Antihypertensive Drugs In Patients Research Articles

Long-Term Results of Antihypertensive Therapy in Patients With Diabetes

The article discusses the results of observational studies to evaluate the efficacy of antihypertensive drugs in patients with diabetes who participated in the randomized clinical trials. The role of such studies to clarify the tactics of application of antihypertensive drugs in patients with diabetes. The possible conditions that ensure a lasting effect of antihypertensive drugs, in particular the choice of drugs belonging to the class definition.

Triple Combination Therapy for Global Cardiovascular Risk: Atorvastatin, Perindopril, and Amlodipine.

Statins, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers (CCBs) have markedly changed the clinical progression of patients with coronary artery disease (CAD). The goal of this paper is to review the rationale and evidence for combining these three drug classes in hypertensive patients with hypercholesterolemia or CAD. Data sources include a literature search for publications on the use of a statin combined with various antihypertensive drugs in patients with hypertension and hypercholesterolemia or stable CAD. Hypercholesterolemia and hypertension constitute major physiological risk factors of ischemic heart disease. Current guidelines recommend a global approach to risk management, using agents that address as many risk factors as possible. Dual combination therapies are an important component of guideline-recommended therapy in hypertension. Our review of the literature indicates that triple therapy with a statin, ACE inhibitor, and CCB is associated with a significant reduction in major cardiovascular events. For example, a post hoc analysis in 1056 patients with stable CAD participating in the EUROPA trial indicated that the addition of perindopril to a CCB and a lipid-lowering agent was associated with a 46% reduction in the composite of cardiovascular death, myocardial infarction, and resuscitated cardiac arrest (p=0.023). In addition, single pill formulations are known to result in better adherence to the treatment. Single-pill formulations that combine a statin, an ACE inhibitor, and a CCB appear to offer an effective approach to the management of global cardiovascular risk.

To study the preferred antihypertensive drugs in patients suffering from diabetes mellitus at a tertiary care hospital of Uttarakhand with an emphasis on compelling indications

Background: People with diabetes are more likely to also have high blood pressure. Hypertension can increase the risk of diabetes complications and is a powerful risk factor for development of a wide variety of cardiovascular, cerebrovascular and renal diseases. The treatment of hypertension in patients with diabetes thus becomes all the more important and may effectively prevent cardiovascular events. This study was thus planned with the aim to study the preferred antihypertensive drugs in patients suffering from diabetes mellitus and to teach UG students about the clinical importance of compelling indications in the treatment of hypertension.Methods: A total of 100 prescriptions of patients suffering from hypertension and diabetes mellitus were collected from diabetic hypertensive visiting the department of Medicine. Data was analysed in terms of percentage to find out the most and least preferred antihypertensive drugs in diabetes mellitus.Results: ACE inhibitors (30.95%) and ARBs (30.16%) were the most preferred, diuretics (19.84%), and CCBs (11.9%), and beta blockers (7.14%) were the least preferred antihypertensive drugs in diabetes patients. Three patients were on non-pharmacological treatment and among the remaining 97 prescriptions, monotherapy was the most common mode (70.1%) of therapy for hypertension, and drugs in combination were prescribed to 29.89% patients.Conclusions: ACE-I and ARBs were the preferred antihypertensive drugs prescribed in diabetic hypertensive. Treatment of hypertension should be individualized depending upon the compelling indications. This should be taught to undergraduate students in a practical way in collaboration with Medicine department.

Antihypertensive therapy in patients with coexisting hypertension and bronchial asthma

