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Stroke and Vascular Neurology Oct 2022Current guidelines recommend blood pressure (BP) lowering in patients after acute intracerebral haemorrhage (ICH) without guidance on initial choice of antihypertensive... (Clinical Trial)
Clinical Trial
INTRODUCTION
Current guidelines recommend blood pressure (BP) lowering in patients after acute intracerebral haemorrhage (ICH) without guidance on initial choice of antihypertensive class. This study sought to determine if initial antihypertensive class differentially effects acute BP lowering in a large multiethnic ICH cohort.
METHODS
Subjects enrolled in the Ethnic/Racial Variations in ICH study between August 2010 and August 2017 with elevated admission BP and who received labetalol, nicardipine or hydralazine monotherapy as initial antihypertensive were analysed. Primary outcomes were systolic and diastolic BP changes from baseline to first BP measurement after initial antihypertensive treatment. Secondary outcomes included haematoma expansion (HE), hospital length of stay (LOS) and modified Rankin Score (mRS) up to 12 months after ICH. Exploratory outcomes assessed effects of race/ethnicity. Linear and logistic regression analyses, adjusted for relevant covariates, were performed to determine associations of antihypertensive class with outcomes.
RESULTS
In total, 1156 cases were used in analyses. Antihypertensive class was associated with diastolic BP change (p=0.003), but not systolic BP change (p=0.419). Initial dosing with nicardipine lowered acute diastolic BP than labetalol (least square mean difference (labetalol-nicardipine)=5.47 (2.37, 8.57), p<0.001). Initial antihypertensive class was also found to be associated with LOS (p=0.028), but not with HE (p=0.406), mortality (p=0.118), discharge disposition (p=0.083) or mRS score at discharge, 3, 6 and 12 months follow-up (p=0.262, 0.276, 0.152 and 0.36, respectively). Race/ethnicity variably affected multivariable models.
CONCLUSION
In this large acute ICH cohort, initial antihypertensive class was associated with acute diastolic, but not systolic, BP-lowering suggesting differential effects of antihypertensive agents.
TRIAL REGISTRATION NUMBER
NCT01202864.
Topics: Humans; Antihypertensive Agents; Blood Pressure; Cerebral Hemorrhage; Hydralazine; Hypertension; Labetalol; Nicardipine
PubMed: 35443984
DOI: 10.1136/svn-2021-001101 -
American Journal of Obstetrics and... Feb 2022Chronic hypertension complicates 1% to 2% of pregnancies, and it is increasingly common. Women with chronic hypertension are an easily recognized group who are in touch... (Review)
Review
Chronic hypertension complicates 1% to 2% of pregnancies, and it is increasingly common. Women with chronic hypertension are an easily recognized group who are in touch with a wide variety of healthcare providers before, during, and after pregnancy, mandating that chronic hypertension in pregnancy be within the scope of many practitioners. We reviewed recent data on management to inform current care and future research. This study is a narrative review of published literature. Compared with normotensive women, women with chronic hypertension are at an increased risk of maternal and perinatal complications. Women with chronic hypertension who wish to be involved in their care can do by measuring blood pressure at home. Accurate devices for home blood pressure monitoring are now readily available. The diagnostic criteria for superimposed preeclampsia remain problematic because most guidelines continue to include deteriorating blood pressure control in the definition. It has not been established how angiogenic markers may aid in confirmation of the diagnosis of superimposed preeclampsia when suspected, over and above information provided by routinely available clinical data and laboratory results. Although chronic hypertension is a strong risk factor for preeclampsia, and aspirin decreases preeclampsia risk, the effectiveness specifically among women with chronic hypertension has been questioned. It is unclear whether calcium has an independent effect in preeclampsia prevention in such women. Treating hypertension with antihypertensive therapy halves the risk of progression to severe hypertension, thrombocytopenia, and elevated liver enzymes, but a reduction in preeclampsia or serious maternal complications has not been observed; however, the lack of evidence for the latter is possibly owing to few events. In addition, treating chronic hypertension neither reduces nor increases fetal or newborn death or morbidity, regardless of the gestational age at which the antihypertensive treatment is started. Antihypertensive agents are not teratogenic, but there may be an increase in malformations associated with chronic hypertension itself. At present, blood pressure treatment targets used in clinics are the same as those used at home, although blood pressure values tend to be inconsistently lower at home among women with hypertension. Although starting all women on the same antihypertensive medication is usually effective in reducing blood pressure, it remains unclear whether there is an optimal agent for such an approach or how best to use combinations of antihypertensive medications. An alternative approach is to individualize care, using maternal characteristics and blood pressure features beyond blood pressure level (eg, variability) that are of prognostic value. Outcomes may be improved by timed birth between 38 0/7 and 39 6/7 weeks' gestation based on observational literature; of note, confirmatory trial evidence is pending. Postnatal care is facilitated by the acceptability of most antihypertensives (including angiotensin-converting enzymes inhibitors) for use in breastfeeding. The evidence base to guide the care of pregnant women with chronic hypertension is growing and aligning with international guidelines. Addressing outstanding research questions would inform personalized care of chronic hypertension in pregnancy.
