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Hale G, Puchades E, Jacomino G, El-Mcharfie L, Perez A. Use trends of chlorthalidone and hydrochlorothiazide among United States adults with hypertension: National Health and Nutrition Examination Survey 2009-2018. J Hypertens 2024; 42:490-496. [PMID: 37965736 DOI: 10.1097/hjh.0000000000003622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
OBJECTIVES To estimate the national prevalence of chlorthalidone and hydrochlorothiazide use among adults diagnosed with hypertension by sociodemographic subgroup, healthcare access status, and clinical factors. METHODS Data was extracted from the National Health and Nutrition Examination Survey for 2009-2010 through 2017-2018 survey waves. Patients at least 20 years old, diagnosed with hypertension, and on hydrochlorothiazide or chlorthalidone were included. Uni-variable logistic regression models estimated the odds of being on chlorthalidone compared with hydrochlorothiazide use by sociodemographic and clinical factors. Analyses were adjusted for multi-stage complex survey design and are nationally representative. RESULTS Two thousand five hundred and eighty-five participants were included with 95.2% participants using hydrochlorothiazide and 4.8% using chlorthalidone. Participants over 65 years were more likely to be on chlorthalidone compared with younger counterparts [odds ratio (OR) 1.8; 95% confidence interval (CI) 1.12-2.88]. Participants with hypokalemia (OR 2.62; 95% CI 1.56-4.42) or hyponatremia [OR 2.298; 95% CI 1.23-4.30) were more likely to be using chlorthalidone compared with patients with normal levels. CONCLUSION Chlorthalidone, a potent and effective first-line antihypertensive agent and thoroughly studied thiazide diuretic with substantial cardiovascular benefits, continues to be underutilized in patients with hypertension. Findings demonstrated that individuals receiving chlorthalidone were more likely to be 65 years or older and to experience hyponatremia or hypokalemia. Sociodemographic factors, healthcare access and use, clinical factors, and medical conditions did not appear to sway the choice in thiazide diuretic use.
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Affiliation(s)
- Genevieve Hale
- Nova Southeastern University Barry and Judy Silverman College of Pharmacy, Palm Beach Campus, North Military Trial Palm Beach Gardens
| | - Emily Puchades
- Nova Southeastern University Barry and Judy Silverman College of Pharmacy, Fort Lauderdale-Davie Campus, 3200 S University Drive, Davie, Florida, USA
| | - Gema Jacomino
- Nova Southeastern University Barry and Judy Silverman College of Pharmacy, Fort Lauderdale-Davie Campus, 3200 S University Drive, Davie, Florida, USA
| | - Layall El-Mcharfie
- Nova Southeastern University Barry and Judy Silverman College of Pharmacy, Fort Lauderdale-Davie Campus, 3200 S University Drive, Davie, Florida, USA
| | - Alexandra Perez
- Nova Southeastern University Barry and Judy Silverman College of Pharmacy, Fort Lauderdale-Davie Campus, 3200 S University Drive, Davie, Florida, USA
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Pitt B, Auchus RJ. Chlorthalidone or Spironolactone for Patients With TRH and Advanced Chronic Kidney Disease? Hypertension 2024; 81:107-109. [PMID: 37909173 DOI: 10.1161/hypertensionaha.123.21962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Affiliation(s)
- Bertram Pitt
- Division of Cardiology (B.P.), University of Michigan, Ann Arbor, MI
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine (R.J.A.), University of Michigan, Ann Arbor, MI
- Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, MI
- Endocrinology and Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI (R.J.A.)
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Georgianos PI, Agarwal R. Hypertension in chronic kidney disease-treatment standard 2023. Nephrol Dial Transplant 2023; 38:2694-2703. [PMID: 37355779 PMCID: PMC10689140 DOI: 10.1093/ndt/gfad118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Indexed: 06/26/2023] Open
Abstract
Hypertension is very common and remains often poorly controlled in patients with chronic kidney disease (CKD). Accurate blood pressure (BP) measurement is the essential first step in the diagnosis and management of hypertension. Dietary sodium restriction is often overlooked, but can improve BP control, especially among patients treated with an agent to block the renin-angiotensin system. In the presence of very high albuminuria, international guidelines consistently and strongly recommend the use of an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker as the antihypertensive agent of first choice. Long-acting dihydropyridine calcium channel blockers and diuretics are reasonable second- and third-line therapeutic options. For patients with treatment-resistant hypertension, guidelines recommend the addition of spironolactone to the baseline antihypertensive regimen. However, the associated risk of hyperkalemia restricts the broad utilization of spironolactone in patients with moderate-to-advanced CKD. Evidence from the CLICK (Chlorthalidone in Chronic Kidney Disease) trial indicates that the thiazide-like diuretic chlorthalidone is effective and serves as an alternative therapeutic opportunity for patients with stage 4 CKD and uncontrolled hypertension, including those with treatment-resistant hypertension. Chlorthalidone can also mitigate the risk of hyperkalemia to enable the concomitant use of spironolactone, but this combination requires careful monitoring of BP and kidney function for the prevention of adverse events. Emerging agents, such as the non-steroidal mineralocorticoid receptor antagonist ocedurenone, dual endothelin receptor antagonist aprocitentan and the aldosterone synthase inhibitor baxdrostat offer novel targets and strategies to control BP better. Larger and longer term clinical trials are needed to demonstrate the safety and efficacy of these novel therapies in the future. In this article, we review the current standards of treatment and discuss novel developments in pathophysiology, diagnosis, outcome prediction and management of hypertension in patients with CKD.
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Affiliation(s)
- Panagiotis I Georgianos
- 2nd Department of Nephrology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
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Kollias A, Kyriakoulis KG, Stergiou GS. Chlorthalidone versus hydrochlorothiazide for preventing cardiovascular disease in hypertension: Is the case closed? Hellenic J Cardiol 2023; 73:84-85. [PMID: 37429505 DOI: 10.1016/j.hjc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023] Open
Abstract
The optimal diuretic choice [hydrochlorothiazide (HCTZ) or chlorthalidone (CTD)] for the management of hypertension has been an ongoing debate for several years. HCTZ is widely used in the form of single-pill combinations, whereas CTD is a more potent drug vs. HCTZ, especially in reducing nighttime blood pressure (BP), with some indirect evidence suggesting a superiority in terms of cardiovascular (CV) risk reduction. In addition, recent data showed that CTD was safe and effective in terms of BP lowering in predialysis patients with stage 4 chronic kidney disease. The Diuretic Comparison Project was the first head-to-head pragmatic, open-label trial that randomly assigned elderly patients with hypertension under HCTZ therapy to continue with HCTZ or to switch to CTD (equivalent doses). Office BP was similar for both groups throughout the study. The trial showed no difference in major CV events or non-cancer-related deaths during a median follow-up of 2.4 years; yet, CTD was associated with a benefit in participants with a previous myocardial infarction or stroke, which might be a chance finding but could also indicate that a high-risk population is more suitable for revealing the impact of slight differences in the 24-hour BP profile in a relatively short-term follow-up. Interestingly CTD vs. HCTZ was associated with higher hypokalemia rates apart from the latter group of patients where there was no difference. Overall, the available data do not confirm the superiority of CTD over HCTZ in general, but this could be questionable in selected patients.
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Affiliation(s)
- Anastasios Kollias
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Konstantinos G Kyriakoulis
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George S Stergiou
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Sahoo SK, Pathni AK, Krishna A, Sharma B, Cazabon D, Moran AE, Hering D. Financial implications of protocol-based hypertension treatment: an insight into medication costs in public and private health sectors in India. J Hum Hypertens 2023; 37:828-834. [PMID: 36271130 PMCID: PMC10471490 DOI: 10.1038/s41371-022-00766-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/20/2022] [Accepted: 09/30/2022] [Indexed: 11/10/2022]
Abstract
Hypertension is a major public health challenge in low- and middle-income countries (LMICs) and calls for large-scale effective hypertension control programs. Adoption of drug and dose-specific treatment protocols recommended by the World Health Organization-HEARTS Initiative is key for hypertension control programs in LMICs. We estimated the annual medication cost per patient using three such protocols (protocol-1 and protocol-2 with Amlodipine, Telmisartan, using add-on doses and different drug orders, adding Chlorthalidone; protocol-3 with a single-pill combination (SPC) of Amlodipine/Telmisartan with dose up-titration, and addition of Chlorthalidone, if required) in India. The medication cost was simulated with different hypertension control assumptions for each protocol and calculated based on prices in the public and private sectors in India. The estimated annual medication cost per patient for protocol-1 and protocol-2 was $33.88-58.44 and $51.57-68.83 for protocol-3 in the private sector. The medication cost was lower in the generic stores ($5.78-9.57 for protocol-1 and protocol-2, and $7.35-9.89 for protocol-3). The medication cost for patients was the lowest ($2.05-3.89 for protocol-1 and protocol-2, and $2.94-3.98 for protocol-3) in the public sector. At less than $4 per patient per annum, scaling up a hypertension control program with specific treatment protocols is a potentially cost-effective public health intervention. Expanding low-cost generic retail networks would extend affordability in the private sector. The cost of treatment with SPC is comparable with non-SPC protocols and can be adopted in a public health program considering the advantage of simplified logistics, reduced pill burden, improved treatment adherence, and blood pressure control.
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Affiliation(s)
| | | | | | | | | | - Andrew E Moran
- Resolve to Save Lives, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Dagmara Hering
- Department of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland.
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Ebell MH. Chlorthalidone No Better Than Hydrochlorothiazide for Hypertension. Am Fam Physician 2023; 108:Online. [PMID: 37725471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
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Götzinger F, Kunz M, Lauder L, Böhm M, Mahfoud F. Arterial Hypertension-clinical trials update 2023. Hypertens Res 2023; 46:2159-2167. [PMID: 37443261 DOI: 10.1038/s41440-023-01359-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/04/2023] [Accepted: 06/11/2023] [Indexed: 07/15/2023]
Abstract
Arterial hypertension is associated with increased morbidity and mortality and research in the field is highly dynamic. This summary reviews the most important clinical trials published in 2022 and early 2023. Findings on new pharmacological approaches to treat resistant hypertension are presented and new knowledge about the optimal timing of the antihypertensive medication intake is discussed. It is focused on optimal blood pressure treatment targets and the problem of treatment and guideline inertia is acknowledged. Information about pregnancy-related hypertension is presented and blood pressure control following percutaneous thrombectomy after ischemic stroke is discussed. Finally, novel clinical data on device-based approaches to treat hypertension are summarized. The hypertension trials update summarizes the most important clincal trials on hypertension research in 2022 and early 2023. CTD - chlorthalidone, CV - cardiovascular, HCT - hydrochlorothiazide, SBP - systolic blood pressure, RDN - renal denervation *depicts systolic blood pressure only.
