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Query: UMLS:C0018801 (heart failure)
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The prevention and treatment of hypertension remain as major challenges for clinicians all over the world. The recently published Sixth Report of the Joint National Committee for the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-VI) uses evidence-based medicine in providing guidelines to aid clinicians in the prevention, detection and treatment of high blood pressure, including pharmacological approaches. Calcium antagonists are used widely for the treatment of hypertension, and JNC-VI focuses on specific situations where calcium antagonists could be considered as preferred treatments. There are a large number of calcium antagonists available, with a variety of pharmacodynamic and pharmacokinetic actions. Several sustained-release formulations of these drugs are also available. In terms of blood pressure control, calcium antagonists are more effective as antihypertensive treatments than beta-blockers, ACE inhibitors and angiotensin II receptor blockers in Black patients. The dihydropyridine calcium antagonists have been shown to reduce morbidity and mortality in elderly patients with isolated systolic hypertension. The rate-lowering calcium antagonists can be used as alternatives to beta-blockers in patients with coronary artery disease and hypertension. Calcium antagonists can be used as alternatives to ACE inhibitors in patients with hypertension and concomitant diabetes mellitus and/or renal disease. Some dihydropyridine calcium antagonists may be useful as alternatives to ACE inhibitors in patients with hypertension and systolic heart failure. Calcium antagonists appear to be extremely useful in patients with cyclosporin-induced hypertension, and in patients with hypertension and concomitant Raynaud's phenomenon and/or migraine. The rate-lowering agents can be used in patients with atrial tachyarrhythmias and hypertension. Clinicians should be aware of drug-drug interactions involving calcium antagonists, especially after the recent problems with mibefradil. Although retrospective studies have caused controversy regarding the safety of calcium antagonists in patients with hypertension, recent prospective studies have revealed no major safety concerns with these drugs.
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PMID:How to use calcium antagonists in hypertension: putting the JNC-VI guidelines into practice. Joint National Committee for the Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 1055 31

It is clear that antihypertensive regimens based on a low dose thiazide diuretic are effective for the primary prevention of stroke, particularly in older patients. In patients with diabetes mellitus who are at a higher risk of stroke, low dose thiazide diuretics and ACE inhibitors are of benefit. In those with isolated systolic hypertension, long-acting dihydropyridine calcium antagonists, in addition tolow dose thiazide diuretics, have also been shown to significantly reduce stroke risk. However, to attain sufficient lowering of blood pressure (BP) to most effectively reduce the risk of stroke (i.e. to levels of 140-150/80-85 mm Hg or lower and perhaps to <140/<80 mm Hg in patients with diabetes mellitus) combination therapy will be required. Immediately following stroke BP tends to fall spontaneously and therapy is probably not required in the great majority of patients during the first few days poststroke. If treatment is required shortly after this period, agents with a slow and gentle onset of action appear to be preferable; some preliminary data suggest that ACE inhibitors, despite lowering systemic BP, have no significant effect on cerebral blood flow. However, there is little clinical outcome data to clearly define the role of antihypertensive treatment in the early poststroke period. Whether existing antihypertensive therapy should be continued following stroke is also unclear, but such decisions may be influenced by factors such as the actual BP level, other indications for treatment (e.g. angina pectoris or cardiac failure) or the presence of dysphagia. There is more evidence to suggest that, some weeks to months following stroke (particularly a minor stroke), lower rather than higher BP is favourable, and better control of high BP with therapy reduces stroke recurrence.
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PMID:Antihypertensive therapy in the prevention of stroke: what, when and for whom? 1055 36

