Demographic considerations in the selection of antihypertensive therapy

Because of the growing number of antihypertensive agents that are suitable for initial therapy in mild and moderate hypertension, it is important to identify factors that influence the response to various medications. Although individual patient considerations, such as associated illnesses and potential side effects, are of primary importance in choosing therapy, the influence of demographic factors has received increasing attention. The effect of age, race and gender on the response to antihypertensive therapy will be examined. Several studies have indicated that the beta blockers and angiotensin converting enzyme (ACE) inhibitors are more effective in younger than in older patients. Conversely, there is a trend toward greater responses in older subjects to the diuretics and calcium antagonists. In the few studies available that have compared agents in various classes, it appears that diuretics, and probably calcium antagonists, are significantly more effective than beta blockers or ACE inhibitors in patients over 60 years of age. However, the interdrug differences in young patients are probably less important. With regard to race, the relative lack of effect of beta blockers and ACE inhibitors in blacks is well accepted; in comparative studies, diuretics proved significantly better. From the few available studies, it does not appear that the calcium antagonists are more potent in either racial group, but they may be superior to the beta blockers and ACE inhibitors in blacks. Far less information is available concerning differences in antihypertensive responses between men and women. There is some suggestion that women may be less responsive to beta blockers than men.(ABSTRACT TRUNCATED AT 250 WORDS)     

Relative efficacy of, and some adverse reactions to, different antihypertensive regimens

Although it is a common belief that all antihypertensive agents are equally effective in reducing blood pressure, there is some evidence to the contrary, both in the general population and when specific patient demographics are considered. In black patients, beta blockers and angiotensin-converting enzyme (ACE) inhibitors have been shown to be less effective at reducing blood pressure than the thiazide diuretics. After age 60, the percentage of responders to beta blockers is less than with calcium antagonists, and a higher percentage of elderly patients also achieve normotensive blood pressure levels with diuretic therapy than with beta blockers. When a thiazide diuretic is added to an ACE inhibitor, beta blocker or calcium antagonist, the number of normotensive responders increases significantly. Combinations of some other agents (i.e., an ACE inhibitor plus a beta blocker) may not, however, improve efficacy. Diuretics, beta blockers and ACE inhibitors are all generally well tolerated, with a 9 to 10% incidence of subjective side effects. The use of calcium antagonists and especially the centrally acting adrenergic inhibitors may result in more frequent adverse effects. Data from long-term, diuretic-based clinical trials do not support the statement that diuretic therapy results in sustained elevations in lipid levels. These trials have shown cholesterol levels to be at or below baseline after long-term diuretic therapy. The use of beta blockers, on the other hand, may result in long-term elevation of triglyceride levels and a slight decrease in high-density lipoprotein cholesterol. Calcium antagonists and ACE inhibitors do not affect lipid levels, and alpha blockers may actually lower cholesterol levels and increase high-density lipoprotein levels.(ABSTRACT TRUNCATED AT 250 WORDS)     

Angiotensin-converting enzyme inhibitors for systemic hypertension in young and elderly patients.

Whereas many physicians have been reluctant to treat hypertension in the elderly because of perceived limited benefits and the risk of side effects associated with traditional antihypertensive agents such as diuretics and beta blockers, studies and clinical experience have shown that elderly as well as younger patients can benefit from treatment. In recent years, angiotensin-converting enzyme (ACE) inhibitors have been found to be safe and effective in both young and elderly hypertensive patients without many of the adverse effects associated with traditional agents. ACE inhibitors possess characteristics that meet many of the special needs of elderly patients, including reduction of left ventricular mass, lack of metabolic and lipid disturbances, no central nervous system effects, no risk of induction of cardiac failure, and low risk of orthostatic hypotension.     