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Affiliation(s)
- Felix Götzinger
- From the Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Saarland, 66424, Homburg, Germany.
| | - Michael Kunz
- From the Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Saarland, 66424, Homburg, Germany
| | - Lucas Lauder
- From the Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Saarland, 66424, Homburg, Germany
| | - Michael Böhm
- From the Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Saarland, 66424, Homburg, Germany
| | - Felix Mahfoud
- From the Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Saarland, 66424, Homburg, Germany
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Llàcer P, Núñez J, Croset F, García M, Fabregate M, Ruiz R, López G, Fernández C, Del Hoyo B, Campos J, Gomis A, Manzano L. Usefulness of urinary potassium to creatinine ratio to predict diuretic response in patients with acute heart failure and preserved ejection fraction. Clin Cardiol 2023; 46:906-913. [PMID: 37287326 PMCID: PMC10436792 DOI: 10.1002/clc.24040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Patients with acute heart failure (AHF) require intensification in the diuretic strategy. However, the optimal diuretic strategy remains unclear. In this work, we aimed to evaluate the role of urinary potassium to creatinine ratio (K/Cr) to predict diuretic and natriuretic response to thiazide or mineralocorticoid receptor antagonists (MRAs) in a cohort of patients with AHF and preserved ejection fraction (AHF-pEF). HYPOTHESIS Patients with a high urinary K/Cr ratio will have a better diuretic and natriuretic response with spironolactone versus chlorthalidone. METHODS This is a study of 44 patients with AHF-pEF with suboptimal loop diuretic response. The primary endpoint was the baseline K/Cr associated with natriuretic and diuretic effect of chlorthalidone versus spironolactone at 24 and 72 h. Mixed linear regression models were used to analyze the endpoints. Estimates were reported as least squares mean with their respective 95% confidence interval (CIs). RESULTS The median age of the study population was 85 years (82.5-88.5), and 30 (68.2%) were women. The inferential multivariate analysis suggested a greater natriuretic and diuretic effect of chlorthalidone across K/Cr levels. In the upper category, chlorthalidone translated into a statistically increase in natriuresis at 24 and 72 h. Chlorthalidone versus spironolactone showed ∆uNa of 25.7 mmol/L at 24 h (95% CI = -3.7 to 55.4, p = .098) and ∆uNa of 24.8 mmol/L at 72 h (95% CI = -4 to 53.6, p = .0106). The omnibus p value is .027. Multivariate analyses revealed a significant increase in 72 h cumulative diuresis irrespective of K/Cr status in those on chlorthalidone. CONCLUSIONS In patients with AHF-pEF and suboptimal diuretic response, diuresis and natriuresis are higher with the administration of chlorthalidone over spironolactone. These data don't support the hypothesis that the K/Cr ratio can help guide the choice of thiazide diuretic versus MRA in AHF-pEF patients on loop diuretic.
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Affiliation(s)
- Pau Llàcer
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de AlcaláMadridSpain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico UniversitarioUniversitat de València, INCLIVAValenciaSpain
- CIBER CardiovascularMadridSpain
| | - François Croset
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de AlcaláMadridSpain
| | - Marina García
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Martín Fabregate
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Raúl Ruiz
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Genoveva López
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Cristina Fernández
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Beatriz Del Hoyo
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Jorge Campos
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Antonio Gomis
- Nephrology DepartmentHospital Universitario Ramón y CajalMadridSpain
| | - Luis Manzano
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de AlcaláMadridSpain
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Bavishi C. In older adults with hypertension, chlorthalidone vs. hydrochlorothiazide did not reduce major CV events or deaths at 2.4 y. Ann Intern Med 2023; 176:JC39. [PMID: 37011397 DOI: 10.7326/j23-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
SOURCE CITATION Diuretic Comparison Project Writing Group; Ishani A, Cushman WC, Leatherman SM, et al. Chlorthalidone vs. hydrochlorothiazide for hypertension-cardiovascular events. N Engl J Med. 2022;387:2401-10. 36516076.
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Gnanenthiran SR, Webster R, Silva AD, Maulik PK, Salam A, Selak V, Guggilla RK, Schutte AE, Patel A, Rodgers A. Reduced efficacy of blood pressure lowering drugs in the presence of diabetes mellitus-results from the TRIUMPH randomised controlled trial. Hypertens Res 2023; 46:128-135. [PMID: 36229537 DOI: 10.1038/s41440-022-01051-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/08/2022] [Accepted: 09/19/2022] [Indexed: 02/03/2023]
Abstract
We investigated whether diabetes mellitus (DM) affects the efficacy of a low-dose triple combination pill and usual care among people with mild-moderate hypertension. TRIUMPH (TRIple pill vs Usual care Management for Patients with mild-to-moderate Hypertension) was a randomised controlled open-label trial of patients requiring initiation or escalation of antihypertensive therapy. Patients were randomised to a once-daily low-dose triple combination polypill (telmisartan-20mg/amlodipine-2.5 mg/chlorthalidone-12.5 mg) or usual care. This analysis compared BP reduction in people with and without DM, both in the intervention and control groups over 24-week follow-up. Predicted efficacy of prescribed therapy was calculated (estimation methods of Law et al.). The trial randomised 700 patients (56 ± 11 yrs, 31% DM). There was no difference in the number of drugs prescribed or predicted efficacy of therapy between people with DM and without DM. However, the observed BP reduction from baseline to week 24 was lower in those with DM compared to non-diabetics in both the triple pill (25/11 vs 31/15 mmHg, p ≤ 0.01) and usual care (17/7 vs 22/11 mmHg, p ≤ 0.01) groups, and these differences remained after multivariable adjustment. DM was a negative predictor of change in BP (β-coefficient -0.08, p = 0.02). In conclusion, patients with DM experienced reduced efficacy of BP lowering therapies as compared to patients without DM, irrespective of the type of BP lowering therapy received.
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Affiliation(s)
- Sonali R Gnanenthiran
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Ruth Webster
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- School of Population Health, UNSW, Sydney, Australia
| | - Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | | | - Abdul Salam
- The George Institute for Global Health, Hyderabad, India
| | - Vanessa Selak
- Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Rama K Guggilla
- Department of Population Medicine and Lifestyle Diseases Prevention, Faculty of Medicine with the Division of Dentistry and Division of Medical Education in English, Medical University of Bialystok, Bialystok, Poland
| | - Aletta E Schutte
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.
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Ishani A, Cushman WC, Leatherman SM, Lew RA, Woods P, Glassman PA, Taylor AA, Hau C, Klint A, Huang GD, Brophy MT, Fiore LD, Ferguson RE. Chlorthalidone vs. Hydrochlorothiazide for Hypertension-Cardiovascular Events. N Engl J Med 2022; 387:2401-2410. [PMID: 36516076 DOI: 10.1056/nejmoa2212270] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Whether chlorthalidone is superior to hydrochlorothiazide for preventing major adverse cardiovascular events in patients with hypertension is unclear. METHODS In a pragmatic trial, we randomly assigned adults 65 years of age or older who were patients in the Department of Veterans Affairs health system and had been receiving hydrochlorothiazide at a daily dose of 25 or 50 mg to continue therapy with hydrochlorothiazide or to switch to chlorthalidone at a daily dose of 12.5 or 25 mg. The primary outcome was a composite of nonfatal myocardial infarction, stroke, heart failure resulting in hospitalization, urgent coronary revascularization for unstable angina, and non-cancer-related death. Safety was also assessed. RESULTS A total of 13,523 patients underwent randomization. The mean age was 72 years. At baseline, hydrochlorothiazide at a dose of 25 mg per day had been prescribed in 12,781 patients (94.5%). The mean baseline systolic blood pressure in each group was 139 mm Hg. At a median follow-up of 2.4 years, there was little difference in the occurrence of primary-outcome events between the chlorthalidone group (702 patients [10.4%]) and the hydrochlorothiazide group (675 patients [10.0%]) (hazard ratio, 1.04; 95% confidence interval, 0.94 to 1.16; P = 0.45). There were no between-group differences in the occurrence of any of the components of the primary outcome. The incidence of hypokalemia was higher in the chlorthalidone group than in the hydrochlorothiazide group (6.0% vs. 4.4%, P<0.001). CONCLUSIONS In this large pragmatic trial of thiazide diuretics at doses commonly used in clinical practice, patients who received chlorthalidone did not have a lower occurrence of major cardiovascular outcome events or non-cancer-related deaths than patients who received hydrochlorothiazide. (Funded by the Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT02185417.).
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Affiliation(s)
- Areef Ishani
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - William C Cushman
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Sarah M Leatherman
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Robert A Lew
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Patricia Woods
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Peter A Glassman
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Addison A Taylor
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Cynthia Hau
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Alison Klint
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Grant D Huang
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Mary T Brophy
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Louis D Fiore
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Ryan E Ferguson
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
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12
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Wang SY, Hanna JM, Gongal P, Onuma OK, Nanna MG. Choice of antihypertensive agent in isolated systolic hypertension and isolated diastolic hypertension: A secondary analysis of the ALLHAT trial. Am Heart J 2022; 254:30-34. [PMID: 35932912 PMCID: PMC10908340 DOI: 10.1016/j.ahj.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 06/15/2023]
Abstract
Despite broad treatment recommendations, there are limited published reports comparing the efficacy of different antihypertensive agents in patients with isolated systolic hypertension or isolated diastolic hypertension. This study was a secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. We compared the use of chlorthalidone, amlodipine, or lisinopril on the primary outcome of combined coronary heart disease, stroke, or all-cause mortality in patients with isolated systolic hypertension or isolated diastolic hypertension.
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Affiliation(s)
- Stephen Y Wang
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jonathan M Hanna
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Prajesh Gongal
- Department of Internal Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Oyere K Onuma
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
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13
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Kunz M, Götzinger F, Emrich I, Schwenger V, Böhm M, Mahfoud F. Cardio-renal interaction - Clinical trials update 2022. Nutr Metab Cardiovasc Dis 2022; 32:2451-2458. [PMID: 36064690 DOI: 10.1016/j.numecd.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 10/31/2022]
Abstract
AIMS Chronic kidney disease is a common cardiovascular risk indicator and strongly associated with increased morbidity and mortality. The heart and kidneys are pathophysiologically closely connected, which becomes particularly obvious in patients with cardiorenal syndrome. This review summarizes clinically relevant studies on the cardio-renal interaction published in 2021 and 2022. DATA SYNTHESIS Selected trials published in high-impact journals were chosen from the database Pubmed and included in this review. New evidence about the selective mineralocorticoid receptor antagonist finerenone and the renoprotective sodium-glucose co-transporter-2-inhibitors (SGLT2-Inhibitors) are discussed and we update on novel insights about the treatment of arterial hypertension in patients with severe chronic kidney disease with the thiazide-like diuretic chlorthalidone. Finally, data on infective endocarditis in patients on chronic hemodialysis and the treatment of secondary hyperparathyroidism with the calcimimetic drug etelcalcetide in patients with end stage kidney disease are critically reviewed. CONCLUSION Several important studies investigating cardio-renal interactions were recently published may affect clinical practice. The graphical abstract (Fig. 1) depicts the most relevant clinical studies investigating cardio-renal interactions.
