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Reith C, Preiss D, Blackwell L, Emberson J, Spata E, Davies K, Halls H, Harper C, Holland L, Wilson K, Roddick AJ, Cannon CP, Clarke R, Colhoun HM, Durrington PN, Goto S, Hitman GA, Hovingh GK, Jukema JW, Koenig W, Marschner I, Mihaylova B, Newman C, Probsfield JL, Ridker PM, Sabatine MS, Sattar N, Schwartz GG, Tavazzi L, Tonkin A, Trompet S, White H, Yusuf S, Armitage J, Keech A, Simes J, Collins R, Baigent C, Barnes E, Fulcher J, Herrington WG, Kirby A, O'Connell R, Amarenco P, Arashi H, Barter P, Betteridge DJ, Blazing M, Blauw GJ, Bosch J, Bowman L, Braunwald E, Bulbulia R, Byington R, Clearfield M, Cobbe S, Dahlöf B, Davis B, de Lemos J, Downs JR, Fellström B, Flather M, Ford I, Franzosi MG, Fuller J, Furberg C, Glynn R, Goldbourt U, Gordon D, Gotto, Jr A, Grimm R, Gupta A, Hawkins CM, Haynes R, Holdaas H, Hopewell J, Jardine A, Kastelein JJP, Kean S, Kearney P, Kitas G, Kjekshus J, Knatterud G, Knopp RH, Koren M, Krane V, Landray M, LaRosa J, Latini R, Lonn E, Lucci D, MacFadyen J, Macfarlane P, MacMahon S, Maggioni A, Marchioli R, Moyé L, Murphy S, Neil A, Nicolis EB, Packard C, Parish S, Pedersen TR, Peto R, Pfeffer M, Poulter N, Pressel S, Probstfield J, Rahman M, Robertson M, Sacks F, Schmieder R, Serruys P, Sever P, Shaw J, Shepherd J, Simpson L, Sleight P, Smeeth L, Tobert J, Tognoni G, Varigos J, Wanner C, Wedel H, Weis S, Welch KM, Wikstrand J, Wilhelmsen L, Wiviott S, Yamaguchi J, Young R, Zannad F. Effects of statin therapy on diagnoses of new-onset diabetes and worsening glycaemia in large-scale randomised blinded statin trials: an individual participant data meta-analysis. Lancet Diabetes Endocrinol 2024; 12:306-319. [PMID: 38554713 PMCID: PMC7615958 DOI: 10.1016/s2213-8587(24)00040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Previous meta-analyses of summary data from randomised controlled trials have shown that statin therapy increases the risk of diabetes, but less is known about the size or timing of this effect, or who is at greatest risk. We aimed to address these gaps in knowledge through analysis of individual participant data from large, long-term, randomised, double-blind trials of statin therapy. METHODS We conducted a meta-analysis of individual participant data from randomised controlled trials of statin therapy that participated in the CTT Collaboration. All double-blind randomised controlled trials of statin therapy of at least 2 years' scheduled duration and with at least 1000 participants were eligible for inclusion in this meta-analysis. All recorded diabetes-related adverse events, treatments, and measures of glycaemia were sought from eligible trials. Meta-analyses assessed the effects of allocation to statin therapy on new-onset diabetes (defined by diabetes-related adverse events, use of new glucose-lowering medications, glucose concentrations, or HbA1c values) and on worsening glycaemia in people with diabetes (defined by complications of glucose control, increased use of glucose-lowering medication, or HbA1c increase of ≥0·5%). Standard inverse-variance-weighted meta-analyses of the effects on these outcomes were conducted according to a prespecified protocol. FINDINGS Of the trials participating in the CTT Collaboration, 19 trials compared statin versus placebo (123 940 participants, 25 701 [21%] with diabetes; median follow-up of 4·3 years), and four trials compared more versus less intensive statin therapy (30 724 participants, 5340 [17%] with diabetes, median follow-up of 4·9 years). Compared with placebo, allocation to low-intensity or moderate-intensity statin therapy resulted in a 10% proportional increase in new-onset diabetes (2420 of 39 179 participants assigned to receive a statin [1·3% per year] vs 2214 of 39 266 participants assigned to receive placebo [1·2% per year]; rate ratio [RR] 1·10, 95% CI 1·04-1·16), and allocation to high-intensity statin therapy resulted in a 36% proportional increase (1221 of 9935 participants assigned to receive a statin [4·8% per year] vs 905 of 9859 participants assigned to receive placebo [3·5% per year]; 1·36, 1·25-1·48). For each trial, the rate of new-onset diabetes among participants allocated to receive placebo depended mostly on the proportion of participants who had at least one follow-up HbA1c measurement; this proportion was much higher in the high-intensity than the low-intensity or moderate-intensity trials. Consequently, the main determinant of the magnitude of the absolute excesses in the two types of trial was the extent of HbA1c measurement rather than the proportional increase in risk associated with statin therapy. In participants without baseline diabetes, mean glucose increased by 0·04 mmol/L with both low-intensity or moderate-intensity (95% CI 0·03-0·05) and high-intensity statins (0·02-0·06), and mean HbA1c increased by 0·06% (0·00-0·12) with low-intensity or moderate-intensity statins and 0·08% (0·07-0·09) with high-intensity statins. Among those with a baseline measure of glycaemia, approximately 62% of new-onset diabetes cases were among participants who were already in the top quarter of the baseline distribution. The relative effects of statin therapy on new-onset diabetes were similar among different types of participants and over time. Among participants with baseline diabetes, the RRs for worsening glycaemia were 1·10 (1·06-1·14) for low-intensity or moderate-intensity statin therapy and 1·24 (1·06-1·44) for high-intensity statin therapy compared with placebo. INTERPRETATION Statins cause a moderate dose-dependent increase in new diagnoses of diabetes that is consistent with a small upwards shift in glycaemia, with the majority of new diagnoses of diabetes occurring in people with baseline glycaemic markers that are close to the diagnostic threshold for diabetes. Importantly, however, any theoretical adverse effects of statins on cardiovascular risk that might arise from these small increases in glycaemia (or, indeed, from any other mechanism) are already accounted for in the overall reduction in cardiovascular risk that is seen with statin therapy in these trials. These findings should further inform clinical guidelines regarding clinical management of people taking statin therapy. FUNDING British Heart Foundation, UK Medical Research Council, and Australian National Health and Medical Research Council.
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Wu R, Williams C, Zhou J, Schlackow I, Emberson J, Reith C, Keech A, Robson J, Armitage J, Gray A, Simes J, Baigent C, Mihaylova B, Armitage J, Baigent C, Barnes E, Blackwell L, Collins R, Davies K, Emberson J, Fulcher J, Halls H, Herrington WG, Holland L, Keech A, Kirby A, Mihaylova B, O'Connell R, Preiss D, Reith C, Simes J, Wilson K, Blazing M, Braunwald E, Lemos JD, Murphy S, Pedersen TR, Pfeffer M, White H, Wiviott S, Clearfield M, Downs JR, Gotto A, Weis S, Fellström B, Holdaas H, Jardine A, Pedersen TR, Gordon D, Davis B, Furberg C, Grimm R, Pressel S, Probstfield JL, Rahman M, Simpson L, Koren M, Dahlöf B, Gupta A, Poulter N, Sever P, Wedel H, Knopp RH, Cobbe S, Fellström B, Holdaas H, Jardine A, Schmieder R, Zannad F, Betteridge DJ, Colhoun HM, Durrington PN, Fuller J, Hitman GA, Neil A, Braunwald E, Davis B, Hawkins CM, Moyé L, Pfeffer M, Sacks F, Kjekshus J, Wedel H, Wikstrand J, Wanner C, Krane V, Franzosi MG, Latini R, Lucci D, Maggioni A, Marchioli R, Nicolis EB, Tavazzi L, Tognoni G, Bosch J, Lonn E, Yusuf S, Armitage J, Bowman L, Collins R, Keech A, Landray M, Parish S, Peto R, Sleight P, Kastelein JJ, Pedersen TR, Glynn R, Gotto A, Kastelein JJ, Koenig W, MacFadyen J, Ridker PM, Keech A, MacMahon S, Marschner I, Tonkin A, Shaw J, Simes J, White H, Serruys PW, Knatterud G, Blauw GJ, Cobbe S, Ford I, Macfarlane P, Packard C, Sattar N, Shepherd J, Trompet S, Braunwald E, Cannon CP, Murphy S, Collins R, Armitage J, Bowman L, Bulbulia R, Haynes R, Parish S, Peto R, Sleight P, Amarenco P, Welch KM, Kjekshus J, Pedersen TR, Wilhelmsen L, Barter P, Gotto A, LaRosa J, Kastelein JJ, Shepherd J, Cobbe S, Ford I, Kean S, Macfarlane P, Packard C, Roberston M, Sattar N, Shepherd J, Young R, Arashi H, Clarke R, Flather M, Goto S, Goldbourt U, Hopewell J, Hovingh GK, Kitas G, Newman C, Sabatine MS, Schwartz GG, Smeeth L, Tobert J, Varigos J, Yamamguchi J. Long-term cardiovascular risks and the impact of statin treatment on socioeconomic inequalities: a microsimulation model. Br J Gen Pract 2024; 74:BJGP.2023.0198. [PMID: 38373851 PMCID: PMC10904120 DOI: 10.3399/bjgp.2023.0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 09/19/2023] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND UK cardiovascular disease (CVD) incidence and mortality have declined in recent decades but socioeconomic inequalities persist. AIM To present a new CVD model, and project health outcomes and the impact of guideline-recommended statin treatment across quintiles of socioeconomic deprivation in the UK. DESIGN AND SETTING A lifetime microsimulation model was developed using 117 896 participants in 16 statin trials, 501 854 UK Biobank (UKB) participants, and quality-of-life data from national health surveys. METHOD A CVD microsimulation model was developed using risk equations for myocardial infarction, stroke, coronary revascularisation, cancer, and vascular and non-vascular death, estimated using trial data. The authors calibrated and further developed this model in the UKB cohort, including further characteristics and a diabetes risk equation, and validated the model in UKB and Whitehall II cohorts. The model was used to predict CVD incidence, life expectancy, quality-adjusted life years (QALYs), and the impact of UK guideline-recommended statin treatment across socioeconomic deprivation quintiles. RESULTS Age, sex, socioeconomic deprivation, smoking, hypertension, diabetes, and cardiovascular events were key CVD risk determinants. Model-predicted event rates corresponded well to observed rates across participant categories. The model projected strong gradients in remaining life expectancy, with 4-5-year (5-8 QALYs) gaps between the least and most socioeconomically deprived quintiles. Guideline-recommended statin treatment was projected to increase QALYs, with larger gains in quintiles of higher deprivation. CONCLUSION The study demonstrated the potential of guideline-recommended statin treatment to reduce socioeconomic inequalities. This CVD model is a novel resource for individualised long-term projections of health outcomes of CVD treatments.
