Effect of two different therapeutic approaches on total and cardiovascular mortality in a Cardiovascular Study in the Elderly (CASTEL)

Sex Differences in Longitudinal Determinants of Carotid Intima Medial Thickening With Aging in a Community-Dwelling Population: The Baltimore Longitudinal Study on Aging

Background Common carotid intima medial thickness (IMT) increases with aging. However, the longitudinal association between IMT and other age-associated hemodynamic alterations in men and in women are not fully explored. Methods and Results We analyzed repeated measures of IMT, blood pressure, and carotid-femoral pulse wave velocity over a 20-year period in 1067 men and women of the Baltimore Longitudinal Study on Aging; participants were ages 20 to 92 years at entry and free of overt cardiovascular disease. Linear mixed-effects models were used to calculate the individual rates of change (_Change) of IMT, pulse pressure, mean arterial pressure, and pulse wave velocity, among other covariates. Multivariate regression analysis was used to examine the association of IMT_Change with baseline and rates of change of hemodynamic parameters and cardiovascular risk factors. IMT increased at accelerating rates from 0.02 mm/decade at age 50 years to 0.05 mm/decade at age 80 years greater rates in men than in women. IMT_Change was positively associated with baseline low-density lipoprotein, low-density lipoprotein_Change, and baseline systolic blood pressure and systolic blood pressure_Change, but inversely with baseline diastolic blood pressure and diastolic blood pressure_Change. When blood pressure was expressed as pulse pressure and MAP, IMT_Change was positively associated with baseline pulse pressure and pulse pressure_Change and inversely with baseline mean arterial pressure and mean arterial pressure_Change. In sex-specific analysis, these associations were observed in women, but not in men. Conclusions In summary, our analyses showed that IMT increases at accelerating rates with aging. Age-associated changes in IMT were modulated by concurrent changes of low-density lipoprotein in both sexes, and of pulsatile and mean blood pressure in women but not men.

Pharmacotherapy for hypertension in adults 60 years or older

BACKGROUND

This is the second substantive update of this review. It was originally published in 1998 and was previously updated in 2009. Elevated blood pressure (known as 'hypertension') increases with age - most rapidly over age 60. Systolic hypertension is more strongly associated with cardiovascular disease than is diastolic hypertension, and it occurs more commonly in older people. It is important to know the benefits and harms of antihypertensive treatment for hypertension in this age group, as well as separately for people 60 to 79 years old and people 80 years or older.

OBJECTIVES

Primary objective• To quantify the effects of antihypertensive drug treatment as compared with placebo or no treatment on all-cause mortality in people 60 years and older with mild to moderate systolic or diastolic hypertensionSecondary objectives• To quantify the effects of antihypertensive drug treatment as compared with placebo or no treatment on cardiovascular-specific morbidity and mortality in people 60 years and older with mild to moderate systolic or diastolic hypertension• To quantify the rate of withdrawal due to adverse effects of antihypertensive drug treatment as compared with placebo or no treatment in people 60 years and older with mild to moderate systolic or diastolic hypertension SEARCH METHODS: The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to 24 November 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We contacted authors of relevant papers regarding further published and unpublished work.

SELECTION CRITERIA

Randomised controlled trials of at least one year's duration comparing antihypertensive drug therapy versus placebo or no treatment and providing morbidity and mortality data for adult patients (≥ 60 years old) with hypertension defined as blood pressure greater than 140/90 mmHg.

DATA COLLECTION AND ANALYSIS

Outcomes assessed were all-cause mortality; cardiovascular morbidity and mortality; cerebrovascular morbidity and mortality; coronary heart disease morbidity and mortality; and withdrawal due to adverse effects. We modified the definition of cardiovascular mortality and morbidity to exclude transient ischaemic attacks when possible.

MAIN RESULTS

This update includes one additional trial (MRC-TMH 1985). Sixteen trials (N = 26,795) in healthy ambulatory adults 60 years or older (mean age 73.4 years) from western industrialised countries with moderate to severe systolic and/or diastolic hypertension (average 182/95 mmHg) met the inclusion criteria. Most of these trials evaluated first-line thiazide diuretic therapy for a mean treatment duration of 3.8 years.Antihypertensive drug treatment reduced all-cause mortality (high-certainty evidence; 11% with control vs 10.0% with treatment; risk ratio (RR) 0.91, 95% confidence interval (CI) 0.85 to 0.97; cardiovascular morbidity and mortality (moderate-certainty evidence; 13.6% with control vs 9.8% with treatment; RR 0.72, 95% CI 0.68 to 0.77; cerebrovascular mortality and morbidity (moderate-certainty evidence; 5.2% with control vs 3.4% with treatment; RR 0.66, 95% CI 0.59 to 0.74; and coronary heart disease mortality and morbidity (moderate-certainty evidence; 4.8% with control vs 3.7% with treatment; RR 0.78, 95% CI 0.69 to 0.88. Withdrawals due to adverse effects were increased with treatment (low-certainty evidence; 5.4% with control vs 15.7% with treatment; RR 2.91, 95% CI 2.56 to 3.30. In the three trials restricted to persons with isolated systolic hypertension, reported benefits were similar.This comprehensive systematic review provides additional evidence that the reduction in mortality observed was due mostly to reduction in the 60- to 79-year-old patient subgroup (high-certainty evidence; RR 0.86, 95% CI 0.79 to 0.95). Although cardiovascular mortality and morbidity was significantly reduced in both subgroups 60 to 79 years old (moderate-certainty evidence; RR 0.71, 95% CI 0.65 to 0.77) and 80 years or older (moderate-certainty evidence; RR 0.75, 95% CI 0.65 to 0.87), the magnitude of absolute risk reduction was probably higher among 60- to 79-year-old patients (3.8% vs 2.9%). The reduction in cardiovascular mortality and morbidity was primarily due to a reduction in cerebrovascular mortality and morbidity.

AUTHORS' CONCLUSIONS

Treating healthy adults 60 years or older with moderate to severe systolic and/or diastolic hypertension with antihypertensive drug therapy reduced all-cause mortality, cardiovascular mortality and morbidity, cerebrovascular mortality and morbidity, and coronary heart disease mortality and morbidity. Most evidence of benefit pertains to a primary prevention population using a thiazide as first-line treatment.

First-line drugs for hypertension

BACKGROUND

This is the first update of a review published in 2009. Sustained moderate to severe elevations in resting blood pressure leads to a critically important clinical question: What class of drug to use first-line? This review attempted to answer that question.

OBJECTIVES

To quantify the mortality and morbidity effects from different first-line antihypertensive drug classes: thiazides (low-dose and high-dose), beta-blockers, calcium channel blockers, ACE inhibitors, angiotensin II receptor blockers (ARB), and alpha-blockers, compared to placebo or no treatment.Secondary objectives: when different antihypertensive drug classes are used as the first-line drug, to quantify the blood pressure lowering effect and the rate of withdrawal due to adverse drug effects, compared to placebo or no treatment.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to November 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We contacted authors of relevant papers regarding further published and unpublished work.

SELECTION CRITERIA

Randomized trials (RCT) of at least one year duration, comparing one of six major drug classes with a placebo or no treatment, in adult patients with blood pressure over 140/90 mmHg at baseline. The majority (over 70%) of the patients in the treatment group were taking the drug class of interest after one year. We included trials with both hypertensive and normotensive patients in this review if the majority (over 70%) of patients had elevated blood pressure, or the trial separately reported outcome data on patients with elevated blood pressure.

DATA COLLECTION AND ANALYSIS

The outcomes assessed were mortality, stroke, coronary heart disease (CHD), total cardiovascular events (CVS), decrease in systolic and diastolic blood pressure, and withdrawals due to adverse drug effects. We used a fixed-effect model to to combine dichotomous outcomes across trials and calculate risk ratio (RR) with 95% confidence interval (CI). We presented blood pressure data as mean difference (MD) with 99% CI.

MAIN RESULTS

The 2017 updated search failed to identify any new trials. The original review identified 24 trials with 28 active treatment arms, including 58,040 patients. We found no RCTs for ARBs or alpha-blockers. These results are mostly applicable to adult patients with moderate to severe primary hypertension. The mean age of participants was 56 years, and mean duration of follow-up was three to five years.High-quality evidence showed that first-line low-dose thiazides reduced mortality (11.0% with control versus 9.8% with treatment; RR 0.89, 95% CI 0.82 to 0.97); total CVS (12.9% with control versus 9.0% with treatment; RR 0.70, 95% CI 0.64 to 0.76), stroke (6.2% with control versus 4.2% with treatment; RR 0.68, 95% CI 0.60 to 0.77), and coronary heart disease (3.9% with control versus 2.8% with treatment; RR 0.72, 95% CI 0.61 to 0.84).Low- to moderate-quality evidence showed that first-line high-dose thiazides reduced stroke (1.9% with control versus 0.9% with treatment; RR 0.47, 95% CI 0.37 to 0.61) and total CVS (5.1% with control versus 3.7% with treatment; RR 0.72, 95% CI 0.63 to 0.82), but did not reduce mortality (3.1% with control versus 2.8% with treatment; RR 0.90, 95% CI 0.76 to 1.05), or coronary heart disease (2.7% with control versus 2.7% with treatment; RR 1.01, 95% CI 0.85 to 1.20).Low- to moderate-quality evidence showed that first-line beta-blockers did not reduce mortality (6.2% with control versus 6.0% with treatment; RR 0.96, 95% CI 0.86 to 1.07) or coronary heart disease (4.4% with control versus 3.9% with treatment; RR 0.90, 95% CI 0.78 to 1.03), but reduced stroke (3.4% with control versus 2.8% with treatment; RR 0.83, 95% CI 0.72 to 0.97) and total CVS (7.6% with control versus 6.8% with treatment; RR 0.89, 95% CI 0.81 to 0.98).Low- to moderate-quality evidence showed that first-line ACE inhibitors reduced mortality (13.6% with control versus 11.3% with treatment; RR 0.83, 95% CI 0.72 to 0.95), stroke (6.0% with control versus 3.9% with treatment; RR 0.65, 95% CI 0.52 to 0.82), coronary heart disease (13.5% with control versus 11.0% with treatment; RR 0.81, 95% CI 0.70 to 0.94), and total CVS (20.1% with control versus 15.3% with treatment; RR 0.76, 95% CI 0.67 to 0.85).Low-quality evidence showed that first-line calcium channel blockers reduced stroke (3.4% with control versus 1.9% with treatment; RR 0.58, 95% CI 0.41 to 0.84) and total CVS (8.0% with control versus 5.7% with treatment; RR 0.71, 95% CI 0.57 to 0.87), but not coronary heart disease (3.1% with control versus 2.4% with treatment; RR 0.77, 95% CI 0.55 to 1.09), or mortality (6.0% with control versus 5.1% with treatment; RR 0.86, 95% CI 0.68 to 1.09).There was low-quality evidence that withdrawals due to adverse effects were increased with first-line low-dose thiazides (5.0% with control versus 11.3% with treatment; RR 2.38, 95% CI 2.06 to 2.75), high-dose thiazides (2.2% with control versus 9.8% with treatment; RR 4.48, 95% CI 3.83 to 5.24), and beta-blockers (3.1% with control versus 14.4% with treatment; RR 4.59, 95% CI 4.11 to 5.13). No data for these outcomes were available for first-line ACE inhibitors or calcium channel blockers. The blood pressure data were not used to assess the effect of the different classes of drugs as the data were heterogeneous, and the number of drugs used in the trials differed.