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Affiliation(s)
- Michael Kunz
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Saarland, Saarland University, 66424 Homburg, Germany.
| | - Felix Götzinger
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Saarland, Saarland University, 66424 Homburg, Germany
| | - Insa Emrich
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Saarland, Saarland University, 66424 Homburg, Germany
| | - Vedat Schwenger
- Department of Nephrology, Klinikum der Landeshauptstadt Stuttgart gKAöR - Katharinenhospital, 70174 Stuttgart, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Saarland, Saarland University, 66424 Homburg, Germany
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Saarland, Saarland University, 66424 Homburg, Germany
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14
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Abstract
PURPOSE OF REVIEW Existing guidelines offer little direction about the use of thiazide and loop diuretics in patients with chronic kidney disease (CKD). This review summarizes recent studies impacting indications and safety considerations for these agents in patients with CKD. RECENT FINDINGS Chlorthalidone reduces blood pressure compared to placebo in patients with advanced CKD, challenging the belief that thiazide diuretics lose efficacy at lower glomerular filtration rates (GFR). Existing studies show no clear impact of thiazide or loop diuretic use on kidney or cardiovascular outcomes in patients with CKD. Sodium-glucose co-transporter type 2 (SGLT2) inhibitors have diuretic effects, but concomitant use of a diuretic does not diminish the preventive benefits of these agents against acute kidney injury (AKI). Despite theoretical concerns, thiazide diuretics likely do not worsen circulating vasopressin levels or cyst progression in polycystic kidney disease and may be useful for alleviating polyuria from tolvaptan. Diuretics cause multiple adverse effects, including electrolyte abnormalities, hemodynamic-mediated decrease in estimated GFR, and AKI. SUMMARY Recent evidence supports expanded indications for diuretics in patients with kidney disease, including chlorthalidone for hypertension in advanced CKD. Monitoring electrolytes and estimated GFR is critical to ensure patient safety when prescribing these agents for patients with CKD.
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Affiliation(s)
- Sehrish Ali
- Selzman Institute for Kidney Health, Section of Nephrology,
Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Michael E. DeBakey Veterans Affairs
Medical Center, Houston, TX
| | - Sankar D. Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology,
Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Michael E. DeBakey Veterans Affairs
Medical Center, Houston, TX
- Veterans Affairs Health Services Research and Development
Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Institute of Clinical and Translational Research, Baylor
College of Medicine, Houston, TX
| | - Salim S. Virani
- Veterans Affairs Health Services Research and Development
Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Division of Cardiology, Baylor College of Medicine,
Houston, TX
- Division of Cardiology, Department of Medicine, Michael E.
DeBakey VA Medical Center, Houston, TX
| | - L. Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology,
Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Michael E. DeBakey Veterans Affairs
Medical Center, Houston, TX
- Veterans Affairs Health Services Research and Development
Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
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15
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| | - Arjun D Sinha
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| | - Wanzhu Tu
- Department of Biostatistics & Health Data Science, Richard M. Fairbanks School of Public Health, Indiana University Center for Aging Research, Indiana University School of Medicine, Regenstrief Institute, Indianapolis, IN, USA
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Georgianos PI, Agarwal R. Management of hypertension in advanced kidney disease. Curr Opin Nephrol Hypertens 2022; 31:374-379. [PMID: 35727171 PMCID: PMC9728619 DOI: 10.1097/mnh.0000000000000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to present recent developments in pharmacotherapy of hypertension in patients with advanced chronic kidney disease (CKD). RECENT FINDINGS In the AMBER trial, compared with placebo, the potassium-binder patiromer mitigated the risk of hyperkalaemia and enabled more patients with uncontrolled resistant hypertension and stage 3b/4 CKD to tolerate and continue spironolactone treatment; add-on therapy with spironolactone provoked a clinically meaningful reduction of 11-12 mmHg in unattended automated office SBP over 12 weeks of follow-up. In the BLOCK-CKD trial, the investigational nonsteroidal mineralocorticoid-receptor-antagonist (MRA) KBP-5074 lowered office SBP by 7-10 mmHg relative to placebo at 84 days with a minimal risk of hyperkalaemia in patients with advanced CKD and uncontrolled hypertension. The CLICK trial showed that the thiazide-like diuretic chlorthalidone provoked a placebo-subtracted reduction of 10.5 mmHg in 24-h ambulatory SBP at 12 weeks in patients with stage 4 CKD and poorly controlled hypertension. SUMMARY Enablement of more persistent spironolactone use with newer potassium-binding agents, the clinical development of novel nonsteroidal MRAs with a more favourable benefit-risk profile and the recently proven blood pressure lowering action of chlorthalidone are three therapeutic opportunities for more effective management of hypertension in high-risk patients with advanced CKD.
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Affiliation(s)
- Panagiotis I. Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
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Llàcer P, Núñez J, García M, Ruiz R, López G, Fabregate M, Fernández C, Croset F, Del Hoyo B, Gomis A, Manzano L. Comparison of chlorthalidone and spironolactone as additional diuretic therapy in patients with acute heart failure and preserved ejection fraction. Eur Heart J Acute Cardiovasc Care 2022; 11:350-355. [PMID: 35167653 DOI: 10.1093/ehjacc/zuac006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 01/17/2022] [Accepted: 02/02/2022] [Indexed: 06/14/2023]
Abstract
AIMS Patients with acute heart failure (AHF) require intensification in the diuretic strategy. However, the optimal diuretic strategy remains unclear. In this work, we aimed to evaluate the effect of chlorthalidone compared with spironolactone on diuretic efficacy and safety profile in a cohort of patients with AHF and preserved ejection fraction (AHF-pEF). METHODS AND RESULTS It was a prospective observational study in a single centre in Spain, included 44 consecutive patients admitted between June 2020 and March 2021, with AHF-pEF in which an additional diuretic was prescribed. The primary endpoint was changes in urinary sodium at 24 and 72 h, and the secondary were urine output, and other security endpoints. Mixed linear regression models were used to analyse the endpoints. Estimates were reported as least squares mean with their respective 95% confidence intervals. The median age of the study population was 85 years (82.5-88.5), and 30 (68.2%) were women. After multivariate analysis, the linear mixed regression analysis confirmed a greater natriuretic response of chlorthalidone over spironolactone, especially at 24 h (P = 0.009). Multivariate analysis also showed a greater cumulative diuretic response in those treated with chlorthalidone (P = 0.001). We did not find significant differences in glomerular filtration rate, serum sodium, and serum potassium at 72 h, neither significant differences were found in 24 and 72 h in systolic blood pressure. CONCLUSION In patients with AHF and left ventricular ejection fraction ≥50% receiving intravenous loop diuretics, chlorthalidone administration was associated with a greater short-term natriuresis.
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Affiliation(s)
- Pau Llàcer
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario, Universitat de València, INCLIVA, Valencia, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Marina García
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Raúl Ruiz
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Genoveva López
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Martín Fabregate
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Cristina Fernández
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - François Croset
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Beatriz Del Hoyo
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Antonio Gomis
- Nephrology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, IRYCIS, Madrid, Spain
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19
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Abstract
BACKGROUND Little evidence has been available to support the use of thiazide diuretics to treat hypertension in patients with advanced chronic kidney disease. METHODS We randomly assigned patients with stage 4 chronic kidney disease and poorly controlled hypertension, as confirmed by 24-hour ambulatory blood-pressure monitoring, in a 1:1 ratio to receive chlorthalidone at an initial dose of 12.5 mg per day, with increases every 4 weeks if needed to a maximum dose of 50 mg per day, or placebo; randomization was stratified according to previous use of loop diuretics. The primary outcome was the change in 24-hour ambulatory systolic blood pressure from baseline to 12 weeks. Secondary outcomes were the change from baseline to 12 weeks in the urinary albumin-to-creatinine ratio, N-terminal pro-B-type natriuretic peptide level, plasma renin and aldosterone levels, and total body volume. Safety was also assessed. RESULTS A total of 160 patients underwent randomization, of whom 121 (76%) had diabetes mellitus and 96 (60%) were receiving loop diuretics. At baseline, the mean (±SD) estimated glomerular filtration rate was 23.2±4.2 ml per minute per 1.73 m2 of body-surface area and the mean number of antihypertensive medications prescribed was 3.4±1.4. At randomization, the mean 24-hour ambulatory systolic blood pressure was 142.6±8.1 mm Hg in the chlorthalidone group and 140.1±8.1 mm Hg in the placebo group and the mean 24-hour ambulatory diastolic blood pressure was 74.6±10.1 mm Hg and 72.8±9.3 mm Hg, respectively. The adjusted change in 24-hour systolic blood pressure from baseline to 12 weeks was -11.0 mm Hg (95% confidence interval [CI], -13.9 to -8.1) in the chlorthalidone group and -0.5 mm Hg (95% CI, -3.5 to 2.5) in the placebo group. The between-group difference was -10.5 mm Hg (95% CI, -14.6 to -6.4) (P<0.001). The percent change in the urinary albumin-to-creatinine ratio from baseline to 12 weeks was lower in the chlorthalidone group than in the placebo group by 50 percentage points (95% CI, 37 to 60). Hypokalemia, reversible increases in serum creatinine level, hyperglycemia, dizziness, and hyperuricemia occurred more frequently in the chlorthalidone group than in the placebo group. CONCLUSIONS Among patients with advanced chronic kidney disease and poorly controlled hypertension, chlorthalidone therapy improved blood-pressure control at 12 weeks as compared with placebo. (Funded by the National Heart, Lung, and Blood Institute and the Indiana Institute of Medical Research; CLICK ClinicalTrials.gov number, NCT02841280.).
