Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004—BHS IV

Medición de la presión arterial en el domicilio

Measurement of blood pressure (BP) by the own patient at home has become a popular procedure. Both a great offer of simple electronic devices and publication of multiple studies supporting its usefulness for the diagnosis and control of hypertension have contributed to this fact. In fact, this technique has various advantages over the conventional clinical measurement such as a higher reproducibility, better representation of the usual BP profile of the patient, greater correlation with target organs damage and greater morbimortality predictive value. Besides, there is a potential benefit on the control of patients under antihypertensives and, maybe, a reduction in health expenses at long-term follow-up. Currently, the main hypertension societies recommend the home measurement of BP in some clinical situations. However, it cannot be considered an alternative to the clinical measurement but rather a complementary technique in the evaluation of the hypertensive patient. Here we review the indications and limitations of this procedure in clinical practice.

Endovascular aortic coarctation stenting in adolescents and adults: Angiographic and hemodynamic outcomes

OBJECTIVES

To assess the procedural, clinical, angiographic, and hemodynamic outcomes, including ambulatory blood pressure monitoring at 1 year in adolescent and adult patients undergoing primary stenting for treatment of aortic coarctation.

BACKGROUND

Stenting is widely used for treatment of aortic coarctation. Data regarding efficacy of this treatment for control of hypertension at 1 year is scant, with only one reported series of planned angiographic follow up. The impact of newer type stents for this procedure is also unknown.

METHODS

Thirty-seven patients undergoing stenting for aortic coarctation, over a 3-year period in a tertiary centre were studied as part of an observational protocol.

RESULTS

Peak gradient across the coarctation fell from 28.3 +/- 15.1 to 3.7 +/- 4.1 post procedure and was 11.9 +/- 8.9 mmHg (P < 0.05 compared to baseline) at 1 year. There was one major complication (2.7%), with no deaths. Small aneurysms were seen in three patients (13%) on follow up angiography at 1 year. Right arm systolic blood pressures fell from 155 +/- 19 to 132 +/- 22 (P < 0.05) at 6 weeks and was 132 +/- 16 mmHg (P < 0.05 compared to baseline) at 1 year. Ambulatory average systolic blood pressures fell from 142 +/- 14 to 133 +/- 15 at 6 weeks (P < 0.05) and to 125 +/- 12 mmHg (P < 0.05 compared to baseline) at 1 year. No significant differences were seen in procedural outcomes between patients receiving Palmaz and CPNumed stents.

CONCLUSION

Primary stenting of aortic coarctation in adolescents and adults results in excellent clinical and angiographic outcomes and sustained hemodynamic benefits at 1 year as evidenced by significant reduction in systolic blood pressure and gradients. Close follow up is required to monitor aneurysm formation.

Pathophysiology of Antihypertensive Therapy with Diuretics

Recent progress in antihypertensive therapy has widened the selection of drugs, and large clinical trials have attracted attention to newer classes of antihypertensives. Consequently, the use of diuretics as antihypertensive agents has been relatively reduced, particularly since the newer drugs are associated with fewer adverse metabolic reactions. However, diuretics have a specific activity of removing sodium from the body fluid, thereby rendering the blood pressure insensitive to sodium intake, relieving the overload to systemic circulation, and normalizing the circadian rhythm of blood pressure from a non-dipper to a dipper pattern. At low doses, diuretics are known to be as effective as all other antihypertensive agents for reducing nearly all types of cardiovascular events. In this brief review, the indication for thiazide diuretics will be discussed based on the pathophysiology of hypertension and antihypertensive therapy with diuretics mainly from the point of view of sodium metabolism. Low-dose diuretics will continue to be an important agent in the treatment of hypertension, mostly in combination with vasodilators such as modulators of the reninangiotensin system and calcium channel blockers.

Prevalence, awareness, treatment and control of hypertension in Turkey (the PatenT study) in 2003

OBJECTIVE

To determine the distribution of blood pressure (BP) and prevalence, awareness, treatment and control of hypertension in Turkey (PatenT).

DESIGN

A population-based cross-sectional epidemiology survey was carried out in 2003.

SETTING

Twenty-six cities from seven geographical provinces of Turkey, with proportional representation of urban and rural populations.

PARTICIPANTS

A two-stage stratified sampling method was used to select a sample of the adult population over 18 years of age. The total number of participants was 4910.

INTERVENTIONS

Data collection and BP measurements were conducted by specifically trained physicians in the households of the participants.

MAIN OUTCOME MEASURES

The mean systolic and diastolic BP levels, distribution of blood pressure, prevalence of hypertension (mean systolic BP>or=140 mmHg or mean diastolic BP>or=90 mmHg, or previously diagnosed and/or taking antihypertensive drugs), awareness, treatment and control of hypertension were assessed.

RESULTS

The overall age-adjusted and sex-adjusted prevalence of hypertension in Turkey was 31.8%, and it was higher in women than in men (36.1 versus 27.5%, P<0.001). In the whole group, 32.2% had never had their BP measured. Overall, 40.7% of those with hypertension were aware of their diagnosis, only 31.1% were receiving pharmacologic treatment and only 8.1% had their BP under control. The subjects who were aware and treated had a control ratio of 20.7%.

