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African Americans represent a population with the highest prevalence of hypertension in the world, associated with earlier onset, more severity, poorer control rates, and more cardiovascular and renal complications than White Americans. The high prevalence of type 2 diabetes mellitus in African Americans, compared with Whites, compounds the excessive burden of cardiovascular and kidney disease. The Hypertension in African American Working Group of the International Society of Hypertension in Blacks recently developed a consensus document that presented a practical, evidence-based approach aimed at achieving better blood pressure control. It was thought that a new approach, targeted at US Blacks, was needed to achieve better blood pressure control and enhanced target tissue protection. Key elements of the document include (i) emphasis on the importance of therapeutic lifestyle modification such as weight loss, decreased sodium ingestion, increased potassium intake, exercise, and weight loss, to name a few; (ii) recommendation of combination antihypertensive agents because of the high prevalence of individuals with >15 mm Hg above SBP goal and/or 10 mmHg above DBP goal (140/90 unless there is also diabetes and/or kidney disease with >1 g proteinuria daily). Effective combinations include beta-adrenoceptor antagonist/diuretic, ACE inhibitor/diuretic, ACE inhibitor/calcium channel antagonist, and angiotensin receptor antagonist/diuretic; and (iii) the recommendations do not differ from other racial/ethnic groups where specific or compelling indications for the use of specific classes of antihypertensive agents exist.
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PMID:Clinical guidelines for the treatment of hypertension in African Americans. 1563 32

We assessed the morbidity and mortality of subjects with transiently elevated diastolic pressure in the General Practice Hypertension Study Group (GPHSG) population. A total of 23 578 patients (aged 18-65 years) from seven UK general practices were screened in 1974 for a diastolic blood pressure (DBP4) of > or = 90 mmHg. Two further readings of DBP4 determined hypertensive (either DBP4 > or = 90 mmHg) or transient hypertensive (both DBP4 < 90 mmHg) status. Transients (n = 850) were matched with normotensive controls (n = 824) and risk ratios calculated over a mean follow-up of 18.7 years. Rescreening was conducted in six of the practices (n = 20 942) after 7.7 years. Male transients had a higher relative hazard for cardiovascular mortality than controls (11.8%, 8.6%, adjusted relative hazard 1.59, P = 0.056). Female transients had a lower relative hazard for cardiovascular mortality than controls (3.6%, 5.4%, adjusted relative hazard 0.39, P = 0.018). In all, 422 patients with transient hypertension were rescreened along with 367 matched controls. Significantly more transients were on antihypertensive treatment compared with their controls (odds ratio (OR) [95% CI]) for both male (4.2 [1.6-11.1]) and female patients (2.4 [1.0-5.56]) and more untreated female transients developed hypertension. Male transients had a higher rates of diabetes mellitus (adj OR = 5.1, P = 0.04) and stroke (adj OR 15.9, P = 0.03). This study has shown that transiently elevated DBP in GPHSG is associated with a significantly higher risk of later hypertension in men and women and of diabetes, stroke and cardiovascular mortality in men. Women with this condition have a significantly lower cardiovascular mortality.
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PMID:Transiently elevated diastolic blood pressure is associated with a gender-dependent effect on cardiovascular risk. 1574 34

The relationship between time factors of elevated blood pressure (BP) and carotid atherosclerosis (CA) is still unclear. The associations between time-weighted average 24 h ambulatory systolic BP (TWA-SBP), duration of hypertension in years (hypertension-year), and CA were investigated in a petrochemical company sample of 95 executives and 91 gender- and age-matched non-executives employees. Intima-media thickness (IMT) and plaque scores of extracranial carotid artery (ECCA) were determined bilaterally by high-resolution B-mode ultrasound. The determinants of segment-specific carotid IMT and odds ratios for CA, in terms of thicker IMT (IMT > or = 75th percentile) and ECCA score > or = 3, were evaluated by multivariate regression analysis. Results revealed TWA-SBP and hypertension-year were two major determinants of IMT at common carotid artery (CCA) and carotid bulb by using mixed regression models. However, TWA-DBP was a negative determinant of IMT at CCA and carotid bulb. Meanwhile, the executives were found to be a negative association with IMT at carotid bulb. Measurements at both internal carotid artery and bulb identified duration of diabetes mellitus as significant determinant of IMT. After controlling covariates, multivariate logistic regression analysis identified TWA-SBP and hypertension-year as the important determinants for thicker IMT and ECCA > or = 3. And, TWA-DBP was found as a negative determinant for CA. In conclusion, both TWA-SBP and hypertension-year were two major determinants for carotid IMT and CA, which seem to imply that both short-term and long-term durations of elevated BP are probably crucial in the pathogenesis of CA.
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PMID:Twenty-four-hour ambulatory blood pressure and duration of hypertension as major determinants for intima-media thickness and atherosclerosis of carotid arteries. 1593 57

