The benefit of treating isolated systolic hypertension

Angiotensin‐receptor blockers and diuretics—Advantages of combination

Surveys have shown that in as many as half of patients treated for hypertension, blood pressure (BP) is not controlled to target levels; many more persons have undertreated hypertension. Uncontrolled hypertension is a serious risk factor for cardiovascular events such as stroke, heart failure, myocardial infarction and target-organ diseases. Studies have shown that strict BP control significantly reduces the occurrence of these cardiovascular outcomes, in the majority of patients, effective BP control requires two or more antihypertensive agents. The combination of an angiotensin-receptor blocker (ARB) and a thiazide diuretic is appealing, since these agents have complimentary effects on BP reduction, left ventricular hypertrophy and progression of renal diseases. In addition, this combination provide excellent tolerability. The combination of an ARB and a thiazide diuretic may be of particular value in patient populations who tend to have poor BP control on monotherapy, or have additional cardiovascular or renal risk factors.

Association Between Change in Systolic Blood Pressure and Cognitive Decline Among Elderly Mexican Americans: Data from the Hispanic Established Population for Epidemiology Study of the Elderly

The longitudinal association between the rate of change in blood pressure and cognitive decline was examined in an area probability sample from a population-based survey of elderly Mexican Americans, 65 years of age or older obtained in 1993--1994, 1995--1996, 1998--1999, and 2000--2001 (n = 2859). The sample was divided into two groups at baseline: hypertensives had a systolic blood pressure (SBP) > or = 140 mm Hg, a diastolic blood pressure (DBP) > or = 90 mm Hg, or indicated a prior diagnosis of hypertension, and the normotensive group. Cognition was indexed by the Mini-Mental State Examination (MMSE). Neither SBP nor DBP at baseline predicted cognitive decline. However, the mean slope for SBP in the normotensive group showed an increase of 4.55mm Hg (increase from Time 1 to Time 2 was 123mm Hg to 132 mm Hg) and was significant in a regression model predicting cognitive decline even after adjusting for covariates. These findings suggest an association between increasing SBP and cognitive decline for normotensive elderly in this study population.

Effects of body mass index, plasma glucose and cholesterol levels on isolated systolic hypertension

Despite the high cardiovascular risk of diabetic patients, there is a paucity of data on isolated systolic hypertension (ISH) in diabetic patients. In this cross-sectional study, we examined the risk of ISH and its associated factors in Chinese type 2 diabetic patients. Isolated systolic hypertension was defined as systolic blood pressure (SBP) > or =140 mm Hg and diastolic blood pressure (DBP) <90 mm Hg. The mean value of two BP measurements taken 1 min apart was used. There were 1048 type 2 diabetic patients recruited from the Prince of Wales Hospital Diabetes Clinic. Another 1043 age- and sex-matched non-diabetic subjects were recruited from the community. The mean age of the 2091 subjects was 40.6 +/- 7.6 years (median: 40 years, range: 16-69 years). Diabetic patients had an increased risk of ISH compared to non-diabetic subjects (7.6% vs. 3.4%, p < 0.001) with an odd ratio of 2.38. On multivariate analysis, age, body mass index, total cholesterol and duration of diabetes in diabetic subjects while age and waist-hip ratio (WHR) in non-diabetic subjects were independently associated with ISH. In conclusion, Chinese type 2 diabetic patients had increased risk to develop ISH than non-diabetic subjects. Age, obesity, lipid and duration of diabetes were independent associated with ISH. These findings suggest that control of body weight and metabolic profile might have beneficial effects on ISH.

[Spontaneous intracerebral hemorrhages]

Spontaneous intracerebral hemorrhage (ICH) accounts for 8-15% of all cases of stroke and among patients receiving oral anticoagulants this number increases up to 40%. Mortality and morbidity are considerably higher in patients with ICH compared to patients with ischemic stroke. Large randomized controlled trials provide only little evidence for therapeutic strategies in patients with spontaneous ICH. In this review we summarize the available data and give recommendations on the management of spontaneous ICH.