AUTHORS' CONCLUSIONS

First-line low-dose thiazides reduced all morbidity and mortality outcomes in adult patients with moderate to severe primary hypertension. First-line ACE inhibitors and calcium channel blockers may be similarly effective, but the evidence was of lower quality. First-line high-dose thiazides and first-line beta-blockers were inferior to first-line low-dose thiazides.

Pharmacotherapy for hypertension in adults aged 18 to 59 years

BACKGROUND

Hypertension is an important risk factor for adverse cardiovascular events including stroke, myocardial infarction, heart failure and renal failure. The main goal of treatment is to reduce these events. Systematic reviews have shown proven benefit of antihypertensive drug therapy in reducing cardiovascular morbidity and mortality but most of the evidence is in people 60 years of age and older. We wanted to know what the effects of therapy are in people 18 to 59 years of age.

OBJECTIVES

To quantify antihypertensive drug effects on all-cause mortality in adults aged 18 to 59 years with mild to moderate primary hypertension. To quantify effects on cardiovascular mortality plus morbidity (including cerebrovascular and coronary heart disease mortality plus morbidity), withdrawal due adverse events and estimate magnitude of systolic blood pressure (SBP) and diastolic blood pressure (DBP) lowering at one year.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to January 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We contacted authors of relevant papers regarding further published and unpublished work.

SELECTION CRITERIA

Randomized trials of at least one year' duration comparing antihypertensive pharmacotherapy with a placebo or no treatment in adults aged 18 to 59 years with mild to moderate primary hypertension defined as SBP 140 mmHg or greater or DBP 90 mmHg or greater at baseline, or both.

DATA COLLECTION AND ANALYSIS

The outcomes assessed were all-cause mortality, total cardiovascular (CVS) mortality plus morbidity, withdrawals due to adverse events, and decrease in SBP and DBP. For dichotomous outcomes, we used risk ratio (RR) with 95% confidence interval (CI) and a fixed-effect model to combine outcomes across trials. For continuous outcomes, we used mean difference (MD) with 95% CI and a random-effects model as there was significant heterogeneity.

MAIN RESULTS

The population in the seven included studies (17,327 participants) were predominantly healthy adults with mild to moderate primary hypertension. The Medical Research Council Trial of Mild Hypertension contributed 14,541 (84%) of total randomized participants, with mean age of 50 years and mean baseline blood pressure of 160/98 mmHg and a mean duration of follow-up of five years. Treatments used in this study were bendrofluazide 10 mg daily or propranolol 80 mg to 240 mg daily with addition of methyldopa if required. The risk of bias in the studies was high or unclear for a number of domains and led us to downgrade the quality of evidence for all outcomes.Based on five studies, antihypertensive drug therapy as compared to placebo or untreated control may have little or no effect on all-cause mortality (2.4% with control vs 2.3% with treatment; low quality evidence; RR 0.94, 95% CI 0.77 to 1.13). Based on 4 studies, the effects on coronary heart disease were uncertain due to low quality evidence (RR 0.99, 95% CI 0.82 to 1.19). Low quality evidence from six studies showed that drug therapy may reduce total cardiovascular mortality and morbidity from 4.1% to 3.2% over five years (RR 0.78, 95% CI 0.67 to 0.91) due to reduction in cerebrovascular mortality and morbidity (1.3% with control vs 0.6% with treatment; RR 0.46, 95% CI 0.34 to 0.64). Very low quality evidence from three studies showed that withdrawals due to adverse events were higher with drug therapy from 0.7% to 3.0% (RR 4.82, 95% CI 1.67 to 13.92). The effects on blood pressure varied between the studies and we are uncertain as to how much of a difference treatment makes on average.

AUTHORS' CONCLUSIONS

Antihypertensive drugs used to treat predominantly healthy adults aged 18 to 59 years with mild to moderate primary hypertension have a small absolute effect to reduce cardiovascular mortality and morbidity primarily due to reduction in cerebrovascular mortality and morbidity. All-cause mortality and coronary heart disease were not reduced. There is lack of good evidence on withdrawal due to adverse events. Future trials in this age group should be at least 10 years in duration and should compare different first-line drug classes and strategies.

Antihypertensive pharmacotherapy for prevention of sudden cardiac death in hypertensive individuals

BACKGROUND

High blood pressure is an important public health problem because of associated risks of stroke and cardiovascular events. Antihypertensive drugs are often used in the belief that lowering blood pressure will prevent cardiac events, including myocardial infarction and sudden death (death of unknown cause within one hour of the onset of acute symptoms or within 24 hours of observation of the patient as alive and symptom free).

OBJECTIVES

To assess the effects of antihypertensive pharmacotherapy in preventing sudden death, non-fatal myocardial infarction and fatal myocardial infarction among hypertensive individuals.

SEARCH METHODS

We searched the Cochrane Hypertension Specialised Register (all years to January 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (2016, Issue 1), Ovid MEDLINE (1946 to January 2016), Ovid EMBASE (1980 to January 2016) and ClinicalTrials.gov (all years to January 2016).

SELECTION CRITERIA

All randomised trials evaluating any antihypertensive drug treatment for hypertension, defined, when possible, as baseline resting systolic blood pressure of at least 140 mmHg and/or resting diastolic blood pressure of at least 90 mmHg. Comparisons included one or more antihypertensive drugs versus placebo, or versus no treatment.

DATA COLLECTION AND ANALYSIS

Review authors independently extracted data. Outcomes assessed were sudden death, fatal and non-fatal myocardial infarction and change in blood pressure.

MAIN RESULTS

We included 15 trials (39,908 participants) that evaluated antihypertensive pharmacotherapy for a mean duration of follow-up of 4.2 years. This review provides moderate-quality evidence to show that antihypertensive drugs do not reduce sudden death (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.81 to 1.15) but do reduce both non-fatal myocardial infarction (RR 0.85, 95% CI 0.74, 0.98; absolute risk reduction (ARR) 0.3% over 4.2 years) and fatal myocardial infarction (RR 0.75, 95% CI 0.62 to 0.90; ARR 0.3% over 4.2 years). Withdrawals due to adverse effects were increased in the drug treatment group to 12.8%, as compared with 6.2% in the no treatment group.

AUTHORS' CONCLUSIONS

Although antihypertensive drugs reduce the incidence of fatal and non-fatal myocardial infarction, they do not appear to reduce the incidence of sudden death. This suggests that sudden cardiac death may not be caused primarily by acute myocardial infarction. Continued research is needed to determine the causes of sudden cardiac death.

Effects of antihypertensive treatment in patients over 65 years of age: a meta-analysis of randomised controlled studies

CONTEXT

Despite the high incidence of hypertension, the elderly population is not represented in clinical trials as they have upper age limits or do not present age-specific results.

OBJECTIVES

The present study was designed to systematically review prospective randomized trials and assess the effects of antihypertensive treatment on cardiovascular, all-cause mortality, stroke and heart failure in patients over 65 years of age.

DATA SOURCES

We systematically searched the electronic databases, MEDLINE, PUBMED, EMBASE and Cochrane for prospective randomized studies (1970-2012) in which patients were randomized either to antihypertensive treatment and non-drug control group or to different antihypertensive treatments.

STUDY SELECTION

We identified 18 clinical studies, with 19 control arms and 19 treatment arms examining 59285 controls, 55569 hypertensive patients with an average follow up duration of 3.44 years. The mean age of patients on treatment was 71.04 years.

DATA EXTRACTION

Included studies were divided and analyzed in 2 subgroups: i) studies comparing treatment group vs non-drug placebo group with a BP decrease of 27.3/11.1 mmHg and ii) studies comparing two anti-hypertensive regimens with baseline BP ∼157/86, and BP reduction to less than 140/80.

RESULTS

A significant reduction in all four outcomes was found in the first group of studies. In the second group similar BP reduction resulted in equivalent risk reduction in both treatment groups. In the meta-regression analysis mean SBP difference was linearly associated with all-cause, cardiovascular, stroke and heart failure risk reduction.