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Affiliation(s)
- Runguo Wu
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Claire Williams
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Junwen Zhou
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Iryna Schlackow
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jonathan Emberson
- Nuffield Department of Population Health and Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Christina Reith
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anthony Keech
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - John Robson
- Clinical Effectiveness Group, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jane Armitage
- Nuffield Department of Population Health and Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Alastair Gray
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John Simes
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Colin Baigent
- Nuffield Department of Population Health and Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London; associate professor and senior health economist, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Barzilay JI, Lai D, Davis BR, Pressel S, Previn HE, Arnett DK. The Interaction of a Diabetes Gene Risk Score With 3 Different Antihypertensive Medications for Incident Glucose-level Elevation. Am J Hypertens 2019; 32:343-349. [PMID: 30590387 DOI: 10.1093/ajh/hpy199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/27/2018] [Accepted: 12/24/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Elevations of fasting glucose (FG) levels are frequently encountered in people treated with thiazide diuretics. The risk is lower in people treated with ACE inhibitors (ACEi). To determine if genetic factors play a role in FG elevation, we examined the interaction of a diabetes gene risk score (GRS) with the use of 3 different antihypertensive medications. METHODS We examined 376 nondiabetic hypertensive individuals with baseline FG <100 mg/dl who were genotyped for 24 genes associated with risk of elevated glucose levels. All participants had ≥1 follow-up FG level over 6 years of follow-up. Participants were randomized to treatment with a thiazide-like diuretic (chlorthalidone), a calcium channel blocker (CCB; amlodipine), or an ACEi (lisinopril). Outcomes were an FG increase of ≥13 or ≥27 mg/dl, the upper 75% and 90% FG increase in the parent cohort from which the present cohort was obtained. Odds ratios were adjusted for factors that increase FG levels. RESULTS For every 1 allele increase in GRS, the adjusted odds ratios (ORs) were 1.06 (95% confidence interval (CI): 0.99, 1.14; P = 0.06) and 1.09 (95% CI: 0.99, 1.20; P = 0.08). When results were examined by randomized medications, participants randomized to amlodipine had statistically significant odds for either outcome (OR: 1.23; 95% CI: 1.03, 1.48; P = 0.01 and OR: 1.31; 95% CI: 1.06, 1.62; P = 0.01). No such risk increase was found in participants randomized to the other 2 medications. CONCLUSIONS A diabetes GRS predicts FG elevation in people treated with a CCB, but not with an ACEi or diuretic. These findings require confirmation. CLINICAL TRIALS REGISTRATION Trial number NCT00000542.
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Affiliation(s)
- Joshua I Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia and Division of Endocrinology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dejian Lai
- Department of Biostatistics, University of Texas School of Public Health, Houston, Texas, USA
| | - Barry R Davis
- Clinical Trial Center, University of Texas School of Public Health, Houston, Texas, USA
| | - Sara Pressel
- Clinical Trial Center, University of Texas School of Public Health, Houston, Texas, USA
| | - Hannah E Previn
- Department of Biostatistics, University of Texas School of Public Health, Houston, Texas, USA
| | - Donna K Arnett
- Department of Epidemiology, University of Kentucky College of Public Health, Lexington, Kentucky, USA
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Shams T, Auchus AP, Oparil S, Wright CB, Wright J, Furlan AJ, Sila CA, Davis BR, Pressel S, Yamal JM, Einhorn PT, Lerner AJ. Baseline Quality of Life and Risk of Stroke in the ALLHAT Study (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). Stroke 2017; 48:3078-3085. [PMID: 28954920 DOI: 10.1161/strokeaha.117.016062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 08/09/2017] [Accepted: 08/11/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The visual analogue scale is a self-reported, validated tool to measure quality of life (QoL). Our purpose was to determine whether baseline QoL predicted strokes in the ALLHAT study (Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial) and evaluate determinants of poststroke change in QoL. In the ALLHAT study, among the 33 357 patients randomized to treatment arms, 1525 experienced strokes; 1202 (79%) strokes were nonfatal. This study cohort includes 32 318 (97%) subjects who completed the baseline visual analogue scale QoL estimate. METHODS QoL was measured on a visual analogue scale and adjusted using a Torrance transformation (transformed QoL [TQoL]). Kaplan-Meier curves and adjusted proportional hazards analyses were used to estimate the effect of TQoL on the risk of stroke, on a continuous scale (0-1) and by quartiles (≤0.81, >0.81≤0.89, >0.89≤0.95, >0.95). We analyzed the change from baseline to first poststroke TQoL using adjusted linear regression. RESULTS After adjusting for multiple stroke risk factors, the hazard ratio for stroke events for baseline TQoL was 0.93 (95% confidence interval, 0.89-0.98) per 0.1 U increase. The lowest baseline TQoL quartile had a 20% increased stroke risk (hazard ratio=1.20 [95% confidence interval, 1.00-1.44]) compared with the reference highest quartile TQoL. Poststroke TQoL change was significant within all treatment groups (P≤0.001). Multivariate regression analysis revealed that baseline TQoL was the strongest predictor of poststroke TQoL with similar results for the untransformed QoL. CONCLUSIONS The lowest baseline TQoL quartile had a 20% higher stroke risk than the highest quartile. Baseline TQoL was the only factor that predicted poststroke change in TQoL. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.
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Affiliation(s)
- Tanzila Shams
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.).
| | - Alexander P Auchus
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Suzanne Oparil
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Clinton B Wright
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Jackson Wright
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Anthony J Furlan
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Cathy A Sila
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Barry R Davis
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Sara Pressel
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Jose-Miguel Yamal
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Paula T Einhorn
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Alan J Lerner
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
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Oparil S, Puttnam R, Davis B, Pressel S, Whelton P, Cushman W, Louis G, Margolis K, Williamson J, Ghosh A, Einhorn P, Barzilay J. Abstract 100: Hip and Pelvic Fracture Risk in Adults Treated with Three Different Classes of Antihypertensive Medications: The ALLHAT Study. Hypertension 2016. [DOI: 10.1161/hyp.68.suppl_1.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Observational studies suggest that thiazide-type diuretics reduce fracture risk compared to other antihypertensive medications. The effects of calcium channel blockers (CCB) and angiotensin converting-enzyme inhibitors (ACEi) on fracture risk have not been well studied. We examined the relationship of antihypertensive drug therapy and hip and pelvic fracture hospitalizations in the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack
Trial
(
ALLHAT
). It included >33,000 participants randomized to the thiazide-type diuretic chlorthalidone (C), ACEi lisinopril (L), or CCB amlodipine (A) as first line hypertension (HTN) therapy. Mean follow up was 4.9 years during the randomized phase (in-trial), and 5 additional years after the conclusion of the trial (post-trial) using linkage to national data bases. Risks of hip and pelvic fractures for L and A relative to C were derived from Cox models. There were 341 hip and pelvic fractures in-trial.
Participants assigned C had the lowest risk and those assigned L the highest (
Figure 1a).
The adjusted risk for L compared to C was 1.33 (95% CI 1.02-1.73; p=.04). Participants assigned A had intermediate risk compared to C (HR 1.22, 95% CI 0.93-1.59). During the combined in-trial and post-trial periods (
Figure 1b
), there were 646 fractures; the results were similar to the in-trial results, although differences were not statistically significant. Participants randomized to C continued to have the lowest risk of fractures after in-trial period, suggesting a legacy effect from prior C use. These findings have public health importance given the high prevalence of HTN in older adults and the widespread use of A and L in older adults.
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Affiliation(s)
| | | | - Barry Davis
- Univ of Texas Sch of Public Health, Houston, TX
| | | | - Paul Whelton
- Tulane Univ Sch of Public Health, New Orleans, LA
| | | | - Gail Louis
- Tulance Univ Sch of Public Health, New Orleans, LA
| | - Karen Margolis
- HealthPartners Institute for Education and Rsch, Minneapolis, MN
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Kostis WJ, Moreyra A, Sargsyan D, Cabrera J, Cosgrove N, Kostis J, Cushman W, Pantazopoulos J, Pressel S, Davis B. ASSOCIATION OF ORTHOSTATIC HYPERTENSION WITH MORTALITY IN THE SYSTOLIC HYPERTENSION IN THE ELDERLY PROGRAM. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)32014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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7
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Ware RE, Davis BR, Schultz WH, Brown RC, Aygun B, Sarnaik S, Odame I, Fuh B, George A, Owen W, Luchtman-Jones L, Rogers ZR, Hilliard L, Gauger C, Piccone C, Lee MT, Kwiatkowski JL, Jackson S, Miller ST, Roberts C, Heeney MM, Kalfa TA, Nelson S, Imran H, Nottage K, Alvarez O, Rhodes M, Thompson AA, Rothman JA, Helton KJ, Roberts D, Coleman J, Bonner MJ, Kutlar A, Patel N, Wood J, Piller L, Wei P, Luden J, Mortier NA, Stuber SE, Luban NLC, Cohen AR, Pressel S, Adams RJ. Hydroxycarbamide versus chronic transfusion for maintenance of transcranial doppler flow velocities in children with sickle cell anaemia-TCD With Transfusions Changing to Hydroxyurea (TWiTCH): a multicentre, open-label, phase 3, non-inferiority trial. Lancet 2016; 387:661-670. [PMID: 26670617 PMCID: PMC5724392 DOI: 10.1016/s0140-6736(15)01041-7] [Citation(s) in RCA: 313] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND For children with sickle cell anaemia and high transcranial doppler (TCD) flow velocities, regular blood transfusions can effectively prevent primary stroke, but must be continued indefinitely. The efficacy of hydroxycarbamide (hydroxyurea) in this setting is unknown; we performed the TWiTCH trial to compare hydroxyurea with standard transfusions. METHODS TWiTCH was a multicentre, phase 3, randomised, open-label, non-inferiority trial done at 26 paediatric hospitals and health centres in the USA and Canada. We enrolled children with sickle cell anaemia who were aged 4-16 years and had abnormal TCD flow velocities (≥ 200 cm/s) but no severe vasculopathy. After screening, eligible participants were randomly assigned 1:1 to continue standard transfusions (standard group) or hydroxycarbamide (alternative group). Randomisation was done at a central site, stratified by site with a block size of four, and an adaptive randomisation scheme was used to balance the covariates of baseline age and TCD velocity. The study was open-label, but TCD examinations were read centrally by observers masked to treatment assignment and previous TCD results. Participants assigned to standard treatment continued to receive monthly transfusions to maintain 30% sickle haemoglobin or lower, while those assigned to the alternative treatment started oral hydroxycarbamide at 20 mg/kg per day, which was escalated to each participant's maximum tolerated dose. The treatment period lasted 24 months from randomisation. The primary study endpoint was the 24 month TCD velocity calculated from a general linear mixed model, with the non-inferiority margin set at 15 cm/s. The primary analysis was done in the intention-to-treat population and safety was assessed in all patients who received at least one dose of assigned treatment. This study is registered with ClinicalTrials.gov, number NCT01425307. FINDINGS Between Sept 20, 2011, and April 17, 2013, 159 patients consented and enrolled in TWiTCH. 121 participants passed screening and were then randomly assigned to treatment (61 to transfusions and 60 to hydroxycarbamide). At the first scheduled interim analysis, non-inferiority was shown and the sponsor terminated the study. Final model-based TCD velocities were 143 cm/s (95% CI 140-146) in children who received standard transfusions and 138 cm/s (135-142) in those who received hydroxycarbamide, with a difference of 4·54 (0·10-8·98). Non-inferiority (p=8·82 × 10(-16)) and post-hoc superiority (p=0·023) were met. Of 29 new neurological events adjudicated centrally by masked reviewers, no strokes were identified, but three transient ischaemic attacks occurred in each group. Magnetic resonance brain imaging and angiography (MRI and MRA) at exit showed no new cerebral infarcts in either treatment group, but worsened vasculopathy in one participant who received standard transfusions. 23 severe adverse events in nine (15%) patients were reported for hydroxycarbamide and ten serious adverse events in six (10%) patients were reported for standard transfusions. The most common serious adverse event in both groups was vaso-occlusive pain (11 events in five [8%] patients with hydroxycarbamide and three events in one [2%] patient for transfusions). INTERPRETATION For high-risk children with sickle cell anaemia and abnormal TCD velocities who have received at least 1 year of transfusions, and have no MRA-defined severe vasculopathy, hydroxycarbamide treatment can substitute for chronic transfusions to maintain TCD velocities and help to prevent primary stroke. FUNDING National Heart, Lung, and Blood Institute, National Institutes of Health.
