Choice Of Antihypertensive Agent Research Articles

Current practice toward the use of antihypertensive agents in the management of hypertension – A cross-sectional study among Indian physicians

Objective: The objective of this study was to assess current practices and usage patterns of antihypertensive medications in managing hypertension (HTN) in India. Materials and Methods: A cross-sectional, observational digital study was conducted among health-care practitioners (HCPs) across India (November 2022–March 2023). Results: A total of 792 HCPs (cardiologists, consulting, and general physicians) participated in this study. According to 63.38% of HCPs, 20–50 essential HTN patients seek consultation weekly. The majority of patients were in the age range of 40–60 years (84.09%). A total of 67.55% of HCPs mentioned that systolic blood pressure (BP) ranged between 140 and 160 mmHg. Type 2 diabetes mellitus was the most common comorbidity among hypertensive patients (84.09%). In total, 53.79% and 37.37% of HCPs preferred angiotensin receptor blockers (ARBs)/angiotensin-converting enzyme and calcium channel blockers (CCBs) as the first choice of antihypertensive agents. The majority of HCPs (>69%) preferred prescribing a triple-drug fixed-dose combination (FDC) of CCBs + ARB + diuretics in hypertensive patients with coronary artery disease (CAD) and resistant HTN. The majority (89.90%) of HCPs preferred prescribing FDC of CCBs over monotherapy. Amlodipine (>55%) followed by cilnidipine (>32%) were preferred CCBs for young and older hypertensive patients. In patients with essential HTN without any CVD, amlodipine (72.85%) was the preferred CCB. Vascular selectivity (59.09%) and longer half-life (54.55%) were important factors for prescribing CCBs. Resistant HTN, inadequate BP control with monotherapy, and the presence of CAD were all (62.63%) important considerations for FDC with CCBs. The underutilization of CCBs in managing HTN (63.88%) was highlighted. Conclusion: Overall responses provide a comprehensive overview of the prevailing perception and the usage patterns of antihypertensive agents employed by HCPs in India.

Abstract 13384: Choice of Antihypertensive Agent in Isolated Systolic Hypertension and Isolated Diastolic Hypertension: A Secondary Analysis of the Allhat Trial

Introduction: Although isolated systolic hypertension (ISH) and isolated diastolic hypertension (IDH) exhibit differing pathophysiology and phenotypes, it is unclear whether specific antihypertensive agents are preferred for each condition. Methods: Using data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), we set out to determine whether certain antihypertensive agents had differential effects on clinical outcomes in patients with ISH or IDH. We defined ISH as SBP ≥140mmHg and DBP <90mmHg, and we defined IDH as SBP <140mmHg and DBP ≥90mmHg. We used risk-adjusted cox regression to evaluate the primary outcome (a composite of all-cause mortality, combined CHD, or stroke) by antihypertensive agent in cohorts of patients with ISH or IDH. We also evaluated achievement of normotension using risk-adjusted logistic regression. Results: We identified 12,845 patients with ISH and 1,259 patients with IDH. The adjusted hazard of the primary outcome was similar across antihypertensive agents for both ISH (aHR=1.01, 95% CI 0.94-1.09 for amlodipine vs chlorthalidone, and aHR=1.03, 95% CI 0.95-1.10 for lisinopril vs chlorthalidone) and IDH (aHR=1.06, 95% CI 0.80-1.41 for amlodipine vs chlorthalidone, and aHR=1.11, 95% CI 0.84-1.47 for lisinopril vs chlorthalidone) (Figure). There were no significant differences across antihypertensive agents in the achievement of normotension at six years for ISH (OR=1.01, 95% CI 0.89-1.15 for amlodipine vs chlorthalidone; and OR=0.97, 95% CI 0.85-1.10 for lisinopril vs chlorthalidone) or IDH (aOR=0.92, 95% CI 0.59-1.42 for amlodipine vs chlorthalidone; and aOR=0.77, 95% CI 0.49-1.21 for lisinopril vs chlorthalidone). Conclusions: In this large cohort of patients, clinical events were similar across antihypertensive agents for both ISH or IDH. These results lend credence to the flexible treatment recommendations in current hypertension guidelines.

