1
|
Rahman ARA, Magno JDA, Cai J, Han M, Lee HY, Nair T, Narayan O, Panyapat J, Van Minh H, Khurana R. Management of Hypertension in the Asia-Pacific Region: A Structured Review. Am J Cardiovasc Drugs 2024; 24:141-170. [PMID: 38332411 PMCID: PMC10973088 DOI: 10.1007/s40256-023-00625-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 02/10/2024]
Abstract
This article reviews available evidence regarding hypertension management in the Asia-Pacific region, focussing on five research questions that deal with specific aspects: blood pressure (BP) control, guideline recommendations, role of renin-angiotensin-aldosterone system (RAAS) inhibitors in clinical practice, pharmacological management and real-world adherence to guideline recommendations. A PubMed search identified 2537 articles, of which 94 were considered relevant. Compared with Europeans, Asians have higher systolic/diastolic/mean arterial BP, with a stronger association between BP and stroke. Calcium channel blockers are the most-commonly prescribed monotherapy in Asia, with significant variability between countries in the rates of angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs) and single-pill combination (SPC) use. In clinical practice, ARBs are used more commonly than ACEis, despite the absence of recommendation from guidelines and clinical evidence supporting the use of one class of drug over the other. Ideally, antihypertensive treatment should be tailored to the individual patient, but currently there are limited data on the characteristics of hypertension in Asia-Pacific individuals. Large outcome studies assessing RAAS inhibitor efficacy and safety in multi-national Asian populations are lacking. Among treated patients, BP control rates were ~ 35 to 40%; BP control in Asia-Pacific is suboptimal, and disproportionately so compared with Western nations. Strategies to improve the management of hypertension include wider access/availability of affordable treatments, particularly SPCs (which improve adherence), effective public health screening programs targeting patients to drive health-seeking behaviours, an increase in physician/patient awareness and early implementation of lifestyle changes. A unified Asia-Pacific guideline on hypertension management with pragmatic recommendations, particularly in resource-limited settings, is essential.
Collapse
Affiliation(s)
- Abdul R A Rahman
- An Nur Specialist Hospital, Jalan Gerbang Wawasan 1, Seksyen 15, 43650, Bandar Baru Bangi, Selangor, Malaysia.
| | - Jose Donato A Magno
- Division of Cardiovascular Medicine, Philippine General Hospital, Cardiovascular Institute, University of the Philippines College of Medicine, Angeles University Foundation Medical Center, Angeles, Philippines
| | - Jun Cai
- Hypertension Center, Fuwai Hospital, Beijing, People's Republic of China
| | - Myint Han
- Grand Hantha International Hospital, Yangon, Myanmar
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, 101, Daehak-ro Chongno-gu, Seoul, 03080, South Korea
| | - Tiny Nair
- PRS Hospital, Trivandrum, Kerala, India
| | - Om Narayan
- The Northern Hospital, 185 Cooper St., Epping, VIC, 3122, Australia
| | - Jiampo Panyapat
- Bhumibol Adulyadej Hospital, 171 Paholyothin Road, Saimai, Bangkok, 10220, Thailand
| | - Huynh Van Minh
- Department of Internal Medicine, Hue University of Medicine and Pharmacy, Hue, 530000, Vietnam
| | - Rohit Khurana
- The Harley Street Heart and Vascular Center, Gleneagles Hospital, Singapore, 258500, Singapore
| |
Collapse
|
2
|
Katayama Y, Yanai R, Itaya T, Nagamine Y, Tanigawa K, Miyawaki Y. Risk factors for cardiovascular diseases in patients with systemic lupus erythematosus: an umbrella review. Clin Rheumatol 2023; 42:2931-2941. [PMID: 37142864 DOI: 10.1007/s10067-023-06608-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/06/2023]
Abstract
Cardiovascular disease in patients with systemic lupus erythematosus (SLE) remains one of the most common causes of death and is caused by several factors, including both traditional and disease-specific risk factors. We aimed to systematically appraise the evidence of cardiovascular disease risk factors focusing on the SLE population. The protocol for this umbrella review is registered in PROSPERO (registration no. CRD42020206858). A systematic literature search was conducted in PubMed, Embase, and the Cochrane Library from database inception to June 22, 2022, for systematic reviews and meta-analyzes that examined cardiovascular disease risk factors in patients with SLE. Two reviewers independently extracted data and assessed the quality of the included studies using the "Assessing the Methodological Quality of Systematic Reviews 2 (AMSTER 2)" tool. Of the 102 identified articles, nine systematic reviews were included in this umbrella review. All included systematic reviews were assessed as critically low quality according to the AMSTER 2 tool. The traditional risk factors identified in this study were older age, male sex, hypertension, dyslipidemia, smoking, and a family history of cardiovascular disease. SLE-specific risk factors were long-term disease duration, lupus nephritis, neurological disorders, high disease activity, organ damage, use of glucocorticoids, azathioprine, and antiphospholipid antibodies, including anticardiolipin antibodies and lupus anticoagulant. This umbrella review identified some cardiovascular disease risk factors in patients with SLE; however, the study quality of all included systematic reviews was critically low. Key Points • We examined the evidence of cardiovascular disease risk factors focusing on patients with systemic lupus erythematosus. • We found that long-term disease duration, lupus nephritis, neurological disorders, high disease activity, organ damage, use of glucocorticoids, azathioprine, and antiphospholipid antibodies, including anticardiolipin antibodies and lupus anticoagulant, were cardiovascular disease risk factors among patients with systemic lupus erythematosus. • The review indicates the need for well-validated and high-quality future reviews that assess major adverse cardiovascular events as an outcome in patients with systemic lupus erythematosus.
Collapse
Affiliation(s)
- Yu Katayama
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Ryo Yanai
- Division of Rheumatology, Department of Medicine, Showa University Graduate School of Medicine, Tokyo, Japan
| | - Takahiro Itaya
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Yusuke Nagamine
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kyosuke Tanigawa
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshia Miyawaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan.
| |
Collapse
|
3
|
Yang R, Zhu Y, Xu M, Tao Y, Cong W, Cai J. Intensive blood pressure lowering and the risk of new-onset diabetes in patients with hypertension: a post-hoc analysis of the STEP randomized trial. Eur J Prev Cardiol 2023; 30:988-995. [PMID: 37036035 DOI: 10.1093/eurjpc/zwad105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 04/02/2023] [Accepted: 04/05/2023] [Indexed: 04/11/2023]
Abstract
AIMS The strategy of blood pressure intervention in the elderly hypertensive patients (STEP) trial reported the cardiovascular benefit of intensive systolic blood pressure (SBP) control in patients with hypertension. The association between intensive SBP lowering and the risk of new-onset diabetes is unclear. This study aimed to evaluate the effect of intensive SBP lowering on the incidence of new-onset diabetes. METHODS AND RESULTS Participants in STEP who had baseline fasting serum glucose (FSG) concentrations <7.0 mmol/L and no history of diabetes or hypoglycaemic medication use were included. The primary outcome was new-onset diabetes defined as the time to first occurrence of FSG concentrations ≥7.0 mmol/L. The secondary outcome was new-onset impaired fasting glucose (FSG: 5.6-6.9 mmol/L) in participants with normoglycemia. A competing risk proportional hazards regression model was used for analysis. The cohort comprised 5601 participants (mean age: 66.1 years) with a mean baseline SBP of 145.9 mmHg. Over a median follow-up of 3.42 years, 273 (9.6%) patients in the intensive SBP group (target, 110 to <130 mmHg) and 262 (9.5%) in the standard SBP group (target, 130 to <150 mmHg) developed diabetes (adjusted hazard ratio, 1.01; 95% confidence interval (CI), 0.86-1.20). The adjusted hazard ratio for the secondary outcome was 1.04 (95% CI, 0.91-1.18). The mean highest FSG concentration during the follow-up was 5.82 and 5.84 mmol/L in the intensive and standard groups, respectively. CONCLUSION Intensive SBP lowering is not associated with an altered risk of new-onset diabetes or impaired fasting glucose in hypertensive patients. REGISTRATION STEP ClinicalTrials.gov, number: NCT03015311.
Collapse
Affiliation(s)
- Ruixue Yang
- Hypertension Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beilishi Road 167, Xicheng District, Beijing 100037, China
| | - Yanqi Zhu
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 100 Haining Road, Hongkou District, Shanghai 200080, China
| | - Mengdan Xu
- Department of General Practice, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 100 Haining Road, Hongkou District, Shanghai, 200080, China
| | - Yanhua Tao
- Department of Internal Medicine, Nanchang Sixth Hospital, No. 24 Luojiatang Road, Xihu District, Nanchang, Jiangxi 330003, China
| | - Wenwen Cong
- Hypertension Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beilishi Road 167, Xicheng District, Beijing 100037, China
| | - Jun Cai
- Hypertension Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beilishi Road 167, Xicheng District, Beijing 100037, China
| |
Collapse
|
4
|
Matsuo M, Doi T, Katsuki M, Yoshimura Y, Ito H, Fukahara K, Yoshimura N, Yamazaki M. Association between intraoperative pulmonary artery pressure and cardiovascular complications after off-pump coronary artery bypass surgery: a single-center observational study. BMC Anesthesiol 2023; 23:114. [PMID: 37024786 PMCID: PMC10077666 DOI: 10.1186/s12871-023-02057-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/20/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND The impact of intraoperative pulmonary hemodynamics on prognosis after off-pump coronary artery bypass (OPCAB) surgery remains unknown. In this study, we examined the association between intraoperative vital signs and the development of major adverse cardiovascular events (MACE) during hospitalization or within 30 days postoperatively. METHODS This retrospective study analyzed data from a university hospital. The study cohort comprised consecutive patients who underwent isolated OPCAB surgery between November 2013 and July 2021. We calculated the mean and coefficient of variation of vital signs obtained from the intra-arterial catheter, pulmonary artery catheter, and pulse oximeter. The optimal cut-off was defined as the receiver operating characteristic curve (ROC) with the largest Youden index (Youden index = sensitivity + specificity - 1). Multivariate logistic regression analysis ROC curves were used to adjust all baseline characteristics that yielded P values of < 0.05. RESULTS In total, 508 patients who underwent OPCAB surgery were analyzed. The mean patient age was 70.0 ± 9.7 years, and 399 (79%) were male. There were no patients with confirmed or suspected preoperative pulmonary hypertension. Postoperative MACE occurred in 32 patients (heart failure in 16, ischemic stroke in 16). The mean pulmonary artery pressure (PAP) was significantly higher in patients with than without MACE (19.3 ± 3.0 vs. 16.7 ± 3.4 mmHg, respectively; absolute difference, 2.6 mmHg; 95% confidence interval, 1.5 to 3.8). The area under the ROC curve of PAP for the prediction of MACE was 0.726 (95% confidence interval, 0.645 to 0.808). The optimal mean PAP cut-off was 18.8 mmHg, with a specificity of 75.8% and sensitivity of 62.5% for predicting MACE. After multivariate adjustments, high PAP remained an independent risk factor for MACE. CONCLUSIONS Our findings provide the first evidence that intraoperative borderline pulmonary hypertension may affect the prognosis of patients undergoing OPCAB surgery. Future large-scale prospective studies are needed to verify the present findings.
