Quality of life and cough on antihypertensive treatment: a randomised trial of eprosartan, enalapril and placebo

Adverse effects and non-adherence to antihypertensive medications in University of Gondar Comprehensive Specialized Hospital

Background

A considerable proportion of cardiovascular events could be attributed to poor adherence to antihypertensive medications. Adverse effects can be severe enough to affect adherence to antihypertensive medications. This study aimed to measure the contribution of adverse effects on antihypertensive medications adherence.

Methods

The study was conducted from May 1 to June 30, 2017, at the ambulatory clinic of University of Gondar Comprehensive Specialized Hospital (UOGCSH) in Gondar town. A binary logistic regression was performed to determine the significance of the association between adverse effects and adherence to antihypertensive medications. An institution-based cross-sectional study was conducted by administering a questionnaire to hypertensive patients who came for follow-up at the ambulatory clinic of UOGCSH. Level of adherence to antihypertensive medications was used as outcome measure.

Results

A total of 249 patients were included in the final analysis with a mean age of 56.51 years and a female majority (53%). The following variables were identified as predictors of poor adherence: tiredness [AOR (95% CI): 3.802 (1.723-8.391), p = 0.001], muscle pain [AOR (95% CI): 5.199 (1.407-19.214), p = 0.013], poor sleep [AOR (95% CI): 4.891 (1.578-15.160), p = 0.006] and, believing that the symptoms were caused by antihypertensive medications [AOR (95% CI): 3.249 (1.248-8.456), p = 0.016].

Conclusion

Adverse effect significantly contributes to antihypertensive medication non-adherence among hypertensive patients.

Blockade of the angiotensin system improves mental health domain of quality of life: A meta-analysis of randomized clinical trials

OBJECTIVE

It is unclear whether blockade of the angiotensin system has effects on mental health. Our objective was to determine the impact of angiotensin converting enzyme inhibitors and angiotensin II type 1 receptor (AT1R) blockers on mental health domain of quality of life.

STUDY DESIGN

Meta-analysis of published literature.

DATA SOURCES

PubMed and clinicaltrials.gov databases. The last search was conducted in January 2017.

STUDY SELECTION

Randomized controlled trials comparing any angiotensin converting enzyme inhibitor or AT1R blocker versus placebo or non-angiotensin converting enzyme inhibitor or non-AT1R blocker were selected. Study participants were adults without any major physical symptoms. We adhered to meta-analysis reporting methods as per PRISMA and the Cochrane Collaboration.

DATA SYNTHESIS

Eleven studies were included in the analysis. When compared with placebo or other antihypertensive medications, AT1R blockers and angiotensin converting enzyme inhibitors were associated with improved overall quality of life (standard mean difference = 0.11, 95% confidence interval = [0.08, 0.14], p < 0.0001), positive wellbeing (standard mean difference = 0.11, 95% confidence interval = [0.05, 0.17], p < 0.0001), mental (standard mean difference = 0.15, 95% confidence interval = [0.06, 0.25], p < 0.0001), and anxiety (standard mean difference = 0.08, 95% confidence interval = [0.01, 0.16], p < 0.0001) domains of QoL. No significant difference was found for the depression domain (standard mean difference = 0.05, 95% confidence interval = [0.02, 0.12], p = 0.15).

CONCLUSIONS

Use of angiotensin blockers and inhibitors for the treatment of hypertension in otherwise healthy adults is associated with improved mental health domains of quality of life. Mental health quality of life was a secondary outcome in the included studies. Research specifically designed to analyse the usefulness of drugs that block the angiotensin system is necessary to properly evaluate this novel psychiatric target.

Tolerability of angiotensin-receptor blockers in patients with intolerance to angiotensin-converting enzyme inhibitors: a systematic review and meta-analysis

BACKGROUND

Between 5% and 20% of patients treated with angiotensin-converting enzyme inhibitors (ACE inhibitors) develop intolerance. Angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) can be used as an alternative treatment.

OBJECTIVE

In this study we aimed to evaluate the tolerability of ARBs in patients with intolerance to ACE inhibitors.

DATA SOURCES

The electronic databases PubMed, MEDLINE/EMBASE via Dialog, CENTRAL, and ISI Web of Knowledge were searched.

STUDY SELECTION

Randomized controlled trials (RCTs) evaluating ARBs in patients with intolerance to ACE inhibitors were selected.

DATA SYNTHESIS

Risk ratio (RR) and 95% confidence intervals (CIs) were estimated assuming the random effects method. We found 11 RCTs comparing ARBs with ACE inhibitors, diuretics, or placebo, and one RCT comparing high-dose versus low-dose ARB.

