Search

Background: An important issue in clinical practice is how to treat patients whose blood pressure does not respond to the first antihypertensive drug selected. Objective: To analyze the antihypertensive response of patients who had failed to achieve their diastolic blood pressure goal (

Older hypertensive patients benefit from long term antihypertensive agents such as diuretics, beta blockers, calcium channel blockers or angiotensin converting enzyme inhibitors. Significant reductions in coronary events and mortality were achieved in various degrees among different races. These results were derived from different trials involving thousands of hypertensive men. Summaries of these trials are presented., When you are treating a middle-aged or older patient with elevated blood pressure, you need the answers to three key questions: * What levels of blood pressure require treatment? * [...]

This discussion of documented and possible cardioprotective effects of angiotensin-converting enzyme (ACE) inhibitors examines the variety of sites along the pathway to end-stage heart disease at which they might intervene. In addition to their antihypertensive activity, their effects on left ventricular hypertrophy, lipid profiles, and insulin sensitivity are discussed in comparison to the effects of other classes of antihypertensive agents on these risk factors. The ability of ACE inhibitors to prevent the progression of congestive heart failure and reduce mortality is documented and a summary of data demonstrating benefits of their use In postmyocardial infarction patients with low ejection fraction Is presented. (Am J Cardiol 1992;70:10 [-17 1)

Congestive heart failure (CHF) is the inability of the heart to pump blood, and leads to fluid congestion in the lungs. It is associated with impaired function of the left heart ventricle, which is characterized by ventricular dilation and an ejection fraction of less than 35 to 40 percent. (The ejection fraction is the proportion of blood emptied from the left ventricle at the end of a contraction.) Effective treatment of severe CHF should prolong survival and improve the patient's quality of life, whereas treatment of mild-to-moderate heart failure should decrease symptoms and provide clinical benefits, such as improved ability to exercise. In patients without symptoms of CHF, treatment should prolong survival, slow the progression of CHF, and maintain the function of the left ventricle. Angiotensin converting-enzyme (ACE) inhibitors are cardiovascular drugs that prevent the formation of angiotensin, a factor that causes blood vessels to constrict. Evidence showing the effectiveness of ACE inhibitors in treating various degrees of CHF is discussed. In addition to preventing the production of angiotensin, ACE inhibitors act through various mechanisms. They have effects on prostaglandins, the sympathetic nervous system, circulatory factors, heart metabolism, and decrease the incidence of abnormal heart rhythms. These agents have been shown to be more effective than other vasodilators, such as nitrates, hydralazine, alpha-adrenergic blockers, and calcium antagonists. ACE inhibitors are also more effective in improving survival and slowing the impairment of left ventricular function than digoxin, an agent commonly used to treat CHF. ACE inhibitors are well tolerated, but may cause hypotension (an abnormal drop in blood pressure) and worsen kidney function in vulnerable patients. The benefits of ACE inhibitors in the treatment of patients with CHF far outweigh the risks. (Consumer Summary produced by Reliance Medical Information, Inc.)

