Antihypertensive agents, serum lipoproteins and glucose metabolism

Genome-wide meta-analysis of variant-by-diuretic interactions as modulators of lipid traits in persons of European and African ancestry

Hypertension (HTN) is a significant risk factor for cardiovascular morbidity and mortality. Metabolic abnormalities, including adverse cholesterol and triglycerides (TG) profiles, are frequent comorbid findings with HTN and contribute to cardiovascular disease. Diuretics, which are used to treat HTN and heart failure, have been associated with worsening of fasting lipid concentrations. Genome-wide meta-analyses with 39,710 European-ancestry (EA) individuals and 9925 African-ancestry (AA) individuals were performed to identify genetic variants that modify the effect of loop or thiazide diuretic use on blood lipid concentrations. Both longitudinal and cross sectional data were used to compute cohort-specific interaction results, which were then combined through meta-analysis in each ancestry. These ancestry-specific results were further combined through trans-ancestry meta-analysis. Analysis of EA data identified two genome-wide significant (p < 5 × 10-8) loci with single nucleotide variant (SNV)-loop diuretic interaction on TG concentrations (including COL11A1). Analysis of AA data identified one genome-wide significant locus adjacent to BMP2 with SNV-loop diuretic interaction on TG concentrations. Trans-ancestry analysis strengthened evidence of association for SNV-loop diuretic interaction at two loci (KIAA1217 and BAALC). There were few significant SNV-thiazide diuretic interaction associations on TG concentrations and for either diuretic on cholesterol concentrations. Several promising loci were identified that may implicate biologic pathways that contribute to adverse metabolic side effects from diuretic therapy.

Differential Metabolic Effects of Beta-Blockers: an Updated Systematic Review of Nebivolol

Blood pressure management in hypertensive patients with metabolic abnormalities is challenging, since many of the antihypertensive drugs adversely affect metabolism. Besides effective control of blood pressure in patients with hypertension, third-generation beta-blockers such as nebivolol offer additional benefits for central hemodynamics and neutral or beneficial effects on metabolism. Emerging clinical data suggest that nebivolol also has similar effects on metabolism in obese hypertensive and hypertensive diabetic patients. The present article will provide a systematic analysis of the pathophysiological links among hypertension, insulin resistance, and metabolic syndrome. We will also summarize the available clinical evidence regarding the metabolic effects of beta-blockers in hypertensive patients, with an emphasis on nebivolol. Nebivolol exerts neutral or beneficial effects on insulin sensitivity and lipid metabolism in hypertensive patients, owing to its nitric oxide-mediated vasodilatory and antioxidative properties. Thus, nebivolol could be a favorable therapeutic option for the treatment of hypertension in patients with impaired glucose and lipid metabolism.

Pathophysiological Mechanisms and Correlates of Therapeutic Pharmacological Interventions in Essential Arterial Hypertension

Treating arterial hypertension (HT) remains a hard task. The hypertensive patient is often a subject with several comorbidities and metabolic abnormalities. Clinicians everyday have to choose the right drug for the single patient among the different classes of antihypertensives. Apart from lowering blood pressure, a main therapeutic target should be that of counteracting all the possible pathophysiological mechanisms involved in HT itself and in existing/potential comorbidities. All the ancillary positive and negative effects of the administered drugs should be considered: in particular, since hypertensive patients are often glucose intolerant/diabetic, carrier of serum lipids disorder, have already developed atherosclerotic diseases and endothelial dysfunction, they should not be treated with drugs negatively interfering with these conditions but with molecules that, if possible, improve them. The main pathophysiological mechanisms and correlates of therapeutic pharmacological interventions in essential HT are reviewed here.

Proton pump inhibitors do not impair the effectiveness of metformin in patients with diabetes

AIMS

In order to exert its pharmacodynamic effect, the diabetes drug metformin needs to be taken up into hepatocytes by the organic cation transporter (OCT) system. A recent in vitro study found that proton pump inhibitors (PPIs) inhibit OCT1, OCT2 and OCT3, suggesting that PPIs might reduce metformin's effectiveness. This pharmacoepidemiologic study looked for evidence of a clinical effect of such an interaction.

METHODS

This was an observational cohort study examining changes in glycosylated haemoglobin (HbA1c) with exposure to metformin and to PPIs as single agents and in combination. The aim was to assess evidence of a deleterious drug-drug interaction.

RESULTS

PPIs did not reduce the effectiveness of metformin, and indeed were associated with a minimally better glycaemic response by - 0.06 HbA1c percentage points (95% confidence interval, -0.10, -0.01) in metformin initiators.

CONCLUSIONS

Despite a mechanistic basis for a potential drug-drug interaction, we found no evidence of a deleterious interaction between PPIs and metformin.

Enalapril/lercanidipine combination on markers of cardiovascular risk: a randomized study

The aim of this study was to evaluate enalapril/lercanidipine combination effects on markers of cardiovascular risk stratification in hypertensive patients. A total of 359 patients were randomized to enalapril 20 mg, lercanidipine 10 mg, or enalapril/lercanidipine 20/10 mg fixed combination. We evaluated blood pressure (BP), fasting plasma glucose (FPG), lipid profile, lipoprotein(a) (Lp[a]), soluble receptor for advanced glycation end products (sRAGE), soluble CD40 ligand (sCD40 L), serum myeloperoxidase (MPO), high sensitivity C-reactive protein (Hs-CRP), and tumor necrosis factor-α (TNF-α). We recorded a decrease of BP in all groups, with the enalapril/lercanidipine combination being more effective in reducing BP compared with single monotherapies. Lipid profile or FPG were not affected by various treatments. Lercanidipine, but not enalapril, improved Lp(a) levels compared with baseline, with enalapril/lercanidipine having a greater effect on Lp(a) reduction. All treatments increased sRAGE levels, and decreased sCD40 L and MPO, even if enalapril/lercanidipine combination was more effective than single monotherapies. TNF-α and Hs-CRP were greater reduced by enalapril/lercanidipine combination compared with enalapril (P < .05 for both). The enalapril/lercanidipine fixed combination was more effective than single monotherapies in decreasing BP, but also in improving markers of cardiovascular risk stratification in hypertensive patients.

