Multicenter prospective survey of prognosis of hypertensive elderly outpatient under antihypertensive treatment--morbidity and mortality of cardiovascular diseases and cancer]

Although calcium-channel blockers and angiotensin-I-converting enzyme inhibitors are often used for treatment of hypertension in the elderly in Japan compared to those in the United States and in European countries, there have been few investigations on the prognosis of the elderly receiving these antihypertensive treatments. The Research Group for "Guidelines on the Treatment of Hypertension in the Elderly" collaborated with the Comprehensive Research Projects on Aging and Health group of the Ministry of Health and Welfare of Japan in performing a 3-year survey on the outcome of 700 hypertensive elderly outpatients (> or = 60 years) receiving treatment of antihypertensive drugs. Antihypertensive drugs including dihydropyridine-type calcium channel blockers, beta blockers, angiotensin-I-converting enzyme inhibitors, diltiazem, diuretics and old-type antihypertensives (hydralazine, budralazine, and centrally acting drugs such as clonidine, methyldopa and guanabenz) were administered to 71.3%, 30.4%, 26.2%, 14.0%, 8.6%, and 6.4% of the 642 elderly patients surveyed for three years, at the time of registration, respectively. Morbidity and mortality rates of total cerebro-cardiovascular diseases, stroke, and heart diseases, were 27.6 and 7.81/1,000 patient-years, 15.1 and 3.6/1,000 patient-years, 10.4 and 4.2/1,000 patient-years, respectively. These results were similar or even better than those of megatrials of antihypertensive treatments for elderly patients in Europe and United States. After adjustment for potential confounding factors, multiple logistic analysis revealed that a past history of ischemic heart disease, use of the old-type antihypertensive drugs, male gender, and diastolic high blood pressure were independent risk factors for the morbidity of cerebro-cardiovascular diseases taking the group of non-cerebro-cardiovascular disease as the reference group. We also identified 22 cases of newly occurred malignancies including 7 fatal cases. However, none of the antihypertensives was significantly related to the occurrence of malignancies. These results lead support to the tendencies in the use of antihypertensive drugs in Japan.     

Pharmacotherapy of arterial hypertension and pharmacoeconomic aspects of hypotensive therapy in elderly patients in Poland

The aim of our study was to examine the use of pharmacological therapy and to evaluate the economical aspects of treating hypertension (HT) in elderly patients in Poland. Two hundred and sixty eight elderly persons (147 females, 121 males; mean age: 72.2 +/- 6.0 years) were selected from Polish population by stratified and cluster random sampling with quotas. BP measurement was performed 3 times every 2 minutes at respondents home. In the questionnaire, awareness of HT was assessed. Prevalence of hypertension among subjects aged 65 years and over by JNC VI criteria (SAP > or = 140 mm Hg, DAP > or = 90 mm Hg or hypotensive therapy) was 74%. Awareness of HT was equal to 61%. Eleven percent of all hypertensives were well controlled. Among hypertensives, 71% took prescribed antihypertensive drugs on a regular basis. Patients with HT were taking the following antihypertensive drugs: diuretics 16%, diuretics and reserpine 20%, beta-blockers 19%, ACE inhibitors 53%, calcium antagonists 30%, and other 3%. Newer drugs were prescribed in 7%, and multi-source (generic) products in 93%. The average cost of treatment with one drug was 147 PLN (37.5 USD) per year (newer drugs: 413 PLN; multi-source product 126 PLN). Assuming those data and number of elderly people in Poland (4.335 mln), we estimated that 3.208 mln of subjects have had hypertension according to JNC VI criteria. Only 1.957 mln of patients with HT have been detected and only 0.353 mln of hypertensives have been well controlled. The approximate global cost of antihypertensive drugs per year in elderly patients in Poland has been equal to 285 mln PLN (72.8 mln USD). In hypothetical situation with optimal (100%) detection and control of HT the global cost by the actual rate of regularity in taking drugs would increase to 569 mln PLN (145.3 mln USD). The prevalence of HT in elderly people in Poland is very high. In elderly hypertensives ACE inhibitors are used most often. More than 90% of prescribed drugs are multi-source products. An optimal improvement of HT detection and control would cause a two-fold augmentation of the costs of pharmacological therapy.     

