2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)

Differential effectiveness of ARB plus CCB therapy and high-dose ARB therapy in high-risk elderly hypertensive patients: subanalysis of the OSCAR study

The OSCAR study was a multicenter prospective randomized study that examined the relative benefit of combined ARB (olmesartan 20 mg per day) plus calcium channel blocker (CCB) therapy vs. high-dose ARB monotherapy (olmesartan 40 mg per day) for prevention of cardiovascular events in elderly Japanese hypertensive patients. The present subanalysis of patients enrolled in the OSCAR study (n = 1078) was performed to assess whether baseline eGFR coupled with cardiovascular disease (CVD) could predict the relative benefit of these two treatments. Patients with baseline CVD (n = 769) and patients without baseline CVD (n = 309) were divided into two groups based on baseline eGFR; (i) patients with eGFR of < 60 ml min(-1) 1.73 m(-)(2) and (ii) those with eGFR of ⩾ 60 ml min(-1) 1.73 m(-2). There was a significant treatment-subgroup interaction among these four subgroups in relation to the incidence of primary outcome events(P = 0.007 for interaction). In patients with CVD and with eGFR of <60 ml min(-1) 1.73 m(-2), ARB plus CCB therapy was associated with a lower incidence of primary events than high-dose ARB therapy and the difference of the relative risk was statistically significant (hazard ratio: 3.525, 95% confidence interval (CI): 1.676-7.412, P < 0.001). The greater benefit of ARB plus CCB therapy vs. high-dose ARB therapy in this subgroup was associated with less visit-to-visit variability of systolic BP and diastolic BP. In conclusion, baseline eGFR coupled with baseline CVD seems to be a predictor of the relative efficacy of ARB plus CCB therapy vs. high-dose ARB therapy in the elderly hypertensive patients. ARB plus CCB therapy appears to be superior to high-dose ARB therapy for preventing cardiovascular events in the patients with CVD and with eGFR of <60 ml min(-1) 1.73 m(-2).

Risk assessment for preeclampsia in nulliparous women at 11-13 weeks gestational age: prospective evaluation of two algorithms

OBJECTIVE

To evaluate two algorithms for prediction of preeclampsia in a population of nulliparous women in Norway.

DESIGN

Prospective screening study.

SETTING

National Centre for Fetal Medicine in Trondheim, Norway.

POPULATION

Five hundred and forty-one nulliparous women.

METHODS

The women were examined between 11(+0) and 13(+6) weeks with interviews for maternal characteristics and measurements of mean arterial pressure, uterine artery pulsatility index, pregnancy-associated plasma protein A and placental growth factor. The First Trimester Screening Program version 2.8 by The Fetal Medicine Foundation (FMF) was compared with the Preeclampsia Predictor TM version 1 revision 2 by Perkin Elmer (PREDICTOR).

MAIN OUTCOME MEASURES

Prediction of preeclampsia requiring delivery before 37 weeks, before 42 weeks and late preeclampsia (delivery after 34 weeks).

RESULTS

The performance of the two algorithms was similar, but quite poor, for prediction of preeclampsia requiring delivery before 42 weeks with an area under the curve of 0.77 (0.67-0.87) and sensitivity 40% (95% CI 19.1-63.9) at a fixed 10% false positive rate for FMF and 0.74 (0.63-0.84) and sensitivity 30% (95% CI 11.9-54.3) at a fixed 10% false positive rate for PREDICTOR. The FMF algorithm for preeclampsia requiring delivery <37 weeks had an area under the curve of 0.94 (0.86-1.0) and sensitivity of 80% (95% CI 28.4-99.5) at a 10% fixed false positive rate.

CONCLUSIONS

Fetal Medicine Foundation and PREDICTOR algorithms had similar and only modest performance in predicting preeclampsia. The results indicate that the FMF algorithm is suitable for prediction of preterm preeclampsia.

