Obesity Paradox in Patients with Hypertension and Coronary Artery Disease
The American Journal of Medicine
Volume 120, Issue 10, October 2007, Pages 863-870
Abstract
Purpose
An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.
Methods
A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66 ± 9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m2 (thin), 20 to 25 kg/m2 (normal weight), 25 to 30 kg/m2 (overweight), 30 to 35 kg/m2 (class I obesity), and 35 kg/m2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.
Results
With patients of normal weight (BMI 20 to <25 kg/m2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P <.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P <.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5 ± 21.9 mm Hg/−9.8 ± 12.4 mm Hg vs −20.7 ± 23.1 mm Hg /−10.6 ± 12.5 mm Hg, P <.001).
Conclusion
In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.
Showing posts with label Arterial Hypertension. Show all posts
Showing posts with label Arterial Hypertension. Show all posts
Friday, November 16, 2007
Thursday, October 11, 2007
High BP greatly increases women's diabetes risk
High BP greatly increases women's diabetes risk
MedWire News
10 October 2007
Eur Heart J 2007; Advance online publication
MedWire News: Women with high blood pressure (BP) levels are three times more likely to develop Type 2 diabetes than those with optimal BP levels, irrespective of their body mass index (BMI) and presence of other cardiovascular and diabetes risk factors, US study findings reveal.
The authors report in the European Heart Journal that both baseline BP and BP progression strongly predict incident Type 2 diabetes in initially healthy women, and say their findings highlight the need to consider cardiovascular risk factors in combination.
David Conen (Harvard Medical School, Boston, Massachusetts, USA) and colleagues followed-up over 38,000 female health professionals enrolled in the Women's Health Study for 10 years. The women were all free of diabetes and cardiovascular disease at study entry.
"Despite several studies finding a close relationship between hypertension and Type 2 diabetes, little information exists on the relationship between BP levels and the subsequent development of Type 2 diabetes," explained Conen. "Data for women are particularly limited."
The team divided the women into four groups: those with optimal BP (<120/75 mmHg); those with normal BP (120-129/75-84 mmHg); those with high normal BP (130-139/85-89 mmHg); and those with established hypertension (≥140/90 mmHg), and/or self-reported history of hypertension or antihypertensive treatment.
At follow-up, the incidence of Type 2 diabetes was 1.4% in the optimal BP group, 2.9% in those with normal BP, 5.7% in high-normal BP participants, and 9.4% in the established hypertension group.
Multivariable adjusted hazard ratios (HRs) for diabetes across the BP categories were 0.66, 1.00 (referent group), 1.45, and 2.03 (p for trend <0.0001).
Stratification by BMI gave similar results. "Analyses showed that the relationship... was similar among women who were normal weight, overweight, or obese," Conen reported. "There was a three-fold increase in risk from the lowest to the highest BP category within all three weight categories."
Women whose BP increased over time during the study also had an increased risk for developing diabetes. Adjusted HRs for incident diabetes at 2 years among women who had no BP progression, those in whom BP increased but remained normotensive, and women who developed hypertension were 1.0, 1.26, and 1.64, respectively, compared with 2.39 in women with baseline hypertension (p for trend <0.0001).
The authors conclude: "Our findings provide strong evidence that BP and progression of BP are associated with an increased risk of diabetes. They highlight the fact that cardiovascular risk factors are interrelated and occur in clusters.
"Thus, an important message for physicians and future guidelines is that none of the cardiovascular risk factors should be looked at individually. The combination of all risk factors should be used to make treatment decisions."
Journal
MedWire News
10 October 2007
Eur Heart J 2007; Advance online publication
MedWire News: Women with high blood pressure (BP) levels are three times more likely to develop Type 2 diabetes than those with optimal BP levels, irrespective of their body mass index (BMI) and presence of other cardiovascular and diabetes risk factors, US study findings reveal.
The authors report in the European Heart Journal that both baseline BP and BP progression strongly predict incident Type 2 diabetes in initially healthy women, and say their findings highlight the need to consider cardiovascular risk factors in combination.
David Conen (Harvard Medical School, Boston, Massachusetts, USA) and colleagues followed-up over 38,000 female health professionals enrolled in the Women's Health Study for 10 years. The women were all free of diabetes and cardiovascular disease at study entry.
"Despite several studies finding a close relationship between hypertension and Type 2 diabetes, little information exists on the relationship between BP levels and the subsequent development of Type 2 diabetes," explained Conen. "Data for women are particularly limited."
The team divided the women into four groups: those with optimal BP (<120/75 mmHg); those with normal BP (120-129/75-84 mmHg); those with high normal BP (130-139/85-89 mmHg); and those with established hypertension (≥140/90 mmHg), and/or self-reported history of hypertension or antihypertensive treatment.
At follow-up, the incidence of Type 2 diabetes was 1.4% in the optimal BP group, 2.9% in those with normal BP, 5.7% in high-normal BP participants, and 9.4% in the established hypertension group.
Multivariable adjusted hazard ratios (HRs) for diabetes across the BP categories were 0.66, 1.00 (referent group), 1.45, and 2.03 (p for trend <0.0001).
Stratification by BMI gave similar results. "Analyses showed that the relationship... was similar among women who were normal weight, overweight, or obese," Conen reported. "There was a three-fold increase in risk from the lowest to the highest BP category within all three weight categories."
Women whose BP increased over time during the study also had an increased risk for developing diabetes. Adjusted HRs for incident diabetes at 2 years among women who had no BP progression, those in whom BP increased but remained normotensive, and women who developed hypertension were 1.0, 1.26, and 1.64, respectively, compared with 2.39 in women with baseline hypertension (p for trend <0.0001).
The authors conclude: "Our findings provide strong evidence that BP and progression of BP are associated with an increased risk of diabetes. They highlight the fact that cardiovascular risk factors are interrelated and occur in clusters.
"Thus, an important message for physicians and future guidelines is that none of the cardiovascular risk factors should be looked at individually. The combination of all risk factors should be used to make treatment decisions."
Journal
Monday, October 8, 2007
Obesity Paradox in Patients with Hypertension and Coronary Artery Disease
Obesity Paradox in Patients with Hypertension and Coronary Artery Disease
The American Journal of Medicine
Volume 120, Issue 10, Pages 825-918 (October 2007)
Abstract
Purpose
An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.
Methods
A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66±9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m2 (thin), 20 to 25 kg/m2 (normal weight), 25 to 30 kg/m2 (overweight), 30 to 35 kg/m2 (class I obesity), and 35 kg/m2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.
Results
With patients of normal weight (BMI 20 to<25 kg/m2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P<.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P<.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5±21.9 mm Hg/−9.8±12.4 mm Hg vs −20.7±23.1 mm Hg /−10.6±12.5 mm Hg, P<.001).
Conclusion
In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.
Study Limitations
This was a post hoc analysis and thus suffers from the limitations of such studies. Our conclusions should be considered to be hypothesis generating. The INVEST did not collect the waist-to-hip ratio data; therefore, we could not compare BMI with waist-to-hip ratio. Although we did find differences in the primary and secondary outcomes between BMI groups, the baseline characteristics of the BMI categories were not well matched. Although a stepwise model was used, the impact of these baseline differences cannot be ruled out.
The American Journal of Medicine
Volume 120, Issue 10, Pages 825-918 (October 2007)
Abstract
Purpose
An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.
Methods
A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66±9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m2 (thin), 20 to 25 kg/m2 (normal weight), 25 to 30 kg/m2 (overweight), 30 to 35 kg/m2 (class I obesity), and 35 kg/m2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.
Results
With patients of normal weight (BMI 20 to<25 kg/m2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P<.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P<.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5±21.9 mm Hg/−9.8±12.4 mm Hg vs −20.7±23.1 mm Hg /−10.6±12.5 mm Hg, P<.001).
Conclusion
In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.
Study Limitations
This was a post hoc analysis and thus suffers from the limitations of such studies. Our conclusions should be considered to be hypothesis generating. The INVEST did not collect the waist-to-hip ratio data; therefore, we could not compare BMI with waist-to-hip ratio. Although we did find differences in the primary and secondary outcomes between BMI groups, the baseline characteristics of the BMI categories were not well matched. Although a stepwise model was used, the impact of these baseline differences cannot be ruled out.
Wednesday, September 26, 2007
Anger and stress increase risk for hypertension and CHD in men
Anger and stress increase risk for hypertension and CHD in men
By Sara Carrillo de Albornoz
26 September 2007
Ann Fam Med 2007; 5: 403-411
MedWire News: Prehypertensive men with high levels of trait anger and stress are at high risk for hypertension and coronary heart disease (CHD), research shows.
Marty Player and colleagues from the Medical University of South Carolina in Charleston, USA, examined data from the prospective population-based Atherosclerosis risk in communities (ARIC) study on 2334 men and women aged 45-64 years who had prehypertension but were free of heart disease or stroke.
They then investigated whether psychosocial factors were associated with progression from prehypertension to hypertension and to CHD during the follow-up period from 1987 to 1998.
The researchers measured trait anger - a stable personality trait characterized by the frequency, intensity, and duration of anger - using the Spielberger trait anger scale. Psychological stress was assessed using the Maastricht questionnaire.
After adjusting for age, gender, ethnic background, and cardiovascular risk factors, patients with high levels of trait anger were significantly more likely to progress from prehypertension to hypertension than patients with low/moderate levels (odds ratio [OR]=1.53).
High trait anger scores were also significantly associated with CHD risk (OR=1.71), compared with low trait anger scores.
Nevertheless, stratification by gender revealed that high trait anger was only a risk factor for hypertension and CHD in men, at ORs of 1.71 and 1.92, respectively.
Both men and women with high levels of stress were significantly more likely to develop CHD than those with low/moderate levels (OR=1.68). However, long-term stress did not significantly increase the likelihood of prehypertension progressing to hypertension.
Player et al conclude in the Annals of Family Medicine: "This study adds to the growing evidence of the role of psychological factors in the development of cardiovascular disease."
They add: "Further studies may help determine whether treatment of anger by counseling, medication, or other means will have a beneficial effect on slowing progression from prehypertension to CHD."
Free full text
By Sara Carrillo de Albornoz
26 September 2007
Ann Fam Med 2007; 5: 403-411
MedWire News: Prehypertensive men with high levels of trait anger and stress are at high risk for hypertension and coronary heart disease (CHD), research shows.
Marty Player and colleagues from the Medical University of South Carolina in Charleston, USA, examined data from the prospective population-based Atherosclerosis risk in communities (ARIC) study on 2334 men and women aged 45-64 years who had prehypertension but were free of heart disease or stroke.
They then investigated whether psychosocial factors were associated with progression from prehypertension to hypertension and to CHD during the follow-up period from 1987 to 1998.
The researchers measured trait anger - a stable personality trait characterized by the frequency, intensity, and duration of anger - using the Spielberger trait anger scale. Psychological stress was assessed using the Maastricht questionnaire.