Update on the use of calcium antagonists on hypertension

Calcium antagonists represent an important group of drugs for the treatment of hypertension; they are effective in the whole range of severity of the disease. Dihy- dropyridine derivatives are most frequently used, and can be used in association with other antihypertensive drugs; meanwhile phenylalkylamines and benzothiazepines are contraindicated in association with beta-blocker drugs. Calcium antagonists with slow starting effect and long duration of action are the choice for use in long-term antihypertensive treatment. This group of drugs is specially indicated in elderly patients, in those with diabetes mellitus and in patients with coronary heart disease. Phenylalkylamines and benzothiazepine derivatives are also used in patients with supraventricular arrhythmias. This group of agents is as safe as diuretics, angiotensin-converting enzyme-inhibitors and beta-blocking drugs in the long-term treatment of hypertension.     

The effect of antihypertensive drugs on in vivo platelet activity in essential hypertension.

OBJECTIVE: To investigate whether antihypertensive drugs have a beneficial effect upon the abnormal in vivo platelet function found in patients with essential hypertension. DESIGN: A cross-sectional study in which plasma beta-thromboglobulin, a marker of in vivo platelet activation, was measured in patients with essential hypertension on various antihypertensive drugs. All were free from any other diseases which might affect platelet function. METHODS: Plasma beta-thromboglobulin was measured in 24 patients with untreated essential hypertension, 21 normotensive control patients, 16 patients receiving angiotensin converting enzyme (ACE) inhibitors, 16 patients receiving a beta-adrenoceptor blocker, 12 patients receiving calcium antagonists and 12 patients receiving a diuretic alone. RESULTS: Untreated hypertensives had significantly elevated plasma beta-thromboglobulin levels compared with controls. Plasma beta-thromboglobulin levels in patients receiving beta-blockers and diuretics were not significantly different from untreated hypertensives. Treatment with calcium antagonists was associated with lower plasma beta-thromboglobulin levels, but this difference was not statistically significant. In contrast, treatment with ACE inhibitors was associated with significantly lower plasma beta-thromboglobulin levels compared with untreated hypertensives. CONCLUSION: These results suggest that antihypertensive drugs have different effects upon abnormal in vivo platelet function in patients with essential hypertension. The apparent beneficial effect of ACE inhibitors may mean that they have more impact than other drug groups in the prevention of coronary heart disease.     

老年高血压合并代谢异常特征及其对靶器官的影响

目的分析老年原发性高血压患者合并不同代谢异常的临床特征及其对靶器官的影响。方法选择老年高血压患者460例,根据合并代谢异常情况分为6组:A组(单纯高血压,21例),高血压合并腹型肥胖、血脂异常、糖尿病、高尿酸血症及代谢综合征分别为B组(32例)、C组(73例)、D组(54例)、E组(27例)和F组(253例),行相关生化指标检测和超声等检查,综合评估其靶器官损害和并发症情况。结果单纯高血压患者仅占4.6%,95.4%的患者合并1项以上代谢异常。与A组比较,F组体重指数、腰围、空腹血糖、餐后2 h血糖、糖化血红蛋白、TG、尿酸及血肌酐明显升高(P<0.05),HDI-C明显下降(P<0.05);各组高血压病程和血压控制水平相当,但F组较其他组需要多种的抗高血压药物(P<0.05);D组与F组颈动脉内膜中层厚度、尿微量白蛋白/肌酐以及合并冠心病和脑血管病差异有统计学意义(P<0.05)。结论老年高血压患者以多重代谢性危险因素聚集为特征,该特征使靶器官损害和心脑血管病的发生明显增加,且需要多种抗高血压药物联用以控制血压。     

Pharmacologic treatment of hypertension in the Department of Veterans Affairs during 1995 and 1996