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Affiliation(s)
- Rajiv Agarwal
- From the Division of Nephrology, Department of Medicine (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and the Department of Biostatistics and Health Data Science, Richard M. Fairbanks School of Public Health (F.O., W.T.), Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and Indiana University Center for Aging Research, Regenstrief Institute (W.T.) - all in Indianapolis
| | - Arjun D Sinha
- From the Division of Nephrology, Department of Medicine (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and the Department of Biostatistics and Health Data Science, Richard M. Fairbanks School of Public Health (F.O., W.T.), Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and Indiana University Center for Aging Research, Regenstrief Institute (W.T.) - all in Indianapolis
| | - Andrew E Cramer
- From the Division of Nephrology, Department of Medicine (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and the Department of Biostatistics and Health Data Science, Richard M. Fairbanks School of Public Health (F.O., W.T.), Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and Indiana University Center for Aging Research, Regenstrief Institute (W.T.) - all in Indianapolis
| | - Mary Balmes-Fenwick
- From the Division of Nephrology, Department of Medicine (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and the Department of Biostatistics and Health Data Science, Richard M. Fairbanks School of Public Health (F.O., W.T.), Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and Indiana University Center for Aging Research, Regenstrief Institute (W.T.) - all in Indianapolis
| | - Jazmyn H Dickinson
- From the Division of Nephrology, Department of Medicine (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and the Department of Biostatistics and Health Data Science, Richard M. Fairbanks School of Public Health (F.O., W.T.), Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and Indiana University Center for Aging Research, Regenstrief Institute (W.T.) - all in Indianapolis
| | - Fangqian Ouyang
- From the Division of Nephrology, Department of Medicine (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and the Department of Biostatistics and Health Data Science, Richard M. Fairbanks School of Public Health (F.O., W.T.), Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and Indiana University Center for Aging Research, Regenstrief Institute (W.T.) - all in Indianapolis
| | - Wanzhu Tu
- From the Division of Nephrology, Department of Medicine (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and the Department of Biostatistics and Health Data Science, Richard M. Fairbanks School of Public Health (F.O., W.T.), Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center (R.A., A.D.S., A.E.C., M.B.-F., J.H.D.), and Indiana University Center for Aging Research, Regenstrief Institute (W.T.) - all in Indianapolis
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Edwards C, Hundemer GL, Petrcich W, Canney M, Knoll G, Burns K, Bugeja A, Sood MM. Comparison of Clinical Outcomes and Safety Associated With Chlorthalidone vs Hydrochlorothiazide in Older Adults With Varying Levels of Kidney Function. JAMA Netw Open 2021; 4:e2123365. [PMID: 34524440 PMCID: PMC8444030 DOI: 10.1001/jamanetworkopen.2021.23365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Thiazide diuretics are commonly prescribed for the treatment of hypertension, a disease highly prevalent among older individuals and in those with chronic kidney disease. How specific thiazide diuretics compare in regard to safety and clinical outcomes in these populations remains unknown. OBJECTIVE To compare safety and clinical outcomes associated with chlorthalidone or hydrochlorothiazide use among older adults with varying levels of kidney function. DESIGN, SETTING, AND PARTICIPANTS This population-based retrospective cohort study was conducted in Ontario, Canada, from 2007 to 2015. Participants included adults aged 66 years or older who initiated chlorthalidone or hydrochlorothiazide during this period. Data were analyzed from December 2019 through September 2020. EXPOSURES New chlorthalidone users were matched 1:4 with new hydrochlorothiazide users by a high-dimensional propensity score. Time-to-event models accounting for competing risks examined the associations between chlorthalidone vs hydrochlorothiazide use and the outcomes of interest overall and within estimated glomerular filtration rate (eGFR) categories (≥60, 45-59, and <45 mL/min/1.73 m2). MAIN OUTCOMES AND MEASURES The outcomes of interest were adverse kidney events (ie, eGFR decline ≥30%, dialysis, or kidney transplantation), cardiovascular events (composite of myocardial infarction, coronary revascularization, heart failure, or atrial fibrillation), all-cause mortality, and electrolyte anomalies (ie, sodium or potassium levels outside reference ranges). RESULTS After propensity score matching, the study cohort included 12 722 adults (mean [SD] age, 74 [7] years; 7063 [56%] women; 5659 [44%] men; mean [SD] eGFR, 69 [19] mL/min/1.73 m2), including 2936 who received chlorthalidone and 9786 who received hydrochlorothiazide. Chlorthalidone use was associated with a higher risk of eGFR decline of 30% or greater (hazard ratio [HR], 1.24 [95% CI, 1.13-1.36]) and cardiovascular events (HR, 1.12 [95% CI, 1.04-1.22]) across all eGFR categories compared with hydrochlorothiazide use. Chlorthalidone use was also associated with a higher risk of hypokalemia compared with hydrochlorothiazide use, which was more pronounced among those with higher eGFR (eGFR ≥60 mL/min/1.73 m2: HR, 1.86 [95% CI, 1.67-2.08]; eGFR 45-59 mL/min/1.73 m2: HR, 1.57 [95% CI, 1.25-1.96]; eGFR <45 mL/min/1.73 m2: HR, 1.10 [95% CI, 0.84-1.45]; P for interaction = .001). No significant differences were observed between chlorthalidone and hydrochlorothiazide for dialysis or kidney transplantation (HR, 1.44 [95% CI, 0.88-2.36]), all-cause mortality (HR, 1.10 [95% CI, 0.93-1.29]), hyperkalemia (HR, 1.05 [95% CI, 0.79-1.39]), or hyponatremia (HR, 1.14 [95% CI, CI 0.98-1.32]). CONCLUSIONS AND RELEVANCE This cohort study found that among older adults, chlorthalidone use was associated with a higher risk of eGFR decline, cardiovascular events, and hypokalemia compared with hydrochlorothiazide use. The excess risk of hypokalemia with chlorthalidone was attenuated in participants with reduced kidney function. Placed in context with prior observational studies comparing the safety and clinical outcomes associated with thiazide diuretics, these results suggest that there is no evidence to prefer chlorthalidone over hydrochlorothiazide.
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Affiliation(s)
- Cedric Edwards
- Ottawa Hospital Research Institute, Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Gregory L. Hundemer
- Ottawa Hospital Research Institute, Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | | | - Mark Canney
- Ottawa Hospital Research Institute, Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Greg Knoll
- Ottawa Hospital Research Institute, Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Kevin Burns
- Ottawa Hospital Research Institute, Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Ann Bugeja
- Ottawa Hospital Research Institute, Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Manish M. Sood
- Ottawa Hospital Research Institute, Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, Canada
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Trujillo H, Caravaca-Fontán F, Caro J, Morales E, Praga M. The Forgotten Antiproteinuric Properties of Diuretics. Am J Nephrol 2021; 52:435-449. [PMID: 34233330 DOI: 10.1159/000517020] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/30/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although diuretics are one of the most widely used drugs by nephrologists, their antiproteinuric properties are not generally taken into consideration. SUMMARY Thiazide diuretics have been shown to reduce proteinuria by >35% in several prospective controlled studies, and these values are markedly increased when combined with a low-salt diet. Thiazide-like diuretics (indapamide and chlorthalidone) have shown similar effectiveness. The antiproteinuric effect of mineralocorticoid receptor antagonists (spironolactone, eplerenone, and finerenone) has been clearly established through prospective and controlled studies, and treatment with finerenone reduces the risk of chronic kidney disease progression in type-2 diabetic patients. The efficacy of other diuretics such as amiloride, triamterene, acetazolamide, or loop diuretics has been less explored, but different investigations suggest that they might share the same antiproteinuric properties of other diuretics that should be evaluated through controlled studies. Although the inclusion of sodium-glucose cotransporter-2 inhibitors (SGLT2i) among diuretics is a controversial issue, their renoprotective and cardioprotective properties, confirmed in various landmark trials, constitute a true revolution in the treatment of patients with kidney disease. Recent subanalyses of these trials have shown that the early antiproteinuric effect induced by SGLT2i predicts long-term preservation of kidney function. Key Message: Whether the early reduction in proteinuria induced by diuretics other than finerenone and SGLT2i, as summarized in this review, also translates into long-term renoprotection requires further prospective and observational studies. In any case, it is important for the clinician to be aware of the antiproteinuric properties of drugs so often used in daily clinical practice.
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Affiliation(s)
- Hernando Trujillo
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain,
| | | | - Jara Caro
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Goldenberg R, Bell A, Cheng W, Fils-Aimé N, Burrows M, Blavignac J, Parron E, Barakat M. Real-world effectiveness of treatments for type 2 diabetes, hypercholesterolemia, and hypertension in Canadian routine care - Results from the CardioVascular and metabolic treatment in Canada: Assessment of REal-life therapeutic value (CV-CARE) registry, 12-months results. Diabetes Res Clin Pract 2020; 170:108416. [PMID: 32891688 DOI: 10.1016/j.diabres.2020.108416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/25/2020] [Accepted: 08/24/2020] [Indexed: 11/21/2022]
Abstract
AIMS The CV-CARE registry provides RWE in Canadian routine clinical practice. METHODS CV-CARE is a multi-site, observational, prospective Canadian registry enrolling patients initiating treatment with metformin hydrochloride extended-release (MetER) for T2D; colesevelam (C) for HCh; and azilsartan (AZI), azilsartan/chlorthalidone (AZI/CHL) or diltiazem extended-release (TXC) for HTN. Patient characteristics/assessment were performed at baseline and 12 ± 6 months. Primary outcome was absolute change in HbA1c and FPG (MetER); % change in LDL-C (C); and absolute change in BP (AZI-AZI/CHL-TXC). RESULTS Of the 4194 patients in the primary analysis population, 24% were taking MetER, 39% were taking C, 33% were taking AZI, 12% were taking AZI/CHL, and 3% were taking TXC. At 12 months, MetER-treated patients had an absolute mean (95% CI) change in HbA1c of -0.3% [-0.4; -0.2] and in FPG of 0.7 mmol/L [-1.0; -0.4]. C-treated patients had a mean (95% CI) % change in LDL-C of -13.0% [-14.6; -11.4]. Absolute mean (95% CI) changes in SBP were -18.7 mmHg [-19.7; -17.7](AZI), -21.3 mmHg [-23.1; -19.5](AZI/CHL), and -12.3 mmHg [-15.1; -9.6](TXC). CONCLUSION In a real-world Canadian setting, MetER, C, AZI, AZI/CHL, and TXC show improvement of the cardiometabolic profile of T2D, HCh, and HTN patients.
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Affiliation(s)
- Ronald Goldenberg
- LMC Diabetes and Endocrinology, 1600 Steeles Ave W #5, Concord, ON L4K 4M2, Canada.
| | - Alan Bell
- University of Toronto, 27 King's College Cir, Toronto, ON M5S XXX, Canada.
| | - Willoon Cheng
- Tillsonburg Medical Centre, 200 Broadway, Tillsonburg, ON N4G 5A7, Canada.
| | | | - Melonie Burrows
- Bausch Health, 2150 Boul. St-Elzéar, Laval, QC H7L 4A8, Canada.
| | | | - Emilia Parron
- Bausch Health, 2150 Boul. St-Elzéar, Laval, QC H7L 4A8, Canada.
| | - Maxime Barakat
- Bausch Health, 2150 Boul. St-Elzéar, Laval, QC H7L 4A8, Canada.
