Amlodipine Besylate versus Candesartan Cilexetil in Hypertensive Patients - Office and Self-Measured Blood Pressure : A Randomised, Double-Blind, Comparative, Multicentre Trial

OBJECTIVE

The aim of this study was to compare the antihypertensive efficacy and tolerability of the calcium channel antagonist amlodipine besylate versus the angiotensin II type 1 receptor antagonist candesartan cilexetil in hypertensive patients.

PATIENTS AND METHODS

After a 2-week placebo washout period, 326 patients with essential hypertension were randomised to receive amlodipine 5mg once daily or candesartan cilexetil 8mg once daily in a double-blind, parallel-group design with a 12-week active treatment period followed by a 4-day placebo drug-free period. The initial daily dose could be doubled at week 6 if office diastolic blood pressure (DBP) was still >/=90mm Hg. BP changes were assessed daily through patient self-measurements, and fortnightly by office BP measurements.

RESULTS

A total of 294 patients (151 amlodipine and 143 candesartan cilexetil) were included in the per-protocol analysis of the primary endpoint of BP change from baseline at 12 weeks. Reductions in sitting office systolic BP (SBP) [amlodipine 24.4mm Hg, candesartan cilexetil 22.3mm Hg] and DBP (amlodipine 14.9mm Hg, candesartan cilexetil 14.8mm Hg) were statistically equivalent within the chosen range of equivalence (5mm Hg for SBP and 3mm Hg for DBP). The proportion of controlled patients (office BP <140/90mm Hg) at the end of therapy was similar in both treatment groups (amlodipine 46.9%, candesartan cilexetil 44.4%). The reduction in self-measured DBP was significantly greater (p < 0.05) for amlodipine (7.2mm Hg) compared with candesartan cilexetil (4.8mm Hg). There was no significant difference between the two treatments in the incidence of adverse events reported.

CONCLUSIONS

Amlodipine besylate and candesartan cilexetil were both very effective in lowering office BP after 12 weeks of treatment. There was a trend towards a better self-measured BP reduction with amlodipine compared with candesartan cilexetil. The overall incidence of adverse events was comparable between the two treatments.

Health-related quality of life during treatment of elderly patients with hypertension: results from the Study on COgnition and Prognosis in the Elderly (SCOPE)

The Study on COgnition and Prognosis in the Elderly (SCOPE) was a multinational, randomised, double-blind study to assess the effects of candesartan 8-16 mg daily on cardiovascular events and cognitive function in elderly patients (aged 70-89 years) with mild to moderate hypertension. A total of 4937 patients were randomised to candesartan or placebo with other antihypertensive drugs (mostly diuretics, beta-blockers, and calcium antagonists) added as needed to control blood pressure. Only 16% of the patients in the control group received placebo alone. The mean follow-up was 3.7 years. The aim of this health-related quality of life (HRQL) substudy analysis was to investigate changes in HRQL during antihypertensive treatment, and possible differences in patients receiving candesartan-based or other antihypertensive treatment. Three validated HRQL instruments were used: the Psychological General Well-being (PGWB) Index, the Subjective Symptoms Assessment Profile (SSA-P), and the EuroQoL Health Utility Index (EuroQoL). The HRQL was generally good at baseline and well preserved during follow-up in the presence of substantial blood pressure reductions in both treatment groups. Several of the observed changes in score from baseline to last visit favoured candesartan-based compared to control treatment, particularly the changes in PGWB Anxiety (-0.5 vs -1.0, P=0.01), PGWB Positive well-being (-0.8 vs -1.1, P=0.04), SSA-P Cardiac symptoms (0.03 vs 0.10, P=0.03), and EuroQoL Current health (-3.1 vs -5.3, P=0.008). This favourable result may be related to the somewhat lower blood pressure associated with candesartan-based treatment. In conclusion, there should be no reason to withhold modern antihypertensive therapy in elderly patients due to concerns for a negative effect on HRQL.

Pulse Pressure Responses in Patients Treated with Valsartan and Hydrochlorothiazide Combination Therapy

In a randomized, double-blind, parallel-group study of middle-aged and elderly patients, we examined the effects of treatment with the angiotensin receptor blocker valsartan (Val) in combination with hydrochlorothiazide (HCTZ) on pulse pressure (PP). After a 2-week washout period, patients entered a 4-week single-blind Val 160 mg once daily run-in period before randomization to one of three treatment groups: Val 160 mg ( n = 666), Val 160 mg/HCTZ 12.5 mg ( n = 670) or Val 160 mg/HCTZ 25 mg ( n = 666), once daily for eight weeks. Sitting PP at baseline was similar in all groups. From baseline to randomization, Val monotherapy reduced PP by 4.7 ± 10.2 mmHg (mean ± SD). At the end of the study, overall reductions in PP were 6.7 mmHg for Val 160/HCTZ 12.5 and 7.5 mmHg for Val 160/HCTZ 25. Val monotherapy reduced PP in mild-to-moderate hypertensive patients. Val combined with HCTZ provides an additional dose-related reduction in PP.

