Meeting lung cancer value based care requirements with documentation of patient goals and preferences

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Background: Non-small cell lung cancer (NSCLC) accounts for 25% of all cancer deaths with 5-year survival of 6%. Recent scientific advances in molecular based treatments and immunotherapy and insurers’ emphasis on patient-centered care is changing patient care. This study sought to incorporate patients’ perceptions, goals, and preferences into treatment planning. Methods: After provider education and using electronic care planning software (CPS), a pilot of 50 patients with advanced NSCLC from two academic centers completed tablet-based surveys addressing treatment goals, decision-making preferences, and interest in clinical trials. Results were shared with the provider during the visit. Once treatment was selected, the CPS generated a personalized care management plan. Results: Participants were mean age 65 (range 41-86), 52% female, and 78% white. 60% (12/20) Stage IV patients believed that their cancer was curable. 62% (31/50) were not interested in clinical trial participation. 48% (24/50) wanted to share treatment decision making; 34% (12/50) wanted to make the final decision after seriously considering the doctor’s opinion; 6% (3/ 50) wanted the provider to make the final decision but consider their opinion, and 10% (5/50) wanted to leave all decisions to the provider. Conclusions: Patient perception of curability and decision-making preferences were important domains identified by personalized-care management planning in this Lung Cancer pilot study. Pre-visit CPS use provided the opportunity for the provider to address treatment intent and decision-making at the point-of-care. Academic centers generally expect their patients to have strong interest in clinical trials; Investigation for the reasons for disinterest warrants further exploration.

Real-world practice patterns of providers managing older patients with non-small cell lung cancer

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Background: Most patients with non-small cell lung cancer (NSCLC) have advanced disease at diagnosis and are older with median age 72 years. Evidence-based treatment (EBT) selection requires availability of molecular testing (MT) results at time of treatment decision and geriatric assessment (GA) helps determine a patient’s ability to tolerate therapy. This study describes practice patterns and evidence based treatment selections of providers managing older patients with NSCLC. Methods: After provider education and using care planning software (CPS), 50 patients with advanced NSCLC from two academic centers completed surveys regarding treatment goals and decision-making preferences, and patients ≥ 65 completed a modified GA that included activities of daily living and comorbidity assessment. Once treatment was selected, a personalized care plan was generated. Comparison treatment data from 17 community patients was obtained. Results: Participants were mean age 65, 52% female, and 78% white. Of 28 stage IV patients, 79% had MT and results available at time of treatment decision, and 100% met EBT guidelines. The community cohort had 47% testing, 29% results available, and 65% met guidelines. GA results in 24 patients were 46% frail, 29% intermediate fit, and 25% fit. Two patients (8%) were frail and had a plan change due to GA results. Conclusions: Obtaining timely MT results remains challenging. Continued strategies to ensure MT and timely results should be explored, including quality assurance monitoring given the increasing importance of MT in treatment selection. GA was less impactful in this setting, likely due to later stage patients, presumed frailty, and treatment goal being palliation. We believe GA would have greater impact in early stage NSCLC where aggressive treatments are offered with curative intent.

Are Australian smokers interested in using low-nitrosamine smokeless tobacco for harm reduction?

AIMS

To determine (1) whether Australian smokers are aware of low-nitrosamine smokeless tobacco (LNSLT) products and (2) whether they would be interested in using LNSLT either as a long-term substitute for smoking or as an aid to quitting, if these products were to become legally available.

METHODS

401 daily smokers were recruited by a market research company to complete an internet questionnaire about their smoking history, knowledge of smokeless tobacco and intentions to purchase LNSLT under different scenarios.

FINDINGS

Just under half (48%) indicated they were willing to buy an LNSLT product. Predictors of an interest in purchasing LNSLT were low income, poorer health, prior SLT use, belief that SLT is less harmful than cigarettes, switching to a lower tar cigarette in the past year, ever using nicotine replacement therapy products for quitting or other reasons, having made a failed cessation attempt in the previous year and not planning to quit smoking. Analysis of quitting and LNSLT purchasing intentions under different scenarios suggest that making LNSLT available at a much lower cost than smoked cigarettes while increasing taxes on cigarettes could provide a greater reduction in the number of smokers than the same tax increase alone. These results support further examination of the potential for LNSLT to reduce smoking-related harm in Australia.

Methadone maintenance treatment reduces heroin injection in New South Wales prisons

The purpose of this study was to examine whether methadone maintenance treatment reduces injecting risk behaviour (and therefore transmission of blood-borne viral infections) among prisoners in New South Wales (NSW), using comparison of retrospective reports of drug use in prisons for people who received standard drug treatment, time-limited methadone treatment and methadone maintenance treatment. The setting for the study was the NSW prison system. One hundred and eighty-five injecting drug users who had been recently released from NSW prisons were recruited in 1993. Self-reported drug use and injecting risk behaviour were compared in inmates who received standard drug treatment (counselling), time-limited methadone treatment and methadone maintenance treatment. HIV status was determined by serology. Intervention comprised high and low dose methadone treatment and counselling. The groups were similar in terms of most basic demographic characteristics but subjects who had been maintained on methadone reported a significantly lower prevalence of heroin injection, syringe sharing and scored lower on an HIV Risk-taking Behavioural Scale than subjects who received standard drug treatment and time-limited methadone treatment. This study suggests that methadone treatment is associated with reduced injecting risk behaviour in prison with adequate (greater than 60 mg) dose and duration in treatment. These treatment conditions are known to increase effectiveness in community-based methadone programmes. Prospective studies are required to evaluate the effectiveness of methadone programmes in the prevention of HIV and other blood-borne viral infections among IDU prisoners.

Predicting the future prevalence of cigarette smoking in Australia: how low can we go and by when?

BACKGROUND

In Australia, smoking prevalence has declined in men since the 1950s and in women since the 1980s. Future smoking prevalence in Australia is predicted from estimates of previous and current age-specific and sex-specific cessation rates and smoking uptake in young people derived from national survey data on the prevalence of smoking between 1980 and 2007.

METHODS

A dynamic forecasting model was used to estimate future smoking prevalence in the Australian population based on a continuation of these current trends in smoking uptake and cessation.

RESULTS

The results suggest that Australia's smoking prevalence will continue to fall while current rates of initiation and cessation are maintained. But a continuation of current smoking cessation and initiation patterns will see around 14% of adults still smoking in 2020.

CONCLUSIONS

Smoking cessation rates will need to double for Australian smoking prevalence to reach a policy target of 10% by 2020.