A summary of the effects of antihypertensive medications on measured blood pressure

BACKGROUND: Epidemiologic analysis of family data on blood pressure (BP) is often compromised by the effects of antihypertensive medications. A review of numerous clinical trials that investigated the effects of BP-lowering medications is summarized here. METHODS: Published clinical trials, including 137 clinical trials with monodrug therapies and 28 clinical trials of combination drug therapies with a total of 11,739 participants, were reviewed from PubMed. Six major classes/groups of antihypertensive medications were categorized by ethnicity, including angiotensin-converting enzyme (ACE) inhibitors, alpha1-blockers, cardioselective beta-blockers (beta1-blockers), calcium channel blockers, thiazide and thiazide-like diuretics, and loop diuretics. RESULTS: Using sitting or supine BP, for ethnic groups combined, monodrug therapy with ACE inhibitors showed a weighted average effect of lowering the systolic and diastolic BP by 12.5/9.5 mm Hg; alpha1-blockers by 15.5/11.7 mm Hg; beta1-blockers by 14.8/12.2 mm Hg; calcium channel blockers by 15.3/10.5 mm Hg; thiazide diuretics by 15.3/9.8 mm Hg; and loop diuretics by 15.8/8.2 mm Hg. However, ACE inhibitors, alpha1-blockers, and beta1-blockers were less effective in African Americans than in non-African Americans, whereas calcium channel blockers, thiazide diuretics, and loop diuretics were more effective in African Americans than in non-African Americans. For two-drug combination therapy with ethnic groups combined, the BP-lowering effect of the second medication, when compared to its effect as monodrug therapy, was 84% and 65% for systolic and diastolic BP, respectively. CONCLUSIONS: The BP-lowering effects reported here may be used to impute the pretreatment BP levels, which can improve the information content and hence the power of epidemiologic analysis in studies where use of antihypertensive medications is a confounding factor in the BP measurements.     

Comparison of the effects of angiotensin converting-enzyme inhibitors and beta blockers on survival in elderly patients with reduced left ventricular function after myocardial infarction

PURPOSE: Angiotensin converting-enzyme (ACE) inhibitors decrease mortality after myocardial infarction among patients with depressed left ventricular function. Beta blockers may also improve survival in these patients. We compared the relative effects of these agents on the survival of elderly patients with a left ventricular ejection fraction less than 40% after myocardial infarction. SUBJECTS AND METHODS: The Cooperative Cardiovascular Project collected data on patients aged 65 years and older who were admitted with myocardial infarction from April 1994 to July 1995, including 20,902 with a measured left ventricular ejection fraction less than 40% before discharge. Using proportional hazard regression models that adjusted for patient characteristics and in-hospital treatments, we compared survival among patients discharged on ACE inhibitors, beta blockers, both medications, or neither medication. RESULTS: Among patients surviving hospitalization with reduced left ventricular function, 9,108 (44%) were discharged on ACE inhibitors, 2,613 (13%) on beta blockers, 3,309 (16%) on both medications, and 5,872 (28%) on neither medication. Patients treated with ACE inhibitors were more likely to have a prior diagnosis of heart failure and less likely to have undergone revascularization, whereas those treated with beta blockers were more often treated with thrombolytic therapy and aspirin. Patients treated with ACE inhibitors [hazard ratio (HR = 0.80), 0.80; 95% confidence interval (CI), 0.73 to 0.87] or beta blockers (HR = 0.76, 0.76; 95% CI, 0.64 to 0.90) had lower adjusted 1-year mortality than those who were not treated with either medication. The combination of both medications was associated with additional benefit (HR = 0.68, 0.68; 95% CI, 0.59 to 0.80). The relative benefit of each medication was greatest among patients with an ejection fraction less than 30%, a serum creatinine level 2.0 mg/dL or greater, or both. To prevent a death within a year, the number of patients who needed to be treated with both medications varied from 5 to 15, depending on ejection fraction and renal function. CONCLUSION: ACE inhibitors and beta blockers were associated with similar improvements in survival among elderly patients with reduced left ventricular ejection fraction after myocardial infarction. Our results suggest that patients who can tolerate both medications gain additional benefit from the combination.     

First‐line treatment of essential hypertension: A real‐world analysis across four antihypertensive treatment classes