[Ideal combination partners in therapy of hypertension. Calcium antagonists are much better than their reputation]

Calcium antagonists are a chemically heterogeneous group of substances that effectively reduce elevated blood pressure in all age groups and also show organoprotective properties. A number of randomized studies have revealed a reduction in morbidity, in particular stroke. These substances are the drugs of first choice in the elderly, in left-ventricular hypertrophy and in obstructive pulmonary disease. Care must be exercised when congestive heart failure or acute coronary syndrome presents. Calcium antagonists are ideal combination drugs that help achieve targeted blood pressure levels.

AT1-receptor blocker-based combination therapy in hypertension

Despite an increase in the number of patients treated for hypertension, blood pressure control is achieved in a minority of patients. The use of rational, well-tolerated combination regimens with complementary modes of action, such as an AT1-receptor blocker administered with a low dose of a thiazide diuretic, provides an effective and well-tolerated management strategy for patients who require more than monotherapy to control blood pressure. In clinical trials in patients with mild-to-moderate hypertension, a newly available combination of candesartan cilexetil-hydrochlorothiazide (HCT) 16/12.5 mg was significantly more effective than either monotherapy. This combination was also more effective than losartan-HCT 50/12.5 mg in two double-blind, randomized studies in patients with mild, moderate or severe hypertension. Furthermore, the antihypertensive efficacy of candesartan cilexetil-HCT was evident at up to 48 h following the last dose, while the effect of losartan-HCT declined rapidly during this period. Thus, the new fixed-dose AT1-receptor blocker/diuretic combination, candesartan cilexetil-HCT 16/12.5 mg combines enhanced efficacy with excellent tolerability and sets a new standard for the treatment of hypertension requiring more than monotherapy.

Combination therapy with AT(1)-receptor blockers

Although current hypertension management guidelines recommend increasingly stringent blood pressure targets, these targets are seldom achieved in clinical practice. Even in patients with mild-to-moderate hypertension, monotherapy is only effective in approximately 50-70% of patients, and thus there is a clear need for combination therapy if stringent blood pressure targets are to be achieved. Drugs used in combination therapy should satisfy a number of prerequisites, including complementary mechanisms of action, enhanced efficacy in combination, and maintained (or improved) tolerability. Evidence is accumulating that combination therapy with an AT(1)-receptor blocker and a diuretic represents a rational and effective treatment option. In clinical trials, the combination of candesartan cilexetil, 16 mg, and hydrochlorothiazide, 12.5 mg, has been shown to be more effective in lowering blood pressure than either agent alone. Furthermore, this combination has been shown to reduce blood pressure to a greater extent, and control blood pressure in a higher proportion of patients, than the combination of losartan, 50 mg, and hydrochlorothiazide, 12.5 mg, both when used instead of or in addition to previous antihypertensive therapy. The placebo-like tolerability of AT(1)-receptor blockers was maintained when these drugs were used in combination with hydrochlorothiazide. The combination of candesartan and a dihydropyridine calcium antagonist has also been shown to be more effective than either component alone. Furthermore, in the Candesartan and Lisinopril Microalbuminuria (CALM) Study, the combination of candesartan and lisinopril reduced blood pressure to a greater extent than either agent alone, and tended to have a greater effect on microalbuminuria.

Potential for antihypertensive treatment with an AT(1)-receptor blocker to reduce dementia in the elderly

Hypertension is an established risk factor for stroke and other cerebrovascular disorders. Both stroke and small lacunar infarcts or white matter lesions can cause cognitive impairment and dementia, and there is evidence that vascular risk factors play a major role in the development of both Alzheimer's disease and vascular dementia. Several large epidemiological studies have shown that raised blood pressure in midlife is a strong risk factor for dementia later in life; however, blood pressure often decreases following the development of dementia. The cognitive function hypothesis proposes that elevated blood pressure increases the risk of decline of cognitive function, and that this can be reversed by active lowering of blood pressure. Evidence in support of this hypothesis comes from the Syst-Eur Dementia project, and from a number of smaller studies. SCOPE (Study on Cognition and Prognosis in the Elderly) is a large prospective study involving almost 5000 elderly patients (age 70-89 years), who are randomised to receive candesartan cilexetil, 8-16 mg, or placebo. Candesartan was chosen for this study because it is effective and well tolerated in elderly patients. SCOPE should provide important information on the long-term effects of AT(1)-receptor blocker treatment with candesartan on morbidity-including effects on cognitive function-and cardiovascular mortality in elderly hypertensive patients.

[Intrapulmonary tumor cell embolism from cancer of the bladder as the cause of a subacute cor pulmonale]

HISTORY AND CLINICAL FINDINGS

A 61-year-old man had over 3 weeks experienced increasing dyspnoea on effort and loss of appetite. He reported previous chronic pain with a "stiffened hip" treated long-term with diclofenac, and three transurethral surgical interventions. It was only at the latest admission that bladder cancer (first diagnosed 2 years previously) became known as the reason for the interventions. On admission pallor, sinus tachycardia, fever of 38 degrees C and dyspnoea on light exertion were noted, but blood pressure was normal.

INVESTIGATIONS

Chest X-ray was normal, but the patient had marked respiratory insufficiency (pO2 30.8 mmHg, pCO2 31.6 mmHg) on room air. Echocardiography showed a dilated right ventricle with paradoxical septal movement. There was no evidence of thrombosis in the leg veins on ultrasound. D-dimers were normal.