CONCLUSION

Reducing BP to a level of 150/80 mmHg is associated with large benefit in stroke, cardiovascular and all-cause mortality as well as heart failure risk in elderly individuals. Different antihypertensive regimens with equal BP reduction have similar effects on cardiovascular outcomes. SBP rather than DBP reduction is significantly related to lower cardiovascular risk in this population.

DIURETIC-BASED COMBINATION THERAPY IN PATIENTS WITH ARTERIAL HYPERTENSION: RESULTS OF THE RUSSIAN TRUST STUDY

Arterial hypertension (AH) is one of the most important problems of the modern medicine, due to its exceptionally high prevalence. This study focused on effectiveness and safety of the diuretic-based combination therapy among patients aged >18 years (1476 men and 2989 women) with a clinical diagnosis of Stage 1–3 AH. All patients received fixed-dose combination therapy with atenolol and chlorthalidone. The findings from the TRUST study have confirmed safety and effectiveness of the fixed-dose combination of atenolol and chlorthalidone. 

Pulse pressure and subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis

BACKGROUND

Brachial pulse pressure (PP) has been found to be associated with markers of subclinical cardiovascular disease, including carotid intima-media thickness and left-ventricular mass index (LVMI), but it is unclear whether these associations are independent of traditional cardiovascular risk factors and of the steady, nonpulsatile component of blood pressure (BP). Moreover, it is unknown whether these associations are modified by gender, age, or race/ethnicity.

METHODS

We used multivariate linear regression models to assess the relationship between brachial PP and three markers of subclinical cardiovascular disease (CVD) (common carotid intima-media thickness (CC-IMT), internal carotid intima-media thickness (IC-IMT), and LVMI) in four race/ethnic groups in the Multi-Ethnic Study of Atherosclerosis. The models were adjusted for traditional Framingham risk factors (age, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, diabetes, smoking status), use of lipid-lowering medication, use of antihypertensive medication, study site, and mean arterial pressure (MAP).

RESULTS

The assessment was done on 6,776 participants (2,612 non-Hispanic white, 1,870 African-American, 1,494 Hispanic, and 800 Chinese persons). The associations between brachial PP and CC-IMT, IC-IMT, and LVMI were significant in fully adjusted models. The three subclinical markers also showed significant interactions with gender (P < 0.0001), with stronger interactions in men. There was an interaction with age for LVMI (P = 0.004) and IC-IMT (P = 0.008). Race/ethnicity modified the association of PP with CC-IMT.

CONCLUSIONS

Brachial PP was independently associated with subclinical CVD after adjustment for cardiovascular risk factors and mean arterial pressure (MAP). The strength of the association differed significantly for strata of gender, age, and race/ethnicity.

Pharmacotherapy for hypertension in the elderly

BACKGROUND

Elevated blood pressure (known as hypertension) increases with age, and most rapidly over age 60. Systolic hypertension is more strongly associated with cardiovascular disease than diastolic hypertension, and occurs more commonly in older people. It is important to know the benefits and harms of antihypertensive treatment of hypertension in this age group.

OBJECTIVES

To quantify antihypertensive drug effect on overall mortality, cardiovascular mortality and morbidity and withdrawal due to adverse effects in people 60 years and older with mild to moderate systolic or diastolic hypertension.

SEARCH STRATEGY

Updated search of electronic database of EMBASE, CENTRAL, MEDLINE until Dec 2008; previous search of two Japanese databases (1973-1995) and WHO-ISH Collaboration register (August 1997); references from reviews, trials and previously published meta-analyses; and experts.

SELECTION CRITERIA

Randomized controlled trials of at least one year duration in hypertensive elders (at least 60 years old) comparing antihypertensive drug therapy with placebo or no treatment and providing morbidity and mortality data.

DATA COLLECTION AND ANALYSIS

Outcomes assessed were total mortality (including cardiovascular, coronary heart disease and cerebrovascular mortality); total cardiovascular morbidity and mortality (representing combined coronary heart disease and cerebrovascular morbidity and mortality); and withdrawal due to adverse events.

MAIN RESULTS

Fifteen trials (24,055 subjects >/= 60 years) with moderate to severe hypertension were identified. These trials mostly evaluated first-line thiazide diuretic therapy for a mean duration of treatment of 4.5 years. Treatment reduced total mortality, RR 0.90 (0.84, 0.97); event rates per 1000 participants reduced from 116 to 104. Treatment also reduced total cardiovascular morbidity and mortality, RR 0.72 (0.68, 0.77); event rates per 1000 participants reduced from 149 to 106. In the three trials restricted to persons with isolated systolic hypertension the benefit was similar. In very elderly patients >/= 80 years the reduction in total cardiovascular mortality and morbidity was similar RR 0.75 [0.65, 0.87] however, there was no reduction in total mortality, RR 1.01 [0.90, 1.13]. Withdrawals due to adverse effects were increased with treatment, RR 1.71 [1.45, 2.00].

AUTHORS' CONCLUSIONS

Treating healthy persons (60 years or older) with moderate to severe systolic and/or diastolic hypertension reduces all cause mortality and cardiovascular morbidity and mortality. The decrease in all cause mortality was limited to persons 60 to 80 years of age.

Hypertension in the elderly and the very old

High systolic blood pressure represents a challenge for the modern world. Epidemiologists are in the best position to appreciate the importance of systolic hypertension and its cardiovascular consequences. Although the label of hypertension seems to have lower importance in the elderly, and above all in the very old, than in younger people, high systolic and high pulse pressure are risk factors for cardiovascular events and necessitates treatment. Unfortunately, due to indolence and lack of aggressiveness, only a limited fraction of elderly hypertensive patients receives adequate therapy.

First-line drugs for hypertension

BACKGROUND

Sustained elevated blood pressure, unresponsive to lifestyle measures, leads to a critically important clinical question: What class of drug to use first-line? This review answers that question.

PRIMARY OBJECTIVE

To quantify the benefits and harms of the major first-line anti-hypertensive drug classes: thiazides, beta-blockers, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, alpha-blockers, and angiotensin II receptor blockers (ARB).

SEARCH STRATEGY

Electronic search of MEDLINE (Jan. 1966-June 2008), EMBASE, CINAHL, the Cochrane clinical trial register, using standard search strategy of the hypertension review group with additional terms.

SELECTION CRITERIA

Randomized trials of at least one year duration comparing one of 6 major drug classes with a placebo or no treatment. More than 70% of people must have BP >140/90 mmHg at baseline.

DATA COLLECTION AND ANALYSIS

The outcomes assessed were mortality, stroke, coronary heart disease (CHD), cardiovascular events (CVS), decrease in systolic and diastolic blood pressure, and withdrawals due to adverse drug effects. Risk ratio (RR) and a fixed effects model were used to combine outcomes across trials.

MAIN RESULTS

Of 57 trials identified, 24 trials with 28 arms, including 58,040 patients met the inclusion criteria. Thiazides (19 RCTs) reduced mortality (RR 0.89, 95% CI 0.83, 0.96), stroke (RR 0.63, 95% CI 0.57, 0.71), CHD (RR 0.84, 95% CI 0.75, 0.95) and CVS (RR 0.70, 95% CI 0.66, 0.76). Low-dose thiazides (8 RCTs) reduced CHD (RR 0.72, 95% CI 0.61, 0.84), but high-dose thiazides (11 RCTs) did not (RR 1.01, 95% CI 0.85, 1.20). Beta-blockers (5 RCTs) reduced stroke (RR 0.83, 95% CI 0.72, 0.97) and CVS (RR 0.89, 95% CI 0.81, 0.98) but not CHD (RR 0.90, 95% CI 0.78, 1.03) or mortality (RR 0.96, 95% CI 0.86, 1.07). ACE inhibitors (3 RCTs) reduced mortality (RR 0.83, 95% CI 0.72-0.95), stroke (RR 0.65, 95% CI 0.52-0.82), CHD (RR 0.81, 95% CI 0.70-0.94) and CVS (RR 0.76, 95% CI 0.67-0.85). Calcium-channel blocker (1 RCT) reduced stroke (RR 0.58, 95% CI 0.41, 0.84) and CVS (RR 0.71, 95% CI 0.57, 0.87) but not CHD (RR 0.77 95% CI 0.55, 1.09) or mortality (RR 0.86 95% CI 0.68, 1.09). No RCTs were found for ARBs or alpha-blockers.

AUTHORS' CONCLUSIONS

First-line low-dose thiazides reduce all morbidity and mortality outcomes. First-line ACE inhibitors and calcium channel blockers may be similarly effective but the evidence is less robust. First-line high-dose thiazides and first-line beta-blockers are inferior to first-line low-dose thiazides.

[Prevention of arteriosclerosis. Importance of the treatment of arterial hypertension]

In most European countries and Northern America, cardiovascular diseases induced by atherosclerosis are the most common cause of death in older people. People surviving acute myocardial infarction or stroke suffer often by disabilities or handicaps. The lifelong care of such patients is expensive and plays a major role for increment of costs in public health systems. Prevention of atherosclerosis will reduce cardiovascular morbidity and mortality, enhance quality of life and prolong lifetime of patients. Therefore the worldwide accepted risk factors of atherosclerosis have to be treated consequently and early enough within the meaning of primary prevention. Hypertension is one of the six major cardiovascular risk factors and is defined as elevated blood pressure above 140/90 mmHg. In case of hypertension, diagnostic efforts has to be focussed on detection of additional cardiovascular risk factors, secondary forms of hypertension, end organ damage or associated diseases. All therapeutic strategies are based on life style changes, which cover weight reduction, sodium restriction, controlled alcohol consumption and increment in physical activity. Pharmacotherapy will be added in regard to the global risk of the patient and the success of the life style changes. Selection of antihypertensives and their optimal combination will be determined by associated diseases (compelling indication), side effects and individual response in blood pressure. Goal of treatment is the normalization of blood pressure below 140/90 mmHg independent of age or sex. In diabetics and in case of nephropathy the goal is set lower (below 130/80 mmHg).There is strong evidence that reduction in blood pressure is followed by a decrease in the incidence of myocardial infarction, stroke, heart failure, nephropathy, and even in cardiovascular mortality. The success of antihypertensive therapy is greater in high risk patients like older people, patients with isolated systolic hypertension or diabetics. Risk reduction correlates well with the degree in blood pressure reduction. However, to minimize cardiovascular risk in hypertensives all additional risk factors have to be treated too.