Erectile dysfunction in heart failure patients: a critical reappraisal

Heart failure (HF) is a complex clinical syndrome with a constantly increasing incidence and prevalence in western countries. Total absence of sexual activity is registered in 30% of HF patients. Moreover, HF-induced reduction in exercise tolerance, side effects of HF medications and the coexistence of shared risk factors between HF and sexual dysfunction may further aggravate the sexual health of HF patients. The purpose of this review is to examine the pathophysiological mechanisms behind the association of erectile dysfunction (ED) and HF, the potential therapeutic approaches and the eventual indications for sexual activity in HF patients. Medline and Cochrane Library search was performed from January 1970 through October 2012 to retrieve relevant papers outlining the association between ED and HF. Many evidences have outlined a tight association between ED and HF pathophysiological standpoint. Shared risk factors, common pathogenic traits and epidemiologic association represent some of the links between these conditions. Erectile dysfunction has been recognized as an earlier predictor of cardiovascular events; moreover, HF itself may cause and/or worsen ED because of its particular feature and co-morbidities. Furthermore, some cardiovascular drugs may contribute to impaired erectile function. In stable patients with stable HF, sexual activity is generally not contraindicated but it should be encouraged, as a form of moderate-intensity physical exertion. An effective treatment of ED in HF patients should be founded on the correction of reversible risk factors, on the choice of cardiovascular drugs with the lowest effect upon patient's erectile function, and on the use of phosphodiesterase-5-inhibitors. Physicians should be aware of the close relation between HF and ED and of the related clinical and therapeutic implications, in order to improve patients quality of life and clinical outcome.

Dyslipidaemia in hypertensive obese type 2 diabetic patients in Jamaica

INTRODUCTION

Hypertension and obesity are common problems among diabetic patients accelerating progression of vascular diabetic complications.

MATERIALS AND METHODS

A two-stage stratified random sampling design was used, and individuals aged 15 years and over were interviewed. This cross-sectional study evaluated lipid abnormalities of 117 obese type 2 diabetic patients (28 males and 89 females), and 56 hypertensive obese type 2 diabetic patients (22 males and 34 females). Total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), very-low-density lipoprotein cholesterol (VLDL-C) and high-density lipoprotein cholesterol (HDL-C) concentrations were assayed using standard biochemical methods.

RESULTS

Hypertensive obese type 2 diabetic females had significantly higher mean serum concentrations of TC (p = 0.043), TG (p = 0.046), LDL-C (p= 0.040), TC/HDL-C ratio (p = 0.001) and LDL-C/HDL-C ratio (p = 0.003) compared with hypertensive obese non-diabetic females. Similar results were found in hypertensive obese type 2 diabetic males compared with hypertensive obese non-diabetic males. Hypertensive obese type 2 diabetic females had significantly higher serum TC, TG and TC/HDL-C ratio (p < 0.05) than hypertensive obese type 2 diabetic males. Hypertensive obese type 2 diabetic females had significantly higher mean serum concentrations of TG (p = 0.03) and TC (p = 0.01) than obese type 2 diabetic females. There was a significant association between blood glucose and LDL-C concentrations in type 2 diabetic subjects (r = 0.36; p< 0.05).

CONCLUSION

Obese hypertensive type 2 diabetic females are exposed more profoundly to risk factors including atherogenic dyslipidaemia compared with males.

Characterization of lipid parameters in diabetes mellitus--a Nigerian report

BACKGROUND

Diabetes mellitus (DM) is a disorder that is often associated with cardiovascular events and underlying lipid abnormalities. Cardiovascular complications are common causes of DM deaths in Nigeria yet dyslipidaemia is one aspect of DM that is underdiagnosed and undertreated in our patients. This report seeks to determine the prevalence and pattern of lipid abnormalities in Nigerians with types I and 2 DM.

METHODS

A total of 600 patients with DM aged between 22 - 79 years were evaluated for lipid abnormalities. The anthropometric indices, glycosylated haemoglobin, pattern of DM treatment and co-morbidities were noted. Total cholesterol (TCHOL), triglyceride (TG), high density lipoproteins (HDL-C), low density lipoproteins cholesterol (LDL-C) levels and the atherogenic indices levels were documented. Test statistic used included student's t test and chi2.

RESULTS

Well over half (89%) of the study subjects had lipid abnormalities and there was no statistically significant difference in the proportions of subjects with type 1 and 2 DM with lipid abnormalities. Elevated LDL-C, TCHOL, TG and reduced HDL-C were noted in 74%, 42%, 13%, and 53% respectively of the study subjects. The commonly noted combined lipid abnormalities were elevated TG and reduced HDL-C. Hypertension, significant histories of smoking and alcohol ingestion were found to be potential determinants of the occurrence of dyslipidaemia. Age, sex, type of DM and anthropometric indices were found to be determinants of the the pattern of dyslipidaemia. Only a small proportion - (8%)-of the subjects with dyslipidaemia were on treatment for it.

CONCLUSION

Having defined the scope of dyslipidaemia in our patients and also highlighting its gross undertreatment, we hope that our data will help sensitize health care practitioners on screening for and treating dyslipidaemia. Elevated LDL-C and reduced HDL-C should be the primary targets of treatment in our patients with dyslipidaemia.

A Review of Critical Differences among Loop, Thiazide, and Thiazide-Like Diuretics

Diuretics are a drug class with heterogeneous assortments. This article reviews general pharmacologic mechanisms and clinical implications of loop, thiazide, and thiazide-like diuretics.

Loop diuretics act in the loop of Henle by blocking the sodium-potassium-chloride (Na+-K+-2Cl-) symport. They are effective in relieving congestive symptoms and edematous signs of heart failure. Activation of the neurohormonal system and subsequent pathologic myocardial remodeling limit the use of loop diuretics unless fluid balance is not met to relieve patients' symptoms with life-saving pharmacologic modalities. Adverse effects on electrolyte balance may cause life-threatening consequences. The combination of K+-sparing diuretics or angiotensin-converting enzyme inhibitors with loop diuretics may not only prevent life-threatening complications caused by electrolyte imbalance, but also may delay progression of the disease with proven mortality benefit. Recent findings of worsening renal function and higher mortality rate with the use of oral and intravenous loop diuretics further demands appropriate use of these drugs.

Thiazide diuretics and thiazide-like diuretics act in the distal convoluted tubule by blocking Na+-Cl- symport. Thiazide diuretics reduce cardiovascular mortality by achieving target blood pressure in patients with hypertension. Compared with other antihypertensive drugs, thiazide diuretics have less desirable metabolic effects. However, it has not yet been shown that the negative metabolic effects of these drugs are associated with negative mortality and morbidity. Based on the need for a multidrug regimen to reach target blood pressure in most patients with hypertension, thiazide diuretics may be used in addition to a drug or drugs without metabolic complications.

Metabolic profile of indapamide sustained-release in patients with hypertension: data from three randomised double-blind studies

OBJECTIVE

To evaluate the influence of indapamide sustained-release (SR) 1.5 mg/day, a thiazide-related sulfonamide diuretic, on serum levels of lipids (total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol and triglycerides), glucose and uric acid, and renal function (serum urea and creatinine levels).