Topics: Antihypertensive Agents; Aspirin; Blood Pressure Monitoring, Ambulatory; Calcium; Chronic Disease; Contraindications, Drug; Decision Making, Shared; Delivery, Obstetric; Female; Humans; Hypertension; Platelet Aggregation Inhibitors; Pre-Eclampsia; Pregnancy; Pregnancy Complications, Cardiovascular; Prenatal Care
PubMed: 32687817
DOI: 10.1016/j.ajog.2020.07.026 -
International Journal of Molecular... May 2023Arterial hypertension (AH) is a global challenge that greatly impacts cardiovascular morbidity and mortality worldwide. AH is a major risk factor for the development and... (Review)
Review
Arterial hypertension (AH) is a global challenge that greatly impacts cardiovascular morbidity and mortality worldwide. AH is a major risk factor for the development and progression of kidney disease. Several antihypertensive treatment options are already available to counteract the progression of kidney disease. Despite the implementation of the clinical use of renin-angiotensin aldosterone system (RAAS) inhibitors, gliflozins, endothelin receptor antagonists, and their combination, the kidney damage associated with AH is far from being resolved. Fortunately, recent studies on the molecular mechanisms of AH-induced kidney damage have identified novel potential therapeutic targets. Several pathophysiologic pathways have been shown to play a key role in AH-induced kidney damage, including inappropriate tissue activation of the RAAS and immunity system, leading to oxidative stress and inflammation. Moreover, the intracellular effects of increased uric acid and cell phenotype transition showed their link with changes in kidney structure in the early phase of AH. Emerging therapies targeting novel disease mechanisms could provide powerful approaches for hypertensive nephropathy management in the future. In this review, we would like to focus on the interactions of pathways linking the molecular consequences of AH to kidney damage, suggesting how old and new therapies could aim to protect the kidney.
Topics: Humans; Hypertension; Kidney; Renin-Angiotensin System; Antihypertensive Agents; Hypertension, Renal
PubMed: 37298378
DOI: 10.3390/ijms24119422 -
Journal of Hypertension Sep 2010The role of alpha-1 adrenoceptor antagonists (alpha-blockers) in the management of hypertension continues to evolve. Recent data support their use as add-on therapy in... (Review)
Review
The role of alpha-1 adrenoceptor antagonists (alpha-blockers) in the management of hypertension continues to evolve. Recent data support their use as add-on therapy in uncontrolled hypertension when used in combination with all other major classes of antihypertensive drug and there is increasing evidence suggesting that they have modest but significant beneficial effects on lipid and glucose metabolism. The availability of extended-release formulations has contributed to an excellent tolerability profile. New data from an observational analysis of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) suggest that doxazosin gastrointestinal therapeutic system (GITS) used as a third-line antihypertensive agent lowered blood pressure and caused modest reductions in plasma lipids. Furthermore, use of doxazosin in ASCOT was not associated with an increased risk of heart failure, in contrast to the earlier finding of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Overall, currently available data support the use of alpha-blockers as safe, well tolerated and effective add-on antihypertensive drugs, which have additional favourable metabolic effects.