The relative efficacy of antihypertensive treatment has been assessed primarily by randomized clinical trials (RCTs). The increasing availability of electronic medical records (EMR) allows results from RCT to be compared to data from actual clinical practice. EMR from TriNetX were used to compare patients starting and adhering to antihypertensive treatment on diuretics, beta blockers, angiotensin II or ACE inhibitors, or calcium channel blockers for at least 36 months. Cardiovascular (CV) events as defined by ICD‐10 codes were evaluated for an observation period of three years. Outcomes were assessed with and without propensity score matching for confounding factors. A total of 79 288 patients fulfilled the criteria for first‐line therapy and adherence (17.4% diuretics, 25.9% beta blockers, 45.1% inhibitors of the renin‐angiotensin system, and 11.6% calcium channel blockers). Differences in demography and comorbidities were consistent with expectations based on treatment guidelines. RAS blockers showed the best BP control (28.7% episodes of uncontrolled BP) and, together with diuretics, the lowest rate of CV events (diuretics, 5.2%; RAS blockers, 5.4%). Beta blockers were associated with the highest rate of uncontrolled BP (45.9%) and a high CV event rate (9.5%). These trends remained after matching the cohorts for confounding factors. EMR show that actual prescribing behavior for first‐line treatment of essential hypertension reflects treatment guidelines. Patients taking either RAS blockers or diuretics experienced the lowest CV event rates. Beta blockers, even when adjusted for pre‐existing cardiovascular conditions, do not seem to be as protective against CV events as the three other classes.     

Persistence of treatment and blood pressure control in elderly hypertensive patients treated with different classes of antihypertensive drugs

Unsatisfactory blood pressure (BP) control in the treated hypertensive patient is largely related to poor compliance with antihypertensive drug regimens. The aim of the present study was to prospectively evaluate the rate of persistence on treatment and the extent of BP control in 301 elderly, uncomplicated grade I or II hypertensive patients randomly allocated to monotherapy with angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers (CCBs), beta-blockers, angiotensin II receptors (ARBs), or diuretics according to an open-label single-blind study design. After 24 months, the percentage of patients continuing their initial therapy was higher in those treated with ARBs (68.5%) and ACE inhibitors (64.5%) and lower in patients taking diuretics (34.4%; P<.01). The logistic regression model using ARBs as reference term showed that patients treated with ACE inhibitors (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.79-0.99) or CCBs (OR, 0.76; 95% CI, 0.54-0.85) were more likely to continue their initial antihypertensive therapy when compared with those treated with beta-blockers (OR, 0.67; 95% CI, 0.57-0.79) or diuretics (OR, 0.56; 95% CI, 0.38-0.84). The average systolic and diastolic BP decrease was greater in patients treated with ARBs (-11.2+/-4/-5.8+/-2 mm Hg), ACE inhibitors (-10.5+/-4/-5.1+/-2 mm Hg), and CCBs (-8.5+/-3/-4.6+/-2 mm Hg) and lesser in those treated with diuretics (-2.3+/-4/-2.1+/-3 mm Hg, P<.05) and beta-blockers (-4.0+/-2/-2.3+/-2 mm Hg; P<.05). The study confirms the importance of persistence with treatment for the effective management of hypertension in clinical practice.     

Safety and tolerability of the direct renin inhibitor aliskiren: a pooled analysis of clinical experience in more than 12,000 patients with hypertension

While the safety of renin-angiotensin system (RAS)-blocking drugs such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers is well known, less is known about the new direct renin inhibitor aliskiren. The authors pooled data from 12 randomized controlled trials of aliskiren in patients with hypertension and analyzed the incidence and types of adverse events (AEs) and laboratory abnormalities. Studies were characterized as short-term (≤2 months) placebo-controlled or long-term (>2 months) active-controlled. Relative risks for AEs of particular interest for RAS blockers were calculated. In short-term studies, AEs occurred in similar proportions of aliskiren 150 mg and 300 mg (33.6% and 31.6%, respectively) and placebo treatment groups (36.8%). In long-term studies, a lower proportion of patients treated with aliskiren 150 mg and 300 mg had AEs (33.7% and 43.2%, respectively) than those treated with ACE inhibitors (60.1%), angiotensin receptor blockers (53.9%), and thiazide diuretics (48.9%). Events of special interest, including angioedema, hyperkalemia, and diarrhea occurred in similar proportions of patients taking aliskiren, placebo, and comparator agents. In studies of up to 36 weeks, patients treated with aliskiren were significantly less likely to develop cough than those treated with ACE inhibitors. At the registered doses of 150 mg and 300 mg daily, aliskiren has safety and tolerability profiles similar to placebo, other RAS blockers, and diuretics. Cough rates are lower with aliskiren compared with ACE inhibitors.     