DIAGNOSIS, TREATMENT AND COURSE

Pulmonary artery embolism of unknown origin was suspected. Despite anticoagulation with low-molecular heparin the patient's condition deteriorated. Spiral computed tomography of the thorax did not show thrombi in the pulmonary arterial vessels. Perfusion scintigraphy demonstrated definite perfusion deficits bilaterally in the upper lobes of the lung, consistent with pulmonary embolism. As his condition gradually worsened rt-PA was started to achieve fibrinolysis, but failed to produce any change in haemodynamic and respiratory functions. He died a few hours later. Microscopic examination at autopsy revealed multiple tumour emboli with intimal fibrosis in the peripheral arteries. A poorly differentiated urothelial carcinoma of the bladder with extensive infiltration of blood vessels was found (carcinomatous haemangiosis).

CONCLUSION

A malignant tumour with micro-embolization of tumour cells should be considered as a possible diagnosis when the clinical picture indicates pulmonary embolism of unknown genesis.

Efficacy and tolerability of candesartan cilexetil in special patient groups

Patients with hypertension do not comprise a homogeneous group, and the majority present with a variety of concomitant and associated conditions. Antihypertensive therapies should therefore be effective and well tolerated in a wide range of patients and should, ideally, ameliorate the negative target-organ effects of hypertension, such as atherosclerosis, cardiovascular remodelling and renal impairment. Evidence is accumulating that the new angiotensin II type 1 receptor blocker, candesartan cilexetil, lowers blood pressure effectively and is well tolerated in a variety of patient groups, including women and the elderly. In patients with severe hypertension, a treatment schedule based on candesartan cilexetil, with the addition of diuretic and calcium antagonist therapy as needed, has been found to control blood pressure successfully. Candesartan cilexetil does not affect glucose tolerance or lipid profiles in patients with diabetes mellitus, and it is not associated with any of the side effects of other antihypertensive agents that would make it unsuitable for use in patients with pulmonary disease. Initial clinical studies have indicated that candesartan cilexetil is well tolerated and effective in patients with heart failure. Furthermore, the available evidence shows that treatment with candesartan cilexetil can reverse the negative effects of hypertension on left ventricular hypertrophy and microalbuminuria. It therefore appears that the pronounced efficacy and placebo-like tolerability of candesartan cilexetil, as demonstrated in large clinical trials of patients with mild to moderate hypertension, can be extended to a wide range of specific patient groups.

Reducing cardiovascular morbidity and mortality in the elderly

Candesartan cilexetil is highly effective at lowering blood pressure, whilst maintaining placebo-like tolerability, in a wide range of patient groups. Although the benefit of lowering blood pressure in elderly patients with moderate hypertension has been demonstrated in several large-scale clinical trials, elderly patients with mild hypertension have rarely been studied. The high incidence of cardiovascular and cerebrovascular mortality and morbidity, including dementia, in the elderly means that control of blood pressure is particularly important in this patient group. A major new international clinical trial - SCOPE (Study on COgnition and Prognosis in the Elderly) - has therefore been initiated. This is a prospective, randomized, double-blind, parallel comparison of the effects of candesartan cilexetil, 8 or 16 mg once daily, and placebo in about 5000 patients who will be followed for a mean of 2.5 years. SCOPE is the first study designed to assess the effect of antihypertensive therapy in elderly patients (70-89 years of age) with mild hypertension (sitting systolic blood pressure of 160-179 mmHg and/or sitting diastolic blood pressure of 90-99 mmHg). The primary objective of the study is to determine the effect of candesartan cilexetil on major cardiovascular events (cardiovascular death, non-fatal stroke and myocardial infarction, and silent myocardial infarction), while an important secondary objective is to determine the effect of such treatment on the prevention of cognitive impairment. SCOPE should provide definitive evidence of the cardiovascular and cerebrovascular benefits of treating mildly hypertensive elderly patients with angiotensin II type 1 receptor blockers, which not only reduce blood pressure, but may also provide significant protection from the negative effects of angiotensin II on target organs.

Candesartan Cilexetil, a Novel Angiotensin II Type 1 (AT1) Receptor Blocker, Reduces Microalbuminuria in Patients with Type II Diabetes Mellitus and Mild Hypertension

