Blood pressure reduction is not the only determinant of outcome.
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Adrenergic beta-Antagonists↗
Biomedical subjects
Neil R Poulter
Publications and source records attributed to Neil R Poulter.
Improvement in hypertension management in England: results from the Health Survey for England 2003.
OBJECTIVE: To evaluate the mean levels of blood pressure and hypertension (> or = 140 mmHg systolic or > or = 90 mmHg diastolic pressure or on treatment for hypertension) in the adult English population, and to evaluate any changes in the efficacy of hypertension management between 1994 and 2003. DESIGN/METHODS: Cross-sectional surveys. England, 2003. A nationally representative sample of 8834 non-institutionalized adults (aged > or = 16 years). Rates of awareness, treatment and control of hypertension. RESULTS: Since 1994, mean systolic blood pressure has fallen by 1.6 and 4.3 mmHg in male and female adults, respectively. The rates of awareness and treatment have increased, and control rates (< 140 mmHg systolic and < 90 mmHg diastolic) among hypertensive men and women have approximately doubled to 21.5 and 22.8%, respectively. Of those on treatment for hypertension, the majority (56%) are on two or more agents compared with 40% in 1994 and 1998. CONCLUSION: Hypertension management has improved greatly since 1994, with more awareness, treatment and control. Nevertheless, in 2003 the majority of hypertensive adults in England had blood pressure levels above the currently recommended targets.
Adolescent↗
The effect of non-steroidal anti-inflammatory drugs and other commonly used non-narcotic analgesics on blood pressure level in adults.
This review explores the blood pressure effects of three non-narcotic analgesics: non-selective non-steroidal anti-inflammatory drugs (NSAID), paracetamol and aspirin. The current evidence suggests that in normotensive, otherwise healthy adults, short-term use (1-2 weeks) of NSAIDs is not associated with a significant increase in blood pressure. Those with existing hypertension are more likely to see a blood pressure elevation, although the magnitude of the effect is less predictable and may vary with age, baseline blood pressure, type of NSAID and concurrent antihypertensive therapy. The magnitude of the blood pressure increase appears to be similar for both NSAIDs and paracetamol, while low-dose aspirin may have more modest effects. In hypertensive adults who experience deterioration of blood pressure control on NSAIDs, there is some, albeit suboptimal, evidence that the blood pressure-raising effects of NSAIDs are less when used in conjunction with dihydropyridine calcium-channel blockers than angiotensin-converting enzyme inhibitors.
Acetaminophen↗
Levels of dyslipidaemia and improvement in its management in England: results from the Health Survey for England 2003.
OBJECTIVE: To evaluate blood lipid levels in the adult English population and to report changes in the use and efficacy of lipid-lowering treatment between 1998 and 2003. DESIGN: Cross-sectional surveys. Participants Nationally representative sample of 8,269 non-institutionalized adults (>or= 16 years) living in England, taking part in the Health Survey for England 2003. MEASUREMENTS: Mean levels of total, HDL, non-HDL and total : HDL cholesterol ratio; prevalence of hypercholesterolaemia; use of lipid-lowering agents and lipid levels among those on treatment; blood pressure. Information on smoking and history of cardiovascular events and diabetes were recorded by the interviewer. RESULTS: In 2003 69.9% of adults had a total cholesterol >or= 5 mmol/l and 6.2% reported lipid-lowering treatment. Treatment rates among those with a total cholesterol >or= 5 mmol/l and a history of coronary heart disease or stroke, hypertension or diabetes were 71.1%, 32.7% and 50.9%, respectively in men; and 55.8%, 22.4% and 50.0% in women. In all these groups, more than half of those treated were controlled (< 5 mmol/l). Only small changes in levels of dyslipidaemia were seen since 1998 (when 67.5% of adults had a total cholesterol >or= 5 mmol/l), but use of lipid-lowering treatment has more than doubled and control rates have increased by approximately fourfold. CONCLUSIONS: Treatment and control rates of lipids have improved importantly between 1998 and 2003 but remain suboptimal. Reductions in major cardiovascular events are likely to result from these changes and may be further enhanced by adherence to the new general practitioner contract.
Adolescent↗
Different time course for prevention of coronary and stroke events by atorvastatin in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm (ASCOT-LLA).
