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Effect of Calcium Channel Blockers versus Diuretics for Hypertension. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:3739463. [PMID: 36017016 PMCID: PMC9388284 DOI: 10.1155/2022/3739463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 12/04/2022]
Abstract
Background Although calcium channel blockers (CCBs) are recognized as clinical first-line agents for the treatment of hypertension, their use in combination with diuretics in cardiovascular disease caused by hypertension remains controversial. Methods We searched the three major databases of the Cochrane Library, EMBASE, and PubMed for the terms “calcium channel blockers,” “thiazide diuretics,” “loop diuretics,” and “hypertension,” “randomized controlled trials” and “meta-analysis trials.” These terms were searched from January 1991 to October 2021. Results For the primary outcome, in 5 studies including 35,057 patients, there was no statistically significant difference in all-cause mortality with calcium channel blockers compared with diuretics (RR = 0.98, 95% CI 0.92–1.04, I2 = 0). In four studies including 33,643 patients with major cardiovascular events, there was no statistically significant difference in major cardiovascular events with calcium channel blockers compared with diuretics (RR = 1.00, 95% CI 1.04–1.09, I2 = 0). Conclusion There is no statistically significant difference between calcium channel blockers and diuretics in terms of cardiovascular clinical prognosis in hypertensive patients, but there are positive implications for clinical guidance, which need to be fully validated in new large randomized controlled trials.
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Carland C, Hansra B, Parsons C, Lyubarova R, Khandelwal A. Adequate enrollment of women in cardiovascular drug trials and the need for sex-specific assessment and reporting. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 17:100155. [PMID: 38559887 PMCID: PMC10978324 DOI: 10.1016/j.ahjo.2022.100155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 04/04/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of death for women in the United States and globally. There is an abundance of evidence-based trials evaluating the efficacy of drug therapies to reduce morbidity and mortality in CVD. Additionally, there are well-established influences of sex, through a variety of mechanisms, on pharmacologic treatments in CVD. Despite this, the majority of drug trials are not powered to evaluate sex-specific outcomes, and much of the data that exists is gathered post hoc and through meta-analysis. The FDA established a committee in 1993 to increase the enrollment of women in clinical trials to improve this situation. Several authors, reviewing committees, and professional societies have highlighted the importance of sex-specific analysis and reporting. Despite these statements, there has not been a major improvement in representation or reporting. There are ongoing efforts to assess trial design, female representation on steering committees, and clinical trial processes to improve the representation of women. This review will describe the pharmacologic basis for the need for sex-specific assessment of cardiovascular drug therapies. It will also review the sex-specific reporting of landmark drug trials in hypertension, coronary artery disease (CAD), hyperlipidemia, and heart failure (HF). In reporting enrollment of women, several therapeutic areas like antihypertensives and newer anticoagulation trials fare better than therapeutics for HF and acute coronary syndromes. Further, drug trials and cardiometabolic or lifestyle intervention trials had a higher percentage of female participants than the device or procedural trials.
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Affiliation(s)
- Corinne Carland
- Department of Medicine, University of Pennsylvania, United States of America
| | - Barinder Hansra
- Division of Cardiology and Department of Critical Care Medicine, UPMC, United States of America
| | - Cody Parsons
- Cardiovascular Health, Stanford Health Care, United States of America
| | - Radmila Lyubarova
- Division of Cardiology, Albany Medical College, United States of America
| | - Abha Khandelwal
- Division of Cardiology, Stanford School of Medicine, United States of America
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Zhu J, Chen N, Zhou M, Guo J, Zhu C, Zhou J, Ma M, He L. Calcium channel blockers versus other classes of drugs for hypertension. Cochrane Database Syst Rev 2022; 1:CD003654. [PMID: 35000192 PMCID: PMC8742884 DOI: 10.1002/14651858.cd003654.pub6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND This is the first update of a review published in 2010. While calcium channel blockers (CCBs) are often recommended as a first-line drug to treat hypertension, the effect of CCBs on the prevention of cardiovascular events, as compared with other antihypertensive drug classes, is still debated. OBJECTIVES To determine whether CCBs used as first-line therapy for hypertension are different from other classes of antihypertensive drugs in reducing the incidence of major adverse cardiovascular events. SEARCH METHODS For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials (RCTs) up to 1 September 2020: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 1), Ovid MEDLINE, Ovid Embase, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted the authors of relevant papers regarding further published and unpublished work and checked the references of published studies to identify additional trials. The searches had no language restrictions. SELECTION CRITERIA Randomised controlled trials comparing first-line CCBs with other antihypertensive classes, with at least 100 randomised hypertensive participants and a follow-up of at least two years. DATA COLLECTION AND ANALYSIS Three review authors independently selected the included trials, evaluated the risk of bias, and entered the data for analysis. Any disagreements were resolved through discussion. We contacted study authors for additional information. MAIN RESULTS This update contains five new trials. We included a total of 23 RCTs (18 dihydropyridines, 4 non-dihydropyridines, 1 not specified) with 153,849 participants with hypertension. All-cause mortality was not different between first-line CCBs and any other antihypertensive classes. As compared to diuretics, CCBs probably increased major cardiovascular events (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.00 to 1.09, P = 0.03) and increased congestive heart failure events (RR 1.37, 95% CI 1.25 to 1.51, moderate-certainty evidence). As compared to beta-blockers, CCBs reduced the following outcomes: major cardiovascular events (RR 0.84, 95% CI 0.77 to 0.92), stroke (RR 0.77, 95% CI 0.67 to 0.88, moderate-certainty evidence), and cardiovascular mortality (RR 0.90, 95% CI 0.81 to 0.99, low-certainty evidence). As compared to angiotensin-converting enzyme (ACE) inhibitors, CCBs reduced stroke (RR 0.90, 95% CI 0.81 to 0.99, low-certainty evidence) and increased congestive heart failure (RR 1.16, 95% CI 1.06 to 1.28, low-certainty evidence). As compared to angiotensin receptor blockers (ARBs), CCBs reduced myocardial infarction (RR 0.82, 95% CI 0.72 to 0.94, moderate-certainty evidence) and increased congestive heart failure (RR 1.20, 95% CI 1.06 to 1.36, low-certainty evidence). AUTHORS' CONCLUSIONS For the treatment of hypertension, there is moderate certainty evidence that diuretics reduce major cardiovascular events and congestive heart failure more than CCBs. There is low to moderate certainty evidence that CCBs probably reduce major cardiovascular events more than beta-blockers. There is low to moderate certainty evidence that CCBs reduced stroke when compared to angiotensin-converting enzyme (ACE) inhibitors and reduced myocardial infarction when compared to angiotensin receptor blockers (ARBs), but increased congestive heart failure when compared to ACE inhibitors and ARBs. Many of the differences found in the current review are not robust, and further trials might change the conclusions. More well-designed RCTs studying the mortality and morbidity of individuals taking CCBs as compared with other antihypertensive drug classes are needed for patients with different stages of hypertension, different ages, and with different comorbidities such as diabetes.
