Effect of baseline cognitive function and antihypertensive treatment on cognitive and cardiovascular outcomes: Study on COgnition and Prognosis in the Elderly (SCOPE)

BACKGROUND

We examined whether cognitive function at baseline affected cognitive and cardiovascular outcomes in the Study on COgnition and Prognosis in the Elderly (SCOPE), a blood pressure (BP)-lowering intervention trial.

METHODS

SCOPE included 4937 patients, aged 70 to 89 years, with mild-to-moderate hypertension and Mini Mental State Examination (MMSE) score > or =24. Double-blind treatment was initiated with candesartan or placebo. Open-label therapy was added as needed to control BP, both in the candesartan (49%) and control (66%) groups. Mean follow-up was 3.7 years. Low cognitive function (LCF) at baseline was defined as MMSE score 24 to 28 (N = 2070), and high cognitive function (HCF) as MMSE score 29 to 30 (N = 2867).

RESULTS

Mean BP reductions were approximately 20/10 mm Hg both in LCF and HCF patients, with greater reductions in the candesartan group than in the control group. The incidence of dementia was higher in LCF than in HCF patients. A higher cardiovascular event rate observed in LCF patients was explained by older age and other cardiovascular risk factors at baseline. In LCF patients, the MMSE score declined less in the candesartan than in the control group (mean difference 0.49, 95% confidence interval 0.02 to 0.97, P = .04). Nonfatal stroke was reduced in the candesartan group in the total sample (28%, P = .04), with no difference between LCF (27%) and HCF (29%) patients.

CONCLUSIONS

Elderly patients with mild-to-moderate hypertension and slightly impaired cognitive function (MMSE 24 to 28) are at increased risk of dementia and cardiovascular events. This analysis indicates that effective antihypertensive therapy may reduce cognitive decline and stroke incidence in these patients.

Results of the Controlled ONset Verapamil INvestigation of Cardiovascular Endpoints (CONVINCE) trial by geographical region

OBJECTIVE

To examine regional differences in the Controlled ONset Verapamil INvestigation of Cardiovascular Endpoints (CONVINCE) trial.

DESIGN

Double-blind, randomized, international clinical trial.

SETTING

Six hundred and sixty-one clinical centers in 15 countries.

PATIENTS

Hypertensive volunteers (n = 16,602) with > or =1 additional cardiovascular risk factor, grouped into four regions: USA (n = 8144), Canada (n = 3405), Western Europe (Spain, UK, Italy, Sweden, Germany; n = 2048) or 'other' (Bulgaria, Israel, Mexico, Czech Republic, Hungary, Poland, Slovakia, Brazil; n = 2879); subgroupings included country and state/province within the USA and Canada.

INTERVENTIONS

Randomized to COER-verapamil or the investigator's choice of either atenolol or hydrochlorothiazide, titrated and additional drugs added as required.

MAIN OUTCOME MEASURES

Baseline characteristics; blood pressure control, medication adherence and lost-to-follow-up at 2 years; and composite primary endpoint (stroke, myocardial infarction, cardiovascular death) by regional groupings.

RESULTS

Regional differences were found at baseline for age, gender, blood pressure, percentage receiving antihypertensive drug therapy, initial choice of atenolol or hydrochlorothiazide, and risk factor profile. Blood pressure control rates increased markedly during follow-up in all regions, but varied significantly by region. Blood pressure control, medication adherence and lost-to-follow-up rates were poorest in the USA. After adjustment for baseline differences, the primary-event rate for each region was significantly lower than for the USA. Although baseline factors, blood pressure control and event rates varied by region, treatment differences did not.

CONCLUSION

Despite differences in baseline and follow-up measures across geographical regions, the absence of treatment differences by region suggests that the overall findings of CONVINCE are robust.

Properties of recombinant human plasma procarboxypeptidase U produced in mammalian and insect cells

BACKGROUND

Carboxypeptidase U (EC 3.4.17.20, TAFIa) is a new member of the metallocarboxypeptidase family circulating in human plasma as a zymogen. It is activated during coagulation and is considered as an important player in the regulation of fibrinolysis.

METHODS

Heterologous expression of human plasma procarboxypeptidase U (proCPU, TAFI) was obtained in mammalian cells (C127 and DON) and in insect cells (Sf21 and H5 cells). Conditioned media were purified by cation-exchange chromatography and plasminogen affinity chromatography to yield an essentially pure protein.

RESULTS

All systems gave high expression levels (6-20 mg/l). Due to differences in glycosylation of the activation peptide, the recombinant variants of proCPU migrated differently on SDS-PAGE (52-65 kDa). However, after activation, all active recombinant enzymes migrated at 35 kDa, similar to native CPU and no evidence for post-translational modification of the catalytic domains could be detected. For the mammalian cell produced variants, activation was more efficient after desialylation. After activation, CPU showed low solubility (0.2 mg/ml) but was inhibited similarly as native CPU.

CONCLUSIONS

Mammalian cell systems were the most efficient for the production of human plasma recombinant proCPU. The obtained zymogen differs with respect to the extent and the heterogeneity of glycosylation but, after activation, the experiments did not reveal any alteration between the recombinant and native protein.

The Study on COgnition and Prognosis in the Elderly (SCOPE); outcomes in patients not receiving add-on therapy after randomization

OBJECTIVE

To assess clinical outcomes in the Study on COgnition and Prognosis in the Elderly (SCOPE) in patients who did not receive add-on antihypertensive therapy after randomization, i.e. in patients that best reflect the original intention of a placebo-controlled trial.

DESIGN

Post-hoc analysis of a prospective, randomized, controlled trial.

SETTINGS AND PARTICIPANTS

Five hundred and twenty-seven centres in 15 countries participated in SCOPE. Patients aged 70-89 years, with systolic blood pressure 160-179 mmHg and/or diastolic blood pressure 90-99 mmHg, and preserved cognitive function were eligible. Out of 4937 patients in SCOPE, 2098 did not receive add-on therapy.

INTERVENTION

The number of patients who received candesartan 8-16 mg once daily was 1253, and 845 received placebo. Mean follow-up was 3.7 and 3.5 years, respectively.

MAIN OUTCOME MEASURES

Primary: major cardiovascular events (cardiovascular mortality, non-fatal stroke or non-fatal myocardial infarction). Secondary: total mortality, cardiovascular mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, cognitive function, and dementia.

RESULTS

The treatment groups were generally well balanced for baseline characteristics. Blood pressure fell by 21.8/11.0 mmHg in the candesartan group and by 17.2/8.4 mmHg in the placebo group. There were significant relative risk reductions with candesartan in major cardiovascular events (32%, P = 0.013), cardiovascular mortality (29%, P = 0.049), and total mortality (27%, P = 0.018). There were no significant differences between the treatment groups in cognitive outcomes. Both treatments were generally well tolerated.

CONCLUSIONS

Treatment of elderly patients with mild hypertension is beneficial and supports current recommendations. Candesartan appears an appropriate therapy in such patients, in view of its favourable tolerability profile and ability to reduce major cardiovascular events.

