The CARE Study: a postmarketing evaluation of ramipril in 11,100 patients. The Clinical Altace Real-World Efficacy (CARE) Investigators

Hypertension in Athletes and Active Populations

Hypertension continues to be the most common cardiovascular disorder in the USA and worldwide. While generally considered a disorder of aging individuals, hypertension is more prevalent in athletes and the active population than is generally appreciated. The timely detection, diagnosis, and appropriate treatment of hypertension in athletes must focus on both adequately managing the disorder and ensuring safe participation in sport while not compromising exercise capacity. This publication focuses on appropriately diagnosing hypertension, treating hypertension in the athletic population, and suggesting follow-up and participation guidelines for athletes.

Factors that favor the occurrence of cough in patients treated with ramipril--a pharmacoepidemiological study

Background

Dry cough is a common cause for the discontinuation of ramipril treatment. The aim of this pharmacoepidemiological study was to assess the incidence of ramipril-related cough among the Polish population and to characterize patients at risk of experiencing the adverse effect of cough during ramipril treatment.

Material/Methods

This was a prospective observational study involving 10,380 patients treated with ramipril for a period of no longer than 8 weeks, consisting of 3 visits: baseline, first follow-up (after 4–8 weeks) and second follow-up visit (after 4–8 weeks of cessation of ramipril, conducted only for evaluating coughing patients).

Results

The incidence of ramipril-related cough was 7.1%. Logistic regression analysis identified female sex (OR=1.35), cigarette smoking (OR=2.50), chronic obstructive pulmonary disease (OR=1.70), asthma (OR=1.60) and previous history of tuberculosis (OR=6.20) to be significantly and independently associated with the onset of ramipril-related cough.

Coughing subsided within a period of 2–20 days after ramipril was discontinued. In all patients reporting the appearance of cough within the first 5 days after therapy initiation, the adverse effect subsided after therapy discontinuation. If cough appeared within 6–10 days, it subsided after discontinuation in 81.6% of subjects. Cough persisted in 30.4% of those reporting later onset.

Conclusions

1. Female sex, cigarette smoking, COPD, asthma, and previous history of tuberculosis increase the risk of ramipril-related cough. 2. The later the cough occurs during treatment, the less often the drug is the causative agent and the cough and also less likely to disappear after discontinuation of ramipril.

Zofenopril and incidence of cough: a review of published and unpublished data

OBJECTIVE

Cough is a typical side effect of angiotensin-converting enzyme (ACE) inhibitors, though its frequency quantitatively varies among the different compounds. Data on the incidence of cough with the lipophilic third-generation ACE inhibitor zofenopril are scanty and never systematically analyzed. The purpose of this paper is to give an overview on the epidemiology, pathophysiology, and treatment of ACE inhibitor-induced cough and to assess the incidence of cough induced by zofenopril treatment.

METHODS

Published and unpublished data from randomized and postmarketing zofenopril trials were merged together and analyzed.

RESULTS

Twenty-three studies including 5794 hypertensive patients and three studies including 1455 postmyocardial infarction patients exposed for a median follow-up time of 3 months to zofenopril at doses of 7.5-60 mg once-daily were analyzed. The incidence of zofenopril-induced cough was 2.6% (range 0%-4.2%): 2.4% in the hypertension trials (2.4% in the double-blind randomized studies and 2.4% in the open-label postmarketing studies) and 3.6% in the doubleblind randomized postmyocardial infarction trials. Zofenopril-induced cough was generally of a mild to moderate intensity, occurred significantly (P < 0.001) more frequently in the first 3-6 months of treatment (3.0% vs 0.2% 9-12 months), and always resolved or improved upon therapy discontinuation. Zofenopril doses of 30 mg and 60 mg resulted in significantly (P = 0.042) greater rate of cough (2.1% and 2.6%, respectively) than doses of 7.5 mg and 15 mg (0.4% and 0.7%, respectively). In direct comparison trials (enalapril and lisinopril), incidence of cough was not significantly different between zofenopril and other ACE inhibitors (2.4% vs 2.7%).

