Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. Systolic Hypertension in China (Syst-China) Collaborative Group

Systolic blood pressure reduction with olmesartan medoxomil versus nitrendipine in elderly patients with isolated systolic hypertension

OBJECTIVE

The prevalence of isolated systolic hypertension (ISH) is high in the elderly, and the objective of this study was to compare the antihypertensive efficacy of olmesartan medoxomil with that of nitrendipine in elderly (65-74 years) and very elderly (>/= 75 years) male and female patients with ISH.

METHODS

Patients were randomized to 24 weeks of treatment with either olmesartan medoxomil 20 mg daily (n = 256) or nitrendipine 20 mg (n = 126) twice daily, with possible dose increase (to 40 mg daily) and addition of hydrochlorothiazide (HCTZ) 12.5 or 25 mg daily if required.

RESULTS

On the primary endpoint [reduction in mean sitting systolic blood pressure (SBP) after 12 weeks of treatment], the two treatments were similar (olmesartan medoxomil, -30.0 mmHg; nitrendipine, -31.4 mmHg). No significant difference between the treatment groups was observed, and non-inferiority of olmesartan medoxomil to nitrendipine was demonstrated using an analysis of covariance (ANCOVA) model. Reductions in mean sitting and standing SBP and diastolic blood pressure (DBP) up to week 24 were also similar with both treatments. Blood pressure (BP) goal attainment rates (sitting SBP </= 135 mmHg) increased consecutively, and were higher with olmesartan medoxomil (62.5%) than with nitrendipine (56.0%) at week 24 (not significant). Both treatments were well tolerated.

CONCLUSIONS

In elderly patients with ISH, the mean reduction in SBP produced by olmesartan is similar to that produced by nitrendipine.

Calcium antagonists and renal failure progression

Although tighter blood pressure control is considered the main mechanism for preventing the progression of chronic renal failure, angiotensin-converting enzyme inhibitors and angiotensin receptors blockers seem to have an additional organ protective role. The effects of calcium antagonists in renal disease are not so clearly defined. Calcium antagonists have pleiotropic effects that might contribute to protect the kidney, such as attenuating mesangial entrapment of macromolecules, countervailing the mitogenic effect of platelet-derived growth factors and platelet-activating factors, and suppressing mesangial cell proliferation. They could also act as free radical scavengers and inhibit the renal effects of endothelin. Some evidence has been accumulated demonstrating that certain new dihydropyridinic calcium antagonists may affect postglomerular as well as preglomerular vessels, resulting in decreased filtration fraction and nephroprotective effect as renin-angiotensin axis-blocking drugs. Though there are few reports on the clinical renal effects of new calcium antagonists, they have rendered promising results. Manidipine does not increase proteinuria as do some classic calcium antagonists, and lercanidipine combined with renin-angiotensin axis-blocking drugs reduce proteinuria. Both drugs have been shown to decrease microalbuminuria when administered alone.

Ambulatory blood pressure: associations with coronary heart disease in the aged Finnish population

BACKGROUND AND AIMS

Ambulatory blood pressure (ABP) has been shown to be a better predictor of cardiovascular events than clinical blood pressure (BP) in middle-aged and older populations. This study studied the association of various components of ABP (daytime, night-time, 24-hour ABP) in the presence of coronary heart disease (CHD) in an older Finnish population.

METHODS

This cross-sectional, observational, population-based study was carried out in The Lieto Health Centre, Finland, in 1998-99. The study population consisted of 502 subjects (237 men, 265 women) aged 64-87 years. ABP measurements for 24 hours, daytime (awake) and night-time (asleep), were made. Resting electrocardiograms (ECG) were recorded. A person was considered to have CHD if at least one of the following criteria was met: (I) history of coronary by-pass surgery or coronary angioplasty, (II) diagnosis of CHD in previous medical records, (III) ischemia-related changes on ECG.

RESULTS

CHD increased by 30% with a 10 mmHg increase in night-time systolic blood pressure (SBP) (OR 1.30, 95% Cl 1.15-1.47). When ambulatory 24-hour and daytime SBP values were each entered separately into the multivariate model, 24-hour SBP, but not daytime SBP, was associated with CHD.

CONCLUSIONS

The most important information gained from 24-h BP monitoring in subjects with CHD is night-time BP. Night-time BP may provide new information about the CHD risk which is not identified in common clinical diagnoses of hypertension. ABP measurements should be made to confirm sufficient control of night-time BP, especially SBP, in older people with CHD.

Renal sodium-glucose cotransporter activity and aquaporin-2 expression in rat kidney during chronic nitric oxide synthase inhibition

BACKGROUND/AIMS

The renal sodium glucose cotransporter (SGLT2) and the water channel aquaporin-2 (AQP2) play a critical role in tubular sodium and water reabsorption and in the regulation of extracellular fluid volume both in physiologic and pathophysiologic conditions. However, there is little information about SGLT2 and AQP2 expression and/or activity in hypertension and there are no reports during hypertension induced by chronic nitric oxide synthase (NOS) inhibition.

METHODS

Hypertension was induced in rats by oral administration of N(G)-nitro-L-arginine methyl ester (L-NAME) (20 mg/kg/24 h) for 6 (H6) or 12 (H12) weeks. SGLT2 activity was measured using alpha-(14)C-methylglucose active uptake. The expression level of transporters was assessed by immunohistochemistry and/or immunoblotting.