The lipid-lowering properties of statins reduce rates of coronary artery disease (CAD) events and strokes. Findings of recently conducted, longitudinal intervention studies suggest that these benefits occur early and may be, in part, independent of the lipid-lowering properties of statin therapy. We analyzed data from the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm (ASCOT-LLA) to determine the timing of cardiovascular risk reduction. Relative risk reductions in CAD events were large compared with placebo, becoming apparent at 30 days and significant within 3 months, but they tended to decrease with time. Risk reductions in stroke were also apparent at 30 days but remained constant throughout the trial. Significant differences in hazard ratio between atorvastatin and placebo occurred at 2-year follow-up. Such apparently differential effects on CAD and stroke events suggest that mechanisms of action for CAD and stroke prevention may be different. These observations support the hypothesis that non-lipid-lowering actions of atorvastatin may have contributed to early protection against CAD in ASCOT-LLA.
Atorvastatin↗
Angiotensin receptor blockers: therapeutic targets and cardiovascular protection.
In the prevention and treatment of cardiovascular disease, pharmacological treatment strategies should have several aims: (i) in individuals without overt cardiovascular disease, but with risk factors such as hypertension and/or diabetes, pharmacotherapy should prevent or delay disease development; (ii) in patients who have already progressed to cardiovascular disease, pharmacotherapy should help either to prevent or regress target organ damage (TOD); and (iii) in patients with TOD, pharmacotherapy should prevent events. Any medication intended for long-term therapy also should be well tolerated. Inhibiting the renin-angiotensin system has proven a successful therapeutic strategy in cardiovascular and renal medicine. Angiotensin-converting enzyme (ACE) inhibitors have demonstrated important advantages over conventional agents such as beta-blockers and thiazide diuretics, and have become a relevant part of treatment for heart failure post-myocardial infarction, left ventricular dysfunction and renal disease. Tolerability concerns may prevent their use in some patients, however. Angiotensin AT1 receptor blockers (ARBs) provide a different form of blockade of the renin-angiotensin system and a growing body of evidence suggests that this alternative approach may confer additional cardiovascular protection for some patient subgroups. In addition, ARBs generally are better tolerated than ACE inhibitors, enhancing patient compliance and persistence with long-term therapy. Furthermore, evidence in favour of combining an ACE inhibitor and an ARB in certain circumstances is continuously growing.
Angiotensin II Type 1 Receptor Blockers↗
Reduction in cardiovascular events with atorvastatin in 2,532 patients with type 2 diabetes: Anglo-Scandinavian Cardiac Outcomes Trial--lipid-lowering arm (ASCOT-LLA).
OBJECTIVE: This study aims to establish the benefits of lowering cholesterol in diabetic patients with well-controlled hypertension and average/below-average cholesterol concentrations, but without established coronary disease. RESEARCH DESIGN AND METHODS: In the lipid-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-LLA), 10,305 hypertensive patients with no history of coronary heart disease (CHD) but at least three cardiovascular risk factors were randomly assigned to receive 10 mg atorvastatin or placebo. Effects on total cardiovascular outcomes in 2,532 patients who had type 2 diabetes at randomization were compared. RESULTS: During a median follow-up of 3.3 years, concentrations of total and LDL cholesterol among diabetic participants included in ASCOT-LLA were approximately 1 mmol/l lower in those allocated atorvastatin compared with placebo. There were 116 (9.2%) major cardiovascular events or procedures in the atorvastatin group and 151 (11.9%) events in the placebo group (hazard ratio 0.77, 95% CI 0.61-0.98; P = 0.036). For the individual components of this composite end point, the number of events occurring in the diabetes subgroup was small. Therefore, although fewer coronary events (0.84, 0.55-1.29; P = 0.14) and strokes (0.67, 0.41-1.09; P = 0.66) were observed among the patients allocated atorvastatin, these reductions were not statistically significant. CONCLUSIONS: Atorvastatin significantly reduced the risk of major cardiovascular events and procedures among diabetic patients with well-controlled hypertension and without a history of CHD or markedly elevated cholesterol concentrations. The proportional reduction in risk was similar to that among participants who did not have diagnosed diabetes. Allocation to atorvastatin prevented approximately 9 diabetic participants from suffering a first major cardiovascular event or procedure for every 1,000 treated for 1 year.
Adult↗
Cost-effectiveness of atorvastatin for the prevention of coronary and stroke events: an economic analysis of the Anglo-Scandinavian Cardiac Outcomes Trial--lipid-lowering arm (ASCOT-LLA).
