Sex differences in arterial hypertension

There is strong evidence that sex chromosomes and sex hormones influence blood pressure (BP) regulation, distribution of cardiovascular (CV) risk factors and co-morbidities differentially in females and males with essential arterial hypertension. The risk for CV disease increases at a lower BP level in females than in males, suggesting that sex-specific thresholds for diagnosis of hypertension may be reasonable. However, due to paucity of data, in particularly from specifically designed clinical trials, it is not yet known whether hypertension should be differently managed in females and males, including treatment goals and choice and dosages of antihypertensive drugs. Accordingly, this consensus document was conceived to provide a comprehensive overview of current knowledge on sex differences in essential hypertension including BP development over the life course, development of hypertension, pathophysiologic mechanisms regulating BP, interaction of BP with CV risk factors and co-morbidities, hypertension-mediated organ damage in the heart and the arteries, impact on incident CV disease, and differences in the effect of antihypertensive treatment. The consensus document also highlights areas where focused research is needed to advance sex-specific prevention and management of hypertension.

[Influence of percutaneous coronary intervention in non ST-elevation acute coronary syndromes on prescription of secondary prevention medications. Data from the S-Témoin Registry]

BACKGROUND

The interaction between the use of percutaneous coronary intervention (PCI) for non-ST-elevation acute coronary syndromes and the use of secondary prevention medications was analysed in the French S-Témoin Registry.

METHODS

The population consisted of 2433 patients seen by their cardiologists at an outpatient clinic 2-12 months after non ST-elevation ACS; the survey was carried out from September 2004 to April 2005.

RESULTS

Overall, patients undergoing PCI (75% of the population) had higher levels of prescription of recommended secondary prevention medications. Multivariate logistic regression analysis showed that the use and type of coronary intervention (drug eluting versus bare metal stents) was an independent correlate of the use of dual antiplatelet therapy. In addition, time from the acute episode was also a strong correlate of dual antiplatelet therapy. Statins were also more often used in patients with PCI.

CONCLUSION

Patients not treated with PCI are less likely to receive appropriate secondary prevention medications after non ST-elevation acute coronary syndromes. Specific efforts should be directed towards these patients, in particular as regards the prescription of dual antiplatelet therapy.

Heart failure with preserved systolic function: a diagnostic algorithm for a pragmatic definition

Heart failure is a major health problem which often concerns the elderly. Prevalence of heart failure with preserved systolic function is increasing and varies from 40 to 50%. In the literature, and in the large epidemiological studies, it is commonly designed with the term of "diastolic heart failure", even if a precise analysis of diastolic function is not performed. A diagnostic algorithm is proposed in order to better define the concept of heart failure with preserved systolic function. It consists of seven steps from symptoms and clinical signs to the echocardiographic analysis of diastolic function, in order to confirm the definition of heart failure with preserved systolic function.

[Do beta-blockers prevent coronary events in hypertensive patients?]