After adjusting for age, gender, ethnic background, and cardiovascular risk factors, patients with high levels of trait anger were significantly more likely to progress from prehypertension to hypertension than patients with low/moderate levels (odds ratio [OR]=1.53).
High trait anger scores were also significantly associated with CHD risk (OR=1.71), compared with low trait anger scores.
Nevertheless, stratification by gender revealed that high trait anger was only a risk factor for hypertension and CHD in men, at ORs of 1.71 and 1.92, respectively.
Both men and women with high levels of stress were significantly more likely to develop CHD than those with low/moderate levels (OR=1.68). However, long-term stress did not significantly increase the likelihood of prehypertension progressing to hypertension.
Player et al conclude in the Annals of Family Medicine: "This study adds to the growing evidence of the role of psychological factors in the development of cardiovascular disease."
They add: "Further studies may help determine whether treatment of anger by counseling, medication, or other means will have a beneficial effect on slowing progression from prehypertension to CHD."
Free full text
Wednesday, September 19, 2007
ESC Congress - News - 2007 - HYPERTENSION
Hypertension: New insights and implications for management
Prof. G. Y. H. LipBirmingham, United KingdomNucleus member of the Working Group on Hypertension and the Heart
There is a dose-response relationship between an increasing blood pressure and an increasing risk of stroke and coronary heart disease . The treatment of hypertension results in a 30-35% reduction in strokes and a 20% reduction in heart attacks . It is therefore crucial to detect, treat and control high blood pressure, and if management of hypertension is inadequate or inappropriate this could even be considered as negligent. It is no longer a question of ‘do we treat’ hypertension, but more a question of ‘who to treat’ and ‘how to treat’ hypertension.
Who to treat?
Hypertension can be defined pragmatically as that level of blood pressure above which the use of antihypertensive treatment does more good than harm. Indeed, hypertensive patients do not make up a homogeneous population and hypertension per se is not a condition that can be regarded in isolation. All major hypertension management guidelines recommend the use of risk stratification, in the context of a patient’s total cardiovascular risk , . Indeed, risk factors such as diabetes mellitus, hyperlipidaemia, smoking, age and gender need to be taken into account, as these risk factors are cumulative to the overall cardiovascular risk burden. All risk factors must therefore be managed in a holistic manner, in a ‘package of care’ that includes treating high risk groups, with non-pharmacological and pharmacological measures.
How to treat?
Until recently, the thiazide diuretics and beta-blockers have been regarded as the mainstay of hypertension treatment. However, there is an increasing recognition that beta-blockers are ineffective as first-line agents in the elderly and in Afro-Caribbean patients - whether beta-blockers are even effective in reducing endpoints in hypertension, especially in the elderly has been extensively debated , . On the other hand, thiazides are cheap and effective agents, but the lowest possible dose should be used, as there is no dose-response antihypertensive effect, whilst higher doses of thiazides are associated with increasing metabolic effects .
Many randomised controlled trials have also compared the newer antihypertensive agents, such as the alpha blockers, calcium antagonists, ACE inhibitors and angiotensin receptor antagonists to the ‘old’ drugs, thiazides and beta-blockers. The largest was the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) in ‘high-risk’ hypertensive patients who were initially randomised to a diuretic (chlorthalidone) versus each of three ‘alternative’ (newer) antihypertensive drugs: an alpha-adrenergic blocker (doxazosin), an ACE-inhibitor (lisinopril), and a CCB (amlodipine) . The doxazosin arm was stopped early due to an excess of cardiovascular events, especially heart failure. For the thiazide, ACE inhibitor, and dihydropyridine calcium antagonist arms of the study, the incidence of the primary endpoints of fatal coronary heart disease (CHD) and non-fatal myocardial infarction (MI), was essentially identical, although there was an apparent excess of stroke endpoints in the lisinopril arm, and more heart failure with lisinopril and amlodipine compared to thiazide. The merits (or otherwise!) of the ALLHAT trial have recently been extensively discussed.
Recent recognition of the value of lipid lowering therapy in hypertension is provided by the MRC/BHF Heart Protection Study (HPS) , which studied patients at ‘high risk’ of death due to coronary heart disease (41% were hypertensive), where the use of simvastatin 40mg/day reduced all cause mortality (12.9% versus placebo, 14.7%). There were also significant decreases in non fatal myocardial infarctions, fatal or non fatal strokes and coronary or non coronary revascularisations. These data from the HPS were complemented by the lipid-lowering arm data from the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) study . In the latter, atorvastatin 10mg daily was associated with a significant reduction in the primary end point of fatal myocardial infarction and nonfatal coronary heart disease events (by 36%), together with significant reductions in the secondary end points of stroke (by 27%), all cardiovascular events and procedures (by 21%), and total coronary events (by 29%). Risk reductions in CHD events in both HPS and ASCOT were unrelated to baseline cholesterol levels and were consistent across the whole range of cholesterol. The merits and issues with regard to using lipid lowering in hypertension have recently been discussed .
Implications for management
The recent trials have proven the value of a holistic approach to cardiovascular risk management in hypertensive patients with additional risk factors, by the addition of statin therapy, irrespective of serum cholesterol level. It is clear that we have to move away from treating individual risk factors such as hypertension or hyperlipidaemia in isolation, and all risk factors need a complete, comprehensive ‘package of care’ of cardiovascular risk management.
The data from ALLHAT also would advise some degree of caution with the use of alpha-blockers in hypertensives at risk of heart failure. Most trials also confirm the need for combination therapy to achieve adequate blood pressure control – generally <140/85mmHg in non-diabetics and <130/80mmHg in diabetes – and as an average, half of all hypertensives will require two or more drugs, whilst a third will require three or more drugs to achieve adequate blood pressure control. It therefore makes sense to use antihypertensive agents that are synergistic in action to each other, as well as minimising adverse effects (if any) from each other.
Prof. G. Y. H. LipBirmingham, United KingdomNucleus member of the Working Group on Hypertension and the Heart
There is a dose-response relationship between an increasing blood pressure and an increasing risk of stroke and coronary heart disease . The treatment of hypertension results in a 30-35% reduction in strokes and a 20% reduction in heart attacks . It is therefore crucial to detect, treat and control high blood pressure, and if management of hypertension is inadequate or inappropriate this could even be considered as negligent. It is no longer a question of ‘do we treat’ hypertension, but more a question of ‘who to treat’ and ‘how to treat’ hypertension.
Who to treat?
Hypertension can be defined pragmatically as that level of blood pressure above which the use of antihypertensive treatment does more good than harm. Indeed, hypertensive patients do not make up a homogeneous population and hypertension per se is not a condition that can be regarded in isolation. All major hypertension management guidelines recommend the use of risk stratification, in the context of a patient’s total cardiovascular risk , . Indeed, risk factors such as diabetes mellitus, hyperlipidaemia, smoking, age and gender need to be taken into account, as these risk factors are cumulative to the overall cardiovascular risk burden. All risk factors must therefore be managed in a holistic manner, in a ‘package of care’ that includes treating high risk groups, with non-pharmacological and pharmacological measures.
How to treat?
Until recently, the thiazide diuretics and beta-blockers have been regarded as the mainstay of hypertension treatment. However, there is an increasing recognition that beta-blockers are ineffective as first-line agents in the elderly and in Afro-Caribbean patients - whether beta-blockers are even effective in reducing endpoints in hypertension, especially in the elderly has been extensively debated , . On the other hand, thiazides are cheap and effective agents, but the lowest possible dose should be used, as there is no dose-response antihypertensive effect, whilst higher doses of thiazides are associated with increasing metabolic effects .
Many randomised controlled trials have also compared the newer antihypertensive agents, such as the alpha blockers, calcium antagonists, ACE inhibitors and angiotensin receptor antagonists to the ‘old’ drugs, thiazides and beta-blockers. The largest was the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) in ‘high-risk’ hypertensive patients who were initially randomised to a diuretic (chlorthalidone) versus each of three ‘alternative’ (newer) antihypertensive drugs: an alpha-adrenergic blocker (doxazosin), an ACE-inhibitor (lisinopril), and a CCB (amlodipine) . The doxazosin arm was stopped early due to an excess of cardiovascular events, especially heart failure. For the thiazide, ACE inhibitor, and dihydropyridine calcium antagonist arms of the study, the incidence of the primary endpoints of fatal coronary heart disease (CHD) and non-fatal myocardial infarction (MI), was essentially identical, although there was an apparent excess of stroke endpoints in the lisinopril arm, and more heart failure with lisinopril and amlodipine compared to thiazide. The merits (or otherwise!) of the ALLHAT trial have recently been extensively discussed.
Recent recognition of the value of lipid lowering therapy in hypertension is provided by the MRC/BHF Heart Protection Study (HPS) , which studied patients at ‘high risk’ of death due to coronary heart disease (41% were hypertensive), where the use of simvastatin 40mg/day reduced all cause mortality (12.9% versus placebo, 14.7%). There were also significant decreases in non fatal myocardial infarctions, fatal or non fatal strokes and coronary or non coronary revascularisations. These data from the HPS were complemented by the lipid-lowering arm data from the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) study . In the latter, atorvastatin 10mg daily was associated with a significant reduction in the primary end point of fatal myocardial infarction and nonfatal coronary heart disease events (by 36%), together with significant reductions in the secondary end points of stroke (by 27%), all cardiovascular events and procedures (by 21%), and total coronary events (by 29%). Risk reductions in CHD events in both HPS and ASCOT were unrelated to baseline cholesterol levels and were consistent across the whole range of cholesterol. The merits and issues with regard to using lipid lowering in hypertension have recently been discussed .
Implications for management
The recent trials have proven the value of a holistic approach to cardiovascular risk management in hypertensive patients with additional risk factors, by the addition of statin therapy, irrespective of serum cholesterol level. It is clear that we have to move away from treating individual risk factors such as hypertension or hyperlipidaemia in isolation, and all risk factors need a complete, comprehensive ‘package of care’ of cardiovascular risk management.
The data from ALLHAT also would advise some degree of caution with the use of alpha-blockers in hypertensives at risk of heart failure. Most trials also confirm the need for combination therapy to achieve adequate blood pressure control – generally <140/85mmHg in non-diabetics and <130/80mmHg in diabetes – and as an average, half of all hypertensives will require two or more drugs, whilst a third will require three or more drugs to achieve adequate blood pressure control. It therefore makes sense to use antihypertensive agents that are synergistic in action to each other, as well as minimising adverse effects (if any) from each other.
Friday, September 7, 2007
Electrocardiography / Left Ventricular Hypertrophy / Arterial hypertension: Systematic Review
Accuracy of electrocardiography in diagnosis of left ventricular hypertrophy in arterial hypertension: systematic review
BMJ, doi:10.1136/bmj.39276.636354.AE (published 28 August 2007)
Research
Correspondence to: M Egger egger@ispm.unibe.ch
Objective To review the accuracy of electrocardiography in screening for left ventricular hypertrophy in patients with hypertension.