METHODS

Pooled data from three randomised, double-blind, controlled studies are analysed. Two of these studies were of short duration (2 and 3 months), one of which included a 9-month nonblind extension phase, and the third was a 12-month prospective study. Short- and long-term metabolic effects of the treatment could thus be analysed. All studies were conducted in patients with mild-to-moderate hypertension; the total population randomised in these studies comprised 1195 patients, of whom 505 had left ventricular hypertrophy (LVH).

RESULTS

After 2 to 3 months' treatment with indapamide SR 1.5 mg/day, there was no significant change from baseline in serum lipid levels and glucose levels. This neutral effect was maintained after 9 and 12 months of treatment. Renal function was not affected by short- or long-term indapamide SR 1.5 mg/day therapy. Serum uric acid level was slightly increased after short-term therapy, but was restored to baseline values during long-term therapy with indapamide SR 1.5 mg/day.

CONCLUSIONS

Indapamide SR 1.5 mg/day has no deleterious effect on glucose metabolism, serum levels of lipids and uric acid, or renal function. This antihypertensive agent can be considered to be an attractive therapeutic choice for all patients with mild-to-moderate hypertension, including the elderly and patients with increased cardiovascular risks, i.e. those with LVH.

Impact of an ACE inhibitor and calcium antagonist on microalbuminuria and lipid subfractions in type 2 diabetes: a randomised, multi-centre pilot study

BACKGROUND

Microalbuminuria (MA) is associated with increased cardiovascular risk and lipid abnormalities in people with type 2 diabetes. ACE inhibitors and calcium channel blockers (CCBs) reduce MA and are neutral on total cholesterol and triglycerides. The effect of ACE inhibitors and CCBs on lipid subfractions such as Lp(a), apolipoprotein (apo) A1, apo B, and others, however, is unclear. The current study tests the hypothesis that a fixed-dose combination of an ACE inhibitor, benazepril (B) with the dihydropyridine CCB, amlodipine (A), will further reduce arterial pressure and reduce atherogenic lipid fractions compared to either agent alone.

DESIGN

A multicentre, randomised, open-label, parallel group design was used to study 27 participants with type 2 diabetes. Measurements for total cholesterol, high- and low-density lipoprotein (HDL and LDL), triglycerides, apo A1, apo B, Lp(a), MA, arterial pressure and creatinine clearance were obtained at baseline and at 12-week intervals during the 36 week study.

RESULTS

Arterial pressure was significantly reduced at 36 weeks in all three groups (P = 0.0078 for A, P = 0.0039 for B, and P = 0.0313 for A+B). MA was lowered in all groups with relatively greater reductions in the B (P < 0.05) and A+B groups (P < 0.03) vs A. An increase in mean HDL-cholesterol from baseline was noted in the B and A+B groups; P < 0.05), but not in the A group. A trend was also observed between the rise in HDL-cholesterol and the reduction in MA in the B and A+B groups. Additionally, only the B group exhibited a decrease in the median value of Lp(a) (P < 0.05).

CONCLUSION

These data support the concept that ACE inhibition with B reduces the atherogenic profile by decreasing Lp(a) and increasing HDL-cholesterol, the latter being correlated with reductions in MA. While A+B exhibited similar trends in lipid subfractions and MA as B, this group had the greatest reduction in systolic blood pressure of the three groups. Thus, use of A+B offers the benefits of a decreased atherogenic profile with a higher probably of achieving goal blood pressure as recommended by national guidelines.

Growth inhibitory activity of indapamide on vascular smooth muscle cells

Abnormal vascular smooth muscle cell proliferation has a fundamental role in the pathogenesis of vascular diseases. Indapamide is an oral diuretic antihypertensive drug effective for patients with mild or moderate essential hypertension. We now investigated the effects of indapamide on the growth of aortic vascular smooth muscle cells (A10 cell line). Indapamide inhibited cell proliferation as measured by the tetrazolium salt XTT (sodium 3'-[1-(phenylamino-carbonyl)-3,4-tetrazolium]-bis(4-methoxy-6-nitro)benzene sulfonic acid hydrate) test. The increase in cell number was significantly reduced in the presence of indapamide 10(-6) and 5 x 10(-4) M (P < 0.05 n = 3 and P < 0.01, n = 3, respectively). Serum-induced DNA synthesis, determined as the incorporation of 5-bromo-2'-deoxyuridine (BrdU), was concentration-dependently inhibited by indapamide. BrdU incorporation was 47.2+/-1.6% (10% foetal calf serum). Indapamide treatment markedly prevented BrdU incorporation (37.2+/-2.1%, 29.2+/-4.8%, 15.0+/-1.8%, 8.7+/-2.1%) indapamide 10(-6), 10(-5), 5 x 10(-5) and 5 x 10(-4) M, respectively. Cell-cycle progression was also evaluated. Flow cytometry analysis of DNA content in synchronised cells revealed blocking of the serum-inducible cell-cycle progression by indapamide. This inhibition was abolished when the drug was added 2 h after serum repletion, indicating that indapamide must act at the early events of a cell cycle to be fully effective against DNA synthesis. In addition, serum-induced intracellular Ca2+ movements and also p44/p42 mitogen-activated protein kinase (MAPK) phosphorylation were studied in the presence or absence of indapamide. Indapamide 10(-5) and 5 x 10(-5) M decreased significantly cytosolic free calcium, and the p44/p42 mitogen-activated protein kinase phosphorylation (5 x 10(-5) M) stimulated by 10% foetal calf serum. In accordance with this finding, indapamide (5 x 10(-4) M) caused a 95% to 99% decrease in the early elevation of c-fos expression as evaluated by northern blot analysis of mRNA induced after serum addition. In conclusion, our results indicate that indapamide reduces vascular smooth muscle cell proliferation by a mechanism which involves a decrease in the intracellular Ca2+ movements that might link with the mitogen-activated protein kinase (MAPK) pathway, altering cell-cycle progression.