Microalbuminuria is a predictor of nephropathy in patients with type I or type II diabetes mellitus, and interventions that decrease albuminuria are likely to postpone the development of severe renal impairment. Suppression of the renin-angiotensin system by angiotensin-converting enzyme (ACE) inhibition has been effective in this respect. However, direct inhibition of the negative cardiovascular effects of angiotensin II by means of an angiotensin II type 1 (AT 1 ) receptor blocker would be expected to produce reductions in albuminuria similar to those produced by ACE inhibition. In this study, we assessed the effect of candesartan cilexetil on microalbuminuria in patients with type II diabetes mellitus and mild hypertension. The analysis was performed in a subset of patients ( n = 35) with microalbuminuria (10-100 mg in an overnight urine sample) at randomization in a large double-blind, placebo-controlled study. The subset was part of a study investigating the effect of candesartan cilexetil on blood glucose homeostasis and the blood lipid profile in patients with stable type II diabetes mellitus, mild hypertension (diastolic blood pressure 90-100 mmHg) and serum creatinine levels below 150 &#55 mol/l for men and below 120 &#119 mol/l for women. Patients were randomized, after a 4-week placebo run-in period, to 12 weeks of double-blind treatment with candesartan cilexetil, 8-16 mg ( n = 83), or placebo ( n = 78) once daily. After 12 weeks of treatment, candesartan cilexetil did not influence blood glucose homeostasis or the blood lipid profile compared with placebo. Body weight remained unchanged in both treatment groups. Median urinary albumin excretion decreased by 57%, from 28.5 to 12.2 mg/12 h, in patients treated with candesartan cilexetil ( n = 15), whereas it increased by 9%, from 30.2 to 32.8 mg/12 h, in the placebo group ( n = 20; p = 0.03 for the difference between treatments). The mean reduction in diastolic blood pressure was 6.4 mmHg in the group given candesartan cilexetil and 3.6 mmHg in the group given placebo. In conclusion, 12 weeks of treatment with the AT 1 -receptor antagonist candesartan cilexetil reduced microalbuminuria in patients with stable type II diabetes mellitus and mild hypertension. Thus, candesartan cilexetil appears to have the potential for renal protection in this patient category.

Hypertension as a risk factor for cardiovascular morbidity and mortality in an elderly German population; the prospective STEPHY II study. Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly

AIM

To prospectively study the relationship between blood pressure levels and subsequent cardiovascular morbidity and mortality in a population aged 65 years and older.

METHODS

Participants of the 1992 baseline survey of the population-based Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly (STEPHY, 394 men and 588 women above age 65) were followed up for 3 years. Total mortality was assessed by official death data. Cardiovascular morbidity, that is, the occurrence of non-fatal events (new cases of acute myocardial infarction, angina pectoris, stroke, and heart failure) could be assessed in 681 of the 863 survivors by a second interview and analysis of general practitioners' records. The mortality and morbidity risks were compared for hypertensives (baseline blood pressure > or = 160/95 mmHg or antihypertensive treatment) and non-hypertensives.

RESULTS

During follow-up a total of 55 men and 64 women died resulting in a 2.7-year cumulative mortality in this population of 12%. Mortality was higher in men (14%) than in women (11%). Hypertensives had no increased risk of death compared to non-hypertensives (adjusted relative risk (RR)=0. 92; 95% CI: 0.48-1.76 for men and RR=1.36; 95% CI 0.67-2.78 for women). This was confirmed in age-stratified analyses. However, among survivors hypertension was associated with a significantly higher occurrence of non-fatal cardiovascular events. After controlling for potentially confounding baseline conditions, the relative risk for any event (RR=1.44; 95% CI: 1.04-2.0) and, in particular, of acute myocardial infarction (RR=5.5; 95% CI: 1.6-18. 7) was raised among hypertensives. Higher rates for angina pectoris (RR=1.4; 95% CI: 0.9-2.4) and heart failure (RR 1.7; 95% CI: 0.9-2. 9) were of borderline significance. Positive risk associations were confined to the age group 65 to 75 years and not detected at higher ages.

CONCLUSION

This study demonstrates for a Central European population older than 65 years the impact of hypertension as a risk factor for cardiovascular and cerebrovascular morbidity. To address the issue that risk of death showed no significant relationship to blood pressure, a longer follow-up period might be necessary.

[Study on intervention in arterial hypertension. Recommendations by experts and practical antihypertensive therapy. German Hypertension League]

Important intervention trials performed during the last decades and years are presented and critically reviewed. These long-term studies with hard end points have demonstrated positive results for four different antihypertensive classes: diuretics, beta blockers, calcium channel blockers and ACE inhibitors. The major issue is the prevention of hypertensive complications such as myocardial infarction, heart failure or stroke. For achieving this primary goal blood pressure reduction--or ideally normalization--is of decisive importance. As recommended by the Deutsche Hochdruckliga (German "Hypertension League") specific and individualized treatment of hypertension should consider target organ protecting effects of the various antihypertensive agents. In many cases combination therapy will be necessary to control hypertension (blood pressure target < 140/90 mmHg).

Effects of candesartan cilexetil on glucose homeostasis. Multicenter Study Group

In a multicenter, randomized, double-blind, placebo-controlled clinical trial the effects of candesartan cilexetil (cand.cil.), a novel angiotensin II antagonist selective for the AT1 receptor with long-lasting antihypertensive activity, on glucose homeostasis--and the serum lipid profile--were assessed in patients with mild hypertension and stable type II diabetes mellitus. A total of 161 men and women, 30-75 years old, with mild hypertension (sitting diastolic blood pressure 90-100 mmHg) and type II diabetes (HbA1c 5.5-9.0%), both measured after a 4-week placebo run-in period, were randomized to double-blind treatment with cand.cil. 8 mg o.i.d. (n = 83) or placebo (n = 78). Dose was increased to 16 mg o.i.d., if diastolic blood pressure remained > or = 90 mmHg. At randomization and after 12 weeks of treatment HbA1c (primary effect variable), blood glucose and the serum lipid profile (including total cholesterol, HDL and LDL cholesterol, triglycerides) were assessed. The statistical analysis of the differences between treatments was based on changes from randomization to the end of the study. Cand.cil. had no significant effect on HbA1c, blood glucose, and serum lipids compared to placebo. The median HbA1c both at baseline and after 12 weeks was 7.1% in patients on cand.cil., and 7.2% and 7.1% in patients on placebo. The 95% confidence interval for the median difference in change between the groups was narrow (-0.25; 0.16), including zero, which excluded any clinically important difference. The same held true for blood glucose (-1.10; 0.20), total cholesterol (-0.40; 0.20), and the other lipid parameters. More than 60% of the patients reached a diastolic blood pressure < 90 mmHg; adverse events and withdrawals were similar in both groups. Thus, in patients with mild hypertension and type II diabetes, cand.cil. 8 to 16 mg o.i.d. for 12 weeks does not affect glucose homeostasis respectively serum lipids. Blood pressure was controlled in most patients and cand.cil. was well tolerated.