RESULTS

ARBs had fewer cough events versus ACE inhibitors (RR 0.37; 95% CI 0.28, 0.48). ARBs had drug discontinuation (RR 0.99; 95% CI 0.84, 1.17) and cough risk (RR 1.01; 95% CI 0.74, 1.39) rates similar to placebo. Angioedema risk with ARBs was also similar to placebo (RR 1.62; 95% CI 0.17, 15.79). Compared with placebo, hypotension (RR 2.63; 95% CI 1.77, 3.92), renal dysfunction (RR 2.07; 95% CI 1.45, 2.95) and hyperkalemia (RR 3.37; 95% CI 1.60, 7.11) were more frequent with ARBs.

CONCLUSIONS

ACE inhibitor rechallenge should be discouraged in patients with previous intolerance to ACE inhibitors due to a higher risk of cough. ARBs had cough and angioedema incidences similar to placebo. Despite a significantly higher incidence of hypotension, renal dysfunction and hyperkalemia, discontinuation of ARBs was similar to placebo.

Antihypertensive effects and safety of eprosartan: a meta-analysis of randomized controlled trials

PURPOSE

The benefits of reducing blood pressure (BP) have been well established, but uncertainty remains about the comparative effects of different BP-lowering regimens. We aimed to estimate the efficacy and the tolerability of eprosartan compared with other agents as monotherapy.

METHODS

PubMed, EMBASE, and Cochrane Library were searched for relevant studies. A meta-analysis of randomized controlled trials (RCTs) meeting the criteria was performed using Review Manager and Stata/SE.

RESULTS

Twenty-two articles were ultimately included out of 78 studies, involving 6,460 patients. Eprosartan had a greater systolic blood pressure (SBP) reduction than placebo [weighted mean difference (WMD): 6.55, 95% confidence interval (CI) 4.86-8.25] and losartan (WMD: 2.24, 95% CI 0.08-4.40) and a greater diastolic blood pressure (DBP) reduction than placebo (WMD 3.95, 95% CI 2.77-5.13). Therapeutic response rate of BP favored eprosartan [risk ratio (RR) 1.13, 95% CI 1.03-1.24] compared with enalapril. There were no statistical differences in SBP or DBP reductions comparing eprosartan with enalapril or telmisartan. Original RCTs included comparing eprosartan with valsartan and nitrendipine reported no differences in BP-lowering efficacy.

CONCLUSIONS

Eprosartan monotherapy is equivalent to many first-line antihypertensive agents and is effective for the treatment of essential hypertension, especially for isolated systolic hypertension. The favorable efficacy and tolerability make eprosartan worthwhile to be taken into consideration by physicians.

Improving quality of life in hypertension management using a fixed-dose combination of olmesartan and amlodipine in primary care

OBJECTIVES

To assess quality of life (QoL) in unselected patients in primary care treated with a fixed-dose combination of olmesartan and amlodipine. Research design and methods. Multicenter, noninterventional, noncontrolled observational study in 8241 patients seen by 2187 physicians over 12 - 18 weeks.

MAIN OUTCOME MEASURES

Changes in QoL were assessed by using the Short Form 12 (SF-12) questionnaire completed by 5434 patients (65.9%) at baseline and 4924 patients (59.8%) at the follow-up visit.

RESULTS

Patients had a mean age of 62.8 ± 11.8 years (48.1% female), mean blood pressure [BP] at baseline was 161.8 ± 16.6/93.6 ± 10.2 mmHg and 74.8% had at least one co-morbid risk factor or condition. All 12 items of the SF-12 improved over the observational period (p < 0.0001) as did the physical (46.8 vs 40.4; p < 0.0001) and mental summary scores (52.4 vs 47.5; p < 0.0001). Correlations of changes in systolic and diastolic BP, pulse pressure and heart rate with scores were significant, although weak (maximum -0.2055 for physical health and changes in systolic blood pressure).

CONCLUSIONS

The fixed-dose combination of olmesartan and amlodipine significantly improves QoL in an unselected population of patients in primary-care practice. This might translate into improved patient compliance and improved long-term antihypertensive efficacy.

Quality of life in hypertension management using olmesartan in primary care

OBJECTIVE

Differences in quality of life (QoL) using antihypertensive drugs may account for differences in compliance, persistence and blood pressure control. As this is the prerequisite for cardiovascular risk reduction, QoL was investigated using highly tolerable drugs (such as olmesartan).