Hypertension therapy: mixing, matching, and meeting targets

The inappropriate control of hypertension is a public health problem worldwide. It is notable that although there are several causes for this situation, lack of effective pharmacotherapy is not among them. It has long been known that combinations of antihypertensive drugs are highly effective in most patients; the problem is implementing treatment recommendation guidelines into clinical practice with the most effective and best tolerated therapies. The latest guidelines on therapies for hypertension from the World Health Organization/International Society of Hypertension, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (US), and the European Societies of Hypertension and Cardiology consistently emphasize this need of combination treatments in a large part of the hypertensive patient population. This review focuses on the combination of one of the oldest drugs, thiazide diuretics, with one of the youngest, angiotensin-receptor blockers, and analyzes the available literature regarding potential applications in specific populations. This represents one of the most widely used, rational and effective combination therapies, combining excellent control of blood pressure with unequalled tolerability. In addition, angiotensin-receptor blocker/diuretic combinations may have cardiovascular benefits beyond those from blood pressure lowering itself.

Strokes and their relationship to hypertension

PURPOSE OF REVIEW

There is rapidly growing appreciation that stroke morbidity and the risk of an ischaemic stroke becoming haemorrhagic can be influenced by new information about prophylaxis, rapid diagnosis and treatment.

RECENT FINDINGS

Strokes are strongly associated with hypertension mainly because hypertension is strongly associated with atheromatous deposits blocking or narrowing brain arteries, predisposing to local clot formation. Atheroma and its ischaemic consequences may damage cerebral arterioles and the brain tissue they supply. Cerebral infarcts are more common than spontaneous cerebral haemorrhages. High blood pressure itself cannot directly rupture cerebral blood vessels because their small size protects them and intracerebral haemorrhage usually follows previous ischaemic vascular damage. It is obvious that lowering blood pressure would reduce the risk and extent of bleeding into the brain once a break in an arteriolar wall has occurred, but it is not clear why lowering blood pressure should protect against cerebral infarction. One might expect that slowing down the rate of cerebral blood flow would give more time for local clots to form. It seems most likely that induced hypotension protects against ischaemic strokes by preventing pressure- or ischaemia-induced arteriolar spasm and by advantageous vasodilation of some of the more ischaemic territories. Added protection can be provided by coenzyme-A reductase inhibitors (statins), but probably not by antioxidants.

SUMMARY

Lowering blood pressure strongly protects against ischaemic and haemorrhagic stroke. Recent work shows that more accurate and faster diagnosis of stroke pathology is urgently needed, so that appropriate treatment (e.g. with tissue plasminogen activators) can be started before local bleeding has occurred.

Randomized, comparative, double-blind study of amlodipine vs. nicardipine as a treatment of isolated systolic hypertension in the elderly

A 90-day, multicenter, randomized, double-blind, parallel-group study was conducted to compare the efficacy of amlodipine (once a day) with nicardipine (two to three times a day), in the treatment of isolated systolic hypertension (ISH) in the elderly. Patients (n = 133) aged > or = 60 years, with ISH were randomized to receive either amlodipine 5 mg/day, or nicardipine 60 mg/day (titrated if necessary to 10 mg/day and 100 mg/day, respectively) for 90 days. Efficacy was assessed by measuring office blood pressure (BP), and 24-h ambulatory blood pressure monitoring (ABPM). The two treatments substantially and comparably reduced office systolic blood pressure (SBP) and pulse pressure (PP), and also produced a slight decrease in diastolic blood pressure (DBP). Amlodipine reduced SBP, as assessed by ABPM, to a significantly greater extent than nicardipine. Both treatments were well-tolerated. The sustained effect of amlodipine, compared with nicardipine, was reflected in its significantly greater antihypertensive activity, particularly during the nocturnal period, as assessed by ABPM. The study demonstrates that once a day dose of amlodipine is an effective antihypertensive treatment for elderly ISH patients.