High blood pressure and diabetes mellitus: are all antihypertensive drugs created equal?

The Association between Deductibles and Cardiovascular Medication Adherence: A Retrospective Inception Cohort Study

OBJECTIVE

Drug non-adherence in primary preventive cardiovascular therapy is one of the most important modifiable drivers of cardiovascular events. The effect of deductibles in healthcare cost-sharing plans (the amount that has to be paid for healthcare services before the insurance company starts to pay) on such non-adherence in a European setting is unknown. Therefore, we estimated the association between deductibles and the adherence to primary preventive antihypertensive and antihyperlipidemic medication.

METHODS

Using the claims database of Menzis Health Insurer in the Netherlands, we applied ordered beta regression mixed modelling to estimate the association between deductibles and adherence taking several demographic and social-economic factors, repeated measurements and within-patient variation into account.

RESULTS

All in all, 106,316 patients starting primary preventive antihypertensive or antihyperlipidemic monotherapy were eligible for analysis. At index date, mean age of the study population was 58 years and 52% were male. Reaching the deductible limit and no need to pay for medication anymore increased the adherence [relative adherence ratio (RAR) 1.03, 95% confidence interval (95% CI): 1.00-1.05] for antihyperlipidemic therapy and 1.02 (95% CI: 1.00-1.04) for antihypertensive therapy. A larger deductible amount decreases the adherence of antihyperlipidemic and antihypertensive therapy (RAR 0.83; 95% CI: 0.69-1.00 and RAR 0.85, 95% CI: 0.74-0.98, respectively).

CONCLUSION

Independent of other risk factors for non-adherence, presence of deductibles in health insurance is associated with a small negative effect on the adherence to both primary preventive antihypertensive as well as antihyperlipidemic therapy. Further study is needed on the potential health-economic consequences.

Association of Cardiovascular Health Score With Early- and Later-Onset Diabetes and With Subsequent Vascular Complications of Diabetes

BACKGROUND Little attention has been paid to how well the American Heart Association's cardiovascular health (CVH) score predicts early-onset diabetes in young adults. We investigated the association of CVH score with early- and later-onset diabetes and with subsequent complications of diabetes. METHODS AND RESULTS Our sample included 4547 Black and White adults in the CARDIA (Coronary Artery Risk Development in Young Adults) study without diabetes at baseline (1985-1986; aged 18-30 years) with complete data on the CVH score at baseline, including smoking, body mass index, physical activity, diet quality, total cholesterol, blood pressure, and fasting blood glucose. Incident diabetes was determined based on fasting glucose, 2-hour postload glucose, hemoglobin A1c, or self-reported medication use throughout 8 visits for 30 years. Multinomial logistic regression was used to assess the association between CVH score and diabetes onset at age <40 years (early onset) versus age ≥40 years (later onset). Secondary analyses assessed the association between CVH score and risk of complications (coronary artery calcium, clinical cardiovascular disease, kidney function markers, diabetic retinopathy, and diabetic neuropathy) among a subsample with diabetes. We identified 116 early- and 502 later-onset incident diabetes cases. Each 1-point higher CVH score was associated with lower odds of developing early-onset (odds ratio [OR], 0.64 [95% CI, 0.58-0.71]) and later-onset diabetes (OR, 0.78 [95% CI, 0.74-0.83]). Lower estimates of diabetic complications were observed per 1-point higher CVH score: 19% for coronary artery calcification≥100, 18% for cardiovascular disease, and 14% for diabetic neuropathy. CONCLUSIONS Higher CVH score in young adulthood was associated with lower early- and later-onset diabetes as well as diabetic complications.

Forecast of ameliorating effect of dietary flavonol consumption in white tea with or without aerobic training on type 2 diabetes (T2D) in females

BACKGROUND AND AIMS

Diabetes Mellitus (D.M.) is a chronic metabolic disease characterized by hyperglycemia due to insufficient or inefficient insulin secretory response that has become a widespread epidemic primarily due to the increasing prevalence and incidence of type 2 diabetes. Phytochemicals such as flavonoids and regular physical activity have recently attracted attention to developing new anti-diabetic drugs or alternative therapy to control diabetes. The aim of this study was to compare effects of dietary Flavonol consumption in white tea, with or without aerobic training, among patients with type 2 diabetes mellitus as a randomized trial.

METHODS

49 women with T2D were randomly assigned into groups including control, white tea, aerobic training, and aerobic training + white tea. The interventions were carried out for six months. Weight, Body Mass Index (BMI), body Fat, peak oxygen consumption (VO2_Max), and Blood Pressure were evaluated at both the first and last days of the research period. Blood samples were withdrawn on the same days via venipuncture to test blood glucose, insulin, low-density lipoprotein (LDL), high-density lipoprotein (HDL), cholesterol, and triglycerides (T.G.).

RESULTS

Characteristics analysis showed significant improvements in treated groups. In addition, glucose, insulin, LDL, Cholesterol, and T.G. were significantly reduced while HDL was remarkably increased in treated groups compared to pre-experiment values or the diabetic control group.

CONCLUSION

Collectively, white tea combined with aerobic training favorably affects glycemic parameters, lipid profile, blood pressure, and VO2_Max in six months in women with T2D. Registered under Clinical Trials.gov Identifier no. NCT00123456.

Latin American Consensus on the management of hypertension in the patient with diabetes and the metabolic syndrome

: The prevalence of hypertension, type 2 diabetes mellitus (DM2) and the metabolic syndrome continues to increase in Latin America, while the rates of diagnosis, treatment and control of these disorders remain low. The frequency of the risk factors that constitute the metabolic syndrome and are associated with an increased risk of cardiovascular disease has not diminished since the publication of the previous consensus. This document discusses the socioeconomic, demographic, environmental and cultural characteristics of most associated Latin American countries and partially explains the lack of better results in improving clinical and public health actions that allow high morbidity and mortality rates caused by cardiovascular diseases and DM2 to be reduced through programs aligned with the so-called precision medicine, which should be predictive, preventive, personalized and participatory. The Consensus ratifies the diagnostic criteria expressed in the previous consensus to define hypertension and DM2 but, for the metabolic syndrome, and in the absence of evidence, the recommendation is to implement a cohort study that determines the abdominal perimeter value associated with hard outcomes, such as DM2 and CVD. Meanwhile, we recommend modifying the criterion to more than 94 cm in men and more than 84 cm in women according to WHO recommendations. We also recommend the carrying out of a study that identifies the situation of hypertension and DM2 in people of African ancestry who, in Latin America, exceed 75 million and whose epidemiology does not include solid studies. With respect to the proposed therapeutic targets, we recommended maintaining those defined in the previous consensus, but insisting that early pharmacological management of prediabetes with metformin should be introduced, as should the treatment of diabetic hypertensive patients with a combination therapy of two fixed-dose antihypertensive drugs and management with statins. To increase adherence, the use of different drugs combined in a single pill (polypill) is recommended. The simplification of the therapeutic regimen is accompanied by greater control of cardiovascular risk factors, both in primary and secondary prevention, and has been shown to be cost-effective. The consensus recommends the use of the currently available polypill combining an angiotensin-converting enzyme inhibitor, a statin and aspirin for secondary cardiovascular prevention and in patients with a high cardiovascular risk, such as hypertension patients with DM2.

