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Hamam O, Gudenkauf J, Moustafa R, Cho A, Montes D, Sharara M, Moustafa A, Radmard M, Nabi M, Chen K, Sepehri S, Shin C, Mazumdar I, Kim M, Mohseni A, Malhotra A, Romero J, Yedavalli V. Hypoperfusion Intensity Ratio as an Indirect Imaging Surrogate in Patients With Anterior Circulation Large-Vessel Occlusion and Association of Baseline Characteristics With Poor Collateral Status. J Am Heart Assoc 2024; 13:e030897. [PMID: 39158547 DOI: 10.1161/jaha.123.030897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 11/15/2023] [Indexed: 08/20/2024]
Abstract
BACKGROUND Collateral status (CS) plays a crucial role in infarct growth rate, risk of postthrombectomy hemorrhage, and overall clinical outcomes in patients with acute ischemic stroke (AIS) secondary to anterior circulation large-vessel occlusions (LVOs). Hypoperfusion intensity ratio has been previously validated as an indirect noninvasive pretreatment imaging biomarker of CS. In addition to imaging, derangements in admission laboratory findings can also influence outcomes in patients with AIS-LVO. Therefore, our study aims to assess the relationship between admission laboratory findings, baseline characteristics, and CS, as assessed by hypoperfusion intensity ratio in patients with AIS-LVO. METHODS AND RESULTS In this retrospective study, consecutive patients presenting with AIS secondary to anterior circulation LVO who underwent pretreatment computed tomography perfusion were included. The computed tomography perfusion data processed by RAPID (Ischema View, Menlo Park, CA) generated the hypoperfusion intensity ratio. Binary logistic regression models were used to assess the relationship between patients' baseline characteristics, admission laboratory findings, and poor CS. A total of 221 consecutive patients with AIS-LVO between January 2017 and September 2022 were included in our study (mean±SD age, 67.0±15.8 years; 119 men [53.8%]). Multivariable logistic regression showed that patients with AIS caused by cardioembolic and cryptogenic causes (adjusted odds ratio [OR], 2.67; 95% CI, 1.20-5.97; P=0.016), those who presented with admission National Institutes of Health Stroke Scale score ≥12 (adjusted OR, 3.12; 95% CI, 1.61-6.04; P=0.001), and male patients (adjusted OR, 2.06; 95% CI, 1.13-3.77; P=0.018) were associated with poor CS. CONCLUSIONS Stroke caused by cardioembolic or cryptogenic causes, admission National Institutes of Health Stroke Scale score of ≥12, and male sex were associated with poor CS, as defined by hypoperfusion intensity ratio in the patients with AIS-LVO.
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Affiliation(s)
- Omar Hamam
- Department of Radiology, Massachusetts General Hospital Harvard Medical School Boston MA
| | - Julie Gudenkauf
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Rawan Moustafa
- Department of Cardiovascular Medicine Robert Wood Johnson Medical School New Brunswick NJ
- School of Arts and Sciences Rutgers University-Newark Newark NJ
| | - Andrew Cho
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Daniel Montes
- Radiology Resident University of Colorado, Anschutz Medical Campus Aurora CO
| | | | - Abdallah Moustafa
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Mahla Radmard
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Mehreen Nabi
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Kevin Chen
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Sadra Sepehri
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | | | - Ishan Mazumdar
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Minsoo Kim
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Alireza Mohseni
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | | | - Javier Romero
- Department of Radiology, Massachusetts General Hospital Harvard Medical School Boston MA
| | - Vivek Yedavalli
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
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Insani WN, Whittlesea C, Wei L. Prevalence of cardiovascular drug-related adverse drug reactions consultations in UK primary care: A cross-sectional study. PLoS One 2024; 19:e0307237. [PMID: 39046945 PMCID: PMC11268649 DOI: 10.1371/journal.pone.0307237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 06/28/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Adverse drug reactions (ADRs) represent a significant barrier to achieve optimal treatment outcomes. Cardiovascular drugs, including antihypertensive drugs, lipid-lowering drugs, and antithrombotic drugs, are among the most prescribed medications in the primary care setting. OBJECTIVES To estimate the prevalence of cardiovascular drug-related ADRs consultations in United Kingdom (UK) primary care and identify risk factors of these ADRs. METHODS This was a cross-sectional study of cardiovascular drug users between 2000-2019 using UK IQVIA Medical Research Data. ADRs consultations were identified using database screening method employing standardised designated codes. The overall and annual age-standardised prevalence was estimated using direct standardisation method using 2019 mid-year UK population. Risk factors of ADRs consultations were estimated using logistic regression model stratified by therapeutic areas. RESULTS The standardised prevalence of consultations related to cardiovascular drugs ADRs was 10.60 (95% CI. 10.46, 10.75) per 1000 patients. Patients aged 70-79 years had the highest occurrence of ADRs consultations. The most frequently drug classes implicated in the ADRs consultations were statins (n = 9,993 events, 27.09%), beta-blockers (n = 8,538 events, 23.15%), ACEIs/ARBs (n = 8,345 events, 22.62%), and aspirin (n = 6,482 events, 17.57%). Risk factors of ADRs consultations were previous history of cardiovascular diseases, e.g., myocardial infarction and stroke; advanced age, comorbidities; diabetes and dyslipidaemia; and polypharmacy. CONCLUSIONS The burden of cardiovascular drug-related ADRs consultations in primary care was considerable. Statins, beta-blockers, ACEIs/ARBs, and aspirin were the most frequently implicated drug classes. Closer clinical monitoring should be performed for patients affected by the ADRs to mitigate the risk of suboptimal treatment outcomes.
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Affiliation(s)
- Widya N. Insani
- Department of Pharmacology and Clinical Pharmacy, Padjadjaran University, Bandung, Indonesia
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
- Centre of Excellence for Pharmaceutical Care Innovation, Padjadjaran University, Bandung, Indonesia
| | - Cate Whittlesea
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Jung HH. Blood pressure control in patients aged above and below 75 years. PLoS One 2024; 19:e0297103. [PMID: 38300966 PMCID: PMC10833546 DOI: 10.1371/journal.pone.0297103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/24/2023] [Indexed: 02/03/2024] Open
Abstract
It remains unclear what the blood pressure target is and at which point in life it is appropriate for antihypertensive treatment. This study aimed to determine age-specific systolic blood pressure (SBP) targets. In a nationwide cohort of 296,470 hypertensive patients aged ≥75 years and a representative cohort of 259,028 hypertensives aged 45-74 years, multivariable-adjusted incidence rates of cardio-kidney composite events, overt dementia, and all-cause deaths were estimated across yearly-averaged on-treatment SBP levels according to age and the presence of 4 additional risk factors (diabetes, dyslipidemia, albuminuria, and smoking). For cardio-kidney events, on-treatment SBP showed positive curvilinear associations with higher risks at ≥135 mm Hg in most while an attenuated association in age ≥85 years. For overt dementia, SBP showed flat or slightly inverted associations in elderly while a small positive association in age 45-64 years. For all-cause mortality, SBP showed J-shaped associations having right-shifting tendency with age. For risk categories with ≥2, 1, and no additional risk factors, the respective mortality rate differences between SBP 145-154 mm Hg and 125-134 mm Hg were 4.6 (95% confidence interval [CI], 2.0 to 7.3), 1.2 (95% CI, -0.3 to 2.8), and 0.1 (95% CI, -1.4 to 1.8) per 1000 person-years in age ≥75 years and 2.9 (95% CI, 1.7 to 4.3), 0.7 (95% CI, 0.1 to 1.4), and 0.9 (95% CI, 0.2 to 1.6) per 1000 person-years in age 45-74 years. In conclusion, the BP target can be relaxed in very old patients and in elderly patients with few risk factors. However, strict BP control may be needed in patients with multiple risk factors even in those with advanced age.
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Affiliation(s)
- Hae Hyuk Jung
- Department of Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South Korea
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Tsabedze N, Naicker RD, Mrabeti S. Efficacy of beta-blockers on blood pressure control and morbidity and mortality endpoints in hypertensives of African ancestry: an individual patient data meta-analysis. Front Cardiovasc Med 2024; 10:1280953. [PMID: 38322274 PMCID: PMC10844441 DOI: 10.3389/fcvm.2023.1280953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/11/2023] [Indexed: 02/08/2024] Open
Abstract
Introduction Compared with first-line antihypertensives, beta-blockers (BB) have been reported to lower the central aortic blood pressure suboptimally and are associated with increased stroke risk. This observation has not been investigated in hypertensives of African ancestry. We hypothesised that an individual patient data meta-analysis (IPD-MA) on the efficacy of second- or third-generation beta-blockers (STGBBs) in hypertensives of African descent may provide new insights. Methods A single-stage IPD-MA analysed the efficacy of STGBB in lowering the mean arterial blood pressure and reducing the composite outcomes: cardiovascular death, stroke, and myocardial infarction. Results A total of 11,860 participants from four randomised control trials were included in the analysis. Second- or third-generation beta-blockers reduced the mean arterial pressure by 1.75 mmHg [95% confidence interval (CI):1.16-2.33; P < 0.001] in all participants included in the analysis, and by 1.93 mmHg (95% CI: 0.86-3.00; P < 0.001) in hypertensive Africans. In patients with established cardiovascular disease, where the benefits of BB therapy are well established, STGBBs were associated with an adjusted odds ratio of 1.33 (95% CI: 1.06-1.65; P = 0.015) of the composite outcome, most likely due to confounding. Similarly, the risk of total myocardial infarction was 1.76 times higher (95% CI: 1.15-2.68; P = 0.008) in hypertensives of African ancestry on STGBBs. Conclusion The STGBBs reduced the mean arterial pressure comparably to other antihypertensives, and they were not associated with an increased risk of stroke.
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Affiliation(s)
- Nqoba Tsabedze
- Division of Cardiology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - R. Darshni Naicker
- Medical Department, Healthcare Division, Merck Pty Ltd, Modderfontein, South Africa
| | - Sanaa Mrabeti
- Medical Affairs EMEA, Merck Serono Middle East FZ-LLC, Dubai, United Arab Emirates
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Fall M, Grenet G, Le HH, Kassaï B, Lega JC, Boussageon R, Mainbourg S, Marchant I, Gafsi J, Dieye AM, Gueyffier F. [Does aspirin have a place in primary cardiovascular prevention by the polypill ? Simulation study on a realistic virtual population]. Therapie 2023; 78:667-678. [PMID: 36841655 DOI: 10.1016/j.therap.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/19/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The polypill strategy could become widely accepted in cardiovascular prevention due to reduced costs and its simplicity, which promote compliance. Aspirin is often included as a component of the polypill for primary prevention, but three powerful recent trials failed to show any favorable net benefit even in high-risk subgroups. Our objective is to estimate the net benefit associated with aspirin in primary cardiovascular prevention. METHODS We simulated the impact of different polypill compositions combining pravastatin, ramipril, hydrochlorothiazide, with or without aspirin, on a realistic French virtual population between 35 and 65 years old. We assessed how this impact on myocardial infarction and stroke varied according to gender, diabetes, and arterial hypertension. We identified the subgroup of individuals whose specific benefit from aspirin was greater than twice the risk of serious bleeding it induced. RESULTS The absolute benefit associated with aspirin was reduced by co-prescriptions. No subgroup of women benefited from aspirin, and the subgroup of women with a clear net benefit represented 128 women out of 529,421. Men at high risk of cardiovascular death, or with diabetes and hypertension, had a benefit from aspirin exceeding the risk of bleeding induced, but this risk represented more than half of the benefit. No subgroup analyzed did show a benefit greater than twice the risk of bleeding. The proportion of men whose expected benefit from aspirin was greater than twice the risk of bleeding represented 3% of all men. An optimal polypill strategy in primary prevention between the ages of 35 and 65, combining three drugs but not aspirin, can hope to save two out of three strokes and more than one out of two myocardial infarctions. It would prevent a major cardiovascular accident every 16 to 193 individuals treated according to the subgroups considered. CONCLUSION Until proven otherwise, aspirin has only a limited place in individuals between 35 and 65 years without a cardiovascular history. We showed how simulating therapeutic strategies on a realistic virtual population could be used for best applying available evidence.
