Additional Antihypertensive Agents Research Articles

Captopril to Lisinopril Conversion in Pediatric Cardiothoracic Surgery Patients Less Than 7Years of Age (RISE-7).

Hypertension after cardiothoracic surgery is common, often requiring pharmacologic management. The recommended first-line antihypertensives in pediatrics are angiotensin converting enzyme inhibitors. Captopril and enalapril are approved for infants and children; however, lisinopril is only approved for > 7years of age. This study evaluated safety and efficacy of converting from captopril to lisinopril in patients utilizing a pre-defined conversion of 3mg captopril to 1mg lisinopril. This was a single center, retrospective study including patients less than 7years of age admitted for cardiothoracic surgery who received both captopril and lisinopril from 01/01/2017 to 06/01/2022.The primary outcome was mean change in systolic blood pressure (SBP) from baseline for 72h after conversion of captopril to lisinopril. A total of 99 patients were enrolled. There was a significant decrease in mean SBP (99.12mmHg vs 94.86mmHg; p = 0.007) with no difference in DBP (59.23mmHg vs 61.95mmHg; p = 0.07) after conversion to lisinopril. Of the 99 patients who were transitioned to lisinopril, 79 (80%) had controlled SBP, 20 (20%) remained hypertensive, 13 (13%) received an increase in their lisinopril dose, and 2 (2%) required an additional antihypertensive agent. There was a low overall rate of AKI (3%) and hyperkalemia (4%) respectively. This study demonstrates that utilizing lisinopril with a conversion rate of 3mg of captopril to 1mg of lisinopril was safe and effective for controlling hypertension in pediatric patients following cardiothoracic surgery.

Short-term effects of transcatheter aortic valve replacement on blood pressure and cardiac function in elderly patients with severe aortic stenosis.

Transcatheter aortic valve replacement (TAVR) is a standard treatment for elderly and high-risk patients with aortic valve stenosis (AS); however, its short-term effects on blood pressure (BP) and cardiac function are not clear. Therefore, we aimed to determine the short-term effects of TAVR in elderly patients (>75 years), who reflect the clinical situation in Japan. Twenty-eight consecutive elderly patients with severe AS and hypertension who underwent TAVR under general anesthesia were retrospectively investigated. All patients had hypertension that was well controlled with antihypertensive drugs. Serum brain natriuretic peptide level and peak velocity in the aortic valve were significantly reduced. TAVR induces an increase in BP that requires additional antihypertensive agents. There was no correlation between the change rate of SBP and stroke volume index (SVI), but there was a positive correlation between the rate of change in pulse pressure (PP) and SVI. This tendency was particularly observed in patients with low brachial-ankle pulse wave velocity (baPWV). We observed post-TAVR hypertension and required additional antihypertensive drugs. The increases in SVI and PP after TAVR resulted in post-TAVR hypertension. Moreover, post-TAVR hypertension is less likely to occur in elderly patients with a high baPWV, which indicates advanced arteriosclerosis.

Use of continuous infusion of nicardipine to control persistent postpartum hypertension: A retrospective study

To evaluate the effect of continuous infusion of nicardipine on the management of uncontrolled blood pressure (BP) during postpartum period. This retrospective study included 209 women diagnosed in hospital with hypertensive disorders during pregnancy and had uncontrolled BP after delivery between January 2018 to December 2020 Uncontrolled BP was defined as persistent elevation of systolic BP ≥ 160 mm Hg or diastolic BP ≥ 110 mm Hg. Patients were divided into 2 groups: nicardipine (N = 53; continuous nicardipine infusion and additional bolus of labetalol or hydralazine) and control (N = 156; consecutive bolus of labetalol or hydralazine). BP data were analyzed using the Mann-Whitney U and χ2 tests by dividing the time interval of 4 hours by the delivery time. The highest BP trends showed that the mean values of both systolic and diastolic BP immediately before delivery were higher in the nicardipine group than in the control. After 8 to 12 hours following delivery, both systolic and diastolic BP were lower in the nicardipine group than in the control. Subsequently, 16 to 20 hours after delivery, both systolic and diastolic BP were significantly lower in the nicardipine group than in the control (137/80 vs 141/84 mm Hg). Initially, the proportions of uncontrolled BP in the nicardipine group were higher than those in the control; however, it then became lower at all time intervals 8 hours after delivery. The proportions of patients who received additional antihypertensive agents and the median cumulative dosages were lower in the nicardipine group than in the control. Continuous infusion of nicardipine can help manage uncontrolled BP during the postpartum period.

