Concomitant Cardiovascular Risk Factors Research Articles

Structurally-functional features of left ventricular myocardium and endothelial dysfunction in rheumatoid arthritis depending on presence of hypertension

Система комплексной поддержки и сопровождения научного журнала Elpub позволяет запустить двуязычный сайт журнала со встроенной системой электронной редакции в соответствии с лучшими издательскими практиками, а так же предусматривает техническую и методическую поддержку со стороны специалистов НЭИКОН.

Effect of exercise on blood pressure control in hypertensive patients

Several large epidemiological studies have reported an inverse relationship between blood pressure and physical activity. However, longitudinal intervention studies are more appropriate for assessing the effects of physical activity. We performed meta-analyses of randomized controlled trials involving dynamic aerobic endurance training or resistance training. The meta-analysis on endurance training involved 72 trials and 105 study groups. After weighting for the number of trained participants, training induced significant net reductions in resting and daytime ambulatory blood pressure of, respectively, 3.0/2.4 mmHg (P<0.001) and 3.3/3.5 mmHg (P<0.01). The reduction in resting blood pressure was more pronounced in the 30 hypertensive study groups (-6.9/-4.9) than in the others (-1.9/-1.6; P<0.001 for all). Systemic vascular resistance decreased by 7.1% (P<0.05), plasma norepinephrine by 29% (P<0.001), and plasma renin activity by 20% (P<0.05). Body weight decreased by 1.2 kg (P<0.001), waist circumference by 2.8 cm (P<0.001), percentage body fat by 1.4% (P<0.001) and the homeostasis model assessment index of insulin resistance by 0.31 units (P<0.01); high-density lipoprotein cholesterol increased by 0.032 mmol/l (P<0.05). Resistance training has been less well studied. A meta-analysis of nine randomized controlled trials (12 study groups) on mostly dynamic resistance training revealed a weighted net reduction in blood pressure of 3.2 (P=0.10)/3.5 (P<0.01) mmHg associated with exercise. Endurance training decreases blood pressure through a reduction in systemic vascular resistance, in which the sympathetic nervous system and the renin-angiotensin system appear to be involved, and favourably affects concomitant cardiovascular risk factors. The few available data suggest that resistance training can reduce blood pressure. Exercise is a cornerstone therapy for the prevention, treatment and control of hypertension.

A single-pill combination of amlodipine besylate and atorvastatin calcium (update)

This review describes the clinical profile and rationale for the development of a single-pill formulation of the calcium channel blocker amlodipine besylate, a blood-pressure--lowering agent, and atorvastatin calcium, a statin with lipid-lowering antiatherosclerotic properties. Amlodipine and atorvastatin have been demonstrated in numerous clinical trials to be highly effective in lowering blood pressure and low-density lipoprotein cholesterol. Furthermore, both amlodipine and atorvastatin have been demonstrated to reduce cardiovascular events in a broad range of patients' in hypertensive patients with three concomitant cardiovascular risk factors but normal to mildly elevated cholesterol levels, amlodipine combined with atorvastatin demonstrated a reduction in cardiovascular events. The amlodipine/atorvastatin single pill has been shown to improve patients; achievement of national-guideline-recommended blood pressure and lipid target levels and exhibits a safety profile consistent with its parent compounds. The combination pill is now available in parts of Europe in formulations containing either 5 or 10 mg amlodipine and 10 mg atorvastatin. Amlodipine combined with atorvastatin has been demonstrated to reduce cardiovascular events in hypertensive patients at high cardiovascular risk, and the single-pill formulation has the potential to improve adherence and decrease prescription costs. These potential benefits are associated with important implications because hypertensive patients with additional risk factors represent a large proportion of those at risk for cardiovascular events.