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Affiliation(s)
- Mor Fall
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France; Laboratoire de pharmacologie & de pharmacodynamie, UMRED université Iba Der Thiam, BP A967 Thies, Sénégal; Centre hospitalier universitaire Aristide Le Dantec, pharmacie centrale, BP 3001 Dakar, Sénégal
| | - Guillaume Grenet
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France; Service hospitalo universitaire de pharmaco-toxicologie, 69002 Lyon France
| | - Hai-Ha Le
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France
| | - Behrouz Kassaï
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France; Service hospitalo universitaire de pharmaco-toxicologie, 69002 Lyon France
| | - Jean-Christophe Lega
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France
| | - Rémy Boussageon
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France
| | - Sabine Mainbourg
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France
| | - Ivanny Marchant
- Laboratorio de Modelamiento en Medicina, Escuela de Medicina, Universidad de Valparaíso, Viña del Mar, Chile
| | - Johanne Gafsi
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France
| | - Amadou Moctar Dieye
- Service hospitalo universitaire de pharmaco-toxicologie, 69002 Lyon France; Laboratoire de pharmacologie & de pharmacodynamie, université Cheikh Anta Diop, BP 5005 Dakar, Sénégal
| | - François Gueyffier
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France; Pôle de santé publique, Hospices civils de Lyon, 69002 Lyon, France.
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Reinhart M, Puil L, Salzwedel DM, Wright JM. First-line diuretics versus other classes of antihypertensive drugs for hypertension. Cochrane Database Syst Rev 2023; 7:CD008161. [PMID: 37439548 PMCID: PMC10339786 DOI: 10.1002/14651858.cd008161.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Different first-line drug classes for patients with hypertension are often assumed to have similar effectiveness with respect to reducing mortality and morbidity outcomes, and lowering blood pressure. First-line low-dose thiazide diuretics have been previously shown to have the best mortality and morbidity evidence when compared with placebo or no treatment. Head-to-head comparisons of thiazides with other blood pressure-lowering drug classes would demonstrate whether there are important differences. OBJECTIVES To compare the effects of first-line diuretic drugs with other individual first-line classes of antihypertensive drugs on mortality, morbidity, and withdrawals due to adverse effects in patients with hypertension. Secondary objectives included assessments of the need for added drugs, drug switching, and blood pressure-lowering. SEARCH METHODS Cochrane Hypertension's Information Specialist searched the Cochrane Hypertension Specialized Register, CENTRAL, MEDLINE, Embase, and trials registers to March 2021. We also checked references and contacted study authors to identify additional studies. A top-up search of the Specialized Register was carried out in June 2022. SELECTION CRITERIA Randomized active comparator trials of at least one year's duration were included. Trials had a clearly defined intervention arm of a first-line diuretic (thiazide, thiazide-like, or loop diuretic) compared to another first-line drug class: beta-blockers, calcium channel blockers, alpha adrenergic blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, direct renin inhibitors, or other antihypertensive drug classes. Studies had to include clearly defined mortality and morbidity outcomes (serious adverse events, total cardiovascular events, stroke, coronary heart disease (CHD), congestive heart failure, and withdrawals due to adverse effects). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. MAIN RESULTS We included 20 trials with 26 comparator arms randomizing over 90,000 participants. The findings are relevant to first-line use of drug classes in older male and female hypertensive patients (aged 50 to 75) with multiple co-morbidities, including type 2 diabetes. First-line thiazide and thiazide-like diuretics were compared with beta-blockers (six trials), calcium channel blockers (eight trials), ACE inhibitors (five trials), and alpha-adrenergic blockers (three trials); other comparators included angiotensin II receptor blockers, aliskiren (a direct renin inhibitor), and clonidine (a centrally acting drug). Only three studies reported data for total serious adverse events: two studies compared diuretics with calcium channel blockers and one with a direct renin inhibitor. Compared to first-line beta-blockers, first-line thiazides probably result in little to no difference in total mortality (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.84 to 1.10; 5 trials, 18,241 participants; moderate-certainty), probably reduce total cardiovascular events (5.4% versus 4.8%; RR 0.88, 95% CI 0.78 to 1.00; 4 trials, 18,135 participants; absolute risk reduction (ARR) 0.6%, moderate-certainty), may result in little to no difference in stroke (RR 0.85, 95% CI 0.66 to 1.09; 4 trials, 18,135 participants; low-certainty), CHD (RR 0.91, 95% CI 0.78 to 1.07; 4 trials, 18,135 participants; low-certainty), or heart failure (RR 0.69, 95% CI 0.40 to 1.19; 1 trial, 6569 participants; low-certainty), and probably reduce withdrawals due to adverse effects (10.1% versus 7.9%; RR 0.78, 95% CI 0.71 to 0.85; 5 trials, 18,501 participants; ARR 2.2%; moderate-certainty). Compared to first-line calcium channel blockers, first-line thiazides probably result in little to no difference in total mortality (RR 1.02, 95% CI 0.96 to 1.08; 7 trials, 35,417 participants; moderate-certainty), may result in little to no difference in serious adverse events (RR 1.09, 95% CI 0.97 to 1.24; 2 trials, 7204 participants; low-certainty), probably reduce total cardiovascular events (14.3% versus 13.3%; RR 0.93, 95% CI 0.89 to 0.98; 6 trials, 35,217 participants; ARR 1.0%; moderate-certainty), probably result in little to no difference in stroke (RR 1.06, 95% CI 0.95 to 1.18; 6 trials, 35,217 participants; moderate-certainty) or CHD (RR 1.00, 95% CI 0.93 to 1.08; 6 trials, 35,217 participants; moderate-certainty), probably reduce heart failure (4.4% versus 3.2%; RR 0.74, 95% CI 0.66 to 0.82; 6 trials, 35,217 participants; ARR 1.2%; moderate-certainty), and may reduce withdrawals due to adverse effects (7.6% versus 6.2%; RR 0.81, 95% CI 0.75 to 0.88; 7 trials, 33,908 participants; ARR 1.4%; low-certainty). Compared to first-line ACE inhibitors, first-line thiazides probably result in little to no difference in total mortality (RR 1.00, 95% CI 0.95 to 1.07; 3 trials, 30,961 participants; moderate-certainty), may result in little to no difference in total cardiovascular events (RR 0.97, 95% CI 0.92 to 1.02; 3 trials, 30,900 participants; low-certainty), probably reduce stroke slightly (4.7% versus 4.1%; RR 0.89, 95% CI 0.80 to 0.99; 3 trials, 30,900 participants; ARR 0.6%; moderate-certainty), probably result in little to no difference in CHD (RR 1.03, 95% CI 0.96 to 1.12; 3 trials, 30,900 participants; moderate-certainty) or heart failure (RR 0.94, 95% CI 0.84 to 1.04; 2 trials, 30,392 participants; moderate-certainty), and probably reduce withdrawals due to adverse effects (3.9% versus 2.9%; RR 0.73, 95% CI 0.64 to 0.84; 3 trials, 25,254 participants; ARR 1.0%; moderate-certainty). Compared to first-line alpha-blockers, first-line thiazides probably result in little to no difference in total mortality (RR 0.98, 95% CI 0.88 to 1.09; 1 trial, 24,316 participants; moderate-certainty), probably reduce total cardiovascular events (12.1% versus 9.0%; RR 0.74, 95% CI 0.69 to 0.80; 2 trials, 24,396 participants; ARR 3.1%; moderate-certainty) and stroke (2.7% versus 2.3%; RR 0.86, 95% CI 0.73 to 1.01; 2 trials, 24,396 participants; ARR 0.4%; moderate-certainty), may result in little to no difference in CHD (RR 0.98, 95% CI 0.86 to 1.11; 2 trials, 24,396 participants; low-certainty), probably reduce heart failure (5.4% versus 2.8%; RR 0.51, 95% CI 0.45 to 0.58; 1 trial, 24,316 participants; ARR 2.6%; moderate-certainty), and may reduce withdrawals due to adverse effects (1.3% versus 0.9%; RR 0.70, 95% CI 0.54 to 0.89; 3 trials, 24,772 participants; ARR 0.4%; low-certainty). For the other drug classes, data were insufficient. No antihypertensive drug class demonstrated any clinically important advantages over first-line thiazides. AUTHORS' CONCLUSIONS When used as first-line agents for the treatment of hypertension, thiazides and thiazide-like drugs likely do not change total mortality and likely decrease some morbidity outcomes such as cardiovascular events and withdrawals due to adverse effects, when compared to beta-blockers, calcium channel blockers, ACE inhibitors, and alpha-blockers.
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Affiliation(s)
- Marcia Reinhart
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Lorri Puil
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Douglas M Salzwedel
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - James M Wright
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
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Kelleher MG, Ruparelia R, Blum IR. Doctors' Drugs and the Dangers of Dental Decay. Prim Dent J 2023; 12:63-71. [PMID: 36916630 DOI: 10.1177/20501684231156958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Many "anti-something" medications, which are prescribed by medical doctors for older patients, often for dubious reasons, result in a serious reduction in the quantity and quality of saliva. That drug-induced xerostomia can produce dangerous dental decay, particularly in already compromised dentitions.This article suggests that doctors should undertake a personalised "benefits, risks, alternatives, nothing" (BRAN) analysis including an assessment of the possible dental decay risks, especially before prescribing combinations of "anti-" drugs for marginal conditions.Doctors should consider carefully if alternative approaches are feasible which could produce acceptable outcomes without incurring those serious dental decay risks. Alternative approaches may include patients altering their diet and lifestyle to include more physical exercise for controlling conditions such as marginal hypertension, for example, or perhaps prescribing counselling/talking therapies for depression or anxiety.If various "anti-" drugs really do have to be prescribed, this article describes cheap, pragmatic, and effective ways of mitigating the risks of already compromised dentitions developing new decay.
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Affiliation(s)
- Martin G Kelleher
- Consultant and Specialist in Restorative Dentistry, King's College Hospital Dental Institute, London, UK
| | | | - Igor R Blum
- Professor, Hon. Consultant and Specialist in Restorative Dentistry, Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, London, UK
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Esler M, Kjeldsen SE, Pathak A, Grassi G, Kreutz R, Mancia G. Diverse pharmacological properties, trial results, comorbidity prescribing and neural pathophysiology suggest European hypertension guideline downgrading of beta-blockers is not justified. Blood Press 2022; 31:210-224. [PMID: 36029011 DOI: 10.1080/08037051.2022.2110858] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Beta-blockers have solid documentation in preventing cardiovascular complications in the treatment of hypertension; atenolol, metoprolol, oxprenolol and propranolol demonstrate proven cardiovascular prevention in hypertension mega-trials. Hypertension is characterised by activation of the sympathetic nervous system from early to late phases, which makes beta-blockers an appropriate treatment seen from a pathophysiological viewpoint, especially in patients with an elevated heart rate. Beta-blockers represent a heterogenous class of drugs with regard to both pharmacodynamic and pharmacokinetic properties. This position is manifest by reference to another clinical context, beta-blocker treatment of heart failure, where unequivocally there is no class effect (no similar benefit from all beta-blockers); there are good and less good beta-blockers for heart failure. Analogous differences in beta-blocker efficacy is also likely in hypertension. Beta-blockers are widely used for the treatment of diseases comorbid with hypertension, in approximately 50 different concomitant medical conditions that are frequent in patients with hypertension, leading to many de facto beta-blocker first choices in clinical practice. Thus, beta-blockers should be regarded as relevant first choices for hypertension in clinical practice, particularly if characterised by a long half-life, highly selective beta-1 blocking activity and no intrinsic agonist properties.SUMMARYBeta-blockers have solid documentation in preventing cardiovascular complications in the treatment of hypertension; atenolol, metoprolol, oxprenolol and propranolol demonstrate proven cardiovascular prevention in hypertension mega-trialsHypertension is characterised by activation of the sympathetic nervous system from early to late phases, which makes beta-blockers an appropriate treatment seen from a pathophysiological viewpoint, especially in patients with an elevated heart rateBeta-blockers represent a heterogenous class of drugs with regard to both pharmacodynamic and pharmacokinetic propertiesThis position is manifest by reference to another clinical context, beta-blocker treatment of heart failure, where unequivocally there is no class effect (no similar benefit from all beta-blockers); there are good and less good beta-blockers for heart failureAnalogous differences in beta-blocker efficacy is also likely in hypertensionBeta-blockers are widely used for the treatment of diseases comorbid with hypertension, in approximately 50 different concomitant medical conditions that are frequent in patients with hypertension, leading to many de facto beta-blockers first choices in clinical practiceThese observations, in totality, inform our opinion that beta-blockers are relevant first choices for hypertension in clinical practice and this fact needs highlightingFurther, these arguments suggest European hypertension guideline downgrading of beta-blockers is not justified.