Blood pressure control in type 2 diabetic patients

Diabetes mellitus (DM) and essential hypertension are common conditions that are frequently present together. Both are considered risk factors for cardiovascular disease and microvascular complications and therefore treatment of both conditions is essential. Many papers were published on blood pressure (BP) targets in diabetic patients, including several works published in the last 2 years. As a result, guidelines differ in their recommendations on BP targets in diabetic patients. The method by which to control hypertension, whether pharmacological or non-pharmacological, is also a matter of debate and has been extensively studied in the literature. In recent years, new medications were introduced for the treatment of DM, some of which also affect BP and the clinician treating hypertensive and diabetic patients should be familiar with these medications and their effect on BP. In this manuscript, we discuss the evidence supporting different BP targets in diabetics and review the various guidelines on this topic. In addition, we discuss the various options available for the treatment of hypertension in diabetics and the recommendations for a specific treatment over the other. Finally we briefly discuss the new diabetic drug classes and their influence on BP.

Recreational football for disease prevention and treatment in untrained men: a narrative review examining cardiovascular health, lipid profile, body composition, muscle strength and functional capacity

Over the past 10 years, researchers have studied the effects of recreational football training as a health-promoting activity for participants across the lifespan. This has important public health implications as over 400 million people play football annually. Results from the first randomised controlled trial, published in the BJSM in January 2009, showed that football increased maximal oxygen uptake and muscle and bone mass, and lowered fat percentage and blood pressure, in untrained men, and since then more than 70 articles about football for health have been published, including publications in two supplements of the Scandinavian Journal of Medicine and Science in Sports in 2010 and 2014, prior to the FIFA World Cup tournaments in South Africa and Brazil. While studies of football training effects have also been performed in women and children, this article reviews the current evidence linking recreational football training with favourable effects in the prevention and treatment of disease in adult men.

Blood pressure and disability-free survival among community-dwelling diabetic and non-diabetic elderly patients receiving antihypertensive treatment

OBJECTIVE

Although many large-scale trials showed efficacies of antihypertensive treatment in patients with diabetes mellitus and hypertension for reduction of cardiovascular (CV) morbidity/mortality, blood pressure (BP) targets in older hypertensive patients with diabetes still represent the object of debate. We investigated adequate BP targets with respect to the risk of incident disability or mortality in community-dwelling elderly hypertensive patients with and without diabetes.

METHODS

We analyzed 139 diabetic and 431 non-diabetic patients receiving antihypertensive treatment aged 65 years or older. The end-point was the composite outcome of first certification for support/care need or mortality. Relationships among each of four classes of systolic BP (SBP) or diastolic BP (DBP) and the risk of events were estimated using Cox hazards analysis.

RESULTS

Over 4 years, diabetic patients showed significantly higher rates of all events including first certification for support/care need or mortality compared with the non-diabetic subjects (29 [20.8%] and 48 [11.1%] cases, unadjusted hazard ratio [HR] 1.99, 95% confidence interval (CI) 1.26-3.16, P = 0.003). After adjustment for confounding variables, the risk of events was significantly higher in non-diabetic subjects with SBP <120 mmHg (HR 3.90, 95% CI 1.32-11.5, P = 0.014) and SBP ≥160 mmHg (HR 3.42, 95% CI 1.22-9.57, P = 0.019), but only those with SBP ≥160 mmHg (HR 22.8, 95% CI 4.83-118, P < 0.001) in diabetic patients, compared with non-diabetic control subjects with baseline SBP of 140-159 mmHg.

CONCLUSION

These observations showed the critical importance of intensive control of SBP to <160 mmHg for disability-free survival in elderly hypertensive patients with diabetes mellitus.

Effects of an aquatic-based exercise program to improve cardiometabolic profile, quality of life, and physical activity levels in men with type 2 diabetes mellitus

BACKGROUND

The role of structured exercise in improving cardiometabolic profile and quality of life in patients with type 2 diabetes mellitus (2DM) has been widely demonstrated. Little is known about the effects of an aquatic-based exercise program in patients with 2DM.

OBJECTIVE

To evaluate the effects of a supervised aquatic-based exercise program on cardiometabolic profile, quality of life, and physical activity levels in patients with 2DM.

DESIGN AND SETTING

Observational study, community pre-post aquatic-based exercise program, primary care intervention.

PATIENTS

Eighteen men diagnosed with 2DM (52.2 ± 9.3 years).

METHODS

and

MAIN OUTCOME MEASUREMENTS

Cardiometabolic profile, quality of life, and physical activity levels were assessed before and after 12 weeks of an aquatic-based exercise program.

RESULTS

The results show a significant improvement of cardiometabolic assessments (maximum oxygen consumption: 24.1 versus 21.1 mL/kg/min, P < .05; blood pressure: 125.4/77 versus 130.7/82.5 mm Hg, P < .05; fasting blood glucose: 119.6 versus 132.5 mg/dL, P < .05; body mass index: 29.9 versus 31.1 kg/m², P < .005; low-density lipoprotein cholesterol: 95.2 versus 104.9 mg/dL, P < .05; and diastolic function: E/E' 9.1 versus 10.1, P < .005) and an increase in quality of life and physical activity levels (Medical Outcome Study 36-item Short Form Health Survey mental component summary: 72.3 versus 67, P < .05; Problems Area About Diabetes: 20.1 versus 33.2, P < .005) and energy expenditure in general physical activity (physical activity: 3888.7 versus 1239.5 kcal/wk, P < .05).

CONCLUSIONS

These findings demonstrate that an aquatic-based exercise program produces benefits for the cardiovascular system and metabolic profile and appears to be safe and effective in improving quality of life and increasing physical activity levels in patients with 2DM.

Treating hypertension in type 2 diabetes

INTRODUCTION

The co-existence of hypertension and diabetes mellitus is very common. Hypertension remarkably increases the cardiovascular risk in diabetic patients. Lowering blood pressure (BP) in these patients is particularly beneficial.

AREAS COVERED

This paper will discuss what the target BP is for diabetic patients and how that target can be reached.