EXERCISE IS GOOD FOR YOUR BLOOD PRESSURE: EFFECTS OF ENDURANCE TRAINING AND RESISTANCE TRAINING

1. Although several epidemiological studies have not observed significant independent relationships between physical activity or fitness and blood pressure, others have concluded that blood pressure is lower in individuals who are more fit or active. However, longitudinal intervention studies are more appropriate for assessing the effects of physical activity on blood pressure. 2. Previously, we have performed meta-analyses of randomized controlled trials involving dynamic aerobic endurance training or resistance training. Inclusion criteria were: random allocation to intervention and control; physical training as the sole intervention; inclusion of healthy sedentary normotensive and/or hypertensive adults; intervention duration of at least 4 weeks; availability of systolic and/or diastolic blood pressure; and publication in a peer-reviewed journal up to December 2003. 3. The meta-analysis on endurance training involved 72 trials and 105 study groups. After weighting for the number of trained participants, training induced significant net reductions of resting and day time ambulatory blood pressure of 3.0/2.4 mmHg (P < 0.001) and 3.3/3.5 mmHg (P < 0.01), respectively. The reduction of resting blood pressure was more pronounced in the 30 hypertensive study groups (-6.9/-4.9) than in the others (-1.9/-1.6; P < 0.001 for all). Systemic vascular resistance decreased by 7.1% (P < 0.05), plasma noradrenaline by 29% (P < 0.001) and plasma renin activity by 20% (P < 0.05). Bodyweight decreased by 1.2 kg (P < 0.001), waist circumference by 2.8 cm (P < 0.001), percentage body fat by 1.4% (P < 0.001) and the Homeostatic Model Assessment (HOMA) index of insulin resistance by 0.31 units (P < 0.01). High-density lipoprotein-cholesterol increased by 0.032 mmol/L (P < 0.05). 4. Resistance training has been less well studied. A meta-analysis of nine randomized controlled trials (12 study groups) on mostly dynamic resistance training revealed a weighted net reduction of diastolic blood pressure of 3.5 mmHg (P < 0.01) associated with exercise and a non-significant reduction of systolic blood pressure of 3.2 mmHg (P = 0.10). 5. In conclusion, dynamic aerobic endurance training decreases blood pressure through a reduction of systemic vascular resistance, in which the sympathetic nervous system and the renin-angiotensin system appear to be involved, and favourably affects concomitant cardiovascular risk factors. In addition, the few available data suggest that resistance training is able to reduce blood pressure.

Characteristics of Patients Undergoing Bariatric Surgery in Canada

The increasing prevalence of obesity has led to an increased use of bariatric surgery in the treatment of severely obese individuals. The characteristics of patients undergoing bariatric procedures outside of clinical studies and on a national level have not previously been reported. Acute-care hospital discharge data from the Canadian Institute for Health Information were analyzed to determine the demographic and clinical features and in-hospital mortality rates of individuals undergoing bariatric surgery in Canada. Data from individuals undergoing surgery in fiscal year 2002/2003 were compared with data from 1993/1994. Over 1100 bariatric surgeries were performed in Canada in 2002/2003, with the vast majority being performed in middle-aged women. Ten percent of patients had hypertension or diabetes, and only 1% or fewer had dyslipidemia or cardiovascular or cerebrovascular disease. Compared with 1993/1994, patients undergoing surgery in 2002/2003 were older, more likely to have diabetes or hypertension, and had shorter hospital stays. In-hospital mortality rates were <1% in both years. In the last decade, there has been a small increase in the average age and the number of patients with concomitant cardiovascular risk factors who are undergoing bariatric procedures in Canada. However, the vast majority of surgeries are being performed in middle-aged women with little cardiovascular comorbidity, and this is likely contributing to very low in-hospital death rates. Such individuals likely represent a highly selected sample of severely obese patients within Canada.

Effects of Endurance Training on Blood Pressure, Blood Pressure–Regulating Mechanisms, and Cardiovascular Risk Factors