CONCLUSIONS

PatenT data indicate that hypertension is a highly prevalent but inadequately managed health problem in Turkey. There is an urgent need for population-based strategies to improve the prevention, early detection and control of hypertension.

Effect of inhibitors of the renin-angiotensin system and other antihypertensive drugs on renal outcomes: systematic review and meta-analysis

BACKGROUND

A consensus has emerged that angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-II receptor blockers (ARBs) have specific renoprotective effects. Guidelines specify that these are the drugs of choice for the treatment of hypertension in patients with renal disease. We sought to determine to what extent this consensus is supported by the available evidence.

METHODS

Electronic databases were searched up to January, 2005, for randomised trials assessing antihypertensive drugs and progression of renal disease. Effects on primary discrete endpoints (doubling of creatinine and end-stage renal disease) and secondary continuous markers of renal outcomes (creatinine, albuminuria, and glomerular filtration rate) were calculated with random-effect models. The effects of ACE inhibitors or ARBs in placebo-controlled trials were compared with the effects seen in trials that used an active comparator drug.

FINDINGS

Comparisons of ACE inhibitors or ARBs with other antihypertensive drugs yielded a relative risk of 0.71 (95% CI 0.49-1.04) for doubling of creatinine and a small benefit on end-stage renal disease (relative risk 0.87, 0.75-0.99). Analyses of the results by study size showed a smaller benefit in large studies. In patients with diabetic nephropathy, no benefit was seen in comparative trials of ACE inhibitors or ARBs on the doubling of creatinine (1.09, 0.55-2.15), end-stage renal disease (0.89, 0.74-1.07), glomerular filtration rate, or creatinine amounts. Placebo-controlled trials of ACE inhibitors or ARBs showed greater benefits than comparative trials on all renal outcomes, but were accompanied by substantial reductions in blood pressure in favour of ACE inhibitors or ARBs.

INTERPRETATION

The benefits of ACE inhibitors or ARBs on renal outcomes in placebo-controlled trials probably result from a blood-pressure-lowering effect. In patients with diabetes, additional renoprotective actions of these substances beyond lowering blood pressure remain unproven, and there is uncertainty about the greater renoprotection seen in non-diabetic renal disease.

Ezetimibe/simvastatin (INEGY) in the treatment of hyperlipidaemia

Ezetimibe/simvastatin (INEGY), a dual inhibitor of both cholesterol production and absorption, is a new approach to the management of hyperlipidaemia. Recent studies have shown that it produces greater reductions in low-density lipoprotein (LDL) cholesterol than the single inhibition of statin therapy, enabling many more patients to achieve their LDL cholesterol treatment goals. With ezetimibe/simvastatin therapy, reductions of up to 61% from baseline have been seen in LDL cholesterol, with clear improvements in other associated lipid fractions. It has been well tolerated across all studies, with a safety profile similar to that of statin therapy. This article will review clinical experience to date with ezetimibe/simvastatin, commenting upon its place and potential value in the prevention of cardiovascular disease.

Pharmacological treatment of ischemic stroke

Current pharmacological strategies for acute ischemic stroke largely mirror those employed in acute coronary syndromes. However, important differences in the effectiveness and versatility of the principal agents have emerged between these 2 clinical settings. In general, the level of success achieved with drugs in acute coronary syndromes has not carried over to the same extent when the same drug types are used in stroke. The principal reason is that reperfusion or anticoagulant therapies in the setting of brain infarction run a significant risk of hemorrhagic transformation that has no direct equivalent in myocardial infarction. Consequently, a significant challenge in acute stroke therapeutics is the ability to select patients for drugs where only a narrow therapeutic margin exists and to identify methods that can minimize hemorrhage risk. Other brain-specific vascular factors also pertain in explaining differences in outcome of drugs generally regarded as having a broad cardiovascular remit. The relatively limited efficacy of antiplatelets in stroke might relate to the composition and heterogeneity of the cerebrovascular lesion, while the poor outcome associated with acute anti-hypertensive use is partly due to loss of cerebrovascular autoregulation. Finally, downstream consequences of arterial occlusion within the brain such as excitotoxicity and plasticity are organ specific and, as such, deserve their own pharmacological approaches. In this review, we describe the general mechanism of each drug class used in ischemic stroke and then report on the clinical experience and application for each.

Therapy insight: heart disease and the insulin-resistant patient

Insulin-resistance syndromes are of pandemic proportions; 150 million people worldwide and an estimated 43 million people in the US are currently affected by type 2 diabetes mellitus or metabolic syndrome respectively. Treatment of heart disease in the context of type 2 diabetes requires multifactorial risk-factor management, including lifestyle modification and drug treatment for comorbidities. Management of coronary risk extends beyond simple cholesterol lowering. Early use of cardiac imaging and, where appropriate, revascularization should be considered in high-risk or symptomatic patients. Traditionally, patients with type 2 diabetes and coronary arterial disease have been treated surgically, but percutaneous revascularization of these patients is increasingly common. Indeed, revascularization by use of drug-eluting coronary stents combined with administration of novel antiplatelet agents has revolutionized percutaneous coronary intervention in patients with type 2 diabetes. Despite these advances, there is no consensus of opinion regarding revascularization strategies or risk-factor management in insulin-resistant patients with symptomatic or prognostically important coronary arterial disease. Furthermore, specific therapies and preventative strategies for diabetic cardiomyopathy and heart failure in patients with type 2 diabetes remain elusive. The identification of optimized approaches for the prevention and treatment of the metabolic syndrome and heart disease in insulin-resistant, nondiabetic patients remains a major global challenge.

