- Email: [email protected]
Psychosocial factors and risk of hypertension. The coronary artery risk development in young adults (CARDIA) study
Methods: The data from 29 randomized, placebo-controlled trials (n⫽162,341 patients) designed to evaluate ACEis, beta-blockers, ARBs, calcium-channel blockers and diuretics was compared by a systematic overview using several meta-analyses. Trial eligibility included placebo control, random allocation to different BP goals or different classes of antihypertensive drugs and follow-up of at least 1000 patient-years in each group. Trials with specific clinical parameters were eligible, such as isolated hypertension, diabetes, CHD, PVOD, cerebral vascular disease (CVD) and renal disease but not acute myocardial infarction or CHF. Results: The mean follow-up ranged from 2.0 to 8.4 years, representing over 700,000 patient years. Mean age was 65 years and 52% were men. Most were selected on the basis of pre-existing CV disease or more than one CRF at baseline. Baseline BP was 159/92 mm Hg with mean values in studies ranging between 123 and 194 mm Hg systolic and 74 and 106 mm Hg diastolic. Differences in BP attributable to active drug compared to placebo were modest averaging ⫺4 to ⫺8 systolic and ⫺2 to ⫺4 diastolic. The relative risks of total major CVEs were reduced by ACEi, (22%; 95% CI 17–27), CCBs (18%; 95%, 5–29), and ARBs (10%; 4 –17). ACEi and CCBs reduced rates of stroke, CHD, CV and deaths. Greater risk reductions were produced by regimens that targeted lower blood pressure goals (15%; 5–24). There was no significant difference in total major total CVEs between regimens based on ACEis, CCBs, beta-blockers or diuretics, although ACEi-based regimens reduced BP less, and CCBs were the only regimen that did not reduce CHF. For every outcome other than heart failure, the reduction in risk was directly related to BP reduction. Conclusions: Treatment with any commonly used regimen reduces the risk of total major cardiovascular events, and larger reductions in blood pressure produce larger reductions in risk. Perspective: This extensive review supports the conclusion of the largest randomized trial ALLHAT (The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) in which the diuretic chlorthalidone was equivalent to or superior to ACEi and CCBs. Thiazides win the day as being safe and cost effective in mild hypertension. But more than 60% of patients require a second or combination drug, which with available data could be any of the major classes. The exception is in diabetes, the metabolic syndrome and renal failure where blocking the renin-angiotensin system appears valuable. MR
group. The primary outcomes were first occurrence of death (all cause), nonfatal MI or nonfatal stroke. Patients taking beta-blockers within 2 weeks of randomization for an MI in the previous 12 months were excluded. Results: Mean age was 66 years, 52% were women, 48% white, 13% black and 36% hispanic. CAD was diagnosed by a previous MI in 32% and coronary angiography in about 40%, 66% had angina, 5% a stroke, 28% were diabetics and mean BP was 150/86 mm Hg. Previous antihypertensive drugs included ACEi in 51%, calcium antagonists in 41% and diuretics in 37%. At 24 months, in the CAS group, 81.5% were taking verapamil, 63% the combination with trandolapril, and 44% were also taking HCTZ. In the NCAS group, 77.5% were taking atenolol, 60.3% HCTZ, and 52% were taking trandolapril. About 14% of subjects in each group were on three or more drugs. Twoyear BP control was similar with systolic BP goals achieved in 65% and diastolic BP goals in 88% of each group. About 70% of all patients achieved a BP ⬍140/90 mm Hg. At a mean 2.7 years follow-up per patient (61,835 patientyears), about 10% of subjects had a primary outcome that did not differ between groups. There were no subgroups (e.g., age ⬎70 years, gender, race, MI, LVH, CHF, diabetes, revascularization) in which a treatment strategy was preferable, with the exception of less angina and new diabetes in the verapamil⫹trandolopril group. Cough rate was less than 2% in both groups, and other than constipation on verapamil and symptomatic bradycardia with atenolol, there was minimal difference in adverse events. Conclusions: The verapamil-trandolapril– based strategy was as clinically effective as the atenolol-hydrochlorothiazide– based strategy in hypertensive CAD patients. Perspective: This important and unique study demonstrates again that the majority of older persons with hypertension require combination therapy to reach targets. The findings are specific to a high-risk population with hypertension and CAD. Either strategy is reasonable in patients with stable CAD. This is also the first study to demonstrate that hypertensive patients with an MI more than a year earlier, presumably with reasonable LV function, do not necessarily benefit from betablockers. This will be welcome news to those stable CAD and post-MI patients with reasonable LV function who experience significant side effects on beta-blockers. MR
Effects of Different Blood-Pressure-Lowering Regimens on Major Cardiovascular Events: Results of Prospectively Designed Overviews of Randomized Trials
Psychosocial Factors and Risk of Hypertension. The Coronary Artery Risk Development in Young Adults (CARDIA) Study
Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet 2003;362:1527–35.
