Number Of Antihypertensive Agents Research Articles

The elusive type 2 diabetes individual achieving tight blood pressure target: A phenotypic study

Background To describe the characteristics (therapeutic, physical and behavioural) associated with achievement of tight blood pressure (BP) control and its prevalence in type 2 diabetes (T2DM) patients. Methods Cross-sectional observational cohort study. 673 hypertensive patients with T2DM, treated with one or more antihypertensive drugs. Sociodemographic, clinical and laboratory variables compared between patients achieving BP targets (goal-achievers [GAs]) and non-goal-achievers (non-GAs). Results Only 111 patients (16%) achieved BP goals. Markers-factors connected with failure of BP control in non-GAs were: sub-Saharan African ethno-geographical origin, high alcohol consumption and low educational level. Total cholesterol was significantly lower and glycaemic control significantly better in GAs. In addition, prevalence of micro- or macro-albuminuria was clearly lower in GAs. As regards cardiovascular drugs, statins were used to a greater extent by the GAs. Finally, GAs and non-GAs had the same pattern of micro- and macro-vascular diabetic diseases, as well as similar estimated 10-year absolute cardiovascular risk scores. Conclusions This cross-sectional study characterized variables associated with an unmet need in drug-treatment of hypertension in T2DM. One might surmise that using higher dosage and/or number of antihypertensive agents will be required in most T2DM patients in order to reach targets, including new antihypertensive agents.

High prevalence of nocturnal arterial hypertension and non-dipping in lung transplant recipients

Objective— An abnormal circadian blood pressure (BP) profile is associated with adverse cardiovascular and all-cause outcomes. It is highly prevalent after heart, liver and kidney transplantation. We aimed to assess the prevalence of an abnormal ambulatory BP pattern in lung transplant recipients (LTx).Methods— Ambulatory BP monitoring (ABPM) was performed in 53 LTx and compared to those of 42 control subjects matched for age, gender and daytime BP. In 19 patients in whom at least two recordings were performed, we compared the first and the last one.Results— The non-dipping pattern (a less than 10% reduction in nocturnal BP) was more prevalent in LTx than in control subjects (89 versus 64%, P < 0.01). Nighttime BP was higher in LTx than in control subjects (P < 0.01 and < 0.001 for systolic BP (SBP) and diastolic BP (DBP), respectively). The nocturnal reduction of BP was lower in LTx than in control subjects (3 versus 8% for SBP and 6 versus 13% for DBP, both P < 0.001). These results remained significant after adjustment for the presence of diabetes mellitus and creatinine clearance.In the 19 patients in whom ABPM was performed twice (mean interval between the two recordings was 22 months), ambulatory BP values remained unchanged between the two recordings, although the number of antihypertensive agents was significantly higher.Conclusion— An abnormal circadian BP profile is highly prevalent after lung transplantation. It is observed consistently over prolonged periods of time.

High prevalence of nocturnal arterial hypertension and non-dipping in lung transplant recipients.

An abnormal circadian blood pressure (BP) profile is associated with adverse cardiovascular and all-cause outcomes. It is highly prevalent after heart, liver and kidney transplantation. We aimed to assess the prevalence of an abnormal ambulatory BP pattern in lung transplant recipients (LTx). Ambulatory BP monitoring (ABPM) was performed in 53 LTx and compared to those of 42 control subjects matched for age, gender and daytime BP. In 19 patients in whom at least two recordings were performed, we compared the first and the last one. The non-dipping pattern (a less than 10% reduction in nocturnal BP) was more prevalent in LTx than in control subjects (89 versus 64%, P < 0.01). Nighttime BP was higher in LTx than in control subjects (P < 0.01 and < 0.001 for systolic BP (SBP) and diastolic BP (DBP), respectively). The nocturnal reduction of BP was lower in LTx than in control subjects (3 versus 8% for SBP and 6 versus 13% for DBP, both P < 0.001). These results remained significant after adjustment for the presence of diabetes mellitus and creatinine clearance. In the 19 patients in whom ABPM was performed twice (mean interval between the two recordings was 22 months), ambulatory BP values remained unchanged between the two recordings, although the number of antihypertensive agents was significantly higher. An abnormal circadian BP profile is highly prevalent after lung transplantation. It is observed consistently over prolonged periods of time.