The majority of patients with hypertension have one or more additional risk factors for cardiovascular disease. In planning an appropriate treatment program, it is useful to identify and stratify hypertensive patients according to their risk of developing cardiovascular, cerebrovascular, or renal disease. At particular risk are the elderly, patients with diabetes, and those with target-organ damage manifested by impaired renal function. Evidence supports increased risk in these patients, and clinical trial results demonstrate the considerable benefits realized through aggressive blood pressure (BP) control. The number of elderly individuals continues to increase in the United States and other industrialized countries. The prevalence of isolated systolic hypertension (ISH) is higher in the elderly than in younger individuals. ISH is associated with significant morbidity and mortality and should not be considered a physiologic manifestation of the normal aging process. Type 2 diabetes is also increasing in prevalence. Patients with diabetes are at increased risk for coronary heart disease, stroke, renal failure, and other cardiovascular complications. Aggressive treatment of elevated BP can produce dramatic decreases in the cardiovascular complications of diabetes. The incidence of end-stage renal disease has increased 2.5-fold in the past two decades, and poorly controlled BP is a major contributor to the increase. Lowering BP to levels well below the traditional goal of 140/90 mm Hg is needed to slow the progression of renal dysfunction and prevent renal failure in hypertensive patients with renal disease, whether related to diabetes or to another etiology. Aggressive treatment of hypertension in multiple-risk populations (to the goals of JNC VI and the recent WHO-ISH Guidelines for the Management of Hypertension) can be expected to produce significant reductions in the incidence and prevalence of stroke, heart failure, coronary heart disease, chronic renal failure, and total cardiovascular mortality.
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PMID:Treating multiple-risk hypertensive populations. 1059 63

Hypertension (HT) is a common disease in elderly. It has different pathophysiologic, clinical and therapeutic implications in this age group. Due to loss of arterial wall elasticity with age, major vessels including aorta become stiff and less distensible. As age advances, these stiff vessels also lose beta adrenergic responsiveness with unchanged alpha adrenergic responsiveness. These together raise peripheral vascular resistance and aortic impedance which needs a powerful systolic ejection of left ventricle to maintain cardiac output. Result is rise in systolic blood pressure (SBP) and increase in left ventricular (LV) mass with compromised cardiac output and renal blood flow. Participation of renin-angiotensin system and kidney in HT pathogenesis in elderly are minimum. Diagnosis of HT in elderly is made if SBP > 140 mm Hg and/or diastolic blood pressure (DBP) > 90 mm Hg or is taking antihypertensive medications. Isolated systolic hypertension (ISH) means SBP > 140 mm Hg with DBP < 90 mm Hg. Measurement of blood pressure (BP) is problematic, mainly due to pseudo HT, postural hypotension and white-coat HT. HT in absence of end organ changes suggest pseudo HT. Postural hypotension must be detected and treated. Systolodiastolic HT, carried over from middle age is the commonest type of HT in elderly. ISH is also common (10%). Atherosclerotic renovascular disease can cause secondary HT. Therapy is always needed in HT in elderly. Chance of coronary artery disease (CAD) and cerebrovascular accident (CVA) are quite high amongst elderly hypertensives. SBP is more dangerous than DBP. Benefits of therapy are more when compared to young. HT should be treated if SBP > 160 mm Hg and/or DBP > 90 mm Hg. ISH needs therapy if SBP > 160 mm Hg. The benefits of therapy becomes less after 80 years. Treatment goal should be to keep BP below 140/90 mm Hg. Therapy should be gradual and stepwise. Na-restriction should be modest. Diuretics (e.g., thiazide 25 mg/day) are the drug of choice unless contra-indicated. Beta blockers are inferior agents compared to diuretics unless angina or acute myocardial infarction (AMI) is present. Angiotensin converting enzyme (ACE) inhibitors are drug of choice only if congestive cardiac failure (CCF) and/or diabetes is present or other drugs are contra-indicated. Calcium entry blockers (CEB) are new but very good alternative to diuretics in elderly. Due to abnormal physiology, pharmacokinetics and drug interactions, side-effects are very common in elderly. They should be detected early and treated.
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PMID:Hypertension in elderly--an overview. 1065 9