The aim of the research was to study the peculiarities of cardiac and pulmonary hemodynamics, the mechanisms of formation of endothelial dysfunction, as well as their correction with angiotensin converting enzyme inhibitor, Ramipril and angiotensin-II receptor blocker, Irbesartan, in patients with arterial hypertension (HTN) combined with bronchial asthma (BA). Design and methods . Altogether 80 patients with BA of moderate severity combined with HTN of 1, 2 degrees were enrolled in the study. The average age of the patients was 52,9 ± 4,2 years. The eligible patients were randomized for treatment with either Ramipril 5 mg/day or Irbesartan 150 mg/day in combination with bronchodilator inhalation and anti-inflammatory medications for BA (Formoterol/Budesonide 160/4,5 mcg 2 inhalations twice, Ipratropium bromide and Ambroxol through nebulizer devices). The program of instrumental examination included echocardiography (Aloka 1700, Japan; LOGIQ 500, Germany) with ultrasonic sensors of 3,5 MHz. The plasma level of endothelin 1 (ET‑1) was estimated by immune-enzyme assay (Biomedica set, category № 442–0052, Arkray, Japan). Results. Two-month monotherapy with Irbesartan allows to achieve the target blood pressure (BP), leads to the regression of cardiac remodeling and has a positive effect on endothelial function and bronchial patency. Conclusions. Irbesartan is able to provide a stable and reliable control of BP, and delays the progression of pathological cardiovascular changes; it has a favorable impact on the respiratory function, is well tolerated, easy to use, and may be considered as the best antihypertensive drug in patients with co-morbid HTN and BA.

ME 02-1 IS LOWER REALLY BETTER? ISSUE OF THE J CURVE HYPOTHESIS IN HYPERTENSION

The J curve hypothesis propose that the relation between blood pressure and risk for cardiovascular events is non-linear. Instead of a decreased risk with lower blood pressure, the risk increases at lower blood pressures. This issue has been discussed for many years, and is still a hot topic. The debates have most often had its origin in the question about how far blood pressure should be lowered with antihypertensive drugs. One one hand, we know that many patients with hypertension is not treated to targets according to guidelines and that this contributes to the high risk for cardiovascular diseases in patients with hypertension. On the other hand, overtreatment could be one reason for the subobtimal effect of antihypertensive drugs on cardiovascular diseases. The issue about a J curve in the effect of antihypertensive drugs is complicated. The relation between blood pressure and cardiovascular risk is different for different cardiovascular outcomes. For example, the risk for intracerebral hemorrhage seem to increase steeper at higher blood pressure than for most other outcomes. On the other hand, the risk for abdominal aortic aneurysm increases only modestly with higher blood pressure. In addition, end stage renal disease and cognitive decline could have other relations between blood pressure and risk. Age, cardiovascular disease and diabetes have also been found to modify the relation between risk and outcome. Earlier this year, we published a meta-analysis of randomized controlled trials with antihypertensive drugs in patients with diabetes mellitus (ref). Included trials had to compare treatment with an antihypertensive drug against placebo, two antihypertensive agents against one or one blood pressure target against another target. The studies were stratified according to blood pressure at randomization (baseline blood pressure), mimicking the situation you as a clinician meet when you decide to recommend a patients additional antihypertensive therapy or not. We contacted authors to receive data from diabetic subgroups in large studies. Thus, we were able to include more studies than in previous systematic reviews in this field. All together, we included data from 49 randomized controlled trials, including 73 738 patients. The systematic review showed that the effect of antihypertensive drugs on cardiovascular outcomes is different at different blood pressure levels. For most outcomes, adding antihypertensive drugs were beneficial in patients with diabetes mellitus and high blood pressure. However, this benefit decreased with decreasing blood pressure. The risk for cardiovascular death increased when therapy was added in patents with diabetes and systolic blood pressure below 140 mmHg. The benefits of adding antihypertensive treatment at different blood pressure levels are summarized in the figure below. Thus, in patients with diabetes, the relations between treatment effect of antihypertensive drugs are different at different blood pressure levels. Treatment effects differ for different cardiovascular outcomes. These data question previous guidelines that recommend a systolic blood pressure target below 130 mmHg in patients with diabetes mellitus. In a very recent systematic review, we have reexamined the relation between randomization blood pressure and cardiovascular stratified for different baseline blood pressures. The meta-analyses include patients with and without diabetes, with and without previous cardiovascular disease etc. Altogether, 58 trials with 290 000 patients were included. The study shows that the effect of blood pressure lowering on cardiovascular outcomes is dependent on baseline systolic blood pressure but also differ between different subsets of patients. This study is under review and the results will be presented during the lecture.