Comparing the Prevalence of Primary Aldosteronism in Hypertensive Diabetic and Non-diabetic Patients

Background: Primary aldosteronism is the most common cause of secondary hypertension in humans. Its prevalence is estimated to be 10-15% among hypertensive patients. It is also associated with insulin resistance and diabetes mellitus. The aim of our study was to compare the prevalence of primary aldosteronism in hypertensive patients with presence of diabetes mellitus. Methods: We reviewed retrospectively the clinical records of 104 hypertensive patients for whom we also measured plasma renin activity (PRA) and plasma aldosterone concentrations (PAC). Results: Among 104 hypertensive patients, 44 had diabetes and 60 did not. There were no significant differences in clinical characteristics between non-diabetic and diabetic patients except for age and the number of antihypertensive agents. Patients with target organ damage were more common among diabetic patients. There was no correlation between PAC and the number of target organs damaged. In addition, Four patients from the non-diabetic and two from the diabetic group had a rat io over 30 for PRA/PAC and a PAC of over 15 ng/dL. Two non-diabetic patients and one diabetic patient were found, on abdomen CT, to have an adrenal adenoma. The rest of the patients refused further tests. Conclusion: The prevalence of primary aldosteronism in diabetic patients does not differ significantly from that in non-diabetic patients. Therefore, the present routine screening test for primary aldosteronism in

An Open‐Label, Multicenter, Flexible Dose Study to Evaluate the Efficacy and Safety of Viagra® (Sildenafil Citrate) in Korean Men with Erectile Dysfunction and Arterial Hypertension who are Taking Antihypertensive Agents

Erectile dysfunction (ED) is common among men taking antihypertensive agents to control blood pressure. We evaluated the efficacy and safety of sildenafil citrate in men with ED taking antihypertensive agents. A total of 198 male subjects, aged 20 years and older were enrolled. This study was conducted for 10 weeks as an open-label, multicenter and flexible dose trial with a 2-week screening period and an 8-week treatment phase. Subjects were asked to complete Event Log Worksheets, as well as the International Index of Erectile Function (IIEF) and the Global Efficacy Assessment Questions (GEAQ) questionnaires during the study period. The average age among the 167 subjects who completed the study was 55.8 (31.7 to 77.1). The scores for questions 3 and 4 of IIEF improved from 2.3 and 1.8 at baseline to 3.7 and 3.4 at week 4 and 3.8 and 3.4 at week 8, respectively. There were 86.3% of the patients reported improved erectile function at week 8; 88.3% of the patients reported improved ability to achieve sexual intercourse at week 8. There were no significant differences observed in the responses to questions 3 and 4 of IIEF and GEAQ by the number of antihypertensive agents taken. The adverse events were facial flushing (20.1%), headache (11.7%), palpitation (5.0%), rhinitis (2.8%), URI (2.8%), dizziness (2.2%), dyspnea (2.2%), and nausea (1.7%). Sildenafil citrate is an effective treatment for ED; it is safe and well tolerated by patients with ED taking multiple antihypertensive agents for arterial hypertension.

Long‐term outcome of transplant renal artery stenosis managed conservatively or by radiological intervention

The natural history and optimal treatment of transplant renal artery stenosis (TRAS) is poorly defined. Few studies reported long-term clinical outcomes. A single centre analysis of 43 patients diagnosed with TRAS 1990-2003 was performed. Twenty-seven had percutaneous intervention (including 10 patients who had >1 intervention) and 16 were managed conservatively at the discretion of the attending clinicians. Transplant function was assessed by slope of estimated glomerular filtration rate (eGFR) over five yr of follow-up. Patients in the intervention group had lower mean eGFR (36.3 mL/min/1.73 m(2) vs. 46.3 mL/min/1.73 m(2); p = 0.07) at baseline. Five transplants in the intervention group failed (including two as a direct result of intervention) and one in the conservative group failed. There was no significant difference in the rate of deterioration in renal function (mean slope of eGFR minus 0.8 mL/min/yr and minus 1.0 mL/min/yr in the intervention and conservative groups, respectively; p = 0.79). There was no significant difference in blood pressure or number of anti-hypertensive agents between the groups at any time point. Baseline Doppler ultrasound indices showed no significant correlation with slope of eGFR in either group. Our data demonstrate that selected patients with TRAS can be managed without intervention and that this approach is associated with good long-term outcome. Selection of appropriate patients for intervention remains difficult and larger randomized studies are required.