Nicardipine versus nitroglycerin for hypertensive acute heart failure syndrome: a single-center observational study.

Objective: Nitroglycerin is a first-line treatment for hypertensive acute heart failure syndrome (AHFS). However, nicardipine is frequently used to treat hypertensive emergencies, including AHFS. In this study, we compared the effectiveness of nicardipine and nitroglycerin in patients with hypertensive AHFS.Patients and Methods: This single-center, retrospective, observational study was conducted at the intensive care unit of a Japanese hospital. Patients diagnosed with AHFS and systolic blood pressure 140 mmHg on arrival between April 2013 and March 2021 were included. The outcomes were the time to optimal blood pressure control, duration of continuous infusion of antihypertensive agents, duration of positive pressure ventilation, need for additional antihypertensive agents, length of hospital stay, and body weight changes. Outcomes were compared between the nicardipine and nitroglycerin groups. We also compared these outcomes between the groups after excluding patients who received renal replacement therapy.Results: Fifty-eight patients were enrolled (26 and 32 patients were treated with nitroglycerin and nicardipine, respectively). The nicardipine group had a shorter time to optimal blood pressure control (2.0 [interquartile range, 2.0–8.5] h vs. 1.0 [0.5–2.0] h), shorter duration of continuous anti-hypertensive agent infusion (3.0 [2.0–5.0] days vs. 2.0 [1.0–2.0] days), less frequent need for additional anti-hypertensive agents (1 patients [3.1%] vs. 11 patients [42.3%]), and shorter length of hospital stay (17.5 [10.0–33.0] days vs. 9.0 [5.0–15.0] days) than the nitroglycerin group. The duration of positive pressure ventilation and body weight changes were similar between the groups. The outcomes were similar after excluding patients who received renal replacement therapy.Conclusion: Nicardipine may be more effective than nitroglycerin for treating hypertensive AHFS.

Fixed-dose combination of amlodipine/indapamide/perindopril arginine — a rational and safe choice for blood pressure control in actual clinical setting: data of an observational program DOKAZATEL`STVO

Aim. To analyze the efficacy and tolerability of amlodipine/indapamide/perindopril arginine (Triplixam) in a subgroup of 790 people participating in the Russian observational program DOKAZATEL`STVO without use of other antihypertensive agents.Material and methods. The analysis included 790 patients with hypertension (HTN) (men — 37,9%, mean age — 60,0±10,2 years). The drug was administrated in one of 4 recommended dosages for 3 months. We assessed the dynamics of office and home blood pressure (BP) from visit 1 to visit 4 and the frequency of achieving the target BP <140/90 mm Hg in 3 months.Results. After 3 months, office systolic BP (SBP) decreased from 163,4±14,0 to 127,2±7,8 mm Hg, diastolic BP (DBP) — from 95,7±9,5 to 78,3±6,2 mm Hg (p 0,001). Home SBP in the morning decreased from 145,9±12,3 to 128,3±7,8 mm Hg, DBP — from 86,2±7,7 to 78,4±5,6 mm Hg (p<0,001). After 3 months, target office BP (<140/90 mm Hg) was achieved in 88,4% of subjects, home BP (<135/85 mm Hg) — 73%.Conclusion. The administration of Triplixam without additional antihypertensive agents results in a significant BP decrease by 36/17 mm Hg and rapid achievement of BP control in most patients. The combination is safe and well tolerated.

Long-term phase 3 study of esaxerenone as mono or combination therapy with other antihypertensive drugs in patients with essential hypertension