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Affiliation(s)
- Russell E Ware
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Barry R Davis
- University of Texas School of Public Health, Houston, TX, USA
| | | | | | - Banu Aygun
- Cohen Children's Medical Center, New Hyde Park, NY, USA
| | | | - Isaac Odame
- Hospital for Sick Children, Toronto, ON, Canada
| | - Beng Fuh
- East Carolina University, Greenville, NC, USA
| | - Alex George
- Baylor College of Medicine, Houston, TX, USA
| | - William Owen
- Children's Hospital of the King's Daughters, Norfolk, VA, USA
| | | | | | | | | | | | | | | | | | - Scott T Miller
- State University of New York-Downstate, Brooklyn, NY, USA
| | | | | | | | - Stephen Nelson
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | | | - Kerri Nottage
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | - Alexis A Thompson
- Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | | | - Donna Roberts
- Medical University of South Carolina, Charleston, SC, USA
| | - Jamie Coleman
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | - Niren Patel
- Georgia Regents University, Augusta, GA, USA
| | - John Wood
- Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Linda Piller
- University of Texas School of Public Health, Houston, TX, USA
| | - Peng Wei
- University of Texas School of Public Health, Houston, TX, USA
| | - Judy Luden
- Medical University of South Carolina, Charleston, SC, USA
| | - Nicole A Mortier
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Susan E Stuber
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Alan R Cohen
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sara Pressel
- University of Texas School of Public Health, Houston, TX, USA
| | - Robert J Adams
- Medical University of South Carolina, Charleston, SC, USA
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8
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Luchtman-Jones L, Pressel S, Hilliard L, Brown RC, Smith MG, Thompson AA, Lee MT, Rothman J, Rogers ZR, Owen W, Imran H, Thornburg C, Kwiatkowski JL, Aygun B, Nelson S, Roberts C, Gauger C, Piccone C, Kalfa T, Alvarez O, Hassell K, Davis BR, Ware RE. Effects of hydroxyurea treatment for patients with hemoglobin SC disease. Am J Hematol 2016; 91:238-42. [PMID: 26615793 DOI: 10.1002/ajh.24255] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 11/23/2015] [Accepted: 11/24/2015] [Indexed: 11/07/2022]
Abstract
Although hemoglobin SC (HbSC) disease is usually considered less severe than sickle cell anemia (SCA), which includes HbSS and HbS/β(0) -thalassemia genotypes, many patients with HbSC experience severe disease complications, including vaso-occlusive pain, acute chest syndrome, avascular necrosis, retinopathy, and poor quality of life. Fully 20 years after the clinical and laboratory efficacy of hydroxyurea was proven in adult SCA patients, the safety and utility of hydroxyurea treatment for HbSC patients remain unclear. Recent NHLBI evidence-based guidelines highlight this as a critical knowledge gap, noting HbSC accounts for ∼30% of sickle cell patients within the United States. To date, only 5 publications have reported short-term, incomplete, or conflicting laboratory and clinical outcomes of hydroxyurea treatment in a total of 71 adults and children with HbSC. We now report on a cohort of 133 adult and pediatric HbSC patients who received hydroxyurea, typically for recurrent vaso-occlusive pain. Hydroxyurea treatment was associated with a stable hemoglobin concentration; increased fetal hemoglobin (HbF) and mean corpuscular volume (MCV); and reduced white blood cell count (WBC), absolute neutrophil count (ANC), and absolute reticulocyte count (ARC). Reversible cytopenias occurred in 22% of patients, primarily neutropenia and thrombocytopenia. Painful events were reduced with hydroxyurea, more in patients >15 years old. These multicenter data support the safety and potentially salutary effects of hydroxyurea treatment for HbSC disease; however, a multicenter, placebo-controlled, Phase 3 clinical trial is needed to determine if hydroxyurea therapy has efficacy for patients with HbSC disease.
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Affiliation(s)
- Lori Luchtman-Jones
- Division of Hematology; Children's National Medical Center; Washington DC
- Division of Hematology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Sara Pressel
- Coordinating Center for Clinical Trials; University of Texas School of Public Health; Houston Texas
| | - Lee Hilliard
- Division of Pediatric Hematology/Oncology; University of Alabama; Birmingham Alabama
| | - R. Clark Brown
- Division of Pediatric Hematolgoy/Oncology; Emory University/Children's Healthcare of Atlanta; Atlanta Georgia
| | - Mary G. Smith
- Division of Pediatric Hematology/Oncology; University of Mississippi Medical Center; Jackson Mississippi
| | - Alexis A. Thompson
- Division of Hematology Oncology and Stem Cell Transplantation; Ann and Robert H. Lurie Children's Hospital of Chicago; Chicago Illinois
| | - Margaret T. Lee
- Division of Pediatric Hematology Oncology and Stem Cell Transplantation; Columbia University Medical Center; New York New York
| | - Jennifer Rothman
- Division of Pediatric Hematology/Oncology; Duke University Medical Center; Durham North Carolina
| | - Zora R. Rogers
- Division of Pediatric Hematology/Oncology; The University of Texas Southwestern Medical Center; Dallas Texas
| | - William Owen
- Cancer and Blood Disorders Program; Children's Hospital of the King's Daughters; Norfolk Virginia
| | - Hamayun Imran
- Division of Pediatric Hematology/Oncology; University of South Alabama; Mobile Alabama
| | - Courtney Thornburg
- Division of Pediatric Hematology/Oncology; Rady Children's Hospital/University of California San Diego; San Diego California
| | - Janet L. Kwiatkowski
- Division of Pediatric Hematology & Oncology; The Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Banu Aygun
- Division of Hematology Oncology; Cohen Children's Medical Center; New Hyde Park New York
| | - Stephen Nelson
- Hematology/Oncology Division; Children's Hospitals and Clinics of Minnesota; Minneapolis Minnesota
| | - Carla Roberts
- Division of Pediatric Hematology & Oncology; University of South Carolina; South Carolina Columbia
| | - Cynthia Gauger
- Hematology/Oncology; Nemours Children's Clinic; Jacksonville Florida
| | - Connie Piccone
- Pediatric Sickle Cell Anemia Program; University Hospitals/Rainbow Babies and Children's Hospital; Cleveland Ohio
| | - Theodosia Kalfa
- Division of Hematology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Ofelia Alvarez
- Division of Pediatric Hematology/Oncology; University of Miami; Miami Florida
| | - Kathryn Hassell
- Division of Hematology; University of Colorado; Denver Colorado
| | - Barry R. Davis
- Coordinating Center for Clinical Trials; University of Texas School of Public Health; Houston Texas
| | - Russell E. Ware
- Division of Hematology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
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9
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Wood JC, Pressel S, Rogers ZR, Odame I, Kwiatkowski JL, Lee MT, Owen WC, Cohen AR, St. Pierre T, Heeney MM, Schultz WH, Davis BR, Ware RE. Liver iron concentration measurements by MRI in chronically transfused children with sickle cell anemia: baseline results from the TWiTCH trial. Am J Hematol 2015; 90:806-10. [PMID: 26087998 DOI: 10.1002/ajh.24089] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 06/10/2015] [Accepted: 06/12/2015] [Indexed: 01/19/2023]
Abstract
Noninvasive, quantitative, and accurate assessment of liver iron concentration (LIC) by MRI is useful for patients receiving transfusions, but R2 and R2* MRI techniques have not been systematically compared in sickle cell anemia (SCA). We report baseline LIC results from the TWiTCH trial, which compares hydroxyurea with blood transfusion treatment for primary stroke prophylaxis assessed by transcranial Doppler sonography in pediatric SCA patients. Liver R2 was collected and processed using a FDA-approved commercial process (FerriScan®), while liver R2* quality control and processing were performed by a Core Laboratory blinded to clinical site and patient data. Baseline LIC studies using both MRI techniques were available for 120 participants. LICR2* and LICR2 results were highly correlated (r(2) = 0.93). A proportional bias of LIC(R2*)/LIC(R2), decreasing with average LIC, was observed. Systematic differences between LICR2* and LICR2 were also observed by MRI manufacturer. Importantly, LICR2* and LICR2 estimates had broad 95% limits of agreement with respect to each other. We recommend LICR2 and LICR2* not be used interchangeably in SCA patients to follow individual patient trends in iron burden.
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Affiliation(s)
- John C. Wood
- Children's Hospital Los Angeles; Los Angeles California
| | - Sara Pressel
- The University of Texas Health Science Center; Houston Texas
| | - Zora R. Rogers
- University of Texas Southwestern Medical Center; Dallas Texas
| | - Isaac Odame
- Division of Haematology/Oncology, University of Toronto, The Hospital for Sick Children; Toronto Canada
| | | | | | - William C. Owen
- Children's Hospital of the King's Daughters; Norfolk Virginia
| | - Alan R. Cohen
- School of Physics; University of Western Australia; Crawley Australia
| | | | | | | | - Barry R. Davis
- The University of Texas Health Science Center; Houston Texas
| | - Russell E. Ware
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
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Shams T, Auchus AP, Oparil S, Wright C, Wright J, Furlan AJ, Sila CA, Davis B, Pressel S, Yamal JM, Einhorn P, Cutler J, Lerner AJ. Abstract W P172: Baseline Quality of Life and Risk of Stroke in the Antihypertensive and Lipid Lowering to Prevent Heart Attack (ALLHAT) Trial. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.wp172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Quality of Life (QoL) is an integrative health status measure that may predict medical outcomes. No prospective study assessed relationship between QoL, subsequent stroke risk, and post-stroke outcome.
Objective:
Determine how baseline QoL predicted non-fatal stroke, as well as the impact of stroke risk factors on QoL in ALLHAT using visual analogue scale (VAS) – a validated QoL tool.
Methods:
ALLHAT randomized hypertensive patients to Chlorthalidone (C), Amlodipine (A) or Lisinopril (L), and used VAS to measure global QoL (0.00 -1.00) at baseline, 2, 4, and 6 yrs. QoL values underwent statistical Torrance transformation (TQoL). Mean QoL and TQoL pre (baseline) and post non-fatal stroke were analyzed. Hazard ratios (HR) and Kaplan-Meier curves for each quartile of baseline QoL were calculated. Baseline QOL, TQoL, and stroke risk factors were used in a multiple linear regression model to predict post-stroke QoL. QoL changes were examined by study arm, age, gender, and race.
Results:
28,534 (86%) participants completed at least one VAS. Of the 1,517 strokes; 22% (n=322) were fatal. QoL and TQoL results were similar. Patients who experienced in-trial stroke in C and A arms had lower baseline QoL than those who did not (HR =.71 vs .74, p<0.001and .71 vs .74, p=0.004, respectively), but not in L (HR=.73 vs .74, p=0.24). A 10% increment in baseline QoL or TQoL was associated with 5% and 7% reduction in the risk of stroke respectively (adjusted HR; 95% CI = .95; .91 -.99) and .93; .89 –.98). In risk factor adjusted models, lowest baseline QoL quartile had a 20% higher stroke risk (HR =1.20; 95% CI: 1.00-1.44) than highest quartile. QoL worsened post stroke, dropping most in elderly >75 yrs (-.08 units, p<0.0001), compared to groups 55-64 (-.04, p<0.05) and 65-75 yrs, (-.07, p <0.0001), and in A arm (-.09 units, p<0.0001) compared with C (-.05, p=0.0006) and L (-.07, p< 0.0001), but did not differ by gender or race. In a multiple linear regression model, baseline QoL predicted post-stroke QoL.
Conclusions:
Lower baseline QoL was associated with higher stroke risk. Qol was lower post stroke. Baseline QoL was the only factor predicting post stroke QoL, and QoL change increased with age. Investigation of factors determining QoL may be fertile ground for stroke risk reduction.