Twenty-four-hour blood pressure profile and blood pressure responses to head-up tilt tests in Parkinson's disease and multiple system atrophy

OBJECTIVE

To investigate the 24 h blood pressure profile in patients with Parkinson's disease with intact autonomic function or with autonomic failure and patients with multiple system atrophy (MSA), and to assess whether these patients exhibit posture-related variations in blood pressure.

PATIENTS AND METHODS

We studied 24 patients with Parkinson's disease (11 with autonomic failure) and 13 patients with MSA (all with autonomic failure). Autonomic failure was determined by autonomic tests. An oscillometric recorder was used for ambulatory blood pressure monitoring. Tilt-table tests were performed with a head-up tilt position of 60 degrees.

RESULTS

An alteration in the normal 24 h blood pressure profile was observed in 82% of Parkinson's disease patients with autonomic failure and in 85% of those with multiple system atrophy, but not in the patients with intact autonomic function. Head-up tilt tests revealed a significantly higher supine blood pressure in Parkinson's disease patients with autonomic failure and in those with MSA than in Parkinson's disease patients with intact autonomic function. Tilting resulted in a marked fall in blood pressure in patients with MSA; in Parkinson's disease patients with autonomic failure, the fall was comparatively slighter.

CONCLUSIONS

We conclude that autonomic failure contributes to the alterations in the day-night blood pressure profile that may possibly be ascribed to postural dysregulation of blood pressure. We hypothesize that nocturnal hypertension is a risk factor in the development of additional cerebrovascular disease in patients with Parkinson's disease or MSA who are affected by autonomic failure.

Treatment with calcium antagonists does not increase the risk of fatal or non-fatal cancer in an elderly mid-European population: results from STEPHY II. Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly

OBJECTIVE

To assess the relationship between use of calcium antagonists and incidence of fatal or non-fatal cancer over 3 years in the Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly (STEPHY) population.

DESIGN

A prospective cohort study with follow-up analysis after 3 years.

PATIENTS AND METHODS

In 1992 STEPHY workers investigated the total population aged > 65 years (n = 1190) of two villages in Bavaria, Germany. With 982 participants (response rate 83%) the prevalence of 'actual' hypertension (blood pressure > or = 160/95 mmHg or treatment) was 53%. Of all hypertensives (n = 491), 54% were being treated, 28% (n = 137) with calcium antagonists. Participants with a history of cancer or manifest cancer were excluded from further analysis. In 1995 in STEPHY II, the 3-year follow-up, we assessed total mortality (including cases of fatal cancer), cardiovascular events and cases of non-fatal cancer between 1992 and 1995. The evaluation included a second interview, use of case records of general practitioners and hospitals and analysis of the official death certificates. The total incidence of fatal and non-fatal cancer (a combined end point) was calculated for participants treated with calcium antagonists and those not taking calcium antagonists.

RESULTS

Total mortality over 3 years was 12.1 % (n = 119). There were 22 deaths due to cancer and 75 cases of newly diagnosed non-fatal cancer. The combined incidence of fatal and non-fatal cancer (primary end point) was 10.9% (n = 15) for participants treated with calcium antagonists and 9.7% (n = 82) for those not taking calcium antagonists (odds ratio 1.12, 95% confidence interval 0.7-1.8). There was also no significant difference between the incidences of fatal cancer (2.2% in both groups), non-fatal cancer (12.5% for participants treated with calcium antagonists and 10.8% for those not taking calcium antagonists) and total mortality (14.6% for participants taking calcium antagonists and 11.7% for those not treated with calcium antagonists).

CONCLUSION

Use of calcium antagonists does not increase the risk of fatal or non-fatal cancer over 3 years in an elderly mid-European population.