Daily usage and efficiency of remote home monitoring in hypertensive patients over a one-year period

We evaluated daily self-monitored blood pressure (BP) data collected over one year using remote home monitoring. Fifty treated, moderately hypertensive subjects (26 males, mean age 50 years; 17 females, mean age 54 years; seven exclusions) were recruited for the study in which semi-automatic arm-cuff BP measurement devices were used. The daily self-monitoring regimen had two phases of usage: one of initial enthusiasm (the first one to two months) followed by a phase of lower usage (89% versus 64%, P<0.01). Monitoring was missed more often (P < 0.01) during weekends (7.3 instances per patient) compared with workdays (5.0). Lack of motivation was not considered to be a major barrier. Approximately half of the study population was willing to continue the trial at the end of the one-year study. The occurrence of extreme BP values dropped significantly after the initial study month (P = 0.02). In conclusion, routine remote BP monitoring is capable of collecting consistent and accurate data, with sufficient sensitivity to reveal trends.

Use of home blood-pressure monitoring in the detection, treatment and surveillance of hypertension

PURPOSE OF REVIEW

Use of home blood-pressure monitoring is increasing but the technique and the equipment have limitations. We provide an overview of recent evidence in this rapidly evolving field.

RECENT FINDINGS

Home blood-pressure monitoring is an acceptable method for screening patients for hypertension. There is increasing evidence supporting the predictive power of home blood pressure for stroke risk even in the general population. The identification of white-coat and masked hypertension remains an important role for home blood-pressure monitoring. Unvalidated equipment and poor patient technique are major concerns. The purchase of devices needs to be linked to a simple patient-education programme, which is perhaps an opportunity for collaboration between healthcare providers and commercial companies. Devices that store the blood-pressure measurements in the memory are preferred to ensure accuracy of reporting. Data-transmission systems providing automatic storage, transmission and reporting of blood pressure, direct involvement of the patient and potentially a reduced number of hospital/general practitioner visits, offer significant advantages. To reduce patient anxiety, overuse of home blood-pressure monitoring should be avoided but there is the potential for self-modification of treatment, subject to certain safeguards.

SUMMARY

Self-monitoring of blood pressure is developing rapidly, linked to increasing awareness of the impact of reducing high blood pressure on public health and the marketing/advertising strategies used to sell automatic devices. Home blood-pressure monitoring has a role in the detection and management of blood pressure, but not at the expense of careful blood-pressure measurement in the office and adherence to national guidelines.

High-density lipoprotein cholesterol levels increase with age, body mass index, blood pressure and fasting blood glucose in a rural Uygur population in China

OBJECTIVES

To investigate the distribution of the serum high-density lipoprotein cholesterol (HDLC) levels and its relationship with obesity, hypertension and diabetes in a Uygur case-control study on hypertension.

DESIGN

A case-control (339 hypertensive cases, 272 normotensive controls) study on hypertension was conducted, and obesity, hypertension, lipid profiles and fasting blood glucose were analyzed.

METHODS

The demographic data, history of disease and lifestyles, including diet, smoking and salt intake, were recorded and three measurements of blood pressure were obtained by trained observers. The fasting serum lipid profiles and glucose were determined.

RESULTS

The HDLC levels of hypertensive participants were significantly higher than normotensive participants after adjustment for age and gender (1.145 versus 1.117 mmol/l, P = 0.001, power = 0.867). After adjustment for related variables, the HDLC levels slightly increased with age, body mass index and fasting glucose (all P = 0.001, power > 0.80) in normotensive participants and only increased with age among hypertensive participants (P = 0.0001, power = 0.971).

CONCLUSIONS

The serum HDLC levels in Uygur normotensive participants increased with age, body mass index, blood pressure and fasting glucose levels. This was inconsistent with the previous studies and the reason remained unclear. Further study is needed to elucidate both the environmental and genetic determinants of the novel distribution of the HDLC levels and their association with coronary heart disease in the Uygur population.

Arm and ankle blood pressure during caesarean section

BACKGROUND

We have previously reported that measurement of non-invasive blood pressure during caesarean section under spinal anaesthesia fails in over 50% of cases. We felt that errors would be less likely if blood pressure could be measured at the ankle as it is immobile during caesarean section. The purpose of our study was to determine whether blood pressure measurement at the ankle was equivalent to the arm.

METHOD

Following ethical approval, informed consent was obtained from 30 women scheduled for elective caesarean section. Two non-invasive blood pressure cuffs, one on the upper arm and one on the ankle, were used to measure blood pressures at three timed intervals: before spinal insertion, before surgery and after delivery of the neonate.

