Treatment of Hypertension in Patients With Coronary Artery Disease

The Role of Nitroglycerin and Other Nitrogen Oxides in Cardiovascular Therapeutics

The use of nitroglycerin in the treatment of angina pectoris began not long after its original synthesis in 1847. Since then, the discovery of nitric oxide as a biological effector and better understanding of its roles in vasodilation, cell permeability, platelet function, inflammation, and other vascular processes have advanced our knowledge of the hemodynamic (mostly mediated through vasodilation of capacitance and conductance arteries) and nonhemodynamic effects of organic nitrate therapy, via both nitric oxide-dependent and -independent mechanisms. Nitrates are rapidly absorbed from mucous membranes, the gastrointestinal tract, and the skin; thus, nitroglycerin is available in a number of preparations for delivery via several routes: oral tablets, sublingual tablets, buccal tablets, sublingual spray, transdermal ointment, and transdermal patch, as well as intravenous formulations. Organic nitrates are commonly used in the treatment of cardiovascular disease, but clinical data limit their use mostly to the treatment of angina. They are also used in the treatment of subsets of patients with heart failure and pulmonary hypertension. One major limitation of the use of nitrates is the development of tolerance. Although several agents have been studied for use in the prevention of nitrate tolerance, none are currently recommended owing to a paucity of supportive clinical data. Only 1 method of preventing nitrate tolerance remains widely accepted: the use of a dosing strategy that provides an interval of no or low nitrate exposure during each 24-h period. Nitric oxide's important role in several cardiovascular disease mechanisms continues to drive research toward finding novel ways to affect both endogenous and exogenous sources of this key molecular mediator.

[Blood pressure target in 2017]

OBJECTIVE

The issue of how far blood pressure (BP) should be lowered under antihypertensive treatment is still an important matter of scientific debate. The aim of the present review is to consider the clinical relevance of individualized BP goal under treatment in hypertensive patients according to their age, comorbidities or established cardio-vascular (CV) disease.

DATA FROM THE LITERATURE

The French and European recommendations propose a systolic BP target between 130 and 139mmHg (<150mmHg after 80 years) and diastolic BP target <90mmHg in hypertensive patients whatever their level of risk. The results of the recent SPRINT study suggest that a more ambitious systolic BP target, <120mmHg, significantly reduces CV morbidity and mortality, but with an increased iatrogenic risk. Several questions in everyday practice have to be considered. An important issue concerns BP measurement methods in this clinical trial (Dinamap) versus in routine clinical practice and the implications on BP treatment targets. In addition, close monitoring of participants in clinical trials and active orthostatic hypotension research limit the incidence of adverse events related to intensive treatement. Finally, in the presence of an established CV disease, an intensive therapeutic approach could be associated with a J-curve relationship between BP level and CV events.

CONCLUSION

An early and strict BP control in young or middle-aged hypertensive patients in primary prevention should be a priority. In this hypertensive population with low to moderate CV risk, without established CV or renal diseases, more stringent than recommended BP-lowering treatment could potentially prevent hypertensive arterial damage and thus correct the increased residual CV risk later in life. The tolerance of an intensive therapeutic approach should remain a concern in elderly patients and in patients with established CV disease.

Optimal achieved blood pressure for patients with stable coronary artery disease

We aimed to investigate the ideal achieved blood pressure (BP) in ethnic Chinese patients with stable coronary artery disease (CAD) in Taiwan. A total of 2,045 patients (age 63.5 ± 11.9 years, 1,722 male [84.2%]) with stable CAD who had undergone percutaneous coronary interventions were enrolled. The achieved systolic BP was 130.6 ± 17.7 mmHg and diastolic BP was 74.9 ± 12.0 mmHg. In 12 months, patients with systolic BP < 120 mmHg and systolic BP ≥ 160 mmHg had increased risk of total cardiovascular events when compared to those with systolic BP 120-139 mmHg. In 24 months, patients with systolic BP < 120 mmHg and systolic BP ≥ 160 mmHg had increased risk of total cardiovascular events when compared to those with systolic BP 120-139 mmHg; patients with diastolic BP < 70 mmHg had increased risk of total cardiovascular events when compared to those with diastolic BP 70-79 mmHg. In conclusion, systolic BP < 120 mmHg and ≥160 mmHg or diastolic BP < 70 mmHg is associated with increased cardiovascular events, supporting that the optimal BP control should also be justified for stable CAD in non-western cohorts.

