Артериальная гипертония. Это интересно.

[Dr.Vad]

Антигипертензивные новинки: первый анти-рениновый препарат получил одобрение FDA - ализкирен, его некоторые особенности, ограничения, перспективы:

Aliskiren is a novel oral antihypertensive agent, and the first in the new class of direct renin inhibitors. The drug demonstrates effective blood lowering in a number of studies as monotherapy and in combination with a thiazide diuretic (hydrochlorothiazide), an angiotensin-converting enzyme inhibitor (ramipril) and a calcium channel blocker (amlodipine). Other studies applying ambulatory blood pressure monitoring show that aliskiren maintains blood pressure control for more than 24 hours. Aliskiren, 150 mg and 300 mg have demonstrated a placebo-like safety and tolerability profile, with no interactions with a wide range of commonly used drugs.

In a double-blind, randomised parallel-group trial, Gradman and colleagues assigned 652 hypertensive patients once-daily doses of 150 mg, 300 mg, or 600 mg aliskiren, 150 mg irbesartan, or placebo. The reductions in blood pressure (systolic/diastolic) measured at trough after 8 weeks of follow-up and adjusted for baseline values and the difference from placebo averaged 6·1/2·9 mm Hg, 10·5/5·4 mm Hg, 10·4/5·2 mm Hg, and 7·2/2·5 mm Hg on the increasing doses of aliskiren and irbesartan, respectively. The two highest aliskiren doses lowered diastolic blood pressure significantly more than irbesartan p=0·01. The frequency of adverse effects was similar for placebo and aliskiren with the exception of diarrhoea associated with the 600 mg/day dose (1·5 vs 6·9%).

Novartis is now doing phase-III trials of aliskiren to test its effects on intermediate markers of target-organ damage. In the Aliskiren in Left-Ventricular Hypertrophy trial (ALLAY), hypertensive patients with left-ventricular hypertrophy are randomly assigned aliskiren, losartan, or the combination. The primary endpoint is left-ventricular mass and geometry as measured by MRI. Furthermore, in the Aliskiren Observation of Heart Failure Treatment trial (ALOFT), aliskiren is being compared with placebo given in addition to optimum standard treatment. The primary endpoint is the fall in plasma concentration of brain natriuretic peptide. Finally, in the Aliskiren in the Evaluation of Proteinuria In Diabetes trial (AVOID), aliskiren or placebo will be added to treatment with losartan to study the reduction in the urinary albumin-to-creatinine ratio. Each of these three trials will enrol 300–500 patients.

In a meta-analysis of 127 clinical trials, Casas and colleagues showed that the renoprotective effects of ACE inhibitors and angiotensin-receptor blockers beyond blood-pressure lowering are questionable in patients with diabetes as well as those without. Similarly, metaregression highlighted that small differences in the achieved systolic blood pressure were the major determinant of cardiovascular outcomes in primary and secondary prevention trials. The interpretation of the continuing aliskiren trials will therefore not be easy. There are likely to be small between-group differences in blood pressure in the placebo-controlled ALOFT and AVOID studies as well as in the ALLAY trial between the monotherapy and combination-therapy groups. Alternatively, to achieve the same blood-pressure effect in the groups randomised in the aliskiren trials will imply that the background treatment will differ in intensity and thereby confound the results. Furthermore, showing regression of intermediate endpoints versus placebo or the standard of care is a useful step in the development of aliskiren. However, to establish a new drug class as a valuable addition to available therapeutic options requires proof of beneficial effects on morbidity and mortality. For aliskiren, this challenging mission might take another 7 or 8 years.

Compared with ACE inhibitors, renin inhibitors have fewer side-effects, but as with angiotensin-receptor blockers, they might be less powerful in reducing blood pressure, because they do not block the degradation of bradykinin. Renin inhibitors might be clinically indicated in combination therapy with drugs that lead to a reactive increase in the plasma renin activity, such as diuretics, ACE inhibitors and angiotensin-receptor blockers. Renin inhibitors might be useful in younger and white patients, who have a more active renin system than older and non-white people. Renin inhibitors might also be useful in patients intolerant of ACE inhibitors, for the treatment of disorders in which angiotensin II contributes to the pathogenesis, and for secondary prevention of cardiovascular diseases. Moreover, renin inhibitors offer additional safety for patients with cardiovascular disease and concomitant renal dysfunction, because they are preferentially eliminated via the liver without much interference with other drugs. Like ACE inhibitors, renin inhibitors behave as vasodilators with the potential to improve the elasticity of the large arteries. Conversely, they are likely to be subject to the same contraindications as ACE inhibitors and angiotensin-receptor blockers, such as pregnancy and bilateral renal-artery stenoses.