Background: Treatment with angiotensin-converting enzyme (ACE) inhibitors reduces mortality and morbidity in patients with chronic heart failure (CHF), but most affected patients are not receiving these agents or are being treated with doses lower than those found to be efficacious in trials, primarily because of concerns about the safety and tolerability of these agents, especially at the recommended doses. The present study examines the safety and tolerability of high- compared with low-dose lisinopril in CHF. Methods: The Assessment of Lisinopril and Survival study was a multicenter, randomized, double-blind trial in which patients with or without previous ACE inhibitor treatment were stabilized receiving medium-dose lisinopril (12.3 or 15.0 mg once daily [OD]) for 2 to 4 weeks and then randomized to high- (35.0 or 32.5 mg OD) or low-dose (5.0 or 2.5 mg OD) groups. Patients with New York Heart Association classes II to IV CHF and left ventricular ejection fractions of no greater than 0.30 (n = 3164) were randomized and followed up for a median of 46 months. We examined the occurrence of adverse events and the need for discontinuation and dose reduction during treatment, with a focus on hypotension and renal dysfunction. Results: Of 405 patients not previously receiving an ACE inhibitor, doses in only 4.2% could not be titrated to the medium doses required for randomization because of symptoms possibly related to hypotension (2.0%) or because of renal dysfunction or hyperkalemia (2.3%). Doses in more than 90% of randomized patients in the high- and low-dose groups were titrated to their assigned target, and the mean doses of blinded medication in both groups remained similar throughout the study. Withdrawals occurred in 27.1% of the high- and 30.7% of the low-dose groups. Subgroups presumed to be at higher risk for ACE inhibitor intolerance (blood pressure, [is less than] 120 mm Hg; creatinine, [is greater than or equal to] 132.6 [micro]mol/L [[is greater than or equal to] 1.5 mg/dL]; age, [is greater than or equal to] 70 years; and patients with diabetes) generally tolerated the high-dose strategy. Conclusions: These findings demonstrate that ACE inhibitor therapy in most patients with CHF can be successfully titrated to and maintained at high doses, and that more aggressive use of these agents is warranted. Arch Intern Med. 2001;161:165-171

Context: Angiotensin-converting enzyme (ACE) inhibitors have been shown to decrease mortality in patients with myocardial infarction and depressed left ventricular function, but physicians may be reluctant to prescribe ACE inhibitors to patients with concomitant renal insufficiency. Objective: To evaluate whether patients with depressed left ventricular ejection fraction following acute myocardial infarction have a similar reduction in mortality from ACE inhibitors regardless of their renal function. Design: Retrospective cohort study using medical record data. Setting: All nonfederal acute care hospitals. Patients: A cohort of 20902 Medicare beneficiaries aged 65 years and older directly admitted to the hospital from February 1, 1994, through July 30, 1995, and with a documented left ventricular ejection fraction of less than 40% measured by echocardiography, radionuclide scintigraphy, or angiography following a confirmed acute myocardial infarction. Main Outcome Measures: One-year survival for patients who received or who did not receive an ACE inhibitor at hospital discharge, stratified by the patient's level of renal function. Results: For the entire cohort, the receipt of an ACE inhibitor on hospital discharge was associated with greater 1-year survival (hazards ratio, 0.84; 95% confidence interval, 0.77-0.91) after adjusting for patient demographic characteristics, comorbidity, severity of illness (including left ventricular ejection fraction), and the receipt of other therapies. In stratified models, the receipt of an ACE inhibitor was associated with a 37% (16%-52%) lower mortality for patients who had poor renal function (serum creatinine level, [is less than] 265 [micro]mol/L [[is less than] 3 mg/dL]) and a 16% (8%-23%) lower mortality for patients who had better renal function. Use of aspirin therapy attenuated the benefit of ACE inhibitors in patients with poor renal function. Conclusions: Moderate renal insufficiency should not be considered a contraindication to the use of ACE inhibitors in patients with depressed left ventricular ejection fraction following myocardial infarction. Use of aspirin therapy may attenuate the benefit of ACE inhibitors in patients with high serum creatinine levels; therefore, further studies are needed to determine whether treatment with aspirin, alternative antiplatelet agents, or anticoagulation is indicated for these patients. Arch Intern Med. 2000;160:2645-2650