Patterns of antihypertensive drug use, the cost of this care and potential savings with changes of treatment patterns, were studied for all hypertensives treated at US Veterans Affairs (VA) medical facilities for fiscal years 1995 and 1996. Data was aggregated by individual medication as well as by antihypertensive drug class. Cost estimates were based on median cost and number of units for each dosage form of each medication dispensed at all facilities. Potential savings were estimated by substituting β-blockers or diuretics for calcium antagonists. In a subset of patients the prevalence of hypertension, and among hypertensives the prevalence of coronary artery disease, congestive heart failure, and diabetes mellitus, was determined. For these patients, patterns of treatment by antihypertensive drug class was examined.For all VA facilities, of the 10 most frequently prescribed antihypertensives in 1995, four were calcium antagonists, two angiotensin converting enzyme (ACE) inhibitors, two β-blockers, and two diuretics. In 1996, this was changed by the addition of an ACE inhibitor and the subtraction of a diuretic combination. Calcium antagonists accounted for 37% of treatment days in 1995 and 35% in 1996, ACE inhibitor use went from 34% to 36%, β-blockers from 17% to 18%, and diuretic use remained at 12%. In 1996, approximately 86.6 million dollars were spent on calcium antagonists, 51.8 million on ACE inhibitors, 7.9 million on β-blockers, and 3.6 million on diuretics. The estimated annual cost savings for each 1% conversion of calcium antagonists to β-blockers would be $713,000 and to diuretics $758,000. In a subset of 7526 hypertensive patients with known comorbid conditions, calcium antagonists and ACE inhibitors were also the most commonly used drug classes for all categories of patients, including those without coronary artery disease, congestive heart failure, and diabetes mellitus.Calcium antagonists and ACE inhibitors were the most commonly dispensed antihypertensives at VA facilities for both 1995 and 1996, with a small decrease in calcium antagonist use from 1995 to 1996. The cost implications of these practice patterns as compared with the primary use of diuretics and β-blockers are enormous.     

Diuretics for cardiovascular prevention in the elderly

High blood pressure (BP) is a major risk factor for cardiovascular and cerebrovascular diseases in elderly subjects. Antihypertensive drugs have shown clinical benefit both in primary and secondary prevention of cardiovascular events. If BP lowering represents the major determinant of the effects conferred by the antihypertensive treatment for prevention, recent studies have suggested some differences between classes of antihypertensive drugs according to age. Based on the available clinical data, the recent medical guidelines have recommended thiazide-type diuretics as the preferred drug for the treatment of elderly hypertensive patients, followed by long-acting calcium antagonists. Indeed, diuretics constitute one of the most valuable classes of antihypertensive drugs, and in the elderly, diuretic-based treatment studies have been clearly shown to prevent major cardiovascular events, including stroke, heart failure and coronary heart disease.     

Treatment of arterial hypertension with diuretics, beta- and calcium channel blockers in old patients

Hypertension increases in prevalence with age. Population based studies suggest that more than 50% of people over the age of 65 years may have chronic hypertension. Hypertension, especially systolic hypertension, is the single most common, powerful, however, treatable risk factor for cardiovascular morbidity and mortality in the elderly. In order to assess the effectiveness of antihypertensive drug therapy among the elderly, with diuretics, beta-blockers and calcium channel blockers, a literature search was performed at the Cochrane Library, Medline and Excerpta medica. The Cochrane Hypertension Group identified 14 randomised controlled trials of at least one year duration with 21,785 elderly subjects where diuretics, beta-blockers or calcium channel blockers were used in the treatment group as first line drugs. In their meta-analysis (including one small trial with a central acting antiadrenergic drug) there was a decrease in total mortality (111 vs 129 deaths) and cardiovascular morbidity and mortality (126 vs 177 events) within the treatment group. The three trials restricted to persons with isolated systolic hypertension indicated beneficial effects in the treatment group with regard to cardiovascular morbidity and mortality (104 vs 157 events). Trial data on adverse effects is limited. In three studies, where adverse effects were reported, no substantial differences between treatment and control groups in measures of physical, cognitive and emotional function were found. Cardiovascular benefits of treatment with low dose diuretics or beta-blockers are cleared for elderly subjects with either diastolic or isolated systolic hypertension. Treatment with a long-acting dihydropyridine calcium channel blocker shows beneficial effects in reducing cardiovascular morbidity and mortality for elderly people with isolated systolic hypertension. Due to inconsistent findings in a subgroup meta-analysis of antihypertensive drug treatment in very old people, the efficacy of antihypertensive treatment in these subjects still remains unclear.     