RESEARCH DESIGN/METHODS

The non-interventional study was carried out in 4252 primary care patients with 6 weeks of follow up. Documentation of patient characteristics included concomitant diseases and antihypertensive medication, blood pressure, pulse pressure, pulse rate and evaluation of QoL using the SF-12 questionnaire. Comparison of data at 6 weeks after adding or switching to olmesartan treatment (median dose: 20 mg) with baseline values.

MAIN OUTCOME MEASURES

Patients had mild-to-moderate hypertension, 52.6% of whom were male and the mean age was 60.5 +/- 11.9 years. Dyslipidaemia (38.3%), diabetes (20.9%) and coronary heart disease (16.4%) were the most frequent concomitant diseases. After 6 weeks, blood pressure was reduced by -22.8 +/- 14.1/-11.5 +/- 8.3 mmHg (p < 0.001 versus baseline). All items of the SF-12 questionnaire and both sum scores improved over the course of treatment (p < 0.001 versus baseline), and were well compatible with non-hypertensive controls. Improvements were higher when switching from alpha-blockers, calcium channel blockers, beta-blockers, diuretics and angiotensin-converting enzyme inhibitors as compared with angiotensin II type 1 receptors blockers (ARBs), in particular on the mental health scale (p < 0.001). Adverse events were rare (0.66%), with dizziness (n = 8; 0.19%) being the most frequent.

CONCLUSIONS

As was shown in the current study, patients on olmesartan treatment not only achieve adequate blood pressure control but also experienced a substantial improvement of QoL. This may contribute to long-term blood pressure control using ARBs.

Eprosartan

The angiotensin II receptor antagonist eprosartan is approved for the treatment of essential hypertension and may be administered using a convenient once-daily regimen. The drug is a well tolerated and effective antihypertensive agent with benefit in the secondary prevention of cerebrovascular events, independent of blood pressure (BP)-lowering effects. Eprosartan has a low potential for serious adverse events and has not been associated with clinically significant drug interactions, establishing it as a promising agent for combination antihypertensive strategies. Unlike ACE inhibitors such as enalapril, eprosartan does not have a tendency to cause persistent nonproductive cough. Accordingly, eprosartan represents a useful therapeutic option in the management of patients with hypertension, including those who have had a stroke and those with co-morbid type 2 diabetes mellitus.

The beneficial effect of regular endurance exercise training on blood pressure and quality of life in patients with hypertension

Regular aerobic exercise can reduce blood pressure and is recommended as part of the lifestyle modification to reduce high blood pressure and cardiovascular risk. Hypertension itself, or/and pharmacological treatment for hypertension is associated with adverse effects on some aspects of quality of life. This study was performed to evaluate the effects of regular endurance exercise training on quality of life and blood pressure. Patients with mild to moderate hypertension (systolic blood pressure 140-180 or diastolic blood pressure 90-110 mm Hg) were randomized to a moderate-intensity aerobic exercise group training for 3 sessions/week over 10 weeks or to a non-exercising control group. Health-related quality of life was assessed with the Short Form 36-item Health Survey (SF-36) at baseline and after 6 and 10 weeks. In the 102 subjects (47 male, mean age 47 years) who completed the study, reductions in blood pressure in the exercise group at 10 weeks (-13.1/-6.3 mm Hg) were significant (P < 0.001) compared to baseline and to the control group (-1.5/+6.0 mm Hg). Unlike the control group, the exercise group showed an increase in exercise capacity from 8.2 +/- 1.6 to 10.8 +/- 2.2 METS (P < 0.01) and showed higher scores on 7 out of 8 subscales (P < 0.05) of the SF-36. Improvement in bodily pain and general health sub-scores correlated with reduction in systolic blood pressure. Regular endurance training improves both blood pressure and quality of life in hypertensive patients and should be encouraged more widely.

Diabetes, hypertension, and cardiovascular derangements: Pathophysiology and management