Smoking is a well-established risk factor for cardiovascular disease. Studies have indicated that smoking may outweigh the benefit of blood pressure (BP) control. Our aim was to compare cardiovascular risk factors in smokers vs non-smokers from a national sample of treated hypertensives. Data were collected on smoking habits, BP control, total and low-density lipoprotein (LDL) cholesterol, diabetes, left ventricular hypertrophy (LVH), and microalbuminuria (MA), from records of 4424 consecutive patients by 189 physicians. All technical methods were local. Treated hypertensives who smoked had microalbuminuria significantly more often than non-smokers, 26.2% vs 20.5% (p<0.05), and a higher proportion of smokers were suboptimally controlled (DBP > or = 90 mmHg), 32.7% vs 25.0% (p<0.01). Smoking males had a higher prevalence of LVH (25.7% vs 20.1; p<0.05), microalbuminuria (29.7% vs 24.7%; p<0.01), and a higher proportion of subjects with uncontrolled systolic BP (> or = 140 mmHg) (72.8% vs 68.9%; p<0.01). Both DBP and total cholesterol were higher in smoking vs non-smoking females. An increased prevalence of LVH and microalbuminuria was independently associated with smoking. In summary, smokers with treated hypertension show a higher proportion of LVH (men), microalbuminuria and worse diastolic BP control than non-smokers. This may hypothetically reflect either less compliance with drug treatment in smokers or that smoking impairs the pharmacological effects of antihypertensive drugs.
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PMID:Hypertensive smokers have a worse cardiovascular risk profile than non-smokers in spite of treatment--a national study in Sweden. 1603 94

Angiotensin-converting enzyme (ACE) inhibitors have favourable effects on hypertension and diabetic nephropathy, but persistent use may result in incomplete blockade of the renin-angiotensin system. Long-term effects of dual blockade using the ACE inhibitor lisinopril and the long-acting angiotensin II receptor blocker (ARB) telmisartan on blood pressure and albumin excretion rate (AER) were evaluated. Patients with type 2 diabetes mellitus, hypertension (systolic blood pressure [SBP] >or=140 mmHg or diastolic blood pressure [DBP] >or=90 mmHg) and microalbuminuria (AER 30-300 mg/24h) received 20mg of lisinopril or 80 mg of telmisartan once a day for 24 weeks. Patients were then randomised to continuing treatment with the respective monotherapy or with lisinopril plus telmisartan for a further 28 weeks. Significant (P<0.001) declines in SBP (11.1 mmHg versus 10.0 mmHg), DBP (5.6 mmHg versus 5.3 mmHg) and AER (98 mg/24 h versus 80 mg/24 h) were achieved with lisinopril (n=95) or telmisartan (n=97), respectively, after 24 weeks. Subsequent treatment with lisinopril plus telmisartan for 28 weeks resulted in further significant reductions (P<0.001) in SBP, DBP and AER compared with either monotherapy. All treatments were well tolerated. Lisinopril plus telmisartan thus provides superior blood pressure and AER control than either monotherapy. We conclude that use of dual blockade may provide a new approach to prevention of diabetic nephropathy in patients with type 2 diabetes, hypertension and microalbuminuria.
Diabetes Res Clin Pract 2006 Feb
PMID:Beneficial effect of lisinopril plus telmisartan in patients with type 2 diabetes, microalbuminuria and hypertension. 1611 44

Hypertension is predictive of a wide variety of subsequent adverse events in elderly patients, at least up to the age of 80 years. Treatment can reduce these adverse outcomes, although the benefits in the very elderly remain somewhat unclear. In the very elderly, there appears to be a reduction in cardiovascular events, but this reduction is perhaps at the expense of an increase in overall mortality. Target BPs in the elderly remain controversial. Among patients who have not had previous stroke or significant cardiovascular or renal disease, the benefits of reducing the SBP below 159 mm Hg are well documented. There is some evidence to suggest, however, that if doing so increases the day-night difference in BP by more than 20% or is associated with a decline in DBP below 65 mm Hg, then the benefits of treatment may be attenuated or lost. In addition, there is some suggestion that reducing SBP consistently below 135 mm Hg may accelerate cognitive decline. There appears to be a role for sodium restriction in those who can comply without otherwise compromising nutrient intake. Likewise, exercise may be beneficial and have benefits beyond simply lowering BP. Weight loss in those who are overweight may also help in lowering the BP. For most patients, low-dose thiazides such as hydrochlorothiazide are likely to be the appropriate first-line therapy (even in patients who have diabetes) unless they exacerbate or precipitate urinary incontinence or gout or complicate concomitant drug therapy (eg, lithium treatment of bipolar disorder). In very elderly patients, the apparent beneficial effects on strokes, major cardiovascular events, and heart failure rates may justify treating despite lack of benefit on overall mortality.
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PMID:Hypertension in the elderly. 1614 Jan 25

