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Biomedical subjects

M H Alderman

Publications and source records attributed to M H Alderman.

At least 19 recordsLinked to original sources
PubMed2001

Clinical Implications of Recent Findings from the Antihypertensive and Lipid-Lowering Treatment To Prevent Heart Attack Trial (ALLHAT) and Other Studies of Hypertension.

Several recent comparative trials in hypertension have reported that similar blood pressure reductions may not necessarily translate into similar reductions in risk for cardiovascular complications. Thus, the method used to lower blood pressure may be important. In the Antihypertensive and Lipid-Lowering Treatment To Prevent Heart Attack Trial (ALLHAT), low-dose chlorthalidone as the first-line drug was superior to doxazosin. The 25% higher risk for major cardiovascular events associated with doxazosin was attributed primarily to a doubling in the risk for heart failure. A meta-analysis of patients with type 2 diabetes mellitus suggested that despite achieving similar blood pressure reductions, angiotensin-converting enzyme inhibitors are superior to other antihypertensive drugs in reducing the risk for acute myocardial infarction and cardiovascular events, but not stroke. Although individual comparative trials have failed to show conclusively that calcium-channel blockers differ from other antihypertensive drugs, a meta-analysis that included all published trials concluded that calcium-channel blockers are inferior to other classes of drugs in reducing the risk for acute myocardial infarction and heart failure. These observations suggest not only that antihypertensive drugs may have important mechanisms of action apart from blood pressure lowering but also that effective treatment is not a matter of simply lowering blood pressure. These findings have potential implications for the regulatory approval of antihypertensive agents, revisions of treatment guidelines, the design of future randomized trials comparing different antihypertensive drugs and, most important, the selection of drugs for the treatment of hypertensive patients.

Antihypertensive Agents↗
PubMed2001

Serum uric acid as a cardiovascular risk factor for heart disease.

Cardiovascular risk factors are those environmental, behavioral, genetic, and/or personal factors whose presence indicates a heightened risk of subsequent vascular disease events. Smoking, hypertension, and hyperlipidemia, initially identified by astute clinicians, were all subsequently confirmed and defined as risk factors through formal prospective epidemiologic study, long before evidence of causality was available. Ultimately, clinical trials demonstrated a reversible contribution of both high blood pressure and elevated lipids to stroke and heart disease. As a result, these risk factors are now the cornerstones for both assessment of relative cardiovascular risk and targets for preventive intervention. The criterion for risk factor status is a strong, consistent, timely, and statistically significant association to disease events that is independent of and unconfounded by other known risk factors. The purpose of this review is to assess available data to determine whether or not serum uric acid meets the standard for designation as a risk factor.

Female↗
PubMed2001

High and low serum potassium associated with cardiovascular events in diuretic-treated patients.

OBJECTIVE: To determine the relationship of moderately high and low concentrations of serum potassium with cardiovascular disease events among treated hypertensive patients. DESIGN: An observational cohort study with prospectively collected data. SETTING: A worksite treatment program for mild hypertension. PATIENTS: All program participants with baseline and at least one annual follow-up measure of serum potassium; 7,653 individuals with 6.7 years mean follow-up met these criteria. MAIN OUTCOME MEASURES: Outcome events were admissions to hospital because of cardiovascular disease, and deaths. The research question regarding serum potassium categories was formulated after data collection. The serum potassium concentration (mean +/- 2SD) of the study population was used to define low (3.0-3.5 mmol/l), high (5.1-5.9 mmol/l) and middle (3.6-5.0 mmol/l) categories. RESULTS: Individuals with low (n = 146) and high (n = 226) serum potassium had significantly greater risk for cardiovascular disease events than those in the middle category (n = 7,281). Multivariate adjusted hazard ratios from Cox models were 2.6 [95% confidence intervals (CI) 1.5-4.4] for the low potassium group and 1.7 (95% CI 1.0-2.7) for the high potassium group, with the middle group as reference. Among 1,679 individuals who regularly took diuretics, hazard ratios were 4.3 (95% CI 2.4-7.9) for the low potassium group and 6.7 (95% CI 2.8-15.9) for the high group. Neither low nor high potassium was significantly associated with outcome events for those not regularly using diuretics. CONCLUSIONS: These data confirm an association of mild hypokalemia with increased cardiovascular events among diuretic-treated hypertensive patients. In addition, we have found a similar increased cardiovascular risk associated with modest hyperkalemia among these patients. Whether modification of these serum potassium concentrations would alter that risk remains to be determined.

Cardiovascular Diseases↗
PubMed2001

Trend of stroke hospitalization, United States, 1988-1997.

