Efficacy and Tolerability of Candesartan Cilexetil in Special Patient Groups

[Gerontology Issues in Cardiology Practice]

Increase in life expectancy during the second part of the 20th century is accompanied by increase in proportion of elderly and senile age population. However, despite the increase in life expectancy, the prevalence of most chronic diseases and functional impairments rises with age. Elderly and senile age is associated with the risk of cardiovascular diseases (CVD), therefore the problem of managing elderly patients with CVD becomes especially urgent.

Regression of left ventricular hypertrophy by a candesartan-based regimen in clinical practice The VIPE study

The VIPE study was a prospective, non-comparative, open-label clinical evaluation of 97 hypertensive patients (69.1% female; 68.9±9.5 years; mean blood pressure (BP) 160±12/90±9 mmHg) with echocardiographic evidence of left ventricular hypertrophy (LVH). Patients were treated for six months with a candesartan-based regimen (8 mg/16 mg + HCTZ 12.5 mg + additional drugs to lower BP < 140/90 mmHg). After six months, systolic/diastolic BP was decreased by 19.3±8/9.4±5 mmHg (p<0.001 for both), and left ventricular mass index (LVMI) decreased 17.01 g/m2 (95%CI: -13.2 to -20.99; p<0.001). During treatment with the candesartan-based regimen all echocardiographic parameters related to LVMI were significantly reduced and 28% achieved a target LVMI [< 134 g/m2 (men) and < 110 g/m2 (women) ]. No significant changes were observed in ejection fraction, shortening fraction or LV diastolic function. Univariate analysis showed that both age (p=0.03) and diabetes (p=0.029) were predictive of LVH regression.

Thus, a candesartan-based regimen for six months significantly reduced echocardiographic LVH in hypertensive patients in general practice. The drug was very well tolerated and no serious adverse events were reported.

The effect of chronic candesartan therapy on the metabolic profile and renal tissue cytokine levels in the obese Zucker rat

The effect of candesartan, an angiotensin-II type-1 receptor antagonist, on the metabolic profile and renal inflammation is unclear. We evaluated this relationship by feeding male lean (LZ) and obese (OZ) Zucker rats chow or chow with candesartan (23.5 mg/kg · diet) for 14 weeks (n = 6–8/treatment/body type). Candesartan reduced serum triglycerides, plasma creatinine, urine albumin, and renal cortical collagen and glycogen deposition in the OZ. An ELISA-based cytokine array revealed that candesartan normalized elevated renal interleukin (IL) 1-β and monocyte chemoattractant protein-1 (MCP-1) levels in OZ. Nonetheless, candesartan impaired glucose tolerance, and did not lower blood insulin or glucose levels. Moreover, renal IL-1α, -2, -4, -6 and -10 tumor necrosis factor-α, interferon-γ, were significantly reduced in OZ relative to LZ, and increased by candesartan. Furthermore, candesartan increased growth-regulated oncogene, transforming growth factor-β1 and IL-18 in OZ kidneys to a level higher than LZ or untreated OZ. Candesartan did not affect renal cytokine levels in LZ. Overall, candesartan attenuated renal disease and improved renal function in OZ, despite mixed effects on metabolic factors and cytokines. Reduced plasma triglycerides and/or renal MCP-1 and IL-1β may have had a role in this protection. However, these effects were clearly independent of any improvement in glucose tolerance.

Candesartan: from left ventricular hypertrophy to heart failure, a global approach

Cardiovascular disease is a continuum, starting with risk factors resulting from physiological changes and extending to vascular pathology associated with adverse clinical outcomes. The overactivation of the renin-angiotensin-aldosterone system has been related to the development and worsening of risk factors associated with cardiovascular diseases such as hypertension and heart failure. Treatment at each stage along the continuum may prevent, or at least delay, the next one, and so it is crucial to initiate therapy as early as possible in such patients so as to provide optimal care. Candesartan, a long-acting angiotensin receptor antagonist, has been shown to be an effective, and well-tolerated therapy, in both the early and late phases of cardiovascular disease (prehypertension, hypertension, left ventricular hypertrophy and heart failure). This article reviews the data supporting the use of candesartan in cardiovascular medicine, with a focus on left ventricular hypertrophy and ultimately heart failure. Particular emphasis is given to the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM) program, which has shown a positive impact of candesartan in patients with chronic heart failure in terms of reducing the incidence of cardiovascular deaths and chronic heart failure hospitalizations.