Design Systematic review of studies of test accuracy of six electrocardiographic indexes: the Sokolow-Lyon index, Cornell voltage index, Cornell product index, Gubner index, and Romhilt-Estes scores with thresholds for a positive test of 4 points or 5 points.
Data sources Electronic databases ((Pre-)Medline, Embase), reference lists of relevant studies and previous reviews, and experts.
Study selection Two reviewers scrutinised abstracts and examined potentially eligible studies. Studies comparing the electrocardiographic index with echocardiography in hypertensive patients and reporting sufficient data were included.
Data extraction Data on study populations, echocardiographic criteria, and methodological quality of studies were extracted.
Data synthesis Negative likelihood ratios, which indicate to what extent the posterior odds of left ventricular hypertrophy is reduced by a negative test, were calculated.
Results 21 studies and data on 5608 patients were analysed. The median prevalence of left ventricular hypertrophy was 33% (interquartile range 23-41%) in primary care settings (10 studies) and 65% (37-81%) in secondary care settings (11 studies). The median negative likelihood ratio was similar across electrocardiographic indexes, ranging from 0.85 (range 0.34-1.03) for the Romhilt-Estes score (with threshold 4 points) to 0.91 (0.70-1.01) for the Gubner index. Using the Romhilt-Estes score in primary care, a negative electrocardiogram result would reduce the typical pre-test probability from 33% to 31%. In secondary care the typical pre-test probability of 65% would be reduced to 63%.
Conclusion Electrocardiographic criteria should not be used to rule out left ventricular hypertrophy in patients with hypertension.
BMJ, doi:10.1136/bmj.39276.636354.AE (published 28 August 2007)
Research
Correspondence to: M Egger egger@ispm.unibe.ch
Objective To review the accuracy of electrocardiography in screening for left ventricular hypertrophy in patients with hypertension.
Design Systematic review of studies of test accuracy of six electrocardiographic indexes: the Sokolow-Lyon index, Cornell voltage index, Cornell product index, Gubner index, and Romhilt-Estes scores with thresholds for a positive test of 4 points or 5 points.
Data sources Electronic databases ((Pre-)Medline, Embase), reference lists of relevant studies and previous reviews, and experts.
Study selection Two reviewers scrutinised abstracts and examined potentially eligible studies. Studies comparing the electrocardiographic index with echocardiography in hypertensive patients and reporting sufficient data were included.
Data extraction Data on study populations, echocardiographic criteria, and methodological quality of studies were extracted.
Data synthesis Negative likelihood ratios, which indicate to what extent the posterior odds of left ventricular hypertrophy is reduced by a negative test, were calculated.
Results 21 studies and data on 5608 patients were analysed. The median prevalence of left ventricular hypertrophy was 33% (interquartile range 23-41%) in primary care settings (10 studies) and 65% (37-81%) in secondary care settings (11 studies). The median negative likelihood ratio was similar across electrocardiographic indexes, ranging from 0.85 (range 0.34-1.03) for the Romhilt-Estes score (with threshold 4 points) to 0.91 (0.70-1.01) for the Gubner index. Using the Romhilt-Estes score in primary care, a negative electrocardiogram result would reduce the typical pre-test probability from 33% to 31%. In secondary care the typical pre-test probability of 65% would be reduced to 63%.
Conclusion Electrocardiographic criteria should not be used to rule out left ventricular hypertrophy in patients with hypertension.
Thursday, August 16, 2007
Reversing Cocaine's Effects On The Cardiovascular System
Reversing Cocaine's Effects On The Cardiovascular System
16 Aug 2007
UT Southwestern Medical Center researchers have discovered a treatment that counteracts the effects of cocaine on the human cardiovascular system, including lowering the elevated heart rate and blood pressure often found in cocaine users.
"We have found that cocaine's effects on the cardiovascular system can be reversed by the use of a drug called dexmedetomidine, which is currently approved by the Food and Drug Administration for anesthetic purposes in operating rooms or intensive care units," said Dr. Wanpen Vongpatanasin, associate professor of internal medicine and senior author of a study appearing in the Aug. 14 issue of the Journal of the American College of Cardiology.
Researchers used dexmedetomidine to test whether cocaine's effect on the cardiovascular system could be muted.
They found that the drug was effective in reversing the actions of cocaine on heart rate, blood pressure and vascular resistance in the skin by interfering with the ability of cocaine to increase nerve activity.
"Typically, patients with cocaine overdoses in the emergency room are treated with nitroglycerin, sedatives such as Valium, and some blood-pressure medications such as calcium channel blockers and some beta blockers," Dr. Vongpatanasin said.
"However, the standard treatments don't alleviate all of the adverse effects of cocaine on the heart, blood pressure and central nervous system."
The study examined results from 22 healthy adults who reported to have never used cocaine.
The investigators administered a small, medically approved dose of cocaine nose drops to the study participants, which doubled their sympathetic nerve activity, part of the body's 'automatic' response system that becomes more active during times of stress.
Participants experienced increases in several cardiovascular parameters including heart rate, blood pressure and resistance to blood flow in the skin. Microelectrodes, similar to acupuncture needles, were used to record sympathetic nerve activity following doses of intranasal cocaine.
Research subjects who were treated with dexmedetomidine had a decrease in sympathetic nerve activity as well as in all three cardiovascular parameters, which returned to baseline levels measured before administration of cocaine.
Dexmedetomidine proved to be more effective than intravenous saline, which was used as a placebo in another group of study participants.
Cocaine abuse in the U.S. is widespread, with nearly 35 million Americans reporting having ever tried cocaine and an estimated 7.3 million users, including 15 percent of young adults ages 18 to 25, according to the National Institute on Drug Abuse.
Life-threatening emergencies related to cocaine use include sudden cardiac death, high blood pressure, stroke and acute myocardial infarctions.
"We also found that dexmedetomidine was equally effective in counteracting effects of cocaine in subjects with a rare genetic mutation thought to disrupt the effects of dexmedetomidine," said Dr. Ronald Victor, professor of internal medicine and co-author of the study.
"Because this particular mutation is more common in African-Americans than in Caucasians, our study results are applicable to a more diverse, multiethnic population."
Further research is needed, study authors said, to determine whether the treatment would be effective for acute cocaine overdose in the emergency room and to gauge whether it would be effective in reversing cocaine-induced constriction of the coronary vessels to the same degree it does in skin vessels.
Article adapted by Medical News Today from original press release.
16 Aug 2007
UT Southwestern Medical Center researchers have discovered a treatment that counteracts the effects of cocaine on the human cardiovascular system, including lowering the elevated heart rate and blood pressure often found in cocaine users.
"We have found that cocaine's effects on the cardiovascular system can be reversed by the use of a drug called dexmedetomidine, which is currently approved by the Food and Drug Administration for anesthetic purposes in operating rooms or intensive care units," said Dr. Wanpen Vongpatanasin, associate professor of internal medicine and senior author of a study appearing in the Aug. 14 issue of the Journal of the American College of Cardiology.
Researchers used dexmedetomidine to test whether cocaine's effect on the cardiovascular system could be muted.
They found that the drug was effective in reversing the actions of cocaine on heart rate, blood pressure and vascular resistance in the skin by interfering with the ability of cocaine to increase nerve activity.
"Typically, patients with cocaine overdoses in the emergency room are treated with nitroglycerin, sedatives such as Valium, and some blood-pressure medications such as calcium channel blockers and some beta blockers," Dr. Vongpatanasin said.
"However, the standard treatments don't alleviate all of the adverse effects of cocaine on the heart, blood pressure and central nervous system."
The study examined results from 22 healthy adults who reported to have never used cocaine.
The investigators administered a small, medically approved dose of cocaine nose drops to the study participants, which doubled their sympathetic nerve activity, part of the body's 'automatic' response system that becomes more active during times of stress.
Participants experienced increases in several cardiovascular parameters including heart rate, blood pressure and resistance to blood flow in the skin. Microelectrodes, similar to acupuncture needles, were used to record sympathetic nerve activity following doses of intranasal cocaine.
Research subjects who were treated with dexmedetomidine had a decrease in sympathetic nerve activity as well as in all three cardiovascular parameters, which returned to baseline levels measured before administration of cocaine.
Dexmedetomidine proved to be more effective than intravenous saline, which was used as a placebo in another group of study participants.
Cocaine abuse in the U.S. is widespread, with nearly 35 million Americans reporting having ever tried cocaine and an estimated 7.3 million users, including 15 percent of young adults ages 18 to 25, according to the National Institute on Drug Abuse.
Life-threatening emergencies related to cocaine use include sudden cardiac death, high blood pressure, stroke and acute myocardial infarctions.
"We also found that dexmedetomidine was equally effective in counteracting effects of cocaine in subjects with a rare genetic mutation thought to disrupt the effects of dexmedetomidine," said Dr. Ronald Victor, professor of internal medicine and co-author of the study.
"Because this particular mutation is more common in African-Americans than in Caucasians, our study results are applicable to a more diverse, multiethnic population."
Further research is needed, study authors said, to determine whether the treatment would be effective for acute cocaine overdose in the emergency room and to gauge whether it would be effective in reversing cocaine-induced constriction of the coronary vessels to the same degree it does in skin vessels.
Article adapted by Medical News Today from original press release.
Sunday, August 5, 2007
Hostile Men Could Have Greater Risk For Heart Disease
Hostile Men Could Have Greater Risk For Heart Disease
Brain, Behavior, and Immunity, 21(6), 2007.
05 Aug 2007
Men who are hostile and prone to frequent intense feelings of anger and depression could be harming their immune systems and putting themselves at risk for coronary heart disease as well as related disorders like type 2 diabetes and high blood pressure, a new study finds.
Steven Boyle, Ph.D., of Duke University Medical Center and colleagues studied 313 male Vietnam veterans who were part of a larger 20-year study on the effects of Agent Orange.
For the study, which appears in the August issue of the journal Brain, Behavior, and Immunity, the veterans underwent a standard psychological test used to assess hostility, depression and anger.
The men had a series of blood levels taken on three occasions between 1992 and 2002.
Researchers measured two immune system proteins known as C3 and C4. Both are markers of inflammation, which is the body's response to injury or infection. Changes in C3 and C4 are associated with a number of diseases, including some that negatively can affect the arteries around the heart, such as diabetes.
Men whose psychological screening showed the highest level of hostility, depressive symptoms and anger had a 7.1 percent increase in their C3 levels, while men with low levels of these attributes showed no change over the 10-year study period.
The researchers factored in other risk factors for higher C3 levels such as smoking, age, race, alcohol use and body mass index (a measure of obesity). They also could find no known influence of Agent Orange exposure on the increased C3 levels.
"We showed positives associations between psychological attributes and 10-year changes in C3 among initially healthy middle-aged males," the researchers write. Neither group showed significant increases in C4 levels. "Hostile, depressed and angry people see the world around them in a different way, and sometimes they see it as them against the world," said study co-author Edward Suarez, Ph.D.
"That kind of lifestyle often leads to greater stress and possibly changes in the way the body functions that could lead to disease.