The shifting paradigm in the treatment of type 2 diabetes mellitus-A cardiologist's perspective

In patients with diabetes mellitus, cardiovascular (CV) disease is the leading cause of morbidity and mortality. A multitude of contemporary antidiabetic agents presents different CV safety profiles. Metformin forms the cornerstone agent to reduce CV events. Newer agents, such as glucagon-like peptide-1 agonists and sodium-glucose cotransporter-2 inhibitors, have appealing CV benefits. Insulin, dipeptidyl peptidase-4 inhibitors, and sulfonylureas have neutral CV effects. Cardiologists should familiarize themselves with these agents to promote comprehensive CV care in patients with diabetes mellitus.

Blood Pressure Targets and Clinical Outcomes in Patients with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES

The optimal blood pressure (BP) target in patients with a history of acute myocardial infarction (MI) remains as a subject of debate. The 'J curve phenomenon' has been suggested as a target for BP control, however, it is unclear whether this phenomenon can be applied to MI patients. We analyzed patients with acute MI and investigated whether the 'J curve phenomenon' exists in this population.

SUBJECTS AND METHODS

Data were obtained from a nationwide prospective Korea Acute Myocardial Infarction Registry, which included 10337 patients with acute MI who underwent percutaneous coronary intervention (PCI) between 2011 and 2014. The patients were divided into quintiles according to systolic blood pressure (SBP) and diastolic blood pressure (DBP), which were measured during a two-year clinical follow up. Two-year cumulative incidence of major adverse cardiac events (MACE) was analyzed among the groups.

RESULTS

MACE was defined as a composite of cardiac death, need for recurrent revascularization (repeated PCI or coronary arterial bypass graft due to recurrent anginal symptoms or reoccurrence of MI), ischemic cerebrovascular accident, and need for hospitalization due to heart failure. During the two-year follow up, the total cumulative incidence of MACE was 9.7% (n=1005). BP-MACE analysis showed a U-shaped curve for both SBP and DBP, with the lowest MACE rate in quintiles with an average SBP of 112.2 mmHg and DBP of 73.3 mmHg. On Cox regression analysis, the U-shaped relation was statistically significant.

CONCLUSION

In patients with acute MI, a 'U curve phenomenon' was observed when assessing patient BP control versus MACE rate.

The effects of food essential oils on cardiovascular diseases: A review

Essential oils (EO) are complex secondary metabolites, which are produced by aromatic plants and identified by their powerful odors. Present studies on EO and their isolated ingredients have drawn the attention of researchers to screen these natural products and evaluate their effect on the cardiovascular system. Some EO, and their active ingredients, have been reported to improve the cardiovascular system significantly by affecting vaso-relaxation, and decreasing the heart rate and exert a hypotension activity. Several mechanisms have been proposed for the role of EO and their main active components in promoting the health of the cardiovascular system. The objective of this review is to highlight the current state of knowledge on the functional role of EO extracted from plants for reducing the risk of cardiovascular diseases and their mechanisms of action. Research on EO has the potential to identify new bioactive compounds and formulate new functional products for the treatment of cardiovascular diseases such as arterial hypertension, angina pectoris, heart failure, and myocardial infarction.

Treatment of Heart Failure with Abnormal Left Ventricular Systolic Function in Older Adults

Heart failure (HF) with abnormal left ventricular (LV) ejection fraction should be identified and treated. Treat hypertension with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Treat myocardial ischemia with nitrates and β-blockers. Treat volume overload and HF with diuretics. Treat HF with ACE inhibitors and β-blockers. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in chronic symptomatic HF and abnormal LV ejection fraction. Add isosorbide dinitrate/hydralazine in African Americans with class II to IV HF treated with diuretics, ACE inhibitors, and β-blockers. Exercise training is recommended. Indications for implantable cardioverter-defibrillator and cardiac resynchronization therapy are discussed.

Renal Denervation to Modify Hypertension and the Heart Failure State

Sympathetic overactivation of renal afferent and efferent nerves have been implicated in the development and maintenance of several cardiovascular disease states, including resistant hypertension and heart failure with both reduced and preserved systolic function. With the development of minimally invasive catheter-based techniques, percutaneous renal denervation has become a safe and effective method of attenuating sympathetic overactivation. Percutaneous renal denervation, therefore, has the potential to modify and treat hypertension and congestive heart failure. Although future randomized controlled studies are needed to definitively prove its efficacy, renal denervation has the potential to change the way we view and treat cardiovascular disease.

