Which blood pressure measurement is more important in the elderly?
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Age Factors↗
Biomedical subjects
W J Elliott
Publications and source records attributed to W J Elliott.
Intensive antihypertensive treatment to the new lower blood pressure targets.
The recommendations of several authoritative bodies that blood pressure be lowered to lower-than-traditional goals in patients with high-risk hypertension have recently been validated by data from several randomized clinical trials. In the Hypertension Optimal Treatment (HOT) trial, the best prognosis was in diabetic patients treated to a diastolic blood pressure of 80 mm Hg. In the United Kingdom Prospective Diabetes Study 38, a major reduction in nearly every type of cardiovascular event was noted among patients with type II diabetes who were treated to the lower blood pressure goal of less than 150/85 mm Hg. In the quality-of-life substudy of the HOT trial, the greatest improvement was found in patients treated to the lowest diastolic blood pressure goal of less than or equal to 80 mm Hg. Two economic analyses suggest that attainment of the lower blood pressure goal not only is possible and effective in reducing cardiovascular risk but also saves money overall by reducing expenditures for stroke, myocardial infarction, and other cardiovascular events.
Antihypertensive Agents↗
Circadian variation in blood pressure: implications for the elderly patient.
In most people, blood pressure (BP) displays a characteristic diurnal pattern, with a decline during sleep and a sharp increase around the time of awakening. The early morning surge in BP is synchronous with an increase in the risk of catastrophic cardiovascular events, including acute myocardial infarction, sudden cardiac death, and stroke. Although most clinical investigations have centered on modulating or even preventing the morning surge, emerging data suggest that it may be important to avoid nocturnal hypotension, especially in elderly patients and in those with established atherosclerotic disease. Considerable evidence has been accumulated to suggest that excessive lowering of BP at night (whether naturally or through the use of antihypertensive medications) can result in untoward ischemic phenomena, including silent cerebral damage (Binswanger's disease) or ophthalmologic symptoms (eg, anterior ischemic optic neuropathy). Controlled-onset extended-release verapamil, through its unique delivery system, tends to diminish the morning BP surge, whereas it preserves a normal nocturnal BP decline; its effect on preventing early morning cardiovascular catastrophes (while preserving relatively normal nocturnal BP) is currently being tested in a large, international clinical trial.
Adult↗
Detection, treatment, and control of adult hypertension in northwest Indiana. Ispat Inland/United Steelworkers of America Health Care Network.
Recent data from the third National Health and Nutrition Examination Survey (NHANES-IIIB) suggest that detection and treatment of hypertension is improving, but only 27.4% of American hypertensives achieved controlled blood pressure ([BP] < 140 and < 90 mm Hg). Our objective was to assess the degree of BP control in a group of steelworkers and their families whose health care is financed by a large corporation. A random sample of 792 adults (age > 18 years, average 55 +/- 1 years, 50.4% male) was selected from a roster of patients who were known (from claims data) to have visited a physician in 1995 to 1996. Office charts were reviewed by trained nurses, who abstracted dates of 4095 visits, 3352 BP readings, and 3331 prescribed medications. Filled prescriptions were identified from 54,689 claims submitted for pharmacy services. Hypertension, defined (per NHANES) as more than one BP reading of 140/90 or higher, or taking antihypertensive medication, was found in 437 (55%). At least one antihypertensive medication was prescribed for 386 (88%) of the hypertensives; only 10 failed to have any prescription for antihypertensive medications filled. Controlled hypertension, as defined by Healthcare Employer Data Information Sheet (HEDIS) 3.0 (average BP < 140 and < 90 mm Hg in the office during a year-long period of observation), was observed in 189 patients (43% of total sample, or 50% of the 382 with at least one recorded BP measurement). These data suggest that in this population, insured by a jointly run employer-union health benefits plan, Healthy People 2000's BP goal-at least 50% of hypertensives having BP under control by the turn of the century-may be achieved ahead of schedule.