Yan LL, Liu K, Matthews KA, Daviglus ML, Ferguson TF, Kiefe CI. JAMA 2003;290:2138 – 48.
Study Question: Is there a comparable relationship between reduction in blood pressure and reduction in risk of cardiovascular events with the commonly used antihypertensive drug regimens?
Study Question: Is there a relationship between psychosocial factors of time urgency/importance (TUI), achievement
ACC CURRENT JOURNAL REVIEW Feb 2004
20
Study Question: The investigators sought to assess the effect of rosiglitazone on markers of endothelial cell activation and acute-phase reactants in non-diabetic patients with coronary artery disease (CAD). Methods: Patients with stable, angiographically documented CAD without diabetes mellitus were investigated. Patients were randomized in a double-blind manner to receive treatment with placebo or rosiglitazone (4 mg/day for 8 weeks followed by 8 mg/day for 4 weeks) for 12 weeks. Eightyfour patients completed the study. Fasting glucose, insulin, lipid profile, markers of endothelial activation and inflammatory markers were measured at baseline and after 12 weeks. Results: Rosiglitazone treatment resulted in a significant reduction in E-selectin (p⫽0.03), von Willebrand factor (p⫽0.007), C-reactive protein (p⬍0.001), fibrinogen (p⫽0.003) and the homeostasis model of insulin resistance index (p⫽0.02), compared with placebo. Significant elevations in low-density lipoprotein and triglyceride levels were observed in the rosiglitazone group (p⬍0.01). Within the rosiglitazone-treated group, reductions in C-reactive protein and von Willebrand factor were significantly correlated with a reduction in insulin resistance. Conclusions: The authors concluded that rosiglitazone significantly reduces markers of endothelial cell activation and levels of acute-phase reactants in CAD patients without diabetes. Potential underlying mechanisms include insulin sensitization and direct modification of transcription within the vessel wall. Perspective: This study demonstrated that the PPAR-gamma agonist rosiglitazone reduces markers of endothelial cell activation, CRP, and fibrinogen levels in non-diabetic patients with CAD. Potential mechanisms underlying this beneficial effect include insulin sensitization and direct modulation of transcriptional activity in the vessel wall. Further clinical studies are warranted to determine whether this anti-inflammatory action translates into a therapeutic benefit in atherosclerotic coronary disease and whether the benefits are a class effect with other glitazones. DM
striving/competitiveness (ASC), depression and anxiety on long-term risk of hypertension in young adults. Methods: This study is from the population-based, prospective, observational Coronary Artery Risk Development in Young Adults (CARDIA) study. A total of 2916 of the original cohort of 5115 white and black young adults 18–30 years recruited from four US metropolitan areas had adequate baseline psychological profiling data, follow-up and no exclusion criteria (e.g., hypertension at baseline). Primary outcome was the cumulative 15-year incidence of hypertension defined as sBP ⱖ140 mm Hg, dBP ⱖ90 mm Hg or taking antihypertensive medication in subjects who were normotensive at year 0 or year 5. Baseline data on TUI, ASC and hostility were obtained at year 0 and for depression, anxiety and hostility at year 5. Results: The mean age at time 0 was 25 years. At baseline, higher TUI scores were more likely in women, whites, smokers, those with a sedentary lifestyle and lower sBP. ASC was associated with men, blacks, higher education and more physically activity. Men scored higher on hostility, but lower on depression and anxiety. Positive associations were observed between depression, hostility and anxiety and black race, smoking, drinking alcohol and BMI. Negative associations were observed between the three factors and age, years of education and physical activity. The incidence of hypertension at year 15 was 15% with about 1⁄2 taking medication, and 13.6% at year 5. There was a significant graded positive relationship between TUI, hostility and depression (weakly) with age-, race- and sex-adjusted 15-year incidence of hypertension. After adjusting for hypertension risk factors (age, gender, alcohol, physical activity, education, BMI and baseline SBP), higher TUI and hostility were significantly associated with development of hypertension at 15 years. There were no consistent patterns for ASC, depression or anxiety. Conclusions: Among young adults, TUI and hostility were associated with a dose response increase in long-term risk of hypertension. Perspective: Depression and anxiety did not correlate with the development of hypertension. Would this have been the case if the psychological profile was re-evaluated during follow-up and blood pressure assessment was more often? Causal studies in hypertension are challenging and results often differ by study design. The etiology and severity of hypertension at any given time point involves genetic predisposition, behavioral factors (diet, physical activity, alcohol), environmental stress and the psychological factors which are environmental, situational, and genetic as well. MR
Rapid Effect of 3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibition on Coronary Endothelial Function Wassmann S, Faul A, Hennen B, Scheller B, Bohm M, Nicking G. Circ Res 2003;93:e98 – e103. Study Question: What is the rapidity of the effect of statins on the coronary vasculature as reflected by coronary endothelial function? Methods: A randomized, double-blind trial in 27 patients with stable angina pectoris and average LDL-C comparing the effect of 40 mg of pravastatin vs. placebo on coronary endothelial function. Endothelial-dependent vasoreactivity was determined by the response to intracoronary (IC) acetylcholine and non– endothelial-dependent vasoreactivity
The Effects of Rosiglitazone, a Peroxisome Proliferator-Activated Receptor-Gamma Agonist, on Markers of Endothelial Cell Activation, C-Reactive Protein, and Fibrinogen Levels in Non-Diabetic Coronary Artery Disease Patients Sidhu JS, Cowan D, Kaski JC. J Am Coll Cardiol 2003;42:1757– 63.