Increased oxidative stress and reduced nitric oxide (NO) bioactivity are key features of diabetes mellitus that eventually result in cardiovascular abnormalities. We assessed whether N-acetylcysteine (NAC), an antioxidant and glutathione precursor, could prevent the hyperglycaemia induced increase in oxidative stress, restore NO availability and prevent depression of arterial blood pressure and heart rate in vivo in experimental diabetes. Control (C) and streptozotocin-induced diabetic (D) rats were treated or not treated with NAC in drinking water for 8 weeks, initiated 1 week after induction of diabetes. At termination, plasma levels of free 15-F2t-isoprostane, a specific marker of oxygen free radical induced lipid peroxidation, was increased while the plasma total antioxidant concentration was decreased in untreated diabetic rats as compared to control rats (P<0.05). This was accompanied by a significant reduction of plasma levels of nitrate and nitrite, stable metabolites of NO, (P<0.05, D vs. C) and a reduced endothelial NO synthase protein expression in the heart and in aortic and mesenteric artery tissues. Systolic, diastolic and mean arterial blood pressures (SBP, DBP and MAP) and heart rate (HR) were reduced in diabetic rats (P<0.05 vs. C) and NAC normalised the changes that occurred in the diabetic rats. The protective effects may be attributable to restoration of NO bioavailability in the circulation.
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PMID:Antioxidant N-acetylcysteine restores systemic nitric oxide availability and corrects depressions in arterial blood pressure and heart rate in diabetic rats. 1639 Aug 27

To obtain reliable data on the epidemiology, co-morbidities and risk factor profile of peripheral arterial disease (PAD), we evaluated the clinical significance of the ankle brachial index (ABI) as an indicator of PAD in Chinese patients at high cardiovascular (CV) risk. ABI was measured in 5,646 Chinese patients at high CV risk, and PAD was defined as an ABI<0.9 in either leg. Multivariable logistic regression analyses were performed to identify factors associated with PAD. A total of 5,263 patients were analyzed, 52.9% male, mean age 67.3 years, mean body mass index (BMI) 24.2 kg/m2, mean systolic/diastolic blood pressure (SBP/DBP) 139/80.7 mmHg. The prevalence of PAD in the total group of patients was 25.4%, and the prevalence was higher in females than in males (27.1% vs. 23.9%; odds ratio [OR]: 1.64). Patients with PAD were older than those without PAD (72.3+/-9.9 years vs. 65.6+/-11.7 years; OR: 1.06), and more frequently had diabetes (43.3% vs. 31.3%; OR: 2.02), coronary heart disease (CHD) (27.0% vs. 18.8%; OR: 1.67), stroke (44.4% vs. 28.3%; OR: 1.78), lipid disorders (57.2% vs. 50.7%; OR: 1.3) and a smoking habit (42.7% vs. 38.6%; OR: 1.52). The ORs for the PAD group compared with the non-PAD group demonstrated that these conditions were inversely related to ABI. Statin, angiotensin-converting enzyme-inhibitors and antiplatelet agents were only used in 40.5%, 53.6% and 69.1% of PAD patients, respectively. The data demonstrated the high prevalence and low treatment of PAD in Chinese patients at high CV risk. A lower ABI was associated with generalized atherosclerosis. Based on these findings, ABI should be a routine measurement in high risk patients. Aggressive medication was required in these patients.
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PMID:Ankle brachial index as a marker of atherosclerosis in Chinese patients with high cardiovascular risk. 1671 50