Antihypertensive efficacy of manidipine and enalapril in hypertensive diabetic patients

Recent studies showed that in diabetic hypertensive patients, administration of angiotensin-converting enzyme (ACE)-inhibitors or calcium antagonists can effectively lower blood pressure (BP) and prevent diabetes-related cardiovascular complications with no adverse metabolic effects. We sought to assess the antihypertensive and metabolic effects of the new dihydropyridine calcium antagonist manidipine (M) in patients with diabetes mellitus and essential hypertension as compared with the ACE inhibitor enalapril (E). After 3 weeks of placebo, 101 (62 men; age range, 34-72 years) hypertensives with type II diabetes mellitus were randomized to M 10-20 mg or E 10-20 mg, od, for 24 weeks. At the end of the placebo period and the active-treatment phase, BP was measured with a mercury sphygmomanometer (office, O) and over the 24 h by ambulatory (A) monitoring. ABP recordings were analyzed to obtain 24-h, day (6 a.m. to midnight), and night (midnight to 6 a.m.) average systolic (S) and diastolic (D) BP and heart rate (HR) values. Homogeneity of the antihypertensive effect over the 24 h was assessed by the smoothness index [SI: i.e., the ratio between the average of the 24 hourly BP changes after treatment and the corresponding standard deviation (the higher the SI, the more uniform is the BP control by treatment over the 24 h]. The O SBP and DBP were significantly (p < 0.01) and similarly reduced by M (16 +/- 10 and 13 +/- 6 mm Hg, n = 49) and E (15 +/- 10 and 13 +/- 6 mm Hg, n = 45). The percentage of patients whose O DBP was reduced < or = 85 mm Hg (i.e., the value indicated to be the optimal DBP goal in diabetic hypertensives) was similar for M (37%) and E (40%). The reduction of 24-h BP also was similar between M (n = 38) and E (n = 38) for both drugs (systolic, 6 +/- 11 and 8 +/- 10 mm Hg; diastolic, 5 +/- 8 and 5 +/- 7; NS, M vs. E). The antihypertensive effect was distributed in a similar homogeneous fashion throughout the dosing interval, as shown by the similar SI values (M, 0.6 +/- 1.2 for SBP and 0.6 +/- 0.9 for DBP; E, 0.6 +/- 0.8 for SBP and 0.5 +/- 0.7 for DBP; NS, M vs. E). O and A HR were unchanged by either treatment. Markers of glucose and lipid metabolism and renal function were not significantly modified by treatment both with M and with E. In the diabetic hypertensives, M was as effective and metabolically neutral as the ACE-inhibitor E.

Diuretics and beta-blockers: is there a risk for dyslipidemia?

BACKGROUND

Hypertension is a major risk factor for cardiovascular disease, particularly in combination with other risk factors such as obesity, smoking, diabetes, and dyslipidemia. Effective management of hypertension, even a modest reduction in blood pressure, results in reduced mortality and morbidity from cerebrovascular and cardiovascular disease.

METHODS

Data from clinical trials were examined to assess the effect of low-dose diuretics or beta-blockers on lipoprotein profile.

RESULTS

Results of numerous clinical trials demonstrate that low doses of thiazides or cardioselective beta-blockers alone or in combination result in minimal changes in lipid profile.

CONCLUSIONS

Low doses of thiazide diuretics or beta-blockers are a safe and effective approach to the management of uncomplicated essential hypertension and have the advantage of an association with an evidence-based reduction in morbidity and mortality in long-term clinical trials. There is little or no evidence that the minimal changes in serum lipid profile associated with use of these drugs have resulted in a negation of the beneficial effects of these agents on blood pressure.

Special considerations in the therapy of diabetic hypertension

Patients with diabetes mellitus have an increased prevalence of hypertension and associated cardiovascular disease (CVD), including coronary and cerebrovascular disease. The risk of an individual of developing CVD is much greater when both diseases coexist and is further magnified by their frequent association with dyslipidemia, coagulation, platelet, and endothelial abnormalities. Metabolic abnormalities frequently associated with hypertension are insulin resistance, enhanced coagulation, and decreased fibrinolytic activity. Drug treatment of hypertension in diabetic subjects is fraught with potential difficulties, including altered efficacy of medications, possible side effects, worsening of glycemic control, and impairment of lipid metabolism. Because hypertension is a major contributor to morbidity and mortality in diabetes, it should be recognized and treated early and aggressively despite these difficulties. This article reviews the efficacy and side effects of the various classes of antihypertensive agents in patients with diabetes mellitus.

Metabolic effects of temocapril in hypertensive patients with diabetes mellitus type 2

Compared with other angiotensin-converting enzyme (ACE) inhibitors, the elimination of temocapril is less dependent on renal function. To investigate the metabolic and antihypertensive effects of temocapril in diabetic hypertensives, 30 patients with diabetes mellitus type 2 and mild to moderate hypertension [diastolic blood pressure (BP) 90-115 mm Hg] and without azotemia (plasma creatinine < 180 microM) were evaluated in a prospective randomized double-blind placebo-controlled study. After a 4-week placebo run-in, they received temocapril, 20 mg daily (n = 19), or placebo (n = 11) for 6 weeks. Insulin sensitivity index (SI), determined by the Minimal Model method of Bergman, serum lipoproteins, plasma renin activity, fibrinogen, and microalbuminuria were assessed at the end of the placebo run-in phase and the double-blind treatment phases. Temocapril but not placebo administration produced a significant decrease in supine BP (152/92+/-5/3 vs. 162/98+/-5/2 mm Hg; p < 0.01) and increase in plasma renin (p < 0.05). Variation of SI during temocapril treatment did not reach statistical significance (0.95+/-0.2 before vs. 1.44+/-0.4 x 10(-4)/min/mU/L after treatment). During administration of temocapril or placebo, no significant changes in fasting plasma glucose, insulin, and serum levels of total triglycerides, cholesterol, lipoprotein cholesterol fractions, or fibrinogen were observed. Microalbuminuria decreased significantly on temocapril treatment (49+/-10 vs. 79+/-17 mg/24 h; p < 0.01) but not on placebo. These findings demonstrate that in hypertensive patients with diabetes mellitus type 2, short-term treatment with temocapril is neutral to insulin sensitivity, lipoprotein metabolism, and fibrinogen, and significantly reduces microalbuminuria.

Long-term morbidity and mortality trials with amlodipine

Prospective controlled clinical trials with cardiovascular events and mortality as end points are needed to provide clinicians with a fully informed choice of optimal hypertensive therapy. Seven trials (six of them still ongoing) have provided insight into the effects of the third-generation calcium antagonist, amlodipine, on mortality and end-organ damage in patients with hypertension or other forms of cardiovascular disease. The completed PRAISE study has addressed the safety of amlodipine in patients with advanced heart failure (CHF). The trial showed that amlodipine does not increase mortality or morbidity in CHF patients and significantly reduces the risk for these end points in patients whose CHF has a nonischemic etiology. The PRAISE-2 study is now under way to further evaluate the benefits of amlodipine in nonischemic CHF patients. The ALLHAT trial compares the effects of standard diuretic treatment with three alternative treatments (amlodipine, lisinopril, and doxazosin) on the incidence of fatal coronary artery disease (CAD) and nonfatal myocardial infarction (MI) in 40,000 hypertensive patients. The ASCOT trial compares the effects of amlodipine +/- perindopril with atenolol +/- bendrofluazide on fatal CAD and nonfatal MI in 18,000 high-risk patients. The PREVENT trial tests a similar hypothesis, looking at the effects of amlodipine on arterial atherosclerotic lesions, and the AASK trial is evaluating the effects of amlodipine on renal disease. The PRAISE trial has provided valuable information on the safety and efficacy of amlodipine in preventing death and disability in patients with CHF. The six ongoing trials will provide important additional information on the effect of amlodipine in patients with heart disease of other etiologies.

