIVE

To examine the long-term association of metabolic syndrome with mortality among those at high risk for cardiovascular disease (CVD).

RESEARCH DESIGN AND METHODS

A total of 10,950 Multiple Risk Factor Intervention Trial (MRFIT) survivors were followed for mortality an additional median 18.4 years (1980-1999). Proportional hazards models examined multivariate-adjusted risks associated with Adult Treatment Panel III-defined metabolic syndrome conditions, with BMI substituted for waist circumference.

RESULTS

At MRFIT annual visit 6, 4,588 (41.9%) men, mean age (+/-SD) 53.0 +/- 5.9 years, had metabolic syndrome and 6,362 did not. Comparing men with metabolic syndrome to men without, adjusted hazard ratios (HRs) were 1.21 (95% CI 1.13-1.29), 1.49 (1.35-1.64), and 1.51 (1.34-1.70) for 18-year total, CVD, and coronary heart disease mortality, respectively. Among men with metabolic syndrome, elevated glucose (1.54 [1.34-1.78]) and low HDL cholesterol (1.45 [1.17-1.54]) were most predictive of CVD mortality, followed by elevated BMI (1.34 [1.17-1.54]), elevated blood pressure (1.25 [0.98-1.58]), and elevated triglycerides (1.06 [0.86-1.30]). In contrast, for men without metabolic syndrome, the HR for low HDL cholesterol was 1.02 (0.86-1.22). Among metabolic syndrome men with no nonfatal CVD event, smokers with elevated LDL cholesterol showed higher CVD mortality (1.79 [1.22-2.63]) compared with nonsmokers without elevated LDL cholesterol; this additional risk was even greater for metabolic syndrome men with a nonfatal CVD event (2.11 [1.32-3.38]).

CONCLUSIONS

Metabolic syndrome is associated with an increased risk of mortality. Among those with metabolic syndrome, risk is further increased by having more metabolic syndrome conditions, by cigarette smoking, and by elevated LDL cholesterol. Primary prevention of each metabolic syndrome condition should be emphasized, and presence of each condition should be treated in accordance with current guidelines.

The efficiency of switching from infliximab to etanercept and vice-versa in patients with rheumatoid arthritis

OBJECTIVE

To determine whether it may be successful to try another TNF-alpha antagonist (infliximab or etanercept) when one has failed due to non response or the development of side effects.

METHODS

In a cohort of 282 patients with rheumatoid arthritis treated with infliximab or etanercept, we observed 38 patients who had received both agents.

RESULTS

Twenty-four patients received infliximab first and 14 received etanercept first. Discontinuation was due to a lack of efficiency for 29 patients and to the occurence of an adverse effect for 9 patients. For 25 out of the 38 patients, the switch was a success according to the global physician's assessment 3 months after switching. This result was correlated to a significant decrease of DAS 28 measurements and CRP values (p < 0.05). The response after switching was recorded as a success for 18 out of the 24 patients who were treated with infliximab first, and for 12 out of the 14 patients who were treated with etanercept first. There was no statistical difference concerning the response after the switch between the two groups. Among the 29 patients who discontinued the first anti TNF-alpha treatment due to lack of efficiency, only 6 did not respond to the second anti TNF-alpha treatment. Only one out of the 9 patients who stopped a first anti TNF-alpha treatment after developing a side effect underwent an adverse event with the second anti TNF-alpha treatment.

CONCLUSION

Our study suggests that switching between TNF-alpha antagonists seems to be relevant, regardless of which one was used first. It is legitimate to try to switch TNF-alpha blockers before contemplating other therapeutic strategies.

Effect of bicycle racing saddle design on transcutaneous penile oxygen pressure

AIM

To determine the reliability of monitoring penile transcutaneous oxygen (tpO2) during cycling, and to assess the influence of seat design and cycling position on tpO2.

METHODS

EXPERIMENTAL DESIGN

repeated measures analysis of the effects of seat design and riding position on tpO2 values.

PARTICIPANTS

31 male cyclists between the ages of 20 and 50 years participated. Subject inclusion criteria were: averaged=or>80 miles of road bicycling per week during the 2 months prior to enrollment in this study; no history of vascular disease, diabetes, or sexual dysfunction; and had an erection within 15 days prior to study.

MEASURES

mean tpO2 values were calculated for seated and standing positions using 3 current bicycle seat designs.

