Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials

Blood Pressure and Metabolic Effect of a Combination of Lercanidipine with Different Antihypertensive Drugs in Clinical Practice

The aim of this study is to assess the blood pressure (BP) and metabolic effects of lercanidipine when combined with other classes of first-line antihypertensive drugs in day-to-day clinical practice. For this study, we consecutively enrolled 162 patients with uncomplicated primary hypertension, who are partial responders to the treatment with lercanidipine over a period of 24 months. Patients were then allocated to the combination of lercanidipine (10–20 mg/day) with β-blockers, diuretics, angiotensin-converting enzyme inhibitors, and angiotensin-II receptor blockers according to compelling indications (if any) and/or suggestions of European Society of Hypertension–European Society of Cardiology (ESH–ESC) guidelines. All the enrolled patients completed the study and no adverse drug reaction was registered during the research period. The association of a second drug with lercanidipine determined an additional BP decrease of either systolic BP or diastolic BP independently from the type of drug added (P always <0.05). The additional effect of lercanidipine appears widely distributed with no significant differences in the size of BP decrease. From the metabolic point of view, the addition of a second drug did not determine a significant variation in the serum levels of total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol (P always >0.05). Conversely, a significant decrease in fasting plasma glucose and serum levels of triglycerides has been observed in patients where lercanidipine has been combined with an angiotensin-converting enzyme inhibitor or an angiotensin-II receptor blocker. In conclusion, in our study we observed that lercanidipine-based protocols are well tolerated and efficacious in reducing BP. Moreover, the association of lercanidipine with renin–angiotensin system blockers is also associated with significant improvements in triglycerides and fasting plasma glucose.

End-organ protection in patients with hypertension: focus on the role of angiotensin receptor blockers on renal function

The renin-angiotensin system (RAS) plays a key role in a number of pathophysiological mechanisms that are involved in the development and progression of cardiovascular and renal disease. For these reasons, pharmacological antagonism of this system, particularly the blockade of formation or the receptor antagonism of angiotensin II, has been demonstrated to be an effective and safe strategy to reduce the burden of cardiovascular disease. Among different drug classes, angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) have provided an excellent alternative to ACE inhibitors, representing a more selective and a better tolerated pharmacological approach to interfere with the RAS. Results derived from large, international, randomized clinical trials have consistently indicated that ARB-based therapeutic strategies may effectively provide cardiovascular and renal disease prevention and protection in different clinical conditions across the entire cardiovascular continuum. This article reviews the pathophysiological rationale of RAS involvement in the pathogenesis of renal diseases, focusing on the beneficial effects provided by ARBs in terms of renal protection.

Azilsartan: a newly approved angiotensin II receptor blocker

Hypertension is a common chronic disease that leads to significant cardiovascular morbidity and mortality. Blood pressure control is essential to prevent end-organ complications, such as stroke, myocardial infarction, heart failure, or kidney disease. Azilsartan is the eighth angiotensin II receptor blocker approved for the management of hypertension, alone or in combination with other agents. At the approved dosage, it reduces systolic blood pressure by 12 to 15 mm Hg and diastolic blood pressure by 7 to 8 mm Hg. A higher dose of azilsartan (80 mg) was superior to valsartan 320 mg or olmesartan 40 mg in lowering systolic blood pressure in short-term studies. Additional blood pressure reduction is expected when azilsartan is used adjunctively with a diuretic. However, the effects of azilsartan on cardiovascular morbidity or mortality are still lacking. Azilsartan is well tolerated; the most common side effects are headache and diarrhea. No cases of hyperkalemia have been reported in 6-week clinical trials. Worsening of renal function and hypotension should be monitored, particularly in those with baseline risk factors. It is unknown whether azilsartan would join angiotensin-converting enzyme inhibitors and other angiotensin receptor blockers as the preferred hypertensive agents for end-organ protection. At this time, azilsartan should be considered as an alternative agent for mild-to-moderate hypertension, or as an adjunctive therapy when preferred agents fail to maintain optimal blood pressure control. It is also an option for those patients who have contraindications or cannot tolerate other antihypertensive agents, including dry cough induced by angiotensin-converting enzyme inhibitors.

Direct renin inhibition: from pharmacological innovation to novel therapeutic opportunities

Nowadays, social and economic burden related to cardiovascular and renal diseases still remains extremely high, although there has been a dramatic improvement of diagnostic options and therapeutic strategies reported in the last 30 years. The progressively higher attention towards integrated pharmacological strategies, which are able to interfere with different pathophysiological mechanisms, has certainly led to better control of cardiovascular and renal diseases. In view of the large involvement of the renin-angiotensin system (RAS) in the vast majority of pathophysiological mechanisms leading to the development and progression of cardiovascular and renal diseases, it can be easily understood why it has been long viewed as the 'ideal' target for the pharmacological treatment of several clinical conditions. Recently, besides the well known therapeutic approaches for RAS blockade, based on the use of ACE inhibitors, angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) and aldosterone antagonists, both the scientific and medical community have focused their attention on a novel therapeutic option. In 2007, aliskiren, the first compound of a new drug class, the direct renin inhibitors (DRIs), has become available for clinical use, being a novel and innovative therapeutic option. Aliskiren is able to interfere with the enzymatic activity of renin by blocking the catalytic site of the molecule and inducing an 'upstream' RAS blockade. This leads to a modulation of the biological properties of renin, thus resulting in the missed cleavage of angiotensinogen to angiotensin I. Aliskiren has demonstrated antihypertensive efficacy comparable or even superior to that of other classes of antihypertensive drugs, both in monotherapy and in combination therapies. Its safety and tolerability are comparable with those of other antihypertensive drug classes and almost similar to placebo. In addition, it has been demonstrated to reduce progression of cardiac and renal organ damage in addition to ACE inhibitors or ARBs. An ambitious and large clinical trial programme specifically designed for this innovative antihypertensive drug will evaluate the efficacy of aliskiren in terms of reduced incidence of major cardiovascular and renal outcomes in patients with hypertension and cardiovascular disease, besides the use of optimal (standard) therapeutic strategies, including ACE inhibitors and ARBs.

Ten most important things to learn from the ACCF/AHA 2011 expert consensus document on hypertension in the elderly

The American College of Cardiology Foundation/American Heart Association 2011 Expert Consensus Document on Hypertension in the Elderly has been published in the Journal of the American College of Cardiology and in Circulation, and will be published in the Journal of the American Society of Hypertension and the Journal of Geriatric Cardiology. This document has also been developed in collaboration with the American Academy of Neurology, the American Geriatrics Society, the American Society of Preventive Cardiology, the American Society of Hypertension, the American Society of Nephrology, the Association of Black Cardiologists, and the European Society of Hypertension. The present article is a short summary emphasizing the 10 most important things to learn from this document.