Serum lipid physiology and the influence of glaucoma medications

Understanding the effect of serum lipid levels on risk factors for coronary heart disease and how they are influenced by medical therapy may lead to overall better care of the glaucoma patient. Elevated low-density lipoprotein and total cholesterol levels are major risk factors for heart disease. In contrast, high-density lipoprotein (HDL) is protective for heart disease. beta-adrenergic blockers, a class of medicines used to treat glaucoma, may influence serum lipid levels. Oral nonselective beta-adrenergic blockers reduce HDL cholesterol by 19% and increase triglycerides by 20-40%. Furthermore, topical nonselective beta-adrenergic blockers also decrease serum HDL and worsen the total cholesterol/HDL ratio. However, beta-blockers with intrinsic sympathomimetic activity appear to be lipid neutral. At present, there is no clear clinical evidence to indicate that changes in serum lipids with use of topical beta-adrenergic blockers significantly affect the clinical course of the patient. Little information is available for other classes of medicines used topically to treat glaucoma. However, oral preparations of prostaglandins, alpha-adrenergic agonists, angiotensin-converting enzyme inhibitors, and calcium channel blockers do not adversely affect serum lipid levels. Further study is required on newer glaucoma preparations to determine their specific actions on lipid levels. Additionally, further work is required to understand the significance of not only the adverse effect of beta-adrenergic blockers on lipid levels, but their overall effect on long-term cardiac morbidity and mortality.

Fixed combination of benazepril and low-dose amlodipine in the treatment of mild to moderate essential hypertension: evaluation by 24-hour noninvasive ambulatory blood pressure monitoring

The antihypertensive efficacy and tolerability of a fixed combination of benazepril (10 mg) and low-dose amlodipine (2.5 mg) were assessed in 24 patients (mean age, 43.9 years) with uncomplicated mild to moderate essential hypertension [supine diastolic blood pressure (DBP) > or = 95 and < or = 120 mm Hg)]. After 2 weeks of washout taking placebo, patients were randomized to receive the fixed combination or placebo, both administered once daily for 3 weeks, according to a double-blind, crossover design. Patients were checked at the end of the washout period and every 3 weeks thereafter. At each visit, 24-h ambulatory BP monitoring (ABPM) was performed by a noninvasive device (Spacelabs 90207); casual BP (by mercury sphygmomanometer), heart rate (HR), and body weight also were measured. The fixed combination significantly reduced systolic (SBP) and DBP values throughout the 24 h as compared with placebo, without affecting the normal BP circadian variability. The antihypertensive effect of the fixed combination could be observed to a similar extent during the day and night and was still significant 24 h after dosing. HR and body weight were not affected by the treatment. The fixed combination of benazepril 10 mg/amlodipine 2.5 mg was well tolerated, and no patient withdrew from the study because of side effects.

Effects of calcium antagonists on insulin sensitivity and other metabolic parameters

The antihypertensive efficacy of calcium antagonists appears to be comparable to that of oral diuretics when used as monotherapy. Peripheral vascular dilation appears to be the principal mechanism of the long-term blood pressure-lowering effects of calcium antagonists. The calcium antagonists appear to have beneficial effects with respect to maintenance of renal blood flow and glomerular filtration rate. Metabolic abnormalities associated with diuretic and beta-blocker antihypertensive therapy, such as hypokalemia, hypercalcemia, hyperuricemia, lipid changes, and hyperglycemia, are generally not observed with calcium antagonists.

Effects of atenolol versus enalapril on cardiovascular fitness and serum lipids in physically active hypertensive men

An ideal drug regimen for physically active hypertensive patients should not offset exercise-induced improvements in cardiovascular health or fitness. In this randomized, double-blind, placebo-controlled, crossover study of 39 physically active men with uncomplicated essential hypertension, we compared the effects of atenolol and enalapril on cardiovascular fitness and serum lipids. Drugs (atenolol, 50 or 100 mg once daily; enalapril, 10 or 20 mg once daily) were each administered for 4 weeks and each active drug period was preceded by 4 weeks of placebo therapy. Both drugs effectively (p < 0.001) lowered resting blood pressure when measured at the time of theoretical peak (i.e., 3 to 4 hours postdrug) and trough (i.e., 24 hours postdrug) drug blood levels. Atenolol reduced maximal oxygen uptake (by 7.3%, p < 0.001) 3 to 4, but not 24, hours after drug ingestion; no changes occurred with enalapril. Similarly, whereas serum lipids were essentially unchanged with enalapril, serum triglycerides (18.9% increase), high-density lipoprotein cholesterol (10.6% decrease), and ratio of low-density to high-density lipoprotein cholesterol (15.4% increase) were adversely impacted (p < or = 0.05) with atenolol. It is concluded that in contrast to enalapril, atenolol adversely impacts cardiovascular fitness and serum lipids and lipoproteins in physically active hypertensive men.

Requirements for antihypertensive therapy in diabetic patients: metabolic aspects

AIM OF ANTIHYPERTENSIVE TREATMENT IN DIABETICS: Prevention or treatment of hypertensive in diabetic patients reduces the incidence and progression of diabetic complications of retinopathy and nephropathy, cerebro- and cardio-vascular disease, and widespread macroangiopathy. Therefore, in patients with diabetes and hypertension beside good glucose control, the basic and probably major intervention steps is to normalize blood pressure. Antihypertensive treatment usually means life-long use of antihypertensive drugs. METABOLIC EFFECTS OF DIFFERENT DRUG CLASSES: Given the known diabetogenic properties of several antihypertensive drugs and their high rate of use, in probably a substantial proportion of patients with diabetes or prone to develop diabetes, treating arterial hypertension with conventional diuretics and/or beta-blockers might, in the long term, offset the beneficial effects of lowering blood pressure. Furthermore, there are conflicting reports of increased mortality in patients treated with diuretics, beta-blockers or calcium antagonists. Consequently, metabolic aspects and side effects of antihypertensive drugs are key elements in determining the preference for a specific antihypertensive regimen. Although the impact of hyperinsulinemia/insulin resistance on morbidity and mortality is an open question, it is preferable that antihypertensive treatment does not increase insulin resistance and/or hyperinsulinemia. Chronic beta-blocker treatment can be accompanied by an increase in insulin resistance. Calcium antagonists and angiotensin converting enzyme (ACE) inhibitors and alpha(1)-blockers are neutral or might even improve insulin resistance and lipid profile. Thiazides impair glucose tolerance, increase low-density lipoprotein cholesterol and decrease potassium, although these side effects are dose-dependent. Unless diuretics are needed for reasons other than hypertension, treatment of diabetics with thiazides should be avoided until the influence of these agents on prognosis is clarified. If the addition of a diuretic is needed, the metabolically neutral indapamide would seem a reasonable choice. PREFERRED FIRST-LINE TREATMENT: On the basis of favorable pharmacological profiles, ACE inhibitors and certain calcium antagonists have emerged as the preferred first-line drugs in the treatment of the hypertensive diabetic patient. In diabetics with nephropathy, therapy is usually initiated with an ACE inhibitor. Moreover, the combination of an ACE inhibitor and a calcium antagonist that lowers the heart rate (such as verapamil) might offer even greater advantages than either class of drug alone, since they combine metabolic neutrality with added antihypertensive and renal protective efficacy.