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Affiliation(s)
- Jiaying Zhu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Department of Emergency, Gui Zhou Provincial People's Hospital, Guiyang, China
| | - Ning Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Muke Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Cairong Zhu
- Epidemic Disease & Health Statistics Department, School of Public Health, Sichuan University, Chengdu, China
| | - Jie Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mengmeng Ma
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Du XL, Simpson LM, Tandy BC, Bettencourt J, Davis BR. Effects of Posttrial Antihypertensive Drugs on Morbidity and Mortality: Findings from 15-Year Passive Follow-Up after ALLHAT Ended. Int J Hypertens 2021; 2021:2261144. [PMID: 34925915 PMCID: PMC8677412 DOI: 10.1155/2021/2261144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/17/2021] [Accepted: 11/25/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) ended in 2002, but it is important to study its long-term outcomes during the posttrial period by incorporating posttrial antihypertensive medication uses in the analysis. PURPOSES The primary aim is to explore the patterns of antihypertensive medication use during the posttrial period from Medicare Part-D data over the 11-year period from 2007 to 2017. The secondary aim is to examine the potential effects of these posttrial antihypertensive medications on the observed mortality and morbidity benefits. METHODS This is a posttrial passive follow-up study of ALLHAT participants in 567 US centers in 1994-1998 with the last date of active in-trial follow-up on March 31, 2002, by linking with their Medicare and National Death Index data through 2017 among 8,007 subjects receiving antihypertensive drugs (3,637 for chlorthalidone, 2,189 for amlodipine, and 2,181 for lisinopril). Outcomes included posttrial antihypertensive drug use, all-cause mortality, and cardiovascular disease (CVD) mortality. RESULTS Of 8007 subjects, 3,637 participants were initially randomized to diuretic (chlorthalidone). The majority (67.9%) of them still received diuretics in 2007, and 52.7%, 47.2%, and 44.0% received β-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers (CCBs), respectively. Compared to participants who received diuretic-based antihypertensives, those who received CCB had a nonsignificantly higher risk of all-cause mortality (1.17, 0.99-1.37), whereas those who received ACE/ARB (angiotensin receptor blockers) had a significantly higher risk of all-cause mortality (1.26, 1.09-1.45). For the combined fatal or nonfatal hospitalized events, the risk of CVD was significantly higher in patients receiving CCB (1.30, 1.04-1.61) and ACE/ARB (1.49, 1.22-1.81) as compared to patients receiving diuretics. CONCLUSION After the conclusion of the ALLHAT, almost all patients switched to combination antihypertensive therapies, independently by the original drug class, and the combination therapies (mostly based on diuretics) reduced the incidence of major cardiovascular outcomes and mortality.
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Affiliation(s)
- Xianglin L. Du
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Lara M. Simpson
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Brian C. Tandy
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Judy Bettencourt
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Barry R. Davis
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
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Pothen L, Balligand JL. Legacy in Cardiovascular Risk Factors Control: From Theory to Future Therapeutic Strategies? Antioxidants (Basel) 2021; 10:antiox10111849. [PMID: 34829720 PMCID: PMC8614708 DOI: 10.3390/antiox10111849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 12/12/2022] Open
Abstract
In medicine, a legacy effect is defined as the sustained beneficial effect of a given treatment on disease outcomes, even after cessation of the intervention. Initially described in optimized control of diabetes, it was also observed in clinical trials exploring intensification strategies for other cardiovascular risk factors, such as hypertension or hypercholesterolemia. Mechanisms of legacy were particularly deciphered in diabetes, leading to the concept of metabolic memory. In a more discreet manner, other memory phenomena were also described in preclinical studies that demonstrated long-lasting deleterious effects of lipids or angiotensin II on vascular wall components. Interestingly, epigenetic changes and reactive oxygen species (ROS) appear to be common features of “memory” of the vascular wall.
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Zhu J, Chen N, Zhou M, Guo J, Zhu C, Zhou J, Ma M, He L. Calcium channel blockers versus other classes of drugs for hypertension. Cochrane Database Syst Rev 2021; 10:CD003654. [PMID: 34657281 PMCID: PMC8520697 DOI: 10.1002/14651858.cd003654.pub5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND This is the first update of a review published in 2010. While calcium channel blockers (CCBs) are often recommended as a first-line drug to treat hypertension, the effect of CCBs on the prevention of cardiovascular events, as compared with other antihypertensive drug classes, is still debated. OBJECTIVES To determine whether CCBs used as first-line therapy for hypertension are different from other classes of antihypertensive drugs in reducing the incidence of major adverse cardiovascular events. SEARCH METHODS For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials (RCTs) up to 1 September 2020: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 1), Ovid MEDLINE, Ovid Embase, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted the authors of relevant papers regarding further published and unpublished work and checked the references of published studies to identify additional trials. The searches had no language restrictions. SELECTION CRITERIA Randomised controlled trials comparing first-line CCBs with other antihypertensive classes, with at least 100 randomised hypertensive participants and a follow-up of at least two years. DATA COLLECTION AND ANALYSIS Three review authors independently selected the included trials, evaluated the risk of bias, and entered the data for analysis. Any disagreements were resolved through discussion. We contacted study authors for additional information. MAIN RESULTS This update contains five new trials. We included a total of 23 RCTs (18 dihydropyridines, 4 non-dihydropyridines, 1 not specified) with 153,849 participants with hypertension. All-cause mortality was not different between first-line CCBs and any other antihypertensive classes. As compared to diuretics, CCBs probably increased major cardiovascular events (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.00 to 1.09, P = 0.03) and increased congestive heart failure events (RR 1.37, 95% CI 1.25 to 1.51, moderate-certainty evidence). As compared to beta-blockers, CCBs reduced the following outcomes: major cardiovascular events (RR 0.84, 95% CI 0.77 to 0.92), stroke (RR 0.77, 95% CI 0.67 to 0.88, moderate-certainty evidence), and cardiovascular mortality (RR 0.90, 95% CI 0.81 to 0.99, low-certainty evidence). As compared to angiotensin-converting enzyme (ACE) inhibitors, CCBs reduced stroke (RR 0.90, 95% CI 0.81 to 0.99, low-certainty evidence) and increased congestive heart failure (RR 1.16, 95% CI 1.06 to 1.28, low-certainty evidence). As compared to angiotensin receptor blockers (ARBs), CCBs reduced myocardial infarction (RR 0.82, 95% CI 0.72 to 0.94, moderate-certainty evidence) and increased congestive heart failure (RR 1.20, 95% CI 1.06 to 1.36, low-certainty evidence). AUTHORS' CONCLUSIONS For the treatment of hypertension, there is moderate certainty evidence that diuretics reduce major cardiovascular events and congestive heart failure more than CCBs. There is low to moderate certainty evidence that CCBs probably reduce major cardiovascular events more than beta-blockers. There is low to moderate certainty evidence that CCBs reduced stroke when compared to angiotensin-converting enzyme (ACE) inhibitors and reduced myocardial infarction when compared to angiotensin receptor blockers (ARBs), but increased congestive heart failure when compared to ACE inhibitors and ARBs. Many of the differences found in the current review are not robust, and further trials might change the conclusions. More well-designed RCTs studying the mortality and morbidity of individuals taking CCBs as compared with other antihypertensive drug classes are needed for patients with different stages of hypertension, different ages, and with different comorbidities such as diabetes.
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Affiliation(s)
- Jiaying Zhu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ning Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Muke Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Cairong Zhu
- Epidemic Disease & Health Statistics Department, School of Public Health, Sichuan University, Chengdu, China
| | - Jie Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | | | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Viñas Esmel E, Naval Álvarez J, Sacanella Meseguer E. The Legacy Effect in the Prevention of Cardiovascular Disease. Nutrients 2020; 12:E3227. [PMID: 33105611 PMCID: PMC7690390 DOI: 10.3390/nu12113227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/15/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
The "legacy effect" describes the long-term benefits that may persist for many years after the end of an intervention period, involving different biological processes. The legacy effect in cardiovascular disease (CVD) prevention has been evaluated by a limited number of studies, mostly based on pharmacological interventions, while few manuscripts on dietary interventions have been published. Most of these studies are focused on intensive treatment regimens, whose main goal is to achieve tight control of one or more cardiovascular risk factors. This review aims to summarise the legacy effect-related results obtained in those studies and to determine the existence of this effect in CVD prevention. There is sufficient data to suggest the existence of a legacy effect after intensive intervention on cardiovascular risk factors; however, this effect is not equivalent for all risk factors and could be influenced by patient characteristics, disease duration, and the type of intervention performed. Currently, available evidence suggests that the legacy effect is greater in subjects with moderately-high cardiovascular risk but without CVD, especially in those patients with recent-onset diabetes. However, preventive treatment for CVD should not be discontinued in high-risk subjects, as the level of existing evidence on the legacy effect is low to moderate.