Previous meta-analyses of randomized controlled trials on the effects of chronic dynamic aerobic endurance training on blood pressure reported on resting blood pressure only. Our aim was to perform a comprehensive meta-analysis including resting and ambulatory blood pressure, blood pressure-regulating mechanisms, and concomitant cardiovascular risk factors. Inclusion criteria of studies were: random allocation to intervention and control; endurance training as the sole intervention; inclusion of healthy sedentary normotensive or hypertensive adults; intervention duration of > or =4 weeks; availability of systolic or diastolic blood pressure; and publication in a peer-reviewed journal up to December 2003. The meta-analysis involved 72 trials, 105 study groups, and 3936 participants. After weighting for the number of trained participants and using a random-effects model, training induced significant net reductions of resting and daytime ambulatory blood pressure of, respectively, 3.0/2.4 mm Hg (P<0.001) and 3.3/3.5 mm Hg (P<0.01). The reduction of resting blood pressure was more pronounced in the 30 hypertensive study groups (-6.9/-4.9) than in the others (-1.9/-1.6; P<0.001 for all). Systemic vascular resistance decreased by 7.1% (P<0.05), plasma norepinephrine by 29% (P<0.001), and plasma renin activity by 20% (P<0.05). Body weight decreased by 1.2 kg (P<0.001), waist circumference by 2.8 cm (P<0.001), percent body fat by 1.4% (P<0.001), and the homeostasis model assessment index of insulin resistance by 0.31 U (P<0.01); HDL cholesterol increased by 0.032 mmol/L(-1) (P<0.05). In conclusion, aerobic endurance training decreases blood pressure through a reduction of vascular resistance, in which the sympathetic nervous system and the renin-angiotensin system appear to be involved, and favorably affects concomitant cardiovascular risk factors.

Systematic review of long-term weight loss studies in obese adults: clinical significance and applicability to clinical practice

Obesity is a common health problem that requires a long-term care approach. We systematically reviewed long-term (> or =2 y) studies investigating dietary/lifestyle, pharmacologic, and surgical weight loss methods to assess (1) weight loss efficacy, defined by absolute weight loss and the proportion of subjects with > or =5% weight loss, (2) effects of weight loss on cardiovascular risk factors, and (3) applicability of findings from studies to everyday clinical practice. The MEDLINE, HealthSTAR, and the Cochrane Controlled Trials databases were searched for studies investigating the long-term efficacy of weight loss methods in overweight and obese adults. Data were extracted for (i) weight loss after 1 y (pharmacologic studies only), 2 y, 3 y, and 4 y, (ii) proportion of subjects with > or =5% weight loss at the end of follow-up, and (iii) changes (end-of follow-up minus baseline values) in blood lipids, fasting blood glucose, and systolic and diastolic blood pressure. Dietary/lifestyle therapy provides <5 kg weight loss after 2-4 y, pharmacologic therapy provides 5-10 kg weight loss after 1-2 y, and surgical therapy provides 25-75 kg weight loss after 2-4 y. Weight loss of > or =5% baseline weight is not consistently associated with improvements in cardiovascular risk factors and these benefits appear to be intervention specific and occur mainly in people with concomitant cardiovascular risk factors. Weight loss studies have methodologic limitations that restrict the applicability of findings to unselected obese people assessed in everyday clinical practice. These limitations include an inadequate study duration, large proportions of subjects lost to follow-up, a lack of an appropriate usual care group, and a lack of reporting of outcomes in high-risk subgroups. Dietary/lifestyle and pharmacologic weight loss interventions provide modest weight loss, and may improve markers of cardiovascular risk factors although these benefits occur mainly in patients with cardiovascular risks. Studies investigating weight loss have methodologic limitations that restrict the applicability of findings to obese patients assessed in clinical practice.

Abklärung und praxisbasierte Risikostratifizierung bei arterieller Hypertonie. Fokus EKG

Risk stratification and treatment decision of arterial hypertension is influenced by blood pressure grade, concomitant cardiovascular risk factors, associated clinical conditions and the presence of target organ damage. The general practitioner can completely evaluate many patients without referring them for special investigations. ECG is among the routine practice methods. The sensitivity in detecting left ventricular hypertrophy is low but the specificity is very high. The new ECG parameter Cornell Strain Index with higher sensitivity is presented.

Cyclosporine: Advantages versus Disadvantages vis‐a‐vis Tacrolimus

AbstractFor Abstract see ChemInform Abstract in Full Text.