Metabolic manifestations of low-dose diuretics

Hypertension has been defined and treated as a disease of abnormal systolic and diastolic blood pressure. Recent data have, however, demonstrated that effective blood-pressure control has not resulted in the expected decrease in coronary artery disease. These findings are probably a result of hypertension being a complex inherited syndrome of cardiovascular risk factors, all of which are genetically linked and all of which contribute to the development of cardiovascular disease in these patients. Included in the hypertension syndrome are abnormalities of lipid profile, insulin resistance, changes in renal function, left ventricular hypertrophy and reduced arterial compliance. In many patients, high blood pressure is a late manifestation of this disease process. Since all cardiovascular risk factors contribute to heart disease in these patients, they should all be considered in the management of this disease process. Diuretics and beta blockers, when used at high doses, negatively impact lipid metabolism and insulin sensitivity, while angiotensin converting enzyme (ACE) inhibitors and calcium antagonists tend to have a neutral effect on these metabolic risk factors. These findings have resulted in decreased use of diuretics and beta blockers in favor of newer agents such as ACE inhibitors and calcium antagonists. However, recent data have demonstrated that when used at low doses (6.25 or 12.5 mg of hydrochlorothiazide), diuretics lack significant metabolic side effects while bringing about significant reductions in blood pressure. Thus, at these doses, hydrochlorothiazide is a useful drug in the treatment of hypertension, both as monotherapy and in combination therapy.

Effect of manidipine and delapril on insulin sensitivity in type 2 diabetic patients with essential hypertension

The open trial was designed to evaluate the effects of long-term antihypertensive treatment with the calcium-channel blocker, manidipine and the angiotensin converting enzyme (ACE) inhibitor, delapril on insulin sensitivity in Japanese non-insulin dependent diabetes mellitus (NIDDM) patients with essential hypertension. We measured the insulin sensitivity index (SI) and the glucose-effectiveness (SG) by the use of Bergman's minimal model method in 18 hypertensive NIDDM patients before and after administration of manidipine (group A) or delapril (group B) for 3 months. Manidipine treatment for 3 months significantly improved SI in group A from 3.35 +/- 0.61 (x 10(-4) min-1 microU-1 ml-1) to 4.70 +/- 1.34 (P < 0.05). Delapril treatment for 3 months also significantly improved SI in group B from 3.56 +/- 1.04 to 5.00 +/- 0.87 (P < 0.05). Manidipine significantly improved SG in group A from 1.60 +/- 0.64 (x 10(-2) min) to 2.19 +/- 0.38 (P < 0.05). Delapril treatment also significantly improved SG in the group B from 1.41 +/- 0.56 to 1.91 +/- 0.35 (P < 0.05). Manidipine and delapril did not affect urinary C-peptide excretion for 24 h in the hypertensive NIDDM patients. Treatment with manidipine or delapril significantly reduced systolic and diastolic blood pressures in the hypertensive NIDDM patients. There were no differences between plasma glucose, serum total triglycerides, and cholesterol or lipoprotein cholesterol fractions, heart rate and body weight after 3 months on manidipine or delapril. This study confirmed the improving effects on SI and SG by long-term treatment with manidipine or delapril in the hypertensive NIDDM patients.

Metabolic neutrality of perindopril: focus on insulin sensitivity in overweight patients with essential hypertension

To assess the effects of antihypertensive treatment with the angiotensin-converting enzyme (ACE) inhibitor perindopril on insulin sensitivity, plasma insulin, and lipoprotein metabolism in overweight hypertensive patients, we measured the insulin sensitivity index (SI, determined according to the minimal model method of Bergman), fasting plasma insulin and glucose concentrations, serum total triglyceride and lipoprotein cholesterol fractions, and blood pressure (BP) in 30 overweight [mean body mass index (BMI) 30.9 kg/m2], nondiabetic patients with essential hypertension after a 4-week run-in period and after 6 weeks of perindopril (n = 20) or placebo (n = 10) administered in a double-blind fashion. Furthermore, we estimated their state of physical fitness using the Conconi bicycle ergometer test before and after perindopril or placebo administration. SI was low in our study population (3.2 vs. 13.3 10(-4) ml.microU-1.min-1 in normal lean control subjects). It did not differ between the perindopril and placebo group after the placebo run-in period (3.1 vs. 3.3 x 10(-4) ml.microU-1.min-1) and was not influenced by perindopril (3.3 x 10(-4) ml.microU-1.min-1) or placebo (3.6 x 10(-4) ml.microU-1.min-1) treatment. Moreover, no significant changes were apparent in fasting plasma insulin and glucose, the areas under the glucose and insulin curves, the glucose disappearance rates, serum total triglycerides (TG), or cholesterol or lipoprotein cholesterol fractions between run-in and active treatment phases in the perindopril or the placebo group, respectively. Heart rate (HR), body weight, and anaerobic threshold remained stable in both groups. Compliance, assessed by pill counting was > 90% in both groups at all visits. Therefore, the ACE inhibitor perindopril is neutral with regard to insulin sensitivity, plasma insulin and glucose, and lipoprotein metabolism in overweight, nondiabetic patients with essential hypertension.

Felodipine or hydrochlorothiazide/triamterene for treatment of hypertension in the elderly: effects on blood pressure, hypertensive heart disease, metabolic and hormonal parameters

The aim of the study was to compare the antihypertensive efficacy of either felodipine or the diuretic combination hydrochlorothiazide/triamterene in a group (n = 65) of elderly (> or = 70 years) hypertensives (office blood pressure > or = 160/95 mmHg) with special regard to ambulatory blood pressure monitoring, hypertensive heart disease and metabolic parameters. This was a randomized, double-blind study with a treatment period of 6 months. Reduction of office and 24-hr ambulatory blood pressure was comparable with both treatment regimens; after 6 months. 18 of 29 patients in the felodipine group (62%) and 20 of 27 patients in the diuretic group (74%; p = 0.4) were controlled. While episodes of ischemic type ST-segment depression were significantly reduced in the felodipine group (from 49 to 9 episodes), there was no significant change in the diuretic group (from 24 to 21 episodes). Both regimens decreased left ventricular wall thickness, but the decline in left ventricular muscle mass index was significant only for felodipine. Felodipine did not induce any change in metabolic or hormonal parameters; the diuretic combination significantly increased serum creatinine, uric acid, plasma renin activity, and plasma prorenin. Thus, the antihypertensive efficacy of felodipine and the diuretic combination was comparable in elderly hypertensives; only felodipine, however, improved parameters of hypertensive heart disease and showed a neutral metabolic and hormonal profile.