Background: We conducted a retrospective cohort study on a random sample of adult patients with hypertension in a large health maintenance organization to assess the feasibility of documenting blood pressure (BP) control and to compare different measures for defining BP control. Methods: Three criteria for BP control were assessed: systolic BP less than 140 mm Hg; diastolic BP less than 90 mm Hg; and combined BP control, with systolic BP less than 140 mm Hg and diastolic BP less than 90 mm Hg. Four methods of assessing hypertension control by the above criteria were examined: proportion of patients with BP under control at 75% and 50% or more of their office visits; the mean of all pressures during the study period; and the BP from the last visit during the study period. Results: The proportion of patients meeting each criterion for control was similar whether we used the mean BP for all visits, the last recorded BP, or control at 50% or more of visits. Control rates were substantially lower when the more stringent assessment, 75% of visits, was used. The proportion of patients with combined BP control at 75% or more of their visits was half that of the other methods. Conclusions: In this health maintenance organization population, results with the use of the simplest approach, the last BP measurement recorded, were similar to results with the mean BP. Our findings indicate that evaluation of BP control in a large health maintenance organization will find substantial room for improvement, and clinicians should be encouraged to be more aggressive in their management of hypertension, especially with regard to the systolic BP, which until recent years has been underemphasized. Arch Intern Med. 1999;159:2673-2677

Background: Studies to determine whether care by cardiologists improves the survival of patients with acute myocardial infarction (MI) have produced conflicting results, and it is not known what accounts for differences in patient outcome by physician specialty. Objectives: To evaluate whether cardiologists provide more recommended therapies to elderly patients with acute MI and, if so, to determine whether variations in processes of care account for differences in patient outcome. Design: Retrospective cohort study using medical chart data and administrative data files. Setting: All nonfederal acute care hospitals in California. Patients: A cohort of 7663 Medicare beneficiaries 65 years and older directly admitted to the hospital with a confirmed acute MI from April 1994 to July 1995 with complete data regarding potential contraindications to recommended therapies. Main Outcome Measures: Percentage of 'good' and 'ideal' candidates for a given acute MI therapy who actually received that therapy, percentage who received exercise stress testing or coronary angiography, percentage who underwent revascularization, and 1-year mortality, stratified by specialty of the attending physician. Results: During hospitalization, good candidates for aspirin were more likely to receive aspirin if they were treated by cardiologists (87%) than by medical subspecialists (73%; P [is less than] .001), general internists (84%; P = .003), or family practitioners (81%; P [is less than] .001). Cardiologists were also more likely to treat good candidates with thrombolytic therapy (51%) than were medical subspecialists (29%; P [is less than] .001), general internists (40%; P [is less than] .001), or family practitioners (27%; P [is less than] .001). Patients of cardiologists were 2- to 4-fold more likely to undergo a revascularization procedure. Despite these differences in utilization, we found similar 30-day mortality rates across physician specialties. However, 1-year mortality rates were greater for patients treated by medical subspecialists (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.6-2.3), general internists (OR, 1.4; 95% CI, 1.3-1.6), and family practitioners (OR, 1.7; 95% CI, 1.4-1.9) than for those treated by cardiologists. Adjusting for differences in patient and hospital characteristics markedly reduced the ORs for those treated by medical subspecialists (OR, 1.2; 95% CI, 0.9-1.4), general internists (OR, 1.1; 95% CI, 1.0-1.3), and family practitioners (OR, 1.3; 95% CI, 1.1-1.6), whereas further adjustment for medication use and revascularization procedures had little effect. Conclusions: Differences in the use of recommended therapies by physician specialty are generally small and do not explain differences in patient outcome. In comparison, differences among patients treated by physicians of various specialties (case mix) have a large impact on patient outcome and may account for the residual survival advantage of patients treated by cardiologists. With the exception of the in-hospital use of aspirin, recommended MI therapies are markedly underused, regardless of the specialty of the physician. Arch Intern Med. 1999;159:1429-1436