RESULTS

Using the method of Bland and Altman we found that there was only marginal agreement between the two methods. On eight out of 15 occasions where there was a greater than 20% fall in arm systolic blood pressure, this was not detected at the ankle.

CONCLUSION

We cannot recommend the use of the ankle to measure blood pressure during caesarean section.

Accuracy of the pressure scale of sphygmomanometers in clinical use within primary care

BACKGROUND

It is widely recommended that sphygmomanometers are maintained and calibrated regularly to ensure that the pressure scale remains accurate to within the European Standard specification of +/-3 mmHg. In primary care, however, such checks are reported to be only rarely performed. This paper describes a survey of the accuracy of the absolute static pressure scale of aneroid, mercury and automated sphygmomanometers in clinical use in primary care.

METHODS

On-site measurements of sphygmomanometer pressure scale accuracy were carried out in 45 general practices within Lambeth, Southwark and Lewisham. A total of 279 sphygmomanometers from these practices were included in the study. The device pressure scales were calibrated using an accurate electronic reference pressure sensor.

RESULTS

The key finding of this study is that 17.9% (50 out of 279) of all surveyed devices gave errors exceeding the +/-3 mmHg threshold. Of these, 53.2% (33 out of 62) of aneroid devices were found to be reading in error by more than +/-3 mmHg compared with 7.8% (16 out of 217) of the combined population of mercury and automated devices. The difference between these groups is statistically significant (P=0.002). Significant differences in the performance of specific models of aneroid, mercury and automated devices were also identified.

CONCLUSION

A service model for improving the accuracy of blood pressure monitoring in primary care needs to take into account the current proliferation of pressure scale errors in these devices, the lack of uptake of regular checks and the poor quality of some of the devices currently in use.

Queen Mary Utilization of Antihypertensive Drugs Study: side-effects of antihypertensive drugs

BACKGROUND AND OBJECTIVE

Effective prevention of cardiovascular events in hypertensive patients requires good control of blood pressure. Side-effects of antihypertensive drugs affect tolerability and compliance. Accordingly, we surveyed side-effects in the hypertension outpatient clinic.

METHODS

A total of 228 patients (109 men, 119 women) were interviewed in April-May 2004 in the Queen Mary Utilization of Antihypertensive Drugs Study.

RESULTS

The percentage of patients receiving no drug (life-style modification), one, two, three and over three drugs were 3, 30, 40, 22 and 6% respectively. The proportion of patients taking calcium channel blockers, beta-blockers (BB), angiotensin-converting enzyme inhibitors, thiazide diuretics, alpha-blockers and angiotensin receptor blockers were 65, 64, 33, 24, 4 and 7% respectively. Blood pressure on treatment was 144+/-21/82+/-11 mmHg. Among patients on antihypertensive drug therapy, 34% reported adverse effects: dizziness (9%), ankle swelling (7%), headache (5%), fatigue (4%), chest discomfort (3%) and cough (3%). Fewer patients on BBs reported side-effects (OR 0.46, P=0.008). The likelihood of experiencing side-effects was unrelated to sex, age, weight, BMI, years of treatment, number of drugs used, heart rate on treatment or compliance.

CONCLUSIONS

To achieve good blood pressure control, multiple drugs are used. Thiazides are underused whereas BBs are popular. The popularity of the latter may be related to its tolerability.

Queen Mary Utilization of Antihypertensive Drugs Study: use of antihypertensive drug classes in the hypertension clinic 1996-2004

BACKGROUND

Utilization of antihypertensive drugs in the hypertension outpatient clinic is surveyed periodically in the Queen Mary Utilization of Antihypertensive Drugs Study (QUADS).

METHODS

Two hundred and fifty-one patients (123 men, 128 women) were interviewed in April to December 1996, 439 patients (232 men, 207 women) in January to December 99 and 228 patients (109 men, 119 women) in April to May 2004. Their case notes were reviewed.

RESULTS

The percentages of patients receiving no drug (lifestyle modification), one, two, three and over three drugs were 7%, 48%, 36%, 7%, 3%, respectively, in 1996; 14%, 34%, 36%, 13% and 1%, respectively, in 1999; and 3%, 30%, 40%, 22% and 6%, respectively, in 2004. The number of drugs correlated with age and overweight. In 1996, 51% patients received calcium channel blockers (CCB); 46% beta-blockers (BB); 32% angiotensin-converting enzyme inhibitors (ACEI); 15% thiazide diuretics; 5% alpha-blockers; and 0% angiotensin receptor blockers (ARB). In 1999, the respective figures were 52% CCB, 49% BB, 24% ACEI, 22% thiazide diuretics, 4%alpha-blockers and 2% ARB. In 2004, the respective figures were 65% CCB, 64% BB, 33% ACEI, 24% thiazide diuretics, 4% alpha-blockers and 7% ARB. Fewer patients on BBs reported side-effects. Only 11% were on alpha statin and 9% on aspirin. Blood pressure on treatment was 147 +/- 21/84 +/- 11 mmHg in 1999 and 144 +/- 21/82 +/- 11 mmHg in 2004.