Effects of hydrochlorothiazide and captopril on lipoprotein lipid composition in patients with essential hypertension

OBJECTIVE

Effective antihypertensive agents may differ in their capacity to reduce cardiovascular risk because they induce potentially atherogenic alterations in lipoprotein composition.

PATIENTS

To assess this possibility, the effects of five months' treatment with either hydrochlorothiazide (HCTZ) or the converting enzyme inhibitor captopril (CAPT) on lipoprotein lipid composition were compared in thirty normolipidaemic patients with essential hypertension (EH).

RESULTS

The sixteen patients treated with HCTZ showed the expected directional alterations in plasma TG (+31%), HDL2-C (-16%), and CHOL (+7.6%); in contrast TG and CHOL were unchanged after captopril in fourteen patients and their HDL2-C declined (-16%). Neither drug altered lipoprotein core lipid composition, but small increases were observed in the HDL2 sphingomyelin/lecithin ratio after both agents. The plasma free (unesterified) cholesterol (FC) lecithin (L) ratio, a new index of cardiovascular risk, was abnormally increased before treatment and was not altered by either drug.

CONCLUSION

These findings indicate that HCTZ and CAPT treatment have small, but demonstrable effects on lipoprotein surface lipid composition in patients with EH that are confined to the HDL2 subfraction.

Physiologic effects of long-term hypertension control

Various antihypertensive agents may reduce blood pressure to a similar degree, yet they produce different outcomes with respect to long-term end-organ damage. Effective antihypertensive therapy can prevent or even reverse established left ventricular hypertrophy. The most rapid and extensive regression occurs with agents that block the reninangiotensin system or reduce entry of calcium into the cells. Other classes of drugs that reliably reverse left ventricular hypertrophy are centrally acting adrenergic inhibitors and beta blockers. The effect of antihypertensive agents on atherosclerosis appears to differ widely with regard to lipid metabolism, insulin sensitivity, and the biology of endothelium and vascular smooth muscle. Hypertension and chronic renal failure (diabetic and nondiabetic) are closely allied, but available antihypertensive agents are not equally potent in reducing intraglomerular pressure.

Associations between serum lipids and indicators of adiposity in men with spinal cord injury

Several reports indicate that dyslipidemia, primarily depressed high density lipoprotein cholesterol, is common in persons with spinal cord injury. The purpose of this study was to assess the relationships between anthropometric and near infrared interactance measurements to the serum lipoprotein profiles of 46 men with spinal cord injury of > 6 months duration. Mean age (+/- SD) was 49.5 +/- 15.0 y and duration of injury was 17.5 +/- 13.0 y. Forty-one percent of the subjects had low high density lipoprotein cholesterol (< 35 mg dl-1) and 57% had elevated total cholesterol to high density lipoprotein cholesterol ratios (> 4.5). Abdominal circumference was most closely associated with the overall lipid profile and abdominal circumference/height ratio was the second strongest correlate. Body mass index, conicity index, and percent body fat estimated by near infrared interactance were significantly related to some lipid parameters; however, the relationships were weaker than for abdominal circumference or abdominal circumference/height. Significant correlations were found between abdominal circumference and serum high density lipoprotein cholesterol (r = -0.421, P < 0.01) and log10 triglyceride (r = 0.587, P < 0.001) concentrations as well as the total cholesterol:high density lipoprotein cholesterol (r = 0.482, P < 0.01) and low density lipoprotein cholesterol-to-high density lipoprotein cholesterol (r = 0.387, P < 0.05) ratios. Based on these findings, the sample was partitioned by abdominal circumference into low (< 95 cm), moderate, and high (> or = 102 cm) risk subgroups.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative effects of atenolol versus celiprolol on serum lipids and blood pressure in hyperlipidemic and hypertensive subjects

Antihypertensive drugs may affect serum lipoprotein levels in mixed populations but data in hyperlipidemic patients are scanty. Atenolol versus celiprolol effects on serum lipoproteins were compared in 159 hyperlipoproteinemic hypertensive patients. This was a randomized, double-blind, parallel-group, positive-controlled multicenter trial with centralized lipoprotein laboratory and diet constancy monitoring. Blood pressure reduction and serum lipoprotein and apoprotein levels were monitored for 3 months. Both drugs reduced systolic and diastolic blood pressures. Atenolol had greater effects than celiprolol on diastolic pressure, but effects on systolic blood pressure were not different. Patients receiving atenolol had lower serum high-density lipoprotein cholesterol levels and higher low-density lipoprotein/high-density lipoprotein cholesterol ratios, whereas patients treated with celiprolol showed no contrasting changes. These differences in lipoprotein levels between drug treatment groups were statistically significant at weeks 9 and 12. The difference between drug treatments was also significant if the values of the 9- and 12-week visits were averaged. Patients taking atenolol had statistically significantly higher serum levels of total cholesterol, triglycerides and apoprotein B at 9 weeks. These divergent directional changes were consistent throughout and statistically significantly different between drugs.

Disparate cardiovascular response to stress tests during isradipine and fosinopril therapy

Optimal antihypertensive therapy should control blood pressure at rest and during stress while preserving the physiologic hemodynamic response. In patients with mild to moderate hypertension, the hemodynamic profile and catecholamine response at rest, during isometric, mental, and orthostatic stresses were compared before and 12 weeks after angiotensin-converting enzyme inhibition or calcium channel blockade. Antihypertensive therapy was titrated either with the angiotensin-converting enzyme inhibitor fosinopril (10 to 40 mg; n = 9) or with the calcium antagonist isradipine (5 to 20 mg; n = 10) until diastolic blood pressure < 90 mm Hg was achieved. Groups were comparable in race, sex, body mass index, pretreatment mean arterial pressure and response to isometric stress (25% increase in mean arterial pressure) before treatment. At rest, total peripheral resistance was reduced to the same extent (18%) in both groups. After fosinopril, the percent increase in stroke volume was higher and heart rate lower than with isradipine. During isometric stress, the percent increase in mean arterial pressure and cardiac output was higher, with isradipine (p < 0.05) reaching pretreatment levels. Plasma catecholamines were also higher with isradipine (p < 0.05), increasing by 100% with plasma norepinephrine compared with 16% before treatment. During orthostatic stress significant reductions in mean arterial pressure and stroke volume were observed after isradipine but not after fosinopril. Neither medication significantly modified the response to mental stress. Our data suggest that despite a comparable reduction in total peripheral resistance at rest, fosinopril preserves a more physiologic hemodynamic response to isometric and orthostatic stress than isradipine.(ABSTRACT TRUNCATED AT 250 WORDS)

Contrasting effects of pyrazinoylguanidine and hydrochlorothiazide in patients with renal insufficiency

A single blind crossover study with washout phases showed that pyrazinoylguanidine (PZG) reduced elevated serum concentrations of urea, triglycerides, and cholesterol in patients with renal insufficiency. Pyrazinoylguanidine was saluretic, without affecting serum potassium or glucose concentrations. The onset of PZG's antihypertensive effect occurred within 4 hours. In contrast, hydrochlorothiazide (HCTZ) increased serum concentrations of urea, triglycerides, and glucose, without affecting cholesterol.

