An American TROPHY in the prevention of hypertension

Potential roles of melatonin and chronotherapy among the new trends in hypertension treatment

The number of well-controlled hypertensives is unacceptably low worldwide. Respecting the circadian variation of blood pressure, nontraditional antihypertensives, and treatment in early stages of hypertension are potential ways to improve hypertension therapy. First, prominent variations in circadian rhythm are characteristic for blood pressure. The revolutionary MAPEC (Ambulatory Blood Pressure Monitoring and Cardiovascular Events) study, in 3000 adult hypertensives investigates, whether chronotherapy influences the cardiovascular prognosis beyond blood pressure reduction per se. Second, melatonin, statins and aliskiren are hopeful drugs for hypertension treatment. Melatonin, through its scavenging and antioxidant effects, preservation of NO availability, sympatholytic effect or specific melatonin receptor activation exerts antihypertensive and anti-remodeling effects and may be useful especially in patients with nondipping nighttime blood pressure pattern or with nocturnal hypertension and in hypertensives with left ventricular hypertrophy (LVH). Owing to its multifunctional physiological actions, this indolamine may offer cardiovascular protection far beyond its hemodynamic benefit. Statins exert several pleiotropic effects through inhibition of small guanosine triphosphate-binding proteins such as Ras and Rho. Remarkably, statins reduce blood pressure in hypertensive patients and more importantly they attenuate LVH. Addition of statins should be considered for high-risk hypertensives, for hypertensives with LVH, and possibly for high-risk prehypertensive patients. The direct renin inhibitor, aliskiren, inhibits catalytic activity of renin molecules in circulation and in the kidney, thus lowering angiotensin II levels. Furthermore, aliskiren by modifying the prorenin conformation may prevent prorenin activation. At present, aliskiren should be considered in hypertensive patients not sufficiently controlled or intolerant to other inhibitors of renin-angiotensin system. Third, TROPHY (Trial of Preventing Hypertension) is the first pharmacological intervention for prehypertensive patients revealing that treatment with angiotensin II type 1 receptor blocker attenuates hypertension development and thus decreases the risk of cardiovascular events.

Blood pressure variability causes spurious identification of hypertension in clinical studies: a computer simulation study

BACKGROUND

The blood pressure (BP) of an individual varies considerably from day to day. Hypertension is commonly identified based on the average of two BPs taken at each of two visits, a practice consistent with current guidelines. We hypothesized that (i) in the setting of high-normal BP ("prehypertension"), this practice results in frequent spurious detection of hypertension, and (ii) that random, spurious detection of hypertension and flawed study design together explain why in the Trial of Preventing Hypertension (TROPHY) study candesartan appeared to suppress the development of hypertension for 2 years after cessation of therapy.

METHODS

We used Monte Carlo simulation to quantify spurious detection of hypertension at repeated clinic visits in one million subjects with unchanging usual systolic BPs (SBPs) between 130 and 139 mm Hg and normal BP variability. Criteria for identifying hypertension derived from Rosner and Polk, Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), and the Trials of Hypertension Prevention (TOHP), TROPHY, and Framingham studies were applied to Canadian Heart Health Survey data. On the basis of these simulations, we created a three-parameter model of Kaplan-Meier curves recorded in the TROPHY study. We used the model to analyze the rates at which hypertension was identified in the TROPHY study.

RESULTS

TROPHY criteria spuriously identify hypertension in 76% of subjects over 18 clinic visits. Higher rates of spurious detection of hypertension are seen with JNC 7, TOHP and Framingham study criteria. Even highly conservative criteria falsely identify hypertension in 27% of subjects over 18 visits. Our three-parameter model suggests no postdiscontinuation benefit of candesartan.

CONCLUSIONS

When applied over multiple visits, current criteria for detecting hypertension are intolerant of normal BP variation. The use of conservative criteria would reduce spurious identification of hypertension. The apparent long-term beneficial effect of candesartan seen in the TROPHY study can be explained by an inadequate method for detecting hypertension, and flawed study design.