Blood pressure dependent and independent effects of antihypertensive treatment on clinical events in the VALUE Trial

The Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial was designed to test whether, for the same achieved blood pressures, regimens based on valsartan or amlodipine would have differing effects on cardiovascular endpoints in high risk hypertension. But inequalities in blood pressure, favouring amlodipine, throughout the multiyear trial precluded comparison of outcomes. A technique of serial median matching, applied at 6 months when treatment adjustments intended to achieve control of blood pressure were complete, created 5006 valsartan-amlodipine patient pairs matched exactly for systolic blood pressure, age, sex, and the presence or absence of previous coronary disease, stroke, or diabetes. Subsequent combined cardiac events, myocardial infarction, stroke, and mortality were almost identical in the two cohorts, but admission to hospital for heart failure was significantly lower with valsartan. Reaching blood pressure control (systolic <140 mm Hg) by 6 months, independent of drug type, was associated with significant benefits for subsequent major outcomes; the blood pressure response after just 1 month of treatment predicted events and survival.

Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial

BACKGROUND

The Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial was designed to test the hypothesis that for the same blood-pressure control, valsartan would reduce cardiac morbidity and mortality more than amlodipine in hypertensive patients at high cardiovascular risk.

METHODS

15?245 patients, aged 50 years or older with treated or untreated hypertension and high risk of cardiac events participated in a randomised, double-blind, parallel-group comparison of therapy based on valsartan or amlodipine. Duration of treatment was event-driven and the trial lasted until at least 1450 patients had reached a primary endpoint, defined as a composite of cardiac mortality and morbidity. Patients from 31 countries were followed up for a mean of 4.2 years.

FINDINGS

Blood pressure was reduced by both treatments, but the effects of the amlodipine-based regimen were more pronounced, especially in the early period (blood pressure 4.0/2.1 mm Hg lower in amlodipine than valsartan group after 1 month; 1.5/1.3 mm Hg after 1 year; p<0.001 between groups). The primary composite endpoint occurred in 810 patients in the valsartan group (10.6%, 25.5 per 1000 patient-years) and 789 in the amlodipine group (10.4%, 24.7 per 1000 patient-years; hazard ratio 1.04, 95% CI 0.94-1.15, p=0.49).

INTERPRETATION

The main outcome of cardiac disease did not differ between the treatment groups. Unequal reductions in blood pressure might account for differences between the groups in cause-specific outcomes. The findings emphasise the importance of prompt blood-pressure control in hypertensive patients at high cardiovascular risk.

Kinetics of cytokine gene expression in human CD4+ and CD8+ T-lymphocyte subsets using quantitative real-time PCR

The time kinetics of five cytokines [interleukin-2 (IL-2), IL-5, interferon-gamma (IFN-gamma), granulocyte macrophage-colony stimulating factor (GM-CSF) and tumour necrosis factor-alpha (TNF-alpha)] and one cytotoxic effector protein (granzyme B) was analysed by real-time quantitative polymerase chain reaction (PCR) following in vitro stimulation of human CD4 and CD8 T lymphocytes. Two stimuli were used, a mitogen [phytohemagglutinin (PHA)] and a recall antigen [purified protein derivative (PPD)]. The pattern of cytokine mRNA expression was found to be dependent on the T-cell subset and stimulus used. A wide interindividual variability in the cytokine gene expression pattern was demonstrated. Two expression patterns were observed. A bell-shaped expression profile was seen for most cytokines upon PHA activation in both subsets and PPD-activated CD4 T cells, whereas a biphasic/multiphasic expression pattern was noted in CD8 T cells upon PPD stimulation. For most cytokines, the time to induction was within 30 min of activation, and maximum accumulation seemed to be obtained after 4-8 h of activation. A sustained high level could, however, be noticed for up to 24 h. Granzyme B gene expression was also induced within 30 min of activation but showed a continuous gradual increase and late maximal accumulation (48-72 h). The findings of the present study are of importance when designing studies using the cytokine gene expression profile as a marker for antigen-specific T lymphocytes. It might be recommended that cytokine gene expression (IL-2, IL-5 and IFN-gamma) should be measured after 4-8 h of specific activation but also up to 24 h of stimulation is acceptable. Granzyme B should preferentially be measured after 48-72 h of activation.

Increase in signal-to-noise ratio of > 10,000 times in liquid-state NMR

A method for obtaining strongly polarized nuclear spins in solution has been developed. The method uses low temperature, high magnetic field, and dynamic nuclear polarization (DNP) to strongly polarize nuclear spins in the solid state. The solid sample is subsequently dissolved rapidly in a suitable solvent to create a solution of molecules with hyperpolarized nuclear spins. The polarization is performed in a DNP polarizer, consisting of a super-conducting magnet (3.35 T) and a liquid-helium cooled sample space. The sample is irradiated with microwaves at approximately 94 GHz. Subsequent to polarization, the sample is dissolved by an injection system inside the DNP magnet. The dissolution process effectively preserves the nuclear polarization. The resulting hyperpolarized liquid sample can be transferred to a high-resolution NMR spectrometer, where an enhanced NMR signal can be acquired, or it may be used as an agent for in vivo imaging or spectroscopy. In this article we describe the use of the method on aqueous solutions of [13C]urea. Polarizations of 37% for 13C and 7.8% for 15N, respectively, were obtained after the dissolution. These polarizations correspond to an enhancement of 44,400 for 13C and 23,500 for 15N, respectively, compared with thermal equilibrium at 9.4 T and room temperature. The method can be used generally for signal enhancement and reduction of measurement time in liquid-state NMR and opens up for a variety of in vitro and in vivo applications of DNP-enhanced NMR.

Excess morbidity and cost of failure to achieve targets for blood pressure control in Europe

AIM

To estimate the burden of failing to achieve targets for blood pressure (BP) control in France, Germany, Italy, Sweden and the UK.

METHODS

A cost of illness model was constructed to estimate the impact of uncontrolled hypertension to each national healthcare system. Prevalence of uncontrolled hypertension was taken from published data. Relationships between achieved BP and the cardiovascular events of symptomatic acute myocardial infarction, congestive heart failure and stroke were estimated from the HOT study. Costs were taken from public sources. The acute medical costs of these events were estimated at current prevalence of uncontrolled hypertension and if BP were treated to target.

RESULTS

The model estimated that 29 million adults in the five countries (13% population) have BP levels above 160/95 mmHg, and an additional 46 million (21% population) have BP in the range 140/90-160/95 mmHg. The model estimated that healthcare system costs of 1.26 billion euros could be avoided if hypertension management did achieve BP targets. This does not consider the cost of interventions required to reduce the risk of cardiovascular disease.

CONCLUSIONS

Failing to achieve BP targets contributes substantially to healthcare system costs and preventable events in the countries studies.

Personality and self-variables: important determinants of subjective quality of life in schizophrenia out-patients

OBJECTIVE

To investigate factors determining severely mentally ill patients' self-rated quality of life. The study hypothesized that objective life circumstances, personality, self-variables, and psychopathology would be determinants of quality of life.

METHOD

A total of 117 individuals with schizophrenia and related disorders were investigated. Structural equation modelling was used to: 1). investigate if one or more subfactors best described the covariance within each potential determinant and quality of life, 2). explore the relations between all variables and factors extracted in step 1.

RESULTS

A multi-factorial model indicated that a self-factor and two psychopathology factors worked as mediators of self-rated quality of life, in turn composed of an internal and an external aspect. Personality dimensions and objective life circumstances accounted directly or indirectly for substantial parts of quality of life.

CONCLUSION

The relative importance of individual characteristics and objective indices was shown. Trait-like properties, such as the self-factor and personality, explained most of the variation in self-rated quality of life.