RESULTS

SGLT2 activity was reduced in both H6 and H12; this was due neither to a decrease in SGLT2 expression nor to a change in membrane phospholipid composition. In H6, AQP2 expression diminished only in the inner medulla (IM), while in H12 it diminished in both outer (OM) and IM. This reduced expression of AQP2 may partially account for the increased urinary volume and decreased urinary osmolality in H12, since we obtained a strong correlation between AQP2 expression and these urinary parameters in both OM and IM.

CONCLUSION

We propose that in rats in which hypertension is induced by NOS inhibition, SGLT2 activity and AQP2 expression are modified to compensate for the elevated arterial pressure. However, we cannot discount the possibility that the observed changes are due to the decrease in NO production itself.

Antihypertensive efficacy and safety of manidipine versus amlodipine in elderly subjects with isolated systolic hypertension: MAISH study

BACKGROUND AND OBJECTIVE

Isolated systolic hypertension (ISH) affects 10-20% of the elderly population and is strongly related to the risk of cardiovascular events. Elevated systolic BP values are primarily caused by reduced large vessel compliance with a consequent increase in total peripheral resistance. Vasodilating drugs, such as calcium channel antagonists, have proven to be effective in controlling ISH in elderly patients. This study set out to compare the antihypertensive efficacy and safety of two different calcium channel antagonists, manidipine and amlodipine, administered once daily in elderly subjects with ISH.

METHODS

In a European, randomised, double-blind, multicentre, parallel-group study, after a 2-week placebo run-in period, 195 patients aged >or=60 years with ISH received manidipine 10-20 mg once daily or amlodipine 5-10 mg once daily. Chlortalidone 25mg once daily could be added to the high dose of test drug in the event of insufficient antihypertensive control. The primary efficacy parameter was the proportion of patients with a reduction in office sitting systolic BP (SBP) >or=15 mm Hg, measured at trough, at the final visit. Secondary efficacy parameters included: the proportion of patients with a normal sitting SBP value (<140 mm Hg) at the final visit; a change from baseline to the final visit in mean office trough sitting SBP; a change from baseline to the final visit in the cardiovascular risk score as measured by the INDANA (INdividual Data ANalysis of Antihypertensive intervention trials) project score; the proportion of patients with at least a two-point reduction in the cardiovascular risk score; the percentage of patients requiring upward dose titration and diuretic add-on treatment and the investigator's final judgement. Safety and tolerability evaluations were based on adverse events, ECG and laboratory tests, and clinically relevant reports of abnormalities.

RESULTS

In the intention-to-treat population (n = 189), 76% and 72% of patients in the manidipine and amlodipine groups, respectively, had a reduction in sitting SBP of >or=15 mm Hg (p-value not significant for between-group comparison). The percentage of patients with a normal sitting SBP value was 52% in the manidipine group and 51% in the amlodipine group (p-value not significant for between-group comparison). Sitting SBP reductions at the end of treatment were -19.5 +/- 11.8 mm Hg in patients receiving manidipine and -18.4 +/- 11.1 mm Hg in patients receiving amlodipine. Both treatments induced a small reduction in cardiovascular risk score, with 45% of patients in both treatment groups having a two-point reduction in the final score. At the final visit, approximately half of the patients in both treatment groups were still being treated with the low dose of one of the test drugs (manidipine 10mg or amlodipine 5mg). Chlortalidone was added to the high dose of test drugs in 7% and 11% of patients in the amlodipine and manidipine groups, respectively. Both drugs were well tolerated, with a higher incidence of oedema in the amlodipine group (9% vs 4%). No clinically relevant changes in heart rate were induced by either treatment.

CONCLUSION

In elderly patients with ISH, treatment with manidipine for 12 weeks was well tolerated and effective and the antihypertensive effects obtained with manidipine were the same as those obtained with amlodipine.

Cardiovascular diseases in China

Statistics from the National Population Census of China revealed a significant increase in the Chinese population, from 590 million in 1953 to 1.26 billion in 2000. The average life expectancy increased to 71.4 years in 2000 compared with the expectancy of 68.6 years a decade before. World Health Organization statistics on the death rate for total cardiovascular disease, coronary heart disease, and stroke in men and women aged 35-74 years revealed discrepancies between rural and urban parts of China. The China Multicenter Collaborative Study of Cardiovascular Epidemiology indicated that cardiovascular disease was the major cause of death for both men and women, with stroke accounting for over 40% of deaths. Ischemia was shown to be the most common subtype of stroke in both sexes. Smoking was an independent risk factor for cardiovascular disease. The World Health Organization reported that the death rate attributable to tobacco was 6.0% worldwide and 9.2% in China in 1990. The latter is projected to reach 16.6% by 2020. In China, the prevalence of hypertension and diabetes mellitus, the two key risk factors of cardiovascular disease, have also increased significantly in the past 20 years. In addition, elevated blood pressure and plasma cholesterol were two important determinants of increased cardiovascular disease in eastern Asia. These studies indicate that an integrated management of comprehensive risk is urgently required to address China's increasing cardiovascular disease burden.

Does a change in angiotensin II formation caused by antihypertensive drugs affect the risk of stroke?