While these results describe the potential for aliskiren use as an antihypertensive, the ultimate role of the drug will depend on long-term clinical trials powered to measure significant cardiovascular outcomes such as myocardial infarction, heart failure, stroke, left ventricular hypertrophy, and cardiovascular morality. Until these benefits can be demonstrated, aliskiren will likely be reserved for adjunctive or second-line therapy in patients intolerant of or resistant to ACE inhibitors and ARBs.

Staessen JA, Li Y, Richart T.
Oral renin inhibitors.
Lancet. 2006 Oct 21;368(9545):1449-56.

[Igor73]

Stefanos N. Kales. Emergency Duties and Deaths from Heart Disease among Firefighters in the United States. NEJM 356:1207-1215 March 22, 2007
[Ссылки доступны только зарегистрированным пользователям ]

ABSTRACT

Background Heart disease causes 45% of the deaths that occur among U.S. firefighters while they are on duty. We examined duty-specific risks of death from coronary heart disease among on-duty U.S. firefighters from 1994 to 2004.

Methods We reviewed summaries provided by the Federal Emergency Management Agency of the deaths of all on-duty firefighters between 1994 and 2004, except for deaths associated with the September 11, 2001, terrorist attacks. Estimates of the proportions of time spent by firefighters each year performing various duties were obtained from a municipal fire department, from 17 large metropolitan fire departments, and from a national database. Odds ratios and 95% confidence intervals for death from coronary heart disease during specific duties were calculated from the ratios of the observed odds to the expected odds, with nonemergency duties as the reference category.

Results Deaths from coronary heart disease were associated with suppressing a fire (32.1% of all such deaths), responding to an alarm (13.4%), returning from an alarm (17.4%), engaging in physical training (12.5%), responding to nonfire emergencies (9.4%), and performing nonemergency duties (15.4%). As compared with the odds of death from coronary heart disease during nonemergency duties, the odds were 12.1 to 136 times as high during fire suppression, 2.8 to 14.1 times as high during alarm response, 2.2 to 10.5 times as high during alarm return, and 2.9 to 6.6 times as high during physical training. These odds were based on three estimates of the time that firefighters spend on their duties.

Conclusions Certain emergency firefighting duties were associated with a risk of death from coronary heart disease that was markedly higher than the risk associated with nonemergency duties. Fire suppression was associated with the highest risk, which was approximately 10 to 100 times as high as that for nonemergency duties.

И при чём тут стресс-индуцированная АГ?
1. Есть такая мысль, что заболеваемость (АГ, ИБС) и смертность (в том числе и сердечно-сосудистая) существенно выше у людей, испытывающих постоянный стресс на рабочем месте (for example, INTERHEART).
2. Если работу врача-реаниматолога приравнять к тушению пожара, то риск заболеть и умереть, видимо, существенно превышает среднестатистический уровень.
3. Хотим позаботиться о наших любимых врачах БИТ, хирургах и попробовать разобраться с таким пока неведомым зверем, как стресс-индуцированная АГ. Приглашаю коллег присоединиться к обсуждению дизайна возможного исследования.

[Dr.Vad]

Подсчитали еще разок:

J Hypertens. 2007 May;25(5):951-958.
Blood pressure-dependent and independent effects of agents that inhibit the renin-angiotensin system.
Blood Pressure Lowering Treatment Trialists' Collaboration.