This study investigated the long-term antihypertensive effects of esaxerenone, a novel nonsteroidal mineralocorticoid receptor blocker, alone or in combination with a calcium channel blocker (CCB) or a renin–angiotensin system (RAS) inhibitor, in Japanese patients with essential hypertension. Patients were treated with esaxerenone starting at 2.5 mg/day increasing to 5 mg/day if required to achieve blood pressure (BP) targets as a monotherapy or with a CCB or RAS inhibitor. After the first 12 weeks of treatment, an additional antihypertensive agent could be added if required to achieve the target BP; the total treatment period was 28 or 52 weeks. The primary endpoint was a change from baseline in sitting BP. Of the 368 enrolled patients, 245 received monotherapy, and 59 and 64, respectively, took a CCB or RAS inhibitor concurrently. Mean changes from baseline in sitting systolic/diastolic BP (95% confidence intervals) at weeks 12, 28 and 52 were −16.1 (−17.3, −14.9)/−7.7 (−8.4, −6.9), −18.9 (−20.2, −17.7)/−9.9 (−10.7, −9.2), and −23.1 (−25.0, −21.1)/−12.5 (−13.6, −11.3) mmHg, respectively (all P < 0.0001 vs baseline). Similar BP reductions at these weeks were observed between all patient subgroups stratified by age, and the observed decreases in 24-h ambulatory BP were consistent with the efficacy observed in sitting BP. Esaxerenone was also well-tolerated with a rate of hyperkalemia at 5.4% (serum potassium ≥5.5 mEq/L), indicating a good safety profile for treatment over the long-term or in combination with a CCB or RAS inhibitor. In conclusion, esaxerenone may be a promising treatment option for patients with hypertension.

Comparison of Nicardipine with Clevidipine in the Management of Hypertension in Acute Cerebrovascular Diseases

In acute stroke, hypertension worsens outcomes. Guidelines do not mention a preferred antihypertensive agent. This present study aimed to compare the efficacy and safety of nicardipine and clevidipine in acute stroke. This retrospective review compared nicardipine with clevidipine for hypertension in acute stroke patients from March 17, 2015 to December 23, 2016. Ischemic and hemorrhagic stroke types were evaluated. Patients were excluded if under 18 years, had traumatic brain injury, had intracranial neoplasm, were on dialysis, had both study drugs during the stroke admission, or the study drug was infused for less than 1 hour. Efficacy outcomes were: time to goal blood pressure, percent time in goal, blood pressure range, and need for additional antihypertensive agents during the infusion. A composite of in-hospital death, 30-day readmission, rebleeding, ischemic to hemorrhagic conversion, and hematoma expansion were compared. Other clinical outcomes included length of intensive care unit and hospital stay, hypotension, bradycardia, tachycardia, onset of atrial fibrillation, and acute kidney injury. Mean time to goal blood pressure was 65.5 minutes and 65.8 minutes in the nicardipine and clevidipine group, respectively (P = .83). No efficacy outcome was significantly different between 2 groups after multivariate analysis. Both nicardipine and clevidipine are reasonable antihypertensive agents in stroke, although cost and volume restriction could differentiate preference.

Oral labetalol compared to oral nifedipine for postpartum hypertension: A randomized controlled trial

ABSTRACTObjective: To determine whether oral labetalol is associated with a shorter time to blood pressure control compared to oral extended release nifedipine for management of persistent postpartum hypertension. Study Design: This randomized controlled trial conducted between June 2014 and June 2015 included women who delivered at ≥32 weeks’ gestation with persistent postpartum hypertension (sustained blood pressure ≥150/100 mmHg) requiring an oral antihypertensive agent. We included women with gestational hypertension, preeclampsia, or chronic hypertension not previously on medication. Women were randomized to labetalol or nifedipine, and the allocated study drug was incrementally increased to achieve blood pressure control. The primary outcome was time to sustained blood pressure control defined as the absence of severe hypertension for at least 12 hours. Secondary outcomes included postpartum length of stay, need for increased dosing, need for additional oral antihypertensive agents, and patient reported side effects. Twenty women were needed in each group as determined by the sample size calculation. Results: We randomized 25 women to oral labetalol and 25 women to oral extended release nifedipine. The time to achieve BP control was similar between labetalol and nifedipine groups (37.6 hours versus 38.2 hours, p = 0.51). Secondary outcomes including postpartum length of stay, need for increased dosing, and need for additional oral antihypertensive agents were similar between groups. For women discharged on a single agent, significantly more subjects in the labetalol group (16/21) compared to the nifedipine group (10/22) achieved BP control with the initial starting dose (76% versus 46%, p = 0.04). No major side effects were observed. Minor side effects were significantly more common in women taking nifedipine compared to labetalol (48% versus 20%, p = 0.04). Conclusions: Both labetalol and nifedipine were effective for control of persistent postpartum hypertension. However, labetalol achieved control significantly more often with the starting dose and had fewer side effects. Clinical Trial Registration: Oral nifedipine versus oral labetalol, NCT02168309. https://clinicaltrials.gov/ct2/show/NCT02168309?term=labetalol+versus+nifedipine&rank=2

The efficacy of rituximab in adult frequently relapsing minimal change disease.

