2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)

The Hyper-Pract Study : a multicentre survey on the accuracy of the echocardiographic assessment of hypertensive left ventricular hypertrophy in clinical practice

Left ventricular hypertrophy (LVH) assessed by echocardiography has a relevant impact in clinical decision making in hypertensive patients. We investigated the precision and accuracy of hypertensive LVH determination in current clinical practice by a regional-based survey. The study included 211 patients with essential hypertension consecutively attending six hospital outpatient hypertension clinics in the northern Italian region of Lombardy; all subjects had undergone an echocardiographic examination for hypertension-related problems in a non-academic or research ultrasound laboratory within 2 years. The original echocardiographic report was examined to ascertain whether the diagnosis of LVH was based on calculation of left ventricular (LV) mass according to validated formulae and indexed to body size (primary outcome) and whether LV geometrical patterns and indices of diastolic function were provided (secondary outcome). A total of 211 echocardiograms performed by 120 physicians operating in 73 different hospital and out-of-hospital ultrasound laboratories were collected. Absolute LV mass, LV mass index and relative wall thickness were calculated in 45.5%, 24.6% and 12.3% of the cases, respectively. Parameters of LV diastolic filling were measured in two-thirds of the cases and estimation of E/A ratio was provided by less than 20% of the examinations. This study shows that a large majority of echocardiographic examinations, routinely performed in hypertensive subjects in order to detect cardiac damage, do not report qualifying data on LV mass, LV geometry and diastolic function. These results indicate that a quantitative assessment of LVH and LV function is rarely provided in clinical practice.

Clinical effects of torasemide prolonged release in mild-to-moderate hypertension: a randomized noninferiority trial versus torasemide immediate release

The efficacy of a new torasemide prolonged release (PR) formulation to torasemide immediate release (IR) was compared in a randomized noninferiority double-blind trial. Patients with newly diagnosed mild-to-moderate hypertension or unresponsive or poor tolerability to previous antihypertensive monotherapy received 5 mg/day of torasemide-PR (n = 219) or torasemide-IR (n = 223) for 12 weeks (uptitration to 10 mg/day if no response at 4 or 8 weeks). Mean diastolic blood pressure (DBP) reduction in the torasemide-PR group (11.6 +/- 7.1 mmHg, 95% confidence interval [CI] 10.6-12.5) versus torasemide-IR (11.3 +/- 7.5 mmHg, 95% CI 10.2-12.3) met the noninferiority criterion of a nonsided 97.5% CI lower than the preestablished margin of 2 mmHg. A significantly higher percentage of patients in the torasemide-PR group achieved adequate BP control after 8 and 12 weeks. Ambulatory 24-h BP monitoring (ABPM) measurements in a subset of 100 patients showed greater daytime SBP reductions in the torasemide-PR group (128.4 +/- 9.9 mmHg vs. 133.5 +/- 10.4 mmHg, P < 0.05). Safety and tolerability of both formulations were similar.

Carvedilol in hypertension treatment

Although β-blockers have been previously shown to effectively reduce blood pressure (BP) and have been used for hypertension treatment for over 40 years, their effect on cardiovascular morbidity and mortality in hypertensive patients remains controversial and its use in uncomplicated hypertension is currently under debate. However, data on the above field derive mainly from studies which were conducted with older agents, such as atenolol and metoprolol, while considerable pharamacokinetic and pharmacodynamic heterogeneity is present within the class of β-blockers. Carvedilol, a vasodilating non-cardioselective β-blocker, is a compound that seems to give the opportunity to the clinician to use a cardioprotective agent without the concerning hemodynamic and metabolic actions of traditional β-blocker therapy. In contrast with conventional β-blockers, carvedilol maintains cardiac output, has a less extended effect on heart rate and reduces BP by decreasing vascular resistance. Further, several studies has shown that carvedilol has a beneficial or at least neutral effect on metabolic parameters, such as glycemic control, insulin sensitivity, and lipid metabolism, suggesting that they could be used in subjects with the metabolic syndrome or diabetes without negative consequences. This article summarizes the distinct pharmacologic, hemodynamic, and metabolic properties of carvedilol in relation to conventional β-blockers, attempting to examine the potential use of this agent for hypertension treatment.