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Affiliation(s)
- Murray Esler
- Baker Heart and Diabetes Institute, Human Neurotransmitters Laboratory and Monash University, Melbourne, Australia
| | - Sverre E Kjeldsen
- Department of Cardiology, Ullevaal Hospital, University of Oslo, Oslo, Norway
| | - Atul Pathak
- Department of Cardiology, and UMR UT3 CNRS 5288 Hypertension and heart failure: molecular and clinical investigations, INI-CRCT F-CRIN, GREAT Networks, Centre Hospitalier Princesse Grace, Monte Carlo, Monaco
| | | | - Reinhold Kreutz
- Charité - Medical University of Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
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Mao Y, Ge S, Qi S, Tian QB. Benefits and risks of antihypertensive medication in adults with different systolic blood pressure: A meta-analysis from the perspective of the number needed to treat. Front Cardiovasc Med 2022; 9:986502. [PMID: 36337902 PMCID: PMC9626501 DOI: 10.3389/fcvm.2022.986502] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background The blood pressure (BP) threshold for initial pharmacological treatment remains controversial. The number needed to treat (NNT) is a significant indicator. This study aimed to explore the benefits and risks of antihypertensive medications in participants with different systolic BPs (SBPs), and cardiovascular disease status from the perspective of the NNT. Methods We conducted a meta-analysis of 52 randomized placebo-controlled trials. The data were extracted from published articles and pooled to calculate NNTs. The participants were divided into five groups, based on the mean SBP at entry (120–129.9, 130–139.9, 140–159.9, 160–179.9, and ≥180 mmHg). Furthermore, we stratified patients into those with and without cardiovascular disease. The primary outcomes were the major adverse cardiovascular events (MACEs), and adverse events (AEs) leading to discontinuation. Results Antihypertensive medications were not associated with MACEs, however, it increased AEs, when the SBP was <140 mmHg. For participants with cardiovascular disease or at a high risk of heart failure and stroke, antihypertensive treatment reduced MACEs when SBP was ≥130 mmHg. Despite this, only 2–4 subjects had reduced MACEs per 100 patients receiving antihypertensive medications for 3.50 years. The number of individuals who needed to treat to avoid MACEs declined with an increased cardiovascular risk. Conclusion Pharmacological treatment could be activated when SBP reaches 140 mmHg. For people with cardiovascular disease or at a higher risk of stroke and heart failure, 130 mmHg may be a better therapeutic threshold. It could be more cost-effective to prioritize antihypertensive medications for people with a high risk of developing cardiovascular disease.
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10
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Looking back on 60 years of DTB: antihypertensive drugs in 1962. Drug Ther Bull 2022; 60:e2. [PMID: 35606103 DOI: 10.1136/dtb.2022.000029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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11
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Wang TD, Chiang CE, Chao TH, Cheng HM, Wu YW, Wu YJ, Lin YH, Chen MYC, Ueng KC, Chang WT, Lee YH, Wang YC, Chu PH, Chao TF, Kao HL, Hou CJY, Lin TH. 2022 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension. ACTA CARDIOLOGICA SINICA 2022; 38:225-325. [PMID: 35673334 PMCID: PMC9121756 DOI: 10.6515/acs.202205_38(3).20220321a] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/22/2022] [Indexed: 11/23/2022]
Abstract
Hypertension is the most important modifiable cause of cardiovascular (CV) disease and all-cause mortality worldwide. Despite the positive correlations between blood pressure (BP) levels and later CV events since BP levels as low as 100/60 mmHg have been reported in numerous epidemiological studies, the diagnostic criteria of hypertension and BP thresholds and targets of antihypertensive therapy have largely remained at the level of 140/90 mmHg in the past 30 years. The publication of both the SPRINT and STEP trials (comprising > 8,500 Caucasian/African and Chinese participants, respectively) provided evidence to shake this 140/90 mmHg dogma. Another dogma regarding hypertension management is the dependence on office (or clinic) BP measurements. Although standardized office BP measurements have been widely recommended and adopted in large-scale CV outcome trials, the practice of office BP measurements has never been ideal in real-world practice. Home BP monitoring (HBPM) is easy to perform, more likely to be free of environmental and/or emotional stress, feasible to document long-term BP variations, of good reproducibility and reliability, and more correlated with hypertension-mediated organ damage (HMOD) and CV events, compared to routine office BP measurements. In the 2022 Taiwan Hypertension Guidelines of the Taiwan Society of Cardiology (TSOC) and the Taiwan Hypertension Society (THS), we break these two dogmas by recommending the definition of hypertension as ≥ 130/80 mmHg and a universal BP target of < 130/80 mmHg, based on standardized HBPM obtained according to the 722 protocol. The 722 protocol refers to duplicate BP readings taken per occasion ("2"), twice daily ("2"), over seven consecutive days ("7"). To facilitate implementation of the guidelines, a series of flowcharts encompassing assessment, adjustment, and HBPM-guided hypertension management are provided. Other key messages include that: 1) lifestyle modification, summarized as the mnemonic S-ABCDE, should be applied to people with elevated BP and hypertensive patients to reduce life-time BP burden; 2) all 5 major antihypertensive drugs (angiotensin-converting enzyme inhibitors [A], angiotensin receptor blockers [A], β-blockers [B], calcium-channel blockers [C], and thiazide diuretics [D]) are recommended as first-line antihypertensive drugs; 3) initial combination therapy, preferably in a single-pill combination, is recommended for patients with BP ≥ 20/10 mmHg above targets; 4) a target hierarchy (HBPM-HMOD- ambulatory BP monitoring [ABPM]) should be considered to optimize hypertension management, which indicates reaching the HBPM target first and then keeping HMOD stable or regressed, otherwise ABPM can be arranged to guide treatment adjustment; and 5) renal denervation can be considered as an alternative BP-lowering strategy after careful clinical and imaging evaluation.
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Affiliation(s)
- Tzung-Dau Wang
- Cardiovascular Center and Divisions of Cardiology and Hospital Medicine, Department of Internal Medicine, National Taiwan University Hospital
- Department of Internal Medicine, School of Medicine, National Taiwan University College of Medicine
| | - Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Ting-Hsing Chao
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Hao-Min Cheng
- School of Medicine, Institute of Public Health and Community Medicine Research Center, and Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University
- Center for Evidence-based Medicine, Department of Medical Education, Taipei Veterans General Hospital, Taipei
| | - Yen-Wen Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
- Division of Cardiology, Cardiovascular Medical Center, and Department of Nuclear Medicine, Far Eastern Memorial Hospital
| | - Yih-Jer Wu
- Department of Medicine, Mackay Medical College, New Taipei City
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital
| | - Yen-Hung Lin
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Michael Yu-Chih Chen
- Division of Cardiology, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien
| | - Kwo-Chang Ueng
- Department of Internal Medicine, Chung-Shan Medical University Hospital, Taichung
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan
| | - Ying-Hsiang Lee
- Department of Medicine, Mackay Medical College, New Taipei City
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital
| | - Yu-Chen Wang
- Division of Cardiology, Department of Medicine, Asia University Hospital
- Department of Medical Laboratory Science and Biotechnology, Asia University
- Division of Cardiology, Department of Internal Medicine, China Medical University College of Medicine and Hospital, Taichung
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital
- School of Medicine, Chang Gung University, Taoyuan
| | - Tzu-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei
| | - Hsien-Li Kao
- Department of Internal Medicine, School of Medicine, National Taiwan University College of Medicine
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Charles Jia-Yin Hou
- Department of Medicine, Mackay Medical College, New Taipei City
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine Kaohsiung Medical University Hospital
- Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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12
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Mancia G, Kjeldsen SE, Kreutz R, Pathak A, Grassi G, Esler M. Individualized Beta-Blocker Treatment for High Blood Pressure Dictated by Medical Comorbidities: Indications Beyond the 2018 European Society of Cardiology/European Society of Hypertension Guidelines. Hypertension 2022; 79:1153-1166. [PMID: 35378981 DOI: 10.1161/hypertensionaha.122.19020] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Several hypertension guidelines have removed beta-blockers from their previous position as first-choice drugs for the treatment of hypertension. However, this downgrading may not be justified by available evidence because beta-blockers lower blood pressure as effectively as other major antihypertensive drugs and have solid documentation in preventing cardiovascular complications. Suspected inconveniences of beta-blockers such as increased risk of depression or erectile dysfunction may have been overemphasized, while patients with chronic obstructive pulmonary disease or peripheral artery disease, that is, conditions in which their use was previously restricted, will benefit from beta-blocker therapy. Besides, evidence that from early to late phases, hypertension is accompanied by activation of the sympathetic nervous system makes beta-blockers pathophysiologically an appropriate treatment in hypertension. Beta-blockers have favorable effects on a variety of clinical conditions that may coexist with hypertension, making their use either as specific treatment or as co-treatment potentially common in clinical practice. Guidelines typically limit recommendations on specific beta-blocker use to cardiac conditions including angina pectoris, postmyocardial infarction, or heart failure, with little or no mention of the additional cardiovascular or noncardiovascular conditions in which these drugs may be needed or preferred. In the present narrative review, we focus on multiple additional diseases and conditions that may occur and affect patients with hypertension, often more frequently than people without hypertension, and that may favor the choice of beta-blocker. Notwithstanding, beta-blockers represent an in-homogenous group of drugs and choosing beta-blockers with documented effect in prevention and treatment of disease is important for first choice in guidelines.
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Affiliation(s)
| | - Sverre E Kjeldsen
- Department of Cardiology, University of Oslo, Ullevaal Hospital, Norway (S.E.K.)
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Germany (R.K.)
| | - Atul Pathak
- Department of Cardiology, Centre Hospitalier Princesse Grace, Monte Carlo, Monaco (A.P.)
| | - Guido Grassi
- University of Milano-Bicocca, Milan, Italy (G.M., G.G.)
| | - Murray Esler
- Human Neurotransmitters Laboratory, Baker Heart and Diabetes Institute, and Monash University, Melbourne, Australia (M.E.)
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14
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Do recent meta-analyses truly prove that treatment with blood pressure-lowering drugs is beneficial at any blood pressure value, no matter how low? A critical review. J Hypertens 2022; 40:839-846. [PMID: 35191413 DOI: 10.1097/hjh.0000000000003056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Current European guidelines for the management of hypertension and on cardiovascular disease prevention place the threshold for pharmacological treatment at a SBP level of 140 mmHg or above, with the exception of patients at very high risk (mainly because of coronary heart disease). This is in agreement with the current definition of hypertension, that is, the level of blood pressure at which the benefits of treatment outweigh the risks of treatment, as documented by clinical trials. This rationale and definition was recently challenged by meta-analyses using individual participant-level data from 48 randomized trials by the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC). The authors calculated for a fixed 5 mmHg pharmacological reduction of SBP an overall 10% risk reduction for major cardiovascular events. It was concluded that there was no reliable evidence of heterogeneity of treatment effects by baseline SBP categories; that the effect was independent from the presence of cardiovascular disease; applied also to old and very old individuals up to 84 years or beyond; and that BP-lowering was also beneficial in individuals with normal or high-normal SBP down to a baseline SBP less than 120 mmHg. In this report, we identify and discuss a number of shortcomings of the BPLTTC meta-analyses. In our view, the conclusions by the BPLTTC must be - together with accompanying suggestions to abandon the definition of hypertension - strongly rejected as they are not justified and may be harmful for cardiovascular health in individuals without hypertension.