Blutdruck und Gehirn

During acute cerebral infarction, autoregulation is abolished. Brain perfusion therefore directly depends on perfusion pressure and cardiac output. For this reason, in the early state of stroke, elevated blood pressure improves cerebral blood flow and only values of 210 mmHg systolic or above should be lowered. With the development of a vasogenic brain edema or a dysfunctional blood-brain barrier (usually on day 2 to 4 after infarction), blood pressure must be normalized in order to avoid hemorrhage and to minimize edema. In the presence of space occupying edema or intracranial hemorrhage, only those antihypertensive substances may be used which do not cause a dilatation of brain vessels. Direct vasodilators and calcium antagonists are not suitable in this situation. Furthermore, antihypertensive medication which causes bradycardia (e.g. beta blockers) should be avoided, because in acute stroke, brain perfusion also depends on the cardiac output. For primary and secondary stroke prevention normalization of blood pressure is essential. Efficacy is basically independent of the kind of antihypertensive medication used. Effective normalization of blood pressure probably helps to prevent vascular dementias of all kinds. Convincing studies however are still lacking for most sorts of antihypertensive medication.

Blood Pressure Reduction and Cardiovascular Prevention: An Update Including the 2003-2004 Secondary Prevention Trials

In a meta-analysis published in June 2003, we reported that new and old classes of antihypertensive drugs had similar long-term efficacy and safety. Furthermore, we observed that in clinical trials in hypertensive or high-risk patients gradients in systolic blood pressure (SBP) accounted for most differences in outcome. To test whether our previous conclusions would hold, we updated our quantitative overview with new information from clinical trials published before 2005. To compare new and old antihypertensive drugs, we computed pooled odds ratios from stratified 2 x 2 contingency tables. In a meta-regression analysis, we correlated these odds ratios with corresponding between-group differences in SBP. We then contrasted observed odds ratios with those predicted from gradients in SBP. The main finding of our overview was that reduction in SBP largely explained cardiovascular outcomes in the recently published actively controlled trials in hypertensive patients and in placebo-controlled secondary prevention trials. The published results suggested that dihydropyridine calcium-channel blockers might offer a selective benefit in the prevention of stroke and inhibitors of the renin-angiotensin system in the prevention of heart failure. For prevention of myocardial infarction, the published results were more equivocal, because of the benefit of amlodipine over placebo or valsartan in 2 trials, whereas other placebo-controlled trials of calcium-channel blockers or angiotensin converting enzyme inhibitors did not substantiate the expected benefit with regard to cardiac outcomes. In conclusion, the hypothesis that new antihypertensive drugs might influence cardiovascular prognosis over and beyond their antihypertensive effect remains unproven. Our overview emphasizes the need of tight blood pressure control, but does not allow determining to what extent blood pressure must be lowered for optimal cardiovascular prevention.

Blood Pressure and Stroke

Background— The last few years have seen a considerable increase in the amount of information available concerning blood pressure (BP) and stroke associations. This article provides an overview of published reviews of the effects on stroke seen in trials of BP-lowering drugs and compares these with the results available from cohort studies.

Summary of Review— We present a review of major overviews of prospective cohort studies and an updated meta-analysis of >40 randomized controlled trials of BP lowering, which included >188 000 participants and approximately 6800 stroke events. Cohort studies now indicate that in the Asia Pacific region as well as in North America and Western Europe, each 10 mm Hg lower systolic BP is associated with a decrease in risk of stroke of approximately one third in subjects aged 60 to 79 years. The association is continuous down to levels of at least 115/75 mm Hg and is consistent across sexes, regions, and stroke subtypes and for fatal and nonfatal events. The proportional association is age dependent but is still strong and positive in those aged 80 years. Data from randomized controlled trials, in which mean age at event was approximately 70 years, indicate that a 10 mm Hg reduction in systolic BP is associated with a reduction in risk of stroke of approximately one third. Per mm Hg systolic BP reduction, the relative benefits for stroke appear similar between agents, by baseline BP levels, and whether or not individuals have a past history of cardiovascular disease. There is, however, evidence of greater benefit with a larger BP reduction.

Conclusions— The epidemiologically expected benefits of BP lowering for stroke risk reduction are broadly consistent across a range of different population subgroups. There are greater benefits from larger BP reductions, and initiating and maintaining BP reduction for stroke prevention is a more important issue than choice of initial agent.

Blood pressure and stroke: an overview of published reviews

BACKGROUND

The last few years have seen a considerable increase in the amount of information available concerning blood pressure (BP) and stroke associations. This article provides an overview of published reviews of the effects on stroke seen in trials of BP-lowering drugs and compares these with the results available from cohort studies.

SUMMARY OF REVIEW

We present a review of major overviews of prospective cohort studies and an updated meta-analysis of >40 randomized controlled trials of BP lowering, which included >188 000 participants and approximately 6800 stroke events. Cohort studies now indicate that in the Asia Pacific region as well as in North America and Western Europe, each 10 mm Hg lower systolic BP is associated with a decrease in risk of approximately one third in subjects aged 60 to 79 years. The association is continuous down to levels of at least 115/75 mm Hg and is consistent across sexes, regions, and stroke subtypes and for fatal and nonfatal events. The proportional association is age dependent but is still a strong and positive association in those aged 80 years. Data from randomized controlled trials, in which mean age at event was approximately 70 years, indicate that a 10 mm Hg reduction in systolic BP is associated with a reduction in risk of stroke of approximately one third. Per mm Hg systolic BP reduction, the benefits for stroke appear similar between agents, by baseline BP levels, and whether or not individuals have a past history of cardiovascular disease. There is, however, evidence of greater benefit with a larger BP reduction.

CONCLUSIONS

The epidemiologically expected benefits of BP lowering for stroke risk reduction are broadly consistent across a range of different population subgroups. There are greater benefits from larger BP reductions, and initiating and maintaining BP reduction for stroke prevention is a more important issue than choice of initial agent.

Calcium channel blockers: an update

This paper reviews the current literature pertaining to calcium channel blockers, including their classification, properties, and therapeutic indications, in light of several recent trials that have addressed their safety. Calcium channel blockers are a structurally and functionally heterogeneous group of medications that are used widely to control blood pressure and manage symptoms of angina. They are classified as dihydropyridines or nondihydropyridines. As a class, they are well tolerated and are associated with few side effects. The question of whether they may precipitate cardiovascular events has been largely settled by recent trials, such as the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), the International Verapamil Slow-Release/Trandolapril Study (INVEST), and the Controlled Onset Verapamil Investigation of Cardiovascular Endpoints (CONVINCE) study, in which no such association was found. Even so, the use of these agents has been linked with an increased risk of heart failure. Thus, long-acting calcium channel blockers may be safely used in the management of hypertension and angina. However, as a class, they are not as protective as other antihypertensive agents against heart failure.

Use of Calcium Channel Antagonists for the Treatment of Hypertension in the Elderly

Systolic blood pressure and pulse pressure increase continuously throughout adult life and the prevalence of arterial hypertension rises accordingly, reaching 53-78% among those aged 65-74 years. Estimates of the prevalence of isolated systolic hypertension in the elderly range from 34-65%, with more women than men affected. It has been shown that within all age groups a difference in usual systolic blood pressure of 20 mm Hg or a difference in usual diastolic blood pressure of 10 mm Hg is associated with an approximately 2-fold difference in the risk of dying from stroke or ischaemic heart disease. Intervention trials using predominantly diuretics and/or beta-adrenoceptor antagonists have proven the efficacy and tolerability of antihypertensive treatment in elderly patients. For many years there have been ongoing discussions about the safety of calcium channel antagonists, especially in patients with diabetes mellitus. However, according to a recently published large prospective, randomised, double-blind, controlled clinical trial with more than 33,000 patients enrolled, no indications for increased total mortality, cancer rate or gastrointestinal bleeding for participants on amlodipine, a long-acting dihydropyridine calcium channel antagonist, were found. With calcium channel antagonists, protective effects against cardiovascular disease have been proven in large trials with elderly patients, particularly against stroke. There is good evidence to suggest that calcium channel antagonists may be superior to other antihypertensive agents in diabetic patients with isolated systolic hypertension. These agents are well tolerated and probably delay the progression of dementia. The lack of adverse metabolic effects that, in the case of a diuretic-based regimen, may have important long-term implications concerning cardiovascular risk, make calcium channel antagonists an attractive choice when antihypertensive treatment decisions need to be made in a predominantly overweight or obese elderly population.