Antihypertensive Medication Use and Its Effects on Blood Pressure and Haemodynamics in a Tri-ethnic Population Cohort: Southall and Brent Revisited (SABRE).

Objectives:We characterised differences in BP control and use of antihypertensive medications in European (EA), South Asian (SA) and African-Caribbean (AC) people with hypertension and investigated the potential role of type 2 diabetes (T2DM), reduced arterial compliance (Ca), and antihypertensive medication use in any differences.Methods:Analysis was restricted to individuals with hypertension [age range 59–85 years; N = 852 (EA = 328, SA = 356, and AC =168)]. Questionnaires, anthropometry, BP measurements, echocardiography, and fasting blood assays were performed. BP control was classified according to UK guidelines operating at the time of the study. Data were analysed using generalised structural equation models, multivariable regression and treatment effect models.Results:SA and AC people were more likely to receive treatment for high BP and received a greater average number of antihypertensive agents, but despite this a smaller proportion of SA and AC achieved control of BP to target [age and sex adjusted odds ratio (95% confidence interval) = 0.52 (0.38, 0.72) and 0.64 (0.43, 0.96), respectively]. Differences in BP control were partially attenuated by controlling for the higher prevalence of T2DM and reduced Ca in SA and AC. There was little difference in choice of antihypertensive agent by ethnicity and no evidence that differences in efficacy of antihypertensive regimens contributed to ethnic differences in BP control.Conclusions:T2DM and more adverse arterial stiffness are important factors in the poorer BP control in SA and AC people. More effort is required to achieve better control of BP, particularly in UK ethnic minorities.

P0178COMPARATIVE EFFECTIVENESS OF RENIN-ANGIOTENSIN SYSTEM INHIBITORS AND CALCIUM CHANNEL BLOCKERS IN INDIVIDUALS WITH ADVANCED CHRONIC KIDNEY DISEASE: A NATIONWIDE COHORT STUDY

Abstract Background and Aims There is a lack of data that could help to guide the choice of antihypertensive agents in patients with advanced chronic kidney disease (CKD). We evaluated whether initiating treatment with a renin-angiotensin system inhibitor (RASi) is superior to calcium channel blockers (CCB) in preventing mortality, major adverse cardiovascular events (MACE) or kidney replacement therapy (KRT) in patients with advanced CKD. Method Observational study from the Swedish Renal Register, 2007-2017. We identified all nephrologist-referred patients in Sweden who initiated RASi or CCB treatment and had non-dialysis dependent advanced CKD (eGFR <30 ml/min/1.73m2). The associations between RASi vs CCB initiation, mortality, MACE and KRT were assessed by Cox regression. Analyses were adjusted with propensity score weighting for a wide range of confounders, including demographics, blood pressure, laboratory measures, comorbidities and medications. As a positive control we evaluated new use of the same drugs in patients with CKD G3 (N = 2608; eGFR between 30-60 ml/min/1.73m2). Furthermore subgroup, as-treated and competing risk analyses were performed. Results The propensity-score weighted cohort included 2479 RASi and 2327 CCB initiators who were well-matched for baseline confounders (all standardized differences <0.1). Median follow-up was 4.1 years, with a maximum follow-up of over 10 years. Compared to CCB, initiation of RASi was associated with a similar risk of mortality (adjusted HR 0.94; 95% CI 0.85-1.03) and MACE (0.99; 0.87-1.13), but with a lower risk of KRT (0.87; 0.78-0.98). Results were consistent across subgroups, in as-treated analyses and after accounting for the competing risk of death. In the control cohort of patients with CKD G3, initiation of RASi (versus CCB) was associated with lower KRT risk (adjusted HR 0.67; 0.47-0.96), and similar risk of mortality (0.91; 0.76-1.08) and MACE (1.06; 0.82-1.35). Conclusion Compared with CCB, initiation of RASi in patients with advanced CKD was associated with a lower risk of KRT, but no different risk of mortality or MACE.