Need for better blood pressure measurement in developing countries to improve prevention of cardiovascular disease

Hypertension is now the foremost cause of disability and is responsible for the highest percentage of attributable death among risk factors. These global changes are mainly due to the increase in the prevalence of hypertension in most low- and middle-income countries (LMICs) as a consequence of relevant socioeconomic changes occurring during the last decades. Implementation of global prevention efforts urgently needs to be accelerated because of the increasing incidence of haemorrhagic stroke, renal failure, and hypertensive heart disease in developing countries. Blood pressure (BP) measurement has different implications in epidemiological studies performed in low-resource settings. First, the frequency of blood pressure measurement is a simple but reliable indicator of access to healthcare in epidemiological studies, which may disclose the favourable effects of urbanization; the opportunity to have BP measured increases hypertension awareness, facilitates drug treatment, and leads to better achievement of BP control. Second, BP measurement is a key element in cardiovascular risk stratification, focusing solely on the preferred strategy in low-resource settings where costs of biochemical tests might be less sustainable. Third, the issue of obtaining reliable estimation of BP values is crucial to achieve sound data on the burden of hypertension in LMICs, and some aspects of BP measurement, such as the use of reliable automated devices, the number of measurements/visits to achieve a consistent diagnosis of hypertension, and the possible confounding effect of environmental factors, must be closely considered.

Early vascular aging in young and middle-aged ischemic stroke patients: the Norwegian Stroke in the Young Study

Background

Ischemic stroke survivors have high risk of cardiovascular morbidity and mortality even at young age, suggesting that early arterial aging is common among such patients.

Methods

We measured aortic stiffness by carotid-femoral pulse wave velocity (PWV) in 205 patients (69% men) aged 15–60 years with acute ischemic stroke in the prospective Norwegian Stroke in the Young Study. High for age carotid-femoral PWV was identified in the reference normogram.

Results

Patients were on average 49±10 years old, 34% had a history of hypertension and 37% had metabolic syndrome (MetS). In the total study population, higher PWV was associated with history of hypertension (β = 0.18), higher age (β = 0.34), systolic blood pressure (BP) (β = 0.28) and serum creatinine (β = 0.18) and lower high-density lipoprotein (HDL) cholesterol (β = –0.10, all p<0.01) in multivariate linear regression analysis (multiple R² = 0.42, p<0.001). High for age PWV was found in 18% of patients. In univariate analyses, known hypertension was associated with a 6-fold, MetS with a 4-fold and presence of carotid plaque with a 3.7-fold higher risk for high for age PWV (all p<0.01). In multiple logistic regression analysis higher systolic BP (odds ratio [OR] 1.04; 95% confidence interval [CI] 1.02–1.06; p<0.01), history of hypertension (OR 3.59; 95% CI 1.52–8.51; p<0.01), low HDL cholesterol (OR 3.03; 95% CI 1.00–9.09; p = 0.05) and higher serum creatinine (OR 1.04; 95% CI 1.01–1.06; p<0.01) were associated with high for age PWV.

Conclusions

Higher PWV is common in younger and middle-aged ischemic stroke patients and associated with a clustering of classical cardiovascular risk factors.

ClinicalTrials.gov NCT01597453

Cardiac rehabilitation with a nurse case manager (GoHeart) across local and regional health authorities improves risk factors, self-care and psychosocial outcomes. A one-year follow-up study

OBJECTIVES

In Denmark, the local and regional health authorities share responsibility for cardiac rehabilitation (CR). The objective was to assess effectiveness of CR across sectors coordinated by a nurse case manager (NCM).

DESIGN

A one-year follow-up study.

SETTING

A CR programme (GoHeart) was evaluated in a cohort at Lillebaelt Hospital Vejle, DK from 2010 to 2011.

PARTICIPANTS

Consecutive patients admitted to CR were included. The inclusion criteria were the event of acute myocardial infarction or stable angina and invasive revascularization (left ventricular ejection fraction (LVEF) ≥45%).

MAIN OUTCOME MEASURES

Cardiac risk factors, stratified self-care and self-reported psychosocial factors (SF12 and Hospital Anxiety and Depression Scale (HADS)) were assessed at admission (phase IIa), at three months at discharge (phase IIb) and at one-year follow-up (phase III). Intention-to-treat and predefined subgroup analysis on sex was performed.