RESULTS

Test-retest reliability for seated cycling tpO2 values had an ICC (3,1) of 0.76 and mean absolute difference of 5.1 mmHg. Test-retest reliability for standing cycling tpO2 values had an ICC(3,1) of 0.88 and mean absolute difference of 7.23 mmHg. No interaction effect occurred between seat design and position. Seat design had no significant effect on tpO2 values. Seated cycling significantly reduced tpO2 levels compared with standing cycling (P<0.05). Mean percent decreases in tpO2 from standing to seated cycling were; Vetta 76%, Terry 73%, and Specialized 62%.

CONCLUSION

The data suggest that penile tpO2 monitoring is reliable for use during cycling studies. None of the seats exhibited any significant ability to spare penile tpO2. The implications of decreased penile tpO2 over different time intervals on penile physiology remain to be investigated.

Azithromycin for the secondary prevention of coronary events

BACKGROUND

Epidemiologic, laboratory, animal, and clinical studies suggest that there is an association between Chlamydia pneumoniae infection and atherogenesis. We evaluated the efficacy of one year of azithromycin treatment for the secondary prevention of coronary events.

METHODS

In this randomized, prospective trial, we assigned 4012 patients with documented stable coronary artery disease to receive either 600 mg of azithromycin or placebo weekly for one year. The participants were followed for a mean of 3.9 years at 28 clinical centers throughout the United States.

RESULTS

The primary end point, a composite of death due to coronary heart disease, nonfatal myocardial infarction, coronary revascularization, or hospitalization for unstable angina, occurred in 446 of the participants who had been randomly assigned to receive azithromycin and 449 of those who had been randomly assigned to receive placebo. There was no significant risk reduction in the azithromycin group as compared with the placebo group with regard to the primary end point (risk reduction, 1 percent [95 percent confidence interval, -13 to 13 percent]). There were also no significant risk reductions with regard to any of the components of the primary end point, death from any cause, or stroke. The results did not differ when the participants were stratified according to sex, age, smoking status, presence or absence of diabetes mellitus, or C. pneumoniae serologic status at baseline.

CONCLUSIONS

A one-year course of weekly azithromycin did not alter the risk of cardiac events among patients with stable coronary artery disease.

The National Lipid Association surveys of consumers, physicians, and pharmacists regarding an over-the-counter statin in the United States: is this a good idea?

Surveys commissioned by the National Lipid Association (NLA) were conducted to determine the current attitudes and perceptions of physicians, consumers, and pharmacists regarding the impact of an over-the-counter (OTC) statin. Individuals from preexisting independent databases were randomly invited to participate in the online surveys that were open from January 26 to 30, 2004 for physicians and consumers and from March 1 to 12, 2004 for pharmacists. The results of these surveys indicate that consumers and pharmacists are more positive regarding the idea of an OTC statin, whereas physicians are more guarded. Concerns of both physicians and pharmacists included the discontinuation by patients of their prescription cholesterol-lowering therapy without consulting their physician, safety issues such as potential drug interactions and side effects, and patient ability to self-manage OTC statins. Consumers interested in purchasing an OTC statin reported that they would consult their physician before doing so, and pharmacists were interested in supporting consumers who use OTC statins. Although such support would require further training and time, pharmacists believed that they could facilitate consumer self-care programs and follow-up with physicians.

Understanding physician and consumer attitudes concerning cholesterol management: results from the National Lipid Association surveys

Two online surveys commissioned by the National Lipid Association (NLA) were conducted to determine the current attitudes of physicians and consumers regarding cholesterol and heart disease. Physicians and consumers from preexisting independent panels were randomly invited to participate in the online surveys that were open from January 26 to 30, 2004. Both physicians (n = 200) and consumers (n = 600) agreed that high cholesterol and coronary artery disease (CAD) are significant health risks. Physicians reported the primary barriers for patients being prescribed cholesterol-lowering medication as patient fear of side effects (61%) and reluctance to take prescription medications (52%). While most physicians were aware of and felt they adhered to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines, considerably fewer thought the same of other physicians. The consumer survey focused on untreated moderate-risk patients (an approximate 10% to 20% 10-year risk of myocardial infarction and cardiac death) because this group is often undertreated. Untreated moderate-risk patients reported that their physicians did not advise them to take prescription cholesterol-lowering drugs (51%) and that they were trying to control their cholesterol with diet and exercise (58%). Consumers believe they are taking an increased role in their own health management and decision making. Current attitudes of physicians and consumers are similar with regard to their recognition of the significance of cholesterol and CAD for health, but differ with regard to why patients do not take prescription medications.