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Affiliation(s)
- Tanzila Shams
- Neurology/ Cerebrovascular Neurology, Univ Hosps Case Med Cntr, Cleveland, TX
| | | | | | - Clinton Wright
- Dept of Neurology, Univ of Miami Health System, Miami, FL
| | - Jackson Wright
- Dept of Medicine, Univ Hosps Case Med Cntr, Cleveland, OH
| | | | - Cathy A Sila
- Dept of Neurology, Univ Hosps Case Med Cntr, Cleveland, OH
| | - Barry Davis
- Dept of Neurology, Univ of Texas Sch of Public Health, Houston, TX
| | | | | | - Paula Einhorn
- NIH, National Heart Lung and Blood Institute, Bethesda, MD
| | - Jeff Cutler
- NIH, National Heart Lung and Blood Institute, Bethesda, MD
| | - Alan J Lerner
- Dept of Neurology, Univ Hosps Case Med Cntr, Cleveland, OH
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11
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Kostis JB, Sedjro JE, Cabrera J, Cosgrove NM, Pressel S, Davis BR. VISIT-TO-VISIT VARIABILITY OF SYSTOLIC BLOOD PRESSURE PREDICTS OUTCOMES MAINLY IN THE ACTIVE TREATMENT GROUP RATHER THAN THE PLACEBO GROUP IN THE SYSTOLIC HYPERTENSION IN THE ELDERLY PROGRAM: PATHOPHYSIOLOGIC IMPLICATIONS. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)61400-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Bartholomew LK, Cushman WC, Cutler JA, Davis BR, Dawson G, Einhorn PT, Graumlich JF, Piller LB, Pressel S, Roccella EJ, Simpson L, Whelton PK, Williard A, Allhat Collaborative Research Group. Getting clinical trial results into practice: design, implementation, and process evaluation of the ALLHAT Dissemination Project. Clin Trials 2009; 6:329-43. [PMID: 19587068 PMCID: PMC2897824 DOI: 10.1177/1740774509338234] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Conventional dissemination of clinical trial results has inconsistent impact on physician practices. A more comprehensive plan to influence determinants of prescribing practices is warranted. PURPOSE To report the response from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial to the National Heart, Lung, and Blood Institute's requirement for dissemination and evaluation of trials with potential immediate public health applicability. METHODS ALLHAT's dissemination plan had two-components: (1) a traditional approach of media coverage, scientific presentation, and publication; and (2) a theory-based approach targeting determinants of clinician behavior. Strategies included: (1) academic detailing, in which physicians approach colleagues regarding blood pressure management, (2) direct patient messages to stimulate communication with physicians regarding blood pressure control, (3) approaches to formulary systems to use educational and economic incentives for evidence-based prescription, and (4) direct professional organization appeals to clinicians. RESULTS One hundred and forty-seven Investigator Educators reported 1698 presentations to 18,524 clinicians in 41 states and the District of Columbia. The pre- and post-test responses of 1709 clinicians in the face-to-face meetings indicated significant changes in expectations for positive patient outcomes and intention to prescribe diuretics. Information was mailed to 55 individuals representing 20 professional organizations and to eight formulary systems. Direct-to-patient messages were provided to 14 sites that host patient newsletters and Web sites such as health plans and insurance companies, 62 print mass media outlets, and 12 broadcast media sites. LIMITATIONS It was not within the scope of the project to conduct a randomized trial of the impact of the dissemination. However, impact evaluation using quasi-experimental designs is ongoing. CONCLUSION A large multi-method dissemination of clinical trial results is feasible. Planning for dissemination efforts, including evaluation research, should be considered as a part of the funding and design of the clinical trial and should begin early in trial planning.
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Affiliation(s)
- L Kay Bartholomew
- University of Texas Health Science Center - Houston, School of Public Health, Houston, TX, USA
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13
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Nwachuku CE, Bastien A, Cutler JA, Grob GM, Margolis KL, Roccella EJ, Pressel S, Davis BR, Caso M, Sheps S, Weber M. Management of High Blood Pressure in Clinical Practice: Perceptible Qualitative Differences in Approaches Utilized by Clinicians. J Clin Hypertens (Greenwich) 2008; 10:822-9. [DOI: 10.1111/j.1751-7176.2008.00035.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wright JT, Harris-Haywood S, Pressel S, Barzilay J, Baimbridge C, Bareis CJ, Basile JN, Black HR, Dart R, Gupta AK, Hamilton BP, Einhorn PT, Haywood LJ, Jafri SZ, Louis GT, Whelton PK, Scott CL, Simmons DL, Stanford C, Davis BR. Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med 2008; 168:207-17. [PMID: 18227370 PMCID: PMC2805022 DOI: 10.1001/archinternmed.2007.66] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Antihypertensive drugs with favorable metabolic effects are advocated for first-line therapy in hypertensive patients with metabolic/cardiometabolic syndrome (MetS). We compared outcomes by race in hypertensive individuals with and without MetS treated with a thiazide-type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), an alpha-blocker (doxazosin mesylate), or an angiotensin-converting enzyme inhibitor (lisinopril). METHODS A subgroup analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind hypertension treatment trial of 42 418 participants. We defined MetS as hypertension plus at least 2 of the following: fasting serum glucose level of at least 100 mg/dL, body mass index (calculated as weight in kilograms divided by height in meters squared) of at least 30, fasting triglyceride levels of at least 150 mg/dL, and high-density lipoprotein cholesterol levels of less than 40 mg/dL in men or less than 50 mg/dL in women. RESULTS Significantly higher rates of heart failure were consistent across all treatment comparisons in those with MetS. Relative risks (RRs) were 1.50 (95% confidence interval, 1.18-1.90), 1.49 (1.17-1.90), and 1.88 (1.42-2.47) in black participants and 1.25 (1.06-1.47), 1.20 (1.01-1.41), and 1.82 (1.51-2.19) in nonblack participants for amlodipine, lisinopril, and doxazosin comparisons with chlorthalidone, respectively. Higher rates for combined cardiovascular disease were observed with lisinopril-chlorthalidone (RRs, 1.24 [1.09-1.40] and 1.10 [1.02-1.19], respectively) and doxazosin-chlorthalidone comparisons (RRs, 1.37 [1.19-1.58] and 1.18 [1.08-1.30], respectively) in black and nonblack participants with MetS. Higher rates of stroke were seen in black participants only (RR, 1.37 [1.07-1.76] for the lisinopril-chlorthalidone comparison, and RR, 1.49 [1.09-2.03] for the doxazosin-chlorthalidone comparison). Black patients with MetS also had higher rates of end-stage renal disease (RR, 1.70 [1.13-2.55]) with lisinopril compared with chlorthalidone. CONCLUSIONS The ALLHAT findings fail to support the preference for calcium channel blockers, alpha-blockers, or angiotensin-converting enzyme inhibitors compared with thiazide-type diuretics in patients with the MetS, despite their more favorable metabolic profiles. This was particularly true for black participants.
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Affiliation(s)
- Jackson T. Wright
- General Clinical Research Center, University Hospitals of Cleveland, Cleveland, Ohio
| | | | - Sara Pressel
- University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
| | | | - Charles Baimbridge
- University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
| | | | | | - Henry R. Black
- Rush Presbyterian—St. Luke’s Medical Center, Chicago, Illinois
| | | | - Alok K. Gupta
- Pennington Biomedical Research Center, Baton Rouge, LA
| | | | - Paula T. Einhorn
- Division of Prevention and Population Sciences, National Heart Lung, and Blood Institute, Bethesda, Maryland
| | - L. Julian Haywood
- University of Southern California Medical Center, Los Angeles, California
| | | | - Gail T. Louis
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Paul K. Whelton
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | | | - Debra L. Simmons
- University of Arkansas for Medical Sciences--Endocrinology, Little Rock, Arkansas
| | | | - Barry R. Davis
- University of Texas Health Science Center at Houston School of Public Health, Houston, Texas (former); Amgen, Thousand Oaks, California
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Danesh J, Erqou S, Walker M, Thompson SG, Tipping R, Ford C, Pressel S, Walldius G, Jungner I, Folsom AR, Chambless LE, Knuiman M, Whincup PH, Wannamethee SG, Morris RW, Willeit J, Kiechl S, Santer P, Mayr A, Wald N, Ebrahim S, Lawlor DA, Yarnell JWG, Gallacher J, Casiglia E, Tikhonoff V, Nietert PJ, Sutherland SE, Bachman DL, Keil JE, Cushman M, Psaty BM, Tracy RP, Tybjaerg-Hansen A, Nordestgaard BG, Frikke-Schmidt R, Giampaoli S, Palmieri L, Panico S, Vanuzzo D, Pilotto L, Simons L, McCallum J, Friedlander Y, Fowkes FGR, Lee AJ, Smith FB, Taylor J, Guralnik J, Phillips C, Wallace R, Blazer D, Khaw KT, Jansson JH, Donfrancesco C, Salomaa V, Harald K, Jousilahti P, Vartiainen E, Woodward M, D'Agostino RB, Wolf PA, Vasan RS, Pencina MJ, Bladbjerg EM, Jorgensen T, Moller L, Jespersen J, Dankner R, Chetrit A, Lubin F, Rosengren A, Wilhelmsen L, Lappas G, Eriksson H, Bjorkelund C, Cremer P, Nagel D, Tilvis R, Strandberg T, Rodriguez B, Bouter LM, Heine RJ, Dekker JM, Nijpels G, Stehouwer CDA, Rimm E, Pai J, Sato S, Iso H, Kitamura A, Noda H, Goldbourt U, Salomaa V, Salonen JT, Nyyssönen K, Tuomainen TP, Deeg D, Poppelaars JL, Meade T, Cooper J, Hedblad B, Berglund G, Engstrom G, Döring A, Koenig W, Meisinger C, Mraz W, Kuller L, Selmer R, Tverdal A, Nystad W, Gillum R, Mussolino M, Hankinson S, Manson J, De Stavola B, Knottenbelt C, Cooper JA, Bauer KA, Rosenberg RD, Sato S, Naito Y, Holme I, Nakagawa H, Miura H, Ducimetiere P, Jouven X, Crespo C, Garcia-Palmieri M, Amouyel P, Arveiler D, Evans A, Ferrieres J, Schulte H, Assmann G, Shepherd J, Packard C, Sattar N, Cantin B, Lamarche B, Després JP, Dagenais GR, Barrett-Connor E, Wingard D, Bettencourt R, Gudnason V, Aspelund T, Sigurdsson G, Thorsson B, Trevisan M, Witteman J, Kardys I, Breteler M, Hofman A, Tunstall-Pedoe H, Tavendale R, Lowe GDO, Ben-Shlomo Y, Howard BV, Zhang Y, Best L, Umans J, Onat A, Meade TW, Njolstad I, Mathiesen E, Lochen ML, Wilsgaard T, Gaziano JM, Stampfer M, Ridker P, Ulmer H, Diem G, Concin H, Rodeghiero F, Tosetto A, Brunner E, Shipley M, Buring J, Cobbe SM, Ford I, Robertson M, He Y, Ibanez AM, Feskens EJM, Kromhout D, Collins R, Di Angelantonio E, Kaptoge S, Lewington S, Orfei L, Pennells L, Perry P, Ray K, Sarwar N, Scherman M, Thompson A, Watson S, Wensley F, White IR, Wood AM. The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases. Eur J Epidemiol 2007; 22:839-69. [PMID: 17876711 DOI: 10.1007/s10654-007-9165-7] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Accepted: 07/02/2007] [Indexed: 01/22/2023]
Abstract
Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.
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Rowntree JK, Duckett JG, Mortimer CL, Ramsay MM, Pressel S. Formation of specialized propagules resistant to desiccation and cryopreservation in the threatened moss Ditrichum plumbicola (Ditrichales, Bryopsida). Ann Bot 2007; 100:483-96. [PMID: 17666410 PMCID: PMC2533608 DOI: 10.1093/aob/mcm141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Accepted: 05/25/2007] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS Successful cryopreservation of bryophytes is linked to intrinsic desiccation tolerance and survival can be enhanced by pre-treatment with abscisic acid (ABA) and sucrose. The pioneer moss Ditrichum plumbicola is naturally subjected to desiccation in the field but showed unexpectedly low survival of cryopreservation, as well as a poor response to pre-treatment. The effects of the cryopreservation protocol on protonemata of D. plumbicola were investigated in order to explore possible relationships between the production in vitro of cryopreservation-tolerant asexual propagules and the reproductive biology of D. plumbicola in nature. METHODS Protonemata were prepared for cryopreservation using a four-step protocol involving encapsulation in sodium alginate, pre-treatment for 2 weeks with ABA and sucrose, desiccation for 6 h and rapid freezing in liquid nitrogen. After each stage, protonemata were prepared for light and electron microscopy and growth on standard medium was monitored. Further samples were prepared for light and electron microscopy at intervals over a 24-h period following removal from liquid nitrogen and re-hydration. KEY RESULTS Pre-treatment with ABA and sucrose caused dramatic changes to the protonemata. Growth was arrested and propagules induced with pronounced morphological and cytological changes. Most cells died, but those that survived were characterized by thick, deeply pigmented walls, numerous small vacuoles and lipid droplets in their cytoplasm. Desiccation and cryopreservation elicited no dramatic cytological changes. Cells returned to their pre-dehydration and cryopreservation state within 2 h of re-hydration and/or removal from liquid nitrogen. Regeneration was normal once the ABA/sucrose stimulus was removed. CONCLUSIONS The ABA/sucrose pre-treatment induced the formation of highly desiccation- and cryopreservation-tolerant propagules from the protonemata of D. plumbicola. This parallels behaviour in the wild, where highly desiccation-tolerant rhizoids function as perennating organs allowing the moss to endure extreme environmental conditions. An involvement of endogenous ABA in the desiccation tolerance of D. plumbicola is suggested.