OBJECTIVES: To evaluate the blood pressure-dependent and independent effects of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) on major cardiovascular events.
METHODS: Using data from 26 large-scale trials comparing an ACEI or an ARB with placebo or another drug class, meta-regression analyses were conducted in which treatment-specific relative risks for major cause-specific outcomes [stroke, major coronary heart disease (CHD) events and heart failure] were regressed against follow-up blood pressure differences.
RESULTS: From a total of 146 838 individuals with high blood pressure or an elevated risk of cardiovascular disease, 22 666 major cardiovascular events were documented during follow-up. The analyses showed comparable blood pressure-dependent reductions in risk with ACEI and ARB (P >/= 0.3 for all three outcomes). The analyses also showed that ACEI produced a blood pressure-independent reduction in the relative risk of CHD of approximately 9% (95% confidence interval 3-14%). No similar effect was detected for ARB, and there was some evidence of a difference between ACEI and ARB in this regard (P = 0.002). For both stroke and heart failure there was no evidence of any blood pressure-independent effects of either ACEI or ARB.
CONCLUSION: There are similar blood pressure-dependent effects of ACEI and ARB for the risks of stroke, CHD and heart failure. For ACEI, but not ARB, there is evidence of blood pressure-independent effects on the risk of major coronary disease events.

[Igor73]

Доступен для скачивания новый гайд по артериальной гипертензии 2007.
[Ссылки доступны только зарегистрированным пользователям ]
The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)
После регистрации доступ бесплатный

При беглом просмотре обращает на себя внмание позиция по Б-адреноблокаторам:
1. "4.4.5 Trials with b-blockers
The benefit of b-blockers compared with that of other antihypertensive agents has recently been questioned on the basis of the results of two large randomized trials, the LIFE study [332] and the ASCOT study [330], both of
which showed superiority of an angiotensin receptor antagonist and, respectively, a calcium antagonist over therapy initiated by a b-blocker as far as stroke (LIFE) or stroke and mortality (ASCOT) were concerned. These
two large trials have strongly influenced a recent metaanalysis [343] which concluded that b-blocker initiated therapy is inferior to others in stroke prevention, but not in prevention of myocardial infarction and reduction in
mortality.."
2. "These conclusions must be considered with care but also with a critical mind"
3. "In any case, the above quoted meta-analyses of b-blocker initiated trials [297,343] well illustrate the difficulties inherent in many recent trials in which combination therapy hinders the attribution of either benefits or harms
to individual compounds."

И вообще, много всего интересного

[Dr.Vad]

Blood pressure targets in men and women with coronary artery disease or who are at high risk should be 130/80 mm Hg, according to the American Heart Association.(Circulation. 2007;115;2761-2788)

[Ссылки доступны только зарегистрированным пользователям ]

[Igor73]

David Conen et al.
Risk of cardiovascular events among women with high normal blood pressure or blood pressure progression: prospective cohort study.
BMJ 2007;335;432-; originally published online 19 Aug 2007 [Ссылки доступны только зарегистрированным пользователям ] (FREE)
ABSTRACT

Objective

To compare cardiovascular risk among women with high normal blood pressure (130-9/85-9mm Hg) against those with normal blood pressure (120-9/75-84 mm Hg) and those with baseline hypertension.

Design Prospective cohort study. Setting Women’s health study, United States.

Participants 39 322 initially healthy women classified into four categories according to self reported baseline blood pressure and followed for a median of 10.2 years.

Main outcome measures Time to cardiovascular death, myocardial infarction, or stroke (major cardiovascular event—primary end point); progression to hypertension.

Results 982 (2.5%) women developed a major cardiovascular event, and 8686 (30.1%) women without baseline hypertension progressed to hypertension. The age adjusted event rate for the primary end point was 1.6/1000 person years among women with normal blood pressure, 2.9/1000 person years among those with high normal blood pressure, and 4.3/1000 person years among those with baseline hypertension. Compared with women with high normal blood pressure (reference group), those with normal blood pressure had a lower risk of a major cardiovascular event (adjusted hazard ratio 0.61, 95% confidence interval 0.48 to 0.76) and of incident hypertension (0.42, 0.40 to 0.44). The hazard ratio for a major cardiovascular event in women with baseline hypertension was 1.30 (1.08 to 1.57). Women who progressed to hypertension (reference group) during the first 48 months of the study had a higher cardiovascular risk than those who remained normotensive (adjusted hazard ratio 0.64, 0.50 to 0.81). Women with high normal blood pressure at baseline who progressed to hypertension (reference group) had similar outcome rates to women with baseline hypertension (adjusted hazard ratio 1.17, 0.88 to 1.55).