Impact of beta-blockers on sleep in patients with mild hypertension: a randomized trial between nebivolol and metoprolol

INTRODUCTION

Sleep is an innate and essential part of human life. Various aspects of sleep are negatively affected by beta-blockers. We compared the impact of two beta-blockers, metoprolol succinate (extended release) and nebivolol, on sleep quality in patients with stage 1 hypertension.

METHODS

This was a prospective, randomized, open-label, parallel-group study. Eligible patients were administered the Pittsburgh Sleep Quality Index (PSQI) questionnaire by a blinded interviewer and were randomized to receive metoprolol (starting dose 25 mg) or nebivolol (starting dose 2.5 mg) once daily for 6 weeks. The first dose was administered before patients left the clinic. Visits were scheduled for 1, 2, 4, and 6 weeks after the initiation of therapy. At the end of the study, patients were readministered the PSQI questionnaire by the same interviewer, as before blinded to treatment allocation.

RESULTS

A total of 22 patients in the nebivolol group and 17 patients in the metoprolol group completed the study and were included in the data analysis (mean age of patients, 40.7 years). At study entry, systolic blood pressure (BP), diastolic BP, and PSQI scores were similar in the two groups. Over 6 weeks of treatment, systolic and diastolic BP normalized in both groups. Global PSQI score improved significantly in patients in the nebivolol group, whereas it worsened in the metoprolol group. The difference in effect of two beta-blockers was statistically significant (P<0.001).

CONCLUSION

Nebivolol was associated with improved sleep (as assessed by the PSQI), whereas metoprolol was associated with a worsening of sleep characteristics.

Proactive compared with passive adverse event recognition: calcium channel blocker-associated edema

This article examines the concept of passive compared with proactive surveillance for monitoring adverse events occurring with antihypertensive medications, using the example of calcium channel blocker (CCB)-induced peripheral edema. Monitoring adverse events and clinical trial safety are important functions and dependent on investigator protocols and data and safety monitoring teams. Compared with proactive surveillance, voluntary reporting systems tend to yield a lower frequency of adverse events occurrence. Limitation of data has the potential to directly influence clinical and prescribing practices. This discussion addresses advantages of proactive surveillance accomplished by patient solicitation of adverse events and investigators' direct clinical examination. A literature search between the years 2000 and 2007 was conducted on MEDLINE for randomized clinical trials and meta-analyses reporting the incidence of dihydropyridine-associated peripheral edema. The incidence of edema was high in clinical trials in which patients were actively questioned about edema development and tended to be higher than reported in the prescribing information. The incidence of dihydropyridine CCB-induced edema appears to be dependent on the method of edema assessment.

Left ventricular longitudinal systolic dysfunction is an independent marker of cardiovascular risk in patients with hypertension

BACKGROUND

To explore the prognostic value of left ventricular (LV) longitudinal systolic dysfunction in patients with hypertension.

METHODS

In 156 hypertensive subjects, LV longitudinal systolic function was assessed by echocardiographic measurement of M-mode left atrioventricular plane displacement (AVPD) and Tissue Doppler (TD)-derived mitral annulus peak systolic velocity (Sm). Patients were followed for development of the following cardiovascular events: congestive heart failure requiring hospitalization, new-onset angina, nonfatal myocardial infarction, coronary revascularization procedures, transient ischemic attack, nonfatal stroke, and cardiovascular death.