Collapse
Affiliation(s)
- Mitsuhiro Matsuo
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, 2630 Sugitani, 930-0194, Toyama, Japan.
| | - Toshio Doi
- First Department of Surgery, University of Toyama, Toyama, Japan
| | - Masahito Katsuki
- Department of Neurosurgery, Itoigawa General Hospital, Itoigawa, Japan
| | | | - Hisakatsu Ito
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, 2630 Sugitani, 930-0194, Toyama, Japan
| | - Kazuaki Fukahara
- First Department of Surgery, University of Toyama, Toyama, Japan
| | - Naoki Yoshimura
- First Department of Surgery, University of Toyama, Toyama, Japan
| | - Mitsuaki Yamazaki
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, 2630 Sugitani, 930-0194, Toyama, Japan
- Department of Anesthesiology, Toyama Nishi General Hospital, Toyama, Japan
| |
Collapse
|
5
|
Incident Stroke Events in Clinical Trials of Antihypertensive Drugs in Cardiovascular Disease Patients: A Network Meta-analysis of Randomized Controlled Trials. Curr Probl Cardiol 2023; 48:101551. [PMID: 36529232 DOI: 10.1016/j.cpcardiol.2022.101551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Antihypertensive drugs are commonly used in cardiovascular diseases (CVD), less is known about the comparative effectiveness of different antihypertensive drugs on stroke events in CVD patients. We searched MEDLINE, EMBASE, the Cochrane Library, and the Web of Science for randomized controlled trails comparing the different antihypertensive drugs for stroke events in CVD patients from inception until November, 2022. Pairwise and network meta-analysis were performed to compare of different antihypertensive drugs for the incidence of stroke events in CVD patients. The protocol was registered on the PROSPERO database (CRD42022375038). 33 trials involving 141,217 CVD patients were included. The incidence of stroke in CVD patients for each antihypertensive drugs was placebo (3.0%), ACEI (2.4%), ARB (4.1%), CCB (1.8%), β blocker (1.3%), and diuretic (3.6%). Antihypertensive drug was significantly reducing stroke events in CVD patients when compared with placebo (OR 0.82; 95% CI 0.75 to 0.89). Specifically, ACEI (OR 0.82; 95% CI, 0.69-0.97), ARB (OR 0.87; 95% CI, 0.77-0.98), CCB (OR 0.69; 95% CI, 0.54-to 0.87), and diuretic (OR 0.74; 95% CI, 0.57-0.95) were significantly reducing stroke events in CVD patients when compared with placebo. Network meta-analysis suggested CCB and diuretic ranked the first and second in reducing the incidence of stroke events in CVD patients with the SUCRA value of 90.9% and 73.8%. CCB and diuretic had the greatest possibility to reduce the incidence of stroke events in CVD patients, while, ACEI was the worst antihypertensive agents in reducing the incidence of stroke events in CVD patients.
Collapse
|
6
|
Ferrario CM, Saha A, VonCannon JL, Meredith WJ, Ahmad S. Does the Naked Emperor Parable Apply to Current Perceptions of the Contribution of Renin Angiotensin System Inhibition in Hypertension? Curr Hypertens Rep 2022; 24:709-721. [PMID: 36272015 DOI: 10.1007/s11906-022-01229-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To address contemporary hypertension challenges, a critical reexamination of therapeutic accomplishments using angiotensin converting enzyme inhibitors and angiotensin II receptor blockers, and a greater appreciation of evidence-based shortcomings from randomized clinical trials are fundamental in accelerating future progress. RECENT FINDINGS Medications targeting angiotensin II mechanism of action are essential for managing primary hypertension, type 2 diabetes, heart failure, and chronic kidney disease. While the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to control blood pressure is undisputed, practitioners, hypertension specialists, and researchers hold low awareness of these drugs' limitations in preventing or reducing the risk of cardiovascular events. Biases in interpreting gained knowledge from data obtained in randomized clinical trials include a pervasive emphasis on using relative risk reduction over absolute risk reduction. Furthermore, recommendations for clinical practice in international hypertension guidelines fail to address the significance of a residual risk several orders of magnitude greater than the benefits. We analyze the limitations of the clinical trials that have led to current recommended treatment guidelines. We define and quantify the magnitude of the residual risk in published hypertension trials and explore how activation of alternate compensatory bioprocessing components within the renin angiotensin system bypass the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to achieve a significant reduction in total and cardiovascular deaths. We complete this presentation by outlining the current incipient but promising potential of immunotherapy to block angiotensin II pathology alone or possibly in combination with other antihypertensive drugs. A full appreciation of the magnitude of the residual risk associated with current renin angiotensin system-based therapies constitutes a vital underpinning for seeking new molecular approaches to halt or even reverse the cardiovascular complications of primary hypertension and encourage investigating a new generation of ACE inhibitors and ARBs with increased capacity to reach the intracellular compartments at which Ang II can be generated.
Collapse
Affiliation(s)
- Carlos M Ferrario
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA.
| | - Amit Saha
- Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Jessica L VonCannon
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Wayne J Meredith
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Sarfaraz Ahmad
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| |
Collapse
|
7
|
Randomized Controlled Trials on Renin Angiotensin Aldosterone System Inhibitors in Chronic Kidney Disease Stages 3–5: Are They Robust? A Fragility Index Analysis. J Clin Med 2022; 11:jcm11206184. [PMID: 36294504 PMCID: PMC9605379 DOI: 10.3390/jcm11206184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/17/2022] Open
Abstract
Inhibition of the renin-angiotensin-aldosterone system (RAAS) is broadly recommended in many nephrological guidelines to prevent chronic kidney disease (CKD) progression. This work aimed to analyze the robustness of randomized controlled trials (RCTs) investigating the renal and cardiovascular outcomes in CKD stages 3–5 patients treated with RAAS inhibitors (RAASi). We searched for RCTs in MEDLINE (PubMed), EMBASE databases, and the Cochrane register. Fragility indexes (FIs) for every primary and secondary outcome were calculated according to Walsh et al., who first described this novel metric, suggesting 8 as the cut-off to consider a study robust. Spearman coefficient was calculated to correlate FI to p value and sample size of statistically significant primary and secondary outcomes. Twenty-two studies met the inclusion criteria, including 80,455 patients. Sample size considerably varied among the studies (median: 1693.5, range: 73–17,276). The median follow-up was 38 months (range 24–58). The overall median of both primary and secondary outcomes was 0 (range 0–117 and range 0–55, respectively). The median of FI for primary and secondary outcomes with a p value lower than 0.05 was 6 (range: 1–117) and 7.5 (range: 1–55), respectively. The medians of the FI for primary outcomes with a p value lower than 0.05 in CKD and no CKD patients were 5.5 (range 1–117) and 22 (range 1–80), respectively. Only a few RCTs have been shown to be robust. Our analysis underlined the need for further research with appropriate sample sizes and study design to explore the real potentialities of RAASi in the progression of CKD.
Collapse
|
8
|
Wang X, Carcel C, Woodward M, Schutte AE. Blood Pressure and Stroke: A Review of Sex- and Ethnic/Racial-Specific Attributes to the Epidemiology, Pathophysiology, and Management of Raised Blood Pressure. Stroke 2022; 53:1114-1133. [PMID: 35344416 DOI: 10.1161/strokeaha.121.035852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Raised blood pressure (BP) is the leading cause of death and disability worldwide, and its particular strong association with stroke is well established. Although systolic BP increases with age in both sexes, raised BP is more prevalent in males in early adulthood, overtaken by females at middle age, consistently across all ethnicities/races. However, there are clear regional differences on when females overtake males. Higher BP among males is observed until the seventh decade of life in high-income countries, compared with almost 3 decades earlier in low- and middle-income countries. Females and males tend to have different cardiovascular disease risk profiles, and many lifestyles also influence BP and cardiovascular disease in a sex-specific manner. Although no hypertension guidelines distinguish between sexes in BP thresholds to define or treat hypertension, observational evidence suggests that in terms of stroke risk, females would benefit from lower BP thresholds to the magnitude of 10 to 20 mm Hg. More randomized evidence is needed to determine if females have greater cardiovascular benefits from lowering BP and whether optimal BP is lower in females. Since 1990, the number of people with hypertension worldwide has doubled, with most of the increase occurring in low- and-middle-income countries where the greatest population growth was also seen. Sub-Saharan Africa, Oceania, and South Asia have the lowest detection, treatment, and control rates. High BP has a more significant effect on the burden of stroke among Black and Asian individuals than Whites, possibly attributable to differences in lifestyle, socioeconomic status, and health system resources. Although pharmacological therapy is recommended differently in local guidelines, recommendations on lifestyle modification are often very similar (salt restriction, increased potassium intake, reducing weight and alcohol, smoking cessation). This overall enhanced understanding of the sex- and ethnic/racial-specific attributes to BP motivates further scientific discovery to develop more effective prevention and treatment strategies to prevent stroke in high-risk populations.
Collapse
Affiliation(s)
- Xia Wang
- The George Institute for Global Health (X.W., C.C., M.W., A.E.S.), University of New South Wales, Sydney, Australia
| | - Cheryl Carcel
- The George Institute for Global Health (X.W., C.C., M.W., A.E.S.), University of New South Wales, Sydney, Australia.,Sydney School of Public Health, Sydney Medical School, The University of Sydney, New South Wales, Australia (C.C.)
| | - Mark Woodward
- The George Institute for Global Health (X.W., C.C., M.W., A.E.S.), University of New South Wales, Sydney, Australia.,The George Institute for Global Health, School of Public Health, Imperial College London, United Kingdom (M.W.)
| | - Aletta E Schutte
- The George Institute for Global Health (X.W., C.C., M.W., A.E.S.), University of New South Wales, Sydney, Australia.,School of Population Health (A.E.S.), University of New South Wales, Sydney, Australia.,Hypertension in Africa Research Team, Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa (A.E.S.)
| |
Collapse
|
9
|
Pinho-Gomes AC, Azevedo L, Copland E, Canoy D, Nazarzadeh M, Ramakrishnan R, Berge E, Sundström J, Kotecha D, Woodward M, Teo K, Davis BR, Chalmers J, Pepine CJ, Rahimi K. Blood pressure-lowering treatment for the prevention of cardiovascular events in patients with atrial fibrillation: An individual participant data meta-analysis. PLoS Med 2021; 18:e1003599. [PMID: 34061831 PMCID: PMC8168843 DOI: 10.1371/journal.pmed.1003599] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 03/25/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Randomised evidence on the efficacy of blood pressure (BP)-lowering treatment to reduce cardiovascular risk in patients with atrial fibrillation (AF) is limited. Therefore, this study aimed to compare the effects of BP-lowering drugs in patients with and without AF at baseline. METHODS AND FINDINGS The study was based on the resource provided by the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC), in which individual participant data (IPD) were extracted from trials with over 1,000 patient-years of follow-up in each arm, and that had randomly assigned patients to different classes of BP-lowering drugs, BP-lowering drugs versus placebo, or more versus less intensive BP-lowering regimens. For this study, only trials that had collected information on AF status at baseline were included. The effects of BP-lowering treatment on a composite endpoint of major cardiovascular events (stroke, ischaemic heart disease or heart failure) according to AF status at baseline were estimated using fixed-effect one-stage IPD meta-analyses based on Cox proportional hazards models stratified by trial. Furthermore, to assess whether the associations between the intensity of BP reduction and cardiovascular outcomes are similar in those with and without AF at baseline, we used a meta-regression. From the full BPLTTC database, 28 trials (145,653 participants) were excluded because AF status at baseline was uncertain or unavailable. A total of 22 trials were included with 188,570 patients, of whom 13,266 (7%) had AF at baseline. Risk of bias assessment showed that 20 trials were at low risk of bias and 2 trials at moderate risk. Meta-regression showed that relative risk reductions were proportional to trial-level intensity of BP lowering in patients with and without AF at baseline. Over 4.5 years of median follow-up, a 5-mm Hg systolic BP (SBP) reduction lowered the risk of major cardiovascular events both in patients with AF (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.83 to 1.00) and in patients without AF at baseline (HR 0.91, 95% CI 0.88 to 0.93), with no difference between subgroups. There was no evidence for heterogeneity of treatment effects by baseline SBP or drug class in patients with AF at baseline. The findings of this study need to be interpreted in light of its potential limitations, such as the limited number of trials, limitation in ascertaining AF cases due to the nature of the arrhythmia and measuring BP in patients with AF. CONCLUSIONS In this meta-analysis, we found that BP-lowering treatment reduces the risk of major cardiovascular events similarly in individuals with and without AF. Pharmacological BP lowering for prevention of cardiovascular events should be recommended in patients with AF.