Conclusion The cardiovascular risk of women with high normal blood pressure is higher than that of women with normal blood pressure. The cardiovascular risk of women who progress to hypertension is increased shortly after a diagnosis of hypertension has been made.

Trial registration Clinical trials NCT00000479.

[Igor73]

На сайте [Ссылки доступны только зарегистрированным пользователям ] в бесплатном доступе выложены 4 главы из книги O’Brien "Measurement of blood pressure". [Ссылки доступны только зарегистрированным пользователям ]/[Ссылки доступны только зарегистрированным пользователям ]/[Ссылки доступны только зарегистрированным пользователям ]/[Ссылки доступны только зарегистрированным пользователям ]. In: ABC of Hypertension. Fifth Edition. BMJ/Blackwell Publishing. Oxford. UK. 2007. pp.17-32. Первая часть: [Ссылки доступны только зарегистрированным пользователям ]
P.S. суммарно на 11 МBт.

[Igor73]

Inadequate Control of Hypertension in US Adults With Cardiovascular Disease Comorbidities in 2003-2004
Nathan D. Wong, PhD; Victor A. Lopez, BS; Gilbert L'Italien, PhD; Roland Chen, MD; Sue Ellen J. Kline, PhD; Stanley S. Franklin, MD

Arch Intern Med. 2007;167(22):2431-2436.
[Ссылки доступны только зарегистрированным пользователям ]
Background Cardiovascular risks associated with hypertension (HTN) and the importance of its control are well established; however, the prevalence and adequacy of its treatment and control in persons with cardiovascular comorbidities (CVCs) are uncertain.
Methods To examine the prevalence, treatment, and control of HTN among US adults with and without CVCs, we analyzed data from adults at least 18 years of age (n = 4646, N [projected sample size] = 192.4 million) in the National Health and Nutrition Examination Survey 2003-2004, a nationally representative cross-sectional survey of the noninstitutionalized civilian US population. Prevalence, treatment, and control rates of HTN in patients with CVCs vs those without, including coronary artery disease, congestive heart failure, stroke, chronic kidney disease, peripheral artery disease, and diabetes mellitus, and distance to blood pressure goal in those whose HTN was not controlled were the main outcomes.
Results The overall prevalence rate of HTN was 31.4% (n = 1671, N = 60.5 million), ranging from 23.1% in those without CVCs to 51.8% to 81.8% in those with CVCs (P < .01). Despite HTN treatment rates for diabetes mellitus, stroke, heart failure, and coronary artery disease that are higher (83.4%-89.3%) than the rates of those without these conditions (66.5%) (P < .01), control rates for treatment remained poor (23.2%-49.3%) (P < .001 to P = .048). Isolated systolic HTN was the most common hypertensive subtype in those with CVCs ([Изображения доступны только зарегистрированным пользователям] 63.5%) with systolic blood pressure averaging at least 20 mm Hg from goal.
Conclusions Nearly three-fourths of adults with CVCs have HTN. Poor control rates of systolic HTN remain a principal problem that further compromises their already high cardiovascular disease risk.

[Igor73]

При домашнем измерении АД пациенты принимают меньше препаратов (1.47 против 2.48) и экономят деньги ($3222 vs $4420 на 100 пациентов в месяц; P<0.001), но при этом по данным СМАД через 12 месяцев АД было немного выше в группе self-measurement (125.9 vs 123.8 mm Hg (P<0.05) для САД и 77.2 vs 76.1 mm Hg (P<0.05) для ДАД). Различия по микроальбумиурии, индексу массы миокарда ЛЖ, а также по уровню АД между группами были недостоверны.