RESULTS

Of 241 patients, 183 (75.9%) were included (mean age 63.8 years). At discharge improvements were found in total-cholesterol (p < 0.001), low density lipoprotein (LDL; p < 0.001), functional capacities (metabolic equivalent of tasks (METS), p < 0.01), self-care management (p < 0.001), Health status Short Form 12 version (SF12; physical; p < 0.001 and mental; p < 0.01) and in depression symptoms (p < 0.01). At one-year follow-up these outcomes were maintained; additionally there was improvement in body mass index (BMI; p < 0.05), and high density lipoprotein (HDL; p < 0.05). There were no sex differences.

CONCLUSION

CR shared between local and regional health authorities led by a NCM (GoHeart) improves risk factors, self-care and psychosocial factors. Further improvements in most variables were at one-year follow-up.

A prospective study of screening for hypertensive disorders of pregnancy at 11-13 weeks in a Scandinavian population

OBJECTIVE

To investigate the prediction of preeclampsia and gestational hypertension using maternal characteristics, mean arterial pressure (MAP), uterine artery pulsatility index (UtAPI), pregnancy-associated plasma protein-A (PAPP-A) and placental growth factor (PlGF) at gestational weeks 11-13 in a Scandinavian population with a medium to high prior risk for developing hypertensive disorders of pregnancy.

DESIGN

Prospective screening study.

SETTING

National Center for Fetal Medicine, Trondheim, Norway.

POPULATION

579 women who were nulliparous or had a previous history of preeclampsia or gestational hypertension.

METHODS

Women were examined between 11(+0) and 13(+6) weeks, with interviews for maternal characteristics and measurements of MAP, UtAPI, PAPP-A and PlGF. The tests were evaluated separately and in combined models with receiver operating characteristics (ROC) curves.

MAIN OUTCOME MEASURES

Prediction of preeclampsia, severe preeclampsia and gestational hypertension.

RESULTS

The best model for severe preeclampsia (MAP+UtAPI+PlGF+PAPP-A) achieved an area under the ROC curve of 0.866 [95% confidence interval (95% CI) 0.756-0.976]. The best models for preeclampsia (MAP+UtAPI+age) achieved 0.738 (0.634-0.841), gestational hypertension (MAP) 0.820 (0.727-0.913) and hypertensive disorders in pregnancy overall (MAP+PlGF+age) 0.783 (0.709-0.856). Using the best model we could identify 61.5% (95% CI 31.6-86.1) of severe preeclampsia, 38.5% (95% CI 20.2-59.4) of preeclampsia and 42.9% (95% CI 21.8-66) of gestational hypertension at a fixed 10% false-positive rate.

CONCLUSIONS

Maternal characteristics, MAP, UtAPI, PAPP-A and PlGF showed limited value as screening tests. Further research on biochemical and biophysical tests and algorithms combining these parameters is needed before first trimester screening for hypertensive disorders of pregnancy is included in antenatal care in Scandinavia.

Disease activity and left ventricular structure in patients with rheumatoid arthritis

OBJECTIVE

Increased left ventricular (LV) wall thickness/internal diameter ratio (relative wall thickness) was recently reported in RA patients. The aim of this study was to assess the association between LV relative wall thickness and RA disease activity.

METHODS

Clinical and echocardiographic data from 129 RA patients without established cardiovascular disease and 102 controls were used. RA disease activity was assessed by different composite scores and active RA defined by the Simplified Disease Activity Index (SDAI) level exceeding the cut-off for remission (SDAI >3.3).

RESULTS

The RA patients were on average 61.3 years old, 77% were women and 67% had active RA (SDAI >3.3). Patients with active RA had greater LV relative wall thickness and included more patients with treated hypertension (all P < 0.05), but had LV mass index and blood pressure comparable to patients in remission. Having active RA by the SDAI score (β = 0.20, P = 0.008) was also independently associated with greater LV relative wall thickness after adjusting for systolic blood pressure, wall stress, age and sex in a multivariate model. This association was robust also in secondary models including other disease activity composite scores such as the Clinical Disease Activity Index and 28-joint DAS.