CONCLUSIONS

Increasingly, multiple drugs were used for blood pressure control. Blood pressure control needs improvement, especially in diabetics. CCBs and BBs were consistently popular. Thiazide diuretics, ARBs, statins and aspirin were underused, despite favourable clinical trial evidence.

The domino effect: obesity, type 2 diabetes and cardiovascular disease

Rising levels of obesity in the UK are leading to corresponding increases in type 2 diabetes and threaten to jeopardize recent successes in combating cardiovascular disease. This article will discuss the key role district nurses have to play in breaking this continuum. Through health promotion activities, patient assessment and facilitating the early diagnosis of type 2 diabetes, community nurses can help reduce cardiovascular risk factors and ensure that holistic treatment regimens are initiated early on in the disease process. An overview of current regimens is provided. Effective monitoring of patients response to treatment will help diabetes specialists set and prioritize appropriate treatment goals.

Detection of hypertension in the emergency department

OBJECTIVES

To assess whether an emergency department (ED) is a suitable location for the targeted screening of hypertension.

METHODS

This was a prospective targeted screening study based at the ED of an inner city teaching hospital. Non-acute subjects over 18 years were recruited consecutively from the "minors" section of the ED and invited to participate. All subjects had their blood pressure measured twice. A verbal numerical pain score (PS) out of 10 using a visual analogue scale was obtained. Those with a mean systolic blood pressure > 140 mmHg or a mean diastolic blood pressure > 90 mmHg (WHO JNC stage 1 hypertension) were invited for a subsequent follow up measurement. The primary outcome measure was the proportion of subjects with hypertension at follow up. The secondary outcome measure was the correlation between a subject's mid blood pressure (MBP) and their PS.

RESULTS

In total, 765 subjects were tested, of whom 213 subjects were hypertensive at presentation (28.7%). After excluding those on anti-hypertensive medication (n = 43; 5.6%) and those who were non-UK residents (n = 44; 5.8%), 126 subjects were invited for follow up, of whom 51 subjects actually attended (40% attendance, 6.6% of study population). The MBP of those who re-attended was significantly lower than at presentation (p < 0.001); 39 subjects (5% of the study population, 76.4% of those attending follow up) remained hypertensive. There was no correlation between a subject's PS and their MBP (Pearson correlation coefficient = -0.02). A 10/10 PS was associated with an 8.4 mmHg rise in MBP compared to the mean MBP of subjects with PS 0-9 (p < 0.1). Of those originally presenting with PS > 5/10, 62% still had hypertension at follow up when the painful stimulus was significantly reduced (mean PS = 0.6).

CONCLUSION

The ED provides an opportunity for identifying those individuals with hypertension who may otherwise remain undiagnosed. Caution is advised when diagnosing hypertension in those individuals suffering from anxiety and/or acute severe pain on presentation.

Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial

BACKGROUND

The apparent shortfall in prevention of coronary heart disease (CHD) noted in early hypertension trials has been attributed to disadvantages of the diuretics and beta blockers used. For a given reduction in blood pressure, some suggested that newer agents would confer advantages over diuretics and beta blockers. Our aim, therefore, was to compare the effect on non-fatal myocardial infarction and fatal CHD of combinations of atenolol with a thiazide versus amlodipine with perindopril.

METHODS

We did a multicentre, prospective, randomised controlled trial in 19 257 patients with hypertension who were aged 40-79 years and had at least three other cardiovascular risk factors. Patients were assigned either amlodipine 5-10 mg adding perindopril 4-8 mg as required (amlodipine-based regimen; n=9639) or atenolol 50-100 mg adding bendroflumethiazide 1.25-2.5 mg and potassium as required (atenolol-based regimen; n=9618). Our primary endpoint was non-fatal myocardial infarction (including silent myocardial infarction) and fatal CHD. Analysis was by intention to treat.

FINDINGS

The study was stopped prematurely after 5.5 years' median follow-up and accumulated in total 106 153 patient-years of observation. Though not significant, compared with the atenolol-based regimen, fewer individuals on the amlodipine-based regimen had a primary endpoint (429 vs 474; unadjusted HR 0.90, 95% CI 0.79-1.02, p=0.1052), fatal and non-fatal stroke (327 vs 422; 0.77, 0.66-0.89, p=0.0003), total cardiovascular events and procedures (1362 vs 1602; 0.84, 0.78-0.90, p<0.0001), and all-cause mortality (738 vs 820; 0.89, 0.81-0.99, p=0.025). The incidence of developing diabetes was less on the amlodipine-based regimen (567 vs 799; 0.70, 0.63-0.78, p<0.0001).

INTERPRETATION

The amlodipine-based regimen prevented more major cardiovascular events and induced less diabetes than the atenolol-based regimen. On the basis of previous trial evidence, these effects might not be entirely explained by better control of blood pressure, and this issue is addressed in the accompanying article. Nevertheless, the results have implications with respect to optimum combinations of antihypertensive agents.

Fluvastatin: efficacy and safety in reducing cardiac events

The importance of statin therapy in lipid-lowering and its role in primary and secondary prevention has been borne out of numerous clinical trials conducted over the last two decades. Concurrently, much concern has been expressed over the safety and tolerability of these drugs. Fluvastatin has demonstrated good clinical efficacy and safety. This paper reviews the various pharmacological properties and evidence supporting its use in the prevention of cardiac events.