BACKGROUND: The aim of this study is to assess the cost-effectiveness of the lipid-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-LLA) where patients from seven countries with hypertension and no history of coronary heart disease (CHD) were randomized to receive 10 mg atorvastatin or placebo. DESIGN: Economic analysis of a randomized controlled trial. METHODS: Data on resource use were aggregated for all patients during the entire trial period (median 3.3 years) and multiplied with unit costs for Sweden and the UK. The total number of cardiovascular events and procedures avoided was used as the measure of effectiveness. RESULTS: Patients treated with atorvastatin had an additional net costs of 449 euro (4114 SEK) in Sweden and 414 euro (260 pounds sterling) in the UK, but fewer events per patient (0.097 compared to 0.132). The incremental cost-effectiveness ratios were 12673 euro (116119 SEK) and 11693 euro (7349 pounds sterling) per event avoided. CONCLUSION: Based on comparisons with the WOSCOPS and 4S studies, atorvastatin at 10 mg to treat patients as in the ASCOT study, appears to be a cost-effective strategy.
Atorvastatin↗
Birth weight and blood pressure in childhood: results from the Health Survey for England.
Findings of previous reports relating low birth weight with raised blood pressure in childhood and adolescence have been inconsistent. The present study uses cross-sectional data from a series of nationally representative annual surveys--the Health Survey for England--between 1995 and 2002, totaling a sample of 15 629 children aged 5 to 15. A significant negative relationship between birth weight, in quartiles or dichotomized as low (<2.5 kg) and normal (> or =2.5 kg) and systolic blood pressure was apparent. Linear regression analyses confirmed these findings. When current weight was included in the model, the strength of the relationship increased. An interaction term between birth weight and current weight was not significant. A life-course plot for those aged 13 to 15 (n=3900), converting the weight measurements at birth and as a teenager to standard deviation scores to make the regression coefficients comparable, showed the importance of weight gain on blood pressure (1 standard deviation increase in weight from birth to age 13 to 15 was associated with an increase in systolic blood pressure of 0.8 mm Hg). Separating those with low and normal birth weight demonstrated that the increase in weight from birth to adolescence had an effect on blood pressure in both those with low and normal birth weight. Postnatal changes in size have a more important effect on blood pressure in childhood and adolescence than birth weight. Reducing the prevalence of overweight among children may reduce their systolic blood pressure importantly and, particularly among children with lower birth weight, the prevalence of hypertension later in life.
Adolescent↗
NICE and BHS guidelines on hypertension differ importantly.
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Humans↗
British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary.
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Algorithms↗
Hypertension management and control among English adults aged 65 years and older in 2000 and 2001.
OBJECTIVE: To describe blood pressures, and hypertension and its management among older people. DESIGN: Two combined annual cross-sectional surveys. SETTING: England 2000 and 2001. PARTICIPANTS: Nationally-representative sample of 3513 non-institutionalized people aged more than 64 years (elderly). MAIN OUTCOME MEASURES: (1). Use of antihypertensive agents, and hypertension according to two definitions: receiving blood pressure decreasing treatment, or either: systolic blood pressure > or= 160 mmHg or diastolic blood pressure > or= 90 mmHg (old); or systolic blood pressure > or= 140 mmHg or diastolic blood pressure > or=90 mmHg (new). (2). Rates of treatment and control (old: < 160/90 mmHg; new: < 140/85 mmHg). (3). Isolated systolic hypertension stage 1 (systolic blood pressure > or= 140-159 mmHg and diastolic blood pressure < 90 mmHg), or stage 2 (systolic blood pressure > or= 160 mmHg and diastolic blood pressure < 90 mmHg). RESULTS: In 2000/2001, 62 and 81% of elderly adults were hypertensive according to the old and new definitions, respectively. Among those with hypertension (new definition) treatment and control rates were 56 and 19% (control rates among those treated were 36% in men and 30% in women). Of those treated, 54% were receiving one drug, 35% were receiving two, and 10% were receiving three or more drugs. Among untreated hypertensive individuals, 23% had increased systolic and diastolic pressures, 76% had isolated systolic hypertension and 1% had isolated diastolic hypertension. CONCLUSIONS: These data suggest that, according to current guidelines more than 67% of older English adults should receive antihypertensive medication. To pre-empt this situation, population-based strategies to reduce the current rate of increase in blood pressure throughout adult life should be urgently implemented. Only then will the current epidemic of hypertension among the elderly, with the huge cost associated with its management and adverse cardiovascular sequelae, be averted.