Sodium reduction for hypertension prevention in overweight adults: further results from the Trials of Hypertension Prevention Phase II

Sodium reduction is efficacious for primary prevention of hypertension, but the feasibility of achieving this effect is unclear. The objective of the paper is detailed analyses of adherence to and effects of the sodium reduction intervention among overweight adults in the Trials of Hypertension Prevention, Phase II. Sodium reduction (comprehensive education and counselling about how to reduce sodium intake) was tested vs no dietary intervention (usual care) for 36-48 months. A total of 956 white and 203 black adults, ages 30-54 years, with diastolic blood pressure 83-89 mmHg, systolic blood pressure (SBP) <140 mmHg, and body weight 110-165% of gender-specific standard weight were included in the study. At 36 months, urinary sodium excretion was 40.4 mmol/24 h (24.4%) lower in sodium reduction compared to usual care participants (P<0.0001), but only 21% of sodium reduction participants achieved the targeted level of sodium excretion below 80 mmol/24 h. Adherence was positively related to attendance at face-to-face contacts. Net decreases in SBP at 6, 18, and 36 months of 2.9 (P<0.001), 2.0 (P<0.001), and 1.3 (P=0.02) mmHg in sodium reduction vs usual care were associated with an overall 18% lower incidence of hypertension (P=0.048); were relatively unchanged by adjustment for ethnicity, gender, age, and baseline blood pressure, BMI, and sodium excretion; and were observed in both black and white men and women. From these beneficial but modest results with highly motivated and extensively counselled individuals, sodium reduction sufficient to favourably influence the population blood pressure distribution will be difficult to achieve without food supply changes.

Troponin I in Patients without Chest Pain

Background: Testing for troponin has important clinical value for patients who present with typical symptoms of acute coronary syndromes (ACS) such as chest pain (CP). Much less is known about the value of troponin testing for patients who present with other symptoms of ACS (anginal equivalent symptoms).

Methods: The utilization and prognostic value of cardiac troponin I (cTnI) were evaluated at a Veterans Affairs Acute Care Facility. Clinical charts of 1184 predominantly male patients, who submitted specimens for initial cTnI testing by AxSYM, were evaluated for demographic data, cardiovascular risk factors, major diseases, and complaints at the time of testing. The endpoint was defined as all-cause death during a 200-day period after initial testing.

Results: Sixty-one percent of cTnI tests were ordered for patients who did not present with CP. Patients presenting with symptoms other than CP did not have significantly lower plasma cTnI than patients with CP. However, patients with symptoms other than CP were rarely diagnosed with ACS unless cTnI was ≥2 μg/L. The mortality during the follow-up period was severalfold higher among patients presenting with symptoms other than CP (CP, 6%; without CP, 22%; P &lt;0.0001, χ2 test). cTnI ≥0.2 μg/L provided significant additional predictive information for patients who presented with anginal equivalent symptoms such as shortness of breath or general weakness.

Conclusion: Patients with anginal equivalent symptoms of ACS and low-positive cTnI are less often diagnosed with ACS and have a higher mortality than patients with CP.

A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial

CONTEXT

Despite evidence of efficacy of antihypertensive agents in treating hypertensive patients, safety and efficacy of antihypertensive agents for coronary artery disease (CAD) have been discerned only from subgroup analyses in large trials.

OBJECTIVE

To compare mortality and morbidity outcomes in patients with hypertension and CAD treated with a calcium antagonist strategy (CAS) or a non-calcium antagonist strategy (NCAS).

DESIGN, SETTING, AND PARTICIPANTS

Randomized, open label, blinded end point study of 22 576 hypertensive CAD patients aged 50 years or older, which was conducted September 1997 to February 2003 at 862 sites in 14 countries.

INTERVENTIONS

Patients were randomly assigned to either CAS (verapamil sustained release) or NCAS (atenolol). Strategies specified dose and additional drug regimens. Trandolapril and/or hydrochlorothiazide was administered to achieve blood pressure goals according to guidelines from the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) of less than 140 mm Hg (systolic) and less than 90 mm Hg (diastolic); and less than 130 mm Hg (systolic) and less than 85 mm Hg (diastolic) if diabetes or renal impairment was present. Trandolapril was also recommended for patients with heart failure, diabetes, or renal impairment.

MAIN OUTCOME MEASURES

Primary: first occurrence of death (all cause), nonfatal myocardial infarction, or nonfatal stroke; other: cardiovascular death, angina, adverse experiences, hospitalizations, and blood pressure control at 24 months.