Self-Measurement of Blood Pressure at Home Reduces the Need for Antihypertensive Drugs

A Randomized, Controlled Trial

Willem J. Verberk et al for the Home Versus Office Measurement, Reduction of Unnecessary Treatment Study Investigators (HOMERUS)
[Ссылки доступны только зарегистрированным пользователям ]

It is still uncertain whether one can safely base treatment decisions on self-measurement of blood pressure. In the present study, we investigated whether antihypertensive treatment based on self-measurement of blood pressure leads to the use of less medication without the loss of blood pressure control. We randomly assigned 430 hypertensive patients to receive treatment either on the basis of self-measured pressures (n=216) or office pressures (OPs; n=214). During 1-year follow-up, blood pressure was measured by office measurement (10 visits), ambulatory monitoring (start and end), and self-measurement (8 times, self-pressure group only). In addition, drug use, associated costs, and degree of target organ damage (echocardiography and microalbuminuria) were assessed. The self-pressure group used less medication than the OP group (1.47 versus 2.48 drug steps; P<0.001) with lower costs ($3222 versus $4420 per 100 patients per month; P<0.001) but without significant differences in systolic and diastolic OP values (1.6/1.0 mm Hg; P=0.25/0.20), in changes in left ventricular mass index (–6.5 g/m2 versus –5.6 g/m2; P=0.72), or in median urinary microalbumin concentration (–1.7 versus –1.5 mg per 24 hours; P=0.87). Nevertheless, 24-hour ambulatory blood pressure values at the end of the trial were higher in the self-pressure than in the OP group: 125.9 versus 123.8 mm Hg (P<0.05) for systolic and 77.2 versus 76.1 mm Hg (P<0.05) for diastolic blood pressure. These data show that self-measurement leads to less medication use than office blood pressure measurement without leading to significant differences in OP values or target organ damage. Ambulatory values, however, remain slightly elevated for the self-pressure group.

[Igor73]

[Ссылки доступны только зарегистрированным пользователям ]A Risk Score for Predicting Near-Term Incidence of Hypertension: The Framingham Heart Study. Annals of Internal Medicine 2008.


[Ссылки доступны только зарегистрированным пользователям ]

Background: Studies suggest that targeting high-risk, nonhypertensive individuals for treatment may delay hypertension onset, thereby possibly mitigating vascular complications. Risk stratification may facilitate cost-effective approaches to management.
Objective: To develop a simple risk score for predicting hypertension incidence by using measures readily obtained in the physician's office.
Design: Longitudinal cohort study.
Setting: Framingham Heart Study, Framingham, Massachusetts.
Patients: 1717 nonhypertensive white individuals 20 to 69 years of age (mean age, 42 years; 54% women), without diabetes and with both parents in the original cohort of the Framingham Heart Study, contributed 5814 person-examinations.
Measurements: Scores were developed for predicting the 1-, 2-, and 4-year risk for new-onset hypertension, and performance characteristics of the prediction algorithm were assessed by using calibration and discrimination measures. Parental hypertension was ascertained from examinations of the original cohort of the Framingham Heart Study.
Results: During follow-up (median time over all person-examinations, 3.8 years), 796 persons (52% women) developed new-onset hypertension. In multivariable analyses, age, sex, systolic and diastolic blood pressure, body mass index, parental hypertension, and cigarette smoking were significant predictors of hypertension. According to the risk score based on these factors, the 4-year risk for incident hypertension was classified as low (<5%) in 34% of participants, medium (5% to 10%) in 19%, and high (>10%) in 47%. The c-statistic for the prediction model was 0.788, and calibration was very good.
Limitations: The risk score findings may not be generalizable to persons of nonwhite race or ethnicity or to persons with diabetes. The risk score algorithm has not been validated in an independent cohort and is based on single measurements of risk factors and blood pressure.
Conclusion: The hypertension risk prediction score can be used to estimate an individual's absolute risk for hypertension on short-term follow-up, and it represents a simple, office-based tool that may facilitate management of high-risk individuals with prehypertension.

[Igor73]

The Lancet 2008; 371:821-827
Effect of immunisation against angiotensin II with CYT006-AngQb on ambulatory blood pressure: a double-blind, randomised, placebo-controlled phase IIa study[Ссылки доступны только зарегистрированным пользователям ] et al.




BackgroundHypertension can be controlled adequately with existing drugs such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Nevertheless, treatment success is often restricted by patients not adhering to treatment. Immunisation against angiotensin II could solve this problem. We investigated the safety and efficacy of CYT006-AngQb—a vaccine based on a virus-like particle—that targets angiotensin II to reduce ambulatory blood pressure.