Aged↗
Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial.
BACKGROUND: The lowering of cholesterol concentrations in individuals at high risk of cardiovascular disease improves outcome. No study, however, has assessed benefits of cholesterol lowering in the primary prevention of coronary heart disease (CHD) in hypertensive patients who are not conventionally deemed dyslipidaemic. METHODS: Of 19 342 hypertensive patients (aged 40-79 years with at least three other cardiovascular risk factors) randomised to one of two antihypertensive regimens in the Anglo-Scandinavian Cardiac Outcomes Trial, 10,305 with nonfasting total cholesterol concentrations 6.5 mmol/L or less were randomly assigned additional atorvastatin 10 mg or placebo. These patients formed the lipid-lowering arm of the study. We planned follow-up for an average of 5 years, the primary endpoint being non-fatal myocardial infarction and fatal CHD. Data were analysed by intention to treat. FINDINGS: Treatment was stopped after a median follow-up of 3.3 years. By that time, 100 primary events had occurred in the atorvastatin group compared with 154 events in the placebo group (hazard ratio 0.64 [95% CI 0.50-0.83], p = 0.0005). This benefit emerged in the first year of follow-up. There was no significant heterogeneity among prespecified subgroups. Fatal and non-fatal stroke (89 atorvastatin vs 121 placebo, 0.73 [0.56-0.96], p = 0.024), total cardiovascular events (389 vs 486, 0.79 [0.69-0.90], p = 0.0005), and total coronary events (178 vs 247, 0.71 [0.59-0.86], p = 0.0005) were also significantly lowered. There were 185 deaths in the atorvastatin group and 212 in the placebo group (0.87 [0.71-1.06], p = 0.16). Atorvastatin lowered total serum cholesterol by about 1.3 mmol/L compared with placebo at 12 months, and by 1.1 mmol/L after 3 years of follow-up. INTERPRETATION: The reductions in major cardiovascular events with atorvastatin are large, given the short follow-up time. These findings may have implications for future lipid-lowering guidelines.
Adult↗
Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial.
BACKGROUND: The lowering of cholesterol concentrations in individuals at high risk of cardiovascular disease improves outcome. No study, however, has assessed benefits of cholesterol lowering in the primary prevention of coronary heart disease (CHD) in hypertensive patients who are not conventionally deemed dyslipidaemic. METHODS: Of 19342 hypertensive patients (aged 40-79 years with at least three other cardiovascular risk factors) randomised to one of two antihypertensive regimens in the Anglo-Scandinavian Cardiac Outcomes Trial, 10305 with non-fasting total cholesterol concentrations 6.5 mmol/L or less were randomly assigned additional atorvastatin 10 mg or placebo. These patients formed the lipid-lowering arm of the study. We planned follow-up for an average of 5 years, the primary endpoint being non-fatal myocardial infarction and fatal CHD. Data were analysed by intention to treat. FINDINGS: Treatment was stopped after a median follow-up of 3.3 years. By that time, 100 primary events had occurred in the atorvastatin group compared with 154 events in the placebo group (hazard ratio 0.64 [95% CI 0.50-0.83], p=0.0005). This benefit emerged in the first year of follow-up. There was no significant heterogeneity among prespecified subgroups. Fatal and non-fatal stroke (89 atorvastatin vs 121 placebo, 0.73 [0.56-0.96], p=0.024), total cardiovascular events (389 vs 486, 0.79 [0.69-0.90], p=0.0005), and total coronary events (178 vs 247, 0.71 [0.59-0.86], p=0.0005) were also significantly lowered. There were 185 deaths in the atorvastatin group and 212 in the placebo group (0.87 [0.71-1.06], p=0.16). Atorvastatin lowered total serum cholesterol by about 1.3 mmol/L compared with placebo at 12 months, and by 1.1 mmol/L after 3 years of follow-up. INTERPRETATION: The reductions in major cardiovascular events with atorvastatin are large, given the short follow-up time. These findings may have implications for future lipid-lowering guidelines.
Adult↗
Influence of hormone replacement therapy on C-reactive protein: population-based data.
