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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

The already strong case for drug treatment of hypertensive patients aged over 60 has been reinforced by the reports on the SHEP, STOP, and, to a lesser extent, MRC trials. SHEP showed benefit in "isolated systolic" hypertension, mainly in relation to stroke, but with a strong trend towards also reducing myocardial infarction. SHEP demonstrated advantages from low-dose chlorthalidone, especially if hypokalemia was prevented. STOP in patients aged 70-84 at entry demonstrated a reduction in stroke and all-cause mortality but not in myocardial infarction; benefit was apparent in women as well as men. The MRC trial, in subjects over 65, many of whom had "isolated systolic" hypertension, found a reduction in stroke but not in coronary events or all-cause mortality. Extensive cross-contamination of allocated treatment groups restricted worthwhile evaluation of different drug regimens in MRC. Potential benefits from antihypertensive drug treatment in old people are substantial but are in danger of being discredited because of intemperate and inaccurate claims.
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PMID:The case for antihypertensive drug treatment in subjects over the age of 60. 129 77

The Swedish trial in old patients with hypertension (STOP-Hypertension) is a multicentre, randomized, double-blind study of beta-blockers/diuretics versus placebo in old hypertensives. Primary end-points are stroke and myocardial infarction (fatal and non-fatal) as well as other cardiovascular mortality. To evaluate the logistics of STOP-Hypertension, a pilot study was carried out. All patients aged 70-84 years in 31 centres were consecutively registered in a log-book. Altogether 4668 patients were screened: 41.5% had previously been treated for hypertension and 13.5% had blood pressures greater than or equal to 180/105 mmHg. Thus, 55% were 'hypertensive'. In all, 465 patients (18% of the 'hypertensive' patients) started a 3-month washout period (previously treated, n = 396) or a 4-week run-in period (previously untreated, n = 69) period. The most frequent reasons for not starting the run-in/washout were other indications for treatment with beta-blockers/diuretics (13%), unwillingness to participate (8%) or isolated systolic hypertension (4%). The pilot study was evaluated after 1 year: 89 patients (1.9%) had been randomized, 66 patients (1.4%) were still in the run-in/washout period and the majority of the remaining patients were not randomized because they had not reached the inclusion blood pressure (greater than or equal to 180 mmHg systolic and/or greater than or equal to 105 mmHg diastolic) following withdrawal of their antihypertensive medication. During the run-in/washout period there were few serious clinical events: one case of myocardial infarction, three patients had strokes (two fatal), 10 developed congestive heart failure, three tachyarrhythmia and two pneumonia (one fatal).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:STOP-Hypertension--preliminary communication from the pilot study of the Swedish Trial in Old Patients with Hypertension. 289 71

The aim of the present work was to study changes in cardiac output (CO) and arterial blood pressure (ABP) following either interruption of artificial efferent vagal stimulations (STOP), or suppression of negative chronotropic effects, during uninterrupted vagal stimulations (PACE). Experiments were performed on 7 anesthetized, open-chest dogs. A computerized data acquisition system was used to record CO (electromagnetic flowmeter), ABP, right atrial pressure and electrocardiogram; 9 parameters were automatically elaborated. The peripheral stumps of both vagus nerves, sectioned at the neck, were stimulated for long control periods (at least 3 min) with brief trains of stimuli triggered by atrial P waves. Records were started during steady-state vagal stimulations, and consisted of paired trials: in the first step the vagal stimulators were turned off (STOP); in the second step the heart was paced at the same rate reached at the end of the preceding step, but vagal stimulation was continued (PACE). Observations lasted two min after each step. Results indicate rapid rise in CO and ABP after STOP, up to 30% and 10%, respectively, in 10 s, followed by slow reduction in CO and further increase in ABP (22% and 15%, respectively, at 120 s). Thus STOP caused rapid and sustained improvements in the cardiac performance. After PACE changes in CO and ABP were smaller and followed a slower time-course. The greater effects of STOP with respect to PACE were attributed to non-chronotropic mechanisms, accounting for about 50% of the overall haemodynamic consequences of vagal withdrawal. Since peak aortic flow velocity and acceleration were increased after STOP, stroke volume was reduced much less than after PACE, despite equal rise in heart rate, and similar shortening in the ejection time. Evidence was presented of enhanced atrial and ventricular contractility after STOP. Experiments performed after beta-blockade in 5 dogs substantially confirmed the results. It is concluded that vagal withdrawal, which is an important aspect in many physiological situations, constitutes a rather powerful strategy for rapid enhancement of the cardiovascular performance, through different mechanisms, in addition to cardioacceleration.
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PMID:Haemodynamic effects of withdrawal of efferent cervical vagal stimulation on anesthetized dogs--relative importance of chronotropic and non-chronotropic mechanisms. 406 79