RESULTS

Over a follow-up of 23.3 +/- 5.4 months, 24 patients had 29 events. Both longitudinal systolic indices were predictive of outcome (hazard ratios: AVPD, 0.24, P < 0.001; Sm, 0.22; P < 0.001). AVPD < or = 11.4 mm (75.0% sensitivity and 53.8% specificity) and Sm < or = 8.9 cm/s (79.2% sensitivity and 61.4% specificity) were identified as the best cutoffs for the prediction of cardiovascular events (area under curve: AVPD, 0.66, P < 0.01; Sm, 0.71; P < 0.0001). Compared to conventional indices of circumferential systolic function, AVPD and Sm showed similar overall diagnostic performance, but higher sensitivity and lower specificity. Coexistence of longitudinal and circumferential systolic dysfunction was associated with the worst prognosis (P < 0.0001). Multivariate analysis confirmed an independent association of longitudinal indices with clinical outcome, incremental to circumferential systolic impairment, and other confounding variables.

CONCLUSIONS

Longitudinal systolic dysfunction is an independent marker of cardiovascular risk in hypertensive patients. Despite similarity in predictive accuracy, longitudinal indices are more sensitive but less specific than circumferential indices for the prediction of cardiovascular events in these subjects.

Expert recommendations on the challenges of hypertension in Asia

A consensus meeting of leading Asian hypertension experts was held in January 2007 in Seoul, Korea, to discuss how to address the growing challenge of hypertension management in the region. This report summarises key recommendations from the group, including: raising public awareness about the impact of hypertension; improving physician education and training; increasing early detection, for example through routine blood pressure measurement; and development and adoption of pan-Asian treatment guidelines, which would greatly facilitate research into hypertension and its management. The group conclude that these challenges can only be met through a collaborative effort of government, healthcare professionals, food and healthcare industries, and patients and the public. Food and healthcare industries need to develop healthy foods and support healthy living programmes, while increasing research into antihypertensive medications in Asia. Government officials and policy makers need to be made aware of the value of investing in hypertension awareness, prevention and management programmes.

Managing hypertension in cardiology practice according to risk profile

Cardiologists play a central role in managing hypertensive patients, although recent surveys reveal a marked discrepancy between cardiologists' appreciation of their patients' risk status and the measures taken to reduce that risk. The diagnosis and the management of hypertension, in fact, must be viewed today not in isolation, but as part of a patients' global cardiovascular (CV) risk, resulting from the concomitant presence of a variety of risk factors, organ damage (left ventricular hypertrophy, carotid or peripheral atherosclerosis, microalbuminuria or impaired glomerular filtration rate), and hypertension-related clinical conditions. The choice of timing and the intensity of antihypertensive treatment should be based on blood pressure (BP)-lowering efficacy and the propensity to favourably impact patient's individual absolute CV disease risk profile. As part of this paradigm shift in CV disease prevention strategy, cardiologists can take several key steps to help improve standards of hypertension control: (i) increase the awareness of total risk management; (ii) initiate an integrated management strategy tailored to the individual patient's global CV risk (e.g. hypertension, hypercholesterolaemia, diabetes, age, smoking and gender); (iii) use any elevation in BP as a gateway to begin total risk management and (iv) utilise combination therapies (particularly fixed-dose combinations) to achieve more rapid and persistent BP control and improve patient compliance/persistence with therapy. To help improve standards of hypertension control in the cardiology setting, this review examines the concept of treating hypertension using a global risk assessment approach and proposes effective hypertensive therapy as part of global risk management in patients typically seen in cardiology practice.

Felodipine attenuates vascular inflammation in a fructose-induced rat model of metabolic syndrome via the inhibition of NF-kappaB activation

AIM

Metabolic syndrome is associated with an increased incidence of atherosclerosis. Clinical studies have shown that calcium channel blockers (CCB) inhibit the progression of atherosclerosis. However, the underlying mechanism is unclear. We investigated the inhibitory effect of felodipine on adhesion molecular expression and macrophage infiltration in the aorta of high fructose-fed rats (FFR).

METHODS

Male Wistar rats were given 10% fructose in drinking water. After 32 weeks of high fructose feeding, they were treated with felodipine (5 mg x kg(-1) x d(-1)) for 6 weeks. The control rats were given a normal diet and water. The aortic expression of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) and the infiltration of macrophages were measured by real-time RT-PCR and/or immunohistochemistry. NF-kappaB activity was measured by electrophoretic mobility shift assay (EMSA).