The Perindopril Protection Against Recurrent Stroke Study (PROGRESS): clinical implications for older patients with cerebrovascular disease

Blood pressure levels are strongly predictive of the risks of first-ever and recurrent stroke. The benefits of blood pressure-lowering therapy for the prevention of fatal and non-fatal stroke in middle-aged individuals are well established. However, until recently, there has been uncertainty about the consistency of such benefits across different patient groups and in particular, for older people and in those with a history of stroke. This paper discusses the evidence surrounding the effectiveness of blood pressure-lowering therapy, specifically in older patients with a history of stroke, with particular attention paid to the results from the Perindopril Protection Against Recurrent Stroke Study (PROGRESS). PROGRESS was a randomised, double-blind, placebo-controlled trial of 6105 individuals with a history of cerebrovascular disease recruited from 172 hospital outpatient clinics in ten countries. Participants (mean age 64 years; range 26-91 years) were randomly assigned to receive active treatment with an ACE inhibitor-based blood pressure-lowering regimen (perindopril) with or without addition of the diuretic indapamide, or matched placebo. At the end of follow up (mean of 4 years), active treatment reduced the incidence of total stroke by 28% (95% CI 17-38%) and the rate of major vascular events by 26% (95% CI 16-34%). Importantly, benefits of treatment were consistent across key patient subgroups, including those with and without hypertension, patients who were Asian and non-Asian, and for both ischaemic and haemorrhagic strokes subtypes. Current evidence is now strong for clinicians to consider blood pressure-lowering therapy as pivotal in the prevention of stroke, especially in patients with a known history of cerebrovascular disease (and vascular disease, in general), irrespective of blood pressure levels, as soon as patients are clinically stable after an acute stroke or other vascular event. Additional age-specific analyses of the PROGRESS data, together with those from other completed trials, will provide more reliable information about the size of the benefits of blood pressure-lowering therapy, specifically for different age groups, and particularly in the oldest old (those aged >80 years). In the meantime though, an ACE inhibitor plus diuretic treatment regimen that maximises the degree of blood pressure reduction has a good safety profile and is an effective treatment that should be considered in all patients with stroke, including the elderly.

Cardiovascular prevention and blood pressure reduction: a quantitative overview updated until 1 March 2003

BACKGROUND

In a meta-analysis published in October 2001, we reported that new and old classes of antihypertensive drugs had similar long-term efficacy and safety. Furthermore, we observed that in clinical trials in hypertensive or high-risk patients gradients in systolic pressure accounted for most differences in outcome.

OBJECTIVE

To test whether our previous conclusions would hold, we updated our quantitative overview with new information from 14 clinical trials presented before 1 March 2003.

METHODS

To compare new and old antihypertensive drugs, we computed pooled odds ratios from stratified 2 x 2 contingency tables. If Zelen's test of heterogeneity was significant, we used a random effects model. In a meta-regression analysis, we correlated odds ratios with corresponding between-group differences in systolic pressure. We then contrasted observed odds ratios with those predicted from gradients in systolic pressure.

MAIN OUTCOMES

Differences in achieved systolic blood pressure and incidence of total and cardiovascular mortality, cardiovascular events, stroke, myocardial infarction and heart failure. NEW VERSUS OLD DRUGS: In 15 trials, 120 574 hypertensive patients were randomized to old drugs (diuretics or beta-blockers) or new agents [calcium-channel blockers, alpha-blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin type-1 receptor (AR1) blockers]. Old and new drugs provided similar protection against total and cardiovascular mortality and fatal plus non-fatal myocardial infarction. Calcium-channel blockers, including (-8%, P = 0.07) or excluding verapamil (-10%, P = 0.02), as well as AR1 blockers (-24%, P = 0.0002) resulted in better stroke prevention than did the old drugs, whereas the opposite trend was observed for ACE inhibitors (+10%, P = 0.03). The risk of heart failure was higher (P < 0.0001) on calcium-channel blockers (+33%) and alpha-blockers (+102%) than on conventional therapy involving diuretics. META-REGRESSION: Between-group differences in achieved systolic pressure ranged from 0.1 to 3.2 mmHg in seven actively controlled trials (73 237 patients), and from 2.1 to 22.1 mmHg in seven studies comparing varying intensities of blood pressure lowering (11 128 patients). For these 14 new trials, we predicted outcome from achieved systolic blood pressure using our previously published meta-regression models based on 30 trials with 149 407 patients. In general, predicted and observed odds ratios were similar. Larger reductions in systolic pressure (weighted mean 1.8 mmHg) in two trials accounted for the advantage of AR1 blockers over conventional therapy in the prevention of stroke. Only for cardiovascular mortality in very old patients (P = 0.02) and for cardiovascular events and myocardial infarction in old Australians (P < 0.05), the observed odds ratios deviated from our predictions based on the gradients in systolic blood pressure.

INTERPRETATION

The hypothesis that new antihypertensive drugs, such as calcium-channel blockers, alpha-blockers, ACE inhibitors or AR1 blockers might influence cardiovascular prognosis over and beyond their antihypertensive effects remains unproven. The finding that blood pressure differences largely accounted for cardiovascular outcome emphasizes the desirability of tight blood pressure control. However, the level to which blood pressure must be lowered to achieve maximal benefit remains currently unknown.

Benefits of antihypertensive pharmacologic therapy and blood pressure reduction in outcome trials

In a quantitative overview of published trials, we investigated whether pharmacologic properties of antihypertensive drugs, as opposed to reduction in blood pressure, explain cardiovascular outcomes in hypertensive or high-risk patients. We used meta-regression to investigate the association between the odds ratios of outcome (experimental vs. reference treatment) and the corresponding blood pressure differences between study groups. Thus, we correlated odds ratios with between-group differences in systolic pressure. We then compared odds ratios of benefit observed in recent trials with those predicted by meta-regression on the basis of the differences in systolic pressure between randomized groups. Among nine actively-controlled trials in hypertension, significant differences in systolic pressure (follow-up minus baseline) between randomized groups (experimental minus reference) were observed in the ALLHAT, CAPPP, MIDAS, and NORDIL trials. Furthermore, the differences in achieved systolic and/or diastolic pressure between study groups were also significant in the hypertension trials and studies in high-risk patients, which involved untreated control patients. The differences between the observed odds ratios and those predicted by meta-regression did not reach statistical significance except for NORDIL and the single-drug therapy subgroup of the PROGRESS trial. In NORDIL, the risk of stroke was lower on diltiazem than on the older drug classes despite a 3.1 mm Hg higher systolic pressure on the calcium channel blocker. In PROGRESS, perindopril alone reduced blood pressure by 5/3 mm Hg, but did not affect the incidence of all cardiovascular events or the recurrence of stroke. In conclusion, the finding that in the reviewed trials blood pressure reduction largely accounted for outcome emphasizes the desirability of tight blood pressure control. The hypothesis that blood pressure-lowering medications might influence cardiovascular prognosis over and beyond their antihypertensive effect remains to a large extent unproved.

Conventional therapy and newer drug classes for cardiovascular protection in hypertension

Recently published actively controlled outcome trials in hypertension compared conventional therapy (diuretics and beta-blockers) with newer antihypertensive drug classes, including angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, and angiotensin II antagonists. In a quantitative overview of nine trials including 62,605 randomized patients, it was found that conventional therapy and newer drug classes had similar long-term efficacy in preventing cardiovascular complications of hypertension. BP lowering largely accounted for most, if not all, of the observed benefits in cardiovascular outcome. These findings emphasize the desirability of lowering BP as much as possible to maximize the reduction in cardiovascular complications. Furthermore, several clinical trials have been specifically designed to highlight specific mechanisms of action of the newer drugs by measuring intermediate end points, such as carotid intima-media thickening or renal dysfunction, or by studying subgroups of patients with specific disorders, such as diabetes mellitus. In these trials, calcium channel blockers were more effective than conventional therapy in preventing carotid intima-media thickening and mild renal dysfunction, whereas use of calcium channel blockers or angiotensin-converting enzyme inhibitors was associated with a lower incidence of diabetes mellitus in some studies. However, whether or not these specific effects of the newer drugs on intermediary and/or metabolic end points in the long run also lead to fewer cardiovascular complications remains to be proved.

Pulse pressure and coronary mortality in elderly men and women from general population

The aim of this work was to evaluate whether pulse pressure (PP) in elderly people is a better predictor of coronary mortality than systolic and diastolic blood pressure taken alone. For this aim, 3282 elderly subjects aged >or=65 years were studied in a population-based frame. Blood pressure was repeatedly measured and averaged; historical data, anthropometrics, blood tests and 14-year coronary mortality were recorded. Statistics included analysis of covariance, Cox analysis and bivariate vectorial analysis. Coronary mortality in women was predicted by PP (1.01 excess risk/mm Hg PP) and was significantly higher in the 3rd than in the 1st tertile of PP (relative risk 2.90); neither systolic nor diastolic pressure taken alone influenced mortality. When systolic and diastolic pressures were both entered into a Cox model, the former had a positive and the latter a negative effect on survival, confirming a prognostic role of PP. For any given level of systolic pressure, mortality was inversely associated with diastolic pressure. Finally, the mean vector representing both systolic and diastolic pressures of non-surviving women was characterised by higher systolic and lower diastolic components than in non-surviving. No significant trend of mortality in relation to either systolic blood pressure or PP was observed in men. In conclusion, the combination of systolic and diastolic pressure called PP is an independent predictor of coronary mortality in elderly females, and a better predictor than systolic or diastolic pressure alone.

Benefits of treating hypertension in the elderly: should age affect treatment decisions?

Do the benefits of treating hypertension extend equally to all age groups, particularly the very elderly? Several large controlled trials have been published in recent years that confirm the benefits of the treatment of hypertension in terms of morbidity and mortality. However, these trials included only relatively small numbers of patients aged > or = 80 years. Data regarding such patients have been extracted and subjected to meta-analysis, but with inconclusive results. Further difficulties arise as a result of the range of therapeutic agents employed. Therefore, uncertainty still surrounds the value of treating very elderly patients with hypertension. The J-curve hypothesis, i.e. that a blood pressure threshold exists below which there is an increase in the rate of cardiac events, has been a concern in treating elderly patients. Upon close examination, this appears to be spurious. The Hypertension in the Very Elderly Trial study sets out to provide conclusive evidence for the benefits or otherwise of treating hypertension in the very elderly and has just commenced. The results of this trial will not be available for some time. In the meantime, should physicians initiate or continue treatment for very elderly individuals with hypertension? If so, what regimens should be employed and should target blood pressure levels be set? At the present time, it would appear sensible to provide treatment for very elderly patients with hypertension, particularly those with evidence of complications or target organ damage. In relatively healthy individuals with mild-to-moderate hypertension, the guiding principle should be 'the lower the blood pressure the better'. Regarding the choice of therapeutic agent, a low-dose diuretic remains the first choice therapy.