Black/white differences in symptoms and health satisfaction reported by older hemodialysis patients

Although Black end-stage renal disease (ESRD) patients on dialysis report better functioning and well-being than do White patients, little is known about the association of race with disease symptoms and treatment side effects. Interviews were conducted with 183 older Black and 125 older White in-center hemodialysis (HD) patients in Georgia. Patients were identified in a stratified (by race and sex) random sample of patients aged 60+ years selected from the ESRD Network census of all patients in that age category. Self-assessed disease symptoms and/or side effects of treatment, disability days, and health satisfaction were measured. Data were analyzed via logistic or linear regression, controlling for the effects of patients' gender, age, months on dialysis, primary diagnosis of diabetes, cardiovascular co-morbidity, HD treatment time, and usual interdialytic weight gain. Older Whites, compared to older Blacks, were at increased risk for reporting nausea, sexual dysfunction, recent bed disability days, fatigue, greater HD recovery time, and health dissatisfaction. The relation of these complaints to dialysis adequacy and patients' nutritional status merits continued study.

Allowing the medical use of cannabis

Cannabis has been advocated as a treatment for nausea, vomiting, wasting, pain and muscle spasm in cancer, HIV/AIDS, and neurological disorders. Such uses are prohibited by law; cannabinoid drugs are not registered for medical use in Australia and a smoked plant product is unlikely to be registered. A New South Wales Working Party has recommended granting exemption from prosecution to patients who are medically certified to have specified medical conditions. This proposal deserves to be considered by other State and Territory governments.

Risk factors for kidney stones in older women in the southern United States

BACKGROUND

The occurrence of kidney stones is disproportionate in the southern region of the United States. Risk factors for the occurrence of kidney stones in this geographic area have not been reported previously.

METHODS

The Women's Health Initiative (WHI) is an ongoing multicenter clinical investigation of strategies for the prevention of common causes of morbidity and mortality among postmenopausal women. A case-control ancillary study was conducted on 27,410 (white or black) women enrolled in the 9 southern WHI clinical centers. There were 1,179 cases (4.3%) of kidney stones at the baseline evaluation. Risk factors for stone formation were assessed in cases versus age- and race-matched control subjects.

RESULTS

Risk factors (univariate) included low dietary potassium (2,404 versus 2,500 mg/day, P = 0.006), magnesium (243 versus 253 mg/day, P = 0.003) and oxalate (330 versus 345 mg/day, P = 0.02) intake, as well as increased body mass index (28.5 versus 27.7 kg/m2, P = 0.001) and a history of hypertension (42% versus 34%, P = 0.001). A slightly lower dietary calcium intake (683 versus 711 mg/day, P = 0.04) was noted in case subjects versus control subjects, but interpretation was confounded by the study of prevalent rather than incident cases. Supplemental calcium intake >500 mg/day was inversely associated with stone occurrence.

CONCLUSION

Multivariate risk factors for the occurrence of kidney stones in postmenopausal women include a history of hypertension, a low dietary intake of magnesium, and low use of calcium supplements.

Coronary heart disease in African Americans

African Americans have the highest overall mortality rate from coronary heart disease (CHD) of any ethnic group in the United States, particularly out-of-hospital deaths, and especially at younger ages. Although all of the reasons for the excess CHD mortality among African Americans have not been elucidated, it is clear that there is a high prevalence of certain coronary risk factors, delay in the recognition and treatment of high-risk individuals, and limited access to cardiovascular care. The clinical spectrum of acute and chronic CHD in African Americans is similar to that in whites. However, African Americans have a higher risk of sudden cardiac death and present more often with unstable angina and non-Q-wave myocardial infarction than whites. African Americans have less obstructive coronary artery disease on angiography, but may have a similar or greater total burden of coronary atherosclerosis. Ethnic differences in the clinical manifestations of CHD may be explained largely by the inherent heterogeneity of the coronary syndromes, and the disproportionately high prevalence and severity of hypertension and type 2 diabetes in African Americans. Identification of high-risk individuals for vigorous risk factor modification-especially control of hypertension, regression of left ventricular hypertrophy, control of diabetes, treatment of dyslipidemia, and smoking cessation--is key for successful risk reduction.

Antihypertensive pharmacogenetics: getting the right drug into the right patient

Pharmacogenetic investigation seeks to identify genetic factors that contribute to interpatient and interdrug variation in responses to antihypertensive drug therapy. Classical studies have characterized single gene polymorphisms of drug metabolizing enzymes that are responsible for large interindividual differences in pharmacokinetic responses to several antihypertensive drugs. Progress is being made using candidate gene and genome scanning approaches to identify and characterize many additional genes influencing pharmacodynamic mechanisms that contribute to interindividual differences in responses to antihypertensive drug therapy. Knowledge of polymorphic variation in these genes will help to predict individual patients' blood pressure responses to antihypertensive drug therapy and may also provide new insights into molecular mechanisms responsible for elevation of blood pressure.

How many dependent heroin users are there in Australia?

OBJECTIVE

To estimate the prevalence of dependent or daily heroin users in Australia, and to compare the prevalence in Australia with that in other developed countries.

DESIGN

We applied three different methods of estimation (back-projection, capture-recapture, and multiplier) to data on national opioid overdose deaths in Australia, first-time entrants to methadone maintenance treatment, and heroin-related arrests in New South Wales. We compared our estimates with estimates derived by similar methods in countries of the European Union.

DATA SOURCES

Data on national opioid overdose deaths were obtained from the Australian Bureau of Statistics. Data on methadone entrants in NSW were extracted from a database maintained by the NSW Department of Health. Data on arrests for heroin-related offences were supplied by the NSW Police Service.

RESULTS

The best estimates of the number of dependent heroin users in Australia in 1997-1998 from the three methods of estimation were between 67 000 and 92 000 and the median estimate was 74 000. The population prevalence was 6.9 per 1000 adults aged 15-54 years. The prevalence of heroin dependence in Australia is the same as that in Britain (7 per 1000) and within the range of recently derived estimates in the European Union (3-8 per 1000 adults aged 15-54 years).

CONCLUSIONS

Although the exact figures need to be interpreted with caution, our estimates suggest that Australia has a substantial public health problem with dependent heroin use that is of a magnitude similar to that in comparable European societies.

Functional impairment, depression, and life satisfaction among older hemodialysis patients and age-matched controls: a prospective study

OBJECTIVE

To compare change over time in functional impairment, depression, and life satisfaction among older dialysis patients and age-matched controls.

DESIGN

Prospective cohort study over 3 years.

SETTING

Urban and rural communities throughout Georgia.

SUBJECTS

One hundred thirteen prevalent renal failure patients on in-center hemodialysis and 286 controls.

MAIN OUTCOME MEASURES

Ordinal functional impairment index and life satisfaction rating, and Center for Epidemiologic Studies Depression Scale.

