Follow-up of Antihypertensive Therapy Improves Blood Pressure Control: Results of HYT (HYperTension survey) Follow-up.

INTRODUCTION: Although improved during the past few years, blood pressure control remains sub optimal. AIM: The impact of follow-up assessment on blood pressure control was evaluated in a group of patients of the HYT (HYperTension survey), treated with a combination of different dihydropyridine calcium-channel blockers (CCBs regimen) and inhibitors of renin-angiotensin-aldosterone system (RAAS) and with uncontrolled blood pressure. This was obtained assessing (a) the rate of blood pressure control at 3 and 6 months of follow-up in the whole group of patients, (b) the rate of blood pressure control and the average blood pressure values in subjects treated with different DHP-CCBs regimen. METHODS: From the 4993 patients with uncontrolled blood pressure, (BP ≥ 140/90 or ≥140/85 in patients with diabetes), 3729 (mean age 61.2 ± 11.5 years), maintained CCBs regimen combined wih RAAS blockers and were evaluated at 3 and 6 months follow-up. At each visit BP (semiautomatic device, Omron-M6, 3 measurements), heart rate, adverse events and treatment persistence were collected. RESULTS: At 1st and 2nd follow-up the rate of controlled BP was 63.5 and 72.8% respectively (p < 0.05 vs 35.3% at baseline), whereas in diabetes was 32.5 and 37.9% respectively (p < 0.05 vs 20% at baseline). No differences in heart rate were observed. No differences in control rate were observed between the different CCBs regimen. The incidence of drugs related adverse events was 3.6%. CONCLUSIONS: These findings provide evidence that: (a) the follow-up of hypertensive patients under therapy increase the rate of blood pressure control; (b) there is no significant difference in the antihypertensive effect between different CCBs regimen;

The efficacy of telmisartan compared with perindopril in patients with mild-to-moderate hypertension.

In this study, efficacy of the angiotensin II type 1 receptor blocker telmisartan given as monotherapy was compared with that of perindopril monotherapy in patients with mild-to-moderate hypertension. After a 2-week, single-blind, placebo run-in period, 60 patients were randomised to double-blind, once-daily treatment with telmisartan 80 mg or perindopril 4 mg for 6 weeks. Clinic and ambulatory blood pressure measurements and clinical laboratory evaluation were performed at the end of the placebo run-in and active treatment phases. Both telmisartan and perindopril significantly (p < 0.0001) reduced clinic systolic blood pressure (SBP) and diastolic blood pressure (DBP) compared with baseline values. Also, both drugs significantly (p < 0.0001) reduced 24-h mean ambulatory SBP and DBP compared with baseline. Comparison of the mean hourly antihypertensive activities showed that the reduction in mean ambulatory DBP for the last 8 h of the dosing interval was significantly greater (p < 0.05) in telmisartan-treated patients. A 24-h mean DBP of <85 mmHg was observed in 66.6% of the telmisartan-treated patients but in only 46.6% of the perindopril-treated patients (p < 0.05). It is concluded that telmisartan and perindopril both produce significant reductions in clinic SBP and DBP, but the mean reduction in ambulatory DBP during the last 8 h of the dosing interval is greater in patients treated with telmisartan.

Clinically additive effect between doxazosin and amlodipine in the treatment of essential hypertension.

The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure has reported that combinations of low doses of antihypertensive agents from different classes may provide additional antihypertensive efficacy and minimize the likelihood of dose-dependent adverse effects. Doxazosin and amlodipine, alone and in combination, were compared for efficacy in reducing blood pressure (BP) in 75 patients with predominantly moderate (Stage 2) hypertension. This was a double-blind, randomized, crossover study. After a 2-week washout period, patients in group A (n = 37) received amlodipine 10 mg and patients in group B (n = 38) received doxazosin 4 mg for 6 weeks. All patients then received reduced-dose combination therapy (amlodipine 5 mg and doxazosin 2 mg) for 6 weeks. Subsequently, patients received 6 weeks of monotherapy with the alternate medication (group A received doxazosin 4 mg and group B received amlodipine 10 mg). During both monotherapy periods, doxazosin and amlodipine significantly reduced systolic and diastolic BP (P < .001 v baseline). BP further decreased with combination therapy (P < .01 v monotherapy). The percentage of patients with Stage 2 hypertension who achieved a target BP of < 140/< 90 mm Hg increased from 78% with monotherapy to 94% with combination therapy. Fewer adverse effects were observed during combination therapy. It is concluded that there is an additional fall in blood pressure when reduced doses of doxazosin and amlodipine are used in combination for the treatment of hypertension, suggesting that doxazosin should be considered as an effective add-on treatment to calcium-channel blockers.