Effect of different antihypertensive drug classes on central aortic pressure

Central aortic systolic blood pressure (BP) is an important determinant of cardiac workload and cardiac hypertrophy. The relationship of central aortic systolic BP and brachial BP varies depending on the stiffness of blood vessels. It is not certain whether the different drug classes affect the brachial and aortic systolic BP in a similar manner.In a double-blind crossover study, we measured the effects of the four major drug classes compared with placebo on central aortic pressure. Central aortic pressure and various indices were determined using the Sphygmo Cor apparatus. The study was undertaken in patients aged 65 to 85 years with systolic BP >150 mm Hg at study entry. Results are reported for 32 patients who had satisfactory applanation tonometry in all five periods.Calcium channel blockers and diuretics caused a greater fall in brachial artery systolic BP than angiotensin-converting enzyme (ACE) inhibitors or beta-blocking drugs. On placebo, central aorta augmentation pressure and index were 23 mm Hg and 33.3%; on ACE inhibitors the values were 18 mm Hg and 30%; on beta-blockers, 26 mm Hg and 38.5%; on calcium channel blockers, 16 mm Hg and 28%; and on diuretics, 17 mm Hg and 28.8%. The augmentation pressure on beta-blocking drugs was greater than on the other three drug classes (P <.05), and augmentation pressures on ACE inhibitors, calcium channel blockers, and diuretics were less than on placebo (P <.05). The lowest central aortic pressures were achieved with calcium blocking drugs and diuretics.Therapy based on brachial artery recordings may thus overestimate the effect of beta-blocking drugs on central aortic systolic BP and underestimate the effectiveness of ACE inhibitors and calcium blocking drugs. The clinical importance of this discrepancy needs to be evaluated.     

Beta blockers with ACE inhibitors in mild heart failure

ACE inhibitors are standard therapy for treating both symptomatic and asymptomatic patients with left ventricular dysfunction. However, recent clinical trials have shown that beta blockers further reduce mortality in patients with symptomatic heart failure treated with ACE inhibitors. However, the evidence in support of adding beta blockers to ACE inhibitor therapy in patients with asymptomatic left ventricular dysfunction is less certain. The mechanisms by which ACE inhibitors and beta blockers may exert benefit in patients with heart failure are discussed, and studies assessing the association of beta blockade with outcome in patients with mild heart failure receiving ACE inhibitor therapy are reviewed. (c)2000 by CHF, Inc.     

Underutilization of aspirin,beta blockers,angiotensin-converting enzyme inhibitors,and lipid-lowering drugs and overutilization of calcium channel blockers in older persons with coronary artery disease in an academic nursing home

BACKGROUND: We report the prevalence of use of aspirin, beta blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers, statins, and calcium channel blockers in older persons with coronary artery disease (CAD) in an academic nursing home. METHODS: We investigated the prevalence of use of aspirin, beta blockers, ACE inhibitors or angiotensin II type 1 receptor blockers, lipid-lowering drugs, and calcium channel blockers in older persons with a mean age of 77 +/- 9 years, in an academic nursing home with documented CAD and no contraindications to the use of aspirin, beta blockers, ACE inhibitors or angiotensin II type 1 receptor blockers, and lipid-lowering drugs. RESULTS: CAD was documented in 77 of 255 persons (30%). Of 77 persons with CAD, 48 persons (62%) were treated with aspirin, 45 persons (58%) with ACE inhibitors or angiotensin II type 1 receptor blockers, 44 persons (57%) with beta blockers, 21 persons (27%) with calcium channel blockers, and 16 persons (21%) with statins. Of the 61 persons with CAD not treated with statins, serum low-density lipoprotein (LDL) cholesterol was measured in only 22 persons (36%) and was increased in 14 of the 22 persons (64%). CONCLUSIONS: These data show underutilization of aspirin, beta blockers, ACE inhibitors, lipid-lowering drugs, and measurement of serum LDL cholesterol and overutilization of calcium channel blockers in older persons with CAD in an academic nursing home.     