CONCLUSION

Among RA patients, higher disease activity was independently associated with greater LV relative wall thickness, reflecting subclinical heart disease. The findings point to the importance of disease activity control in RA patients to prevent progression to clinical heart disease.

Comprehensive approach to diabetic nephropathy

Diabetic nephropathy (DN) is a leading cause of mortality and morbidity in patients with diabetes. This complication reflects a complex pathophysiology, whereby various genetic and environmental factors determine susceptibility and progression to end-stage renal disease. DN should be considered in patients with type 1 diabetes for at least 10 years who have microalbuminuria and diabetic retinopathy, as well as in patients with type 1 or type 2 diabetes with macroalbuminuria in whom other causes for proteinuria are absent. DN may also present as a falling estimated glomerular filtration rate with albuminuria as a minor presenting feature, especially in patients taking renin-angiotensin-aldosterone system inhibitors (RAASi). The pathological characteristic features of disease are three major lesions: diffuse mesangial expansion, diffuse thickened glomerular basement membrane, and hyalinosis of arterioles. Functionally, however, the pathophysiology is reflected in dysfunction of the mesangium, the glomerular capillary wall, the tubulointerstitium, and the vasculature. For all diabetic patients, a comprehensive approach to management including glycemic and hypertensive control with RAASi combined with lipid control, dietary salt restriction, lowering of protein intake, increased physical activity, weight reduction, and smoking cessation can reduce the rate of progression of nephropathy and minimize the risk for cardiovascular events. This review focuses on the latest published data dealing with the mechanisms, diagnosis, and current treatment of DN.

How aortic stiffness in postmenopausal women is related to common cardiovascular risk factors

Objective. Our study investigates major common cardiovascular risk factors relation with aortic stiffness on 269 postmenopausal women by global pulse wave velocity (PWVg), useful to relate PWVg to risk of major cardiovascular events. Patients and Methods. Women were categorized as hypertensive (H), hypercholesterolemic (C), or diabetic (D). Aortic stiffness was assessed by PWVg measured with pulsed Doppler, at the left ventricular outflow tract (LVOT) and at the right common femoral artery. Results. All population mean PWVg was 8.2 m/s. 85 (26.5%) women were H; mean PWVg was 7.9 m/s. HC women were 118 (36.7%), with mean PWVg 8.3 m/s. HD women were 30 (9.5%), with mean PWVg 7.8 m/s. HDC women were 36 (11.2%), with mean PWVg 9.3 m/s. 52 (16.1%) menstruate women without risk factor were control group (CG), with mean PWVg 6.5 m/s. Highly significant was the statistical difference in PWVg between HDC women and each other group: P < 0.0005 versus CG; P < 0.01 versus H; P < 0.03 versus HC, and P < 0.05 versus HD. No difference in PWG was observed comparing the other groups. There was difference for age among all groups, except for CG, made by younger women. Conclusion. PWVg was highly increased in postmenopausal women affected by hypertension, diabetes, and hypercholesterolemia all at once. Hypertension is the major determinant for PWVg. The only addition of diabetes or hypercholesterolemia did not increase significantly PWVg. Our study supports the usefulness of the assessment of aortic stiffness as a marker of cardiovascular disease.

Personalized approach to primary and secondary prevention of ischemic stroke

Primary and secondary prevention of ischemic stroke represents a significant part of stroke management and health care. Although there are official guidelines concerning stroke management, new knowledge are introduced to them with a slight delay. This article provides an overview of current information on primary and secondary prevention of ischemic stroke. It summarizes information especially in the field of cardioembolic stroke, the use of new anticoagulants and the management of carotid stenosis based on the results of recent clinical studies. The optimal approach in stroke management is to follow these recommendations, to know new strategies and to apply an individual personalized approach in our clinical decisions.