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15
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Chrysant SG, Chrysant GS. Antihypertensive and cardioprotective effects of three generations of beta-adrenergic blockers: an historical perspective. Hosp Pract (1995) 2022; 50:196-202. [PMID: 35157531 DOI: 10.1080/21548331.2022.2040920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
There are currently, 3 generations of beta-adrenergic blockers for the treatment of hypertension and cardiovascular diseases. The 1st generation caused vasoconstriction and bronchoconstriction due to β1 + β2 receptor blockade and unopposed α1 receptors. The 2nd generation of beta-blockers has lesser adverse effects than the 1st generation with the 3rd generation beta-blockers having much lesser effects than the other two generations. Current US and International guideline do not recommend beta-blockers as first line therapy of hypertension, but only in the presence of coronary artery disease or heart failure due to their lesser antihypertensive effect. These recommendations are disputed by several older and recent studies which have shown that the beta-blockers are effective and safe for the treatment of hypertension and could be used as first line therapy. To clarify this issue a Medline search of the English language literature was conducted between 2012 and 2021 and 30 pertinent papers were selected. The data from these studies show that the beta-blockers have inferior antihypertensive and stroke protective effect compared with the other classes of antihypertensive drugs and should be used as first line therapy only in patients with hypertension associated with coronary artery disease or heart failure. The information from these papers and collateral literature will be discussed in this perspective.
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Affiliation(s)
- Steven G Chrysant
- Department of Cardiology University of Oklahoma Health Sciences Center, Oklahoma, OK, USA
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16
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Ho VS, Cenzer IS, Nguyen BT, Lee SJ. Time to benefit for stroke reduction after blood pressure treatment in older adults: A meta-analysis. J Am Geriatr Soc 2022; 70:1558-1568. [PMID: 35137952 PMCID: PMC9106841 DOI: 10.1111/jgs.17684] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/24/2021] [Accepted: 01/09/2022] [Indexed: 12/19/2022]
Abstract
Background Hypertension treatment in older adults can decrease mortality, cardiovascular events, including heart failure, cognitive impairment, and stroke risk, but may also lead to harms such as syncope and falls. Guidelines recommend targeting preventive interventions with immediate harms and delayed benefits to patients whose life expectancy exceeds the intervention's time to benefit (TTB). Our objective was to estimate a meta‐analyzed TTB for stroke prevention after initiation of more intensive hypertension treatment in adults aged ≥65 years. Methods Studies were identified from two Cochrane systematic reviews and a search of MEDLINE and Google Scholar for subsequent publications until August 31, 2021. We abstracted data from randomized controlled trials comparing standard (untreated, placebo, or less intensive treatment) to more intensive treatment groups in older adults (mean age ≥ 65 years). We fit Weibull survival curves and used a random‐effects model to estimate the pooled annual absolute risk reduction (ARR) between control and intervention groups. We applied Markov chain Monte Carlo methods to determine the time to ARR thresholds (0.002, 0.005, and 0.01) for a first stroke. Results Nine trials (n = 38,779) were identified. The mean age ranged from 66 to 84 years and study follow‐up times ranged from 2.0 to 5.8 years. We determined that 1.7 (95%CI: 1.0–2.9) years were required to prevent 1 stroke for 200 persons (ARR = 0.005) receiving more intensive hypertensive treatment. Heterogeneity was found across studies, with those focusing on tighter systolic blood pressure control (SBP < 150 mmHg) showing longer TTB. For example, in the SPRINT study (baseline SBP = 140 mmHg, achieved SBP = 121 mmHg), the TTB to avoid 1 stroke for 200 patients treated was 5.9 years (95%CI: 2.2–13.0). Conclusions More intensive hypertension treatment in 200 older adults prevents 1 stroke after 1.7 years. Given the heterogeneity across studies, the TTB estimates from individual studies may be more relevant for clinical decision‐making than our summary estimate. See related Editorial by Mark A. Supiano in this issue.
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Affiliation(s)
- Vanessa S Ho
- College of Medicine, California Northstate University, Elk Grove, California, USA.,Medical Student Training in Aging Research (MSTAR) Program, Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA
| | - Irena S Cenzer
- Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA
| | - Brian T Nguyen
- Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA.,Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Northern California Institute for Research and Education, San Francisco, California, USA
| | - Sei J Lee
- Medical Student Training in Aging Research (MSTAR) Program, Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA.,Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA.,Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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17
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Brust JC. Stroke and Substance Abuse. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00039-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs. Nat Rev Cardiol 2022; 19:59-74. [PMID: 34331033 DOI: 10.1038/s41569-021-00593-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 02/06/2023]
Abstract
Sexual health has a fundamental role in overall health and well-being, and a healthy and dynamic sex life can make an important contribution to a good quality of life. Sexual dysfunction, and especially erectile dysfunction (ED) in men, is highly prevalent in patients with cardiovascular disease (CVD). CVD and ED have shared risk factors and pathophysiological links, such as endothelial dysfunction, inflammation and low plasma testosterone levels. ED has been shown to be an independent and early harbinger of future CVD events, providing an important window to initiate preventive measures. Therefore, screening and diagnosing ED is essential for the primary and secondary prevention of CVD because the assessment of ED offers an easy and low-cost prognostic tool that is an alternative to other investigational cardiovascular biomarkers. Moreover, ED is a major contributing factor to the discontinuation of, or poor adherence to, cardiovascular therapy. Cardiovascular drugs have divergent effects on erectile function, with diuretics and β-blockers having the worst profiles, and renin-angiotensin-aldosterone system inhibitors and nebivolol having the best profiles. Pharmacological treatment of ED has an equivocal effect on the risk of CVD, suggesting a complex interaction between ED and drugs for CVD. In this Review, we discuss how sexual function could be incorporated into the patient history taken by physicians treating individuals with CVD, not merely as part of the diagnostic work-up but as a means to pursue tangible and essential benefits in quality of life and cardiovascular outcomes.
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Heidari B, Avenatti E, Nasir K. Pharmacotherapy for Essential Hypertension: A Brief Review. Methodist Debakey Cardiovasc J 2022; 18:5-16. [PMID: 36561082 PMCID: PMC9733188 DOI: 10.14797/mdcvj.1175] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Hypertension is one of the leading causes of disability-adjusted life years and mortality, with approximately 15% prevalence worldwide. Most patients with hypertension from low- to high-income countries do not receive treatment. Among those who receive treatment, the majority remain undertreated and do not achieve their blood pressure goals. Therefore, new hypertension guidelines introduce more conscientious treatment strategies to maximize the probability of achieving the new strict blood pressure goals compared with the previous guidelines. Who should receive treatment for hypertension? Which antihypertensive medications have the strongest supporting data? Are generic and more affordable medications as effective as expensive brand medications? What are the different treatment strategies to maximize success in controlling blood pressure? Here, we briefly review pharmacotherapy for hypertension and provide answers to these questions as well as some other common questions regarding treatment of hypertension.
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Affiliation(s)
- Behnam Heidari
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
| | - Eleonora Avenatti
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
| | - Khurram Nasir
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
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20
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Matar A, McEvoy JW. Blood Pressure Limbo-How Low Can You Go? Diabetes Care 2021; 44:1910-1912. [PMID: 34417276 DOI: 10.2337/dci21-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Aishah Matar
- Division of Cardiology, Department of Medicine, Saolta University Healthcare Group, University Hospital Galway, Galway, Ireland
| | - John W McEvoy
- Division of Cardiology, Department of Medicine, Saolta University Healthcare Group, University Hospital Galway, Galway, Ireland .,National Institute for Prevention and Cardiovascular Health, School of Medicine, National University of Ireland, Galway, Galway, Ireland
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Abstract
BACKGROUND Meta-analyses from randomized outcome-based trials have challenged the role of beta-blockers for the treatment of hypertension. However, because they often include trials on diseases other than hypertension, the role of these drugs in the choice of the blood pressure (BP)-lowering treatment strategies remains unclear. METHODS Electronic databases were searched for randomized trials that compared beta-blockers vs. placebo/no-treatment/less-intense treatment (BP-lowering trials) or beta-blockers vs. other antihypertensive agents in patients with or without hypertension (comparison trials). Among BP-lowering trials and according to baseline comorbidity, we separately considered trials in hypertension, trials without chronic heart failure or acute myocardial infarction, and trials with either chronic heart failure or acute myocardial infarction. Seven fatal and nonfatal outcomes were calculated (random-effects model) for BP-lowering or comparison trials. RESULTS A total of 84 BP-lowering or comparison trials (165 850 patients) were eligible. In 67 BP-lowering trials (68 478 patients; mean follow-up 2.5 years; baseline SBP/DBP, 136/82 mmHg), beta blockers were associated with a lower incidence of major cardiovascular events [risk ratio 0.85 and 95% confidence interval (95% CI) 0.78-0.92] and all-cause death (risk ratio 0.81 and 95% CI 0.75-0.86). Restriction of the analysis to five trials recruiting exclusively hypertensive patients (18 724 patients; mean follow-up 5.1 years; baseline SBP/DBP 163/94 mmHg), a -10.5/-7.0 mmHg BP decrease was accompanied by reduction of major cardiovascular events by 22% (95% CI, 6-34). In 24 comparison trials (103 764 patients, 3.92 years of mean follow-up), beta-blockers compared with other agents were less protective for stroke and all-cause death in all trials and in trials conducted exclusively in hypertensive patients (averaged risk ratio increase 20 and 6%, respectively, for both cases). CONCLUSION Compared with other antihypertensive agents, beta-blockers appear to be substantially less protective against stroke and overall mortality. However, they exhibit a substantial risk-reducing ability for all events when prescribed to lower BP in patients with modest or more clear BP elevations, and therefore can be used as additional agents in hypertensive patients.
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22
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Zhang ZY, Yu YL, Asayama K, Hansen TW, Maestre GE, Staessen JA. Starting Antihypertensive Drug Treatment With Combination Therapy: Controversies in Hypertension - Con Side of the Argument. Hypertension 2021; 77:788-798. [PMID: 33566687 PMCID: PMC7884241 DOI: 10.1161/hypertensionaha.120.12858] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text.
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Affiliation(s)
- Zhen-Yu Zhang
- From the Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (Z.-Y.Z., Y.-L.Y., K.A.)
| | - Yu-Ling Yu
- From the Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (Z.-Y.Z., Y.-L.Y., K.A.)
| | - Kei Asayama
- From the Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (Z.-Y.Z., Y.-L.Y., K.A.)
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A.)
- Tohoku Institute for Management of Blood Pressure, Sendai, Japan (K.A.)
- Research Institute Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (K.A., G.E.M., T.W.H., J.A.S)
| | - Tine W. Hansen
- Research Institute Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (K.A., G.E.M., T.W.H., J.A.S)
- Steno Diabetes Center Copenhagen, Capital Region of Denmark, Denmark (T.W.H.)
| | - Gladys E. Maestre
- Research Institute Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (K.A., G.E.M., T.W.H., J.A.S)
- Department of Neurosciences and Department of Human Genetics, University of Texas Rio Grande Valley School of Medicine, Brownsville, TX (G.E.M.)
- Alzheimer´s Disease Resource Center for Minority Aging Research, University of Texas Rio Grande Valley, Brownsville, TX (G.E.M.)
| | - Jan A. Staessen
- Research Institute Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (K.A., G.E.M., T.W.H., J.A.S)
- Biomedical Sciences Group, Faculty of Medicine, University of Leuven, Belgium (J.A.S.)
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Albasri A, Hattle M, Koshiaris C, Dunnigan A, Paxton B, Fox SE, Smith M, Archer L, Levis B, Payne RA, Riley RD, Roberts N, Snell KIE, Lay-Flurrie S, Usher-Smith J, Stevens R, Hobbs FDR, McManus RJ, Sheppard JP. Association between antihypertensive treatment and adverse events: systematic review and meta-analysis. BMJ 2021; 372:n189. [PMID: 33568342 PMCID: PMC7873715 DOI: 10.1136/bmj.n189] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the association between antihypertensive treatment and specific adverse events. DESIGN Systematic review and meta-analysis. ELIGIBILITY CRITERIA Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up. INFORMATION SOURCES Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020. MAIN OUTCOME MEASURES The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ2). RESULTS Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ2=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ2=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ2=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ2=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ2=0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction. CONCLUSIONS This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function. REGISTRATION PROSPERO CRD42018116860.