"Could psychological treatment reduce C3 levels? "At present, we do not know if interventions to reduce hostility and anger would lead to a decrease in C3 or other markers of inflammation," Boyle said. However, he added, "Even if inflammation is not decreased by such interventions, lower levels of anger and hostility will likely lead to better relationships and increased well-being.
Boyle SH, Jackson WG, Suarez EC. Hostility, anger, and depression predict increases in C3 over a 10-year period. Brain, Behavior, and Immunity, 21(6), 2007.
Thursday, July 26, 2007
Cardiovascular risk prediction based on home blood pressure measurement: The Didima Study.
Cardiovascular risk prediction based on home blood pressure measurement: The Didima Study.
Journal of Hypertension. 25(8):1590-1596, August 2007.
Stergiou, George S; Baibas, Nikos M; Kalogeropoulos, Petros G
Abstract:
Objective: Although home blood pressure (HBP) is being used increasingly in clinical practice, the evidence on its prognostic value is still limited. This study in the general population investigated the value of HBP compared to office measurements (OBP) in predicting cardiovascular risk.
Subjects and methods: In 1997 all adults of the Didima area in Greece were invited to participate in a cross-sectional study involving OBP (two visits) and HBP measurements (3 days). Incident cardiovascular morbidity and cause-specific mortality were assessed after 8.2 +/- 0.2 years (mean +/- SD). Average OBP and HBP were used in Cox regression analysis of fatal and non-fatal cardiovascular events with age, gender, history of cardiovascular disease, use of antihypertensive medication, smoking and diabetes as covariates.
Results: A total of 662 subjects were analysed (mean age at baseline 54.1 +/- 17.6 years). During follow-up 78 deaths (42 cardiovascular) and 67 cardiovascular events (fatal and non-fatal) were documented. Unadjusted hazard ratios for cardiovascular events per 1 mmHg blood pressure increase were for HBP systolic 1.034 (P < 0.001) and diastolic 1.037 (P < 0.01) and for OBP systolic 1.035 (P < 0.001) and diastolic 1.021 (P = 0.07). After adjustment for all available cardiovascular risk predictors, only diastolic OBP remained significant. The addition of HBP in the models already including OBP did not significantly improve the predictive ability. White coat but not masked hypertensives were at high risk.
Conclusions: This study showed that both HBP and OBP are significant predictors of cardiovascular risk in the general population. However, no prognostic superiority of HBP compared to OBP has been demonstrated.
Friday, July 20, 2007
Hypertension Combo Works, With Risks
Wall Street Journal - July 20, 2007
Novartis’s Hypertension Combo Works, With Risks
When you sell as many blood pressure drugs as Novartis, it’s natural to get creative, mixing and matching medicines to create new combinations.
But while combinations may lower blood pressure more effectively than a single drug, they may also heighten risk, as a [1] study published in this week’s Lancet shows.
The company’s blood pressure drugs already include single agents Tekturna and Diovan, as well as combination pills Exforge and Lotrel. (For an analysis of the sales of all these drugs, see [2] this Health Blog post.)
The new study enrolled 1797 patients and compared a combination of Tekturna and Diovan against each drug individually and against placebo. Diastolic blood pressure (the second number in a blood pressure reading) went down an average of 12.2 millimeters of mercury for patients who received the combination, compared with 9.7 mm Hg for Diovan, 9.0 mm Hg for Tekturna and 4.1 mm Hg for placebo. The study was funded by Novartis, which also paid medical writers to edit the manuscript.
The authors note that the percentage of patients with a high level of potassium in the blood was higher for patients who received the combination — 4%, compared with 3% for placebo and 2% for each of the single drugs. But they point out that the increase was not associated with serious medical problems and tended to return to normal by the study’s eight-week endpoint.
“Physicians have managed these mild increases in potassium very successfully for over 20 years,” the study’s [3] lead author, Suzanne Oparil of the University of Alabama Birmingham, said in a [4] statement issued by Novartis.
But a [5] commentary accompanying the study strikes a more cautious note about the heightened potassium levels, which, the authors note, can be associated with severe complications including paralysis and cardiac arrest. (One of the commentary’s authors, Willem H Birkenhäger of Erasmus University Rotterdam, claims no conflicts of interest; the other, Jan A Staessen of University of Leuven, reports funding from AstraZeneca and Pfizer, among other companies.)
The commentary argues that there may be a small group of patients suited to the Tekturna-Diovan combination. “However,” they conclude, “because of the potential life-threatening side-effects, which require biochemical monitoring, this concept of treatment is unlikely to make it to general practice or even to primary prevention in specialist care.”
Novartis’s Hypertension Combo Works, With Risks
When you sell as many blood pressure drugs as Novartis, it’s natural to get creative, mixing and matching medicines to create new combinations.
But while combinations may lower blood pressure more effectively than a single drug, they may also heighten risk, as a [1] study published in this week’s Lancet shows.
The company’s blood pressure drugs already include single agents Tekturna and Diovan, as well as combination pills Exforge and Lotrel. (For an analysis of the sales of all these drugs, see [2] this Health Blog post.)
The new study enrolled 1797 patients and compared a combination of Tekturna and Diovan against each drug individually and against placebo. Diastolic blood pressure (the second number in a blood pressure reading) went down an average of 12.2 millimeters of mercury for patients who received the combination, compared with 9.7 mm Hg for Diovan, 9.0 mm Hg for Tekturna and 4.1 mm Hg for placebo. The study was funded by Novartis, which also paid medical writers to edit the manuscript.
The authors note that the percentage of patients with a high level of potassium in the blood was higher for patients who received the combination — 4%, compared with 3% for placebo and 2% for each of the single drugs. But they point out that the increase was not associated with serious medical problems and tended to return to normal by the study’s eight-week endpoint.
“Physicians have managed these mild increases in potassium very successfully for over 20 years,” the study’s [3] lead author, Suzanne Oparil of the University of Alabama Birmingham, said in a [4] statement issued by Novartis.
But a [5] commentary accompanying the study strikes a more cautious note about the heightened potassium levels, which, the authors note, can be associated with severe complications including paralysis and cardiac arrest. (One of the commentary’s authors, Willem H Birkenhäger of Erasmus University Rotterdam, claims no conflicts of interest; the other, Jan A Staessen of University of Leuven, reports funding from AstraZeneca and Pfizer, among other companies.)
The commentary argues that there may be a small group of patients suited to the Tekturna-Diovan combination. “However,” they conclude, “because of the potential life-threatening side-effects, which require biochemical monitoring, this concept of treatment is unlikely to make it to general practice or even to primary prevention in specialist care.”
Friday, July 13, 2007
High Blood Pressure May Mask Potentially Deadly Heart Condition - Correlation Between Hypertension And Chest Pain, May Help Explain Silent Ischemia
Medical News Today News Article
High Blood Pressure May Mask Potentially Deadly Heart Condition - Correlation Between Hypertension And Chest Pain, May Help Explain Silent Ischemia
New research published in Psychophysiology finds a relationship between increased blood pressure and decreased pain perception in a variety of circumstances, including among individuals with heart disease. This phenomenon extends to those who typically suffer chest pain during exercise, and may be correlated with a potentially deadly heart condition.
The new study draws on data collected from over 900 patients undergoing exercise stress testing to diagnose possible myocardial ischemia (MI), a condition where oxygenated blood is prevented from reaching the heart because an artery has become blocked or constricted.
Generally, exercise should produce pain in these situations; however some patients experience "silent" cases of MI in which no pain is felt. Previous studies have suggested that high blood pressure and silent ischemia may be correlated, and this new research provides further validation.
"This has implications for several areas, such as the effects of stress, non-adherence to treatment and silent myocardial ischemia," says Bianca D'Antono, author of the study. "Further research will be needed to better understand the relationship between blood pressure, pain perception and heart disease."
Psychophysiology is the oldest, first, and most established journal in its field. This prestigious international journal plays a key role in advancing psychophysiological science and human neuroscience, covering research on the interrelationships between the physiological and psychological aspects of brain and behavior
High Blood Pressure May Mask Potentially Deadly Heart Condition - Correlation Between Hypertension And Chest Pain, May Help Explain Silent Ischemia
New research published in Psychophysiology finds a relationship between increased blood pressure and decreased pain perception in a variety of circumstances, including among individuals with heart disease. This phenomenon extends to those who typically suffer chest pain during exercise, and may be correlated with a potentially deadly heart condition.
The new study draws on data collected from over 900 patients undergoing exercise stress testing to diagnose possible myocardial ischemia (MI), a condition where oxygenated blood is prevented from reaching the heart because an artery has become blocked or constricted.
Generally, exercise should produce pain in these situations; however some patients experience "silent" cases of MI in which no pain is felt. Previous studies have suggested that high blood pressure and silent ischemia may be correlated, and this new research provides further validation.
"This has implications for several areas, such as the effects of stress, non-adherence to treatment and silent myocardial ischemia," says Bianca D'Antono, author of the study. "Further research will be needed to better understand the relationship between blood pressure, pain perception and heart disease."
Psychophysiology is the oldest, first, and most established journal in its field. This prestigious international journal plays a key role in advancing psychophysiological science and human neuroscience, covering research on the interrelationships between the physiological and psychological aspects of brain and behavior
Tuesday, July 3, 2007
Dark Chocolate and Blood-Pressure Reduction
A piece of dark chocolate a day keeps the doctor away
July 3, 2007
When it comes to dark chocolate and blood-pressure reduction, it would seem that a little goes a long way. A new randomized controlled study has shown that just one square of dark chocolate a day reduces blood pressure by a few mm Hg in healthy people with above-optimum blood pressure.
Dr Dirk Taubert (University Hospital of Cologne, Germany) and colleagues report their findings in the July 4, 2007 issue of the Journal of the American Medical Association.
Taubert told heartwire that this is the first research to show the benefits of cocoa in dark chocolate long-term—the study lasted 18 weeks. They were also able to demonstrate a feasible mechanism for the BP-lowering effects of dark chocolate, he noted.
Hypertension expert Dr Franz H Messerli (Columbia University, New York), who was not involved in this research, told heartwire: "This is now study 6 showing the same phenomenon. It is an exceedingly well-done, very thorough study, which I think is nothing short of revolutionary."
Dark chocolate increases production of nitric oxide
Taubert et al say that short-term studies have previously shown that high doses of cocoa for two weeks can improve endothelial function and reduce blood pressure, due to the action of cocoa polyphenols. "But the clinical effect of low habitual cocoa intake on BP and the underlying BP-lowering mechanisms are unclear."
They conducted arandomized, controlled, investigator-blinded, parallel-group trialwith 44 adults, aged 56 to 73, with untreated upper-range prehypertension or stage 1 hypertension without concomitant risk factors. The participants were randomly assigned to receive either one square (6.3 g) of a commercial brand of dark chocolate per day, constituting just 30 kcal, or matching polyphenol-free white chocolate for 18 weeks.