Targets and self monitoring in hypertension: randomised controlled trial and cost effectiveness analysis

OBJECTIVES

To assess whether blood pressure control in primary care could be improved with the use of patient held targets and self monitoring in a practice setting, and to assess the impact of these on health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences, and costs.

DESIGN

Randomised controlled trial.

SETTING

Eight general practices in south Birmingham.

PARTICIPANTS

441 people receiving treatment in primary care for hypertension but not controlled below the target of < 140/85 mm Hg.

INTERVENTIONS

Patients in the intervention group received treatment targets along with facilities to measure their own blood pressure at their general practice; they were also asked to visit their general practitioner or practice nurse if their blood pressure was repeatedly above the target level. Patients in the control group received usual care (blood pressure monitoring by their practice).

PRIMARY OUTCOME

change in systolic blood pressure at six months and one year in both intervention and control groups.

SECONDARY OUTCOMES

change in health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences of method of blood pressure monitoring, and costs.

RESULTS

400 (91%) patients attended follow up at one year. Systolic blood pressure in the intervention group had significantly reduced after six months (mean difference 4.3 mm Hg (95% confidence interval 0.8 mm Hg to 7.9 mm Hg)) but not after one year (mean difference 2.7 mm Hg (- 1.2 mm Hg to 6.6 mm Hg)). No overall difference was found in diastolic blood pressure, anxiety, health behaviours, or number of prescribed drugs. Patients who self monitored lost more weight than controls (as evidenced by a drop in body mass index), rated self monitoring above monitoring by a doctor or nurse, and consulted less often. Overall, self monitoring did not cost significantly more than usual care (251 pounds sterling (437 dollars; 364 euros) (95% confidence interval 233 pounds sterling to 275 pounds sterling) versus 240 pounds sterling (217 pounds sterling to 263 pounds sterling).

CONCLUSIONS

Practice based self monitoring resulted in small but significant improvements of blood pressure at six months, which were not sustained after a year. Self monitoring was well received by patients, anxiety did not increase, and there was no appreciable additional cost. Practice based self monitoring is feasible and results in blood pressure control that is similar to that in usual care.

Arguing about the evidence: readers, writers and inscription devices in coronary heart disease risk assessment

This paper examines the history of tools developed to assess an individual's risk of coronary heart disease. A close reading of the tools themselves is combined with an analysis of debates published in medical journals such as the British Medical Journal (BMJ) and The Lancet. These literary conversations between scientists and doctors reveal complex negotiations about the form and meaning of medical technologies that have yet to become fully 'stable'. Early tools were promoted as a response to the high cost of cholesterol-lowering drugs (statins), but came to embody broader attempts to shape medical practice. These include the promotion of what has been understood as evidence-based medicine and regulation by political and professional actors, as well as the spread of 'risk thinking' more generally. Despite having a central place in recent British guidelines and policy, there is a surprising variety of tools in circulation, and ongoing uncertainty about their use and value.

Total risk factor management in patients with type 2 diabetes

Type 2 diabetes is a multisystem metabolic syndrome. Its increasing prevalence therefore presents a major challenge not only in the management of diabetes but also in the treatment of cardiovascular disease.

Nifedipine gastrointestinal therapeutic system--hypertension management to improve cardiovascular outcomes

Hypertension is a major cardiovascular risk factor, and its increasing prevalence is of great clinical concern. Despite the availability of numerous effective therapies, hypertension remains under-diagnosed and under-treated. Hypertension often coexists with other risk factors, and current guidelines recommend a multifactorial approach to management, with the aim of not only controlling blood pressure but also reducing overall cardiovascular risk. Nifedipine gastrointestinal therapeutic system (GITS) is a long-acting formulation of a calcium channel blocker. Once-daily dosing with nifedipine GITS has been shown to achieve smooth and continuous blood pressure control, identical to conventional first-line diuretic therapy. Small-scale clinical trials have also shown that nifedipine GITS positively affects markers of atherosclerotic disease, which may signify an additional clinical benefit, but this is yet to be demonstrated. The recently completed ACTION (A Coronary Disease Trial Investigating Outcome with Nifedipine GITS) trial provides further evidence that nifedipine GITS can be used safely in high-risk patients to treat angina, lower blood pressure and significantly improve clinical outcomes.

Ethnic differences in cardiovascular and all-cause mortality in Birmingham, England: The Birmingham Factory Screening Project

OBJECTIVES

To compare cardiovascular and all-cause mortality, among white Europeans, African-Caribbeans and South-Asians, in relation to baseline demographic characteristics and blood pressure variables.

DESIGN

Observational follow-up study.

SETTING

Community settings in Birmingham, UK.

PARTICIPANTS

Two thousand and eighty-nine white European and 340 African-Caribbean men and women, and 195 South-Asian men whose survival status on 31 December 2003 was known.

INTERVENTIONS

Follow-up for assessment of all-cause and cardiovascular mortality over a mean (SD) 20.3 (4.2) years.