Collapse
Affiliation(s)
| | - Luis Azevedo
- Department of Community Medicine, Information and Health Decision Sciences, Centre for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Emma Copland
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Dexter Canoy
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Milad Nazarzadeh
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Rema Ramakrishnan
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Eivind Berge
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute for Clinical Medicine, University of Tromsø, Norway
| | | | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Department of Epidemiology and Biostatistics, Imperial College, London, United Kingdom
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Barry R. Davis
- The University of Texas School of Public Health, Houston, Texas, United States of America
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Carl J. Pepine
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Kazem Rahimi
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
- * E-mail:
| | | |
Collapse
|
10
|
Copland E, Canoy D, Nazarzadeh M, Bidel Z, Ramakrishnan R, Woodward M, Chalmers J, Teo KK, Pepine CJ, Davis BR, Kjeldsen S, Sundström J, Rahimi K. Antihypertensive treatment and risk of cancer: an individual participant data meta-analysis. Lancet Oncol 2021; 22:558-570. [PMID: 33794209 PMCID: PMC8024901 DOI: 10.1016/s1470-2045(21)00033-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Some studies have suggested a link between antihypertensive medication and cancer, but the evidence is so far inconclusive. Thus, we aimed to investigate this association in a large individual patient data meta-analysis of randomised clinical trials. METHODS We searched PubMed, MEDLINE, The Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from Jan 1, 1966, to Sept 1, 2019, to identify potentially eligible randomised controlled trials. Eligible studies were randomised controlled trials comparing one blood pressure lowering drug class with a placebo, inactive control, or other blood pressure lowering drug. We also required that trials had at least 1000 participant years of follow-up in each treatment group. Trials without cancer event information were excluded. We requested individual participant data from the authors of eligible trials. We pooled individual participant-level data from eligible trials and assessed the effects of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), β blockers, calcium channel blockers, and thiazide diuretics on cancer risk in one-stage individual participant data and network meta-analyses. Cause-specific fixed-effects Cox regression models, stratified by trial, were used to calculate hazard ratios (HRs). The primary outcome was any cancer event, defined as the first occurrence of any cancer diagnosed after randomisation. This study is registered with PROSPERO (CRD42018099283). FINDINGS 33 trials met the inclusion criteria, and included 260 447 participants with 15 012 cancer events. Median follow-up of included participants was 4·2 years (IQR 3·0-5·0). In the individual participant data meta-analysis comparing each drug class with all other comparators, no associations were identified between any antihypertensive drug class and risk of any cancer (HR 0·99 [95% CI 0·95-1·04] for ACEIs; 0·96 [0·92-1·01] for ARBs; 0·98 [0·89-1·07] for β blockers; 1·01 [0·95-1·07] for thiazides), with the exception of calcium channel blockers (1·06 [1·01-1·11]). In the network meta-analysis comparing drug classes against placebo, we found no excess cancer risk with any drug class (HR 1·00 [95% CI 0·93-1·09] for ACEIs; 0·99 [0·92-1·06] for ARBs; 0·99 [0·89-1·11] for β blockers; 1·04 [0·96-1·13] for calcium channel blockers; 1·00 [0·90-1·10] for thiazides). INTERPRETATION We found no consistent evidence that antihypertensive medication use had any effect on cancer risk. Although such findings are reassuring, evidence for some comparisons was insufficient to entirely rule out excess risk, in particular for calcium channel blockers. FUNDING British Heart Foundation, National Institute for Health Research, Oxford Martin School.
Collapse
Affiliation(s)
- Emma Copland
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Dexter Canoy
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Milad Nazarzadeh
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Zeinab Bidel
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rema Ramakrishnan
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Department of Epidemiology and Biostatistics, The George Institute for Global Health, Imperial College London, London, UK; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Koon K Teo
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Carl J Pepine
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Barry R Davis
- School of Public Health, University of Texas, Houston, TX, USA
| | - Sverre Kjeldsen
- Department of Cardiology, University of Oslo, Ullevaal Hospital, Oslo, Norway
| | - Johan Sundström
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden
| | - Kazem Rahimi
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| |
Collapse
|
11
|
Chu C, Zeng S, Hasan AA, Hocher CF, Krämer BK, Hocher B. Comparison of infection risks and clinical outcomes in patients with and without SARS-CoV-2 lung infection under renin-angiotensin-aldosterone system blockade: Systematic review and meta-analysis. Br J Clin Pharmacol 2020; 87:2475-2492. [PMID: 33217033 PMCID: PMC7753617 DOI: 10.1111/bcp.14660] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/28/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023] Open
Abstract
Aims Angiotensin‐converting enzyme‐2 (ACE2) is the receptor for SARS‐CoV‐2. Animal studies suggest that renin–angiotensin–aldosterone system (RAAS) blockers might increase the expression of ACE2 and potentially increase the risk of SARS‐CoV‐2 infection. Methods and Results The effect of ACE inhibitor (ACEI) treatment on the pneumonia incidence in non‐COVID‐19 patients (25 studies, 330 780 patients) was associated with a 26% reduction of pneumonia risk (odds ratio [OR]: 0.74, P < .001). Pneumonia‐related death cases in ACEI‐treated non‐COVID‐19 patients were reduced by 27% (OR: 0.73, P = .004). However, angiotensin II receptor blockers (ARB) treatment (10 studies, 275 621 non‐COVID‐19 patients) did not alter pneumonia risk in patients. Pneumonia‐related death cases in ARB‐treated non‐COVID‐19 patients was analysed only in 1 study and was significantly reduced (OR, 0.47; 95% confidence interval, 0.30 to 0.72). Results from 11 studies (8.4 million patients) showed that the risk of getting infected with the SARS‐CoV‐2 virus was reduced by 13% (OR: 0.87, P = .014) in patients treated with ACEI, whereas analysis from 10 studies (8.4 million patients) treated with ARBs showed no effect (OR, 0.92, P = .354). Results from 34 studies in 67 644 COVID‐19 patients showed that RAAS blockade reduces all‐cause mortality by 24% (OR = 0.76, P = .04). Conclusion ACEIs reduce the risk of getting infected with the SARS‐CoV‐2 virus. Blocking the RAAS may decrease all‐cause mortality in COVID‐19 patients. ACEIs also reduce the risk of non‐COVID pneumonia. All‐cause mortality due to non‐COVID pneumonia is reduced by ACEI and potentially by ARBs.
Collapse
Affiliation(s)
- Chang Chu
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany.,Department of Nephrology, Charité-Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Shufei Zeng
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany.,Department of Nephrology, Charité-Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Ahmed A Hasan
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany.,Department of Nutritional Toxicology, Institute of Nutritional Science, University of Potsdam, Nuthetal, Germany.,Department of Biochemistry, Faculty of Pharmacy, Zagazig University, Egypt
| | - Carl-Friedrich Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany
| | - Bernhard K Krämer
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany.,European Center of Angioscience, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Berthold Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany.,Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, School of Medicine, Hunan Normal University, Changsha, China.,Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China.,IMD Institut für Medizinische Diagnostik Berlin-Potsdam GbR, Berlin, Germany
| |
Collapse
|
12
|
Kikuchi N, Ogawa H, Kawada‐Watanabe E, Arashi H, Jujo K, Sekiguchi H, Yamaguchi J, Hagiwara N. Impact of age on clinical outcomes of antihypertensive therapy in patients with hypertension and coronary artery disease: A sub‐analysis of the Heart Institute of Japan Candesartan Randomized Trial for Evaluation in Coronary Artery Disease. J Clin Hypertens (Greenwich) 2020; 22:1070-1079. [DOI: 10.1111/jch.13891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 03/29/2020] [Accepted: 04/05/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Noriko Kikuchi
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Hiroshi Ogawa
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Erisa Kawada‐Watanabe
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Hiroyuki Arashi
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Kentaro Jujo
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Haruki Sekiguchi
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Junichi Yamaguchi
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Nobuhisa Hagiwara
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| |
Collapse
|
13
|
Wanas Y, Bashir R, Islam N, Furuya-Kanamori L. Assessing the risk of angiotensin receptor blockers on major cardiovascular events: a systematic review and meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2020; 20:188. [PMID: 32316917 PMCID: PMC7175553 DOI: 10.1186/s12872-020-01466-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/05/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Angiotensin receptor blockers (ARBs) are commonly used as a treatment for many cardiovascular diseases, but their safety has been called into question. The VALUE trial found an increased risk of myocardial infarction in participants receiving ARBs compared to other antihypertensive. The aim of the meta-analysis was to synthetize the available evidence of randomised controlled trials (RCTs) and elucidate if ARBs increase the risk of cardiovascular events. METHODS A comprehensive search was conducted to identify RCTs that assessed the safety of ARBs. Titles and abstracts of all papers were independently screened by two authors. Data extraction and quality assessment were also performed independently. The relative risk (RR) of all-cause mortality, myocardial infarction, and stroke were pooled using the IVhet model. Multiple sensitivity analyses were conducted to assess the effect of ARBs by restricting the analysis to different participants' characteristics. RESULTS Forty-five RCTs comprising of 170,794 participants were included in the analysis. The pooled estimates revealed that ARBs do not increase the risk of all-cause mortality (RR 1.00; 95%CI 0.97-1.04), myocardial infarction (RR 1.01; 95%CI 0.96-1.06), and stroke (RR 0.92; 95%CI 0.83-1.01). The sensitivity analysis did not yield a particular group of patients at increased risk of cardiovascular events with ARBs. Risk of all-cause mortality and stroke decreased with ARB when the proportion of smokers in a population was < 25% (RR 0.91; 95%CI 0.84-0.98) and in females (RR 0.76; 95%CI 0.68-0.84), respectively. CONCLUSIONS ARBs do not increase the risk of major cardiovascular events and are safe for use in patients.
Collapse
Affiliation(s)
- Yara Wanas
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Rim Bashir
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Nazmul Islam
- Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar.
| | - Luis Furuya-Kanamori
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar.,Research School of Population Health, ANU College of Health and Medicine, Australian National University, Acton, Australia
| |
Collapse
|
14
|
Tanaka K, Jujo K, Yamaguchi J, Ogawa H, Hagiwara N. Optimal Blood Pressure in Patients With Coronary Artery Disease and Chronic Kidney Disease: HIJ-CREATE Substudy. Am J Med Sci 2019; 358:219-226. [DOI: 10.1016/j.amjms.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 06/21/2019] [Accepted: 06/28/2019] [Indexed: 10/26/2022]
|
15
|
Effects of blood pressure-lowering treatment on cardiovascular outcomes and mortality: 14 - effects of different classes of antihypertensive drugs in older and younger patients: overview and meta-analysis. J Hypertens 2019; 36:1637-1647. [PMID: 29847487 DOI: 10.1097/hjh.0000000000001777] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES The five major classes of blood pressure (BP)-lowering drugs have all been shown to significantly reduce the risk of major cardiovascular events when compared with placebo, and when directly (head-to-head) compared, no significant differences in their overall effectiveness have been detected, except for minor differences in cause-specific events. It is unknown, however, whether age-related differences exist and if some classes of drugs are differently effective in older or younger individuals. This clinically relevant question has been the object of a systematic search and meta-analysis of all available data. METHODS Two databases we had previously identified [72 placebo-controlled BP-lowering randomized clinical trials (RCTs) in 260 210 individuals and 50 RCTs head-to-head comparing treatments with BP-lowering drugs of different classes in 247 006 individuals) were searched for separately reported data on patients older or younger than 65 years, and the data were further stratified according to the class of drug [diuretics, beta-blockers, calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers] compared with placebo or with other drug classes. Seven fatal and nonfatal outcomes were considered for benefits. Adverse events were investigated as permanent treatment discontinuations for adverse events. Risk ratios and absolute risk changes were calculated by a random effects model. Effects at older and younger ages were compared by heterogeneity test. RESULTS We identified 20 placebo-controlled RCTs on 55 645 older individuals and 21 on 99 621 younger individuals, and 21 head-to-head drug comparison RCTs on 94 228 older individuals and 27 on 100 232 younger individuals (for a total of 349 726 individuals). When compared with placebo, all five classes of BP-lowering drugs significantly reduced the risk of major cardiovascular events or stroke, with no significant difference between older and younger patients. However, in head-to-head comparisons, no significant difference was found between older and younger patients in the effects of diuretics, calcium antagonists, ACE inhibitors and angiotensin receptor blockers on all cardiovascular outcomes, whereas beta-blockers revealed an age-dependent effectiveness, being equally effective as the other agents at an age below 65 years, but less effective at an older age. CONCLUSION Most BP-lowering classes are equally effective in preventing risk of fatal and nonfatal cardiovascular events both in older and younger patients, whereas beta-blockers, though being equally effective as the other agents in patients younger than 65, loose some of their effectiveness at an older age.