Evidence-based evaluation of calcium channel blockers for hypertension: equality of mortality and cardiovascular risk relative to conventional therapy

OBJECTIVES; We present a meta-analysis based on three recent, substantial, randomized outcome trials and several smaller trials that compared calcium channel blockers (CCBs) with conventional therapy (diuretics or beta-blockers) or with angiotensin-converting enzyme (ACE) inhibitors.

BACKGROUND

There is continuing uncertainty about the safety and efficacy of CCBs in the treatment of hypertension. Previous meta-analyses conflict and suggest that CCBs increase myocardial infarction (MI) or protect from stroke.

METHODS

Standard procedures for meta-analysis were used to analyze three major trials on 21,611 patients and another three lesser studies to a total of 24,322 patients.

RESULTS

Calcium channel blockers have a strikingly similar risk of total and cardiovascular mortality and of major cardiovascular events to conventional therapy. Calcium channel blockers give a lower risk of nonfatal stroke (-25%, p = 0.001) and a higher risk of total MI (18%, p = 0.013), chiefly nonfatal (18%). After performing the Bonferroni correction for multiplicity, these p values become 0.004 and 0.052, respectively. When compared with ACE inhibitors in 1,318 diabetic patients, CCBs had a substantially higher risk of nonfatal (relative risk [RR] = 2.259) and total MI (RR = 2.204, confidence interval 1.501 to 3.238; p = 0.001 or 0.004 with Bonferroni correction). Total and cardiovascular mortality rates are similar. To confirm the hypothesis that ACE inhibitors are superior to CCBs in diabetic patients requires more trial data, especially with renal end points.

CONCLUSIONS

Mortality (total and cardiovascular) and major cardiovascular events with CCBs were apparently similar to those events seen with conventional first-line therapy (diuretics or beta-blockers). Stroke reduction more than balanced increased MI. In diabetics, CCBs may be less safe than ACE inhibitors.

Weak effect of hypertension and other classic risk factors in the elderly who have already paid their toll

The aim of the CASTEL, a population-based (n=3282) prospective study which began 14 years ago, was to identify those items which had a prognostic impact in the elderly, and to evaluate whether the typical cardiovascular risk factors, particularly arterial hypertension, play a role after the age of 65 years. Initial screening, final follow-up and annual detection of mortality were performed. Mantel-Hanszel approach and multivariate Cox model were used for statistics. Cardiovascular mortality was 23.3% in normotensive, 23.3% in borderline, and 25% in the sustained hypertensive subjects (insignificant difference). In women, the incidence of stroke and coronary artery disease weakly depended on pulse pressure. Historical stroke and myocardial infarction predicted cardiovascular mortality in women; diabetes, uricaemia and high heart rate in men. In the very old, the predictors were less numerous, and blood pressure was not a predictor whatsoever; pulse blood pressure and murmurs at the neck were especially predictive in women, historical heart failure, proteinuria and tachycardia in men, historical stroke and myocardial infarction, pulmonary disease, left ventricular hypertrophy, diabetes and uricaemia in both genders. The elderly have a different cardiovascular risk pattern compared to younger people. Hypertension is not a predictor of coronary and stroke mortality. Prognosis depends on pulse pressure rather than on the label 'hypertension'. Hypercholesterolaemia is not a risk factor. This could simply indicate that elderly persons are the survivors in a population where significant mortality has already made its mark, eliminating those with the worst risk pattern. The two genders have a different risk profile due to sex-specific susceptibility to risk factors.

Results of antihypertensive treatment trials in the elderly

The prevalence of arterial hypertension is age-dependent, and with the prolongation of life expectancy the number of elderly subjects with arterial hypertension is very relevant. Epidemiologic studies have shown that arterial hypertension is a risk factor in elderly patients and therefore the physician must know if the pharmacologic and nonpharmacologic reduction of blood pressure values is associated with a corresponding decrease in systolic-diastolic or isolated systolic hypertension. Clinical trials have shown that the lowering of blood pressure values is commonly associated with a decrease in cardiovascular events. So far, the reduction of blood pressure per se appears more relevant to the cardiovascular benefit than does a particular class of antihypertensive agents. The benefit of antihypertensive treatment has been shown up to the age of 80 years, while there are no clear indications of a benefit in persons older than 80 years. While sufficient data suggest that a diastolic blood pressure between 80 and 90 mm Hg is associated with a clear benefit in elderly patients, the data in support of a systolic reduction below 140 mm Hg require further direct confirmation.

Calcium channel antagonists in the treatment of hypertension

Calcium channel antagonists are widely used antihypertensive agents. Their popularity among primary care physicians is not only due to their blood pressure-lowering effects, but also because they appear to be effective regardless of the age or ethnic background of the patients. The first available calcium channel antagonists utilized immediate-release formulations which, although effective in patients with angina pectoris, were not approved by the US FDA for use in hypertension. When long-acting once-daily formulations were approved in this indication, the short-acting preparations--which had by then become generic and inexpensive--retained some residual unapproved use for hypertension. An observational case-controlled trial, based on such usage, noted that these agents were associated with a greater risk of myocardial infarctions than conventional agents such as diuretics and beta-adrenoceptor antagonists. Further case-controlled trials showed, in fact, that the dangers of calcium channel antagonists were confined to the short-acting agents and that approved long-acting agents were at least as well tolerated and effective as other antihypertensive drugs. Cardiovascular outcomes during treatment with calcium channel antagonists have been examined in randomized, controlled trials. Compared with placebo, the calcium channel antagonists clearly prevented strokes and other cardiovascular events and reduced mortality. The effects of these agents on survival and clinical outcomes were similar to those with other antihypertensive drugs. There is a slight tendency for the calcium channel antagonists to be more effective than other drug types in preventing stroke, but slightly less effective in preventing coronary events. These observations extend to high-risk patients with hypertension including those with diabetes mellitus. Even so, patients with evidence of nephropathy should not receive monotherapy with calcium channel antagonists. Such patients are optimally treated with angiotensin receptor antagonists or ACE inhibitors, although addition of other drugs, including calcium channel antagonists, is often required to achieve the tight blood pressure control necessary to provide adequate renal protection. Calcium channel antagonists have a highly acceptable tolerability profile and careful reviews of available data have shown that their use is not associated with increased bleeding or promotion of tumor formation. It is now recognized that reduction of blood pressure in patients with hypertension to levels often <130/85 mm Hg should be undertaken in presence of other cardiovascular risk factors or evidence of end organ damage. Because of this important concept, calcium channel antagonists, like the other antihypertensive drug classes, are progressively being prescribed less often as monotherapy, but more typically as part of combination regimens.

Calcium channel blockers in treatment of hypertension

Calcium channel blockers (CCBs) are among the most often prescribed drugs for the treatment of hypertension, but there is still uncertainty regarding the risks and benefits of their use as first-line drugs in the treatment of hypertension. Compared with placebo, dihydropyridine CCBs (long-acting nifedipine and nitrendipine) reduce the risk for cardiovascular endpoints, and in a pooled analysis of available studies on treatment of hypertension, significantly decrease the risk for strokes and cardiovascular and total mortality. This also holds true for patients with diabetes who have a clearly reduced risk when treated with CCBs as compared with placebo. However, compared with other active treatments in mixed study populations, CCBs are associated with a small risk increase for myocardial infarction and heart failure, but for cardiovascular mortality, there is only a very small and nonsignificant trend to a risk increase, and total mortality is similar. Among patients with diabetes, compared with angiotensin-converting enzyme inhibitors in particular, available data suggest that CCB use is associated with a moderate increase in cardiac endpoints. Therefore, among patients with diabetes and those with heart failure, angiotensin-converting enzyme inhibitors are preferable as first-line drugs; among the large fraction of patients without these conditions, there is no convincing evidence that long-acting dihydropyridine or nondihydropyridine CCBs are inferior to other blood pressure-lowering drugs. In these patients, the choice of blood pressure-lowering medication can be based on the expected tolerability, costs, and personal preferences.

Cardiovascular protection and blood pressure reduction: a meta-analysis

BACKGROUND

Whether antihypertensive drugs offer cardiovascular protection beyond blood pressure lowering has not been established. We aimed to investigate whether pharmacological properties of antihypertensive drugs or reduction of systolic pressure accounted for cardiovascular outcome in hypertensive or high-risk patients.

METHODS

In a meta-analysis we extracted summary statistics from published reports, and calculated pooled odds ratios for experimental versus reference treatment. We correlated across-trials odd ratios for differences in systolic pressure between groups.

FINDINGS

We analysed nine randomised trials comparing treatments in 62605 hypertensive patients. Compared with old drugs (diuretics and b-blockers), calcium-channel blockers and angiotensin converting-enzyme inhibitors offered similar overall cardiovascular protection, but calcium-channel blockers provided more reduction in the risk of stroke (13.5%, 95% CI 1.3-24.2, p=0.03) and less reduction in the risk of myocardial infarction (19.2%, 3.5-37.3, p=0.01). Heterogeneity was significant between trials because of high risk of cardiovascular events on doxazosin in one trial, and high risk of stroke on captopril in another; but systolic pressure differed between groups in these two trials by 2-3 mm Hg. Similar systolic differences occurred in a trial of diltiazem versus old drugs, and in three trials of converting-enzyme inhibitor against placebo in high-risk patients. Meta-regression across 27 trials (136124 patients) showed that odds ratios could be explained by achieved differences in systolic pressure.