Adolescent↗
Comparison of two strategies for intensifying antihypertensive treatment: low-dose combination (enalapril + felodipine ER) versus increased dose of monotherapy (enalapril). LEVEL (Lexxel vs Enalapril) Study Group.
To compare two popular strategies for intensifying treatment for hypertension, a double-blind, randomized, prospective, parallel-group, and partial crossover study was done. After 2 weeks of placebo run-in (baseline) and 3 weeks of 5 mg enalapril once daily, 217 patients were randomized to 6 weeks of treatment with either a low-dose combination therapy (5 mg enalapril + 5 mg felodipine ER once daily, Lexxel, Astra Merck, Inc.), or a higher dose of monotherapy (10 mg enalapril once daily, Vasotec, Merck & Co., Inc.). The group randomized to the combination had significantly greater reductions in sitting systolic/diastolic blood pressure (BP)--14.2/10.6 mm Hg compared with baseline versus 9.6/7.4 mm Hg (P < .05/.01)--as well as a greater percentage of patients having achieved either diastolic BP < 90 mm Hg or a decline of at least 10 mm Hg (responders), 59% v 41% (P < .01). When patients originally taking 10 mg enalapril were crossed over to the combination therapy for a further 6 weeks, there was a further BP reduction and increase in response rate, with loss of significant differences compared with those treated continuously with the combination for the entire 12 weeks. The greater BP-lowering efficacy of the combination was independent of age, gender, and race. There were no significant differences in tolerability between the regimens. These data support the hypothesis that in patients who do not achieve goal BP reduction with a low dose of an antihypertensive agent, a combination of two drugs with complementary mechanisms of action is more effective than increasing the dose of the first agent.
Aged↗
Double-blind comparison of eprosartan and enalapril on cough and blood pressure in unselected hypertensive patients. Eprosartan Study Group.
The effects of a new angiotensin receptor antagonist, eprosartan (200 or 300 mg b.i.d.) and enalapril (5-20 mg u.i.d.) on cough and blood pressure were compared in a 26-week, double-blind, randomised, parallel-group, multicentre, international study involving 528 patients with hypertension. Uptitration of doses was based on clinic blood pressure measurements during the first 12 weeks, after which hydrochlorothiazide (12.5-25 mg/day) could be added. The frequency and intensity of cough was assessed by a standardised questionnaire administered at each clinic visit. The primary end-point was the incidence of persistent, dry cough not due to upper respiratory infection; change in sitting diastolic blood pressure and overall incidence of cough were secondary end-points. During the first 12 weeks of double-blind therapy, enalapril treatment was associated with a 3.45-fold higher risk of definite cough (14/261 vs 4/259, P = 0.018). Overall cough incidence (from spontaneous reports from patients, or investigator's observation) was also more frequent with enalapril, as compared to eprosartan. Both agents reduced blood pressure significantly compared to baseline, although the eprosartan-treated group had a slightly higher response rate (defined as sitting diastolic blood pressure <90 mm Hg, or at least a 10 mm Hg reduction from baseline), both at end of titration (70.3% vs 62.6%, P < 0.05) and after 26 weeks (81.7% vs 73.5%, P= 0.018). These data suggest that, in unselected hypertensive patients, eprosartan is associated with less cough and a somewhat higher responder rate than enalapril.
Acrylates↗
Comparison of effects of controlled onset extended release verapamil at bedtime and nifedipine gastrointestinal therapeutic system on arising on early morning blood pressure, heart rate, and the heart rate-blood pressure product.