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Affiliation(s)
- Esther Viñas Esmel
- Department of Internal Medicine, Hospital Clínic, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; (E.V.E.); (J.N.Á.)
| | - José Naval Álvarez
- Department of Internal Medicine, Hospital Clínic, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; (E.V.E.); (J.N.Á.)
| | - Emilio Sacanella Meseguer
- Department of Internal Medicine, Hospital Clínic, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; (E.V.E.); (J.N.Á.)
- Ciber Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Juraschek SP, Simpson LM, Davis BR, Shmerling RH, Beach JL, Ishak A, Mukamal KJ. The effects of antihypertensive class on gout in older adults: secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. J Hypertens 2020; 38:954-960. [PMID: 31977576 DOI: 10.1097/hjh.0000000000002359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Gout is a common complication of blood pressure management and a frequently cited cause of medication nonadherence. Little trial evidence exists to inform antihypertensive selection with regard to gout risk. METHODS The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized clinical trial on the effects of first-step hypertension therapy with amlodipine, chlorthalidone, or lisinopril on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). Trial participants were linked to CMS and VA gout claims (ICD9 274.XX). We determined the effect of drug assignment on gout with Cox regression models. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) with gout. RESULTS Claims were linked to 23 964 participants (mean age 69.8 ± 6.8 years, 45% women, 31% black). Atenolol use was reported by 928 participants at the 1-month visit. Over a mean follow-up of 4.9 years, we documented 597 gout claims. Amlodipine reduced the risk of gout by 37% (hazard ratio 0.63; 95% CI 0.51--0.78) compared with chlorthalidone and by 26% (hazard ratio 0.74; 95% CI 0.58--0.94) compared with lisinopril. Lisinopril nonsignificantly lowered gout risk compared with chlorthalidone (hazard ratio 0.85; 95% CI 0.70--1.03). Atenolol use was not associated with gout risk (adjusted hazard ratio 1.18; 95% CI 0.78--1.80). Gout risk reduction was primarily observed after 1 year of follow-up. CONCLUSION Amlodipine lowered long-term gout risk compared with lisinopril or chlorthalidone. This finding may be useful in cases where gout risk is a principal concern among patients being treated for hypertension.This trial is registered at clinicaltrials.gov, number: NCT00000542.
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Affiliation(s)
- Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Lara M Simpson
- Department of Biostatistics, Health Science Center at Houston, University of Texas, Houston, Texas
| | - Barry R Davis
- Department of Biostatistics, Health Science Center at Houston, University of Texas, Houston, Texas
| | - Robert H Shmerling
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jennifer L Beach
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Anthony Ishak
- Healthcare Associates, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kenneth J Mukamal
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Legacy Effect in the Treatment of Hypertension: Persistent Cardiovascular Protection after Conclusion of Randomized Clinical Trials in Hypertension. Curr Hypertens Rep 2019; 21:85. [DOI: 10.1007/s11906-019-0991-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Legacy effect on mortality in antihypertensive drug comparison trials. J Hypertens 2019; 37:1532-1534. [DOI: 10.1097/hjh.0000000000002123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Dillon P, Smith SM, Gallagher PJ, Cousins G. Association between gaps in antihypertensive medication adherence and injurious falls in older community-dwelling adults: a prospective cohort study. BMJ Open 2019; 9:e022927. [PMID: 30837246 PMCID: PMC6429731 DOI: 10.1136/bmjopen-2018-022927] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE Growing evidence suggests that older adults are at an increased risk of injurious falls when initiating antihypertensive medication, while the evidence regarding long-term use of antihypertensive medication and the risk of falling is mixed. However, long-term users who stop and start these medications may have a similar risk of falling to initial users of antihypertensive medication. Our aim was to evaluate the association between gaps in antihypertensive medication adherence and injurious falls in older (≥65 years) community-dwelling, long-term (≥≥1 year) antihypertensive users. DESIGN Prospective cohort study. SETTING Irish Community Pharmacy. PARTICIPANTS Consecutive participants presenting a prescription for antihypertensive medication to 106 community pharmacies nationwide, community-dwelling, ≥65 years, with no evidence of cognitive impairment, taking antihypertensive medication for ≥1 year (n=938). MEASURES Gaps in antihypertensive medication adherence were evaluated from linked dispensing records as the number of 5-day gaps between sequential supplies over the 12-month period prior to baseline. Injurious falls during follow-up were recorded via questionnaire during structured telephone interviews at 12 months. RESULTS At 12 months, 8.1% (n=76) of participants reported an injurious fall requiring medical attention. The mean number of 5-day gaps in medication refill behaviour was 1.47 (SD 1.58). In adjusted, modified Poisson models, 5-day medication refill gaps at baseline were associated with a higher risk of an injurious fall during follow-up (aRR 1.18, 95% CI 1.02 to 1.37, p=0.024). CONCLUSION Each 5-day gap in antihypertensive refill adherence increased the risk of self-reported injurious falls by 18%. Gaps in antihypertensive adherence may be a marker for increased risk of injurious falls. It is unknown whether adherence-interventions will reduce subsequent risk. This finding is hypothesis generating and should be replicated in similar populations.
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Affiliation(s)
- Paul Dillon
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Susan M Smith
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Gráinne Cousins
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
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12
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Gupta A, Mackay J, Whitehouse A, Godec T, Collier T, Pocock S, Poulter N, Sever P. Long-term mortality after blood pressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomised factorial trial. Lancet 2018; 392:1127-1137. [PMID: 30158072 DOI: 10.1016/s0140-6736(18)31776-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 07/23/2018] [Accepted: 07/26/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND In patients with hypertension, the long-term cardiovascular and all-cause mortality effects of different blood pressure-lowering regimens and lipid-lowering treatment are not well documented, particularly in clinical trial settings. The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy Study reports mortality outcomes after 16 years of follow-up of the UK participants in the original ASCOT trial. METHODS ASCOT was a multicentre randomised trial with a 2 × 2 factorial design. UK-based patients with hypertension were followed up for all-cause and cardiovascular mortality for a median of 15·7 years (IQR 9·7-16·4 years). At baseline, all patients enrolled into the blood pressure-lowering arm (BPLA) of ASCOT were randomly assigned to receive either amlodipine-based or atenolol-based blood pressure-lowering treatment. Of these patients, those who had total cholesterol of 6·5 mmol/L or lower and no previous lipid-lowering treatment underwent further randomisation to receive either atorvastatin or placebo as part of the lipid-lowering arm (LLA) of ASCOT. The remaining patients formed the non-LLA group. A team of two physicians independently adjudicated all causes of death. FINDINGS Of 8580 UK-based patients in ASCOT, 3282 (38·3%) died, including 1640 (38·4%) of 4275 assigned to atenolol-based treatment and 1642 (38·1%) of 4305 assigned to amlodipine-based treatment. 1768 of the 4605 patients in the LLA died, including 903 (39·5%) of 2288 assigned placebo and 865 (37·3%) of 2317 assigned atorvastatin. Of all deaths, 1210 (36·9%) were from cardiovascular-related causes. Among patients in the BPLA, there was no overall difference in all-cause mortality between treatments (adjusted hazard ratio [HR] 0·90, 95% CI 0·81-1·01, p=0·0776]), although significantly fewer deaths from stroke (adjusted HR 0·71, 0·53-0·97, p=0·0305) occurred in the amlodipine-based treatment group than in the atenolol-based treatment group. There was no interaction between treatment allocation in the BPLA and in the LLA. However, in the 3975 patients in the non-LLA group, there were fewer cardiovascular deaths (adjusted HR 0·79, 0·67-0·93, p=0·0046) among those assigned to amlodipine-based treatment compared with atenolol-based treatment (p=0·022 for the test for interaction between the two blood pressure treatments and allocation to LLA or not). In the LLA, significantly fewer cardiovascular deaths (HR 0·85, 0·72-0·99, p=0·0395) occurred among patients assigned to statin than among those assigned placebo. INTERPRETATION Our findings show the long-term beneficial effects on mortality of antihypertensive treatment with a calcium channel blocker-based treatment regimen and lipid-lowering with a statin: patients on amlodipine-based treatment had fewer stroke deaths and patients on atorvastatin had fewer cardiovascular deaths more than 10 years after trial closure. Overall, the ASCOT Legacy study supports the notion that interventions for blood pressure and cholesterol are associated with long-term benefits on cardiovascular outcomes. FUNDING Pfizer.