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Affiliation(s)
- Ali Albasri
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | | | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Anna Dunnigan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ben Paxton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Emma Fox
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Margaret Smith
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | | | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
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Lioutas VA, Ivan CS, Himali JJ, Aparicio HJ, Leveille T, Romero JR, Beiser AS, Seshadri S. Incidence of Transient Ischemic Attack and Association With Long-term Risk of Stroke. JAMA 2021; 325:373-381. [PMID: 33496774 PMCID: PMC7838926 DOI: 10.1001/jama.2020.25071] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 12/03/2020] [Indexed: 12/24/2022]
Abstract
Importance Accurate estimation of the association between transient ischemic attack (TIA) and risk of subsequent stroke can help to improve preventive efforts and limit the burden of stroke in the population. Objective To determine population-based incidence of TIA and the timing and long-term trends of stroke risk after TIA. Design, Setting, and Participants Retrospective cohort study (Framingham Heart Study) of prospectively collected data of 14 059 participants with no history of TIA or stroke at baseline, followed up from 1948-December 31, 2017. A sample of TIA-free participants was matched to participants with first incident TIA on age and sex (ratio, 5:1). Exposures Calendar time (TIA incidence calculation, time-trends analyses), TIA (matched longitudinal cohort). Main Outcomes and Measures The main outcomes were TIA incidence rates; proportion of stroke occurring after TIA in the short term (7, 30, and 90 days) vs the long term (>1-10 years); stroke after TIA vs stroke among matched control participants without TIA; and time trends of stroke risk at 90 days after TIA assessed in 3 epochs: 1954-1985, 1986-1999, and 2000-2017. Results Among 14 059 participants during 66 years of follow-up (366 209 person-years), 435 experienced TIA (229 women; mean age, 73.47 [SD, 11.48] years and 206 men; mean age, 70.10 [SD, 10.64] years) and were matched to 2175 control participants without TIA. The estimated incidence rate of TIA was 1.19/1000 person-years. Over a median of 8.86 years of follow-up after TIA, 130 participants (29.5%) had a stroke; 28 strokes (21.5%) occurred within 7 days, 40 (30.8%) occurred within 30 days, 51 (39.2%) occurred within 90 days, and 63 (48.5%) occurred more than 1 year after the index TIA; median time to stroke was 1.64 (interquartile range, 0.07-6.6) years. The age- and sex-adjusted cumulative 10-year hazard of incident stroke for patients with TIA (130 strokes among 435 cases) was 0.46 (95% CI, 0.39-0.55) and for matched control participants without TIA (165 strokes among 2175) was 0.09 (95% CI, 0.08-0.11); fully adjusted hazard ratio [HR], 4.37 (95% CI, 3.30-5.71; P < .001). Compared with the 90-day stroke risk after TIA in 1948-1985 (16.7%; 26 strokes among 155 patients with TIA), the risk between 1986-1999 was 11.1% (18 strokes among 162 patients) and between 2000-2017 was 5.9% (7 strokes among 118 patients). Compared with the first epoch, the HR for 90-day risk of stroke in the second epoch was 0.60 (95% CI, 0.33-1.12) and in the third epoch was 0.32 (95% CI, 0.14-0.75) (P = .005 for trend). Conclusions and Relevance In this population-based cohort study from 1948-2017, the estimated crude TIA incidence was 1.19/1000 person-years, the risk of stroke was significantly greater after TIA compared with matched control participants who did not have TIA, and the risk of stroke after TIA was significantly lower in the most recent epoch from 2000-2017 compared with an earlier period from 1948-1985.
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Affiliation(s)
- Vasileios-Arsenios Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Framingham Heart Study, Framingham, Massachusetts
| | - Cristina S. Ivan
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Jayandra J. Himali
- Framingham Heart Study, Framingham, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Glenn Biggs Institute for Alzheimer’s Disease and Neurodegenerative Diseases, University of Texas Health San Antonio
- Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio
| | - Hugo J. Aparicio
- Framingham Heart Study, Framingham, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | | | - Jose Rafael Romero
- Framingham Heart Study, Framingham, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Alexa S. Beiser
- Framingham Heart Study, Framingham, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Sudha Seshadri
- Framingham Heart Study, Framingham, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Glenn Biggs Institute for Alzheimer’s Disease and Neurodegenerative Diseases, University of Texas Health San Antonio
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Tan EJ, Hayen A, Clarke P, Jackson R, Knight J, Hayes AJ. Trends in Ischaemic Heart Disease in Australia, 2001-2015: A Comparison of Urban and Rural Populations. Heart Lung Circ 2021; 30:971-977. [PMID: 33454212 DOI: 10.1016/j.hlc.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/24/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Ischaemic heart disease (IHD) is a major source of disease burden worldwide. Recent trends show incidence is declining but it is unclear whether the trends are similar in urban and rural populations. This study examines the trends of IHD events (i.e. hospitalisations and deaths) in New South Wales, Australia by rurality. METHODS This was a retrospective analysis of linked administrative data for hospitalisation and death records across NSW between 2001 and 2015. Participants were NSW residents aged 15-105 years who died or were hospitalised with a principal diagnosis of IHD. The main outcome measures were annual age-standardised mortality and hospitalisations for IHD by calendar year and rurality. RESULTS Between 2001 and 2015, age-standardised annual IHD hospitalisations declined in urban areas from 587 to 260 and in rural areas from 766 to 395 per 100,000 people. The annual decline in hospitalisations was greater in urban than rural areas, with Annual Percentage Change (APC) of -5.6% (95% CI, -6.1%, -5.0%) and -4.5% (95% CI, -5.0%, -4.0%), respectively (p=0.012). Ischaemic heart disease mortality declined at a similar rate in urban and rural regions (APC -7.6% and -6.7% per annum, p=0.28). Absolute inequalities in IHD deaths persisted until 2015 when there were 49 (urban) and 70 (rural) IHD deaths per 100,000 people. CONCLUSIONS Ischaemic heart disease hospitalisations and mortality have declined considerably between 2001 and 2015 in both rural and urban areas, yet inequalities persist, suggesting more intensive preventive efforts are required to further reduce the burden of IHD in rural populations.
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Affiliation(s)
- Eng Joo Tan
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney, NSW, Australia
| | - Andrew Hayen
- Discipline of Public Health, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Philip Clarke
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rod Jackson
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Josh Knight
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Vic, Australia
| | - Alison J Hayes
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney, NSW, Australia.
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Cortese F. Why Should We Focus on Fitness to Reduce Cardiovascular Disease Mortality? J Am Coll Cardiol 2020; 75:1548-1550. [PMID: 32241370 DOI: 10.1016/j.jacc.2020.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/03/2020] [Accepted: 02/10/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Francesca Cortese
- Cardiology Unit, "Giovanni Paolo II" Hospital, Policoro (MT), Italy.
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27
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Tschanz CMP, Cushman WC, Harrell CTE, Berlowitz DR, Sall JL. Synopsis of the 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: The Diagnosis and Management of Hypertension in the Primary Care Setting. Ann Intern Med 2020; 173:904-913. [PMID: 32866417 DOI: 10.7326/m20-3798] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION In January 2020, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the diagnosis and management of hypertension in the primary care setting. METHODS The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature from 15 December 2013 to 25 March 2019 and developed and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. RECOMMENDATIONS This synopsis summarizes key features of the guideline in several key areas: the measurement of blood pressure, the definition of hypertension, target treatment goals, and nonpharmacologic and pharmacologic treatment of essential and resistant hypertension.
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Affiliation(s)
| | - William C Cushman
- University of Tennessee Health Science Center, Memphis, Tennessee (W.C.C.)
| | | | - Dan R Berlowitz
- University of Massachusetts Lowell, Lowell, Massachusetts (D.R.B.)
| | - James L Sall
- U.S. Department of Veterans Affairs, Washington, DC (J.L.S.)
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28
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Manolis A, Doumas M, Ferri C, Mancia G. Erectile dysfunction and adherence to antihypertensive therapy: Focus on β-blockers. Eur J Intern Med 2020; 81:1-6. [PMID: 32693940 DOI: 10.1016/j.ejim.2020.07.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/15/2020] [Accepted: 07/15/2020] [Indexed: 11/19/2022]
Abstract
The management of arterial hypertension is very challenging in everyday clinical practice. Blood pressure control rates remain disappointingly low, despite intense efforts. Poor adherence to antihypertensive treatment is among the main causes of inadequate blood pressure control. Among the various parameters leading to poor adherence, medication adverse events seem to be the prevailing cause of treatment discontinuation. Β-blockers are a class of drugs commonly used in the management of hypertension. However, β-blockers use has been associated with various adverse events, among which, erectile dysfunction is a prevalent one. Accumulating evidence supports the detrimental role of β-blockers on erectile function. Older studies have shown contradictory findings, which however may be attributed to methodological errors related with the assessment of erectile function. More recent studies, however, unveiled the negative impact of this drug category on erectile function. Nevertheless, β-blockers represent a class of drugs with substantial within class heterogeneity. Nebivolol presents a unique mode of action through enhanced nitric oxide bioavailability that may be associated with benefits on erectile function. Indeed, studies of nebivolol have shown improvement in erectile function, suggesting that nebivolol represents the only exception in this class of drugs in terms of erectile function.
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Affiliation(s)
| | - Michael Doumas
- 2nd Prop. Department of Internal Medicine, Aristotle University, 126, Vas. Olgas street, 54645 Thessaloniki, Greece.
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Lunny C, Heran BS, Beaumier J, Salzwedel DM, Adams SP, Jauca CD, Musini VM, Wright JM. First-line drug classes for hypertension in adults: a network meta-analysis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Carole Lunny
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
| | - Balraj S Heran
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
| | - Jonathan Beaumier
- School of Population and Public Health; University of British Columbia; Vancouver Canada
| | - Douglas M Salzwedel
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
| | - Stephen P Adams
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
| | - Ciprian D Jauca
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
| | - Vijaya M Musini
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
| | - James M Wright
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res 2020; 42:1235-1481. [PMID: 31375757 DOI: 10.1038/s41440-019-0284-9] [Citation(s) in RCA: 1059] [Impact Index Per Article: 264.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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The Story of the Silent Killer : A History of Hypertension: Its Discovery, Diagnosis, Treatment, and Debates. Curr Hypertens Rep 2020; 22:72. [PMID: 32852612 DOI: 10.1007/s11906-020-01077-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Hypertension is the leading risk factor for death and disability-adjusted life-years lost globally. Despite this tremendous impact on health, blood pressure measurement and treatment are relatively new to medical practice, with widespread measurement beginning just over 100 years ago. How, in such a short time, did blood pressure become such an integral measurement in medical practice that it is now considered one of the vital signs? Key revelations through Stephen Hales and his horse experiment, Riva-Rocci's modern blood pressure cuff, Korotkoff sounds, and President Roosevelt's death set the stage for discovery. Landmark trials such as the VA Cooperative studies of the 1960s through the recent Systolic Blood Pressure Intervention Trial and Prevention with Mediterranean Diet trials provide the foundation for modern clinical practice. An understanding of the history of hypertension can directly affect current clinical practice and offers unique insights into how the medical community has approached the management of one of the deadliest medical conditions in history.
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Abstract
The prevalence of isolated diastolic hypertension (IDH) has been increased in hypertensive subjects with the new 2017 ACC/AHA blood pressure treatment guidelines to 6.5% from 1.3% by the JNC-7 guidelines. However, its clinical significance as a cause of adverse cardiovascular (CV) events especially in older subjects has been debated by several investigators, who have demonstrated no adverse CV effects of untreated IDH, but not by others. It is also more common in the young subjects who are at low CV risk and quite rare in the older subjects, who are at increased CV risk. Treatment of IDH in the older subjects could increase the CV complications due to a J-curve effect and, in addition, could increase the incidence of stroke from further lowering the normal systolic blood pressure (SBP). Very low SBP and DBP cannot be sustained by the cerebral blood flow autoregulation and could lead to cerebral ischemia. In order to get a better perspective of the current status of the treatment of IDH, a review of the English language literature of the available studies was conducted and 12 papers with pertinent information were retrieved. The analysis of results from these studies suggests that IDH is associated with adverse CV events in younger persons and it should be treated. In contrast, the prevalence of IDH is low in older subjects and is not associated with adverse CV events in the majority of cases. Thus, its further lowering should be avoided to prevent further decrease in normal SBP and prevent the onset of adverse CV events. However, the decision to treat IDH in older subjects should be individualized.
