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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Treatment of hypertension in the elderly has so far mainly been based on clinical judgment and very few large controlled trials. During the last year several large new trials have been published, the so-called STOP-Hypertension, SHEP, and MRC trials. All have shown that drug treatment of hypertension in the elderly (65-85 years) with permanent diastolic hypertension or isolated systolic hypertension reduces stroke incidence. Most patients have needed combined drug treatment with diuretics and beta-blockers. When thiazide diuretics are used, serum potassium should be followed very closely and most likely amiloride should be added to the thiazide therapy, since this was done both in the STOP and the MRC trials. Since many elderly patients with hypertension suffer from other diseases that might represent contraindications to thiazide diuretics or beta-blockers, the choice of drug must be made after careful clinical evaluation. With the newer classes of antihypertensive agents (calcium antagonists, ACE inhibitors and alpha-blockers) side effects are probably seen less often, but long-term data on morbidity and mortality are still lacking.
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PMID:Treatment of hypertension in the elderly--what have we learned from the recent trials? 129 75

Pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), cardiac output (CO), blood pressure (BP) were monitored before and after hypoxia, Captopril and Nitrendipine injected (7 mg/kg and 100 micrograms/kg) in group A(n = 9), and group B(n = 7) respectively results showed that during hypoxia PAP in all the pigs increased significantly (P < 0.05), compared with normoxia, and after captopril and nitrendipine intravenous injection, the PAP dropped significantly (from 3.76 +/- 0.25 to 3.43 +/- 0.1 kPa versus from 4.21 +/- 0.19 to 3.18 +/- 0.17 kPa. ACE in captopril group was significant reduced P < 0.05 (58.4 +/- to 27.0 +/- 3.0 mumol.min-1/L), but in nitrendipine group was not markedly changed (P > 0.05), we found that reducing the degree of PAP and its duration time, lowered the pulmonary vascular resistance (PVR) and right ventricle stroke index (RVSWI), also improved capacity of oxygen delivery. Nitrendipine was better than captopril, maybe it is an useful drug for patients with pulmonary hypertension.
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PMID:[Comparative studies between the effects of captopril and nitrendipine on the hemodynamics and angiotensin converting enzyme of pigs with acute hypoxic pulmonary hypertension]. 133 19

Twenty-nine patients with severe heart failure (NYHA III) were randomly assigned to receive therapy with an angiotensin converting enzyme inhibitor (ACE inhibitor), either captopril or enalapril. The mean daily dosage of captopril was 56 +/- 5 mg and of enalapril 9.5 +/- 0.4 mg. After a mean of 8 +/- 1 days, the influence of both ACE inhibitors on hemodynamics and renal function was compared. The mean arterial pressure in the group treated with captopril (Group A) fell by 9 +/- 3 mmHg (p less than 0.01), and in the group treated with enalapril (Group B) it fell by 12 +/- 3 mmHg (p less than 0.001). The difference between the groups was not significant. Heart rate decreased in both groups; however, the change was significant (p less than 0.05) only in patients treated with enalapril (-11 +/- 3 bpm in Group B vs. -7 +/- 4 bpm in Group A). Stroke volume index increased by 6 +/- 3 ml/m2 in Group A (p less than 0.05) vs. 10 +/- 2 ml/m2 in Group B (p less than 0.01). The increase in stroke volume index was not significantly different between the two groups. Mean decreases in pulmonary artery and right atrial pressure were also comparable in both groups. Thus, hemodynamic improvements were similar during therapy with either captopril or enalapril. Serum sodium and potassium before therapy were 137 +/- 1 mmol/l and 4.1 +/- 0.1 mmol/l, respectively, in group A and 139 +/- 1 mmol/l and 4.0 +/- 0.1 mmol/l, respectively, in group B.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Comparison of captopril with enalapril in the treatment of heart failure: influence on hemodynamics and measures of renal function. 139 Mar 31