Changing patterns of initial drug therapy for the treatment of hypertension in a Medicaid population, 2001-2005

Thiazide diuretics have been recommended as one preferred choice for the initial treatment of hypertension. This study was undertaken to determine whether Maine physicians initiating monotherapy for newly diagnosed hypertensive patients from 2001-2005 used this guideline. The Maine Medicaid database was searched for the drug classes used to initiate monotherapy for patients followed for at least 6 months. A total of 5373 patients were included. In 2001, the use of beta-blockers was 23.5%, diuretics 17.5%, angiotensin-converting enzyme inhibitors 37.5%, calcium channel blockers 9.5%, angiotensin receptor blockers 3.8%, and others 8.2%. By 2005, the use of beta-blockers was 27.8%, diuretics 25.5%, angiotensin-converting enzyme inhibitors 30.9%, calcium channel blockers 6.4%, angiotensin receptor blockers 1.6%, and others 7.7%. There was an increase in the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in diabetics but no other condition affected drug choice. Although there was an increase in the use of diuretics as initial therapy in 2003 and 2004, this decreased in 2005. The increase in initial diuretic use was not reflected in patterns of ongoing antihypertensive use from 1997 to 2005. There appears to have been limited impact from the guidelines on initial drug choice and even less so on ongoing drug therapy.     

Comparison of various blood pressure lowering treatments on the primary prevention of cardiovascular outcomes in recent randomised clinical trials

Randomised clinical trials completed over the past 8 to 10 years have provided much new evidence regarding the cardiovascular risks and benefits of treatment with newer blood pressure lowering drugs, particularly ACE inhibitors and calcium channel blockers (CCB). Trials of active treatment against placebo have now established that ACE inhibitors and CCBs reduce the risk of coronary heat disease and stroke in subjects with elevated blood pressure and that ACE inhibitors reduce the risk of heart failure but calcium antagonists do not. Clinical trials comparing active treatment regimens based on different blood pressure lowering drug classes, have provided convincing evidence that ACE inhibitors, CCBs, and "conventional treatment" with diuretics/beta-blockers are equally effective in the primary prevention of coronary heart disease, but that minor differences of the order of 5-12% favouring calcium antagonists may exist. The one area with a major difference is again for the primary prevention of heart failure where calcium antagonists are clearly inferior to diuretics/ beta-blockers and to ACE inhibitors. There is now convincing evidence that blood pressure lowering is effective in the secondary prevention of cardiovascular outcomes in subjects with established coronary heart disease, cerebrovascular disease, diabetes and chronic kidney disease, especially diabetic nephropathy. Clinical trial evidence comprising regimens based on different drug classes for the secondary prevention of cardiovascular outcomes is still very limited. It is possible that longer differences will be found between the efficacy and safety of drugs in secondary prevention than have been reported so far in primary prevention.     

Effect of an educational program on the prevalence of use of antiplatelet drugs, beta blockers, angiotensin-converting enzyme inhibitors, lipid-lowering drugs, and calcium channel blockers prescribed during hospitalization and at hospital discharge in patients with coronary artery disease

BACKGROUND: There is a marked underutilization of antiplatelet drugs, beta blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and lipid-lowering drugs, and an overutilization of calcium channel blockers in elderly patients with coronary artery disease (CAD). METHODS: An ongoing educational program is being given by Dr. Wilbert Aronow on the appropriate utilization of cardiovascular drugs in patients with CAD during hospitalization and at hospital discharge. In a prospective study, charts of 200 unselected patients hospitalized for CAD at least 6 months after the onset of the educational program were analyzed by a medical resident to investigate the appropriate utilization of cardiovascular drugs. The 200 patients included 115 men and 85 women, mean age 70 years, with documented CAD. Of the 200 patients, 127 (64%) had the diagnosis of prior CAD. The use of cardiovascular medications in these 127 patients prior to hospitalization served as a control group. RESULTS: After the educational program, aspirin, clopidogrel, or warfarin was given to 93% of patients compared with 67% in the control group; beta blockers were given to 81% of patients compared with 56% in the control group; ACE inhibitors or ARBs were given to 70% of patients compared with 42% in the control group. Lipid-lowering drugs if dyslipidemia were given to 88% of patients compared with 52% in the control group; calcium channel blockers were given to 18% of patients compared with 24% in the control group. CONCLUSIONS: In patients with CAD, the educational program increased the use of antiplatelet drugs by 26%, beta blockers by 25%, ACE inhibitors or ARBs by 28%, and lipid-lowering drugs by 36%, and decreased the use of calcium channel blockers by 6%.     