CONCLUSION

Evidence from a limited number of studies indicates a relatively low incidence of zofenopril-induced cough. Large head-to-head comparison studies versus different ACE inhibitors are needed to highlight possible differences between zofenopril and other ACE inhibitors in the incidence of cough.

First-line antihypertensive treatment in patients with pre-diabetes: rationale, design and baseline results of the ADaPT investigation

BACKGROUND

Recent clinical trials reported conflicting results on the reduction of new-onset diabetes using RAS blocking agents. Therefore the role of these agents in preventing diabetes is still not well defined. Ramipril is an ACE inhibitor (ACEi), that has been shown to reduce cardiovascular events in high risk patients and post-hoc analyses of the HOPE trial have provided evidence for its beneficial action in the prevention of diabetes.

METHODS

The ADaPT investigation ("ACE inhibitor-based versus diuretic-based antihypertensive primary treatment in patients with pre-diabetes") is a 4-year open, prospective, parallel group phase IV study. It compares an antihypertensive treatment regimen based on ramipril versus a treatment based on diuretics or betablockers. The primary evaluation criterion is the first manifestation of type 2 diabetes. The study is conducted in primary care to allow the broadest possible application of its results. The present article provides an outline of the rationale, the design and baseline characteristics of AdaPT and compares these to previous studies including ASCOT-BLPA, VALUE and DREAM.

RESULTS

Until March 2006 a total of 2,015 patients in 150 general practices (general physicians and internists) throughout Germany were enrolled. The average age of patients enrolled was 67.1 +/- 10.3 years, with 47% being male and a BMI of 29.9 +/- 5.0 kg/m2. Dyslipidemia was present in 56.5%. 37.8% reported a family history of diabetes, 57.8% were previously diagnosed with hypertension (usually long standing). The HbA1c value at baseline was 5.6 %. Compared to the DREAM study patients were older, had more frequently hypertension and patients with cardiovascular disease were not excluded.

CONCLUSION

Comparing the ADaPT design and baseline data to previous randomized controlled trial it can be acknowledged that AdaPT included patients with a high risk for diabetes development. Results are expected to be available in 2010. Data will be highly valuable for clinical practice due to the observational study design.

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

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

Efficacy and Safety of Amlodipine

BACKGROUND

This study set out to assess the safety and efficacy of amlodipine in two cohorts of patients who were attended in primary- and specialised-care centres, respectively.

METHODS

Prospective, observational, multicentre pharmacovigilance study including patients aged >18 years who presented with a diagnosis of hypertension (systolic blood pressure [SBP] >or=140 mm Hg and diastolic blood pressure [DBP] >or=90 mm Hg) of >6 months' duration, which was either untreated or uncontrolled, and who were followed up by general practitioners and specialists over a period of 4-6 months.

RESULTS

Of the total of 4277 patients included in the study, 2520 (58.9%) were attended in primary care and 1757 (41.1%) in specialised care. 2982 patients (69.7%) were receiving monotherapy, the rest were receiving combined therapy. Over the course of the study, 308 patients (7.2%) experienced adverse events related to the study drug, mostly mild to moderate in nature. There were 20 serious events, although none was related to the study drug. By the end of the study, 1617 patients (37.8%) had achieved the therapeutic goal (SBP <140 mm Hg and DBP <90 mm Hg), with the greatest degree of control being registered among patients receiving combined therapy compared with monotherapy (38.7% vs 35.7%), and in those treated in a specialised-care setting versus a primary-care setting (43.5% vs 33.8%; p < 0.005).

CONCLUSIONS

Amlodipine was shown to be a well tolerated and effective drug in one in three patients, and achieved the therapeutic goal in a higher proportion of patients at specialised-care centres compared with those in primary care, and in those receiving combined therapy compared with monotherapy.