Antihypertensive treatment with candesartan cilexetil does not affect glucose homeostasis or serum lipid profile in patients with mild hypertension and type II diabetes

This multicentre, randomized, controlled clinical trial assessed the effects of candesartan cilexetil (cand.cil.), a novel angiotensin II antagonist selective for the AT1 receptor with long-lasting antihypertensive activity, compared to placebo on glucose homeostasis and serum lipid profile in mild hypertensives with type II diabetes. A total of 161 men and women, 30-75 years old, with mild hypertension (sitting diastolic blood pressure 90-100 mmHg) and type II diabetes (HbA1c 5.5-9.0%), both measured after a 4-week placebo run-in period, were randomized to double-blind treatment with cand.cil. 8 mg o.i.d. (n = 83) or placebo (n = 78). Dose was increased to 16 mg o.i.d. if diastolic blood pressure remained >90 mmHg. At randomization and after 12 weeks of treatment HbA1c (primary effect variable), blood glucose and the serum lipid profile (including total cholesterol, HDL and LDL cholesterol, triglycerides) were assessed. The statistical analysis of the differences between treatments was based on changes from randomization to the end of the study. Cand.cil. had no significant effect on HbA1c, blood glucose and serum lipids compared to placebo. The median HbA1c both at baseline and after 12 weeks was 7.1% in patients on cand.cil., and 7.2% and 7.1% in patients on placebo. The 95% confidence interval for the median difference in change between the groups was narrow (-0.25; 0.16), including zero, which excluded any clinically important difference. The same held true for blood glucose (-1.10; 0.20), total cholesterol (-0.40; 0.20) and the other lipid parameters. More than 60% of the patients reached a diastolic blood pressure <90 mmHg; adverse events and withdrawals were similar in both groups. Thus, in patients with mild hypertension and type II diabetes, cand.cil. 8-16 mg o.i.d. for 12 weeks does not affect glucose homeostasis and serum lipids. Blood pressure was controlled in most patients, and cand.cil. was well tolerated.

Severe spontaneous carotid artery dissection and multiple aneurysmal dilatations. A case report

Spontaneous cervical artery dissections or arterial aneurysms associated with deficiencies of alpha(1)-antitrypsin (alpha(1)-AT) or other inhibitors of proteolytic enzymes have occasionally been reported. However, a coexistence of severe spontaneous internal carotid artery dissection and multiple aneurysmal dilatations associated with alpha(1)-AT phenotype M1S have not yet been presented; herein the authors describe such a patient. In order to avoid the risks associated with intraarterial angiography in a patient in whom an underlying arteriopathy is suspected, only noninvasive techniques were employed. This case demonstrates that magnetic resonance imaging combined with magnetic resonance angiography is a valuable noninvasive method for use in diagnosis and follow-up of carotid artery dissection.

Plasma renin activity and plasma prorenin are not suppressed in hypertensives surviving to old age

An age related decline in plasma renin activity (PRA) has been described in normotensive and hypertensive subjects. Moreover, hypertensive patients are reported to have lower plasma prorenin levels. We therefore investigated whether that pattern of renin and prorenin suppression was apparent in white hypertensives and normotensives surviving to an older age. The study population consisted of 65 untreated hypertensives (office blood pressure > or = 160/95 mm Hg; mean age 79 +/- 6 SD; range 69 to 94 years) and 26 normotensives (mean age 77 +/- 8; range 66 to 99 years). The PRA in this population of older hypertensives (1.7 +/- 1.6 ng/mL/h) was not significantly different from normotensives of similar age (1.5 +/- 0.8 ng/mL/h). PRA was not correlated to age in either normotensives and hypertensives, but was inversely correlated to office blood pressure in the hypertensives (r = -0.25; P = .05). Plasma prorenin was also not significantly lower in older hypertensives (14.6 +/- 8.6 ng/mL/h) than in the normotensive controls (15.1 +/- 7.0 ng/mL/h). In normal subjects, but not in hypertensive patients, there was a positive relationship between plasma prorenin and age (r = 0.82; P < .001). However, elderly normotensive men had lower plasma prorenin levels (11.6 +/- 4.1 ng/mL/h) than normotensive women (18.6 +/- 7.4 ng/mL/h; P < .05). "Total renin" (PRA + plasma prorenin) was also lower in elderly normotensive men compared to women (13.2 +/- 3.9 ng/mL/h v 20.0 +/- 7.5 ng/mL/h; P < .05). In conclusion, neither PRA nor plasma prorenin are suppressed in normotensive or hypertensive subjects who survive to an old age. However, since an inverse relationship between PRA and age has been reported, it remains to be determined whether the renin/prorenin parameters were suppressed at any time or if normal renin and normal prorenin patients preferentially survive to an old age. The wide spectrum of plasma renin levels in the elderly indicates that treatment of these patients too can profitably be guided by pretreatment plasma renin levels.

Felodipine or hydrochlorothiazide/triamterene for treatment of hypertension in the elderly: effects on blood pressure, hypertensive heart disease, metabolic and hormonal parameters

The aim of the study was to compare the antihypertensive efficacy of either felodipine or the diuretic combination hydrochlorothiazide/triamterene in a group (n = 65) of elderly (> or = 70 years) hypertensives (office blood pressure > or = 160/95 mmHg) with special regard to ambulatory blood pressure monitoring, hypertensive heart disease and metabolic parameters. This was a randomized, double-blind study with a treatment period of 6 months. Reduction of office and 24-hr ambulatory blood pressure was comparable with both treatment regimens; after 6 months. 18 of 29 patients in the felodipine group (62%) and 20 of 27 patients in the diuretic group (74%; p = 0.4) were controlled. While episodes of ischemic type ST-segment depression were significantly reduced in the felodipine group (from 49 to 9 episodes), there was no significant change in the diuretic group (from 24 to 21 episodes). Both regimens decreased left ventricular wall thickness, but the decline in left ventricular muscle mass index was significant only for felodipine. Felodipine did not induce any change in metabolic or hormonal parameters; the diuretic combination significantly increased serum creatinine, uric acid, plasma renin activity, and plasma prorenin. Thus, the antihypertensive efficacy of felodipine and the diuretic combination was comparable in elderly hypertensives; only felodipine, however, improved parameters of hypertensive heart disease and showed a neutral metabolic and hormonal profile.

