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 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The recommendations of the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), published in 2003, are largely relevant today. Lowering blood pressure (BP) to goal in hypertensive patients is of primary importance in reducing cardiovascular risk. Antihypertensive drugs vary in their efficacy to lower BP and can have BP-independent effects on cardiovascular events, as seen especially with regard to preventing heart failure and stroke. Thiazide-type diuretics were recommended as the preferred initial drugs for treatment of hypertension in most patients, and this is still an appropriate recommendation. Several other classes were recommended as next in priority, but beta-blockers should now have a lesser role in the management of uncomplicated hypertension. Although a new JNC report would be reassuring to practitioners and should include some changes since JNC 7, I consider most of the recommendations to still be relevant today.
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PMID:JNC-7 guidelines: are they still relevant? 1817 84

Blacks have the highest rates of hypertension and cardiovascular disease, with earlier onset, greater severity, and more target organ damage including coronary disease, heart failure, stroke, and end-stage renal disease. A major reason is the greater prevalence of other cardiovascular disease risk factors, particularly obesity, inactivity, and diabetes mellitus, along with socioeconomic differences, adherence, and achievement of goals. This review focuses on the burden of cardiovascular disease in blacks. Therapeutic lifestyle changes and pharmacologic interventions to decrease clinical events in this high-risk group are described. Intensive blood pressure control is a primary means of "stopping the clock" in the progression of cardiovascular disease and renal disease. Thiazide diuretics remain primary first-step agents, especially for uncomplicated hypertension; calcium channel blockers are also efficacious. However, renin-angiotensin system modulators may also be beneficial, especially with a diuretic, considering the high prevalence in this group of patients of compelling indications for use of such agents.
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PMID:Cardiovascular disease in blacks: can we stop the clock? 1845 98

The incidence of hypertension continues to increase worldwide and, according to recent estimates, its incidence is approximately 30% of the U.S. population. However, the control of blood pressure (BP) to recommended levels of < 140/90 mmHg for uncomplicated hypertension, recommended in the 7th Report of the Joint National Committee (JNC-7) on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, remains low at 36.8%. Because the level of BP is directly related to cardiovascular and stroke morbidity and mortality, aggressive treatment and control of hypertension are strongly indicated. Since monotherapy alone is not effective for the control of stage 2 hypertension, fixed-dose combination therapy with two complementary drugs has been recommended by the JNC-7 guidelines as initial therapy for subjects with diastolic BP > or = 100 mmHg and systolic BP > or = 160 mmHg. There are several fixed-dose combination preparations already available, each with its individual indications. The recently FDA-approved fixed-dose combinations of amlodipine with either olmesartan or valsartan are very effective in treating hypertension and are safe and well tolerated. In addition to reducing BP, these new fixed-dose combinations have also demonstrated significant reductions in the inciendence of edema associated with amlodipine monotherapy, which makes them more acceptable to patients. In addition, due to the metabolic neutrality of both component drugs, these preparations are preferable for the treatment of hypertensive patients with diabetes or the metabolic syndrome, in addition to other cardiovascular risk factors.
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PMID:Amlodipine/ARB fixed-dose combinations for the treatment of hypertension: focus on amlodipine/olmesartan combination. 1859 98

Beta-blockers (beta-blockers) have demonstrated their value across the cardiovascular disease spectrum. Beta-blockers effectively lower blood pressure in patients with hypertension and provide symptomatic or mortality benefits in patients with heart failure and in post-myocardial infarction patients. However, despite their utility, beta-blockers remain underused. There have been recent concerns that beta-blockers as a class are not as effective as once thought in uncomplicated hypertension due to a relatively weak effect on reduction of stroke and the absence of an effect on coronary heart disease when compared with placebo or no treatment. Underuse can, in part, be related to tolerability concerns. Beta-blockers have been traditionally associated with side effects including depression, fatigue, sexual dysfunction, and cold extremities, which limit their acceptance by patients and physicians and may lead to discontinuation of therapy. Because of inherent heterogeneity of the beta-blocker class in terms of adrenergic receptor selectivity, intrinsic sympathomimetic activity, and vasodilatory activity, these agents vary in tolerability profile. Recently, more attention has been focused on the third-generation vasodilatory beta-blockers (ie, carvedilol, labetalol, and nebivolol), with the recognition that these agents may diverge in meaningful ways from the traditional beta-blockers. By examining the differences among members of the beta-blocker class, it may be possible to determine whether and which tolerability issues are indeed a class effect of beta-blockers or whether these agents should be evaluated on a case-by-case basis.
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PMID:Are tolerability concerns a class effect of beta-blockers in treating patients with hypertension? 1917 10