Case Study: Screening and Treatment of Pre-Diabetes in Primary Care

J.M., a 48-year-old Hispanic man, was seen in the primary care clinic for routine follow-up of hypertension, for which he had been treated for the past 8 years. His only medication was lisinopril, 20 mg/day. Home blood pressure monitoring averaged 128/82 mmHg. He had a family history for hypertension, type 2 diabetes, and coronary artery disease. J.M. reported a 20-lb weight gain over the past year, along with a sedentary lifestyle with no regular exercise routine. Other medical history was negative, including symptoms of fatigue, polyuria, or polydipsia. He denied past or current tobacco use. J.M. presented with a waist size of 42 inches, BMI of 34 kg/m2, and blood pressure of 125/80 mmHg. A subsequent lipoprotein profile demonstrated the common pattern associated with pre-diabetes, including a low HDL cholesterol (30 mg/dl) and a high triglyceride level (185 mg/dl). The LDL was mildly elevated (132 mg/dl), and total cholesterol was 199 mg/dl. His fasting glucose was 111 mg/dl, with a repeat value of 115 mg/dl one week later. 1. Does this patient have pre-diabetes? 2. When should patients be screened for pre-diabetes? 3. How should pre-diabetes be treated in primary care settings? Type 2 diabetes is a significant cause of death, disability, and health care burden in the United States, affecting an estimated 16 million Americans. A prodromal phase of this disease, in which patients manifest impaired glucose metabolism, has recently been identified as “pre-diabetes” by the U.S. Secretary of Health and Human Services.1 Pre-diabetes is also a major health care burden estimated to affect at least an additional 16 million Americans,2 and possibly as many as 43 million with the new criteria for impaired fasting glucose (IFG) being reduced to 100 mg/dl.3 Pre-diabetes is highly associated with concomitant cardiovascular risk factors and has been found to confer …

Managing hypertension in African-American patients.

Epidemiologic evidence indicates that African Americans are at greater risk for hypertension compared with other ethnic groups in the United States. The prevalence of hypertension is estimated to be approximately 37% for this group, compared with 20%-25% for non-Hispanic whites. Hypertension seems to follow a more malignant course in African Americans, possibly as a result of the higher prevalence of concomitant cardiovascular risk factors in this population. Compared with white persons with hypertension, these patients are at increased risk for left ventricular hypertrophy, heart failure, and end-stage renal disease. Data suggest that ethnicity may influence the response to certain types of antihypertensive medication. Additional data indicate that more aggressive use of combination therapy may improve clinical outcomes among high-risk hypertensive patients. Based on these findings, recommendations are made for the optimal clinical management of hypertension in African-American patients.

Cyclosporine: advantages versus disadvantages vis-à-vis tacrolimus

Despite a different molecular structure and biochemical properties, cyclosporine and tacrolimus—by inhibiting calcineurin activity—have been shown in the previous two decades of solid organ transplantation to be well tolerated and effective immunosuppressants. Initial randomized clinical trials showed a lower incidence of acute rejection in tacrolimus than in cyclosporine-treated patients, in combination with steroids and azathioprine. But in conjunction with mycophenolate mofetil, the difference in the incidence of acute rejection episodes is less clear. In general, short- and medium-term outcome variables (1-year serum creatinine, graft and patient survival) with cyclosporine and tacrolimus are excellent, and (almost) identical, with both substances having the same intrinsic nephrotoxic potential. On the other hand, cyclosporine and tacrolimus have a different impact on cardiovascular risk factors with tacrolimus having a better profile on arterial tension and lipid metabolism and cyclosporine on glucose metabolism. However, at present no data are available to discern that these differences in risk profile alter patient or graft survival or long-term cardiovascular morbidity/mortality. Therefore, prospective long-term trials are needed to study the quantitative impact of different immunosuppressive agents and concomitant cardiovascular risk factors on long-term patient and graft survival, before evidence-based (patient, graft, or cardiovascular) risk reduction can be firmly claimed by tailoring calcineurin inhibitors.

Diabetic patients after myocardial infarction

Diabetes mellitus is not just another risk factor for cardiovascular events; it per se defines maximal risk for target organ damage including the cardiovascular system. Diabetes is one of the main drivers in the race towards a higher incidence in cardiovascular disease worldwide. In addition, it is also one of the often unrecognized predecessors of myocardial infarction and sudden cardiac death. About three quarters of patients post-MI show impaired glucose tolerance or full blown diabetes. The MONICA/KORA data have shown that the higher risk for mortality and morbidity in diabetics is maintained past the first event. However, the STENO-2 trial has shown that consequently managing diabetes and concomitant cardiovascular risk factors can significantly reduce the risk for cardiovascular events in this high-risk group.