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Johnson K, Oparil S, Davis BR, Tereshchenko LG. Prevention of Heart Failure in Hypertension-Disentangling the Role of Evolving Left Ventricular Hypertrophy and Blood Pressure Lowering: The ALLHAT Study. J Am Heart Assoc 2020; 8:e011961. [PMID: 30943832 PMCID: PMC6507192 DOI: 10.1161/jaha.119.011961] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Hypertension is a known risk factor for heart failure (HF), possibly via the mechanism of cardiac remodeling and left ventricular hypertrophy (LVH). We studied the extent to which blood pressure (BP) change and evolving LVH contribute to the effect that lisinopril, doxazosin, and amlodipine have on HF compared with chlorthalidone. Methods and Results We conducted causal mediation analysis of ALLHAT (Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial) data (1994‐2002; in‐trial follow‐up). ALLHAT participants with available serial ECGs and BP measurements were included (n=29 892; mean age 67±4 years; 32% black; 56% men): 11 008 were randomized to chlorthalidone, 5967 to doxazosin, 6593 to amlodipine, and 6324 to lisinopril. Evolving ECG LVH and BP lowering served as mediators. Incident symptomatic HF was the primary outcome. Linear regression (for mediator) and logistic regression (for outcome) models were adjusted for mediator‐outcome confounders (demographic and clinical characteristics known to be associated both with both LVH/hypertension and HF). A large majority of participants (96%) had ECG LVH status unchanged, but 4% developed evolving ECG LVH. On average, BP decreased by 11/7 mm Hg. In adjusted Cox regression analyses, progressing ECG LVH (hazard ratio [HR] 1.78 [95% CI 1.43‐2.22]), resolving ECG LVH (HR 1.33 [95% CI 1.03‐1.70]), and baseline ECG LVH (1.17 [95% CI 1.04‐1.31]) carried risk of incident HF. After full adjustment, evolving ECG LVH mediated 4% of the effect of doxazosin on HF. Systolic BP lowering mediated 12% of the effect of doxazosin, and diastolic BP lowering mediated 10% of the effect of doxazosin, 7% of the effect of amlodipine, and borderline 9% of the effect of lisinopril on HF. Conclusions Evolving ECG LVH and BP change account for 4% to 13% of the mechanism by which antihypertensive medications prevent HF. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542. See Editorial Ferdinand and Maraboto
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Affiliation(s)
- Kyle Johnson
- The Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
| | - Suzanne Oparil
- Department of MedicineSchool of MedicineUniversity of Alabama at BirminghamAL
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24
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Dineva S, Uzunova K, Pavlova V, Filipova E, Kalinov K, Vekov T. Comparative efficacy and safety of chlorthalidone and hydrochlorothiazide-meta-analysis. J Hum Hypertens 2019; 33:766-774. [PMID: 31595024 PMCID: PMC6892412 DOI: 10.1038/s41371-019-0255-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/02/2019] [Accepted: 08/14/2019] [Indexed: 12/18/2022]
Abstract
Hypertension is a complex syndrome of multiple hemodynamic, neuroendocrine, and metabolic abnormalities. The goals of treatment in hypertension are to optimally control high blood pressure and to reduce associated cardiovascular morbidity and mortality using the most suitable therapy available. Hydrochlorothiazide (HCTZ) and chlorthalidone (CTLD) are with proven hypertensive effects. The topic of our meta-analysis is to compare the efficacy of HCTZ and CTLD therapy in patient with hypertension. A search of electronic databases PubMed, MEDLINE, Scopus, PsyInfo, eLIBRARY.ru was performed. We chose the random-effects method for the analysis and depicted the results as forest plots. Sensitivity analyses were performed in order to evaluate the degree of significance of each study. Of the 1289 identified sources, only nine trials directly compared HCTZ and CTLD and were included in the meta-analysis. Changes in SBP lead to WMD (95% CI) equal to -3.26 mmHg showing a slight but statistically significant prevalence of CTLD. Results from analyzed studies referring to DBP lead to WMD (95% CI) equal to -2.41 mmHg, which is also statistically significant. During our analysis, we found that there were not enough studies presenting enough data on the effect of CTLD and HCTZ on levels of serum potassium and serum sodium. Our meta-analysis has demonstrated a slight superiority for CTLD regarding blood pressure control. At the same time, the two medications do not show significant differences in their safety profile.
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Affiliation(s)
- Stela Dineva
- Science Department, Tchaikapharma High Quality Medicines, Inc, 1 G.M. Dimitrov Blvd, 1172, Sofia, Bulgaria.
| | - Katya Uzunova
- Science Department, Tchaikapharma High Quality Medicines, Inc, 1 G.M. Dimitrov Blvd, 1172, Sofia, Bulgaria
| | - Velichka Pavlova
- Science Department, Tchaikapharma High Quality Medicines, Inc, 1 G.M. Dimitrov Blvd, 1172, Sofia, Bulgaria
| | - Elena Filipova
- Science Department, Tchaikapharma High Quality Medicines, Inc, 1 G.M. Dimitrov Blvd, 1172, Sofia, Bulgaria
| | - Krassimir Kalinov
- Department of Informatics, New Bulgarian University, 21 Montevideo Str, 1618, Sofia, Bulgaria
| | - Toni Vekov
- Department of Pharmacy, Medical University, Pleven, Bulgaria
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25
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Juraschek SP, Simpson LM, Davis BR, Beach JL, Ishak A, Mukamal KJ. Effects of Antihypertensive Class on Falls, Syncope, and Orthostatic Hypotension in Older Adults: The ALLHAT Trial. Hypertension 2019; 74:1033-1040. [PMID: 31476905 PMCID: PMC6739183 DOI: 10.1161/hypertensionaha.119.13445] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypertension treatment has been implicated in falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether the choice of antihypertensive agent influences the risk of falls, syncope, and OH in older adults is unknown. ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) was a randomized clinical trial that compared the effects of hypertension first-step therapy on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). In a subpopulation of ALLHAT participants, age 65 years and older, we determined the relative risk of falls, syncope, OH, or a composite based on Centers for Medicare and Medicaid Services and Veterans Affairs claims, using Cox regression. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) on outcomes in Cox models adjusted for age, sex, and race. Among 23 964 participants (mean age 69.8±6.8 years, 45% women, 31% non-Hispanic black) followed for a mean of 4.9 years, we identified 267 falls, 755 syncopes, 249 OH, and 1157 composite claims. There were no significant differences in the cumulative incidences of events across randomized drug assignments. However, amlodipine increased risk of falls during the first year of follow-up compared with chlorthalidone (hazard ratio [95% CI]: 2.24 [1.06-4.74]; P=0.03) or lisinopril (hazard ratio [95% CI]: 2.61 [1.03-6.72]; P=0.04). Atenolol use (N=928) was not associated with any of the 3 individual or composite claims. In older adults, the choice of antihypertensive agent had no effect on risk of fall, syncope, or OH long-term. However, amlodipine increased risk of falls within 1 year of initiation. These short-term findings require confirmation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.
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Affiliation(s)
- Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Lara M Simpson
- University of Texas, Health Science Center at Houston, Department of Biostatistics, Houston, TX
| | - Barry R Davis
- University of Texas, Health Science Center at Houston, Department of Biostatistics, Houston, TX
| | - Jennifer L Beach
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Anthony Ishak
- Healthcare Associates, Beth Israel Deaconess Medical Center
| | - Kenneth J Mukamal
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA
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Carmel AS, Cornelius-Schecter A, Frankel B, Jannat-Khah D, Sinha S, Pelzman F, Safford MM. Evaluation of the Patient Activated Learning System (PALS) to improve knowledge acquisition, retention, and medication decision making among hypertensive adults: Results of a pilot randomized controlled trial. Patient Educ Couns 2019; 102:1467-1474. [PMID: 30928344 DOI: 10.1016/j.pec.2019.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 05/23/2023]
Abstract
BACKGROUND There are few engaging, patient centered, and reliable e-Health sources, particularly for patients with low health literacy. OBJECTIVES We tested the Patient Activated Learning System (PALS) against WebMD. We hypothesized that participants using PALS would have higher knowledge scores, greater perceived learning, comfort, and trust than participants using WebMD. METHODS Participants with hypertension from an urban Internal Medicine practice were randomized to view 5 web pages in PALS orWebMD containing information about chlorthalidone. We assessed knowledge, learning perceptions, comfort, and trust through surveys immediately and one week following the intervention. RESULTS 104 participants completed both survey sets (PALS = 51,WebMD = 53). Immediate post intervention mean knowledge scores were higher for the PALS participants [(4.33 vs. 3.62 (P = .003)]. A greater proportion of PALS participants answered ≥4/5 questions correctly (82% vs. 57%; IRR 1.46 [95% CI 1.13-1.89]). A greater proportion of PALS participants agreed they would feel comfortable taking chlorthalidone if prescribed to them (73% vs. 55%; IRR 1.38 [95% CI 1.04-1.84]). One-week recall and trust were similar in the two groups. CONCLUSIONS PALS may have advantages overWebMD for immediate knowledge acquisition, perceived learning, and comfort. IMPLICATIONS PALS is a promising new approach to eHealth patient education. ClinicalTrials.gov registration identifier: NCT03156634.
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Affiliation(s)
- Amanda S Carmel
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Anna Cornelius-Schecter
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Brittney Frankel
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Deanna Jannat-Khah
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Sanjai Sinha
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Fred Pelzman
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Monika M Safford
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.
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27
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Mehanna M, Wang Z, Gong Y, McDonough CW, Beitelshees AL, Gums JG, Chapman AB, Schwartz GL, Bailey KR, Johnson JA, Turner ST, Cooper-DeHoff RM. Plasma Renin Activity Is a Predictive Biomarker of Blood Pressure Response in European but not in African Americans With Uncomplicated Hypertension. Am J Hypertens 2019; 32:668-675. [PMID: 30753254 PMCID: PMC6558666 DOI: 10.1093/ajh/hpz022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/04/2019] [Accepted: 02/06/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Interindividual variability in blood pressure (BP) response to antihypertensives has been reported. Although plasma renin activity (PRA) is a potential biomarker for personalizing antihypertensive therapy in European American (EA) and African American (AA) hypertensives, clinical utility of PRA-guided prescribing is incompletely understood. METHODS Using systematic-phased approach, PRA's clinical utility was assessed. After categorizing by baseline PRA, clinic systolic BP (SBP) responses to metoprolol and chlorthalidone were compared in 134 EAs and 102 AAs enrolled in the Pharmacogenomics Evaluation of Antihypertensive Responses-2 (PEAR-2) trial. Receiver operating characteristic (ROC) analysis was conducted in EAs. Data from PEAR-2 AAs were used to estimate an optimal PRA cut point using multivariable linear regression models. The derived cut point in AAs was tested in a meta-analysis of 2 independent AA cohorts, and its sensitivity and specificity were assessed. RESULTS EAs with PRA < 0.65 ng/ml/hour had a greater decrease in SBP to chlorthalidone than metoprolol (by -15.9 mm Hg, adjusted P < 0.0001), whereas those with PRA ≥ 0.65 ng/ml/hour had a greater decrease in SBP to metoprolol than chlorthalidone (by 3.3 mm Hg, adjusted P = 0.04). Area under ROC curve (0.69, P = 0.0001) showed that PRA can predict SBP response among EAs. However, we observed no association between PRA and SBP response in PEAR-2 AAs. Among independent AA cohorts, those with PRA ≥ 1.3 ng/ml/hour (PEAR-2-derived cut point) responded better to atenolol/candesartan than hydrochlorothiazide (meta-analysis P = 0.01). However, sensitivity of the derived cut point was 10%. CONCLUSIONS PRA at the previously established 0.60-0.65 ng/ml/hour cut point is an effective predictive biomarker of BP response in EAs. However, we were unable to identify PRA cut point that could be used to guide antihypertensive selection in AAs. TRIAL REGISTRATION NCT01203852, NCT00246519, NCT00005520.
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Affiliation(s)
- Mai Mehanna
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Zhiying Wang
- Human Genetics and Institute of Molecular Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | | | - John G Gums
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Arlene B Chapman
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Gary L Schwartz
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Bailey
- Department of Statistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Stephen T Turner
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Collier DJ, Juhasz A, Agabiti‐Rosei E, Lloyd E, Hisada M, Zhao L, Kupfer S, Caulfield MJ. Efficacy and safety of azilsartan medoxomil/chlortalidone fixed-dose combination in hypertensive patients uncontrolled on azilsartan medoxomil alone: A randomized trial. J Clin Hypertens (Greenwich) 2018; 20:1473-1484. [PMID: 30302936 PMCID: PMC8030929 DOI: 10.1111/jch.13376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/17/2018] [Accepted: 08/03/2018] [Indexed: 12/14/2022]
Abstract
Patients with grade 2-3 essential hypertension and postplacebo mean clinic systolic blood pressure (SBP) 160-190 mm Hg and 24-hour SBP 140-175 mm Hg by ambulatory blood pressure monitoring (ABPM) received 40 mg azilsartan medoxomil (AZL-M) monotherapy for 4 weeks. "Nonresponders" were then randomized to 8 weeks of double-blind treatment with AZL-M 40 mg, AZL-M/chlortalidone (CLD) 40/25, or AZL-M/CLD 40/12.5 mg. After 8 weeks, mean clinic SBP change was -21.1 (±1.04) mm Hg for AZL-M/CLD 40/25 mg, -15.8 (±1.08) mm Hg for AZL-M/CLD 40/12.5 mg, and -6.4 (±1.05) mm Hg for AZL-M 40 mg (P < 0.001 for both AZL-M/CLD vs AZL-M, ANCOVA). Drug discontinuation rates were 8.9% (AZL-M/CLD 40/25 mg), 7.5% (AZL-M 40 mg), and 3.9% (AZL-M/CLD 40/12.5 mg). Creatinine increased in 8.1% (AZL-M/CLD 40/25), 3.1% (AZL-M/CLD 40/12.5 mg), and 3.0% (AZL-M 40 mg) of patients. AZL-M/CLD was effective and well tolerated in patients not achieving blood pressure targets with AZL-M.
