Hypertension And Old And New

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Information about Hypertension And Old And New

Published on December 10, 2007

Author: rtrafaelmd

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10th Post Graduate Course PAFP Pangasinan Chapter

The Relationship of Systolic and Diastolic Blood Pressure to Cardiovascular Disease Risk: Observational Data

Hypertension Awareness, Treatment, and Control: US 1976 to 2000 NHANES, National Health and Nutrition Examination Survey. Chobanian AV et al. JAMA. 2003;289:2560-2572. Incidence (%) NHANES II 1976-1980 NHANES III (Phase 1) 1988-1991 NHANES III (Phase 2) 1991-1994 NHANES 1999-2000

Prevalence of Hypertension in the United States* † *Based on NHANES 1999  2000 data. Hypertension is defined as blood pressure  140/90 mmHg or antihypertensive treatment. † Low reliability due to large relative error. Fields et al. Hypertension . 2004:44;398-404 . Hypertension Prevalence Age

Hypertension Prevalence by Age and Race/Ethnicity in Men and Women Hypertension Prevalence Based on NHANES 1999-2000. Error bars indicate 95% confidence intervals. Data are weighted to the US population. Non-Hispanic White Non-Hispanic Black Mexican American Hajjar I, Kotchen TA. JAMA. 2003;290:199-206. Age, y Men Women Age, y

Lifetime Risk of Developing Hypertension Among Adults Aged 55 to 65 Years* *Residual lifetime risk of developing hypertension among adults aged 55 to 65 years with a blood pressure <140/90 mmHg. Risk of Hypertension (%) Years Men Women Vasan RS, et al. JAMA . 2002; 287:1003-1010. Copyright 2002, American Medical Association.

Mortality According to Blood Pressure in Men Age 50 to 69 Society of Actuaries. Blood Pressure Study, 1939. Ratio (%) of actual to expected mortality Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)

Blood Pressure and Risk for Coronary Heart Disease in Men Age-adjusted annual incidence of CHD per 1000 Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at baseline Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Age 65-94 Age 35-64 Age 65-94 Age 35-64 Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.

Risk of CHD Death According to SBP and DBP in MRFIT Relative risk of CHD mortality He J, et at. Am Heart J. 1999;138:211-219. Copyright 1999, Mosby Inc. <112 <71 Decile 112- 71- 118- 76- 121- 79- 125- 81- 129- 84- 132- 86- 137- 89- 142- 92- > 151 > 98 (lowest 10%) (highest 10%) SBP (mmHg) DBP (mmHg) Systolic blood pressure (SBP) Diastolic blood pressure (DBP) CHD=coronary heart disease 1 2 3 4 5 6 7 8 9 10

Risk of Stroke Death According to Blood Pressure: MRFIT Relative Risk of Stroke Death <112 <71 1 2 3 4 5 6 7 8 9 10 Decile 112  71  118  76  121  79  125  81  129  84  132  86  137  89  142  92  ≥ 151 ≥98 (Lowest 10%) (Highest 10%) SBP (mmHg) DBP (mmHg) Systolic Blood Pressure (SBP) Diastolic Blood Pressure (DBP) Stamler J, et al. Arch Intern Med . 1993;153:598-615; He J, Whelton PK. Am Heart J . 1999;138(Pt 2):211-219. MRFIT, Multiple Risk Factor Intervention Trial.

Isolated Systolic Hypertension and CVD Risk in Framingham Heart Study Age-adjusted annual CVD event rate per 1000 Wilking SV et al. JAMA. 1988;260:3451-3455. Men Women ISH BP  160/<95 mmHg BP <140/95 mmHg 82 43 33 2.4 18 2.5 CVD=cardiovascular disease ISH=isolated systolic hypertension P<0.001 for difference between both men and women with ISH and blood pressure (BP) <140/95 mmHg

 

Old and New Antihypertensive Therapy and Diabetes: Important Findings of 4 Major Studies

Old and New Antihypertensive Therapy and Diabetes: Important Findings of 4 Major Studies STOP-2 (1999) The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes INSIGHT (2000) The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications NORDIL (2000) The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death ARIC (2000) In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk

STOP-2 (1999)

The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes

INSIGHT (2000)

The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications

NORDIL (2000)

The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death

ARIC (2000)

In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes

Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk

STOP-2 The S wedish T rial in O ld P atients With Hypertension- 2 (STOP-2) was a prospective, randomized trial enrolling 6,614 patients, 70-84 years old, with hypertension (systolic BP  180 mmHg, diastolic BP  105 mmHg, or both) Patients were assigned to treatment with conventional antihypertensive drugs (n=2,213), ACE inhibitors (n=2,205), or calcium channel blockers (n=2,196) Endpoints were fatal stroke, fatal myocardial infarction, and other fatal cardiovascular disease 719 patients (10.9%) had diabetes at baseline Hansson L, et al. Lancet. 1999;354:1751-1756.