RESULTS

At 24 months, in the CAS group, 6391 patients (81.5%) were taking verapamil sustained release; 4934 (62.9%) were taking trandolapril; and 3430 (43.7%) were taking hydrochlorothiazide. In the NCAS group, 6083 patients (77.5%) were taking atenolol; 4733 (60.3%) were taking hydrochlorothiazide; and 4113 (52.4%) were taking trandolapril. After a follow-up of 61 835 patient-years (mean, 2.7 years per patient), 2269 patients had a primary outcome event with no statistically significant difference between treatment strategies (9.93% in CAS and 10.17% in NCAS; relative risk [RR], 0.98; 95% confidence interval [CI], 0.90-1.06). Two-year blood pressure control was similar between groups. The JNC VI blood pressure goals were achieved by 65.0% (systolic) and 88.5% (diastolic) of CAS and 64.0% (systolic) and 88.1% (diastolic) of NCAS patients. A total of 71.7% of CAS and 70.7% of NCAS patients achieved a systolic blood pressure of less than 140 mm Hg and diastolic blood pressure of less than 90 mm Hg.

CONCLUSION

The verapamil-trandolapril-based strategy was as clinically effective as the atenolol-hydrochlorothiazide-based strategy in hypertensive CAD patients.

Beta-blockers for treatment of hypertension

Beta-blockers are an established class in the management of hypertension, and numerous randomized, controlled trials have shown that these drugs can prevent cardiovascular events in this population. However, beta-blockers are underutilized in managing the general hypertensive population. This phenomenon may stem in part from concerns about side effects. On the contrary, beta-blockers demonstrate comparable efficacy, safety, and tolerability compared with other classes of antihypertensive drugs. Because beta-blockers offer unique cardiovascular protection, they should be considered an integral part of the treatment regimen for patients with hypertension who are at risk for cardiovascular events.

Hydrochlorothiazide versus chlorthalidone: evidence supporting their interchangeability

Thiazide diuretics are one of the preferred pharmacologic treatments for hypertension. Hydrochlorothiazide and chlorthalidone have been the 2 most commonly used diuretics in major clinical trials. Treatment guidelines and compendia often consider these 2 drugs interchangeable agents within the class of thiazide or thiazide-like diuretics. Many sources list them as equipotent. Despite these beliefs, there is some suggestion that cardiovascular outcomes are not necessarily the same with these 2 drugs. We conducted a literature search from 1960 to 2003 to identify studies that evaluated the pharmacokinetic and blood pressure-lowering effects of these 2 agents. There are significant pharmacokinetic and pharmacodynamic differences between these diuretics. Chlorthalidone is approximately 1.5 to 2.0 times as potent as hydrochlorothiazide, and the former has a much longer duration of action. Whether these pharmacokinetic and pharmacodynamic features cause differences in outcomes is not known.

Impact of incident diabetes and incident nonfatal cardiovascular disease on 18-year mortality: the multiple risk factor intervention trial experience

OBJECTIVE

To report long-term risks for total, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality associated with incident diabetes (using current diagnostic criteria) and with incident nonfatal CVD (NF-CVD).

RESEARCH DESIGN AND METHODS

A total of 11645 participants without diabetes or CVD at baseline from the Multiple Risk Factor Intervention Trial who survived to the end of the trial were grouped by during-trial incident diabetes and/or NF-CVD events: neither diabetes nor NF-CVD, diabetes only, NF-CVD only, or both diabetes and NF-CVD. Incident diabetes was defined by use of hypoglycemic agents or fasting glucose >or=126 mg/dl at any time over the 6 trial years. Proportional hazards models tested group differences in mortality over 18 post-trial years.

RESULTS

Among 3859 total deaths were 1846 from CVD and 1277 from CHD, with death rates per 10000 person-years of 203, 97, and 67, respectively. Multivariate-adjusted hazard ratios (HRs) for total mortality were 2.75 (P < 0.0001) for those with NF-CVD and diabetes both, 1.92 (P < 0.0001) for those with NF-CVD only, and 1.49 (P < 0.0001) for those with diabetes only, relative to neither diabetes nor NF-CVD. NF-CVD was associated with a higher hazard of death than diabetes for total (HR 1.29, P = 0.0004), CVD (HR 1.76, P < 0.0001), and CHD (HR 1.88, P < 0.0001) mortality. Only the subgroup of participants on hypoglycemic agents showed an equivalent risk of total mortality relative to participants with NF-CVD (HR 0.93, P = 0.54).

CONCLUSIONS

Current diabetes diagnostic criteria conferred significantly increased total, CVD, and CHD mortality risks independent of the impact of NF-CVD. NF-CVD was more strongly predictive of mortality.