EXPERT OPINION

Previous guidelines recommended lowering BP < 130/80 mmHg in diabetic patients. However, recent studies did not support this target and accordingly most recent guidelines recommend lowering BP to < 140/90 mmHg in diabetic patients. Non-pharmacological approaches are recommended in all patients. If BP levels are above the target despite non-pharmacological treatment, drug therapy should be initiated. Despite the lack of clear evidence, blockers of the renin-angiotensin-aldosterone system (RAAS) represent the cornerstone of the antihypertensive arsenal; however, in most patients combination therapy is required. Combination of RAAS blocker and a calcium antagonist is the preferred one. In many patients three or four drugs are needed. Treatment should be individualized according to concomitant risk factors and diseases and according hemodynamic and laboratory parameters as well as age. In order to maximally reduce cardiorenal risk, lipid and glycemic control should also be achieved.

Upregulation of caveolin-1 contributes to aggravated high-salt diet-induced endothelial dysfunction and hypertension in type 1 diabetic rats

AIMS

Endothelial dysfunction and hypertension is more common in individuals with diabetes than in the general population. This study was aimed to investigate the underlying mechanisms responsible for endothelial dysfunction of type 1 diabetic rats fed with high-salt diet.

MAIN METHODS

Type 1 diabetes (DM) was induced by intraperitoneal injection of streptozotocin (70 mg·kg(-1)). Normal or diabetic rats were randomly fed high-salt food (HS, 8% NaCl) or standard food (CON) for 6 weeks.

KEY FINDINGS

Both HS (143±10 mmHg) and DM+HS (169±11 mmHg) groups displayed significantly higher systolic blood pressure than those in the CON group (112±12 mmHg, P<0.01). DM+HS rats exhibited more pronounced impairment of vasorelaxation to acetylcholine and insulin compared with either DM or HS. Akt/endothelial nitric oxide synthase (eNOS) phosphorylation levels and nitric oxide (NO) concentration in DM+HS were significantly lower than in DM. The levels of caveolin-1 (cav-1) in DM+HS were significantly higher than that in DM and HS. Co-immunoprecipitation results showed increased interaction between cav-1 and eNOS in the DM+HS group. In the presence of cav-1 small interfering RNA (siRNA), eNOS phosphorylations in human umbilical vein endothelial cells (HUVEC) were significantly increased compared with control siRNA. Cav-1 was slightly but not significantly lower in HUVEC cultured with high glucose and high-salt buffer solution and pretreated with wortmannin or l-nitro-arginine methyl ester.

SIGNIFICANCE

Impaired endothelial Akt activation and increased cav-1 expression and resultant decreased eNOS activation contributes to aggravated high-salt diet-induced endothelial dysfunction and hypertension in DM rats.

Assessment of demographics, treatment strategies, and evidence-based medicine use among diabetic and non-diabetic patients with acute coronary syndrome: A cohort study

Objectives:

To evaluate and compare clinical and epidemiological characteristics, treatment strategies, and utilization of evidence-based medicine (EBM) among coronary artery disease (CAD) patients with or without diabetes.

Materials and Methods:

Prospective observational cohort study from a tertiary care hospital in India among patients with CAD (myocardial infarction, unstable angina, or chronic stable angina). Data included demographic information, vital signs, personal particulars, risk factors for CAD, treatment strategies, and discharge medications. We evaluated epidemiologic characteristics and treatment strategies for diabetic and non-diabetic patients.

Results:

Of 1,073 patients who underwent angiography, 960 patients (30% diabetic) had CAD. Proportion of hypertensive patients was higher among diabetic patients (58 vs 35% non-diabetic, P < 0.001). Similar proportion of patients received medical management in diabetic vs non-diabetic CAD patients (35 vs 34%, P = 0.091); in diabetics the use of surgical procedure was higher (22 vs 17%, P = 0.0230) than interventional strategy (percutaneous transluminal coronary angioplasty, 43 vs 49%, P = 0.0445). Key medications (antiplatelet agents, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), beta-blockers, and ahtihyperlipidemic agents) were prescribed in 95, 53/12, 67, and 91% diabetic (n = 252) and 96, 51/8, 67, and 94% non-diabetic (n = 673) patients, respectively on discharge.

Conclusions:

Clustering of several risk factors at presentation, typically diabetes and hypertension, is common in CAD patients. Though diabetic patients are managed more conservatively, utilization of EBM for diabetic and non-diabetic patients is consistent with the recommendations.

Should we change the target blood pressure in diabetic patients?

Hypertension is a major modifiable risk factor for cardiovascular morbidity and mortality in diabetic patients. Guidelines recommend lowering blood pressure (BP) to less than 130/80 mmHg in diabetic patients. These recommendations are based on several studies in diabetic patients that showed the benefit of intensive BP control. However in all the studies the achieved BP was higher than 130/80 mmHg. Re-evaluation of earlier studies, as well as more recently accumulated data suggest that intensive BP control is associated with a significant reduction in all-cause mortality and stroke rate, but with no benefit for other microvascular or macrovascular (cardiac, renal and retinal) outcomes. Intensive BP control is associated with an increased risk of serious adverse effects, particularly for systolic BPs levels lower than 130 mmHg. When determining the target BP in diabetic patients one should balance the potential cerebrovascular protection against the increased risk of serious side effects, and the absence of benefit for other circulatory system. It seems therefore, that lowering BP to levels close to 130/80 mmHg should be the main goal of treatment in diabetic patients.

Metabolic effects of manidipine

The calcium channel antagonists (CCAs) were originally introduced as vasodilators for the treatment of coronary heart disease, but are now also noted for their clinical efficacy in the management of hypertension. Data from large clinical studies have shown that CCAs are not associated with the undesirable metabolic effects (e.g. worsening of dyslipidemia and reduction of insulin sensitivity) seen with older agents such as thiazide diuretics and beta-adrenoceptor antagonists (beta-blockers) that are used to treat hypertension. Indeed, reductions in cardiovascular risk and rates of onset of new cases of diabetes mellitus have been reported in trials in patients with hypertension treated with CCAs. These beneficial effects extend beyond those expected to accompany reductions in BP. Until recently, the biochemical effects underlying these metabolic changes were only poorly understood, but pharmacologic studies have now started to shed more light on these issues. Of particular interest are studies with manidipine, some of which suggest that this agent may be associated with greater improvements in insulin sensitivity and may have better renal protective properties than other CCAs. Confirmation of potential differences among CCAs in terms of the relative magnitude of any beneficial metabolic effects requires further study. Ongoing research is expected to clarify further the action of these agents at the cellular level and to assist with the optimization of antihypertensive therapy, particularly in patients with elevated cardiovascular risk profiles.

Provider and systems factors in diabetes quality of care

A gap exists in knowledge and the observed frequency with which patients with diabetes actually receive treatment for optimal cardiovascular risk reduction. Many interventions to improve quality of care have been targeted at the health systems level and provider organizations. Changes in several domains of care and investment in quality by organizational leaders are needed to make long-lasting improvements. In the studies reviewed, the most effective strategies often have multiple components, whereas the use of one single strategy, such as reminders only or an educational intervention, is less effective. More studies are needed to examine the effect of several care management strategies simultaneously, such as use of clinical information systems, provider financial incentives, and organizational model on processes of care and outcomes.

