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Biomedical subjects

N Poulter

Publications and source records attributed to N Poulter.

At least 19 recordsLinked to original sources
PubMed2006

ESH-ESC guidelines for the management of hypertension.

The following is a brief statement of the 2003 European Society of Hypertension (ESH)-European Society of Cardiology (ESC) guidelines for the management of arterial hypertension. The continuous relationship between the level of blood pressure and cardiovascular risk makes the definition of hypertension arbitrary. Since risk factors cluster in hypertensive individuals, risk stratification should be made and decision about the management should not be based on blood pressure alone, but also according to the presence or absence of other risk factors, target organ damage, diabetes, and cardiovascular or renal damage, as well as on other aspects of the patient's personal, medical and social situation. Blood pressure values measured in the doctor's office or the clinic should commonly be used as reference. Ambulatory blood pressure monitoring may have clinical value, when considerable variability of office blood pressure is found over the same or different visits, high office blood pressure is measured in subjects otherwise at low global cardiovascular risk, there is marked discrepancy between blood pressure values measured in the office and at home, resistance to drug treatment is suspected, or research is involved. Secondary hypertension should always be investigated. The primary goal of treatment of patient with high blood pressure is to achieve the maximum reduction in long-term total risk of cardiovascular morbidity and mortality. This requires treatment of all the reversible factors identified, including smoking, dislipidemia, or diabetes, and the appropriate management of associated clinical conditions, as well as treatment of the raised blood pressure per se. On the basis of current evidence from trials, it can be recommended that blood pressure, both systolic and diastolic, be intensively lowered at least below 140/90 mmHg and to definitely lower values, if tolerated, in all hypertensive patients, and below 130/80 mmHg in diabetics. Lifestyle measures should be instituted whenever appropriate in all patients, including subjects with high normal blood pressure and patients who require drug treatment. The purpose is to lower blood pressure and to control other risk factors and clinical conditions present. In most, if not all, hypertensive patients, therapy should be started gradually, and target blood pressure achieved progressively through several weeks. To reach target blood pressure, it is likely that a large proportion of patients will require combination therapy with more than one agent. The main benefits of antihypertensive therapy are due to lowering of blood pressure per se. There is also evidence that specific drug classes may differ in some effect or in special groups of patients. The choice of drugs will be influenced by many factors, including previous experience of the patient with antihypertensive agents, cost of drugs, risk profile, presence or absence of target organ damage, clinical cardiovascular or renal disease or diabetes, patient's preference.

Age Factors↗
PubMed2005

ADVANCE: action in diabetes and vascular disease.

The burden of Type II diabetes is growing rapidly worldwide, across high-, middle- and low-income countries. This burden is associated primarily with increased risks of macrovascular and microvascular diseases, and it is agreed that multifactorial treatment regimens are required to reduce it. ADVANCE (Action in Diabetes and Vascular disease: Preterax and Diamicron-MR Controlled Evaluation) is a large-scale, 2 x 2 factorial, randomised clinical trial. It will investigate the potential benefits of blood pressure lowering, using a fixed low-dose combination of perindopril and indapamide vs placebo, and of tighter glucose control, using an intensive gliclazide-MR-based glucose control regimen vs a standard guidelines-based regimen, separately and together. The two primary outcomes are a composite macrovascular end point of nonfatal stroke, nonfatal myocardial infarction and cardiovascular death; and a composite microvascular end point of new or worsening nephropathy or microvascular eye disease. Following successful recruitment and randomisation of 11,140 participants by March 2003, the study is currently half way through its planned follow-up of 4.5 years. Adherence to randomised study treatment is good; and loss to follow-up is minimal. It is hoped that the study will answer a number of unresolved issues. The blood pressure lowering arm will investigate the possible reduction in major vascular disease in patients with Type II diabetes whether or not they have hypertension, and the possible benefits of blood pressure lowering in such patients already receiving background therapy with the ACE inhibitor perindopril. The glucose control arm will investigate the possible reduction in both macrovascular and microvascular disease achieved with tighter glucose control, targeting an HbA1c of 6.5% and a fasting blood glucose of 6.0 mmol/l. Finally, the factorial design will enable investigation of the combined effects of more intensive glucose control and tighter control of blood pressure.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2003

Comparison of methods to identify individuals at increased risk of coronary disease from the general population.