ANMCO/GICR-IACPR/SICI-GISE Consensus Document: the clinical management of chronic ischaemic cardiomyopathy

Stable coronary artery disease (CAD) is a clinical entity of great epidemiological importance. It is becoming increasingly common due to the longer life expectancy, being strictly related to age and to advances in diagnostic techniques and pharmacological and non-pharmacological interventions. Stable CAD encompasses a variety of clinical and anatomic presentations, making the identification of its clinical and anatomical features challenging. Therapeutic interventions should be defined on an individual basis according to the patient's risk profile. To this aim, management flow charts have been reviewed based on sustainability and appropriateness derived from recent evidence. Special emphasis has been placed on non-pharmacological interventions, stressing the importance of lifestyle changes, including smoking cessation, regular physical activity, and diet. Adherence to therapy as an emerging risk factor is also discussed.

Blood Pressure Reduction and Secondary Stroke Prevention

Current recommendations do not specifically address the optimal blood pressure (BP) reduction for secondary stroke prevention in patients with previous cerebrovascular events. We conducted a systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using data from randomized controlled clinical trials of secondary stroke prevention. For all reported events during each eligible study period, we calculated the corresponding risk ratios to express the comparison of event occurrence risk between patients randomized to antihypertensive treatment and those randomized to placebo. On the basis of the reported BP values, we performed univariate metaregression analyses according to the achieved BP values under the random-effects model (Method of Moments) for those adverse events reported in ≥10 total subgroups of included randomized controlled clinical trials. In pairwise meta-analyses, antihypertensive treatment lowered the risk for recurrent stroke (risk ratio, 0.73; 95% confidence interval, 0.62–0.87; P <0.001), disabling or fatal stroke (risk ratio, 0.71; 95% confidence interval, 0.59–0.85; P <0.001), and cardiovascular death (risk ratio, 0.85; 95% confidence interval, 0.75–0.96; P =0.01). In metaregression analyses, systolic BP reduction was linearly related to the lower risk of recurrent stroke ( P =0.049), myocardial infarction ( P =0.024), death from any cause ( P =0.001), and cardiovascular death ( P <0.001). Similarly, diastolic BP reduction was linearly related to a lower risk of recurrent stroke ( P =0.026) and all-cause mortality ( P =0.009). Funnel plot inspection and Egger statistical test revealed no evidence of publication bias. The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebrovascular and cardiovascular events. Strict and aggressive BP control seems to be essential for effective secondary stroke prevention.

Associations Between Blood Pressure and Outcomes Among Blacks in the Jackson Heart Study

BACKGROUND

In 2014, new hypertension guidelines liberalized blood pressure goals for persons 60 years and older. Little is known about the implications for blacks.

METHODS AND RESULTS

Using data from 2000 through 2011 for 5280 participants in the Jackson Heart Study, a community-based black cohort in Jackson, Mississippi, we examined whether higher blood pressure was associated with greater risk of mortality and heart failure hospitalization, and whether the risk was the same across age groups. We investigated associations between baseline blood pressure and both mortality and heart failure hospitalization. We also tested for interactions between age and blood pressure in the mortality model. Median systolic and diastolic blood pressures at baseline were 125 mm Hg (25th-75th percentile, 114-137 mm Hg) and 79 mm Hg (72-86 mm Hg), respectively. Median follow-up was 9 years for mortality and 7 years for heart failure hospitalization. After multivariable adjustment, every 10 mm Hg increase in systolic blood pressure was associated with greater risks of mortality (hazard ratio, 1.12; 95% CI, 1.06-1.17) and heart failure hospitalization (1.07; 95% CI, 1.00-1.14). The mortality risk per 10 mm Hg increase in systolic blood pressure was greater in participants younger than 60 years (1.26; 95% CI, 1.13-1.42) than among participants 60 years and older (1.09; 95% CI, 1.03-1.15).

CONCLUSIONS

Adults in all age groups were at greater risk of mortality as systolic blood pressure increased. In the context of the 2014 hypertension guidelines, these findings should be considered when determining treatment goals in black patients.

