Gene/Protein Disease Symptom Drug Enzyme Compound
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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

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

The following summary of the physiologic and epidemiologic evidence may help the clinician in making decisions when caring for persons with ISH: ISH is predominantly found in older age groups, being present in 1% to 4% of the population under age 40, 10% to 15% between ages 60 and 70, and 25% to 30% over age 70. ISH is more prevalent in women than in men. The development of ISH in the aged is associated with a decrease in arterial compliance. The relationship whereby ISH is both a cause and a result of atherosclerotic vessels needs further delineation. Neurohumoral factors also have a part in determining arterial compliance. An elevated SBP is an important contributor to the risk of developing coronary artery disease, and in persons over 45 years old it is a more powerful predictor of coronary events than DBP. SBP is a better discriminator of risk for strokes at all ages than DBP is. The relative risk in persons with ISH for the development of coronary artery disease and stroke is two to five times that of normotensive persons, but is no worse than the risk for these events among treated hypertensives. Although the relative risk of ISH is not strikingly large, the high prevalence of ISH among aged individuals, the increasing size of the population over 65 years old, and the high incidence rate of cardiovascular events in the aged give ISH a sizable attributable risk in the population (13 to 28 deaths per 1,000 individuals). It remains to be shown that lowering SBP in ISH removes the risk of ISH. Studies are needed that monitor the costs and adverse effects of therapy as well as the possible benefits when a condition such as ISH is most commonly seen in the aged.
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PMID:Isolated systolic hypertension: how common? How risky? 389 52

In contrast with the expected results, the Captopril Prevention Project study has found that the relative risk of stroke was greater by 25% in patients treated with ACEI than in patients receiving the conventional diuretics +/- betablockers regimen (Hanson et al. ISH Amsterdam, June 98). This difference persisted after adjustment for the initial differences of blood pressure levels between the groups after randomisation. This does not mean that ACEI would worsen the risk of stroke when compared to a placebo, since a potent protective effect of diuretics and betablockers on the relative risk of stroke has long been demonstrated. Nonetheless, these results suggest that for a similar blood pressure lowering effect, conventional therapy is more effective than ACEI to prevent stroke. This finding, in discrepancy with the current prevailing opinion that ACEI have emerged as the most effective preventive treatment to reduce cardiovascular morbidity, is regarded as surprising by the investigators. However, a number of animal experimental data may help to envisage the complete inhibition of angiotensin II formation as a two-edged sword, because of the multiplicity of its receptors mediating different, and even opposite effects. In a series of experimental studies in mammals, the group of Fernandez has provided a bundle of observations suggesting that angiotensin II contributes to early reperfusion following acute ischemia by enabling the recruitment of pre-existing collateral vascularisation, an effect mediated via the stimulation of non-AT1 receptors (possibly AT2). Indeed, the worsening of stroke in the gerbil after incomplete ligation of the carotid by pre-treatment with ACEI had been demonstrated by these authors (J Cerebral Blood Flow Metab, 1988; 24:937), and they further show that pre-administration of losartan significantly reduced the ischemic brain damage and the mortality induced by the abrupt ligation of one carotid, but that this preventive effect of losartan was abolished if enalapril was co-administrated (J Cardiovasc Pharmacol 1994; 24:937). The first available clinical data on stroke risk with ACEI reported in the CPP study, showing a less effective prevention of stroke with ACEI than diuretics supports the hypothesis that similar mechanism may also prevail in humans, and lead us to propose to discuss the rationale for a large multicentric trial aiming to compare the protective effect of ARAT1 and ACEI on the risk of recurrence of stroke.
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PMID:[Could angiotensin II type I receptor antagonists have a superior beneficial effect than that of angiotensin II converting enzyme inhibitors with respect to the risk of cerebrovascular accident?]. 1048 53