We assessed the differential effects of a chronotherapeutic agent (controlled-onset extended release [COER] verapamil), administered at bedtime versus a conventional, homeostatic therapy (nifedipine gastrointestinal therapeutic system [GITS]) taken in the morning, on early morning and 24-hour blood pressure (BP), heart rate (HR), and the HR x systolic BP product. The study was a multicenter (n = 51), randomized, double-blind prospective clinical trial with a 10-week treatment period. Dose titration was performed by study investigators based on systolic and diastolic BP values at the doctor's office. Ambulatory BP monitoring was performed at placebo baseline, after 4 weeks of stable double-blind therapy, and at end of the study. Twenty-four-hour BP profiles were studied in 557 hypertensive patients. Changes in BP, HR, slope of the rate of rise of BP and HR, and the HR-systolic BP product during the 4 hours from 1 hour before to 3 hours after awakening were evaluated. The study was powered to show equivalence between the 2 regimens, predefined as a difference between treatment groups in mean change from baseline in early morning BP of +/- 5 mm Hg systolic and +/- 3 mm Hg diastolic. Changes in the early morning BP fell within the definition of equivalence for the 2 treatment strategies (-12.0/-8.2 mm Hg for COER-verapamil and -13.9/-7.3 mm Hg for nifedipine GITS). Changes in both the early morning HR and rate-pressure product were significantly greater following COER-verapamil therapy versus nifedipine GITS (HR, -3.8 beats/minute vs +2.6 beats/minute, p < 0.001 and HR-systolic BP product, -1,437 beats/min x mm Hg vs -703 beats/min x mm Hg, respectively, p < 0.001). Changes in ambulatory BP demonstrated clinically similar reductions for the awake period, but nifedipine GITS lowered systolic BP to a greater extent than COER-verapamil during sleep (-11.0 vs -5.8 mm Hg, p < 0.001). COER-verapamil and nifedipine GITS had equivalent effects (+/- 5/3 mm Hg) on early morning BP. In addition, both extended-release calcium antagonists effectively lowered 24-hour BP. However, COER-verapamil had greater effects than nifedipine GITS on early morning hemodynamics (HR, HR-systolic BP product, rate of rise of BP and HR) and lesser effects during sleep due to its intrinsic pharmacologic properties and chronotherapeutic delivery system.
Analysis of Variance↗
Rationale and design for the Controlled ONset Verapamil INvestigation of Cardiovascular Endpoints (CONVINCE) Trial.
The Controlled ONset Verapamil INvestigation of Cardiovascular Endpoints (CONVINCE) Trial is a randomized, prospective, double-blind, parallel-group, two-arm, actively controlled, multicenter, international 5-year clinical trial involving 15,000 patients. CONVINCE will compare the incidence of fatal or nonfatal myocardial infarction (MI), fatal or nonfatal stroke, or cardiovascular-disease-related death in two antihypertensive treatment regimens. One treatment arm begins with controlled onset-extended release (COER)-verapamil, which has its major antihypertensive effect 6-12 hours after administration. The other arm (standard of care (SOC)) begins with either hydrochlorothiazide (HCTZ) or atenolol, one of which is preselected by the investigator for an individual patient prior to randomization. Secondary objectives include comparisons of the regimens for each of the components of the primary endpoint (separately), death or hospitalization related to cardiovascular disease, efficacy in lowering blood pressure to goal, primary events occurring between 6 am and noon, all-cause mortality, withdrawals from blinded therapy, cancer, and hospitalizations due to bleeding. Patients may be enrolled if they are hypertensive and at least 55 years of age and have an established second risk factor for cardiovascular disease. Initial medications include COER-verapamil (180 mg/d), HCTZ (12.5 mg/d), or atenolol (50 mg/d). Initial doses are doubled if blood pressure (BP) does not reach goal (systolic BP < 140 mm and diastolic BP < 90 mm Hg). If BP is not controlled by the higher dose of the initial medication, HCTZ is added to COER-verapamil, or the SOC choice not initially selected is added in the SOC arm. An ACE-inhibitor is recommended (although nearly any open-label medication is allowed) as the third step for patients whose BP is not adequately controlled or who have a contraindication to one of the two SOC medications. Patients take two sets of tablets daily, one in the morning and one in the evening. Although most patients switch from an established antihypertensive medication to randomized treatment, untreated patients with stages I-III hypertension (SBP between 140 and 190 or DBP between 90 and 110 mm Hg) are eligible. Outcomes are monitored by an independent Data and Safety Monitoring Board. Enrollment began during the third quarter of 1996, and follow-up is to be completed in the third quarter of 2002.