BACKGROUND

Stroke prevention by antihypertensive therapy is believed to be related to the fall in blood pressure (BP). Experimental data have documented that activation of non-AT1 receptors of angiotensin II may exert anti-ischaemic mechanisms in the brain. The present meta-analysis of various randomized clinical trials attempts to relate stroke risk to angiotensin II formation during antihypertensive therapy.

METHODS

Primary and secondary stroke prevention was examined in 26 prospective, randomized clinical trials including 206,632 patients without heart failure, in whom a total of 7,108 strokes occurred. The trials were selected because a difference in angiotensin II generation was expected between the two treatment arms on the basis of the drugs' pharmacodynamic effects, and allowed 36 evaluations of the relative risk of stroke.

FINDINGS

In placebo-controlled trials, stroke risk was significantly higher with angiotensin II-decreasing than increasing drugs, but systolic BP decreased less in the former. Compared with an active therapy having a neutral effect on angiotensin II formation, stroke risk was also higher with angiotensin-decreasing drugs than with angiotensin-increasing drugs, whereas BP decrease was comparable with both drug classes. When angiotensin II-decreasing drugs were directly compared with angiotensin II-increasing drugs in the same trials, stroke risk was significantly increased. On-treatment systolic BP was minimally and significantly higher with angiotensin II-decreasing drugs, but not large enough to explain the excess in stroke risk.

CONCLUSION

Within the limitations of the methodology, our meta-analysis supports the hypothesis that angiotensin II-decreasing drugs are less stroke protective than angiotensin II-increasing drugs, although this difference is not entirely explained by their smaller BP-lowering effect.

Emerging data on calcium-channel blockers: the COHORT study

Multiple studies have demonstrated dihydropyridine calcium-channel blocker (CCB) therapy to be appropriate for the treatment of hypertension, as is reflected in treatment guidelines such as the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure in the United States and the 1999 World Health Organization-International Society of Hypertension report. As with any drug class, successful treatment with CCBs depends on good patient compliance, which often hinges on drug tolerability. The differing characteristics among the various generations of CCBs may contribute to some compounds demonstrating superior tolerability. To test this hypothesis, the COHORT trial (named for the large group of participants) was undertaken in 828 elderly hypertensive patients aged > or = 60 years. This trial investigated the possible differences in patient tolerability between the third-generation agent amlodipine and the latest-generation agents lercanidipine and lacidipine. The primary endpoint of the study was the percentage of patients reporting edema, the most common side effect associated with CCB therapy. The study results indicated that while all three treatments were similarly efficacious in lowering blood pressure, lercanidipine and lacidipine were much better tolerated than amlodipine whether they were used as single agents or as initial therapy combined with other antihypertensive drugs. These newest-generation dihydropyridine CCBs offer the potential to reduce side effects, improve patient compliance, and ultimately help patients reach target blood pressures as recommended by the aforementioned guidelines.

Clinical trial experience around the globe: focus on calcium-channel blockers

Although certain classes of drugs appear to possess benefits apart from their blood-pressure lowering capability, reduction of blood pressure remains the single most important action of antihypertensive therapy. Calcium-channel blockers (CCBs) have long been recognized as potent agents for hypertension therapy. This is especially true for the prevention of stroke in hypertensive patients as evidenced from the Systolic Hypertension in Europe (Syst-Eur) and Systolic Hypertension in China (Syst-China) trials with a long acting dihydropyridine CCB. The same can be said for beta blockers in patients post myocardial infarction. However, most recent clinical trials have underscored the necessity of multiple drug therapy to achieve the goals of blood pressure reduction coupled with outcomes reduction. For example, the many recent large-scale clinical trials have required an average of three or more agents to achieve goal. Thus, the paradigm for hypertension management has been altered to determine the best treatment regimen rather than the best initial agent. While response rates to individual agents across a wide spectrum of patients vary little, not all drugs are equally suited as companion products. In this article, we discuss the most recent outcome trials with the long acting CCBs alone or in combination with other drugs. The evidence shows that calcium antagonists remain an important part of hypertension management, including in those individuals at risk of cardiac and cerebrovascular events.

Effect of the Ca Antagonist Nilvadipine on Stroke Occurrence or Recurrence and Extension of Asymptomatic Cerebral Infarction in Hypertensive Patients with or without History of Stroke (PICA Study)

BACKGROUND

We examined the effect of a Ca antagonist (nilvadipine) on the occurrence or recurrence of symptomatic stroke in hypertensive patients with MRI-defined asymptomatic cerebral infarction (ACI), periventricular hyperintensity (PVH), and deep and subcortical white matter hyperintensity (DSWMH), with or without a history of stroke, and evaluated the effect of long-term treatment on the lesions.

METHODS

Patients with hypertension and incidental ACI were divided into those with (group B, 235 patients) or without (group A, 181 patients) a history of symptomatic stroke, and were given nilvadipine 4-8 mg/day for 3 years. Primary evaluation points were occurrence of symptomatic ischemic stroke and development or extension of asymptomatic ischemic lesions.

RESULTS

Male sex, hyperuricemia, diabetes, maximum diameter of infarction and PVH severity were stronger risk factors for group B. Numbers of cerebral infarctions were 31 +/- 28 (group A) and 42 +/- 32 (group B) at enrollment (p < 0.001). Infarctions were larger and located more frequently on the internal capsule, putamen, thalamus and brainstem in group B. The severity of PVH and DSWMH paralleled the number of cerebral infarctions in both groups.