SUN-174 EFFICACY AND SAFETY OF INTRAVENOUS LABETALOL FOR HYPERTENSIVE CRISIS IN CHILDREN

Hypertensive crisis is uncommon in children. American Association of Pediatrics acknowledges the lack of robust evidence-based management guidelines for the same. Most data on the choice of drugs is extrapolated from adults and small case series in children. The objectives of this study were to determine the efficacy and safety of IV labetalol as a first-line agent or an add on drug compared to IV nitroprusside/nitroglycerine in the management of hypertensive crisis in children. A retrospective chart review of 56 consecutive children (age 1 month to ≤ 12 years) with hypertensive crisis admitted to pediatric intensive care unit (PICU) during a 10-year period (July 2009- 2019) was done. Data with respect to baseline demographics, clinical presentation, etiological workup, treatment details, and blood pressure (BP) trends were recorded. The choice of antihypertensive agents was left to the clinician's discretion. The proportion of patients, attaining target BP (95th percentile) in >12 to ≤ 48 hours after admission was taken as primary endpoint. The secondary endpoints were PICU needs, morbidity, and mortality. The median age of the children was 7 years (range 1-12). Hypertensive crisis comprised < 1 % of PICU admissions. Most crisis presented as hypertensive emergency (89%) and had renal etiology as the leading cause (61%). The proportion of children attaining the primary endpoint was significantly more in the group receiving labetalol (n=23) as compared to those not receiving labetalol (n=33) (62% vs. 29%, p < 0.0001). The proportion of children having precipitous fall in BP before 12 hours, leading to hypotension was similar in both treatment groups (13% vs 15%). The PICU needs for ventilation (0% vs 27%, p < 0.0001), renal replacement therapy (0% vs 9%, p = 0.003) and raised intracranial pressure (ICP) (0% vs 9%, p = 0.003) were significantly less in the labetalol group. The central nervous system (CNS) morbidity was also significantly reduced in the labetalol group (41% vs. 9%, p < 0.0001). One child compared to three died in the labetalol and non-labetalol group respectively (4.3% vs. 9%, p = 0.2). The data were also analyzed for practice variations between two periods of five years each (2009-2013 and 2014-2019). There latter cohort showed significantly more use of labetalol (74% for 2014-2019 vs. 26% for 2009-2013, p < 0.0001). Labetalol, when used alone or as an add on drug was more efficacious than IV nitroprusside/nitroglycerine in attaining the primary endpoint. There was a lesser need for ventilation and renal replacement therapy with labetalol. The CNS morbidity at discharge was also lesser. The propensity to hypotension was however similar in both groups. There is only one study looking at the safety and efficacy of labetalol in children with hypertensive crisis up to ≤ 24 months of age. Ours is the only study to the best of our knowledge in children up to 12 years of age. However, our study suffers from the inherent problems of a retrospective analysis. In conclusion, our study shows that labetalol is safe and efficacious in hypertensive crisis in children up to ≤ 12 years of age.

Abstract MP72: The Effects of Antihypertensive Class on Falls, Syncope, and Orthostatic Hypotension in Older Adults: the ALLHAT Trial