The aim of our study was to investigate the metabolic effect of telmisartan and irbesartan in subjects treated with rosiglitazone, a well-known insulin-sensitizing drug, in order to clarify the direct metabolic effects of the two former drugs. Patients were enrolled, evaluated, and followed at 3 Italian centers. We evaluated 188 type 2 diabetic patients with metabolic syndrome (94 males and 94 females in total; 49 males and 46 females, aged 56+/-5, treated with telmisartan; and 45 males and 48 females, aged 55+/-4, treated with irbesartan). All had been diabetic for at least 6 months, and glycemic control by the maximum tolerated dietary changes and maximum tolerated dose of oral hypoglycemic agents had been attempted and failed in all cases. All patients took a fixed dose of rosiglitazone, 4 mg/day. We administered telmisartan (40 mg/day) or irbesartan (150 mg/day) in a randomized, controlled, double-blind clinical manner. We evaluated body mass index (BMI), glycemic control (HbA1c fasting plasma glucose and insulin levels [FPG, and FPI, respectively], and homeostasis model assessment [HOMA] index), lipid profile (total cholesterol [TC], low density lipoprotein-cholesterol [LDL-C], high density lipoprotein-cholesterol [HDL-C], and triglycerides [TG]), systolic and diastolic blood pressure (SBP and DBP), tumor necrosis factor-alpha (TNF-alpha), and leptin during the 12 months of this treatment. No BMI change was observed after 6 or 12 months in either group. Significant decreases in HbAlc and FPG were observed after 6 months in the telmisartan group, and after 12 months in both groups. The decrease in HbA1c and FPG at 12 months was statistically significant only in the telmisartan group. A significant decrease in FPI was observed at 12 months in both groups, and this decrease was significantly greater in the telmisartan group. Significant decreases in the HOMA index were observed at 6 and 12 months in both groups, and the decrease in the HOMA index after 12 months was significantly greater in the telmisartan group than in the irbesartan group. Significant changes in SBP, DBP, TC, and LDL-C were observed after 6 and 12 months in both groups. Significant decreases in TNF-alpha and leptin levels were observed after 6 months in the telmisartan group, and after 12 months in both groups. In conclusion, in this study of patients with type 2 diabetes mellitus and metabolic syndrome, telmisartan seemed to result in a greater improvement in glycemic and lipid control and metabolic parameters related to metabolic syndrome compared to irbesartan. These observed metabolic effects of different angiotensin type 1 receptor blockers could be relevant when choosing a therapy to correct metabolic derangement of patients affected by metabolic syndrome and diabetes.
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PMID:Telmisartan and irbesartan therapy in type 2 diabetic patients treated with rosiglitazone: effects on insulin-resistance, leptin and tumor necrosis factor-alpha. 1734 84

Knowledge about the current status of diabetes management is indispensable for the improvement of diabetes management. We performed a survey to investigate the current trend of diabetes management in elderly Koreans, at eight hospitals located throughout the country. A total of 539 patients with type 2 diabetes older than 65 years (men=224, women=315) were recruited. Their mean age was 71.5+/-4.9 years and BMI 24.3+/-3.4 (men=23.6+/-2.8, women=24.9+/-3.7)kg/m(2), and 38.2% of the patients were obese (BMI> or =25 kg/m(2), men=29.5%, women=44.4%). The mean duration of the diabetes was 13.1+/-9.2 years. Although 37.3% of the patients had A1C below 7.0%, 33.8% of the patients had A1C more than 8.0%. Three hundred and sixty three patients (67.4%) were treated with oral hypoglycemic agents and 175 patients (32.5%) were treated with insulin or combination with oral agents. The glycemic control was better in patients treated with oral agents (oral agent group=7.7+/-4.6%, insulin group=8.5+/-1.9%). Although mean SBP and DBP were 131.4+/-16.7 and 75.9+/-10.4 mmHg, respectively, 67.4% of the patients had hypertension and 38.2% of the patients with hypertension did not reach the goal (<130/80 mmHg). Of 539 elderly patients, 253 patients (47.4%) had dyslipidemia (LDL-C> or =4.1 mmol/l and/or triglyceride> or =2.5 mmol/l and/or HDL-C<1.1 mmol/l) and 72.7% of the patients with dyslipidemia took the lipid lowering agents. However, 47.4% of them did not achieve the goal (LDL-C<2.6 mmol/l and/or triglyceride<1.7 mmol/l and/or HDL-C>1.1 mmol/l). Twenty-eight patients (5.5%) had been admitted to the hospital because of severe hypoglycemia. Half of the patients (57%) had microvascular complications (retinopathy, neuropathy or overt proteinuria), and 28% of the patients had macro-vascular complications (CVD, stroke or peripheral vascular disease). As elderly diabetic patients are usually polymorbid, diabetes mellitus in old age is needed a more comprehensive approach to not only the treatment of hyperglycemia but also of hypertension, dyslipidemia and other associated diseases.
Diabetes Res Clin Pract 2007 Sep
PMID:Current status of diabetes management in elderly Koreans with diabetes. 1748 70

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