RESULTS

After 32 weeks of high fructose feeding, FFR displayed increased body weight, systolic blood pressure (SBP), serum insulin, and triglycerides when compared with the control rats. The aortic expressions of ICAM-1 and VCAM-1 were significantly increased in FFR than in the control rats and accompanied by the increased activity of NF-kappaB. FFR also showed significantly increased CD68- positive macrophages in the aortic wall. After treatment with felodipine, SBP, serum insulin, and the homeostasis model assessment decreased significantly. In addition to reducing ICAM-1 and VCAM-1, felodipine decreased macrophages in the aortic wall. EMSA revealed that felodipine inhibited NF-kappaB activation in FFR.

CONCLUSION

Felodipine inhibited vessel wall inflammation. The inhibition of NF-kappaB may be involved in the modulation of vascular inflammatory response by CCB in metabolic syndrome.

The relationship between angiotensin-converting enzyme insertion/deletion polymorphism and proliferative retinopathy in type 2 diabetes

A total of 136 type 2 diabetic patients with nonproliferative and 94 patients with proliferative diabetic retinopathy (PDR) without nephropathy were studied. The DD genotype of the angiotensin-converting enzyme polymorphism was more common in the PDR group (P<0.001). In multivariate regression, the association remained significant (OR=3.516).

Independent association of coronary flow reserve with left ventricular relaxation and filling pressure in arterial hypertension

BACKGROUND

It has been recognized that "cross-talk" occurs between coronary flow and left ventricular (LV) function. This study tested the hypothesis that impairment of coronary flow reserve (CFR) in arterial hypertension is associated with LV systolic and diastolic dysfunction, independent of abnormalities in LV geometry.

METHODS

We studied 59 newly diagnosed, never-treated hypertensive patients, using transthoracic Doppler echocardiography including pulsed Tissue Doppler of mitral annulus and CFR on left anterior descending artery (low-dose dipyridamole). The study population was divided into two groups on the basis of age-normalized relative wall thickness (RWTn): 36 patients with normal LV geometry (RWTn < or = 0.41) and 23 patients with LV concentric geometry (RWTn > 0.41).

RESULTS

Patients with LV concentric geometry (RWTn > 0.41) had significantly lower values of midwall shortening (but not of endocardial shortening), longer isovolumic relaxation time (IVRT), lower Tissue Doppler-derived early diastolic velocity (Em), higher ratio of transmitral E velocity to Em, and lower CFR as compared to patients with normal LV geometry (RWTn < or = 0.41). In the whole population, a lower CFR was significantly associated with lower values of midwall shortening and Em, longer IVRT, and higher E/Em ratio. After controlling for heart rate, mean blood pressure, and RWTn, only the relation of CFR with IVRT, Em, and E/Em ratio remained significant.

CONCLUSIONS

Reduced midwall mechanics is associated with lower CFR, a relationship that depends on LV concentric geometry. A reduced CFR is associated with both impaired relaxation and increased filling pressure, a relation that is independent of LV geometry and pressure load.

Inhibition of the renin-angiotensin system and chronic kidney disease

Chronic kidney disease (CKD), a major worldwide public-health problem which affects about 10% of the population, has an increased annual incidence rate of about 5-8%. This increased incidence is mainly due to type 2 diabetes and hypertension and the increasing incidence of elderly patients with CKD. Although the progression to end-stage renal failure (ESRF) is mainly based upon the underlying disease, comorbid conditions such as an initial low renal function, severe proteinuria, and high levels of blood pressure also play important roles in the development of ESRF. Since experimental and clinical evidence suggest that angiotensin II plays a central role in the progression of CKD, pharmacological inhibition of the renin-angiotensin-aldosteron system (RAAS) with angiotensin converting enzyme inhibitors or angiotensin II receptor antagonists has been suggested as first-line treatment for hypertension and prevention of ESRF in these patients. Aliskiren, a novel renin inhibitor is also a promising medical intervention. However, independently of the category of the drugs used, low target blood pressure levels seem to be equally or more important for the delay or prevention of CKD. In this review the results of studies with pharmacological inhibition of the RAAS in patients with diabetic and nondiabetic nephropathy is discussed.

