Usefulness of the alpha1-blocker doxazosin as a third-line antihypertensive drug.

It has been reported that a substantial majority of hypertensives receive insufficient blood pressure (BP) control. As combination therapy for the treatment of hypertension, Ca channel blockers (CCBs), angiotensin II (AII) receptor blockers (ARBs), and/or AII-converting enzyme (ACE) inhibitors are mainly prescribed, while the efficacy of alpha(1)-blockers in such combination therapy remains unknown. The aim of this study was to investigate the efficacy of a low dose of an alpha(1)-blocker added to combination therapy with CCBs and either ARBs or ACE inhibitors for the treatment of hypertension. Subjects were 41 hypertensive patients (23 women and 18 men, mean age 66+/-12 years) who had been followed at the National Kyushu Medical Center. All patients showed poor BP control despite haven taken a combination of CCBs and ARBs or ACE inhibitors for more than 3 months. Doxazosin at a dose of 1 to 2 mg was added to each treatment regimen. The changes in various clinical parameters, including BP and blood chemistry, following the addition of doxazosin were then evaluated. The mean follow-up period was 170 days. BP decreased from 152+/-14/81+/-12 mmHg to 135+/-14/70+/-11 mmHg after the addition of doxazosin at a mean dose of 1.5 mg/day (p<0.001). When good systolic blood pressure (SBP) control was defined as <140 mmHg, the prevalence of patients with good SBP control increased from 24% to 61% (p<0.01). Similarly, the prevalence of patients with good diastolic blood pressure (DBP) control (<90 mmHg) increased from 78% to 98% (p<0.01). Patients whose SBP decreased more than 10 mmHg (n=25) showed significantly higher baseline SBP, serum total cholesterol and low-density lipoprotein (LDL) cholesterol levels compared to those who showed less SBP reduction (<10 mmHg) (n=16, p<0.01). Comparable BP reductions were obtained between obese (body mass index [BMI] > or =25, DeltaBP at 3 months: -15+/-15/-12+/-9 mmHg, n=18) and non-obese (BMI<25, DeltaBP: -14+/-19/-7+/-8 mmHg, n=23) patients. The results suggest that addition of a low dose of the alpha(1)-blocker doxazosin effectively reduces BP in patients taking CCBs and ARBs or ACE inhibitors. Thus, doxazosin seems to be useful as a third-line antihypertensive drug.     

Diabetes and hypertension, the deadly duet: importance, therapeutic strategy, and selection of drug therapy

Large, placebo-controlled RCTs that involve only diabetic patients who have hypertension have not been performed. Subgroup analyses of hyper-tension control from several recent RCTs un-equivocally demonstrated greater benefit in diabetic populations (see Table 3) with ACE inhibitors, TDs, and CCBs. Treatment with fBs(atenolol) also was beneficial in diabetic patients who had hypertension in the actively-controlled UKPDS. The results of three RCTs support intensive BP control in diabetic patients (see Table 4). In these trials, diabetic patients gained more benefit than nondiabetic patients. Such an effect is consistent with the fact that diabetics are at higher risk for CV events. Although there are limited data from RCTs with head-to-head comparison of newer agents (eg,ACE inhibitors, ARBs, CCBs) to show that these drugs are better than diuretics and betaBs in reducing CV events by treating hypertension in the diabetic population, the available data support ACE inhibitors (and ARBs if ACE inhibitors are not tolerated) as an initial drug of choice in diabetic,hypertensive patients (see Table 5). Most diabetic patients require three or four drugs to control their BP to target range; as such, it is not necessary to justify the choice of any single class of drug.Tight BP control is cost-effective and is more rewarding than hyperglycemic control in diabetic,hypertensive patients. The optimal goal in diabetics should be to achieve BP that is less than 130/80 mm Hg. Appropriate action should be taken if BP is greater than 140/85 mm Hg. In subjects who have diabetes and renal insufficiency,the BP should be decreased to less than 125/75 mm Hg to delay the progression of renal failure. Limited data suggest that an ACE inhibitor or an ARB is the agent of choice, especially in patients who have proteinuria or renal insufficiency. betaBs can be the first-line agent in diabetics who have CAD. TDs and CCBs are the second line drugs.AAAs should be avoided. Most hypertensive patients require more than one agent to adequately control their BP. There is no evidence to support one combination regimen over the others, nevertheless, the combination of an ACE inhibitor with a TD or a fPB may be more beneficial and cost effective than other combinations in the diabetic population. Large outcome studies that compare different combination therapies in hypertensive,diabetic patients are needed.     