The Results of Long-Term Observation of Patients Who Participated in the ADVANCE Trial

We present in this article data on the prevalence and risk of complications in patients with diabetes and hypertension. From the standpoint of current guidelines on the management of arterial hypertension we consider problems of target blood pressure levels and choice of antihypertensive drugs in patients with diabetes, including those with diabetic nephropathy. We also present results of long-term observation of participants of the ADVANCE trial that have shown that reduction of mortality achieved because of antihypertensive therapy in the randomized study persisted throughout follow-up. Discussion of possible mechanisms of this phenomenon and the advantages of fixed perindopril/indapamide combination is presented as well.

The effect of vitamin D supplementation on blood pressure in patients with elevated blood pressure and vitamin D deficiency: a randomized, double-blind, placebo-controlled trial.

The present evidence indicates a reverse correlation between vitamin D status and blood pressure (BP). The present study determined the effect of oral vitamin D supplementation on BP in patients with elevated BP and vitamin D deficiency. In this randomized, double-blind, placebo-controlled trial, 42 outpatients with elevated BP and vitamin D deficiency were assigned randomly to two groups: the vitamin D-supplemented group (VDG), who received one capsule containing 50 000 IU of cholecalciferol weekly, and the placebo group (PG), who received one similar capsule containing oral liquid paraffin as placebo for 8 weeks. The systolic (SBP) and diastolic (DBP) blood pressures, mean arterial blood pressure (MAP), pulse pressure, serum 25-hydroxyvitamin D, parathormone, calcium, phosphorus, magnesium, sodium, and potassium were measured before and after the intervention. In all, 92.7% of the VDG recovered from vitamin D deficiency. At the end of the intervention, the mean SBP and DBP, and the MAP decreased significantly in VDG compared with the PG, whereas at the beginning of the intervention, there was no significant difference between the two groups. The mean changes in SBP (-6.4±5.3 vs. 0.9±3.7 mmHg, P(V)<0.001), DBP (-2.4±3.7 vs. 1.0±2.7 mmHg, P(V)=0.003), and MAP (-3.7±3.6 vs. 0.9±2.5 mmHg, P(V)<0.001) were lower in the VDG than PG. The findings of the study showed that the weekly administration of 50 000 IU of oral vitamin D for 8 weeks as an adjunct supplement of antihypertensive drugs in patients with vitamin D deficiency could help prevent vitamin D deficiency and aid control of SBP, DBP, and MAP.

Effect of Combined Treatment with AT1 Receptor Antagonists and Tiagabine on Seizures, Memory and Motor Coordination in Mice.

Losartan and telmisartan, angiotensin AT1 receptor antagonists, are widely used antihypertensive drugs in patients. It is also known that arterial hypertension is often present in people with epilepsy, therefore, drug interactions between AT1 receptor antagonists and antiepileptic drugs can occur in clinical practice. The aim of the current study was to assess the effect of losartan and telmisartan on the anticonvulsant activity of tiagabine, asecond-generation antiepileptic drug, in mice. Additionally, the effect of the combined treatment with AT1 receptor antagonists and TGB on long-term memory and motor coordination has been assessed in animals. The study was performed on male Swiss mice. Convulsions were examined in the maximal electroshock seizure threshold test. Long-term memory was measured in the passive-avoidance task and motor coordination was evaluated in the chimney test. AT1 receptor antagonists and TGB were administered intraperitoneally. Losartan (50 mg/kg) or telmisartan (30 mg/kg) did not influence the anticonvulsant activity of TGB applied at doses of 2, 4and 6mg/kg. However, both AT1 receptor antagonists in combinations with TGB (6mg/kg) impaired motor coordination in the chimney test. The concomitant treatment of the drugs did not decrease retention in the passive avoidance task. It is suggested that losartan and telmisartan should not affect the anticonvulsant action of TGB in people with epilepsy. Because the combined treatment with AT1 receptor antagonists and TGB led to neurotoxic effects in animals, caution is advised during concomitant use of these drugs in patients.

First-line drugs inhibiting the renin angiotensin system versus other first-line antihypertensive drug classes for hypertension.

First-line drugs inhibiting the renin angiotensin system versus other first-line antihypertensive drug classes for hypertension.