The four most popular classes of antihypertensive drugs may all be considered suitable choices when initiating treatment for hypertension. The practitioner must decide which agent is appropriate for each individual patient. The main goal of treatment should be to prevent coronary events and stroke, while preserving quality of life. A 40% reduction in stroke can probably be achieved with any antihypertensive treatment, a reduction in coronary events is much harder to achieve. Available evidence from studies in men, summarized in this review, indicates that beta-blockade is superior to thiazide diuretics for the prevention of coronary events. Clinical trials have not yet produced long-term prognostic data on the effects of ACE-inhibitors or calcium antagonists on coronary events in hypertensive patients. A recent review on calcium antagonists in post-MI patients concluded that the results were disappointing, as pooled data actually showed a trend towards increased mortality with calcium antagonists as compared with placebo. Because of the large number of hypertensive patients at increased risk for coronary events in the community, the difference observed in coronary events between beta-blockade and other first-line drugs in hypertension (24%) may have important implications for clinical practice. This overall conclusion, however, has to be accepted with some reservations in view of the following observations. Firstly, no reduction in sudden death has been observed with the hydrophilic beta-blockers. Secondly, no reduction in coronary mortality in the smoking subgroup has been observed with the non-selective beta-blockers. Thus, it seems that the prevention of coronary events is more likely to be observed in patients given beta-blockers with certain pharmacological characteristics: relative lipophilicity, which enables passage of the beta-blocker through the blood-brain barrier to exert effects on pertinent central nervous beta 1-receptors. This is potentially useful in reducing the risk of sudden death. The addition of beta 1-selectivity is important for the risk reduction in smokers. Cardioselectivity is also an advantage in relation to side-effects and quality of life. The reduced risk for coronary events with certain beta-blockers is probably independent of the reduction in blood pressure: possible mechanisms studied are cardiac anti-ischaemic effects, antifibrillatory effects, antiatherosclerotic and anti-thrombotic effects.
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PMID:Reducing the risk for coronary heart disease and stroke in hypertensives--comments on mechanisms for coronary protection and quality of life. 154 19

Age-related changes (e.g., decrease in plasma renin activity and total body potassium, increase in plasma catecholamines, volume depletion) need to be taken into account when selecting an antihypertensive agent for the elderly patient. A number of large scale clinical trials (e.g., Systolic Hypertension in the Elderly Program, Veterans Administration Cooperative Study, European Working Party on High Blood Pressure in the Elderly) have demonstrated that antihypertensive therapy with diuretics substantially reduced cardiovascular mortality and stroke incidence. However, since diuretics, even potassium-sparing agents, may induce hypokalemia, newer antihypertensive agents (angiotensin-converting enzyme [ACE] inhibitors and calcium antagonists) may also be appropriate as first-line monotherapy for this patient population. ACE inhibitors are effective antihypertensive agents and are associated with a lower rate of adverse effects than diuretics, beta blockers, and centrally acting agents. Nevertheless, periodic monitoring of serum potassium, creatinine levels, and renal function is advisable. An important feature of calcium antagonists is that they lower blood pressure with no negative effect on serum lipids or glucose metabolism. Typically, they have few side effects, peripheral edema being the most commonly reported. A recent double-blind randomized study comparing a new sustained release nifedipine formulation and the ACE inhibitor lisinopril found the 2 drugs equivalent in efficacy with no differences in the rate of adverse events.
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PMID:Hypertension in the elderly with a special focus on treatment with angiotensin-converting enzyme inhibitors and calcium antagonists. 157 76

Hypertension should be detected and treated early in diabetic patients. It markedly affects the morbidity and mortality of diabetic individuals as a result of both atherosclerosis and microvascular disease. Antihypertensive treatment is an effective tool in slowing the progression of early and advanced diabetic nephropathy. No prospective studies have addressed the effects of antihypertensive regimens on the incidence of congestive heart failure, stroke, and coronary artery disease in large groups of diabetic patients. Such studies are urgently needed. Special consideration should be given to the effects of antihypertensive drugs on glycemic control and the lipid profile of the diabetic patient. Because hyperinsulinemia (and insulin resistance) have been advocated as hypertensive and atherosclerotic risk factors, the effects of antihypertensive drugs on insulin action and plasma insulin levels may become an important element in the selection an antihypertensive agent. More information, however, is needed in these areas. ACE inhibitors, calcium channel blockers, and alpha-adrenergic blockers probably offer a more favorable metabolic profile as compared with diuretics and beta-blockers. The former agents should be used as initial drugs in most clinical settings.
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PMID:Management of hypertension in diabetes. 161 71

The most common cause of death in hypertensive patients is myocardial infarction (MI), being three times more common than stroke. Lowering raised BP results in 40% fewer strokes, but only 14% fewer MIs. This may be because other coronary risk factors that often accompany hypertension (e.g. obesity, lipid and thrombotic disturbances, insulin insensitivity, increased plasma renin activity and increased sympathetic activity) are either unaffected or exacerbated by some of the traditional antihypertensive agents. Some of these risk factors show a diurnal rhythm peaking at 07.00-10.00 hours, thus this time constitutes a 'vulnerable period' for sudden death or death from MI. beta-blockers and diuretics have been effective in preventing stroke, but diuretics (at least potassium-losing diuretics) might actually increase the incidence of sudden death and MI in young to middle-aged hypertensive subjects (though elderly patients may benefit). Quality of life can be impaired by some beta-blockers, and diuretics can cause metabolic upset and male impotence. Thus, antihypertensive agents that are not only effective and well tolerated but are beneficial to the broader coronary risk profile are desirable. ACE inhibitors should prove particularly useful in terms of: good quality of life; non-exacerbation or improvement of coronary risk factors; treating patients with impaired left ventricular function; reversing left ventricular hypertrophy and vascular wall hypertrophy, thus improving coronary flow reserve; atheroma regression; renal protection, particularly in diabetes; and prevention or regression of LV dilatation (remodelling) following MI.
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PMID:What does the future hold for ACE inhibitors? 179 18