OBJECTIVES: To evaluate the guidelines on measurement of cholesterol in the national service framework for coronary heart disease and to compare alternative strategies for identifying people at high risk of coronary disease in the general population. DESIGN: Comparison of methods (national service framework criteria, Sheffield tables, age threshold of 50 years, estimated risk assessment using fixed cholesterol values) for identifying people with a 10 year coronary event risk of 15% or greater. SETTING: Health survey for England 1998. SUBJECTS: 6307 people aged between 30 and 74 years with no history of myocardial infarction, stroke, or angina. MAIN OUTCOME MEASURES: Proportion of the total population selected for measurement of cholesterol and proportion of people at 15% or greater risk identified. RESULTS: The national service framework guidelines selected 43.4% (95% confidence interval 42.2% to 44.6%) of the study population for cholesterol measurement and identified 81.2% (80.2% to 82.2%) of those at 15% or greater risk. The Sheffield tables selected 73.1% (72.0% to 74.2%) for cholesterol measurement and identified 99.91% (99.83% to 99.99%) of those at 15% or greater risk. An age threshold of 50 years selected 46.3% (45.1% to 47.5%) for cholesterol measurement and identified 92.8% (92.1% to 93.4%) of those at 15% or greater risk. Estimated risk assessments using fixed cholesterol values selected 17.8% (16.8% to 18.7%) for cholesterol measurement and identified 75.9% (74.8% to 76.9%) of those at 15% or greater risk. CONCLUSION: Measuring the cholesterol concentration of everyone aged 50 years and over is a simple and efficient method of identifying people at high risk of coronary disease in the general population.

Adolescent↗
PubMed2003

Global risk of cardiovascular disease.

UK death rates from coronary heart disease are among the highest in the world. This is because the UK has high levels of standard risk factors and a low level of intervention on those risk factors. The most important modifiable cardiovascular risk factors are dyslipidaemia (particularly high LDL cholesterol and low HDL cholesterol), smoking, hypertension, glucose intolerance, and central obesity. Intervention strategies that do not target those individuals at highest cardiovascular risk are likely to be less cost effective. Global risk estimation is increasingly recognised by management guidelines as a clinically and cost effective means of guiding treatment. However, an over reliance on short term absolute risk may result in under treatment of young people (particularly women) at high relative risk and over treatment of older people (particularly men) at low relative risk.

Cholesterol, LDL↗
PubMed2002

Pre-eclampsia, antiretroviral therapy, and immune reconstitution.

Antiretrovirals are standard treatment for HIV-1-positive women during pregnancy in the UK, but little is known about maternal or fetal safety. In our cohort study of 214 pregnant women with HIV-1 infection, those who received no antiretroviral therapy had a rate of pre-eclampsia significantly lower (none of 61) than those on triple antiretroviral therapy (8 of 76; odds ratio 15.3, 95% CI 0.9-270, p=0.0087). However, the rate of pre-eclampsia in HIV-1-positive women on treatment did not differ from that in uninfected controls (12 of 214; p=0.2). The association of HIV-1-related immune deficiency with a low rate of pre-eclampsia, and the restoration of this rate in women treated with triple antiretroviral therapy to the expected rate indicates a pivotal role of the immune system in the pathogenesis of pre-eclampsia. The clinical presentation of pre-eclampsia and toxic effects of antiretroviral therapy could overlap and complicate diagnosis and management in these patients.

Adult↗
PubMed2002

Duration, frequency, recency, and type of migraine and the risk of ischaemic stroke in women of childbearing age.

BACKGROUND: Migraine is recognised increasingly as a risk factor for ischaemic stroke in women of childbearing age. Migraine with aura poses a higher risk than migraine without aura. OBJECTIVE: To investigate further the effect of duration, frequency, recency, and type of migraine on the risk of ischaemic stroke. METHODS: Additional analyses of a previously reported multicentre case-control study of the relation between stroke and migraine in women aged 20-44 years. RESULTS: Among 86 cases of ischaemic stroke and 214 controls, the adjusted risk of ischaemic stroke was significantly associated with: (1) migraine of more than 12 years duration, odds ratio (OR) 4.61 (1.27-16.8); (2) initial migraine with aura, OR 8.37 (2.33-30.1); (3) particularly if attacks were more frequent than 12 times per year, OR 10.4 (2.18-49.4). In no case did correction for oral contraception usage significantly alter these odds ratios. Increasing risk of ischaemic stroke was related to a change to increased frequency of headaches (trend p <or= 0.03). CONCLUSIONS: These data support earlier reports of a relation between ischaemic stroke and migraine with aura. The risk seems particularly high in those whose initial migraine type involved aura occurring more than 12 times per year.

Adult↗
PubMed2000

Ethnic and gender differences in electrocardiographic QT length and QT dispersion in hypertensive subjects.