Effect of Combined Treatment with AT1 Receptor Antagonists and Tiagabine on Seizures, Memory and Motor Coordination in Mice*

Background. Losartan and telmisartan, angiotensin AT1 receptor antagonists, are widely used antihypertensive drugs in patients. It is also known that arterial hypertension is often present in people with epilepsy, therefore, drug interactions between AT1 receptor antagonists and antiepileptic drugs can occur in clinical practice.Objectives. The aim of the current study was to assess the effect of losartan and telmisartan on the anticonvulsant activity of tiagabine, a second-generation antiepileptic drug, in mice. Additionally, the effect of the combined treatment with AT1 receptor antagonists and TGB on long-term memory and motor coordination has been assessed in animals.Material and Methods. The study was performed on male Swiss mice. Convulsions were examined in the maximal electroshock seizure threshold test. Long-term memory was measured in the passive-avoidance task and motor coordination was evaluated in the chimney test. AT1 receptor antagonists and TGB were administered intraperitoneally.Results. Losartan (50 mg/kg) or telmisartan (30 mg/kg) did not influence the anticonvulsant activity of TGB applied at doses of 2, 4 and 6 mg/kg. However, both AT1 receptor antagonists in combinations with TGB (6 mg/kg) impaired motor coordination in the chimney test. The concomitant treatment of the drugs did not decrease retention in the passive avoidance task.Conclusion. It is suggested that losartan and telmisartan should not affect the anticonvulsant action of TGB in people with epilepsy. Because the combined treatment with AT1 receptor antagonists and TGB led to neurotoxic effects in animals, caution is advised during concomitant use of these drugs in patients.

Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomised controlled trial

SummaryBackgroundHigh blood pressure is associated with poor outcome after stroke. Whether blood pressure should be lowered early after stroke, and whether to continue or temporarily withdraw existing antihypertensive drugs, is not known. We assessed outcomes after stroke in patients given drugs to lower their blood pressure.MethodsIn our multicentre, partial-factorial trial, we randomly assigned patients admitted to hospital with an acute ischaemic or haemorrhagic stroke and raised systolic blood pressure (systolic 140–220 mm Hg) to 7 days of transdermal glyceryl trinitrate (5 mg per day), started within 48 h of stroke onset, or to no glyceryl trinitrate (control group). A subset of patients who were taking antihypertensive drugs before their stroke were also randomly assigned to continue or stop taking these drugs. The primary outcome was function, assessed with the modified Rankin Scale at 90 days by observers masked to treatment assignment. This study is registered, number ISRCTN99414122.FindingsBetween July 20, 2001, and Oct 14, 2013, we enrolled 4011 patients. Mean blood pressure was 167 (SD 19) mm Hg/90 (13) mm Hg at baseline (median 26 h [16–37] after stroke onset), and was significantly reduced on day 1 in 2000 patients allocated to glyceryl trinitrate compared with 2011 controls (difference −7·0 [95% CI −8·5 to −5·6] mm Hg/–3·5 [–4·4 to −2·6] mm Hg; both p<0·0001), and on day 7 in 1053 patients allocated to continue antihypertensive drugs compared with 1044 patients randomised to stop them (difference −9·5 [95% CI −11·8 to −7·2] mm Hg/–5·0 [–6·4 to −3·7] mm Hg; both p<0·0001). Functional outcome at day 90 did not differ in either treatment comparison—the adjusted common odds ratio (OR) for worse outcome with glyceryl trinitrate versus no glyceryl trinitrate was 1·01 (95% CI 0·91–1·13; p=0·83), and with continue versus stop antihypertensive drugs OR was 1·05 (0·90–1·22; p=0·55).InterpretationIn patients with acute stroke and high blood pressure, transdermal glyceryl trinitrate lowered blood pressure and had acceptable safety but did not improve functional outcome. We show no evidence to support continuing prestroke antihypertensive drugs in patients in the first few days after acute stroke.FundingUK Medical Research Council.

