UMLS:C0011849 - FACTA Search

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It is well-known that patients with terminal renal insufficiency are at increased risk for a future cardiovascular event. A relevant relationship also appears to apply to the early stages of renal insufficiency. The HOPE study has shown that the incidence of myocardial infarction, apoplexy and cardiovascular mortality in patients with incipient renal insufficiency is significantly raised. The study also found that the incidence of cardiovascular events is in direct proportion to the level of serum creatinine. Against this background, patients at risk can be readily identified. The HOPE study documents a considerable cardiovascular risk for patients with incipient renal insufficiency and concomitant uncomplicated hypertension, atherosclerosis or diabetes. In view of this, the use of ACE inhibitors in patients with moderate renal insufficiency should now be introduced. In the HOPE subjects, ramipril was found not only to lower the cardiovascular risk, but also to improve renal insufficiency.
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PMID:[Renal failure and cardiovascular risk. Increased borderline serum creatinine--a warning sign?]. 1177 Mar 72

The term "blood pressure" was coined almost 300 years ago by the man who first measured it, the Reverend Stephen Hales of England. However, our understanding of the pathogenesis and consequences of hypertension, as well as the available treatments for it, have remained greatly limited and inadequate until only the past 30 years. Starting in 1977, reports from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of Hypertension (JNC) have provided regular updates on developments in hypertension management, and have set guidelines for the diagnosis and treatment of hypertension. More than 20 years ago, the JNC stratified blood pressure (BP) levels into categories of mild, moderate, and severe (later renamed stages 1, 2, and 3, respectively). A stepped-care approach to hypertension therapy was originally recommended. With each revised JNC report, there was a reduction in target BP and a growing recognition of the importance of high-normal BP and isolated systolic hypertension. The sixth and most current report of the Joint National Committee, JNC VI, emphasizes treatment of comorbidities of hypertension, sets a lower BP goal (<130/85 mm Hg) for high-risk patients-eg, those with diabetes or renal disease-than for those with uncomplicated hypertension (<140/90 mm Hg), and places a greater emphasis on disease prevention. For the future, the current trend toward lower BP goals suggests that more effective and better tolerated antihypertensive therapies will be needed. Multiple antihypertensive agents used concomitantly will likely be needed to control elevated levels of BP in the majority of hypertensive patients.
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PMID:Hypertension management in 2002: where have we been? where might we be going? 1238 90

"The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure" provides a new guideline for hypertension prevention and management. The following are the key messages(1) In persons older than 50 years, systolic blood pressure (BP) of more than 140 mm Hg is a much more important cardiovascular disease (CVD) risk factor than diastolic BP; (2) The risk of CVD, beginning at 115/75 mm Hg, doubles with each increment of 20/10 mm Hg; individuals who are normotensive at 55 years of age have a 90% lifetime risk for developing hypertension; (3) Individuals with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CVD; (4) Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); (5) Most patients with hypertension will require 2 or more antihypertensive medications to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes or chronic kidney disease); (6) If BP is more than 20/10 mm Hg above goal BP, consideration should be given to initiating therapy with 2 agents, 1 of which usually should be a thiazide-type diuretic; and (7) The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with and trust in the clinician. Empathy builds trust and is a potent motivator. Finally, in presenting these guidelines, the committee recognizes that the responsible physician's judgment remains paramount.
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PMID:The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. 1296 19

Some hypertension treatment guidelines published in the late 1990's recommended that diuretics and betha-blockers be used as 1st line drugs for treating uncomplicated hypertension, reserving new antihypertensive drugs for special indications. This recommendation is predicated on the fact that large trials showing cardiovascular protection with antihypertensive drugs used betha-blockers and diuretics. Other guidelines suggested all antihypertensives are equal and that drug selection should be individualized. These disparate guidelines arise from the controversy over "are all antihypertensives created equal?" Since these guidelines, many large hypertension trials have been conducted. This paper will review the recent hypertension trials, the meta-analyses of some of these trials, highlight some of the flaws inherent in the trials that making interpretation difficult, and finally outline a rationale approach to initial treatment of the uncomplicated hypertensive patient. It will provide a rationale for 1) using diuretic and not beth-blocker as the 1st line agent in treating uncomplicated hypertension, 2) switching to an angiotensin converting enzyme inhibitor or angiotensin receptor blocker should side effects occur on diuretic, 3) reserving calcium channel blocker, betha-blocker, and alpha-blocker for 2nd or 3(rd) line therapy, 4) employing a diuretic in combination with any other antihypertensive class, and 5) considering use of lower doses of 2 or more antihypertensives to limit side effects while optimizing blood pressure control. If the incidence of de novo diabetes is indeed higher with diuretics and cost-analysis confirm long-term savings with using a more expensive but less diabetogenic drug to treat hypertension, then the recommendation may shift to using an antihypertensive that acts on the renin-angiotensin axis.
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PMID:Initial therapy for uncomplicated hypertension: insights from the alphabetic maze of recent studies. 1460 87