Effects of sibutramine plus verapamil sustained release/trandolapril combination on blood pressure and metabolic variables in obese hypertensive patients

OBJECTIVE

The management of obese hypertensive subjects may require the administration of anti-obesity and antihypertensive drugs. Sibutramine use has raised concerns regarding a potential increase in subjects' blood pressure and heart rate. The primary end-points of this study were an evaluation of the effect of sibutramine together with a verapamil sustained release/trandolapril combination tablet versus verapamil sustained release/trandolapril alone on the blood pressure and heart rate in obese hypertensive patients.

RESEARCH DESIGN/METHODS

Patients received a low-fat low-calorie diet and were randomly allocated to open-label verapamil sustained release/trandolapril 180/2 mg (n = 26) or sibutramine 10 mg together with verapamil sustained release/trandolapril 180/2 mg (n = 28) daily for 6 months.

RESULTS

Significant reductions in the subjects' systolic blood pressure and diastolic blood pressure were observed in both groups (p < 0.01 versus baseline). At 6 months a greater fall in blood pressure was observed in the sibutramine/verapamil sustained release/trandolapril group compared with the verapamil sustained release/trandolapril group (systolic blood pressure 21.9 +/- 8.1 versus 15.9 +/- 12.3 mmHg and diastolic blood pressure 15.7 +/- 8.1 versus 9.1 +/- 9.9 mmHg) but this was only significant (p = 0.03) for diastolic blood pressure. The subjects' heart rate did not change significantly in any group. No significant sibutramine-associated attenuation of blood pressure reduction was observed during the study. The sibutramine/verapamil sustained release/trandolapril treatment resulted in significantly greater improvement in the subjects' anthropometric variables, homeostasis model assessment and lipid profiles compared with verapamil sustained release/trandolapril administration. The subjects' small dense low-density lipoprotein cholesterol, high-sensitivity C-reactive protein and visfatin plasma levels were only measured in the sibutramine/verapamil sustained release/trandolapril group (all decreased by p < 0.05 versus baseline).

CONCLUSIONS

The sibutramine/verapamil sustained release/trandolapril combination in obese hypertensive patients significantly reduced their blood pressure and improved their anthropometric and metabolic variables without affecting the heart rate.

Study of nycthemeral variations in blood pressure in patients with heart failure

OBJECTIVE

The objective of this study was to describe and analyse the nycthemeral variations in blood pressure (BP) by ambulatory BP monitoring (ABPM) over 24 h in patients with heart failure (HF).

METHODS

The study population included 50 stable HF patients hospitalized in a cardiology department for acute pulmonary oedema. Parameters studied were: New York Heart Association class, clinical resting BP and heart rate in sitting and then standing positions, ABPM parameters, distance covered during a 6-min walking test, echographic left ventricular ejection fraction (LVEF), natremia, kaliemia, creatininemia, plasma haemoglobin and N-terminal fragment of brain-type natriuretic peptide levels.

RESULTS

Clinical hypertension was noted in 20% of patients (10/50) and orthostatic hypotension in 16% (8/50). Nine of 50 patients (18%) were hypertensive during the day and 21 (42%) at night. Thirty-nine of the 50 patients (78%) are nondippers. Nondipper patients are more prevalent when the HF has been present for more than 24 months (95 vs. 67%, P=0.04). This prevalence does not differ depending on New York Heart Association class or LVEF. Furthermore, there exists: (i) a significant positive relationship (R=0.46, P=0.02) between the diastolic BP (DBP) over 24 h and the distance covered during the walking test; (ii) a significant negative relationship between the day-night differences (in mmHg) of the systolic BP (SBP) (R=-0.46, P=0.01) and DBP (R=-0.33, P=0.03) and the duration of HF, between the day-night difference of the DBP and the LVEF (R=-0.34, P=0.02) and (iii) between the day-night differences of the SBP (R=-0.48, P=0.001) and the DBP (R=-0.32, P=0.03) and natremia. The day-night difference of the SBP has a positive correlation with plasma haemoglobin level (R=0.32, P=0.03).