BackgroundCorticosteroids are the basis of treatment for nephrotic syndrome due to minimal change disease (MCD), but 25% of patients have frequently relapsing nephrotic syndrome (FRNS) and 30% become steroid dependent. Prolonged use of conventional immunosuppressants causes significant toxicity. Rituximab (RTX) is now included in guidelines for childhood MCD. Evidence for use in adult MCD is limited. We describe a single-centre experience of RTX use in adult MCD.MethodsOutcomes of all adult MCD patients treated with RTX for FRNS between 2008 and 2015 were retrospectively analysed.ResultsThirteen patients received RTX; 11/13 had childhood-onset MCD. All had FRNS and 10 were steroid dependent. Eleven patients experienced one or more major treatment side effect from conventional therapy. At the time of RTX treatment, six patients were relapsing. All entered remission after RTX. The median length of follow-up after the first RTX treatment was 20 months (range 6–85). After RTX, the rate of relapse was reduced from 4 to 0.4/year (Wilcoxon signed rank P ≤ 0.05). Seven patients relapsed after RTX after a median of 10 months (range 1–11). All seven relapsing patients were successfully re-treated with RTX and none developed RTX-resistant nephrosis. The median number of courses of RTX per patient was 1 (range 1–5). The number of additional immunosuppressants, steroid dependency and antihypertensive agents were also reduced. At the last follow-up, two patients remained on low-dose steroids. No RTX-related adverse events were observed.ConclusionRTX is safe and effective in adults with FRNS due to MCD. The median rate of relapse is significantly reduced following RTX treatment and additional immunosuppressant exposure is minimized.

Scleroderma renal crisis and renal involvement in systemic sclerosis.

Scleroderma renal crisis (SRC) is a rare, potentially life-threatening complication that affects 2-15% of patients with systemic sclerosis (SSc, also known as scleroderma). SRC typically presents in patients with early, rapidly progressive, diffuse cutaneous SSc within the first 3-5 years after the onset of a non-Raynaud sign or symptom. SRC is characterized by an acute, usually symptomatic increase in blood pressure, a rise in serum creatinine levels, oliguria and thrombotic microangiopathy in about 50% of patients. The prognosis of SRC substantially improved in the 1980s with the introduction of angiotensin-converting-enzyme inhibitors for rapid blood pressure control, with additional antihypertensive agents as required. However, the survival of patients with SRC can still be improved. Current patient survival is 70-82% at 1 year, but decreases to 50-60% at 5 years despite dialysis support. Patients with SRC who show no signs of renal functional recovery despite timely blood pressure control are candidates for transplantation. In this Review, we discuss progress made in the identification and proactive management of patients at risk of SRC and make recommendations aimed at optimizing management for those who progress to chronic kidney failure.

Abstract 656: Efficacy and Safety of Valsartan/Amlodipine Single-Pill Combination in Chinese Elderly Hypertensive Patients with Chronic Kidney Disease: Subgroup analysis of the CHINA STATUS II study