RESULTS

Dialysis patients, compared with controls, reported significantly more functional impairment at baseline, and also at follow-up after adjusting for baseline impairment and covariates. Dialysis patients had higher depression scores at baseline, and also at follow-up after adjusting for baseline depression and covariates. In contrast, dialysis patients reported lower life satisfaction at baseline than did controls, but the two cohorts were not significantly different on reported life satisfaction at follow-up, after adjusting for baseline life satisfaction and race. In both cohorts, functional impairment and depression were significantly related.

CONCLUSION

Older dialysis patients' life satisfaction at a 3-year follow-up, which was similar to life satisfaction among age-matched controls, indicates the value of delivered dialysis care; the value of this care would be increased by reducing excess functional impairment in these patients.

Pitfalls in the diagnosis and management of systolic hypertension

BACKGROUND

Systolic blood pressure (SBP) is even more important than diastolic blood pressure (DBP) with regard to the risk of cardiovascular complications.

METHODS AND RESULTS

Pitfalls in the diagnosis of systolic hypertension include the auscultatory gap, use of the proper size cuff (obese adult size for mid-arm circumference >33 cm and child's cuff for mid-arm circumference <23 cm), a "white coat" effect of about 17 mm Hg, regression toward the mean, and a tendency to focus only on hypertension rather than all of the cardiovascular risk factors. Pitfalls in the pharmacologic management of systolic hypertension include being too aggressive with "acute" therapy, too fast in up-titration, too complacent about adverse effects, too unaware of important drug or food interactions, and too content with the achieved level of SBP.

CONCLUSION

In treated hypertensives, SBP is typically less well controlled than DBP. Clinicians must not generally be content with partial control of SBP.

Representation of blacks, women, and the very elderly (aged > or = 80) in 28 major randomized clinical trials

OBJECTIVE

The purpose of this manuscript is to precisely quantify the representation of women, blacks, and very old (aged 80 or more) participants in 28 past or ongoing randomized clinical trials on hypertension, cardiovascular disease, renal disease, and diabetes mellitus.

METHODS

Selection of the 28 studies was arbitrary, based primarily on the reference being often quoted or cited as relevant data for women, blacks, the elderly, or persons with diabetes mellitus.

RESULTS

Twenty-three of the 28 studies enrolled a majority of men. Many of the completed trials had an under-representation of blacks (0% to 8%). An adequate number (1,091) of very old (aged 80 or more) persons have been studied for isolated systolic hypertension, but the number of such patients thus far studied for diastolic hypertension is too small to allow evidence-based recommendations for therapy. Reported studies in diabetes have included a majority of men (average, 58%) and four of the five trials reviewed enrolled relatively few blacks (average, 4.6%).

CONCLUSIONS

Women, blacks, and the very old (aged 80 or more) have been under-represented in many past randomized clinical trials, but ongoing studies will resolve this discrepancy in most instances. The Women's Health Initiative (WHI) will provide data on 161,861 multi-ethnic postmenopausal women. ALLHAT results will include 15,133 hypertensive blacks, and AASK will have 1,094 hypertensive blacks with nephrosclerosis. ALLHAT, STOP-2, and HYVET will include more than 5,000 persons aged 80 or more. Future trials on diabetes mellitus must be designed to improve the representation of women and blacks.

Risk reduction associated with lowering systolic blood pressure: review of clinical trial data

Hypertension is very common in adults >/=60 years of age. Isolated systolic hypertension (ISH) in particular is a good predictor of events associated with elevated blood pressure such as stroke, coronary heart disease, and congestive heart failure. Two large studies, the Systolic Hypertension in the Elderly Program (SHEP) and the Systolic Hypertension in Europe study (Syst-Eur), have demonstrated that antihypertensive drug therapy for elderly patients with ISH reduces the risk of stroke and other major cardiovascular events. SHEP demonstrated that antihypertensive drug treatment with a diuretic-based regimen in patients >/=60 years of age with ISH reduced the incidence of total stroke by 36%. SHEP also demonstrated a 32% reduction in the incidence of cardiovascular events for patients receiving active treatment. The 5-year average systolic blood pressure (SBP) was 155 mm Hg in the placebo group (n = 2371) compared with 143 mm Hg for the active treatment group (n = 2365). Results from the recently completed Syst-Eur study also support the benefits of antihypertensive treatment in patients >/=60 years of age with ISH. Active treatment in Syst-Eur consisted of the calcium channel blocker nitrendipine, with the addition of enalapril and hydrochlorothiazide as needed to reduce SBP to <150 mm Hg. In the active treatment group, total stroke decreased by 42%, and all cardiovascular events decreased by 31%. At 2 years, sitting SBP had decreased by 13 mm Hg in the placebo group (n = 2297) compared with 23 mm Hg in the active treatment group (n = 2398).

Opioid overdose mortality in Australia, 1964-1997: birth-cohort trends

OBJECTIVE

To examine trends in rates of opioid overdose deaths from 1964 to 1997 in different birth cohorts.

DESIGN

Age-period-cohort analysis of national data from the Australian Bureau of Statistics.

MAIN OUTCOME MEASURES

Annual population rates of death attributed to opioid dependence or accidental opioid poisoning in people aged 15-44 years, by sex and birth cohort (in five-year intervals, 1940-1944 to 1975-1979).

RESULTS

The rate of opioid overdose deaths increased 55-fold between 1964 and 1997, from 1.3 to 71.5 per million population aged 15-44 years. The rate of opioid overdose deaths also increased substantially over the eight birth cohorts, with an incidence rate ratio of 20.70 (95% confidence interval, 13.60-31.46) in the 1975-1979 cohort compared with the 1940-1944 cohort. The age at which the cumulative rate of opioid overdose deaths reached 300 per million fell in successive cohorts (for men, from 28 years among those born 1955-1959 to 22 years among those born 1965-1974; for women, from 33 years among those born 1955-1959 to 27 years among those born 1965-1969).

CONCLUSIONS

Heroin use in Australia largely began in the early 1970s and rates of heroin use have markedly increased in birth cohorts born since 1950.

A rational approach to the treatment of hypertension in special populations

Hypertension in blacks is usually characterized by low renin, expanded volume and sensitivity to salt. Diuretics are the preferred initial therapy, but response to calcium channel antagonists is also good. The blood pressure response to monotherapy with beta blockers or angiotensin-converting enzyme (ACE) inhibitors is blunted, but this effect is abolished with concomitant use of diuretics. The two major types of hypertension in older persons are isolated systolic hypertension and combined systolic and diastolic hypertension. Strong data support the treatment of combined hypertension in patients 60 to 79 years of age and isolated systolic hypertension in patients 60 to 96 years of age. Diuretics and long-acting dihydropyridine calcium channel antagonists are the recommended initial therapies for isolated systolic hypertension. More studies are necessary before recommendations can be made about the treatment of combined hypertension in patients 80 years of age and older.