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Affiliation(s)
- Ajay Gupta
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Judith Mackay
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Andrew Whitehouse
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Thomas Godec
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Neil Poulter
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Peter Sever
- National Heart and Lung Institute, Imperial College London, London, UK.
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Affiliation(s)
- Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, The University of Alabama at Birmingham, Birmingham 1034, AL, USA.
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Barzilay JI, Davis BR, Pressel SL, Ghosh A, Rahman M, Einhorn PT, Cushman WC, Whelton PK, Wright JT. The Effects of eGFR Change on CVD, Renal, and Mortality Outcomes in a Hypertensive Cohort Treated With 3 Different Antihypertensive Medications. Am J Hypertens 2018; 31:609-614. [PMID: 29360915 DOI: 10.1093/ajh/hpx223] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 01/10/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Impaired renal function is a risk factor for cardiovascular disease, end-stage renal disease (ESRD), and mortality. The impact of short-term renal function decline on outcomes is less well studied. The association of antihypertensive medications with the impact of short-term estimated glomerular filtration rate (eGFR) decline is not known. METHODS We examined 20,207 hypertensive participants with baseline and 2-year creatinine levels from which eGFR changes were estimated. The associations between eGFR change with incident coronary heart disease (CHD), stroke, heart failure (HF), all-cause mortality, and ESRD during 2.9 years of in-trial follow up, and with mortality during in-trial and post-trial follow-up (7.6 years), were studied. Results were assessed by primary hypertension (HTN) treatment (chlorthalidone, lisinopril, and amlodipine) and adjusted for baseline eGFR levels. RESULTS In the short run, an eGFR decline below the cohort median (-1.28 ml/minute/1.73 m2/2 years) vs. above the median, or a 5 ml/min/1.73 m2/year decline vs. no decline, was associated with significant hazard risk for CHD (1.06-1.28), HF (1.24-1.91), ESRD (2.84-6.01), and mortality (1.08-1.19), but not with stroke risk. In the long term, there was a significant association with mortality (1.11-1.34). Interaction terms for outcomes by antihypertensive treatments were not statistically significant except for ESRD between amlodipine vs. chlorthalidone (hazard ratio: 3.17 [2.59, 3.88] vs. 2.41 [1.98, 2.97]; P interaction = 0.005) for a 5 ml/min/1.73 m2/year eGFR decline. CONCLUSION Decline in eGFR over 2 years is associated with increased risk of clinical outcomes beyond the effects of baseline eGFR. These risks were the same irrespective of the primary medication used to treat HTN.
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Affiliation(s)
- Joshua I Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia, and the Division of Endocrinology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Barry R Davis
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas, USA
| | - Sara L Pressel
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas, USA
| | - Alokananda Ghosh
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas, USA
| | - Mahboob Rahman
- Division of Nephrology, University Hospitals Case Western Reserve University, Cleveland, Ohio, USA
| | - Paula T Einhorn
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - William C Cushman
- Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Paul K Whelton
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Jackson T Wright
- Division of Nephrology and Hypertension, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
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15
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Influence of Prevalent and Incident Atrial Fibrillation on Post-Trial Major Events in ALLHAT. J Natl Med Assoc 2017; 109:172-181. [PMID: 28987246 DOI: 10.1016/j.jnma.2017.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 02/14/2017] [Accepted: 02/14/2017] [Indexed: 11/20/2022]
Abstract
AIMS Limited information is available on long-term antihypertensive and lipid-lowering therapy effects on hypertensive patients with atrial fibrillation/flutter (AF/AFL) compared to those without. AF/AFL at baseline or during the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) (mean follow-up 4.9 years) markedly increased risk of stroke, heart failure, CHD, and all-cause mortality. We aimed to determine if AF/AFL continued to impact outcomes during post-trial follow-up (mean 3.8 years). METHODS Patients were randomized to chlorthalidone, amlodipine, or lisinopril, and to pravastatin vs. usual care in the lipid-lowering trial (LLT). Of 31,473 available subjects, AF/AFL occurred in 854; 383/14,371 chlorthalidone (2.7%), 247/8565 amlodipine (2.9%), and 224/8537 lisinopril (2.6%). Post-hoc analyses utilized administrative databases for post-trial data. Individuals with AF/AFL were compared to those without during post-trial. Outcomes were analyzed by treatment groups for the antihypertensive and LLT trials. RESULTS Among 854 AF/AFL participants, 491 (57.5%) died: 220 in-trial, 271 post-trial. Ten-year all-cause mortality rates for those with in-trial AF/AFL were similar for chlorthalidone and lisinopril, but lower for amlodipine (68, 66, and 49 per 100 persons, respectively); adjusted HR for amlodipine vs. chlorthalidone was 0.68 (95% CI, 0.54-0.87). Ten-year all-cause mortality rates were 57 vs. 65 per 100 persons (pravastatin vs. usual care); non-CVD mortality rates, 18 vs. 39 per 100 persons (pravastatin vs. usual care) (adjusted HR = 0.46, 95% CI, 0.24-0.86). CONCLUSION Post-trial follow-up revealed continued deleterious AF/AFL effects. The amlodipine (ALLHAT) and pravastatin (ALLHAT-LLT) treatment groups showed lower all-cause and non-CVD mortality compared to the chlorthalidone and usual-care groups, respectively.
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Sahle BW, Owen AJ, Wing LMH, Beilin LJ, Krum H, Reid CM. Long-term survival following the development of heart failure in an elderly hypertensive population. Cardiovasc Ther 2017; 35. [PMID: 28859261 DOI: 10.1111/1755-5922.12303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 06/23/2017] [Accepted: 08/22/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Available data on the prognosis of heart failure (HF) patients are predominantly limited to patients diagnosed at time of hospitalization. AIMS To describe the long-term survival of incident HF patients and identify clinical characteristics associated with mortality. METHODS The Second Australian National Blood Pressure Study (ANBP2) randomized 6083 hypertensive subjects aged 65-84 years to angiotensin-converting enzyme (ACE) inhibitor or thiazide diuretic-based therapy and followed them for a median of 4.1 years. One hundred forty-five participants who developed HF and 5938 who remained free from HF during the trial period were followed for a median of 6.7 years during a posttrial follow-up. RESULTS Three quarters, 110 (76%) of HF patients had died at the end of the follow-up. The five- and ten-year survival rates following HF diagnosis during the trial period were 37% and 15%, respectively, in men, compared with 60% and 33%, respectively, in women. In non-heart failure participants, the five- and ten-year survival rates, following enrollment into the study, were 92% and 76%, respectively. Mortality following HF diagnosis increased with advancing age (HR = 1.09, 95% CI: 1.04-1.33). In addition, male gender and preexisting diabetes were predictive of mortality, while ACE inhibitor-based therapy for the initial trial was associated with 39% decrease (HR = 0.61, 95% CI: 0.41-0.91) in mortality compared with a thiazide diuretic-based regimen. CONCLUSIONS Long-term survival in elderly HF patients is poor, especially in men. Mortality in HF patients increased progressively with advancing age, while allocation to the ACE inhibitor-based regimen for the initial trial significantly improved HF outcome.