BACKGROUND: Prolonged QT intervals and/or increased QT dispersion (QTd) are associated with various pathological conditions and predict death in healthy individuals. Among hypertensives, QTd correlates with blood pressure (BP) and left ventricular mass index (LVMI) and QT intervals are prolonged in those with left ventricular hypertrophy (LVH). In normotensives, heart-rate corrected QT length (QTc) is longer in females than males, but QTd is greater in males than females. There are few data comparing QT parameters between different ethnic groups and none specifically in hypertensives. Among normotensives, compared with whites, QTc is reported to be shorter in African-Americans and longer in Chinese. We looked for ethnic and gender differences in QT parameters in hypertensive subjects. METHODS: Untreated hypertensives were selected from a Hypertension Clinic database. Black and white subjects were matched for age, sex, BP and LVMI. Male and female subjects were matched for age, race, BP and the presence or absence of echocardiographic LVH. Maximum QT intervals (QTm), rate-corrected maximum QT intervals (QTc) and QT dispersion (QTd) were measured or calculated from ECGs. Data are presented as mean +/- s.d. Differences in QT parameters were sought between groups using Student's t-tests. RESULTS: No ethnic or gender differences in QT parameters achieved statistical significance. However there was a tendency for QTm and QTc to be prolonged in blacks compared with whites (443 +/- 52 vs 421 +/- 47; P = 0.08 and 480 +/- 65 vs 463 +/- 40: P = 0.24 respectively), and for QTc to be prolonged in females compared with males (479 +/- 52 vs 461 +/- 45 ms; P= 0.13). CONCLUSION: In small groups of matched hypertensives, no ethnic or gender differences in QT parameters achieved statistical significance. However, similar to findings in normotensives, QTc tended to be longer in hypertensive females than males. In hypertensives, we failed to confirm the finding that QTc is shorter in blacks than whites, as seen in US normotensives. Whether this represents a difference between hypertensives and normotensives, or between US and UK blacks requires further investigation. Whether the prognostic significance of QT parameters in hypertensives differs between different gender and ethnic groups needs to be established from prospective studies. Journal of Human Hypertension (2000) 14, 403-405

Adult↗
PubMed1999

Migraine and stroke in young women: case-control study. The World Health Organisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception.

OBJECTIVE: To investigate the association between migraine and ischaemic or haemorrhagic stroke in young women. DESIGN: Hospital based case-control study. SETTING: Five European centres participating in the World Health Organisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. SUBJECTS: 291 women aged 20-44 years with ischaemic, haemorrhagic, or unclassified arterial stroke compared with 736 age and hospital matched controls. INTERVENTION: Questionnaire. MAIN OUTCOME MEASURE: Self reported history of headaches. RESULTS: Adjusted odds ratios associated with a personal history of migraine were 1.78 (95% confidence intervals, 1.14 to 2.77), 3.54 (1.30 to 9.61), and 1.10 (0.63 to 1.94) for all stroke, ischaemic stroke, and haemorrhagic stroke respectively. Odds ratios for ischaemic stroke were similar for classical migraine (with aura) (3.81, 1.26 to 11.5) and simple migraine (without aura) (2.97, 0.66 to 13.5). A family history of migraine, irrespective of personal history, was also associated with increased odds ratios, not only for ischaemic stroke but also haemorrhagic stroke. In migrainous women, coexistent use of oral contraceptives or a history of high blood pressure or smoking had greater than multiplicative effects on the odds ratios for ischaemic stroke associated with migraine alone. Change in the frequency or type of migraine on using oral contraceptives did not predict subsequent stroke. Between 20% and 40% of strokes in women with migraine seemed to develop directly from a migraine attack. CONCLUSIONS: Migraine in women of childbearing age significantly increases the risk of ischaemic but not haemorrhagic stroke. The coexistence of oral contraceptive use, high blood pressure, or smoking seems to exert a greater than multiplicative effect on the risk of ischaemic stroke associated with migraine.

Adult↗
PubMed1999

Coronary heart disease is a multifactorial disease.

Coronary heart disease (CHD) is the leading cause of death in the Western World. For effective treatment and prevention strategies to be put in place, the major risk factors associated with this disease must be identified. Data show that almost 300 variables are statistically associated with CHD. However, evidence suggests that the vast majority of coronary events can be explained on the basis of blood pressure, lipids, smoking, and diabetes. Laboratory, experimental, and epidemiologic data identify dyslipidemia as a pivotal CHD risk factor, in the absence of which other risk factors cease to produce any important increase in absolute risk of events. For example, in populations with relatively low levels of low-density lipoprotein cholesterol, such as China and Japan, the incidence of CHD remains low even when smoking and hypertension are highly prevalent. Observational data have clearly established that CHD risk factors tend to cluster in individuals. The impact of coexisting risk factors is greater than additive, and indeed is usually multiplicative. The implications of such an interactive effect are that relatively normal levels of two or more risk factors in coexistence may have a profound impact on risk. Despite these findings, in the past most treatment algorithms have viewed risk factors separately and have recommended discrete treatment targets. More recent guidelines have taken a broader view and provide simple, yet accurate, methods of evaluating absolute risk based on the consideration of several risk factors. Coronary heart disease is clearly a multifactorial disease with risk factors that tend to cluster and interact in an individual to determine the level of coronary risk. The current trend towards a more holistic approach in CHD risk evaluation and preventive management appears logical based on evidence from animal-experimental, observational, and clinical trial evidence.