The Women's Health Trial Feasibility Study in Minority Populations: changes in dietary intakes

This randomized clinical trial examined the feasibility of low-fat dietary interventions among postmenopausal women of diverse backgrounds. During 1992-1994, 2,208 women aged 50-79 years, 28% of whom were black and 16% Hispanic, enrolled at clinics in Atlanta, Georgia, Birmingham, Alabama, and Miami, Florida. Intervention/support groups met periodically with a nutritionist to reduce fat intake to 20% of energy and to make other diet modifications. At 6 months postrandomization, the intervention group reduced fat intake from 39.7% of energy at baseline to 26.4%, a reduction of 13.3% of energy, compared with 2.3% among controls. Saturated fatty acid and cholesterol intakes were reduced, but intakes of fruits and vegetables, but not grain products, increased. Similar effects were observed at 12 and 18 months. Black and non-Hispanic white women had similar levels of reduction in fat, but the decrease in Hispanic women was less. Changes did not vary significantly by education. While bias in self-reported intakes may have resulted in somewhat overestimated changes in fat intake, the reported reduction was similar to the approximately 10% of energy decrease found in most trials and suggests that large changes in fat consumption can be attained in diverse study populations and in many subgroups.

Effects of ephedrine enantiomers on conditioned taste aversion and kaolin intake in rats

The ephedrine (EPH) enantiomers, (-)-EPH and (+)-EPH, have different biological activity in the rat, with the (-)-EPH enantiomer exerting a greater impact on suppression of feeding, induction of locomotion, and activation of brown adipose tissue thermogenesis. Recent studies document that (-)-EPH treatment produces an alteration of extracellular dopamine in the brain, an effect that is consistent with the locomotor-stimulating and reinforcing effects of this drug. Whether the EPH enantiomers exert aversive actions in the rat is unknown. Experiment 1 examined the impact of systemically administered (+)-EPH (0, 5, 10, or 20 mg/kg) or (-)-EPH (0, 5, 10, or 20 mg/kg) on conditioned taste aversion (CTA) in adult male rats relative to the effect of 32 mg/kg lithium chloride (LiCl). No dose of either enantiomer produced CTA, whereas strong CTA was evident for LiCl. In Experiment 2, consumption of kaolin (a nonnutritive clay) over a 24-h period was used to assess drug toxicity. Rats treated with either 0, 5, 10, 20, or 40 mg/kg (+)-EPH or 0, 5, 10, 20, or 40 mg/kg (-)-EPH did not exhibit alteration of kaolin intake. In contrast, systematic increases in kaolin intake were observed in rats after systemic administration of LiCl (0, 16, 32, 64, and 96 mg/kg). These findings suggest that the enantiomers of EPH do not exert aversive effects at behaviorally relevant doses.

Abnormalities of kidney function as a cause and a consequence of cardiovascular disease

Hypertension, left ventricular hypertrophy (LVH), hypercreatininemia, and microalbuminuria (MA) are independent risk factors for cardiovascular disease (CVD). Hypertension increases the risk of CVD by two- to three-fold and LVH (especially concentric) is a risk factor for coronary heart disease, heart failure, stroke, and peripheral arterial disease. In people with hypertension, a serum creatinine level of 1.7 mg/dL or more may be an even stronger CVD risk factor than diabetes, smoking, LVH, or systolic blood pressure. Similarly, MA is a strong and independent predictor of CVD morbidity and mortality in people with and without diabetes and/or hypertension. Impaired renal sodium handling and sodium retention are physiological hallmarks of the very early stages of heart failure. Heart failure is a physiologically delicate condition that can decompensate with excess dietary salt intake or over diuresis, or compensate with cautious therapy designed to block the sodium retention and simultaneously interrupt excessively activated neurohumoral mechanisms.

Low-dose combination therapy as first-line hypertension treatment for blacks and nonblacks

To assess the efficacy and safety of bisoprolol/6.25-mg hydrochlorothiazide (HCTZ), amlodipine, and enalapril in black and nonblack patients, data from two comparative studies were pooled and subgroup analyses performed. Both studies had similar designs and included all three active treatments. The second study also included a placebo group. Subjects (n = 541) with a sitting diastolic blood pressure of 95-114 mmHg were titrated to achieve a diastolic blood pressure < or = 90 mmHg. The studies included 114 blacks and 427 nonblacks. Results of an intention-to-treat analysis of mean change from baseline after 12 weeks of treatment showed the following: 1) blood pressure was significantly lowered by all three active drugs compared with baseline or placebo; 2) in blacks, bisoprolol/6.25-mg HCTZ resulted in significantly greater reductions of systolic and diastolic blood pressure than enalapril or placebo, but was not significantly different from amlodipine; 3) in nonblacks, bisoprolol/6.25-mg HCTZ resulted in significantly greater reduction of diastolic blood pressure than amlodipine, enalapril, or placebo. The placebo-corrected change in blood pressure was greater for blacks than whites on the bisoprolol/6.25-mg HCTZ combination, but this was not statistically significant. Bisoprolol/6.25-mg HCTZ controlled diastolic blood pressure to < or = 90 mmHg in significantly more patients than enalapril or placebo in blacks and nonblacks. The difference in control rates was not significant versus amlodipine. The incidence of drug-related adverse events was similar between treatments; however, bisoprolol/6.25-mg HCTZ had a lower discontinuation rate due to lack of blood pressure control or adverse experiences in both blacks and nonblacks.

A bleach program for inmates in NSW: an HIV prevention strategy

Syringe cleaning guidelines for injecting drug users (IDUs) were revised in 1993. This paper examines efforts by IDUs in NSW prisons to adopt the revised guidelines in 1994. Consecutive inmates (229) nearing release were visited and asked to call a toll free number for an interview once released. Respondents (102) did not differ from non-respondents (127). Many respondents (64%) reported ever injecting and many of these reported injecting (58%), sharing (48%) and syringe cleaning (46%) when last in prison. Some (23%) respondents reported adopting the revised syringe cleaning guidelines. Tattooing (38%) was reported more often than sexual activity in prison (4%). A new methodology for prison research was found to be feasible in this study. The potential for HIV to spread in prison still poses major public health challenges.

Comparison of the efficacy of dihydropyridine calcium channel blockers in African American patients with hypertension. ISHIB Investigators Group. International Society on Hypertension in Blacks

BACKGROUND

Hypertension is a prevalent disease among African Americans, and successful treatment rates are low. Since calcium channel blockers are well-tolerated and efficacious in African Americans, we undertook this study to compare the efficacy, safety, and tolerability of 3 commonly prescribed calcium channel blockers: amlodipine besylate (Norvasc), nifedipine coat core (CC) (Adalat CC), and nifedipine gastrointestinal therapeutic system (GITS) (Procardia XL).