MAIN OUTCOME MEASURES

All-cause and cardiovascular mortality.

RESULTS

There were no significant ethnic differences in all-cause or cardiovascular mortality for men [adjusted hazard ratio (HR) = 1.02; 95% confidence interval (CI), 0.80-1.28 and HR = 1.33; 95% CI, 0.99-1.79, respectively] or women (adjusted HR = 0.61; 95% CI, 0.29-1.32 and HR = 1.19; 95% CI, 0.41-3.45, respectively) in either univariate or multivariate analyses. The only independent predictors of both all-cause and cardiovascular mortality were age, sex, smoking and mean systolic blood pressure or hypertension.

CONCLUSIONS

It appears that ethnicity per se is not an independent risk factor for all-cause and cardiovascular mortality between white Europeans and African-Caribbeans in the present study. The data concerning ethnic differences in all-cause and cardiovascular mortality for South-Asians is limited, given that significantly fewer South-Asian men could be traced by the Office for National Statistics (ONS), hence we do not know their survival status, and the total lack of data on South-Asian women.

How accurate are automated blood pressure monitors?

Increasingly, automated blood pressure devices are replacing mercury sphygmomanometers to monitor blood pressure in primary care settings. Practitioners have raised questions about the accuracy of these new devices, so a mini-review was undertaken to examine the evidence. A systematic search of the Medline database identified seven studies that were of sufficient quality. Eight devices were examined, all of which had passed validation procedures, achieving A or B grades according to current protocols. All were 'recommended for clinical use', despite the tendency of the devices to produce inaccurate measurements in high blood pressure ranges. The review demonstrates that 'accuracy' of the new devices does not equate to the accustomed accuracy of the mercury sphygmomanometer.

Prehypertension and cardiovascular morbidity

PURPOSE

The Seventh Report of the Joint National Commission (JNC 7) on High Blood Pressure established prehypertension (120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic) as a new risk category. We aim to determine the risk of major cardiovascular events associated with blood pressure in the prehypertensive range in a longitudinal, population-based cohort.

METHODS

Analyses were conducted on participants in the National Health and Nutrition Examination Survey I (1971-1975) observed for 18 years for major cardiovascular disease events. Cox proportional hazard ratios were calculated to assess relative risk of cardiovascular disease, including stroke, myocardial infarction, and heart failure, in participants with prehypertension and normal blood pressure (<120/80 mm Hg).

RESULTS

Prehypertension was associated with increased risk for cardiovascular disease (1.79 [95% confidence interval (CI) 1.40-2.24]) in unadjusted analysis. After adjustment for cardiovascular risk factors, the relationship of prehypertension to cardiovascular disease was diminished but persisted (1.32 [95% CI 1.05-1.65]). Ninety-three percent of prehypertensive individuals had at least 1 cardiovascular risk factor. Low prehypertension (120-129/80-84 mm Hg) was associated with increased cardiovascular disease in unadjusted analyses (1.56 [95% CI 1.23-1.98]) but was not statistically significant in adjusted analyses (1.24 [95% CI 0.96-1.59]). High-normal blood pressure (130-139/85-89 mm Hg) remained a predictor of cardiovascular disease in unadjusted (2.13 [95% CI 1.64-2.76]) and adjusted (1.42 [95% CI 1.09-1.84]) analyses.

CONCLUSIONS

In a longitudinal, population-based, US cohort, prehypertension was associated with increased risk of major cardiovascular events independently of other cardiovascular risk factors. These findings, along with the presence of cardiovascular risk factors in the majority of participant sample with prehypertension, support recommendations for physicians to actively target lifestyle modifications and multiple risk reduction in their prehypertensive patients.

Type 2 diabetes mellitus: a cardiovascular perspective

Diabetes mellitus is a disease, which is at the epitome of cardiovascular risk factors causing considerable morbidity and mortality. In addition to microvascular complications, there is two- to six-fold increased risk of macrovascular diseases, such as coronary artery disease, peripheral artery disease and stroke. While the mortality from coronary artery disease in patients without diabetes has declined over the past 20 years, the mortality in men with type 2 diabetes mellitus has not changed. Furthermore, the prevalence of diabetes in the UK has increased by 30% since 1991 and the same among the world population in 2010 is expected to be twice in 1990. This dramatic increase has serious implications from a cardiovascular perspective and thus the aggressive management of blood pressure, dyslipidaemia and blood glucose in diabetes is of vital importance. The aim of this review is to evaluate the current evidence and to discuss the implications of type 2 diabetes and its relevance to clinical practice in cardiology. We address this broad subject in discussing (i) the pathophysiology of cardiovascular disease in the setting of type 2 diabetes and (ii) the prevalence of cardiovascular risk, complications and prognostic implications in type 2 diabetes, with a discussion of current therapeutic interventions for the prevention or delay of these consequences where relevant.