Collapse
|
16
|
Datzmann T, Fuchs S, Andree D, Hohenstein B, Schmitt J, Schindler C. Systematic review and meta-analysis of randomised controlled clinical trial evidence refutes relationship between pharmacotherapy with angiotensin-receptor blockers and an increased risk of cancer. Eur J Intern Med 2019; 64:1-9. [PMID: 31060961 DOI: 10.1016/j.ejim.2019.04.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 12/26/2022]
Abstract
AIMS The potential influence of angiotensin-receptor blockers (ARBs) on carcinogenesis is a much-debated topic. Both observational, as well as preclinical studies in rodent carcinogenic assays, suggest a major role of the Renin-Angiotensin-Aldosterone-System (RAAS) in cancer development. Therefore, a systematic review and meta-analysis with available study data on ARBs and carcinogenicity in general as primary outcome were conducted. Secondary outcomes were defined as tumour-specific mortality rates and the frequency of new cases of specific tumour types with particular emphasis on lung, breast, and prostate cancer. METHODS A systematic literature research was performed in MEDLINE, EMBASE, Cochrane Library, and TOXLINE. We used a combination of MeSH terms, keywords and substance names of ARBs and searched between 1950 and 2016. At least 100 participants in each study arm and a minimum follow-up for one year were necessary for study inclusion. Odds ratios (OR) were calculated by a random-effects model. RESULTS A total of 8818 potentially eligible publications were identified of whom seven randomised controlled trials, four case-control studies and one cohort study met our inclusion criteria. As a key result, we found no effect on carcinogenesis in randomised controlled trials for ARB usage. (OR 1.02, 95% CI 0.87-1.19; p = .803). Conflicting results with observational studies could be explained by poor reporting- and study qualities. CONCLUSIONS The results of our meta-analysis focusing only on high evidence levels and study designs (RCTs) did not reveal any relationship between pharmacotherapy with an ARB and an increased risk for cancer in general.
Collapse
Affiliation(s)
| | - Susanne Fuchs
- Department for Gynaecology and Obstetrics, Kreiskrankenhaus Freiberg, Freiberg, Germany
| | - Daniel Andree
- Department of Medicine, Spital Limmattal, Zurich, Switzerland
| | - Bernd Hohenstein
- Nephrological Center Villingen-Schwenningen, Villingen-Schwenningen, Germany; TU Dresden, Medizinische Fakultät Carl Gustav Carus, Medical Clinic 3, Division of Nephrology, Dresden, Germany.
| | - Jochen Schmitt
- TU Dresden, Medizinische Fakultät Carl Gustav Carus, Center for Evidence-Based Healthcare, Dresden, Germany; National Center for Tumour Diseases, Dresden, Germany.
| | - Christoph Schindler
- Hannover Medical School, Clinical Research Center Hannover & MHH Center for Pharmacology and Toxicology, Hannover Medical School, Hannover, Germany.
| |
Collapse
|
17
|
Kamishima K, Ogawa H, Jujo K, Yamaguchi J, Hagiwara N. Relationships between blood pressure lowering therapy and cardiovascular events in hypertensive patients with coronary artery disease and type 2 diabetes mellitus: The HIJ-CREATE sub-study. Diabetes Res Clin Pract 2019; 149:69-77. [PMID: 30735770 DOI: 10.1016/j.diabres.2019.01.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/10/2019] [Accepted: 01/30/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The effects of intensive blood pressure (BP) lowering for hypertensive patients with coronary artery disease (CAD) and diabetes mellitus on their clinical outcomes have not been fully evaluated. The aim was to explore the optimal systolic BP target in such patients in a substudy of a prospective, randomized trial. METHODS Of a total of 2049 hypertensive patients with CAD who were enrolled in the HIJ-CREATE study, type 2 diabetes was diagnosed in 780 (38.1%). Titration of antihypertensive agents was performed to reach the target BP of <130/85 mmHg. The primary endpoint was the occurrence of a first major adverse cardiovascular event (MACE). Achieved BP was defined as the mean value of systolic BP in patients who did not develop MACEs and as the mean value of systolic BP prior to MACEs in those who developed MACEs during follow-up. RESULTS During a median follow-up of 4.2 years, the primary outcome occurred in 259 (33.2%) diabetic patients and in 293 (23.1%) non-diabetic patients (p < 0.0001). The diabetic patients were divided into quartiles based on the mean systolic BP during follow-up. The relationships between achieved BP and the incidence of MACEs did not follow a J-shaped curve. Intensive systolic BP lowering to less than 120 mmHg did not correlate with an increased risk of MACEs. CONCLUSIONS Our results suggest that the intensive BP lowering may not impair patients' clinical courses even in a high-risk population. The establishment of an optimal management strategy for hypertensive patients with diabetes and CAD is essential.
Collapse
Affiliation(s)
- K Kamishima
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, Japan
| | - H Ogawa
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, Japan.
| | - K Jujo
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, Japan
| | - J Yamaguchi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, Japan
| | - N Hagiwara
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, Japan
| |
Collapse
|
18
|
Sayutina EV. Fixed combinations in modern hypertension treatment algorithms. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2018. [DOI: 10.15829/1728-8800-2018-6-86-94] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Modern appropriate treatment of hypertension involves the use of combination antihypertensive therapy. According to updated version of European Society of Cardiology 2018 guidelines, renin-angiotensin-aldosterone system blockers must be used as first-line drugs, including in combination with hydrochlorothiazide. This article presents the algorithms for the management of patients with uncomplicated and asymptomatic (with target lesions) arterial hypertension. It also described the management of patients with concomitant cardiovascular, cerebrovascular, renal pathology and diabetes mellitus, and use of fixed combination of candesartan and hydrochlorothiazide. The article presents research data that confirmed not only the high antihypertensive efficacy of this combination, but also demonstrated its neutral metabolic profile, organ-protective effects, the ability to use in patients with chronic kidney disease, chronic heart failure, prior stroke, as well as high tolerability and treatment adherence.
Collapse
|
19
|
Chen Y, Lei L, Wang JG. Methods of Blood Pressure Assessment Used in Milestone Hypertension Trials. Pulse (Basel) 2018; 6:112-123. [PMID: 30283753 DOI: 10.1159/000489855] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/18/2018] [Indexed: 01/13/2023] Open
Abstract
In the present review, we summarized the blood pressure (BP) measurement protocols of contemporary outcome trials in hypertension. In all these trials, clinic BP was used for the diagnosis and therapeutic monitoring of hypertension. In most trials, BP was measured in the sitting position with mercury sphygmomanometers or automated electronic BP monitors by trained observers. BP readings were taken on each occasion at least twice with a 30-to-60-s interval after 5 min of rest. Details regarding the arm side, cuff size, and the timing of BP measurement were infrequently reported. If clinic BP continues being used in future hypertension trials, the measurement should strictly follow current guidelines. The observers must be trained and experienced, and the device should be validated by automated electronic BP monitors. On each occasion, BP readings should be taken 2-3 times. The time interval between successive measurements has to be 30-60 s, and the resting period before the measurement should be at least 5 min in the supine or seated position and 1-3 min standing. BP should usually be measured in the seated position. The higher arm side and an appropriate size cuff should be chosen and noted. BP should be measured at defined trough hours. Automated office BP measurement has recently been used and seems to have less white-coat effect. The out-of-office BP measurement, either ambulatory or home BP monitoring, was only used in a subset of study participants of few hypertension trials. Future trials should consider these novel office or out-of-office BP measurements in guiding the therapy and preventing cardiovascular events.
Collapse
Affiliation(s)
- Yi Chen
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Lei
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ji-Guang Wang
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
20
|
Shen T, Wang J, Yu Y, Yu J. Comparison of real-world effectiveness between valsartan and non-RAS inhibitor monotherapy on the incidence of new diabetes in Chinese hypertensive patients: An electronic health recording system based study. Clin Exp Hypertens 2018; 41:244-254. [DOI: 10.1080/10641963.2018.1469640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Tian Shen
- Department of Health Behavior and Health Education, Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China
- Department of Community Health and Behavioral Medicine, School of Public Health, Shanghai Jiao Tong University, Shanghai, China
| | - Jiwei Wang
- Department of Health Behavior and Health Education, Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China
| | - Yingjun Yu
- Medical Affairs of Great China Region of Novartis, Beijing, China
| | - Jinming Yu
- Department of Health Behavior and Health Education, Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China
| |
Collapse
|
21
|
Hagiwara N, Kawada-Watanabe E, Koyanagi R, Arashi H, Yamaguchi J, Nakao K, Tobaru T, Tanaka H, Oka T, Endoh Y, Saito K, Uchida T, Matsui K, Ogawa H. Low-density lipoprotein cholesterol targeting with pitavastatin + ezetimibe for patients with acute coronary syndrome and dyslipidaemia: the HIJ-PROPER study, a prospective, open-label, randomized trial. Eur Heart J 2018; 38:2264-2276. [PMID: 28430910 PMCID: PMC5837267 DOI: 10.1093/eurheartj/ehx162] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 03/16/2017] [Indexed: 01/02/2023] Open
Abstract
Aims To elucidate the effects of intensive LDL-C lowering treatment with a standard dose of statin and ezetimibe in patients with dyslipidaemia and high risk of coronary events, targeting LDL-C less than 70 mg/dL (1.8 mmol/L), compared with standard LDL-C lowering lipid monotherapy targeting less than 100 mg/dL (2.6 mmol/L). Methods and results The HIJ-PROPER study is a prospective, randomized, open-label trial to assess whether intensive LDL-C lowering with standard-dose pitavastatin plus ezetimibe reduces cardiovascular events more than standard LDL-C lowering with pitavastatin monotherapy in patients with acute coronary syndrome (ACS) and dyslipidaemia. Patients were randomized to intensive lowering (target LDL-C < 70 mg/dL [1.8 mmol/L]; pitavastatin plus ezetimibe) or standard lowering (target LDL-C 90 mg/dL to 100 mg/dL [2.3–2.6 mmol/L]; pitavastatin monotherapy). The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, unstable angina, and ischaemia-driven revascularization. Between January 2010 and April 2013, 1734 patients were enroled at 19 hospitals in Japan. Patients were followed for at least 36 months. Median follow-up was 3.86 years. Mean follow-up LDL-C was 65.1 mg/dL (1.68 mmol/L) for pitavastatin plus ezetimibe and 84.6 mg/dL (2.19 mmol/L) for pitavastatin monotherapy. LDL-C lowering with statin plus ezetimibe did not reduce primary endpoint occurrence in comparison with standard statin monotherapy (283/864, 32.8% vs. 316/857, 36.9%; HR 0.89, 95% CI 0.76–1.04, P = 0.152). In, ACS patients with higher cholesterol absorption, represented by elevated pre-treatment sitosterol, was associated with significantly lower incidence of the primary endpoint in the statin plus ezetimibe group (HR 0.71, 95% CI 0.56–0.91). Conclusion Although intensive lowering with standard pitavastatin plus ezetimibe showed no more cardiovascular benefit than standard pitavastatin monotherapy in ACS patients with dyslipidaemia, statin plus ezetimibe may be more effective than statin monotherapy in patients with higher cholesterol absorption; further confirmation is needed. Trial No UMIN000002742, registered as an International Standard Randomized Controlled Trial.