Proceedings from Duke resistant hypertension think tank

To identify patients at increased risk for cardiovascular outcomes, apparent treatment resistant hypertension (aTRH) is defined as having a blood pressure (BP) above goal despite the use of ≥3 antihypertensive therapies of different classes at maximally tolerated doses, ideally including a diuretic. In light of growing scientific interest in the treatment of this group, a multistakeholder think tank was convened to discuss the current state of knowledge, improve the care of these patients, and identify appropriate study populations for future observational and randomized trials in the field. Although recent epidemiologic studies in selected populations estimate that the prevalence of aTRH is 10% to 15% of hypertensive patients, further large-scale observational studies will be needed to better elucidate risk factors. To spur the development of therapies for aTRH, the development of an "aTRH" label for pharmacologic and device therapies with a developmental pathway including treatment added to the use of existing therapies is favored. Although demonstration of adequate BP lowering should be sufficient to gain Food and Drug Administration approval for therapies targeting aTRH, assessment of improvement in quality of life and cardiovascular outcomes is also desirable and considered in Centers for Medicare and Medicaid Services coverage decisions. Device trials under the aTRH label will need uniform and consistent processes for defining appropriate patient populations as well as postapproval registries assessing both long-term safety and duration of responses. Finally, patients with aTRH are likely to benefit from evaluation by a hypertension team to assure proper patient identification, diagnostic work-up, and therapeutic management before consideration of advanced or novel therapies to lower BP.

Expert consensus on blood pressure management of diabetic patients in China

This Expert Consensus proposed by the Chinese Society of Endocrinology (CSE) updates concepts on hypertension management in patients with diabetes. It focuses on clinical outcomes literature published within the past 5 years and currently in press, and incorporates these new observations into modifications of established guidelines. Complications and mortality in diabetic patients are increased when hypertension is present. The present update focuses on questions such as what to do when a diabetic patient has an elevated blood pressure level when therapy is initiated and whether combinations of agents should be used as soon as possible. Although the strategies and principles of treatment remain unchanged, approaches to specific patient-related issues influencing cardiovascular outcomes in people with diabetes have changed. Finally, an updated integrated management of multiple cardiovascular risk factors is provided and is suggested as a starting point to achieve blood pressure goals. In addition to controlling blood pressure, the CSE suggests that individualized strategies are equally important and that attention should be paid to other factors, including safety (which is the most important), feasibility, and health economic evaluation.

Evaluation of the efficacy and tolerability of fixed-dose combination therapy of azilsartan and amlodipine besylate in Japanese patients with grade I to II essential hypertension

BACKGROUND

Guidelines for the management of hypertension recommend using drugs with different mechanisms of action in antihypertensive regimens that include simple single-pill fixed-dose combination (FDC) products.

OBJECTIVE

The objective of this study was to compare the efficacy and tolerability of the FDC of azilsartan (AZI) and amlodipine besylate (AML) with those of AZI monotherapy and AML monotherapy in Japanese patients with grade 1 to 2 essential hypertension.

METHODS

This was a multicenter, randomized, double-blind, parallel-group study. After receiving placebo during a 4-week run-in period in a single-blind manner, patients were randomized to receive 1 of the following 5 treatments for 8 weeks: FDC containing AZI 20 mg and AML 5 mg (AZI/AML 20/5 mg), FDC containing AZI 20 mg and AML 2.5 mg (AZI/AML 20/2.5 mg), AZI 20 mg, AML 5 mg, or AML 2.5 mg once daily in a fasting or fed state. The primary end point was the change from baseline (week 0) in the seated trough diastolic blood pressure at week 8 (last observation carried forward [LOCF]), and the secondary end point was the change from baseline in the seated trough systolic blood pressure at week 8 (LOCF). Tolerability was assessed based on adverse events, vital signs, and physical examination findings.