Cognitive function and health-related quality of life in elderly patients with hypertension--baseline data from the study on cognition and prognosis in the elderly (SCOPE)

The Study on COgnition and Prognosis in the Elderly (SCOPE) study is a multi-centre, prospective, randomized, double-blind, and parallel-group study aiming at comparing the effects of candesartan cilexetil and placebo on cardiovascular events and cognitive function in elderly patients with hypertension. The aim of this sub-analysis was to present data on cognitive function and health-related quality of life (HRQL) at baseline (randomization), and to investigate whether cognitive function was related to HRQL. More specifically, the main aim was to investigate the possible relationship between the Mini-Mental State Examination on one hand, and the Psychological General Well-Being (PGWB) index, the Subjective Symptom Assessment (SSA-P) Profile and the EuroQoL Health Utility Index (EQ-5D) on the other. All the instruments are extensively validated. A general finding was that cognitive function was positively associated with higher well-being (PGWB total score and self-control) and higher utility value (EQ-SD current health) but was unrelated to the occurrence of subjective adverse symptoms (SSA-P). Age and the use of psychotropic drugs, but not gender and education level, influenced this relationship significantly.

VALUE trial: Long-term blood pressure trends in 13,449 patients with hypertension and high cardiovascular risk

BACKGROUND

The Valsartan Antihypertensive Long-term Use Evaluation (VALUE) study compares cardiovascular outcomes in 15,314 eligible patients from 31 countries randomized to valsartan or amlodipine-based treatment.

METHODS

The blood pressure (BP) trends are analyzed in 13,449 of VALUE study patients who had baseline BP and 24 months BP and treatment data.

RESULTS

In a cohort of 12,570 patients, baseline 24 and 30 months BP, but not 30 months treatment data, were available. Of 13,449 patients, 92% (N = 12,398) received antihypertensive therapy at baseline. The baseline BP was 153.5/86.9 mm Hg in treated compared to 168.1.8/95.3 mm Hg in 1051 untreated patients. After 6 months both groups had indistinguishable BP values. At 12 months the BP decreased to 141.2/82.9 mm Hg (P <.0001 for systolic BP and diastolic BP versus baseline), at 24 months to 139.1/80 mm Hg (P <.0001 v 12 months), and to 138/79 mm Hg at 30 months (P <.0001 v 24 months). The systolic BP control (<140 mm Hg) at 30 months increased from 21.9% at baseline to 62.2%, the diastolic BP (< 90 mm Hg) from 54.2% to 90.2% and the combined control (<140 and <90 mm Hg) from 18.9% to 60.5%. At 24 months 85.8% of patients were on protocol drugs: monotherapy = 39.7%, added hydrochlorothiazide = 26.6%, add-on drugs = 15.1%, and protocol drugs in nonstandard doses = 4.3%.

CONCLUSIONS

The achieved BP control exceeds values reported in most published large-scale trials. The VALUE study is executed in regular clinical settings and 92% of the patients received antihypertensive drugs at baseline. When an explicit BP goal is set, and a treatment algorithm is provided, the physicians can achieve better control rates than in their regular practice.

Comparison of home and office blood pressure in treated hypertensives in the Nordic Diltiazem (NORDIL) Study

The aim of the Nordic Diltiazem (NORDIL) Study was to compare cardiovascular morbidity and mortality in calcium-antagonist-based treatment with diltiazem and conventional diuretic/beta-blocker-based treatment in essential hypertension. The objective of the present sub-study was to compare self-measured home blood pressure with office blood pressure at a time-point in the study when the patients' blood pressures had been treated to the level that the investigators conceived to be the blood pressure target. The NORDIL study was prospective, randomized, open and endpoint-blinded. It enrolled 10881 patients aged 50-74 years at health centers in Norway and Sweden who had diastolic blood pressure (BP) of 100 mmHg or more. The present sub-study group (n = 87) was small but fairly representative for the entire study population regarding baseline characteristics. Both systolic (4.0 mmHg, p = 0.01) and diastolic blood pressures (3.1 mmHg, p < 0.001) were significantly lower at home than in the office. Pearson correlation coefficients between the respective office and home readings were statistically highly significant (p < 0.001), but of moderate strength ranging from r = 0.41 for heart rate to r = 0.46 and r = 0.58 for diastolic and systolic blood pressures, respectively. Altman plots also gave statistical support to some inconsistency between the two methods of measurements. Pearson correlation coefficients between afternoon and morning measurements showed strong relationships with r-values >0.9 for both blood pressures and heart rate. The Altman plots also suggested excellent consistency between afternoon and morning measurements. Thus, motivated and trained hypertensive patients can perform home recordings of blood pressure and heart rate with precision; however, there are differences between recordings at home and in the investigators' offices that suggest some degree of "white coat effect" in these treated hypertensives.

The Study on Cognition and Prognosis in the Elderly (SCOPE): principal results of a randomized double-blind intervention trial

BACKGROUND

The prognostic benefits of blood pressure lowering treatment in elderly hypertensive patients were established more than a decade ago, but are less clear in those with mildly to moderately elevated blood pressure.

OBJECTIVE

To assess whether candesartan-based antihypertensive treatment in elderly patients with mildly to moderately elevated blood pressure confers a reduction in cardiovascular events, cognitive decline and dementia.

DESIGN

Prospective, double-blind, randomized, parallel-group study conducted in 1997-2002.

SETTING AND PARTICIPANTS

The study was of 4964 patients aged 70-89 years, with systolic blood pressure 160-179 mmHg, and/or diastolic blood pressure 90-99 mmHg, and a Mini Mental State Examination (MMSE) test score >or= 24. A total of 527 centres in 15 countries participated in the study.

INTERVENTION

Patients were assigned randomly to receive the angiotensin receptor blocker candesartan or placebo, with open-label active antihypertensive therapy added as needed. As a consequence, active antihypertensive therapy was extensively used in the control group (84% of patients). Mean follow-up was 3.7 years.

MAIN OUTCOME MEASURES

The primary outcome measure was major cardiovascular events, a composite of cardiovascular death, non-fatal stroke and non-fatal myocardial infarction. Secondary outcome measures included cardiovascular death, non-fatal and fatal stroke and myocardial infarction, cognitive function measured by the MMSE and dementia.

RESULTS

Blood pressure fell by 21.7/10.8 mmHg in the candesartan group and by 18.5/9.2 mmHg in the control group. A first major cardiovascular event occurred in 242 candesartan patients and in 268 control patients; risk reduction with candesartan was 10.9% [95% confidence interval (CI), -6.0 to 25.1, P = 0.19]. Candesartan-based treatment reduced non-fatal stroke by 27.8% (95% CI, 1.3 to 47.2, P = 0.04), and all stroke by 23.6% (95% CI, -0.7 to 42.1, P = 0.056). There were no significant differences in myocardial infarction and cardiovascular mortality. Mean MMSE score fell from 28.5 to 28.0 in the candesartan group and from 28.5 to 27.9 in the control group (P = 0.20). The proportions of patients who had a significant cognitive decline or developed dementia were not different in the two treatment groups.

CONCLUSIONS

In elderly hypertensive patients, a slightly more effective blood pressure reduction during candesartan-based therapy, compared with control therapy, was associated with a modest, statistically non-significant, reduction in major cardiovascular events and with a marked reduction in non-fatal stroke. Cognitive function was well maintained in both treatment groups in the presence of substantial blood pressure reductions. Both treatment regimens were generally well tolerated.