Collapse
Affiliation(s)
- Nobuhisa Hagiwara
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Erisa Kawada-Watanabe
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Ryo Koyanagi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Hiroyuki Arashi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Koichi Nakao
- Division of Cardiology, Cardiovascular Center, Saisei-Kai Kumamoto Hospital, 5-3-1 Chikami, Minami-ku, Kumamoto-shi, Kumamoto 861-4193, Japan
| | - Tetsuya Tobaru
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu-shi, Tokyo 183-0003, Japan
| | - Hiroyuki Tanaka
- Division of Cardiology, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu-shi, Tokyo 183-8524, Japan
| | - Toshiaki Oka
- Department of Cardiology, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu-shi, Shizuoka 430-8558, Japan
| | - Yasuhiro Endoh
- Department of Cardiology, Saisei-Kai Kurihashi Hospital, 714-6 Kouemon, Kuki-shi, Saitama 349-1105, Japan
| | - Katsumi Saito
- Department of Cardiology, Nishiarai Heart Center, 1-12-8, Nishiarai-honcho, Adachi-Ku, Tokyo 123-0845, Japan
| | - Tatsuro Uchida
- Department of Cardiology, Cardiovascular Center of Sendai, 1-6-12 Izumichuo, Izumi-ku, Sendai-shi, Miyagi 981-3133, Japan
| | - Kunihiko Matsui
- Department of General and Community Medicine, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Hiroshi Ogawa
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| |
Collapse
|
22
|
Salvador GL, Marmentini VM, Cosmo WR, Junior EL. Angiotensin-converting enzyme inhibitors reduce mortality compared to angiotensin receptor blockers: Systematic review and meta-analysis. Eur J Prev Cardiol 2017; 24:1914-1924. [PMID: 28862020 DOI: 10.1177/2047487317728766] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background There are few reviews comparing the long-term outcomes of the use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in a hypertensive population because both are effective in reducing blood pressure. None of them compared angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers with a placebo group in patients with essential hypertension, because few studies exist with this design. Methods A systematic search of PUBMED, LILACS, SCIELO, ICTRP, Cochrane, EMBASE and ClinicalTrials.gov from 1 January 2000 until 31 December 2015 selected prospective studies that reported an association between the use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in the following cardiovascular outcomes: heart failure/hospitalisation, stroke, acute myocardial infarction, total cardiovascular deaths, total deaths and total outcomes. Summary odds ratios (ORs) and 95% confidence intervals (CIs) were combined by using a fixed-effects model. Results Seventeen studies ( n = 73,761) were included of which 12 studies were randomly assigned to angiotensin II receptor blocker therapy ( n = 24,697) and five to angiotensin-converting enzyme inhibitors ( n = 12,170). Angiotensin-converting enzyme inhibitors proved to be significant in reducing total deaths (OR 0.85, 95% CI 0.78-0.93) and cardiovascular deaths (OR 0.77, 95% CI 0.69-0.87). Angiotensin II receptor blocker therapy did not show a reduction in total deaths (OR 1.02, 95% CI 0.96-1.09) or cardiovascular deaths (OR 0.95, 95% CI 0.86-1.06). For acute myocardial infarction, stroke and heart failure/hospitalisation, the reductions were significant for both classes. Conclusion Angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use is similar in preventing major cardiovascular outcomes regarding acute myocardial infarction, stroke and heart failure/hospitalisation. However, the use of angiotensin-converting enzyme inhibitors is more effective in reducing total deaths and cardiovascular deaths than angiotensin II receptor blockers.
Collapse
Affiliation(s)
| | | | - Willian R Cosmo
- Internal Medicine Department, Federal University of Parana, Brazil
| | - Emilton L Junior
- Internal Medicine Department, Federal University of Parana, Brazil
| |
Collapse
|
23
|
Abstract
Following extensive clinical research, drugs affecting the renin-angiotensin system have been used for the treatment of patients with congestive heart failure, myocardial infarction, hypertension, diabetic nephropathy, chronic renal failure and for reducing the risk of developing major cardiovascular (CV) events. This review examines all mega trials (those involving >1000 patients) and smaller pivotal trials involving angiotensin-converting enzyme inhibitors (ACE-Is; 25 mega trials) and angiotensin receptor blockers (ARBs; 27 mega trials) to provide perspective on the huge database of evidence that has accumulated on the use of these drugs. Our review demonstrates that ACE-Is and ARBs are generally as effective as conventional therapies in the treatment of hypertension, but offer additional cardioprotective benefits in patients with heart failure, and in those who have experienced myocardial infarction. Also, both ACE-Is and ARBs are capable of renal protection in addition to their blood-pressure-lowering effects. Although ACE-Is and ARBs provide major benefits to CV patients, doubts remain over the concept of blood-pressure-independent CV protection offered by both classes of drugs. ACE-Is and ARBs appear to be equally effective with respect to morbidity and mortality endpoints, but ARBs are better tolerated. Considering the available evidence, the combined use of an ACE-I and ARB should be avoided and full doses of either ACE-I or ARB should be aimed for as evidence suggests they provide a greater prognostic benefit.
Collapse
Affiliation(s)
- Rainer Düsing
- Hypertoniezentrum Bonn, Am Burgweiher 52-54, 53123 Bonn, Germany
| |
Collapse
|
24
|
Kawada-Watanabe E, Ogawa H, Koyanagi R, Arashi H, Yamaguchi J, Matsui K, Hagiwara N. Rationale, design features, and baseline characteristics: The Heart Institute of Japan-PRoper level of lipid lOwering with Pitavastatin and Ezetimibe in acute coRonary syndrome (HIJ-PROPER). J Cardiol 2017; 69:536-541. [DOI: 10.1016/j.jjcc.2016.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/12/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
|
25
|
|
26
|
Impact of left ventricular ejection function on blood pressure-lowering therapy in hypertensive patients with coronary artery disease. J Hypertens 2016; 34:1011-8. [DOI: 10.1097/hjh.0000000000000874] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
27
|
Effects of blood pressure-lowering on outcome incidence in hypertension: 5. Head-to-head comparisons of various classes of antihypertensive drugs - overview and meta-analyses. J Hypertens 2016; 33:1321-41. [PMID: 26039526 DOI: 10.1097/hjh.0000000000000614] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES We have recently published an overview and meta-analysis of the effects of the five major classes of blood pressure-lowering drugs on cardiovascular outcomes when compared with placebo. However, possible differences in effectiveness of the various classes can correctly be estimated only by head-to-head comparisons of different classes of agents. This has been the objective of a new survey and meta-analysis. METHODS A database search between 1966 and August 2014 ide ntified 50 eligible randomized controlled trials for 58 two-drug comparisons (247 006 patients for 1 029 768 patient-years). Risk ratios and their 95% confidence intervals of seven outcomes were estimated by a random-effects model. RESULTS The effects of all drug classes are not significantly different on most outcomes when their blood pressure effect is equivalent. However, there are also significant differences involving almost all classes of drugs. When compared to all other classes together, diuretics are superior in preventing heart failure; beta-blockers less effective in preventing stroke; calcium antagonists superior in preventing stroke and all-cause death, but inferior in preventing heart failure; angiotensin-converting enzyme inhibitors more effective in preventing coronary heart disease and less in preventing stroke; angiotensin receptor blockers inferior in preventing coronary heart disease; and renin-angiotensin system blockers more effective in preventing heart failure. When stratifying randomized controlled trials according to total cardiovascular risk, no drug class was found to change in effectiveness with the level of risk. CONCLUSIONS The results of all available evidence from head-to-head drug class comparisons do not allow the formulation of a fixed paradigm of drug choice valuable for all hypertensive patients, but the differences found may suggest specific choices in specific conditions, or preferable combinations of drugs.
Collapse
|
28
|
Effects of blood pressure-lowering treatment. 6. Prevention of heart failure and new-onset heart failure – meta-analyses of randomized trials. J Hypertens 2016; 34:373-84; discussion 384. [DOI: 10.1097/hjh.0000000000000848] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
29
|
Aronow WS. Current treatment of hypertension in patients with coronary artery disease recommended by different guidelines. Expert Opin Pharmacother 2016; 17:205-15. [PMID: 26373919 DOI: 10.1517/14656566.2015.1091881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
30
|
Arashi H, Ogawa H, Yamaguchi JI, Kawada-Watanabe E, Hagiwara N. Impact of visit-to-visit variability and systolic blood pressure control on subsequent outcomes in hypertensive patients with coronary artery disease (from the HIJ-CREATE substudy). Am J Cardiol 2015; 116:236-42. [PMID: 25966826 DOI: 10.1016/j.amjcard.2015.04.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 04/09/2015] [Accepted: 04/09/2015] [Indexed: 10/23/2022]
Abstract
Although visit-to-visit variability in systolic blood pressure (BP) is a strong predictor of stroke, the impact on subsequent major adverse cardiac events (MACEs) in patients with coronary artery disease (CAD) in terms of secondary prevention remains unclear. The aim of this study was to clarify the prognostic significance of visit-to-visit variability in systolic BP on subsequent MACE in hypertensive patients with CAD. In the Heart Institute of Japan Candesartan Randomised Trial for Evaluation in Coronary Artery Disease, a total of 2,049 hypertensive patients with CAD were enrolled. Incidence of MACEs in addition to biochemistry tests and office BP were determined during follow-up. Achieved BP was defined as the mean value of systolic BP in patients who did not experience MACE and the mean value of systolic BP before MACE in those who experienced MACE during follow-up. In the present study, 1,734 patients had multiple follow-up visits (≥3 times) until their final follow-up. During a median follow-up of 4.2 years, the primary outcome occurred in 317 patients (18.3%). Visit-to-visit variability of systolic BP was defined as the SD. Participants were divided into equal quartiles based on the mean systolic BP during follow-up and visit-to-visit variability of systolic BP, respectively. Although there was no relation between visit-to-visit variability of systolic BP and the incidence of MACE, the highest quartile based on mean systolic BP showed a significant relation with subsequent MACE. In conclusion, in hypertensive patients with CAD, inadequate BP control is a strong predictor of subsequent MACE, whereas visit-to-visit variability of systolic BP is not.