CONCLUSION

The study design and status of asymptomatic ischemic brain lesions in hypertensive subjects at enrollment are presented.

Hypertension and kidney protection in the elderly: what is the evidence in 2007?

Hypertension and diabetes mellitus are the two most widely recognized risk factors for cardiovascular disease (CVD), chronic kidney disease (CKD), and end-stage renal disease (ESRD) requiring dialysis/transplantation; both become increasingly important as one ages. Common pathways and mechanisms are involved in the development of renal vascular lesions in both conditions, and effective treatments for each are now available to reduce morbidity, mortality and progression of organ damage. Although this review will focus primarily on the ability to protect the kidney and vasculature elsewhere by lowering blood pressure in the elderly, other approaches, specifically dietary restriction of protein, strict control of diabetes mellitus, and the management of the different dyslipidemias, must be used in conjunction with the antihypertensive agents to obtain optimum protection.

Blood pressure and ageing

Isolated systolic hypertension, an elevation in systolic but not diastolic pressure, is the most prevalent type of hypertension in those aged 50 or over, occurring either de novo or as a development after a long period of systolic-diastolic hypertension with or without treatment. The increase in blood pressure with age is mostly associated with structural changes in the arteries and especially with large artery stiffness. It is known from various studies that rising blood pressure is associated with increased cardiovascular risk. In the elderly, the most powerful predictor of risk is increased pulse pressure due to decreased diastolic and increased systolic blood pressure. All evidence indicates that treating the elderly hypertensive patient will reduce the risk of cardiovascular events. However, there is no evidence yet for the very elderly. This population is particularly susceptible to side effects of treatments and the reduction of blood pressure, although reducing the risk of cardiovascular events such as stroke, may result in increased mortality.

Incidence and predictors of hypertension over 8 years among Chinese men and women

OBJECTIVE

To determine the 8-year incidence of hypertension and its risk factors among Chinese adults.

METHODS

A population-based sample of 10,525 Chinese adults aged > or = 40 years and free from hypertension at baseline was followed up from 1991 to 1999-2000. Incident hypertension was defined as systolic pressure > or = 140 mmHg, diastolic pressure > or = 90 mmHg, or current use of antihypertensive medication.

RESULTS

Over a mean of 8.2 years of follow-up, 28.9% of men and 26.9% of women developed hypertension. Among men, independent predictors of incident hypertension were baseline age [relative risk (RR) per 5 years: 1.10; 95% confidence interval (CI): 1.07, 1.13], living in urban regions versus rural regions (RR: 0.74; 95% CI: 0.64, 0.85), alcohol drinking versus non-drinking (RR: 1.13; 95% CI: 1.02, 1.24), prehypertension versus normotension (RR: 1.70; 95% CI: 1.53, 1.88), heart rate (RR of third versus first tertile: 1.27; 95% CI: 1.13, 1.44), body mass index (RR of third versus first tertile: 1.28; 95% CI: 1.12, 1.46) and low versus high physical activity (RR: 1.27; 95% CI: 1.10, 1.47). Results were similar for women, with current smoking in place of alcohol drinking and opposite results for region. The population-attributable risk of modifiable risk factors was between 25 and 50%.

CONCLUSIONS

These data indicate that the incidence of hypertension is high among these Chinese adults, and suggest that 25-50% of new hypertension cases could be prevented with risk factor modification. Given the excess cardiovascular mortality associated with hypertension, these data call for urgent improvements in hypertension prevention and control programs in China.

Effects of chronic hyperglycaemia on incident stroke in Hong Kong Chinese patients with type 2 diabetes

BACKGROUND

It remains unclear whether hyperglycaemia as measured by HbA(1c) is a significant risk factor for stroke in patients with type 2 diabetes mellitus (T2DM).

METHODS

A case-control study nested in a prospective cohort with 1 : 3 controls matched on age, gender, systolic blood pressure and low-density lipoprotein cholesterol (LDL-C) was conducted. The case group included 105 patients who developed incident stroke during 2.88 years (SD: 1.59) of follow-up of 4150 T2DM patients and 299 matched patients without incident stroke, used as the control group. Stratified Cox proportional hazard regression was used to obtain hazard ratio (HR).

RESULTS

Median age was 71 years (IQR: 9.0 for the case and 10.0 for the control). HbA(1c) was significantly higher in the cases than in the controls (median 8.0% [IQR: 2.0] versus 7.2% [2.1], p < 0.0001). After controlling for smoker status, haematocrit, drug treatments and other covariates, 1% increase in HbA(1c) was associated with 1.49 (95% CI: 1.18-1.88, p = 0.0008) folds risk of occurrence of incident stroke. Patients with a history of coronary heart disease (CHD) were also at increased risk of stroke (HR: 8.25, 95% CI: 2.22-30.73, p = 0.0016). Smoker status and haematocrit were marginally significant predictors of incident stroke. Every adjusted month using lipid-lowering drugs was significantly associated with reduced risk of incident stroke (HR: 0.95, 95% CI: 0.90-0.99, p = 0.0199). Similar analysis using ACEI or ARB as a drug group was marginally significant (p = 0.0555).

CONCLUSION

Chronic hyperglycaemia is a risk factor of stroke in Chinese patients with T2DM.

Is it Time for a Cardiovascular Primary Prevention Trial in the Elderly?