Deciding who to treat should be based on estimation of the total cardiovascular risk, not just the blood pressure (BP), so that patients with established cardiovascular disease or at high risk of cardiovascular disease should have their BP lowered even though it may be in the "normal range". Drug treatment should build upon effective lifestyle measures. Meta-analyses from the Blood Pressure Lowering Treatment Trialists' Collaboration have shown that differences between drug classes are quite small, even across different age groups, compared to the benefits of maximizing the reduction in BP, especially the systolic pressure. The major guidelines now recommend a focus on building effective drug combinations rather than arguing about which drug to use, and they approve initiation of treatment with combinations in high risk groups. While clinical trials have demonstrated some differences in the efficacy of individual drug classes in reducing cause specific outcomes such as coronary disease, stroke or heart failure, there are still very few comparisons between drug combinations. Our own preferred combinations include angiotensin converting enzyme inhibitors (ACEI) and diuretics, which comprise my first choice for Caucasians and Asians, and angiotensin receptor blockers (ARB) which are best used with diuretics when ACEI are not tolerated. ACEI and calcium channel blockers (CCB) are also very effective and CCB and diuretics are preferred for black subjects or those with isolated systolic hypertension. Combinations to avoid in patients with uncomplicated hypertension include ACEI and beta-blockers and ACEI and ARBs, since their beneficial effects are not additive.
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PMID:Management of hypertension: evidence from the Blood Pressure Lowering Treatment Trialists' Collaboration and from major clinical trials. 1969 19

Beta-blockers were documented to reduce reinfarction rate more than 3 decades ago and subsequently touted as being cardioprotective for a broad spectrum of cardiovascular indications such as hypertension, diabetes, angina, atrial fibrillation as well as perioperatively in patients undergoing surgery. However, despite lowering blood pressure, beta-blockers have never shown to reduce morbidity and mortality in uncomplicated hypertension. Also, beta-blockers do not prevent heart failure in hypertension any better than any other antihypertensive drug class. Beta-blockers have been shown to increase the risk on new onset diabetes. When compared with nondiuretic antihypertensive drugs, beta-blockers increase all-cause mortality by 8% and stroke by 30% in patients with new onset diabetes. Beta-blockers are useful for rate control in patients with chronic atrial fibrillation but do not help restore sinus rhythm or have antifibrillatory effects in the atria. Beta-blockers provide symptomatic relief in patients with chronic stable angina but do not reduce the risk of myocardial infarction. Adverse effects of beta-blockers are common including fatigue, dizziness, depression and sexual dysfunction. However, beta-blockers remain a cornerstone in the management of patients having suffered a myocardial infarction and for patients with heart failure. Thus, recent evidence argues against universal cardioprotective properties of beta-blockers but attest to their usefulness for specific cardiovascular indications.
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PMID:Cardioprotection with beta-blockers: myths, facts and Pascal's wager. 1970 92

Systolic blood pressure (SBP) increases with age, and hypertension affects approximately two-thirds of adults in the US aged >60 years. Blood pressure (BP) increases as a consequence of age-related structural changes in large arteries, which lead to loss of elasticity and reduced vascular compliance. Increased pulse wave velocity augments SBP, resulting in a high prevalence of isolated systolic hypertension. Because age itself elevates cardiovascular risk, effective treatment of hypertension in an older (aged >or=65 years) patient population prevents many more events per 1000 patients treated than treatment of younger hypertensive patients. Recommendations for treating hypertension are similar in older patients compared with the general population. The Seventh Report of the Joint National Committee on Detection, Prevention, Evaluation, and Treatment of High Blood Pressure recommends target BP goals of <140/90 mmHg for patients with uncomplicated hypertension, and <130/80 mmHg for those with diabetes mellitus or renal disease. Recent guidelines and position papers have extended these aggressive treatment goals to include patients with coronary artery disease, other types of vascular disease and heart failure. Randomized clinical trials have demonstrated the efficacy of calcium channel antagonists (calcium channel blockers [CCBs]), low-dose diuretics, ACE inhibitors and angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) in reducing the risk of stroke and other adverse cardiovascular outcomes in older patients; beta-adrenoceptor antagonists are less effective in terms of endpoint reduction. The majority of older patients require two or more drugs to achieve BP goals. Despite active treatment, half of these patients do not achieve target BP, in part because of the reluctance of physicians to intensify treatment, a phenomenon referred to as 'clinical inertia'. ARBs are effective antihypertensive agents in older patients and have been shown to reduce cardiovascular endpoints in patients with hypertension, diabetic nephropathy, cerebrovascular disease and heart failure. ARBs produce additive BP reduction when combined with diuretics or CCBs. They also have the advantage of placebo-like tolerability, and this contributes favourably to patient compliance with long-term treatment, which is a prerequisite for reducing morbidity and mortality.
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PMID:Role of angiotensin II type 1 receptor antagonists in the treatment of hypertension in patients aged >or=65 years. 1972 49