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Affiliation(s)
- J K Rowntree
- Micropropagation Unit, Royal Botanic Gardens Kew, Richmond, Surrey TW9 3AB, UK.
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Rahman M, Pressel S, Davis BR, Nwachuku C, Wright JT, Whelton PK, Barzilay J, Batuman V, Eckfeldt JH, Farber MA, Franklin S, Henriquez M, Kopyt N, Louis GT, Saklayen M, Stanford C, Walworth C, Ward H, Wiegmann T. Cardiovascular outcomes in high-risk hypertensive patients stratified by baseline glomerular filtration rate. Ann Intern Med 2006; 144:172-80. [PMID: 16461961 DOI: 10.7326/0003-4819-144-3-200602070-00005] [Citation(s) in RCA: 172] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Chronic kidney disease is common in older patients with hypertension. OBJECTIVE To compare rates of coronary heart disease (CHD) and end-stage renal disease (ESRD) events; to determine whether glomerular filtration rate (GFR) independently predicts risk for CHD; and to report the efficacy of first-step treatment with a calcium-channel blocker (amlodipine) or an angiotensin-converting enzyme inhibitor (lisinopril), each compared with a diuretic (chlorthalidone), in modifying cardiovascular disease (CVD) outcomes in high-risk patients with hypertension stratified by GFR. DESIGN Post hoc subgroup analysis. SETTING Multicenter randomized, double-blind, controlled trial. PARTICIPANTS Persons with hypertension who were 55 years of age or older with 1 or more risk factors for CHD and who were stratified into 3 baseline GFR groups: normal or increased (> or = 90 mL/min per 1.73 m2; n = 8126 patients), mild reduction (60 to 89 mL/min per 1.73 m2; n = 18,109 patients), and moderate or severe reduction (< 60 mL/min per 1.73 m2; n = 5662 patients). INTERVENTIONS Random assignment to chlorthalidone, amlodipine, or lisinopril. MEASUREMENTS Rates of ESRD, CHD, stroke, and combined CVD (CHD, coronary revascularization, angina, stroke, heart failure, and peripheral arterial disease). RESULTS In participants with a moderate to severe reduction in GFR, 6-year rates were higher for CHD than for ESRD (15.4% vs. 6.0%, respectively). A baseline GFR of less than 53 mL/min per 1.73 m2 (compared with >104 mL/min per 1.73 m2) was independently associated with a 32% higher risk for CHD. Amlodipine was similar to chlorthalidone in reducing CHD (16.0% vs. 15.2%, respectively; hazard ratio, 1.06 [95% CI, 0.89 to 1.27]), stroke, and combined CVD (CHD, coronary revascularization, angina, stroke, heart failure, and peripheral arterial disease), but less effective in preventing heart failure. Lisinopril was similar to chlorthalidone in preventing CHD (15.1% vs. 15.2%, respectively; hazard ratio, 1.00 [CI, 0.84 to 1.20]), but was less effective in reducing stroke, combined CVD events, and heart failure. LIMITATIONS Proteinuria data were not available, and combination therapies were not tested. CONCLUSIONS Older high-risk patients with hypertension and reduced GFR are more likely to develop CHD than to develop ESRD. A low GFR independently predicts increased risk for CHD. Neither amlodipine nor lisinopril is superior to chlorthalidone in preventing CHD, stroke, or combined CVD, and chlorthalidone is superior to both for preventing heart failure, independent of level of renal function.
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Whelton PK, Barzilay J, Cushman WC, Davis BR, Iiamathi E, Kostis JB, Leenen FHH, Louis GT, Margolis KL, Mathis DE, Moloo J, Nwachuku C, Panebianco D, Parish DC, Pressel S, Simmons DL, Thadani U. Clinical outcomes in antihypertensive treatment of type 2 diabetes, impaired fasting glucose concentration, and normoglycemia: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ACTA ACUST UNITED AC 2005; 165:1401-9. [PMID: 15983290 DOI: 10.1001/archinte.165.12.1401] [Citation(s) in RCA: 223] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Optimal first-step antihypertensive drug therapy in type 2 diabetes mellitus (DM) or impaired fasting glucose levels (IFG) is uncertain. We wished to determine whether treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor decreases clinical complications compared with treatment with a thiazide-type diuretic in DM, IFG, and normoglycemia (NG). METHODS Active-controlled trial in 31 512 adults, 55 years or older, with hypertension and at least 1 other risk factor for coronary heart disease, stratified into DM (n = 13 101), IFG (n = 1399), and NG (n = 17 012) groups on the basis of national guidelines. Participants were randomly assigned to double-blind first-step treatment with chlorthalidone, 12.5 to 25 mg/d, amlodipine besylate, 2.5 to 10 mg/d, or lisinopril, 10 to 40 mg/d. We conducted an intention-to-treat analysis of fatal coronary heart disease or nonfatal myocardial infarction (primary outcome), total mortality, and other clinical complications. RESULTS There was no significant difference in relative risk (RR) for the primary outcome in DM or NG participants assigned to amlodipine or lisinopril vs chlorthalidone or in IFG participants assigned to lisinopril vs chlorthalidone. A significantly higher RR (95% confidence interval) was noted for the primary outcome in IFG participants assigned to amlodipine vs chlorthalidone (1.73 [1.10-2.72]). Stroke was more common in NG participants assigned to lisinopril vs chlorthalidone (1.31 [1.10-1.57]). Heart failure was more common in DM and NG participants assigned to amlodipine (1.39 [1.22-1.59] and 1.30 [1.12-1.51], respectively) or lisinopril (1.15 [1.00-1.32] and 1.19 [1.02-1.39], respectively) vs chlorthalidone. CONCLUSION Our results provide no evidence of superiority for treatment with calcium channel blockers or angiotensin-converting enzyme inhibitors compared with a thiazide-type diuretic during first-step antihypertensive therapy in DM, IFG, or NG.
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Affiliation(s)
- Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
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Rahman M, Pressel S, Davis BR, Nwachuku C, Wright JT, Whelton PK, Barzilay J, Batuman V, Eckfeldt JH, Farber M, Henriquez M, Kopyt N, Louis GT, Saklayen M, Stanford C, Walworth C, Ward H, Wiegmann T. Renal outcomes in high-risk hypertensive patients treated with an angiotensin-converting enzyme inhibitor or a calcium channel blocker vs a diuretic: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ACTA ACUST UNITED AC 2005; 165:936-46. [PMID: 15851647 DOI: 10.1001/archinte.165.8.936] [Citation(s) in RCA: 265] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study was performed to determine whether, in high-risk hypertensive patients with a reduced glomerular filtration rate (GFR), treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor lowers the incidence of renal disease outcomes compared with treatment with a diuretic. METHODS We conducted post hoc analyses of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Hypertensive participants 55 years or older with at least 1 other coronary heart disease risk factor were randomized to receive chlorthalidone, amlodipine, or lisinopril for a mean of 4.9 years. Renal outcomes were incidence of end-stage renal disease (ESRD) and/or a decrement in GFR of 50% or more from baseline. Baseline GFR, estimated by the simplified Modification of Diet in Renal Disease equation, was stratified into normal or increased (> or =90 mL /min per 1.73 m(2), n = 8126), mild reduction (60-89 mL /min per 1.73 m(2), n = 18 109), or moderate-severe reduction (<60 mL /min per 1.73 m(2), n = 5662) in GFR. Each stratum was analyzed for effects of the treatments on outcomes. RESULTS In 448 participants, ESRD developed. Compared with patients taking chlorthalidone, no significant differences occurred in the incidence of ESRD in patients taking amlodipine in the mild (relative risk [RR], 1.47; 95% confidence interval [CI], 0.97-2.23) or moderate-severe (RR, 0.92; 95% CI, 0.68-1.24) reduction in GFR groups. Compared with patients taking chlorthalidone, no significant differences occurred in the incidence of ESRD in patients taking lisinopril in the mild (RR, 1.34; 95% CI, 0.87-2.06) or moderate-severe (RR, 0.98; 95% CI, 0.73-1.31) reduction in GFR groups. In patients with mild and moderate-severe reduction in GFR, the incidence of ESRD or 50% or greater decrement in GFR was not significantly different in patients treated with chlorthalidone compared with those treated with amlodipine (odds ratios, 0.96 [P = .74] and 0.85 [P = .23], respectively) and lisinopril (odds ratios, 1.13 [P = .31] and 1.00 [P = .98], respectively). No difference in treatment effects occurred for either end point for patients taking amlodipine or lisinopril compared with those taking chlorthalidone across the 3 GFR subgroups, either for the total group or for participants with diabetes at baseline. At 4 years of follow-up, estimated GFR was 3 to 6 mL /min per 1.73 m(2) higher in patients assigned to receive amlodipine compared with chlorthalidone, depending on baseline GFR stratum. CONCLUSIONS In hypertensive patients with reduced GFR, neither amlodipine nor lisinopril was superior to chlorthalidone in reducing the rate of development of ESRD or a 50% or greater decrement in GFR. Participants assigned to receive amlodipine had a higher GFR than those assigned to receive chlorthalidone, but rates of development of ESRD were not different between the groups.
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Affiliation(s)
- Mahboob Rahman
- Division of Nephrology and Hypertension, Case Western Reserve University, University Hospitals of Cleveland, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
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Rahman M, Brown CD, Coresh J, Davis BR, Eckfeldt JH, Kopyt N, Levey AS, Nwachuku C, Pressel S, Reisin E, Walworth C. The Prevalence of Reduced Glomerular Filtration Rate in Older Hypertensive Patients and Its Association With Cardiovascular Disease A Report From the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. ACTA ACUST UNITED AC 2004; 164:969-76. [PMID: 15136305 DOI: 10.1001/archinte.164.9.969] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The prevalence of reduced glomerular filtration rate (GFR) in older hypertensive patients and the relationship between level of GFR and cardiovascular disease (CVD) and its risk factors are not well known. METHODS We evaluated baseline renal function in 40 514 hypertensive patients 55 years or older who were enrolled in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). We used the simplified Modification of Diet in Renal Disease study equation to estimate GFR and examined the prevalence of CVD in patients with different levels of GFR. RESULTS Fifty-seven percent of patients had mild (60-89 mL/min per 1.73 m(2)), 17.2% had moderate (30-59 mL/min per 1.73 m(2)), and 0.6% had severe (<or=29 mL/min per 1.73 m(2)) reductions in GFR. Compared with patients with normal or mildly reduced GFR, patients with moderate or severe reductions in GFR were more likely to have had a prior myocardial infarction or stroke (19.2% and 23.4% vs 28.7% and 26.9%, respectively), have ischemic changes on electrocardiography (ECG) (16.0% and 18.9% vs 24.6% and 34.1%, respectively), and have left ventricular hypertrophy on ECG (ECG-LVH) (3.9% and 4.2% vs 6.0% and 11.2%, respectively). A decrease in GFR of 10 mL/min per 1.73 m(2) was independently associated with a 6% higher risk for CVD and 14% higher risk for ECG-LVH. The increase in risk was marked at a GFR of approximately 60 to 70 mL/min per 1.73 m(2). CONCLUSIONS The prevalence of reduced GFR is high in older hypertensive patients. Patients with moderate or severe reduction in GFR are more likely to have a history of CVD and ECG-LVH. Even modest reductions in GFR are independently associated with a higher prevalence of CVD and ECG-LVH.