METHODS

One hundred ninety-two hypertensive patients across 10 study centers were randomly assigned to double-blind monotherapy with amlodipine besylate (5 mg/d), nifedipine CC (30 mg/d), or nifedipine GITS (30 mg/d) for 8 weeks. Patients not achieving therapeutic response after 4 weeks had their dose doubled for the next 4 weeks. The primary end point was a comparison of the average reduction (week 8 minus baseline) in 24-hour ambulatory diastolic blood pressure (DBP). Secondary end points included a comparison of average 24-hour ambulatory systolic blood pressure (SBP), office SBP or DBP reduction, responder rates, safety, and tolerability.

RESULTS

One hundred sixty-three patients were evaluable for efficacy after 8 weeks. There was no significant difference in the average 24-hour ambulatory DBP (-8.5, -9.0, and -6.1 mm Hg, respectively) or SBP (-14.3, -15.7, and -11.8 mm Hg, respectively) reduction. Average office SBP and DBP were reduced to a comparable degree (19-22 mm Hg [P =.50] and 12-14 mm Hg [P =.51], respectively). Responder rates (DBP <90 or reduced by > or = 10 mm Hg) were similar (P = .38). Discontinuation rates and adverse event frequency were distributed similarly across the 3 treatment groups.

CONCLUSION

The efficacy, safety, and tolerability of the 3 dihydropyridine calcium channel blockers are equivalent in African Americans with stages 1 and 2 hypertension.

Low-dose combination treatment for hypertension versus single-drug treatment-bisoprolol/hydrochlorothiazide versus amlodipine, enalapril, and placebo: combined analysis of comparative studies

To assess the efficacy and safety of 2.5, 5, and 10 mg bisoprolol/6. 25 mg hydrochlorothiazide (HCTZ), 2.5, 5, and 10 mg amlodipine; and 5, 10, 20, and 40 mg enalapril in subjects (n = 541) with a sitting diastolic blood pressure of 95 to 114 mm Hg, data from two comparative studies were pooled. All drugs were titrated to a diastolic blood pressure 90 mm Hg or less. Both studies were double-blind, randomized, parallel dose escalation trials with similar designs and included three active treatments. The second study also had a placebo group. The mean change from baseline of systolic and diastolic blood pressure for placebo (n = 79) was -0. 1/-2.2 mm Hg; amlodipine (n = 154), -12.4/-10.3 mm Hg; enalapril (n = 155), -9.4/-8.2 mm Hg; and bisoprolol/HCTZ (n = 155), -14.0/-12.0. Overall efficacy analyses documented a statistically significant decrease in sitting diastolic blood pressure for bisoprolol/6.25 mg HCTZ compared with placebo, amlodipine, and enalapril. There was a significant reduction in sitting systolic blood pressure for bisoprolol/6.25 mg HCTZ compared with placebo and enalapril but not amlodipine. Also, there was a significant decrease in sitting heart rate for bisoprolol/6.25 mg HCTZ (-6.2 beats/min) compared with placebo (+0.1 beats/min), amlodipine (+1.2 beats/min), and enalapril (+0.5 beats/min). The control rate (diastolic blood pressure < or = 90 mm Hg) for bisoprolol/6.25 mg HCTZ (66.5%) was significantly better than for placebo (21.8%) and enalapril (47.1%) but not amlodipine (58.4%). Of those patients achieving and maintaining control, 49% of the bisoprolol/6.25 mg HCTZ subjects were on the lowest two doses compared with 30% of the amlodipine and 26% of the enalapril subjects. Percentages of patients reporting at least one drug-related adverse event through week 12 were 27%, 24%, 28%, and 25% for placebo, bisoprolol/6.25 mg HCTZ, amlodipine, and enalapril (not significant). Lower doses of two drugs in fixed combination can provide as good or better blood pressure control compared with higher doses of a single drug with similar tolerability and safety.

Racial differences in ambulatory blood pressure and echocardiographic left ventricular geometry

We examined the racial differences in left ventricular (LV) geometric pattern in relation to 24-hour ambulatory blood pressure (BP) monitoring and the presence or absence of a nocturnal BP dip. Our study confirms the blunting of nocturnal BP dip among black hypertensives. Body mass index, rather than race, was a major determinant of left ventricular hypertrophy. We did not observe a difference in prevalence of left ventricular hypertrophy by race. However, left ventricular adaptation to hypertension differed in hypertensive black and white individuals; whereas most of the white patients with Stage 1-2 hypertension had a normal ventricular pattern, LV concentric remodeling and concentric hypertrophy were the most common adaptive ventricular patterns in blacks with Stage 1-2 hypertension. A six-fold higher prevalence of concentric remodeling was observed in blacks as compared with whites. The impaired nocturnal BP dip in blacks may contribute to the different hemodynamic pattern. Determinants of myocardial oxygen consumption were significantly higher in black hypertensives.

Fibromuscular dysplasia of the renal artery and adrenal adenoma in a 36-year-old woman with hypertension

A 36-year-old woman had fibrous dysplasia of the left renal artery and an aldosterone-producing adenoma of the right adrenal gland. The patient was evaluated first for secondary hypertension using a renal angiogram that showed fibrous dysplasia with stenosis of the left renal artery; angioplasty was successful. However, 1 month after angioplasty, hypertension recurred. Initially, it was thought that it had restenosed but after a negative angiography, adrenal computed tomography showed a 0.8-cm x 1-cm tumor of the right adrenal gland. The tumor was removed surgically, markedly improving her hypertension.

Short-term effects of blood pressure control and antihypertensive drug regimen on glomerular filtration rate: the African-American Study of Kidney Disease and Hypertension Pilot Study

The African-American Study of Kidney Disease and Hypertension pilot study randomized 94 nondiabetic black men and women (mean age, 53 years; 75% male) with presumed hypertensive nephrosclerosis and a baseline glomerular filtration rate (GFR) of 25 to 70 mL/min/1.73 m2 (mean, 52.3 mL/min/1.73 m2) to blood pressure control at either a low mean arterial pressure (MAP) goal of < or = 92 mm Hg or a usual MAP goal of 102 to 107 mm Hg and an antihypertensive drug regimen that included either a calcium antagonist (amlodipine), a beta-blocker (atenolol), or an angiotensin-converting enzyme (ACE) inhibitor (enalapril). After 3 months of follow-up (n = 90), the mean GFR was similar (53.0 mL/min/1.73 m2 v 53.7 mL/min/1.73 m2) to the baseline levels in participants randomized to the low MAP group (n = 44), whereas the mean GFR increased by 3.9 mL/min/1.73 m2 (P = 0.02) in participants randomized to the usual MAP group (n = 46). During the same period of time, the mean GFR increased significantly in participants randomized to the calcium channel blocker regimen (n = 28) (5.7 mL/min/ 1.73 m2; P = 0.01) but not in participants randomized to the beta-blocker regimen (n = 31) (1.7 mL/min/1.73 m2; P = 0.10) or the ACE inhibitor regimen (n = 31) (1.1 mL/min/1.73 m2; P = 0.52). Changes in GFR at 3 months were significantly different among the three treatment groups (P = 0.04). We conclude that the magnitude of short-term effects of blood pressure control and antihypertensive drug regimens on GFR should be considered when estimating sample size for clinical trials designed to evaluate the effects of these interventions on long-term changes in GFR slope.