The Japanese Guidelines for the Management of Hypertension (JSH2000) have been published in June, 2000, which basically followed the direction of 1999 WHO/ISH and JNC-VI guidelines. Target blood pressures for young or middle-aged hypertensive patients or hypertensives with diabetes are recommended to maintain less than 130/85 mmHg. In contrast, blood pressure control for hypertension in elderly is set taking the subject's age into consideration with systolic blood pressure lower than 140-160 mmHg and diastolic below 90 mmHg. Among hypertensive cardiovascular diseases, stroke is more common while ischemic heart disease is less common in Japanese than in Caucasians. Frequency of hypertension in Japan, which is estimated to be one-fourth of whole population and two-thirds of persons aged 60 years or over, has been declined in recent years, because of increasing treatment of hypertension, resulting in a decrease in stroke mortality and morbidity. However, the number of persons with hypertension controlled to below 140/90 mmHg seems to be about 20 percent of all hypertensives. Therefore, increases in rates of awareness, treatment and appropriate control of hypertension are the important issue for the management of hypertension in Japanese at present state.
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PMID:[Management of hypertension in Japan--current state and clinical issue]. 1139 88

Initial pharmacologic therapy for hypertension is low-dose thiazide diuretics, beta-blockers, and ACE inhibitors. Increasing data have confirmed that ACE inhibitors have specific benefit in patients with diabetes, atherosclerosis, left ventricular dysfunction, and renal insufficiency. CCBs are alternative agents for ISH in the elderly and appear to decrease stroke with perhaps less protection against progression of renal insufficiency and proteinuria, CAD mortality and new onset heart failure versus other initial agents, especially ACE inhibitors. ARBs are well tolerated and effective blood pressure lowering agents but have not been confirmed as effective as ACE inhibitors for reducing renal progression, clinical events, or mortality from heart failure. Effective pharmacologic antihypertensive therapy may avoid disabling and undetected cerebrovascular disease, cognitive dysfunction, and disturbing symptoms of elevated blood pressure. Vasopeptidase inhibitor, such as omapatrilat, and endothelin-1 antagonist, such as bosentan, may become future agents approved for the reduction of morbidity and mortality with hypertension. The ALLHAT trial continues to examine the potential benefits and harms of amlodipine versus chlorthalidone and lisinopril in a diverse high-risk population. Based on ALLHAT data, however, doxazosin is no longer an acceptable initial pharmacological agent. Intensive pharmacologic treatment with blood pressure lowering to less than 130/85 mm Hg is recommended with diabetes, renal insufficiency, and heart failure with additional goal of less than 125/75 mm Hg with renal failure and proteinuria greater than 1 g/24 h, based on multiple outcome studies.
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PMID:Update in pharmacologic treatment of hypertension. 1140 10

The ISH Statement on blood pressure lowering and stroke prevention was finalized after presentation and discussion at the World Health Organization and International Society of Hypertension (WHO-ISH) Meeting on Stroke and Blood Pressure, held in Melbourne Australia, 5-7 December 2002. The meeting was conducted under the auspice of the Austin Hospital Medical Research Foundation, Melbourne.
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PMID:International Society of Hypertension (ISH): statement on blood pressure lowering and stroke prevention. 1265 5

The ISH statement on the management of blood pressure in acute stroke was finalized after presentation and discussion at the World Health Organization and International Society of Hypertension (WHO-ISH) Meeting on Stroke and Blood Pressure, held in Melbourne, Australia, 5-7 December 2002. The meeting was conducted under the auspices of the Austin Hospital Medical Research Foundation, Melbourne.
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PMID:International Society of Hypertension (ISH): statement on the management of blood pressure in acute stroke. 1265 6

To examine the impact of age on the relationship between blood pressure (BP) levels and each of cardiovascular disease mortality and all-cause mortality, a total of 30,226 men and 58,798 women aged 40-79 years who had no history of stroke or heart disease underwent health checkups in Ibaraki-ken, Japan, in 1993 and were followed through 2002. Risk ratios for mortality by BP category based on the 1999 WHO-ISH guidelines were calculated by age subgroups (40-59 years, 60-79 years) using a Cox proportional hazards model. Compared with optimal BP levels, the multivariate risk ratios of cardiovascular mortality for stage 2 or 3 hypertension were 5.99 (95% confidence interval: 2.13-16.8) in middle-aged men and 4.09 (1.70-9.85) in middle-aged women. These excess cardiovascular mortality risks were larger in the 40-59 years age group than in the 60-79 years age group for both genders (p for interaction = 0.01 for both). In men, the population attributable risk percents of cardiovascular mortality were 60% for younger men and 28% for older men, while for women they were 15% for younger women and 7% for older women. Weaker but significant excess risks of total mortality were observed for stage 2 or 3 hypertension in men of both age groups and in the older age group for women. The impact of BP on the risk of cardiovascular mortality was larger among middle-aged persons than among the elderly in both men and women. Our findings indicate the importance of BP control to prevent cardiovascular disease among middle-aged individuals.
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PMID:Age-specific relationship between blood pressure and the risk of total and cardiovascular mortality in Japanese men and women. 1655 79