Management of cardiovascular risk factors in type 2 diabetes mellitus

Cardiovascular disease is by far the major cause of morbidity and mortality in subjects with diabetes mellitus type 2. The risk of cardiovascular disease in persons with type 2 diabetes is greater for any given risk factor, alone or in combination, than it is in persons without diabetes. Independent risk factors for cardiovascular disease in type 2 diabetes are hyperglycemia, hypertension, dyslipidemia and smoking. Subjects with diabetes mellitus type 2 benefit from cardiovascular risk factor modification, either as a primary or secondary intervention, as much as or more than those without diabetes. Risk factor modification includes behavioral modification to affect regular physical activity, healthy diet, weight loss, and smoking cessation. In addition, an optimal glycemic control with HbA1c < 7% is crucial and, aggressive management of hypertension (< 130/80 mmHg) and dyslipidemia are particularly important. Finally, aspirin (100 mg/d) is standard in secondary prophylaxis of cardiovascular events and should strongly be considered in primary prophylaxis if subjects have more than 1 concomitant cardiovascular risk factors.

Hypertension in women.

Hypertension in women has received less attention than hypertension in men, and the major controlled trials of antihypertensive therapy have been carried out in populations made up predominantly of and have emphasised outcomes in men. Recently it has been recognised that women develop high blood pressure, particularly systolic hypertension, at an increased rate as they age, and that this age-related blood pressure increase is exaggerated by the menopause. The age-related rise in blood pressure, particularly systolic blood pressure and pulse pressure, contributes substantially to the age-related increase in risk of heart attack, heart failure, and stroke in middle-aged and elderly women. This article reviews aspects of hypertension epidemiology, pathophysiology, diagnosis and treatment that are important to women's health with particular emphasis on important concomitant cardiovascular disease risk factors such as type 2 diabetes and the menopause. The role of ovarian hormones and their withdrawal in the pathogenesis of hypertension and related target organ damage is considered, as are the results of drug treatment of high blood pressure in women. Blood pressure in pregnancy is discussed in a separate article by Broughton-Pipkin and Roberts.

Comprehensive Nutrition Plan Improves Cardiovascular Risk Factors in Essential Hypertension

Increased arterial pressure is known to be influenced by a variety of nutrients. Compliance with dietary recommendations for risk reduction is often limited by the complexity of their implementation. In addition, how improvements in total diet, rather than single nutrients, influence concomitant cardiovascular risk factors has not been thoroughly explored. We assessed the effects of a nutritionally complete prepared meal program, the Campbell’s Center for Nutrition and Wellness plan (CCNW), compared with dietary therapy in which participants received a structured nutritional assessment and prescription and selected their own foods, in 101 women and men with mild-to-moderate hypertension. Outcome measures included blood pressure (BP), lipids and lipoproteins, glucose, glycosylated hemoglobin (HbA 1c), insulin, homocysteine, nutrient intake, compliance, and quality of life. Both dietary interventions significantly lowered BP ( P < .0001), while simultaneously improving the overall cardiovascular risk profile. Significantly greater benefits were observed with the CCNW plan as compared with the participant selected diet in cholesterol and LDL levels (both P < .0001), LDL:HDL ( P < .001), HbA 1c ( P < .05), homocysteine ( P < .001), total nutrient intake ( P < .0001), compliance ( P < .0001), and quality of life ( P < .001). This study demonstrates that improving the total diet to include the full array of recommended dietary guidelines, rather than focusing on single nutrients, has significant benefits for the cardiovascular risk profile of hypertensive persons beyond BP control. Compared with typical dietary therapy, the comprehensive CCNW meal plan has significantly greater effects on multiple cardiovascular risk factors while yielding greater compliance and improved quality of life.