Management of blood pressure in patients with diabetes

Hypertension is a major modifiable risk factor for cardiovascular morbidity and mortality in patients with diabetes. Lowering blood pressure (BP) to 135/85 mm Hg is the main goal of treatment. A nonpharmcologic approach is recommended in all patients. If BP levels remain above the target despite nonpharmacologic treatment, drug therapy should be initiated. Blockers of the renin-angiotensin-aldosterone system (RAAS) represent the cornerstone of the antihypertensive drug arsenal; however, in most patients, combination therapy is required. For many patients, a combination of RAAS blocker and calcium antagonist is the combination preferred by the treating physician. Often three or even four drugs are needed. Treatment should be individualized according to concomitant risk factors and diseases and depending on the age and hemodynamic and laboratory parameters of the patient. In order to maximally reduce cardio renal risk, control of lipid and glycemic levels should also be ensured.

Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position statement. Exercise and type 2 diabetes

Although physical activity (PA) is a key element in the prevention and management of type 2 diabetes mellitus (T2DM), many with this chronic disease do not become or remain regularly active. High-quality studies establishing the importance of exercise and fitness in diabetes were lacking until recently, but it is now well established that participation in regular PA improves blood glucose control and can prevent or delay T2DM, along with positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life. Structured interventions combining PA and modest weight loss have been shown to lower T2DM risk by up to 58% in high-risk populations. Most benefits of PA on diabetes management are realized through acute and chronic improvements in insulin action, accomplished with both aerobic and resistance training. The benefits of physical training are discussed, along with recommendations for varying activities, PA-associated blood glucose management, diabetes prevention, gestational diabetes, and safe and effective practices for PA with diabetes-related complications.

Hypertension in diabetes: treatment considerations

Treatment of blood pressure in the patient with diabetes remains a challenge. While data extrapolated from many trials seemed to imply that lower blood pressures leads to more favorable cardiovascular outcomes, this paper reviews newer trials designed to treat to blood pressure targets below 130/80 mmHg in patients with long term established diabetes, which showed that this goal may prove more harmful than helpful. In clinical practice this may be less relevant due to the fact that less than half of patients are even at the goal of 130/80. The interaction between glucose control and blood pressure control are also discussed, emphasizing the importance of multifactorial treatment.

Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement

Although physical activity (PA) is a key element in the prevention and management of type 2 diabetes, many with this chronic disease do not become or remain regularly active. High-quality studies establishing the importance of exercise and fitness in diabetes were lacking until recently, but it is now well established that participation in regular PA improves blood glucose control and can prevent or delay type 2 diabetes, along with positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life. Structured interventions combining PA and modest weight loss have been shown to lower type 2 diabetes risk by up to 58% in high-risk populations. Most benefits of PA on diabetes management are realized through acute and chronic improvements in insulin action, accomplished with both aerobic and resistance training. The benefits of physical training are discussed, along with recommendations for varying activities, PA-associated blood glucose management, diabetes prevention, gestational diabetes mellitus, and safe and effective practices for PA with diabetes-related complications.

Effect of marine collagen peptides on markers of metabolic nuclear receptors in type 2 diabetic patients with/without hypertension

OBJECTIVE

To explore Effects of marine collagen peptides (MCPs) on markers of metablic nuclear receptors, i.e peroxisome proliferator-activated receptor (PPARs), liver X receptor (LXRs) and farnesoid X receptor (FXRs) in type 2 diabetic patients with/without hypertension. METHOD Study population consisted of 200 type 2 diabetic patients with/without hypertension and 50 healthy subjects, all of whom were randomly assigned to MCPs-treated diabetics (n = 50), placebo-treated diabetics (n = 50), MCPs-treated diabetics with hypertension (n=50), placebo-treated diabetics with hypertension (n = 50), and healthy controls (n = 50). MCPs or placebo (water-soluble starch) were given daily before breakfast and bedtime over three months. Levels of free fatty acid, cytochrome P450, leptin, resistin, adiponectin, bradykinin, NO, and Prostacyclin were determined before intervention, and 1.5 months, and 3 months after intervention. Hypoglycemia and the endpoint events during the study were recorded and compared among the study groups.

RESULT

At the end of the study period, MCPs-treated patients showed marked improvement compared with patients receiving placebo. The protection exerted by MCPs seemed more profound in diabetics than in diabetics with hypertension. In particular, after MCPs intervention, levels of free fatty acid, hs-CRP, resistin, Prostacyclin decreased significantly in diabetics and tended to decrease in diabetic and hypertensive patients whereas levels of cytochrome P450, leptin, NO tended to decrease in diabetics with/without hypertension. Meanwhile, levels of adiponectin and bradykinin rose markedly in diabetics following MCPs administration.

CONCLUSION

MCPs could offer protection against diabetes and hypertension by affecting levels of molecules involved in diabetic and hypertensive pathogenesis. Regulation on metabolic nuclear receptors by MCPs may be the possible underlying mechanism for its observed effects in the study. Further study into its action may shed light on development of new drugs based on bioactive peptides from marine sources.

Renin-angiotensin system polymorphisms and the association between use of angiotensin II receptor blockers or angiotensin-converting enzyme inhibitors and the risk of diabetes

Introduction. We assessed the influence of genetic polymorphisms in the renin-angiotensin system on the risk of diabetes associated with the use of angiotensin II receptor blockers and angiotensin-converting enzyme (ACE) inhibitors.

Materials and methods. We performed a matched case-control study among antihypertensive drug users. Pharmacy records and questionnaires were used to ascertain incident diabetes (cases), antihypertensive drug use, and risk factors. Controls did not (yet) have diabetes.We genotyped ACE (G4656C, which is in complete linkage disequilibrium with the ACE insertion/deletion polymorphism), angiotensinogen (M235T), and angiotensin II type 1 receptor (A1166C).

Results. Among 495 cases of incident diabetes and 2,624 controls, homozygous 1166C carriers of angiotensin II type 1 receptor who used angiotensin II receptor blockers had an increased risk of diabetes compared to 1166A carriers (interaction odds ratio 5.3 [95% confidence interval: 1.8-16.1]). Homozygous ACE GG subjects who used ACE inhibitors ≥ 1 defined daily dose/day had a higher risk of diabetes compared to subjects with the ACE C allele (interaction odds ratio 2.3 [95% confidence interval: 1.2-4.5]).

Conclusions. Angiotensin II receptor blockers increase the occurrence of diabetes in homozygous 1166C carriers of angiotensin II type 1 receptor, but not in 1166A carriers. ACE inhibitors at doses ≥ 1 defined daily dose/day increase the risk of diabetes among homozygous ACE GG carriers, but not in 4656C carriers.