Persistence on Treatment and Blood Pressure Control with Different First-Line Antihypertensive Treatments: A Prospective Evaluation

We enrolled 347 hypertensive patients, randomly allocated them to different first-line treatments, and followed-up for 24 months. Persistence on treatment was significantly higher in patients treated with ARBs (68.5%) and ACE inhibitors (64.5%) vs. CCBs (51.6%), β-blockers (44.8%), and diuretics (34.4%). No ARB, ACE inhibitor, β-blocker, or diuretic was associated with a greater persistence in therapy as compared with the other molecules used in each therapeutic class. The rate of persistence was significantly higher in patients treated with lercanidipine vs. other CCBs (59.3% vs. 46.6%). Systolic and diastolic BP decreased more in patients treated with ARBs (-11.2/-5.8 mmHg), ACE inhibitors (-10.5/-5.1 mmHg), and CCBs (-8.5/-4.6 mmHg) when compared to ß-blockers (-4.0/-2.3 mmHg) and diuretics (-2.3/-2.1 mmHg).     

Hypertension treatment patterns in American Indians: the Strong Heart Study

Pharmacologic treatment patterns for hypertensive American Indians from 13 communities in Arizona, Oklahoma, South Dakota, and North Dakota were assessed. Participants (2254 women and 1384 men, aged 48 to 79 years) completed a clinical examination between July 1993 and December 1995. The mean of two blood pressure (BP) measurements and detailed medication histories were obtained. The observed prevalence of hypertension was 46.7% (n = 1698). In participants taking antihypertensive medications (n = 1114), four principal drug classes were evaluated: diuretics, calcium channel blocking agents, β-blocking agents, and angiotensin-converting enzyme (ACE) inhibitors. Among treated hypertensive participants, 71.4%, 24.6%, and 4.0% received one, two, and three medications, respectively. Among single drug regimens, ACE inhibitors (n = 340) were used most often (49.4%), with calcium channel blocking agents and diuretics accounting for 24.2% and 19.9%, respectively. Although multiple drug class therapies varied, the combination of a diuretic and ACE inhibitor (n = 120) accounted for 47.4% of dual therapy use. Hypertension control (SBP < 140 mm Hg, DBP < 90 mm Hg) rates were highest for those on dual therapies (65.4%), followed by participants on single (53.8%) and triple (43.6%) therapies. Among monotherapies, diuretics exhibited the best overall hypertension control rate in both diabetics (63.0%) and nondiabetics (68.0%), versus 47% to 61% for other remaining agents. The frequent use of ACE inhibitors, used singly or in combination, reflects the high prevalence of diabetes among American Indians. ACE inhibitors, combined with diuretics, were particularly useful in achieving BP control in this population.     

Angiotensin-converting enzyme inhibitors, calcium channel blockers, and breast cancer

BACKGROUND: The use of angiotensin-converting enzyme (ACE) inhibitors has been linked to a decreased risk of developing cancer, and longer-term use of calcium channel blockers (CCBs) has been associated with an increased risk of developing cancer in general and breast cancer in particular. METHODS: Using data from the General Practice Research Database, we conducted a large case-control analysis. Previous exposure to ACE inhibitors, CCBs, and beta-blockers was compared between 3706 postmenopausal women who were diagnosed with incident breast cancer between 1992 and 1997 and 14155 matched-control women. RESULTS: Compared with nonusers of antihypertensive drugs, women who used ACE inhibitors (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.7-1.5), CCBs (OR, 0.9; 95% CI, 0.7-1.2), or beta-blockers (OR, 1.0; 95% CI, 0.8-1.2) for 5 or more years were not at an increased or decreased risk of developing breast cancer (adjusted for smoking and body mass index [calculated as weight in kilograms divided by the square of height in meters]). The risk of breast cancer did not differ between users of different ACE inhibitors or different CCBs (dihydropyridines, diltiazem hydrochloride, and verapamil hydrochloride) or between users of short-acting (OR, 1.0; 95% CI, 0.7-1.4) or sustained-release (OR, 1.0; 95% CI, 0.8-1.3) nifedipine preparations. CONCLUSION: The findings of this large case-control analysis do not support the hypothesis that longer-term use of ACE inhibitors or CCBs affects the risk of developing breast cancer.     