Principal results of the Controlled Onset Verapamil Investigation of Cardiovascular End Points (CONVINCE) trial

CONTEXT

Hypertensive patients are often given a calcium antagonist to reduce cardiovascular disease risk, but the benefit compared with other drug classes is controversial.

OBJECTIVE

To determine whether initial therapy with controlled-onset extended-release (COER) verapamil is equivalent to a physician's choice of atenolol or hydrochlorothiazide in preventing cardiovascular disease.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, randomized clinical trial conducted at 661 centers in 15 countries. A total of 16 602 participants diagnosed as having hypertension and who had 1 or more additional risk factors for cardiovascular disease were enrolled between September 1996 and December 1998 and followed up until December 31, 2000. After a mean of 3 years of follow-up, the sponsor closed the study before unblinding the results.

INTERVENTION

Initially, 8241 participants received 180 mg of COER verapamil and 8361 received either 50 mg of atenolol or 12.5 mg of hydrochlorothiazide. Other drugs (eg, diuretic, beta-blocker, or an angiotensin-converting enzyme inhibitor) could be added in specified sequence if needed.

MAIN OUTCOME MEASURES

First occurrence of stroke, myocardial infarction, or cardiovascular disease-related death.

RESULTS

Systolic and diastolic blood pressure were reduced by 13.6 mm Hg and 7.8 mm Hg for participants assigned to the COER verapamil group and by 13.5 and 7.1 mm Hg for partcipants assigned to the atenolol or hydrochlorothiazide group. There were 364 primary cardiovascular disease-related events that occurred in the COER verapamil group vs 365 in atenolol or hydrochlorothiazide group (hazard ratio [HR], 1.02; 95% confidence interval [CI], 0.88-1.18; P =.77). For fatal or nonfatal stroke, the HR was 1.15 (95% CI, 0.90-1.48); for fatal or nonfatal myocardial infarction, 0.82 (95% CI, 0.65-1.03); and for cardiovascular disease-related death, 1.09 (95% CI, 0.87-1.37). The HR was 1.05 (95% CI, 0.95-1.16) for any prespecified cardiovascular disease-related event and 1.08 (95% CI, 0.93-1.26) for all-cause mortality. Nonstroke hemorrhage was more common with participants in the COER-verapamil group (n = 118) compared with the atenolol or hydrochlorothiazide group (n = 79) (HR, 1.54 [95% CI, 1.16-2.04]; P =.003). More cardiovascular disease-related events occurred between 6 AM and noon in both the COER verapamil (99/277) and atenolol or hydrochlorothiazide (88/274) groups; HR, 1.15 (95% CI, 0.86-1.53).

CONCLUSIONS

The CONVINCE trial did not demonstrate equivalence of a COER verapamil-based antihypertensive regimen compared with a regimen beginning with a diuretic or beta-blocker. When considered in the context of other trials of calcium antagonists, these data indicate that the effectiveness of calcium-channel therapy in reducing cardiovascular disease is similar but not better than diuretic or beta-blocker treatment.

Benefits and risks of more intensive blood pressure lowering in hypertensive patients of the HOT study with different risk profiles: does a J-shaped curve exist in smokers?

BACKGROUND

The Hypertension Optimal Treatment (HOT) Study investigated 18 790 hypertensives randomized to three diastolic blood pressure (DBP) targets (< or = 90, < or = 85, < or = 80 mmHg) for 3.8 years and found marked, significant reductions in cardiovascular events and mortality the lower the target DBP in the subset of diabetics. We investigated whether the benefits of intensive DBP lowering could be extended to other subgroups, and whether there are hypertensives in whom the risk of aggressive DBP lowering may outnumber the benefits.

METHODS AND RESULTS

The 18 790 patients were stratified as: medium/high-very high global cardiovascular risk; men/women; older/younger; current smokers/non-smokers; higher/lower serum cholesterol; higher/lower serum creatinine; with/without diabetes; with/without ischaemic heart disease (IHD). Comparisons were made between the less aggressive target group (DBP < 90 mmHg) and the two more aggressive target groups together (< or = 85 and < or = 80 mmHg). A Cox proportional hazards model was used to calculate treatment-subgroup interactions and relative risks (RR) with 95% confidence intervals. Benefits were greatest in diabetics (RR 0.53 for cardiovascular events, and 0.67 for cardiovascular death), whereas in smokers more intensive DBP lowering was associated with increased risk of all types of cardiovascular event (RR 1.71-2.67; P = 0.01-0.001), except myocardial infarction. After excluding smokers, intensive DBP lowering was associated with significant reductions in cardiovascular events in diabetics (-49%), high-very high risk patients (-23%), IHD patients (-32%), patients with lower creatinine (-18%), women (-33%) and older patients (-23%).

CONCLUSIONS

Although subanalyses have only a descriptive value, it appears reasonable to recommend intensive antihypertensive treatment to hypertensives with diabetes, IHD and high global cardiovascular risk. In smokers, treatment intensification should be associated with the greatest efforts to induce smoking cessation.

Clinical utility of biochemical markers in colorectal cancer: European Group on Tumour Markers (EGTM) guidelines

In recent years, numerous serum and cell/tissue-based markers have been described for colorectal cancer (CRC). The aim of this article was to provide guidelines for the routine clinical use of some of these markers. Lack of sensitivity and specificity preclude the use of any available serum markers such as carcinoembryonic antigen (CEA), CA 19-9, CA 242, CA 72-4, tissue polypeptide antigen (TPA) or tissue polypeptide-specific antigen (TPS) for the early detection of CRC. However, preoperative measurement of CEA is desirable as this may give independent prognostic information, help with surgical management and provide a baseline level for subsequent determinations. For patients with stage 2 (Dukes' B) and 3 (Dukes' C) disease who may be candidates for liver resection, CEA levels should be measured every 2-3 months for at least 3 years after diagnosis. For monitoring treatment of advanced disease, CEA should also be tested every 2-3 months. Insufficient evidence is presently available to recommend the routine use of other serum markers for monitoring purposes. Similarly, the new cell and tissue-based markers (e.g, ras, P53) cannot yet be recommended for routine clinical use.

Health economics in the Hypertension Optimal Treatment (HOT) study: costs and cost-effectiveness of intensive blood pressure lowering and low-dose aspirin in patients with hypertension

OBJECTIVES

To investigate the marginal cost-effectiveness of different targets for the reduction of blood pressure and the cost-effectiveness of adding acetylsalicylic acid (ASA) to the treatment of hypertension.

DESIGN

Patients with hypertension were randomized to three target groups for blood pressure; < or =90, < or =85 and < or =80 mmHg. Patients were also randomly assigned ASA and placebo. The average follow-up time was 3.8 years. The direct costs for drugs, visits, hospitalizations, and side-effects were calculated and related to clinical outcome.

SETTING

Resource utilization data from all the 26 countries in the study were pooled, and Swedish unit costs were applied to the aggregated resource utilization.

SUBJECTS

A total of 18 790 patients, 50-80 years of age (mean 61.5 years), with a diastolic blood pressure between 100 and 115 mmHg (mean 105 mmHg).

INTERVENTIONS

Antihypertensive treatment with the long-acting calcium antagonist felodipine was given to all patients. Additional therapy and dose increments in four further steps were prescribed to reach the randomized target blood pressure. Fifty per cent of the patients were randomized to a low dose, 75 mg daily, of acetylsalicylic acid.

MAIN OUTCOME MEASURES

Direct health care costs, major cardiovascular (CV) events (myocardial infarction and stroke) and CV death.