Variation in Renin-Angiotensin system and salt-sensitivity genes and the risk of diabetes mellitus associated with the use of thiazide diuretics

BACKGROUND

Variation in the renin-angiotensin system (RAS) and salt-sensitivity genes may influence the effect of thiazides on the risk of diabetes. We assessed whether polymorphisms in RAS and salt-sensitivity genes influenced the risk of diabetes associated with thiazides.

METHODS

Nested case-control study was conducted among antihypertensive drug users. Pharmacy records and questionnaires were used to assess new onset diabetes (cases), to ascertain antihypertensive use and risk factors for diabetes. Cases were matched to controls (up to five) who were not (yet) diagnosed with diabetes mellitus. We genotyped angiotensin-converting enzyme (ACE) (G4656C), angiotensinogen (AGT) (M235T), angiotensin II type 1 receptor, (AGTR1) (A1166C), adducin 1 (alpha) (ADD1) (G460T), guanine nucleotide binding protein (G protein), beta-polypeptide 3 (GNB3) (C825T).

RESULTS

Among 497 incident cases of type 2 diabetes and 2,633 controls, AGTR1 CC genotype carriers had no increased risk of diabetes due to thiazides (odds ratio (OR) 0.63 (95% confidence interval (CI): 0.28-1.40)) compared to AGTR1 1166A allele carriers (OR 1.79 (95% CI: 1.43-2.23)) receiving thiazides (synergy index (SI) for interaction 0.32 (95% CI: 0.15-0.68)). Although homozygous ACE GG subjects and ACE C allele carriers both had an increased risk of diabetes associated with thiazide use, this risk was more increased for ACE GG subjects (SI 1.70 (95% CI: 1.08-2.66)), particularly at doses > or =1 daily defined dose (DDD) (=25 mg hydrochlorothiazide)/day (SI 2.0 (95% CI: 1.20-3.32)). Among GNB3 T allele carriers, the risk of diabetes due to thiazide use was less increased than among homozygous GNB3 CC subjects (SI 0.62 (95% CI: 0.41-0.93)).

CONCLUSION

The risk of diabetes due to thiazide use was not increased among AGTR1 1166 CC homozygous subjects and less increased among GNB3 T allele carriers. The ACE 4656 GG genotype enhanced the risk of diabetes due to thiazides.

Quality of diabetes care among patients managed by teleconsultation

We studied a new teamwork-based teleconsultation model for treating patients with diabetes, where a specialist in diabetes care, a diabetes nurse and a patient attended by videoconference. The study series consisted of all the patients ( n = 101) at three health centres in northern Finland whose care was provided by a single physician at a remote diabetes clinic. A total of 101 patients with diabetes (19 of type 1 and 82 of type 2) were studied at baseline and at 10–14 months after the first consultation. Mean HbA1c was 8.0% at baseline and 7.6% at follow-up ( P = 0.007). The proportion of patients with poor glycaemic control decreased from 32% to 13%. Mean LDL cholesterol was 3.3 mmol/L at baseline and 2.7 mmol/L at follow-up ( P < 0.001). The percentage of patients with optimum lipid levels increased from 20% to 50%. Mean systolic blood pressure was 146 mmHg at baseline and had decreased by 6 mmHg at follow-up ( P = 0.004). The percentage of patients with poor blood pressure control decreased from 19% to 8%. The most common changes in medication were the introduction or modification of insulin treatment and the introduction of statin and antihypertensive drugs and acetylsalicylic acid. Although the study was uncontrolled, there were improvements in glucose and LDL cholesterol levels and blood pressure in patients who were managed by teleconsultation.

Cost-effectiveness of chlorthalidone, amlodipine, and lisinopril as first-step treatment for patients with hypertension: an analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)

OBJECTIVE

To evaluate the cost-effectiveness of first-line treatments for hypertension.

BACKGROUND

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found that first-line treatment with lisinopril or amlodipine was not significantly superior to chlorthalidone in terms of the primary endpoint, so differences in costs may be critical for optimizing decision-making.

METHODS

Cost-effectiveness analysis was performed using bootstrap resampling to evaluate uncertainty.

RESULTS

Over a patient's lifetime, chlorthalidone was always least expensive (mean $4,802 less than amlodipine, $3,700 less than lisinopril). Amlodipine provided more life-years (LYs) than chlorthalidone in 84% of bootstrap samples (mean 37 days) at an incremental cost-effectiveness ratio of $48,400 per LY gained. Lisinopril provided fewer LYs than chlorthalidone in 55% of bootstrap samples (mean 7-day loss) despite a higher cost. At a threshold of $50,000 per LY gained, amlodipine was preferred in 50%, chlorthalidone in 40%, and lisinopril in 10% of bootstrap samples, but these findings were highly sensitive to the cost of amlodipine and the cost-effectiveness threshold chosen. Incorporating quality of life did not appreciably alter the results. Overall, no reasonable combination of assumptions led to 1 treatment being preferred in over 90% of bootstrap samples.

CONCLUSIONS

Initial treatment with chlorthalidone is less expensive than lisinopril or amlodipine, but amlodipine provided a nonsignificantly greater survival benefit and may be a cost-effective alternative. A randomized trial with power to exclude "clinically important" differences in survival will often have inadequate power to determine the most cost-effective treatment.

Evolution of calcium antagonists: past, present, and future

Calcium antagonists were originally introduced as fast-acting vasodilators exhibiting powerful antihypertensive properties. They have now evolved into agents exhibiting a smooth onset and a long duration of action. Early agents, because of their rapid onset of action, were associated with a host of compensatory hemodynamic adverse effects including cardioacceleration and sympathetic stimulation. In contrast, the newer agents appear to retain the antihypertensive properties, but with an improved tolerability profile. Across the cardiovascular disease continuum, the presence of diabetes adds to the risk forcardiovascular events. In diabetic patients with hypertension, multiple drug therapy is clearly indicated. Agents such as calcium antagonists that normalize hemodynamics in this patient population might be expected to demonstrate beneficial effects on mortality. Evidence from the Systolic Hypertension in Europe and the Systolic Hypertension in China trials demonstrated over a 50% reduction in total mortality in the diabetic subgroup in patients treated with calcium antagonists. Among the calcium antagonists, particularly among the dihydropyridine subclasses, the efficacy of the drugs has been accompanied by some side effects, in particular pedal edema. The incidence of pedal edema is dose dependent and is the result of vasodilation and intracapillary hypertension. Newer calcium antagonists demonstrate antihypertensive efficacy similar to that of their predecessors but appear to have a reduced propensity to cause edema.