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Affiliation(s)
- Steven G Chrysant
- Department of Cardiology, University of Oklahoma Health Sciences Center , Oklahoma City, OK, USA
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A prospective study of the effect of antihypertensive medications on the sexual functions of hypertensive adult male patients. Future Sci OA 2020; 6:FSO479. [PMID: 32670607 PMCID: PMC7351083 DOI: 10.2144/fsoa-2020-0030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: The potential for antihypertensive medications to produce deleterious adverse effects on sexual functions among hypertensive adult male patients has been widely reported, such adverse effects may limit drug adherence and compliance. Aim: The aim of this study was to assess the effect of antihypertensive medication use on sexual functions among hypertensive adult male patients. Methodology: The study was carried out at the outpatient clinic of a Nigerian University Teaching Hospital. A total of one hundred and fifty-nine recruited hypertensive adult male patients that were being managed at the center over a 3-month period between January 2017 and April 2017 participated in the study; provided they satisfied the inclusion and exclusion criteria for enrolment. Results: The respondents were between 30 and 98 years of age, (mean of 59 ± 11.1 years). Blood pressure recorded was during their initial medical diagnosis for hypertension. Systolic blood pressure recorded was between 128 and 194 mmHg (mean of 162 ± 16.4 mmHg), while their diastolic blood pressure was between 78 and 120 mmHg (mean of 95 ± 10.7 mmHg). The highest occurrence of sexual dysfunctions was associated with calcium-channel blockers in 32 (20.1%) patients, followed by diuretics in 27 (17.0%) and, angiotensin-converting enzyme inhibitors in 20 (12.6%) patients. Conclusion: Calcium channel blockers caused the highest occurrence of sexual dysfunctions. This prospective study assessed the effect of antihypertensive medications on sexual functions among hypertensive adult male patients attending the medical outpatient clinic of a Nigerian University Teaching Hospital. A total of 159 patients who consented to the study and had been attending the clinic regularly for at least 6-month were enrolled. The respondents aged 30–98 years (mean 59 ± 11.1 years). Antihypertensive medication-associated sexual dysfunctions among the patients were observed in descending order as follows: calcium channel blockers in 32 (20.1%), diuretics in 27 (17.0%), Angiotensin converting enzyme inhibitors in 20 (12.6%), centrally acting antihypertensives in 11 (6.9%), beta receptor blockers in 8 (5.0%), vasodilators in 2 (1.3%), combined alpha- and beta-receptor blockers in 2 (1.3%) and alpha receptor blockers in 1 (0.6%). Antihypertensive medical prescriptions should reflect a balance between efficacy and tendency to cause sexual dysfunctions.
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Birudaraju D, Cherukuri L, Budoff M. Update on Hypertension and Adaptations for Treatment. ACTA ACUST UNITED AC 2020. [DOI: 10.38206/130103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hypertension (HTN) affects 46% of the US adult population and plays a major role in cardiovascular disease (CVD). Approximately, there were 90,098 deaths in 2017 primarily attributed to high blood pressure (BP). Recent guidelines recommend screening all adults for HTN. Management of elevated BP substantially reduces the risk of heart failure, stroke, and myocardial infarction. Recommended lifestyle modifications include weight loss for overweight or obese patients, regular exercise, the dietary approached to stop hypertension (DASH) diet, reduced dietary sodium intake, and reduced alcohol intake. Most HTN patients will need at least 2 drugs to control BP. Current guidelines from the ACC and AHA state that a BP level goal of < 130/80mmHg for adults with confirmed HTN and without additional markers of increased atherosclerotic cardiovascular disease (ASCVD) risk may be acceptable.
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Affiliation(s)
| | | | - Matthew Budoff
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA
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Effects of blood pressure lowering on cardiovascular events, in the context of regression to the mean: a systematic review of randomized trials. J Hypertens 2020; 37:16-23. [PMID: 30499920 DOI: 10.1097/hjh.0000000000001994] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the clinical relevance of regression to the mean for clinical trials and clinical practice. METHODS MEDLINE was searched until February 2018 for randomized trials of BP lowering with over 1000 patient-years follow-up per group. We estimated baseline mean BP, follow-up mean (usual) BP amongst patients grouped by 10 mmHg strata of baseline BP, and assessed effects of BP lowering on coronary heart disease (CHD) and stroke according to these BP levels. RESULTS Eighty-six trials (349 488 participants), with mean follow-up of 3.7 years, were included. Most mean BP change was because of regression to the mean rather than treatment. At high baseline BP levels, even after rigorous hypertension diagnosis, downwards regression to the mean caused much of the fall in BP. At low baseline BP levels, upwards regression to the mean increased BP levels, even in treatment groups. Overall, a BP reduction of 6/3 mmHg lowered CHD by 14% (95% CI 11-17%) and stroke by 18% (15-22%), and these treatment effects occurred at follow-up BP levels much closer to the mean than baseline BP levels. In particular, more evidence was available in the SBP 130-139 mmHg range than any other range. Benefits were apparent in numerous high-risk patient groups with baseline mean SBP less than 140 mmHg. CONCLUSION Clinical practice should focus less on pretreatment BP levels, which rarely predict future untreated BP levels or rule out capacity to benefit from BP lowering in high cardiovascular risk patients. Instead, focus should be on prompt, empirical treatment to maintain lower BP for those with high BP and/or high risk.
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Martínez-Milla J, Raposeiras-Roubín S, Pascual-Figal DA, Ibáñez B. Papel de los bloqueadores beta en la enfermedad cardiovascular en 2019. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2019.02.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Dimmitt SB, Stampfer HG, Martin JH, Ferner RE. Efficacy and toxicity of antihypertensive pharmacotherapy relative to effective dose 50. Br J Clin Pharmacol 2019; 85:2218-2227. [PMID: 31219198 DOI: 10.1111/bcp.14033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 01/09/2023] Open
Abstract
Antihypertensive drugs have usually been approved at doses near the top of their respective dose-response curves. Efficacy plateaus but adverse drug reactions (ADRs), such as falls, cerebral or renal ischaemia, increase as dose is increased, especially in older patients with comorbidities. ADRs reduce adherence and may be difficult to ascertain reliably. Higher doses have generally not been shown to reduce total mortality, which provides a summary of efficacy and safety. Weight loss and other lifestyle measures are essential and may be sufficient treatment in many young and low risk patients. Most antihypertensive drug lower systolic blood pressure by around 10 mmHg, which reduces stroke and heart failure by about a quarter. Clinical trials have not been designed to demonstrate specific blood pressure treatment thresholds and targets, which are mostly extrapolated from epidemiology. Mean population oral effective dose 50 may be the most appropriate dose at which to commence antihypertensive drugs. The dose can then be titrated up if greater efficacy is demonstrated, or lowered if ADRs develop. Lower dose combination therapy may best balance benefit and harms with fewer ADRs and additive, potentially synergistic, efficacy.
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Affiliation(s)
- Simon B Dimmitt
- Division of Internal Medicine, Medical School, University of Western Australia, Crawley, Western Australia, Australia.,University of Newcastle School of Medicine and Public Health, Callaghan, New South Wales, Australia
| | - Hans G Stampfer
- Division of Psychiatry, Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Jennifer H Martin
- University of Newcastle School of Medicine and Public Health, Callaghan, New South Wales, Australia.,Department of Medicine, Hunter New England Local Health District, Newcastle, Australia
| | - Robin E Ferner
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, UK.,Institute of Clinical Sciences, University of Birmingham, UK
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Lopina EA, Dushina AG, Libis RA. [Target Levels of Arterial Pressure in Patients with Arterial Hypertension and Stroke]. ACTA ACUST UNITED AC 2019; 59:72-76. [PMID: 31397232 DOI: 10.18087/cardio.2019.8.n337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/13/2019] [Accepted: 03/26/2019] [Indexed: 11/18/2022]
Abstract
Number of patients with arterial hypertension and stroke steadily grows. "Target" levels of arterial pressure are not established in patients after stroke. In this review, we present results of clinical trials and data of meta-analyses on this problem. Problems related to target levels of arterial pressure after stroke are also covered in a framework of present Russian (2010), European (2018) and American (2017) recommendations on diagnosis and treatment of arterial hypertension.
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Affiliation(s)
- E A Lopina
- Federal State Budgetary Educational Institution of Higher Education «Orenburg State Medical University» of the Ministry of Health of the Russian Federation
| | - A G Dushina
- Federal State Budgetary Educational Institution of Higher Education «Orenburg State Medical University» of the Ministry of Health of the Russian Federation
| | - R A Libis
- Federal State Budgetary Educational Institution of Higher Education «Orenburg State Medical University» of the Ministry of Health of the Russian Federation
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Martínez-Milla J, Raposeiras-Roubín S, Pascual-Figal DA, Ibáñez B. Role of Beta-blockers in Cardiovascular Disease in 2019. ACTA ACUST UNITED AC 2019; 72:844-852. [PMID: 31402328 DOI: 10.1016/j.rec.2019.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/24/2019] [Indexed: 11/17/2022]
Abstract
Beta-blockers are the cornerstone of treatment for various cardiovascular conditions. Although their effects have classically been considered to be driven by their antagonistic and competitive action on beta-adrenergic receptors, nowadays it is known that their effect goes beyond that of mere competition with catecholamines on these receptors. Beta-blockers were discovered as antianginal drugs in the 1960s and are currently widely used in heart failure, arrhythmias, and ischemic heart disease. In this article, we review the evidence for the beneficial effects of beta-blockers in these conditions, as well as the current recommendations in clinical practice guidelines for their use. Surprisingly, despite having been prescribed for more than 4 decades, new, previously unnoticed mechanisms of action on cellular compartments are still being discovered, which continues to open up new horizons for their use. All in all, beta-blockers are one of the most fascinating drug groups in our therapeutic armamentarium.
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Affiliation(s)
- Juan Martínez-Milla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain
| | | | - Domingo A Pascual-Figal
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Universidad de Murcia, El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Borja Ibáñez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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Lee HY, Shin J, Kim GH, Park S, Ihm SH, Kim HC, Kim KI, Kim JH, Lee JH, Park JM, Pyun WB, Chae SC. 2018 Korean Society of Hypertension Guidelines for the management of hypertension: part II-diagnosis and treatment of hypertension. Clin Hypertens 2019; 25:20. [PMID: 31388453 PMCID: PMC6670135 DOI: 10.1186/s40885-019-0124-x] [Citation(s) in RCA: 170] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/25/2019] [Indexed: 02/06/2023] Open
Abstract
The standardized techniques of blood pressure (BP) measurement in the clinic are emphasized and it is recommended to replace the mercury sphygmomanometer by a non-mercury sphygmomanometer. Out-of-office BP measurement using home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) and even automated office BP (AOBP) are recommended to correctly measure the patient’s genuine BP. Hypertension (HTN) treatment should be individualized based on cardiovascular (CV) risk and the level of BP. Based on the recent clinical study data proving benefits of intensive BP lowering in the high risk patients, the revised guideline recommends the more intensive BP lowering in high risk patients including the elderly population. Lifestyle modifications, mostly low salt diet and weight reduction, are strongly recommended in the population with elevated BP and prehypertension and all hypertensive patients. In patients with BP higher than 160/100 mmHg or more than 20/10 mmHg above the target BP, two drugs can be prescribed in combination to maximize the antihypertensive effect and to achieve rapid BP control. Especially, single pill combination drugs have multiple benefits, including maximizing reduction of BP, minimizing adverse effects, increasing adherence, and preventing cardiovascular disease (CVD) and target organ damage.