Endovascular management of atherosclerotic renovascular disease: Early results following primary intervention

This retrospective review examines periprocedural morbidity and early functional responses to primary renal artery angioplasty and stenting (RA-PTAS) for patients with atherosclerotic renovascular disease (RVD). Consecutive patients undergoing primary RA-PTAS for hemodynamically significant atherosclerotic RVD with hypertension and/or ischemic nephropathy were identified from a prospectively maintained registry. Hypertension responses were determined based on pre- and post-intervention blood pressure measurements and medication requirements. Estimated glomerular filtration rate (eGFR) was used to determine renal function responses. Both hypertension and renal function responses were assessed at least three weeks after RA-PTAS. Stepwise multivariable regression analysis was used to examine associations between blood pressure and renal function responses to RA-PTAS and select clinical variables. One-hundred ten primary RA-PTAS were performed on 99 patients with atherosclerotic RVD with a mean angiographic diameter-reducing stenosis of 79.2 +/- 12.9%. All patients had hypertension (mean of 3.4 +/- 1.3 antihypertensive agents). Mean pre-intervention eGFR was 49.9 +/- 22.7 mL/min/1.73 m(2), and 74 patients had a pre-intervention eGFR < 60 mL/min/1.73 m(2). The technical success rate for RA-PTAS was 94.5%. The periprocedural complication rate was 5.5%; there were no periprocedural deaths. Statistically significant decreases in mean systolic blood pressure (161.3 +/- 25.2 vs. 148.5 +/- 25.2 post-intervention, P < .0001), diastolic blood pressure (78.6 +/- 13.3 versus 72.5 +/- 13.5 post-intervention, P < .0001), and number of antihypertensive agents (3.3 +/- 1.2 versus 3.1+/- 1.3 post-intervention, P = .009) were observed. Assessed categorically, hypertension response to RA-PTAS was cured in 1.1%, improved in 20.5%, and unchanged in 78.4%. Categorical eGFR response to RA-PTAS was improved in 27.7%, unchanged in 65.1%, and worsened in 7.2%. Multivariable stepwise regression revealed associations between pre- and post-intervention systolic blood pressure (P < .0001), diastolic blood pressure (P < .0001), and eGFR (P < .0001), as well as a trend toward improved diastolic blood pressure response among patients managed with staged bilateral intervention (P = .0589). Primary RA-PTAS for atherosclerotic RVD was associated with low peri-procedural morbidity and mortality but only modest early improvements in blood pressure and renal function. Results from ongoing prospective trials are needed to assess the long term outcomes associated with RA-PTAS and clarify its role in the management of atherosclerotic RVD.

Association between Erythropoietin Requirements and Antihypertensive Agents

Background: Angiotensin-converting enzyme inhibitors (ACI) and angiotensin II receptor blockers (ARB) have been reported to increase recombinant human erythropoietin (rHuEPO) requirements. We performed a cross-sectional study to investigate an association of antihypertensive agents including these two with the rHuEPO dose in chronic hemodialysis patients. Methods: We studied 625 patients undergoing hemodialysis therapy in 11 dialysis units. The association between the rHuEPO dose and antihypertensive agents was statistically analyzed. Results: The mean hemoglobin (Hb) level and rHuEPO dose corrected by body weight were 10.5 g/dl and 95.2 U/kg/week, respectively. When the patients were subdivided into four groups according to the number of prescribed antihypertensive agents (G-0, G-1, G-2, and G-3; patients prescribed with no medication, 1, 2, and >3 drugs, respectively), a significantly low dose of rHuEPO was observed in G-0 compared to the other groups. Unpaired t test showed a higher dose of rHuEPO in the presence of ARB, α-blockers, or calcium channel blockers (CCB). The rHuEPO dose was higher in the elderly, in females, and in patients with diabetes or hypertension. In multiple regression analysis, age, sex, rHuEPO dose, serum albumin level, and duration of dialysis therapy but not antihypertensive drugs were independent factors for the Hb level. In contrast, the rHuEPO dose was significantly associated with a low level of Hb, age, females, and CCB use. However, since CCB use was strongly associated not only with rHuEPO dose but also with systolic blood pressure and the use of α-blockers and ARB, these findings might be caused by erythropoietin (EPO)-induced hypertension. Conclusion: There was an association between the number of antihypertensive agents and rHuEPO dose in chronic hemodialysis patients. However, no significant relation was indicated between ARB/ACI use and EPO requirements.