The S wedish T rial in O ld P atients With Hypertension- 2 (STOP-2) was a prospective, randomized trial enrolling 6,614 patients, 70-84 years old, with hypertension (systolic BP  180 mmHg, diastolic BP  105 mmHg, or both)

Patients were assigned to treatment with conventional antihypertensive drugs (n=2,213), ACE inhibitors (n=2,205), or calcium channel blockers (n=2,196)

Endpoints were fatal stroke, fatal myocardial infarction, and other fatal cardiovascular disease

719 patients (10.9%) had diabetes at baseline

STOP-2 Change in Supine Blood Pressure From Baseline* Change in BP from baseline (mmHg) Hansson L, et al. Lancet. 1999;354:1751-1756. *Among patients who survived at least 24 months

STOP-2 Frequency of Events Per 1000 Patient Years Events per 1000 patient years Hansson L, et al. Lancet. 1999;354:1751-1756. P=0.018 P=0.025

Old and New Antihypertensive Therapy and Diabetes: Important Findings of 4 Major Studies STOP-2 (1999) The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes INSIGHT (2000) The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications NORDIL (2000) The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death ARIC (2000) In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk

STOP-2 (1999)

The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes

INSIGHT (2000)

The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications

NORDIL (2000)

The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death

ARIC (2000)

In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes

Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk

INSIGHT The I nternational N ifedipine GITS S tudy: I ntervention as a G oal in H ypertension T reatment (INSIGHT) was a prospective, randomized trial that enrolled 6,321 patients, 55-80 years old, with hypertension (BP  150/95 mmHg, or systolic BP  160 mmHg) and at least one additional risk factor Patients were randomized to the calcium channel blocker nifedipine (n=3,157) or to the diuretic combination HCTZ + amiloride (n=3,164) The primary outcomes were cardiovascular death, myocardial infarction, heart failure, and stroke 1,302 patients (20.6%) had type 1 or type 2 diabetes at baseline Brown MJ, et al. Lancet. 2000;356:366-372.

The I nternational N ifedipine GITS S tudy: I ntervention as a G oal in H ypertension T reatment (INSIGHT) was a prospective, randomized trial that enrolled 6,321 patients, 55-80 years old, with hypertension (BP  150/95 mmHg, or systolic BP  160 mmHg) and at least one additional risk factor

Patients were randomized to the calcium channel blocker nifedipine (n=3,157) or to the diuretic combination HCTZ + amiloride (n=3,164)

The primary outcomes were cardiovascular death, myocardial infarction, heart failure, and stroke

1,302 patients (20.6%) had type 1 or type 2 diabetes at baseline

INSIGHT Endpoints Brown MJ, et al. Lancet. 2000;356:366-372. Percent of patients with event *Cardiovascular death, myocardial infarction, heart failure, and stroke P=0.017

Old and New Antihypertensive Therapy and Diabetes: Important Findings of 4 Major Studies STOP-2 (1999) The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes INSIGHT (2000) The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications NORDIL (2000) The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death ARIC (2000) In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk

STOP-2 (1999)

The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes

INSIGHT (2000)

The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications

NORDIL (2000)

The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death

ARIC (2000)

In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes

Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk

NORDIL The NOR dic DIL tiazem (NORDIL) Study was a prospective, randomized, open-label study that enrolled 10,881 patients, 50-74 years old, with diastolic blood pressure  100 mmHg Patients were assigned to a non-dihydropyridine calcium channel blocker, diltiazem (n=5,410), or to diuretics, beta-blockers, or both (n=5,471) Average follow-up was 4.5 years The combined primary endpoint was fatal and non-fatal stroke, fatal and non-fatal myocardial infarction, and other cardiovascular death 727 patients (6.7%) had type 2 diabetes at baseline Hansson L, et al. Lancet. 2000;356:359-365.