Background: Hypertension treatment is believed to contribute to falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether choice of antihypertensive agent influences the incidence of these adverse outcomes is unknown. Hypothesis: Chlorthalidone and atenolol are associated with higher risk of fall, syncope, and OH, compared with amlodipine or lisinopril. Methods: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized clinical trial that compared the effects of first-step therapy with amlodipine, lisinopril, or chlorthalidone on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). We linked participants to CMS and VA claims to determine the incidence of fall, syncope, OH, or a composite outcome (any of fall, syncope, or OH), using Cox regression. The association of baseline or 1-month add-on atenolol use with outcomes was determined via Cox models adjusted for age, sex, race, and randomized drug assignment. Results: Among 23,964 participants (mean age 70.4 ± 6.7 years, 43% women, 31% black), 927 participants took atenolol at baseline. Over a mean follow-up of 4.9 years, there were 267 fall, 755 syncope, 249 OH, and 1,157 composite claims with no significant differences in the cumulative incidence of events across randomized drug assignments ( Figure ). Compared with chlorthalidone, amlodipine and lisinopril were not associated with falls (HR [95%CI]: 1.36 [0.90-2.05] and 0.80 [0.47-1.36], respectively), syncope (0.96 [0.77-1.21] and 1.07 [0.85-1.34], respectively), OH (0.98 [0.66-1.45] and 1.24 [0.87-1.76], respectively), or the composite outcome (1.01 [0.84-1.21] and 1.07 [0.92-1.22], respectively). Similarly, atenolol use was not associated with any of the 3 individual or composite claims. Conclusions: Choice of antihypertensive agent has no effect on risk of fall, syncope, or OH in older adults. This observation should simplify the choice of initiating antihypertensive therapy in this population.

Abstract WP331: Choice of Antihypertensive Agent Prior to Thrombolysis Has No Affect on Door-to-Needle Time: A Single Center Experience

Introduction: Treatment of acute ischemic stroke with intravenous thrombolysis (IVT) should be as rapid as possible. A subset of patients with acute ischemic stroke present with blood pressures above that considered safe for thrombolytic administration, and antihypertensive therapy is necessary. Guideline statements are ambivalent regarding which antihypertensive agent should be used to obtain a satisfactory blood pressure (BP &lt; 185/110 mmHg) prior to IVT. Hypothesis: DTN time will not differ amongst the antihypertensive agent groups. Methods: We reviewed data from consecutive patients at our institution treated with IVT from 01/2014 to 07/2018 and collected door-to-needle (DTN) time, antihypertensive agent (if used), and antihypertensive-to-needle (ATN) time. Patients were grouped by initial agent administered. An independent samples t-test was used to compare the labetalol and nicardipine group DTN and ATN times, as well as DTN times for patients receiving any antihypertensive agent with DTN times for those who did not. We performed a one-way ANOVA to compare DTN times across all groups (no agent, labetalol, nicardipine, hydralazine). Significance was defined as p &lt; 0.05 for all tests. Results: Analysis included 205 patients: 149 receiving no antihypertensive, 42 receiving labetalol, 12 receiving nicardipine, and 2 receiving hydralazine. Those not administered an antihypertensive prior to IVT had shorter DTN times (53.05 min versus 61.96 min, p = 0.039). Although not statistically significant, there was a trend towards longer DTN (64.76 min versus 51.33 min, p = 0.205) and ATN times (18.02 min versus 10.58 min, p = 0.171) in the labetalol group. There was not a difference in DTN time across all groups (F(3,205) = 2.213, p = 0.088), although labetalol trended towards higher times than those not administered any agent on post-hoc Tukey HSD test (p = 0.071). Conclusions: At our institution, patients requiring antihypertensive treatment did experience slower DTN times. Choice of antihypertensive agent did not affect DTN times, however there was a trend towards slower times with labetalol. This study is limited by relatively small sample size. Pooling data from multiple institutions could provide a more robust assessment and inform clinical practice.

Hypertension guidelines: How do they apply to kidney transplant recipients.

Hypertension is common among kidney transplant recipients and may result from traditional risk factors or transplant specific variables, which commonly include donor associated causes, immunosuppression, or transplant renal artery stenosis. Uncontrolled blood pressure in this patient population is associated with increased cardiovascular mortality and morbidity, and decreased graft survival. Despite these negative associations, there are no randomized controlled trials looking at the optimal blood pressure targets and identifying the best antihypertensive regimen for this special patient population. Multiple hypertension guidelines have been published in the last 10 years, but the Kidney Disease: Improving Global Outcomes (KDIGO) and American Society of Transplantation (AST) guidelines are the only to recommended a target blood pressure in kidney transplant recipients. In this manuscript, we will review the available evidence based on randomized clinical trials and large observational studies in kidney transplant recipients. Pending new interventional trials, we believe that: a) a blood pressure target of ≤130/80 is a reasonable goal as suggested by KDIGO; b) the choice of antihypertensive agent should be based on the patients' other comorbidities; and c) achieving good blood pressure control is more important than the choice of the antihypertensive agent; however, the initial choice of antihypertensive medications should be calcium channel blockers, beta-blockers, diuretics, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers as they have all been shown to reduce cardiovascular events in the general population.