The primary outcome measure was change in BP after 18 weeks. Secondary outcomes included changes in plasma markers of vasodilative nitric oxide (S-nitrosoglutathione) and oxidative stress (8-isoprostane) and bioavailability of cocoa polyphenols.
From baseline to 18 weeks, dark-chocolate intake reduced mean systolic BP by 2.9 mm Hg (p<0.001)>
The BP decline was accompanied by a sustained increase of S-nitrosoglutathione by 0.23 nmol/L (p<0.001)white chocolate caused no changes in BP or plasma biomarkers.
"The apparent mechanisms by which dark chocolate lowered BP suggests a chronic increase in the production of nitric oxide in the vascular endothelium," the researchers explain. "It is likely that cocoa flavanols in dark chocolate were responsible for the observed effects on S-nitrosoglutathione and BP."
Long-term RCTs with larger numbers of participants needed.
"This study provides enough evidence to suggest that low amounts of polyphenol-rich dark chocolate as an addition to a healthy diet caused progressive reductions of systolic and diastolic BP in older subjects with prehypertension without inducing weight gain or other adverse effects," Taubert said.
However, he says the findings need to be replicated in other populations (their participants were predominantly white, older, and mildly hypertensive) and that the effects of dark chocolate need to be evaluated in long-term randomized controlled studies with larger numbers of participants.
"A few hundred patients would be needed, with a follow-up of at least one year," he says.
"However, we are more interested in the mechanism, and we are trying to find out which polyphenol in the cocoa is responsible. When we know the substance, we will go back and test it."
Small changes in BP, but big implications
Messerli says the clinical significance of these apparently small changes in blood pressure is nevertheless extremely important. "When you look at this populationwise, there's no question that this achieves a major reduction in heart attacks and stroke."
But he cautions that people must understand that the chocolate has to be dark. "Regular (milk) or white chocolate has no benefit whatsoever. It is completely useless. I now tell my patients, I will take away your Häagen-Dazs and your crème brûlée, but I give you a little bit of dark chocolate. There are no adverse events, in contrast to many BP-lowering pills, and patients are motivated to enjoy a daily treat."
He also points out that the amount of dark chocolate eaten is key, because people still need to keep within their daily limit of calories. The one square in this study was 6.3 g and represented only 30 kcal per day, he notes, "but previous studies have shown that 100 g of dark chocolate lowers BP by 12/8 mm Hg; however, this is somewhat of a Pandora's box."
Taubert D, Roesen R, Lehmann C, et al. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide. A randomized controlled trial. JAMA 2007; 298:49-60
July 3, 2007
When it comes to dark chocolate and blood-pressure reduction, it would seem that a little goes a long way. A new randomized controlled study has shown that just one square of dark chocolate a day reduces blood pressure by a few mm Hg in healthy people with above-optimum blood pressure.
Dr Dirk Taubert (University Hospital of Cologne, Germany) and colleagues report their findings in the July 4, 2007 issue of the Journal of the American Medical Association.
Taubert told heartwire that this is the first research to show the benefits of cocoa in dark chocolate long-term—the study lasted 18 weeks. They were also able to demonstrate a feasible mechanism for the BP-lowering effects of dark chocolate, he noted.
Hypertension expert Dr Franz H Messerli (Columbia University, New York), who was not involved in this research, told heartwire: "This is now study 6 showing the same phenomenon. It is an exceedingly well-done, very thorough study, which I think is nothing short of revolutionary."
Dark chocolate increases production of nitric oxide
Taubert et al say that short-term studies have previously shown that high doses of cocoa for two weeks can improve endothelial function and reduce blood pressure, due to the action of cocoa polyphenols. "But the clinical effect of low habitual cocoa intake on BP and the underlying BP-lowering mechanisms are unclear."
They conducted arandomized, controlled, investigator-blinded, parallel-group trialwith 44 adults, aged 56 to 73, with untreated upper-range prehypertension or stage 1 hypertension without concomitant risk factors. The participants were randomly assigned to receive either one square (6.3 g) of a commercial brand of dark chocolate per day, constituting just 30 kcal, or matching polyphenol-free white chocolate for 18 weeks.
The primary outcome measure was change in BP after 18 weeks. Secondary outcomes included changes in plasma markers of vasodilative nitric oxide (S-nitrosoglutathione) and oxidative stress (8-isoprostane) and bioavailability of cocoa polyphenols.
From baseline to 18 weeks, dark-chocolate intake reduced mean systolic BP by 2.9 mm Hg (p<0.001)>
The BP decline was accompanied by a sustained increase of S-nitrosoglutathione by 0.23 nmol/L (p<0.001)white chocolate caused no changes in BP or plasma biomarkers.
"The apparent mechanisms by which dark chocolate lowered BP suggests a chronic increase in the production of nitric oxide in the vascular endothelium," the researchers explain. "It is likely that cocoa flavanols in dark chocolate were responsible for the observed effects on S-nitrosoglutathione and BP."
Long-term RCTs with larger numbers of participants needed.
"This study provides enough evidence to suggest that low amounts of polyphenol-rich dark chocolate as an addition to a healthy diet caused progressive reductions of systolic and diastolic BP in older subjects with prehypertension without inducing weight gain or other adverse effects," Taubert said.
However, he says the findings need to be replicated in other populations (their participants were predominantly white, older, and mildly hypertensive) and that the effects of dark chocolate need to be evaluated in long-term randomized controlled studies with larger numbers of participants.
"A few hundred patients would be needed, with a follow-up of at least one year," he says.
"However, we are more interested in the mechanism, and we are trying to find out which polyphenol in the cocoa is responsible. When we know the substance, we will go back and test it."
Small changes in BP, but big implications
Messerli says the clinical significance of these apparently small changes in blood pressure is nevertheless extremely important. "When you look at this populationwise, there's no question that this achieves a major reduction in heart attacks and stroke."
But he cautions that people must understand that the chocolate has to be dark. "Regular (milk) or white chocolate has no benefit whatsoever. It is completely useless. I now tell my patients, I will take away your Häagen-Dazs and your crème brûlée, but I give you a little bit of dark chocolate. There are no adverse events, in contrast to many BP-lowering pills, and patients are motivated to enjoy a daily treat."
He also points out that the amount of dark chocolate eaten is key, because people still need to keep within their daily limit of calories. The one square in this study was 6.3 g and represented only 30 kcal per day, he notes, "but previous studies have shown that 100 g of dark chocolate lowers BP by 12/8 mm Hg; however, this is somewhat of a Pandora's box."
Taubert D, Roesen R, Lehmann C, et al. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide. A randomized controlled trial. JAMA 2007; 298:49-60
Saturday, June 30, 2007
Symptomless Hypertension Too Often Ignored
Symptomless Hypertension Too Often Ignored
High blood pressure, the "silent killer," too often gets overlooked by people who have conditions that cause them pain or severe distress, a new study finds.
A survey of more than 51,000 people enrolled in a Pennsylvania state prescription drug program found that people with either physical or psychological problems were markedly less likely to take the pills needed to control their blood pressure, according to a report in the June 28 issue of Hypertension. "It's not so surprising," said study author Dr. Philip Wang. "But what was notable was the consistency with which the presence of other conditions decreased use of antihypertensives [drugs for high blood pressure].
" A wide array of conditions affected use of those drugs, said Wang, an assistant professor of psychiatry, medicine and health-care policy at Harvard Medical School. For example, someone with both high blood pressure and asthma or another chronic lung disease was 57 percent less likely to take blood pressure medication than someone without such a condition. Use of blood pressure medication was 50 percent lower in people with depression, 41 percent lower for people with gastrointestinal complaints, and 37 percent less likely for people with osteoarthritis. The blame lies with both patients and doctors, Wang said.
"A patient with several conditions might deal with those that cause discomfort, even though hypertension is probably as important an issue," he said. "And patients may have financial barriers to taking multiple medications. Or maybe they just run out of time." Doctors know that high blood pressure is a major risk factor for heart attack and stroke, Wang said, so they also play a role in its neglect, though "probably not intentionally.
" He pointed out that doctors usually have a limited amount of time to spend with individual patients "and if you have to deal with multiple conditions in 15 minutes, hypertension might get short shrift."
The study illustrates "the complexity of the illnesses that older people have these days, and the challenge of dealing with them," said Dr. Daniel W. Jones, dean of the University of Mississippi School of Medicine and a spokesman for the American Heart Association. The complexity of the American health-care system also plays a role, Jones said. "It's hard to tell what part cost plays in it," he added.
The overall lesson "for patients and their physicians is that blood pressure medications are effective at improving the length and quality of life," Jones said. "Physicians should take care that the problem doesn't fall between the cracks."
A report in the June 28 issue of Circulation highlighted the importance for older people of another silent risk factor -- C-reactive protein. A study of nearly 4,000 people aged 65 and older found that a high blood level of C-reactive protein is an independent risk factor for heart disease, comparable to high cholesterol levels, the report said. People with the highest levels of C-reactive protein had a 45 percent increase in the risk of developing heart disease over the 10-year course of the study.
"There have been other studies with a shorter-term follow-up, three or four years," said study co-author Dr. Bruce M. Psaty, a professor of pathology and biochemistry at the University of Vermont. "This is the first long-term prospective study in the elderly."
C-reactive protein was almost unknown a decade ago, but a blood test now "is widely available, and is becoming more so over time," Psaty said. There are several ways to lower levels of the protein, including the use of cholesterol-busting statin drugs, he said. And since "one of the biggest things associated with C-reactive protein is obesity, one of the best ways to control it is to lose weight," Psaty added.
Friday, June 22, 2007
Lowering Blood Pressure Improves Diastolic Function, Regardless of Regimen
Lowering Blood Pressure Improves Diastolic Function, Regardless of Regimen
Reductions in blood pressure lead to improved diastolic function — regardless of the antihypertensive drugs used — reports a study in Lancet.
Researchers sought to determine whether the angiotensin-receptor blocker valsartan would be more effective than other antihypertensives at improving diastolic function. They randomized nearly 400 patients with hypertension and evidence of diastolic dysfunction to receive either the ARB or placebo. The patients also received other classes of antihypertensive agents to lower blood pressure to below 135/80 mm Hg.
After 38 weeks, tissue Doppler imaging showed improved diastolic function in both valsartan and placebo recipients, but there was no significant difference between the groups.
Authors of an accompanying commentary note that valsartan might have an advantage in patients with more advanced left ventricular remodeling. Nevertheless, they add, "the good news is that lowering blood pressure improves diastolic function, irrespective of the antihypertensive regimen used."
Lancet article (Free abstract with one-time registration; full text requires subscription)
Lancet comment (Subscription required)
ABSTRACT
The Lancet 2007; 369:2079-2087
Articles
Effect of angiotensin receptor blockade and antihypertensive drugs on diastolic function in patients with hypertension and diastolic dysfunction: a randomised trial
Dr Scott D SolomonMD, et al
Summary
Background
Diastolic dysfunction might represent an important pathophysiological intermediate between hypertension and heart failure. Our aim was to determine whether inhibitors of the renin-angiotensin-aldosterone system, which can reduce ventricular hypertrophy and myocardial fibrosis, can improve diastolic function to a greater extent than can other antihypertensive agents.