Aged↗
Effects of verapamil and trandolapril in the treatment of hypertension. Trandolapril Study Group.
The combination of an angiotensin converting enzyme inhibitor with a calcium antagonist has become a common way of treating patients with essential hypertension who respond insufficiently to monotherapy. This double-blind, randomized, parallel, placebo-controlled, multicenter, outpatient study evaluated the antihypertensive efficacy and safety of a calcium antagonist (verapamil SR) and an angiotensin converting enzyme inhibitor (trandolapril) in patients with mild-to-moderate (stages I and II) essential hypertension. Six hundred thirty-one patients were enrolled in this 10-week study. After a 4-week single-blind placebo phase, patients received one of the following daily dosage regimens in a double-blind fashion for 6 weeks: placebo, 4 mg of trandolapril, 240 mg of verapamil SR, or a combination of 4 mg of trandolapril and 240 mg of verapamil SR. Trough sitting diastolic blood pressure was lowered by 4.5 mm Hg, 4.3 mm Hg, and 8.1 mm Hg more than placebo in the trandolapril, verapamil SR, and combination groups, respectively. In the combination group, sitting diastolic blood pressure was significantly lowered (P < .01) by 3.6 mm Hg more than in the trandolapril group and by 3.8 mm Hg more than in the verapamil SR group. An analysis of the trough-to-peak ratio for sitting diastolic blood pressure revealed values of 0.75 and 0.67, for the 4-mg trandolapril and the combination groups, respectively, at end point. The overall incidence of adverse reactions was similar for all treatment groups. In this study the combination of an angiotensin converting enzyme inhibitor and calcium antagonist was well tolerated and more effective than either agent administered alone for the treatment of mild-to-moderate essential hypertension.
Angiotensin-Converting Enzyme Inhibitors↗
Traditional drug therapy of hypertension in transplant recipients.
Hypertension is a very common condition among recipients of transplanted organs, and is often related to immunosuppressive therapy. In many transplant centres, calcium antagonists are often used as first-line antihypertensive drug therapy, not only because of efficacy in lowering blood pressure, but also because certain members of the class have a 'beneficial' drug-drug interaction with cyclosporin, which decreases the cost of administering this very expensive immunosuppressant. Diuretics are often used both for blood pressure and volume control, and some centres have used either alpha-beta-blockers, angiotensin-converting enzyme inhibitors, and even beta-blockers with success in certain patients. The high frequency of perceived adverse effects of antihypertensive drugs in transplant recipients and the diversity of training of the specialist physicians involved in their care makes choice of traditional antihypertensive drug therapy in these patients a major challenge.
Adrenergic beta-Antagonists↗
Circadian variation in the timing of stroke onset: a meta-analysis.
BACKGROUND AND PURPOSE: Acute myocardial infarction and sudden death display a circadian rhythm, with a higher risk between 6 AM and noon. Some reports suggest that stroke does not follow such a circadian variation and that hemorrhagic stroke occurs more often during the evening. METHODS: A meta-analysis of 31 publications reporting the circadian timing of 11,816 strokes was performed, subdividing (when possible) by the type of stroke, according to the time of onset of symptoms. When precise timing was not given, strokes were distributed evenly (that is, biasing toward the null hypothesis of lack of circadian variation). RESULTS: All subtypes of strokes displayed a significant (P<0.001) circadian variation in time of onset, whether divided into 3-, 4-, or 6-hour time periods. There was a 49% increase (95% confidence interval, 44% to 55%) in stroke of all types between 6 AM and noon (compared with expectations if no circadian variation was present), which is a 79% (95% confidence interval, 72% to 87%) increase over the normalized risk of the other 18 hours of the day. There were 29% fewer strokes between midnight and 6 AM, a 35% decrease compared with the other 18 hours of the day. All three subtypes of stroke had a significantly higher risk between 6 AM and noon (55% for 8250 ischemic strokes; 34% for 1801 hemorrhagic strokes, and 50% for 405 transient ischemic attacks). CONCLUSIONS: These data support the presence of a circadian pattern in the onset of stroke, with a significantly higher risk in the morning.