Baseline laboratory monitoring of cardiovascular medications in elderly health maintenance organization enrollees

Objectives: To identify correlates of laboratory monitoring errors in elderly health maintenance organization (HMO) members at the initiation of therapy with cardiovascular medications.
Design: Cross-sectional study in 10 HMOs.
Setting: United States.
Participants: From a 2 million-member sample, individuals aged 65 and older who received one of seven cardiovascular medications (angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), amiodarone, digoxin, diuretics, potassium supplements, and statins) and did not have recommended baseline monitoring performed during the 180 days before or 14 days after the index dispensing.
Measurements: The proportion of members receiving each drug for whom recommended laboratory monitoring was not performed. Laboratory monitoring error rates stratified by sex, age group, chronic disease score, and HMO site were examined, and logistic regression was used to identify predictors of laboratory monitoring errors.
Results: Error rates varied by medication class, ranging from 23% of patients receiving potassium supplementation without serum potassium and serum creatinine monitoring to 58% of patients receiving amiodarone who did not have recommended monitoring for thyroid and liver function. Highest error rates occurred in the youngest elderly for ACE inhibitors, ARBs, digoxin, diuretics, and potassium supplements, although in patients receiving amiodarone and statins, errors were most frequent in the oldest elderly. Errors occurred more frequently in patients with less comorbidity.
Conclusion: Laboratory monitoring errors occurred frequently in elderly HMO members at the initiation of therapy with cardiovascular medications. Further study must examine the association between these errors and adverse outcomes.     

Hypertension in the elderly with a special focus on treatment with angiotensin-converting enzyme inhibitors and calcium antagonists.

Age-related changes (e.g., decrease in plasma renin activity and total body potassium, increase in plasma catecholamines, volume depletion) need to be taken into account when selecting an antihypertensive agent for the elderly patient. A number of large scale clinical trials (e.g., Systolic Hypertension in the Elderly Program, Veterans Administration Cooperative Study, European Working Party on High Blood Pressure in the Elderly) have demonstrated that antihypertensive therapy with diuretics substantially reduced cardiovascular mortality and stroke incidence. However, since diuretics, even potassium-sparing agents, may induce hypokalemia, newer antihypertensive agents (angiotensin-converting enzyme [ACE] inhibitors and calcium antagonists) may also be appropriate as first-line monotherapy for this patient population. ACE inhibitors are effective antihypertensive agents and are associated with a lower rate of adverse effects than diuretics, beta blockers, and centrally acting agents. Nevertheless, periodic monitoring of serum potassium, creatinine levels, and renal function is advisable. An important feature of calcium antagonists is that they lower blood pressure with no negative effect on serum lipids or glucose metabolism. Typically, they have few side effects, peripheral edema being the most commonly reported. A recent double-blind randomized study comparing a new sustained release nifedipine formulation and the ACE inhibitor lisinopril found the 2 drugs equivalent in efficacy with no differences in the rate of adverse events.     

Blockade of the Renin-Angiotensin System in African Americans With Hypertension and Cardiovascular Disease

There is overwhelming evidence that the reninangiotensin system plays a significant role in the pathophysiology of hypertension and target organ damage. Agents that regulate the renin-angiotensin system, such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and aldosterone antagonists, are not only effective antihypertensive agents but can prevent target organ damage. Although diuretics remain the agents of first choice for the treatment of hypertension in African Americans, ACE inhibitors have a clear role in the management of these patients. ACE inhibitors (usually when used with a diuretic) have been shown to reduce morbidity and mortality in a wide range of patient groups. ACE inhibitors are infrequently used in African Americans because of a belief that these agents are ineffective in this racial group; however, when adequate dosing and appropriate combinations are used, ACE inhibitor therapy provides effective blood pressure control. In particular, the addition of diuretics to ACE inhibitor therapy ameliorates the racial differences in efficacy seen when ACE inhibitors are administered as monotherapy. Although further confirmation in additional clinical trials is required, increased use of these agents in African Americans will likely result in a reduction in target organ damage.     

Chronic heart failure. Examining consensus recommendations for patient management

In the mid 1990s, various organizations published guidelines for the management of chronic heart failure. Subsequent advances in pharmacologic treatment, however, warranted the release of recommendations that accounted for the new developments. Hence the publication in 1999 of the "Consensus recommendations for the management of chronic heart failure." Although there are measures patients can take to help prevent development of heart failure, the recommendations focus primarily on pharmacologic treatment of left ventricular systolic dysfunction. The discussion includes examination of the role of diuretics, ACE inhibitors, beta blockers, cardiac glycosides, as well as alternate agents such as angiotensin II receptor blockers. All of these agents can be used to help achieve a key management goal: decrease disease progression and thereby decrease the risk of hospitalization and death.