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Affiliation(s)
- Berhe W Sahle
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic., Australia.,School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Alice J Owen
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - Lindon M H Wing
- School of Medicine, Flinders University, Adelaide, SA, Australia
| | - Lawrence J Beilin
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Henry Krum
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic., Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia.,School of Public Health, Curtin University, Perth, WA, Australia
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17
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Dhruva SS, Huang C, Spatz ES, Coppi AC, Warner F, Li SX, Lin H, Xu X, Furberg CD, Davis BR, Pressel SL, Coifman RR, Krumholz HM. Heterogeneity in Early Responses in ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). Hypertension 2017; 70:94-102. [PMID: 28559399 DOI: 10.1161/hypertensionaha.117.09221] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 02/17/2017] [Accepted: 03/13/2017] [Indexed: 01/07/2023]
Abstract
Randomized trials of hypertension have seldom examined heterogeneity in response to treatments over time and the implications for cardiovascular outcomes. Understanding this heterogeneity, however, is a necessary step toward personalizing antihypertensive therapy. We applied trajectory-based modeling to data on 39 763 study participants of the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) to identify distinct patterns of systolic blood pressure (SBP) response to randomized medications during the first 6 months of the trial. Two trajectory patterns were identified: immediate responders (85.5%), on average, had a decreasing SBP, whereas nonimmediate responders (14.5%), on average, had an initially increasing SBP followed by a decrease. Compared with those randomized to chlorthalidone, participants randomized to amlodipine (odds ratio, 1.20; 95% confidence interval [CI], 1.10-1.31), lisinopril (odds ratio, 1.88; 95% CI, 1.73-2.03), and doxazosin (odds ratio, 1.65; 95% CI, 1.52-1.78) had higher adjusted odds ratios associated with being a nonimmediate responder (versus immediate responder). After multivariable adjustment, nonimmediate responders had a higher hazard ratio of stroke (hazard ratio, 1.49; 95% CI, 1.21-1.84), combined cardiovascular disease (hazard ratio, 1.21; 95% CI, 1.11-1.31), and heart failure (hazard ratio, 1.48; 95% CI, 1.24-1.78) during follow-up between 6 months and 2 years. The SBP response trajectories provided superior discrimination for predicting downstream adverse cardiovascular events than classification based on difference in SBP between the first 2 measurements, SBP at 6 months, and average SBP during the first 6 months. Our findings demonstrate heterogeneity in response to antihypertensive therapies and show that chlorthalidone is associated with more favorable initial response than the other medications.
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Affiliation(s)
- Sanket S Dhruva
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Chenxi Huang
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Erica S Spatz
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Andreas C Coppi
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Frederick Warner
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Shu-Xia Li
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Haiqun Lin
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Xiao Xu
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Curt D Furberg
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Barry R Davis
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Sara L Pressel
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Ronald R Coifman
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Harlan M Krumholz
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.).
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18
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Jackson EA, Ruppert K, Derby CA, Lian Y, Neal-Perry G, Habel LA, Tepper PG, Harlow SD, Solomon DH. Effect of Race and Ethnicity on Antihypertensive Medication Utilization Among Women in the United States: Study of Women's Health Across the Nation (SWAN). J Am Heart Assoc 2017; 6:JAHA.116.004758. [PMID: 28232324 PMCID: PMC5524010 DOI: 10.1161/jaha.116.004758] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Antihypertensive medication use may vary by race and ethnicity. Longitudinal antihypertensive medication use patterns are not well described in women. Methods and Results Participants from the Study of Women's Health Across the Nation (SWAN), a prospective cohort of women (n=3302, aged 42–52), who reported a diagnosis of hypertension or antihypertensive medication use at any annual visit were included. Antihypertensive medications were grouped by class and examined by race/ethnicity adjusting for potential confounders in logistic regression models. A total of 1707 (51.7%) women, mean age 50.6 years, reported hypertension or used antihypertensive medications at baseline or during follow‐up (mean 9.1 years). Compared with whites, blacks were almost 3 times as likely to receive a calcium channel blocker (odds ratio, 2.92; 95% CI, 2.24–3.82) and twice as likely to receive a thiazide diuretic (odds ratio, 2.38; 95% CI, 1.93–2.94). Blacks also had a higher probability of reporting use of ≥2 antihypertensive medications (odds ratio, 1.95; 95% CI, 1.55–2.45) compared with whites. Use of angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers and thiazide diuretics increased over time for all racial/ethnic groups. Contrary to our hypothesis, rates of β‐blocker usage did not decrease over time. Conclusions Among this large cohort of multiethnic midlife women, use of antihypertensive medications increased over time, with angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers becoming the most commonly used antihypertensive medication, even for blacks. Thiazide diuretic utilization increased over time for all race/ethnic groups as did use of calcium channel blockers among blacks; both patterns are in line with guideline recommendations for the management of hypertension.
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Affiliation(s)
- Elizabeth A Jackson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Kristine Ruppert
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA
| | - Carol A Derby
- The Saul R. Korey Department of Neurology, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Yinjuan Lian
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA
| | - Genevieve Neal-Perry
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Laurel A Habel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Ping G Tepper
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Daniel H Solomon
- Division of Rheumatology, Division of Pharmacoepidemiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Hyponatremia is Associated with Fluid Imbalance and Adverse Renal Outcome in Chronic Kidney Disease Patients Treated with Diuretics. Sci Rep 2016; 6:36817. [PMID: 27841359 PMCID: PMC5108044 DOI: 10.1038/srep36817] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 10/18/2016] [Indexed: 12/21/2022] Open
Abstract
Chronic kidney disease (CKD) is frequently complicated with hyponatremia, probably because of fluid overload or diuretic usage. Hyponatremia in CKD population is associated with increased mortality, but the effect on renal outcome was unknown. We investigated whether hyponatremia is associated with fluid status and is a prognostic indicator for adverse outcomes in a CKD cohort of 4,766 patients with 1,009 diuretic users. We found that diuretic users had worse clinical outcomes compared with diuretic non-users. Hyponatremia (serum sodium <135 mEq/L) was associated with excessive volume and volume depletion, measured as total body water by bioimpedance analysis, in diuretic users, but not in diuretic non-users. Furthermore, in Cox survival analysis, hyponatremia was associated with an increased risk for renal replacement therapy (hazard ratio, 1.45; 95% CI, 1.13-1.85, P < 0.05) in diuretic users, but not in diuretic non-users (P for interaction <0.05); restricted cubic spline model also showed a similar result. Hyponatremia was not associated with all-cause mortality or cardiovascular event whereas hypernatremia (serum sodium >141 mEq/L) was associated with an increased risk for all-cause mortality. Thus, hyponatremia is an indicator of fluid imbalance and also a prognostic factor for renal replacement therapy in CKD patients treated with diuretics.