Antihyperglycaemic therapy in elderly patients with type 2 diabetes: potential role of incretin mimetics and DPP-4 inhibitors

Management of elderly patients with type II diabetes is complicated by age-related changes in physiology, comorbidities, polypharmacy and heterogeneity of functional status. A minimum goal in antidiabetic treatment in this population is to achieve a level of glycaemic control that avoids acute complications of diabetes, adverse effects and reduction in quality of life. Hypoglycaemia is a particular problem in elderly patients, and many antidiabetic agents pose increased risk for hypoglycaemia. In addition, many standard agents pose risks for older patients because of reduced renal function and common comorbidities. Newer agents based on enhancing incretin activity, including the glucagon-like peptide-1 mimetics exenatide and liraglutide and the oral dipeptidyl peptidase-4 inhibitors sitagliptin and vildagliptin, may offer particular advantages in elderly patients with diabetes.

Association between cardiorespiratory fitness and prevalence of carotid atherosclerosis among men with hypertension

BACKGROUND

Carotid atherosclerosis is a risk factor for cardiovascular mortality and may represent hypertension-related target organ damage. Cardiorespiratory fitness is inversely associated with cardiovascular mortality in hypertensive men. We tested the hypothesis that higher levels of cardiorespiratory fitness are inversely associated with the prevalence of carotid atherosclerosis in a cross-sectional study of 2532 (53.2 +/- 8.5 years old) hypertensive men.

METHODS

Men with hypertension (defined as systolic over diastolic blood pressure of > or = 140/90 mm Hg or self-reported use of antihypertensive medication) underwent maximal exercise treadmill testing with expired gas analysis. Carotid atherosclerosis was defined as stenosis of > 25% and/or intima-media thickness of > 1.2 mm using B-mode ultrasonography.

RESULTS

The overall prevalence of carotid atherosclerosis was 13.4%. The prevalence of carotid atherosclerosis was inversely associated with cardiorespiratory fitness category (low 22.5%, moderate 10.9%, and high 8.7%; P < .001 for trend). After adjusting for established risk factors, high and moderate fitness were associated with lower odds ratios for having carotid atherosclerosis, 0.63 (95% CI 0.47-0.85) and 0.62 (95% CI 0.41-0.92), respectively, compared with low fitness. Each metabolic equivalent increment higher peak oxygen uptake was associated with 11% (odds ratio 0.89, 95% CI 0.82-0.97) lower prevalence of carotid atherosclerosis.

CONCLUSIONS

These results suggest that higher levels of cardiorespiratory fitness are inversely associated with the prevalence of carotid atherosclerosis in hypertensive men.

Long-term safety of antihypertensive therapy

Lowering blood pressure (BP) in hypertensive patients reduces morbidity and mortality. However the long-term safety of some antihypertensive agents was a matter of concern. Diuretic, the gold standard treatment in hypertension may impair glucose tolerance and thereby accelerate the development of diabetes mellitus. It was also associated with increased cardiovascular mortality in diabetic patients. However, recent evidence showed that low-medium dose of thiazide diuretic especially when given in combination with potassium sparing agent is effective in reducing BP and cardiovascular morbidity and mortality. Beta blockers are less effective than other antihypertensive agents in the elderly. Therefore they may be appropriate as a first choice in young and middle-age hypertensives, and in those with fast heart rate, but they should not be considered appropriate as the first-line therapy in the elderly with uncomplicated hypertension. Several years ago a plethora of publications showed that short-acting calcium antagonists may increase the risk for myocardial infarction and cancer. A few years ago two studies showed that calcium antagonists are less effective than angiotensin converting enzyme inhibitors in preventing cardiovascular events in diabetic hypertensive patients. However, recent results from large prospective randomized studies showed that calcium antagonists reduce cardiovascular morbidity and mortality in diabetic and non-diabetic hypertensive patients. Some investigators have suggested that angiotensin receptor blockers (ARBs) may increase the risk of myocardial infarction in hypertensive patients. However, recent meta analyses refuted this conclusions and showed that ARBs are probably as effective as other antihypertensive agents in prevention of myocardial infarction. Despite the concern that has been raised regarding the long-term safety of some antihypertensive agents, it is clear that lowering BP is safe and beneficial.

Endothelial nitric oxide synthase haplotypes affect the susceptibility to hypertension in patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) and hypertension (HT) commonly coexist. While endothelial nitric oxide synthase (eNOS) haplotypes have been associated with HT, it is unknown whether eNOS genotypes/haplotypes are associated with altered susceptibility to HT in patients with T2DM. We studied the distribution of three eNOS genetic polymorphisms: a single nucleotide polymorphism in the promoter region (T(-786)C), in exon 7 (Glu298Asp), and a variable number of tandem repeats in intron 4(b/a). Genotypes were determined for 102 healthy controls, 119 patients with HT, 66 patients with T2DM, and 113 patients with T2DM+HT. In addition, we also compared the distribution of eNOS haplotypes in the four groups of subjects. No differences were found in genotype and allele distribution among the four groups. Conversely, the haplotypes "C Glu b" and "C Asp b" were, respectively, more and less common in healthy controls than in HT or in T2DM+HT groups (24% versus 6% and 5%, respectively; both P<0.00625; and 8% versus 18% and 18%, respectively; both P<0.00625). Moreover, DM patients presented an overall distribution of eNOS haplotypes that was not different from healthy controls (P>0.05). Additionally, the haplotypes "C Glu b" and "C Asp b" were, respectively, more and less common in T2DM group than in T2DM+HT group (19% versus 5%; and 7% versus 18%, respectively; both P<0.00625). Our findings suggest a protective effect for eNOS haplotype "C Glu b" against the development of hypertension, and that haplotype "C Asp b" increases the susceptibility to hypertension in patients without or with T2DM.

Therapeutic Controversies in Hypertension

Although numerous prospective randomized trials since the Veterans Administration studies clearly have attested to the efficacy and safety of antihypertensive therapy, there remain some controversial issues with all classes of antihypertensive drugs. Thiazide diuretics increase the risk for new-onset diabetes and their long-term safety has been questioned. Alpha-blockers do not reduce morbidity and mortality in uncomplicated hypertension but are well known to cause a variety of poorly tolerated side effects. The safety of calcium antagonists has been questioned for many years, although recent large prospective randomized trials such as Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, International Verapamil-Trandolapril Study, Intervention as a Goal in Hypertension, Valsartan Antihypertensive Long-Term Use Evaluation and the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) have attested to their safety and efficacy. Angiotensin-converting enzyme inhibitors, in general, are well tolerated but have potentially fatal adverse effects in a few patients. Angiotensin-receptor blockers are exceedingly well tolerated, but may be less-efficacious antihypertensive agents than other drug classes. Most antihypertensive drug classes have an effect on new-onset diabetes that should be taken into account in patients at risk. No head-to-head comparison of combination therapy looking at efficacy and safety has been available. The long-term safety of antihypertensive therapy is documented poorly because most trials only last 4 to 6 years. Despite these drawbacks and concerns, the benefits of antihypertensive therapy clearly outweigh its potential risk.