Background and Purpose— Statins have been shown conclusively to reduce the risk of cardiovascular events in subjects with clinical cardiovascular disease or diabetes aged 65 to 80 years of age. However, few data are available for primary prevention of cardiovascular disease in those aged ≥70 years.

Summary of Review— A moderate-dose statin was of little benefit in a population aged 70 to 82 years when given for 3 years in the setting of suboptimally treated blood pressure. More evidence supports the use of blood pressure–lowering medications, but few data are available regarding the appropriate blood pressure target and most effective agents in the elderly. Some evidence also suggests that the elderly could experience higher mortality with antihypertensive treatment. These findings, along with greater safety concerns and an increasing number of competing risks and medical conditions with advancing age, make it imperative to carefully evaluate the risk/benefit balance from treating hypercholesterolemia and hypertension in persons aged ≥70 years.

Conclusions— We propose a 5-year 2×2 factorial trial of primary prevention in the elderly that will (1) evaluate whether statin therapy will reduce the risk of cardiovascular events when added to the treatment of hypertension to achieve a blood pressure <140/90 mm Hg in most patients and (2) determine the most appropriate blood pressure regimen for the prevention of cardiovascular and renal events.

Pulse wave analysis and pulse wave velocity: a review of blood pressure interpretation 100 years after Korotkov

The pulsatile component of blood pressure (ie, pulse pressure) has received considerable attention as an important risk factor for cardiovascular disease. In particular, central blood pressure measurements in the ascending aorta or in the carotid artery are expected to be more useful than conventional brachial pressure measurements for predicting cardiovascular events because central pressure, not the brachial pressure, is the pressure that target organs encounter. Due to wave reflection, the blood pressure in the upper limb does not represent the central blood pressure; therefore, leading researchers have enthusiastically promoted a noninvasive method of measuring central blood pressure and the resulting aortic stiffness. Until now, there has been an increasing body of evidence to support the accuracy and superiority of central blood pressure measurements as well as the assessment of aortic properties over classical brachial pressure measurements. In this review, the information regarding these "central" indices derived from 2 main methods, namely "pulse wave analysis" and "pulse wave velocity", for the application of central blood pressure measurements and arterial stiffness to clinical study and practice, has been summarized.

Nationwide efficacy-safety study of nebivolol in mildly hypertensive patients

Nebivolol has been adequately tested in clinical efficacy trials of patients with mild hypertension. Clinical efficacy trials or their meta-analyses did not accurately predict the outcome of subsequent large studies. The primary objective was to assess the efficacy/safety of nebivolol 5-10 mg daily in a nationwide study of patients with mild hypertension. Secondary objectives were (1) to compare efficacy/safety as monotherapy versus add-on therapy and (2) to assess the effect of nebivolol on ISH. This was an open-label, 6-week follow-up study of 6,356 patients with mild hypertension or ISH, as defined by the 1999 World Health Organization guidelines, recruited from 2,700 facilities. Previous monotherapies were continued except for beta-blockers. Results are reported as means+/-SDs. Intention-to-treat analysis is given. A total of 5,740 patients completed the study; of the withdrawals, 90% were lost for follow-up or were noncompliant, 38% were untreated before, 23% had beta-blockers. In the accumulated data, mean systolic and diastolic blood pressures fell by 24+/-14 and 13+/-9 mm Hg (both P<0.001). The differences between the blood pressure-reducing effects of nebivolol monotherapy and add-on therapy were not statistically significant: 28+/-16 and 22+/-14 mm Hg for systolic and 15+/-11 and 11+/-8 mm Hg for diastolic blood pressures. Adverse events were limited to 0.5% of the patients, no serious adverse events were observed. In the ISH patients, diastolic blood pressure fell by 4+/-6 mm Hg compared with 15+/-10 mm Hg in the no-ISH patients (P<0.01). Efficacy-safety effects of nebivolol in patients with mild hypertension can be generalized in a nationwide assessment. The efficacy of nebivolol as monotherapy and as the efficacy as add-on therapy are very similar. Nebivolol is highly efficacious in patients with ISH.

Pulse pressure and vascular risk in the elderly: associations and clinical implications

Pulse pressure provides information beyond systolic and diastolic blood pressures, from which it is calculated. The majority of individuals older than 70 years have a widened pulse pressure resulting from age-related stiffening of the central elastic arteries and systolic hypertension. A widened pulse pressure is associated with cardiovascular risk factors such as diabetes, hypertension, and smoking. It also predicts a higher risk of subsequent cardiovascular events, stroke, renal disease, heart failure, and mortality, particularly in the elderly. The authors review the mechanisms that contribute to pulse pressure and the association between pulse pressure, vascular risk factors, and outcomes.

A review of stroke in patients with hypertension and coronary artery disease: Focus on calcium channel blockers

Stroke is a major cause of morbidity and mortality worldwide. Hypertension is one of the most important risk factors for stroke - increasing the risk significantly. The presence and severity of coronary artery disease (CAD), which often coexists with hypertension, also predicts an increased risk of stroke. Lowering blood pressure (BP) to target in patients with hypertension can significantly reduce the incidence of fatal and non-fatal stroke. Effective BP control is even more important in CAD patients who are at greater risk of stroke. Data regarding the effects of antihypertensive therapy on stroke in patients with angina or CAD are limited and have been variable. To date, BP management strategies in patients with CAD have relied on small subsets of data based on high-risk hypertensive patients. Results with calcium channel blockers (CCBs) have been more positive than those with other classes of antihypertensive agents. Findings from the ACTION trial have provided a significant insight into the benefits of CCBs in patients with CAD and hypertension. Nifedipine gastrointestinal therapeutic system (GITS), in addition to best practice therapy for stable angina pectoris, contributes to a significant reduction in the risk of stroke in patients with CAD and hypertension who are at high risk and require effective BP control. Moreover, the incidence of stroke is significantly related to baseline BP, which may be an important factor to consider when deciding on treatment strategies in high-risk patients with CAD.