INTERPRETATION

Our findings emphasise that blood pressure control is important. All antihypertensive drugs have similar long-term efficacy and safety. Calcium-channel blockers might be especially effective in stroke prevention. We did not find that converting-enzyme inhibitors or a-blockers affect cardiovascular prognosis beyond their antihypertensive effects.

A critique of hypertension treatment trials and of their evaluation

Progressive improvements in antihypertensive drug therapy over the past four decades have provided clear benefits in limiting cardiovascular complications. Unfortunately, and largely inexplicably, the inclusion in meta-analyses of defective trials plus the employment of inappropriate diagnostic criteria for adverse coronary events have led to spurious, exaggerated claims for the advantages of such treatment. The consequence has been a devaluation of the very real worth of prophylactic drug therapy for hypertension.

Cardiovascular mortality in non-insulin-dependent diabetes mellitus. A controlled study among 683 diabetics and 683 age- and sex-matched normal subjects

Although non-insulin-dependent diabetes mellitus (NIDDM) is considered a major cause of death, the role of some independent risk factors in diabetic patients is under debate. In fact the prognosis of NIDDM diabetes varies considerably in relation to the individual risk pattern, and the different studies are not directly comparable because of differences in size, age and geography of the samples, and type of statistical analysis. The aim of the study is to identify the independent predictors of mortality in a cohort of subjects with NIDDM, and to verify whether the relative risk (RR) of cardiovascular mortality is different in comparison to that of coeval non-diabetic subjects from a general population. The study includes 683 patients with NIDDM from the Northern Italian town of Pordenone, followed up for 6 years and age- and sex-matched to 683 non-diabetic subjects from a Northern Italian general population. When the two cohorts were compared, NIDDM turned out to be a strong risk factor for cardiovascular mortality (RR: 2.67). Age, coronary artery disease (RR: 1.78), arterial hypertension (RR: 1.39), macro- (RR: 2.97) and microalbuminuria (RR: 2.01) were independent predictors of cardiovascular mortality in the diabetics. In conclusion, survival of diabetic patients is worse than that of non-diabetic coeval subjects. Only few items are able to predict cardiovascular mortality in the diabetics, namely age, hypertension, CAD, macro- and microalbuminuria.

Health outcomes associated with calcium antagonists compared with other first-line antihypertensive therapies: a meta-analysis of randomised controlled trials

BACKGROUND

Several observational studies and individual randomised trials in hypertension have suggested that, compared with other drugs, calcium antagonists may be associated with a higher risk of coronary events, despite similar blood-pressure control. The aim of this meta-analysis was to compare the effects of calcium antagonists and other antihypertensive drugs on major cardiovascular events.

METHODS

We undertook a meta-analysis of trials in hypertension that assessed cardiovascular events and included at least 100 patients, who were randomly assigned intermediate-acting or long-acting calcium antagonists or other antihypertensive drugs and who were followed up for at least 2 years.

FINDINGS

The nine eligible trials included 27,743 participants. Calcium antagonists and other drugs achieved similar control of both systolic and diastolic blood pressure. Compared with patients assigned diuretics, beta-blockers, angiotensin-converting-enzyme inhibitors, or clonidine (n=15,044), those assigned calcium antagonists (n=12,699) had a significantly higher risk of acute myocardial infarction (odds ratio 1.26 [95% CI 1.11-1.43], p=0.0003), congestive heart failure (1.25 [1.07-1.46], p=0.005), and major cardiovascular events (1.10 [1.02-1.18], p=0.018). The treatment differences were within the play of chance for the outcomes of stroke (0.90 [0.80-1.02], p=0.10) and all-cause mortality (1.03 [0.94-1.13], p=0.54).

INTERPRETATION

In randomised controlled trials, the large available database suggests that calcium antagonists are inferior to other types of antihypertensive drugs as first-line agents in reducing the risks of several major complications of hypertension. On the basis of these data, the longer-acting calcium antagonists cannot be recommended as first-line therapy for hypertension.

Risks of coronary heart disease in women: current understanding and evolving concepts

The population of older individuals in the United States is growing rapidly. Because women generally live longer than men and make up the majority of this aging population, the elucidation of health issues related to older women is important. Cardiovascular disease is the leading cause of death and disability for women and claims the lives of more women than the next 14 causes combined. The majority of these deaths are due to atherosclerotic coronary heart disease, with nearly 250,000 women dying of myocardial infarction each year. There is evidence that women with suspected or established cardiovascular disease have not benefited fully from recent advances in the detection and management of coronary heart disease. Regardless of the mechanism and extent of the effect that sex differences have on approaches to cardiovascular disease, women appear to benefit from proven efficacious therapies, and the longer-term outcomes associated with these treatments are positive. The data regarding women and coronary heart disease are rapidly evolving and sometimes conflicting. The intent of this article is to summarize the most current understanding of coronary heart disease risks in women, highlighting the impact of prevention, and to discuss the latest novel findings that may become important in our armamentarium for prevention of coronary heart disease.

Pharmacotherapy for hypertension in women of different races

OBJECTIVES

To assess whether the relative and absolute benefit of hypertension treatment in women varies with age or race.

SEARCH STRATEGY

Literature search of studies from 1966 to 1998 using MEDLINE, reviews, and consultation with experts.

SELECTION CRITERIA

Studies were eligible if they were randomized controlled trials of pharmacological treatment of primary hypertension, with cardiovascular morbidity and mortality outcomes, and with over one hundred women enrolled.

DATA COLLECTION AND ANALYSIS

The pooled population included 23,000 women. Relative risks were combined for each endpoint to form summary risk ratios (RR) using meta-analytic techniques based on a random-effects model. Summary RR's were converted to numbers needed to treat (NNT). Data were dichotomized by age to approximate menopausal status (30 to 54 years, and 55 years and older), and by race (white and African American).

MAIN RESULTS

In women ages 55 years or older (90% white), hypertension treatment results in a 38% risk reduction in fatal and nonfatal cerebrovascular events (95% confidence interval (CI) 27-47%, 5 year NNT 78), a 25% reduction in fatal and nonfatal cardiovascular events (95% CI 17-33%, 5 year NNT 58), and a 17% reduction in cardiovascular mortality (95% CI 3-29%, 5 year NNT 282). In women ages 30 to 54 years (79% white), hypertension treatment results in a 41% risk reduction in fatal and nonfatal cerebrovascular events (95% CI 8-63%, 5 year NNT 264), and a 27% risk reduction in fatal and nonfatal cardiovascular events (95% CI 4-44%, 5 year NNT 259). Hypertension treatment in African American women (mean age 52 years) reduced the risk of fatal and nonfatal cerebrovascular events by 53% (95% CI 29-69%, 5 year NNT 39), fatal and nonfatal cardiovascular events by 45% (95% CI 18-63%, 5 year NNT 21), fatal and nonfatal coronary events by 33% (95% CI 6-52%, 5 year NNT 48), and all cause mortality by 34% (95% CI 14-49%, 5 year NNT 32). Analyses in white women 30 to 54 years old did not show any statistically significant treatment benefit or harm.

REVIEWER'S CONCLUSIONS

Hypertension treatment lowers the relative and absolute risk of cardiovascular morbidity and mortality in women ages 55 years and older, and in African American women of all ages. A greater effort should be made to increase awareness and treatment in these groups of women. Although relative risk reductions for cerebrovascular and cardiovascular events are similar for younger and older women, the NNT of younger women is at least 4 times higher. Decisions for treatment of hypertension in younger white women should be influenced by the individual patient's absolute risk of cardiovascular disease.

Pharmacotherapy for hypertension in the elderly

OBJECTIVES

To quantify the long-term effects of antihypertensive drug therapy on morbidity and mortality in the elderly. To characterize co morbid risk profiles of trial participants.

SEARCH STRATEGY

Electronic search of WHO-ISH Collaboration register (August 1997), The Cochrane Library (1997; Issue 1), MEDLINE (1966 to April 1997) and two Japanese databases (1973-1995); references from reviews, trials and 10 previously published meta-analyses; and experts.

SELECTION CRITERIA

Randomized controlled trials of at least one year duration in hypertensive elders (at least 60 years old) assessing antihypertensive drug therapy and providing morbidity and mortality data.

DATA COLLECTION AND ANALYSIS

At least two independent reviewers abstracted data on morbidity and mortality results and trial characteristics. The following outcomes were assessed: total mortality; coronary heart disease (CHD) mortality; combined CHD morbidity and mortality; cerebrovascular mortality; combined cerebrovascular morbidity and mortality; cardiovascular mortality; combined cardiovascular morbidity and mortality; and drop outs due to side effects of treatment.

MAIN RESULTS

Fifteen trials including 21,908 elderly subjects were identified. The average prevalence of cardiovascular risk factors, cardiovascular disease, and competing co morbid diseases was lower among trial participants than the general population of hypertensive elderly persons. Most subjects were 60 to 80 years old. Most trials were conducted in Western, industrialized countries and evaluated diuretic and beta-blocker therapies. Event rates per 1000 participants over approximately 5 years indicated that antihypertensive drug therapy was beneficial. Cardiovascular morbidity and mortality was reduced from 177 to 126 events (95% CI of the difference 31 to 73). Cardiovascular mortality was reduced from 69 to 50 deaths (95% CI of the difference 9 to 31). Total mortality was reduced from 129 to 111 deaths (95% CI of difference 4 to 28). The data from the three trials restricted to persons with isolated systolic hypertension indicated a significant benefit: cardiovascular morbidity and mortality over approximately 5 years was reduced from 157 to 104 events per 1000 participants (95% CI of the difference 12 to 89). Numbers of participants who dropped out of trials secondary to adverse drug effects were often not reported. The four trials that did report this data showed a wide variation in drop out rates ranging from no significant differences between treatment and control groups to as many as one out of four patients dropping out due to side effects of treatment.