Lack of effect of long-term amlodipine on insulin sensitivity and plasma insulin in obese patients with essential hypertension

To evaluate the effects of long-term treatment antihypertensive with the dihydropyridine calcium antagonist amlodipine on insulin sensitivity, plasma insulin, and lipoprotein metabolism in obese hypertensive patients. We measured the insulin sensitivity index (SI), determined by the Minimal Model Method of Bergman, fasting plasma insulin and glucose concentrations, serum total triglyceride and lipoprotein cholesterol fractions, and blood pressure in 20 obese, non-diabetic patients with essential hypertension before and after 6 weeks of placebo and again after 6 months of amlodipine. Ten patients [mean body mass index (BMI) 30.2 kg.m-2] had been on prior treatment with a thiazide diuretic in low dosage and/or a beta-adrenoceptor blocker (group A), and 10 matched patients [BMI 31.8 kg.m-2] had been previously untreated (group B). Amlodipine was started in a dose of 5 mg and was increased to 10 mg once daily in 14 patients who were hypertensive after 8 weeks on the lower dosage. At entry (before placebo), SI was slightly but not significantly lower in group A than B [2.7 vs. 3.6 x 10(-4) ml.microU-4.min-1]; fasting plasma insulin was 13.6 vs. 12.9 microU.ml-1. After 6 weeks on placebo, S1 averaged 3.7 in group A and 4.4 x 10(-4) microU.ml-1.min-1 in group B; fasting plasma insulin was 14.6 vs. 15.1 microU.ml-1, and glucose 5.5 vs. 5.5 mmol.l-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathogenesis and treatment of hypertension associated with diabetes mellitus

The pathogenesis of hypertension associated with diabetes mellitus (DM) involves an interplay of hereditary and acquired mechanisms. A familial trait for essential hypertension appears to be a risk factor for the development of both hypertension and nephropathy in type I DM and coexists commonly with impaired insulin sensitivity, relative hyperinsulinemia, and dyslipidemia, which can already be detected before the appearance of hypertension, obesity, or upper abdominal redistribution of body fat. The latter finding helps explain the frequent development of hypertension as well as dyslipidemia and/or type II DM in given individuals. Obesity is an important factor promoting these complications. Type I or II DM but not uncomplicated essential hypertension is characteristically accompanied by excess body Na+. This abnormality complements a tendency toward vascular hyperreactivity and a presumably morphologic and functional vasculopathy, thereby promoting the pathogenesis of hypertension in diabetic patients. For the treatment of hypertension in diabetic patients, nonpharmacologic measures are indispensable. If drugs are needed, angiotensin-converting enzyme (ACE) inhibitors and some but not all calcium antagonists are the preferred agents. Monotherapy or a combination of these drug types allows effective blood pressure control in most diabetic patients without further metabolic impairment; ACE inhibitors even tend to improve glucose control. Ketanserin may be a potential alternative, and if a diuretic is also needed, the metabolically neutral indapamide is a reasonable choice. If these agents do not allow satisfactory blood pressure highly selective beta 1-blockers or alpha 1-blockers may be introduced as a second choice. In diabetic patients with nephropathy, effective antihypertensive therapy can reduce proteinuria and slow the progression of the nephropathy; ACE inhibitors may improve diabetic proteinuria even at unchanged systemic blood pressure levels. Unless diuretics are needed for reasons other than hypertension, the treatment of diabetic patients with thiazides or loop diuretics in conventional dosage should probably be avoided until clarification of their influence on prognosis. Nevertheless, whether and to what extent other agents and nonpharmacologic measures can modify the prognosis in diabetic patients is also unclear, and the approach to antihypertensive therapy is therefore still largely empiric.

Risk factors not addressed in antihypertensive therapy based solely on blood pressure control

There has been a considerable revolution in the field of hypertension therapy. We have gone through an era in which patients with severe hypertension and those with accelerated hypertension had a very short life expectancy. Currently blood pressure can be readily controlled with a marked improvement in longevity. We have gone from an era in which stroke was common due to hypertensive cardiovascular disease to an era in which patients are effectively treated and there has been a marked reduction in the incidence of stroke. The challenge is whether we can reduce the very high mortality due to coronary artery disease in patients with hypertension as we have done with stroke. New groups of drugs that may have a more favorable effect on metabolic and hemodynamic risk considerations have been developed over the last decade. These agents may reduce the risk for coronary heart disease to a greater extent than previously employed therapy. While there are no randomized placebo-controlled studies demonstration this, a theoretical basis does exist to give the physician reason to think about prioritizing therapies and tailoring them to the needs of the individual patient.

Cyclosporin A has no impact on alterations of the lipid profile after renal transplantation

The literature contains conflicting ideas regarding the role of cyclosporin A (CyA) in the induction of posttransplant dyslipidemia. The available studies contain small numbers of patients, especially on CyA monotherapy. We compared 65 patients on conventional azathioprine-prednisone therapy (AP) with 85 patients on CyA monotherapy, 19 on CyA-azathioprine therapy (CA), 20 on CyA-prednisone therapy (CP), and 52 on a triple therapy with CyA, azathioprine, and prednisone (CAP). From the results, it is concluded that patients on CyA monotherapy had lower serum cholesterol levels, with a lower high-density lipoprotein (HDL)-cholesterol level, probably due to the lower total cholesterol, compared with AP patients. From all groups, the CyA monotherapy group showed the most beneficial lipid profile. No additive negative influences of CyA when combined with other immunosuppressive drugs were noted. Thus, a correlation between derangements of the lipid profile and CyA therapy could not be confirmed. Further analysis of our data showed negative influences of antihypertensive treatment on lipid metabolism, particularly in the case of treatment with beta-blockers or diuretics. It cannot be excluded that studies showing a negative influence of CyA therapy on lipid homeostasis were biased by secondary factors like antihypertensive therapy, which was often not taken into account.