Starnberg trial on epidemiology of Parkinsonism and hypertension in the elderly. Prevalence of Parkinson's disease and related disorders assessed by a door-to-door survey of inhabitants older than 65 years

OBJECTIVE

To investigate the prevalence of different types of parkinsonism (PS) in the elderly, regardless of health care service or drug prescription, by a door-to-door survey in two German villages.

DESIGN

We investigated the prevalence of PS in a rural Bavarian population of individuals older than 65 years (982 participants; response rate, 82.5%) using a door-to-door-survey and a biphasic approach.

MAIN OUTCOME MEASURES

Two investigators employed a pretest screening questionnaire and motor tests for signs of PS. Individuals suspected of suffering from PS were reinvestigated by two neurologists trained in movement disorders, and computed tomographic scans were performed.

RESULTS

The prevalence of Parkinson's disease in individuals older than 65 years was 0.71% (95% confidence interval, 0.19% to 1.23%), with a male predominance (five men, two women). Parkinsonism of other pathogenesis included drug-induced PS (0.41%, four of 982 inhabitants), vascular PS (0.20%, two of 982), multiple system atrophy (0.31%, three of 982), and Fahr's disease (0.10%, one of 982). The high prevalence of normal-pressure hydrocephalus (0.41%, four of 982 inhabitants) was an unexpected finding that was confirmed by computed tomography. Fifty percent of cases of PS were newly diagnosed.

CONCLUSIONS

This study represents the first door-to-door survey on PS in Germany. In addition, for the first time, it includes a clinical differentiation between Parkinson's disease, multiple system atrophy (of the striatonigral type), and PS of other pathogenesis. The prevalence of Parkinson's disease corresponds to that reported in other surveys of people older than 65 years. Normal-pressure hydrocephalus and multiple system atrophy, on the other hand, were more prevalent than expected, and all these cases were newly diagnosed.

Improving the therapeutic balance between efficacy and tolerability in antihypertensive drugs--the rationale and benefits of combining felodipine and metoprolol

Several studies, most recently the Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly (STEPHY), have shown that BP is not adequately controlled in a substantial proportion of treated hypertensive patients. This finding highlights the need for new treatment strategies that are sufficiently effective throughout the dosing interval, well tolerated, and available in a convenient, once-daily regimen. Monotherapy with any individual drug class is often unable to fulfil all of these criteria in more than a minority of patients. In contrast, once-daily therapy with rational combinations of antihypertensive drugs offers a promising approach to improving treatment of hypertension. The highly vascular selective calcium antagonist felodipine and the cardioselective beta-blocker metoprolol have complementary mechanisms of action, making them appropriate for use together in the management of hypertension. A new extended-release (ER) formulation, combining felodipine, 5 mg, and metoprolol, 50 mg*, has therefore been developed. This formulation has been shown to provide significantly greater reductions and higher antihypertensive response rates than either agent used alone. This high efficacy is achieved with maintained good tolerability. In comparative trials, felodipine-metoprolol has also been shown to be more effective than combination treatment with nifedipine and atenolol, or captopril and hydrochlorothiazide. It is concluded that the felodipine-metoprolol ER tablet offers predictably high 24 h antihypertensive response rates from a convenient and well-tolerated once-daily dose.

[Gastrointestinal amyloidosis in IgG-chi-light chain plasmacytoma. Diagnostic problems despite advanced changes]

A 50-year-old man with an IgG-chi light chain multiple myeloma stage IIIA, developed--in a phase of low disease activity, after 18 months of an uncomplicated course--marked malabsorption syndrome with 20 kg weight loss, diarrhoea and meteorism. Although the H2-breath test indicated intestinal bacterial colonisation, neither antibacterial treatment with trimethoprim/sulphamethoxazole and metronidazole nor prokinetic treatment with cisapride (30 mg daily) and erythromycin (1 g twice daily) improved the symptoms. Suspected amyloidosis was not demonstrable at first, despite repeated step biopsies of stomach, duodenum and rectum. Amyloidosis of the entire gastrointestinal tract was proven only by repeated biopsies deep into the submucosa. Despite treatment of the underlying disease with melphalan and prednisone (Alexanian's scheme) the amyloidosis advanced further to involve liver, spleen, lung, kidneys and heart. The patient died, 2 years after diagnosis of the multiple myeloma, from recurrent pulmonary emboli due to atrial fibrillation.