ACC CURRENT JOURNAL REVIEW Feb 2004
21
group. The primary outcomes were first occurrence of death (all cause), nonfatal MI or nonfatal stroke. Patients taking beta-blockers within 2 weeks of randomization for an MI in the previous 12 months were excluded. Results: Mean age was 66 years, 52% were women, 48% white, 13% black and 36% hispanic. CAD was diagnosed by a previous MI in 32% and coronary angiography in about 40%, 66% had angina, 5% a stroke, 28% were diabetics and mean BP was 150/86 mm Hg. Previous antihypertensive drugs included ACEi in 51%, calcium antagonists in 41% and diuretics in 37%. At 24 months, in the CAS group, 81.5% were taking verapamil, 63% the combination with trandolapril, and 44% were also taking HCTZ. In the NCAS group, 77.5% were taking atenolol, 60.3% HCTZ, and 52% were taking trandolapril. About 14% of subjects in each group were on three or more drugs. Twoyear BP control was similar with systolic BP goals achieved in 65% and diastolic BP goals in 88% of each group. About 70% of all patients achieved a BP ⬍140/90 mm Hg. At a mean 2.7 years follow-up per patient (61,835 patientyears), about 10% of subjects had a primary outcome that did not differ between groups. There were no subgroups (e.g., age ⬎70 years, gender, race, MI, LVH, CHF, diabetes, revascularization) in which a treatment strategy was preferable, with the exception of less angina and new diabetes in the verapamil⫹trandolopril group. Cough rate was less than 2% in both groups, and other than constipation on verapamil and symptomatic bradycardia with atenolol, there was minimal difference in adverse events. Conclusions: The verapamil-trandolapril– based strategy was as clinically effective as the atenolol-hydrochlorothiazide– based strategy in hypertensive CAD patients. Perspective: This important and unique study demonstrates again that the majority of older persons with hypertension require combination therapy to reach targets. The findings are specific to a high-risk population with hypertension and CAD. Either strategy is reasonable in patients with stable CAD. This is also the first study to demonstrate that hypertensive patients with an MI more than a year earlier, presumably with reasonable LV function, do not necessarily benefit from betablockers. This will be welcome news to those stable CAD and post-MI patients with reasonable LV function who experience significant side effects on beta-blockers. MR
Effects of Different Blood-Pressure-Lowering Regimens on Major Cardiovascular Events: Results of Prospectively Designed Overviews of Randomized Trials
Psychosocial Factors and Risk of Hypertension. The Coronary Artery Risk Development in Young Adults (CARDIA) Study
Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet 2003;362:1527–35.
Yan LL, Liu K, Matthews KA, Daviglus ML, Ferguson TF, Kiefe CI. JAMA 2003;290:2138 – 48.
Study Question: Is there a comparable relationship between reduction in blood pressure and reduction in risk of cardiovascular events with the commonly used antihypertensive drug regimens?
