How well can blood pressure be controlled? Progress report on the Systolic Hypertension in Europe Follow-Up Study (Syst-Eur 2)

Hypertension in the elderly and the very old

High systolic blood pressure represents a challenge for the modern world. Epidemiologists are in the best position to appreciate the importance of systolic hypertension and its cardiovascular consequences. Although the label of hypertension seems to have lower importance in the elderly, and above all in the very old, than in younger people, high systolic and high pulse pressure are risk factors for cardiovascular events and necessitates treatment. Unfortunately, due to indolence and lack of aggressiveness, only a limited fraction of elderly hypertensive patients receives adequate therapy.

Effectiveness and tolerability of fixed-dose combination enalapril plus nitrendipine in hypertensive patients: results of the 3-month observational, post-marketing, multicentre, prospective CENIT study

BACKGROUND AND OBJECTIVE

Monotherapy with any class of antihypertensive drug effectively controls blood pressure (BP) in only about 50% of patients. Consequently, the majority of patients with hypertension require combined therapy with two or more medications. This study aimed to evaluate the effectiveness (systolic BP [SBP]/diastolic BP [DBP] control) and tolerability of the fixed-dose combination enalapril/nitrendipine 10 mg/20 mg administered as a single daily dose in hypertensive patients.

METHODS

This was a post-authorization, multicentre, prospective, observational study conducted in primary care with a 3-month follow-up. Patients throughout Spain with uncontrolled hypertension (> or =140/90 mmHg for patients without diabetes mellitus, or > or =130/85 mmHg for patients with diabetes) on monotherapy or with any combination other than enalapril + nitrendipine, or who were unable to tolerate their previous antihypertensive therapy, were recruited. Change from previous to study treatment was according to usual clinical practice. BP was measured once after 5 minutes of rest in the sitting position. Therapeutic response was defined as follows: 'controlled' meant controlled BP (<140/90 mmHg for nondiabetic patients, or <130/85 mmHg for diabetic patients); 'response' meant controlled BP, or a decrease in SBP of > or =20 mmHg and in DBP of > or =10 mmHg. The main laboratory test parameters were documented at baseline and after 3 months. Patients aged >65 years, with diabetes, with isolated systolic hypertension (ISH; SBP > or =140 mmHg for patients without diabetes, SBP > or =130 mmHg for patients with diabetes) and who were obese (body mass index [BMI] > or =30 kg/m2) were analysed separately.

RESULTS

Of 6537 patients included, 5010 and 6354 patients were assessed in effectiveness and tolerability analyses, respectively. In the tolerability analysis population, there were 3023 men (47.6%) and 3321 women (52.4%). The mean (+/- SD) age of the tolerability analysis group was 62.8 (+/- 10.7) years. A total of 71.1% of the patients presented at least one clinical cardiovascular risk factor other than hypertension, with the most frequent being dyslipidaemia (42.3%), obesity (29.2%) and diabetes (23.9%). After 3 months of treatment, SBP and DBP showed mean (+/- SD) decreases of 26.5 (+/- 14.4) mmHg and 14.9 (+/- 9.0) mmHg, respectively, and 73.0% of patients responded to treatment while 40.9% achieved BP control (70.8%/36.1% in 2658 patients aged >65 years; 61.7%/46.8% in 1521 patients with diabetes; 55.3%/44.2% in 731 patients with ISH; 72.0%/36.4% in 1762 obese patients). Adverse events were reported in 10.8% of patients (n = 689). During the follow-up period, ten patients died and seven patients had serious adverse events; in no case was a causal relationship attributed to the study product.

CONCLUSIONS

The rate of SBP/DBP control achieved demonstrates the effectiveness of the fixed-dose enalapril/nitrendipine 10 mg/20 mg combination administered as a single daily dose in patients with essential hypertension not adequately controlled with monotherapy or with any combination other than enalapril + nitrendipine. The proportion and type of adverse events reported were as expected and have already been described for both components of the enalapril/nitrendipine 10 mg/20 mg combination. These results confirm the effectiveness of a strategy based on a fixed-dose enalapril/nitrendipine 10 mg/20 mg combination in reducing BP and achieving BP control goals.