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.     

Patient satisfaction with antihypertensive therapy

The objective of the study was to assess factors associated with treatment satisfaction among patients receiving antihypertensive therapy. A weighted cross-sectional online survey was conducted with hypertensive patients participating in a chronic disease panel in the US. Patients on monotherapy with medications from the following classes were identified: ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta blockers (BBs), calcium channel blockers (CCBs), and diuretics. The control group included patients without treatment. Pairwise comparisons between groups were conducted for factors that may affect patients' satisfaction. The study population had a mean age of 54.7+/-14.2 years and was 56.7% female. Participants with blood pressure (BP) controlled to JNC 7 guidelines were more satisfied with their medication than those with uncontrolled BP (90.3 vs 71.5%, P<0.05). Patients who had not experienced adverse events had higher satisfaction than patients experiencing adverse events (90.9 vs 75.8%, P<0.05). The most frequently self-reported adverse events were frequent urination, sexual dysfunction, and fatigue ranging from 7.0 to 9.6% across classes. The adverse event rates differed by class and were lowest among the ARBs. Patients on ARBs were the most likely to have switched from a previous antihypertensive class as compared to other classes (57.1% ARBs vs 49.8% ACEIs, 38.7% diuretics, 36.3% CCBs, and 31.7% BBs). Physician recommendation was the most common reason for switching. In conclusion, the ability to effectively treat hypertension depends upon a patient's satisfaction with antihypertensive therapy, which may be improved by achieving BP control and minimizing the occurrence of adverse events.     

Angiotensin-converting enzyme inhibitors and calcium channel blockers for coronary heart disease and stroke prevention

We investigated whether protection from coronary heart disease (CHD) and stroke conferred by angiotensin-converting enzyme inhibitors (ACEIs) and calcium channel blockers (CCBs) in hypertensive or high-risk patients may be explained by the specific drug regimen. We extracted summary statistics regarding CHD and stroke from 28 outcome trials that compared either ACEIs or CCBs with diuretics, beta-blockers, or placebo for a total of 179,122 patients, 9509 incident cases of CHD, and 5971 cases of stroke. CHD included myocardial infarction and coronary death. In placebo-controlled trials, ACEIs decreased the risk of CHD (P<0.001), and CCBs reduced stroke incidence (P<0.001). There were no significant differences in CHD risk between regimens based on diuretics/beta-blockers and regimens based on ACEIs (P=0.46) or CCBs (P=0.52). The risk of stroke was reduced by CCBs (P=0.041) but not by ACEIs (P=0.15) compared with diuretics/beta-blockers. Because heterogeneity between trials was significant, we investigated potential sources of heterogeneity by metaregression. Examined covariates were the reduction in systolic blood pressure (BP), drug treatment (ACEIs versus CCBs), their interaction term, sex, age at randomization, year of publication, and duration of treatment. Prevention of CHD was explained by systolic BP reduction (P<0.001) and use of ACEIs (P=0.028), whereas prevention of stroke was explained by systolic BP reduction (P=0.001) and use of CCBs (P=0.042). These findings confirm that BP lowering is fundamental for prevention of CHD and stroke. However, over and beyond BP reduction, ACEIs appear superior to CCBs for prevention of CHD, whereas CCBs appear superior to ACEIs for prevention of stroke.     

Blood Pressure and Serum Potassium Levels in Hypertensive Patients Receiving or Not Receiving Antihypertensive Treatment