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Affiliation(s)
- David J. Collier
- William Harvey Research Institute & the NIHR Biomedical Research Centre at BartsQueen Mary University of LondonLondonUK
| | | | | | - Eric Lloyd
- Takeda Development Center Americas, IncDeerfieldIllinois
| | - Michie Hisada
- Takeda Development Center Americas, IncDeerfieldIllinois
| | - Lin Zhao
- Takeda Development Center Americas, IncDeerfieldIllinois
| | - Stuart Kupfer
- Takeda Pharmaceuticals InternationalDeerfieldIllinois
| | - Mark J. Caulfield
- William Harvey Research Institute & the NIHR Biomedical Research Centre at BartsQueen Mary University of LondonLondonUK
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29
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Mukhtar O, Cheriyan J, Cockcroft JR, Collier D, Coulson JM, Dasgupta I, Faconti L, Glover M, Heagerty AM, Khong TK, Lip GYH, Mander AP, Marchong MN, Martin U, McDonnell BJ, McEniery CM, Padmanabhan S, Saxena M, Sever PJ, Shiel JI, Wych J, Chowienczyk PJ, Wilkinson IB. A randomized controlled crossover trial evaluating differential responses to antihypertensive drugs (used as mono- or dual therapy) on the basis of ethnicity: The comparIsoN oF Optimal Hypertension RegiMens; part of the Ancestry Informative Markers in HYpertension program-AIM-HY INFORM trial. Am Heart J 2018; 204:102-108. [PMID: 30092411 PMCID: PMC6234107 DOI: 10.1016/j.ahj.2018.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 05/18/2018] [Indexed: 02/06/2023]
Abstract
Background Ethnicity, along with a variety of genetic and environmental factors, is thought to influence the efficacy of antihypertensive therapies. Current UK guidelines use a “black versus white” approach; in doing so, they ignore the United Kingdom's largest ethnic minority: Asians from South Asia. Study design The primary purpose of the AIM-HY INFORM trial is to identify potential differences in response to antihypertensive drugs used as mono- or dual therapy on the basis of self-defined ethnicity. A multicenter, prospective, open-label, randomized study with 2 parallel, independent trial arms (mono- and dual therapy), AIM-HY INFORM plans to enroll a total of 1,320 patients from across the United Kingdom. Those receiving monotherapy (n = 660) will enter a 3-treatment (amlodipine 10 mg od; lisinopril 20 mg od; chlorthalidone 25 mg od), 3-period crossover, lasting 24 weeks, whereas those receiving dual therapy (n = 660) will enter a 4-treatment (amlodipine 5 mg od and lisinopril 20 mg od; amlodipine 5 mg od and chlorthalidone 25 mg od; lisinopril 20 mg od and chlorthalidone 25 mg od; amiloride 10 mg od and chlorthalidone 25 mg od), 4-period crossover, lasting 32 weeks. Equal numbers of 3 ethnic groups (white, black/black British, and Asian/Asian British) will ultimately be recruited to each of the trial arms (ie, 220 participants per ethnic group per arm). Seated, automated, unattended, office, systolic blood pressure measured 8 weeks after each treatment period begins will serve as the primary outcome measure. Conclusion AIM-HY INFORM is a prospective, open-label, randomized trial which aims to evaluate first- and second-line antihypertensive therapies for multiethnic populations.
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Affiliation(s)
- Omar Mukhtar
- Experimental Medicine & Immunotherapeutics Division, Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
| | - Joseph Cheriyan
- Experimental Medicine & Immunotherapeutics Division, Department of Medicine, University of Cambridge, and Cambridge, and Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - John R Cockcroft
- Department of Cardiology, Columbia University Medical Center, New York
| | - David Collier
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, London, United Kingdom
| | - James M Coulson
- School of Medicine, Cardiff University, Heath Park Campus, Cardiff, United Kingdom
| | - Indranil Dasgupta
- Department of Renal Medicine, Heartlands Hospital, Birmingham, United Kingdom
| | - Luca Faconti
- Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, London, United Kingdom
| | - Mark Glover
- Division of Therapeutics and Molecular Medicine, University of Nottingham, and NIHR Nottingham Biomedical Research Centre, Nottingham, United Kingdom
| | - Anthony M Heagerty
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Teck K Khong
- Blood Pressure Unit, Cardiology Clinical Academic Group, St George's University of London, Cranmer Terrace, London, United Kingdom
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Adrian P Mander
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
| | - Mellone N Marchong
- Office for Translational Research, Cambridge University Health Partners and University of Cambridge, Cambridge, United Kingdom
| | - Una Martin
- Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Barry J McDonnell
- Department of Biomedical Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Carmel M McEniery
- Experimental Medicine & Immunotherapeutics Division, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Sandosh Padmanabhan
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Manish Saxena
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, London, United Kingdom
| | - Peter J Sever
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Julian I Shiel
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, London, United Kingdom
| | - Julie Wych
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
| | - Phil J Chowienczyk
- Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, London, United Kingdom
| | - Ian B Wilkinson
- Experimental Medicine & Immunotherapeutics Division, Department of Medicine, University of Cambridge, and Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Weber MA, Sever P, Juhasz A, Roberts A, Cao C. A randomized trial of the efficacy and safety of azilsartan medoxomil combined with chlorthalidone. J Renin Angiotensin Aldosterone Syst 2018; 19:1470320318795000. [PMID: 30175930 PMCID: PMC6122257 DOI: 10.1177/1470320318795000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/24/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION We measured the effects of azilsartan medoxomil co-administered with chlorthalidone 25 mg in stage 2 hypertension. METHODS Azilsartan medoxomil 40 or 80 mg plus chlorthalidone were compared with placebo plus chlorthalidone once daily in a randomized, double-blind, 6-week trial. The primary endpoint was change from baseline in 24-hour mean systolic blood pressure by ambulatory blood pressure monitoring. RESULTS Patients ( N=551; mean age 59 years; 51.7% men) were randomly assigned to placebo plus chlorthalidone ( n=184), azilsartan medoxomil 40 mg plus chlorthalidone ( n=185), or azilsartan medoxomil 80 mg plus chlorthalidone ( n=182). Baseline systolic blood pressures were similar among groups. After 6 weeks, least squares mean (standard error) reductions with azilsartan medoxomil 40 mg and 80 mg plus chlorthalidone were similar in magnitude (-31.7 (1.0) and -31.3 (1.0) mmHg, respectively), but greater than chlorthalidone alone (-15.9 (1.0) mmHg). Hypotension and serum creatinine elevations were more frequent with azilsartan medoxomil plus chlorthalidone than chlorthalidone alone (reversed with drug discontinuation). Notably, plasma potassium reduction of 0.43 meq/L with chlorthalidone was attenuated to 0.13 and 0.05 meq/L by azilsartan medoxomil 40 mg and 80 mg, respectively. CONCLUSION Azilsartan medoxomil 40 mg or 80 mg plus chlorthalidone 25 mg was significantly more efficacious than chlorthalidone alone in reducing blood pressure and was well tolerated. Clinicaltrial.gov , https://clinicaltrials.gov/ct2/show/NCT00591773 , NCT00591773.
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Affiliation(s)
- Michael A Weber
- Division of Cardiovascular Medicine,
Downstate Medical Center, State University of New York, USA
| | - Peter Sever
- Faculty of Medicine, Imperial College
London, UK
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Slíva J. [The current position of hydrochlorothiazide among thiazide and thiazide-like diuretics]. Vnitr Lek 2018; 64:83-85. [PMID: 29498881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Thiazide and thiazide-like diuretics are an important group of drugs used in the treatment of essential arterial hyper-tension. While their beneficial therapeutic effect in monotherapy is evident, they are increasingly used in fixed combinations, particularly with ACE inhibitors or sartans. The aim of this article was to summarize the current status of hydrochlorothiazide and compare its effects with other substances in this subgroup of diuretics.Key words: diuretics - HCTZ - hydrochlorothiazide - hypertension - chlorthalidone - indapamide - thiazide.
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Shahin MH, Sá AC, Webb A, Gong Y, Langaee T, McDonough CW, Riva A, Beitleshees AL, Chapman AB, Gums JG, Turner ST, Boerwinkle E, Scherer SE, Sadee W, Cooper-DeHoff RM, Johnson JA. Genome-Wide Prioritization and Transcriptomics Reveal Novel Signatures Associated With Thiazide Diuretics Blood Pressure Response. ACTA ACUST UNITED AC 2017; 10:CIRCGENETICS.116.001404. [PMID: 28115488 DOI: 10.1161/circgenetics.116.001404] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 11/21/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Thiazide diuretics are among the most commonly prescribed antihypertensives. However, <50% of thiazide-treated patients achieve blood pressure (BP) control. Herein, we used different omics (genomics and transcriptomics) to identify novel biomarkers of thiazide diuretics BP response. METHODS AND RESULTS Genome-wide analysis included 228 white hypertensives with BP determined at baseline and after 9 weeks of hydrochlorothiazide. Single-nucleotide polymorphisms with P <5×10-5 were prioritized according to their biological function, using RegulomeDB, haploreg, and Genome-Wide Annotation of Variants. The results from the prioritization approach revealed rs10995 as the most likely functional single-nucleotide polymorphism, among single-nucleotide polymorphisms tested, that has been associated with hydrochlorothiazide BP response. The rs10995 G-allele was associated with better BP response to hydrochlorothiazide versus noncarriers (Δ systolic BP/Δ diastolic BP: -12.3/-8.2 versus -6.8/-3.5 mm Hg, respectively, Δ systolic BP P=3×10-4, Δ diastolic BP P=5×10-5). This association was replicated in independent participants treated with chlorthalidone. In addition, rs10995 G-allele was associated with increased mRNA expression of VASP (vasodilator-stimulated phosphoprotein). Moreover, baseline expression of the VASP mRNA was significantly higher in 25 good responders to hydrochlorothiazide compared with 25 poor responders (P=0.01). This finding was replicated in independent participants treated with chlorthalidone (P=0.04). Last, allelic-specific expression analysis revealed a significant but modest imbalance with rs10995 and rs10156, a single-nucleotide polymorphism in high linkage disequilibrium (r2=0.7) with rs10995, which both could contribute to the observed genetic effects by affecting VASP mRNA expression. CONCLUSIONS This study highlights the strength of using different omics to identify novel biomarkers of drug response and suggests VASP as a potential determinant of thiazide diuretics BP response. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00246519 and NCT01203852.