It has been demonstrated that hypertension can lead to coronary heart disease, heart failure, stroke, and memory loss. In this study we investigated the effect of acute and chronic hypertension on the avoidance and spatial learning and memory in rats. The forty male rats were divided into acute hypertensive, chronic hypertensive and control for each group rats. Hypertension was induced by Deoxy Corticosterone Acetate (DOCA)-salt method. DOCA was injected 30mg/kg of body weight subcutaneously, twice a week. These rats received NaCl 1% instead of tap water for drinking throughout the experiment. The control group received normal saline injection with usual drinking water. Spatial learning and memory was investigated by Morris water maze test and passive avoidance learning by Shuttle box test in the rats after hypertension induction. Results showed that acute hypertension impaired short-term memory in passive avoidance learning. However, acute and chronic hypertension did not affect spatial learning and memory. These data suggest that simple uncomplicated hypertension does not remarkably alter cognition.
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PMID:Effect of acute and chronic hypertension on short- and long-term spatial and avoidance memory in male rats. 1976 67

In the past 4 decades, beta blockers (BBs) have been widely used in the treatment of uncomplicated hypertension and are still recommended as first-line agents in national and international guidelines. Their putative cardioprotective properties, however, derive from the extrapolation into primary prevention of data relative to the reduction of mortality observed in the 1970s in patients with previous myocardial infarctions. In the past 5 years, a critical reanalysis of older trials, together with several meta-analyses, has shown that in patients with uncomplicated hypertension BBs exert a relatively weak effect in reducing stroke compared to placebo or no treatment, do not have any protective effect with regard to coronary artery disease and, compared to other drugs, such as calcium channel blockers, renin-angiotensin-aldosterone system inhibitors or thiazide diuretics, show evidence of worse outcomes, particularly with regard to stroke. Several reasons can explain their reduced cardioprotection: their suboptimal effect in lowering blood pressure compared to other drugs; their "pseudoantihypertensive" efficacy (failure to lower central aortic pressure); their undesirable adverse effects, which reduce patients' compliance; their unfavorable metabolic effects; their lack of an effect on regression of left ventricular hypertrophy and endothelial dysfunction. In conclusion, the available evidence does not support the use of BBs as first-line drugs in the treatment of hypertension. Whether newer BBs, such as nebivolol and carvedilol, which show vasodilatory properties and a more favorable hemodynamic and metabolic profile, will be more efficacious in reducing morbidity and mortality remains to be determined.
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PMID:Why beta-blockers should not be used as first choice in uncomplicated hypertension. 2045 90

The concept of the J-curve effect has been around for a long time and is a subject of contention among various investigators. The J-curve effect describes an inverse relation between low blood pressure (BP) and cardiovascular complications. Because the coronary arteries are perfused during diastole, this effect is seen mostly with low diastolic BP in the range of 70 to 80 mm Hg, depending on preexisting coronary artery disease, hypertension, or left ventricular hypertrophy. Although national and international guidelines recommend aggressive BP control to <140/90 mm Hg for uncomplicated hypertension or <130/80 mm Hg for hypertension associated with coronary artery disease, diabetes, or chronic kidney disease, recent large clinical outcomes trials have observed a J-curve effect between diastolic BP <80 mm Hg as well as systolic BP <130 mm Hg and have cast some doubt regarding the aggressive BP treatment, or "the lower the better," concept. Other recent studies have shown no benefit with respect to cardiovascular complications between aggressive and less aggressive BP control. In contrast to cardiovascular complications, no J-curve effect has been noted for strokes. A Medline search of English-language reports published from 1992 to 2010 regarding this topic was conducted, and 11 reports were selected and are discussed in this brief review, together with collateral published research. In conclusion, most of the reviewed publications suggest a J-curve effect with low diastolic and systolic BP for cardiovascular disease complications but not stroke complications.
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PMID:Effectiveness of lowering blood pressure to prevent stroke versus to prevent coronary events. 2081 23


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