Antihypertensive treatment with felodipine but not with a diuretic reduces episodes of myocardial ischaemia in elderly patients with hypertension

Episodes of transient myocardial ischaemia can frequently be observed in hypertensive patients. To assess the effects of antihypertensive treatment with the calcium antagonist felodipine or the diuretic combination hydrochlorothiazidel triamterene on episodes of ischaemic-type ST-segment depression (ST-D), simultaneous ambulatory electrocardiographic and blood pressure (BP) monitoring was performed in 42 elderly hypertensives without manifest coronary artery disease. All patients (mean age 79 +/- 6 years, office BP > or = 160/95 mmHg) were evaluated off any antihypertensive or anti-ischaemic therapy and after 3 months treatment with either felodipine or the diuretic (randomized, double-blind study) for episodes of significant ST-D (> or = 0.1 mV, duration > or = 1 min, interval > or = 1 min). The reduction in office BP and daytime ambulatory BP was similar for both agents, as was a significant reduction in the heart rate x systolic BP product (DP) over 24 h (felodipine: 12,441 +/- 2076 vs 11,643 +/- 1953 mmHg.min-1; P = 0.048; diuretic: 12,366 +/- 2782 vs 11,062 +/- 2012 mmHg.min-1; P = 0.003). While felodipine significantly decreased the total number of ST-D (from 40 to six episodes; P = 0.03), the total number of ST-D remained unchanged with the diuretic (non-significant increase from 31 to 45 episodes; P = 0.24). The same trend was observed for the number of patients with ST-D.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiovascular risk factors in patients over 65-years of age in Germany. Results of the STEPHY Study (Starnberg Trial on Epidemiology of Parkinsonism and Hypertension in the Elderly)]

The aim of the study was to assess the current cardiovascular risk factor profile including data on treatment of a representative population over the age of 65 in Germany. From a total of 1190 inhabitants > or = 65 years living in two Bavarian villages near Munich, 982 could be visited at home ("door-to-door" survey), where a questionnaire and the measurement section were performed (response rate 82.5%). Blood pressure was measured three times in the sitting position with a standard sphygmomanometer, ("actual") hypertension was defined as systolic blood pressure > or = 160 mm Hg and/or diastolic blood pressure > or = 95 mm Hg or effective antihypertensive treatment. Obesity was defined as body mass index > or = 27.8 kg/m2 for men or > or = 27.3 kg/m2 for women, hypercholesterolemia as total cholesterol > or = 250 mg/dl (6.5 mmol/l), diabetes as fasting serum glucose > 120 mg/dl, glucosuria or treatment with insulin or oral antidiabetics. With a prevalence of 53% hypertension was the leading risk factor, followed by obesity with 35% and hypercholesterolemia with 21%; smoking and diabetes were observed in < 10%. Hypertension and obesity tended to be more prevalent in women, diabetes in men; hypercholesterolemia was significantly more prevalent in women. While the prevalence of hypertension increased up to the age groups "75-79 years" in men and "80-84 years" in women, there was a constant decrease with age for obesity, hypercholesterolemia and smoking. Three-quarters of the participants showed a minimum of one cardiovascular risk factor, the risk factor combination "hypertension/hypercholesterolemia/smoking" was observed however only in 1%.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence, awareness, treatment and control of hypertension in a population over the age of 65 years: results from the Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly (STEPHY)

OBJECTIVE

To assess the prevalence of hypertension and isolated systolic hypertension and the level of awareness, treatment and control of hypertension, in a population aged over 65 years.

DESIGN

Cross-sectional survey of the total population aged > or = 65 years of two Bavarian villages with a representative age distribution.

PATIENTS

From a total of 1190 inhabitants aged > or = 65 years, 982 (394 male, 588 female) participated (response rate 82.5%).

METHODS

All of the participants were visited at home by physician observers. After a standardized questionnaire, blood pressure was measured three times on one occasion with the subject in the sitting position, using a standard mercury sphygmomanometer. 'Actual' hypertension was defined as systolic blood pressure (SBP) > or = 160 or diastolic blood pressure (DBP) > or = 95 mmHg, or both, or current use of antihypertensive drugs given for the indication hypertension in patients with blood pressure < 160/95 mmHg. Isolated systolic hypertension was defined as SBP > or = 160 and DBP < 90 mmHg. All 'actual' hypertensives were further classified as 'unaware' of hypertension, 'aware' (but not treated), 'treated' (current use of antihypertensive drugs for the indication hypertension and blood pressure > or = 160/95 mmHg) or 'controlled' (treated and blood pressure < 160/95 mmHg).

RESULTS

Mean +/- SD blood pressure was 154.5 +/- 24.4/84.9 +/- 11.6 mmHg (when 52 institutionalized participants were excluded, 155.6 +/- 24.4/85.3 +/- 11.6 mmHg). The SBP was significantly higher in females than in males and increased up to the age group 80-84 years both in males and in females. The DBP decreased with age. The prevalence of 'actual' hypertension was 53% and increased up to the age group 75-79 years in males and 80-84 years in females. The prevalence of isolated systolic hypertension was 17% (with patients currently using antihypertensive drugs excluded). Of the patients with 'actual' hypertension, 34% were 'unaware' of the diagnosis, 12% 'aware', 32% 'treated' and 22% 'controlled'.

CONCLUSIONS

In central Europe hypertension, with a prevalence of > 50%, remains the most common cardiovascular risk factor in the elderly. Although most elderly hypertensives are currently treated with antihypertensive agents, less than one-quarter are controlled, and more than one-third are still unaware of the diagnosis. These levels of awareness and control call for better strategies in the diagnosis and treatment of hypertension in the elderly.