Predicting the anti-hypertensive effect of nitrendipine from plasma concentration profiles using artificial neural networks

Nitrendipine is an effective and safe calcium-channel blocker for the treatment of mild to moderate hypertension. The aim of this study is to show that an artificial neural network (ANN) model of the relationship between nitrendipine plasma levels and pharmacodynamic effects can be built and used for pressure-drop prediction after oral administration of the drug in spite of the poor correlation between plasma concentrations and the effect. To achieve the goal, the following steps were taken: evaluation of the quality of the database for training the ANN, definition of the optimal input set for the ANN, and prediction of the diastolic pressure drop using the ANN. The possible consequences of successful ANN modelling are an optimisation of the drug administration regimen, to achieve the best possible effect, as well as optimal drug formulation for drugs with complicated pharmacokinetic/pharmacodynamic relationships.

Achieving good glycemic control: initiation of new antihyperglycemic therapies in patients with type 2 diabetes from the Kaiser Permanente Northern California Diabetes Registry

OBJECTIVE

To compare the effectiveness of antihyperglycemic therapies in type 2 diabetic patients with poor glycemic control (baseline glycosylated hemoglobin [HbA1C] > 8%).

STUDY DESIGN

Longitudinal (cohort) study.

METHODS

Study patients were 4775 type 2 diabetic patients who initiated new antihyperglycemic therapies and maintained them for up to 1 year. The study setting was Kaiser Permanente Northern California Medical Group, an integrated, prepaid, healthcare delivery organization. Treatment regimens were 1 or more of the following: insulin, thiazolidinediones, sulfonylureas, biguanides (metformin), or other less frequently used options (including meglitinides or alpha-glucosidase inhibitors).

RESULTS

In this cohort, the mean HbA1C was 9.9% when therapy was initiated. Within 1 year, there was a drop of 1.3 percentage points in the mean HbA1C (to 8.6%), and 18% of new initiators achieved HbA1C values of < or = 7%. After adjusting for baseline clinical differences, the proportion of patients treated to goal was greatest among those receiving thiazolidinediones in combination (24.6%-25.7%) or a regimen of metformin and insulin (24.9%), while the least success was experienced by those receiving sulfonylureas alone (12.5%) or insulin-sulfonylureas regimens (10.9%). The probability of achieving the target goal was most strongly predicted by the level of glycemic control before initiation, but patient behaviors (eg, frequent self-monitoring, lower rates of missed appointments) also were strongly associated with greater levels of control.

CONCLUSION

Overall, therapy initiation resulted in an impressive population-level benefit. However, since most new initiators still had not achieved good control within 12 months, careful monitoring and prompt therapy intensification remain important.

Prevention of Cardiovascular Events in Elderly People

BACKGROUND AND OBJECTIVE

Cardiovascular disease has been identified as the leading cause of morbidity and mortality in developed countries. Given the increase in life expectancy and the development of cardiovascular preventive measures, it has become increasingly important to detect and prevent cardiovascular diseases in the elderly. We reviewed the scientific literature concerning cardiovascular prevention to assess the importance of cardiovascular preventive measures in old (> or =65 years of age) individuals.

METHODS

We undertook a systematic search for references relating to prevention of cardiovascular disease in the elderly, mainly ischaemic stroke, coronary artery disease and heart failure, on the MEDLINE database 1962-2005. For cardiovascular prevention by drugs or surgery, emphasis was placed on randomised controlled trials, review articles and meta-analyses. For cardiovascular prevention by lifestyle modification, major cohort studies were also considered.