Efficacy and safety of combination therapy using high- or low-dose hydrochlorothiazide with valsartan or other Angiotensin-receptor blockers

Only a minority of patients treated for hypertension achieve controlled blood pressure (BP) levels. Therapy with fixed-dose combinations of an angiotensinreceptor blocker (ARB) and low-dose hydrochlorothiazide (HCTZ) is commonly prescribed but not always sufficient to achieve the target BP. The efficacy and safety of the fixed-dose combination of valsartan 160 mg and HCTZ 25 mg was evaluated in patients in whom BP had not been controlled with a fixed-dose combination of another ARB and low-dose HCTZ (12.5 mg) in a multicenter trial. After a wash-out period for antihypertensive drugs, patients with a mean sitting diastolic BP (DBP) at trough (3)100 mm Hg but <110 mm Hg were treated with candesartan cilexetil 16 mg plus HCTZ 12.5 mg or telmisartan 80 mg plus HCTZ 12.5 mg for 4 weeks (phase 1). Patients whose BP was still uncontrolled (DBP (3)90 mm Hg) after 4 weeks of therapy were then given valsartan 160 mg plus HCTZ 25 mg for an additional 4 weeks (phase 2). The primary efficacy parameter was the reduction in DBP between week 4 and week 8 in the intention-to-treat (ITT) population. BP reduction during phase 1 was -14.3+/-11.3/-7.5+/-3.9 mm Hg. DBP was controlled in 26% of the patients after phase 1. In patients treated with valsartan 160 mg plus HCTZ 25 mg during phase 2, DBP decreased by an additional 10.3+/-6.5 mm Hg and the mean sitting systolic BP (SBP) by an additional 11.0+/-11.7 mm Hg. The additional decrease was significant (P<.0001) for both parameters and independent of the fixed-dose combination used during phase 1. Among patients whose BP remained uncontrolled during phase 1, 74% achieved a controlled DBP after phase 2. The incidence of adverse events during both phases was comparably low and the results of laboratory tests were unremarkable. Treatment with valsartan 160 mg/HCTZ 25 mg offered a substantial benefit for patients with hypertension not controlled with the combination of candesartan cilexetil 16 mg or telmisartan 80 mg and low dose HCTZ, while maintaining a comparable safety and tolerability profile.

Pharmacotherapy and blood pressure control in elderly hypertensives in a primary care setting in Bahrain

BACKGROUND AND AIMS

Antihypertensive treatment in the elderly has important beneficial effects in terms of reduced cardiovascular morbidity and mortality. The aim of this study was to determine, in elderly hypertensives, the adherence of primary care physicians to World Health Organization/International Society of Hypertension (WHO/ISH) guidelines for the drug management of hypertension and extent of blood pressure (BP) control.

METHODS

A multicentric therapeutic audit of medical records of elderly hypertensives was performed in nine primary care health centers in the Kingdom of Bahrain.

RESULTS

In elderly hypertensives (> or =60 years), the WHO/ISH-1999 recommended BP targets of <140/<90 mmHg and BP<130/85 mmHg were achieved in 11.1% of elderly hypertensives and 4.1% of elderly diabetic hypertensives, respectively. Antihypertensive combination therapy was used in approximately half of the elderly. No significant difference in BP was found in elderly hypertensives treated either with monotherapy or combination therapy. As regards mono- and overall drug utilization, beta-blockers were the most frequently prescribed drugs in hypertensives, and angiotensin-converting enzyme (ACE) inhibitors in diabetic hypertensives. Diuretics and calcium channel blockers, the preferred antihypertensives for the elderly, were less often prescribed, particularly in patients with isolated systolic hypertension.

CONCLUSIONS

Approximately one out of 9 elderly hypertensives and one out of 24 diabetic hypertensives achieved optimal BP control. Although preference for antihypertensives was markedly influenced by comorbidity with diabetes, tailoring of drug therapy was suboptimal and did not adhere to the recommended guidelines in elderly hypertensives. Efforts to improve the drug management of hypertension at primary care level, particularly in the elderly, are required.

Role of exercise training on cardiovascular disease in persons who have type 2 diabetes and hypertension

Exercise training is an essential component in the medical management of patients who have type 2 diabetes and hypertension. Regular exercise improves the cardiovascular health of individuals who have these conditions through multiple mechanisms (Fig. 1). These mechanisms include improvements in endothelial vasodilator function,left ventricular diastolic function, arterial stiffness.systematic inflammation, and reducing left ventricular mass. Exercise training also reduces total and abdominal fat, which mediate improvements in insulin sensitivity and blood pressure, and possibly, endothelial function. Persons who are in a prediabetic stage or those who have the metabolic syndrome may be able to prevent or delay the progression to overt diabetes by adopting a healthier lifestyle, of which increasing habitual levels of physical activity isa vital component. Most persons who have diabetes and hypertension or are at risk for these conditions should be able to initiate an exercise program safely after appropriate medical screen-ing and the establishment of an individualized exercise prescription. Despite the increasing amount of evidence that shows the benefits of exercise training, this modality of prevention and treatment continues to be underused. Although patients' lack of knowledge of the benefits of exercise or lack of motivation contributes to this underuse, a lack of clear and specific guidelines from health care professionals also is an important factor. Clinicians need to educate patients about the benefits of exercise for managing their type 2 diabetes and assist in formulating specific advice for increasing physical activity. Specific instructions should be given to patients, rather than general advice, such as "you should exercise more often." Many cardiac re-habilitation and clinical exercise programs can accommodate patients who have type 2 diabetes and hypertension. Such programs can establish individualized exercise prescriptions and provide an environment that is conducive for "lifestyle change" that underlies long-term compliance to exercise and risk factor modification.

Unique characteristics of the geriatric diabetic population and the role for therapeutic strategies that enhance glucagon-like peptide-1 activity

PURPOSE OF REVIEW

Care for elderly diabetic patients poses a unique clinical challenge. This review highlights distinct aspects of the pathophysiology and the risks for secondary complications in the geriatric diabetic population. Based on these considerations, we discuss emerging therapeutic options based on the actions of the incretin hormone glucagon-like peptide (GLP)-1, which may be ideal for achieving glycemic control in the elderly diabetic patient.

RECENT FINDINGS

Aging is associated with diminished capacity of pancreatic beta-cells to respond to glucose. This functional decline in beta-cell insulin secretion is a major contributor to the development of diabetes in the older patient. In addition, elderly diabetics suffer from a broader range of diabetic complications than do younger diabetics, warranting aggressive glycemic control. GLP-1 is known to improve beta-cell insulin secretion, increase beta-cell mass, and suppress glucagon secretion. Recent studies investigating improved GLP-1 activity have yielded promising results, with improved glycemic control in elderly patients with type 2 diabetes and without significant risk for hypoglycemia.

SUMMARY

Elderly diabetics are a growing subset of the type 2 diabetic population with unique pathophysiologic characteristics and diabetic risk profiles. Therapeutic strategies that incorporate enhancement of GLP-1 action on beta-cells to improve beta-cell insulin secretion and glycemic control may be ideal for this distinct population and should be validated with further long-term clinical studies.