A meta-analysis of randomized trials of telmisartan versus active controls for insulin resistance in hypertensive patients

To determine whether telmisartan improves insulin resistance compared with other antihypertensive drugs, we performed a meta-analysis of randomized controlled trials (RCTs) of telmisartan. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through December 2013. Eligible studies were prospective RCTs of telmisartan versus other antihypertensive drugs, enrolling individuals with hypertension and reporting insulin levels and/or homeostasis model assessment-insulin resistance (HOMA-IR) as outcomes. Of 67 potentially relevant articles screened initially, 33 reports of RCTs enrolling a total of 2033 patients with hypertension were identified and included. Pooled analyses of only the eight double-blind-design trials demonstrated statistically significant reductions in percent changes of insulin levels (mean difference, −5.19%; 95% confidence interval, −8.94% to −1.43%; P = .007) and HOMA-IR (−15.34%; −26.39% to −4.28%; P = .007) with telmisartan relative to other antihypertensive drugs. When data from all the 33 trials were pooled, telmisartan was associated with statistically significant reductions in percent changes of insulin levels (−10.92%; −15.60% to −6.23%; P < .00001) and HOMA-IR (−15.89%; −22.01% to −9.78%; P < .00001) relative to other antihypertensive drugs. In conclusion, telmisartan appears to significantly improve insulin resistance compared with other antihypertensive drugs in patients with hypertension.

Assessment of postoperative changes in antihypertensive drug consumption in patients with primary aldosteronism using the defined daily dose

The number of antihypertensive drug classes cannot accurately reflect the total consumption of antihypertensive drugs used to control blood pressure. The defined daily dose has been adopted to permit consumption analysis of many prescribed drugs. The aim of the present study was to assess postoperative changes in antihypertensive drug consumption in patients with primary aldosteronism using the defined daily dose as the unit of measurement. This retrospective study included 110 Japanese patients who underwent unilateral laparoscopic adrenalectomy between 1995 and 2012. Antihypertensive drug doses were calculated according to the standard of the defined daily dose recommended by the World Health Organization to compare drug use. After assessing postoperative changes in antihypertensive drug consumption, univariate and multivariate analyses were performed to identify clinical predictors for a 75% or greater decrease in the defined daily dose. Consumption of antihypertensive drugs decreased postoperatively in 95.4% of patients. The median decrease in the defined daily dose was 76.8%. A postoperative decrease of 75% or greater in the defined daily dose was confirmed in 52.7% of patients. Multivariate analysis identified no medical history of cardiovascular disease, low body mass index, and short duration of hypertension as independent predictors of a postoperative decrease of 75% or greater in the defined daily dose. The defined daily dose is a useful tool for assessing total changes in the consumption of antihypertensive drugs in patients with primary aldosteronism. Using the defined daily dose, clinicians could explain in detail to patients with primary aldosteronism the predicted postoperative change in antihypertensive drug consumption.

The Incidence of Antihypertensive Drug-induced Side Effects in Patients with Diabetes Mellitus Type 2 and Hypertension.

Objective:To determine types and frequency of side effects of antihypertensive drugs in patients with diabetes mellitus (DM) type 2 and hypertension.Subjects and Methods:We performed a prospective study of 79 patients with DM type 2 and hypertension, randomly selected by systematic sampling, who were followed over a period of six months. Patients were assessed at baseline and once a month measuring following parameters: types of used antihypertensive drugs and frequency of side effects, the values (mmHg) of systolic (SBP) and diastolic blood pressure (DBP).Results:Out of 79 patients, 48/79 (60.8%) were males and 31/79 (39.2%) were females. The median age in males was 53 years (IQR=48 to 55 years), in females was 53 years (IQR=49 to 56 years). There was no statistically significant difference in median age between males and females (P=0.368). There is a statistically significant difference in the values of SBP [χ2(5)=312.296, P<0.001] and DBP [χ2(5)=216.051, P<0.001] over a period of six months follow-up. The drug side effects were noted in 9/79 (11.4%) patients between 1-2 months, in 6/79 (7.6%) between 2-3 months, in 1/79 (1,3%) between 3-4 months. The most common side effect was cough (11/79 or 13.9%) associated with the combination of ACE inhibitor and thiazide diuretics. In 5/79 (6.3%) patients there were reports of: flushing, palpitations, headache, dizziness and leg edema associated with Ca blockers.Conclusion:The most common side effect of antihypertensive treatment was cough (13.9%) associated with the combination of ACE inhibitor and thiazide diuretic.