Systolic hypertension in older persons: how aggressive should treatment be?

Systolic hypertension (SH) is a major public health concern predominantly affecting older persons. A key message of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) is that SH is a much more important cardiovascular disease risk factor than diastolic hypertension, particularly in older persons. Consequently, aggressive control of elevations of systolic blood pressure (SBP) is recommended. Despite increasing attention, SH is on the rise: isolated elevations of SBP in a national sampling of Veteran's Administration patients have increased from 57% in 1990 to 1995 to 76% of patients in 1999. This article considers several clinically pertinent issues, including the evidence for treating older patients with elevations in SBP, treating SH in the "oldest old" (those aged >85 years), and how aggressively these patients should be treated. In addition, issues regarding clinical decision making in older patients with SH are discussed.

New Generation Calcium Channel Blockers in Hypertensive Treatment

During a couple of decades, a number of antihypertensive drugs have been developed, and the choice of hypertension treatment has been expanded. Among antihypertensive drugs, calcium channel blockers, which inhibit L-type voltage-gated calcium channels, are potent vasodilators, and have been used as a first- or second-line drug. Dihydropyridine-class calcium channel blockers are categorized into three generations according to the length of activity, and long-acting calcium channel blockers cause less activation of sympathetic nervous system, and are reported to offer beneficial action compared with short-action agents. Furthermore, novel types of calcium channel blockers have been developed that possess the blocking action on other calcium channel subtypes (T- and N-type), and exert agent-specific action apart from their class effects, such as the effects on heart rate and renin/aldosterone release. These additional benefits conferred by T/N-type calcium channel blockade are anticipated to provide organ protective actions in the treatment of hypertension, in addition to the blood pressure-lowering effect of L-type calcium channel blockade. In conclusion, novel calcium channel blockers with sustained activity and T/N-type calcium channel blocking action could provide more beneficial effects than classical blockers, and may expand the clinical utility of these agents.

The effects of blood pressure lowering on development of cognitive impairment and dementia in patients without apparent prior cerebrovascular disease

BACKGROUND

Hypertension and cognitive impairment are prevalent in older people. It is known that hypertension is a direct risk factor for vascular dementia and recent studies have suggested hypertension also impacts upon prevalence of Alzheimer's disease. The question is therefore whether treatment of hypertension lowers the rate of cognitive decline.

OBJECTIVES

To assess the effects of blood pressure lowering treatments for the prevention of dementia and cognitive decline in patients with hypertension but no history of cerebrovascular disease.

SEARCH STRATEGY

The trials were identified through a search of CDCIG's Specialised Register, CENTRAL, MEDLINE, EMBASE, PsycINFO and CINAHL on 27 April 2005.

SELECTION CRITERIA

Randomized, double-blind, placebo controlled trials in which pharmacological or non-pharmacological interventions to lower blood pressure were given for at least six months.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed trial quality and extracted data. The following outcomes were assessed: incidence of dementia, cognitive change from baseline, blood pressure level, incidence and severity of side effects and quality of life.

MAIN RESULTS

Three trials including 12,091 hypertensive subjects were identified. Average age was 72.8 years. Participants were recruited from industrialised countries. Mean blood pressure at entry across the studies was 170/84 mmHg. All trials instituted a stepped care approach to hypertension treatment, starting with a calcium-channel blocker, a diuretic or an angiotensin receptor blocker. The combined result of the three trials reporting incidence of dementia indicated no significant difference between treatment and placebo (Odds Ratio (OR) = 0.89, 95% CI 0.69, 1.16). Blood pressure reduction resulted in a 11% relative risk reduction of dementia in patients with no prior cerebrovascular disease but this effect was not statistically significant (p = 0.38) and there was considerable heterogeneity between the trials. The combined results from the two trials reporting change in Mini Mental State Examination (MMSE) did not indicate a benefit from treatment (Weighted Mean Difference (WMD) = 0.10, 95% CI -0.03, 0.23). Both systolic and diastolic blood pressure levels were reduced significantly in the two trials assessing this outcome (WMD = -7.53, 95% CI -8.28, -6.77 for systolic blood pressure, WMD = -3.87, 95% CI -4.25, -3.50 for diastolic blood pressure). Two trials reported adverse effects requiring discontinuation of treatment and the combined results indicated a significant benefit from placebo (OR = 1.18, 95% CI 1.06, 1.30). When analysed separately, however, more patients on placebo in SCOPE were likely to discontinue treatment due to side effects; the converse was true in SHEP 1991. Quality of life data could not be analysed in the three studies. There was difficulty with the control group in this review as many of the control subjects received antihypertensive treatment because their blood pressures exceeded pre-set values. In most cases the study became a comparison between the study drug against a usual antihypertensive regimen.