Modern clinical management of arterial hypertension: fixed or free combination therapies?

Blood pressure control is a key element in any cardiovascular prevention strategy. However, it is also one of the least frequently achieved goals in modern strategies for the clinical management of cardiovascular diseases, resulting in high impact in terms of cardiovascular morbidity and mortality. Among different factors that can be identified as the causes of poor blood pressure (BP) control in the general population of patients with hypertension, the excessive use of monotherapy, as opposed to combination therapy, is arguably one of the most significant. In this perspective, the use of combination therapies having synergic and complementary actions has been shown to reduce BP levels to increase the percentage of patients who respond to antihypertensive treatment and achieve the recommended BP targets. Moreover, recent studies have demonstrated that these strategies provide effective protection against hypertension-related organ damage, as well as a significant reduction of major cardiovascular events. While currently available evidence supports an increasingly important role of combination therapies compared with monotherapies, several other issues remain to be clarified. Among these, it has not yet been clearly established which classes of drugs should be considered for combination strategies, at what doses each component should be used, and whether combination strategies may be definitively considered as a first choice for the treatment of hypertensive patients at cardiovascular risk. Another relevant aspect concerns the choice between fixed and free combination therapies. This article discusses and analyses the different factors that may contribute to achieve effective BP control. In particular, the potential benefits and drawbacks associated with the use of fixed versus free combination therapies for hypertension treatment will be examined and discussed. The benefits of using combination strategies based on drugs that antagonize the renin-angiotensin system and dihydropyridine calcium antagonists will also be discussed, with a particular focus on amlodipine besylate combination therapies.

Blood pressure-lowering efficacy of an olmesartan medoxomil/hydrochlorothiazide-based treatment algorithm in elderly patients (age ≥65 years) stratified by age, sex and race: subgroup analysis of a 12-week, open-label, single-arm, dose-titration study

INTRODUCTION

Hypertension is a leading risk factor for development of heart failure, stroke and renal disease in the elderly.

OBJECTIVE

The objective of this study was to evaluate, by means of a prespecified secondary analysis of a 12-week, open-label, single-arm, dose-titration study, the blood pressure (BP)-lowering efficacy and safety of an olmesartan medoxomil (OM)/hydrochlorothiazide (HCTZ)-based titration regimen in patients aged ≥65 years with hypertension. Subgroups were stratified by age (≥65 to ≤75 or >75 years), sex (male or female) and race (Black or non-Black).

METHODS

Following a 2- to 3-week placebo run-in phase, patients received OM 20 mg, uptitrated to OM 40 mg, followed by addition of HCTZ 12.5-25 mg step-wise at 3-week intervals if seated cuff BP (SeBP) was ≥120/70 mmHg. Patients below this target SeBP were maintained at their current dose but uptitrated to the next consecutive dose if mean seated cuff systolic BP (SBP) was ≥140 mmHg and/or mean seated cuff diastolic BP was ≥90 mmHg at follow-up visits. Efficacy was assessed by 24-hour ambulatory BP monitoring (ABPM) and SeBP measurements. The primary efficacy variable was the change from baseline in mean 24-hour ambulatory SBP after 12 weeks. Secondary efficacy endpoints included the change from baseline in mean 24-hour ambulatory SBP; change from baseline in ambulatory BP during the daytime (8:00 am-4:00 pm), nighttime (10:00 pm-6:00 am) and the last 6, 4 and 2 hours of the dosing interval; change from baseline in SeBP at each titration step and at study end; and the proportion of patients achieving mean 24-hour ambulatory BP targets and SeBP goals at week 12. The frequency and severity of treatment-emergent adverse events (TEAEs) were also documented.

RESULTS

Baseline and week 12 ABPM data were available for 150 out of 178patients who entered the active treatment phase. Changes from baseline in mean 24-hour ambulatory BP were -26.0/-12.5 mmHg and -24.9/-12.0 mmHg in patients aged ≥65 to ≤75 years (n = 128) and >75 years (n = 48), respectively (all p < 0.0001 vs baseline). Changes from baseline in mean 24-hour ambulatory BP were -26.0/-13.0 mmHg and -25.4/-11.5 mmHg in male (n = 92) and female (n = 84) patients, respectively (all p < 0.0001 vs baseline) and -26.7/-11.8 mmHg and -25.6/-12.4 mmHg in Black (n = 28) and non-Black (n = 148) patients, respectively (all p < 0.0001 vs baseline). Clinically significant ambulatory BP reductions were observed during the daytime, nighttime and the last 6, 4 and 2 hours of the dosing interval in all subgroups. Changes from baseline at week 12 in mean SeBP were similar to 24-hour ambulatory BP changes reported previously. At week 12, the proportion of patients achieving the 24-hour ambulatory BP target of <130/80 mmHg ranged from 67.5% to 77.4% and achieving the SeBP goal of <140/90 mmHg ranged from 60.7% to 68.8% across the subgroups. Most TEAEs and drug-related TEAEs were mild or moderate in severity, and there were no trends across subgroups.

CONCLUSIONS

In a subgroup analysis based upon age, sex and race in patients aged ≥65 years with hypertension, an OM/HCTZ-based algorithm was efficacious and well tolerated. ClinicalTrials.gov Identifier: NCT00412932.

Could NICE guidance on the choice of blood pressure lowering drugs be simplified?

Reecha Sofat and colleagues argue that prescribing advice needs updating in the light of recent evidence that all classes of blood pressure lowering drugs are broadly equivalent

Salt sensitivity of blood pressure: developmental and sex-related effects

Epidemiologic studies have shown convincingly that drastically reducing salt intake in the community is accompanied by blood pressure reductions that are comparable to those achieved by antihypertensive medication. Moreover, many subjects with hypertension are salt sensitive. This implies that, in these subjects, blood pressure is more responsive to changes in salt intake than in subjects with normal blood pressure. The presence of conventional risk factors associated with the metabolic syndrome correlates with salt sensitivity. However, women appear to be more salt sensitive than men. Sparse data indicate that the salt sensitivity of blood pressure is greater in subjects with low birth weight. Experimental studies in rats have also shown that hypertensive offspring of dams maintained on low-protein diets throughout or in late pregnancy are more salt sensitive. This is accompanied by increased expression of the thick ascending limb Na-K-2Cl symporter (NKCC2). Perinatal interventions aimed at persistently lowering blood pressure in genetically hypertensive rats have consistently proven to be very effective and are often accompanied by a wave of natriuresis exclusively at 4 wk of age. In sum, in addition to conventional metabolic risk factors for cardiovascular disease, low birth weight and possibly its sequels such as catch-up growth should be viewed as modifiable risk factors for salt sensitivity of blood pressure. Female sex may also be a nonmodifiable risk factor for salt sensitivity. Experimental data indicate that NKCC2 may well be an important determinant of salt sensitivity in acquired (developmental) hypertension.