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Cadeddu C, Franconi F, Cassisa L, Campesi I, Pepe A, Cugusi L, Maffei S, Gallina S, Sciomer S, Mercuro G. Arterial hypertension in the female world. J Cardiovasc Med (Hagerstown) 2016; 17:229-36. [DOI: 10.2459/jcm.0000000000000315] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Alderman MH, Davis BR, Piller LB, Ford CE, Baraniuk MS, Pressel SL, Assadi MA, Einhorn PT, Haywood LJ, Ilamathi E, Oparil S, Retta TM. Should Antihypertensive Treatment Recommendations Differ in Patients With and Without Coronary Heart Disease? (from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial [ALLHAT]). Am J Cardiol 2016; 117:105-15. [PMID: 26589819 PMCID: PMC4690772 DOI: 10.1016/j.amjcard.2015.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 10/09/2015] [Accepted: 10/09/2015] [Indexed: 01/13/2023]
Abstract
Thiazide-type diuretics have been recommended for initial treatment of hypertension in most patients, but should this recommendation differ for patients with and without coronary heart disease (CHD)? The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized, double-blind hypertension treatment trial in 42,418 participants with high risk of combined cardiovascular disease (CVD) (25% with preexisting CHD). This post hoc analysis compares long-term major clinical outcomes in those assigned amlodipine (n = 9048) or lisinopril (n = 9,054) with those assigned chlorthalidone (n = 15,255), stratified by CHD status. After 4 to 8 years, randomized treatment was discontinued. Total follow-up (active treatment + passive surveillance using national databases for deaths and hospitalizations) was 8 to 13 years. For most CVD outcomes, end-stage renal disease, and total mortality, there were no differences across randomized treatment arms regardless of baseline CHD status. In-trial rates of CVD were significantly higher for lisinopril compared with chlorthalidone, and rates of heart failure were significantly higher for amlodipine compared with chlorthalidone in those with and without CHD (overall hazard ratios [HRs] 1.10, p <0.001, and 1.38, p <0.001, respectively). During extended follow-up, significant outcomes according to CHD status interactions (p = 0.012) were noted in amlodipine versus chlorthalidone comparison for CVD and CHD mortality (HR 0.88, p = 0.04, and 0.84, p = 0.04, respectively) in those with CHD at baseline (HR 1.06, p = 0.15, and 1.08, p = 0.17) and in those without. The results of the overall increased stroke mortality in lisinopril compared with chlorthalidone (HR 1.2; p = 0.03) and hospitalized heart failure in amlodipine compared with chlorthalidone (HR 1.12; p = 0.01) during extended follow-up did not differ by baseline CHD status. In conclusion, these results provide no reason to alter our previous recommendation to include a properly dosed diuretic (such as chlorthalidone 12.5 to 25 mg/day) in the initial antihypertensive regimen for most hypertensive patients.
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Affiliation(s)
- Michael H Alderman
- Department of Epidemiology & Population Health, Department of Medicine (General Internal Medicine), Albert Einstein College of Medicine, Bronx, New York
| | - Barry R Davis
- The University of Texas School of Public Health, Coordinating Center for Clinical Trials, Houston, Texas
| | - Linda B Piller
- The University of Texas School of Public Health, Coordinating Center for Clinical Trials, Houston, Texas.
| | - Charles E Ford
- The University of Texas School of Public Health, Coordinating Center for Clinical Trials, Houston, Texas
| | - M Sarah Baraniuk
- The University of Texas School of Public Health, Coordinating Center for Clinical Trials, Houston, Texas
| | - Sara L Pressel
- The University of Texas School of Public Health, Coordinating Center for Clinical Trials, Houston, Texas
| | - Mahshid A Assadi
- State University of New York Health Sciences Center at Brooklyn, Brooklyn, New York
| | - Paula T Einhorn
- Division of Prevention and Population Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - L Julian Haywood
- LAC + USC Medical Center, Keck School of Medicine, Los Angeles, California
| | | | - Suzanne Oparil
- Department of Medicine and Physiology & Biophysics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tamrat M Retta
- Department of Medicine, Howard University College of Medicine, Washington, District of Columbia
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Jafar TH, Jehan I, Liang F, Barbier S, Islam M, Bux R, Khan AH, Nadkarni N, Poulter N, Chaturvedi N, Ebrahim S. Control of Blood Pressure and Risk Attenuation: Post Trial Follow-Up of Randomized Groups. PLoS One 2015; 10:e0140550. [PMID: 26540210 PMCID: PMC4634976 DOI: 10.1371/journal.pone.0140550] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 09/25/2015] [Indexed: 11/19/2022] Open
Abstract
Background Evidence on long term effectiveness of public health strategies for lowering blood pressure (BP) is scarce. In the Control of Blood Pressure and Risk Attenuation (COBRA) Trial, a 2 x 2 factorial, cluster randomized controlled trial, the combined home health education (HHE) and trained general practitioner (GP) intervention delivered over 2 years was more effective than no intervention (usual care) in lowering systolic BP among adults with hypertension in urban Pakistan. However, it was not clear whether the effect would be sustained after the cessation of intervention. We conducted 7 years follow-up inclusive of 5 years of post intervention period of COBRA trial participants to assess the effectiveness of the interventions on BP during extended follow-up. Methods A total of 1341 individuals 40 years or older with hypertension (systolic BP 140 mm Hg or greater, diastolic BP 90 mm Hg or greater, or already receiving treatment) were followed by trained research staff masked to randomization status. BP was measured thrice with a calibrated automated device (Omron HEM-737 IntelliSense) in the sitting position after 5 minutes of rest. BP measurements were repeated after two weeks. Generalized estimating equations (GEE) were used to analyze the primary outcome of change in systolic BP from baseline to 7- year follow-up. The multivariable model was adjusted for clustering, age at baseline, sex, baseline systolic and diastolic BP, and presence of diabetes. Findings After 7 years of follow-up, systolic BP levels among those randomised to combined HHE plus trained GP intervention were significantly lower (2.1 [4.1–0.1] mm Hg) compared to those randomised to usual care, (P = 0.04). Participants receiving the combined intervention compared to usual care had a greater reduction in LDL-cholesterol (2.7 [4.8 to 0.6] mg/dl. Conclusions The benefit in systolic BP reduction observed in the original cohort assigned to the combined intervention was attenuated but still evident at 7- year follow-up. These findings highlight the potential for scaling-up simple strategies for cardiovascular risk reduction in low- and middle- income countries. Trial Registration ClinicalTrials.gov NCT00327574
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Affiliation(s)
- Tazeen H. Jafar
- Program in Health Services & Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore
- Department of Community Health Science, Aga Khan University, Karachi, Pakistan
- Section of Nephrology, Department of Medicine, Aga Khan University, Karachi, Pakistan
- * E-mail:
| | - Imtiaz Jehan
- Department of Community Health Science, Aga Khan University, Karachi, Pakistan
| | - Feng Liang
- Program in Health Services & Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Sylvaine Barbier
- Centre for Quantitative Medicine, Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Muhammad Islam
- Department of Community Health Science, Aga Khan University, Karachi, Pakistan
| | - Rasool Bux
- Department of Community Health Science, Aga Khan University, Karachi, Pakistan
| | - Aamir Hameed Khan
- Section of Cardiology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Nivedita Nadkarni
- Centre for Quantitative Medicine, Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Neil Poulter
- National Heart & Lung Institute, Imperial College, London, United Kingdom
| | - Nish Chaturvedi
- Institute of Cardiovascular Sciences, University College, London, United Kingdom
| | - Shah Ebrahim
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Goeres LM, Williams CD, Eckstrom E, Lee DSH. Pharmacotherapy for hypertension in older adults: a systematic review. Drugs Aging 2015; 31:897-910. [PMID: 25323058 DOI: 10.1007/s40266-014-0219-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hypertension increases with increasing age. Optimal treatment of hypertension is important to reduce cardiovascular disease. Recent guidelines for hypertension have made recommendations for older adults but are supported by evidence that includes younger individuals. This systematic review evaluates the benefits and harms of antihypertensive agents in adults aged ≥65 years. METHODS We searched MEDLINE and ClinicalTrials.gov for studies from 1996 to 2014. Eligible studies included participants aged ≥65 years with hypertension. Eligible studies had clearly defined treatment assignments, blood pressure (BP) targets, and evaluated endpoints of cardiovascular morbidity, mortality, and/or harms of antihypertensive medications. We abstracted study characteristics, cardiovascular benefits, and harms. RESULTS Thirty-one articles met the inclusion criteria. Most studies compared different antihypertensive agents and/or placebo groups. These studies consistently demonstrated reduced cardiovascular morbidity and mortality compared with no treatment. Seven studies examined optimal BP targets. Strict control [systolic BP (SBP)<140 mmHg] was not consistently better than mild control (SBP<150 mmHg) for adults aged ≥65 years. Mild SBP control benefitted subjects in all age ranges over 65 years. Few studies assessed and explicitly reported harms. CONCLUSIONS In this review, older adults with hypertension had decreased cardiovascular morbidity and mortality with antihypertensives compared with no treatment. Strict control was not consistently better than mild control in older adults. There was enormous heterogeneity in these studies, and reporting of harms stratified by age is lacking. The current evidence is insufficient to determine the safest, most beneficial hypertension regimen in older adults.