In the span of little more than half a year, three major, prospective, placebo-controlled intervention trials against hypertension in the elderly were published, i.e., the Systolic Hypertension in the Elderly Program (SHEP) from the United States in 1991, the Swedish Trial in Old Patients with Hypertension (STOP Hypertension), also in 1991, and the Medical Research Council (MRC) Study in older adults from the United Kingdom in 1992. These trials compared active antihypertensive treatment in elderly patients to placebo, and all found significant benefits from active treatment, particularly against stroke. In the SHEP trial, coronary heart morbidity was also positively affected, and in the STOP Hypertension study total mortality was reduced significantly. In all the three studies, active treatment consisted of diuretics and/or beta-blockers, usually given in combination. It is conceivable that novel classes of compounds, e.g., the calcium antagonists, might have shown even better results in the prevention of cardiovascular morbidity and mortality, in view of their neutral metabolic profile and possible antiatherosclerotic effect. Studies are currently in progress to test this possibility, e.g., the STOP-Hypertension-2 study. While the results of such ongoing trials are awaited, it is worth noting that treatment with calcium antagonists in the elderly, e.g., with lacidipine, in several studies has been shown to be remarkably effective and well tolerated. This raises the possibility that results of antihypertensive treatment in the elderly could become even better than those already obtained in the SHEP, STOP-Hypertension, and MRC trials.
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PMID:Treatment of hypertension in the elderly. 760 9

During 1991 and 1992 three major intervention trials were published that dealt with the value of antihypertensive treatment in the elderly. The three studies were the American Systolic Hypertension in the Elderly Program (SHEP), the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension) and the British Medical Research Council Trial of Treatment of Hypertension in Older Adults. (MRC trial.) The three trials all compared active antihypertensive treatment, mainly consisting of diuretics or beta-adrenoceptor blocking agents or the two in combination, with placebo. Two of the trials were double-blind (SHEP and STOP) whereas the MRC trial was single-blind. All three were multicenter and prospective, and patients were randomized to either of the treatment modalities. One of the trials (SHEP) was specifically designed to evaluate antihypertensive treatment in patients with isolated systolic hypertension. The SHEP, STOP and MRC trials all showed that treatment of hypertension in the elderly reduces the risk of stroke and cardiovascular events. In the STOP-Hypertension trial, which included the oldest patients with the most severe hypertension, total mortality was reduced by 43%. It could be argued that novel antihypertensive compounds offer equal or better results than the ones obtained with beta blockers and/or diuretics. Angiotensin converting enzyme inhibitors and calcium antagonists are currently being compared with diuretics and beta-blockers in the STOP-Hypertension-2 study which prospectively evaluates morbidity and mortality in hypertensive patients aged 70-84 years.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Treatment of hypertension in the elderly with special reference to urapidil. 780 12

The only antihypertensive treatment regimen with documented effect on morbidity and mortality from stroke and coronary heart disease is based on diuretics and/or beta-blockers. However, new antihypertensive drugs are now widely used. These compounds may also prevent cardiovascular complications, but, as yet, this has not been proven. The clinical trials of the 1990s such as STOP II, CAPPP and NORDIL will test whether antihypertensive treatment with ACE-inhibitors and calcium-blockers are more effective than diuretics and beta-blockers in preventing cardiovascular complications. Also, a large-scale study (HOT) is being undertaken to examine how far diastolic blood pressure should be treated, and whether a small dose of aspirin has a protective effect when combined with good control of blood pressure. These studies will hopefully lead to better guidelines for the future treatment of hypertension.
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PMID:[Can treatment of hypertension prevent myocardial infarction? New controlled clinical trials are proposed]. 809 58