The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.
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PMID:Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 1503 59

Guideline committees recommend targets of treatment based on trial data on efficacy and effectiveness. Quality-assurance initiatives apply these parameters in the general practice setting. Therefore, targets must be feasible and achievable by the practicing physicians who are judged by these targets as goals for care. We evaluated 437 patients in the Rush University Hypertension Clinic using the Health Employer Data Information Set (HEDIS) measures for 2000 to assess goal achievement in a practice-based setting. We compared guideline achievement of uncomplicated hypertensive and diabetic subjects to standards dictated by HEDIS, the 6th Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI), and the American Diabetic Association (ADA)/National Kidney Foundation (NKF). Overall, 276 (63%) patients achieved SBP goal, with 376 (86%) achieving DBP goal and 358 (59%) achieving both goals. However, in the 20% of patients who were diabetic, only 52% had a BP of <140 mm Hg and <90 mm Hg, whereas only 22% achieved the more stringent goals of JNC VI of <130 mm Hg systolic and <85 mm Hg diastolic and only 15% achieved the ADA/NKF goals of <130 mm Hg systolic and <80 mm Hg diastolic. Although goal was achievable in most uncomplicated hypertension, hypertension in diabetes was more difficult to control, despite being more likely to receive enhanced benefit from effective management. Goal-oriented strategy, especially in diabetic subjects, should be aggressively sought rather than relaxing goals to promote achievement.
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PMID:Guidelines for hypertension: are quality-assurance measures on target? 1475 6

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure emphasizes the urgent need to lower blood pressure (BP) to a goal of <140/90 mm Hg in patients with uncomplicated hypertension and to <130/80 mm Hg in high-risk patients, such as those with diabetes mellitus or chronic kidney disease, to prevent cardiovascular disease morbidity and mortality. Consequently, a meaningful measure of the efficacy of an antihypertensive therapy is its ability to achieve BP reduction to below the recommended BP goals. Angiotensin II receptor blockers (ARB) are highly effective antihypertensive agents with excellent tolerability profiles similar to those of placebo. A literature search using MEDLINE, EMBASE, and BIOSIS to identify studies reporting data on the percentage of patients attaining BP goals found that monotherapy with an ARB can generally result in the attainment of the diastolic BP (DBP) goal of <90 mm Hg in approximately 50% of hypertensive patients. However, to our knowledge, the attainment of the systolic BP (SBP) and combined SBP/DBP goals with ARB monotherapy has not been reported. Therefore, a secondary analysis of BP efficacy data from a published study that directly compared recommended starting doses of four currently marketed ARB was performed to assess combined SBP and DBP goal attainment. This analysis showed that the percentage of patients achieving the combined SBP/DBP goal rate of <140/90 mm Hg was highest with olmesartan medoxomil (32.4%) compared with recommended starting doses of losartan potassium (16.1%), valsartan (14.5%), or irbesartan (25.9%). Optimal ARB monotherapy can achieve recommended BP goals in a significant proportion of hypertensive patients. However, the majority of hypertensive patients will require combination therapy with two or more antihypertensive agents.
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PMID:Role of angiotensin receptor blockers as monotherapy in reaching blood pressure goals. 1575 58