CONCLUSION

This study confirms the feasibility of carrying out ABPM with an adapted device in HF patients with atrial fibrillation. ABPM allows diagnosis to be more precise than the clinical measuring of BP abnormalities, which have a pejorative prognosis (e.g. hypertension, hypotension, nondipper status).

Effects of renin-angiotensin system blockers on renal outcomes and all-cause mortality in patients with diabetic nephropathy: an updated meta-analysis

BACKGROUND

In contrast to previous studies, recent data questioned the ability of renin-angiotensin-aldosterone system (RAAS) blockers to delay progression of diabetic nephropathy. This study evaluated the effect of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) in patients with diabetic nephropathy.

METHODS

A systematic literature search of MEDLINE/PubMed and EMBASE databases was performed to identify randomized trials published up to June 2007 comparing the effects of ACEIs or ARBs with placebo and/or a regimen not including a RAAS blocker on the incidence of end-stage renal disease (ESRD), doubling of serum creatinine (DSC), or death from any cause in patients with diabetic nephropathy. Treatment effects were summarized as relative risks (RRs) using the Mantel-Haenszel fixed-effects model.

RESULTS

Of the 1,028 originally identified studies, 24 fulfilled the inclusion criteria (20 using ACEIs and 4 using ARBs). Use of ACEIs was associated with a trend toward reduction of ESRD incidence (RR 0.70; 95% confidence interval (CI) 0.46-1.05) and use of ARBs with significant reduction of ESRD risk (RR 0.78; 95% CI 0.67-0.91). Both drug classes were associated with reduction in the risk of DSC (RR 0.71; 95% CI 0.56-0.91 for ACEIs and RR 0.79; 95% CI 0.68-0.91 for ARBs) but none affected all-cause mortality (RR 0.96; 95% CI 0.85-1.09 for ACEIs and RR 0.99; 95% CI 0.85-1.16 for ARBs).

CONCLUSION

Treatment of patients with diabetic nephropathy with a RAAS blocker reduces the risks of ESRD and DSC, but does not affect all-cause mortality. These findings are added to the evidence of a renoprotective role of RAAS blockers in such patients.

Current status and characteristics of hypertension treatment by primary physicians in Korea: data from Korean epidemiology study on hypertension (KEY study)

BACKGROUND

This study was designed to investigate the characteristics, control rate, and factors affecting BP control in hypertensive patients treated by primary physicians in Korea.

METHODS

The study was a multicenter, nationwide, cross-sectional, population-based survey conducted to identify the current status of hypertension treatment in Korean patients. A direct mail survey was sent to a random sample of 800 primary-care clinics across the nation. A total of 529 physicians in 510 clinics agreed to participate in this study (63.8%). Among the recruited 13,452 patients, 13,184 were included in the analysis.

RESULTS

BP was controlled in 6,723 patients (51.0%). However, the control rate was lower in patients with diabetes (21.6%) or chronic kidney disease (CKD) (19.9%). Furthermore, the mean systolic and diastolic BP levels were higher in patients with diabetes and/or CKD. The mean BP level was higher in patients undergoing combination therapy than those undergoing single-drug therapy. Male gender, cardiovascular comorbidities, long duration of hypertension, and unhealthy lifestyle were associated with poor control of hypertension. In multivariate analysis, diabetes (odds ratio: 5.57; 95% confidence interval: 5.05-6.13) and CKD (odds ratio: 3.40; 95% confidence interval: 2.54-4.54) were the most significant independent factors related to poor BP control.

CONCLUSION

BP control is still largely unsatisfactory, especially in patients with diabetes and kidney disease, who could benefit the most from effective BP control. The reasons for poor BP control and high BP levels in those patients need to be investigated to improve BP control in Korea.