Objective. Serum potassium has a fundamental role in blood pressure (BP) regulation, and there is evidence highlighting the importance of potassium homeostasis in hypertension. The aim of this study was to determine the relationship between serum potassium levels and office BP in untreated essential hypertensives and the effect of antihypertensive medication on serum potassium levels. Setting and Participants. In a retrospective analysis, we collected data for consecutive patients first visiting our Hypertension Clinic from 1999–2004. From this population, we first selected patients who were not taking any antihypertensive medication. Patients who had conditions that could affect potassium metabolism, such as history of arrhythmias treated with digitalis, diabetes mellitus under insulin treatment, and hypo- and hyperthyroidism, were excluded from the study. From the remaining patients, those who had impaired renal function (serum creatinine ≥1.6 mg/dL for men and ≥1.4 mg/dl for women) and patients with secondary forms of hypertension were also excluded. The final population consisted of 817 subjects. Multivariate linear regression analysis was applied, and models were created associating serum potassium with systolic BP, diastolic BP, mean BP, or pulse pressure. The population for the second part of the study consisted of patients first visiting our Hypertension Clinic who were on one antihypertensive agent. This second group included 757 patients, 218 of whom were on β-blockers, 42 on diuretics, 187 on angiotensin-converting enzyme (ACE) inhibitors, 287 on calcium channel blockers (CCBs), and 28 on angiotensin receptor blockers (ARBs). Results. After adjusting for age, gender, and body mass index, significant negative correlations were found between serum potassium levels and systolic BP (R?=??0.093, p?=?0.007), diastolic BP (R?=??0.078, p?=?0.03), mean BP (R?=??0.122, p?=?0.002), and pulse pressure (R?=??0.071, p?=?0.044). The levels of potassium were found to be significantly lower among patients receiving diuretics than those receiving one of the other four drug categories of antihypertensive (p < 0.05 for β-blockers, ACE inhibitors, and CCBs; p < 0.001 for ARBs). In addition, hypokalemia was found to be significantly more prevalent in the group using diuretics than the other groups. Conclusions. The observed reverse relation between serum potassium and BP supports a close pathophysiological connection between serum potassium and essential hypertension. Moreover, diuretic therapy is a significant cause of hypokalemia and requires systematic monitoring.     

Characterization of systemic hypertension in the San Francisco Chinese community

This report examines the prevalence of hypertension, its management and control, and the use of antihypertensive medication, diet, and exercise in Chinese adults residing in the San Francisco community. Blood pressure (BP) was measured objectively using an automated oscillometric Dinamap recorder on 708 Chinese adults (295 men and 413 women; age range from 19 to 98 years, mean 59.7), and hypertension, defined as BP >140/90 mm Hg and/or the use of antihypertensive medications, was found in 489 (69%), most of them immigrants from China. Although 202 patients (41%) received antihypertensive medications, only 28 (14%) achieved BP control (<140/90 mm Hg), and in examining the self-management of hypertension, it was found that only 45% of patients used low-sodium diets, and 49% performed regular exercises for > or = 30 minutes > or = 3 times weekly.     

Trends in hypertension care in eastern and south-western Finland during 1982-2002

OBJECTIVE: To assess the trends in blood pressure (BP) levels and the control of hypertension in eastern and south-western Finland during 1982-2002. DESIGN: Five independent cross-sectional population surveys conducted in 1982, 1987, 1992, 1997 and 2002. SETTING: The provinces of North Karelia and Kuopio in eastern Finland and the region of Turku-Loimaa in south-western Finland. PARTICIPANTS: Stratified random samples of men and women aged 25-64 years were selected from the national population register. The total number of participants was 29 127. MAIN OUTCOME MEASURES: Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP), the prevalence and control of hypertension. The distribution of all subjects with no antihypertensive drug treatment in 2002 according to the modified risk stratification scheme introduced in 2003 European Society of Hypertension-European Society of Cardiology guidelines. RESULTS: Mean SBP and DBP and the prevalence of hypertension decreased significantly in all areas. The proportion of treated hypertensive subjects with adequately controlled BP (SBP < 140 mmHg and DBP < 90 mmHg) increased from 13.7 to 33.3% in men (P < 0.001) and from 11.4 to 32.0% in women (P < 0.001). The unsatisfactory treatment of hypertension was mainly a result of the lack of control of high SBP. According to the 2003 guidelines, 35.9% of the entire population currently not on antihypertensive drug treatment should have been prescribed such treatment within a year. CONCLUSIONS: Hypertension care has improved significantly in Finland during 1982-2002. However, the difference between the actual situation at the population level and the treatment goals presented by the hypertension guidelines remains vast.     

Persistence on treatment and blood pressure control with different first-line antihypertensive treatments: a prospective evaluation

We enrolled 347 hypertensive patients, randomly allocated them to different first-line treatments, and followed-up for 24 months. Persistence on treatment was significantly higher in patients treated with ARBs (68.5%) and ACE inhibitors (64.5%) vs. CCBs (51.6%), beta-blockers (44.8%), and diuretics (34.4%). No ARB, ACE inhibitor, beta-blocker, or diuretic was associated with a greater persistence in therapy as compared with the other molecules used in each therapeutic class. The rate of persistence was significantly higher in patients treated with lercanidipine vs. other CCBs (59.3% vs. 46.6%). Systolic and diastolic BP decreased more in patients treated with ARBs (-11.2/-5.8 mmHg), ACE inhibitors (-10.5/-5.1 mmHg), and CCBs (-8.5/-4.6 mmHg) when compared to beta-blockers (-4.0/-2.3 mmHg) and diuretics (-2.3/-2.1 mmHg).     