RESULTS

The average cost of drugs and visits increased with more intensive treatment. The increase in treatment costs was partly but not fully offset by a nonsignificant reduction in the cost of CV hospitalizations. For patients with diabetes there were no significant differences in total cost between the target groups. The cost of avoiding a major CV event was negative in the base case analysis, SEK -10 360 (CI: -78 195, 75 630), and SEK 18 450 (CI: -88 789, 192 980) in a sensitivity analysis. For patients on ASA, costs were slightly but significantly higher than for patients on placebo. The estimates of the cost of avoiding a major CV event varied between SEK 41 600 and SEK 477 400, with very wide confidence intervals.

CONCLUSIONS

The treatment cost increases as the target for hypertension treatment is lowered. In patients with diabetes, intensive treatment to a lower target is cost-effective. Because of the nonsignificant difference in events, no conclusion can be made for all patients in the study. Furthermore, no conclusive evidence was found regarding the cost-effectiveness of adding ASA to the treatment of hypertension.

Bronchodilation by an inhaled VPAC(2) receptor agonist in patients with stable asthma

BACKGROUND

The synthetic vasoactive intestinal peptide (VIP) analogue Ro 25-1553 is a selective VIP-PACAP type 2 (VPAC(2)) receptor agonist that causes a bronchodilatory effect in guinea pigs in vivo. The effect of Ro 25-1553 given by inhalation to patients with asthma was studied and compared with that of a long acting beta(2) adrenoceptor agonist.

METHODS

Twenty four patients with moderate stable asthma participated in a double blind, randomised, placebo controlled, crossover study. The primary variable was bronchodilatory effect (increase in forced expiratory volume in 1 second, FEV(1)) after inhalation of Ro 25-1553 (100 microg or 600 microg) and formoterol (4.5 microg), respectively. Putative side effects were characterised by monitoring sitting blood pressure, serum potassium, electrocardiography and echocardiography.

RESULTS

Inhalation of 600 microg Ro 25-1553 caused a rapid bronchodilatory effect (geometric mean increase in FEV(1) compared with placebo) within 3 minutes of 6% (95% CI 4 to 9), as did inhalation of formoterol (8% (95% CI 5 to 10)). The corresponding maximum bronchodilatory effect during 24 hours was similar for 600 microg Ro 25-1553 (7% (95% CI 4 to 10)) and the reference bronchodilator formoterol (10% (95% CI 7 to 12)). However, for both doses of Ro 25-1553 the bronchodilatory effect was attenuated 5 hours after inhalation whereas formoterol still had a bronchodilatory effect 12 hours after inhalation. Neither Ro 25-1553 nor formoterol produced any clinically relevant side effects. No drug related difference in adverse events was observed.

CONCLUSION

Inhalation of a synthetic selective VPAC(2) receptor agonist constitutes a promising approach for bronchodilation in patients with asthma.

Activation of platelet-derived growth factor pathway in human asthmatic pulmonary-derived mesenchymal cells

Cell cultures of mesenchymal type were obtained from biopsies taken after bronchoscopy from patients with asthma. It was possible to achieve outgrowth of fibroblast-like cells from these lung biopsies, which stained for alpha-smooth actin indicating that they were of myofibroblast type. Morphologically, two types of myofibroblasts could be observed: one intermediate form with more stretched cell shape and lamellipodia protrusions, and one more differentiated compact form of myofibroblast. The intermediate form was the most dominant type in these patients, indicating an active ongoing remodelling process. Further studies showed that platelet-derived growth factor (PDGF) might be the factor that stimulates the formation of the intermediate type of myofibroblasts, since it enhance migration of normal human lung fibroblasts 4-fold compared to control through an induced formation of stress fibers and lamellipodia protrusions. Additionally, intracellular signalling pathways involved in migration, such as RhoA and MAPkinase were stimulated 1.5-fold and 3.5-fold, respectively. By using two-dimensional (2-D) gel electrophoresis and protein identification by peptide mass finger printing matrix assisted laser desporption/ionization - time of flight - mass spectrometry (MALDI-TOF-MS) it was possible to confirm that PDGF affected the synthesis of proteins involved in the remodelling process, such as collagen VI and post-translational forms thereof. PDGF also stimulated the production of FK506 binding protein of 65 kDa, a protein involved in smooth muscle differentiation, and proteins involved in the rearrangement of the cytoskeleton connected to migration such as the actin related protein ARP3, the T-complex protein and the heat shock protein 60. We demonstrate that PDGF has a potential pathological role in asthma and formation of subepithelial fibrosis by inducing changes in the proteome.

Comparison of user assessed needs for care between psychiatric inpatients and supported community residents

The aim of the present study was to compare user assessed needs for care for psychiatric patients in inpatient settings with that of residents in supported community residences. The Camberwell Assessment of Need was administered to 75 patients and residents in different housing settings. Residents in supported community settings had more needs for care (8.1), than patients in inpatient settings (5.8), partly because of differences in duration of illness. A greater proportion of those living in supported community residences reported needs in the areas of psychotic symptoms, accommodation, food, daytime activities, sexual expression and looking after the home. There were no differences in numbers of unmet needs. Relatives and friends provided emotional and social support predominantly in the areas of company and psychological distress. In conclusion, living in supported community residences does not imply more unmet needs, or less adequate response to needs from services, despite a greater number of needs being reported. In some areas of need, relatives and friends play an important role in the provision of support.

Calcium antagonist lacidipine slows down progression of asymptomatic carotid atherosclerosis: principal results of the European Lacidipine Study on Atherosclerosis (ELSA), a randomized, double-blind, long-term trial

BACKGROUND

Most cardiovascular events associated with hypertension are complications of atherosclerosis. Some antihypertensive agents influence experimental models of atherosclerosis through mechanisms independent of blood pressure lowering.

METHODS AND RESULTS

The European Lacidipine Study on Atherosclerosis (ELSA) was a randomized, double-blind trial in 2334 patients with hypertension that compared the effects of a 4-year treatment based on either lacidipine or atenolol on an index of carotid atherosclerosis, the mean of the maximum intima-media thicknesses (IMT) in far walls of common carotids and bifurcations (CBM(max)). This index has been shown by epidemiological studies to be predictive of cardiovascular events. A significant (P<0.0001) effect of lacidipine was found compared with atenolol, with a treatment difference in 4-year CBM(max) progression of -0.0227 mm (intention-to-treat population) and -0.0281 mm (completers). The yearly IMT progression rate was 0.0145 mm/y in atenolol-treated and 0.0087 mm/y in lacidipine-treated patients (completers, 40% reduction; P=0.0073). Patients with plaque progression were significantly less common, and patients with plaque regression were significantly more common in the lacidipine group. Clinic blood pressure reductions were identical with both treatments, but 24-hour ambulatory systolic/diastolic blood pressure changes were greater with atenolol (-10/-9 mm Hg) than with lacidipine (-7/-5 mm Hg). No significant difference between treatments was found in any cardiovascular events, although the relative risk for stroke, major cardiovascular events, and mortality showed a trend favoring lacidipine.

CONCLUSION

The greater efficacy of lacidipine on carotid IMT progression and number of plaques per patient, despite a smaller ambulatory blood pressure reduction, indicates an antiatherosclerotic action of lacidipine independent of its antihypertensive action.

Living situation, subjective quality of life and social network among individuals with schizophrenia living in community settings

OBJECTIVE

To investigate the relationships between characteristics of the living situation in the community and subjective quality of life and social network among community-based individuals with schizophrenia.

