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Although atrial fibrillation (AF) guidelines indicate that pharmacological blockade of the renin-angiotensin system may be considered for primary AF prevention in hypertensive patients, previous studies have yielded conflicting results. We sought to determine whether randomization to lisinopril reduces incident AF or atrial flutter (AFL) compared with chlorthalidone in a large clinical trial cohort with extended post-trial surveillance. We performed a secondary analysis of the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), a randomized, double-blind, active-controlled clinical trial that enrolled hypertensive individuals ≥55 years of age with at least one other cardiovascular risk factor. Participants were randomly assigned to receive amlodipine, lisinopril, or chlorthalidone. Individuals with elevated fasting low-density lipoprotein cholesterol levels were also randomized to pravastatin versus usual care. The primary outcome was the development of either AF or AFL as diagnosed by serial study ECGs or by Medicare claims data. Among 14 837 participants without prevalent AF or AFL, 2514 developed AF/AFL during a mean 7.5±3.2 years of follow-up. Compared with chlorthalidone, randomization to either lisinopril (hazard ratio, 1.04; 95% confidence interval, 0.94-1.15; P=0.46) or amlodipine (hazard ratio, 0.93; 95% confidence interval, 0.84-1.03; P=0.16) was not associated with a significant reduction in incident AF/AFL. Compared with chlorthalidone, treatment with lisinopril is not associated with a meaningful reduction in incident AF or AFL among older adults with a history of hypertension. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.

A report determines whether an angiotensin-converting enzyme (ACE) inhibitor or calcium channel blockers (CCB) is superior to a thiazide-type diuretic in reducing cardiovascular disease (CVD) incidence in racial subgroups. While the improved outcomes with chlorthalidone were more pronounced for some outcomes in African Americans than in Americans, thiazide-type diureti remain the drugs of choice for initial therapy of hypertension in both these hypertenve patients.

Objectives. African Americans have been shown to have longer delay times than the majority population in seeking care for acute cardiac problems. The purpose of this study was to determine whether socioeconomic factors affect delay times. Methods. Structured interviews were administered to 254 African Americans admitted to a public hospital and 194 African Americans admitted to a private hospital for suspected acute myocardial infarction. Results. Patient characteristics found by multiple regression analysis to affect decision-making and travel time for care-seeking were structural access to care, persistence of symptoms, degree of incapacitation, consultation with a layperson, consultation with medical professionals, and mode of transportation. Conclusions. Within-group differences were found to be related to socioeconomic status. Strategies to increase knowledge about heart attack symptoms, improve access to care, and improve the socioeconomic status of at-risk African Americans are indicated. (Am J Public Health. 1994;84:965-970), Delay time in seeking health-care for chest pain among African-Americans may differ depending on socioeconomic status. Between 1988 and 1990, in-patients admitted for chest pain were interviewed at two Los Angeles hospitals. One served patients with no insurance and no other source of medical care (254 patients interviewed), the other was part of a private health maintenance organization and all patients had insurance and a regular doctor (194 patients interviewed). Factors affecting delay in obtaining care were similar to those involving white patients. In making the decision to seek care, these factors included hospital site, severity of symptoms, consulting with friend or family, and consulting a doctor. Factors affecting the delay in obtaining care included transportation mode, and informing friends or family. The group attending the public hospital took 40% to 80% longer to arrive at the hospital.

Abstract Background The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a randomized, double-blind, active-controlled trial designed to compare the rate of coronary heart disease events in high-risk hypertensive participants initially randomized to a diuretic (chlorthalidone) versus each of three alternative antihypertensive drugs: alpha-adrenergic blocker (doxazosin), ACE-inhibitor (lisinopril), and calcium-channel blocker (amlodipine). Combined cardiovascular disease risk was significantly increased in the doxazosin arm compared to the chlorthalidone arm (RR 1.25; 95% CI, 1.17–1.33; P < .001), with a doubling of heart failure (fatal, hospitalized, or non-hospitalized but treated) (RR 2.04; 95% CI, 1.79–2.32; P < .001). Questions about heart failure diagnostic criteria led to steps to validate these events further. Methods and Results Baseline characteristics (age, race, sex, blood pressure) did not differ significantly between treatment groups (P < .05) for participants with heart failure events. Post-event pharmacologic management was similar in both groups and generally conformed to accepted heart failure therapy. Central review of a small sample of cases showed high adherence to ALLHAT heart failure criteria. Of 105 participants with quantitative ejection fraction measurements provided, (67% by echocardiogram, 31% by catheterization), 29/46 (63%) from the chlorthalidone group and 41/59 (70%) from the doxazosin group were at or below 40%. Two-year heart failure case-fatalities (22% and 19% in the doxazosin and chlorthalidone groups, respectively) were as expected and did not differ significantly (RR 0.96; 95% CI, 0.67–1.38; P = 0.83). Conclusion Results of the validation process supported findings of increased heart failure in the ALLHAT doxazosin treatment arm compared to the chlorthalidone treatment arm.

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) consisted of 42,418 participants randomized to one of four antihypertensive treatment groups: chlorthalidone, amlodipine, lisinopril, or doxazosin. A subset of these participants with fasting low-density lipoprotein cholesterol levels 100-189 mg/dL were randomized into a lipid-lowering component: 5170 to receive pravastatin (40 mg daily) and 5185 to receive usual care. This report describes the characteristics and lipid distribution of these participants. There were no important differences between the randomized treatment groups. Women had higher total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol than men. There was a similar finding for black participants compared with whites, except blacks had lower triglycerides. Diabetics had lower high-density lipoprotein cholesterol and higher triglycerides than nondiabetics, and patients with body mass index <25 kg/m² had higher high-density lipoprotein cholesterol but lower low-density lipoprotein cholesterol and triglycerides than patients with higher body mass index. The success of the randomization of this large, diverse population and the differences in the lipid distributions among its subgroups will allow further understanding of optimal lipid-lowering treatment. [ABSTRACT FROM AUTHOR]

The ability to identify patients with special psychosocia1 needs is necessary to effectively target cardiac rehabilitation. Recent evidence suggests that social relationships and social support may influence recovery from a myocardial infarction (MI). A panel study is used to explore the predictive value of assessing social support in MI recovery and to examine its relative contribution to multiple recovery outcomes when compared to illness severity, pre-illness stressful life events, and personal sense of control. Analysis of data collected through structured interviews during acute hospitalization (N = 114) and again 6 months later (N = 75) and one year later (N = 60) finds statistically significant associations between measures of support and psychological, functional, and physical outcomes. Multiple regression analysis indicates that the relative contribution of support to outcome variance is less than that of the patient's sense of personal control. Methodological and clinical implications of the study are discussed. [ABSTRACT FROM PUBLISHER]