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Affiliation(s)
- Hae-Young Lee
- 1Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jinho Shin
- 2Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Gheun-Ho Kim
- 2Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungha Park
- 3Department of Internal Medicine, Yonsei University, Seoul, Korea
| | - Sang-Hyun Ihm
- 4Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Chang Kim
- 3Department of Internal Medicine, Yonsei University, Seoul, Korea
| | - Kwang-Il Kim
- 5Department of Internal Medicine, Seoul National University, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ju Han Kim
- Department of Internal Medicine, School of Medicine, Chonnam University, GwangJu, Korea
| | - Jang Hoon Lee
- 7Division of Cardiology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jong-Moo Park
- 8Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Wook Bum Pyun
- 9Cardiovascular Center, Seoul Hospital, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Shung Chull Chae
- 7Division of Cardiology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Bouhanick B, Blacher J, Huyghe E, Colson MH, Boivin JM, Mounier-Vehier C, Denolle T, Fauvel JP. [Sexual dysfunction and antihypertensive treatment: Involvement of the different therapeutic classes and what to do about the treatment of hypertension]. Presse Med 2019; 48:1222-1228. [PMID: 31303372 DOI: 10.1016/j.lpm.2019.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/27/2019] [Indexed: 11/19/2022] Open
Abstract
Erectile dysfunction (ED) is not routinely discussed with patients in cardiology practices whereas it may impact the ability of patients to stay on therapy. Most of the studies about ED and antihypertensive therapies have several methodological limitations. Diuretics and beta-blockers have been shown to have a deleterious effect on ED. ISRA inhibitors, calcium antagonists, vasodilator beta-blockers and alpha-blockers have been shown to have a neutral impact on ED. Angiotensin 2 inhibitors, nebivolol and alpha-blockers use has sometimes beneficial effect on ED. In case of ED due to antihypertensive treatment, drugs can be switched each other but careful attention in patients with a high cardiovascular risk is required.
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Affiliation(s)
- Béatrice Bouhanick
- CHU Rangueil, université Toulouse 3, service d'hypertension artérielle et thérapeutique, UMR1027, TSA 50032, 1, avenue J. Poulhes, 31059 Toulouse cedex 9 France.
| | - Jacques Blacher
- AP-HP, université Paris-Descartes, Hôtel-Dieu, Centre de diagnostic et de thérapeutique, 75004 Paris, France
| | - Eric Huyghe
- CHU Toulouse, EA 3694 human fertility research group, Paule de Viguier, reproductive medicine department, 31059 Toulouse, France
| | | | - Jean-Marc Boivin
- CHU de Nancy, université de Lorraine, institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, CIC-P Pierre Drouin, Inserm, 54000 Vandoeuvre-lès-Nancy, France
| | | | - Thierry Denolle
- Centre d'Excellence Européen en HTA Rennes-Dinard, 35800 Dinard, France
| | - Jean-Pierre Fauvel
- Université C Bernard Lyon 1, hospices civils de Lyon, 69000 Lyon, France
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Effects of blood pressure-lowering treatment on cardiovascular outcomes and mortality: 14 - effects of different classes of antihypertensive drugs in older and younger patients: overview and meta-analysis. J Hypertens 2019; 36:1637-1647. [PMID: 29847487 DOI: 10.1097/hjh.0000000000001777] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES The five major classes of blood pressure (BP)-lowering drugs have all been shown to significantly reduce the risk of major cardiovascular events when compared with placebo, and when directly (head-to-head) compared, no significant differences in their overall effectiveness have been detected, except for minor differences in cause-specific events. It is unknown, however, whether age-related differences exist and if some classes of drugs are differently effective in older or younger individuals. This clinically relevant question has been the object of a systematic search and meta-analysis of all available data. METHODS Two databases we had previously identified [72 placebo-controlled BP-lowering randomized clinical trials (RCTs) in 260 210 individuals and 50 RCTs head-to-head comparing treatments with BP-lowering drugs of different classes in 247 006 individuals) were searched for separately reported data on patients older or younger than 65 years, and the data were further stratified according to the class of drug [diuretics, beta-blockers, calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers] compared with placebo or with other drug classes. Seven fatal and nonfatal outcomes were considered for benefits. Adverse events were investigated as permanent treatment discontinuations for adverse events. Risk ratios and absolute risk changes were calculated by a random effects model. Effects at older and younger ages were compared by heterogeneity test. RESULTS We identified 20 placebo-controlled RCTs on 55 645 older individuals and 21 on 99 621 younger individuals, and 21 head-to-head drug comparison RCTs on 94 228 older individuals and 27 on 100 232 younger individuals (for a total of 349 726 individuals). When compared with placebo, all five classes of BP-lowering drugs significantly reduced the risk of major cardiovascular events or stroke, with no significant difference between older and younger patients. However, in head-to-head comparisons, no significant difference was found between older and younger patients in the effects of diuretics, calcium antagonists, ACE inhibitors and angiotensin receptor blockers on all cardiovascular outcomes, whereas beta-blockers revealed an age-dependent effectiveness, being equally effective as the other agents at an age below 65 years, but less effective at an older age. CONCLUSION Most BP-lowering classes are equally effective in preventing risk of fatal and nonfatal cardiovascular events both in older and younger patients, whereas beta-blockers, though being equally effective as the other agents in patients younger than 65, loose some of their effectiveness at an older age.
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Effects of blood pressure-lowering treatment on cardiovascular outcomes and mortality: 13 - benefits and adverse events in older and younger patients with hypertension: overview, meta-analyses and meta-regression analyses of randomized trials. J Hypertens 2019; 36:1622-1636. [PMID: 29847485 DOI: 10.1097/hjh.0000000000001787] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is overwhelming evidence that blood pressure (BP)-lowering treatment can reduce cardiovascular outcomes also in the elderly, but some important aspects influencing medical practice are controversial as sufficient evidence has not been provided by single randomized controlled trials (RCTs), whereas evidence may result from a systematic search and meta-analysis of all available data. OBJECTIVES The following clinically relevant issues concerning the effects of BP lowering in older and younger individuals have been investigated: differences in benefits; the oldest and the youngest age range for which evidence of BP-lowering effects is available; the SBP level at which BP-lowering treatment should be initiated; the SBP and DBP levels treatment should be aimed at; differences in treatment burdens and harms. METHODS A database we previously identified of 72 BP-lowering RCTs in 260 210 patients was searched for separately reported data on older and younger individuals [cutoffs of 65 (primary analyses), 70, 75, 80, 60 and 55 years). The data were further stratified according to the levels of baseline (untreated) BP, and of on-treatment achieved SBP or DBP. Seven fatal and nonfatal outcomes were considered for benefits. Burdens and harms were investigated as permanent treatment discontinuations for adverse events, and hypotension/syncope. Risk ratios and absolute risk changes were calculated by a random effects model. Effects at older and younger ages were compared by heterogeneity test. RESULTS Thirty-two RCTs provided data on 96 549 patients older than 65 years, and 31 RCTs on 114 009 patients younger than 65 years. All cardiovascular outcomes were significantly reduced by treatment both in older and younger individuals, without significant age-dependent differences in relative risk reduction but with significantly higher absolute risk reductions in older individuals. The extreme age ranges for which evidence of significant benefits of treatment were available was greater than 80 and less than 55 years. Only one RCT provided data on benefits of BP-lowering at age greater than 65 when treatment was initiated at SBP values in the grade 1 range, but more consistent evidence was provided when age was greater than 60 years. Both in patients older and younger than 65 years, significant reductions of cardiovascular outcomes were found at on-treatment SBP less than 140 mmHg and DBP less than 80 mmHg. There was no evidence that treatment discontinuations for adverse events or hypotension/syncope were more frequent at age greater than 65. CONCLUSION Antihypertensive treatment should be recommended to all individuals with elevated BP, independent of age. The prudent recommendation to initiate treatment at SBP values 140-159 mmHg is supported at older age defined as greater than 60 years. SBP and DBP values lower than 140 mmHg and, respectively, 80 mmHg can be aimed at with incremental benefits without disproportionate burdens until age 80 years, above which available evidence is for benefits at on-treatment SBP 140-149 mmHg.
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Musini VM, Tejani AM, Bassett K, Puil L, Wright JM. Pharmacotherapy for hypertension in adults 60 years or older. Cochrane Database Syst Rev 2019; 6:CD000028. [PMID: 31167038 PMCID: PMC6550717 DOI: 10.1002/14651858.cd000028.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND This is the second substantive update of this review. It was originally published in 1998 and was previously updated in 2009. Elevated blood pressure (known as 'hypertension') increases with age - most rapidly over age 60. Systolic hypertension is more strongly associated with cardiovascular disease than is diastolic hypertension, and it occurs more commonly in older people. It is important to know the benefits and harms of antihypertensive treatment for hypertension in this age group, as well as separately for people 60 to 79 years old and people 80 years or older. OBJECTIVES Primary objective• To quantify the effects of antihypertensive drug treatment as compared with placebo or no treatment on all-cause mortality in people 60 years and older with mild to moderate systolic or diastolic hypertensionSecondary objectives• To quantify the effects of antihypertensive drug treatment as compared with placebo or no treatment on cardiovascular-specific morbidity and mortality in people 60 years and older with mild to moderate systolic or diastolic hypertension• To quantify the rate of withdrawal due to adverse effects of antihypertensive drug treatment as compared with placebo or no treatment in people 60 years and older with mild to moderate systolic or diastolic hypertension SEARCH METHODS: The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to 24 November 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We contacted authors of relevant papers regarding further published and unpublished work. SELECTION CRITERIA Randomised controlled trials of at least one year's duration comparing antihypertensive drug therapy versus placebo or no treatment and providing morbidity and mortality data for adult patients (≥ 60 years old) with hypertension defined as blood pressure greater than 140/90 mmHg. DATA COLLECTION AND ANALYSIS Outcomes assessed were all-cause mortality; cardiovascular morbidity and mortality; cerebrovascular morbidity and mortality; coronary heart disease morbidity and mortality; and withdrawal due to adverse effects. We modified the definition of cardiovascular mortality and morbidity to exclude transient ischaemic attacks when possible. MAIN RESULTS This update includes one additional trial (MRC-TMH 1985). Sixteen trials (N = 26,795) in healthy ambulatory adults 60 years or older (mean age 73.4 years) from western industrialised countries with moderate to severe systolic and/or diastolic hypertension (average 182/95 mmHg) met the inclusion criteria. Most of these trials evaluated first-line thiazide diuretic therapy for a mean treatment duration of 3.8 years.Antihypertensive drug treatment reduced all-cause mortality (high-certainty evidence; 11% with control vs 10.0% with treatment; risk ratio (RR) 0.91, 95% confidence interval (CI) 0.85 to 0.97; cardiovascular morbidity and mortality (moderate-certainty evidence; 13.6% with control vs 9.8% with treatment; RR 0.72, 95% CI 0.68 to 0.77; cerebrovascular mortality and morbidity (moderate-certainty evidence; 5.2% with control vs 3.4% with treatment; RR 0.66, 95% CI 0.59 to 0.74; and coronary heart disease mortality and morbidity (moderate-certainty evidence; 4.8% with control vs 3.7% with treatment; RR 0.78, 95% CI 0.69 to 0.88. Withdrawals due to adverse effects were increased with treatment (low-certainty evidence; 5.4% with control vs 15.7% with treatment; RR 2.91, 95% CI 2.56 to 3.30. In the three trials restricted to persons with isolated systolic hypertension, reported benefits were similar.This comprehensive systematic review provides additional evidence that the reduction in mortality observed was due mostly to reduction in the 60- to 79-year-old patient subgroup (high-certainty evidence; RR 0.86, 95% CI 0.79 to 0.95). Although cardiovascular mortality and morbidity was significantly reduced in both subgroups 60 to 79 years old (moderate-certainty evidence; RR 0.71, 95% CI 0.65 to 0.77) and 80 years or older (moderate-certainty evidence; RR 0.75, 95% CI 0.65 to 0.87), the magnitude of absolute risk reduction was probably higher among 60- to 79-year-old patients (3.8% vs 2.9%). The reduction in cardiovascular mortality and morbidity was primarily due to a reduction in cerebrovascular mortality and morbidity. AUTHORS' CONCLUSIONS Treating healthy adults 60 years or older with moderate to severe systolic and/or diastolic hypertension with antihypertensive drug therapy reduced all-cause mortality, cardiovascular mortality and morbidity, cerebrovascular mortality and morbidity, and coronary heart disease mortality and morbidity. Most evidence of benefit pertains to a primary prevention population using a thiazide as first-line treatment.