Hypertension frequently coexists with diabetes mellitus, occurring twice as frequently in diabetic as in nondiabetic persons. It accounts for up to 75% of added cardiovascular disease (CVD) risk in people with diabetes, contributing significantly to the overall morbidity and mortality in this high-risk population. Patients with hypertension are two times more prone to have diabetes than are normotensive persons. Hypertension substantially increases the risk for coronary heart disease (CHD), stroke, retinopathy, and nephropathy. In patients with type 2 diabetes, hypertension usually clusters with the other components of the cardiometabolic syndrome, such as microalbuminuria, central obesity, insulin resistance, dyslipidemia, hypercoagulation, increased inflammation, and left ventricular hypertrophy (LVH). In type 1 diabetes, hypertension often occurs subsequent to the development of diabetic nephropathy. Hypertension in people with diabetes is characterized by volume expansion, increased salt sensitivity, isolated systolic blood pressure (BP) elevation, loss of the nocturnal dipping of BP and pulse, and increased propensity toward orthostatic hypotension and albuminuria. Among the treatment strategies tested in hypertensive diabetic persons, low-density lipoprotein (LDL)-cholesterol lowering to less than 100 mg/dL and aggressive BP control to less than 130/80 mm Hg have proven effective in CVD risk reduction. The combination of two or more drugs is usually necessary to achieve the target BP.

A Double Blind Randomized Trial to Compare the Effects of Eprosartan and Enalapril on Blood Pressure, Platelets, and Endothelium Function in Patients With Essential Hypertension

The renin-angiotensin system is the major contributor to development of hypertension, atherosclerosis, and many other cardiovascular diseases. Angiotensin II, one of the main effectors of this system, contributes to the pathogenesis of hypertension and plays an important role in monocyte, platelet, and endothelium interactions. The effects on platelet and endothelial function, either by angiotensin converting enzyme inhibitors or angiotensin receptor antagonists, are still not well understood. A double-blind, randomized, prospective trial of either enalapril (10-20 mg daily) or eprosartan (400-800 mg daily) over a 10-week period was conducted in 42 patients (27 males, 15 females). Platelet activation was evaluated by measuring platelet factor 4 (PF-4), beta-thromboglobulin (beta-TG), the ratio of platelet factor 4 to beta-thromboglobulin, and endothelial function by measuring total plasma nitrate levels, von Willebrand factor (vWF) levels, and blood flow using venous occlusive plethysmography. After a 10-week treatment with enalapril or eprosartan, the sitting blood pressure in both the enalapril group (from 152.2 +/- 18.7 mmHg to 141.9 +/- 23.5 mmHg, P < 0.05) and eprosartan group (from 151 +/- 10.0 mmHg to 142.3 +/- 12.9 mmHg, P < 0.05) was significantly reduced. Significant diastolic blood pressure (DPB) reduction (from 94 +/- 8.7 to 84.5 +/- 9.6 mmHg, P < 0.05) and a greater DBP reduction response were found in the eprosartan group (63% in eprosartan versus 25% in enalapril). Additionally, dose-dependent reductions in the indices of platelet activation and endothelial dysfunction were observed in patients administered high dose treatments of eprosartan and enalapril, and the beneficial effects of these agents were not correlated with the reduction of blood pressure using both agents. Eprosartan is effective and well-tolerated in the treatment of mid-to-moderate hypertension, and the DBP response reduction to eprosartin was better than that to enalapril. A high dose of either eprosartan or enalapril significantly decreased the indices of platelet activation and endothelial dysfunction in hypertensive patients. The benefits of both agents cannot be explained solely by their antihypertensive effects and possibly may be mediated through their unique effect on angiotensin blockade.

Risk-benefit assessment of angiotensin II receptor antagonists

Inhibiting the renin-angiotensin-aldosterone system through the use of angiotensin-converting enzyme (ACE) inhibitors has proven very useful in the treatment of hypertension, congestive heart failure (CHF) and progressive renal failure. More recently, agents that directly block the angiotensin II Type 1 (AT(1)) receptor--angiotensin II receptor antagonists (AIIRAs)--have been developed. These agents are thought to have a more specific mechanism of action since they do not affect other hormone systems as do the ACE inhibitors. Whether such specificity results in a different efficacy profile is still being determined. However, these drugs are extremely well-tolerated and very safe. AIIRAs are effective in the reduction of both systolic and diastolic blood pressure and compare favourably to other classes of agents. Recent results indicate that at least one AIIRA has a favourable effect on stroke in hypertensive patients with left ventricular hypertrophy. Additional studies with other members of the class will provide further information on similar outcomes. In CHF patients, ACE inhibitors remain the drug of choice and AIIRAs are best utilised in patients who cannot tolerate an ACE inhibitor or in those receiving an ACE inhibitor who cannot tolerate a beta-blocker and need additional therapy. AIIRAs are effective in slowing the progression of renal failure in patients with Type II diabetes and may be effective in other proteinuric conditions. Whether they are more or less effective than ACE inhibitors is unknown. Overall, AIIRAs represent an important addition to the armamentarium of cardiovascular therapies with an excellent safety record and an emerging profile of utility in multiple cardiovascular conditions.