Antihypertensive drug therapy and survival by treatment status in a national survey

The Mechanism of Acupuncture in Treating Essential Hypertension: A Narrative Review

Essential hypertension has a high incidence worldwide, and patients with essential hypertension endure a lifetime of medication, leading to a heavy economic burden on the patient's family and causing serious impacts on the patient's quality of life. Much evidence has demonstrated that acupuncture as an adjunctive therapy can lower blood pressure in patients with hypertension, but the mechanism of its action is unclear. This article reviews the research from 2000 to 2018 regarding the mechanism of acupuncture for hypertension, and we summarize the current knowledge about using acupuncture for hypertension. We found that the mechanism whereby acupuncture lowers blood pressure is related to the regulation of renin-angiotensin-aldosterone system, vascular endothelium, oxidative stress, neuroendocrine system, and so on. Besides, there may be cross-talk between multiple systems and multiple targets. We also investigate the influence factors of acupuncture for hypertension. These results may provide evidence and research ideas for the treatment of hypertension via acupuncture.

The joint association of physical activity, blood-pressure control, and pharmacologic treatment of hypertension for all-cause mortality risk

BACKGROUND

We conducted a study to determine the joint association of physical activity, pharmacologic treatment for hypertension, and the control of blood pressure (BP) on all-cause mortality risk.

METHODS

The study subjects were 10,665 adults from the Third National Health and Nutrition Examination Survey (NHANES III) and the Continuous NHANES survey (1999-2000 and 2000-2001). Cox proportional hazards analyses were used to estimate differences in mortality risk according to physical activity, pharmacologic treatment for hypertension, and BP control, with physically active, treated, and controlled as the referent category.

RESULTS

The average follow-up time in the study was 8.6±4.8 years. The main effect of physical activity was significant independently of pharmacologic treatment and BP control (P < 0.001). Physically inactive adults with hypertension had a higher risk of mortality than did physically active adults with treated and controlled hypertension (inactive, treated and controlled hypertension: HR, 1.42; 95% CI, 1.17-1.72; P < 0.01; inactive, treated, and uncontrolled hypertension: HR, 1.55; 95% CI, 1.30-1.84; P < 0.01; inactive, untreated, and uncontrolled hypertension: HR, 1.27; 95% CI, 1.07-1.52, P < 0.01). However, the risk of mortality for physically active adults with hypertension did not differ significantly with or without treatment for hypertension if their hypertension remained uncontrolled (active, treated and uncontrolled hypertension: HR, 1.17; 95% CI 0.98-1.40; P = 0.08; active, untreated and uncontrolled hypertension: HR, 0.90; 95% CI, 0.76-1.08; P = 0.25). Physically active, normotensive individuals had a lower all-cause mortality risk than did the referent group of physically active individuals being treated with antihypertensive medication and who had controlled hypertension (HR, 0.72; 95% CI, 0.60-0.86; P < 0.01), whereas physically inactive, normotensive individuals had a risk of mortality similar to that of the referent group (HR, 1.08; 95% CI, 0.90-1.30; P = 0.42).

CONCLUSION

Physical activity may be as or even more important than pharmacotherapy for reducing the risk of mortality in adults with hypertension. However, the risk of mortality remained higher for physically active adults with treated and controlled hypertension than did the risk of mortality for physically active normotensive populations. Prevention of hypertension is therefore imperative for reducing the all-cause risk of premature mortality in adults.

Novel therapeutic targets for hypertension

Despite the existence of established, effective therapies for hypertension, new methods of blood pressure and cardiovascular risk reduction are still needed. Novel approaches are targeted towards treating resistant hypertension, improving blood-pressure control, and achieving further risk reduction beyond blood-pressure lowering. Modulation of the renin-angiotensin-aldosterone system (RAAS) provides the rationale for current antihypertensive therapies, including the relatively new agents eplerenone and aliskiren. Novel targets for antihypertensive therapy are also likely to be RAAS-related. The stimulation of angiotensin II type 2 receptors, or supplementation with renalase, could counteract the effects of angiotensin II type 1 receptor stimulation or catecholamine release. Combined angiotensin-converting-enzyme and neutral endopeptidase blockade decreases blood pressure, but is associated with a high incidence of angioedema. Aldosterone synthase inhibitors might improve tolerability in aldosterone antagonism. A (pro)renin-receptor blocker could prevent the deleterious angiotensin-independent actions of renin that are not inhibited by aliskiren. Finally, new minimally invasive surgical procedures have revived the concept of renal denervation, and could be a therapeutic option for patients with resistant hypertension. All of these strategies are exciting prospects, but which of them will prove valuable in clinical setting remains to be discovered.

Irbesartan improves arterial compliance more than lisinopril

BACKGROUND

Antihypertensive agents can reduce arterial stiffness. We hypothesized that an angiotensin receptor blocker (ARB) irbesartan and an angiotensin converting enzyme inhibitor (ACEI) lisinopril improved arterial compliance.