BACKGROUND AND PURPOSE: Age-adjusted stroke mortality in the United States has declined in recent decades. However, the course of stroke incidence is less certain. To address this issue, we determined trends of stroke hospitalization and in-hospital case fatality during 1988-1997. METHODS: Stroke hospitalization was estimated from National Hospital Discharge Survey as numerator and Current Population Survey as denominator. Hospitalization rates were determined and stratified by patient characteristics. Average length of hospital stay was also determined. In-hospital mortality was specified by sex, age, and other patient characteristics. The change in these rates over 10 years and average annual percent changes were calculated. RESULTS: During 1988-1997, age-adjusted stroke hospitalization rate increased 18.6% (from 560 to 664/100 000; P=0.043), while total hospitalization increased from 592 811 to 821 760. This increase was limited to persons aged >/=65 years. Patients in the South had the highest stroke hospitalization rates, and those in the West had the lowest. Overall, 58% of strokes were classified as ischemic, 13% as hemorrhagic, and 29% as other. Over these 10 years, stroke patients having coincident diabetes, hypertension, and congestive heart failure increased 17.4% (P=0.17), 34% (P=0.05), and 31% (P=0.091), respectively. The average length of hospital stay fell from 11.1 to 6.2 days (44.1%; P=0.012). As a result, despite an increase in hospitalizations for stroke, the total person-days in hospital actually decreased by 22% (P=0.06). CONCLUSIONS: The declining age-adjusted stroke mortality in the United States has not been accompanied by a fall in hospitalization over recent years. Thus far, however, decrease in length of stay has more than offset increased admission. At the same time, the sharp drop in hospital case fatality rates suggests that continuing decline in stroke mortality may be due, in large part, to improved survival after acute stroke.

Acute Disease↗
PubMed2000

Health outcomes associated with calcium antagonists compared with other first-line antihypertensive therapies: a meta-analysis of randomised controlled trials.

BACKGROUND: Several observational studies and individual randomised trials in hypertension have suggested that, compared with other drugs, calcium antagonists may be associated with a higher risk of coronary events, despite similar blood-pressure control. The aim of this meta-analysis was to compare the effects of calcium antagonists and other antihypertensive drugs on major cardiovascular events. METHODS: We undertook a meta-analysis of trials in hypertension that assessed cardiovascular events and included at least 100 patients, who were randomly assigned intermediate-acting or long-acting calcium antagonists or other antihypertensive drugs and who were followed up for at least 2 years. FINDINGS: The nine eligible trials included 27,743 participants. Calcium antagonists and other drugs achieved similar control of both systolic and diastolic blood pressure. Compared with patients assigned diuretics, beta-blockers, angiotensin-converting-enzyme inhibitors, or clonidine (n=15,044), those assigned calcium antagonists (n=12,699) had a significantly higher risk of acute myocardial infarction (odds ratio 1.26 [95% CI 1.11-1.43], p=0.0003), congestive heart failure (1.25 [1.07-1.46], p=0.005), and major cardiovascular events (1.10 [1.02-1.18], p=0.018). The treatment differences were within the play of chance for the outcomes of stroke (0.90 [0.80-1.02], p=0.10) and all-cause mortality (1.03 [0.94-1.13], p=0.54). INTERPRETATION: In randomised controlled trials, the large available database suggests that calcium antagonists are inferior to other types of antihypertensive drugs as first-line agents in reducing the risks of several major complications of hypertension. On the basis of these data, the longer-acting calcium antagonists cannot be recommended as first-line therapy for hypertension.

Aged↗
PubMed2000

Serum uric acid and cardiovascular mortality the NHANES I epidemiologic follow-up study, 1971-1992. National Health and Nutrition Examination Survey.