Treatment of hypertension during pregnancy

Hypertensive disorders of pregnancy are on the increase and remain important causes of maternal and perinatal morbidity and mortality. The different classes of hypertension carry different risks but severe hypertension in itself remains a medical emergency. Pre-eclampsia is a particularly dangerous condition that may progress rapidly. During pregnancy mild hypertension without end-organ disease does not require treatment until levels of 150/100mmHg are reached. Acute severe hypertension must be diagnosed and treated expeditiously. The choice of anti-hypertensive agents is limited in pregnancy and physicians should choose agents which are regarded as safe and which they feel comfortable in using. After acute management, oral maintenance therapy will be indicated in many cases, although delivery is regarded as the only defi nitive treatment for pregnancy specifi c conditions such as pre-eclampsia. Previous pre-eclampsia is associated with increased rates of cardiovascular and metabolic disease in later life. This should prompt subsequent lifestyle education and intervention.

Blood pressure treatment levels and choice of antihypertensive agent in people with diabetes mellitus: an overview of systematic reviews.

Multiple systematic reviews address the effect of antihypertensive treatment in people with diabetes. Here, we summarize current systematic reviews concerning antihypertensive treatment effect at different blood pressure (BP) levels, and relative treatment effect of different antihypertensive agents. We searched MEDLINE, BIOSIS, DARE and CDSR during years 2005-2016. Eligibility criteria, number of trials and participants, outcomes analysed, statistical methods used for data synthesis, and principal results were extracted for each review. Review quality was assessed using the assessment of multiple systematic reviews tool. We found four reviews concerning BP treatment level. These consistently showed that the effect of antihypertensive treatment on mortality, cardiovascular disease and coronary heart disease was attenuated at lower BP levels. If SBP was more than 140 mmHg, treatment reduced all-cause and cardiovascular mortality, cardiovascular disease, stroke, myocardial infarction and heart failure. If SBP was less than 140 mmHg, treatment increased the risk of cardiovascular death. We found eight reviews concerning choice of agent. We found no difference between angiotensin-converting enzyme inhibitors, angotensin receptor blockers, beta-blockers, calcium channel blockers and diuretics in preventing all-cause or cardiovascular mortality, combined cardiovascular disease, coronary heart disease and end-stage renal disease. Minor differences exist for stroke and heart failure. Data were limited on people with type 1 diabetes and very elderly patients with type 2 diabetes. None of the reviews concerning choice of agent included all relevant trials. The available evidence supports treatment in people with type 2 diabetes and SBP more than 140 mmHg, using any of the major antihypertensive drug classes.

New Insights into Blood Pressure Control for Intracerebral Haemorrhage.