Treatment of hypertension in peripheral arterial disease

Peripheral arterial disease (PAD) causes considerable morbidity and mortality. Hypertension is a risk factor for PAD. Treatment for hypertension must be compatible with the symptoms of PAD. Controversy regarding the effects of beta-adrenoreceptor blockade for hypertension in patients with PAD has led many physicians to stop prescribing beta-adrenoreceptor blockers. Little is known about the effects of other classes of anti-hypertensive drugs in the presence of PAD. This is the second update of a Cochrane review first published in 2003. To determine the effects of anti-hypertensive drugs in patients with both raised blood pressure and symptomatic PAD in terms of the rate of cardiovascular events and death, symptoms of claudication and critical leg ischaemia, and progression of atherosclerotic PAD as measured by ankle brachial index (ABI) changes and the need for revascularisation (reconstructive surgery or angioplasty) or amputation. For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Cochrane Peripheral Vascular Diseases Group Specialised Register (last searched March 2013) and CENTRAL (2013, Issue 2). Randomised controlled trials (RCTs) of at least one anti-hypertensive treatment against placebo or two anti-hypertensive medications against each other, with interventions lasting at least one month. Trials had to include patients with symptomatic PAD. Data were extracted by one author (DAL) and checked by the other (GYHL). Potentially eligible studies were excluded when the results presentation prevented adequate extraction of data and enquiries to authors did not yield raw data. Eight RCTs were included with a total of 3610 PAD patients. Four studies compared a recognised class of anti-hypertensive treatment with placebo and four studies compared two anti-hypertensive treatments with each other. Studies were not pooled due to the variation of the comparisons and the outcomes presented. Overall the quality of the available evidence was unclear, primarily as a result of a lack of detail in the study reports on the randomisation and blinding procedures and incomplete outcome data. Two studies compared angiotensin converting enzyme (ACE) inhibitors against placebo. In one study there was a significant reduction in the number of cardiovascular events in patients receiving ramipril (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.58 to 0.91; n = 1725). In the second trial using perindopril (n = 52) there was a marginal increase in claudication distance but no change in ABI and a reduction in maximum walking distance. A trial comparing the calcium antagonist verapamil versus placebo in patients undergoing angioplasty (n = 96) suggested that verapamil reduced restenosis (per cent diameter stenosis (± SD) 48.0% ± 11.5 versus 69.6% ± 12.2; P < 0.01), although this was not reflected in the maintenance of a high ABI (0.76 ± 0.10 versus 0.72 ± 0.08 for verapamil versus placebo). Another study (n = 80) demonstrated no significant difference in arterial intima-media thickness (IMT) in men receiving the thiazide diuretic hydrochlorothiazide (HCTZ) compared to those receiving the alpha-adrenoreceptor blocker doxazosin (-0.12 ± 0.14 mm and -0.08 ± 0.13 mm, respectively; P = 0.66). A study (n = 36) comparing telmisartan to placebo found a significant improvement in maximum walking distance at 12 months with telmisartan (median (interquartile range (IQR)) 191 m (157 to 226) versus 103 m (76 to 164); P < 0.001) but no differences in ABI (median (IQR) 0.60 (0.60 to 0.77) versus 0.52 (0.48 to 0.67)) or arterial IMT (median (IQR) 0.08 cm (0.07 to 0.09) versus 0.09 cm (0.08 to 0.10)). Two studies compared the beta-adrenoreceptor blocker nebivolol with either the thiazide diuretic HCTZ or with metoprolol. Both studies found no significant differences in intermittent or absolute claudication distance, ABI, or all-cause mortality between the anti-hypertensives. A subgroup analysis of PAD patients (n = 2699) in a study which compared a calcium antagonist-based strategy (verapamil slow release (SR) ± trandolapril) to a beta-adrenoreceptor blocker-based strategy (atenolol ± hydrochlorothiazide) found no significant differences in the composite endpoints of death, non-fatal myocardial infarction or non-fatal stroke with or without revascularisation (OR 0.90, 95% CI 0.76 to 1.07 and OR 0.96, 95% CI 0.82 to 1.13, respectively). Evidence on the use of various anti-hypertensive drugs in people with PAD is poor so that it is unknown whether significant benefits or risks accrue. However, lack of data specifically examining outcomes in PAD patients should not detract from the overwhelming evidence on the benefit of treating hypertension and lowering blood pressure.