Objective: To evaluate the efficacy and safety of Valsartan/Amlodipine SPC in a sub-group analysis of elderly hypertensive patients (aged ≥65 years) with Chronic Kidney Disease (CKD) treated for 8 weeks in the CHINA STATUS II study. Methods: This post-hoc analysis was conducted in 3297 hypertensive elderly patients from CHINA STATUS II study(CSII), whose blood pressure (BP) was not controlled by monotherapy . 116 patients had CKD (aged 75.5±6.8 years) while 3181 were without CKD (aged 74.4±6.3 years). All patients in CSII received Valsartan/Amlodipine 80/5 mg SPC for 8 weeks. The patients did not achieve BP control at the end of 4 weeks (BP≥ 130/80 mmHg for patients with diabetes or CKD and≥140/90 mmHg for others), an additional antihypertensive agent added. T -test and chi-square test were used for statistical analysis. Results: After valsartan/amlodipine SPC treatment for 8 weeks, mean sitting systolic blood pressure (MSBP) decreased, 25.4±13.3 mmHg and 28.3±12.5 mmHg from baseline in patients with and without CKD, respectively. Mean sitting diastolic blood pressure (MSDP) was reduced by10.4±9.3 mmHg and 13.5±9.5 mmHg from baseline in patients with and without CKD, respectively. 17.2%patients with CKD achieved their BP target of &lt;130/80 mmHg and 77.8% non-CKD patients achieved their BP goal, &lt;140/90 mmHg. The incidence of adverse events was 0.9% in patients without CKD, while none were reported in patients with CKD. Two serious adverse events (SAEs), which were not drug-related, occurred in non-CKD patients and no SAE was reported in CKD patients. 100% of the patients with CKD and 99.2% of patients without CKD rated the tolerance to therapy as ‘good’ or ‘very good’, respectively. Conclusions: Valsartan/amlodipine SPC showed good safety and tolerance in hypertensive patients aged ≥65 with CKD whose BP was uncontrolled by previous monotherapy. Lower proportion of elderly patients with CKD achieved the strict BP target compared to elderly patients without CKD. In view of the limitation of this being a post-hoc analysis, the reason for the observed low BP control rate in elderly patients with CKD needs further analysis and research.

Abstract 636: Factors Impacting Blood Pressure Control in the Elderly and very Elderly Hypertensive Patients After 8 Weeks Valsartan/Amlodipine SPC Treatment: CHINA STATUS II Subgroup Analysis

Objective: To determine the factors that impact BP control in Chinese elderly (aged 65-79 years) and very elderly (aged ≥80 years) hypertensive patients after 8-week treatment with val/aml SPC in the CSII study. Design and Methods: 3609 elderly and very elderly hypertensive patients uncontrolled by monotherapy with BP ≥140/90 mm Hg (≥130/80 mm Hg for diabetes or CKD) were analyzed. It was a post-hoc analysis of subgroups from the CSII study. All patients received val/aml 80/5 mg SPC for 8 weeks. An additional antihypertensive agent added in patients who were still uncontrolled at the end of 4 weeks. Complications, previous antihypertensive treatment and demographic factors were recorded. Chi-square test, Student’s t-test and logistic regression analysis were conducted. Results: After 8 weeks treatment, 61.5% elderly (n=459) and 63.3% very elderly (n=1811) patients achieved BP control. In the 740 elderly patients, low BP control rates were observed in patients with coronary heart disease (CHD) [P &lt;0.05 vs without CHD]. Significant decrease of BP control rates also were observed in 620 elderly type 2 diabetes mellitus (DM) patients (P&lt;0.0001 vs. non-diabetics) and 89 elderly heart failure (HF) patients (P&lt;0.05, vs without HF) while stroke had no effect(P&gt;0.05). Previous antihypertensive treatment (ACEI, ARB, CCB, βblocker and diuretic) had no significant influence on BP control (P&gt;0.05 ) . Among cardiovascular risk factors , while dyslipidemia influenced the BP control rate(P&lt;0.05); patient’s sex, BMI, smoking and alcohol consumption had no effect(P&gt;0.05). In very elderly patients, DM led to low BP control (P&lt;0.0001), but there was no significant impact of CHD, HF and stroke. Previous antihypertensive drugs did not influence the BP control rate (P&gt;0.05), but alcohol consumption had a significant impact (P&lt;0.05). Conclusion: CHD, DM, HF and dyslipidemia negatively influenced BP control in the elderly patients. In the very elderly patients, diabetes and history of alcohol consumption were associated with low BP control rates. The effect of the above risk factors on BP control should be considered during the management of hypertension in the elderly and very elderly Chinese patients with above complications as they would need stricter BP control.