Although blood pressure (BP) levels may rise in the weeks preceding intracerebral haemorrhage (ICH), in contrast to findings in the ischaemic stroke population, the initial post-ICH BP is often much higher than the last pre-morbid level. Elevated BP is therefore common in acute ICH, often with markedly elevated levels, and is associated with poor outcomes, though the exact pathophysiological mechanisms remain unclear. The Antihypertensive Treatment of Acute Cerebral Haemorrhage (ATACH) trial and the INTEnsive blood pressure Reduction in Acute Cerebral haemorrhage Trial (INTERACT) demonstrated that early and intensive lowering of elevated BP in the acute ICH period is feasible and safe. Importantly, recent CT perfusion studies have shown that early, intense BP reduction does not reduce cerebral blood flow or promote cerebral ischaemia. The recent, large INTERACT2 trial confirmed the safety of early BP lowering in ICH and suggested that intensive target-driven BP reduction may improve outcomes, with a non-significant trend towards reduced death and major disability and a significant favourable shift of scores on the modified Rankin scale compared with guideline-based treatment. BP lowering in acute ICH may reduce haematoma growth, particularly when target levels are achieved early and are sustained, though the evidence is partly conflicting. Other aspects of BP may also be important following acute ICH, with maximum systolic BP and systolic BP variability being independent predictors of poor outcomes in a recent study. This chapter gives an overview of the current evidence regarding BP in ICH and covers the following topics: the incidence of elevated BP in acute ICH and the patterns of BP observed before and after the event; the effect of elevated BP on outcomes in ICH and the potential underlying pathophysiological mechanisms; the safety and feasibility of BP lowering; the effects of BP lowering on clinical and radiological outcomes; other important aspects of BP in ICH; and the choice of antihypertensive agent.

Choice of anti-hypertensive agents in diabetic subjects

Hypertension is an extremely common co-morbid condition in diabetes leading to acceleration in micro-vascular and macro-vascular complications. The use of anti-hypertensives in diabetic patients should be considered in the context of preventing the development of complications. Various factors contribute to the pathophysiology of diabetes in hypertension. With the advancements in technology, the understanding of the pathophysiological mechanisms has increased, and this can contribute in providing evidence for beneficial role of certain anti-hypertensives. Many clinical trials have been carried out for use of diuretics, beta blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. The present review gives an overview of pathophysiological mechanisms of hypertension and diabetes in addition to the details of clinical trials of anti-hypertensives in diabetic patients. This is an attempt to provide some evidences for the clinicians, which may serve as a guide for use of anti-hypertensives in clinical practice.

Diagnostics and treatment of chronic kidney disease in modern clinical guidelines: what do practitioners need to know?

Chronic kidney disease (CKD), widely prevalent in real-world clinical practice settings, is associated with an increased risk of cardiovascular and renal complications. Modern clinical guidelines on the management of CKD patients provide recommendations on the early diagnostics of renal functional and structural pathology, as well as on the adequate treatment which prevents or postpones the progression of these pathological changes. Currently, the assessment of glomerular filtration rate and albuminuria severity is considered obligatory in the CKD diagnostics. These criteria are reflected in the CKD classification, presented in the modern clinical guidelines. The presence of CKD requires the administration of effective treatment, including renin-angiotensin-aldosterone system (RAAS) blockers. At the same time, most CKD patients also require antihypertensive combination therapy, which includes RAAS blockers, diuretics, and/or calcium antagonists. The choice of antihypertensive agents is defined by the specific clinical situation. One of the effective calcium antagonists with proven nephroprotective activity is lercanidipine. The treatment of CKD patients should also include adequate glycemia control and lipid-lowering agents.

Indapamide retard as the medication of choice in elderly patients with arterial hypertension

The modern society faces a steady increase in the numbers of elderly people, which is associated with a range of social and medical problems. Age-related aspects of body anatomy and physiology, multiple comorbidity, and cognitive decline restrict the choice of medications in elderly patients. The paper discusses the need for the agreement between the choice of antihypertensive agents in elderly patients and the importance of organoprotection. From the evidence-based medicine standpoint, indapamide retard is considered as the medication which meets all the requirements for arterial hypertension treatment in elderly patients.