Hypertension-related morbidity and mortality in the southeastern United States

Stroke mortality is higher in the Southeast compared with other regions of the United States. The prevalence of hypertension is also higher (black men = 35%, black women = 37.7%, white men = 26.5%, white women = 21.5%), and the proportion of patients whose hypertension is being controlled is poor, especially in white and black men. The prevalence of hypertension-related complications other than stroke is also higher in the Southeast. The five states with the highest death rates for congestive heart failure are all in the southern region. Of the 15 states with the highest rates of end-stage renal disease, 10 are in the Southeast. Obesity is very prevalent (24% to 28%) in the Southeast. Although Michigan tops the ranking for all states, 6 of the top 15 states are in the Southeast, as are 7 of the 10 states with the highest reported prevalence regarding no leisure-time physical activity. Similar to other areas of the United States, dietary sodium and saturated fat intake are high in the Southeast; dietary potassium intake appears to be relatively low. Other factors that may be associated with the high prevalence, poor control, and excess morbidity and mortality of hypertension-related complications in the Southeast include misperceptions of the seriousness of the problem, the severity of the hypertension, lack of adequate follow-up, reduced access to health care, the cost of treatment, and possibly, low birth weights. The Consortium of Southeastern Hypertension Control (COSEHC) is a nonprofit organization created in 1992 in response to a compelling need to improve the disproportionate hypertension-related morbidity and mortality throughout this region. The purpose of this position paper is to summarize the data that document the problem, the consequences, and possible causative factors.

The Women's Health Trial Feasibility Study in Minority Populations: design and baseline descriptions

The Women's Health Trial: Feasibility Study in Minority Populations (WHT:FSMP), a randomized trial of 2208 women, was conducted to investigate three questions. First, can women from minority and low-socioeconomic-status populations be recruited in numbers sufficient to evaluate a dietary intervention designed to lower fat intake. Second, the efficacy of a low fat, increased fruit/vegetable/ grain product intervention for reducing fat consumption. Third, will participation in the intervention lower plasma cholesterol and estradiol levels relative to the controls. The baseline results showed that an adequate number of minority and low SES women could be recruited to test the study hypotheses. A diverse study population of postmenopausal women consuming a high fat diet was recruited: 28% of participants were Black, 16% were Hispanic, 11% had less than a high school level of education, and 15.5% had household incomes of < $15,000.

Management of systolic hypertension in the elderly

This article addresses management of hypertension in the elderly, with a specific focus on systolic hypertension wherever data are available. Validity of office and home blood pressure readings is discussed with attention to a variety of measurement artifacts in the elderly. The efficacy of lifestyle modifications is summarized. The 1994 recommendation (of the National High Blood Pressure Education Program Working Group on Hypertension in the Elderly) to begin antihypertensive drug therapy with low doses of a thiazide or thiazide-like diuretic is defended. Guidelines also are provided for the safe use of alternate or second-line drugs including the beta-blockers, calcium antagonists, and angiotensin converting enzyme inhibitors.

ACE inhibitors. Differential use in elderly patients with hypertension

High blood pressure (BP) in the elderly must not be ignored as a normal consequence of aging. The criteria for the diagnosis of hypertension and the necessity to treat it are the same in elderly and younger patients. The aim of treatment of elderly hypertensive patients is to decrease BP safely and to reduce risk factors associated with cerebrovascular, cardiovascular and renal morbidity and mortality. The treatment of elderly hypertensive patients should be adjusted according to the needs of the individual, based upon age, race, severity of hypertension, co-existing medical problems, other cardiovascular risk factors, target-organ damage, risk-benefit considerations and costs. In addition to the elevated BP, other cardiovascular risk factors include smoking, glucose intolerance, hyperinsulinaemia, dyslipidaemia, hypercreatininaemia, peripheral vascular disease, left ventricular hypertrophy, and microalbuminuria (or albuminuria). Thus, the choice of initial antihypertensive therapy in elderly hypertensive patients should be based not only on the expected response, but also on the effects of therapy on lipid, potassium, glucose and uric acid levels, and left ventricular anatomy and function. Co-existing medical conditions (such as asthma, diabetes mellitus, heart failure, renal failure, gout, coronary artery disease, hyperlipidaemia and peripheral vascular disease) are major determinants for the selection of antihypertensive medications. With previous therapies (diuretics, beta-blockers, etc.), good BP control in the elderly was associated with clear and statistically significant reductions in stroke-related morbidity and mortality, but the overall effects on cardiovascular and renal complications of hypertension was either more variable or less obvious. Angiotensin converting enzyme (ACE) inhibitors are not only efficacious antihypertensive agents in the elderly, but also appear promising in counteracting some of the cardiovascular and renal consequences of hypertension. They are well tolerated and have a relatively low incidence of adverse effects. ACE inhibitors possess ancillary characteristics that are potentially beneficial for many elderly patients, including reduction of left ventricular mass, lack of metabolic and lipid disturbances, no adverse CNS effects, no risk of induction of heart failure, and a low risk of orthostatic hypotension. Since ACE inhibitors may improve perfusion to the heart, kidney and brain, they are well worth considering for the treatment of elderly patients with hypertensive target organ damage, especially in patients with heart failure, and diabetic patients with early nephropathy.

An in-depth examination of the excretion of albumin and other sensitive markers of renal damage in mild hypertension

In an in-depth examination to better define the renal effects of mild hypertension, we used urinary proteins to indicate damage to the glomerulus (albumin), tubular reabsorption capability (retinol-binding protein), and turnover of tubular tissue (alanine aminopeptidase and N-acetyl-beta-D-glucosaminidase) in a group of 18 people with mild hypertension not associated with diabetes and a control group (n = 12). The participants' activity was controlled on a high normal salt diet for 3 days followed by a low salt diet for 4 days. Two distinct patterns of albumin excretion were evident in the hypertensive group: 22% had elevated, highly variable excretion patterns, and the rest had tightly grouped values below 16 mg/g creatinine, 16 micrograms/min, or 16 mg/L, with the lowest within-person biological variability given by albumin calculated as a ratio to creatinine. Albumin and NAG excretion primarily correlated with systolic blood pressure and the best correlations were given by ratios to creatinine. A marked decrease in salt excretion of 71% (to 50.8 mEq/day) resulted in significant (P < .0005) decreases in systolic (13.9 mm Hg), diastolic (6.4 mm Hg), and mean arterial pressures (8.9 mm Hg) only in the group with mild hypertension. However, albumin excretion did not decrease when dietary salt content was lowered. The group with hypertension also had higher urinary excretion of lysosomal N-acetyl-beta-D-glucosaminidase (P < .01), and whites in the group had a higher excretion of retinol-binding protein than did whites in the control group (P < .02). Retinol-binding protein values, however, were within the normal range, indicating that the elevated albumin values were the result of changes in selectivity of the glomerulus.