AUTHORS' CONCLUSIONS

There was no convincing evidence from the trials identified that blood pressure lowering prevents the development of dementia or cognitive impairment in hypertensive patients with no apparent prior cerebrovascular disease. There were significant problems identified with analysing the data, however, due to the number of patients lost to follow-up and the number of placebo patients given active treatment. This introduced bias. More robust results may be obtained by analysing one year data to reduce differential drop-out or by conducting a meta-analysis using individual patient data.

Targeting the renin-angiotensin system for the reduction of cardiovascular outcomes in hypertension: angiotensin-converting enzyme inhibitors and angiotensin receptor blockers

Agents that counteract the negative impact of the renin-angiotensin-aldosterone system (RAAS) are effective antihypertensives and reduce the risk of developing Type 2 diabetes. Contrary to common perception, angiotensin-converting enzyme inhibitors do not share the apparent benefit of angiotensin II receptor blockers (ARBs) in reducing risk of cardiovascular-disease outcomes, particularly stroke, in randomised clinical trials. RAAS agents, especially ARBs, are well tolerated. Use of ARBs alone or in combination with other classes of antihypertensive agents to lower blood pressure and/or medications to control other conditions (e.g., insulin sensitivity) reduces risk of cardiovascular disease outcomes and Type 2 diabetes with excellent tolerability. Selected issues related to use of RAAS agents as antihypertensive therapies (e.g., Type 2 diabetes, global risk management, multiple drug therapy and coronary heart disease) are addressed.

In a population-based prospective study, no association between high blood pressure and mortality after age 85 years

OBJECTIVE

To study the impact of a history of hypertension and current blood pressure on mortality in the oldest old.

DESIGN

An observational population-based cohort study.

SETTING

Community city of Leiden, The Netherlands.

PARTICIPANTS

Five hundred and ninety-nine inhabitants of the birth-cohort 1912-1914 were enrolled on their 85th birthday. There were no selection criteria related to health or demographic characteristics.

INTERVENTIONS

The mean follow-up was 4.2 years. Medical histories were obtained from general practitioners. Medication histories were obtained from the participant's pharmacist. Blood pressure was measured twice at baseline.

MAIN OUTCOME MEASURES

All cause and cardiovascular mortality.

RESULTS

Five hundred and seventy-one participants were included, 39.2% had a history of hypertension. During follow-up 290 participants died, 119 due to cardiovascular causes. Compared to participants without a history of hypertension, those with a history of hypertension had increased mortality from cardiovascular causes [relative risk (RR) 1.60, confidence interval (CI) 1.06-2.40] but equal mortality from all causes (RR 1.19, CI 0.91-1.55). High blood pressure at baseline (age 85) was not a risk factor for mortality. Baseline blood pressure values below 140/70 mmHg (n = 48) were associated with excess mortality, predominantly in participants with a history of hypertension.

CONCLUSION

In the oldest old, high blood pressure is not a risk factor for mortality, irrespective of a history of hypertension. Blood pressure values below 140/70 mmHg are associated with excess mortality.

Systolic hypertension in older persons: complexities in clinical decision making

While the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) challenges clinicians to aggressively manage systolic hypertension, few data are available to guide clinicians in treating older persons with this condition. In older persons, hypertension treatment decisions must often rely on extrapolations and fall into a gray area where optimal choice for an individual patient may be unclear. In these instances, patients must understand the probable outcomes of options, consider the personal value they place on benefits vs. risks, and participate with their practitioners in deciding on treatment. Shared decision making is the process by which the health care provider and patient share all stages of the decision-making process and both discuss treatment preferences and agree on a final management plan. Our challenge as clinicians is to ensure that all older patients have the opportunity to be treated in a way that is evidence-based and patient-centered. As with most health care decisions in older persons, those regarding blood pressure control should promote evidence-based care that is complementary with individualized risk, benefit ratios, patient preferences, and treatment goals.

Valor de la presión de pulso como marcador de riesgo cardiovascular

Pulse pressure is calculated as the difference between the systolic and diastolic components of arterial blood pressure. Epidemiological studies have demonstrated that pulse pressure elevation directly correlates with cardiovascular mortality and morbidity, as well as with target organ damage. From a pathophysiological point of view, pulse pressure can be considered a marker of the rigidity of large arteries, especially aorta. Loss of elastic properties of these large arteries is crucial in the development of isolated systolic hypertension, prevalent in the majority of the elderly, and in difficulties in organ perfusion. Some recent data suggest that both sedentary life and obesity enhance this loss of arterial elasticity. Pulse pressure reduction by antihypertensive treatment in subjects with elevation of this parameter (isolated systolic hypertensives) protects against cardiovascular disease. Nevertheless, the independence of this protection regarding other blood pressure components or the existence of clear differences between antihypertensive drug classes on pulse pressure reduction are still unknown.

The Felodipine Event Reduction (FEVER) Study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients

OBJECTIVE

To compare the incidence of stroke and other cardiovascular events in hypertensive patients receiving a low-dose diuretic and low-dose calcium antagonist combination with those receiving low-dose diuretic monotherapy, and assess the effects of a small blood pressure difference at achieved levels lower than those achieved in previous placebo-controlled trials.