Electrocardiographic left ventricular hypertrophy regression induced by an angiotensin receptor blocker-based regimen in daily clinical practice: the SARA study

AIM

Clinical trials have proved that angiotensin receptor blockers (ARB) are more effective than other antihypertensive agents in reducing left ventricular hypertrophy (LVH); however, information about the efficacy of ARB on LVH regression in daily medical practice is scarce. The aim of the SARA study was to investigate the effect of an ARB on electrocardiographic LVH (ECG-LVH) in a hypertensive outpatient population attending clinical practice.

METHODS

From 276 recruited patients with mild-to-moderate essential hypertension (245 uncontrolled, 31 newly diagnosed), 264 (age: 62.9+/-11.6 years; 51.2% women) completed the study and were valid for the analysis. The patients were treated for a 12-month period with a candesartan-based regimen [(8/16 mg+hydrochlorothiazide 12.5 mg+additional drugs to target BP<140/90 mmHg (<130/80 in diabetics)]. ECG changes were measured at a core laboratory and Cornell product (CorP), Sokolow-Lyon product (SokP) and QRS duration (QRSd) criteria were determined.

RESULTS

At baseline, 27.4% of patients fulfilled the criteria of LVH by CorP. The proportion of patients with ECG-LVH by CorP criteria decreased to 21.1% at the end of the study, relative risk reduction (RRR) was 22.9%, P<0.001. When using SokP the percentage of ECG-LVH reduced from 24.1 to 21.7% (RRR 9.6%, P=0.1). Quantitatively, CorP was reduced by 84.4 mmxms [95% confidence interval (CI): -8.14, -160.66; P=0.03]; a greater reduction was detected in obese patients (P<0.05), diabetics (P<0.07) and patients with baseline ECG-LVH (P<0.05). In the multivariate analysis, female gender, baseline systolic blood pressure, baseline CorP and QRSd values were the main predictive factors for ECG-LVH regression.

CONCLUSION

The SARA study demonstrates that a candesartan-based regimen reduces ECG-LVH in the hypertensive population attending daily in clinical practice.

A large scale study of angiotensin II inhibition therapy in an elderly population: the CHANCE study

This 8-week, multicenter study evaluated the efficacy and safety of candesartan cilexetil (CC, 8-16 mg) in elderly (>65 years) hypertensive patients. Patients (n=3013) received CC 8 mg during 8 weeks which eventually doubled to CC 16 mg at week 4 if blood pressure remained uncontrolled (> or = 140/90 mmHg). At week 8, 65.5% of patients were normalized (BP < 140/90 mmHg). Mean changes at week 8 were -25.8, -13.2, and -12.7 mmHg for systolic, diastolic, and pulse pressure, respectively. Age, sex, and diabetic status did not influence the antihypertensive effect of CC. 68% of the patients treated with, but uncontrolled or intolerant of, prior antihypertensive treatment were normalized by CC 8-16 mg. In summary, CC 8-16 mg once daily was effective and well tolerated in the management of arterial hypertension in elderly subjects.

Erythema Multiforme Associated with Candesartan Cilexetil

Candesartan cilexetil is an angiotensin II receptor antagonist that is widely used in the treatment of hypertension. It is generally well tolerated and rarely has adverse effects. We report the case of a 50-year-old man with a 3-year history of hypertension that was difficult to manage because of intolerance to multiple medications. Treatment with candesartan cilexetil was initiated, and blood pressure control improved markedly. Five weeks later, the patient presented with a 2 x 3-cm ulcerative plaque covered with a fibrinous exudate on the right upper lip. Findings from a biopsy of the upper lip were diagnostic for erythema multiforme. Treatment with candesartan cilexetil was discontinued, and the lesions resolved completely within a few weeks. To our knowledge, this is the first report of erythema multiforme induced by the antihypertensive medication candesartan cilexetil.

Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) Trial of Cardiovascular Events in High-Risk Hypertensive Patients: Rationale, Design, and Methods

Hypertension continues to be a major public health issue in the world. To combat this problem, many anti-hypertensive drugs have been developed and proven effective at controlling blood pressure in the last half century. In recent decades, antihypertensive drugs have been shown to have cardiovascular benefits beyond the reduction of blood pressure, and the focus has shifted to clarification of these effects. Angiotensin II receptor antagonists and calcium channel blockers are the most widely used antihypertensive drugs in Japan. However, these two classes of drugs have not yet been compared with respect to their efficacy for treating cardiovascular events. The Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial described herein is a prospective, multicenter, randomized, open-label, active-controlled, 2-arm parallel group comparison with a response-dependent dose titration and blinded assessment of endpoints in high-risk hypertensive patients treated with either an angiotensin II receptor antagonist (candesartan cilexetil) or a third-generation calcium channel blocker (amlodipine besilate). The eligibility criteria in this study were 1) age between 20 and 85 years; 2) systolic blood pressure (SBP) > or = 140 mmHg in those below 70 years of age or > or = 160 mmHg in those above 70 years of age or diastolic blood pressure (DBP) > or = 90 mmHg on two consecutive measurements at clinic; and 3) at least one of the following high risk factors for cardiovascular events: a) SBP > or = 2180 mmHg or DBP > or = 110 mmHg on two consecutive visits, b) type 2 diabetes mellitus (fasting blood glucose > or = 126 mg/dl, casual blood glucose > or = 200 mg/dl, HbA1c > or = 6.5%, 2 h blood glucose on 75 g oral glucose tolerance test (OGTT) > or = 200 mg/dl, or current treatment with hypoglycemic therapy), c) history of cerebral hemorrhage, cerebral infarction, or transient ischemic attack until 6 months prior to the screening, d) left ventricular hypertrophy on either echocardiography or ECG, angina pectoris, or history of myocardial infarction until 6 months prior to screening, e) proteinuria or serum creatinine > or = 1.3 mg/dl, and f) symptoms of arteriosclerotic artery obstruction. The therapeutic goals of blood pressure control were set as follows: SBP < 130 mmHg and DBP < 85 mmHg for patients below 60 years of age, SBP < 140 mmHg and DBP < 90 mmHg for those in their 60s, SBP < 150 mmHg and DBP < 90 mmHg for those in their 70s, and SBP < 160 mmHg and DBP < 90 mmHg for those in their 80s. A total of 3,200 patients, equally allocated to each of the two treatment arms, were required based on a two-sided alpha level 0.05 and 90% power. The CASE-J is also the first study to employ the newly developed Automatic Bar Code Data-Capturing/Allocation, Booking & Trial Coding, Data Management (ABCD) system for data collection and management. Enrollment of patients started in September 2001 and ended in December 2002. Follow-up data will be collected every 6 months until December 2005. The CASE-J trial will provide important evidence on the comparative effectiveness of candesartan cilexetil and amlodipine besilate on cardiovascular morbidity and mortality among Japanese. In addition, the use of the ABCD system is expected to contribute to the development of more efficient data management systems for large-scale clinical trials.

Candesartan cilexetil improves left ventricular function, left ventricular hypertrophy, and endothelial function in patients with hypertensive heart disease

Patients with hypertension often develop left ventricular (LV) hypertrophy and deterioration of the cardiac and endothelial functions. Recent clinical trials have shown the added benefits of angiotensin II receptor blockers in hypertensive patients. Twenty-nine patients with hypertensive heart disease (HHD) underwent echocardiography, radionuclide ventriculography and the measurement of endothelial function before and after administration of candesartan (8 mg/day). The subjects were divided into poorly controlled blood pressure (BP) (group P, n=6) and well controlled BP (group C, n=23). Endothelial function was evaluated from flow-dependent dilation, which was calculated as the percent change of the radial artery diameter during reactive hyperemia after upper arm occlusion, measured with a high-resolution ultrasound system. In group C, LV diastolic function and endothelial function were significantly (p<0.05) improved at 3 months after administration, LV systolic function and hypertrophy were significantly (p<0.05) improved after 6 months and these effects were maintained at 12 months. Even in group P, LV function, LV hypertrophy, endothelial function and brain natriuretic peptide were significantly (p<0.05) improved at 6 months after administration. In patients with HHD, candesartan improves LV systolic and diastolic function, LV hypertrophy and endothelial function within 6 months of administration, regardless of the control of BP.