The association of body mass index with mortality in the California Teachers Study

Although underweight and obesity have been associated with increased risk of mortality, it remains unclear whether the associations differ by hormone therapy (HT) use and smoking. The authors examined the relationship between body mass index (BMI) and mortality within the California Teachers Study (CTS), specifically considering the impact of HT and smoking. The authors examined the associations of underweight and obesity with risks of all-cause and cause-specific mortality, among 115,433 women participating in the CTS, and specifically examined whether HT use or smoking modifies the effects of obesity. Multivariable Cox proportional hazards regression provided estimates of relative risks (RRs) and 95% confidence intervals (CIs). During follow up, 10,574 deaths occurred. All-cause mortality was increased for underweight (BMI <18.5; adjusted RR = 1.33, 95% CI = 1.20-1.47) and obese participants (BMI ≥ 30: RR = 1.27, 95% CI = 1.19-1.37) relative to BMI of 18.5-24.9). Respiratory disease mortality was increased for underweight and obese participants. Death from any cancer, and breast cancer specifically, and cardiovascular disease was observed only for obese participants. The obesity and mortality association remained after stratification on HT and smoking. Obese participants remained at greater risk for mortality after stratification on menopausal HT and smoking. Obesity was associated with increased all-cause mortality, as well as death from any cancer (including breast), and cardiovascular and respiratory diseases. These findings help to identify groups at risk for BMI-related poor health outcomes.

Risk of thiazide-induced hyponatremia in patients with hypertension

BACKGROUND

Although hyponatremia is a well-recognized complication of treatment with thiazide diuretics, the risk of thiazide-induced hyponatremia remains uncertain in routine care.

METHODS

We conducted a retrospective cohort study using a multicenter clinical research registry to identify 2613 adult outpatients that were newly treated for hypertension between January 1, 2000 and December 31, 2005 at 2 teaching hospitals in Boston, Massachusetts, and followed them for up to 10 years.

RESULTS

Two hundred twenty patients exposed to ongoing thiazide therapy were compared with 2393 patients who were not exposed. In the exposed group, 66 (30%) developed hyponatremia (sodium ≤130 mmol/L). The adjusted incidence rate of hyponatremia was 140 cases per 1000 person-years for patients treated with thiazides, compared with 87 cases per 1000 person-years in those without thiazides. Patients exposed to thiazides were more likely to develop hyponatremia (adjusted incidence rate ratio, 1.61; 95% confidence interval [CI], 1.15-2.25). There was no significant difference in the risk of hospitalizations associated with hyponatremia (adjusted rate ratio, 1.04; 95% CI, 0.46-2.32) or mortality (adjusted rate ratio, 0.41; 95% CI, 0.12-1.42). The number needed to harm (to result in one excess case of incident hyponatremia in 5 years) was 15.02 (95% CI, 7.88-160.30).

CONCLUSIONS

Approximately 3 in 10 patients exposed to thiazides who continue to take them develop hyponatremia.

Management of hypertension in the elderly patient at abidjan cardiology institute (ivory coast)

Background. Since the treatment of hypertension is beneficial for the elderly, we have undertaken this study that aims to evaluate the management of hypertension in elderly patient in Côte d'Ivoire. Methods. A retrospective study was conducted among 854 hypertensive elderly patients of Abidjan Cardiology Institute who were followed for a minimum of one year, between January 2000 and December 2009. Results. The patients mean age was 73.1 ± 5.3 years, and 59% were women. At the first presentation, it was mostly systolic-diastolic hypertension (51.8%) and isolated systolic hypertension (38.5%). Mean blood pressure was 169.4 ± 28.4 mmHg for systolic, 95.3 ± 15.7 mmHg for diastolic, and 74.1 ± 22.8 mmHg for pulse pressure. Pulse pressure was ≥60 mmHg in 80.4%. According to the European Guidelines stratification of the cardiovascular risk-excess attributable to high blood pressure, 82.1% of the sample had a very high added risk. The pharmacological therapy was prescribed in 93.5%. More than 66% of patients were receiving ≥2 antihypertensive drugs including fixed-dose combination drugs. The most common agents used were diuretics (63.5%) followed by angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in 61.3%. The most common agents used for monotherapy were calcium antagonists. When ≥2 drugs were used, diuretics and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers were the most common. Blood pressure control was achieved in 42.6%. Conclusion. The control of elderly hypertension can be effective in Sub-Saharan Africa. He required at least two antihypertensive drugs to meet the recommended blood pressure target.

Hypertension in postmenopausal women: pathophysiology and treatment

Hypertension is the most common chronic disease in industrialized countries and represents the most common major cardiovascular risk factor after the fifth decade of life in both men and women. The prevalence of hypertension is lower in premenopausal women than men, whereas in postmenopausal women it is higher than in men. Mechanisms responsible for the increase in blood pressure are complex and multifactorial, including loss of estrogen, oxidative stress, endothelial dysfunction, modification in renin-angiotensin system spillover and sympathetic activation. In addition, postmenopausal hypertension can be considered an isolated disease, more typical of elderly women, or part of the metabolic syndrome, which is indeed more common in early postmenopausal women. In particular, metabolic syndrome may be considered a potentially unfavourable prognostic factor in hypertensive postmenopausal women, because it seems to worsen the severity of hypertension and reduce the capacity to respond to specific treatments. This article summarizes the different causes of postmenopausal hypertension and the specific treatment recommended by guidelines for this condition.