Prescribing patterns in hypertension: the emerging role of fixed-dose combinations for attaining BP goals in hypertensive patients

BACKGROUND

The attainment of clinical blood pressure (BP) goals can markedly reduce cardiovascular morbidity and mortality, yet approximately two-thirds of treated hypertensive patients in the United States have uncontrolled BP. Consequently, more aggressive management of hypertension, frequently involving combination therapy (e.g., fixed-dose combination [FDC] therapy), is needed to achieve the recommended BP goals of <140/90 mmHg for most patients, and <130/80 mmHg for high-risk patients.

SCOPE

This article, based on data from an extensive Medline search ('hypertension' AND 'prescribe', 'prescribing' OR 'prescription', date range: 1995-2007), focuses on prescribing patterns for antihypertensive medication, and on the emerging role of combination therapy, specifically FDC therapy, in treating hypertensive patients to target BP levels.

FINDINGS

Although the use of antihypertensive combination therapy has increased substantially in US adults over the last 20 years, such therapy remains considerably underutilized. Numerous studies have shown that combination therapies, including FDCs, can markedly reduce BP and adverse events relative to monotherapies, and this paper overviews data for various combination therapies: angiotensin-receptor blocker (ARB) + diuretic; angiotensin-converting enzyme (ACE) inhibitor + diuretic; calcium-channel blocker (CCB) + ACE inhibitor; and CCB + ARB. Specifically, fixed-dose CCB/ARB combinations of amlodipine with losartan, valsartan, or olmesartan medoxomil have recently been developed, and combination therapy schedules of amlodipine plus one of these ARBs have shown greater BP-lowering efficacy compared with the constituent monotherapies. Furthermore, in two large studies in a total of >3000 patients, CCB + ARB combination therapy was associated with significantly lower incidences of headache and peripheral edema than CCB monotherapy.

CONCLUSION

Guidelines for hypertension management clearly support the greater use of multidrug therapy, especially in high-risk patients. FDCs (e.g., various emerging CCB/ARB combinations) are a valuable option for such high-risk patients, as these combinations offer the potential to reduce adverse events, increase compliance, lower treatment costs, and improve BP goal-attainment rates.

Chronotherapy with nifedipine GITS in hypertensive patients: improved efficacy and safety with bedtime dosing

BACKGROUND

Previous studies have shown that the circadian pattern of blood pressure (BP) remains unchanged after either morning or evening dosing of several calcium-channel blockers (CCBs), including amlodipine, isradipine, verapamil, nitrendipine, and cilnidipine. This trial investigated the administration-time dependent antihypertensive efficacy of the slow-release, once-a-day nifedipine gastrointestinal-therapeutic-system (GITS) formulation.

METHODS

We studied 180 untreated hypertensives (86 men and 94 women), 52.5 +/- 10.7 years of age, randomly assigned to receive nifedipine (30 mg/day) as a monotherapy either upon awakening or at bedtime. BP was measured for 48 h before and after 8 weeks of treatment.

RESULTS

The BP reduction after treatment was significantly larger with bedtime dosing mainly during night time sleep (P < 0.012). The number of patients with controlled ambulatory BP after treatment was greater with bedtime than morning treatment (P = 0.016). The baseline prevalence of nondipping was unaltered after ingestion of nifedipine on awakening, but reduced from 51 to 35% after bedtime dosing (P = 0.025). The morning surge of BP, a risk factor for stroke, was significantly reduced (P < 0.001) only after bedtime administration of nifedipine. Bedtime in comparison to awakening-time ingestion of nifedipine was also associated with a reduction in the incidence of edema from 13 to 1% (P < 0.001).

CONCLUSIONS

The increased efficacy on ambulatory BP as well as the significantly reduced prevalence of edema after bedtime as compared to morning ingestion of nifedipine should be taken into account when prescribing this medication to patients with essential hypertension.