RESULTS

Of the 800 patients who provided informed consent, 603 were randomized to receive AZI/AML 20/5 mg (150 patients), AZI/AML 20/2.5 mg (151 patients), AZI 20 mg (151 patients), AML 5 mg (75 patients), or AML 2.5 mg (76 patients). The mean baseline systolic/diastolic blood pressure was 160.7/100.3 mm Hg. The mean change from baseline in seated blood pressure at week 8 (LOCF) was -35.3/-22.3 mm Hg in the AZI/AML 20/5 mg group and -31.4/-19.2 mm Hg in the AZI/AML 20/2.5 mg group, indicating a reduction significantly greater than that in corresponding monotherapy groups (-21.5/-13.9 mm Hg in the AZI 20 mg group, -26.4/-15.5 mm Hg in the AML 5 mg group, and -19.3/-11.6 mm Hg in the AML 2.5 mg group; p < 0.0001 for all contrast tests). No remarkable difference was found in the incidences of adverse events, vital signs, and physical examination findings among the treatment groups.

CONCLUSION

This study found that the FDC of AZI/AML 20/5 mg and 20/2.5 mg exhibited greater antihypertensive effects compared with each monotherapy. The FDC of AZI/AML had a similar safety profile to that of each monotherapy and was tolerable to Japanese patients with grade 1 to 2 essential hypertension.

JAPAN PHARMACEUTICAL INFORMATION CENTER REGISTRATION

Japic CTI-111606.

Antihypertensive efficacy of triple combination perindopril/indapamide plus amlodipine in high-risk hypertensives: results of the PIANIST study (Perindopril-Indapamide plus AmlodipiNe in high rISk hyperTensive patients)

OBJECTIVE

Our objective was to evaluate a triple-drug antihypertensive strategy for blood pressure control in patients with difficult-to-treat hypertension.

DESIGN

The Perindopril-Indapamide plus AmlodipiNe in high rISk hyperTensive patients (PIANIST) trial was an observational, 4-month, open-label study.

PATIENTS AND INTERVENTIONS

A total of 4,731 patients at high or very high cardiovascular risk with hypertension that was not properly controlled [ , and for [corrected] whom study treatment (fixed-dose perindopril 10 mg/indapamide 2.5 mg + amlodipine 5 or 10 mg) was consistent with their existing therapeutic plan, were included.

OUTCOMES

One-sample t tests and Chi-squared tests were performed to evaluate changes in blood pressure.

RESULTS

Mean baseline office blood pressure (OBP) was 160.5 ± 13.3/93.8 ± 8.7 mmHg. After 4 months of therapy, OBP decreased by 28.3 ± 13.5/13.8 ± 9.4 to 132.2 ± 8.6/80.0 ± 6.6 mmHg (p < 0.0001). Blood pressure targets were reached by 72.0% of patients and by 81 and 91% of patients previously treated with an angiotensin-converting enzyme inhibitor/hydrochlorothiazide or an angiotensin receptor blocker/hydrochlorothiazide, respectively. Changes in OBP were 18.7 ± 8.3/9.7 ± 7.2 mmHg for grade 1 (n = 1,679), 30.4 ± 10.1/14.7 ± 8.6 mmHg for grade 2 (n = 2,397), and 45.4 ± 15.1/20.7 ± 12.1 mmHg for grade 3 patients (n = 655; all p < 0.0001). In patients who underwent ambulatory blood pressure monitoring (n = 104), 24-h mean blood pressure decreased from 147.4 ± 13.8/82.1 ± 11.9 to 122.6 ± 9.1/72.8 ± 7.4 mmHg (p < 0.0001). Ankle edema was infrequent (0.2% of patients).

CONCLUSION

Triple combination perindopril/indapamide/amlodipine was effectively and safely administered to a large population of high- and very high-risk hypertensive patients who had not reached target OBP values with previous treatment.