Genetic variants in novel pathways influence blood pressure and cardiovascular disease risk

Blood pressure (BP) is a heritable trait¹ influenced by multiple biological pathways and is responsive to environmental stimuli. Over one billion people worldwide have hypertension (BP ≥140 mm Hg systolic [SBP] or ≥90 mm Hg diastolic [DBP])². Even small increments in BP are associated with increased risk of cardiovascular events³. This genome-wide association study of SBP and DBP, which used a multi-stage design in 200,000 individuals of European descent, identified 16 novel loci: six of these loci contain genes previously known or suspected to regulate BP (GUCY1A3-GUCY1B3; NPR3-C5orf23; ADM; FURIN-FES; GOSR2; GNAS-EDN3); the other 10 provide new clues to BP physiology. A genetic risk score based on 29 genome-wide significant variants was associated with hypertension, left ventricular wall thickness, stroke, and coronary artery disease, but not kidney disease or kidney function. We also observed associations with BP in East Asian, South Asian, and African ancestry individuals. Our findings provide new insights into the genetics and biology of BP, and suggest novel potential therapeutic pathways for cardiovascular disease prevention.

Hypertension in the elderly: Are we all on the same wavelength?

Hypertension is of frequent occurrence in the elderly population. Isolated systolic hypertension (ISH) accounts for the majority of cases of hypertension in the elderly. ISH is associated with a 2-4-fold increase in the risk of myocardial infarction, left ventricular hypertrophy, renal dysfunction, stroke, and cardiovascular mortality. There have been many studies to determine the optimal treatment for hypertension in the elderly. Why, when and how to treat hypertension in the elderly was the scope of the majority of these trials. Despite countless efforts many aspects remain obscure. While a number of novel drugs are being developed, the issue of whether all antihypertensive drugs bestow parallel benefits or whether some agents offer a therapeutic advantage beyond blood pressure control remains of crucial importance. Furthermore, the response of the elderly to different antihypertensive agents also differs from that of younger patients and may explain some of the disparities in outcomes of trials conducted in elderly patients with hypertension.

Cost implications of improving blood pressure management among U.S. adults

OBJECTIVE

To examine the cost-effectiveness of improving blood pressure management from the payer perspective.

DATA SOURCE/STUDY SETTING

Medical record data for 4,500 U.S. adults with hypertension from the Community Quality Index (CQI) study (1996-2002), pharmaceutical claims from four Massachusetts health plans (2004-2006), Medicare fee schedule (2009), and published literature.

STUDY DESIGN

A probability tree depicted blood pressure management over 2 years.

DATA COLLECTION/EXTRACTION METHODS

We determined how frequently CQI study subjects received recommended care processes and attained accepted treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided.

PRINCIPAL FINDINGS

Relative to current care, improved care would cost payers U.S.$170 more per hypertensive person annually (2009 dollars). The incremental cost per person newly attaining treatment goals over 2 years would be U.S.$1,696 overall, U.S.$801 for moderate hypertension, and U.S.$850 for severe hypertension. Among people with severe hypertension, blood pressure would decline substantially but seldom reach goal; the incremental cost per person attaining a relaxed goal (≤ stage 1) would be U.S.$185.

CONCLUSIONS

Under the Health Care Effectiveness Data and Information Set program, which monitors the attainment of blood pressure treatment goals, payers will find it slightly more cost-effective to improve care for moderate than severe hypertension. Having a secondary, relaxed goal would substantially increase payers' incentive to improve care for severe hypertension.

Hypertension and its management in countries in Africa and the Middle East, with special reference to the place of β-blockade

BACKGROUND

The prevalence and clinical consequences of hypertension in countries in Africa and the Middle East have not been studied as well as in other regions.

SCOPE

We have reviewed the literature on the epidemiology and management of hypertension and related cardiovascular complications in countries within Africa and the Middle East. A PubMed search for countries in the region and 'hypertension' was supplemented by articles identified from reviews, and by literature suggested by the authors.

FINDINGS

The prevalence of hypertension is >20% in some countries in the Middle East and Africa, despite an average population age that is some 10-15 years lower than those of developed countries. Hypertension in these countries is associated with an increased risk of cardiovascular risk factors and cardiovascular disease, as elsewhere. Awareness rates of hypertension are low. Hypertension and its complications are undertreated, and mortality rates from cardiovascular disease are higher than in developed countries.

CONCLUSION

Available resources should be brought to bear on the management of hypertension in these countries. In particular, a recent downgrading of the importance of β-blockers in hypertension management guidelines needs to be reassessed. These agents are as effective as other antihypertensive classes both on blood pressures and on cardiovascular event rates. General concerns over an increased rate of new-onset diabetes with β-blockers have been overstated, although these agents should be avoided in metabolic syndrome.

An international randomised placebo-controlled trial of a four-component combination pill ("polypill") in people with raised cardiovascular risk

BACKGROUND

There has been widespread interest in the potential of combination cardiovascular medications containing aspirin and agents to lower blood pressure and cholesterol ('polypills') to reduce cardiovascular disease. However, no reliable placebo-controlled data are available on both efficacy and tolerability.

METHODS

We conducted a randomised, double-blind placebo-controlled trial of a polypill (containing aspirin 75 mg, lisinopril 10 mg, hydrochlorothiazide 12.5 mg and simvastatin 20 mg) in 378 individuals without an indication for any component of the polypill, but who had an estimated 5-year cardiovascular disease risk over 7.5%. The primary outcomes were systolic blood pressure (SBP), LDL-cholesterol and tolerability (proportion discontinued randomised therapy) at 12 weeks follow-up.

FINDINGS

At baseline, mean BP was 134/81 mmHg and mean LDL-cholesterol was 3.7 mmol/L. Over 12 weeks, polypill treatment reduced SBP by 9.9 (95% CI: 7.7 to 12.1) mmHg and LDL-cholesterol by 0.8 (95% CI 0.6 to 0.9) mmol/L. The discontinuation rates in the polypill group compared to placebo were 23% vs 18% (RR 1.33, 95% CI 0.89 to 2.00, p = 0.2). There was an excess of side effects known to the component medicines (58% vs 42%, p = 0.001), which was mostly apparent within a few weeks, and usually did not warrant cessation of trial treatment.

CONCLUSIONS

This polypill achieved sizeable reductions in SBP and LDL-cholesterol but caused side effects in about 1 in 6 people. The halving in predicted cardiovascular risk is moderately lower than previous estimates and the side effect rate is moderately higher. Nonetheless, substantial net benefits would be expected among patients at high risk.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12607000099426.