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Affiliation(s)
- Leah M Goeres
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Corvallis, USA,
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Rosendorff C, Lackland DT, Allison M, Aronow WS, Black HR, Blumenthal RS, Cannon CP, de Lemos JA, Elliott WJ, Findeiss L, Gersh BJ, Gore JM, Levy D, Long JB, O'Connor CM, O'Gara PT, Ogedegbe O, Oparil S, White WB. Treatment of hypertension in patients with coronary artery disease. ACTA ACUST UNITED AC 2015; 9:453-98. [PMID: 25840695 DOI: 10.1016/j.jash.2015.03.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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25
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Rosendorff C, Lackland DT, Allison M, Aronow WS, Black HR, Blumenthal RS, Cannon CP, de Lemos JA, Elliott WJ, Findeiss L, Gersh BJ, Gore JM, Levy D, Long JB, O’Connor CM, O’Gara PT, Ogedegbe G, Oparil S, White WB. Treatment of Hypertension in Patients With Coronary Artery Disease. Hypertension 2015; 65:1372-407. [PMID: 25828847 DOI: 10.1161/hyp.0000000000000018] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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26
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Rosendorff C, Lackland DT, Allison M, Aronow WS, Black HR, Blumenthal RS, Cannon CP, de Lemos JA, Elliott WJ, Findeiss L, Gersh BJ, Gore JM, Levy D, Long JB, O’Connor CM, O’Gara PT, Ogedegbe O, Oparil S, White WB. Treatment of Hypertension in Patients With Coronary Artery Disease. J Am Coll Cardiol 2015; 65:1998-2038. [PMID: 25840655 DOI: 10.1016/j.jacc.2015.02.038] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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27
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Rosendorff C, Lackland DT, Allison M, Aronow WS, Black HR, Blumenthal RS, Cannon CP, de Lemos JA, Elliott WJ, Findeiss L, Gersh BJ, Gore JM, Levy D, Long JB, O'Connor CM, O'Gara PT, Ogedegbe G, Oparil S, White WB. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Circulation 2015; 131:e435-70. [PMID: 25829340 DOI: 10.1161/cir.0000000000000207] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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28
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Piller LB, Simpson LM, Baraniuk S, Habib GB, Rahman M, Basile JN, Dart RA, Ellsworth AJ, Fendley H, Probstfield JL, Whelton PK, Davis BR. Characteristics and long-term follow-up of participants with peripheral arterial disease during ALLHAT. J Gen Intern Med 2014; 29:1475-83. [PMID: 25002161 PMCID: PMC4238201 DOI: 10.1007/s11606-014-2947-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Hypertension is a major risk factor for peripheral artery disease (PAD). Little is known about relative efficacy of antihypertensive treatments for preventing PAD. OBJECTIVES To compare, by randomized treatment groups, hospitalized or revascularized PAD rates and subsequent morbidity and mortality among participants in the Antihypertensive and Lipid-Lower Treatment to Prevent Heart Attack Trial (ALLHAT). DESIGN Randomized, double-blind, active-control trial in high-risk hypertensive participants. PARTICIPANTS Eight hundred thirty participants with specified secondary outcome of lower extremity PAD events during the randomized phase of ALLHAT. INTERVENTIONS/EVENTS In-trial PAD events were reported during ALLHAT (1994-2002). Post-trial mortality data through 2006 were obtained from administrative databases. Mean follow-up was 8.8 years. MAIN MEASURES Baseline characteristics and intermediate outcomes in three treatment groups, using the Kaplan-Meier method to calculate cumulative event rates and post-PAD mortality rates, Cox proportional hazards regression model for hazard ratios and 95 % confidence intervals, and multivariate Cox regression models to examine risk differences among treatment groups. KEY RESULTS Following adjustment for baseline characteristics, neither participants assigned to the calcium-channel antagonist amlodipine nor to the ACE-inhibitor lisinopril showed a difference in risk of clinically advanced PAD compared with those in the chlorthalidone arm (HR, 0.86; 95 % CI, 0.72-1.03 and HR, 0.98; 95 % CI, 0.83-1.17, respectively). Of the 830 participants with in-trial PAD events, 63 % died compared to 34 % of those without PAD; there were no significant treatment group differences for subsequent nonfatal myocardial infarction, coronary revascularizations, strokes, heart failure, or mortality. CONCLUSIONS Neither amlodipine nor lisinopril showed superiority over chlorthalidone in reducing clinically advanced PAD risk. These findings reinforce the compelling need for comparative outcome trials examining treatment of PAD in high-risk hypertensive patients. Once PAD develops, cardiovascular event and mortality risk is high, regardless of type of antihypertensive treatment.
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Affiliation(s)
- Linda B Piller
- The University of Texas School of Public Health, 1200 Herman Pressler St., W-906, Houston, TX, 77030, USA,
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Yamal JM, Oparil S, Davis BR, Alderman MH, Calhoun DA, Cushman WC, Fendley HF, Franklin SS, Habib GB, Pressel SL, Probstfield JL, Sastrasinh S. Stroke outcomes among participants randomized to chlorthalidone, amlodipine or lisinopril in ALLHAT. ACTA ACUST UNITED AC 2014; 8:808-19. [PMID: 25455006 DOI: 10.1016/j.jash.2014.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/30/2014] [Accepted: 08/11/2014] [Indexed: 01/02/2023]
Abstract
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized, double-blind, practice-based, active-control, comparative effectiveness trial in 33,357 high-risk hypertensive participants. ALLHAT compared cardiovascular disease outcomes in participants initially treated with an angiotensin-converting enzyme inhibitor (lisinopril), a calcium channel blocker (amlodipine), or a thiazide-type diuretic (chlorthalidone). We report stroke outcomes in 1517 participants in-trial and 1596 additional participants during post-trial passive surveillance, for a total follow-up of 8-13 years. Stroke rates were higher with lisinopril (6-year rate/100 = 6.4) than with chlorthalidone (5.8) or amlodipine (5.5) in-trial but not including post-trial (10-year rates/100 = 13.2 [chlorthalidone], 13.1[amlodipine], and 13.7 [lisinopril]). In-trial differences were driven by race (race-by-lisinopril/chlorthalidone interaction P = .005, race-by-amlodipine/lisinopril interaction P = .012) and gender (gender-by-lisinopril/amlodipine interaction P = .041), separately. No treatment differences overall, or by race or gender, were detected over the 10-year period. No differences appeared among treatment groups in adjusted risk of all-cause mortality including post-trial for participants with nonfatal in-trial strokes. Among Blacks and women, lisinopril was less effective in preventing stroke in-trial than either chlorthalidone or amlodipine, even after adjusting for differences in systolic blood pressure. These differences abated by the end of the post-trial period.