Efficacy and tolerability of combination therapy with valsartan/hydrochlorothiazide in the initial treatment of severe hypertension

OBJECTIVE

Most patients with severe hypertension are at high risk for cardiovascular events and require prompt blood pressure (BP)-lowering and combination therapy to achieve BP goals. This study evaluated the therapeutic efficacy and tolerability of initial treatment with the combination of valsartan and hydrochlorothiazide (HCTZ) compared with valsartan monotherapy in patients with severe hypertension.

RESEARCH DESIGN AND METHODS

This was a 6-week, randomized, double-blind, multicenter, forced titration study that compared initial therapy with the combination of valsartan/HCTZ 160/12.5 mg (force titrated to 160/25 mg after 2 weeks and to 320/25 mg after 4 weeks) to monotherapy with valsartan 160 mg (force titrated to 320 mg after 2 weeks and sham-titrated to 320 mg after 4 weeks). Eligible patients were 18-80 years old with severe essential hypertension (mean sitting diastolic BP > or = 110 mmHg and < 120 mmHg and mean sitting systolic BP > or = 140 mmHg and < 200 mmHg). The Clinical Trial Registry number was NCT00273299.

MAIN OUTCOME MEASURES

The primary efficacy variable was the rate of BP control (mean sitting BP < 140/90 mmHg) at Week 4. Tolerability was evaluated by monitoring all adverse events, vital signs, and laboratory tests including hematology and biochemistry.

RESULTS

A total of 608 patients were randomized to either valsartan/HCTZ (n = 307) or valsartan monotherapy (n = 301). Significantly more patients achieved overall BP control (< 140/90 mmHg) with valsartan/HCTZ compared to monotherapy at Week 4 (primary efficacy variable and timepoint) (39.6% vs. 21.8%; p < 0.0001) and Week 6 (48.2% vs. 27.2%; p < 0.0001). Mean reductions in BP at Week 4 were significantly greater for valsartan/HCTZ (30.8/22.7 mmHg vs. 21.7/17.5 mmHg; p < 0.0001), with further reductions at Week 6. BP control rates were greater with combination therapy as early as Week 2. The overall incidence of adverse events was comparable between the combination therapy (34.9%) and monotherapy (36.7%) treatment groups. A potential limitation of the forced-titration design is that some patients were titrated to higher doses despite having achieved goal BP. This may impact the interpretation of the incidence of dose-dependent adverse events.

CONCLUSIONS

Initial therapy with valsartan/HCTZ is effective and well tolerated in patients with severe hypertension.

The metabolic syndrome: similar deleterious impact on all-cause mortality in hypertensive and normotensive subjects

OBJECTIVES

Few data are available on the impact of the metabolic syndrome on all-cause mortality risk according to the presence of hypertension. Our aim was to evaluate the 5-year impact of the metabolic syndrome, according to blood pressure status, on all-cause mortality risk in a large French population.

METHODS

The study population included 39 998 men and 20 756 women with no personal history of cardiovascular disease, who had a health check-up at the IPC Center (Paris, France) between 1999 and 2002, and who were followed up for 4.7 +/- 1.2 years. The metabolic syndrome was defined according to the National Cholesterol Educational Program classification (2001). Cox regression models were used to evaluate risk of all-cause mortality after adjustment for age, sex, classical risk factors and socioeconomic categories. Subjects were classified according to blood pressure status: hypertensive subject (systolic blood pressure > or =140 mmHg and/or diastolic blood pressure > or =90 mmHg or treatment) and normotensive subject.

RESULTS

The risk of all-cause mortality associated with the metabolic syndrome was 1.50 (1.24-1.82) [hazard ratio (HR) (95% confidence interval)]. The risk of all-cause mortality associated with the presence of hypertension was 1.60 (1.38-1.85). During the 4.7 years of follow-up, the impact of the metabolic syndrome was similar among normotensive and hypertensive subjects [HR: 1.09 (0.68-1.75) and 1.40 (1.13-1.74), respectively, P for interaction = 0.35].

CONCLUSION

The findings from this study show that, in a large middle-aged French population, the metabolic syndrome has the same deleterious impact on all-cause mortality in hypertensive subjects and normotensive subjects.