Long-term clinical outcome of paediatric kidneys transplanted to adults

We have earlier shown an increase in the size and excellent graft function of paediatric kidneys transplanted to adults up to 1 year following transplantation. This study was performed to assess the long-term outcome of these transplants. From a primary cohort of 19 adults, receiving a first kidney transplant from a paediatric donor <10 years of age, 16 patients were available for a complete long-term follow-up, 5-9 years post-transplant. Of these, eight patients were transplanted with a donor of <5 years. All medical files and registry data of the cohort, from the time of transplantation to the follow-up time point, were recalled and events were registered. The patients' general condition, body weight, blood and urine tests, blood pressure (BP), use of antihypertensive agents and GFR were recorded. To explore the temporal increment in the size of paediatric donor kidneys transplanted to adults, the maximal cranio-caudal length of the kidneys from the time of transplantation to follow-up was established by ultrasound. Volumes (length x width x thickness x pi/6) of en bloc kidneys versus single paediatric kidneys and adult-to-adult transplants were compared. Long-term (7 years, median) patient and graft survival was 95% and 89%, respectively. Mean serum creatinine was 85 micromol/l (range, 32-131). The mean estimated GFR was 84 ml/min/1.73 m(2). The mean BP was 134/79 mmHg (range, 120-185/70-90). The number of antihypertensive agents used was not statistically different from the number used at 1 year post-transplant. None of the patients had significant proteinuria as a sign of hyperfiltration injury of the graft. There were no statistically significant increases in the maximal cranio-caudal length of the transplanted kidney(s) from 1 year post-transplant to follow-up; however, the en bloc kidneys tended to be larger than single paediatric grafts (240 ml and 204 ml) and adult-to-adult grafts (170 ml). Paediatric kidneys transplanted to adults should be considered as excellent for transplantation on a long-term basis.

Renal artery stenting slows the rate of renal function decline

The primary objective of this study was to analyze renal artery interventions performed at a tertiary medical center and to evaluate improvements in hypertension and renal excretory function. A retrospective analysis was performed of patients treated at a tertiary medical center from January 2001 to December 2005. All patients treated with renal artery stenting by the Interventional Radiology or Endovascular Services were included. Descriptive and inferential analyses were performed. Forty patients with renal artery stenosis were evaluated for renal artery stenting, of these 22 were followed up with medical management. Twenty-six renal artery stents were placed in 18 patients (mean age, 70 +/- 8 years), of whom 76% were treated for multidrug resistant hypertension, and 24% were treated for renal salvage. Mean follow-up was 15 months. Patients experienced a significant reduction in hypertension and in the number of antihypertensive agents, but this significance deteriorated at 6 months, when their blood pressure and number of medications returned to preprocedural values. Compared with a cohort that was followed up with medical management, the rate of renal function decline improved from -0.08 mg/dL per month to 0.00 mg/dL per month (P < .05) after intervention. Patients with baseline chronic renal insufficiency experienced the greatest benefit from renal artery stenting. Renal artery stenting initially improves hypertension control, but the durability is lost after 6 months. Renal artery stenting dramatically slows the rate of renal function decline and could potentially delay a patient's requirement for hemodialysis.

Nurse‐led management of uncontrolled hypertension in those with diabetes and high vascular risk

AbstractThe aim of this audit was to determine the effectiveness of a protocol driven, nurse‐led hypertension service for patients with diabetes at high risk.Data for this audit were collected prospectively on referred patients with established diabetes complications and suboptimal hypertension control. Antihypertensive agents were sequentially introduced and dose titrated according to protocol. Patients were discharged once the target systolic blood pressure (SBP) of &lt;140mmHg was achieved or the intended sequence of drug therapy was complete.In all, 124 patients completed the full process. There were significant reductions in SBP (186±24 to 139±12mmHg, p&lt;0.001) and diastolic blood pressure (85±13 to 67±11mmHg, p&lt;0.001). A total of 61% achieved the target SBP of &lt;140mmHg. There were expected increases in the number of antihypertensive agents and the number of agents used to maximum dose. Estimated coronary heart disease risk for the primary prevention group improved significantly despite non‐significant changes in lipid profiles.It was concluded that a systematic approach combining a pre‐set drug protocol itself and its timely implementation under adequate surveillance in a nurse‐led hypertension clinic led to effective outcomes. Copyright © 2007 John Wiley &amp; Sons.