Looking beyond recurrence: comorbidities in cancer survivors

Cancer recurrence is a very real concern for cancer survivors. Surveillance for recurrence and vigilance for development of new cancers are top priorities during follow-up visits after active treatment ends. However, the cancer survivor also is at risk for the development of comorbid conditions. These conditions, including obesity, diabetes, dyslipidemia, menopause, decreased bone mass, hypertension, and hypothyroidism, are discussed with their relevance for general health and their relationships to disease-specific cancers. All of these conditions should be routinely addressed as part of the patient's survivorship care when appropriate. The oncology nurse is in a prime position to educate survivors about the risks for these conditions, both through evidence-based practice guidelines specific to each condition and also through the use of a treatment summary and care plan. This article discusses these selected comorbidities and offers strategies for nurses to address them with survivors during follow-up visits. Clinical practice guidelines for comorbidities are included, along with oncology implications and relevance for survivors. Recommendations for modifiable risk factors and healthy living also are included, along with Web sites for survivorship care plans.

Medical treatment in acute and long-term secondary prevention after transient ischaemic attack and ischaemic stroke

Stroke is a major cause of death and disability worldwide. Without improvements in prevention, the burden will increase during the next 20 years because of the ageing population, especially in developing countries. Major advances have occurred in secondary prevention during the past three decades, which demonstrate the broader potential to prevent stroke. We review the main medical treatments that should be considered for most patients with transient ischaemic attack or ischaemic stroke in the acute phase and the long term, and draw attention to recent developments.

Perindopril and indapamide reverse coronary microvascular remodelling and improve flow in arterial hypertension

OBJECTIVES

Patients and animal models of arterial hypertension are characterized by structural and functional abnormalities of the coronary microcirculation. Using a translational approach, we ascertained whether antihypertensive treatment can reverse microvascular remodelling and improve myocardial perfusion.

METHODS

In 20 hypertensive patients with left ventricular hypertrophy, blood pressure, left ventricular mass index and myocardial blood flow were measured at baseline and after 6 months of treatment with perindopril + indapamide. In spontaneously hypertensive rats, blood pressure, coronary flow and histomorphometry of intramural coronary arterioles were measured after 8 weeks of treatment with placebo or perindopril + indapamide.

RESULTS

In patients, treatment decreased blood pressure (161 ± 10/96 ± 5 to 136 ± 12/81 ± 6 mmHg; P < 0.0001) and left ventricular mass index (93 ± 16 to 85 ± 17 g/m; P < 0.01) while increasing baseline (0.69 ± 0.13 to 0.88 ± 0.36 ml/min per g; P < 0.05) and hyperaemic myocardial blood flow (1.42 ± 0.32 to 1.94 ± 0.99 ml/min per g; P < 0.05). In rats treated with perindopril + indapamide (n = 11), blood pressure was 93 ± 18/55 ± 18 mmHg compared to 215 ± 18/161 ± 17 mmHg in placebo (n = 6; P < 0.001), baseline flow was unchanged whilst hyperaemic coronary flow was 19.89 ± 3.50 vs. 12.15 ± 0.99 ml/min per g, respectively (P < 0.01). The medial area of intramural arterioles was 1613 ± 409 with perindopril + indapamide and 8118 ± 901 μm with placebo (P < 0.001).

CONCLUSION

In patients with arterial hypertension and left ventricular hypertrophy, perindopril + indapamide reduced blood pressure and left ventricular mass index and improved resting and hyperaemic myocardial blood flow. Data in rats provide evidence that the improvement in coronary flow observed after treatment is due to reverse remodelling of intramural coronary arterioles and improved microvascular function.

Peripheral and central arterial pressure and its relationship to vascular target organ damage in carotid artery, retina and arterial stiffness. Development and validation of a tool. The Vaso risk study

Background

Ambulatory blood pressure monitoring (ABPM) shows a better correlation to target organ damage and cardiovascular morbidity-mortality than office blood pressure. A loss of arterial elasticity and an increase in carotid artery intima-media thickness (IMT) has been associated with increased cardiovascular morbidity-mortality. Tools have been developed that allow estimation of the retinal arteriovenous index but not all studies coincide and there are contradictory results in relation to the evolution of the arteriosclerotic lesions and the caliber of the retinal vessels. The purpose of this study is to analyze the relationship between peripheral and central arterial pressure (clinic and ambulatory) and vascular structure and function as evaluated by the carotid artery intima-media thickness, retina arteriovenous index, pulse wave velocity (PWV) and ankle-brachial index in patients with and without type 2 diabetes. In turn, software is developed and validated for measuring retinal vessel thickness and automatically estimating the arteriovenous index.

Methods/Design

A cross-sectional study involving a control group will be made, with a posterior 4-year follow-up period in primary care. The study patients will be type 2 diabetics, with a control group of non-diabetic individuals. Consecutive sampling will be used to include 300 patients between 34-75 years of age and no previous cardiovascular disease, one-half being assigned to each group. Main measurements: age, gender, height, weight and abdominal circumference. Lipids, creatinine, microalbuminuria, blood glucose, HbA1c, blood insulin, high sensitivity C-reactive protein and endothelial dysfunction markers. Clinic and ambulatory blood pressure monitoring. Carotid ultrasound to evaluate IMT, and retinography to evaluate the arteriovenous index. ECG to assess left ventricle hypertrophy, ankle-brachial index, and pulse wave analysis (PWA) and pulse wave velocity (PWV) with the Sphigmocor System.

Discussion

We hope to obtain information on the correlation of different ABPM-derived parameters and PWA to organ target damage - particularly vascular structure and function evaluated from the IMT and PWV - and endothelial dysfunction in patients with and without type 2 diabetes. We also hope to demonstrate the usefulness of the instrument developed for the automated evaluation of retinal vascularization in the early detection of alterations in vascular structure and function and in the prognosis of middle-term cardiovascular morbidity.

Trial Registration

Clinical Trials.gov Identifier: NCT01325064

Liraglutide: effects beyond glycaemic control in diabetes treatment

AIMS

To review the non-glycaemic effects of liraglutide, including potential improvements in body weight, systolic blood pressure (SBP) and pancreatic beta-cell function.

KEY FINDINGS

Liraglutide induced weight loss of around 2-3 kg compared with weight increases of 1-2 kg with active comparators such as insulin glargine, rosiglitazone and glimepiride. Exenatide demonstrated similar weight benefits to liraglutide, but the dipeptidyl peptidase-4 (DPP-4) inhibitors, sitagliptin, saxagliptin and vildagliptin, were weight neutral. Liraglutide was associated with decreases in SBP of 2-7 mmHg, whereas exenatide, vildagliptin and sitagliptin demonstrated SBP reductions of around 2-3 mmHg. Measures of pancreatic beta-cell function were improved with liraglutide vs. placebo, rosiglitazone and exenatide. However, DPP-4 inhibitors appear to have less effect on beta-cell function than glucagon-like peptide-1 (GLP-1) receptor agonists.