METHODS

A randomized, double-blind, double-dummy, controlled crossover trial. Fifteen hypertensive patients, mean age 65.5 +/- 8.9 years (mean +/- SD) were given irbesartan (150 to 300 mg/day) or lisinopril (10 to 20 mg/day) for 12 weeks and then crossed over for 12 weeks. Pulse wave velocity (PWV) in the carotid-femoral (CF), carotid-radial (CR), and femoral dorsalis-pedis (FD) were measured using a Complior((R)) PWV system.

RESULTS

After 12 weeks, systolic blood pressure (SBP) decreased from 162.4 +/- 12.9 to 134.5 +/- 14.8 with irbesartan and to 145.2 +/- 25 mmHg with lisinopril. Irbesartan and lisinopril reduced PWV (CF) in the elastic arterial system from 15.1 +/- 5 to 13.3 +/- 2.6 (p < 0.005) and to 14 +/- 4.7 (p < 0.05) m/s respectively (p = 0.345). Irbesartan reduced PWV (CR) and PWV (FD), whereas lisinopril did not. The difference between treatments was significant after SBP adjustment (p = 0.037 for PWV (CR) and p < 0.001 for PWV (FD)).

CONCLUSIONS

Irbesartan improved arterial compliance in elastic and muscular arteries, whereas lisinopril improved it only in elastic arteries.

Effect of the renin--angiotensin system on the vessel wall: using ACE inhibition to improve endothelial function

Plasma renin activity and cardiovascular disease (CVD) incidence correlate closely in people with hypertension. The effects of angiotensin II (Ang II) on blood pressure (BP) are important in hypertensive patients; accumulating data suggest that the growth effects of Ang II in the cardiovascular system play a critical role in the development of atherosclerosis. Atherosclerosis development in hypertensive patients requires fundamental changes in endothelial structure and function. Key among the factors that may affect the endothelium is the renin--angiotensin--bradykinin system. Ang II, independent of other environmental and neurohormonal factors, mediates the vessel wall changes critical for the development of atherosclerotic disease. A strong correlation appears to exist between Ang II and CVD. Blockade of the renin-angiotensin system has a major impact on arterial structure and function independent of BP. Certain angiotensin-converting enzyme (ACE) inhibitors produce significant improvements in arterial compliance, which may yield a reduction in cardiovascular events. Blockade of the neurohormonal system may be a critical first-line approach to management of hypertension in an effort to prevent or reverse endothelial dysfunction. Moreover, the effects of ACE inhibition, in addition to its effect on BP, suggest that this therapeutic approach may be appropriate for managing patients at risk of CVD who do not yet have hypertension. The ideal antihypertensive agent should yield smooth, consistent BP control over the entire 24-hour period, both to avoid BP variability that places patients at increased risk of cardiovascular events and to offer protection during the vulnerable early morning hours when patients are well known to be at high risk.

Drugs targeting the renin-angiotensin-aldosterone system

Effective antihypertensive therapy has made a major contribution to the reductions in the morbidity and mortality of cardiovascular disease that have been achieved since the 1960s. However, blood-pressure control with conventional drugs has not succeeded in reducing cardiovascular disease risks to levels seen in normotensive persons. Drugs that inhibit or antagonize components of the renin-angiotensin-aldosterone system are addressing this deficiency by targeting both blood pressure and related structural and functional abnormalities of the heart and blood vessels, thus preventing target-organ damage and related cardiovascular events.

Cardiovascular disease, hypertension and renal function in primary hyperparathyroidism

OBJECTIVES

Patients with primary hyperparathyroidism run an increased risk of death in cardiovascular disease. Long ago, hypertension was found to frequently occur in these patients. The aim of this study was to compare the death risk after surgery for hyperparathyroidism of hypertensive patients with that of normotensive ones, and to investigate relations between variables of cardiovascular disease and variables of hyperparathyroidism and renal function.

METHODS

A series of 845 patients with primary hyperparathyroidism and serum creatinine <or=160 micromol L-1 was followed-up mean 10.2 (SD 5.7) years after surgery. Survival and correlation tests were performed. Death risk was estimated using a hazard function according to Poisson.

RESULTS

The death risk of hypertensive hyperparathyroid patients was 50% higher compared with that of the normotensive patients, but the yearly death risk decrease after surgery for the hypertensive patients was almost doubled as compared with the decrease of the normotensive patients. Cardiovascular disease was directly related to serum calcium level, adenoma weight, osteitis fibrosa, and serum creatinine, and inversely related to glomerular filtration rate and urine osmolality, but unrelated to the symptom variables. A negative relation was found between cardiovascular disease and renal stone disease.

CONCLUSIONS

It can be concluded that cardiovascular disease is more a part of primary hyperparathyroidism than just associated with it, being related to both serum calcium and adenoma weight. There was also a relationship between cardiovascular disease and decreased renal function. Death risk decrease after surgery was rather more pronounced for the hypertensive patients compared with the normotensive ones.