Apelin and relaxin plasma levels in young healthy offspring of patients with essential hypertension

Epidemiologic studies have shown that healthy offspring of hypertensive patients exhibit many features of the metabolic syndrome, such as hyperinsulinemia, insulin resistance, and lipid disorders, while hypoapelinemia and hyporelaxinemia may contribute to vascular damage that accelerates atherogenesis. The aim of this study was to determine apelin and relaxin plasma levels in the healthy offspring of hypertensive patients and to compare the findings with those of healthy offspring of healthy parents, matched for age, sex, and body mass index (BMI). Forty-six (24 men and 22 women) healthy offspring of hypertensive patients, mean age 18±3 years and BMI 22.4±1.4 kg/m(2) (group A), and 50 healthy offspring of healthy parents (28 men and 22 women), mean age 18±3.2 years and BMI 22.6±1.7 kg/m(2) (group B), were studied. The apelin and relaxin plasma levels (enzyme-linked immunosorbent assay method) were determined in the study population. The two groups were matched for age, sex, and BMI. Plasma apelin levels (6±3 vs 105 pg/mL, P<.001) and relaxin plasma levels (20±7 vs 29±8 pg/mL, P<.001) were significantly lower in group A compared with group B, respectively. Our findings suggest that healthy offspring of healthy parents have significantly lower plasma apelin and relaxin levels. This group of individuals needs closer follow-up and further examination.

Trends in antihypertensive treatment--lessons from the National Acute Stroke Israeli (NASIS) registry

BACKGROUND

Recent guidelines recommended different approaches to hypertension therapy. Our aim was to evaluate trends in blood pressure (BP) management among patients admitted with acute stroke over the past decade.

METHODS

The study population comprised 6279 consecutive patients, admitted with an acute stroke, and included in a national registry of three consecutive periods conducted during the years 2004-2010. We compared patients' characteristics and temporal trends of antihypertensive therapy utilization before hospital admission.

RESULTS

Among 4727 hypertensive patients, 3940 (83%) patients have taken antihypertensive drug therapy - 1430 (30.2%) a single agent, 1500 (31.7%) two agents and 1010 (21.4%) three or more antihypertensive agents. The most common class used was renin-angiotensin system (RAS) blockers (n = 2575; 54%) followed by beta-blockers (n = 2033; 43%). The same pattern was observed in patients treated with monotherapy. The use of RAS blockers and beta-blockers has increased over the years (p < 0.001 for both), whereas the use of diuretics decreased and the use of calcium antagonists remained stable. Among those who were treated with a single agent, the use of diuretics and calcium antagonists decreased and the use of RAS blockers increased, whereas the use of beta-blockers remained unchanged.

CONCLUSIONS

RAS blockers and beta-blockers are the most common antihypertensive agents used in Israel. Over time, the use of RAS blockers and beta-blockers has increased, whereas the use of diuretics decreased.

Candesartan cilexetil 32 mg/hydrochlorothiazide 25 mg in unselected patients with high or very high cardiovascular risk: efficacy, safety, and metabolic impact

BACKGROUND AND OBJECTIVES

Safety and efficacy of the fixed-dose combination candesartan cilexetil 32 mg/hydrochlorothiazide 25 mg has been demonstrated in a number of randomized clinical trials. Because stringent inclusion and exclusion criteria prohibit many high-risk patients from being investigated in clinical trials we aimed to assess the effectiveness, tolerability, and safety in a large unselected cohort of high-risk patients in primary care. The primary objective was the efficacy of candesartan cilexetil 32 mg/hydrochlorothiazide 25 mg in lowering the office-based blood pressure (BP). Secondary objectives were changes of metabolic parameters and safety.

METHODS

A multicenter, non-interventional study of patients with a BP ≥ 140 mmHg systolic and/or 90 mmHg diastolic and additional cardiovascular risk factors. Patients received the fixed-dose combination of candesartan cilexetil 32 mg and hydrochlorothiazide 25 mg for 24 weeks.