The AUDIT questionnaire: choosing a cut-off score. Alcohol Use Disorder Identification Test

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item questionnaire designed by the World Health Organization to screen for hazardous alcohol intake in primary health care settings. In this longitudinal study we examined its performance in predicting alcohol-related harm over the full range of its scores using receiver operating characteristic analyses. Three hundred and thirty ambulatory care patients were interviewed using a detailed assessment schedule which included the AUDIT questions. After 2-3 years, subjects were reviewed and their experience of alcohol-related medical and social harm assessed by interview and perusal of medical records. AUDIT was a good predictor of both alcohol-related social and medical problems. Cut-off points of 7-8 maximized discrimination in the prediction of trauma and hypertension. Higher cut-offs (12 and 22) provided better discrimination in the prediction of alcohol-related social problems and of liver disease or gastrointestinal bleeding, but high specificity was offset by reduced sensitivity. We conclude that the recommended cut-off score of eight is a reasonable approximation to the optimal for a variety of endpoints.

Benzodiazepine use among injecting heroin users

OBJECTIVES

To determine the extent and patterns of benzodiazepine use among heroin users, and whether preferences for different benzodiazepines exist among this group.

SUBJECTS AND METHODS

210 heroin users who were current users of benzodiazepines volunteered for the study and completed a structured questionnaire.

RESULTS

Heroin users had used a median of five different benzodiazepines, most commonly diazepam. Almost half the subjects (48%; 95% CI, 41-55) had injected benzodiazepines, 17% (95% CI, 12-22) within the preceding six months. Diazepam and temazepam were the most widely injected benzodiazepines.

CONCLUSIONS

Flunitrazepam, diazepam and temazepam should be prescribed to heroin users with caution. A less popular and rarely injected benzodiazepine, nitrazepam, may be a better option for this group.

A multi-center analysis of the use of enalapril and lisinopril in elderly hypertensive patients

OBJECTIVE

To evaluate the clinical use and adverse effects of enalapril and lisinopril in elderly hypertensive subjects.

DESIGN

A multi-center, retrospective, drug use evaluation survey.

SETTING

Ambulatory care clinics at 14 VA and 14 academic medical centers.

PATIENTS

422 elderly (> 60 years of age) patients with hypertension and no clinical evidence of congestive heart failure.

INTERVENTION

At least 3 consecutive months of anti-hypertensive therapy with either enalapril or lisinopril.

MEASUREMENTS

Blood pressure, serum creatinine, serum potassium, concomitant disease states, concurrent medications, and documentation of any adverse event that might be related to ACE inhibitor therapy.

RESULTS

There were no significant differences in systolic and diastolic blood pressures, serum creatinine, or serum potassium between enalapril- and lisinopril-treated patients at baseline and after 3 months of therapy. Both treatments resulted in a significant reduction in diastolic blood pressure. There was no significant difference in the incidence of adverse effects between the two treatments. Significantly more patients were dosed on a twice daily regimen of enalapril than lisinopril.

CONCLUSION

The data from this retrospective study confirm the safe and effective use of enalapril and lisinopril, two long-acting ACE inhibitors, in elderly hypertensive patients.

The effect of chlorthalidone on ventricular ectopic activity in patients with isolated systolic hypertension. The SHEP Study Group

In an ancillary study of the Systolic Hypertension in the Elderly Program (SHEP), the effects of diuretics on ventricular ectopic activity were investigated in 186 patients with isolated systolic hypertension. Ventricular premature complexes (VPCs) were examined as the number of VPCs/24 hours, presence of > or = 1 VPC, presence of > or = 10 VPCs/24 hours, and presence of VPC pairs or ventricular tachycardia. Significant changes in VPCs were not observed either in the 92 patients randomized to chlorthalidone stepped-care (12.5 and 25 mg/day) or in the 94 placebo-treated patients (p > 0.1 for all VPC definitions and both groups). Serum potassium decreased from 4.4 +/- 0.5 to 4.1 +/- 0.5 mEq/liter (p = 0.002) in the chlorthalidone group and did not change (4.4 +/- 0.5 to 4.5 +/- 0.4 mEq/liter) in the placebo group. Potassium was prescribed routinely for confirmed hypokalemia < 3.5 mEq/liter. A relation between serum potassium and VPC or change in serum potassium and change in VPC was not observed in the chlorthalidone group. In summary, in patients with isolated systolic hypertension, chlorthalidone in doses that are effective in decreasing stroke and cardiovascular event rates (12.5 or 25 mg/day), did not increase VPCs.

Lower dose diuretic therapy in the treatment of patients with mild to moderate hypertension

Indapamide (Lozol), an indoline antihypertensive drug with diuretic and vasodilating activities, was evaluated in 195 patients with mild to moderate essential hypertension (sitting DBP between 95 and 110 mmHg) in a multicentre, randomised, double-blind, parallel-group design trial. A four week single-blind placebo wash-out period was followed by an eight week double-blind period. Patients were randomised to indapamide 1.25 mg/day or to placebo. The primary efficacy endpoint was the mean change in sitting DBP from baseline to week 8. Ninety patients in the placebo group (93%) and 82 patients (84%) in the indapamide group completed the eight weeks of double-blind therapy. Indapamide produced a mean (SE) decrease in sitting DBP of 7.4 (0.63) mmHg (from 100.1 to 92.8 mmHg) compared with a decrease of 3.6 (0.75) mmHg (from 99.6 to 95.8 mmHg) produced by placebo (p < 0.0001). Indapamide and placebo also produced mean decreases in standing DBP of 6.8 (0.75) and 2.8 (0.77) mmHg, respectively (p = 0.0002), in sitting SBP of 11.1 (1.18) and 3.2 (1.35) mmHg, respectively (p = 0.0001) and in standing SBP of 11.4 (1.29) and 4.0 (1.43) mmHg, respectively (P = 0.0002). Reduction in BP of > or = 10 mmHg or to a DBP of < or = 90 mmHg was more frequent (P = 0.0005) among indapamide (46.6%) compared with placebo (23.7%) treated patients. During the eight week double-blind treatment period, incidence rates for all adverse experiences and for drug-related adverse experiences were similar between the two treatment groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Continued survival of older hemodialysis patients: investigation of psychosocial predictors