MethodsIn this multicentre, double-blind, randomised, placebo-controlled phase IIa trial, 72 patients with mild-to-moderate hypertension were randomly assigned with a computer-generated randomisation list to receive subcutaneous injections of either 100 μg CYT006-AngQb (n=24), 300 μg CYT006-AngQb (24), or placebo (24), at weeks 0, 4, and 12. 24-h ambulatory blood pressure was measured before treatment and at week 14. The primary outcomes were safety and tolerability. Analyses were done by intention to treat. This study is registered with [Ссылки доступны только зарегистрированным пользователям ], number NCT00500786.

FindingsTwo patients in the 100 μg group, three in the 300 μg group, and none in the placebo group discontinued study treatment. All patients were included in safety analyses; efficacy analyses did not include the five dropouts, for whom no data were available at week 14. Five serious adverse events were reported (two in the 100 μg group, two in the 300 μg group, and one in the placebo group); none were deemed to be treatment related. Most side-effects were mild, transient reactions at the injection site. Mild, transient influenza-like symptoms were seen in three patients in the 100 μg group, seven in the 300 μg group, and none in the placebo group. In the 300 μg group, there was a reduction from baseline in mean ambulatory daytime blood pressure at week 14 by −9·0/−4·0 mm Hg compared with placebo (p=0·015 for systolic and 0·064 for diastolic). The 300 μg dose reduced the early morning blood-pressure surge compared with placebo (change at 0800 h −25/−13 mm Hg; p<0·0001 for systolic, p=0·0035 for diastolic).

InterpretationImmunisation with CYT006-AngQb was associated with no serious adverse events; most observed adverse events were consistent with local or systemic responses similar to those seen with other vaccines. The 300 μg dose reduced blood pressure in patients with mild-to-moderate hypertension during the daytime, especially in the early morning.
[Ссылки доступны только зарегистрированным пользователям ]

[Gilarov]

Предаваться мечтательной созерцательности полезно
American Journal of Hypertension (2008) doi:10.1038/ajh.2007.65
[Ссылки доступны только зарегистрированным пользователям ]

James W. Anderson, Chunxu Liu and Richard J. Kryscio
Background

Prior clinical trials suggest that the Transcendental Meditation technique may decrease blood pressure of normotensive and hypertensive individuals but study-quality issues have been raised. This study was designed to assess effects of Transcendental Meditation on blood pressure using objective quality assessments and meta-analyses.

Methods

PubMed and Cochrane databases through December 2006 and collected publications on Transcendental Meditation were searched. Randomized, controlled trials comparing blood pressure responses to the Transcendental Meditation technique with a control group were evaluated. Primary outcome measures were changes in systolic and diastolic blood pressure after practicing Transcendental Meditation or following control procedures. A specific rating system (0–20 points) was used to evaluate studies and random-effects models were used for meta-analyses.

Results

Nine randomized, controlled trials met eligibility criteria. Study-quality scores ranged from low (score, 7) to high (16) with three studies of high quality (15 or 16) and three of acceptable quality (11 or 12). The random-effects meta-analysis model for systolic and diastolic blood pressure, respectively, indicated that Transcendental Meditation, compared to control, was associated with the following changes: -4.7 mm Hg (95% confidence interval (CI), -7.4 to -1.9 mm Hg) and -3.2 mm Hg (95% CI, -5.4 to -1.3 mm Hg). Subgroup analyses of hypertensive groups and high-quality studies showed similar reductions.

Conclusions

The regular practice of Transcendental Meditation may have the potential to reduce systolic and diastolic blood pressure by [Изображения доступны только зарегистрированным пользователям]4.7 and 3.2 mm Hg, respectively. These are clinically meaningful changes.