CONCLUSIONS

In addition to glycaemic control, liraglutide and the other incretin-based therapies offer additional non-glycaemic benefits to varying degrees. The ability of GLP-1 receptor agonists to provide modest, but clinically relevant improvements in body weight and SBP, and to potentially benefit beta-cell function make them an exciting therapeutic option for individuals with diabetes. In contrast, DPP-4 inhibitors are weight neutral and may have lesser benefits on beta-cell function.

The effects of blood pressure reduction and of different blood pressure-lowering regimens on major cardiovascular events according to baseline blood pressure: meta-analysis of randomized trials

BACKGROUND

The benefits of reducing blood pressure are well established, but there remains uncertainty about whether the magnitude of the effect varies with the initial blood pressure level. The objective was to compare the risk reductions achieved by different blood pressure-lowering regimens among individuals with different baseline blood pressures.

METHODS

Thirty-two randomized controlled trials were included and seven comparisons between different types of treatments were made. For each comparison, the primary prespecified analysis included calculation of summary estimates of effect using random-effects meta-analysis for major cardiovascular events in four groups defined by baseline SBP (<140, 140-159, 160-179, and ≥ 180 mmHg).

RESULTS

There were 201 566 participants among whom 20 079 primary outcome events were observed. There was no evidence of differences in the proportionate risk reductions achieved with different blood pressure-lowering regimens across groups defined according to higher or lower levels of baseline SBP (all P for trend > 0.17). This finding was broadly consistent for comparisons of different regimens, for DBP categories, and for commonly used blood pressure cut-points.

CONCLUSION

It appears unlikely that the effectiveness of blood pressure-lowering treatments depends substantively upon starting blood pressure level. As the majority of patients in the trials contributing to these overviews had a history of hypertension or were receiving background blood pressure-lowering therapy, the findings suggest that additional blood pressure reduction in hypertensive patients meeting initial blood pressure targets will produce further benefits. More broadly, the data are supportive of the utilization of blood pressure-lowering regimens in high-risk patients with and without hypertension.

Olmesartan medoxomil for the treatment of hypertension in children and adolescents

Prevalence of hypertension in children and adolescents has progressively and continuously increased over recent decades. Thus, early and effective control of high blood pressure may be considered an effective therapeutic approach, in order to reduce the burden of hypertension-related cardiovascular disease in future. In the past, due to the absence of prospective, long-term, randomized, controlled clinical trials performed in young hypertensive patients, lifestyle changes have been long seen as the only strategy to reduce high blood pressure levels. More recently, clinical data on the efficacy and safety of five major classes of antihypertensive drugs (including angiotensin converting enzyme inhibitors, angiotensin receptor blockers [ARBs], beta-blockers, calcium-antagonists, and diuretics) have become available. In particular, these trials demonstrated dose-dependent blood pressure reductions and a good tolerability profile of several ARBs in hypertensive children and adolescents. An overview is provided of the clinical benefits of early detection and prompt intervention of high blood pressure levels, with a closer analysis of recent clinical trials, performed with olmesartan medoxomil in young subjects with hypertension.

The Rise and Fall of Hypertension: Lessons Learned from Eastern Europe

Hypertension is a progressive cardiovascular syndrome that arises from many differing, but interrelated, etiologies. Hypertension is the most prevalent cardiovascular disorder, affecting 20% to 50% of the adult population in developed countries. Arterial hypertension is a major risk factor for cardiovascular diseases and death. Epidemiologic data have shown that control of hypertension is achieved in only a small percentage of hypertensive patients. Findings from the World Health Organization project Monitoring Trends and Determinants in Cardiovascular Diseases (MONICA) showed a remarkably high prevalence (about 65%) of hypertension in Eastern Europeans. There is virtually no difference however, between the success rate in controlling hypertension when comparing Eastern and Western European populations. Diagnosing hypertension depends on both population awareness of the dangers of hypertension and medical interventions aimed at the detecting elevated blood pressure, even in asymptomatic patients. Medical compliance with guidelines for the treatment of hypertension is variable throughout Eastern Europe. Prevalence of hypertension increases with age, and the management of hypertension in elderly is a significant problem. The treatment of hypertension demands a comprehensive approach to the patient with regard to cardiovascular risk and individualization of hypertensive therapy.

Blood pressure awareness in Austria: lessons from a 30 years horizon

BACKGROUND

Blood pressure (BP) awareness is a main focus of public health efforts. In Austria, an increase of knowledge and perception regarding hypertension was seen after a nationwide educational campaign in 1978, but subsequent surveys documented only short-term impact. We report results of the latest survey in 2009 in comparison to 1978 and 1998.

METHODS

Balanced for Austrian demographic characteristics 1,005 men and women older than 15 years of age were randomly selected for face-to-face interviews about BP awareness, risk factors, and hazards of hypertension and treatment options including life-style interventions.

RESULTS

Overall, 15% identified themselves as hypertensive, which is similar to results from 1978 (14%) but significantly higher than 1998 (12%; P < 0.01). The proportion of hypertensives not undertaking any measure (i.e., pharmacotherapy or life-style changes) significantly decreased since 1998 (5% vs. 10%; P < 0.0001). Thirty-three percent recalled to have measured their BP within the last 3 months, which is comparable to 1998 (34%) but lower than in 1978 (49%) after the nationwide educational BP campaign (P < 0.0001). Alarmingly, an unchanged proportion of 8% reported no BP measurement ever (1978 and 1998: 8%, respectively). Sixty-one percent believed they would be able to clearly identify symptoms of hypertension, while only 19% knew that hypertension might not be noticeable. Heart attack and stroke were considered the most common sequelae of hypertension.

CONCLUSION

Despite a high understanding of the risks of hypertension among the Austrian population, a widespread misconception regarding BP symptoms and infrequent personal checks are worrisome and might also be valid in other Western countries.

Hypertension in aging patients

Hypertension, especially isolated systolic hypertension, is commonly found in older (60-79 years of age) and elderly (≥80 years of age) people. Antihypertensive drug therapy should be considered in all aging hypertensive patients, as treatment greatly reduces cardiovascular events. Most classes of antihypertensive medications may be used as first-line treatment with the possible exception of α- and β-blockers. An initial blood pressure treatment goal is less than 140/90 mmHg in all older patients and less than 150/80 mmHg in the nonfrail elderly. The current paradigm of delaying therapeutic interventions until people are at moderate or high cardiovascular risk, a universal feature of hypertensive patients over 60 years of age, leads to vascular injury or disease that is only partially reversible with treatment. Future management will likely focus on intervening earlier to prevent accelerated vascular aging and irreversible arterial damage.