The Effect of Trimetazidine in the Treatment of Microvascular Angina.

Although the pathophysiology of microvascular angina is unclear, intracellular metabolic changes are believed to be the main factors. Trimetazidine has an intracellular metabolic effect in coronary insufficiency. The effect of trimetazidine in microvascular angina is unknown. Thirty-five patients (8 men, 27 women, age 36-57 years, mean 43.9 +/- 6.4 years) with microvascular angina were included in this study. The effects of trimetazidine (60 mg daily) were investigated in a placebo-controlled, double-blind study consisting of two 4-week treatment periods. Patients were assessed by symptom-limited exercise testing (Bruce protocol). Heart rate and systolic blood pressure at rest, peak exercise, and the time of 1 mm ST segment depression were not significantly different between placebo and trimetazidine treatment. Trimetazidine prolonged total exercise time and time to 1 mm ST depression compared with placebo. Maximum ST depression was less in patients with trimetazidine therapy than those with placebo. It is concluded that trimetazidine has a beneficial effect in cases with microvascular angina.

The prevalence of silent myocardial ischaemia in patients with white-coat hypertension.

The aim of this study was to estimate the incidence of silent myocardial ischaemia in patients with mild to moderate hypertension, white-coat hypertension (WCH) and those with normal blood pressure. Ambulatory electrocardiographic (ECG) monitoring was carried out in 272 cases with normal blood pressure, 164 cases with mild to moderate hypertension (diastolic blood pressure >95 and <114 mm Hg), and 106 cases with white-coat hypertension who were diagnosed with ambulatory blood pressure monitoring. The ages of the patients of all groups were between 42-61 years. There were no differences between the groups according to age, gender and other parameters. There were no anginal symptoms, and resting ECGs were in normal limits in all cases. The diagnosis of silent ischaemia was considered to be present if there was ST depression >2 mm/at least 120 sec in ambulatory ECG examination without angina or its equivalent cardiac symptoms. The incidence of silent ischaemia was 6.4%, 18.8%, and 26.2% in cases with normal blood pressure, WCH, and hypertension, respectively. The differences between groups were significant. It was concluded that WCH is not a benign condition, but shares some characteristics with essential hypertension.

Therapeutic benefits of cilazapril in patients with syndrome X.

OBJECTIVES: Although the pathophysiology of syndrome X (angina pectoris, positive ECG test findings and normal coronary arteriogram) is unclear, it is generally accepted that intracellular metabolic changes resulting from abnormal constriction of prearteriolar vessels due to endothelium-dependent vasodilation abnormalities may play a role in the pathogenesis. We established the effect of long-term treatment with cilazapril, an angiotensin-converting enzyme inhibitor, which prevents the effect of angiotensin II in the tonic control of vascular resistance. METHODS: 18 patients (15 women and 3 men, mean age 43.2 +/- 4.6 years) with syndrome X were included in this study. A randomized double-blind crossover placebo-controlled trial was done. After a 1-week washout period, patients received either cilazapril 2 x 2.5 mg or placebo for 3 weeks, followed by 3 weeks of the other therapy. At the end of two periods, an exercise ECG test (modified Bruce protocol) was employed. RESULTS: The magnitude of ST segment depression was significantly decreased during treatment with cilazapril compared with placebo. On the other hand, total exercise time and time to 1 mm ST segment depression were significantly prolonged by cilazapril. However, rate pressure products were not significantly different at peak exercise at or at 1 mm of ST segment depression during both therapies. CONCLUSION: Cilazapril exerted a beneficial therapeutic effect in cases with syndrome X. The possible mechanism of this effect may be a modulation of coronary tone at the microcirculation level.

The efficacy of felodipine ER on regression of left ventricular hypertrophy in patients with primary hypertension.