METHOD

A total of 418 individuals with schizophrenia from 10 sites were interviewed with regard to quality of life, psychopathology, social network and needs for care. Characteristics of the living situation investigated were: living alone or not, living with family or not, and having an independent or a sheltered housing situation.

RESULTS

An independent housing situation was related to a better quality of life concerning living situation and living with the family to a better quality of life concerning family relations. An independent housing situation was associated with a better social network regarding availability and adequacy of emotional relations.

CONCLUSION

People with schizophrenia with an independent housing situation have a better quality of life associated with more favorable perceptions of independence, influence, and privacy. Their social network is better irrespective of whether they live alone or not, or with family or not.

Benefit and harm of low-dose aspirin in well-treated hypertensives at different baseline cardiovascular risk

BACKGROUND

The effects of aspirin in subjects without cardiovascular disease are controversial. In the intensively treated patients of the Hypertension Optimal Treatment (HOT) Study, randomization to low-dose aspirin (75 mg daily) versus placebo significantly reduced cardiovascular events (-15%) and myocardial infarction (-36%), but increased major bleedings (+65%). The present analyses of HOT Study data aim at identifying subgroups of hypertensives with different benefit-to-harm ratios from aspirin, in order to provide recommendations about the use of aspirin in hypertension.

METHODS

The 18 790 hypertensive patients (aspirin 9399, placebo 9391; average treatment duration 3.8 years) were stratified for global cardiovascular risk and for individual risk factors. Subgroup-treatment interaction analyses (end points: cardiovascular events, myocardial infarction, major bleedings) were performed by a Cox proportional hazard model. Relative and absolute benefits and harms were calculated.

RESULTS

Interaction analyses indicated that of all subgroups, only patients with serum creatinine > 1.3 mg/dl had a significantly greater reduction of cardiovascular events and myocardial infarction (-13 and -7/1000 patient-years), while risk of bleeding was not significantly different between subgroups. In addition to patients with higher creatinine, a favourable balance between benefit and harm of aspirin was found in subgroups of patients at higher global baseline risk and baseline systolic pressure > or = 180 or diastolic pressure > or = 107 mmHg.

CONCLUSIONS

Low-dose aspirin should be recommended to well-treated hypertensive patients with even moderate increase in serum creatinine. Aspirin may also be recommended in well-treated hypertensives at higher global cardiovascular risk or higher initial blood pressures.

Natural allergen exposure does not diminish the sensitivity of cytokine production to glucocorticosteroids in blood cells of seasonal allergic asthma and rhinitis patients

Glucocorticosteroid (GCS) inhibition of cytokine production is a major anti-inflammatory mechanism. However, increased production of pro-inflammatory cytokines during allergic airway inflammation has been proposed to reduce GCS effects. This study aimed to investigate whether allergic airway inflammation due to natural allergen exposure might decrease the sensitivity of granulocyte-macrophage colony-stimulating factor (GM-CSF) production to GCS in blood cells. Blood samples were collected from patients with seasonal allergic asthma (n = 10) and rhinitis (n = 8) and healthy subjects (n = 9), before, during, and after the birch pollen season. Whole blood cultures were stimulated with LPS (10 ng/ml) and treated with budesonide (10(-11)-10(-7) M) for 20 h. GM-CSF levels were analysed using immunoassay. Birch pollen exposure did not alter LPS-stimulated GM-CSF production, although disease symptoms and blood eosinophils increased in the patients. There were no significant differences in budesonide inhibition of GM-CSF production by blood cells of asthma and rhinitis patients compared with cells of healthy subjects before, during or after the birch pollen season and no change in response to allergen exposure. A concentration of 1 nM budesonide inhibited GM-CSF production by more than 50% at all time points. In conclusion, natural allergen exposure did not reduce the sensitivity of GM-CSF production to GCS inhibition in blood cells of seasonal allergic asthma and rhinitis patients.

Hypertension management in 2002: where have we been? where might we be going?

The term "blood pressure" was coined almost 300 years ago by the man who first measured it, the Reverend Stephen Hales of England. However, our understanding of the pathogenesis and consequences of hypertension, as well as the available treatments for it, have remained greatly limited and inadequate until only the past 30 years. Starting in 1977, reports from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of Hypertension (JNC) have provided regular updates on developments in hypertension management, and have set guidelines for the diagnosis and treatment of hypertension. More than 20 years ago, the JNC stratified blood pressure (BP) levels into categories of mild, moderate, and severe (later renamed stages 1, 2, and 3, respectively). A stepped-care approach to hypertension therapy was originally recommended. With each revised JNC report, there was a reduction in target BP and a growing recognition of the importance of high-normal BP and isolated systolic hypertension. The sixth and most current report of the Joint National Committee, JNC VI, emphasizes treatment of comorbidities of hypertension, sets a lower BP goal (<130/85 mm Hg) for high-risk patients-eg, those with diabetes or renal disease-than for those with uncomplicated hypertension (<140/90 mm Hg), and places a greater emphasis on disease prevention. For the future, the current trend toward lower BP goals suggests that more effective and better tolerated antihypertensive therapies will be needed. Multiple antihypertensive agents used concomitantly will likely be needed to control elevated levels of BP in the majority of hypertensive patients.

The relationship between dose and antihypertensive effect for different AT1-receptor blockers

Hypertensive patients require adequate control of blood pressure to limit the development of cardiovascular complications. The introduction of the angiotensin II type I (AT1)-receptor blockers was an important breakthrough, offering effective control of blood pressure with placebo-like tolerability. The relationship between dose and antihypertensive effect has been more or less well defined for the different AT1-receptor blockers currently available. Attempts to compare the antihypertensive effects of different AT1-receptor blockers using meta-analyses of several studies have been performed, although the results of such analyses are often limited by the inconsistencies of included trials and the inability to examine primary data and methodology. Furthermore, it is important to include data from the most up-to-date studies and to ensure correction of placebo effects, which tend to differ considerably between studies and contribute in varying degrees to the apparent therapeutic efficacies observed. Consequently, while meta-analysis can be useful in determining dose-response relationships for individual drugs, randomized, prospective, double-blind, head-to-head comparative studies are the only accurate means of comparing efficacy between drugs. A number of such trials have confirmed the superior efficacy of candesartan cilexetil and irbesartan compared with losartan in terms of reduction in blood pressure and maintenance of antihypertensive efficacy between doses.

Mental health care reform in Sweden, 1995

OBJECTIVE

To describe the content of the Community Mental Health Care reform in Sweden, in effect from 1995 and directed to severely mentally ill people (SMI).

METHOD

Evaluating changes, at local and national level, in living conditions among SMI and resources of services directed to them, by using registers, questionnaires, interviews and case studies.

RESULTS

A survey, covering 93% of the population, identified 43,000 SMI (prevalence of 0.63%); 4,000 long-stay patients and 400 rehabilitation programmes were transferred from psychiatric services to social services (15% of the budget of psychiatric services). Employment and rehabilitation projects, family support and user programmes and educational projects for social services staff, were launched (funded by state subsidies).

CONCLUSION

SMI still have difficulties in obtaining adequate support on the basis of disability laws and there continue to be barriers between social services and psychiatric services.

Accuracy of a first diagnosis of asthma in primary health care

BACKGROUND

In a postal questionnaire study, the prevalence of asthma in southern Sweden has been found to be 5.5%. However, the register prevalence of asthma obtained from the medical records in the same municipality and age groups was found to be only 2.1%.