The NOR dic DIL tiazem (NORDIL) Study was a prospective, randomized, open-label study that enrolled 10,881 patients, 50-74 years old, with diastolic blood pressure  100 mmHg

Patients were assigned to a non-dihydropyridine calcium channel blocker, diltiazem (n=5,410), or to diuretics, beta-blockers, or both (n=5,471)

Average follow-up was 4.5 years

The combined primary endpoint was fatal and non-fatal stroke, fatal and non-fatal myocardial infarction, and other cardiovascular death

727 patients (6.7%) had type 2 diabetes at baseline

NORDIL Change in Blood Pressure From Baseline* *For patients in study for at least 24 months Hansson L, et al. Lancet. 2000;356:359-365. Change in BP from baseline (mmHg) P<0.001

NORDIL Event Rates Per 1000 Patient Years Hansson L, et al. Lancet. 2000;356:359-365. Event rate per 1000 patient years *Fatal and non-fatal stroke, fatal and non-fatal myocardial infarction, and other cardiovascular death TIA=transient ischemic attack P=0.04

NORDIL Event Rates Per 1000 Patient Years in Diabetics Hansson L, et al. Lancet. 2000;356:359-365. Event rate per 1000 patient years P=NS for primary endpoint and components *Fatal and non-fatal stroke, fatal and non-fatal myocardial infarction, and other cardiovascular death TIA=transient ischemic attack

Old and New Antihypertensive Therapy and Diabetes: Important Findings of 4 Major Studies STOP-2 (1999) The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes INSIGHT (2000) The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications NORDIL (2000) The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death ARIC (2000) In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk

STOP-2 (1999)

The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes

INSIGHT (2000)

The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications

NORDIL (2000)

The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death

ARIC (2000)

In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes

Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk

ARIC The A therosclerosis R isk I n C ommunities (ARIC) Study is an ongoing observational study of clinical and subclinical atherosclerotic vascular disease in 15,792 patients, 45-64 years old, from 4 geographical communities in the United States An interim analysis was conducted on 12,550 nondiabetic subjects enrolled in the ARIC study The risk of developing diabetes was assessed relative to the absence (n=8,746) or presence (n=3,804) of hypertension and according to the type of antihypertensive therapy used Gress TW, et al. N Engl J Med. 2000;342:905-912.

The A therosclerosis R isk I n C ommunities (ARIC) Study is an ongoing observational study of clinical and subclinical atherosclerotic vascular disease in 15,792 patients, 45-64 years old, from 4 geographical communities in the United States

An interim analysis was conducted on 12,550 nondiabetic subjects enrolled in the ARIC study

The risk of developing diabetes was assessed relative to the absence (n=8,746) or presence (n=3,804) of hypertension and according to the type of antihypertensive therapy used

ARIC Substudy Baseline Characteristics Gress TW, et al. N Engl J Med. 2000;342:905-912. Copyright 2000 Massachusetts Medical Society. All rights reserved. No hypertension n=8,746 Hypertension n=3,804 P value Age (yrs) 53.3 55.3 <0.001 Female (%) 55.5 55.6 0.91 Serum glucose (mg/dl) 97.6 101.0 <0.001 Serum insulin (pmol/liter) 68.4 97.8 <0.001 Systolic BP (mmHg) 113.2 134.4 <0.001 Diastolic BP (mmHg) 69.9 80.9 <0.001 Coronary artery disease (%) 3.1 6.2 <0.001 Peripheral vascular disease (%) 0.5 1.2 <0.001 History of stroke (%) 0.7 2.6 <0.001 Hypercholesterolemia (%) 18.9 24.6 <0.001 Renal insufficiency (%) 2.4 5.7 <0.001

ARIC Substudy Incidence of Diabetes Mellitus Incidence rates per 1000 person-years Gress TW, et al. N Engl J Med. 2000;342:905-912.

Summary: Old and New Antihypertensive Therapy in Diabetes Both older and newer antihypertensive agents reduce cardiovascular risks in diabetes Superiority of a single class of antihypertensive agents in diabetes has not been established unequivocally In diabetics with specific co-morbid conditions, newer antihypertensive agents have demonstrated small incremental benefits in several large treatment trials Adverse effects with certain antihypertensive agents have been demonstrated in diabetes CCBs with long duration of action have not showed consistent adverse effects

Both older and newer antihypertensive agents reduce cardiovascular risks in diabetes

Superiority of a single class of antihypertensive agents in diabetes has not been established unequivocally

In diabetics with specific co-morbid conditions, newer antihypertensive agents have demonstrated small incremental benefits in several large treatment trials

Adverse effects with certain antihypertensive agents have been demonstrated in diabetes

CCBs with long duration of action have not showed consistent adverse effects

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