[Igor73]

The ONTARGET Investigators. Telmisartan, Ramipril, or Both in Patients at High Risk for Vascular Events. NEJM 2008
Background
In patients who have vascular disease or high-risk diabetes without heart failure, angiotensin-converting–enzyme (ACE) inhibitors reduce mortality and morbidity from cardiovascular causes, but the role of angiotensin-receptor blockers (ARBs) in such patients is unknown. We compared the ACE inhibitor ramipril, the ARB telmisartan, and the combination of the two drugs in patients with vascular disease or high-risk diabetes.
Methods
After a 3-week, single-blind run-in period, patients underwent double-blind randomization, with 8576 assigned to receive 10 mg of ramipril per day, 8542 assigned to receive 80 mg of telmisartan per day, and 8502 assigned to receive both drugs (combination therapy). The primary composite outcome was death from cardiovascular causes, myocardial infarction, stroke, or hospitalization for heart failure.
Results
Mean blood pressure was lower in both the telmisartan group (a 0.9/0.6 mm Hg greater reduction) and the combination-therapy group (a 2.4/1.4 mm Hg greater reduction) than in the ramipril group. At a median follow-up of 56 months, the primary outcome had occurred in 1412 patients in the ramipril group (16.5%), as compared with 1423 patients in the telmisartan group (16.7%; relative risk, 1.01; 95% confidence interval [CI], 0.94 to 1.09). As compared with the ramipril group, the telmisartan group had lower rates of cough (1.1% vs. 4.2%, P<0.001) and angioedema (0.1% vs. 0.3%, P = 0.01) and a higher rate of hypotensive symptoms (2.6% vs. 1.7%, P<0.001); the rate of syncope was the same in the two groups (0.2%). In the combination-therapy group, the primary outcome occurred in 1386 patients (16.3%; relative risk, 0.99; 95% CI, 0.92 to 1.07); as compared with the ramipril group, there was an increased risk of hypotensive symptoms (4.8% vs. 1.7%, P<0.001), syncope (0.3% vs. 0.2%, P = 0.03), and renal dysfunction (13.5% vs. 10.2%, P<0.001).
Conclusions
Telmisartan was equivalent to ramipril in patients with vascular disease or highrisk diabetes and was associated with less angioedema. The combination of the two drugs was associated with more adverse events without an increase in benefit. (ClinicalTrials.gov number, NCT00153101.)

[Igor73]

Nigel S. Beckett. Treatment of Hypertension in Patients 80 Years
of Age or Older. NEJM 2008
Background
Whether the treatment of patients with hypertension who are 80 years of age or older is beneficial is unclear. It has been suggested that antihypertensive therapy may reduce the risk of stroke, despite possibly increasing the risk of death.
Methods
We randomly assigned 3845 patients from Europe, China, Australasia, and Tunisia who were 80 years of age or older and had a sustained systolic blood pressure of 160 mm Hg or more to receive either the diuretic indapamide (sustained release, 1.5 mg) or matching placebo. The angiotensin-converting–enzyme inhibitor perindopril (2 or 4 mg), or matching placebo, was added if necessary to achieve the target blood pressure of 150/80 mm Hg. The primary end point was fatal or nonfatal stroke.
Results
The active-treatment group (1933 patients) and the placebo group (1912 patients) were well matched (mean age, 83.6 years; mean blood pressure while sitting, 173.0/90.8 mm Hg); 11.8% had a history of cardiovascular disease. Median follow-up was 1.8 years. At 2 years, the mean blood pressure while sitting was 15.0/6.1 mm Hg lower in the active-treatment group than in the placebo group. In an intention-totreat analysis, active treatment was associated with a 30% reduction in the rate of fatal or nonfatal stroke (95% confidence interval [CI], −1 to 51; P = 0.06), a 39% reduction in the rate of death from stroke (95% CI, 1 to 62; P = 0.05), a 21% reduction in the rate of death from any cause (95% CI, 4 to 35; P = 0.02), a 23% reduction in the rate of death from cardiovascular causes (95% CI, −1 to 40; P = 0.06), and a 64% reduction in the rate of heart failure (95% CI, 42 to 78; P<0.001). Fewer serious adverse events were reported in the active-treatment group (358, vs. 448 in the placebo group;
P = 0.001).
Conclusions
The results provide evidence that antihypertensive treatment with indapamide (sustained release), with or without perindopril, in persons 80 years of age or older is beneficial. (ClinicalTrials.gov number, NCT00122811.)

[Dr.]

Кто бы сомневался