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Chávez-Negrete AJ, Rojas-Uribe M, Gallardo-Montoya JM, Intaglietta M. [Hemorrheologic effect of diuretics in the control of blood pressure in the hypertensive patient]. Rev Med Inst Mex Seguro Soc 2017; 55:S343-S349. [PMID: 29791790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Diuretics are the first choice as an antihypertensive, because of its efficacy and cost, however its mechanism of action is not well understood. The aim of this work was to analyze the hemorrheological effect of the diuretics as vasodilators in patients with newly diagnosed arterial hypertension. METHODS Patients with hypertension were given diet and exercise recommendations and 25 mg of chlorthalidone per day were prescribed; Hemoglobin/hematocrit, viscosity, and basal nitric oxide (ON) were determined at 15 and 45 days and compared with healthy subjects. RESULTS We included 28 patients with average age of 48 years old; systolic blood pressure in the treated patients decreased from baseline at 15 days from 130 to 119 mm Hg and at 114 mmHg at 15 to 45 days; diastolic blood pressure decreased from baseline at 15 days from 103 to 97 mm Hg, and at 93 mmHg at 15 to 45 days. The hematocrit increased in both men and women with a statistical significance of the baseline period at 15 days, after that, it remained without significative changes. The viscosity increased similarly to the hematocrit, which conditioned the ON elevation. CONCLUSIONS The increase in hematocrit due to diuretic caused an increase in blood viscosity, which led to an increase in nitric oxide, resulting in lower blood pressure.
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Affiliation(s)
- Adolfo José Chávez-Negrete
- Dirección de Educación en Investigación en salud, Hospital de Especialidades,
Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro
Social, Ciudad de México, México.
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34
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Muheim L. [Not Available]. Praxis (Bern 1994) 2017; 106:271-272. [PMID: 28253804 DOI: 10.1024/1661-8157/a002620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Leander Muheim
- 1 Institut für Hausarztmedizin, Horten-Zentrum für praxisorientierte Forschung und Wissenstransfer, Universitätsspital Zürich
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35
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Hwang AY, Dave C, Smith SM. Trends in Antihypertensive Medication Use Among US Patients With Resistant Hypertension, 2008 to 2014. Hypertension 2016; 68:1349-1354. [PMID: 27777360 DOI: 10.1161/hypertensionaha.116.08128] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/22/2016] [Accepted: 09/01/2016] [Indexed: 01/13/2023]
Abstract
Little is known of US trends in antihypertensive drug use for patients with treatment-resistant hypertension (TRH). We analyzed antihypertensive use among patients with TRH (treated with ≥4 antihypertensive drugs concurrently) from July 2008 through December 2014 using Marketscan administrative data. We included adults aged 18 to 65 years, with ≥6 months of continuous enrollment, a hypertension diagnosis, and ≥1 episode of overlapping use of ≥4 antihypertensive drugs; patients with heart failure were excluded. We identified 411 652 unique TRH episodes from 261 652 patients with a mean age of 55.9 years. From 2008 to 2014, we observed an increased prevalence, among TRH episodes, of β-blockers (+6.8% [79% to 85.8%]) and dihydropyridine calcium antagonists (+8.1% [69.1% to 77.2%]), and a decreased prevalence of angiotensin-converting enzyme inhibitors (-12.5% [60.4% to 47.9%]) and nondihydropyridine calcium antagonists (-5.0% [15% to 10%]). The prevalence of most other classes changed by <5% from 2008 to 2014. Thiazide diuretic use was largely unchanged from 2008 to 2014, with hydrochlorothiazide being by far the most prevalent thiazide diuretic; chlorthalidone use increased only modestly (+2.6% [3.8% to 6.4%]). Aldosterone antagonist use increased only modestly (+2.9% [7.3% to 10.2%]). Use of optimal regimens increased steadily (+13.8% [50.8% to 64.6%]) during the study period, whereas combined angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use declined (-11.4% [17.7% to 6.3%]). Our results highlight the persistent infrequent use of recommended therapies in TRH, including spironolactone and chlorthalidone, and suggest a need for better efforts to increase the use of such approaches in light of recent evidence demonstrating their efficacy.
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Affiliation(s)
- Andrew Y Hwang
- From the Department of Pharmacotherapy and Translational Research (A.Y.H., S.M.S.) and Department of Pharmaceutical Outcomes and Policy (C.D.), College of Pharmacy, and Department of Community Health and Family Medicine, College of Medicine (A.Y.H., S.M.S.), University of Florida, Gainesville
| | - Chintan Dave
- From the Department of Pharmacotherapy and Translational Research (A.Y.H., S.M.S.) and Department of Pharmaceutical Outcomes and Policy (C.D.), College of Pharmacy, and Department of Community Health and Family Medicine, College of Medicine (A.Y.H., S.M.S.), University of Florida, Gainesville
| | - Steven M Smith
- From the Department of Pharmacotherapy and Translational Research (A.Y.H., S.M.S.) and Department of Pharmaceutical Outcomes and Policy (C.D.), College of Pharmacy, and Department of Community Health and Family Medicine, College of Medicine (A.Y.H., S.M.S.), University of Florida, Gainesville.
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Dell'Omo G, Penno G, Del Prato S, Pedrinelli R. Chlorthalidone Improves Endothelial-Mediated Vascular Responses in Hypertension Complicated by Nondiabetic Metabolic Syndrome. J Cardiovasc Pharmacol Ther 2016; 10:265-72. [PMID: 16382262 DOI: 10.1177/107424840501000406] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The study was conducted to evaluate the vascular effects of chlorthalidone, a distal tubule-acting natriuretic agent, in hypertensive patients with nondiabetic metabolic syndrome, an insulin-resistant condition characterized by endothelial dysfunction and high risk for diabetes mellitus development. Methods: Thirteen untreated hypertensive patients with Adult Treatment Panel-III-defined nondiabetic metabolic syndrome were assigned to 3-month treatment with chlorthalidone. The end-points were baseline and post-treatment evaluation of (1) forearm blood flow (strain-gauge plethysmography) responses to graded intra-arterial acetylcholine infusion to test endothelial-mediated vasomotor function, with sodium nitroprusside as a control for endothelium-independent vasodilatation; (2) minimum forearm vascular resistance, the ratio of mean blood pressure and maximal blood flow in response to 13-minute arterial occlusion, as a hemodynamic correlate of arteriolar structure; and (3) transcapillary albumin escape rate (the 1-hour decay rate of 125I-albumin, 6-8 μC ev) as a measure of systemic capillary permeability. Additional measurements included baseline and posttreatment lipids, fasting, and postload glucose and insulin as well as the homeostasis model assessment, an index of insulin sensitivity. Results: Chlorthalidone reduced blood pressure, augmented acetylcholine-mediated vasodilatation, decreased minimum forearm resistance, and slowed the transcapillary albumin escape rate. Metabolic parameters did not change significantly except for an increase in low-density lipoprotein cholesterol levels. Conclusions: Chlorthalidone improved endothelial function, reversed abnormal arteriolar structure, and slowed albumin permeation in hypertensive patients with nondiabetic metabolic syndrome.
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Affiliation(s)
- Giulia Dell'Omo
- Dipartimento Cardio Toracico, Università di Pisa, Pisa, Italy
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Dargad RR, Parekh JD, Dargad RR, Kukrety S. Azilsartan: Novel Angiotensin Receptor Blocker. J Assoc Physicians India 2016; 64:96-98. [PMID: 27731574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To describe the efficacy and safety profile of the new angiotensin receptor blocker (ARB), "Azilsartan Medoxomil", reviewing data available from both clinical and pre-clinical studies. MATERIAL We completed a review of the English literature from PubMed using the keywords- azilsartan medoxomil, angiotensin receptor blockers (ARB), angiotensin converting enzyme inhibitors (ACEi) and hypertension. DATA EVALUATION Many clinical trials have been conducted comparing the efficacy of azilsartan with other ARB's and also with the ACEi ramipril. The trials have shown azilsartan to be more effective in reducing the mean 24-hour systolic blood pressure compared to its counterparts. CONCLUSIONS Azilsartan is a recently approved ARB and appears to be more efficacious in reducing blood pressure (BP) than the other ARBs with a similar safety and tolerability profile. Azilsartan's very high affinity to and slow dissociation from the angiotensin 1 receptor (AT1R) along with its inverse agonistic properties make it a very good candidate for clinical effects beyond simple BP control, potentially counteracting cardiac hypertrophy, cardiac fibrosis and insulin resistance, together with improved reno-protection and atherosclerotic plaque stabilization.
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Affiliation(s)
- Ramesh R Dargad
- Consulting Physician and Cardiologist, Lilavati, Seven Hills and L.H. Hiranandani Hospital
| | - Jai D Parekh
- Medical Graduate, B.J. Medical College, Pune, Maharashtra
| | - Rohit R Dargad
- Senior Registrar, ICU-Fortis Hospital, Mumbai, Maharashtra
| | - Shweta Kukrety
- Internal Medicine Resident, Creighton University, Nebraska, USA
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Abstract
Hypertension contributes greatly to adverse cardiovascular outcomes; the magnitude of this contribution increases with age. The most recent guideline has proposed raising the goal systolic blood pressure to less than 150 mm Hg among those over age 60; however, this recommendation is not endorsed by other organizations. There are multiple contributors to hypertension in the older individual, including increased vascular stiffness, salt sensitivity, and decreased baroreceptor responsiveness. Therapy in the hypertensive patient over age 60 should be individualized and account for patient's health, functional and cognitive status, comorbidities, frailty, and prognosis.
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Affiliation(s)
- Philip A Kithas
- George E. Wahlen Salt Lake Veterans Administration Medical Center, Geriatrics Division, University of Utah School of Medicine, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Mark A Supiano
- George E. Wahlen Department of Veterans Affairs Health Care System, VA Salt Lake City Geriatric Research, Education, and Clinical Center, Geriatrics Division, University of Utah School of Medicine, Salt Lake City GRECC (182), 500 Foothill Drive, Salt Lake City, UT 84148, USA
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Wilson L, Nair KV, Saseen JJ. Comparison of new-onset gout in adults prescribed chlorthalidone vs. hydrochlorothiazide for hypertension. J Clin Hypertens (Greenwich) 2014; 16:864-8. [PMID: 25258088 PMCID: PMC8031516 DOI: 10.1111/jch.12413] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/14/2014] [Accepted: 08/19/2014] [Indexed: 11/30/2022]
Abstract
This study assessed the risk of new-onset gout following prescribing of hydrochlorothiazide (HCTZ) compared with chlorthalidone (CTD). This retrospective cohort analysis used administrative claims from 2000 to 2012 to identify patients aged 18 to 89 years with hypertension who were prescribed CTD or HCTZ. Patients were excluded if they had a prior diagnosis of gout, conditions or prescription claims for medications that alter risk of gout, or if they switched between these two diuretics. A total of 1011 patients prescribed CTD were matched with 2022 patients prescribed HCTZ based on age, sex, and Chronic Condition Indicator. New-onset gout occurred in 17 of 1011 (1.68%) patients in the CTD group and in 26 of 2022 (1.29%) patients in the HCTZ group (P=.27). The number of days to first occurrence of gout was 183.6 days and 152.7 days in the CTD and HCTZ groups, respectively (P=.39). The mean daily dose was 22.7 mg for CTD and 24.3 mg for HCTZ, and the median dose of both CTD and HCTZ was 25 mg at the time of new-onset gout. Patients prescribed CTD for hypertension have a similar risk of developing new-onset gout compared with patients prescribed similar doses of HCTZ.