RESULTS

Stroke, coronary heart disease and heart failure were found to be the main targets for cardiovascular prevention in published studies. Antihypertensive treatment has proven its efficacy in primary prevention of fatal or nonfatal stroke in hypertensive and high-risk patients >60 years of age, particularly through treatment of systolic hypertension. Systolic blood pressure reduction is equally important in the secondary prevention of stroke. Similarly, in nonvalvular atrial fibrillation, an adjusted dose of warfarin with a target International Normalized Ratio (INR) of between 2 to 3 prevents ischaemic stroke in elderly patients with an acceptable haemorrhagic risk but is still under prescribed. Antiplatelet agents are indicated in elderly patients with nonembolic strokes. Few large-scale studies have investigated the effect of HMG-CoA reductase inhibitors (statins) on stroke prevention in old individuals. To date, the largest trials suggest a beneficial effect for stroke prevention with use of statins in high-risk elderly subjects < or =82 years of age. Carotid endarterectomy is indicated in carotid artery stenosis >70% and outcomes are even better in elderly than in younger patients. However, medical treatment is still the first-line treatment in asymptomatic elderly patients with <70% stenosis. In ischaemic heart disease, different trials in elderly individuals have shown that use of statins, antithrombotic agents, beta-adrenoceptor antagonists and ACE inhibitors plays an important role either in primary or in secondary cardiovascular prevention. Hormone replacement therapy has been used to treat climacteric symptoms and postmenopausal osteoporosis and was thought to confer a cardiovascular protection. However, controlled trials in elderly individuals changed this false belief when it was found that there was no benefit and even a harmful cardiovascular effect during the first year of treatment. Smoking cessation, regular physical activity and healthy diet are, as in younger individuals, appropriate and effective measures for preventing cardiovascular events in the elderly. Finally, antihypertensive treatment and influenza vaccination are useful for heart failure prevention in elderly individuals.

CONCLUSIONS

Cardiovascular prevention should be more widely implemented in the elderly, including individuals aged > or =75 years, and this might contribute to improved healthy status and quality of life in this growing population.

Prevalence, pathophysiology and treatment of isolated systolic hypertension in the elderly

Isolated systolic hypertension is the predominant type of hypertension in the elderly and is associated with cardiovascular complications such as stroke, coronary heart disease and heart failure. In this review, the role of arterial stiffness, endothelial function, atherosclerosis and oxidative stress in the pathogenesis of isolated systolic hypertension is extensively discussed. Placebo-controlled intervention trials such as the Systolic Hypertension in Europe Trial and the Systolic Hypertension in the Elderly Program have clearly shown that pharmacological treatment of isolated systolic hypertension improves outcome in the elderly. Nevertheless, isolated systolic hypertension remains the major subtype of untreated and uncontrolled hypertension.

Hypertension and the elderly: more than just blood pressure control

Hypertension is a major risk factor for cardiovascular disease in both young and elderly persons; therefore, good blood pressure control is at the center of improved cardiovascular health. The recently issued seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the European Society of Hypertension/European Society of Cardiology 2003 guidelines for hypertension management emphasize the importance of treatment efficacy rather than age in treating elderly persons with hypertension. Most hypertension clinical trials have been carried out with younger hypertensives, but this is changing with trials such as the Systolic Hypertension in the Elderly Program, the first Swedish Trial of Old Patients With Hypertension, and the Systolic Hypertension in Europe trial. These trials have clearly demonstrated the benefits of good blood pressure control in reducing the risk of stroke in elderly persons. With many safe and effective antihypertensive drugs on the market, the question becomes how elderly persons should be treated. Elderly patients often have isolated systolic hypertension, which is related to loss of arterial elasticity or compliance with aging and is more recalcitrant to treatment than essential hypertension. In addition, with advancing age there is the likelihood that other disease states are present in addition to hypertension. The newer antihypertensive drugs that interfere with the renin angiotensin system, such as angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, have the potential of improving cardiovascular outcomes in elderly persons in addition to offering effective blood pressure reduction. Their use should be considered within a comprehensive risk assessment that includes individualized risk-benefit considerations.