PP088. Oral antihypertensive therapy for severe hypertension in pregnancy

The hypertensive disorders of pregnancy are among the leading causes of maternal mortality and morbidity. The vast majority occurs in low and middle income countries. It is widely accepted that women with severe hypertension are at increased risk of stroke and benefit from blood pressure (BP) reduction. Although traditionally, parenteral antihypertensive agents have been studied for treatment of severe hypertension in pregnancy, oral agents would be ideal for use in the community and in under-resourced settings. To review the published evidence for the effectiveness of oral antihypertensive therapy for severe hypertension in pregnancy. The following databases were searched (to May/11) for randomised controlled trials (RCT) of oral antihypertensive therapy for severe hypertension in pregnancy: MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews. Inclusion criteria were: severe hypertension [an inclusion criterion or average enrollment BP of: systolic BP ⩾160mmHg and/or diastolic BP ⩾110mmHg), use of oral or sublingual antihypertensive therapy in at least one of the treatment arms, and at least one relevant measure of maternal or perinatal outcome within a week of administration. Data were abstracted independently by two reviewers and discrepancies resolved by consensus. The Cochrane Revman 5.1 software was used for statistical analysis according to standardised methodology. We identified 14 eligible trials (796 women). Most compared oral/sublingual (SL) nifedipine 5-10mg (10 trials, 606 women, 8/10 trials specified capsule preparation), with either: intravenous (iv) hydralazine 5-20mg (6 trials, 282 women), oral nifedipine 10mg PA tablets (1 trial), oral prazosin 1mg (1 trial), iv labetalol (1 trial), or iv/intramuscular (im) chlorpromazine 12.5 (1 trial). Three trials (154 women) compared oral methyldopa (250-500mg initially) with either oral labetalol (100mg), atenolol (50-200mg) or kentanserin (80-120mg) (1 trial each). One trial (36 women) compared SL isosorbide 1.25mg with iv magnesium sulphate (4g iv then 1g/hr). No trials were identified that compared oral labetalol with either parenteral hydralazine or oral nifedipine. Nifedipine compared favourably with parenteral hydralazine with no differences seen in BP control or maternal or perinatal outcomes. Heterogeneity between trial results was seen within the oral/SL nifedipine vs. iv hydralazine subgroup in which one trial evaluated treatment success and side effects over 20min, and found that nifedipine was associated with relatively lower success and fewer side effects. The incidence of maternal hypotension in the nifedipine capsule arms of these trials was low (1/102, 3 trials), but hypotension was common in both arms of a trial of nifedipine 10mg capsule vs. 10mg PA tablet trial (i.e., 11/31 vs. 3/33, risk difference 26%, 95% CI7% to 46%). Given the available RCT data on which to base oral antihypertensive treatment of severe hypertension in pregnancy, the choice of antihypertensive agent may need to be driven by the availability of the drug, setting in which it is to be administered, and by whom. For facility use, the evidence supports oral nifedipine capsules.

Epidemiology and optimal management in patients with renal artery stenosis

Renovascular hypertension (hypertension induced by renal artery stenosis) is a form of secondary hypertension caused by overactivation of the renin-angiotensin system by the ischemic kidney. Prevalence of renal artery stenosis (RAS) is estimated to be between 2% (unselected hypertensives) and 40% (older patients with other atherosclerotic comorbidities). Most cases of RAS are caused by atherosclerosis; other causes, including fibromuscular dysplasia, vasculitis, thromboembolism and aneurysms, are less frequent. The most frequent clinical presentation of RAS is hypertension. Acute kidney injury, rapid loss of kidney function and episodes of flash pulmonary edema are other symptoms of RAS, especially in bilateral disease. In current practice, RAS therapy includes antiplatelet (aspirin) and lipid-lowering (statin) therapy as well as angiotensin II receptor blockers or angiotensin-converting enzyme inhibitors as a first choice of antihypertensive agents. Angiotensin blockade, however, is contraindicated in bilateral RAS and in RAS of the solitary kidney. This review summarizes the current status and perspectives on the epidemiology and management of renovascular hypertension.

What Is the Blood Pressure Goal for the Elder Patient 75 Years of Age or Older?