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Affiliation(s)
- Vijaya M Musini
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Science MallVancouverBCCanadaV6T 1Z3
| | - Aaron M Tejani
- University of British ColumbiaTherapeutics Initiative2176 Health Sciences MallVancouverBCCanadaV6T 1Z3
| | - Ken Bassett
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Science MallVancouverBCCanadaV6T 1Z3
| | - Lorri Puil
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine2176 Health Sciences MallVancouverBCCanadaV6T 1Z3
| | - James M Wright
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Science MallVancouverBCCanadaV6T 1Z3
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Lee CJ, Ryu J, Kim HC, Ryu DR, Ihm SH, Kim YJ, Shin JH, Pyun WB, Kang HS, Park JH, Hwang J, Park S. Clinical Benefit of Treatment of Stage-1, Low-Risk Hypertension. Hypertension 2019; 72:1285-1293. [PMID: 30571236 DOI: 10.1161/hypertensionaha.118.11787] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Evidence about the benefits of treating uncomplicated, low-risk, stage-1 hypertension is lacking. The study aimed to investigate the association between mean blood pressure (BP) and clinical outcomes, and to determine optimal BPs in treated, low-risk, stage-1 hypertension. From the National Health Insurance Service Health Examination Database, patients with stage-1 hypertension between 2005 and 2006 were selected. They had a systolic BP of 140 to 159 mm Hg or diastolic BP of 90 to 99 mm Hg. Patients were grouped as controlled (mean BP <140/90 mm Hg; n=99 301) and uncontrolled (mean BP ≥140/90 mm Hg; n=49 460) according to their mean BP recorded during the follow-up health examination. All-cause mortality and cardiovascular outcomes were examined. Mean BPs in the controlled and uncontrolled groups were 131.1/80.9 and 144.6/86.8 mm Hg, respectively. Controlled BP was associated with significantly lower risks of all-cause mortality, all stroke, hemorrhagic stroke, ischemic stroke, and end-stage renal disease. Subgroup analysis demonstrated benefits of controlled BP in hypertensive patients aged <50 years for all-cause mortality, all stroke, hemorrhagic stroke, ischemic stroke, and end-stage renal disease, with no significant interaction according to age. The BP associated with the lowest risk of all-cause mortality was 120 to <130 mm Hg (systolic BP) and 70 to <80 mm Hg (diastolic BP). There was an increased risk of myocardial infarction in patients with mean systolic BP <120 mm Hg and diastolic BP <80 mm Hg. BP <140/90 mm Hg was associated with a significant reduction in the risk of mortality, stroke, and end-stage renal disease, with the lowest mortality risk at BP ranges of 120 to <130 and 70 to <80 mm Hg.
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Affiliation(s)
- Chan Joo Lee
- From the Department of Health Promotion, Severance Hospital, Seoul, Republic of Korea (C.J.L.)
| | - Jiin Ryu
- Department of Statistics and Computer Science, Daegu University, Gyeongbuk, Republic of Korea (J.R., J.H.)
| | - Hyeon-Chang Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (H.-C.K.)
| | - Dong-Ryeol Ryu
- Division of Nephrology (R.R.), Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Sang-Hyun Ihm
- Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.-H.I.)
| | - Yong-Jin Kim
- Division of Cardiology, Seoul National University College of Medicine, Republic of Korea (Y.-J.K.)
| | - Jin-Ho Shin
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea (J.-H.S.)
| | - Wook Bum Pyun
- Cardiovascular Center (W.B.P.), Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Hyoung-Soo Kang
- Department of Big Data Steering, National Health Insurance Service, Wonju, Gangwon, Republic of Korea (H.-S.K., J.-H.P.)
| | - Jong-Heon Park
- Department of Big Data Steering, National Health Insurance Service, Wonju, Gangwon, Republic of Korea (H.-S.K., J.-H.P.)
| | - Jinseub Hwang
- Department of Statistics and Computer Science, Daegu University, Gyeongbuk, Republic of Korea (J.R., J.H.)
| | - Sungha Park
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea (S.P.)
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Macfarlane TV, Pigazzani F, Flynn RW, MacDonald TM. The effect of indapamide vs. bendroflumethiazide for primary hypertension: a systematic review. Br J Clin Pharmacol 2019; 85:285-303. [PMID: 30312512 PMCID: PMC6339968 DOI: 10.1111/bcp.13787] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/25/2018] [Accepted: 09/21/2018] [Indexed: 12/28/2022] Open
Abstract
The aims of the current review were to compare the efficacy of monotherapy with bendroflumethiazide vs. indapamide on mortality, cardiovascular outcomes, blood pressure, need for intensification of treatment and treatment withdrawal. Two authors independently screened the results of a literature search, assessed the risk of bias and extracted relevant data. Randomized clinical trials of hypertensive patients of at least a 1-year duration were included. When there was disagreement, a third reviewer was consulted. Risk ratio (RR) and mean differences were used as measures of effect. Two trials comparing bendroflumethiazide against placebo, one comparing indapamide with placebo and three of short duration directly comparing indapamide and Bendroflumethiazide, were included. No statistically significant difference was found between indapamide and bendroflumethiazide for all deaths [RR 0.82; 95% confidence interval (CI) 0.57, 1.18], cardiovascular deaths (RR 0.82; 95% CI 0.55, 1.20), noncardiovascular deaths (0.81; 95% CI 0.54, 1.22), coronary events (RR 0.73; 95% CI 0.30, 1.79) or all cardiovascular events (RR 0.89; 95% CI 0.67, 1.18). Indapamide performed worse for stroke (RR 2.21; 95% CI 1.19, 4.11), even though a reduction in RR compared with placebo was observed in both groups. There was no statistically or clinically significant difference between indapamide and bendroflumethiazide in blood pressure reduction (mean absolute difference <1 mmHg). The present review highlights a lack of studies to answer the review question but also a lack of evidence of superiority of one drug over the other. Therefore, there is a clear need for new studies directly comparing the effect of these drugs on the outcomes of interest.
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Affiliation(s)
| | - Filippo Pigazzani
- Medicines Monitoring Unit (MEMO), School of MedicineUniversity of DundeeDundeeUK
| | - Robert W.V. Flynn
- Medicines Monitoring Unit (MEMO), School of MedicineUniversity of DundeeDundeeUK
| | - Thomas M. MacDonald
- Medicines Monitoring Unit (MEMO), School of MedicineUniversity of DundeeDundeeUK
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Park S. Ideal Target Blood Pressure in Hypertension. Korean Circ J 2019; 49:1002-1009. [PMID: 31646769 PMCID: PMC6813156 DOI: 10.4070/kcj.2019.0261] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 08/13/2019] [Indexed: 01/02/2023] Open
Abstract
In the Systolic Blood Pressure Intervention Trial (SPRINT), intensive blood pressure (BP) lowering was associated with significant reduction in composite cardiovascular (CV) outcomes in hypertension. Subsequently, several meta-analyses have corroborated the findings from SPRINT and these benefits were more prominent in subjects with higher cardiovascular risk at baseline. As such, the recent American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guideline and the European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guideline recommended the lowering of target BP to less than 130/80 mmHg in most hypertensive subjects. However, one should keep in mind the potential harm of too much BP lowering. Post hoc analysis of clinical trials have demonstrated increased cardiovascular mortality and events with too much BP lowering. Therefore, although intensive BP lowering may be beneficial in further reducing CV outcomes, too much reduction below 120/70 mmHg may actually harmful. In conclusion, although intensive BP lowering to achieve target BP below 130/80 mmHg is beneficial in reducing CV outcomes, one should do so cautiously as to avoid adverse events. As such, the first target of anti-hypertensive treatment should be to achieve BP lowering below 140/90 mmHg. Once that target is achieved, one could target BP below 130/80 mmHg keeping in mind to avoid signs of organ hypoperfusion such as orthostatic hypotension, orthostatic dizziness, weakness and serum creatinine elevation.
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Affiliation(s)
- Sungha Park
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Chang AR, Lóser M, Malhotra R, Appel LJ. Blood Pressure Goals in Patients with CKD: A Review of Evidence and Guidelines. Clin J Am Soc Nephrol 2018; 14:161-169. [PMID: 30455322 PMCID: PMC6364532 DOI: 10.2215/cjn.07440618] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hypertension affects the vast majority of patients with CKD and increases the risk of cardiovascular disease, ESKD, and death. Over the past decade, a number of hypertension guidelines have been published with varying recommendations for BP goals in patients with CKD. Most recently, the American College of Cardiology/American Heart Association 2017 hypertension guidelines set a BP goal of <130/80 mm Hg for patients with CKD and others at elevated cardiovascular risk. These guidelines were heavily influenced by the landmark Systolic Blood Pressure Intervention Trial (SPRINT), which documented that an intensive BP goal to a systolic BP <120 mm Hg decreased the risk of cardiovascular disease and mortality in nondiabetic adults at high cardiovascular risk, many of whom had CKD; the intensive BP goal did not retard CKD progression. It is noteworthy that SPRINT measured BP with automated devices (5-minute wait period, average of three readings) often without observers, a technique that potentially results in BP values that are lower than what is typically measured in the office. Still, results from SPRINT along with long-term follow-up data from the Modification of Diet in Renal Disease and the African American Study of Kidney Disease and Hypertension suggest that a BP goal <130/80 mm Hg will reduce mortality in patients with CKD. Unfortunately, data are more limited in patients with diabetes or stage 4-5 CKD. Increased adverse events, including electrolyte abnormalities and decreased eGFR, necessitate careful laboratory monitoring. In conclusion, a BP goal of <130/80 is a reasonable, evidence-based BP goal in patients with CKD. Implementation of this intensive BP target will require increased attention to measuring BP accurately, assessing patient preferences and concurrent medical conditions, and monitoring for adverse effects of therapy.
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Affiliation(s)
- Alex R Chang
- Kidney Health Research Institute, Geisinger Health System, Danville, Pennsylvania;
| | - Meghan Lóser
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Rakesh Malhotra
- Division of Nephrology and Hypertension, University of California San Diego, San Diego, California; and
| | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
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Sudell M, Kolamunnage-Dona R, Gueyffier F, Tudur Smith C. Investigation of one-stage meta-analysis methods for joint longitudinal and time-to-event data through simulation and real data application. Stat Med 2018; 38:247-268. [PMID: 30209815 PMCID: PMC6492085 DOI: 10.1002/sim.7961] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 08/08/2018] [Accepted: 08/22/2018] [Indexed: 12/28/2022]
Abstract
Background: Joint modeling of longitudinal and time‐to‐event data is often advantageous over separate longitudinal or time‐to‐event analyses as it can account for study dropout, error in longitudinally measured covariates, and correlation between longitudinal and time‐to‐event outcomes. The current literature on joint modeling focuses mainly on the analysis of single studies with a lack of methods available for the meta‐analysis of joint data from multiple studies. Methods: We investigate a variety of one‐stage methods for the meta‐analysis of joint longitudinal and time‐to‐event outcome data. These methods are applied to the INDANA dataset to investigate longitudinally measured systolic blood pressure, with each of time to death, time to myocardial infarction, and time to stroke. Results are compared to separate longitudinal or time‐to‐event meta‐analyses. A simulation study is conducted to contrast separate versus joint analyses over a range of scenarios. Results: The performance of the examined one‐stage joint meta‐analytic models varied. Models that accounted for between study heterogeneity performed better than models that ignored it. Of the examined methods to account for between study heterogeneity, under the examined association structure, fixed effect approaches appeared preferable, whereas methods involving a baseline hazard stratified by study were least time intensive. Conclusions: One‐stage joint meta‐analytic models that accounted for between study heterogeneity using a mix of fixed effects or a stratified baseline hazard were reliable; however, models examined that included study level random effects in the association structure were less reliable.
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Affiliation(s)
- Maria Sudell
- Department of Biostatistics, University of Liverpool, Liverpool, UK
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Rozza F, Manzi MV, Trimarco B. Is there a risk in overtreating a hypertensive patient? J Cardiovasc Med (Hagerstown) 2018; 18 Suppl 1:e50-e53. [PMID: 27801683 DOI: 10.2459/jcm.0000000000000440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Francesco Rozza
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
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