During 1991 and 1992, three major interventional trials were published that dealt with the value of antihypertensive treatment in the elderly. The three studies were the American Systolic Hypertension in the Elderly Program (SHEP), the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension), and the British Medical Research Council (MRC) Trial of Treatment of Hypertension in Older Adults. The three trials all compared active antihypertensive treatment, mainly diuretics or beta-adrenoceptor blocking agents, or the two in combination, with placebo. Two of the trials were double-blind (SHEP and STOP) whereas the MRC trial was single-blind. All three were multicentered, prospective, and included randomization. One of the trials (SHEP) was specifically designed to evaluate antihypertensive treatment in patients with isolated systolic hypertension. The SHEP, STOP, and MRC trials all showed that treatment of hypertension in the elderly reduces the risk of stroke and cardiovascular events. In one of the trials, total mortality was also positively affected. Thus, in the STOP-Hypertension trial, which included the oldest patients with the most severe hypertension, total mortality was reduced by 43%. On the basis of these trials, it is apparent that antihypertensive treatment with low-dose thiazides or beta-blockers, or the two in combination, can produce highly beneficial results in elderly patients, including a reduction in the incidence of stroke and other cardiovascular events as well as in total mortality. Furthermore, special analyses indicate that the cost:benefit aspects of such treatment is at least as positive as in young and middle-aged hypertensive patients.
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PMID:Future goals for the treatment of hypertension in the elderly with reference to STOP-Hypertension, SHEP, and the MRC trial in older adults. 809 6

It is well established that hypertensive patients benefit from drug treatment of their disorder. In recent years three major out-come studies of antihypertensive treatment in elderly hypertensives have shown substantial benefits, i.e. a reduction in the risk of stroke and other cardiovascular mortality and morbidity. In all these studies beta-blockers and/or diuretics were used in comparison with placebo. Newer therapeutic alternatives have, however, at least theoretically, many advantages which could result in further improvements in prognosis. The initial Swedish Trial in Old Patients with Hypertension (STOP-Hypertension 1) was conducted in men and women aged 70-84 years. STOP-Hypertension 2 will evaluate the therapy used in STOP-Hypertension 1 against therapy based on either ACE-inhibitors (enalapril and lisinopril) or on calcium antagonists (isradipine and felodipine), using the PROBE design (Prospective, Randomised, Open, Blinded Endpoint evaluation). The primary aim will be to assess the effect on cardiovascular mortality. Statistical calculations indicate that 6,600 patients, followed for four years will be needed (2p < 0.05, power 90%) to obtain significance if there is a 25% difference between the new and the established therapy. Patients in primary health care (300 centres) will be included if their supine blood pressure is > or = 180/105 mmHg (and/or). Recruitment of patients started in September 1992 and so far more than 100 patients/week have been included.
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PMID:STOP-Hypertension 2: a prospective intervention trial of "newer" versus "older" treatment alternatives in old patients with hypertension. Swedish Trial in Old Patients with Hypertension. 818 Jul 29

Several studies have demonstrated an increased risk of cardiovascular disease (CVD) in relation to high blood pressure in elderly patients aged below 70-75, whereas the risk seemed to decline with age in the older elderly. Early studies on the effect of treatment of mild to moderate hypertension in the elderly indicated (but did not convincingly show) a reduction of CVD. In the 1980s, both the EWPHE trial (European Working Party on High Blood Pressure in the Elderly) and the HEP study (The Randomised Trial of the Treatment of Hypertension in Elderly Patients in Primary Care) provided evidence of the benefit of treating high blood pressure in the elderly, at least up to the age of 70-74. These results have lately been confirmed by three major trials SHEP (Systolic Hypertension in the Elderly Program), STOP (Swedish Trial in Old Patients with Hypertension) and MRC (Medical Research Council), also including older patients (STOP) and those with isolated systolic hypertension (SHEP). This satisfactory effect was not impaired by a low tolerability of the drugs used (beta-blockers and diuretics). In conclusion, drug treatment with beta-blockers and diuretics in hypertensive men and women aged 70 and above confers highly significant and clinically relevant reductions in cardiovascular (especially stroke) morbidity and mortality. The clinical implication of this is that blood pressure lowering therapy should be considered in elderly hypertensives, at least up until they are 80. It should also be remembered that elderly hypertensives often have other diseases as well and that the drug treatment should be adjusted accordingly.
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PMID:Hypertension in the elderly. 826 94


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