Recognition and management of phaeochromocytoma

Phaeochromocytomas are potentially lethal catecholamine secreting tumours. 90% occur in the adrenal glands (10% are bilateral) and 10% are extra adrenal. Clinical presentation depends on the pattern of catecholamine secretion. The symptoms are diverse, but the most common are headache, diaphoresis and palpitations. These tumours are important to the anaesthetist because they can present unexpectedly perioperatively and the mortality is up to 50%. Diagnosis relies on the demonstration of excessive catecholamine production by 24 hour urine measurement. The tumour is usually localized by CT or MRI imaging. Excision of the tumour can only be undertaken safely when pharmacological control of the sympathetic nervous system and normovolaemia have been achieved. A number of antihypertensive agents have been used successfully in the perioperative period to maintain cardiovascular stability. Preoperative preparation should also include an assessment of myocardial function to exclude the presence of phaeochromocytoma associated cardiomyopathy. Adrenalectomy can be performed using an open or laparoscopic approach, with each procedure having implications for the anaesthetist. Management of intraoperative hypertensive surges and arrhythmias requires an understanding of the physiology and pharmacology of phaeochromocytomas. This article details the clinical presentation, diagnosis and perioperative anaesthetic management of elective and emergency phaeochromocytomas.

Angiotensin converting enzyme insertion/deletion polymorphism does not influence postcardiac transplantation hypertension onset or progression

Background The angiotensin converting enzyme insertion deletion polymorphism (ACE I/D) has been associated with much cardiovascular pathology, including posttransplantation hypertension. Hypertension is a significant cause of morbidity and mortality after cardiac transplantation. We investigated the influence of the ACE I/D polymorphism on posttransplantation hypertension. Methods A total of 211 heart transplant recipients and 154 corresponding donors were genotyped for the ACE I/D polymorphism by polymerase chain reaction. ACE enzymatic activity was measured by spectrophotometric kinetic analysis. Sitting systolic and diastolic blood pressures were recorded at 3 consecutive visits, and the mean was calculated. Clinical data, including demographics and medication, were collected for all recipients. Results were analyzed by the chi-square test and analysis of variance, taking a p value of <0.05 to be significant. Results A total of 41.7% of the subjects were hypertensive (diastolic blood pressure >90 mm Hg) at the time of the study, with 79.6% taking at least one antihypertensive agent. We found no difference between the number of antihypertensive agents, cyclosporin dose and level, renal function, or systolic blood pressure for the different recipient or donor genotypes. We also found no significant correlation between ACE enzymatic activity and systolic or diastolic blood pressure. Conclusions Our study of 211 recipients and 154 corresponding donors is the largest investigation of this polymorphism in a cardiac transplantation population. We found no apparent relationship between the ACE genotype (of either donor or recipient) and systemic hypertension (absolute measurements and the number or dose of antihypertensive agents used).

Bimodal Dialysis: An Integrated Approach to Renal Replacement Therapy

Peritoneal dialysis (PD) and hemodialysis (HD) are both widely used as sole therapies for end-stage renal disease (ESRD). There is still controversy over which (if either) is superior in terms of patient outcomes. Peritoneal dialysis offers the advantages of long, slow, continuous ultrafiltration and potentially enhanced protection of residual renal function (RRF). In contrast, HD offers superior solute removal at the cost of undesirable cardiovascular tolerance of high rates of sodium and water removal. The aim of this study was to investigate the clinical feasibility of offering a combined treatment of both modalities [bimodal dialysis (BMD)] to incident patients reaching ESRD. We set out to investigate if it might be possible to utilize the intrinsic advantages of both modalities within a setting of good patient acceptability. We prospectively studied 8 patients. They were recruited in the pre-ESRD phase from a specialist low clearance clinic. An arteriovenous fistula was formed and peritoneal catheters were inserted. The BMD consisted of 2, 3-hour, high efficiency, euvolemic HD sessions per week in combination with 2 PD exchanges per day to provide a degree of solute clearance and all of the ultrafiltration. Adequacy was measured independently for each modality. Patients were followed using the standard range of evaluations in addition to RRF (by creatinine clearance and EDTA clearance), echocardiography (left ventricular mass and ventricular performance), treatment outcomes, patient symptoms, and complications. Mean time on BMD was 346 +/- 74.9 (range 245 - 431) days. Peritonitis rate was 21 months per episode (mean 0.6 +/- 0.9, 0 - 2 episodes per patient). Mean peritoneal ultrafiltration volume was 1.58 +/- 0.32 (1.3 - 2.1) L per day. Delivered Kt/V and weekly PD Kt/V did not change significantly. Patients' RRF was maintained over the study period, as were serum albumin and control of serum phosphorus. Blood pressure was controlled with a reduction in the number of antihypertensive agents. Left ventricular mass index reduced over the treatment period, from a mean of 194 +/- 31.2 (161 - 265) to 156 +/- 21.2 (138 - 189) g/m2 (p = 0.05). Ventricular performance remained unchanged over the study [ejection fraction 50.4 +/- 11.1 (38 - 67) % to 48 +/- 8.0 (48 - 67) %]. Mean time during BMD spent on HD alone was 4.2 +/- 6.9 (0 - 16) days, and on PD alone 9.2 +/- 10.6 (0 - 25) days. This study suggests that BMD is a feasible treatment for ESRD. It is associated with adequate solute removal and good hemodynamic/volume control, and allows increased treatment flexibility for coping with complications normally requiring recourse to unplanned HD with temporary central venous access.