Calcium antagonists

Calcium antagonists were introduced for the treatment of hypertension in the 1980s. Their use was subsequently expanded to additional disorders, such as angina pectoris, paroxysmal supraventricular tachycardias, hypertrophic cardiomyopathy, Raynaud phenomenon, pulmonary hypertension, diffuse esophageal spasms, and migraine. Calcium antagonists as a group are heterogeneous and include 3 main classes--phenylalkylamines, benzothiazepines, and dihydropyridines--that differ in their molecular structure, sites and modes of action, and effects on various other cardiovascular functions. Calcium antagonists lower blood pressure mainly through vasodilation and reduction of peripheral resistance. They maintain blood flow to vital organs, and are safe in patients with renal impairment. Unlike diuretics and beta-blockers, calcium antagonists do not impair glucose metabolism or lipid profile and may even attenuate the development of arteriosclerotic lesions. In long-term follow-up, patients treated with calcium antagonists had development of less overt diabetes mellitus than those who were treated with diuretics and beta-blockers. Moreover, calcium antagonists are able to reduce left ventricular mass and are effective in improving anginal pain. Recent prospective randomized studies attested to the beneficial effects of calcium antagonists in hypertensive patients. In comparison with placebo, calcium antagonist-based therapy reduced major cardiovascular events and cardiovascular death significantly in elderly hypertensive patients and in diabetic patients. In several comparative studies in hypertensive patients, treatment with calcium antagonists was equally effective as treatment with diuretics, beta-blockers, or angiotensin-converting enzyme inhibitors. From these studies, it seems that a calcium antagonist-based regimen is superior to other regimens in preventing stroke, equivalent in preventing ischemic heart disease, and inferior in preventing congestive heart failure. Calcium antagonists are also safe and effective as first-line or add-on therapy in diabetic hypertensive patients. Heart rate-lowering calcium antagonists (verapamil, diltiazem) may have an edge over the dihydropyridines in post-myocardial infarction patients and in diabetic nephropathy. Thus, calcium antagonists may be safely used in the management of hypertension and angina pectoris.

beta-Blockers in hypertension: is carvedilol different?

Most studies assessing the effects of beta-blockers were carried out with traditional, beta(1)-selective beta-blockers, such as metoprolol and atenolol. Pathophysiologic and pharmacologic studies have documented that not all beta-blockers are created equal. In particular, the pharmacologic and clinical profiles of the newer, vasodilating beta-blockers, such as carvedilol, have been shown to differ from those of the traditional beta-blockers. These differences, although relevant in the younger patient with hypertension, are particularly important in elderly patients in whom traditional beta-blockers may not be as effective or as well tolerated as the newer vasodilating agents.

Efficacy and Safety of Valsartan 160mg/Hydrochlorothiazide 25mg Combination in Patients with Hypertension not Adequately Controlled by Valsartan 160mg/Hydrochlorothiazide 12.5mg

BACKGROUND AND OBJECTIVE

Hypertension guidelines emphasise the need to treat high blood pressure (BP) early and aggressively, giving fixed-dose combinations special consideration. Hitherto, it has not been assessed in a sequential way whether hypertensive patients with inadequately controlled hypertension with an angiotensin II receptor antagonist/hydrochlorothiazide combination benefit from a dose increase of the diuretic. We investigated the efficacy and safety of valsartan 160mg/hydrochlorothiazide 25mg combination in patients with hypertension that was not adequately controlled by valsartan 160mg/hydrochlorothiazide 12.5mg.

PATIENTS AND METHODS

This was a multicentre, single-group, prospective study of 646 patients with moderate hypertension (diastolic BP [DBP] 100-109mm Hg). Patients were treated for 4 weeks with valsartan 160mg/hydrochlorothiazide 12.5mg (phase 1: weeks 1-4). In case of non-response (DBP >/=90mm Hg; n = 224) patients were treated for a further 4 weeks with valsartan 160mg/hydrochlorothiazide 25mg (phase 2: weeks 5-8). The primary efficacy measure was a change in mean sitting trough DBP at study end compared with the beginning of phase 2 in the intention-to-treat (ITT) population (n = 221).

RESULTS

Mean age of patients at entry was 58.6 years; 53.7% of patients were female. In phase 1, systolic BP (SBP)/DBP decreased from a baseline value of 161.9/103.3mm Hg by -16.1/-12.4mm Hg (normalisation rate 38.3%, response rate 64.5%). In phase 2, in the ITT non-responder population the additional SBP/DBP decrease was -8.4/-8.3mm Hg. Overall, the normalisation rate in all patients was 55.4% and the responder rate was 76.3%.Tolerability of both the valsartan 160mg/hydrochlorothiazide 12.5mg and the valsartan 160mg/hydrochlorothiazide 25mg combinations was very good, and the switch to the higher dose did not result in an increase in adverse events (AEs) or laboratory abnormalities. Only 16.6% of patients in phase 1 and 10.3% of patients in phase 2 experienced one or more AEs.

CONCLUSION

In patients with moderate hypertension, first-line therapy with the fixed-dose valsartan/hydrochlorothiazide combination leads to high normalisation and response rates. Patients with hypertension not controlled by valsartan 160mg/ hydrochlorothiazide 12.5mg clearly benefit from dose titration to valsartan 160mg/hydrochlorothiazide 25mg with a clinically relevant additional BP response and have excellent tolerability.

The Use of Calcium Antagonists in the Therapy of Hypertension in the Elderly

Calcium antagonists (calcium channel blockers) are widely used in the treatment of hypertension and other cardiovascular diseases. The results of a large number of clinical trials have demonstrated that calcium antagonists are as efficacious as other classes of antihypertensive agents in decreasing blood pressure in the elderly patients. Large clinical trials have shown the effectiveness of calcium antagonists (with long duration of action) in reducing cardiovascular and cerebrovascular morbidity and mortality in elderly hypertensive patients. The calcium antagonists are a chemically, pharmacologically and therapeutically heterogeneous group of agents. Among themselves, they differ in vasoselectivity, effect on cardiac conduction, sympathetic activation, adverse effect profile, ability to protect against target organ damage, suitability for patients with co-morbid conditions, and pharmacodynamic characteristics. The calcium antagonists can be used as single agents or in combination with other antihypertensive drugs. These drugs should not be used as first-line drugs in treating high blood pressure in patients with heart failure, since drugs in other classes provide more benefits. The dihydropyridine calcium antagonists should not be used in post-myocardial infarction patients or in patients with unstable angina; however, non-dihydropyridines may be used in such patients. The adverse effects of dihydropyridines include peripheral and ankle edema, flushing and headache. The short-acting preparations of the older calcium antagonists are no longer used, because of the potential for adverse cardiovascular outcome.