REVIEWER'S CONCLUSIONS

Randomized controlled trials establish that treating healthy older persons with hypertension is highly efficacious. Benefits of treatment with low dose diuretics or beta-blockers are clear for persons in their 60s to 70s with either diastolic or systolic hypertension. Differential treatment effects based on patient risk factors, pre-existing cardiovascular disease and competing co-morbidities could not be established from the published trial data.

Antihypertensive therapy for preventing cardiovascular complications in people with diabetes mellitus

OBJECTIVES

To assess the effect of intervention, both pharmacological and non-parmacological, to reduce blood pressure in people with diabetes mellitus on all cause mortality, specific causes of death, including cardiovascular disease, stroke, ischaemic heart disease and renal disease, morbidity associated with macro- and microvascular complications of diabetes mellitus and also side effects of the interventions and their influence on quality of life and well being.

SEARCH STRATEGY

The search strategy employed was to searching electronic databases such as EMBASE and MEDLINE for all trials of anti-hypertensive treatment in diabetes mellitus. As well as searching specialist journals in the fields of cardiovascular disease, stroke, hypertension and renal diease.

SELECTION CRITERIA

All trials were considered independently and then discussed by 2 reviewers to determine there eligibility for inclusion in the review. Their methodological quality was also assessed from details of the randomisation methods, blinding and whether the intention-to-treat method of analysis was used. Trials included in the review were all randomised contolled trials of the treatment for anti-hypertensive therapy for the specified endpoints which included subjects with diabetes mellitus.

DATA COLLECTION AND ANALYSIS

Data was sought on the number of patients with diabetes with each outcome measure by allocated treatment group, either from previous publications or, if this was not possible, the raw data was obtained and analysed using the intention-to-treat method. If these data were not available the results from the 'Per Protocol' analysis were used. To compare the treatment effect of the intervention with that of placebo on all cause mortality and cardiaovascular mortality and morbidity, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each trial and a meta analysis performed using Peto's ORs as the summary measure.

MAIN RESULTS

The initial search yielded 760 references, from which 23 appropriate trials were identified (3 for primary prevention and 20 for secondary prevention), and 15 of these trials had data available for analysis. For the primary prevention trials the summary ORs (95% CIs) for all cause mortality and CVD were 0.85 (0.62,1.17) and 0.64 (0.50,0.82) respectively. Of the seven trials for long-term secondary prevention (i.e. follow-up greater than one year), the summary OR (95% CI) for all cause mortality was 0.82 (0.69,0.99). Data on CVD mortality and morbidity was only available for 2 of these trials and the summary OR (95% CI) was 0.82 (0.60,1.13). There were five trials for short term secondary prevention trials (i.e. follow-up of less than 1 year) with data available for analysis. The summary ORs (95% CIs) for all cause mortality and CVD were 0.64 (0.50,0.83) and 0.68 (0.43,1.05) respectively.

REVIEWER'S CONCLUSIONS

Primary intervention trials indicated a treatment benefit for CVD, but not for total mortality in people with diabetes. For both short- and long-term secondary prevention, the present meta-analysis indicated a benefit for total mortality in diabetic subjects. However lack of information on CVD outcomes probably reduced the power of the meta-analysis to detect any corresponding benefit for this end-point. This, along with the fact that all published data of randomised control trials of anti-hypertensive therapy in diabetes for all cause mortailty and CVD outcomes are taken from the hypertension trials not specific to diabetes, underlines the need for further high quality trials examining the effects of blood pressure lowering interventions in people with diabetes.

Efficacy of treating hypertension in women

OBJECTIVE

To assess whether the relative and absolute benefit of hypertension treatment in women varies with age or race.

DESIGN

Systematic review of studies from 1966 to 1998 using MEDLINE, reviews, and consultation with experts. Eleven randomized controlled trials of pharmacologic treatment of prJgiary hypertension with cardiovascular morbidity and mortality outcomes were selected, with a pooled population of 23,000 women. Relative risks were combined for each end point to form a summary risk ratio using meta-analytic techniques based on a random-effects model. Summary risk ratios were converted to numbers needed to treat (NNTs). Data were dichotomized by age to approxJgiate menopausal status (30 to 54 years, and 55 years and older), and by race (white and African American).

MAIN RESULTS

In women aged 55 years or older (90% white), hypertension treatment resulted in a 38% risk reduction in fatal and nonfatal cerebrovascular events (95% confidence interval [CI] 27%, 47%; 5-year NNT 78), a 25% reduction in fatal and nonfatal cardiovascular events (95% CI 17%, 33%; 5-year NNT 58), and a 17% reduction in cardiovascular mortality (95% CI 3%, 29%; 5-year NNT 282). In women aged 30 to 54 years (79% white), hypertension treatment resulted in a 41% risk reduction in fatal and nonfatal cerebrovascular events (95% CI 8%, 63%; 5-year NNT 264), and a 27% risk reduction in fatal and nonfatal cardiovascular events (95% CI 4%, 44%; 5-year NNT 259). Hypertension treatment in African-American women (mean age, 52 years) reduced the risk of fatal and nonfatal cerebrovascular events by 53% (95% CI 29%, 69%; 5-year NNT 39), fatal and nonfatal cardiovascular events by 45% (95% CI 18%, 63%; 5-year NNT 21), fatal and nonfatal coronary events by 33% (95% CI 6%, 52%; 5-year NNT 48), and all-cause mortality by 34% (95% CI 14%, 49%; 5-year NNT 32). Analyses in white women aged 30 to 54 years did not show any statistically significant treatment benefit or harm.

CONCLUSIONS

Hypertension treatment lowers the relative and absolute risk of cardiovascular morbidity and mortality in women aged 55 years and older and in African-American women of all ages. A greater effort should be made to increase awareness and treatment in these groups of women. Although relative risk reductions for cerebrovascular and cardiovascular events are sJgiilar for younger and older women, the NNT of younger women is at least 4 tJgies higher. Decisions about treatment of hypertension in younger white women should be influenced by the individual patient's absolute risk of cardiovascular disease.

Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. INDANA Group

BACKGROUND

Beneficial clinical effects of treatment with antihypertensive drugs have been shown in middle-aged patients and in those hypertensive patients over 60 years old, but whether treatment is beneficial in patients over 80 years old is not known.

METHODS

We collected data from all participants aged 80 years and over in randomised controlled trials of antihypertensive drugs through direct contact with study investigators. Our primary outcome was fatal and non-fatal stroke. Secondary outcomes were death from all causes, cardiovascular death, fatal and non-fatal major coronary and cardiovascular events, and heart failure.

FINDINGS

There were 57 strokes and 34 deaths among 874 actively treated patients, compared with 77 strokes and 28 stroke deaths among 796 controls, representing 1 non-fatal stroke prevented for about 100 patients treated each year. The meta-analysis of data from 1670 participants aged 80 years or older suggested that treatment prevented 34% (95% CI 8-52) of strokes. Rates of major cardiovascular events and heart failure were significantly decreased, by 22% and 39%, respectively. However, there was no treatment benefit for cardiovascular death, and a non-significant 6% (-5 to 18) relative excess of death from all causes.

INTERPRETATIONS

The inconclusive findings for mortality contrast with the benefit of treatment for non-fatal events. Results of a large-scale specific trial are needed for definite conclusion that antihypertensive treatment is beneficial in very elderly hypertensive patients. Meanwhile, an age threshold beyond which hypertension should not be treated cannot be justified.

Impaired glucose tolerance and its co-variates among 2079 non-diabetic elderly subjects. Ten-year mortality and morbidity in the CASTEL study. CArdiovascular STudy in the ELderly

This study evaluated the role of impaired glucose tolerance (IGT) as a risk factor in a general population of 2079 non-diabetic elderly subjects. The 10-year cardiovascular morbidity was similar in normal and IGT subjects. Mortality was greater in IGT, but the Cox equations of the hazard rate were different in younger and older subjects: age, sex, lung function (forced expiratory volume in 1 s, FEV1), serum uric acid, IGT and proteinuria were predictors of overall mortality in the age class 65-79 years, while only the first 4 were associated with cardiovascular mortality. The same four items also predicted overall survival in subjects over 79 years old, while only age and uric acid were predictors of cardiovascular mortality. In older subjects, total cholesterol showed an inverse predictive value. Hyperuricaemia (> 6.4 mg/dl) and proteinuria did predict mortality in normal but not in IGT subjects, while reduced FEV1 (< 60% theoretical) was predictive in all. In 65-79-year old subjects IGT predicted mortality provided that FEV1 was normal, while in those 380 years old IGT was not a predictor. These interrelationships should be taken into account to better understand the factors underlying mortality.

Nifedipine gastrointestinal therapeutic system (GITS). A review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy in hypertension and angina pectoris

Nifedipine 'gastrointestinal therapeutic system' (GITS) is a recently developed formulation that slowly releases the drug into the intestinal tract over a 24-hour period. When administered once daily, it is of similar efficacy to sustained release formulations of felodipine, verapamil, and diltiazem and at least as effective as standard formulations of lisinopril and enalapril, and long-acting propranolol and atenolol in the treatment of patients with mild to moderate essential hypertension. Substitution of nifedipine GITS for conventional formulations of nifedipine, diltiazem or verapamil, maintained adequate control of anginal symptoms in patients with stable angina pectoris. Nifedipine GITS appears to maintain quality of life and is apparently better tolerated than those formulations of nifedipine which require 2 or 3 times daily administration in both elderly and younger patients. In addition, it has minimal effect on lipid and glucose metabolism and reverses left ventricular hypertrophy, and is thus suitable for treatment of the majority of patients with mild to moderate hypertension or angina pectoris.