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Am J Hypertens. 2003 Nov;16(11 Pt 2):50S-54S.
Recommendations for the management of special populations: racial and ethnic populations.

Ferdinand KC.

Heartbeats Life Center, Xavier University College of Pharmacy, New Orleans, Louisiana 70117, USA.

One of the current challenges in the treatment of hypertension is the variation in the incidence and morbidity among ethnic populations. For example, in the recent Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), in which 35% of the patients were African American, the diuretic chlorthalidone was associated with greater reductions in blood pressure (BP) than the angiotensin-converting enzyme (ACE) inhibitor lisinopril and was also associated with a relative risk reduction in stroke compared with lisinopril. However, the increased stroke risk associated with lisinopril was experienced among African American but not non-African American patients. ALLHAT did not permit combination therapy with ACE inhibitors plus diuretics; therefore, the benefits of such regimens in this patient population could not be assessed. In the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study, in contrast to the overall study population, African American patients with left ventricular hypertrophy treated with atenolol were at lower risk of experiencing the primary composite end point (death, myocardial infarction, and stroke) than African Americans treated with losartan, with or without diuretics. On the other hand, in the African American Study of Kidney Disease and Hypertension, African American patients treated with the ACE inhibitor ramipril had a significantly lower incidence of the primary composite end point (glomerular filtration rate reduction, end-stage renal disease, or death) than African Americans treated with the calcium channel blocker amlodipine. Although the use of diuretics in African American patients may be a logical first-line choice for BP reduction, most patients will require combination therapy. African American patients with systolic BP > or =15 mm Hg above target level or a diastolic BP > or =10 mm Hg above target should be considered for first-line combination therapy. Although certain combinations have been shown to be effective in non-African American patients, the choice of drugs for combination therapy in African American patients may be different.

online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14625162&dopt=Abstract [PubMed - in process]




Am J Physiol Heart Circ Physiol. 2003 Nov 26 [Epub ahead of print]
ACE-inhibitors and statins acutely improve endothelial dysfunction of human coronary arterioles.

Tiefenbacher CP, Friedrich S, Bleeke T, Vahl C, Chen X, Niroomand F.

Department of Cardiology, University of Heidelberg, Heidelberg, Germany.

Long-term treatment with ACE-inhibitors as well as angiotensin II type 1 (AT(1)) receptor antagonists and statins reduces cardiovascular mortality in patients with coronary artery disease as well as chronic heart failure. Little is known about acute effects of these compounds on vascular reactivity of coronary resistance vessels. Coronary arterioles were obtained from patients undergoing coronary bypass operation (atherosclerosis group) or valve replacement (control group). Responses to endotheliumdependent agonists (histamine, serotonin and acetylcholine) as well as to the endotheliumindependent agonist sodium nitroprusside (SNP) were investigated under baseline conditions and following incubation (15min) with lisinopril (ACE-inhibitor), candesartan (AT(1) receptor antagonist) or fluvastatin. In atherosclerotic vessels vasorelaxation was significantly reduced to all endotheliumdependent agonists, however not to SNP (77+/-8, -24+/-16, -46+/-24 and 98]+/-8% relaxation for histamine, serotonin, acetylcholine and sodium nitroprusside, respectively). Lisinopril and fluvastatin but not candesartan, significantly improved the responses to the endotheliumdependent agonists (lisinopril: 94+/-4, 17+/-22, -20 +/-13%; fluvastatin: 96+/-8, 2+/-21, -25+/-18% relaxation for histamine, serotonin, and acetylcholine, repectively). The effect of lisinopril was prevented by pretreatment with a bradykinin antagonist (HOE 130) and dichloroisocoumarine (DCI), an inhibitor of kinine-forming enzymes. Pretreatment with a NO-synthase inhibitor abolished the improvement of endothelial function by lisinopril and fluvastatin. Vascular reactivity in the control group was not influenced by any of the pharmacological interventions. The data demonstrate that in atherosclerosis, endothelium-dependent relaxation of coronary resistance arteries is severely compromised. The impairment can acutely be reversed by ACEinhibitors and statins via increasing the availability of NO.

online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14644762&dopt=Abstract [PubMed - as supplied by publisher]




J Hypertens. 2003 Dec;21(12):2409-2417.
Results of the pilot study for the Hypertension in the Very Elderly Trial.

Bulpitt CJ, Beckett NS, Cooke J, Dumitrascu DL, Gil-Extremera B, Nachev C, Nunes M, Peters R, Staessen JA, Thijs L; On behalf of the Hypertension in the Very Elderly Trial (HYVET) Working Group.

Faculty of Medicine, Imperial College London, UK, University of Medicine and Pharmacy, Cluj, Romania, Universidad de Granada, Granada, Spain, St Anna Hospital, 1784 Sofia, Bulgaria and Department of Molecular and Cardiovascular Research, Katholic University Leuven, Belgium.

SUMMARY: BACKGROUND The risks and benefits of treating hypertension in individuals older than 80 years are uncertain. A meta-analysis has suggested that a reduction in stroke events of 36% may have to be balanced against a 14% increase in total mortality.OBJECTIVES To report the results of the pilot study of the Hypertension in the Very Elderly Trial (HYVET), which is in progress to address these issues.METHODS The HYVET-Pilot was a multicentre international open pilot trial. In 10 European countries, 1283 patients older than 80 years and with a sustained blood pressure of 160-219/90-109 mmHg were allocated randomly to one of three treatments: a diuretic-based regimen (usually bendroflumethiazide; n = 426), an angiotensin-converting enzyme inhibitor regimen (usually lisinopril; n = 431) or no treatment (n = 426). The procedure permitted doses of the drug to be titrated and diltiazem slow-release to be added to active treatment. Target blood pressure was < 150/80 mmHg and mean follow-up was 13 months.RESULTS In the combined actively treated groups, the reduction in stroke events relative hazard rate (RHR) was 0.47 [95% confidence interval (CI) 0.24 to 0.93] and the reduction in stroke mortality RHR was 0.57 (95% CI 0.25 to 1.32). However, the estimate of total mortality supported the possibility of excess deaths with active treatment (RHR 1.23, 95% CI 0.75 to 2.01).CONCLUSIONS The preliminary results support the need for the continuing main HYVET trial. It is possible that treatment of 1000 patients for 1 year may reduce stroke events by 19 (nine non-fatal), but may be associated with 20 extra non-stroke deaths.

online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14654762&dopt=Abstract [PubMed - as supplied by publisher]





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