Systolic blood pressure (SBP) is a more reliable predictor of cardiovascular disease (CVD) events than is diastolic blood pressure (DBP). Perhaps the reduction of SBP should be more of the imperative of treatment than the reduction of DBP. Although two recent guidelines (WHO/ISH and JNC-VI) have recommended treating SBP to goal, there seems to be a reluctance in the medical community to embrace this paradigm shift and revise treatment plans. The deleterious effects of ignoring these findings are especially damaging to those with isolated systolic hypertension (ISH), which affects approximately two-thirds of hypertensive patients between the ages of 65 and 89 years. Two large clinical trials, the Systolic Hypertension in the Elderly Program (SHEP) and the Systolic Hypertension in Europe (Syst-EUR) trial have confirmed that reducing SBP in the elderly with stages 2 and 3 ISH (SBP > or = 160 mmHg with DBP < 90 mmHg in SHEP and SBP > 160 mmHg with DBP < 95 mmHg in Syst-EUR) reduced morbidity and mortality. Two SHEP sub-studies found that lowering SBP in subjects with non-insulin-dependent diabetes mellitus (NIDDM) and those with a history of myocardial infarction (MI) reduced the incidence of stroke and heart failure, as well as several other endpoints. The beneficial effects were corroborated in Syst-EUR where stroke (fatal and nonfatal), CVD endpoints and mortality were all significantly reduced when SBP was lowered 20 mmHg in subjects > 60 years of age. Despite these findings, however, recent analysis suggests that most hypertension treatment decisions continue to be based on DBP measurements instead of SBP. To combat this treatment gap, we must disseminate this information and motivate physicians and other providers to include reduction of SBP in their treatment plans. We must also encourage the development of antihypertensive drugs that lower SBP more effectively than those that are currently available.
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PMID:Isolated systolic hypertension in the elderly: lessons from clinical trials and future directions. 1070 27

The Framingham Study established hypertension as a major cardiovascular risk factor and quantified its atherogenic cardiovascular disease potential. An historical perspective is presented on the epidemiological insights about hypertension derived from 50 years of Framingham Study research into the prevalence, incidence, determinants and hazards of hypertension. Existing misconceptions about the presence of critical levels of blood pressure, the impact of the systolic and diastolic components of blood pressure, the hazard 'mild' hypertension, the impact in advanced age and the hazard of left ventricular hypertrophy. The importance of isolated systolic hypertension and the pulse pressure were demonstrated. It has been demonstrated that hypertension seldom occurs in isolation of other atherogenic risk factors, with which it tends to cluster. This clustering with other metabolically linked risk factors has been shown to reflect insulin resistance promoted by weight gain and abdominal obesity. Obesity was shown to be one of the major determinants of hypertension in the general population. Left ventricular hypertrophy was shown to be an ominous harbinger of cardiovascular disease rather than an incidental compensatory phenomenon. Multivariate risk profiles for coronary disease, stroke, peripheral artery disease and heart failure have been devised to facilitate incorporation of elevated blood pressure in a global, multivariate cardiovascular risk assessment.
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PMID:Fifty years of Framingham Study contributions to understanding hypertension. 1072 12

The Framingham Study was initiated in 1948 to investigate an epidemic of coronary disease in the USA, using a prospective epidemiological approach. Insights were provided into the prevalence, incidence, full clinical spectrum and predisposing factors. The major "risk factors" (a term coined by the Framingham Study) for coronary disease, stroke, peripheral artery disease and heart failure were identified and clinical misconceptions dispelled about isolated systolic hypertension, left ventricular hypertrophy, dyslipidemia, atrial fibrillation and glucose intolerance. Average values for blood lipids, blood pressure, body weight, glucose and fibrinogen were shown to be dangerously suboptimal and to have a continuous graded relationship to cardiovascular disease without critical values. Dyslipidemia, glucose intolerance and elevated fibrinogen were shown to have smaller hazard ratios in the elderly, but this was offset by a higher absolute risk. Diabetes was shown to operate more strongly in women, eliminating their advantage over men. Serum total cholesterol was shown to derive its atherogenic potential from its LDL component and also to reflect cholesterol being removed in the HDL fraction. The total/HDL-cholesterol ratio was demonstrated to be the most efficient lipid profile for predicting coronary disease. LDL was shown to be correlated with hemostatic factors, suggesting that there would be additional benefits to lowering LDL. High triglyceride associated with reduced HDL, indicating insulin resistance and small dense LDL, was shown to be associated with excess coronary disease. All the risk factors tended to cluster, and this was shown to be promoted by insulin resistance induced by weight gain. Multivariate risk profiles were produced to facilitate risk stratification of candidates for coronary disease, stroke, peripheral artery disease and heart failure. The Framingham Study is now engaged in quantifying the independent contributions of homocysteine Lp(a), insulin resistance, small dense LDL, C reactive protein, clotting factors and genetic determinants of cardiovascular disease. We are now able to estimate the lifetime risk of all the atherosclerotic cardiovascular disease outcomes.
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PMID:The Framingham Study: ITS 50-year legacy and future promise. 1087 16