Evaluation of the Efficacy and Safety of a Hydrochlorothiazide to Chlorthalidone Medication Change in Veterans With Hypertension

BackgroundThere are few data available examining the clinical impact of switching patients from hydrochlorothiazide (HCTZ) to chlorthalidone for blood pressure management. ObjectivesThe goal of this study was to compare within-patient clinic blood pressure readings, serum electrolyte levels, and renal function markers before and after a medication change from HCTZ to chlorthalidone in a veteran population. MethodsThis was a retrospective, pre- and postmeasure, self-controlled study. Veterans Affairs Ann Arbor Healthcare System patients switched from HCTZ to chlorthalidone between January 1, 2001, and January 31, 2012, who had at least 1 follow-up clinic blood pressure reading recorded between 2 and 8 weeks from the date of the medication change were included in the study. Mean pre- and postmeasure values for systolic and diastolic clinic blood pressures, serum potassium, serum sodium, serum calcium, serum creatinine, and blood urea nitrogen were compared by using a 2-tailed, paired t test with a significance level (α) of 0.05. ResultsOf the 40 patients included in the study 95% were male, 65% were white, and the mean age was 64.9 (10.8) years. Both mean systolic (–15.8 mm Hg [95% CI, 8.9 to 22.6], P < 0.0001) and mean diastolic (–4.2 mm Hg [95% CI, 1.5 to 6.9], P = 0.0035) blood pressures showed statistically and clinically significant reductions after the medication change. A statistically significant decrease in mean sodium (–1.1 mmol/L [95% CI, 0.4 to 1.9], P = 0.003) and an increase in mean serum creatinine (0.06 mg/dL [95% CI, –0.09 to –0.02], P = 0.002) was observed; however, these changes may not be viewed as clinically significant by many practitioners. No statistically significant changes were observed in any of the other outcomes examined. Most patients (38 of 40) were taking at least 1 additional antihypertensive agent; 73% of patients were using ≥3 antihypertensive agents at the time of the medication change. ConclusionsIn patients with hypertension already taking HCTZ, switching to chlorthalidone seems to further reduce systolic and diastolic blood pressures without any clinically significant changes in renal function or electrolyte levels.

The Role of Olmesartan Medoxomil-Based Combination Therapy in the Management of Hypertension: A Review for Nurse Practitioners

Background: Uncontrolled hypertension increases the likelihood of cardiovascular morbidity and mortality and places a great burden on health care systems. Hypertension (defined as a blood pressure [BP] of greater than (>) 140/90 mm Hg or >130/80 mm Hg in patients with diabetes) is amenable to treatment through lifestyle changes or pharmacological intervention. Although prevalence of hypertension has remained stable through recent years, advances in patient education and the availability of effective antihypertensive agents has allowed patients to better control their BP. Angiotensin II receptor blockers (ARBs) are a widely prescribed class of antihypertensive agents, and the ARB olmesartan medoxomil (OM) has been shown in clinical trials to effectively reduce BP with a placebo-like safety and tolerability profile.Purpose: To review the efficacy of OM-based treatment algorithms in patients with uncontrolled hypertension in specific demographic groups and to discuss the role of the nurse practitioner in the management of hypertension. Conclusions: Nurse practitioners hold a distinctive role at the forefront of primary care, which enables them to identify at-risk patients, ensure accurate diagnosis of hypertension through the proper measurement of BP, provide counseling on lifestyle changes, and prescribe effective pharmacotherapy. Safety and efficacy profiles of OM facilitate its inclusion into combination treatment algorithms when additional antihypertensive agents are needed to achieve desirable BP control. Clinical Implications: Clinical practice guidelines have established the paradigm that treating patients to defined BP goals may enable better patient outcomes. However, not all patients are managed to established goals. Issues of adherence, regimen complexity, and recognition of the need to escalate from monotherapy to combination therapy are common barriers to effective patient management.

Long-Term Follow-Up of Renal Function and Blood Pressure After Selective Renal Arterial Embolization

Renal arterial embolization is a minimally invasive alternative to the surgical treatment of certain renal diseases. The authors aimed to determine the safety of the procedure with respect to renal function and blood pressure control. This study was a retrospective review of the charts of patients who underwent therapeutic renal arterial embolization between January 1998 and December 2007. Indications for therapeutic renal artery embolizations included either treatment or prevention of renal hemorrhage. Exclusion criteria were total/ partial nephrectomy or dialysis prior to renal artery embolization and lack of appropriate follow-up. A total of 115 procedures were reviewed, and 41 met the inclusion criteria. The mean age was 63 ± 18.87 years. Median follow-up was 13.0 months. The glomerular filtration rate (GFR) of the study population changed from 55.2 mL/min/1.73 m(2) at baseline to 56.63 mL/min/1.73 m(2) at last available follow up (P = .67). At baseline, 22 patients (53.7%) in this study group were hypertensive. Postprocedure, 9 patients required either the initiation of antihypertensive therapy or additional antihypertensive agents. Preexisting renal dysfunction (GFR < 30 mL/min/1.73 m(2)) at baseline did not appear to influence these outcomes. Renal arterial embolization appears to be a safe procedure with respect to renal function. However, these patients should have close surveillance of their blood pressures to detect either the onset of hypertension or worsening of preexisting hypertension.