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Affiliation(s)
- Mahboob Rahman
- Division of Hypertension, Case Western Reserve University, Cleveland, Ohio 44106, USA.
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Wright JT, Cushman WC, Davis BR, Barzilay J, Colon P, Egan D, Lucente T, Nwachuku C, Pressel S, Leenen FH, Frolkis J, Letterer R, Walsh S, Tobin JN, Deger GE. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT): clinical center recruitment experience. Control Clin Trials 2001; 22:659-73. [PMID: 11738122 DOI: 10.1016/s0197-2456(01)00176-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a randomized clinical outcome trial of antihypertensive and lipid-lowering therapy in a diverse population (including substantial numbers of women and minorities) of 42,419 high-risk hypertensives aged > or = 55 years with a planned mean follow-up of 6 years. In this paper, we describe our experience in the identification, recruitment, and selection of clinical centers for this large simple trial capable of meeting the recruitment goals outlined for ALLHAT, and we highlight factors associated with clinical center performance. Over 135,000 recruitment brochures were mailed to physicians. Requests for information and application packets were received from 9351 (6.8%) interested investigators. A total of 1053 completed applications were received and 909 sites (86%) were eventually approved to join the trial. Of the approved sites, 278 either later declined participation or were never activated, and 8 were closed within a year for lack of enrollment. The final 623 randomizing centers exceeded the trial's recruitment goal to enroll at least 40,000 participants into the trial, although the recruitment period was extended 1.5 years longer than planned. Fewer than a quarter of the sites (22.6%) were recruited from academic medical centers or Department of Veterans Affairs Medical Centers. More than half of the sites (54.7%) were private solo or group practices, which contributed 53% of randomized participants. Community health centers comprised about 8% of the ALLHAT sites and 2.9% were part of health maintenance organizations. More than 22% of the principal investigators reported that they had no previous clinical research experience. In summary, ALLHAT was successful in recruiting a diverse group of clinical centers to achieve its patient recruitment goals.
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Affiliation(s)
- J T Wright
- Clinical Hypertension Program, Division of Hypertension, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106-4982, USA.
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Pressel S, Davis BR, Louis GT, Whelton P, Adrogue H, Egan D, Farber M, Payne G, Probstfield J, Ward H. Participant recruitment in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Control Clin Trials 2001; 22:674-86. [PMID: 11738123 DOI: 10.1016/s0197-2456(01)00177-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a practice-based, randomized, multicenter clinical trial in 42,419 high-risk hypertensive patients aged 55 years and older; 10,356 of these patients are also in a lipid-lowering trial component. The purpose of the antihypertensive component is to determine whether the occurrence of fatal coronary heart disease and/or nonfatal myocardial infarction differs between patients randomized to diuretic (chlorthalidone) and those randomized to either calcium antagonist (amlodipine), angiotensin-converting enzyme inhibitor (lisinopril), or alpha-adrenergic blocker (doxazosin) therapy. (The doxazosin arm has been discontinued.) The purpose of the lipid-lowering component is to determine whether lowering low-density lipoprotein cholesterol with a 3-hydroxymethyl-glutaryl coenzyme A reductase inhibitor (pravastatin) in moderately hypercholesterolemic patients will reduce all-cause mortality compared to a control group receiving "usual care." ALLHAT recruited patients from a variety of practice settings from February 1994 through January 1998. Sites were paid for randomizations and are paid for completed follow-up visits and documented study events. Communication and monitoring were facilitated by nine regional coordinator teams. It was recognized from the outset that patient recruitment would be a very large task because of the number of participants (> 40,000) needed, the ambitious nature of the goal for recruitment of African-Americans (> 55%), and the knowledge that many investigators had limited experience recruiting participants for clinical trials. Multiple adjustments in the initial ALLHAT overall recruitment plan facilitated achievement of sample size goals for both components of the trial. The experience obtained from this large trial should be valuable for the planning and implementation of successful recruitment in future trials.
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Affiliation(s)
- S Pressel
- The University of Texas Health Science Center School of Public Health, 1200 Herman Pressler St., Suite E801, Houston, TX 77030, USA.
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Perry HM, Davis BR, Price TR, Applegate WB, Fields WS, Guralnik JM, Kuller L, Pressel S, Stamler J, Probstfield JL. Effect of treating isolated systolic hypertension on the risk of developing various types and subtypes of stroke: the Systolic Hypertension in the Elderly Program (SHEP). JAMA 2000; 284:465-71. [PMID: 10904510 DOI: 10.1001/jama.284.4.465] [Citation(s) in RCA: 242] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT The Systolic Hypertension in the Elderly Program (SHEP) demonstrated that treating isolated systolic hypertension in older patients decreased incidence of total stroke, but whether all types of stroke were reduced was not evaluated. OBJECTIVE To investigate antihypertensive drug treatment effects on incidence of stroke by type and subtype, timing of strokes, case-fatality rates, stroke residual effects, and relationship of attained systolic blood pressure to stroke incidence. DESIGN The SHEP study, a randomized, double-blind, placebo-controlled trial began March 1, 1985, and had an average follow-up of 4.5 years. SETTING AND PARTICIPANTS A total of 4736 men and women aged 60 years or older with isolated systolic hypertension at 16 clinical centers in the United States. INTERVENTIONS Patients were randomly assigned to receive treatment with 12.5 mg/d of chlorthalidone (step 1); either 25 mg/d of atenolol or 0.05 mg/d of reserpine (step 2) could be added (n = 2365); or placebo (n = 2371). MAIN OUTCOME MEASURES Occurrence, type and subtype, and timing of first strokes and stroke fatalities; and change in stroke incidence for participants (whether in active treatment or placebo groups) reaching study-specific systolic blood pressure goal (decrease of at least 20 mm Hg from baseline to below 160 mm Hg) compared with participants not reaching goal. RESULTS A total of 85 and 132 participants in the active treatment and placebo groups, respectively, had ischemic strokes (adjusted relative risk [RR], 0.63; 95% confidence interval [CI], 0.48-0.82); 9 and 19 had hemorrhagic strokes (adjusted RR, 0.46; 95% CI, 0.21-1.02); and 9 and 8 had strokes of unknown type (adjusted RR, 1.05; 95% CI, 0.40-2. 73), respectively. Four subtypes of ischemic stroke were observed in active treatment and placebo group participants, respectively, as follows: for lacunar, n = 23 and n = 43 (adjusted RR, 0.53; 95% CI, 0.32-0.88); for embolic, n = 9 and n = 16 (adjusted RR, 0.56; 95% CI, 0.25-1.27); for atherosclerotic, n = 13 and n = 13 (adjusted RR, 0. 99; 95% CI, 0.46-2.15); and for unknown subtype, n = 40 and n = 60 (adjusted RR, 0.64; 95% CI, 0.43-0.96). Treatment effect was observed within 1 year for hemorrhagic strokes but was not seen until the second year for ischemic strokes. Stroke incidence significantly decreased in participants attaining study-specific systolic blood pressure goals. CONCLUSIONS In this study, antihypertensive drug treatment reduced the incidence of both hemorrhagic and ischemic (including lacunar) strokes. Reduction in stroke incidence occurred when specific systolic blood pressure goals were attained. JAMA. 2000;284:465-471
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Affiliation(s)
- H M Perry
- Washington University, Box 8048, 660 S Euclid Ave, St Louis, MO 63110, USA.
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Wassertheil-Smoller S, Fann C, Allman RM, Black HR, Camel GH, Davis B, Masaki K, Pressel S, Prineas RJ, Stamler J, Vogt TM. Relation of low body mass to death and stroke in the systolic hypertension in the elderly program. The SHEP Cooperative Research Group. Arch Intern Med 2000; 160:494-500. [PMID: 10695689 DOI: 10.1001/archinte.160.4.494] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND There are scant data on the effect of body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) on cardiovascular events and death in older patients with hypertension. OBJECTIVE To determine if low body mass in older patients with hypertension confers an increased risk of death or stroke. PATIENTS Participants were 3975 men and women (mean age, 71 years) enrolled in 17 US centers in the Systolic Hypertension in the Elderly Program trial, a randomized, double-blind, placebo-controlled clinical trial of lowdose antihypertensive therapy, with follow-up for 5 years. MAIN OUTCOME MEASURES Five-year adjusted mortality and stroke rates from Cox proportional hazards analyses. RESULTS There was no statistically significant relation of death or stroke with BMI in the placebo group (P = .47), and there was a U- or J-shaped relation in the treatment group. The J-shaped relation of death with BMI in the treated group (P = .03) showed that the lowest probability of death for men was associated with a BMI of 26.0 and for women with a BMI of 29.6; the curve was quite flat for women across a wide range of BMIs. For stroke, men and women did not differ, and the BMI nadir for both sexes combined was 29, with risk increasing steeply at BMIs below 24. Those in active treatment, however, had lower death and stroke rates compared with those taking placebo. CONCLUSIONS Among older patients with hypertension, a wide range of BMIs was associated with a similar risk of death and stroke; a low BMI was associated with increased risk. Lean, older patients with hypertension in treatment should be monitored carefully for additional risk factors.
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Affiliation(s)
- S Wassertheil-Smoller
- Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY 10461, USA.
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Schron EB, Wassertheil-Smoller S, Pressel S. Clinical trial participant satisfaction: survey of SHEP enrollees. SHEP Cooperative Research Group. Systolic Hypertension in the Elderly Program. J Am Geriatr Soc 1997; 45:934-8. [PMID: 9256844 DOI: 10.1111/j.1532-5415.1997.tb02962.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The purpose of this study was to determine older persons' reasons for joining a clinical trial, and to provide data that could be useful in planning and carrying out clinical trials in older and minority populations. DESIGN A survey. PARTICIPANTS The sample included 4281 men and women 60 years of age or older who were randomized to the Systolic Hypertension in the Elderly Program (SHEP). MEASUREMENTS A 10-item satisfaction/attitude questionnaire was designed to evaluate (1) what personal benefits people expect from participation in this trial, (2) motivation for joining, and (3) satisfaction with clinic staff and operations. Each question had a response category asking for a measure of agreement, satisfaction, or importance. RESULTS The most important reasons for joining the clinical trial were to contribute to science (96%), improve the health of others (96%), and improve their own health (93%). Free medical care and social aspects were less important reasons to join. There were no differences by treatment assignment, but differences in reasons for joining SHEP by age, race, gender, and education were observed. CONCLUSION Older adults were enthusiastic about clinical trial participation. Recruitment, participant management strategies, and allocation of resources should consider the needs of specific patient groups.
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Affiliation(s)
- E B Schron
- National Heart, Lung, and Blood Institute, NIH, Bethesda, MD 20892-7936, USA
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Davis BR, Cutler JA, Gordon DJ, Furberg CD, Wright JT, Cushman WC, Grimm RH, LaRosa J, Whelton PK, Perry HM, Alderman MH, Ford CE, Oparil S, Francis C, Proschan M, Pressel S, Black HR, Hawkins CM. Rationale and design for the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ALLHAT Research Group. Am J Hypertens 1996; 9:342-60. [PMID: 8722437 DOI: 10.1016/0895-7061(96)00037-4] [Citation(s) in RCA: 352] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Are newer types of antihypertensive agents, which are currently more costly to purchase on average, as good or better than diuretics in reducing coronary heart disease incidence and progression? Will lowering LDL cholesterol in moderately hypercholesterolemic older individuals reduce the incidence of cardiovascular disease and total mortality? These important medical practice and public health questions are to be addressed by the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind trial in 40,000 high-risk hypertensive patients. ALLHAT is designed to determine whether the combined incidence of fatal coronary heart disease (CHD) and nonfatal myocardial infarction differs between persons randomized to diuretic (chlorthalidone) treatment and each of three alternative treatments--a calcium antagonist (amlodipine), an angiotensin converting enzyme inhibitor (lisinopril), and an alpha-adrenergic blocker (doxazosin). ALLHAT also contains a randomized, open-label, lipid-lowering trial designed to determine whether lowering LDL cholesterol in 20,000 moderately hypercholesterolemic patients (a subset of the 40,000) with a 3-hydroxymethylglutaryl coenzyme A (HMG CoA) reductase inhibitor, pravastatin, will reduce all-cause mortality compared to a control group receiving "usual care." ALLHAT's main eligibility criteria are: 1) age 55 or older; 2) systolic or diastolic hypertension; and 3) one or more additional risk factors for heart attack (eg, evidence of atherosclerotic disease or type II diabetes). For the lipid-lowering trial, participants must have an LDL cholesterol of 120 to 189 mg/dL (100 to 129 mg/dL for those with known CHD) and a triglyceride level below 350 mg/dL. The mean duration of treatment and follow-up is planned to be 6 years. Further features of the rationale, design, objectives, treatment program, and study organization of ALLHAT are described in this article.