Low-dose aspirin therapy is associated with improved allograft function and prolonged allograft survival after kidney transplantation.

Aspirin treatment has an undoubted beneficial impact on the progression of cardiovascular diseases. We hypothesized that aspirin also protects allograft function and survival in the context of chronic renal allograft dysfunction, which displays decisive pathophysiologic features that are similar to those involved in atherogenesis. A retrospective, multivariate analysis was performed to assess the effect of low-dose aspirin treatment (100 mg/day) on allograft function and survival of 830 renal transplant recipients. Allograft function was evaluated by serum creatinine levels, urine protein levels, and the presence of hematuria. Median allograft survival time was significantly longer in patients receiving low-dose aspirin therapy compared with patients receiving no aspirin treatment (n=205, 13.8 +/- 2.6 vs. 7.8 +/- 0.3 years, n=625; adjusted relative risk=0.443, 95% confidence interval [0.323-0.608], P<0.0001). Statin treatment and a recent time point of transplantation, reflecting the qualitative advances of the applied immunosuppressive therapy, were further positive determinants of renal allograft survival. The number of antihypertensive agents, representing the extent of hypertension, was a negative determinant of allograft survival. Transplant function was better preserved in aspirin-treated patients, who displayed a slower increase of serum creatinine and less proteinuria and hematuria during the observation period. The duration of aspirin treatment was positively associated with better allograft function. Low-dose aspirin therapy substantially improves renal allograft function and allograft survival. These findings suggest that aspirin should be considered to complement long-term posttransplant medical treatment regimens.

Analysis of Recent Papers in Hypertension

Analysis of Recent Papers in Hypertension

Role of organizational factors in poor blood pressure control in patients with type 2 diabetes: the QuED Study Group--quality of care and outcomes in type 2 diabetes.

A large body of evidence supports the need for reducing the cardiovascular burden of diabetes. Only indirect and occasional data describe the adequacy of routine management of hypertension in patients with diabetes. The aim of this study was to explore the interplay of some potential key determinants of quality of antihypertensive care, including the settings, physicians' beliefs about blood pressure (BP) control, and patient-related factors. We evaluated physicians' beliefs about BP control using questionnaire responses at study entry. A sample of 3449 patients with type 2 diabetes mellitus, of whom 1782 (52%) were considered to have hypertension, was recruited by 212 physicians practicing in 125 diabetes outpatients clinics (DOCs) and 106 general practitioners (GPs). We evaluated the type and number of antihypertensive agents used and the BP values at study entry and after 1 year of follow-up. We used multilevel analysis to investigate correlates of poor BP control (> or =160/90 mm Hg). Only 16% of GPs and 14% of DOC physicians targeted BP values of less than 130/85 mm Hg. At study entry, 6% of the patients had values below 130/85 mm Hg, whereas 52% showed values of 160/90 mm Hg or greater. Only 12% of subjects were treated with more than 2 drugs at study entry, compared with 16% at the 1-year follow-up (P =.001). Multilevel analysis showed that patients attending DOCs had a more than 2-fold increased risk for inadequate BP control, compared with those treated by GPs. The risk for poor BP control was 2 times higher for patients treated by male physicians compared with those treated by female physicians, and it was halved when the physician responsible for the diabetes care specialized in diabetology or endocrinology. In a model situation of comorbidity, the overall quality of care depends on structural and organizational factors, which are likely to be more influential than existing guidelines.