Blood pressure response to medical treatment in the emergency department – a retrospective cohort study

Objectives: It is unclear whether blood pressure (BP) without target organ damage should be decreased in patients in the emergency department (ED). It is also uncertain whether any certain class of medications has an advantage over the other in this setting. This study addressed both these questions. Methods: In this retrospective cohort study, all patients attending a tertiary care ED with elevated BP were evaluated. All patients with target organ damage as well as those with significant active co-morbidities, such as myocardial ischemia, were excluded. Baseline characteristics and response of BP to therapy were compared between those treated and untreated in the ED. In addition, BP response to therapy was compared between different classes of antihypertensive medications. Results: Overall, 438 patients were included in the final analysis (62% female), of which 275 (63%) were treated in the ED. Antihypertensive medications were more commonly prescribed in the ED for those with higher systolic and diastolic BP, but other baseline characteristics were similar between the two groups. Only systolic BP significantly decreased in those treated with antihypertensive medications compared with those untreated. The most commonly used classes were angiotensin converting enzyme inhibitors (ACEis) and calcium channel blockers (CCBs). Use of either of these drug classes was not associated with a significant decrease in either systolic or diastolic BP compared with the use of other drug classes. Conclusions: Antihypertensive drug therapy is more commonly prescribed in the ED in individuals with both elevated systolic and diastolic BP, but leads to a significant decrease only in systolic BP. Use of either ACEis or CCBs is not associated with a significant decrease in either systolic or diastolic BP compared with other drug classes.     

Genetic influences on blood pressure within the Stanislas Cohort

OBJECTIVE: To investigate the association of 21 polymorphisms within 13 genes, APOE, APOB, APOC3, CETP, LPL, PON1, MTHFR, FGB, F5, GPIIIa, SELE, ACE and AGT, with inter-individual blood pressure (BP) variation. PARTICIPANTS: Seven hundred and seventy-six men and 836 women, free of antihypertensive and lipid-lowering medications, were selected from the Stanislas Cohort. RESULTS: ANOVA on blood pressure values after adjustment for covariates [age, body mass index (BMI), contraceptive pill, tobacco and alcohol] showed that lipoprotein lipase (LPL) Ser447Ter and glycoprotein IIIA (GpIIIa) Pl polymorphisms were significantly associated with BP in women (0.01 < or = P < or = 0.05), whereas BP levels in men were significantly different according to apolipoprotein CIII (APOC3) 3206T/G and -482C/T polymorphisms (P < or = 0.05). In women, compared to the most common allele, the GpIIIa Pl allele was associated with increased mean arterial pressure (MAP) (P < 0.05) and pulse pressure (PP) (P < 0.001), and the LPL 447Ter allele was associated with decreased systolic blood pressure (SBP) and PP levels (0.001 < or = P < or = 0.05). These two polymorphisms appeared to act independently. In men, the APOC3 3206GG genotype was related to decreased diastolic blood pressure (DBP) and MAP levels (P < or = 0.01), and the APOC3 -482T allele with decreased PP levels (P < or = 0.05). The presence of both the -482C allele and the 3206GG genotype was related to decreased DBP, suggesting that specific haplotypes might be involved. CONCLUSION: The APOC3, LPL and GpIIIa genes were found to be associated with BP levels. The contributions of these genes, although modest, are consistent with the polygenic nature of BP levels.     