Collapse
|
31
|
Elgendy IY, Huo T, Chik V, Pepine CJ, Bavry AA. Efficacy and safety of angiotensin receptor blockers in older patients: a meta-analysis of randomized trials. Am J Hypertens 2015; 28:576-85. [PMID: 25391580 DOI: 10.1093/ajh/hpu209] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 09/29/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The efficacy and safety of angiotensin receptor blockers (ARBs) in the older population is unclear. OBJECTIVES To determine the efficacy and safety of ARBs in older patients. METHODS Randomized trials that compared ARBs to control and reported clinical outcomes in patients with a mean age of 65 years or older were included. Random-effects summary risk ratios (RRs) were constructed. RESULTS A total of 16 trials met our selection criteria, which yielded 113,386 patients. ARBs were associated with a marginal increased risk of all-cause mortality (RR: 1.03, 95% confidence interval (CI): 1.00-1.06, P = 0.05), a nonsignificant increased risk of myocardial infarction (RR: 1.04, 95% CI: 0.96-1.12, P = 0.36), a marginal reduction in heart failure hospitalization (RR: 0.86, 95% CI: 0.74-1.00, P = 0.06), and a significant reduction in the risk of stroke (RR: 0.93, 95% CI: 0.87-0.99, P = 0.03). ARBs were associated with an increased risk of acute kidney injury (RR: 1.48, 95% CI: 1.24-1.77, P < 0.001), hypotension (RR: 1.56, 95% CI: 1.24-1.97, P < 0.001), and hyperkalemia (RR: 1.57, 95% CI: 1.13-2.19, P = 0.008). On the sensitivity analysis including placebo-controlled trials, the risk of all-cause mortality was no longer significant (P = 0.2), while the remainder of the outcomes did not change. CONCLUSION In older patients, the benefit of ARBs compared with control was strongest for stroke reduction, with no (or weak) associations for all-cause mortality, myocardial infarction, and heart failure hospitalization. Benefit was offset by an increased risk of acute kidney injury, hypotension, and hyperkalemia. Thus, ARBs should be used with caution in older patients when clinically indicated.
Collapse
Affiliation(s)
- Islam Y Elgendy
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Tianyao Huo
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Veronica Chik
- North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Anthony A Bavry
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA; North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA.
| |
Collapse
|
32
|
Chang CH, Chang YC, Wu LC, Lin JW, Chuang LM, Lai MS. Different angiotensin receptor blockers and incidence of diabetes: a nationwide population-based cohort study. Cardiovasc Diabetol 2014; 13:91. [PMID: 24886542 PMCID: PMC4039330 DOI: 10.1186/1475-2840-13-91] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 05/07/2014] [Indexed: 12/12/2022] Open
Abstract
Background Angiotensin receptor blockers (ARBs) have been shown to exert various peroxisome proliferator-activated receptor gamma (PPARγ) binding activities and insulin-sensitizing effects. The objective of this study was to investigate the association of different ARBs with new-onset diabetes mellitus. Methods In the respective cohort, a total of 492,530 subjects who initiated ARB treatment between January 2004 and December 2009 were identified from Taiwan National Health Insurance Database. The primary outcome was newly diagnosed diabetes, defined as at least one hospital admission or two or more outpatient visits within a year with an ICD-9-CM code 250. Cox proportional regression was used to estimate the risk of diabetes associated with each ARB, using losartan as the reference. Results A total of 65,358 incident diabetes cases were identified out of 1,771,173 person-years. Olmesartan initiators had a small but significantly increased risk of developing diabetes after adjusting for baseline characteristics and mean daily dose (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.03-1.12). After excluding those followed for less than one year, the increase in diabetes risk are more pronounced (HR, 1.09; 95% CI, 1.05-1.14). This association was consistent across all subgroup analyses. Similar results were observed when a more strict definition of diabetes combining both diabetes diagnosis and anti-diabetic treatment was used. On the other hand, there was no difference in diabetes risk between telmisartan and losartan. Conclusions Among all ARBs, olmesartan might be associated with a slightly increased risk of diabetes mellitus. Our data suggest differential diabetes risks associated with ARBs beyond a class effect.
Collapse
Affiliation(s)
| | | | | | - Jou-Wei Lin
- Institute of Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | | | | |
Collapse
|
33
|
Ferrari R, Boersma E. The impact of ACE inhibition on all-cause and cardiovascular mortality in contemporary hypertension trials: a review. Expert Rev Cardiovasc Ther 2014; 11:705-17. [DOI: 10.1586/erc.13.42] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
34
|
Bakris G, Sarafidis P, Agarwal R, Ruilope L. Review of blood pressure control rates and outcomes. ACTA ACUST UNITED AC 2013; 8:127-41. [PMID: 24309125 DOI: 10.1016/j.jash.2013.07.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 01/22/2023]
Abstract
Despite the high prevalence of hypertension and documented benefits of blood pressure (BP) control, >40% of patients with hypertension are not controlled. A majority of uncontrolled hypertensive patients receive two or more antihypertensive drugs. The current review examined the relationship between antihypertensive combination drug therapy, achievement of goal BP, and cardiovascular (CV) outcomes. Articles were selected from a PubMed search using a prespecified search strategy. Randomized, controlled clinical trials of adult human subjects published in English between January 1991 and January 2013 were included. From 2319 identified articles, 28 met inclusion criteria and contained a total of 226,877 subjects. There were seven placebo-controlled studies and 21 treatment comparator and combination therapy studies. The studies included in this review reported a positive association between the degree of BP lowering, number of medications, and CV outcomes. As combination therapy became available, it was increasingly utilized in clinical trials and enabled an increased proportion of patients to achieve a prespecified BP target. Adverse events with monotherapy and combination therapy were as anticipated for the specific classes of antihypertensive therapy. Although many patients reach BP goal, combination antihypertensive therapy is often needed to reach BP goal. Effective BP lowering has been shown to result in improvements in CV outcomes.
Collapse
Affiliation(s)
- George Bakris
- ASH Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL.
| | - Pantelis Sarafidis
- ASH Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL
| | - Rajiv Agarwal
- Department of Medicine, Indiana University Medical Center, Indianapolis, IN
| | - Luis Ruilope
- Hypertension Unit, Hospital 12 de Octubre, Autonoma University, 28041, Madrid, Spain
| |
Collapse
|
35
|
Ferrari R. RAAS inhibition and mortality in hypertension. Glob Cardiol Sci Pract 2013; 2013:269-78. [PMID: 24689028 PMCID: PMC3963752 DOI: 10.5339/gcsp.2013.34] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/08/2013] [Indexed: 12/13/2022] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) regulates the body's hemodynamic equilibrium, circulating volume, and electrolyte balance, and is a key therapeutic target in hypertension, the world's leading cause of premature mortality. Hypertensive disorders are strongly linked with an overactive RAAS, and RAAS inhibitors, like angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), are routinely used to treat high blood pressure (BP). BP reduction is one of the main goals of current European hypertension guidelines. Oral ACE inhibitors, the oldest category of RAAS inhibitor, were commercially released over 30 years ago in the early 1980s, over a decade before the first ARBs became available. The introduction of ACE inhibitors heralded major changes in the way hypertension and cardiovascular disease were treated. Although the decision of the medical community to replace older ACE inhibitors with more modern ARBs in the 1990s was debatable, it did nevertheless allow scientists to learn more about the angiotensin receptors involved in RAAS stimulation. This and much else of value have been discovered since RAAS inhibitors first became available, but some surprising gaps in our knowledge exist. Until recently, the effect of RAAS inhibition on mortality in hypertension was unknown. This question was recently addressed by a meta-analysis of randomized controlled trials in populations who received contemporary antihypertensive medication. The results of this meta-analysis have helped elucidate the long-term consequences of treatment with RAAS inhibitors on mortality in hypertension. This article will consider the differences between RAAS inhibitors in terms of pharmacological and clinical effects and analyze the impact of the main types of RAAS inhibitor, ACE inhibitors and ARBs, on mortality reduction in hypertensive patients with reference to this latest meta-analysis.
Collapse
Affiliation(s)
- Roberto Ferrari
- Department of Cardiology and LTTA Centre, University Hospital of Ferrara, Italy
| |
Collapse
|
36
|
Yano Y, Briasoulis A, Bakris GL, Hoshide S, Wang JG, Shimada K, Kario K. Effects of antihypertensive treatment in Asian populations: a meta-analysis of prospective randomized controlled studies (CARdiovascular protectioN group in Asia: CARNA). ACTA ACUST UNITED AC 2013; 8:103-16. [PMID: 24157055 DOI: 10.1016/j.jash.2013.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 09/09/2013] [Accepted: 09/13/2013] [Indexed: 12/31/2022]
Abstract
To examine the effects of antihypertensive treatment on cardiovascular disease (CVD) in Asian populations, we systematically evaluated prospective randomized studies carried out in Asia (1991-2013). We identified 18 trials with 23,215 and 21,986 hypertensive patients in the intervention (ie, strict blood pressure [BP] lowering or add-on treatment) and reference groups, respectively (mean age, 65 years; follow-up duration, 3.2 years). Analysis was performed through 1) first subgroup: eight trials that compared active antihypertensive treatment with placebo or intensive with less intensive BP control and 2) second subgroup: 10 trials that compared different antihypertensive treatments. In the first subgroup analysis, BP was reduced from 160.3/87.3 mm Hg to 140.2/78.4 mm Hg in the intervention group with a -6.7/-2.2 mm Hg (P < .001) greater BP reduction than the reference group. Compared with the reference group, the intervention group had a lower risk of composite CVD events (odd ratio [OR], 0.73; 95% confidence interval [CI], 0.66-0.81), myocardial infarction (OR, 0.79; 95% CI, 0.63-1.0), stroke (OR, 0.71; 95% CI, 0.63-0.80), and CVD mortality (OR, 0.81; 95% CI, 0.68-0.97; all P ≤ .05). In the second subgroup analysis, no difference was found for any outcome between renin-angiotensin blockers and calcium-channel blockers or diuretics. The meta-regression line among the 18 trials indicated that a 10 mm Hg reduction in systolic BP was associated with a reduced risk for composite CVD events (-39.5%) and stroke (-30.0%). Our meta-analysis shows a benefit when a BP target of less than 140/80 mm Hg is achieved in Asian hypertensives. BP reduction itself, regardless of BP lowering agents, is important for achieving CVD risk reduction.
Collapse
Affiliation(s)
- Yuichiro Yano
- American Society of Hypertension Comprehensive Hypertension Center, Department of Medicine, University of Chicago Medicine, USA; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Alexandros Briasoulis
- American Society of Hypertension Comprehensive Hypertension Center, Department of Medicine, University of Chicago Medicine, USA.
| | - George L Bakris
- American Society of Hypertension Comprehensive Hypertension Center, Department of Medicine, University of Chicago Medicine, USA
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Ji-Guang Wang
- Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Kazuyuki Shimada
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Japan
| |
Collapse
|
37
|
Abstract
The two major classes of drugs that target the RAS are the angiotensin-converting enzyme (ACE) inhibitors and the selective AT1 receptor blockers (ARBs). Although both of these drug classes target angiotensin II, the differences in their mechanisms of action have implications for their effects on other pathways and receptors that may have therapeutic implications. Both ACEIs and ARBs are effective antihypertensive agents that have been shown to reduce the risk of cardiovascular and renal events. Direct inhibition of renin -the most proximal aspect of the RAS -became clinically feasible from 2007 with the introduction of aliskiren. This latter drug has been shown to be efficacious for the management of hypertension. Combined therapy of direct renin-inhibitors with ACEIs or ARBs has been tested in some clinical situations as congestive HF and proteinuria with diverse results. This article tries to offer an updated review of current knowledge on the use of RAS blocking drugs in clinical settings.