The impact of implementing national hypertension guidelines on prevalence and workload in primary care: a population-based survey of older people

Recently revised UK and US hypertension guidelines have reduced thresholds for both diagnosis and treatment and differ in their recommendations. We have used data from a random, stratified community-based sample of 4784 people aged 65 years and over to compare the prevalence of treatable hypertension and the potential impact on patients and primary care from using current guidelines. BHS, NICE and JNC7 guidelines were applied to blood pressures obtained from primary care medical records (94%) or measured at a screening clinic (6%). Risk factors were obtained by questionnaire and from medical records, supplemented by epidemiological data. Workload was estimated for a representative practice population of 10 000 patients. Blood pressures were obtained on 4514 patients (94%). Prevalence of treatable hypertension was over 67%. Compared to BHS4, prevalence estimates using NICE guidelines were comparable for men but significantly lower for women (P<0.05). They were significantly higher using JNC7 compared with BHS4 and NICE guidance (P<0.05). A general practice of 10 000 patients could expect 1287 older hypertensive patients using BHS4 guidelines and 1231 patients using NICE guidelines. Under BHS4, an extra 94 patients will require annual, rather than 5-yearly review compared with that using the previous guideline. In conclusion, implementation of BHS4 guidelines, with their revised thresholds for diagnosis, will not add materially to the prevalence of treatable hypertension compared to previous BHS3 guidelines but will have a major impact on practice workload. Use of NICE guidelines in preference to BHS4 will result in GPs treating fewer patients and reviewing untreated patients less often.

Reduction in cardiovascular events with atorvastatin in 2,532 patients with type 2 diabetes: Anglo-Scandinavian Cardiac Outcomes Trial--lipid-lowering arm (ASCOT-LLA)

OBJECTIVE

This study aims to establish the benefits of lowering cholesterol in diabetic patients with well-controlled hypertension and average/below-average cholesterol concentrations, but without established coronary disease.

RESEARCH DESIGN AND METHODS

In the lipid-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-LLA), 10,305 hypertensive patients with no history of coronary heart disease (CHD) but at least three cardiovascular risk factors were randomly assigned to receive 10 mg atorvastatin or placebo. Effects on total cardiovascular outcomes in 2,532 patients who had type 2 diabetes at randomization were compared.

RESULTS

During a median follow-up of 3.3 years, concentrations of total and LDL cholesterol among diabetic participants included in ASCOT-LLA were approximately 1 mmol/l lower in those allocated atorvastatin compared with placebo. There were 116 (9.2%) major cardiovascular events or procedures in the atorvastatin group and 151 (11.9%) events in the placebo group (hazard ratio 0.77, 95% CI 0.61-0.98; P = 0.036). For the individual components of this composite end point, the number of events occurring in the diabetes subgroup was small. Therefore, although fewer coronary events (0.84, 0.55-1.29; P = 0.14) and strokes (0.67, 0.41-1.09; P = 0.66) were observed among the patients allocated atorvastatin, these reductions were not statistically significant.

CONCLUSIONS

Atorvastatin significantly reduced the risk of major cardiovascular events and procedures among diabetic patients with well-controlled hypertension and without a history of CHD or markedly elevated cholesterol concentrations. The proportional reduction in risk was similar to that among participants who did not have diagnosed diabetes. Allocation to atorvastatin prevented approximately 9 diabetic participants from suffering a first major cardiovascular event or procedure for every 1,000 treated for 1 year.

Systematic Review of Combined Angiotensin-Converting Enzyme Inhibition and Angiotensin Receptor Blockade in Hypertension

Some evidence suggests that long-term angiotensin-converting enzyme (ACE) inhibition may become less effective, thereby increasing angiotensin II levels, which could be inhibited by the addition of an angiotensin receptor blocker. We conducted a meta-analysis of randomized trials with searches of MEDLINE, EMBASE, and Cochrane databases. Overall, the combination of an ACE inhibitor and an angiotensin receptor blocker reduced ambulatory blood pressure by 4.7/3.0 mm Hg (95% confidence interval [CI], 2.9 to 6.5/1.6 to 4.3) compared with ACE inhibitor monotherapy and 3.8/2.9 mm Hg (2.4 to 5.3/0.4 to 5.4) compared with angiotensin receptor blocker monotherapy. Clinic blood pressure was reduced by 3.8/2.7 mm Hg (0.9 to 6.7/0.8 to 4.6) and 3.7/2.3 mm Hg (0.4 to 6.9/0.2 to 4.4) compared with ACE inhibitor and angiotensin receptor blocker, respectively. However, the majority of these studies used submaximal doses or once-daily dosing of shorter-acting ACE inhibitors and, when a larger dose of shorter-acting ACE inhibitor was given or a longer-acting ACE inhibitor was used, there was generally no additive effect of the angiotensin receptor blocker on blood pressure. Proteinuria was reduced by the combination compared with ACE inhibitor and angiotensin receptor blocker monotherapy, an effect that was independent of blood pressure in several studies, suggesting that the combination could have benefits in proteinuric nephropathies. None of the studies was of sufficient size and duration to determine whether there may be safety concerns. In conclusion, although there is a small additive effect on blood pressure with an ACE inhibitor-angiotensin receptor blocker combination, the routine use of this combination in uncomplicated hypertension is not recommended until more carefully controlled studies are performed.

Guidelines and risk factor management

Efforts to reduce the death rate from cardiovascular disease in the UK are beginning to make a difference.