[Relationship between blood pressure and mortality at 4 years of follow up in a cohort of individuals aged over 80 years]

BACKGROUND AND OBJECTIVES

To study the association between blood pressure and mortality in a cohort of over 80 years olders of the community after four years of follow up.

PATIENTS AND METHODS

An observational study cohort of 323 individuals aged over 80 years the population of Martorell. We collected sociodemographic data, comorbidity, evaluation of the basic activities of daily living and the average blood pressure. The mortality and its causes were evaluated after four years of follow up. The association between blood pressure and mortality was investigated using Cox survival analysis.

RESULTS

One hundred and thirty-five (41.8%) patients died, resulting in a mortality rate of 14.5% for year. In 60% of cases the cause of death was of cardiovascular origin. Subjects with systolic blood pressure (SBP) < 130 mm Hg had a mortality of 63.5% compared to those in the range of SBP = 140-159 mm Hg, who had a mortality of 25.5% (Hazard Ratio [HR]: 0.39; 95% CI: 0.21-0.72; p = 0.003). Female gender (HR: 0.62, 95% CI 0.39-0.97, p < 0.036), age (HR: 1.11, 95% CI: 1.04-1.18, p < 0.001), ischemic heart disease (HR: 2.14, 95% CI 1.23-3.70, p < 0.006), orthostatic hypotension (HR: 3.78, 95% CI: 1.88-7.60, p < 0.001), Barthel Index (HR: 0.97, 95% CI: 0.96-0.98, p < 0.001), and SBP = 140-159 mm Hg (HR: 0.31, 95% CI: 0.13-0.72; p = 0.007) were independent factors associated with mortality at 4 years of follow up.

CONCLUSIONS

There is a high cardiovascular mortality in people aged more than 80 years. The risk factors associated with mortality are being female, older age, history of heart disease, presence of orthostatic hypotension and worse function. SBP below 130 mm Hg is associated with increased mortality.

Adherence to antihypertensive medications and health outcomes among newly treated hypertensive patients

Objective:

To evaluate adherence to antihypertensive therapy (AHT) and the association between adherence to AHT, all-cause mortality, and cardiovascular (CV) morbidity in a large cohort of patients newly treated with antihypertensives in a clinical practice setting.

Methods:

An administrative database kept by the Local Health Unit of Florence (Italy) listing patient baseline characteristics, drug prescription, and hospital admission information was used to perform a population-based retrospective study including patients newly treated with antihypertensives, ≥18 years of age, with a first prescription between January 1, 2004 and December 31, 2006. Patients using antihypertensives for secondary prevention of CV disease, occasional spot users, and patients with early CV events, were excluded from the study cohort. Adherence to AHT was calculated and classified as poor, moderate, good, and excellent. A Cox regression model was conducted to determine the association among adherence to AHT and risk of all-cause mortality, stroke, or acute myocardial infarction.

Results:

A total of 31,306 patients, 15,031 men (48.0%), and 16,275 women (52.0%), with a mean age of 60.2 ± 14.5 years was included in the study. Adherence to AHT was poor in 8038 patients (25.7% of included patients), moderate in 4640 (14.8%), good in 5651 (18.1%), and excellent in 12,977 (41.5%). Compared with patients with poor adherence (hazard ratio [HR] = 1), the risk of all-cause death, stroke, or acute myocardial infarction was significantly lower in patients with good (HR = 0.69, P < 0.001) and excellent adherence (HR = 0.53, P < 0.001).

Conclusions:

These findings indicate that suboptimal adherence to AHT occurs in a substantial proportion of patients and is associated with poor health outcomes already in primary prevention of CV diseases. For health authorities, this preliminary evidence underlines the need for monitoring and improving medication adherence in clinical practice.

The differential effects of EPA and DHA on cardiovascular risk factors

Compelling evidence exists for the cardioprotective benefits resulting from consumption of fatty acids from fish oils, EPA (20:5n-3) and DHA (22:6n-3). EPA and DHA alter membrane fluidity, interact with transcription factors such as PPAR and sterol regulatory element binding protein, and are substrates for enzymes including cyclooxygenase, lipoxygenase and cytochrome P450. As a result, fish oils may improve cardiovascular health by altering lipid metabolism, inducing haemodynamic changes, decreasing arrhythmias, modulating platelet function, improving endothelial function and inhibiting inflammatory pathways. The independent effects of EPA and DHA are poorly understood. While both EPA and DHA decrease TAG levels, only DHA appears to increase HDL and LDL particle size. Evidence to date suggests that DHA is more efficient in decreasing blood pressure, heart rate and platelet aggregation compared to EPA. Fish oil consumption appears to improve arterial compliance and endothelial function; it is not yet clear as to whether differences exist between EPA and DHA in their vascular effects. In contrast, the beneficial effect of fish oils on inflammation and insulin sensitivity observed in vitro and in animal studies has not been confirmed in human subjects. Further investigation to clarify the relative effects of consuming EPA and DHA at a range of doses would enable elaboration of current understanding regarding cardioprotective effects of consuming oily fish and algal sources of long chain n-3 PUFA, and provide clearer evidence for the clinical therapeutic potential of consuming either EPA or DHA-rich oils.

Antihypertensive efficacy and safety of olmesartan medoxomil and ramipril in elderly patients with mild to moderate essential hypertension: the ESPORT study

OBJECTIVE

To compare the efficacy and safety of the angiotensin II antagonist olmesartan medoxomil (O) and the ACE inhibitor ramipril (R) in elderly patients with essential arterial hypertension.

METHODS

After a 2-week placebo wash-out 1102 treated or untreated elderly hypertensive patients aged 65-89 years (office sitting diastolic blood pressure, DBP, 90-109 mmHg and/or office sitting systolic blood pressure, SBP, 140-179 mmHg) were randomized double-blind to 12-week treatment with O 10 mg or R 2.5 mg once-daily. After the first 2 and 6 weeks doses could be doubled in non-normalized [blood pressure (BP) < 140/90 mmHg for nondiabetic and < 130/80 mmHg for diabetic) individuals, up to 40 mg for O and 10 mg for R. Office BPs were assessed at randomization, after 2, 6 and 12 weeks of treatment, whereas 24-h ambulatory BP was recorded at randomization and after 12 weeks.