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Affiliation(s)
- Liza Wilson
- Department of Family MedicineSchool of MedicineUniversity of Missouri ‐ Kansas CityKansas CityMO
| | - Kavita V. Nair
- Department of Clinical PharmacySkaggs School of Pharmacy and Pharmaceutical SciencesUniversity of Colorado Anschutz Medical CampusAuroraCO
| | - Joseph J. Saseen
- Department of Clinical PharmacySkaggs School of Pharmacy and Pharmaceutical SciencesUniversity of Colorado Anschutz Medical CampusAuroraCO
- Department of Family MedicineSchool of MedicineUniversity of Colorado Anschutz Medical CampusAuroraCO
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40
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Kildare L, Jones T, Neher JO, St Anna L. Clinical inquiry: How do hydrochlorothiazide and chlorthalidone compare for treating hypertension? J Fam Pract 2014; 63:227-228. [PMID: 24905126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Kostis WJ, Cabrera J, Messerli FH, Cheng JQ, Sedjro JE, Cosgrove NM, Swerdel JN, Deng Y, Davis BR, Kostis JB. Competing cardiovascular and noncardiovascular risks and longevity in the systolic hypertension in the elderly program. Am J Cardiol 2014; 113:676-81. [PMID: 24388619 DOI: 10.1016/j.amjcard.2013.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 11/04/2013] [Accepted: 11/04/2013] [Indexed: 11/17/2022]
Abstract
We examined the effect of chlorthalidone-based stepped care on the competing risks of cardiovascular (CV) versus non-CV death in the Systolic Hypertension in the Elderly Program (SHEP). Participants were randomly assigned to chlorthalidone-based stepped-care therapy (n = 2,365) or placebo (n = 2,371) for 4.5 years, and all participants were advised to take active therapy thereafter. At the 22-year follow-up, the gain in life expectancy free from CV death in the active treatment group was 145 days (95% confidence interval [CI] 23 to 260, p = 0.012). The gain in overall life expectancy was smaller (105 days, 95% CI -39 to 242, p = 0.073) because of a 40-day (95% CI -87 to 161) decrease in survival from non-CV death. Compared with an age- and gender-matched cohort, participants had markedly higher overall life expectancy (Wilcoxon p = 0.00001) and greater chance of reaching the ages of 80 (81.3% vs 57.6%), 85 (58.1% vs 37.4%), 90 (30.5% vs 22.0%), 95 (11.9% vs 8.8%), and 100 years (3.7% vs 2.8%). In conclusion, Systolic Hypertension in the Elderly Program participants had higher overall life expectancy than actuarial controls and those randomized to active therapy had longer life expectancy free from CV death but had a small increase in the competing risk of non-CV death.
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Affiliation(s)
- William J Kostis
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Javier Cabrera
- Department of Statistics, Rutgers University, Piscataway, New Jersey; The Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Franz H Messerli
- Division of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jerry Q Cheng
- The Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jeanine E Sedjro
- The Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Nora M Cosgrove
- The Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Joel N Swerdel
- The Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Yingzi Deng
- The Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Barry R Davis
- University of Texas Health Science Center, Houston, Texas
| | - John B Kostis
- The Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
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Ferdinand KC. Obesity and hypertension: It's about more than the numbers. Obesity (Silver Spring) 2013; 21:657-8. [PMID: 23512315 DOI: 10.1002/oby.20372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 01/04/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This editorial comments on the recent Obesity Society and American Society of Hypertension joint position paper, justified by the substantial link between obesity and hypertension (HTN). DESIGN AND METHODS The editorial reviews the expert opinions. Other relevant clinical research is highlighted, such as an obesity paradox. Evidence-based lifestyle changes, drugs, and behavorial modification and newer agents are highlighted. RESULTS Areas of controversy are noted. Despite the importance of renin angiotensin system blockage, future federal guidelines may maintain thiazides as first choice, even with metabolic syndrome (MetS) and diabetes (DM). Chlorthalidone, 12.5-25 mg, has shown cardiovascular benefit, including with MetS and DM. CONCLUSION The conclusion calls for more research. However, the identification and elimination of racial/ethnic disparities should be addressed more explicitly. To better understand the obesity-hypertension linkage, curtail costs, and decrease premature disease and death, this excellent position paper is essential.
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Affiliation(s)
- Keith C Ferdinand
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA 70112, USA.
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Cushman WC. Module 2: Rethinking the role of thiazide-type diuretics in the management of hypertension: which diuretic is best? J Fam Pract 2012; 61:S15-S29. [PMID: 22993737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- William C Cushman
- University of Tennessee College of Medicine, Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN, USA
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Abstract
Azilsartan-chlorthalidone fixed combination is a new drug in the management of hypertension. Azilsartan has been shown to have greater blood pressure-lowering effects than other angiotensin-receptor blockers (ARBs), and the debate regarding the superiority of chlorthalidone over hydrochlorothiazide has been ongoing for years. The combination is unique because it is the first to partner an ARB with this, possibly more effective, diuretic. This review will address trials involving both components of this drug, as well as phase III trials involving the fixed-combination product. The article will also discuss the benefit of combination therapy in the treatment of hypertension.
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Affiliation(s)
- Jerrica E Shuster
- University of Michigan Hospitals and Health Centers, Ann Arbor, MI 48109, USA.
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Rahman M, Ford CE, Cutler JA, Davis BR, Piller LB, Whelton PK, Wright JT, Barzilay JI, Brown CD, Colon PJ, Fine LJ, Grimm RH, Gupta AK, Baimbridge C, Haywood LJ, Henriquez MA, Ilamaythi E, Oparil S, Preston R. Long-term renal and cardiovascular outcomes in Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants by baseline estimated GFR. Clin J Am Soc Nephrol 2012; 7:989-1002. [PMID: 22490878 PMCID: PMC3362309 DOI: 10.2215/cjn.07800811] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 02/28/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES CKD is common among older patients. This article assesses long-term renal and cardiovascular outcomes in older high-risk hypertensive patients, stratified by baseline estimated GFR (eGFR), and long-term outcome efficacy of 5-year first-step treatment with amlodipine or lisinopril, each compared with chlorthalidone. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a long-term post-trial follow-up of hypertensive participants (n=31,350), aged ≥55 years, randomized to receive chlorthalidone, amlodipine, or lisinopril for 4-8 years at 593 centers. Participants were stratified by baseline eGFR (ml/min per 1.73 m(2)) as follows: normal/increased (≥90; n=8027), mild reduction (60-89; n=17,778), and moderate/severe reduction (<60; n=5545). Outcomes were cardiovascular mortality (primary outcome), total mortality, coronary heart disease, cardiovascular disease, stroke, heart failure, and ESRD. RESULTS After an average 8.8-year follow-up, total mortality was significantly higher in participants with moderate/severe eGFR reduction compared with those with normal and mildly reduced eGFR (P<0.001). In participants with an eGFR <60, there was no significant difference in cardiovascular mortality between chlorthalidone and amlodipine (P=0.64), or chlorthalidone and lisinopril (P=0.56). Likewise, no significant differences were observed for total mortality, coronary heart disease, cardiovascular disease, stroke, or ESRD. CONCLUSIONS CKD is associated with significantly higher long-term risk of cardiovascular events and mortality in older hypertensive patients. By eGFR stratum, 5-year treatment with amlodipine or lisinopril was not superior to chlorthalidone in preventing cardiovascular events, mortality, or ESRD during 9-year follow-up. Because data on proteinuria were not available, these findings may not be extrapolated to proteinuric CKD.
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Affiliation(s)
- Mahboob Rahman
- Division of Nephrology and Hypertension, Case Western Reserve University, University Hospitals Case Medical Center, USA
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Allan GM, Ivers N, Padwal RS. Best thiazide diuretic for hypertension. Can Fam Physician 2012; 58:653. [PMID: 22859628 PMCID: PMC3374687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- G Michael Allan
- Department of Family Medicine at University of Alberta in Edmonton
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Coca S. Life expectancy after treatment for systolic hypertension. JAMA 2012; 307:1368; author reply 1368-9. [PMID: 22474193 DOI: 10.1001/jama.2012.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Kostis JB, Cabrera J, Cheng JQ, Cosgrove NM, Deng Y, Pressel SL, Davis BR. Association between chlorthalidone treatment of systolic hypertension and long-term survival. JAMA 2011; 306:2588-93. [PMID: 22187278 DOI: 10.1001/jama.2011.1821] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT In the Systolic Hypertension in the Elderly Program (SHEP) trial, conducted between 1985 and 1990, antihypertensive therapy with chlorthalidone-based stepped-care therapy resulted in a lower rate of cardiovascular events than placebo but effects on mortality were not significant. OBJECTIVE To study the gain in life expectancy of participants randomized to active therapy at the 22-year follow-up. DESIGN, SETTING, AND PARTICIPANTS A National Death Index ascertainment of death in the long-term follow-up of a randomized, placebo-controlled, clinical trial (SHEP) of patients aged 60 years or older with isolated systolic hypertension. Recruitment was between March 1, 1985, and January 15, 1988. After the end of a 4.5-year randomized phase of the SHEP trial, all participants were advised to receive active therapy. The time interval between the beginning of recruitment and the ascertainment of death by National Death Index (December 31, 2006) was approximately 22 years (21 years 10 months). MAIN OUTCOME MEASURES Cardiovascular death and all-cause mortality. RESULTS At the 22-year follow-up, life expectancy gain, expressed as the area between active (n = 2365) and placebo (n = 2371) survival curves, was 105 days (95% CI, -39 to 242; P = .07) for all-cause mortality and 158 days (95% CI, 36-287; P = .009) for cardiovascular death. Each month of active treatment was therefore associated with approximately 1 day extension in life expectancy. The active treatment group had higher survival free from cardiovascular death vs the placebo group (hazard ratio [HR], 0.89; 95% CI, 0.80-0.99; P = .03) but similar survival for all-cause mortality (HR, 0.97; 95% CI, 0.90-1.04; P = .42). There were 1416 deaths (59.9%) in the active treatment group and 1435 deaths (60.5%) in the placebo group (log-rank P = .38, Wilcoxon P = .24). Cardiovascular death was lower in the active treatment group (669 deaths [28.3%]) vs the placebo group (735 deaths [31.0%]; log-rank P = .03, Wilcoxon P = .02). Time to 70th percentile survival was 0.56 years (95% CI, -0.14 to 1.23) longer in the active treatment group vs the placebo group (11.53 vs 10.98 years; P = .03) for all-cause mortality and 1.41 years (95% CI, 0.34-2.61; 17.81 vs 16.39 years; P = .01) for survival free from cardiovascular death. CONCLUSION In the SHEP trial, treatment of isolated systolic hypertension with chlorthalidone stepped-care therapy for 4.5 years was associated with longer life expectancy at 22 years of follow-up.
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Affiliation(s)
- John B Kostis
- Cardiovascular Institute, UMDNJ-Robert Wood Johnson Medical School, One Robert Wood Johnson Place, New Brunswick, NJ 08903-0019, USA.
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