Study Question: Is there a relationship between psychosocial factors of time urgency/importance (TUI), achievement
ACC CURRENT JOURNAL REVIEW Feb 2004
20
Study Question: The investigators sought to assess the effect of rosiglitazone on markers of endothelial cell activation and acute-phase reactants in non-diabetic patients with coronary artery disease (CAD). Methods: Patients with stable, angiographically documented CAD without diabetes mellitus were investigated. Patients were randomized in a double-blind manner to receive treatment with placebo or rosiglitazone (4 mg/day for 8 weeks followed by 8 mg/day for 4 weeks) for 12 weeks. Eightyfour patients completed the study. Fasting glucose, insulin, lipid profile, markers of endothelial activation and inflammatory markers were measured at baseline and after 12 weeks. Results: Rosiglitazone treatment resulted in a significant reduction in E-selectin (p⫽0.03), von Willebrand factor (p⫽0.007), C-reactive protein (p⬍0.001), fibrinogen (p⫽0.003) and the homeostasis model of insulin resistance index (p⫽0.02), compared with placebo. Significant elevations in low-density lipoprotein and triglyceride levels were observed in the rosiglitazone group (p⬍0.01). Within the rosiglitazone-treated group, reductions in C-reactive protein and von Willebrand factor were significantly correlated with a reduction in insulin resistance. Conclusions: The authors concluded that rosiglitazone significantly reduces markers of endothelial cell activation and levels of acute-phase reactants in CAD patients without diabetes. Potential underlying mechanisms include insulin sensitization and direct modification of transcription within the vessel wall. Perspective: This study demonstrated that the PPAR-gamma agonist rosiglitazone reduces markers of endothelial cell activation, CRP, and fibrinogen levels in non-diabetic patients with CAD. Potential mechanisms underlying this beneficial effect include insulin sensitization and direct modulation of transcriptional activity in the vessel wall. Further clinical studies are warranted to determine whether this anti-inflammatory action translates into a therapeutic benefit in atherosclerotic coronary disease and whether the benefits are a class effect with other glitazones. DM
striving/competitiveness (ASC), depression and anxiety on long-term risk of hypertension in young adults. Methods: This study is from the population-based, prospective, observational Coronary Artery Risk Development in Young Adults (CARDIA) study. A total of 2916 of the original cohort of 5115 white and black young adults 18–30 years recruited from four US metropolitan areas had adequate baseline psychological profiling data, follow-up and no exclusion criteria (e.g., hypertension at baseline). Primary outcome was the cumulative 15-year incidence of hypertension defined as sBP ⱖ140 mm Hg, dBP ⱖ90 mm Hg or taking antihypertensive medication in subjects who were normotensive at year 0 or year 5. Baseline data on TUI, ASC and hostility were obtained at year 0 and for depression, anxiety and hostility at year 5. Results: The mean age at time 0 was 25 years. At baseline, higher TUI scores were more likely in women, whites, smokers, those with a sedentary lifestyle and lower sBP. ASC was associated with men, blacks, higher education and more physically activity. Men scored higher on hostility, but lower on depression and anxiety. Positive associations were observed between depression, hostility and anxiety and black race, smoking, drinking alcohol and BMI. Negative associations were observed between the three factors and age, years of education and physical activity. The incidence of hypertension at year 15 was 15% with about 1⁄2 taking medication, and 13.6% at year 5. There was a significant graded positive relationship between TUI, hostility and depression (weakly) with age-, race- and sex-adjusted 15-year incidence of hypertension. After adjusting for hypertension risk factors (age, gender, alcohol, physical activity, education, BMI and baseline SBP), higher TUI and hostility were significantly associated with development of hypertension at 15 years. There were no consistent patterns for ASC, depression or anxiety. Conclusions: Among young adults, TUI and hostility were associated with a dose response increase in long-term risk of hypertension. Perspective: Depression and anxiety did not correlate with the development of hypertension. Would this have been the case if the psychological profile was re-evaluated during follow-up and blood pressure assessment was more often? Causal studies in hypertension are challenging and results often differ by study design. The etiology and severity of hypertension at any given time point involves genetic predisposition, behavioral factors (diet, physical activity, alcohol), environmental stress and the psychological factors which are environmental, situational, and genetic as well. MR
Rapid Effect of 3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibition on Coronary Endothelial Function Wassmann S, Faul A, Hennen B, Scheller B, Bohm M, Nicking G. Circ Res 2003;93:e98 – e103. Study Question: What is the rapidity of the effect of statins on the coronary vasculature as reflected by coronary endothelial function? Methods: A randomized, double-blind trial in 27 patients with stable angina pectoris and average LDL-C comparing the effect of 40 mg of pravastatin vs. placebo on coronary endothelial function. Endothelial-dependent vasoreactivity was determined by the response to intracoronary (IC) acetylcholine and non– endothelial-dependent vasoreactivity
The Effects of Rosiglitazone, a Peroxisome Proliferator-Activated Receptor-Gamma Agonist, on Markers of Endothelial Cell Activation, C-Reactive Protein, and Fibrinogen Levels in Non-Diabetic Coronary Artery Disease Patients Sidhu JS, Cowan D, Kaski JC. J Am Coll Cardiol 2003;42:1757– 63.
ACC CURRENT JOURNAL REVIEW Feb 2004
21