OBJECTIVES

The aims of the study were to investigate whether the low register prevalence of asthma was caused by an underdiagnosis of asthma in primary health care and to validate a first diagnosis of asthma set by GPs in primary health care.

METHODS

During a period of 3 months in 1997, all patients seeking care in the primary health care units of the municipality of Lund (population 171 877) with upper or lower airway infections, prolonged cough, allergic rhinitis, fatigue or a first positive diagnosis of asthma were recorded ( n = 3025).

RESULTS

In the whole group of 3025 patients, 99 patients were found to have received a diagnosis of asthma for the first time during the study period. The diagnosis was verified in 52 of those 68 patients who attended a follow-up and examination by a respiratory physician. Among the remaining 2926 patients, 221 patients were selected randomly to constitute a control group. In this group, three patients were found to have asthma. Thus, the specificity of an asthma diagnosis set in primary health care was 0.99 [95% confidence interval (CI) 0.99-1.00] and the sensitivity was 0.59 (95% CI 0.31-0.81).

CONCLUSIONS

The GPs in this study were good at excluding those who did not have asthma (specificity 99%) but less good in correctly diagnosing those who actually had current asthma (sensitivity 59%), which suggests an underdiagnosis of asthma.

Effects of formoterol (Oxis Turbuhaler) and ipratropium on exercise capacity in patients with COPD

Although long-acting inhaled beta 2-agonists improve various outcome measures in COPD, no double-blind study has yet shown a significant effect of these drugs on exercise capacity. In a randomized, double-blind, placebo-controlled, crossover study, patients received formoterol (4, 5, 9, or 18 micrograms b.i.d. via Turbuhaler), ipratropium bromide (80 micrograms t.i.d. via pMDI with spacer), or placebo for 1 week. Main endpoint was time to exhaustion (TTE) in an incremental cycle ergometer test. Secondary endpoints were Borg dyspnoea score during exercise, lung function, and adverse events. Thirty-four patients with COPD were included, mean age 64.8 years, FEV1 55.6% predicted, reversibility 6.1% predicted. All doses of formoterol, and ipratropium significantly improved TTE, FEV1, FEF25-75%, FRC, IVC, RV and sGAW compared with placebo. A negative dose-response relationship was observed with formoterol. Ipratropium increased time to exhaustion more compared with formoterol, 18 micrograms, but not with formoterol, 4.5 and 9 micrograms. No changes in Borg score were found. There was no difference in the adverse event profile between treatments. In conclusion, 1 week of treatment with formoterol and ipratropium significantly improved exercise capacity and lung function compared with placebo. However, a negative dose-response relation for formoterol was unexpected and needs further investigation.

The relationship between coping strategies and family burden among relatives of admitted psychiatric patients

Coping strategies as assessed by a projective coping instrument, showed only a weak relationship to perceived family burden and participation in care among 78 close relatives of voluntarily and compulsorily admitted psychiatric patients in this study conducted in two psychiatric services in Sweden in 1997. The results rather indicate that problem solving coping strategies are used when the relatives are in situations amenable to change and that emotion-focused coping strategies are used in situations that are chronic and unchangeable. Furthermore, no differences in coping strategies were found between the relatives and a Swedish normative sample. No relationships were found between coping strategies and when the relative thought that the patient's mental health had led to mental problems in the relative or if the relative experienced that the relationship with the patient had been negatively affected by the mental illness. The usefulness of coping instruments based on personality components in research on family burden is called into question, and a reconsideration of qualitative research methods is recommended.

Validity of the Body Awareness Scale-Health (BAS-H)

Quality of movement assessment using the Body Awareness Scale-Health (BAS-H) was validated against the following self-rating tests: Nottingham Health Profile (NHP); Arthritis Self-Efficacy Scale (ASES); Psychological General Well-Being (PGWB); Sense of Coherence (SoC); Sivic Psychosomatism test (SPS); Symptom Check List 90-R (SCL 90-R); and Visual Analogue Scale for pain intensity (VAS-pain). In total, 75 persons were included, divided into three groups: psychiatric outpatients (n = 25), chronic pain patients (n = 25) and healthy controls (n = 25). The highest significant correlations were obtained between the BAS-H total index and the sub-indices of grounding/stability to the centre line, centering/breathing and flow on the one hand, and the NHP, the ASES, and the PGWB on the other, with r ranging from 0.36 to 0.73. Multiple regression analysis revealed the NHP to explain 50% and ASES a further 5% of the variance in the BAS-H total index. Significant differences for both the BAS-H total index and the sub-indices were obtained between the two patient groups and the healthy controls. It is concluded that the construct validity of the BAS-H was found to be in accordance with theoretical expectations.

Influence of age, sex and blood pressure on the principal endpoints of the Nordic Diltiazem (NORDIL) Study

BACKGROUND

The aim of the Nordic Diltiazem (NORDIL) Study was to compare patients with essential hypertension receiving calcium-antagonist-based treatment with diltiazem and similar patients receiving conventional diuretic/beta-blocker-based treatment, with respect to cardiovascular morbidity and mortality.

OBJECTIVE

To assess the influence of age, sex, severity of hypertension and heart rate on treatment effects, in a sub-analysis.

METHODS

The NORDIL study was prospective, randomized, open and endpoint-blinded. It enrolled, at health centres in Norway and Sweden, 10 881 patients aged 50-74 years who had diastolic blood pressure (DBP) of 100 mmHg or more. Systolic blood pressure (SBP) and DBP were decreased by 20.3/18.7 mmHg in the diltiazem group and by 23.3/18.7 mmHg in the diuretic/beta-blocker group - a significant difference in SBP (P < 0.001).

RESULTS

The incidence of the primary endpoint - a composite of cardiovascular death, cerebral stroke and myocardial infarction - was similar for the two treatments. Fatal and non-fatal stroke occurred in 159 patients in the diltiazem group and in 196 patients in the conventional treatment group [relative risk (RR) 0.80, 95% confidence interval (CI) 0.65 to 0.99; P = 0.040], whereas there was a non-significant inverse tendency with respect to all myocardial infarction. There were significantly fewer cerebral strokes in patients receiving diltiazem in the subgroups with baseline SBP > 170 mmHg (n = 5420, RR 0.75, 95% CI 0.58 to 0.98; P = 0.032), DBP >/= 105 mmHg (n = 5881, RR 0.74, 95% CI 0.57 to 0.97; P = 0.030) and pulse pressure >/= 66 mmHg (n = 5461, RR 0.76, 95% CI 0.58 to 0.99, P = 0.041), and more myocardial infarctions in those with heart rate less than 74 beats/min (n = 5303, RR 1.13, 95% CI 1.01 to 1.87; P = 0.040). However, the tendencies for fewer strokes and greater incidence of myocardial infarction were present across subgroups when results were analysed for age, sex, severity of hypertension and heart rate, and treatment-subgroup interaction analyses were not statistically significant.

CONCLUSIONS

Compared with a conventional diuretic/beta-blocker-based antihypertensive regimen, there were additional 25% reductions in stroke in the diltiazem-treated patients with blood pressure or pulse pressure greater than the medians, and an increase in myocardial infarction in those with heart rate less than the median. Such findings may be attributable to chance, but the consistency of, in particular, the stroke findings may also suggest an ability of diltiazem, beyond conventional treatment, to prevent cerebral stroke in hypertensive patients with the greatest cardiovascular risk.