Prevalence and therapeutic control of hypertension in French Caribbean regions

OBJECTIVE: To describe characteristics of hypertension in French Caribbean regions. DESIGN: A cross-sectional worksite study. SETTING AND PARTICIPANTS: A random sample of 6136 workers referred for annual check-up from Martinique, French Guyana and Guadeloupe. An average of three consecutive measurements was taken as the blood pressure (BP) level. An additional visit was required in subjects not taking antihypertensive medications with an average BP over 140/90 mmHg. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Hypertension prevalence, awareness, treatment and control. RESULTS: The age-specific prevalence of hypertension, based on two visits, increased from 3.2% in men below 30 years to 46.9% in those older than 50 years. The corresponding values found in women were 1.8 and 42.6%. The overall prevalence was 19.5% in men and 18.9% in women. The rate of awareness remained low while age increased. The use of antihypertensive medications slowly increased with age, but overall the rate remained lower in men compared with women. Up to 71% of hypertensive women received antihypertensive medications. Compared with previous studies, a high proportion of adequately treated patients was found among women (44.9%). Only 30.4% of hypertensive men were treated, and as a result the control rate was lower (13.3%). CONCLUSION: Major sex-related differences are found in the control of high BP, with an unexpected high rate observed among Caribbean women. Better awareness and higher treatment rates play an important role in explaining such results. This may be important, especially in developing countries, where poor control of hypertension is a major cause of cardiovascular diseases.     

Blood pressure control in kidney transplantation: therapeutic implications

Post-transplant hypertension remains a significant risk factor for graft loss, but whether or not specific blood pressure (BP) medications affect graft outcome is still unknown. We assessed the interaction between BP control and antihypertensive drugs on graft outcome. We retrospectively examined clinic BP data for 1662 renal transplant (RTx) patients, transplanted between 1994 and 2000 at our centre. The analysis examined all patients who received central alpha-agonists and peripheral alpha-antagonists, beta-blockers, calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibition (ACEI), angiotensin receptor blockers (ARBs). BP recordings during treatment were categorized for each agent. Thus, a particular BP could be categorized for multiple medications. A total of 1462 patients (pts) (88%) were Caucasian and 800 pts (46%) received cadaveric RTx. There were 10.6+/-6.8 BP measurements for each patient post-RTx. CCBs, alone among the classes of antihypertensive drugs evaluated, reduced the risk for graft loss (RR: 0.736; P=0.035) in the overall analysis. Interestingly, stratifying levels of BP control unmasked a beneficial effect on graft survival of ACEI/ARB therapy in individuals with higher levels of systolic (>152 mmHg) and diastolic blood pressure (>98 mmHg) treated with ACEI/ARBs compared to individuals treated with CCBs (P<0.01 for each). Thus, stabilizing BP is important post-RTx. CCBs are associated with improved rates of graft survival. Their role in a compromised RTx, however, deserves further study. ACEI/ARBs have clear benefits, improving graft survival in individuals with elevated systolic blood pressure and proteinuria. CCBs are not as efficacious in this setting.     

Evidence-based evaluation of calcium channel blockers for hypertension: equality of mortality and cardiovascular risk relative to conventional therapy.

OBJECTIVES; We present a meta-analysis based on three recent, substantial, randomized outcome trials and several smaller trials that compared calcium channel blockers (CCBs) with conventional therapy (diuretics or beta-blockers) or with angiotensin-converting enzyme (ACE) inhibitors. BACKGROUND: There is continuing uncertainty about the safety and efficacy of CCBs in the treatment of hypertension. Previous meta-analyses conflict and suggest that CCBs increase myocardial infarction (MI) or protect from stroke. METHODS: Standard procedures for meta-analysis were used to analyze three major trials on 21,611 patients and another three lesser studies to a total of 24,322 patients. RESULTS: Calcium channel blockers have a strikingly similar risk of total and cardiovascular mortality and of major cardiovascular events to conventional therapy. Calcium channel blockers give a lower risk of nonfatal stroke (-25%, p = 0.001) and a higher risk of total MI (18%, p = 0.013), chiefly nonfatal (18%). After performing the Bonferroni correction for multiplicity, these p values become 0.004 and 0.052, respectively. When compared with ACE inhibitors in 1,318 diabetic patients, CCBs had a substantially higher risk of nonfatal (relative risk [RR] = 2.259) and total MI (RR = 2.204, confidence interval 1.501 to 3.238; p = 0.001 or 0.004 with Bonferroni correction). Total and cardiovascular mortality rates are similar. To confirm the hypothesis that ACE inhibitors are superior to CCBs in diabetic patients requires more trial data, especially with renal end points. CONCLUSIONS: Mortality (total and cardiovascular) and major cardiovascular events with CCBs were apparently similar to those events seen with conventional first-line therapy (diuretics or beta-blockers). Stroke reduction more than balanced increased MI. In diabetics, CCBs may be less safe than ACE inhibitors.     