高龄男性原发性高血压患者降压药物应用现状

目的探讨高龄男性原发性高血压患者的降压药物治疗现状,为临床治疗提供参考。方法对106例75岁以上男性原发性高血压患者出院时降压药物应用方案进行登记并行χ2检验。结果应用最多的是长效钙离子拮抗剂(CCB,77.35%)、其次是β受体阻滞剂(46.23%)、血管紧张素转换酶抑制剂(40.57%)、血管紧张素Ⅱ受体拮抗剂(28.30%)、利尿剂(26.42%)和α受体阻滞剂(0.94%),长效CCB明显高于其他种类降压药物,有78.31%的患者需要两种以上降压药物的联合治疗,平均服降压药物种类(2.19±0.86)种例。结论高龄男性原发性高血压患者适用于以长效CCB为基础的小剂量联合降压治疗方案,而利尿剂不是其一线药物。     

Role of calcium antagonists as initial pharmacologic monotherapy for systemic hypertension in patients over 60 years of age

Hypertension is most prevalent in older patients and is associated with increasing morbidity and mortality with age. The ability of antihypertensive treatment to reduce these complications in the elderly is now well established. However, several aspects of the treatment of hypertension are being evaluated. In particular, there is a growing trend to avoid individualizing the choice of medication. This is of particular concern in older patients who may differ in the pathophysiology of their hypertension, in their accompanying medical conditions, and in how they may respond to antihypertensive drugs. In addition, elderly hypertensives are often taking a number of medications in addition to antihypertensive drugs. This, along with the fact that the elderly often metabolize drugs more slowly, makes this group particularly susceptible to drug-drug interactions and pharmacologically induced toxic side effects. Considering these points, it appears that the calcium channel blockers are attractive antihypertensive agents for the elderly population.     

Diuretics and alternative drugs in geriatric hypertension

Thiazide diuretics are the preferred initial therapy in the majority of elderly hypertensive patients--based upon efficacy and long-term safety data. Alternative therapies may be used in subjects with persistent gout, impotence, fatigue, or electrolyte disturbances. In patients with ischemic heart disease and/or angina, beta adrenergic inhibitors or calcium entry blockers are acceptable initial therapy. Converting enzyme inhibitors may be especially useful in hypertensives with congestive heart failure. The combination of small dose diuretic therapy and one of the above alternative drugs has an important place in the treatment of the elderly hypertensive.     

北京市城乡老年人抗高血压药物7年变化趋势

目的: 了解北京市城乡老年人抗高血压药物使用7年变化情况。 方法: 采用分层、随机、整群等距的抽样原则,于2000、2004和2007年3次选取北京地区≥60岁的2 832、1 828和2 277例老年人进行血压测量及相关资料的收集,应用χ2检验对不同性别、年龄、居住地区与高血压用药7年变化趋势进行单因素分析。结果: 钙通道阻滞剂（CCB）、血管紧张素转换酶抑制剂（ACEI）、利尿剂和β-受体阻滞剂的使用逐年增多,而降压片的使用明显减少。结论: 老年高血压病的治疗已不仅仅局限于降压,还要考虑防治并发症,提高高血压病患者的生命质量。     

Congestive heart failure in elderly readmitted patients]

The clinical features of congestive heart failure in the elderly were investigated in 104 patients (57 males, 47 females, mean age of 79.2). Patients were divided into two subgroups, the readmission group, 33 patients who were readmitted within 6 months after discharge, and the non-readmission group. Chief complaints were dyspnea, edema, chest pain, loss of appetite, chest compression, and palpitation. Heart failure was caused by infection, myocardial ischemia, arrhythmia, inappropriate drug usage including poor drug compliance, the use of beta-blockers, excessive intake of sodium, and anemia. Careful use of drug was essential especially in the readmission group. Major underlying heart disease were ischemic heart disease (39.4%), valvular disease (26.9%), hypertensive heart disease (9.6%), with cardiomyopathy, congenital heart disease seen in the minority. There was no statistically significant difference in underlying heart diseases between the two groups. Supraventricular arrhythmias such as atrial fibrillations, paroxysmal atrial fibrillations, paroxysmal supraventricular tachycardias, and premature atrial contractions were noted in 85.3% of the cases. Drugs for treatment were diuretics, digitalis, isosorbide dinitrate, calcium antagonists. ACE inhibitors and alpha-blockers were also used, showing that vasodilators were more extensively used than before. The major complications were hypertension (39.4%), renal dysfunction (27.9%), cerebrovascular disease (26.9%), diabetes mellitus (16.5%), arteriosclerosis obliterans (7.7%). Renal dysfunction, arteriosclerosis obliterans was seen significantly more frequently in the readmission group. The prognosis at one year after admission was significantly worse in the readmission group. In summary, the major underlying diseases were ischemic heart disease, valvular disease, and hypertensive heart disease. Ischemic heart disease was seen more frequently than in previous investigations at our hospital.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cerebral complications of hypertension in the elderly]