Elevated blood pressure and left ventricular hypertrophy are powerful independent predictors of heart failure. In hypertension, left ventricular hypertrophy at electrocardiography doubles the risk of heart failure. The individual absolute risk of heart failure, however, remains quite low in the absence of myocardial infarction, valvular heart disease and diabetes. For example, in a 60-year-old asymptomatic man with systolic blood pressure 160 mmHg, the risk of developing heart failure is 0.37% per year in the absence of left ventricular hypertrophy and 0.90% per year in the presence of hypertrophy. If ischemic heart disease, valvular heart disease and diabetes coexist in the same subject, the risk of heart failure rises to 5.1% and 9.5% in the absence and presence of left ventricular hypertrophy, respectively. Several mechanisms may explain the increased risk of heart failure in hypertensive subjects with left ventricular hypertrophy. Among these, increased collagen deposition in the interstitial space among myocytes could lead to impaired diffusion of oxygen and other substances towards hypertrophied myocytes, whose metabolic demand is increased. Left ventricular hypertrophy increases the risk of heart failure both at normal (diastolic) and low cardiac output. There is an inverse association between left ventricular mass and velocity of diastolic relaxation. Early diagnosis of left ventricular hypertrophy through electrocardiography or echocardiography and aggressive treatment of patients with hypertrophy are probably the best ways to prevent heart failure associated with hypertension. Controlled intervention studies clearly showed that treatment of hypertension reduces the occurrence of heart failure by 25-50%, particularly in the elderly with isolated systolic hypertension. In a sizable proportion (about 20%) of asymptomatic patients with hypertension, left ventricular systolic performance estimated by echocardiography at mid-wall level is reduced. These patients appear to be at increased risk of major cardiovascular events including heart failure.
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PMID:[Cardiac failure in hypertensive cardiopathy]. 1090 32

The presence of elevated values of both diastolic and systolic arterial blood pressure is one of the most important risk factors for coronary heart disease, stroke, and heart failure; in patients with hypertension, the pharmacological reduction of blood pressure decreases the risk of adverse cardiovascular events, though the optimal blood pressure goal is still being debated. During recent years there has been an increasing interest in isolated systolic hypertension, both as an independent risk factor for cardiovascular disease and as a clinical entity requiring treatment in its own right. The definition of what constitutes isolated systolic hypertension still remains controversial and arbitrary; the criteria generally used is a systolic blood pressure > or = 140 mmHg and a diastolic blood pressure < 90 mmHg. Not only the cut-off levels used to define isolated systolic hypertension, but also the number of occasions on which blood pressure is measured can significantly affect the prevalence of isolated systolic hypertension in the total population. The use of 24-hour ambulatory blood pressure monitoring is a relatively new method for overcoming transient elevations in blood pressure that often occur during clinic measurement; it has a good reproducibility, is subject to little "white-coat" or placebo effect, and finally provides blood pressure measurements within a subject's normal environment. Borderline isolated systolic hypertension (defined as a systolic blood pressure between 140 and 159 mmHg and a diastolic blood pressure < 90 mmHg) is probably the most common type of untreated hypertension among adults over the age of 60; in the following 20 years, about 80% of patients with borderline isolated systolic hypertension will show progression to definite hypertension with increased risk of development of cardiovascular disease. The increase in systolic and diastolic blood pressure with age is typical of Western societies, while it is not observed among some "unacculturated" populations, who tend to be lean and physically active, with a lower daily sodium intake. Maybe environmental, rather than genetic factors may contribute more to the determination of blood pressure throughout life. Pharmacological treatment of isolated systolic hypertension can lead to a significant reduction in total stroke, coronary heart disease, and cardiovascular disease. The question of which antihypertensive agents are most effective is still to be fully elucidated with specifically addressed trials.
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PMID:[Systolic-diastolic arterial hypertension versus isolated systolic hypertension]. 1090 35

Heart failure is a common problem in the elderly population, affecting 10% or more of persons more than 80 years of age. Heart failure is most likely to develop in the elderly population, with an annual incidence of 20 to 30 cases per 1000 persons aged more than 80 years. Heart failure is not only common in the elderly population but also commonly fatal, with fewer than 30% of elderly persons surviving 6 years after their first hospitalization for heart failure. Common risk factors leading to heart failure include coronary heart disease, systolic hypertension, and diabetes mellitus. The global aging of the population will perpetuate the epidemic of heart failure into the next century.
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PMID:Epidemiology and risk factors for heart failure in the elderly. 1091 39

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