ACE-inhibitor therapy with spirapril increases nocturnal hypotensive episodes in elderly hypertensive patients

Nocturnal hypotension in patients after ischemic stroke: does it really matter?

BACKGROUND

We aimed to evaluate the presence of nocturnal hypotension (NHP) in ischemic stroke (IS) survivors using ambulatory blood pressure (BP) monitoring (ABPM).

METHODS

We included fifty consecutive patients presenting at our outpatient clinic for review and who had been discharged for IS in the previous six months. 24-h ABPM was performed with Spacelab 90207 monitor. NHP episodes were considered those values on which the mean arterial pressure (MAP)<70mm Hg. Patients were divided into two groups according to the presence or absence of NHP.

RESULTS

We studied 31 men and 19 women, mean age 68±11years. Episodes of NHP were observed in 21 patients (42%). There were no significant differences with regard to clinical characteristics between groups. With regard to BP, patients with NHP had significantly lower mean 24-hour BPs, mean daytime BPs and mean nighttime BPs. Dipper pattern occurred more often in patients with NHP, although differences were only statistically significant in the diastolic BP values. Mean office readings were 142±26/77±13mm Hg (149±26 versus 133±20; P=0.06; 82±12 versus 71±12; P=0.008). None of the patients showed office SBP <90mmHg and only four had office DBP <60mmHg.

CONCLUSIONS

Episodes of NHP in patients with recent IS are common and difficult to detect with clinical cuff measurements. It is necessary to redefine the target BP levels in secondary stroke prevention, possibly because we are subjecting our patients to increased risk of NHP and cerebral hypoperfusion.

Blood pressure responder rates versus goal rates: which metric matters?

Reducing blood pressure (BP) to guideline-recommended goals associated with reductions in cardiovascular risk is central to effective hypertension management. In addition to measuring BP reduction, clinical trials of antihypertensive agents should assess the percentage of patients responding to treatment. The Food and Drug Administration's defined rate of response required for drug approval is a reduction in diastolic BP (DBP) to <90 mmHg and/or a DBP reduction of > or = 10 mmHg. Consequently, some patients may be counted as responders even if they have not reached DBP <90 mmHg. An antihypertensive agent's effectiveness may be better assessed by the proportion of patients who achieve recommended BP goals. This article analyzes the frequency of response rates versus goal rates as endpoints in randomized trials since January 2001. Data showed that goal rates, especially combined systolic BP (SBP)/DBP goal rates, are consistently lower than response rates in studies evaluating both endpoints. Goal rates incorporating both SBP and DBP, or having a focus on SBP for individuals >50 years of age, provide the most clinically relevant information and are a more clinically relevant metric of an agent's ability to reduce BP than DBP alone.

Zofenopril versus Lisinopril in the Treatment of Essential Hypertension in Elderly Patients

BACKGROUND

Angiotensin-converting enzyme inhibitors have been proposed as first-choice drugs for antihypertensive therapy in elderly subjects because of their demonstrated efficacy and safety. However, no information is currently available on the use of zofenopril in elderly hypertensive patients.

OBJECTIVE

To assess the efficacy and safety of zofenopril (30 or 60mg once daily) compared with lisinopril (10 or 20mg once daily).

PATIENTS AND METHODS

Patients aged >/=65 years with mild to moderate essential hypertension (sitting diastolic blood pressure [DBP] >/=90mm Hg and </=110mm Hg) were included in the study. They were randomised to receive either zofenopril 30mg or lisinopril 10mg. Blood pressure and heart rate were measured at baseline and after 4 and 12 weeks of treatment. Patients underwent electrocardiography and evaluation of laboratory parameters at baseline and after 12 weeks. Ambulatory blood pressure monitoring (ABPM) was also performed at baseline and after 12 weeks. After 4 weeks drug doses were doubled in patients whose sitting DBP was >/=90mm Hg. The primary endpoint was to achieve sitting DBP values <90mm Hg or a reduction of sitting DBP >10mm Hg after 12 weeks of treatment.

RESULTS

181 patients were randomised to treatment and 164 patients completed the study. Thirty-three patients were included in the analysis of 24-hour blood pressure monitoring. The percentage of patients with normalised sitting DBP (<90mm Hg) and the rate of treatment responders (reduction of sitting DBP >/=10mm Hg) were not significantly different between the two treatment groups (normalised: zofenopril 81.3% vs lisinopril 76.7%; responders: zofenopril 74.7% vs lisinopril 77.8%). At the end of the treatment sitting DBP was not significantly different between the two treatment groups (zofenopril 82.2 +/- 6.6mm Hg vs lisinopril 82.0 +/- 7.8mm Hg). Eight percent of patients experienced adverse events in the zofenopril group and 9% in the lisinopril group. A small percentage of adverse events (4%) was related to treatment and reported in the zofenopril group.

CONCLUSIONS

In elderly hypertensive patients, treatment with zofenopril was effective and well tolerated. Efficacy and safety were comparable with those of lisinopril.