Men's Educational Group Appointments in Rural Nicaragua

Men’s preventive health and wellness is largely neglected in rural Nicaragua, where a machismo culture prevents men from seeking health care. To address this issue, a men’s educational group appointment model was initiated at a rural health post to increase awareness about hypertension, and to train community health leaders to measure blood pressure. Men’s hypertension workshops were conducted with patient knowledge pretesting, didactic teaching, and posttesting. Pretesting and posttesting performances were recorded, blood pressures were screened, and community leaders were trained to perform sphygmomanometry. An increase in hypertension-related knowledge was observed after every workshop and community health leaders demonstrated proficiency in sphygmomanometry. In addition, several at-risk patients were identified and follow-up care arranged. Men’s educational group appointments, shown to be effective in the United States in increasing patient knowledge and satisfaction, appear to function similarly in a resource-constrained environment and may be an effective mechanism for reaching underserved men in Nicaragua.

Beta-Adrenergic Receptor Blockers in Hypertension: Alive and Well

Beta-adrenergic receptor blockers (β-blockers) are an appropriate treatment for patients having systemic hypertension (HTN) who have concomitant ischemic heart disease (IHD), heart failure, obstructive cardiomyopathy, aortic dissection or certain cardiac arrhythmias. β-Blockers can be used in combination with other antiHTN drugs to achieve maximal blood pressure control. Labetalol can be used in HTN emergencies and urgencies. β-Blockers may be useful in HTN patients having a hyperkinetic circulation (palpitations, tachycardia, HTN, and anxiety), migraine headache, and essential tremor. β-Blockers are highly heterogeneous with respect to various pharmacologic properties: degree of intrinsic sympathomimetic activity, membrane stabilizing activity, β₁ selectivity, α₁-adrenergic blocking effects, tissue solubility, routes of systemic elimination, potencies and duration of action, and specific properties may be important in the selection of a drug for clinical use. β-Blocker usage to reduce perioperative myocardial ischemia and cardiovascular (CV) complications may not benefit as many patients as was once hoped, and may actually cause harm in some individuals. Currently the best evidence supports perioperative β-blocker use in two patient groups: patients undergoing vascular surgery with known IHD or multiple risk factors for it, and for those patients already receiving β-blockers for known CV conditions.

Update of treatment of heart failure with reduction of left ventricular ejection fraction

Underlying and precipitating causes of heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) should be identified and treated when possible. Hypertension should be treated with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Diuretics are the first-line drugs in the treatment of patients with HFrEF and volume overload. Angiotensin-converting enzyme inhibitors and β-blockers (carvedilol, sustained-release metoprolol succinate, or bisoprolol) should be used in treatment of HFrEF. Use an angiotensin II receptor blocker (ARB) (candesartan or valsartan) if intolerant to ACE inhibitors because of cough or angioneurotic edema. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in patients with chronic symptomatic HFrEF class II or III to further reduce morbidity and mortality. Add an aldosterone antagonist (spironolactone or eplerenone) in selected patients with class II-IV HF who can be carefully monitored for renal function and potassium concentration. (Serum creatinine should be ≤ 2.5 mg/dl in men and ≤ 2.0 mg/dl in women. Serum potassium should be < 5.0 mEq/l). Add isosorbide dinitrate plus hydralazine in patients self-described as African Americans with class II-IV HF being treated with diuretics, ACE inhibitors, and β-blockers. Ivabradine can be used in selected patients with HFrEF.

Risk Factor Optimization and Guideline-Directed Medical Therapy in US Veterans With Peripheral Arterial and Ischemic Cerebrovascular Disease Compared to Veterans With Coronary Heart Disease