The large multicenter trials of treatment in mild to moderate hypertension have shown unequivocally that the risk of stroke is reversed. The impact of treatment on ischemic heart disease is more debatable. Since there is no discontinuity in the risk of different levels of blood pressure, any advice about the level of pressure to treat must be arbitrary. The British Hypertension Society Guidelines recommend a sustained diastolic pressure of 100 mmHg or more over a 3- to 4-month period. This empirical advice is based upon subgroup analysis of the MRC and Australian Therapeutic Trials that suggests most of the benefit in treating the mildest degrees of hypertension occur in this group of patients. The role of newer classes of agent, such as ACE inhibitors or calcium-channel blockers, cannot be fully assessed in the absence of proper end-point trials. Whilst reasons for using these agents as first-line therapy have been put forward, these remain speculative in the absence of such trials. The much greater cost of newer agents in the context of universally cost-constrained health services also has to be borne in mind before recommending their widespread use as first-line therapy.
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PMID:The level at which blood pressure should be treated. 180 96

Arteriosclerosis is the hallmark of hypertension and of its complications, namely stroke, coronary artery disease and ischaemic renal failure. The earliest morphological change in the arteriosclerotic process is vascular smooth muscle hypertrophy and hyperplasia. Angiotensin II is an important growth factor in vascular smooth muscle cells. The chronic administration of ACE inhibitors will reverse many of the changes of vascular hypertrophy in experimental animal models, and will improve vascular compliance in hypertensive patients. Some differences have been reported between different ACE inhibitors with respect to blood pressure-lowering effect and regression of medial hypertrophy in spontaneously hypertensive rats.
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PMID:Reversal of structural changes in hypertensive arteries--a major prospect for the future. 192 14

ISH is a distinct pathogenetic entity defined by SBP readings of greater than or equal to 160 and DBP less than 90 mmHg. The etiology, although not well understood, is in some manner related to a reduction in connective tissue elasticity of large blood vessels and an increase in aortic impedance or a decrease in aortic wall compliance. The pathophysiologic consequences include an increased resistance to systolic ejection of blood and a disproportionate increase in SBP. Although not directly related, there is an important increase in peripheral vascular resistance. The prevalence of ISH in several studies is about 7 percent in those over age 60 and increases with age to nearly 20 percent in those over age 80. There is higher prevalence in females and nonwhites. The guidelines for detection of ISH are similar to those for blood pressure evaluation in general. Precautions for detection and evaluation in the elderly include multiple blood pressure measurements in the fasting state and sitting and supine blood pressure measurements before and during therapy. Pseudohypertension, although rare, should be kept in mind. There is a clear risk associated with ISH for stroke, CVD, and premature death, which increases with age and rising levels of SBP. ISH can be controlled effectively with pharmacologic therapies. A reasonable goal is a 20 mmHg reduction in systolic pressure. Proof of reduced risk for stroke, CHD, and death in those with controlled ISH remains to be demonstrated. The SHEP pilot study has demonstrated feasibility of addressing this issue. The full-scale SHEP study addresses this issue and has completed recruitment of the desired sample size and is in follow-up phase. Scheduled completion is in 1991. While we wait for the SHEP full-scale trial results, the prudent approach is for nonpharmacologic therapy and use of pharmacologic agents in that group of patients who demonstrate a large cardiovascular risk burden or increasing symptoms specifically associated with hypertension. The decision to treat must be on an individual patient basis. Pharmacologic therapy is possible in most patients with few or no adverse effects. The "low and slow" approach to therapy is helpful in minimizing these adverse effects. Low-dose diuretics have been documented to be effective in blood pressure control. Chlorthalidone, 12.5 or 25 mg per day, is suggested. Other agents, such as beta-blockers, reserpine, ACE inhibitors, and calcium channel blockers, are best used as Step 2 agents.
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PMID:Systolic hypertension in the elderly: controlled or uncontrolled. 218 67


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