This study investigated whether social and/or psychologic factors help to predict older dialysis patients' continued survival. A stratified (by race and sex) random sample of patients aged 60+ years was selected from the ESRD Network census of all patients in that age category residing in a single southeastern state (Georgia) and receiving chronic dialysis as of November 1987; personal interviews with patients were completed in 1988. This analysis includes 287 patients (mean age, 69 years) receiving outpatient hemodialysis for whom primary cause of renal failure and functional status data were complete. Patient tracking and vital statistics data determined that 49% of the sample survived as of October 31, 1990. Study variables included demographic, dialysis, health status, social situation, and psychologic outlook variables reported at the patients' 1988 interviews. Log rank tests showed univariate associations between patients' continued survival and race/gender, recovery time following dialysis treatments, cardiovascular co-morbidity, exercise activity score, freedom from health limitation of daily activity, functional status, leisure activity score, self-rated health status, overall life satisfaction, depression, and public religiosity. The Cox proportional hazards model was fit to the data, with continued survival from the time of the 1988 interview as the dependent variable. There was a significantly increased mortality risk for white men relative to the other race/gender groups and for patients reporting severely impaired functional status at the 1988 interview. With functional status in the model, no other social or psychologic variables were significant predictors of mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of antihypertensive medications on quality of life in elderly hypertensive women

The impact of antihypertensive medications on the quality of life of elderly hypertensive women has rarely been systematically evaluated in large clinical trials using drugs from the new generations of pharmaceutic preparations. We carried out a multicenter, randomized double-blind clinical trial with 309 hypertensive women aged 60 to 80 years to assess effects of atenolol, enalapril, and isradipine on measures of quality of life over a 22-week period. The patients had mild to moderate hypertension. Hydrochlorothiazide was added to treatment if monotherapy was inadequate in lowering blood pressure. At the conclusion of the trial the three drug groups did not differ in degree of reduction of diastolic blood pressure or in supplementation with hydrochlorothiazide. Over the 22-week trial, linear trend analysis showed no differences between the treatment groups in change from baseline on quality of life measures of well-being, physical status, emotional status, cognitive functioning, and social role participation. Regarding each of 33 physical side effects over the 22 weeks, we found no general difference between atenolol, enalapril, and isradipine groups on measures of change in distress over symptoms except for enalapril patients who worsened in distress over cough (P = .001) and atenolol patients who worsened in distress over dry mouth (P = .014). Centering on three medications that are relatively new additions to the armamentarium for blood pressure control, the findings underline the increasing opportunities for the physician to select drugs that can control blood pressure while maintaining the quality of life of elderly hypertensive women.

Correlates of ventricular ectopic activity in isolated systolic hypertension. SHEP Cooperative Research Group

Ventricular ectopic activity was recorded at baseline in 5.6% of the 12-lead electrocardiograms and 8.2% of the 2-minute rhythm strips of 4674 subjects with isolated systolic hypertension (systolic blood pressure 160 to 219 mm Hg, diastolic blood pressure < 90 mm Hg) participating in the Systolic Hypertension in the Elderly Program (SHEP). In this study 1.3% had 6 to 10 ventricular premature beats (VPB), and 0.7% had > 10 VPB on the 2-minute rhythm strip. Correlates of VPB presence on the 12-lead ECG were older-age male sex, presence of Q/QS pattern and higher heart rate. Participants with serum potassium < 3.5 mmol/L had a higher prevalence of VPB. Similarly, the number of VPB on the 2-minute rhythm strip was associated with male sex, increasing age, with lower serum potassium, history of palpitations, and presence of Q/QS patterns.

Efficacy and safety of atenolol, enalapril, and isradipine in elderly hypertensive women

PURPOSE

This trial was designed to evaluate the efficacy and safety of three different classes of antihypertensive agents in elderly women.

PATIENTS AND METHODS

The trial had three phases: 4 to 8 weeks of placebo, 6 weeks of titration, and 16 weeks of maintenance. White women between 60 and 80 years old with sitting diastolic blood pressures (DBPs) from 95 through 114 mm Hg treated with placebo were evaluated by history, physical examination, laboratory studies, and quality-of-life interview. After double-blind randomization with low-dose atenolol, enalapril, or isradipine, the dose was increased stepwise and hydrochlorothiazide added as needed to achieve goal DBP (less than 90 mm Hg and greater than 10 mm Hg below baseline). During maintenance, patients not at goal were "stepped up," and patients with uncontrolled DBP at maximum dosage were removed from the study. The pretreatment (baseline) blood pressure of the 315 randomized participants averaged 161/100 mm Hg; 92% had been treated previously for hypertension, 15% had diabetes mellitus, 11% smoked, and 38% consumed alcohol.

RESULTS

For 245 patients completing the trial, the average decrease in blood pressure during treatment was 18.2/15.6 mm Hg. Antihypertensive efficacy was similar for the monotherapy drug regimens, with 84%, 71%, and 80% of patients receiving atenolol, enalapril, and isradipine, respectively, achieving DBP goal. Of the 70 patients who did not complete the trial, 42 left because of symptoms and 19 because of uncontrolled DBP. No important, unexpected drug-induced changes in symptoms or blood chemistries were noted. Symptom frequency differed little among the three dosage levels, becoming maximal by the second visit at the same dosage level.

CONCLUSION

All three drugs lowered DBP comparably, and none produced alarming effects. Thirteen percent of patients left the study because of symptoms.

Comparative effects of atenolol versus celiprolol on serum lipids and blood pressure in hyperlipidemic and hypertensive subjects

Antihypertensive drugs may affect serum lipoprotein levels in mixed populations but data in hyperlipidemic patients are scanty. Atenolol versus celiprolol effects on serum lipoproteins were compared in 159 hyperlipoproteinemic hypertensive patients. This was a randomized, double-blind, parallel-group, positive-controlled multicenter trial with centralized lipoprotein laboratory and diet constancy monitoring. Blood pressure reduction and serum lipoprotein and apoprotein levels were monitored for 3 months. Both drugs reduced systolic and diastolic blood pressures. Atenolol had greater effects than celiprolol on diastolic pressure, but effects on systolic blood pressure were not different. Patients receiving atenolol had lower serum high-density lipoprotein cholesterol levels and higher low-density lipoprotein/high-density lipoprotein cholesterol ratios, whereas patients treated with celiprolol showed no contrasting changes. These differences in lipoprotein levels between drug treatment groups were statistically significant at weeks 9 and 12. The difference between drug treatments was also significant if the values of the 9- and 12-week visits were averaged. Patients taking atenolol had statistically significantly higher serum levels of total cholesterol, triglycerides and apoprotein B at 9 weeks. These divergent directional changes were consistent throughout and statistically significantly different between drugs.