Cardiovascular disease (CVD) is a systemic process involving multiple vascular beds and includes coronary heart disease (CHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD). All these manifestations are associated with an increased risk of subsequent myocardial infarction, stroke, and death. Guideline-directed medical therapy is recommended for all patients with CVD. In a cohort of US veterans, we identified 1,242,015 patients with CVD receiving care in 130 Veterans Affairs facilities from October 1, 2013 to September 30, 2014. CVD included diagnoses of CHD, PAD, or ICVD. We assessed the frequency of risk factor optimization and the use of guideline-directed medical therapy in patients with CHD, PAD alone, ICVD alone, and PAD + ICVD groups. A composite of 4 measures (blood pressure <140/90 mm Hg, A1c <7% in diabetics, statin use, and antiplatelet use in eligible patients), termed optimal medical therapy (OMT) was compared among groups. Multivariate logistic regression was performed with CHD as the referent category. CHD comprised 989,380 (79.7%), PAD alone 70,404 (5.7%), ICVD alone 163,730 (13.2%), and PAD + ICVD 18,501 (1.5%) of the cohort. Overall, only 36% received OMT with adjusted odds ratios of 0.54 (95% CI 0.53 to 0.55), 0.77 (0.76 to 0.78), and 0.97 (0.94 to 1.00) for patients with PAD alone, ICVD alone, and PAD + ICVD, respectively, compared with patients with CHD. In conclusion, OMT was low in all groups. Patients with PAD alone and ICVD alone were less likely to receive OMT than those with CHD and PAD + ICVD.

Cardiac Rehabilitation Delivery Model for Low-Resource Settings: An International Council of Cardiovascular Prevention and Rehabilitation Consensus Statement

Cardiovascular disease (CVD) is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be efficacious and cost-effective for secondary prevention in high-income countries. Given its affordability, CR should be more broadly implemented in middle-income countries as well. Hence, the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) convened a writing panel to recommend strategies to deliver all core CR components in low-resource settings, namely: (1) initial assessment, (2) lifestyle risk factor management (i.e., diet, tobacco, mental health), (3) medical risk factor management (lipids, blood pressure), (4) education for self-management; (5) return to work; and (6) outcome evaluation. Approaches to delivering these components in alternative, arguably lower-cost settings, such as the home, community and primary care, are provided. Recommendations on delivering each of these components where the most-responsible CR provider is a non-physician, such as an allied healthcare professional or community health care worker, are also provided.

Is 60 the New 80 in Hypertension?

Since the release of the "2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8)", much controversy has ensued over the appropriate systolic blood pressure goal for those over the age of 60 years. This guideline suggested liberalizing the target for this population to <150 mmHg, moving away from previous guidelines suggesting a target of <140 mmHg. While some national quality measures have accepted the new relaxed blood pressure goal, the American Heart Association and American College of Cardiology have not. Recently published data show that millions of adults over 60 years of age would be classified as controlled using a threshold of <150 mmHg, but not with a target of <140 mmHg. In addition, emerging randomized trial evidence suggests that targeting a systolic blood pressure well below 140 mmHg is beneficial in older adults. In light of the improved health and vitality of older adults, and the steady decline in cardiovascular and cerebrovascular mortality over recent decades, we do not think it is in good judgment to liberalize the treatment target in adults less than 80 years of age.

Treatment of Hypertension in Patients with Coronary Artery Disease. A Case-Based Summary of the 2015 AHA/ACC/ASH Scientific Statement

The 2015 American Heart Association/American College of Cardiology/American Society of Hypertension Scientific Statement "Treatment of Hypertension in Patients with Coronary Artery Disease" is summarized in the context of a clinical case. The Statement deals with target blood pressures, and the optimal agents for the treatment of hypertension in patients with stable angina, in acute coronary syndromes, and in patients with ischemic heart failure. In all cases, the recommended blood pressure target is <140/90 mm Hg, but <130/80 mm Hg may be appropriate, especially in those with a history of a previous myocardial infarction or stroke, or at high risk for developing either. These numbers may need to be revised after the publication of the SPRINT data. Appropriate management should include beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and in the case of heart failure, aldosterone antagonists. Thiazide or thiazide-like (chlorthalidone) diuretics and calcium channel blockers can be used for the management of hypertension, but the evidence for improved outcomes compared with other agents in hypertension with coronary artery disease is meager. Loop diuretics should be reserved for patients with New York Heart Association Class III and IV heart failure or with a glomerular filtration rate of <30 mL/min.