Cerebral Hemorrhage↗
Rationale and benefits of classification of hypertension severity.
Classification schemes for hypertension are helpful in defining the condition, quantitating risk, estimating prognosis, and guiding management. Most "classic" systems classify hypertension based on the blood pressure level, according to "relative risk" (the proportional likelihood of cardiovascular events occurring as blood pressure--either systolic, diastolic, or both--rises). Several recent systems are based on "absolute risk," and quantify the risk for adverse events related to other cardiovascular risk factors besides hypertension. Classification schemes based on the pattern of blood pressure elevation, extent of damage to target organs from hypertension, and laboratory evaluations have also been suggested, but are, of necessity, more complicated than systems based simply on the blood pressure readings. Two novel systems of classifying hypertension have recently been proposed, incorporating most of the desirable attributes of the simpler (and widely used) methods of "staging" blood pressure, but adding a subscript to indicate the presence ("c") or absence ("u") of complications or other risk factors present in a given patient. This system also uses a subscript "e" to indicate the presence of a widened pulse pressure (more common in the elderly); such patients are more likely to benefit from hypertension treatment. A complete medical history and physical examination and a few inexpensive laboratory tests provide essentially all the information needed to classify an individual as "complicated" or "uncomplicated." This system also provides a guide to treatment, because drug therapy should be used sooner in those with complicated hypertension. Implementation of this system is likely to be enhanced if compensation for health care providers were higher when treating the higher stages of hypertension, especially an elderly patient with complicated hypertension, compared with a younger person with uncomplicated hypertension.
Blood Pressure↗
Diagonal earlobe creases and prognosis in patients with suspected coronary artery disease.
PURPOSE: To determine whether high-risk patients with unilateral, bilateral, or no earlobe creases (ELC) have different prognoses for common sequelae of coronary heart disease. PATIENTS AND METHODS: Two hundred sixty-four consecutive patients from a university-based coronary care unit or catheterization laboratory were blindly followed up for 10 years, using questionnaires, medical records, and death certificates. The primary outcome measure was time to cardiac event; namely, coronary artery bypass graft (CABG), myocardial infarction (MI), or cardiac death. Analyses included log-rank tests and Cox proportional hazards regression modelling. RESULTS: The number of creased ears was significantly associated, in a graded fashion, with 10-year cardiac event free survival: 43.5% +/- 5.7%, 33.0% +/- 6.7%, or 17.5% +/- 4.6% (mean +/- standard error for 0, 1 or 2 ELC, respectively; P = 0.003). After adjustment for 10 known cardiac risk factors, including age and left ventricular ejection fraction, the relative risk for a cardiac event for a unilateral ELC, relative to 0 ELC, was 1.33 (95% confidence interval [CI] 1.10 to 1.61, P = 0.02), and for bilateral ELC, it was 1.77 (95% CI 1.21 to 2.59, P = 0.003). CONCLUSIONS: Ear lobe creases are associated, in a graded fashion, with higher rates of cardiac events in patients admitted to hospital with suspected coronary disease. In such patients, ELC may help to identify those at higher risk for sequelae for coronary disease.
Coronary Disease↗
Higher incidence of discontinuation of angiotensin converting enzyme inhibitors due to cough in black subjects.