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Affiliation(s)
- B R Davis
- University of Texas School of Public Health, Houston, USA
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Wassertheil-Smoller S, Applegate WB, Berge K, Chang CJ, Davis BR, Grimm R, Kostis J, Pressel S, Schron E. Change in depression as a precursor of cardiovascular events. SHEP Cooperative Research Group (Systoloc Hypertension in the elderly). Arch Intern Med 1996; 156:553-61. [PMID: 8604962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine the relationship between increasing depressive symptoms and cardiovascular events or mortality. DESIGN Cohort analytic study of data from randomized placebo-controlled double-blind clinical trial of antihypertensive therapy. Depressive symptoms were assessed semi-annually with the Center for Epidemiological Studies-Depression (CES-D) scale during an average follow-up of 4.5 years. SETTING Ambulatory patients in 16 clinical centers of the Systolic Hypertension in the Elderly Program. PATIENTS Generally healthy men and women aged 60 years or older randomized to active antihypertensive drug therapy or placebo who were 70% white and 53% women and had follow-up CES-D scores and no outcome events during the first 6 months (N=4367). MAIN OUTCOME MEASURES All-cause mortality, fatal or nonfatal stroke, or myocardial infarction. RESULTS Baseline depressive symptoms were not related to subsequent events; however, an increase in depression was prognostic. Cox proportional hazards regression analyses with the CES-D scale as a time-dependent variable, controlling for multiple covariates, indicated a 25% increased risk of death per 5-unit increase in the CES-D score (relative risk [RR], 1.25;95% confidence interval [CI], 1.15 to 1.36). The RR for stroke or myocardial infarction was 1.18(95%CI,1.08 to 1.30). Increase in CES-D score was an independent predictor in both placebo and active drug groups, and it was strongest as a risk factor for stroke among women (RR,1.29;95%CI,1.07 to 1.34). CONCLUSIONS Among elderly persons, a significant and substantial excess risk of death and stroke or myocardial infarction was associated with an increase in depressive symptoms over time, which may be a marker for subsequent major disease events and warrants the attention of physicians to such mood changes. However, further studies of casual pathways are needed before wide-spread screening for depression in clinical practice is to be recommended.
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Bearden D, Allman R, McDonald R, Miller S, Pressel S, Petrovitch H. Age, race, and gender variation in the utilization of coronary artery bypass surgery and angioplasty in SHEP. SHEP Cooperative Research Group. Systolic Hypertension in the Elderly Program. J Am Geriatr Soc 1994; 42:1143-9. [PMID: 7963199 DOI: 10.1111/j.1532-5415.1994.tb06979.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To assess variability in the use of coronary artery bypass grafting (CABG) and percutaneous transluminal angioplasty (PTCA) in the Systolic Hypertension in the Elderly Program (SHEP) cohort with incident coronary heart disease (CHD) by age, sex, and race. DESIGN Retrospective analysis of a multicenter prospective cohort study. SETTING Community-based ambulatory population in academic centers. PATIENTS Among 4736 subjects initially enrolled in SHEP, there were 432 incident cases of CHD, excluding those patients who experienced rapid or sudden cardiac death. MAIN OUTCOME MEASURE Incident cases of CHD who underwent CABG or PTCA. RESULTS Of those participants > or = 60 and < 75 years of age, 7.3% underwent PTCA, compared with 3.9% of those > or = 75 years (P = 0.14). 15.4% of those < 75 underwent CABG surgery, compared with 7.8% of those 75 and older (P = 0.018). When both of these endpoints, CABG and PTCA, were combined, 22.4% of those < 75 underwent a procedure, while only 11.7% of the older cohort did (P = 0.005). Twenty-six percent of men underwent either CABG or PTCA, while only 9.1% of women did (P < 0.001). Of those < 75 years of age, 31.1% of men and 12.3% of women underwent CABG or PTCA (P < 0.001). In the 75 and older age category, 19.5% of men underwent these interventions, compared with 5.9% of women (P = 0.005). Active treatment group was significantly associated with decreased use of procedures in participants < 75 year old with CHD. Race, activity limitations, number of comorbid conditions, education level, marital status, employment status, and social support were not significantly associated with CABG or PTCA use. When the variables studied were entered into a logistic regression model, increased age and female sex remained independently associated with decreased CABG and PTCA use. CONCLUSION In the SHEP trial older patients and women, regardless of comorbid conditions, socioeconomic status, and social support, underwent less intensive cardiovascular interventions than did younger patients and men when they developed CHD.
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Affiliation(s)
- D Bearden
- Division of Geriatrics, University of Alabama at Birmingham 35294-2041
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Applegate WB, Pressel S, Wittes J, Luhr J, Shekelle RB, Camel GH, Greenlick MR, Hadley E, Moye L, Perry HM. Impact of the treatment of isolated systolic hypertension on behavioral variables. Results from the systolic hypertension in the elderly program. Arch Intern Med 1994; 154:2154-60. [PMID: 7944835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Little information has been published on the impact of antihypertensive medications on quality of life in older persons. Particular concern has existed that lowering systolic blood pressure in older persons might have adverse consequences on cognition, mood, or leisure activities. METHODS A multicenter double-blind randomized controlled trial was conducted over an average of 5 years' followup involving 16 academic clinical trial clinics. Participants consisted of 4736 persons (1.06%) selected from 447,921 screenees aged 60 years and older. Systolic blood pressure at baseline ranged from 160 to 219 mm Hg, while diastolic blood pressure was less than 90 mm Hg. Participants were randomized to active antihypertensive drug therapy or matching placebo. Active treatment consisted of 12.5 to 25 mg of chlorthalidone for step 1, while step 2 consisted of 25 to 50 mg of atenolol. If atenolol was contraindicated, 0.05 to 0.10 mg of reserpine could be used for the second-step drug. The impact of drug treatment on measures of cognitive, emotional, and physical function and leisure activities was assessed. RESULTS Our analyses demonstrate that active treatment of isolated systolic hypertension in the Systolic Hypertension in the Elderly Program cohort had no measured negative effects and, for some measures, a slight positive effect on cognitive, physical, and leisure function. The positive findings in favor of the treatment group were small. There was no effect on measures related to emotional state. Measures of cognitive and emotional function were stable in both groups for the duration of the study. Both treatment groups showed a modest trend toward deterioration of some measures of physical and leisure function over the study period. CONCLUSIONS The overall study cohort exhibited decline over time in activities of daily living, particularly the more strenuous ones, and some decline in certain leisure activities. However, mood, cognitive function, basic self-care, and moderate leisure activity were remarkably stable for both the active and the placebo groups throughout the entire study. Results of this study support the inference that medical treatment of isolated systolic hypertension does not cause deterioration in measures of cognition, emotional state, physical function, or leisure activities.
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Davis BR, Wittes J, Pressel S, Berge KG, Hawkins CM, Lakatos E, Moyé LA, Probstfield JL. Statistical considerations in monitoring the Systolic Hypertension in the Elderly Program (SHEP). Control Clin Trials 1993; 14:350-61. [PMID: 8222667 DOI: 10.1016/0197-2456(93)90051-e] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The Systolic Hypertension in the Elderly Program (SHEP), a randomized, double-masked, placebo-controlled trial of 4736 persons, was designed to assess the efficacy of antihypertensive drug treatment to reduce the risk of fatal and nonfatal strokes among people age 60 and over with isolated systolic hypertension. The statistical method used in interim monitoring of results was conditional power (or stochastic curtailment). The findings did not become conclusive until near the completion of the trial, and therefore SHEP was continued to its scheduled closing date. The trial demonstrated a 36% reduction in the incidence of stroke in the active treatment group (P = .0003). In addition to evaluating overall efficacy of treatment, the monitoring process considered such other issues as nonstroke outcomes, lag time between first report of stroke and final confirmation of stroke diagnosis, consistency of results across subgroups, and completeness of follow-up. The purpose of this article is to review these factors with primary emphasis on the statistical aspects.
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Affiliation(s)
- B R Davis
- University of Texas School of Public Health, Houston
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Langford HG, Curb JD, Pressel S, Schneider KA. Effect of thiazide-based therapy on serum alkaline phosphatase. Hypertension Detection and Follow-up Group. J Hum Hypertens 1991; 5:333-8. [PMID: 1956030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This study reports a correlation of alkaline phosphatase (AP) with diastolic blood pressure (DBP), and a reduction of alkaline phosphatase after chlorthalidone therapy that reached a nadir at three years of therapy, then gradually returned toward, but not reaching, baseline values. The data is from the baseline examination and follow-up of 3928 initially untreated stepped-care patients in the Hypertension Detection and Follow-up Program. In multiple regression analysis, both age and DBP were significantly correlated with increased AP in males and females. After initiation of therapy with chlorthalidone, AP levels fell progressively until the third year, when they were reduced by 11 +/- 15 IU in the males and 14 +/- 15 IU in the females. The data are compatible with the interpretation that thiazide-induced reduction in urinary calcium excretion has led to a more positive calcium balance and reduction of bone turnover, and suggests that a beneficial effect of thiazide-based antihypertensive therapy could be decreased osteoporosis.
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Affiliation(s)
- H G Langford
- Department of Medicine, University of Mississippi School of Medicine, Jackson
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Vogt TM, Schron E, Pressel S, Wasserthiel-Smoller S, Eddleman EE, Miller S, Stamler J. Systolic Hypertension in the Elderly Program (SHEP). Part 3: Sociodemographic characteristics. Hypertension 1991; 17:II24-34. [PMID: 1999374 DOI: 10.1161/01.hyp.17.3_suppl.ii24] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Langford HG, Blaufox MD, Borhani NO, Curb JD, Molteni A, Schneider KA, Pressel S. Is thiazide-produced uric acid elevation harmful? Analysis of data from the Hypertension Detection and Follow-up Program. Arch Intern Med 1987; 147:645-9. [PMID: 3827451 DOI: 10.1001/archinte.147.4.645] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Interaction of thiazide diuretics and the serum uric acid and creatinine levels was studied in 3693 stepped care participants in the Hypertension Detection and Follow-up Program not receiving treatment at baseline. Among men grouped into quartiles by their level of uric acid at baseline, the upper quartile (average uric acid, 7.7 mg/dL [458 mumol/L]) had an average serum creatinine level of 1.2 mg/dL (106 mumol/L) and the lowest quartile (uric acid, 4.9 mg/dL [291 mumol/L]) had an average serum creatinine level of 1.1 mg/dL (97 mumol/L). Similar findings were present in women. Therapy with chlorthalidone or other thiazide-type diuretics tended to increase levels of uric acid and creatinine, but the increase in both was less in the upper quartile than in the lower quartile. Among individuals who were prescribed uric acid-lowering drugs, the level of serum creatinine increased just as much as in those whose uric acid level was not pharmacologically lowered. Baseline uric acid level was a weak predictor of mortality in men; the introduction of an interaction term for creatinine suggested that this effect was primarily restricted to those with elevated levels of both uric acid and creatinine at baseline. Change in uric acid level at one year after therapy was inversely correlated with mortality in men. There were few episodes of gout (only 15 recorded in five years among 3693 participants at risk). These results suggest that neither the baseline uric acid level nor the change in uric acid level produced by therapy injures the kidney. These results suggest no reason to lower uric acid levels pharmacologically in the treated hypertensive patient who is not gouty. They leave unanswered whether there is a predictive value to baseline uric acid level not explainable by other correlated cardiovascular risk factors.