RESULTS

In the intention-to-treat population (542 patients O and 539 R) after 12 weeks of treatment baseline-adjusted office SBP and DBP reductions were greater (P < 0.01) with O [17.8 (95% confidence interval: 16.8/18.9) and 9.2 (8.6/9.8) mmHg] than with R [15.7 (14.7/16.8) and 7.7 (7.1/8.3) mmHg]. BP normalization rate was also greater under O (52.6 vs. 46.0% R, P < 0.05). In the subgroup of patients with valid ambulatory BP recording (318 O and 312 R) the reduction in 24-h average BP was larger (P < 0.05) with O [SBP: 11.0 (12.2/9.9) and DBP: 6.5 (7.2/5.8) mmHg] than with R [9.0 (10.2/7.9) and 5.4 (6.1/4.7) mmHg]. The larger blood pressure reduction obtained with O was particularly evident in the last 6 h from the dosing interval; a better homogeneity of the 24-h BP control with O was confirmed by higher smoothness indices. The proportion of patients with drug-related adverse events was comparable in the two groups (3.6 O vs. 3.6% R), as well as the number of patients discontinuing study drug because of a side effect (14 O vs. 19 R).

CONCLUSION

In elderly patients with essential arterial hypertension O provides an effective, prolonged and well tolerated BP control, representing a useful option among first-line drug treatments of hypertension in this age group.

The comparative effects of azilsartan medoxomil and olmesartan on ambulatory and clinic blood pressure

The current study assesses the antihypertensive efficacy and safety of the investigational angiotensin receptor blocker (ARB), azilsartan medoxomil (AZL-M), compared with placebo and the ARB olmesartan medoxomil (OLM-M). This randomized, double-blind, placebo-controlled, multicenter study assessed change from baseline in mean 24-hour ambulatory systolic blood pressure (SBP) following 6 weeks of treatment. Patients with primary hypertension (n=1275) and baseline 24-hour mean ambulatory systolic pressure ≥ 130 mm Hg and ≤ 170 mm Hg were studied; 142 received placebo and the remainder received 20 mg, 40 mg, or 80 mg AZL-M or 40 mg OLM-M. Mean age of participants was 58 ± 11 years, baseline mean 24-hour SBP was 146 mm Hg. Dose-dependent reductions in 24-hour mean SBP at study end occurred in all AZL-M groups. Reduction in 24-hour mean SBP was greater with AZL-M 80 mg than OLM-M 40 mg by 2.1 mm Hg (95% confidence interval, -4.0 to -0.1; P=.038), while AZL-M 40 mg was noninferior to OLM-M 40 mg. The side effect profiles of both ARBs were similar to placebo. AZL-M is well tolerated and more efficacious at its maximal dose than the highest dose of OLM-M.

Moderate versus intensive treatment of hypertension with amlodipine/valsartan for patients uncontrolled on angiotensin receptor blocker monotherapy

OBJECTIVES

Many angiotensin receptor blocker (ARB) monotherapy patients need at least two agents to control blood pressure (BP). We investigated whether initiating intensive treatment with combination amlodipine/valsartan was superior to moderate treatment with amlodipine/valsartan in patients previously uncontrolled on ARB monotherapy.

METHODS

In this 12-week study, patients aged at least 18 years on ARB (other than valsartan) for at least 28 days (with treatment-naïve patients or those not controlled on agents other than an ARB treated with open-label olmesartan 20 or 40 mg, respectively, for 28 days) and with uncontrolled mean sitting systolic blood pressure (MSSBP; ≥ 150-<200 mmHg) were randomized to amlodipine/valsartan 5/320 mg (n = 369) or 5/160 mg (n = 359). At week 2, the dose was increased to 10/320 mg in the intensive arm. Hydrochlorothiazide 12.5 mg was added to both arms at week 4. Optional up-titration with hydrochlorothiazide 12.5 mg at week 8 was allowed if MSSBP was more than 140 mmHg.

RESULTS

At baseline, mean office sitting BP was comparable in the intensive (163.9/95.5 mmHg) and moderate (163.3/95.0 mmHg) groups. Intensive treatment provided greater BP reductions versus moderate treatment (P < 0.05) from week 4 (-23.0/-10.4 versus -19.2/-8.7 mmHg; primary endpoint) to week 12 (-29.0/-14.8 versus -25.3/-12.3 mmHg). Adverse events were reported by a similar percentage of patients in both groups (36.3% intensive, 37.6% moderate); peripheral edema was more common with intensive versus moderate treatment (8.7 versus 4.5%; P = 0.025).

CONCLUSIONS

Initiating treatment with an intensive dose of amlodipine/valsartan provides significantly greater BP lowering versus moderate treatment in hypertensive patients unresponsive to ARB monotherapy. Both treatment regimens were generally well tolerated based on adverse event reports, but the lack of routine laboratory testing after screening limits conclusions on tolerability.

The polypill in the primary prevention of cardiovascular disease: cost-effectiveness in the Dutch population

Objectives The aim of the present study was to estimate the cost-effectiveness of the polypill in the primary prevention of cardiovascular disease. Design A health economic modelling study. Setting Primary healthcare in the Netherlands. Participants Simulated individuals from the general Dutch population, aged 45-75 years. Interventions Opportunistic screening followed by prescription of the polypill to eligible individuals. Eligibility was defined as having a minimum 10-year risk of cardiovascular death as assessed with the Systematic Coronary Risk Evaluation function of alternatively 5%, 7.5% or 10%. Different versions of the polypill were considered, depending on composition: (1) the Indian polycap, with three different types of blood pressure-lowering drugs, a statin and aspirin; (2) as (1) but without aspirin and (3) as (2) but with a double statin dose. In addition, a scenario of (targeted) separate antihypertensive and/or statin medication was simulated. Primary outcome measures Cases of acute myocardial infarction or stroke prevented, quality-adjusted life years (QALYs) gained and the costs per QALY gained. All interventions were compared with usual care. Results All scenarios were cost-effective with an incremental cost-effectiveness ratio between €7900 and 12 300 per QALY compared with usual care. Most health gains were achieved with the polypill without aspirin and containing a double dose of statins. With a 10-year risk of 7.5% as the threshold, this pill would prevent approximately 3.5% of all cardiovascular events. Conclusions Opportunistic screening based on global cardiovascular risk assessment followed by polypill prescription to those with increased risk offers a cost-effective strategy. Most health gain is achieved by the polypill without aspirin and a double statin dose.