CONTEXT: Although many epidemiological studies have suggested that increased serum uric acid levels are a risk factor for cardiovascular mortality, this relationship remains uncertain. OBJECTIVE: To determine the association of serum uric acid levels with cardiovascular mortality. DESIGN AND SETTING: Cross-sectional population-based study of epidemiological follow-up data from the First National Health and Nutrition Examination Survey (NHANES I) from 1971-1975 (baseline) and data from NHANES I Epidemiologic Follow-up Study (NHEFS). PARTICIPANTS: A total of 5926 subjects who were aged 25 to 74 years and had serum uric acid level measurements at baseline. MAIN OUTCOME MEASURES: Ischemic heart disease mortality, total cardiovascular mortality, and all-cause mortality, compared by quartiles of serum uric acid level. RESULTS: In an average of 16.4 years of follow-up, 1593 deaths occurred, of which 731 (45.9%) were ascribed to cardiovascular disease. Increased serum uric acid levels had a positive relationship to cardiovascular mortality in men and women and in black and white persons. Deaths due to ischemic heart disease in both men and women increased when serum uric acid levels were in the highest quartile compared with the lowest quartile (men, >416 vs <321 micromol/L; risk ratio, 1.77 [95% confidence interval [CI], 1.08-3.98]; women, >333 vs <238 micromol/l; risk ratio, 3.00 [95% CI, 1.45-6.28]). Cox regression analysis showed that for each 59.48-micromol/L increase in uric acid level, cardiovascular mortality and ischemic heart disease mortality increased. Hazard ratios for men were 1.09 (95% CI, 1.02-1.18) and 1.17 (95% CI, 1.06-1.28), and for women were 1.26 (95% CI, 1.16-1.36) and 1.30 (95% CI, 1.17-1.45), respectively, after adjustment for age, race, body mass index, smoking status, alcohol consumption, cholesterol level, history of hypertension and diabetes, and diuretic use. Further analysis, stratifying by cardiovascular risk status, diuretic use, and menopausal status, confirmed a significant association of uric acid and cardiovascular mortality in all subgroups except among men using diuretics (n=79) and men with 1 or more cardiovascular risk factors (n=1140). CONCLUSION: Our data suggest that increased serum uric acid levels are independently and significantly associated with risk of cardiovascular mortality.

Adult↗
PubMed2000

Myocardial infarction in treated hypertensive patients: the paradox of lower incidence but higher mortality in young blacks compared with whites.

BACKGROUND: Despite the impressive decline in coronary heart disease death rates, a mortality differential between blacks and whites persists. Our study objective was to determine whether excess mortality among well-controlled hypertensive black men compared with whites is due to differences in disease incidence or in case fatality. METHODS AND RESULTS: Of 3382 male subjects (1266 blacks and 2116 whites) enrolled between 1973 and 1996 and followed up through 1997 in a work-site hypertension control program, 2343 were followed up until 60 years of age, and 1884 were followed up until >60 years of age (either continuing after 60 years [n=845] or beginning treatment at >/=60 years [n=1039]), with a mean follow-up of 5.2 and 5.5 years, respectively. During follow-up, 186 myocardial infarction (MI) events (including 31 revascularizations) occurred, with 63 in patients <60 years and 123 in patients >/=60 years of age. Age-adjusted MI incidence was nearly twice as high for whites as blacks in younger (6.3 versus 3.4/1000 person-years) and older (14.1 versus 7.5 person-years) subjects. In contrast, the age-adjusted case fatality rate was 3-fold higher for younger blacks than for whites (37.8% versus 12.2%). In older patients, case fatality did not differ significantly between blacks and whites (37.6% versus 50. 3%). In separate Cox regression analyses, among younger blacks but not younger whites, history of diabetes and smoking were significantly associated with both incidence and fatality. CONCLUSIONS: In these treated male hypertensive patients with good blood pressure control (139.6/85.7 mm Hg), young blacks, despite a lower MI incidence, had higher MI mortality than did their white counterparts. Their higher case fatality rate was associated with fewer coronary artery revascularizations and a higher prevalence of diabetes and smoking.

Adult↗
PubMed2000

Maternal mortality in New York City: excess mortality of black women.

To assess maternal mortality in New York City, birth certificates and mortality records for New York City from 1988 through 1994 were linked and examined. During these 7 years, maternal mortality in New York City (defined by the International Classification of Diseases, 9th edition [ICD-9], as 630-676) per 100,000 live births significantly exceeded that of the country as a whole (20.2 vs. 8.2, respectively). Within New York City, an even greater variation of maternal mortality by race/ethnicity was noted, with the mortality ratio of whites, blacks, and Hispanics being 7.1, 39.5, and 14.4 per 100,000 live births, respectively. Socioeconomic characteristics such as educational attainment, marital status, and income influenced maternal mortality more in non-blacks than blacks. Analyses of cause-specific mortality revealed that, overall, ectopic pregnancy, embolism, and hypertension were the leading causes of death. However, the major factors explaining the excess maternal mortality among blacks were hypertension (mortality ratio of blacks to whites 5.57, 95% confidence interval 2.30-13.39), ectopic pregnancy (4.78, 95% confidence interval 2.40-9.51), and abortion (4.58, 95% confidence interval 1.72-12.22). These findings confirm a persisting gap in maternal death between black and white women. Indeed, if all New Yorkers who became pregnant enjoyed the survival of the city's non-Hispanic white residents, the difference in maternal mortality between the city and the nation would be eliminated.

Adolescent↗
PubMed2000

Excess risk of myocardial infarction in patients treated with antidepressant medications: association with use of tricyclic agents.