Some of the reported findings of numerous studies on the treatment of hypertension are still giving rise to heated discussions. The result is conflicting recommendations and uncertainty among care-providing physicians. Today, the substances from the group of more recent hypertensive agents (calcium antagonists, ACE-inhibitors and angiotensin 1 receptor blockers) together with the classical agents (diuretics and beta blockers) are recognized as equally justifiable as the five agents of first choice in the treatment of uncomplicated hypertension. If, however, accompanying diseases are present, the choice of primary medication depends on the respective risk (diabetes, etc.) of the individual patient. In many cases, combination treatment should be considered from the very beginning.
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PMID:[Old or new antihypertensives--which are better?]. 1583 60

Although numerous prospective randomized trials since the Veterans Administration studies clearly have attested to the efficacy and safety of antihypertensive therapy, there remain some controversial issues with all classes of antihypertensive drugs. Thiazide diuretics increase the risk for new-onset diabetes and their long-term safety has been questioned. Alpha-blockers do not reduce morbidity and mortality in uncomplicated hypertension but are well known to cause a variety of poorly tolerated side effects. The safety of calcium antagonists has been questioned for many years, although recent large prospective randomized trials such as Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, International Verapamil-Trandolapril Study, Intervention as a Goal in Hypertension, Valsartan Antihypertensive Long-Term Use Evaluation and the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) have attested to their safety and efficacy. Angiotensin-converting enzyme inhibitors, in general, are well tolerated but have potentially fatal adverse effects in a few patients. Angiotensin-receptor blockers are exceedingly well tolerated, but may be less-efficacious antihypertensive agents than other drug classes. Most antihypertensive drug classes have an effect on new-onset diabetes that should be taken into account in patients at risk. No head-to-head comparison of combination therapy looking at efficacy and safety has been available. The long-term safety of antihypertensive therapy is documented poorly because most trials only last 4 to 6 years. Despite these drawbacks and concerns, the benefits of antihypertensive therapy clearly outweigh its potential risk.
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PMID:Therapeutic controversies in hypertension. 1620 95

Hypertension is common in chronic renal disease and is a risk factor for the faster progression of renal damage, and reduction of blood pressure (BP) is an efficient way of preventing or slowing the progression of this damage. International guidelines recommend lowering BP to 140/90 mm Hg or less in patients with uncomplicated hypertension, and to 130/80 mm Hg or less for patients with diabetic or chronic renal disease. The attainment of these goals needs to be aggressively pursued with multidrug antihypertensive regimens, if needed. The pathogenesis of hypertensive renal damage involves mediators from various extracellular systems, including the renin-angiotensin system (RAS). Proteinuria, which occurs as a consequence of elevated intraglomerular pressure, is also directly nephrotoxic. As well as protecting the kidneys by reducing BP, antihypertensive drugs can also have direct effects on intrarenal mechanisms of damage, such as increased glomerular pressure and proteinuria. Antihypertensive drugs that have direct effects on intrarenal mechanisms may, therefore, have nephroprotective effects additional to those resulting from reductions in arterial BP. Whereas BP-lowering effects are common to all antihypertensive drugs, intrarenal effects differ between classes and between individual drugs within certain classes. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) have beneficial effects on proteinuria and declining renal function that appear to be mediated by factors additional to their effects on BP. These RAS inhibitors are recommended as a first-line antihypertensive approach in patients with chronic kidney disease. The addition of diuretics and calcium channel antagonists to RAS inhibitor therapy is also considered to be a rational strategy to reduce BP and preserve renal function. Calcium channel antagonists are a highly heterogeneous class of compounds, and it appears that some agents are more suitable for use in patients with chronic renal disease than others. Manidipine is a third-generation dihydropyridine (DHP) calcium channel antagonist that blocks both L and T-type calcium channels. Unlike older-generation DHPs, which preferentially act on L-type channels, manidipine has been shown to have beneficial effects on intrarenal haemodynamics, proteinuria and other measures of renal functional decline in the first clinical trials involving hypertensive patients with chronic renal failure. Preliminary results from a trial in diabetic patients who had uncontrolled hypertension and microalbuminuria despite optimal therapy with an ACE inhibitor or an ARB suggest that manidipine may be an excellent antihypertensive drug in combination with RAS inhibitor treatment in order to normalise BP and albumin excretion in patients with diabetes.
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PMID:Renal protection in hypertensive patients: selection of antihypertensive therapy. 1639 60

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