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

Cardiac hypertrophy is often seen in hypertensive patients and is associated with arrhythmia, stroke, sudden death and heart failure. Mechanical stretching has been cited as the cause of cardiac hypertrophy, and investigation into this process with angiotensin receptor blockers (ARBs) has indicated that AT(1) receptors are involved in stretch-induced hypertrophic responses. The effects of stretching have also been found to be independent of angiotensin II. These experiments showed that there are two types of ARBs. One is a competitive antagonist, and the other is the inverse agonist which is able to inhibit the activity of the receptors even in the absence of their ligands. Inverse agonism on AT(1) receptors has been demonstrated with candesartan, which may have clinical significance depending on the presence or absence of angiotensin II and the expression of AT(1) receptors.
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PMID:New mechanism of heart protection by angiotensin receptor blockers. 1724 78

BP is the most important determinant of the risk of stroke. A small reduction in BP results in a substantial reduction of both ischemic and hemorrhagic stroke. Any of the commonly used antihypertensive drugs lower the incidence of stroke, with larger reductions in BP resulting in larger reductions in risk. Experimental evidence has linked the renin-angiotensin system (RAS) to the development and progression of cerebrovascular disease. Inhibition of the RAS has beneficial cerebrovascular effects and may reduce the risk of stroke in a manner possibly independent from the alterations of BP. Some clinical trials even suggest that ACE inhibitors and angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) exert cerebroprotective effects beyond BP lowering, but the evidence is controversial. Studies on specific protective actions of antihypertensive drugs are generally hampered by the fact that any treatment-related difference in BP may play a dominant role in the prevention of stroke. There are also indications that the protective potency of ARBs might be superior to that of ACE inhibitors, due to their differential activation of angiotensin II type 2 receptors, but the clinical relevance of this mechanism is unclear. Some studies in primary prevention of stroke, acute stroke, and secondary prevention show advantages for ARBs beyond controlling BP alone. In primary prevention, the LIFE randomized trial showed a significant difference in stroke rate in favor of losartan compared with atenolol despite similar reductions in BP. In acute stroke, the role of hypertension and its treatment remains controversial. ACCESS, however, suggested that an ARB is safe in hypertensive acute stroke patients and may offer advantages independent from BP control. In secondary stroke prevention, there are very few antihypertensive trials. These trials show that BP lowering is at least as successful as in primary prevention, but the absolute stroke risk is much higher. An ACE inhibitor was effective compared with placebo in the PROGRESS trial. The MOSES study showed that eprosartan prevented vascular events more effectively than nitrendipine, despite similar BP-lowering effects. Hypertension is not only the most important risk factor for stroke, but is also closely correlated with cognitive decline and dementia. Therefore, prevention of cognitive decline or even improvement of slightly diminished brain function should be an important goal for antihypertensive treatment in the future. Some clinical data suggest advantages for ACE inhibitors, ARBs, and calcium channel antagonists. Currently, however, the existing data are not sufficient for clinical recommendations. Therefore, ongoing trials will further define the exact role of inhibitors of the RAS and are urgently needed in secondary prevention, in acute stroke, and in the prevention of cognitive decline.
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PMID:Inhibition of the renin-angiotensin system and the prevention of stroke. 1735 64

The renin-angiotensin system is a major regulatory system of cardiovascular and renal function. Basic research has revealed exciting new aspects, which could lead to novel or modified therapeutic approaches. Renin-angiotensin system blockade exerts potent antiatherosclerotic effects, which are mediated by their antihypertensive, anti-inflammatory, antiproliferative, and oxidative stress lowering properties. Inhibitors of the system-ie, angiotensin converting enzyme inhibitors and angiotensin receptor blockers, are now first-line treatments for hypertensive target organ damage and progressive renal disease. Their effects are greater than expected by their ability to lower blood pressure alone. Angiotensin receptor blockers reduce the frequency of atrial fibrillation and stroke. Renin-angiotensin system blockade delays or avoids the onset of type 2 diabetes and prevents cardiovascular and renal events in diabetic patients. Thus, blockade of this system will remain a cornerstone of our strategies to reduce cardiovascular risk.
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PMID:Renin-angiotensin system and cardiovascular risk. 1761 59