Safety and efficacy of angiotensin II receptor antagonists

A disturbing pattern in the management of hypertension is emerging worldwide. More patients are being treated for hypertension, but blood pressures are not decreasing to target levels. Inadequate reduction in blood pressure is a risk factor for coronary artery disease. Poor drug efficacy, side effects, and lack of compliance are important factors leading to inadequate control of blood pressure. Angiotensin II receptor antagonists provide adequate 24-hour blood pressure control, as measured by ambulatory blood pressure monitoring, and have a side-effect profile similar to placebo. They also provide better patient compliance through once-daily dosing. This article compares the safety and efficacy of angiotensin II receptor antagonists with other antihypertensive agents.

Epidemiology of hypertension in African American women

To describe the epidemiology of hypertension in U.S. African American women and to highlight priority areas for future research, data from the nationwide surveys of the U.S. National Center for Health Statistics, from selected multicenter studies of the U.S. National Heart, Lung, and Blood Institute, as well as from selected other population-based studies, were reviewed. In 1988 through 1991, an estimated 3 million African American women aged 18 and older had hypertension. Compared with that in U.S. whites, hypertension in black women is characterized by higher incidence, earlier onset, longer duration, higher prevalence, and higher rates of hypertension-related mortality and morbidity. Risk factors for hypertension incidence in black women include obesity and weight gain. The effectiveness of drug therapy of hypertension has been established in black women, and important gains in rates of treatment and control have been accomplished. Nevertheless, rates of hypertension-related mortality for black women remain among the highest in the industrialized nations. Further research on causes and prevention of hypertension in black women is needed. Goals related to prevention and control of hypertension in African Americans for the year 2000 have been established and must be vigorously pursued.

Antihypertensive therapy in dyslipidemic men. Effects on coronary heart disease incidence and total mortality

To investigate the influence of antihypertensive therapy and the success of blood pressure control on coronary heart disease incidence and total mortality, we studied dyslipidemic middle-aged men participating in the placebo arm of the Helsinki Heart Study, a randomized coronary primary prevention trial with gemfibrozil. Based on blood pressure level and the presence of antihypertensive therapy at study entry, the participants were classified into four categories. Relative risks of coronary heart disease (nonfatal myocardial infarction or cardiac death) and total mortality during the 5-year trial period were calculated using Cox proportional hazards models. With subjects who were not using antihypertensive drugs and who had normal blood pressure (category I) as reference, the relative risks of coronary heart disease during the trial period were 2.1 (95% confidence interval [CI], 1.3 to 3.3) in untreated hypertensive subjects (category II), 0.9 (95% CI, 0.2 to 3.8) in subjects with successful antihypertensive therapy (category III), and 2.0 (95% CI, 1.0 to 4.1) in subjects who remained hypertensive despite drug therapy (category IV). The relative risks of death were 1.9 (95% CI, 0.9 to 3.9) in category II and 1.0 (95% CI, 0.1 to 7.3) in category III; in category IV subjects, those with unsuccessful antihypertensive therapy, the relative risk was 4.4 (95% CI, 2.0 to 9.6). The excess mortality in this category was due to cardiovascular causes and was clustered in subjects with multiple drug therapy for hypertension control. We conclude that successful antihypertensive therapy in dyslipidemic men reduced coronary heart disease incidence despite its adverse effects on high-density lipoprotein cholesterol and triglycerides.(ABSTRACT TRUNCATED AT 250 WORDS)

White blood cell count and hypertension incidence. The NHANES I Epidemiologic Follow-up Study

To test the hypothesis that elevated white blood cell count (WBC) is associated with increased incidence of essential hypertension, data from the NHANES I Epidemiologic Follow-up Study (NHEFS) were analyzed. Incidence of hypertension was determined in a cohort of 5782 white and 674 black persons with complete data who were normotensive at baseline. There was a statistically significant increase of about 50% in risk of hypertension over approximately 10 years' follow-up in white men aged 25-74 years with WBC > 8600 compared to men with WBC < 6200 cells/mm3. The association was independent of other risk variables. In white women, an association of high WBC with increased age-adjusted risk of hypertension was seen only at ages 45-64 and 65-74 years. The association was diminished and no longer significant after controlling for multiple risk variables. Data for black women suggested an increased risk among women with higher WBC compared to those with lower WBC at ages 65-74 after controlling other risk variables (p = 0.0001). No positive association was seen in black men. Thus, data from NHEFS confirm the previously reported association of higher WBC with increased incidence of hypertension in white men, and possibly older white and black women. Given the lack of a compelling biological explanation, further studies of this association are needed, especially in women and blacks.

A Fourier series approach for comparing groups of subjects on ambulatory blood pressure patterns

We develop an approach to the statistical analysis of 24-hour ambulatory blood pressure monitoring where we represent each subject's profile by a different mathematical model. We first smooth the data and then use a Fourier series approach to determine the best model for each subject. We then estimate summary variables based on each subject's model to compare distinct groups of subjects. In comparing 15 adult black male hypertensives to eight adult black male normotensives we found that the two groups differ on the shift away from the mesor for both the systolic and the diastolic blood pressure profile.