Systemic Hypertension: Management in Children and Adolescents.

Recognition of systemic hypertension in children and adolescents requires careful blood pressure measurement using proper technique to compare with appropriate normative data. Selected use of ambulatory blood pressure monitoring can identify children with "white coat" hypertension, thus avoiding unnecessary diagnostic testing and treatment in these children. Nonpharmacologic therapies including dietary sodium restriction, weight loss, and exercise may benefit children and adolescents with borderline hypertension and mild essential hypertension. These therapies may be important adjunctive agents in children requiring antihypertensive therapy as well. Historically, pharmacologic management of hypertension in children has been limited by a lack of controlled studies and age-appropriate formulations. Recent clinical trials have provided new information regarding a number of antihypertensive agents in this age group.

Insulin resistance after renal transplantation: impact of immunosuppressive and antihypertensive therapy.

The purpose of the present study was to validate various surrogate estimates of insulin sensitivity (IS) in a renal transplant population and to assess the influence of immunosuppressive and antihypertensive therapy on insulin resistance (IR) after renal transplantation. A total of 167 consecutive renal transplant recipients without previously known diabetes underwent a 75-g oral glucose tolerance test (OGTT) 3 months after renal transplantation. A total of 43 patients also underwent a euglycemic-hyperinsulinemic glucose clamp study. Six OGTT-derived IS indexes were validated against the euglycemic-hyperinsulinemic glucose clamp-derived IS index (ISI(CLAMP)). The OGTT-derived ISI(TX) correlated closely with the ISI(CLAMP) (r = 0.58, P < 0.001). The other surrogate estimates of IS were also significantly but less well correlated with the ISI(CLAMP) (Spearman's correlation; r = -0.45 to 0.41, P = 0.003-0.050). In the univariate model, BMI, daily prednisolone dose, creatinine clearance, hypertension, number of antihypertensive agents, and use of diuretics or beta-blockers were negatively associated with ISI(TX) (P < 0.05). After multiple regression analysis, BMI (P < 0.001), daily prednisolone dose (P < 0.001), cytomegalovirus infection (P = 0.030), and triglycerides (P = 0.034) were shown to be independent predictors of posttransplant IR. The OGTT-derived ISI(TX) may be a useful estimate of IS in Caucasian renal transplant recipients. Increasing daily prednisolone dose is an independent predictor of IR after renal transplantation. Hypertension and the use of beta-blockers and diuretics may also deteriorate IR in this group of patients.

Efficacy and safety of angiotensin receptor blockers: a review of losartan in essential hypertension

Background: Current guidelines and results from recent clinical trials have refocused attention on the treatment of hypertension. Emphasis has been placed on identifying patients at high risk and treating to lower levels of blood pressure, particularly in patients with diabetes or target organ damage. Due to their proven benefits, diuretics and beta-blockers continue to be suggested as initial therapy for patients with essential hypertension. However, many acknowledge that antihypertensive therapy needs to be individualized, taking into account patient demographic characteristics, concomitant diseases that may be affected beneficially or adversely by the antihypertensive agent chosen, quality of life, cost, and use of other drugs that may lead to drug interactions. Most patients will require combination therapy to achieve adequate blood pressure control. Therefore, a number of antihypertensive agents may be appropriate for first-line or add-on therapy. Objective: The objective of this article was to review current treatment options for hypertension, with particular emphasis on the angiotensin receptor blockers (ARBs). Losartan, the most widely studied agent of this class, is also discussed. Methods: Selected references were sought from MEDLINE® (1990–2000) describing the pharmacology, antihypertensive efficacy, and tolerability of ARBs. Results: In hypertensive patients, losartan has been compared with other antihypertensive agents, including enalapril, amlodipine, and nifedipine gastro-intestinal therapeutic system. In each case, an antihypertensive regimen of losartan once daily with or without hydrochlorothiazide showed comparable blood pressure-lowering effects. Losartan has also consistently demonstrated an excellent tolerability profile, with an overall incidence of adverse effects similar to that of placebo. Subtle pharmacologic differences exist among the agents of the ARB class. However, a recent meta-analysis suggested that no clinically or statistically significant difference in antihypertensive efficacy exists among them. Conclusions: ARBs such as losartan are effective with once-daily dosing and have an excellent safety profile. These agents are clearly a useful first-line or add-on treatment option in patients with hypertension.