Methods
Patients with hypertension and evidence of diastolic dysfunction were randomly assigned to receive either the angiotensin receptor blocker valsartan (titrated to 320 mg once daily) or matched placebo. Patients in both groups also received concomitant antihypertensive agents that did not inhibit the renin-angiotensin system to reach targets of under 135 mm Hg systolic blood pressure and under 80 mm Hg diastolic blood pressure. The primary endpoint was change in diastolic relaxation velocity between baseline and 38 weeks as determined by tissue doppler imaging. Analyses were done by intention to treat.
Findings
186 patients were randomly assigned to receive valsartan; 198 were randomly assigned to receive placebo. 43 patients were lost to follow-up or discontinued the assigned intervention. Over 38 weeks, there was a 12·8 (SD 17·2)/7·1 (9·9) mm Hg reduction in blood pressure in the valsartan group and a 9·7 (17·0)/5·5 (10·2) mm Hg reduction in the placebo group. The difference in blood pressure reduction between the two groups was not significant. Diastolic relaxation velocity increased by 0·60 (SD 1·4) cm/s from baseline in the valsartan group (p<0·0001) and 0·44 (1·4) cm/s from baseline in the placebo group (p<0·0001) by week 38. However, there was no significant difference in the change in diastolic relaxation velocity between the groups (p=0·29).
Interpretation
Lowering blood pressure improves diastolic function irrespective of the type of antihypertensive agent used.
Reductions in blood pressure lead to improved diastolic function — regardless of the antihypertensive drugs used — reports a study in Lancet.
Researchers sought to determine whether the angiotensin-receptor blocker valsartan would be more effective than other antihypertensives at improving diastolic function. They randomized nearly 400 patients with hypertension and evidence of diastolic dysfunction to receive either the ARB or placebo. The patients also received other classes of antihypertensive agents to lower blood pressure to below 135/80 mm Hg.
After 38 weeks, tissue Doppler imaging showed improved diastolic function in both valsartan and placebo recipients, but there was no significant difference between the groups.
Authors of an accompanying commentary note that valsartan might have an advantage in patients with more advanced left ventricular remodeling. Nevertheless, they add, "the good news is that lowering blood pressure improves diastolic function, irrespective of the antihypertensive regimen used."
Lancet article (Free abstract with one-time registration; full text requires subscription)
Lancet comment (Subscription required)
ABSTRACT
The Lancet 2007; 369:2079-2087
Articles
Effect of angiotensin receptor blockade and antihypertensive drugs on diastolic function in patients with hypertension and diastolic dysfunction: a randomised trial
Dr Scott D SolomonMD, et al
Summary
Background
Diastolic dysfunction might represent an important pathophysiological intermediate between hypertension and heart failure. Our aim was to determine whether inhibitors of the renin-angiotensin-aldosterone system, which can reduce ventricular hypertrophy and myocardial fibrosis, can improve diastolic function to a greater extent than can other antihypertensive agents.
Methods
Patients with hypertension and evidence of diastolic dysfunction were randomly assigned to receive either the angiotensin receptor blocker valsartan (titrated to 320 mg once daily) or matched placebo. Patients in both groups also received concomitant antihypertensive agents that did not inhibit the renin-angiotensin system to reach targets of under 135 mm Hg systolic blood pressure and under 80 mm Hg diastolic blood pressure. The primary endpoint was change in diastolic relaxation velocity between baseline and 38 weeks as determined by tissue doppler imaging. Analyses were done by intention to treat.
Findings
186 patients were randomly assigned to receive valsartan; 198 were randomly assigned to receive placebo. 43 patients were lost to follow-up or discontinued the assigned intervention. Over 38 weeks, there was a 12·8 (SD 17·2)/7·1 (9·9) mm Hg reduction in blood pressure in the valsartan group and a 9·7 (17·0)/5·5 (10·2) mm Hg reduction in the placebo group. The difference in blood pressure reduction between the two groups was not significant. Diastolic relaxation velocity increased by 0·60 (SD 1·4) cm/s from baseline in the valsartan group (p<0·0001) and 0·44 (1·4) cm/s from baseline in the placebo group (p<0·0001) by week 38. However, there was no significant difference in the change in diastolic relaxation velocity between the groups (p=0·29).
Interpretation
Lowering blood pressure improves diastolic function irrespective of the type of antihypertensive agent used.
Tuesday, June 19, 2007
2007 American Society of Hypertension Meeting Roundup
American Society of Hypertension
Chicago, IL • May 19 - May 22, 2007
ASH: Dual-drug Treatment Accomplishes Blood Pressure Control (CME/CE) CHICAGO -- Initiating treatment with a combination of anti-hypertensive drugs gets 75% of patients’ blood pressures under control, researchers reported here. http://www.medpagetoday.com/MeetingCoverage/ASHMeeting/mr/5819
ASH: DASH Diet Gets No Respect from Hypertensive Patients (CME/CE) CHICAGO -- The DASH diet plan apparently has not caught on among hypertensive patients. In fact, the percentage of patients adhering to DASH plummeted after the diet was incorporated in national guidelines. http://www.medpagetoday.com/MeetingCoverage/ASHMeeting/mr/5817
ASH: More Proves Better in Treating Hypertension (CME/CE) CHICAGO -- Fixed combination doses of a calcium-channel blocker and an angiotensin-receptor blocker appear to improve hypertension treatment, researchers said here. http://www.medpagetoday.com/MeetingCoverage/ASHMeeting/mr/5714
ASH: Obesity Linked to Diastolic Hypertension Subtypes (CME/CE) CHICAGO -- Obesity appears to be associated with an increased risk of diastolic rather than systolic hypertension subtypes, researchers said here. http://www.medpagetoday.com/MeetingCoverage/ASHMeeting/mr/5697
ASH: Abbreviation at the Core of Choice of Diuretics (CME/CE) CHICAGO -- For the lack of a convenient abbreviation, a diuretic with a good track record for hypertension is often spurned on prescription pads, said researchers here. http://www.medpagetoday.com/MeetingCoverage/ASHMeeting/mr/5690
Chicago, IL • May 19 - May 22, 2007
ASH: Dual-drug Treatment Accomplishes Blood Pressure Control (CME/CE) CHICAGO -- Initiating treatment with a combination of anti-hypertensive drugs gets 75% of patients’ blood pressures under control, researchers reported here. http://www.medpagetoday.com/MeetingCoverage/ASHMeeting/mr/5819
ASH: DASH Diet Gets No Respect from Hypertensive Patients (CME/CE) CHICAGO -- The DASH diet plan apparently has not caught on among hypertensive patients. In fact, the percentage of patients adhering to DASH plummeted after the diet was incorporated in national guidelines. http://www.medpagetoday.com/MeetingCoverage/ASHMeeting/mr/5817
ASH: More Proves Better in Treating Hypertension (CME/CE) CHICAGO -- Fixed combination doses of a calcium-channel blocker and an angiotensin-receptor blocker appear to improve hypertension treatment, researchers said here. http://www.medpagetoday.com/MeetingCoverage/ASHMeeting/mr/5714
ASH: Obesity Linked to Diastolic Hypertension Subtypes (CME/CE) CHICAGO -- Obesity appears to be associated with an increased risk of diastolic rather than systolic hypertension subtypes, researchers said here. http://www.medpagetoday.com/MeetingCoverage/ASHMeeting/mr/5697
ASH: Abbreviation at the Core of Choice of Diuretics (CME/CE) CHICAGO -- For the lack of a convenient abbreviation, a diuretic with a good track record for hypertension is often spurned on prescription pads, said researchers here. http://www.medpagetoday.com/MeetingCoverage/ASHMeeting/mr/5690
New European guidelines on hypertension
New European guidelines on hypertension
Milan, Italy - New guidelines for the management of arterial hypertension have been issued at the European Society of Hypertension (ESH) meeting in Milan, Italy [1]. The recommendations, which were drawn up jointly by task forces from ESH and the European Society of Cardiology (ESC), also appear in the June 2007 issue of the Journal of Hypertension.
Cochair of the task forces, Dr Guy de Backer (University Hospital, Ghent, Belgium), told heartwire that the guidelines are essentially an update to 2003 recommendations. The new document is 82 pages long and lists 825 references, reflecting the vast amount of data published on the subject of hypertension in the past four years, he noted.
Asked to pick out highlights for heartwire, de Backer said this was a difficult task, "as there has been no one dramatic change, rather small changes in each area. The most important thing is that this is an update and the numerous references have been critically evaluated. We have kept the general framework and added what we think is most important from the literature."
For the clinician, the main messages can be found in a number of boxes in the paper, which contain position statements, he noted. "All you need to do is look at the position statements in the boxes, and read the text only if you want more detail." The task forces are working hard to produce a pocket version of the new guidelines for release at the ESC meeting in Vienna in September, he added.
No one choice of first-line therapy
The overall goal for blood-pressure reduction has remained the same—to lower BP to 140/90 mm Hg in the large majority of people. However, there has been a change in the recommendation for those with comorbidities, de Backer said. For example, there is a new goal of 130/80 mm Hg for people with established cardiovascular disease or diabetes.
In terms of treatment recommendations, he said the new guidelines shy away from recommending one particular class of antihypertensive over another as first-line therapy; rather they emphasize the importance of selecting therapy for each individual, according to any comorbidities they may have.
"We have noted the five important drug classes—diuretics, calcium-channel blockers, ACE inhibitors, beta blockers, and angiotensin-receptor blockers," he said. But from then on, "if we have to make a choice it should depend on comorbidities."
For example, the best choice of first-line agent for someone with hypertension who also has diabetes is either an ACE inhibitor or an angiotensin-receptor blocker. For those who have suffered an MI, the most appropriate drug to use first is a beta blocker, and in the elderly, the first-line drug of choice is generally a calcium-channel blocker to reduce the risk of stroke, he noted.
He added, however, that the emphasis on identification of first-line therapy is often pretty futile, because the majority of patients require multiple blood-pressure medications.