Role of Single-Pill Combination Therapy in Optimizing Blood Pressure Control in High-Risk Hypertension Patients and Management of Treatment-Related Adverse Events

J Clin Hypertens (Greenwich). 2012;14:718–726. ©2012 Wiley Periodicals, Inc. Renin-angiotensin-aldosterone system (RAAS) inhibitors in combination with other antihypertensive drugs (eg, calcium channel blockers [CCBs] and/or diuretics) are a preferred treatment option for managing uncontrolled hypertension in high-risk patients with chronic kidney disease (CKD), diabetes, or heart failure because RAAS inhibitors provide cardiorenal benefits in addition to lowering blood pressure (BP). However, when prescribing antihypertensive therapies to high-risk patients, physicians must be aware of the risks of treatment-related adverse events of hyperkalemia and peripheral edema associated with RAAS inhibitors and CCBs, respectively. This review discusses the use of single-pill combination antihypertensive therapy to optimize BP control in high-risk patients with CKD, diabetes, and/or heart failure and provides strategies for preventing and managing hyperkalemia and peripheral edema in this group. Single-pill combination therapy can utilize different classes of antihypertensive drugs to reduce BP while mitigating the risks of treatment-related adverse events, reducing pill burden, lowering medical cost, and improving patient compliance.     

End organ protection by calcium-channel blockers

In recent years, much attention has been given to end organ protection by antihypertensive, anti-heart failure, and anti-ischemic medications. This review describes the available information on end organ protection by calcium-channel blockers (CCBs). In normotensive patients and patients with hypertension treated with long-acting dihydropyridines, medial thickness was thinner than in patients treated with atenolol or in untreated hypertensive patients. Long-term treatment was associated with significant reduction in left ventricular mass. Calcium-channel blockers also improved endothelial-dependent relaxation and reversed the vasoconstrictive response to nitric oxide inhibitors. In diabetic patients, CCBs were effective in preserving kidney function and microalbuminurea. The combination of angiotensin-converting enzyme (ACE) inhibitors and CCBs was more effective than ACE inhibitors alone in preserving kidney function. In animal experiments, CCBs prevented development of coronary atheroschlerosis; however, in humans only limited data are available on their antiatherogenic effect. Some studies suggest that CCBs exert antiplatelets properties and may therefore be beneficial in patients with coronary artery disease.     

Prevalence, awareness, treatment, control and risk factors of hypertension in Korea: the Ansan study

OBJECTIVES: To determine prevalence, awareness, treatment, and control of hypertension, and its risk factors in an urban Korean population. DESIGN AND SETTING: A cross-sectional survey in Ansan-city, Korea. SUBJECTS AND METHODS: Population-based samples of people aged 18-92 years in Ansan-city, Korea, were selected, yielding 2278 men and 1948 women, and their blood pressures were measured using a highly standardized protocol. Hypertension was defined as a systolic BP > or = 140 mmHg or diastolic BP > or = 90 mmHg or reported treatment with antihypertensive medications, and subclassified according to 1999 WHO-ISH guidelines. Isolated systolic hypertension (ISH) defined as a systolic BP > or = 140 mmHg and diastolic BP < 90 mmHg was also examined. Data were stratified by age and sex. RESULTS: The overall prevalence of hypertension in this study was 33.7%. Among these, 64.9% had Grade 1 hypertension, 22.5% Grade 2, and 12.5% Grade 3. Age-specific prevalence of hypertension increased progressively with age, from 14.19% in 18 to 24 year-olds to 71.39% in those 75 years or older. Hypertension prevalence was significantly higher in men (41.5%) than in women (24.5%) (P < 0.001). Isolated systolic hypertension had significantly lower prevalence (4.33%) within the population, although in the elderly aged 55 years or more it rose by 11.13%. Overall, 24.6% of hypertensive individuals were aware that they had high blood pressure, as much as 78.6% were being treated with antihypertensive medications, and 24.3% were under control. Hypertension awareness as well as treatment and control rates varied by sex, with women higher in all three rates. Multivariate analysis revealed that age, body mass index and abdomen circumference were significantly associated with prevalence of hypertension both in men and women. CONCLUSIONS: Hypertension is highly prevalent in Korea. Despite the high rate of treatment, the rates of awareness and control are relatively low, suggesting the nationwide demand for preventing and controlling high blood pressure in Korea in order to avert an epidemic of cardiovascular disease.