METHODS

The Felodipine Event Reduction (FEVER) trial was an investigator-designed, prospective, multicentre, double-blind, randomized, placebo-controlled, parallel group trial. It enrolled 9800 Chinese patients, of either sex, aged 50-79 years, with one or two additional cardiovascular risk factors or disease, whose blood pressure, 6 weeks after switching from previous antihypertensive therapy to low-dose (12.5 mg a day) hydrochlorothiazide, was in the range 140-180 mmHg (systolic) or 90-100 mmHg (diastolic). These patients were randomly assigned either to low-dose felodipine extended release or placebo, and followed at 3-month intervals for an average of 40 months.

RESULTS

The intention-to-treat analysis included 9711 randomly selected patients with only 30 (0.3%) lost to follow-up. A total of 31 842 patient-years of follow-up were accumulated, with 85.9% of patients remaining on blinded randomized treatment. Add-on therapy was given to 33.9% of the hydrochlorothiazide-felodipine patients and to 42.3% of the hydrochlorothiazide-placebo patients. In the felodipine group, systolic blood pressure (SBP)/diastolic blood pressure (DBP) decreased (from randomization to study end) from 154.2/91.0 to 137.3/82.5 mmHg, and in the placebo group from 154.4/91.3 to 142.5/85.0 mmHg, with an average difference throughout the trial of 4.2/2.1 mmHg. In the felodipine group, the primary endpoint (fatal and non-fatal stroke) was reduced by 27% (P = 0.001). Among secondary endpoints, all cardiovascular events were reduced by 27% (P < 0.001), all cardiac events by 35% (P = 0.012), death by any cause by 31% (P = 0.006), coronary events by 32% (P = 0.024), heart failure by 30% (P = 0.239), cardiovascular death by 33% (P = 0.019), cancer by 36% (P = 0.017) in the felodipine group. No significant differences were found in new-onset diabetes. Both treatments were very well tolerated.

CONCLUSIONS

In moderately complicated hypertensive patients from China even a difference in SBP/DBP as small as 4/2 mmHg, such as that induced by adding low-dose felodipine to low-dose hydrochlorothiazide, is associated with very substantial reductions in the incidence of most types of cardiovascular events. As the SBP achieved in the felodipine group was below the recommended goal of less than 140 mmHg, and SBP in the placebo group was slightly above that level, FEVER provides the required evidence in support of the guidelines recommended goal, even for a hypertensive population not entirely consisting of patients with diabetes or previous cardiovascular events.

[Prevention of arteriosclerosis. Importance of the treatment of arterial hypertension]

In most European countries and Northern America, cardiovascular diseases induced by atherosclerosis are the most common cause of death in older people. People surviving acute myocardial infarction or stroke suffer often by disabilities or handicaps. The lifelong care of such patients is expensive and plays a major role for increment of costs in public health systems. Prevention of atherosclerosis will reduce cardiovascular morbidity and mortality, enhance quality of life and prolong lifetime of patients. Therefore the worldwide accepted risk factors of atherosclerosis have to be treated consequently and early enough within the meaning of primary prevention. Hypertension is one of the six major cardiovascular risk factors and is defined as elevated blood pressure above 140/90 mmHg. In case of hypertension, diagnostic efforts has to be focussed on detection of additional cardiovascular risk factors, secondary forms of hypertension, end organ damage or associated diseases. All therapeutic strategies are based on life style changes, which cover weight reduction, sodium restriction, controlled alcohol consumption and increment in physical activity. Pharmacotherapy will be added in regard to the global risk of the patient and the success of the life style changes. Selection of antihypertensives and their optimal combination will be determined by associated diseases (compelling indication), side effects and individual response in blood pressure. Goal of treatment is the normalization of blood pressure below 140/90 mmHg independent of age or sex. In diabetics and in case of nephropathy the goal is set lower (below 130/80 mmHg).There is strong evidence that reduction in blood pressure is followed by a decrease in the incidence of myocardial infarction, stroke, heart failure, nephropathy, and even in cardiovascular mortality. The success of antihypertensive therapy is greater in high risk patients like older people, patients with isolated systolic hypertension or diabetics. Risk reduction correlates well with the degree in blood pressure reduction. However, to minimize cardiovascular risk in hypertensives all additional risk factors have to be treated too.

Hypertension in special populations

Hypertension is a multifaceted disease that may present somewhat differently in various populations. It is clear that hypertensive treatment reduces cardiovascular, renal, and cerebrovascular outcomes for all patients, yet recent clinical trial data suggest that some groups may benefit more than others from specific drug intervention. Furthermore, these data justify specific approaches for some special populations. This article reviews important features of the presentation, rationale for treatment, and treatment recommendations for the treatment of hypertension in special populations. The special populations addressed include diabetic patients, the elderly, and women.

Aggressive hypertension management in patients of advancing and advanced age

Many older patients are not being aggressively managed for hypertension. Healthcare providers are often hesitant to start or even aggressively titrate antihypertensive medication, especially in the aged. Multiple studies have demonstrated that morbidity and mortality can be significantly reduced by appropriate intervention in all age groups. There are some clinical situations, however, where the provider must approach cautiously, such as in patients with a wide pulse pressure or those with a propensity toward adverse reactions. The data are clear that in the United States, undertreatment, rather than overtreatment, appears to be the issue. This article reviews studies that support the aggressive treatment of hypertension. The nuances of aging, which often influence the healthcare provider's treatment decisions, are also discussed. Suggestions for reasonable approaches to these difficult cases will be considered.