Fixed-Dose Combinations of Renin-Angiotensin System Inhibitors and Calcium Channel Blockers in the Treatment of Hypertension: A Comparison of Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors

Fixed-dose combinations (FDCs) of different regimens are recommended in guidelines for the treatment of hypertension. However, clinical studies comparing FDCs of angiotensin receptor blocker (ARB)/calcium channel blocker (CCB) and angiotensin-converting enzyme inhibitor (ACE inhibitor)/CCB in hypertensive patients are lacking.Using a propensity score matching of 4:1 ratio, this retrospective claims database study compared 2 FDC regimens, ARB/CCB and ACE inhibitor/CCB, in treating hypertensive patients with no known atherosclerotic cardiovascular disease. All patients were followed for at least 3 years or until the development of major adverse cardiovascular events (MACEs) during the study period. In addition, the effect of medication adherence on clinical outcomes was evaluated in subgroup analysis based on different portions of days covered.There was no significant difference in MACE-free survival (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 0.98-1.50; P = 0.08) and survival free from hospitalization for heart failure (HR: 1.15; 95% CI: 082-1.61; P = 0.431), new diagnosis of chronic kidney disease (HR: 0.98; 95% CI: 071-1.36; P = 0.906), and initiation of dialysis (HR: 0.99; 95% CI: 050-1.92; P = 0.965) between the 2 study groups. The results remained the same within each subgroup of patients with different adherence statuses.ARBs in FDC regimens with CCBs in the present study were shown to be as effective as ACE inhibitors at reducing the risks of MACEs, hospitalization for heart failure, new diagnosis of chronic kidney disease, and new initiation of dialysis in hypertensive patients, regardless of the medication adherence status.

Grip Strength as a Marker of Hypertension and Diabetes in Healthy Weight Adults

INTRODUCTION

Muscle strength may play a role in cardiometabolic disease. We examined the relationship between hand grip strength and diabetes and hypertension in a sample of healthy weight adults.

METHODS

In 2015, we analyzed the National Health and Nutrition Examination Survey 2011-2012 for adults aged ≥20 years with healthy BMIs (between 18.5 and <25) and no history of cardiovascular disease (unweighted n=1,467; weighted n=61,587,139). Hand grip strength was assessed with a dynamometer. Diabetes was based on hemoglobin A1c level and reported diabetes diagnosis. Hypertension was based on measured blood pressure and reported hypertension diagnosis.

RESULTS

Individuals with undiagnosed diabetes compared with individuals without diabetes had lower grip strength (51.9 vs 69.8, p=0.0001), as did individuals with diagnosed diabetes compared with individuals without diabetes (61.7 vs 69.8, p=0.008). Mean grip strength was lower among individuals with undiagnosed hypertension compared with individuals without hypertension (63.5 vs 71.5, p=0.008) as well as among individuals with diagnosed hypertension compared with those without hypertension (60.8 vs 71.5, p<0.0001). In adjusted analyses controlling for age, sex, race, smoking status, and first-degree relative with disease, mean grip strength was lower for undiagnosed diabetes (β=-10.02, p<0.0001) and diagnosed diabetes (β=-8.21, p=0.03) compared with individuals without diabetes. In adjusted analyses, grip strength was lower among individuals with undiagnosed hypertension (β=-6.6, p=0.004) and diagnosed hypertension (β=-4.27, p=0.04) compared with individuals without hypertension.

CONCLUSIONS

Among healthy weight adults, combined grip strength is lower in individuals with diagnosed and undiagnosed diabetes and hypertension.

Efficacy and Safety of a Traditional Chinese Herbal Formula Xuefu Zhuyu Decoction for Hypertension: A Systematic Review and Meta-Analysis

The cardioprotective role of xuefu zhuyu decoction (XZD), a well-known classical herbal formula, has been documented for hypertension treatment recently. This study aims to summarize the efficacy and safety of XZD in treating hypertension.Seven databases were searched to identify randomized controlled trials evaluating the efficacy of XZD in hypertensive patients. Fifteen studies involving 1364 hypertensive patients were included. All studies compared XZD and antihypertensive drugs with antihypertensive drugs used alone.In all, 15 studies reported significant effects of XZD for lowering blood pressure compared with the control group (P < 0.05), and 7 studies reported significant effects of XZD for improving symptoms compared with the control group (P < 0.00001). Meanwhile, studies reported XZD was more efficacious than antihypertensive drugs in improving total cholesterol, triglycerides, low-density lipoprotein cholesterol, homocysteine, hemorheology, carotid intima-media thickness, and left ventricular mass index (P < 0.05). No severe adverse event was reported.This meta-analysis provides evidence that XZD is beneficial for hypertension. Although concerns regarding selective bias and methodologic flaws were raised, our findings suggests XZD as a new candidate cardioprotective drug for hypertension, which should be given priority for future preclinical and clinical studies.