PURPOSE: This review focuses on cerebral complications of hypertension, which include stroke, impairment of cognitive function, dementia, and possibly depression and anxiety. These conditions are major causes of morbidity and mortality in the elderly. CURRENT KNOWLEDGE AND KEY POINTS: Not only elevated diastolic blood pressure, but also isolated systolic hypertension and elevated pulse pressure play an important role in the development of brain complications. Randomised placebo-controlled trials have provided evidence that reduction of hypertension decreases safely and effectively morbidity and mortality rates in the elderly. The new classes of drugs, in particular calcium-channels blockers and angiotensin-converting enzyme inhibitors, have been shown to be as effective as the originally used diuretics and beta-blockers. FUTURE PROSPECTS AND PROJECTS: Several trials are currently in progress and should provide more information on the benefit of antihypertensive treatment in very elderly persons (Hypertension in the Very Elderly Trial, HYVET) and secondary prevention of stroke (PROGRESS). The importance of assessing new dosages of the presently used antihypertensive drugs as well as the benefit of new classes of drugs is emphasised. Further trials specifically focusing on the prevention of dementia by antihypertensive drugs are needed to confirm the results of the Syst-Eur Vascular Dementia Project. The benefit of calcium antagonists in the prevention of dementia in elderly hypertensive patients should be assessed in the Dementia Prevention in Hypertension trial (DEPHY).     

社区老年人口服抗栓药物预防心脑血管疾病的现况与对策分析

目的分析北京某社区老年人口服抗栓药物进行心脑血管疾病一级预防和二级预防的应用现状。方法2019年10月至2020年3月期间在北京市翠微西里由社区医师通过标准问卷调查老年人的高血压、冠心病、糖尿病、脑梗塞、心房颤动等系统性疾病的患病情况和长期口服抗血小板聚集(APA)与抗凝(AC)药物治疗情况。结果328例老年人参与调查,其中158例(48.2%)长期口服抗栓药物治疗,144例(43.9%)口服APA药物,20例(6.1%)口服AC药物。罹患高血压、糖尿病、脑梗塞、冠心病的老年人仍未抗栓治疗比例分别为44.9%、45.0%、36.7%、8.1%。心房颤动患者AC治疗比例仅为50%,而与APA治疗患者的卒中风险和出血风险无差异。合并1或2种疾病的老年人占大多数(约占26.2%或28.7%),但其抗栓治疗比例仅为29.3%~61.7%。结论社区医师仍需加强对老年人抗栓治疗的教育,特别是罹患疾病较少的患者;房颤患者抗凝治疗亟待提高。     

Does treatment of non-malignant hypertension reduce the incidence of renal dysfunction? A meta-analysis of 10 randomised, controlled trials

OBJECTIVE: It remains controversial whether non-malignant 'benign' hypertension causes renal dysfunction. The effect of lowering blood pressure on the incidence of renal dysfunction among patients with non-malignant hypertension is not clear. This meta-analysis was conducted to determine whether antihypertensive drug therapy reduces the incidence of renal dysfunction in patients with non-malignant hypertension. METHODS: Randomised, controlled trials of antihypertensive drug therapy of more than 1 year duration that reported renal dysfunction as an outcome were identified through MEDLINE search and literature review. A random effects model was used to obtain summary estimates. RESULTS: Ten trials were identified, involving 26, 521 individuals and 114 000 person-years. All excluded subjects with advanced baseline renal disease. Definition of renal dysfunction outcome varied among trials but within each trial was applied similarly to both treatment and control groups. Drug treatment consisted mostly of diuretics and adrenergic blockers. Overall, treated patients had lower blood pressure and fewer cardiovascular events. There were a total of 317 cases of renal dysfunction. Patients randomised to antihypertensive therapy (or more intensive therapy) did not have a significant reduction in their risk of developing renal dysfunction (relative risk = 0.97; 95% confidence interval (CI) 0.78-1.21; P = 0.77). CONCLUSIONS: Among patients with non-malignant hypertension enrolled in randomised trials, treated patients did not have a lower risk of renal dysfunction. The 95% CI suggests that a 25% or more true protective effect of antihypertensive drugs is unlikely.