PURPOSE: Several studies have found that depression and the use of antidepressant medications are associated with an increased risk of cardiovascular disease. We assessed the association between the use of antidepressant drugs and myocardial infarction, and whether that association differs between the tricyclic and selective serotonin reuptake inhibitor (SSRI) classes of medication. PARTICIPANTS AND METHODS: We compared the experience of a cohort of 2,247 working, union health plan members who received at least one prescription for an antidepressant in an accrual period of 1991-1992 with that of 52,750 members who did not. Patients were followed for up to 4.5 years (minimum 6 months). Three antidepressant medication classes were defined: tricyclics, SSRIs, and others. The primary outcome was hospitalization or death due to myocardial infarction. RESULTS: Adjusted for age and sex, antidepressant users had a relative risk of myocardial infarction of 2.2 (95% confidence interval [CI] 1.3 to 3.7) compared with nonusers of antidepressants. There were 16 myocardial infarctions among 1,650 users of tricyclic antidepressants, 2 among 655 SSRI users, and none among 279 users of other antidepressants. Adjusting for age, gender, baseline heart disease, diabetes, hypertension, hyperlipidemia, anxiety, and cancer, the relative risk of myocardial infarction was 2.2 (95% CI 1.2 to 3.8) in users of tricyclic agents and 0.8 (95% CI 0.2 to 3.5) in users of SSRIs, as compared with subjects who did not use antidepressants. CONCLUSION: The association between use of tricyclic antidepressants, but not SSRIs, with an increased risk of myocardial infarction in our patients suggests that an earlier report that there is no difference in risk between the antidepressant classes, based on short-term studies, may not apply to long-term adverse cardiovascular outcomes.

Adult↗
PubMed2000

Plasma renin activity in the emergency department and its independent association with acute myocardial infarction.

Elevated plasma renin activity (PRA) is associated with increased risk of future myocardial infarction (MI) in ambulatory hypertensive patients. The present study evaluated the relationship of PRA to the diagnosis of acute MI in patients presenting to an emergency department with suspected acute MI. PRA was measured upon entry to the emergency department, before any acute treatment, as part of the standard evaluation of 349 consecutive patients who were hospitalized for suspected MI. Diagnosis of acute MI was confirmed in 73 patients, and ruled out in 276. They did not differ in age (65.9 +/- 2 v 66.1 +/- 1 years), systolic (143 +/- 4 v 140 +/- 2 mm Hg), or diastolic (81 +/- 2 v 81 +/- 1 mm Hg) pressures. Median PRA was 2.7-fold higher in acute MI (0.89 v 0.33 ng/L/s; P < .001). In a multivariate analysis controlling for other cardiac risk factors and prior drug therapy, PRA as a continuous variable was the predominant independent factor associated with acute MI (P < .0001), followed by white race (P = .002) and history of hypertension (P = .047). The height of the PRA level upon entry to the emergency department was directly and independently associated with the diagnosis of acute MI. These new findings extend earlier reports because they encompass acute MI patients, include both hypertensive and normotensive patients, and control for potentially confounding variables. Based on these observations, a randomized clinical trial is warranted to determine whether measurement of PRA in acute MI could refine the process by which treatments are applied.

Aged↗
PubMed2000

Serum potassium and cardiovascular mortality.

BACKGROUND: The impact of serum potassium on mortality is inadequately defined. OBJECTIVE: To determine the association of serum potassium with mortality. METHODS: We analyzed NHANES I Epidemiological Follow-up Study data from 1974-1992. Of 2,992 subjects with baseline serum potassium, 156 were excluded because their vital status was not known. A total of 2,836 subjects with serum potassium within 2.7-5.4 mmol/L were studied. All-cause and cardiovascular mortality were assessed controlling for sociodemographic status, smoking, medical history, and clinical characteristics. RESULTS: At baseline, mean age was 46.6 years, and mean serum potassium was 4.07 mmol/L. Subjects were stratified into three groups by mean +/-1 standard deviation of serum potassium: low, 2.7-3.7 mmol/L (N = 477); middle, 3.8-4.4 mmol/L (N = 1,982); and high, 4.5-5.4 mmol/L (N = 377). The cardiovascular mortality rate per 1,000 person-years adjusted for age, gender, and race for the high serum potassium group (8.1) was significantly higher than the middle (5.3) and low (6.5) serum potassium groups. Further analysis, controlling for age, gender, race, smoking status, cholesterol, and history of diabetes, renal disease, and cardiovascular disease, revealed that the increased cardiovascular mortality among subjects with moderately increased serum potassium was most prominent in those reporting use of diuretics (hazard ratio, 2.65; 95% confidence interval [95% CI], 1.20 to 5.85) and those with abnormal renal function (hazard ratio, 1.89; 95% CI, 1.05 to 3.41). CONCLUSION: In this general population sample with mostly normal serum potassium, higher serum potassium was independently associated with increased cardiovascular mortality.

Cardiovascular Diseases↗