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Affiliation(s)
- José-Miguel Yamal
- Coordinating Center for Clinical Trials, Division of Biostatistics, University of Texas School of Public Health, Houston, TX, USA.
| | - Suzanne Oparil
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Barry R Davis
- Coordinating Center for Clinical Trials, Division of Biostatistics, University of Texas School of Public Health, Houston, TX, USA
| | - Michael H Alderman
- Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David A Calhoun
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William C Cushman
- Preventive Medicine Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | | | | | - Gabriel B Habib
- Cardiology Section, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Sara L Pressel
- Coordinating Center for Clinical Trials, Division of Biostatistics, University of Texas School of Public Health, Houston, TX, USA
| | | | - Sithiporn Sastrasinh
- Renal-Hypertension Section, Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
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Abstract
Diuretics have been recommended as first-line treatment of hypertension and are also valuable in the management of hypervolemia and electrolyte disorders. This review summarizes the key features of the most commonly used diuretics. We then provide an update of clinical trials for diuretics during the past 5 years. Compared to other classes of medications, thiazide diuretics are at least as effective in reducing cardiovascular events (CVEs) in patients with hypertension and are more effective than β-blockers and angiotensin-converting enzyme inhibitors in reducing stroke. Observational cohort data and a network analysis have shown that CVEs are lowered by one-fifth from chlorthalidone when compared to the commonly used thiazide, hydrochlorothiazide. Relative to placebo, chlorthalidone increases life expectancy. In those aged 80 years and older, the diuretic, indapamide, lowers CVEs relative to placebo. The aldosterone antagonist, eplerenone, lowers total mortality in early congestive heart failure. The benefit of eplerenone following acute myocardial infarction (MI) is limited to administration within 3 to 6 days post-MI. Aldosterone antagonists have been shown to lower the incidence of sudden cardiac death and to reduce proteinuria. In the setting of heart failure, long acting loop diuretics azosemide and torasemide are more effective in improving heart failure outcomes than the far more commonly used short acting furosemide. Evening dosing of diuretics appears to lower CVEs relative to morning dosing. In conclusion, diuretics are a diverse class of drugs that remain extremely important in the management of hypertension and hypervolemic states.
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Affiliation(s)
- George C Roush
- 1UCONN School of Medicine and St Vincent's Medical Center, Bridgeport, CT, USA
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Abstract
Black individuals are at high risk for hypertension and increased morbidity from cardiovascular and renal disease, in particular. Increased understanding of racial disparities in hypertension, in terms of risk factors, patient/physician behaviors, and treatment outcomes, is key to improving racially oriented care in black patients. Recent data suggest that black patients progress more rapidly from prehypertension to hypertension, highlighting the need for early and prompt intervention. Unfortunately, adherence to and persistence with antihypertensive therapy are generally poor in black patients and are compounded by the increased need for multidrug therapy in this patient population. Treatment strategies currently under investigation are focusing on methods to improve self-care behaviors and medication adherence. Because this is a constantly and rapidly evolving field of study, this article provides an update of recent findings that should be of relevance and interest to practicing clinicians.
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Affiliation(s)
- David S Kountz
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ 07753, USA.
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32
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Margolis KL, Davis BR, Baimbridge C, Ciocon JO, Cuyjet AB, Dart RA, Einhorn PT, Ford CE, Gordon D, Hartney TJ, Julian Haywood L, Holtzman J, Mathis DE, Oparil S, Probstfield JL, Simpson LM, Stokes JD, Wiegmann TB, Williamson JD. Long-term follow-up of moderately hypercholesterolemic hypertensive patients following randomization to pravastatin vs usual care: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT). J Clin Hypertens (Greenwich) 2013; 15:542-54. [PMID: 23889716 DOI: 10.1111/jch.12139] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 03/26/2013] [Accepted: 03/30/2013] [Indexed: 11/30/2022]
Abstract
The authors conducted a randomized, controlled, multicenter trial, in which they assigned well-controlled hypertensive participants aged 55 years and older with moderate hypercholesterolemia to receive pravastatin (n=5170) or usual care (n=5185) for 4 to 8 years, when trial therapy was discontinued. Passive surveillance using national databases to ascertain deaths and hospitalizations continued for a total follow-up of 8 to 13 years to assess whether mortality and morbidity differences persisted or new differences developed. During the post-trial period, fatal and nonfatal outcomes were available for 98% and 64% of participants, respectively. The primary outcome was all-cause mortality and the secondary outcomes included cardiovascular mortality, coronary heart disease (CHD), stroke, heart failure, cardiovascular disease, and end-stage renal disease. No significant differences appeared in mortality for pravastatin vs usual care (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.89-1.03) or other secondary outcomes. Similar to the previously reported in-trial result, there was a significant treatment effect for CHD in black patients (HR, 0.79; 95% CI, 0.64-0.98). However, the in-trial result showing a significant treatment by race effect did not remain significant during the entire follow-up (P=.08). These findings are consistent with evidence from other large trials that show statins prevent CHD and add evidence that they are effective for CHD prevention in black patients.
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Affiliation(s)
- Karen L Margolis
- Health Partners Institute for Education and Research, Minneapolis, MN, USA
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Volpe M, Tocci G. Strategies to improve control of blood pressure in hypertension: moving towards a 70% objective. Expert Rev Cardiovasc Ther 2013; 11:653-6. [DOI: 10.1586/erc.13.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Oparil S, Davis BR, Cushman WC, Ford CE, Furberg CD, Habib GB, Haywood LJ, Margolis K, Probstfield JL, Whelton PK, Wright JT. Mortality and morbidity during and after Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial: results by sex. Hypertension 2013; 61:977-86. [PMID: 23529173 DOI: 10.1161/hypertensionaha.111.00213] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
To determine whether an angiotensin-converting enzyme inhibitor (lisinopril) or calcium channel blocker (amlodipine) is superior to a diuretic (chlorthalidone) in reducing cardiovascular disease incidence in sex subgroups, we carried out a prespecified subgroup analysis of 15 638 women and 17 719 men in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Total follow-up (active treatment + passive surveillance using national administrative databases to ascertain deaths and hospitalizations) was 8 to 13 years. The primary outcome was fatal coronary heart disease or nonfatal myocardial infarction. Secondary outcomes included all-cause mortality, stroke, combined cardiovascular disease (coronary heart disease death, nonfatal myocardial infarction, stroke, angina, coronary revascularization, heart failure [HF], or peripheral vascular disease), and end-stage renal disease. In-trial rates of HF, stroke, and combined cardiovascular disease were significantly higher for lisinopril compared with chlorthalidone, and rates of HF were significantly higher for amlodipine compared with chlorthalidone in both men and women. There were no significant treatment sex interactions. These findings did not persist through the extension period with the exception of the HF result for amlodipine versus chlorthalidone, which did not differ significantly by sex. For both women and men, rates were not lower in the amlodipine or lisinopril groups than in the chlorthalidone group for either the primary coronary heart disease outcome or any other cardiovascular disease outcome, and chlorthalidone-based treatment resulted in the lowest risk of HF. Neither lisinopril nor amlodipine is superior to chlorthalidone for initial treatment of hypertension in either women or men. Clinical Trial Registration- clinicaltrials.gov; Identifier: NCT00000542.
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Affiliation(s)
- Suzanne Oparil
- University of Alabama at Birmingham, Birmingham, AL, USA
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Abstract
Hypertension is the most common modifiable risk factor for cardiovascular disease. Antihypertensive treatment substantially reduces the risk of heart failure, stroke, and myocardial infarction. Current guidelines recommend screening all adults for high blood pressure (BP). Lifestyle modifications to help control high BP include weight loss, exercise, moderation of alcohol intake, and a diet low in sodium and saturated fats and high in fruits and vegetables. Out-of-office BP monitoring should be used to confirm suspected white coat effect, especially in patients with apparent resistant hypertension.
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Affiliation(s)
- Katherine H Winter
- Department of Family Medicine, University of North Carolina at Chapel Hill, 590 Manning Drive, Chapel Hill, NC 27599-7595, USA
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Ferdinand KC, Nasser SA. Improved Understanding and Innovative Approaches for an Aging Dilemma: Resistant Hypertension in Women with Existing Vascular Disease. CURRENT CARDIOVASCULAR RISK REPORTS 2012. [DOI: 10.1007/s12170-012-0252-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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