BACKGROUND: Observational data, possibly resulting from confounding due to self-selection, show that use of hormone replacement therapy (HRT) is associated with reduced coronary risk, while randomized trial data do not. One possible explanation for the trial findings is that adverse effects of HRT-- such as an elevation of C-reactive protein (CRP)--might counterbalance other benefits of HRT. DESIGN: Women aged 40-74 years were identified from a cross-sectional, annual nationally representative study of the English population, the Health Survey for England 1998. Valid data were available from 4,112 of the 4,319 women in this age group. Of these, 710 (17%) were current, 465 (11%) past and 2,937 (71%) never users of HRT. METHODS: To study the association between current and past use of HRT and CRP levels. CRP was expressed as a continuous variable (logged) and in percentiles. RESULTS: Current, past and never users of HRT did not differ in terms of age, body mass index or smoking status. However, compared with past and never users of HRT, current users tended to take more vigorous physical activity and were more likely to drink more alcohol than is currently recommended. Excluding potentially confounding conditions, median CRP levels were significantly higher in current (2.5 mg/l) and in past (1.9 mg/l) than never HRT users (1.4 mg/l). Controlling for age, smoking and body mass index logged CRP remained significantly raised only among current users. CONCLUSIONS: HRT use was significantly and independently associated with raised CRP levels in an English nationally representative sample. Increases in CRP may represent one plausible mechanism by which HRT may adversely affect risk of coronary heart disease.
Adult↗
Predicting coronary risk in the general population--is it necessary to measure high-density lipoprotein cholesterol?
BACKGROUND: The Joint British Societies Coronary Risk Prediction Charts recommend the use of a high-density lipoprotein cholesterol value of 1 mmol/l where actual values have not been measured. It is important to quantify the impact of this advice if risk assessments are to be sufficiently accurate to guide treatment decisions. DESIGN: The risks of 5005 individuals from the Health Survey for England 1998 were calculated using the Joint British Societies charts. Each individual's risk was recalculated assuming a high-density lipoprotein cholesterol value of 1 mmol/l. These risk estimates were compared with those derived from the Framingham equation. METHODS: Using the Framingham equation as the gold standard, the positive and negative predictive values, sensitivity and specificity with 95% confidence intervals of the Joint British charts with actual and estimated high-density lipoprotein cholesterol values were calculated. RESULTS: At the 30% 10-year coronary heart disease risk threshold using measured high-density lipoprotein cholesterol values, the charts had a sensitivity of 83% and specificity of 99%. Using an estimated high-density lipoprotein cholesterol value of 1 mmol/l reduced the sensitivity to 58% with a specificity of 98%. CONCLUSIONS: In the presence of measured high-density lipoprotein cholesterol values there was good agreement between the Framingham equation and the Joint British Societies charts. The use of a fixed high-density lipoprotein cholesterol value of 1 mmol/l introduced important and significant errors into the risk assessment. This study reinforces the need to measure both total and high-density lipoprotein cholesterol when assessing coronary risk.
Biomarkers↗
The influence of economic development on the association between education and the risk of acute myocardial infarction and stroke.
Rates of myocardial infarction and stroke increase as countries "develop." These disorders emerge among higher socio-economic groups, but once "developed," most events occur in lower socio-economic groups. We evaluated the association between education as a measure of socio-economic status and risk of acute myocardial infarction (AMI) and stroke in regions at various stages of development and between stroke risk and life expectancy. The study comprised 2,478 cases of AMI or stroke and 6,819 controls among women aged 19-49, from Africa, Asia, Latin America, and Eastern Europe. Compared to those with high educational attainment, stroke risk was reduced among less educated women in Africa, but was significantly higher in the other three regions. Low education was associated with increased risk of AMI in Eastern Europe but not in the other three regions combined. Educationally related stroke risk was positively correlated with national life expectancy.
Adult↗
Can cardiovascular risk factors explain the association between education and cardiovascular disease in young women?
We sought to explain the observed variation in the relationship between education and cardiovascular disease (CVD) among young women in countries at different stages of economic development. Data comprised 2,478 cases of acute myocardial infarction (AMI) or stroke and 6,819 age-matched controls from Africa, Asia, Eastern Europe, and Latin America. The risks of AMI associated with lower education observed in Eastern Europe and higher education in non-European countries were reduced by 92% in Eastern Europe and totally abolished in non-European countries by adjustment for standard cardiovascular risk factors. The inverse associations between education and stroke risk in the three non-African regions were attenuated by 22, 47, and 60% after adjustment. In Africa, the slight inconsistent trend towards lower stroke risk in less well educated women was unaffected by adjustment. These data suggest that standard risk factors explain a substantial proportion if not all of the difference in AMI risk associated with education but a lesser proportion of educationally linked stroke risk.
Adult↗