Antihypertensive treatment: Preferred drugs as per new European guidelines
Subclinical organ damage - Treatment
LVH - ACE inhibitors, calcium antagonists, angiotensin receptor blockers
Asymptomatic atherosclerosis - Calcium antagonists, ACE inhibitors
Microalbuminuria - ACE inhibitors, angiotensin receptor blockers
Renal dysfunction - ACE inhibitors, angiotensin receptor blockers
Clinical event
Previous stroke - Any BP-lowering agent
Previous MI - Beta blockers, ACE inhibitors, angiotensin receptor blockers
Angina pectoris - Beta blockers, calcium antagonists
Heart failure - Diuretics, beta blocker, ACE inhibitors, angiotensin receptor blockers, antialdosterone agents
Atrial fibrillation
—Recurrent - Angiotensin receptor blockers, ACE inhibitors
—Permanent - Beta blockers, nonhydropyridine calcium antagonists
ESRD/proteinuria - ACE inhibitors, angiotensin receptor blockers, loop diuretics
PAD - Calcium antagonists
Condition
ISH (elderly) - Diuretics, calcium antagonists
Metabolic syndrome - CE inhibitors, angiotensin receptor blockers, calcium antagonists
Diabetes mellitus - ACE inhibitors, angiotensin receptor blockers
Pregnancy - Calcium antagonists, methyldopa, beta blockers
Blacks - Diuretics, calcium antagonists
LVH=left ventricular hypertrophy; ESRD=end-stage renal disease; PAD=peripheral arterial disease; ISH=isolated systolic hypertension
Other subjects on which there is more information in the new guidelines include the taking of ambulatory BP measurements and those performed at home by patients themselves, de Backer noted, adding that the advice for interpreting ambulatory and home BP measurements "is more detailed now."
Extra information can be found on subclinical organ damage, including details about novel markers for renal damage and arterial stiffness.
Source:
Mancia G, de Backer G, Dominiczak A, et al. 2007 guidelines for the management of arterial hypertension. J Hypertens 2007; 25: 1105-1187
LINK: http://www.theheart.org/article/797619.do#
Friday, June 8, 2007
Blood-pressure changes with acupuncture comparable to ACE-inhibitor monotherapy
Blood-pressure changes with acupuncture comparable to ACE-inhibitor monotherapy
Erlangen, Germany - A study billed as the first rigorous, randomized trial in the West to test acupuncture against a sham needle technique to treat hypertension suggests that, performed properly, acupuncture may produce blood-pressure changes on a par with monotherapy in mild to moderate hypertension.
"It's certainly not like a wonder drug; it's not a massive effect, but it's a clear effect," lead investigator Dr Frank A Flachskampf (Universitätsklinikum Erlangen, Germany) told heartwire.
Smaller randomized trials have been performed in China, with mixed results, while one randomized study in the West found no difference in blood-pressure lowering between traditional Chinese acupuncture, standardized acupuncture, and a sham procedure, the authors note. This earlier study did not use ambulatory blood-pressure measurements, believed to be superior to office-based measurements.
Results of their study are published online June 4, 2007 in Circulation.
Needlework
For the study, 160 outpatients with uncomplicated, mild to moderate hypertension were randomized to six weeks of acupuncture performed by Chinese medicine practitioners, trained in China, or to a sham procedure. In both arms, patients underwent 22 sessions, each 30 minutes in length. By the end of the six weeks, 24-hour ambulatory systolic and diastolic blood pressures were significantly reduced from baseline in the acupuncture-treated patients (5.4 mm Hg and 3.0 mm Hg, respectively), and this change was also significantly different from values in the sham-treated patients, in whom no meaningful changes were seen.
After three and six months, however, the blood-pressure reductions disappeared, leading investigators to conclude that ongoing acupuncture treatments would be required to maintain the blood-pressure reductions.
"The main finding is that for the first time in a reasonably sized but still relatively small randomized study, this establishes beyond a reasonable doubt that acupuncture lowers blood pressure," Flachskampf commented. "It's a modest but undeniable effect on both systolic and diastolic blood pressure."
The extent of the blood-pressure reductions are comparable to those seen with ACE-inhibitor monotherapy or aggressive lifestyle changes, including radical salt restrictions, he added.
A "demanding" alternative to drugs
Flachskampf had some caveats, acknowledging that the regular acupuncture sessions used in the study represent a significant time investment: each acupuncture session lasted 30 minutes—not including transportation and administrative time—and took place several times a week. The study subjects were also reasonably healthy, with no other major risk factors and with only mild to moderate hypertension.
"This is clearly something that would probably not work as well with very sick people or people with blood pressure at dangerous levels," he said. "We cannot easily extrapolate to people, for example, with complicated hypertension who have had a myocardial infarction."
Flachskampf believes, however, that acupuncture likely represents an attractive option in specific patients, particularly those averse to taking medical therapy who are open to so-called "alternative" medicine.
"This is probably only for people who somehow relate to this spiritually, who say I am profoundly against taking drugs and I'm very fond of Oriental wisdom or things like that," Flachskampf told heartwire. "I don't want to make a joke about this, but this certainly needs more compliance than taking two or three pills a day. It's much more demanding."
Unlike drugs, acupuncture appeared to have few or no side effects, although two people complained that the needles were painful. "Clearly, many millions of Chinese get acupuncture without any major problems so I think this is really a minor point," Flachskampf observed.
Source:
Flachskampf FA, Gallasch J, Gefeller O, et al. Randomized trial of acupuncture to lower blood pressure. Circulation 2007; DOI: 10.1161/CIRCULATIONAHA.106.661140. Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fwww.circulationaha.org.
Erlangen, Germany - A study billed as the first rigorous, randomized trial in the West to test acupuncture against a sham needle technique to treat hypertension suggests that, performed properly, acupuncture may produce blood-pressure changes on a par with monotherapy in mild to moderate hypertension.
"It's certainly not like a wonder drug; it's not a massive effect, but it's a clear effect," lead investigator Dr Frank A Flachskampf (Universitätsklinikum Erlangen, Germany) told heartwire.
Smaller randomized trials have been performed in China, with mixed results, while one randomized study in the West found no difference in blood-pressure lowering between traditional Chinese acupuncture, standardized acupuncture, and a sham procedure, the authors note. This earlier study did not use ambulatory blood-pressure measurements, believed to be superior to office-based measurements.
Results of their study are published online June 4, 2007 in Circulation.
Needlework
For the study, 160 outpatients with uncomplicated, mild to moderate hypertension were randomized to six weeks of acupuncture performed by Chinese medicine practitioners, trained in China, or to a sham procedure. In both arms, patients underwent 22 sessions, each 30 minutes in length. By the end of the six weeks, 24-hour ambulatory systolic and diastolic blood pressures were significantly reduced from baseline in the acupuncture-treated patients (5.4 mm Hg and 3.0 mm Hg, respectively), and this change was also significantly different from values in the sham-treated patients, in whom no meaningful changes were seen.
After three and six months, however, the blood-pressure reductions disappeared, leading investigators to conclude that ongoing acupuncture treatments would be required to maintain the blood-pressure reductions.
"The main finding is that for the first time in a reasonably sized but still relatively small randomized study, this establishes beyond a reasonable doubt that acupuncture lowers blood pressure," Flachskampf commented. "It's a modest but undeniable effect on both systolic and diastolic blood pressure."
The extent of the blood-pressure reductions are comparable to those seen with ACE-inhibitor monotherapy or aggressive lifestyle changes, including radical salt restrictions, he added.
A "demanding" alternative to drugs
Flachskampf had some caveats, acknowledging that the regular acupuncture sessions used in the study represent a significant time investment: each acupuncture session lasted 30 minutes—not including transportation and administrative time—and took place several times a week. The study subjects were also reasonably healthy, with no other major risk factors and with only mild to moderate hypertension.
"This is clearly something that would probably not work as well with very sick people or people with blood pressure at dangerous levels," he said. "We cannot easily extrapolate to people, for example, with complicated hypertension who have had a myocardial infarction."
Flachskampf believes, however, that acupuncture likely represents an attractive option in specific patients, particularly those averse to taking medical therapy who are open to so-called "alternative" medicine.
"This is probably only for people who somehow relate to this spiritually, who say I am profoundly against taking drugs and I'm very fond of Oriental wisdom or things like that," Flachskampf told heartwire. "I don't want to make a joke about this, but this certainly needs more compliance than taking two or three pills a day. It's much more demanding."
Unlike drugs, acupuncture appeared to have few or no side effects, although two people complained that the needles were painful. "Clearly, many millions of Chinese get acupuncture without any major problems so I think this is really a minor point," Flachskampf observed.
Source:
Flachskampf FA, Gallasch J, Gefeller O, et al. Randomized trial of acupuncture to lower blood pressure. Circulation 2007; DOI: 10.1161/CIRCULATIONAHA.106.661140. Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fwww.circulationaha.org.
Thursday, May 31, 2007
American Society of Hypertension 22nd Annual Meeting and Exposition (ASH)
American Society of Hypertension 22nd Annual Meeting and Exposition (ASH)
Conference News
Impaired Glycemic Control Reversible When Switching Off Diuretic-Based TherapyResults from a six-month extension study have shown that impairment in glycemic control after one year of diuretic-based combination treatment is reversible by switching to treatment not involving a diuretic, in this case, an ACE inhibitor and calcium-channel blocker.
Heartwire, May 25, 2007
Combination Therapy With ARB and Amlodipine Effectively Reduces Blood PressureTwo new studies presented this week suggest that fixed-dose combination therapy with amlodipine and an angiotensin receptor blocker, either valsartan or olmesartan, can achieve significant reductions of blood pressure without an increase in serious adverse events.
Heartwire, May 24, 2007
ACCOMPLISH at 18 Months: Better Blood-Pressure Control With Single-Tablet Combination TherapyInterim data from the ACCOMPLISH study has shown that a single-tablet dual-mechanism therapy initiated in high-risk hypertensive patients is highly effective in reducing blood pressure and significantly better in getting more patients to treatment goals. While some see combination drugs as the wave of the future, others are concerned about going too fast in some patients.
Heartwire, May 22, 2007
Novel ARB Provides Greater Reductions in Proteinuria in Diabetics With Overt NephropathyOne year of treatment with telmisartan provided greater reductions in proteinuria when compared with losartan. The greater protection was not attributed to differences in blood pressure, and the antiproteinuric effects were sustained with telmisartan two months after therapy was stopped.
Heartwire, May 22, 2007
CAMELOT: Obese Patients Benefit the Most From Intensive Antihypertensive Drug TherapyAn analysis of the CAMELOT study has shown that the clinical benefits of intensive antihypertensive therapy in CAD patients is greatest in those considered obese, despite the fact that blood-pressure reductions were lower for obese patients than for lean or overweight patients.
Heartwire, May 21, 2007
Diet of Hypertensive Adults Is Getting Worse: Just 22% Following the DASH DietMore and more Americans are losing out in their mad DASH to good eating habits. A new study reveals that the dietary quality of hypertensive adults has deteriorated since the DASH diet became part of the national guidelines.
Heartwire, May 21, 2007
Conference News
Impaired Glycemic Control Reversible When Switching Off Diuretic-Based TherapyResults from a six-month extension study have shown that impairment in glycemic control after one year of diuretic-based combination treatment is reversible by switching to treatment not involving a diuretic, in this case, an ACE inhibitor and calcium-channel blocker.
Heartwire, May 25, 2007
Combination Therapy With ARB and Amlodipine Effectively Reduces Blood PressureTwo new studies presented this week suggest that fixed-dose combination therapy with amlodipine and an angiotensin receptor blocker, either valsartan or olmesartan, can achieve significant reductions of blood pressure without an increase in serious adverse events.