Increasing the doses of both diuretics and angiotensin receptor blockers is beneficial in subjects with uncontrolled systolic hypertension

Blood pressure (BP) control is frequently difficult to achieve in patients with predominantly elevated systolic BP. Consequently, these patients frequently require combination therapy including a thiazide diuretic such as hydrochlorothiazide (HCTZ) and an agent blocking the renin-angiotensin-aldosterone system. Current clinical practice usually limits the daily dose of HCTZ to 25 mg. This often leads to the necessity of using additional antihypertensive agents to control BP in a high proportion of patients. To compare the efficacy of two doses of losartan (LOS)⁄HCTZ combinations in patients with uncontrolled ambulatory systolic hypertension after six weeks of treatment with LOS 100 mg⁄HCTZ 25 mg (LOS100⁄HCTZ25). Following a two- to four-week washout period, subjects with a mean clinic sitting systolic BP of 160 mmHg or higher and a mean ambulatory daytime systolic BP (MDSBP) of 135 mmHg or higher on LOS100⁄HCTZ25 (n=105; 33 women and 72 men) were randomly assigned to receive LOS 150 mg⁄HCTZ 25 mg (group 1; n=53) or LOS 150 mg⁄HCTZ 37.5 mg (LOS150⁄HCTZ37.5, group 2; n=52). The primary end point was the difference in MDSBP reductions. At the end of the six-week treatment period, the respective additional decreases in MDSBP were 1.2 mmHg (P=0.335) on LOS 150 mg⁄HCTZ 25 mg and 5.6 mmHg (P<0.0001) on LOS150⁄HCTZ37.5 (difference of 4.4 mmHg; P=0.011). Daytime systolic ambulatory BP goal (lower than 130 mmHg) achievement tended to be higher (25% versus 17%; P=0.313) with LOS150⁄HCTZ37.5, while it was significantly higher (65% versus 43%; P=0.024) for mean daytime diastolic BP (lower than 80 mmHg). No deleterious metabolic changes were observed. In patients with uncontrolled systolic ambulatory hypertension receiving LOS100⁄HCTZ25, increasing both HCTZ and LOS dosages simultaneously to LOS150⁄HCTZ37.5 may be an effective strategy that does not affect metabolic parameters.

Comparison of Nebivolol Monotherapy Versus Nebivolol in Combination With Other Antihypertensive Therapies for the Treatment of Hypertension

Nebivolol is a novel, beta1-adrenergic receptor blocker with vasodilatory properties mediated through the activation of the L-arginine/nitric oxide pathway. Short-term randomized clinical trials have demonstrated that nebivolol has antihypertensive efficacy benefits comparable to other beta blockers but with a favorable safety and tolerability profile. The long-term safety and efficacy results of oral nebivolol (5, 10, or 20 mg) 1 time/day, as monotherapy or in combination with other antihypertensive agents, were assessed in a double-blind, multicenter, 9-month extension study of 3 phase III, double-blind, 3-month trials in patients with stage I to II hypertension (mean sitting diastolic blood pressures [BPs]>or=95 and <or=109 mm Hg). Patients were eligible for entry if they had completed 1 of 3 feeder trials of nebivolol monotherapy (1.25 to 40 mg) 1 time/day. Dose titration and use of additional antihypertensive agents were used to achieve a diastolic BP goal of <90 mm Hg. The primary efficacy end point was change in diastolic BP at trough compared with baseline of the feeder study. Of the 845 patients entering this study, 607 patients (72%) were receiving nebivolol monotherapy, 206 patients (24%) were taking nebivolol plus diuretic, 21 patients (2%) were taking nebivolol plus calcium channel blocker, and 11 patients (1%) were taking nebivolol plus other antihypertensive medication at study end. Patients receiving nebivolol monotherapy had decreases in diastolic and systolic BPs of 15.0 and 14.8 mm Hg, respectively. More than 78% of patients were responders to nebivolol monotherapy, and 65% were responders to combination with a diuretic. Overall incidence of adverse events in the extension study was comparable to that seen in the feeder studies and decreased over time. In conclusion, the results demonstrate that nebivolol is a safe and effective antihypertensive therapy that provides long-term BP-lowering effects with a favorable tolerability profile.