OBJECTIVE: To compare the rates of discontinuation of angiotensin converting enzyme (ACE) inhibitors in patients with different racial and ethnic backgrounds. METHODS: A registry from a tertiary hypertension clinic consisting of 892 patients who received their first-ever dose of ACE inhibitor therapy was examined. Surveillance for cough was prospective, systematic, and constant beginning in 1986 and routinely included a trial of sinusitis therapy, followed by withdrawal and rechallenge before discontinuation of drug. RESULTS: The prevalence (per 100 patients) of cough requiring discontinuation of ACE inhibitor therapy was 62 of 644 (9.6 per 100) patients among black subjects compared with six of 248 (2.4 per 100) patients among others (odds ratio, 4.0; 95% confidence interval, 1.7 to 9.1; p < 0.001). There were no significant differences in discontinuation rates across the three most commonly used ACE inhibitors: captopril (6.6%; all black subjects), enalapril (6.1%; 94% black subjects), and lisinopril (7.3%; 90% black subjects). Cough was more common among women (70% of subjects). After adjustment (by backward stepwise multiple logistic regression analysis) for baseline differences, black subjects had a relative risk of 2.58 (95% confidence interval, 1.21 to 4.65; p = 0.01) of discontinuation of ACE inhibitor due to cough. CONCLUSIONS: These data suggest that there may be a race- or ethnicity-related difference in the prevalence of cough attributed to ACE inhibitor therapy. Although a race-related difference in ACE gene polymorphism has been suggested, further work is necessary to define the biological reason and pathophysiology for such a difference.
Angiotensin-Converting Enzyme Inhibitors↗
Comparison of nifedipine alone and with diltiazem or verapamil in hypertension.
Receptor binding studies suggest that combinations of calcium channel blockers may result in either enhanced or diminished pharmacological effects, but clinical data in hypertension are incomplete. In this study, we compared blood pressure reductions using nifedipine alone, nifedipine plus diltiazem, and nifedipine plus verapamil and determined whether combinations alter nifedipine pharmacokinetics. After determination of baseline blood pressures. 16 subjects with essential hypertension (12 men, 4 women; mean age, 48 years) received 30 mg/d open-label, sustained release nifedipine for 2 weeks. If still hypertensive (n = 16), they were randomized (double-blind) to receive either additional sustained release diltiazem or sustained release verapamil, both 180 mg/d, for 2 weeks and were then crossed-over for the final 2 weeks of the study. All medications were once-daily, extended-release formulations. Blood pressures and nifedipine plasma concentrations were measured during the final day of each treatment. Overall, each combination lowered mean systolic and diastolic pressures more than nifedipine alone. Mean supine diastolic pressures were significantly lower at 8 hours (77.6 versus 84.6 mm Hg, P = .001) and 12 hours (81.5 versus 87.1 mm Hg, P = .04) with nifedipine plus diltiazem than nifedipine plus verapamil. Mean nifedipine concentrations were inversely correlated with mean blood pressures. Mean nifedipine area under the curve values were greater with diltiazem than verapamil (1430 versus 1134 ng.h/mL, P = .026), with each greater than nifedipine alone (957 ng.h/mL). Nifedipine plus diltiazem had a greater antihypertensive effect than nifedipine plus verapamil. Diltiazem caused greater increases in nifedipine plasma concentrations than did verapamil. These data suggest that combined calcium channel blockers result in additive antihypertensive effects, perhaps because of a pharmacokinetic interaction.
Adult↗
The costs of treating hypertension: what are the long-term realities of cost containment and pharmacoeconomics?
Cost containment is an important force in medicine today, and there is ample reason to believe that it will soon target the No. 1 health problem for which Americans visit physicians--hypertension. The greatly streamlined (and cost-limited) initial evaluation of hypertensive patients suggested by the latest report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure is but one example. Acquisition cost is certainly an important factor in choice of a drug, but it is only one aspect of total cost of care. Limiting pharmacy benefits may produce short-term cost savings but may lead to unanticipated long-term increases in the healthcare budget. Prescribing large numbers of pills or an increased strength to allow pill-splitting and dispensing free medications provided by many pharmaceutical companies are ways some physicians are limiting the cost of antihypertensive drug therapy for patients. More research and sharing of information are necessary before easily generalizable conclusions can be drawn about the long-term pharmacoeconomics of hypertension therapy.
Adrenergic beta-Antagonists↗
ALLHAT: the largest and most important clinical trial in hypertension ever done in the USA. Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial.
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Antihypertensive Agents↗