Hypertension and left ventricular (LV) hypertrophy are independent risk factors for the development of coronary artery disease. To determine whether patients at higher risk for coronary artery disease can be identified, 40 asymptomatic hypertensive men with LV hypertrophy were prospectively studied using exercise thallium-201 scintigraphy and exercise radionuclide angiography. Endpoints indicative of coronary artery disease were defined as the subsequent development of typical angina pectoris, which occurred in 8 patients during a median follow-up of 38 months, or myocardial infarction, which did not occur. The exercise electrocardiogram was interpreted by standard ST-segment criteria and by a computerized treadmill exercise score. Abnormal ST-segment responses were present in 16 of the 40 hypertensives (40%), whereas the treadmill score was positive in 8 of those same 40 patients (20%). Scintigraphic perfusion defects assessed both visually and semiquantitatively were observed in 8 of 40 (20%) patients. An abnormal ejection fraction response to exercise was present in 40% (16 of 40) of patients, and 3 of 40 (7.5%) developed new wall motion abnormalities during exercise. Six of 8 patients with either perfusion defects or abnormal treadmill score developed typical angina during follow-up. All 5 patients with concordant positive exercise scintigrams and treadmill score developed chest pain during follow-up and had coronary artery disease confirmed by coronary angiography. However, only 7 of 16 (44%) patients with positive ST changes or abnormal ejection fraction responses during exercise developed chest pain during follow-up. In contrast, of 32 patients with negative scintigrams only 2 developed atypical chest pain syndromes, and significant coronary artery disease was excluded by angiography in 1 patient. Thus, both thallium-201 scintigraphy and treadmill score accurately detect coronary artery disease in asymptomatic hypertensive patients with LV hypertrophy and predict the future development of angina symptoms. (Am J Cardiol 1989;64:45-49)

High blood pressure (hypertension) is a known risk factor for the development of atherosclerosis, the narrowing of blood vessels supplying the brain, heart and other tissues. Lowering blood pressure with antihypertensive medication has been shown to reduce some of the consequences of high blood pressure, such as stroke and kidney insufficiency. However, the use of blood pressure lowering drugs has not reduced the overall incidence of cardiac events. A review of antihypertensive drug trials was conducted to determine the relationship between hypertension, atherosclerosis and myocardial ischemia (reduced blood supply to the heart muscle). Many of the studies reviewed failed to demonstrate the positive effects of antihypertensive therapy because the study size, the criteria used for patients to enter the study or the length of the study was inadequate. The inclusion of individuals at low risk with suspected coronary artery disease can contribute to the failure of treatment trials to demonstrate a reduction in coronary heart disease. Patients with silent (painless) coronary artery blockages at the onset of the study will develop the disease regardless of efforts to reduce high blood pressure. Since these are the patients more likely to have future cardiac events, inclusion of these patients in short-term drug trials does not lead to an accurate assessment of the beneficial effects of antihypertensive therapy. Therefore, additional long-term drug trials with predetermined disease status are warranted to determine the impact of antihypertensives on coronary heart disease. (Consumer Summary produced by Reliance Medical Information, Inc.)

Congestive heart failure is the inability of the heart to effectively pump blood, which leads to fluid congestion or accumulation in the lungs. Between the 1960s and 1980s, agents were developed to treat congestive heart failure: diuretics increase the elimination of body fluids; vasodilators dilate blood vessels; and angiotensin converting-enzyme inhibitors prevent the actions of angiotensin to constrict blood vessels. Angiotensin converting-enzyme inhibitors were shown to improve symptoms and prolong life. However, in the 1990s, congestive heart failure remains a major public health problem, affecting nearly four million Americans and causing almost 400,000 deaths each year. In May 1989 a symposium was held in Jerusalem to discuss the most important unresolved issues in heart failure and consider future developments. Issues included the treatment of ventricular arrhythmias (abnormal heart rhythms) in patients with chronic heart failure; the effectiveness of vasodilators, such as nitrates, in the treatment of heart failure; and the role of angiotensin converting-enzyme inhibitors in treating patients with early or mild heart failure. Discussion of future developments focused on the practical management of heart failure and basic scientific research in the biochemistry, and cellular and molecular biology of the heart. (Consumer Summary produced by Reliance Medical Information, Inc.)