Reduced incidence of new-onset atrial fibrillation with angiotensin II receptor blockade: the VALUE trial

Atrial fibrillation (AF) is the most common arrhythmia and increases cardiovascular risk in hypertensive patients. Therefore, in the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) a prespecified objective was to compare the effects of valsartan and amlodipine on new-onset AF. A total of 15 245 hypertensive patients at high cardiovascular risk received valsartan 80-160 mg/day or amlodipine 5-10 mg/day combined with additional antihypertensive agents. Electrocardiograms were obtained every year and analyzed centrally for evidence of left ventricular hypertrophy and new-onset AF. At baseline, AF was diagnosed in 2.6% of 7649 valsartan recipients and 2.6% of 7596 amlodipine recipients. During antihypertensive treatment the incidence of at least one documented occurrence of new-onset AF was 3.67% with valsartan and 4.34% with amlodipine [unadjusted hazard ratio 0.843, [95% confidence interval (CI): 0.713, 0.997], P = 0.0455]. The incidence of persistent AF was 1.35% with valsartan and 1.97% with amlodipine [unadjusted hazard ratio 0.683 (95% CI: 0.525, 0.889), P = 0.0046]. Valsartan-based treatment reduced the development of new-onset AF, particularly sustained AF in hypertensive patients, compared with amlodipine-based therapy. These findings suggest that angiotensin II receptor blockers may result in greater benefits than calcium antagonists in hypertensive patients at risk of new-onset AF.

A Comparison of Nicardipine and Labetalol for Acute Hypertension Management Following Stroke

Evaluate the ease of use and tolerability of labetalol (L) and nicardipine (N) for hypertension management in patients with acute stroke. This is a retrospective, non-randomized study. Consecutive adults within 24 h of hospital admission who received intravenous bolus labetalol or nicardipine infusion as first-line antihypertensive therapy were identified. Hemodynamic data were collected through 24 h of therapy. Ninety patients received either labetalol (N = 64) or nicardipine (N = 26) initially for blood pressure (BP) management. Stroke types were 54% intracerebral hemorrhage (ICH), 22% subarachnoid hemorrhage, and 23% ischemic stroke and were similar between the two drug groups. Baseline patient characteristics and disease severity (APACHE II and GCS) were similar between groups. The average total daily labetalol dose was 40 (10-340) mg and nicardipine infusion was 5 (1-14) mg/h. Initial BP was similar in the two groups. The nicardipine group had less BP variability (N 8.19 vs. L 10.78 mmHg; p = 0.003), fewer dosage adjustments [L 4 (1-17), N 2 (0-5); p < 0.001] and fewer additional antihypertensive agents (L 33%, N 8%; p = 0.013) administered during the 24-h observation period. In patients with ICH, 33% of nicardipine-treated patients achieved target BP within the first 60 min versus 6% of the L group (p = 0.02). Overall, incidence of hypotension (SBP < 90 mmHg) (L 3%; N 0%) and bradycardia (HR < 60 beats per min) (L 20.6%; N 12%) were comparable between the groups. Nicardipine offers an alternative to labetalol with similar tolerability and appears to provide a smoother blood pressure control compared to labetalol.

What factors contribute to the inadequate control of elevated blood pressure?

Inadequate control of blood pressure may be attributed to both provider-related and patient-related factors. Health care provider-related factors may include an excessive reliance on monotherapy and reluctance to increase drug doses or add additional antihypertensive agents to the treatment regimen. The primary patient-related factor is nonadherence with the prescribed antihypertensive medication. Although the high cost of therapy is sometimes a reason for poor adherence, drug side effects or dosing considerations may be more important factors. Better adherence with antihypertensive medication is associated with a significantly greater likelihood of achieving blood pressure control and, consequently, with lower costs and reduced utilization of health care resources. Therefore, strategies that improve long-term adherence should be adopted. Single-pill, or fixed-dose, combination therapy is one approach that improves adherence, while also providing the antihypertensive efficacy needed to help patients achieve their blood pressure goals.