Hypertension is the major risk factor for ischaemic and haemorrhagic clinical strokes as well as for silent brain infarcts with a continuous association between both systolic and diastolic blood pressures. Epidemiological data highlight the increasing burden to come over the next decades. Without any doubt, antihypertensive treatment is the most important therapy to reduce the risk of stroke by approximately 30-40%. International guidelines recommend antihypertensive treatment for primary prevention with evidence level A. Recurrent strokes or transient ischaemic attack (TIA) are an important practical, clinical and economic problem, and have a major impact on the development of vascular dementia. All stroke patients and patients with TIA have to be regarded as very high-risk patients. Hypertension increases the risk of recurrent strokes. Only limited data directly address the role of blood pressure treatment among individuals with stroke or TIA. There is a general lack of definitive data regarding when to start antihypertensive treatment in the initial phase, and treatment of hypertension in the acute period after stroke is still under debate. Experimental and clinical data suggest that reducing the activity of the renin-angiotensin aldosterone system (RAAS) may have beneficial effects beyond the lowering of blood pressure. There is increasing evidence of cerebroprotective effects for medication influencing the RAAS, such as angiotensin receptor antagonists or ACE inhibitors. The MOSES study showed for the first time superiority of an angiotensin receptor antagonist compared with a calcium channel antagonist in antihypertensive treatment for secondary stroke prevention. Optimal blood pressure range in secondary prevention seems to be 120-140/80-90 mm Hg, but questions about a J- or U-shaped curve are still not answered sufficiently. The effects of additional antihypertensive treatment in the evening for stroke patients with 'non-dipping' blood pressure need to be investigated.Currently, the most important goal in primary and secondary prevention of stroke is a strict normotensive blood pressure control. Antihypertensive treatment is recommended for both prevention of recurrent stroke and prevention of other vascular events in individuals who have had an ischaemic stroke or TIA (class I, level of evidence A). Many open questions remain and funding of stroke research needs to be increased in the near future.
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PMID:Drug therapy for the secondary prevention of stroke in hypertensive patients: current issues and options. 1748 41

In the present quantitative overview of outcome trials, we investigated the efficacy of amlodipine or angiotensin receptor blockers in the prevention of stroke and myocardial infarction in patients with hypertension, coronary artery disease, or diabetic nephropathy. The analysis included 12 trials of 94 338 patients. The analysis of trials involving an amlodipine group showed that amlodipine provided more protection against stroke and myocardial infarction than other antihypertensive drugs, including angiotensin receptor blockers (-19%, P<0.0001 and -7%, P=0.03) and placebo (-37%, P=0.06 and -29%, P=0.04). The analysis of trials involving an angiotensin receptor blocker group showed contrasting results between trials versus amlodipine and trials versus other antihypertensive drugs for stroke (+19% versus -25%; P<0.0001) and myocardial infarction (+21% versus +1%; P=0.03). The results of 3 trials comparing an angiotensin receptor blocker with placebo were neutral (P> or =0.14). The within-trial between-group difference in achieved systolic pressure ranged from -1.1 to +4.7 mm Hg for trials involving an amlodipine group and from -2.8 to +4.0 mm Hg for trials involving an angiotensin receptor blocker group. The metaregression analysis correlating odds ratios with blood pressure differences showed a negative relationship (regression coefficients: -3% to -8%), which reached statistical significance (regression coefficient: -6%; P=0.01) for stroke in trials involving an amlodipine group. In conclusion, blood pressure differences largely accounted for cardiovascular outcome.
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PMID:Prevention of stroke and myocardial infarction by amlodipine and Angiotensin receptor blockers: a quantitative overview. 1772 73

Dihydropyridine calcium channel antagonists have been maligned in recent years because of concerns regarding their cardiovascular and overall safety profile. Specifically, it was widely publicised in the mid-1990s that these agents might increase the risk of myocardial infarction, gastrointestinal bleeding and cancer. Data linking these agents with increased cardiovascular risk were based on nonrandomised studies and implicated short-acting, immediate-release agents. These results were inappropriately extrapolated to longer-acting compounds, extended-release products, and to the non-dihydropyridine class. Fortunately, recent studies have vindicated the class from safety allegations. These studies are reviewed herein. Compared with both diuretics and contemporary agents, amlodipine decreases cardiovascular events to a similar or greater extent without evidence for increased coronary heart disease, gastrointestinal bleeding or cancer. Despite these data, initial concerns have had lasting repercussions, as the use of dihydropyridine calcium channel antagonists appears to lag behind what emerging data would support. Dihydropyridine calcium channel antagonists have several noteworthy attributes that merit consideration in the management of hypertension. The blood pressure response to this class of drugs is less contingent on patient factors such as age and race compared with other antihypertensive agents (e.g. ACE inhibitors). Dihydropyridine calcium channel antagonists may exert effects that protect against stroke that are independent of their blood pressure-lowering mechanism. Unlike diuretics and beta-adrenoceptor anatagonists (beta-blockers), dihydropyridine calcium channel antagonists are lipid neutral and do not disturb glucose homeostasis. Dihydropyridine calcium channel antagonists demonstrate a highly desirable profile when administered as part of combination therapy. Combinations of dihydropyridine calcium channel antagonists and ACE inhibitors or angiotensin receptor antagonists display additive efficacy and an enviable adverse-effect profile. Collectively, the cardiovascular benefit, metabolic neutrality and homogeneous blood pressure response illuminated in recent studies, and reviewed here, represent a reaffirmation of the benefit of long-acting dihydropyridine calcium channel antagonists and should serve to help reinforce the critical importance of these agents in the therapeutic armamentarium against cardiovascular disease.
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PMID:Dihydropyridine calcium channel antagonists in the management of hypertension. 1754 73