Collapse
Affiliation(s)
- Nicolás Roberto Robles
- 1Cardiovascular Risk Chair, University of Salamanca School of Medicine, Salamanca, Spain
| | | | | |
Collapse
|
38
|
Koyanagi R, Hagiwara N, Yamaguchi JI, Kawada-Watanabe E, Haruta S, Takagi A, Ogawa H. Efficacy of the combination of amlodipine and candesartan in hypertensive patients with coronary artery disease: a subanalysis of the HIJ-CREATE study. J Cardiol 2013; 62:217-23. [PMID: 23778009 DOI: 10.1016/j.jjcc.2013.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 04/13/2013] [Accepted: 04/22/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND The effects of the combination of angiotensin II receptor blocker (ARB) plus dihydropyridine calcium channel blockers (DHP-CCBs), which is known as a potent antihypertensive drug regimen, on cardiovascular events remain unclear. OBJECTIVE The purpose of this post hoc subgroup analysis was to compare the incidence of major adverse cardiovascular events (MACE) of patients treated with candesartan and amlodipine with that of those with candesartan and non-amlodipine CCBs in hypertensive patients with coronary artery disease (CAD). METHODS HIJ-CREATE was a multicenter, prospective, randomized, controlled study that compared the effects of candesartan-based with those of non-ARB-based standard therapy on MACE in 2049 hypertensive patients with CAD. In the candesartan group, a total of 335 patients were treated with DHP-CCBs (amlodipine: 170 and non-amlodipine-CCBs: 165) at the baseline. In this sub-analysis, we compared, among the participants allocated to candesartan regimen, the long-term effects of amlodipine and non-amlodipine CCBs that were concomitantly given with ARB, although the choice of CCB was not randomized. RESULTS The median follow-up was 3.9 years. Treatment using amlodipine with candesartan reduced the risk of MACE by 38% (hazard ratio, 0.62; 95% confidence interval, 0.41-0.94, p=0.025), as compared to patients treated with non-amlodipine-CCBs and candesartan. In a multivariate analysis, combination therapy of candesartan with amlodipine was an independent predictor of reduced risk of MACE. CONCLUSIONS The results suggest that the combination of amlodipine and candesartan is more beneficial in reducing MACE in hypertensive patients with CAD compared to non-amlodipine-DHP-CCBs in combination therapy with candesartan. Further investigation in larger-scale prospective randomized studies is required to reach any conclusion as to the superiority of combination therapy of candesartan with amlodipine.
Collapse
Affiliation(s)
- Ryo Koyanagi
- The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Supplemental benefit of an angiotensin receptor blocker in hypertensive patients with stable heart failure using olmesartan (SUPPORT) trial--rationale and design. J Cardiol 2013; 62:31-6. [PMID: 23769179 DOI: 10.1016/j.jjcc.2013.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 02/06/2013] [Accepted: 02/18/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although angiotensin receptor blockers (ARBs) are now one of the first-line drug classes for the management of hypertension, recommendations for the management of chronic heart failure (CHF) are limited. The supplemental benefit of angiotensin receptor blocker in hypertensive patients with stable heart failure using olmesartan (SUPPORT) trial investigates whether an additive treatment with an ARB, olmesartan, reduces the mortality and morbidity in hypertensive patients with stable chronic heart failure. METHODS AND RESULTS The SUPPORT trial is a prospective randomized open-label blinded endpoint study. Between October 2006 and March 2010, 1147 stable CHF patients treated with evidence-based medications were successfully randomized to either olmesartan or control group. In the olmesartan group, the ARB was initiated at the dose of 5.0-10mg, and was then increased up to 40mg/day, when possible. No ARBs were allowed in the control group. Primary outcome measure in the SUPPORT trial is the composite of all-cause death, non-fatal acute myocardial infarction, non-fatal stroke and hospital admission due to worsening heart failure. The participants will be followed for at least 3 years until March 2013. CONCLUSIONS The SUPPORT trial will elucidate the supplemental benefits of an ARB, olmesartan, in hypertensive patients with CHF.
Collapse
|
40
|
Sakamoto T, Ogawa H, Nakao K, Koide S, Yamamoto N, Shimomura H, Matsumura T, Oshima S, Kikuta K, Oka H, Kimura K, Matsui K. Rationale, design and baseline characteristics of a study to evaluate effects of candesartan on cardiovascular events after drug-eluting stent implantation in patients with ischemic heart disease. J Atheroscler Thromb 2013; 20:472-80. [PMID: 23411616 DOI: 10.5551/jat.13870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM Few multicenter studies have assessed the effects of angiotensin receptor blockers on cardiovascular events after drug-eluting stent implantation in patients with ischemic heart disease. METHODS An open-label multicenter randomized prospective study is in progress to evaluate the effects of candesartan on cardiovascular events in patients with ischemic heart disease after implantation of sirolimus- and/or paclitaxel-eluting stents. RESULTS A total of 1,145 patients were enrolled at 39 institutes in the Candesartan for prevention of Cardiovascular events after CYPHER or TAXUS Coronary stenting (4C trial). Patients were randomized into a group treated with candesartan (n=602) and a group treated with standard medical therapy without candesartan (n=543). The primary endpoint of the 4C trial is a composite of all-cause death, successful resuscitation after cardiopulmonary arrest and cardiovascular events including non-fatal myocardial infarction, unstable angina requiring emergent hospitalization, congestive heart failure requiring emergent hospitalization and cerebrovascular attacks. All patients will be followed-up for 36 months. CONCLUSIONS The 4C trial will be the first multicenter study to elucidate the effects of candesartan after drug-eluting stent implantation and may provide new information to optimize medical therapy after percutaneous coronary interventions.
Collapse
Affiliation(s)
- Tomohiro Sakamoto
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Yasuno S, Fujimoto A, Nakagawa Y, Kuwahara K, Ueshima K. Fixed-dose combination therapy of candesartan cilexetil and amlodipine besilate for the treatment of hypertension in Japan. Expert Rev Cardiovasc Ther 2012; 10:577-83. [PMID: 22651833 DOI: 10.1586/erc.12.34] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hypertension is one of the most prevalent disorders and the largest contributor to global mortality. The aim of antihypertensive treatment is to reduce the risk of cardiovascular morbidity and mortality by lowering increased blood pressure (BP) to target levels. Despite progress in antihypertensive drug development, BP control remains suboptimal. Accumulating evidence has shown that fixed-dose combination therapy is better in terms of BP control than increasing the dose of one drug or its corresponding combination. Fixed-dose combinations of an angiotensin receptor blocker, candesartan cilexetil, and a calcium channel blocker, amlodipine besilate (candesartan/amlodipine 8/2.5 or 8/5 mg), were approved in Japan for once-daily oral administration in hypertensive patients. Recent data showed that a fixed-dose combination of candesartan and amlodipine lowered BP safely and rapidly, providing a potential opportunity to improve the rate of BP control. Further studies are needed to determine whether this will lead to improvements in long-term clinical outcomes.
Collapse
Affiliation(s)
- Shinji Yasuno
- EBM Research Center, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | | | | | | | | |
Collapse
|
42
|
Tchaikovski V, Lip GYH. Angiotensin receptor blockers and tumorigenesis: something to be (or not to be) concerned about? Curr Hypertens Rep 2012; 14:183-92. [PMID: 22467342 DOI: 10.1007/s11906-012-0263-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The possibility of carcinogenic side effects of antihypertensive therapies due to their chronic administration has been raised multiple times in the past. Recently, the issue has again drawn attention, this time in relation to angiotensin receptor blockers (ARBs). This, among others, caused both American and European drug regulation authorities to review the underlying evidence concerning the relationship between this class of medications and potential adverse carcinogenic outcome. A plethora of both basic science and preclinical evidence has been generated, and three meta-analyses and one nationwide cohort have focused on this specific question. The current review aims to summarize the contemporary multidisciplinary evidence on whether ARBs may be associated with an increased risk of tumorigenesis.
Collapse
Affiliation(s)
- Vadim Tchaikovski
- Haemostasis, Thrombosis and Vascular Biology Unit, University of Birmingham Centre for Cardiovascular Sciences, City Hospital Birmingham, Birmingham, B18 7QH, England, UK
| | | |
Collapse
|
43
|
Volpe M. Preventing cardiovascular events with angiotensin II receptor blockers: a closer look at telmisartan and valsartan. Expert Rev Cardiovasc Ther 2012; 10:1061-72. [PMID: 23030295 DOI: 10.1586/erc.12.80] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Angiotensin II receptor blockers (ARBs) inhibit the renin-angiotensin system. As a result, these agents provide beneficial effects in terms of cardiovascular (CV) and renal protection, independent of their blood pressure-lowering effects. Telmisartan and valsartan are the most intensively studied ARBs for the effects on CV outcomes. Randomized clinical trials assessing morbidity and mortality end points have included a range of patient types, including those with hypertension, hypertension with Type 2 diabetes, high CV risk without hypertension, ischemic heart disease, stroke and heart failure. Few head-to-head comparisons between telmisartan and valsartan have been performed. However, some blood pressure-independent properties of these two ARBs can be scrutinized from separate studies in the available literature.
Collapse
Affiliation(s)
- Massimo Volpe
- Department of Clinical and Molecular Science, Division of Cardiology, Faculty of Medicine, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy.
| |
Collapse
|
44
|
Irie H, Shiraishi J, Sawada T, Koide M, Yamada H, Matsubara H. WITHDRAWN: Cardio-cerebrovascular protective effects of valsartan in high-risk hypertensive patients with overweight/obesity: A post-hoc analysis of the KYOTO HEART Study. Int J Cardiol 2012:S0167-5273(12)00894-7. [PMID: 22795716 DOI: 10.1016/j.ijcard.2012.06.103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 05/06/2012] [Accepted: 06/24/2012] [Indexed: 12/20/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
Collapse
Affiliation(s)
- Hidekazu Irie
- Department of Cardiology, Kyoto First Red Cross Hospital, Honmachi, Higashiyama-ku, Kyoto 605-0981, Japan
| | | | | | | | | | | |
Collapse
|
45
|
Caldeira D, Alarcão J, Vaz-Carneiro A, Costa J. Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: systematic review and meta-analysis. BMJ 2012; 345:e4260. [PMID: 22786934 PMCID: PMC3394697 DOI: 10.1136/bmj.e4260] [Citation(s) in RCA: 167] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To systematically review longitudinal studies evaluating use of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and risk of pneumonia. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline through PubMed, Web of Science with conference proceedings (inception to June 2011), and US Food and Drug Administration website (June 2011). Systematic reviews and references of retrieved articles were also searched. STUDY SELECTION Two reviewers independently selected randomised controlled trials and cohort and case-control studies evaluating the use of ACE inhibitors or ARBs and risk of pneumonia and retrieved characteristics of the studies and data estimates. DATA SYNTHESIS The primary outcome was incidence of pneumonia and the secondary outcome was pneumonia related mortality. Subgroup analyses were carried according to baseline morbidities (stroke, heart failure, and chronic kidney disease) and patients' characteristics (Asian and non-Asian). Pooled estimates of odds ratios and 95% confidence intervals were derived by random effects meta-analysis. Adjusted frequentist indirect comparisons between ACE inhibitors and ARBs were estimated and combined with direct evidence whenever available. Heterogeneity was assessed using the I(2) test. RESULTS 37 eligible studies were included. ACE inhibitors were associated with a significantly reduced risk of pneumonia compared with control treatment (19 studies: odds ratio 0.66, 95% confidence interval 0.55 to 0.80; I(2) = 79%) and ARBs (combined direct and indirect odds ratio estimate 0.69, 0.56 to 0.85). In patients with stroke, the risk of pneumonia was also lower in those treated with ACE inhibitors compared with control treatment (odds ratio 0.46, 0.34 to 0.62) and ARBs (0.42, 0.22 to 0.80). ACE inhibitors were associated with a significantly reduced risk of pneumonia among Asian patients (0.43, 0.34 to 0.54) compared with non-Asian patients (0.82, 0.67 to 1.00; P<0.001). Compared with control treatments, both ACE inhibitors (seven studies: odds ratio 0.73, 0.58 to 0.92; I(2)=51%) and ARBs (one randomised controlled trial: 0.63, 0.40 to 1.00) were associated with a decrease in pneumonia related mortality, without differences between interventions. CONCLUSIONS The best evidence available points towards a putative protective role of ACE inhibitors but not ARBs in risk of pneumonia. Patient populations that may benefit most are those with previous stroke and Asian patients. ACE inhibitors were also associated with a decrease in pneumonia related mortality, but the data lacked strength.