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Wassertheil-Smoller S, Blaufox MD, Langford HG, Oberman A, Cutter G, Pressel S. Prediction of response to sodium intervention for blood pressure control. J Hypertens Suppl 1986; 4:S343-6. [PMID: 3553478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In the Dietary Intervention Study of Hypertension (DISH) we found that patients formerly treated with drugs and assigned to sodium-reduction intervention were twice as likely to remain off medication for up to 56 weeks as were the controls assigned to no-diet intervention, after adjusting for covariates. Within the sodium-restriction group approximately 60% of 131 people were Intervention Successes (IS) (urinary sodium less than or equal to 100 mmol/day at 8 weeks). The rest were classed as Non-Intervention Successes (NIS). Of the IS group, 54% were responders (drug-free for at least 56 weeks), but about 56% of the NIS group also remained drug-free. Multiple logistics showed that no one factor was able to predict response among the IS. We conclude that the IS likely to respond to sodium reduction are not readily identifiable a priori. Furthermore, since both IS and NIS showed similar blood-pressure effects from the sodium-restriction regimen compared with controls, the questions arise: whether a factor other than sodium reduction affects the blood pressure response for the sodium-restriction group; or whether the measurement of sodium intake and excretion is sufficiently precise to distinguish compliers from non-compliers.
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Abernethy J, Borhani NO, Hawkins CM, Crow R, Entwisle G, Jones JW, Maxwell MH, Langford H, Pressel S. Systolic blood pressure as an independent predictor of mortality in the Hypertension Detection and Follow-up Program. Am J Prev Med 1986; 2:123-32. [PMID: 3453169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The Hypertension Detection and Follow-up Program (HDFP) findings demonstrate the predictive value of baseline systolic blood pressure (SBP) and of pulse pressure (PB) in five-year mortality from all causes. Grouping participants into four SBP strata revealed an approximately two-fold increase in age-adjusted mortality rate from SBP stratum I to SBP stratum IV. This effect remained after the contributions of other risk factors were controlled by multivariate analysis. In contrast, baseline diastolic blood pressure (DBP) had little demonstrable effect on mortality in this particular population. The predictive power of pulse pressure was similar to that of SBP. The group mean SBP of every stratum fell progressively during the trial, the change being of greater magnitude in the stepped care (SC) group than in the referred care (RC) group. Also, the reduction in all-cause mortality associated with SC treatment was observed at all levels of baseline SBP. An analysis using life table regression with SBP as a time-dependent variable showed that the postrandomization reduction in SBP was a significant factor in reducing mortality. Similarly, reduced DBP was also contributory. Prospective studies are required to answer definitively the question of the efficacy of treatment of systolic hypertension. Nevertheless, the present analysis of the HDFP data, despite design limitations, supports the advisability of reducing elevated systolic blood pressure.
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Affiliation(s)
- J Abernethy
- Hypertension Detection and Follow-up Program, National Heart, Lung, and Blood Institute, Bethesda, MD 20205
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Curb JD, Ford CE, Pressel S, Palmer M, Babcock C, Hawkins CM. Ascertainment of vital status through the National Death Index and the Social Security Administration. Am J Epidemiol 1985; 121:754-66. [PMID: 4014167 DOI: 10.1093/aje/121.5.754] [Citation(s) in RCA: 147] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Ascertainment of the vital status of individuals is of central importance to epidemiologic studies which monitor mortality as an end point. Utilizing identifying information collected in 1973-1974, the Hypertension Detection and Follow-up Program, a prospective, multicenter study, followed 25,362 individuals to determine eight-year mortality. In the most recent follow-up, there were 617 individuals whose vital status was not known. Available identifying information on these and on all 1,322 participants known to have died in 1979-1981 was submitted to the National Death Index (NDI) for possible confirmation of vital status. A subset of individuals who had Social Security numbers (490 lost to follow-up and 1,154 known deaths) was also submitted to the Social Security Administration (SSA). The NDI correctly identified 87.0% of the known deaths. Of the 1,154 known deaths (those with known Social Security numbers) submitted to both agencies, the NDI identified 93.1% and the SSA 83.6%. Significant variations by race and sex were noted in the identification rates, in part because of Social Security number discrepancies. False matches through the NDI matching process occurred for 10.4% of the known deaths. In the more restrictive SSA search, only 0.5% false matches resulted. For those lost to follow-up, vital status was ascertained in 57.1%. This paper describes the relative efficacy and attributes of the use of these systems to ascertain vital status.
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Wassertheil-Smoller S, Langford HG, Blaufox MD, Oberman A, Hawkins M, Levine B, Cameron M, Babcock C, Pressel S, Caggiula A. Effective dietary intervention in hypertensives: sodium restriction and weight reduction. J Am Diet Assoc 1985; 85:423-30. [PMID: 3884691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A Dietary Intervention Study of Hypertension (DISH) was undertaken to determine whether patients whose high blood pressure had been controlled pharmacologically for a period of more than 5 years could maintain that control with sodium restriction or weight reduction instead of drugs. Four hundred ninety-six patients, classified by degree of overweight, were randomly assigned into one of seven groups. Included were those who would be withdrawn from antihypertensive medication and receive intervention for either sodium restriction or weight reduction. After 8 weeks of intervention, an average reduction of 24-hour urinary sodium output from a baseline of 158 mEq to 106 mEq (p less than .001) and from 130 mEq to 96 mEq (p less than .01) was achieved for the overweight and nonoverweight groups, respectively. That decline was still maintained at 56 weeks. Dietary estimates, obtained by analysis of 3-day food records, underestimated urinary output by an average of 12%, with blacks more likely to underestimate than whites, and the overweight more likely to underestimate than the nonoverweight. An average 10-lb weight loss was achieved, with no difference between men and women. Weight declined for 32 weeks, then leveled off and was maintained up to 56 weeks, indicating that sodium intake modification can be accomplished faster than weight reduction. Modest sodium restriction and weight reduction are feasible and achievable in a free-living population and have a positive effect on control of hypertension.
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Langford HG, Blaufox MD, Oberman A, Hawkins CM, Curb JD, Cutter GR, Wassertheil-Smoller S, Pressel S, Babcock C, Abernethy JD. Dietary therapy slows the return of hypertension after stopping prolonged medication. JAMA 1985; 253:657-64. [PMID: 3881608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This study asks whether prolonged antihypertensive therapy will "cure" a substantial percent of rigorously treated hypertensive patients and whether nutritional change will add an antihypertensive effect and reduce the relapse rate. Of 584 eligible patients normotensive while receiving therapy, 496 were randomized into control and discontinued-medication groups with and without dietary intervention. At 56 weeks, 50% of those who were no longer receiving medication remained normotensive by study criteria. Randomization either to weight-loss group (mean loss of 4.5 kg [10 lb]) or to sodium-restriction group (mean reduction of 40 mEq/day) increased the likelihood of remaining without drug therapy, with an adjusted odds ratio of 2.17 for the sodium group and 3.43 for the weight group. Highest success rates were in the nonoverweight mild hypertensives with sodium restriction (78%) and the overweight mild hypertensives who were reducing their weight (72%). These data demonstrate that weight loss or sodium restriction, in hypertensives controlled for five years, more than doubles success in withdrawal of drug therapy.
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Langford HG, Blaufox MD, Oberman A, Hawkins CM, Curb JD, Cutter GR, Wassertheil-Smoller S, Pressel S, Babcock C, Abernethy JD. Does effective antihypertensive therapy partially "cure" hypertension? Trans Am Clin Climatol Assoc 1985; 96:111-119. [PMID: 6399642 PMCID: PMC2279657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Willett WC, Polk BF, Underwood BA, Stampfer MJ, Pressel S, Rosner B, Taylor JO, Schneider K, Hames CG. Relation of serum vitamins A and E and carotenoids to the risk of cancer. N Engl J Med 1984; 310:430-4. [PMID: 6537988 DOI: 10.1056/nejm198402163100705] [Citation(s) in RCA: 244] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Epidemiologic studies suggest that low carotene intake and low levels of serum retinol may be associated with an increased risk of cancer. Likewise, in some animal studies vitamin E has been associated with a reduced rate of induced cancers. Therefore, we measured retinol, retinol-binding protein, vitamin E (alpha-tocopherol), and total carotenoids in serum collected in 1973 from 111 participants in the Hypertension Detection and Follow-up Program who were free of cancer at the time but were diagnosed as having cancer during the subsequent five years. These measurements were compared with those in 210 controls who were matched for age, sex, race, and time of blood collection, and who remained free of cancer. Mean values for retinol were similar for cases and controls (67.3 and 68.7 micrograms per deciliter, respectively [95 per cent confidence limits for case-control difference, -6.7 to 3.5]). Values were also similar for retinol-binding protein (6.01 and 5.94 mg per deciliter [-0.42 to 0.56]), and carotenoids (114.5 and 111.6 micrograms per deciliter [-9.1 to 15.9]). The mean base-line retinol level in the 18 subjects with subsequent lung cancer was higher than that in their matched controls (79.0 vs. 71.4 micrograms per deciliter, -4.9 to 19.7). Serum vitamin E levels were somewhat lower in subjects who later had cancer than in controls (1.16 and 1.26 mg per deciliter, -0.22 to 0.02), in part because of the confounding effect of serum cholesterol levels (when adjusted for lipid levels, the case-control difference was -0.05 mg per deciliter; -0.17 to 0.07). These data do not support hypotheses relating intake or serum levels of antioxidant vitamins to a reduced cancer risk.
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Abstract
Selenium levels in serum samples collected in 1973 from 111 subjects in whom cancer developed during the subsequent 5 years were compared with those in serum samples from 210 cancer-free subjects matched for age, race, sex, and smoking history. The mean selenium level of cases (0.129 +/- SEM 0.002 micrograms/ml) was significantly lower than that of controls (0.136 +/- 0.002 micrograms/ml). The risk of cancer for subjects in the lowest quintile of serum selenium was twice that of subjects in the highest. Multivariate adjustment for geographical area and serum levels of lipids, vitamins A and E, and carotene, did not alter this relation. The association between low selenium level and cancer was strongest for gastrointestinal and prostatic cancers. Serum levels of vitamins A and E compounded the effect of low selenium; relative risks for the lowest tertile of selenium were 2.4 and 3.9 in the lowest tertiles of vitamins E and A, respectively.
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Abstract
Death certificates representing 766 decedents who had participated in the Hypertension Detection and Follow-up Program (1973-1979) at one of 14 US centers were given to three nosologists for purposes of coding underlying cause of death. Analyses examined interobserver variability among the three nosologists as well as intraobserver variability for each of the three nosologists. All three nosologists agreed on a three-digit International Classification of Diseases, Adapted (ICDA) code in 90.2% of the cases and at least two out of three agreed in 99.7% of the death certificates examined. Agreement rates improved when disease codes were collapsed into broader categories utilized in the Hypertension Detection and Follow-up Program. When particular disease classifications (e.g., cerebrovascular, ischemic heart disease, myocardial infarction, and neoplasms) were examined, three out of three agreement rates were highest for neoplasms (97.8%) and lowest for myocardial infarction (86.5%). Similarly, two out of three agreement was highest for neoplasms (98.5%) and lowest for myocardial infarction (88.0%). Intranosologist agreement rates were based on a recoded 20% sample of death certificates. Agreement rates for three-digit ICDA codes ranged from 94.8% to 96.1% for the three nosologists. The agreement rates for the general disease categories ranged from 96.7% to 97.4%.
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