High blood pressure (BP), once believed to represent a normal and progressive component of the aging process, is now recognized as a manifestation of structural and physiologic abnormalities of arterial function. Two phenotypes exist in the older patient: elevated systolic blood pressure (SBP) and diastolic blood pressure (DBP) with a normal pulse pressure (PP), and elevated SBP with an increased PP. Elevated SBP and increased PP unquestionably increase the risk of both fatal and nonfatal cardiovascular events, including stroke, myocardial infarction, and heart failure. Isolated systolic hypertension, defined as an SBP ≥140mm Hg with a DBP less than 90mm Hg, affects the majority of individuals ages 60years and older. A number of clinical trials have clearly demonstrated that treatment of hypertension significantly reduces the cardiovascular event rate in older patients. However, controversy continues as to the choice of antihypertensive agents and combinations of agents. It is both appropriate and necessary to treat elderly hypertensive patients aggressively to the same target BPs identified for younger patients. It is also appropriate to initiate treatment with lower doses of antihypertensive agents and to bring the pressure down more slowly, monitoring for orthostatic hypotension, impaired cognition, and electrolyte abnormalities.

Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome

Abstract Objective Cerebral hyperperfusion syndrome is a preventable cause of stroke after carotid endarterectomy (CEA). It manifests as headache, seizures, hemiparesis or coma due to raised intracranial pressure or intracerebral haemorrhage (ICH). There is currently no consensus on whether to control blood pressure, blood pressure thresholds associated with cerebral hyperperfusion syndrome, choice of anti-hypertensive agent(s) or duration of treatment. Method A systematic review of the PubMed database (1963–2010) was performed using appropriate search terms according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results A total of 36 studies were identified as fitting a priori inclusion criteria. Following CEA, the incidence of severe hypertension was 19%, that of cerebral hyperperfusion 1% and ICH 0.5%. The postoperative mean systolic blood pressure of patients, who went on to develop cerebral hyperperfusion syndrome, was 164 mmHg (95% confidence interval (CI) 150–178 mmHg) and the cumulative incidence of cases rose appreciably above a postoperative systolic blood pressure of 150 mmHg. The mean systolic blood pressure of cerebral hyperperfusion cases was 189 mmHg (95% CI 183–196 mmHg) at presentation. The incidence of cerebral hyperperfusion in the first week was 92% with a median time to presentation of 5 days (interquartile range (IQR) 3–6 days). 36% of patients presented with seizures 31% with hemiparesis and 33% with both. The proportion of patients with severe hypertension was significantly higher in cases than in post-CEA controls (p Conclusion There is currently level-3 evidence for the prevention of ICH through control of postoperative blood pressure. From the available data, we suggest a definition for cerebral hyperperfusion syndrome, blood pressure thresholds, duration of monitoring and a postoperative blood pressure control strategy for validation in a prospective study. The implications of this are that one in five patients would need intravenous anti-hypertensives and home blood pressure monitoring for 1 week.

Left Ventricular Hypertrophy: Major Risk Factor in Patients with Hypertension: Update and Practical Clinical Applications

Left ventricular hypertrophy is a maladaptive response to chronic pressure overload and an important risk factor for atrial fibrillation, diastolic heart failure, systolic heart failure, and sudden death in patients with hypertension. Since not all patients with hypertension develop left ventricular hypertrophy, there are clinical findings that should be kept in mind that may alert the physician to the presence of left ventricular hypertrophy so a more definitive evaluation can be performed using an echocardiogram or cardiovascular magnetic resonance. Controlling arterial pressure, sodium restriction, and weight loss independently facilitate the regression of left ventricular hypertrophy. Choice of antihypertensive agents may be important when treating a patient with hypertensive left ventricular hypertrophy. Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers followed by calcium channel antagonists most rapidly facilitate the regression of left ventricular hypertrophy. With the regression of left ventricular hypertrophy, diastolic function and coronary flow reserve usually improve, and cardiovascular risk decreases.

The Role of RAS Modification for Primary and Secondary Stroke Prevention

Clinical trial results indicate that the choice of antihypertensive agent can be a determinant of stroke protection, independent of blood pressure (BP) reduction. Angiotensin-converting enzyme inhibitors (ACE-Is) are effective for BP control and stroke protection, but their use may be limited by patient tolerability. Angiotensin receptor blockers appear to provide similar BP control compared with ACE-Is and may also offer the clinician the added benefit of primary and secondary stroke prevention, with the potential for fewer tolerability issues.