Low-dose aspirin does not interfere with the blood pressure-lowering effects of antihypertensive therapy

BACKGROUND

It has been reported that aspirin (ASA) may interfere with the blood pressure (BP)-lowering effect of various antihypertensive agents and attenuate the beneficial effects of angiotensin-converting enzyme (ACE) inhibitors in patients with congestive heart failure.

METHODS AND RESULTS

Data from the Hypertension Optimal Treatment (HOT) Study, in which 18 790 intensively treated hypertensive patients were randomized to either ASA 75 mg daily or placebo for 3.8 years (with a 15% reduction in cardiovascular events and a 36% reduction in myocardial infarction in ASA-treated patients), were reanalysed for the whole group of patients and for various subgroups with particular attention to the possible effects of ASA on BP and renal function. In ASA-treated and placebo-treated patients: (1) systolic blood pressure (SBP) and diastolic blood pressure (DBP) values achieved with antihypertensive treatment were superimposable, with clinically irrelevant differences; (2) these superimposable SBP and DBP were achieved with antihypertensive therapies, that were quantitatively and qualitatively similar, and (3) changes in serum creatinine and in estimated creatinine clearance and the number of patients developing renal dysfunction were also similar. Furthermore, the cardiovascular benefits of ASA were of the same magnitude in hypertensive patients receiving or not receiving ACE-inhibitors.

CONCLUSIONS

Even long-term, low-dose ASA does not interfere with the BP-lowering effect of antihypertensive agents, including combinations with ACE inhibitors, or with renal function. No negative interaction occurs between ACE inhibition and the cardiovascular benefits of small dose of ASA. Our conclusions cannot be extended to larger doses of ASA, or to patients with congestive heart failure.

'Why don't you do as I tell you?' Compliance and antihypertensive regimens

Although hypertension is recognised as one of the major health hazards in the developed world, compliance with antihypertensive regimens is still undesirably low. This brings important costs, both to patients in increased morbidity and mortality, and to society in hospitalisations and lost productivity. This review surveys possible reasons for non-compliance with treatments generally and antihypertensive medications specifically. It also looks at how insights into reasons for non-compliance can help us design more effective treatments, and discusses current and emerging medications in the context of compliance. As one of the reasons for low compliance is thought to be the impact of a drug on the patient's lifestyle, recently developed agents such as angiotensin II-receptor blockers may be expected to have less effect on patients' daily lives than earlier treatments, which brings hope for increased compliance with these regimens.

Proteoglycan and proteome profiling of central human pulmonary fibrotic tissue utilizing miniaturized sample preparation: a feasibility study

The objective of this study was to isolate fibrotic cells from human lung biopsies taken from different central pulmonary locations. A comparison was made of cell morphology, proteoglycan- and protein-expression in mesenchymal cell cultures obtained from human bronchial biopsies from patients with asthmatic-like disorders. We isolated viable cells from 10 out of the 12 biopsies. The fibroblast-like cells were positive for the biomarker a-smooth muscle actin, indicating that the cells were in an activated state. Two different types of fibroblast-like cells were observed from human pulmonary connective tissue; one of contractile type with lamellipodia that facilitate migration and a second cell type with an increased cell size, which most likely is of a synthetic phenotype. This is the first evidence of alterations in the proteoglycan expression pattern of versican, perlecan, biglycan and decorin which can be linked to the pathophysiological state of asthmatics proven by a combination of solid-phase extraction by reversed phase and by peptide mass fingerprinting using matrix-assisted laser desorption/ionization-time of flight mass spectrometry. Protein expression analysis using two-dimensional electrophoresis was interfaced to miniaturized sample preparation techniques using microcapillary extraction. Four protein groups were identified; cytoskeletal, adhesion, scavenger and metabolic proteins. These patient's proteomes showed a high degree of heterogeneity between patients but larger homogeneity within biopsies derived from different locations of the same patient.

How far should we lower blood pressure in the elderly

In the last few years several large intervention trials have addressed the treatment of hypertension in the elderly and how far blood pressure should be lowered in such patients. The positive results of intervention against high blood pressure in the elderly has resulted in a positive attitude towards treatment and today this is an accepted and highly effective medical intervention. Both stroke and coronary morbidity have been shown to be positively affected as has total mortality. The specific issue, how far to lower blood pressure in the elderly was probably best addressed in the Hypertension Optimal Treatment (HOT) stduy in which about a third of the patients, i.e. >6,000 patients, were > or =65 years of age. In most of the early intervention studies of antihypertensive treatment in elderly patients diuretics or beta-blockers or the two in combination were used as the therapy by which blood pressure was lowered. However, novel therapies, in particular calcium antagonists, have shown benefits of the same magnitude as the older therapies, e.g. in the STONE trial, the Syst-Eur study, the Syst-China study and the STOP-Hypertension-2 study. In the latter study a regimen based on either of two ACE inhibitors was also shown to be equally effective as conventional treatment, based on diuretics and/or betablockers, in the elderly. These trials will be briefly reviewed here as will the SCOPE study which is an ogoing trial in which hypertensive patients aged 70-89 years are being treated with an angiotensin II receptor antagonist under double-blind and placebo-controlled conditions. It can be concluded that a wealth of information, based on large intervention trials, has been accumulated during the last decade. It is quite obvious that the elderly hypertensive patients benefit from antihypertensive treatment to at least the same extent as the young and middle-aged. It appears that blood pressure ought to be lowered down to normotensive values also in the elderly in order to minimize their risk if cardiovascular complications, although more studies would be welcome to address this issue specifically in the elderly.

Pathophysiologic and therapeutic importance of tissue ACE: a consensus report

Angiotensin-converting enzyme (ACE) activation and the de novo production of angiotensin II contribute to cardiovascular disease through direct pathological tissue effects, including vascular remodeling and inflammation, as well as indirect action on nitric oxide bioavailability and its consequences. The endothelium plays a pivotal role in both vascular function and structure; thus, the predominant localization of ACE to the endothelium has implications for the pathobiology of vascular disease, such as coronary artery disease. Numerous experimental studies and clinical trials support the emerging realization that tissue ACE is a vital therapeutic target, and that its inhibition may restore endothelial function or prevent endothelial dysfunction. These effects exceed those attributable to blood pressure reduction alone; hence, ACE inhibitors may exert an important part of their effects through direct tissue action. Pharmacologic studies show that while ACE inhibitors may differ according to their binding affinity for tissue ACE the clinical significance remains to be determined.

Epidermal overexpression of stratum corneum chymotryptic enzyme in mice: a model for chronic itchy dermatitis

Identification of tissue-specific mechanisms involved in the pathophysiology of inflammatory skin diseases could offer new possibilities to develop effective therapies with fewer systemic effects. The serine protease stratum corneum chymotryptic enzyme is preferentially expressed in cornifying epithelia. We have previously reported on increased expression of the stratum corneum chymotryptic enzyme in psoriasis. Here is reported an increased epidermal expression of stratum corneum chymotryptic enzyme also found in chronic lesions of atopic dermatitis. Transgenic mice expressing human stratum corneum chymotryptic enzyme in suprabasal epidermal keratinocytes were found to develop pathologic skin changes with increased epidermal thickness, hyperkeratosis, dermal inflammation, and severe pruritus. The results suggest that stratum corneum chymotryptic enzyme may be involved in the pathogenesis of inflammatory skin diseases, and that stratum corneum chymotryptic enzyme and related enzymes should be evaluated as potential targets for new therapies.