Animals↗
PubMed1999

Blood lead and blood pressure: evidence from the Health Survey for England 1995.

OBJECTIVES: To examine the relationship between blood lead and blood pressure (BP) and to estimate the possible effects of a decrease in blood lead on BP. METHODS: A 2-ml blood sample was collected from a sub-sample of those included in the Health Survey for England 1995, a cross-sectional survey of a nationally representative sample of the adult English population. Blood lead concentration was measured by atomic absorption spectrometry and three BP readings were taken under standardised conditions using the Dinamap 8100 monitor. Analyses were carried out using data on 2563 men and 2763 women aged 16 and over. RESULTS: In stepwise multiple regression analyses adjusting for various confounders--age, body mass index, smoking status, social class, region of residence and alcohol intake--blood lead was found to be significantly and positively associated with diastolic BP, and not systolic BP in men, but not in women. These findings were unaffected by the inclusion or exclusion of those on antihypertensive medication, by whether mean or median BP was used in the regression, or by the adjustment for alcohol consumption. A halving of currently prevalent blood lead levels is estimated to be associated with a decrease of between 0.8 to 1.1 mm Hg diastolic BP in men. CONCLUSION: These findings in the context of other published data are consistent with a small pressor effect of environmental lead levels on BP. They support recommendations for further efforts to reduce lead in the environment.

Adolescent↗
PubMed1999

Guidelines for management of hypertension: report of the third working party of the British Hypertension Society.

Use non-pharmacological measures in all hypertensive and borderline hypertensive people. Initiate antihypertensive drug therapy in people with sustained systolic blood pressures (BP) >/=160 mm Hg or sustained diastolic BP >/=100 mm Hg. Decide on treatment in people with sustained systolic BP between 140 and 159 mm Hg or sustained diastolic BP between 90 and 99 mm Hg according to the presence or absence of target organ damage, cardiovascular disease or a 10-year coronary heart disease (CHD) risk of >/=15% according to the Joint British Societies CHD risk assessment programme/risk chart. In people with diabetes mellitus, initiate antihypertensive drug therapy if systolic BP is sustained >/=140 mm Hg or diastolic BP is sustained >/=90 mm Hg. In non-diabetic hypertensive people, optimal BP treatment targets are: systolic BP <140 mm Hg and diastolic BP <85 mm Hg. The minimum acceptable level of control (Audit Standard) recommended is <150/<90 mm Hg. Despite best practice, these levels will be difficult to achieve in some hypertensive people. In diabetic hypertensive people, optimal BP targets are; systolic BP <140 mm Hg and diastolic BP <80 mm Hg. The minimum acceptable level of control (Audit Standard) recommended is <140/<90 mm Hg. Despite best practice, these levels will be difficult to achieve in some people with diabetes and hypertension. In the absence of contraindications or compelling indications for other antihypertensive agents, low dose thiazide diuretics or beta-blockers are preferred as first-line therapy for the majority of hypertensive people. In the absence of compelling indications for beta-blockade, diuretics or long acting dihydropyridine calcium antagonists are preferred to beta-blockers in older subjects. Compelling indications and contraindications for all antihypertensive drug classes are specified. For most hypertensives, a combination of antihypertensive drugs will be required to achieve the recommended targets for blood pressure control. Other drugs that reduce cardiovascular risk must also be considered. These include aspirin for secondary prevention of cardiovascular disease, and primary prevention in treated hypertensive subjects over the age of 50 years who have a 10-year CHD risk >/=15% and in whom blood pressure is controlled to the audit standard. In accordance with existing British recommendations, statin therapy is recommended for hypertensive people with a total cholesterol >/=5 mmol/L and established vascular disease, or 10-year CHD risk >/=30% estimated from the Joint British Societies CHD risk chart. Glycaemic control should also be optimised in diabetic subjects. Specific advice is given on the management of hypertension in specific patient groups, ie, the elderly, ethnic subgroups, diabetes mellitus, chronic renal disease and in women (pregnancy, oral contraceptive use and hormone replacement therapy). Suggestions for the implementation and audit of these guidelines in primary care are provided.

Antihypertensive Agents↗