The purpose of this study was to determine the relationship between hypertension and onset of cardiovascular disease in Japan. As part of an ongoing epidemiological survey of cardiovascular diseases in Hokkaido, Japan, 1,798 subjects (806 males and 992 females; mean age in the initial year of the survey, 58.6+/-11.8 years) were selected, after excluding subjects who had been taking antihypertensive drugs, from a total of 2,136 subjects who had undergone medical examinations in 1991 in the town of Tanno and in 1992 in the town of Sobetsu, two rural communities in Hokkaido. Height, weight, casual systolic and diastolic blood pressures in the sitting position and blood biochemical values of all subjects were measured, and the subjects were divided into blood pressure level groups according to the 1999 World Health Organization/International Society of Hypertension (WHO/ISH) criteria. The follow-up survey was concluded at the end of August in 1999. The endpoints in this study were onset of circulatory disease or death due to circulatory disease. During the follow-up period, circulatory diseases (ischemic heart disease or stroke) occurred in 94 of the subjects. The incidence rates of cardiovascular disease (per 1,000 persons/year) for subjects divided into blood pressure groups according to the 1999 WHO/ISH blood pressure classification were 6.24 for the optimal+normal blood pressure level group, 11.26 for the normal high blood pressure level group, and 15.83 for the grade 1-3 hypertension group. Thus, the incidence rate of circulatory disease increased as the blood pressure level increased, and there was a significant difference between the incidence rate in subjects in the grade 1-3 hypertension group and the incidence rate in subjects in the optimal+normal blood pressure level group (p<0.05). In a Cox's proportional hazards model with onset of circulatory disease as the endpoint, diastolic blood pressure was shown to be an independent risk factor with a relative risk of 1.01. The results suggest that hypertension is an independent risk factor for onset of circulatory disease.
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PMID:Influence of hypertension on the incidence of cardiovascular disease in two rural communities in Japan: the Tanno-Sobetsu [corrected] study. 1791 14

It is now universally accepted that antihypertensive therapy reduces cardiovascular morbidity and mortality both in young and older patients. The clinical relevance of the systolic, diastolic and pulse pressure as independent risk factors is well recognized. The reduction of cardiovascular morbidity and mortality in hypertensive patients is the main therapeutic goal. There is substantial agreement on the treatment of individual risk factors and associated clinical conditions, but the best drug therapy for systolic and diastolic hypertension and/or high pulse pressure is still controversial. The recommendations of the JNC VI are that diuretics or beta-blockers be used as first-step drug therapies. The WHO-ISH guidelines recognize calcium antagonists, ACE-inhibitors, alpha-blockers and angiotensin II receptor antagonists as first-step drug therapies together with diuretics and beta-blockers. All these drugs have a similar hypotensive potential and reduce cardiovascular risk, but with noticeable differences in tolerability and side effects. It has long been demonstrated that diuretics and beta-blockers significantly reduce the cardiovascular risk, but their side effects can be relevant. ACE-inhibitors have proved to be efficacious in hypertensive patients with chronic heart failure and diabetes. Calcium antagonists are useful in the prevention of stroke but results in patients at high risk of coronary artery disease and heart failure are controversial. Alpha-blockers have proved to be unsafe in patients with heart failure but showed beneficial effects in young patients with diastolic hypertension. Angiotensin II receptor antagonists have proved to be safe and efficient but their advantages in comparison to other drugs need to be confirmed.
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PMID:[Systolic, diastolic and pulse pressure: therapeutic options]. 1939 10


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