Comparative effectiveness of renin-angiotensin system blockers and other antihypertensive drugs in patients with diabetes: systematic review and bayesian network meta-analysis

Objective To assess the effects of different classes of antihypertensive treatments, including monotherapy and combination therapy, on survival and major renal outcomes in patients with diabetes.Design Systematic review and bayesian...

Antihypertensive Drugs and Psoriasis

Psoriasis can cause patients to have an increased risk of cardiovascular disease, including hypertension. Many psoriasis patients being treated for hypertension have had adverse reactions to the antihypertensive drugs, causing their psoriasis to return. In some patients without known psoriasis, hypertension medications even brought about new instances of psoriasis. In this paper, we review the literature describing cases of reactions (mainly negative] in psoriasis patients taking antihypertensive medications. We examine different classes of hypertension medications, including ACE inhibitors, beta-blockers, and calcium channel blockers. Since there have been so many reported incidents, physicians using antihypertensive drugs for patients with psoriasis should consider the implications of using each type of drug, and should use this information to prescribe a less-reactive drug type if possible.

Hepatobiliary Quiz-7 (2013)

1.Regarding the molecular virology of hepatitis E virus (HEV) the following are TRUE:1.HEV genome consists of three open reading frames (ORF)2.ORF1 codes for structural proteins3.The 5′ untranslated region is important for viral encapsidation4.The 3′ untranslated region is important for initiation of viral replication5.Unlike other positive strand ribonucleic acid (RNA) viruses, replication of HEV does not require a negative sense RNA intermediary2.Regarding the immunology of HEV the following are TRUE:1.First sign of infection is the detection of IgM antibodies2.Shedding of virus in feces commonly persists after onset of clinical disease3.IgG antibodies persist for years after infection and may protect from future infection4.Liver damage is immune mediated rather than due to direct cytotoxic effect of HEV5.Antibody mediated liver injury is more important than cellular mechanisms3.Regarding chronic HEV infection the following are TRUE:1.Chronic HEV infection is exclusively seen with genotype 3 in immunocompromised individuals2.HEV RNA positivity in solid organ transplant recipients is about 30%3.HEV infection in immunocompromised patients is severe with higher bilirubin and aminotransferase levels4.Chronic HEV infection can progress to cirrhosis5.Risk factors for chronic HEV infection include use of tacrolimus, higher degree of immunosuppression and large heterogeneity of quasispecies of HEV4.Regarding immunosuppressive agents used after liver transplantation the following are TRUE EXCEPT:1.Tacrolimus is more likely to cause diabetes than cyclosporine2.Gingival hyperplasia and hypertrichosis are common with tacrolimus3.Main advantage of using mycophenolate is absence of haematological side effects4.Sirolimus is has additional anti-tumour effects making it useful in cases of transplantation for hepatocellular carcinoma5.Basiliximab and daclizumab are IL-2receptor blocking antibodies5.Regarding involvement of the liver in sarcoidosis the following are TRUE EXCEPT:1.Majority of patients of sarcoidosis will have liver involvement on investigation2.Symptomatic liver disease is common in sarcoidosis3.Pulmonary involvement is absent in about 25% of hepatic sarcoidosis4.Portal hypertension is a common finding in hepatic sarcoidosis5.Sarcoidosis is not a cause for cirrhosis of the liver6.Regarding non-alcoholic fatty liver disease (NAFLD) in Asia the following are TRUE:1.South Asians like Indians are at a higher risk of insulin resistance than their Western counterparts2.India has a low prevalence of NAFLD3.Prevalence of NAFLD is increasing in Asian countries4.PNPLA3 gene polymorphisms are not associated with NAFLD in Asians5.APO C3 gene polymorphisms are associated with NAFLD predominantly in Caucasians7.Regarding liver transplantation for cirrhosis due to non-alcoholic steatohepatitis (NASH) the following are TRUE EXCEPT:1.Recurrence of NAFLD is very common2.Overall survival after transplantation is poorer compared to other etiologies of cirrhosis3.Renal dysfunction after transplantation is less common compared to other etiologies of cirrhosis4.Cardiovascular events are a more common cause of death after transplantation in NASH patients5.Pre-transplant diagnosis of NASH related cirrhosis is an independent predictor of development of metabolic syndrome after transplantation8.Regarding nutritional management of patients with cirrhosis the following are TRUE:1.Resting energy expenditure is lower in patients with cirrhosis2.Late evening snack of complex carbohydrates may improve quality of life and survival3.Protein restriction is not advisable even in patients with hepatic encephalopathy4.Animal protein is preferred to vegetable protein5.Branched chain amino acids improve event free survival9.Regarding management of ascites in cirrhosis the following are TRUE:1.Mean arterial pressure is a predictor of survival in patients of cirrhosis with ascites2.Angiotensin converting enzyme inhibitors are good anti-hypertensive drugs in patients with ascites3.Standard medical therapy consisting of sodium restriction and diuretics is successful in controlling ascites in 90% of cases4.Midodrine is a treatment option for patients with refractory ascites5.Peritoneovenous shunts are a favoured treatment option for refractory ascites10.Regarding spontaneous bacterial peritonitis (SBP) the following are TRUE:1.Culture-negative neutrocytic ascites has better outcome than culture positive SBP2.Monomicrobial non-neutrocytic bacterascites frequently resolves spontaneously3.Albumin infusions decrease mortality in patients with SBP4.Primary prophylaxis for SBP is indicated if Child score is ≥9 and serum bilirubin is ≥3 mg/dl5.Short-term prophylaxis for SBP in patients with gastrointestinal bleeding reduces infection rate but does not affect mortality