RESULTS

A total of 3,390 patients with a mean age of 61.7 ± 10.6 years, 57.8 % being male, and a mean body mass index of 29.7 kg/m(2) were documented. Of these, 70.9 % had at least one additional cardiovascular risk factor such as coronary artery disease (45.5 %) or diabetes mellitus (44.5 %). Baseline BP was 159.6 ± 15.3 over 93.5 ± 9.5 mmHg. BP at 24 weeks was reduced by 32.3 ± 15.8 systolic and 16.1 ± 10.2 mmHg diastolic compared with baseline (p < 0.001 each). Systolic BP (SBP) and diastolic BP (DBP) was normalized (<140/<90 mmHg) in 57.4 % of non-diabetic patients. An SBP <140 mmHg or SBP reduction of ≥ 20 mmHg was achieved by 77.9 % non-diabetic patients. Fasting plasma glucose (-5.9 mg/dL), glycosylated hemoglobin (-0.18 %), low-density lipoprotein cholesterol (-8.5 mg/dL) and triglycerides (-20.3 mg/dL) were reduced significantly, high-density lipoprotein was increased by 0.18 %, while potassium and creatinine levels remained stable. The proportion of patients with adverse drug reactions (ADRs) was 1.3 % (n = 61 events in 45 patients). There were ten serious ADRs in eight patients; four patients died without causal relationship to study drug.

CONCLUSIONS

The results confirm previous randomized clinical trial data supporting the effectiveness, tolerability, and safety of this fixed-dose combination in an unselected patient population with high cardiovascular risk.

Whole body bone tissue and cardiovascular risk in rheumatoid arthritis

Introduction. Atherosclerosis and osteoporosis share an age-independent bidirectional correlation. Rheumatoid arthritis (RA) represents a risk factor for both conditions. Objectives. The study aims to evaluate the connection between the estimated cardiovascular risk (CVR) and the loss of bone tissue in RA patients. Methods. The study has a prospective cross-sectional design and it includes female in-patients with RA or without autoimmune diseases; bone tissue was measured using whole body dual X-ray absorptiometry (wbDXA); CVR was estimated using SCORE charts and PROCAM applications. Results. There were 75 RA women and 66 normal women of similar age. The wbDXA bone indices correlate significantly, negatively, and age-independently with the estimated CVR. The whole body bone percent (wbBP) was a significant predictor of estimated CVR, explaining 26% of SCORE variation along with low density lipoprotein (P < 0.001) and 49.7% of PROCAM variation along with glycemia and menopause duration (P < 0.001). Although obese patients had less bone relative to body composition (wbBP), in terms of quantity their bone content was significantly higher than that of nonobese patients. Conclusions. Female patients with RA and female patients with cardiovascular morbidity have a lower whole body bone percent. Obese female individuals have higher whole body bone mass than nonobese patients.

Calcium channel blocker enhances beneficial effects of an angiotensin II AT1 receptor blocker against cerebrovascular-renal injury in type 2 diabetic mice

Recent clinical trials have demonstrated that combination therapy with renin-angiotensin system inhibitors plus calcium channel blockers (CCBs) elicits beneficial effects on cardiovascular and renal events in hypertensive patients with high cardiovascular risks. In the present study, we hypothesized that CCB enhances the protective effects of an angiotensin II type 1 receptor blocker (ARB) against diabetic cerebrovascular-renal injury. Saline-drinking type 2 diabetic KK-A^y mice developed hypertension and exhibited impaired cognitive function, blood-brain barrier (BBB) disruption, albuminuria, glomerular sclerosis and podocyte injury. These brain and renal injuries were associated with increased gene expression of NADPH oxidase components, NADPH oxidase activity and oxidative stress in brain and kidney tissues as well as systemic oxidative stress. Treatment with the ARB, olmesartan (10 mg/kg/day) reduced blood pressure in saline-drinking KK-A^y mice and attenuated cognitive decline, BBB disruption, glomerular injury and albuminuria, which were associated with a reduction of NADPH oxidase activity and oxidative stress in brain and kidney tissues as well as systemic oxidative stress. Furthermore, a suppressive dose of azelnidipine (3 mg/kg/day) exaggerated these beneficial effects of olmesartan. These data support the hypothesis that a CCB enhances ARB-associated cerebrovascular-renal protective effects through suppression of NADPH oxidase-dependent oxidative stress in type 2 diabetes.