Cardiovascular disease represents a continuum that starts with risk factors, such as hypertension, and progresses to atherosclerosis, target organ damage, and ultimately leads to heart failure or stroke. Renin-angiotensin-aldosterone system (RAAS) blockade with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) has been shown to be beneficial at all stages of this continuum. Both classes of agent can prevent or reverse endothelial dysfunction and atherosclerosis, thereby potentially reducing the risk of cardiovascular events. Such a reduction has been shown with ACE inhibitors in patients with coronary artery disease, but no such data are currently available for ARBs. Both ACE inhibitors and ARBs have been shown to reduce damage in target organs, such as the heart and kidney, and to decrease cardiovascular mortality and morbidity in patients with congestive heart failure. Trials, such as the Ongoing Telmisartan Alone in Combination with Ramipril Global Endpoint Trial (ONTARGET) and the Telmisartan Randomised Assessment Study in ACE-Intolerant Subjects with Cardiovascular Disease (TRANSCEND), that compare telmisartan, ramipril, and their combination in high-risk patients with vascular end-organ damage, should provide important new insights into the benefits of intervention with RAS blockade along the cardiorenovascular continuum.
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PMID:Angiotensin receptor blockers versus angiotensin-converting enzyme inhibitors: where do we stand now? 1830 33

The prevalence of hypertension in blacks in the United States is among the highest in the world. Compared with whites, blacks develop hypertension at an earlier age, their average blood pressures are much higher and they experience worse disease severity. Consequently, blacks have a 1.3 times greater rate of nonfatal stroke, 1.8 times greater rate of fatal stroke, 1.5 times greater rate of heart disease death, 4.2 times greater rate of end-stage kidney disease, and a 50% higher frequency of heart failure; overall, mortality due to hypertension and its consequences is 4 to 5 times more likely in African Americans than in whites. The increased prevalence of hypertension and excessive target organ damage is due to a combination of genetic and, most likely, environmental factors. There are no clinical trial data at present to suggest that lower-than-usual BP targets should be set for high-risk demographic groups such as African Americans. The primary means of prevention and early treatment of hypertension in African Americans will be the appropriate use of lifestyle modification. The International Society of Hypertension in Blacks guidelines realize that most patients will require combination therapy, many of them first-line, to reach appropriate BP goals. Although certain classes and combinations of antihypertensive agents have been well-established to be effective, the choice of drugs for combination therapy in African American patients may be different. Within the African American group, the responsiveness to monotherapy with ACE inhibitors, angiotensin receptor blockers, and beta blockers may be less than the responsiveness to diuretics and calcium channel blockers, but these differences are corrected when diuretics are added to the neurohormonal antagonists. Of note, African American patients with systolic BP >15 mm Hg or a diastolic BP >10 mm Hg above goal should be treated with first-line combination therapy.
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PMID:The management of hypertension in African Americans. 1766 68

Angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) posses multiple beneficial effects such as cardioprotection, cerebroprotection, nephroprotection which provide opportunity to select the most suitable drug for the target vascular bed (e.g. coronary, or cerebral circulation). In some clinical settings, combined therapy ACE-I with ARB (double blockage of the renin-angiotensin-aldosteron system) may appear the most effective. These drugs (especially ARB) may successfully prevent atrial fibrillation and play a protective role in metabolic syndrome. Recently, it has been demonstrated that losartan is able to inhibit vasodilatation of the aorta in Marfan syndrome, which might prevent sudden death due to aorta rupture. An increasing role of ARB is most beneficial in hipotensive therapy (inhibition/regression of hypertension-related organ damage). With particular interest, results of the ONTARGET study are being awaited. This study is focused on the effect of double blockage (ramipril and telmisartan) on reduction of the occurrence of myocardial infarction, stroke, and heart failure.
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PMID:[New therapeutic targets for ACE inhibitors and angiotensin receptor blockers]. 1772 75

Successful treatment of hypertension in patients with type 2 diabetes mellitus increases life expectancy and reduces the risk of many of the complications associated with diabetes, such as heart disease, stroke, and retinopathy. Controlling blood pressure also protects against advancing renal disease, with several recent studies having clearly shown the advantage of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in slowing the progression of renal disease. Here, the authors review current guidelines for the management of hypertension in patients with type 2 diabetes mellitus and explore ways in which nurse practitioners can improve care for these patients.
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PMID:Taking the pressure off type 2 diabetes mellitus: implementing hypertension guidelines. 1778 92


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