Heartwire, May 24, 2007
ACCOMPLISH at 18 Months: Better Blood-Pressure Control With Single-Tablet Combination TherapyInterim data from the ACCOMPLISH study has shown that a single-tablet dual-mechanism therapy initiated in high-risk hypertensive patients is highly effective in reducing blood pressure and significantly better in getting more patients to treatment goals. While some see combination drugs as the wave of the future, others are concerned about going too fast in some patients.
Heartwire, May 22, 2007
Novel ARB Provides Greater Reductions in Proteinuria in Diabetics With Overt NephropathyOne year of treatment with telmisartan provided greater reductions in proteinuria when compared with losartan. The greater protection was not attributed to differences in blood pressure, and the antiproteinuric effects were sustained with telmisartan two months after therapy was stopped.
Heartwire, May 22, 2007
CAMELOT: Obese Patients Benefit the Most From Intensive Antihypertensive Drug TherapyAn analysis of the CAMELOT study has shown that the clinical benefits of intensive antihypertensive therapy in CAD patients is greatest in those considered obese, despite the fact that blood-pressure reductions were lower for obese patients than for lean or overweight patients.
Heartwire, May 21, 2007
Diet of Hypertensive Adults Is Getting Worse: Just 22% Following the DASH DietMore and more Americans are losing out in their mad DASH to good eating habits. A new study reveals that the dietary quality of hypertensive adults has deteriorated since the DASH diet became part of the national guidelines.
Heartwire, May 21, 2007
Friday, May 25, 2007
Impaired Glycemic Control Reversible When Switching Off Diuretic-Based Therapy
American Society of Hypertension 22nd Annual Meeting and Exposition (ASH)
May 19 - 22, 2007, Chicago, Illinois
Impaired Glycemic Control Reversible When Switching Off Diuretic-Based Therapy
from Heartwire
May 25, 2007 Chicago, IL – Results from a six-month extension study have shown that impairment in glycemic control after one year of diuretic-based combination treatment is reversible by switching to treatment not involving a diuretic, in this case, an ACE inhibitor and calcium-channel blocker [1].
"When we looked at who developed new-onset diabetes, the plan was to then switch these patients over to the ACE-inhibitor/calcium-channel-blocker combination to see whether we could regress or bring back to baseline these metabolic changes," lead investigator Dr George Bakris (University of Chicago, IL) told heartwire. "This effect of new-onset diabetes, at least if you intervene within a short time of starting the therapy, does not appear to be permanent."
The hypothesis-generating study, an extension of the Study of Trandolapril/Verapamil SR And Insulin Resistance (STAR), was presented earlier this week at the American Society of Hypertension 2007 Scientific Sessions. In the original STAR study, published in 2006, investigators showed that in patients with impaired glucose tolerance, normal kidney function, and hypertension, the fixed-dose combination of trandolapril and verapamil reduces the risk of new-onset diabetes compared with a losartan/hydrochlorothiazide-based therapy.
Undoing the damage of the diuretic
Speaking with heartwire, Bakris said clinicians previously believed marrying diuretic therapy to an ACE inhibitor or angiotensin receptor blocker (ARB) might provide protection from new-onset diabetes, although this turned out not to be true. The risk of new-onset diabetes is also dose dependent, he said, such that at 25-mg hydrochlorothiazide (HCTZ) there is substantial risk of impairing the glucose response.
Testing the hypothesis that impaired glycemic control might be reversible early in the diuretic/losartan-combination treatment by switching to an ACE-inhibitor/calcium-channel-blocker combination, investigators assessed glycemic changes after six months of additional treatment with trandolapril and verapamil in both treatment groups in the STAR study. Bakris noted that only 53% of the original cohort stayed in the extension trial, although there were no statistically significant demographic differences between those who stayed and those who did not continue in the trial.
Those patients switching from losartan/HCTZ to trandolapril/verapamil experienced greater improvements in glucose and insulin response. The primary outcome measure, change in two-hour glucose using the oral glucose tolerance test (OGTT), decreased from 154 mg/dL at baseline to 131 mg/dL at six months in those who switched from the diuretic to the ACE-inhibitor/calcium-channel-blocker combination. At baseline, 10 patients in the losartan/HCTZ-treatment arm had diabetes, but six months after they switched to trandolapril/verapamil, this number was cut in half.
Blood pressure was sacrificed to some degree, noted Bakris, increasing from 128 mm Hg systolic at baseline to 137 mm Hg at six months. He said that while diuretics are cheap and have decades of outcomes data to support their use, clinicians might decide the cost of using the drug with respect to new-onset diabetes is too high.
"Looking at this overall, from a cost perspective, from a morbidity perspective, and from a patient perspective, why would you use a therapy to treat one condition only to express another condition that now requires additional medicine and has a potentially greater cardiovascular risk?" he said.
1. Bakris G, Molitch M, Sowers J et al. Reversal of new onset diabetes by nondiuretic based fixed dose antihypertensive drug combinations? Results of the STAR 6-month extension (STAR-LET). American Society of Hypertension 2007 Scientific Sessions; May 20, 2007; Chicago, IL.
Related Links:
American Society of Hypertension 22nd Annual Meeting and Exposition
May 19 - 22, 2007, Chicago, Illinois
Impaired Glycemic Control Reversible When Switching Off Diuretic-Based Therapy
from Heartwire
May 25, 2007 Chicago, IL – Results from a six-month extension study have shown that impairment in glycemic control after one year of diuretic-based combination treatment is reversible by switching to treatment not involving a diuretic, in this case, an ACE inhibitor and calcium-channel blocker [1].
"When we looked at who developed new-onset diabetes, the plan was to then switch these patients over to the ACE-inhibitor/calcium-channel-blocker combination to see whether we could regress or bring back to baseline these metabolic changes," lead investigator Dr George Bakris (University of Chicago, IL) told heartwire. "This effect of new-onset diabetes, at least if you intervene within a short time of starting the therapy, does not appear to be permanent."
The hypothesis-generating study, an extension of the Study of Trandolapril/Verapamil SR And Insulin Resistance (STAR), was presented earlier this week at the American Society of Hypertension 2007 Scientific Sessions. In the original STAR study, published in 2006, investigators showed that in patients with impaired glucose tolerance, normal kidney function, and hypertension, the fixed-dose combination of trandolapril and verapamil reduces the risk of new-onset diabetes compared with a losartan/hydrochlorothiazide-based therapy.
Undoing the damage of the diuretic
Speaking with heartwire, Bakris said clinicians previously believed marrying diuretic therapy to an ACE inhibitor or angiotensin receptor blocker (ARB) might provide protection from new-onset diabetes, although this turned out not to be true. The risk of new-onset diabetes is also dose dependent, he said, such that at 25-mg hydrochlorothiazide (HCTZ) there is substantial risk of impairing the glucose response.
Testing the hypothesis that impaired glycemic control might be reversible early in the diuretic/losartan-combination treatment by switching to an ACE-inhibitor/calcium-channel-blocker combination, investigators assessed glycemic changes after six months of additional treatment with trandolapril and verapamil in both treatment groups in the STAR study. Bakris noted that only 53% of the original cohort stayed in the extension trial, although there were no statistically significant demographic differences between those who stayed and those who did not continue in the trial.
Those patients switching from losartan/HCTZ to trandolapril/verapamil experienced greater improvements in glucose and insulin response. The primary outcome measure, change in two-hour glucose using the oral glucose tolerance test (OGTT), decreased from 154 mg/dL at baseline to 131 mg/dL at six months in those who switched from the diuretic to the ACE-inhibitor/calcium-channel-blocker combination. At baseline, 10 patients in the losartan/HCTZ-treatment arm had diabetes, but six months after they switched to trandolapril/verapamil, this number was cut in half.
Blood pressure was sacrificed to some degree, noted Bakris, increasing from 128 mm Hg systolic at baseline to 137 mm Hg at six months. He said that while diuretics are cheap and have decades of outcomes data to support their use, clinicians might decide the cost of using the drug with respect to new-onset diabetes is too high.
"Looking at this overall, from a cost perspective, from a morbidity perspective, and from a patient perspective, why would you use a therapy to treat one condition only to express another condition that now requires additional medicine and has a potentially greater cardiovascular risk?" he said.
1. Bakris G, Molitch M, Sowers J et al. Reversal of new onset diabetes by nondiuretic based fixed dose antihypertensive drug combinations? Results of the STAR 6-month extension (STAR-LET). American Society of Hypertension 2007 Scientific Sessions; May 20, 2007; Chicago, IL.
Related Links:
American Society of Hypertension 22nd Annual Meeting and Exposition
Thursday, May 17, 2007
ALISKIREN - Doubts about the effectiveness
Hypertension rebels voice doubts about ALISKIREN
New York, NY - Doubts about the effectiveness of the new renin inhibitor antihypertensive aliskiren (Tektura, Novartis) have been voiced in a somewhat controversial review article in the May 2007 issue of the American Journal of Hypertension [1].
The authors, Dr John Laragh (editor of the journal) and his wife and fellow hypertension researcher Dr Jean Sealey (New York Hospital/Cornell University Medical Center, New York), say that aliskiren is no more effective than current antihypertensives and suggest that its ability to lower blood pressure may be limited by reactive renin secretion, an effect that may actually increase blood pressure in certain patient groups.
In an interview with heartwire, Laragh said: "We don't have an urgent need for a new drug like this. It is not a breakthrough. It is a weak antihypertensive drug. It is no better than what we already have, and it will be much more expensive. In addition, aliskiren causes a greater reactive rise in renin production than any other antihypertensive, which could be dangerous for patients with the most highly reactive renin systems."
Laragh and Sealey are no strangers to controversy, having been at the center of a bitter row with the American Society of Hypertension (ASH), which resulted in the American Journal of Hypertension no longer being the official journal of ASH and the end of Laragh's and Sealey's involvement with ASH.
New York, NY - Doubts about the effectiveness of the new renin inhibitor antihypertensive aliskiren (Tektura, Novartis) have been voiced in a somewhat controversial review article in the May 2007 issue of the American Journal of Hypertension [1].
The authors, Dr John Laragh (editor of the journal) and his wife and fellow hypertension researcher Dr Jean Sealey (New York Hospital/Cornell University Medical Center, New York), say that aliskiren is no more effective than current antihypertensives and suggest that its ability to lower blood pressure may be limited by reactive renin secretion, an effect that may actually increase blood pressure in certain patient groups.
In an interview with heartwire, Laragh said: "We don't have an urgent need for a new drug like this. It is not a breakthrough. It is a weak antihypertensive drug. It is no better than what we already have, and it will be much more expensive. In addition, aliskiren causes a greater reactive rise in renin production than any other antihypertensive, which could be dangerous for patients with the most highly reactive renin systems."
Laragh and Sealey are no strangers to controversy, having been at the center of a bitter row with the American Society of Hypertension (ASH), which resulted in the American Journal of Hypertension no longer being the official journal of ASH and the end of Laragh's and Sealey's involvement with ASH.
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