Blockade of the Renin-Angiotensin System in Hypertensive Patients with Atherosclerotic Renal Artery Stenosis

Renin angiotensin system (RAS) blockers are generally considered as contraindicated when an atheromatous renal artery stenosis (ARAS) is diagnosed. The main reason is the fear of inducing renal ischemia and, hence, accelerating renal fibrosis and the progression towards end stage renal disease, albeit RAS blocker have been shown to be highly effective in controlling blood pressure. Part of the solution came by the development of the revascularization. There is now growing evidence showing no superiority of angioplasty over medical treatment on cardiovascular events and mortality, renal function and blood pressure control. Hence, RAS blockers resurfaced based on their proven beneficial effects on blood pressure control and cardiovascular prevention in high risk atherosclerotic patients. Thus, RAS blockers belong today to the standard treatment of hypertensive patients with ARAS. However they were not systematically prescribed in trials focusing on ARAS. The ongoing CORAL trial will give us further information on the place of this class of antihypertensive drugs in patients with ARAS.

Current perspectives on treatment of hypertensive patients with chronic obstructive pulmonary disease

Systemic hypertension and chronic obstructive pulmonary disease (COPD) frequently coexist in the same patient, especially in the elderly. Today, a wide variety of antihypertensive drugs with different mechanisms of action are available to the prescribing physician. In addition, combination drugs for hypertension are becoming increasingly popular. Certain antihypertensive drugs can affect pulmonary function. Therefore the management of such patients can present therapeutic challenges. We have examined the literature pertaining to the use of antihypertensive drugs in patients with systemic hypertension and coexisting COPD. Although data are often limited or of poor quality, we have attempted to review and then provide recommendations regarding the use of all the specific classes of antihypertensive drug therapies including combination drugs in patients with COPD. The antihypertensive agents reviewed include diuretics, aldosterone receptor blockers, beta blockers, combined alpha and beta blockers, angiotensin-converting enzyme inhibitors, angiotensin II antagonists, calcium channel blockers, alpha-1 blockers, centrally acting drugs, direct vasodilators, and combinations of these drugs. Of these classes, calcium channel blockers and angiotensin II antagonists appear to be the best initial choices if hypertension is the only indication for treatment. However, the limited data available on many of these drugs suggest that additional studies are needed to more precisely determine the best treatment choices in this widely prevalent patient group.