The aim of the study was to evaluate the efficacy over 1 year of of felodipine ER 5 and 10 mg once daily (od) in 12 Caucasian patients with left ventricular hypertrophy secondary to primary hypertension. After a placebo period of 20 days, a physical examination and an echocardiography were performed in each patient. All patients started treatment with felodipine ER 5 mg. In 3 of the 12 patients the dose was increased to 10 mg od to control blood pressure (BP). BP was recorded every 2 weeks during the first 3 months, and at monthly intervals from the 3rd to the 12th months. An echocardiogram was taken at the end of the 3rd, 6th, 9th and 12th months. At the end of the placebo period, the mean SBP/DBP (+/-SD) was 178 +/- 11/104 +/- 5 mmHg. Mean SBP and DBP decreased significantly (p < 0.001) during the first 2 months to 138 +/- 10/86 +/- 3 mmHg and remained at this level until the end of the study. Mean left ventricular mass index (LVMI) decreased from 170 +/- 33 g/m2 after the placebo period to 115 +/- 19 g/m2 after 1 year (p < 0.01). It is concluded that felodipine ER 5 and 10 mg od over 1 year statistically significantly reduced both BP and LVMI.

Electrocardiographic diagnosis of left ventricular hypertrophy in the presence of right bundle branch block in cases with essential hypertension.

Right bundle branch block was diagnosed in electrocardiograms of 37 of 1085 patients with essential hypertension. Echocardiographically left ventricular hypertrophy was diagnosed in 14 of these 37 patients. Eighteen electrocardiographic (ECG) criteria, which were previously recommended, were determined in these 37 patients. The sensitivities of five criteria were found to be better than 50%. These are SV1 > or = 2 mm; RV6 > RV5; S III + (R+S) maximum precordial lead > or = 30 mm; P/PR > or = 1.6; R aVL > or = 11 mm. However, their specificities ranged from 56.5% to 95.6%. When the combination of RV6 > RV5 and S III + (R+S) maximum precordial lead > or = 30 mm was used, sensitivity was 57.1 and specificity was 100%. It is concluded that the presence of right bundle branch block these ECG criteria can be used for the diagnosis of left ventricular hypertrophy.

Combination therapy with verapamil and nitrendipine in patients with hypertension.

Forty patients with mild to moderate hypertension were divided into two groups, 20 patients (group A) received 240 mg verapamil and 20 patients (group B) received 20 mg nitrendipine daily during the first six weeks. During the second six weeks, all 40 patients were given 10 mg nitrendipine plus 120 mg verapamil. After the combination therapy, group B received verapamil, 240 mg and group A nitrendipine 20 mg for a further period of six weeks. When verapamil and nitrendipine were used alone, BP decreased significantly in each group. However, BP decreased more when the combination therapy was used and increased when the treatment was changed to single drug therapy from the two-drug combination. In addition, side-effects were three to four times fewer during the combination therapy. It is concluded that the combination of two different calcium antagonists in the treatment of hypertension provides a new dimension to therapy.

Venous-phase angiography in subclavian-steal syndrome.

The value of demonstrating the venous phase of angiography in patients with subclavian-steal syndrome was evaluated in 17 patients. In patients with mild symptoms, there was no difference between the left and right jugular-vein opacification, but minimal or no opacification was observed in patients with severe symptoms. The authors believe evaluating venous phases in angiography in patients with subclavian-steal syndrome is useful because the findings correlate well with the severity of symptoms.

[Prevention by pindolol of electrocardiographic changes during bronchoscopy performed under local and general anesthesia]. / Prévention par le pincolol des modifications de l'électrocardiogramme au cours de la bronchoscopie pratiquée sous anesthésie locale et générale.

Sixty patients were studied with respect to ECG modifications during bronchoscopy under local or general anesthesia, using dynamic electrocardiography. The increase in heart rate and incidence of extra-systoles were greater under local than general anesthesia. When pindolol, a beta-blocker with practically no bronchospastic effect was administered before the procedure, there was a significant decrease in the incidence of tachycardia and extra-systoles. This drug appears to be useful before bronchoscopy.

Q-I-IIA-OS formula for predicting left atrial pressure in mitral stenosis.

The relation of the phonocardiographic time intervals (Q-I) and (IIA-OS) and the use of two formulas (Q-I, IIA-OS difference versus their ratio) for estimation of left atrial pressure were investigated in 70 cases of pure mitral stenosis. It was noted that, in cases with normal blood pressure and pluse rate, there was a fair correlation of the two intervals to left atrial pressure. In our studies the best correlation was obtained by using the ratio of these two intervals (Q-I)/(IIA-OS). These results indicate that it is possible to use a new formula and equation that are dependable for phonocardiographic evaluation of left atrial pressure.