Managing the burden of Type 2 diabetes: an international survey of physicians

AbstractThis prospective, cross‐sectional study was designed to gather information about the management of patients with Type 2 diabetes (NIDDM). It was conducted in three of the largest European healthcare providing countries: France, Germany and the UK. Three hundred and five physicians completed five sections of a diary card (covering aspects of workload, demography, treatment, condition and tests conducted) anonymously for 3,043 pharmacologically‐treated Type 2 patients attending for a consultation. The majority of the patient population were elderly, had had a long diagnosis of diabetes, were overweight and had several coexisting complications. Neuropathy, nephropathy and retinopathy were present in 23%, 24% and 15% of the patients, respectively. Concomitant cardiovascular risk factors such as hypertension, hypercholesterolaemia and ischaemic heart disease were present in 49%, 40% and 34% of patients, respectively. Fifty per cent of patients had undergone a change in therapy in the previous five years: the major reason being ‘insufficient glycaemic control’. In the remainder, adverse effects of weight gain and hypoglycaemia were most commonly reported. This information provides an insight into the present and future clinical burden that diabetes places on patients, physicians and healthcare systems.

Clinical Aspects of Hypertension.

A number of controversies concerning clinical aspects of hypertension are addressed. These include the need for out-of-the-office blood pressure readings in order not to incorrectly label the many people who have white-coat elevations of pressure as being hypertensive. A second issue is determining the need for antihypertensive drug therapy after institution of an appropriate program of lifestyle modifications. Emphasis is placed upon the need to go beyond the level of blood pressure and to incorporate both the degree of target organ damage and the presence of concomitant cardiovascular risk factors in deciding upon the need for drug therapy. Once therapy is begun, the choice of initial therapy should be based upon certain demographic features and, mainly, the concomitant conditions that may be either adversely or positively influenced by the agent chosen. Since a J-curve of coronary disease likely exists, caution is advised not to lower the pressure below the lower limit of coronary perfusion. Lastly, the potential for prevention of hypertension is supported. (Hypertens Res 1994; 17: 205-213)

Management of hypertension

To provide maximal protection against the cardiovascular complications that accompany hypertension, the disease must be managed in ways to minimize the total cardiovascular risk burden. These involve five major steps: (1) careful monitoring of the blood pressure in response to appropriate therapy; (2) assessment of concomitant cardiovascular risk factors; (3) institution of life-style modifications needed to control both hypertension and other risk factors; (4) use of antihypertensive drugs, chosen to best manage the individual patient's overall risk burden and provided in a manner that will lower the pressure gently while avoiding adverse reactions; and (5) identifying and reaching the goal of therapy: levels of blood pressure that are neither too high to avoid increased risks for cerebral and renal damage nor too low to avoid increased risks for coronary ischemia. This monograph builds on the 30-year experience of one of the leading clinical investigators in the field to translate the multiple advances made in the management of hypertension into practical guidelines for improved care of the many millions of patients with this disease. Particular emphasis is directed toward certain therapeutic challenges, including the elderly, diabetic patients, and resistant hypertensive patients.

Epidemiology, pathophysiology, and management of isolated systolic hypertension in the elderly

Isolated systolic hypertension (ISH) is a common disorder in the elderly, carrying with it a high risk of cardiovascular morbidity and mortality. Environmental and age-related factors believed to contribute to ISH include obesity, declining physical activity, stress, and such dietary changes as increased salt intake and decreased intake of calcium and potassium. Increased rigidity of the aorta resulting in reduced compliance is an important hemodynamic feature, but factors that increase peripheral resistance also appear to play a role. Antihypertensive drugs have been shown to effectively and safely lower the systolic blood pressure elevations characteristic of ISH. To date, use of low drug doses and careful titration of dosage have avoided significant orthostatic hypotension and undue lowering of the diastolic pressure. Studies of relatively small groups of patients suggest that antihypertensive drugs can lower the risk of cardiovascular morbidity/mortality associated with ISH but the definitive answer awaits results of the on-going large-scale Systolic Hypertension in the Elderly Program trial. In the interim, management should begin with conservative measures such as weight loss, salt restriction and, possibly, calcium supplementation. If this fails, drug therapy should be considered in patients with systolic blood pressures above 180 mm Hg and in those with systolic readings between 160 and 180 mm Hg who have concomitant cardiovascular risk factors. To date, no controlled trials of sufficient size have demonstrated that one drug class is more effective than another in treating ISH. Drug therapy should be tailored to the individual patient, starting with a low dose of a single drug and, if necessary, slowly increasing dosage until a systolic blood pressure under 160 mm Hg is attained.