Determinants of persistence in hypertensive patients treated with irbesartan: results of a postmarketing survey

BACKGROUND

Persistence is a key factor for long-term blood pressure control, which is of high prognostic importance for patients at increased cardiovascular risk. Here we present the results of a post-marketing survey including 4769 hypertensive patients treated with irbesartan in 886 general practices in Switzerland. The goal of this survey was to evaluate the tolerance and the blood pressure lowering effect of irbesartan as well as the factors affecting persistence in a large unselected population.

METHODS

Prospective observational survey conducted in general practices in all regions of Switzerland. Previously untreated and uncontrolled pre-treated patients were started with a daily dose of 150 mg irbesartan and followed up to 6 months.

RESULTS

After an observation time slightly exceeding 4 months, the average reduction in systolic and diastolic blood pressure was 20 (95% confidence interval (CI) -19.6 to -20.7 mmHg) and 12 mmHg (95% CI -11.4 to -12.1 mmHg), respectively. At this time, 26% of patients had a blood pressure < 140/90 mmHg and 60% had a diastolic blood pressure < 90 mmHg. The drug was well tolerated with an incidence of adverse events (dizziness, headaches,...) of 8.0%. In this survey more than 80% of patients were still on irbesartan at 4 month. The most important factors predictive of persistence were the tolerability profile and the ability to achieve a blood pressure target < or = 140/90 mmHg before visit 2. Patients who switched from a fixed combination treatment tended to discontinue irbesartan more often whereas those who abandoned the previous treatment because of cough (a class side effect of ACE-Inhibitors) were more persistent with irbesartan.

CONCLUSION

The results of this survey confirm that irbesartan is effective, well tolerated and well accepted by patients, as indicated by the good persistence. This post-marketing survey also emphasizes the importance of the tolerability profile and of achieving an early control of blood pressure as positive predictors of persistence.

The HOPE TIPS: The HOPE Study Translated into Practices

The HOPE TIPS study assessed the practicality and tolerability of ramipril titration to a target dose of 10 mg (as achieved in definitive efficacy studies) in a clinical practice setting. 3881 patients at high cardiovascular risk (HOPE study criteria) were recruited in primary and specialist care settings in 9 countries by 439 investigators. Dose titration of ramipril from 2.5 mg to 10 mg daily took place over 9-12 weeks. The mean age of the patients was 64 years, 60% were male and 79% Asian. The target dosage of 10 mg daily was reached in 73% of patients with 96% of patients achieving 5 mg or 10 mg daily. During the study period uncontrolled hypertension (> 160/90) was recorded in 15% of patients, myocardial infarction or unstable angina 1.6%, heart failure 0.4%, new diabetes 0.6%. Only 9.8% of patients discontinued treatment with 5.9% attributed to treatment side-effects and 4% related to cough. The large majority of patients in a wide range of clinical practice settings with high cardiovascular risk can be treated with ramipril titrated to 10 mg daily with good tolerability.

The KARTAN study: A postmarketing assessment of Irbesartan in patients with hypertension

BACKGROUND

An important purpose of postmarketing surveillance of drugs is to better characterize the safety profile of drug therapy in the clinical setting. Another goal is to confirm the effectiveness of these drugs in patients who are candidates for antihypertensive therapy and who may have been excluded from Phase III studies. Irbesartan is a long-acting angiotensin II-receptor blocker specific for the angiotensin 1-receptor subtype that, in clinical trials in patients with hypertension, reduces blood pressure.

OBJECTIVES

The KARTAN (this word was derived from the first and last syllables of Karvea [trademark of Bristol-Myers Squibb Group, Madrid, Spain] and irbesartan) study was designed to confirm and extend the findings from previous clinical trials using data from a large number of patients with hypertension treated with irbesartan in routine clinical practice. The primary goal was to assess the types and incidences of adverse drug reactions (ADRs) occurring at a low frequency (<0.05%) with irbesartan. The secondary objectives were to study the effect of irbesartan as an antihypertensive agent, to assess the types and incidences of the most frequent ADRs (>/=0.05%) occurring in routine clinical practice, and to detect possible interactions between irbesartan and other drugs frequently used in the primary care setting.