Collapse
Affiliation(s)
- Daniel Caldeira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon
| | | | | | | |
Collapse
|
46
|
Shiraishi J, Sawada T, Koide M, Yamada H, Matsubara H. Cardio-cerebrovascular protective effects of valsartan in high-risk hypertensive patients with coronary artery disease (from the Kyoto Heart Study). Am J Cardiol 2012; 109:1308-14. [PMID: 22325086 DOI: 10.1016/j.amjcard.2011.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 12/19/2011] [Accepted: 12/19/2011] [Indexed: 10/14/2022]
Abstract
The objective was to examine whether previous coronary artery disease (CAD) influences the add-on effects of the angiotensin II receptor blocker (ARB) valsartan on cardio-cerebrovascular morbidity and mortality in high-risk hypertensive patients who participated in the Kyoto Heart Study. The primary end point was the same as in the main study: a composite of new-onset and/or worsening of cardiovascular and cerebrovascular events. Median follow-up was 3.27 years. According to the presence of previous CAD at baseline, the study population was divided into 2 groups (with CAD, n = 707; without CAD, n = 2,324) in which primary end-point events occurred more frequently in patients with CAD than in patients without CAD (15.1% vs 5.6%, hazard ratio [HR] 2.68, 95% confidence interval [CI] 2.11 to 3.42). Add-on valsartan significantly decreased the occurrence of the primary end-point events in patients with CAD (11.3% vs 19.0%, HR 0.59, 95% CI 0.41 to 0.85) and without CAD (3.7% vs 7.6%, HR 0.49, 95% CI 0.34 to 0.70) compared to non-ARB treatment. In the presence of previous CAD, patients with valsartan add-on treatment had a significantly lower prevalence of angina pectoris and stroke than those with non-ARB treatment, whereas the valsartan add-on effects on angina and stroke were not significant in the absence of CAD. Changes in blood pressure during the follow-up period did not differ significantly between study subgroups. In conclusion, in the presence or absence of previous CAD, valsartan add-on treatment prevented more cardio-cerebrovascular events than conventional non-ARB treatment in high-risk hypertensive patients. In addition, valsartan add-on treatment conferred not only an antianginal effect but also stroke prevention exclusively in hypertensive patients with CAD compared to those without CAD.
Collapse
|
47
|
van Vark LC, Bertrand M, Akkerhuis KM, Brugts JJ, Fox K, Mourad JJ, Boersma E. Angiotensin-converting enzyme inhibitors reduce mortality in hypertension: a meta-analysis of randomized clinical trials of renin-angiotensin-aldosterone system inhibitors involving 158,998 patients. Eur Heart J 2012; 33:2088-97. [PMID: 22511654 PMCID: PMC3418510 DOI: 10.1093/eurheartj/ehs075] [Citation(s) in RCA: 269] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aims Renin–angiotensin–aldosterone system (RAAS) inhibitors are well established for the reduction in cardiovascular morbidity, but their impact on all-cause mortality in hypertensive patients is uncertain. Our objective was to analyse the effects of RAAS inhibitors as a class of drugs, as well as of angiotensin-converting enzyme (ACE) inhibitors and AT1 receptor blockers (ARBs) separately, on all-cause mortality. Methods and results We performed a pooled analysis of 20 cardiovascular morbidity–mortality trials. In each trial at least two-thirds of the patients had to be diagnosed with hypertension, according to the trial-specific definition, and randomized to treatment with an RAAS inhibitor or control treatment. The cohort included 158 998 patients (71 401 RAAS inhibitor; 87 597 control). The incidence of all-cause death was 20.9 and 23.3 per 1000 patient-years in patients randomized to RAAS inhibition and controls, respectively. Overall, RAAS inhibition was associated with a 5% reduction in all-cause mortality (HR: 0.95, 95% CI: 0.91–1.00, P= 0.032), and a 7% reduction in cardiovascular mortality (HR: 0.93, 95% CI: 0.88–0.99, P= 0.018). The observed treatment effect resulted entirely from the class of ACE inhibitors, which were associated with a significant 10% reduction in all-cause mortality (HR: 0.90, 95% CI: 0.84–0.97, P= 0.004), whereas no mortality reduction could be demonstrated with ARB treatment (HR: 0.99, 95% CI: 0.94–1.04, P= 0.683). This difference in treatment effect between ACE inhibitors and ARBs on all-cause mortality was statistically significant (P-value for heterogeneity 0.036). Conclusion In patients with hypertension, treatment with an ACE inhibitor results in a significant further reduction in all-cause mortality. Because of the high prevalence of hypertension, the widespread use of ACE inhibitors may result in an important gain in lives saved.
Collapse
Affiliation(s)
- Laura C van Vark
- Department of Cardiology, Thoraxcenter, Erasmus MC, 's Gravendijkwal 230, 3015 GE Rotterdam, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
48
|
Nakao YM, Teramukai S, Tanaka S, Yasuno S, Fujimoto A, Kasahara M, Ueshima K, Nakao K, Hinotsu S, Nakao K, Kawakami K. Effects of renin-angiotensin system blockades on cardiovascular outcomes in patients with diabetes mellitus: A systematic review and meta-analysis. Diabetes Res Clin Pract 2012; 96:68-75. [PMID: 22197527 DOI: 10.1016/j.diabres.2011.11.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 11/16/2011] [Accepted: 11/28/2011] [Indexed: 10/14/2022]
Abstract
AIM To determine whether renin-angiotensin system (RAS) blockade is beneficial for cardiovascular outcomes in patients with diabetes mellitus (DM) using meta-analysis. METHODS The MEDLINE and Cochrane library databases were searched for randomized controlled trials published up to June 2010. We also reviewed reference lists from identified trials and review articles to identify any other relevant studies, and the ClinicalTrials.gov website to identify randomized controlled trials that were registered as completed but not yet published. A random-effects model was used to combine the estimates for risk ratios (RR). RESULTS Eligible studies were randomized controlled trials (including post hoc analyses) assessing the effects of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers on cardiovascular events compared to controls in patients with DM. Nineteen clinical trials with 41,042 patients and 6039 cardiovascular events were identified. RAS blockade significantly reduced the risk of major cardiovascular events (RR 0.92, 95% confidence interval [CI] 0.84-1.00, I(2) statistic 53%) and myocardial infarction (RR 0.82, 95% CI 0.72-0.94, I(2)=55%). There were trends towards fewer strokes and lower all-cause mortality but these were not statistically significant. CONCLUSIONS The available evidence shows that treatment with RAS blockade can routinely be considered for diabetic patients to reduce major cardiovascular events.
Collapse
Affiliation(s)
- Yoko M Nakao
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Rakugi H, Ogihara T, Miyata Y, Sasai K, Totsuka N. Evaluation of the efficacy and tolerability of combination therapy with candesartan cilexetil and amlodipine besilate compared with candesartan cilexetil monotherapy and amlodipine besilate monotherapy in Japanese patients with mild-to-moderate essential hypertension: a multicenter, 12-week, randomized, double-blind, placebo-controlled, parallel-group study. Clin Ther 2012; 34:838-48. [PMID: 22440192 DOI: 10.1016/j.clinthera.2012.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Blood pressure is reported to be insufficiently controlled in >50% of patients with hypertension. Guidelines for the management of hypertension recommend using drugs with different mechanisms of action when >1 agent is needed to achieve the blood pressure target. The combination of an angiotensin II receptor blocker and a calcium channel blocker is recommended as the preferred antihypertensive medication combination, and candesartan cilexetil (CC) and amlodipine besilate (AML) are commonly used in Japan. OBJECTIVE The objective of our study was to determine if the combination of CC 8 mg and AML 5 mg has a greater blood pressure-lowering effect than monotherapy with either component, and if the combination of CC 4 mg and AML 2.5 mg has a greater blood pressure-lowering effect than placebo. METHODS This was a multicenter, randomized, double-blind, placebo-controlled, parallel-group study in Japanese patients with mild-to-moderate essential hypertension. After receiving placebo during a 4-week run-in period in a single-blind manner, patients were randomized to receive the combination of CC 4 or 8 mg with AML 2.5 or 5 mg, CC 8 mg monotherapy, AML 5 mg monotherapy, or placebo once daily in the fasting or fed state for 12 weeks. The primary end point was change from baseline in trough diastolic blood pressure, and the secondary end point was change from baseline in trough systolic blood pressure at the end of treatment. Tolerability was assessed based on adverse events, vital signs, and physical findings. RESULTS Of 548 patients who received placebo during the run-in period, 444 were randomized to receive CC 8 mg/AML 5 mg (CC/AML 8/5 mg) (n = 101), 8/2.5 mg (n = 36), 4/5 mg (n = 36), 4/2.5 mg (n = 35), CC 8 mg (n = 100), AML 5 mg (n = 100), or placebo (n = 36). These 444 patients included 272 men and 172 women. The mean (SD) age was 56.9 (10.7) years and the mean baseline BP was 153.4/95.7 mm Hg. The antihypertensive effect in the CC/AML 8/5 mg group (-27.4/-16.3 mm Hg) was significantly higher than in the CC 8 mg group (-13.9/-7.8 mm Hg) or the AML 5 mg group (-19.9/-11.2 mm Hg) in terms of reduction in the seated trough diastolic blood pressure and systolic blood pressure (both P < 0.0001). The incidence and severity of adverse events in the CC/AML combination groups did not differ significantly from those in the monotherapy and placebo groups. CONCLUSIONS In Japanese adult patients with mild-to-moderate essential hypertension, CC/AML 8/5 mg combination therapy was more effective in lowering blood pressure than CC 8 mg or AML 5 mg monotherapy. These combinations were also well tolerated. Japan Pharmaceutical Information Center registration number: Japic CTI-101054.
Collapse
Affiliation(s)
- Hiromi Rakugi
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka. Suita, Osaka, Japan.
| | | | | | | | | |
Collapse
|
50
|
Sugiura R, Ogawa H, Oka T, Koyanagi R, Hagiwara N. Candesartan-based therapy and risk of cancer in patients with systemic hypertension (Heart Institute of Japan Candesartan Randomized Trial for Evaluation in Coronary Artery Disease [HIJ-CREATE] substudy). Am J Cardiol 2012; 109:576-80. [PMID: 22100194 DOI: 10.1016/j.amjcard.2011.09.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 09/29/2011] [Accepted: 09/29/2011] [Indexed: 10/15/2022]
Abstract
The aim of the present study was to clarify the influence of candesartan-based therapy on subsequent carcinogenesis and cancer death in patients with coronary artery disease with hypertension in a substudy of a multicenter, prospective, randomized, controlled trial. That trial compared the effects of candesartan-based therapy with those of non-angiotensin receptor blocker (ARB)-based standard therapy on major adverse cardiovascular events. Hypertensive patients with coronary artery disease were randomly assigned to receive either candesartan-based (n = 1,024) or non-ARB-based pharmacotherapy, including angiotensin-converting enzyme inhibitors (n = 1,025). During a median follow-up of 4.2 years, 1,606 adverse events (798 in the candesartan group and 808 in the non-ARB standard group) were reported. Among them, new cancer occurred in 5.37% of subjects in the candesartan group and 5.66% of subjects in the standard therapy group (hazard ratio 0.95, 95% confidence interval 0.65 to 1.38). Cancer deaths occurred in 1.66% in the candesartan group and 2.44% in the standard therapy group, respectively (hazard ratio 0.74, 95% confidence interval 0.39 to 1.39). Kaplan-Meier estimates of survival without new cancer and cancer deaths demonstrated that candesartan-based therapy does not accelerate the occurrence of new cancer (log-rank, p = 0.84) or cancer death (p = 0.39) compared to standard therapy. Advanced age and male gender were independently and significantly correlated with the subsequent incidence of cancer. In conclusion, the results of the present study suggest that candesartan-based therapy is not associated with either carcinogenesis or cancer death compared to non-ARB standard therapy.
Collapse
|