Beta-blockers have been considered for decades as effective agents in preventing coronary events in hypertensive patients. Actually, the scrutiny of the available data arises some doubts over the real value of this pharmacological class. In primary prevention, the clinical benefits of beta-blockers are poorly documented: the studies conducted against placebo (MRC, IPPPSH...) did not show any significant differences regarding the rate of coronary events (except within non smokers); moreover, the beneficial effect of propranolol in preventing sudden deaths and silent myocardial infarctions has been reported byjust one retrospective analysis. Likewise in HAPPHY study, the comparison with diuretics did not emphasize a clear superiority of one of both classes; the better effect of metoprolol regarding overall mortality and fatal coronary events was shown in the pecular subset MAPHY, only. Furthermore, in elderly people, HEP, MRC OA and STOP studies did not find any significant effect of beta-blockers in preventing coronary events, as compared with placebo. However, SHEP study, which involved patients older than 60 years with isolated systolic hypertension receiving first a diuretic, then a beta-blocker(atenolol) in 1/4 of the cases, demonstrated a significant reduction versus placebo both in strokes and in coronary events. Finally, in UKPDS, CAPP, LIFE and CONVINCE studies, atenolol turned out to have a similar efficacy as captopril, losartan and verapamil, in preventing ischemic heart disease. Among the numerous published meta-analyses, that of Psaty pointed out the absence of a primary cardioprotective effect by beta-blockers; more recently, that of Carlberg, emphasized atenolol given alone as the first-line drug to fail in significantly reducing coronary events and strokes. In secondary prevention, some more convincing data may be found in the literature, regarding post myocardial infarction patients (meta-analyses of Staessen, 1982, Yusuf, 1985 and Soriano, 1997), as well as those with stable angina (BIP study in diabetics) or silent ischemia (ASIST study: significant reduction in number and duration of ischemic events by atenolol). Moreover, INVEST study recently showed atenolol and verapamil to have an equivalent efficacy in the hypertensive patients with stable coronary artery disease. Last, hypertension should be reminded as resulting in many cases of heart failure, a pathology where beta-blockers have clearly demonstrated their beneficial effects.

[Validation of the therapeutic role of amlodipine in 31,946 French hypertensive patients]

Amlodipine, a dihydropyridine calcium channel blocker (CCB), with a long duration of action, has been the subject of numerous controlled studies which showed its effectiveness and good tolerance in arterial hypertension in once-daily doses. We report the results of a large, multicentric, French, prospective phase IV study which evaluated the effectiveness and tolerance of amlodipine administered at a rate of 5 to 10 mg in only one daily dose. We also assess the evolution of the quality of life after 12 weeks of treatment among 31,946 hypertensive patients followed up to the ambulatory stage by general practitioners. The response rate--defined as the patients having had a reduction of 10 mmHg or more diastolic blood pressure--was 88%. The blood pressure standardization--defined by a diastolic blood pressure lower than 90 mmHg--was achieved for 70% of the patients. Amlodipine was administered in stand-alone therapy in 78% of the cases. The occurrence of an undesirable event was noted in the course of treatment in 12% of the patients and justified interruption of the treatment for 3.7% of the total population. The index average of quality of life was improved by the end of the 12-week treatment. This study carried out on a significant number of hypertensive patients (n = 31,946) under real prescription conditions confirms the efficacy and good tolerance of amlodipine, as has already been demonstrated in the preliminary developmental studies.

[What role to assign for calcium channel blockers in the treatment of arterial hypertension in 1997?]

What is the place of calcium channel blockers in the treatment of hypertension (HT)? And, more importantly, what is the place of any molecule recognised as being effective to reduce blood pressure figures in the treatment of HT? Beyond the hypotheses which have dominated the rational approach up until now, suggesting a possible answer to these two questions, medical practice is developing towards evidence-based medicine. This opposes two lines of logic:--that which argues that the benefit of treatment of HT is exclusively related to a reduction of blood pressure figure obtained with the use of the most effective molecule or class which is best tolerated in a given clinical context; that which argues that it is impossible to prescribe widely and indefinitely molecules whose real effect on the clinical prognosis of HT and long-term safety are unknown. This new logic no longer recognizes the reduction of blood pressure figures independently of the means used to achieve this reduction as the exclusive guarantee of the benefit of treatment and proposes that treatments which are widely prescribed must have a more detailed clinical evaluation file than that authorized by current practice. Calcium channel blockers were recently adopted as the main subject of this opposition between two logics, probably because several molecules of this class, evaluated in therapeutic trials conducted outside of the context of HT, demonstrated harmful cardiovascular effects and that case-control studies in the context of HT have indicated the possibility of extracardiac adverse effects. It therefore seems useful to try to redefine their place in the treatment of HT in the light of this recent debate and, more importantly, to extend the discussion to several principles of the pharmacological treatment of HT. Leaving current controversies to one side, this review is designed to present several elements of these opposing logics.