METHODS

This 6-month, observational, open-label, uncontrolled, national, longitudinal, prospective study was conducted by 852 primary care physicians across Spain. Men and women aged >/=18 years with mild to moderate hypertension who, in their physicians' opinion, should have been treated with irbesartan were included. Each patient was followed up for 6 months, attending visits at baseline (ie, the start of treatment) and 1, 3, and 6 months after the start of treatment. A sample size of 3219 patients was calculated for the detection of >/=1 low-incidence (<0.05%) ADR. After the baseline visit, therapy typically was begun with irbesartan 150 mg/d. The initial dose was titrated up, at 300-mg increments based on the patient's response, at each visit as needed to achieve the treatment goals (systolic blood pressure, <140 mm Hg; diastolic blood pressure, <90 mm Hg). Information regarding ADRs was collected on case-report forms designed for each visit and analyzed by the scientific committee of the study. All recruited patients were included in the tolerability analysis.

RESULTS

A total of 4887 patients were enrolled (2165 men, 2 772 women; mean [SD] age, 61.1 [11.0] years [range, 19-94 years]; 23.3% of patients were aged >70 years); 4612 were assessable for efficacy. One hundred eight patients (2.2%) experienced ADRs over the 6-month treatment period; 3 of these patients (0.1%) experienced >1 ADR. Of the total number of clinical manifestations of ADRs, 24 occurred at an incidence <0.05%. Irbesartan produced reductions in blood pressure that were statistically significant from the first visit (all p < 0.001), and 39.9% of the patients achieved the treatment goal at the end of the follow-up period.

CONCLUSION

In this postmarketing surveillance study of patients with hypertension treated in routine clinical practice, irbesartan showed a satisfactory tolerability profile that was consistent with that seen in randomized, controlled trials.

Blockade of the renin-angiotensin system in African Americans with hypertension and cardiovascular disease

There is overwhelming evidence that the renin-angiotensin system plays a significant role in the pathophysiology of hypertension and target organ damage. Agents that regulate the renin-angiotensin system, such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and aldosterone antagonists, are not only effective antihypertensive agents but can prevent target organ damage. Although diuretics remain the agents of first choice for the treatment of hypertension in African Americans, ACE inhibitors have a clear role in the management of these patients. ACE inhibitors (usually when used with a diuretic) have been shown to reduce morbidity and mortality in a wide range of patient groups. ACE inhibitors are infrequently used in African Americans because of a belief that these agents are ineffective in this racial group; however, when adequate dosing and appropriate combinations are used, ACE inhibitor therapy provides effective blood pressure control. In particular, the addition of diuretics to ACE inhibitor therapy ameliorates the racial differences in efficacy seen when ACE inhibitors are administered as monotherapy. Although further confirmation in additional clinical trials is required, increased use of these agents in African Americans will likely result in a reduction in target organ damage.

Efficacy of ramipril in therapy-resistant hypertension

In an open, 48-week study the antihypertensive efficacy of ramipril when administered as add-on therapy to existing triple antihypertensive treatment (diuretics, beta-blockers, vasodilators) was investigated in 56 patients (24 females, 32 males) with therapy-resistant hypertension. The main variable (sitting diastolic blood pressure) decreased from 112 mmHg at baseline to 91 mmHg at week 8 (p < 0.01) and remained stable thereafter until the end of the trial. The systolic blood pressure in the sitting position decreased from 175 mmHg at baseline to 146 mmHg at week 8 (p < 0.01) and also remained stable thereafter until the end of the trial. Ramipril doses between week 8 and the end of the trial were not changed in 82% of patients. 45% of patients were treated with 5 mg ramipril/day, 33% with 10 mg/day and 22% with 20 mg/day at the end of the study. Addition of ramipril allowed a reduction in the doses of concurrrent therapy, especially in relation to beta-blockers (p < 0.02) and vasodilators (p < 0.01). The safety was good--no serious adverse events were observed. Ramipril is, therefore, a suitable drug for the patients with therapy-resistant hypertension allowing reduction of the doses of concomitant medication.