Topics: Adrenergic alpha-1 Receptor Antagonists; Antihypertensive Agents; Blood Pressure; Clinical Trials as Topic; Doxazosin; Drug Therapy, Combination; Heart Failure; Humans; Hypertension; Lipids; Myocardial Infarction; Practice Guidelines as Topic
PubMed: 20543713
DOI: 10.1097/HJH.0b013e32833b912c -
The Cochrane Database of Systematic... Oct 2009Hypertension is associated with an increased risk of stroke, myocardial infarction and congestive heart failure. Methyldopa is a centrally acting antihypertensive agent,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Hypertension is associated with an increased risk of stroke, myocardial infarction and congestive heart failure. Methyldopa is a centrally acting antihypertensive agent, which was commonly used in the 1970's and 80's for blood pressure control. Its use at present has largely been replaced by antihypertensive drug classes with less side effects, but it is still used in developing countries due to its low cost. A review of its relative effectiveness compared to placebo on surrogate and clinical outcomes is justified.
OBJECTIVES
To quantify the effect of methyldopa compared to placebo in randomized controlled trials (RCTs) on all cause mortality, cardiovascular mortality, serious adverse events, myocardial infarctions, strokes, withdrawals due to adverse effects and blood pressure in patients with primary hypertension.
SEARCH STRATEGY
We searched the following databases: Cochrane Central Register of Controlled Trials (1960-June 2009), MEDLINE (2005-June 2009), and EMBASE (2007-June 2009). Bibliographic citations from retrieved studies were also reviewed. No language restrictions were applied.
SELECTION CRITERIA
We selected RCTs studying patients with primary hypertension. We excluded studies of patients with secondary hypertension or gestational hypertension.
DATA COLLECTION AND ANALYSIS
Two reviewers independently extracted data and assessed trial quality using the risk of bias tool. Data synthesis and analysis was performed using RevMan 5. Data for blood pressure were combined using the generic inverse variance method.
MAIN RESULTS
Twelve trials (N=595) met the inclusion criteria for this review. None of these studies evaluated the effects of methyldopa compared to placebo on mortality and morbidity outcomes. Data for withdrawals due to adverse effects were not reported in a way that permitted meaningful meta-analysis. Data from six of the twelve trials (N=231) were combined to evaluate the blood pressure lowering effects of methyldopa compared to placebo. This meta-analysis shows that methyldopa at doses ranging from 500-2250 mg daily lowers systolic and diastolic blood pressure by a mean of 13 (95%CI 6-20) / 8 (95% CI 4-13) mmHg. Overall, the risk of bias was considered moderate.
AUTHORS' CONCLUSIONS
Methyldopa lowers blood pressure to varying degrees compared to placebo for patients with primary hypertension. Its effect on clinical outcomes, however, remains uncertain.
Topics: Antihypertensive Agents; Blood Pressure; Humans; Hypertension; Methyldopa; Randomized Controlled Trials as Topic
PubMed: 19821316
DOI: 10.1002/14651858.CD003893.pub3 -
American Heart Journal Dec 2022Despite broad treatment recommendations, there are limited published reports comparing the efficacy of different antihypertensive agents in patients with isolated...
Despite broad treatment recommendations, there are limited published reports comparing the efficacy of different antihypertensive agents in patients with isolated systolic hypertension or isolated diastolic hypertension. This study was a secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. We compared the use of chlorthalidone, amlodipine, or lisinopril on the primary outcome of combined coronary heart disease, stroke, or all-cause mortality in patients with isolated systolic hypertension or isolated diastolic hypertension.
Topics: Humans; Antihypertensive Agents; Isolated Systolic Hypertension; Hypertension; Chlorthalidone; Amlodipine; Lisinopril; Treatment Outcome
PubMed: 35932912
DOI: 10.1016/j.ahj.2022.07.006 -
Current Hypertension Reports Jul 2014While there are strong trial data to guide the selection of initial hypertension treatment choice and limited data to support second agent choice, beyond the first two... (Review)
Review
While there are strong trial data to guide the selection of initial hypertension treatment choice and limited data to support second agent choice, beyond the first two agents, subsequent steps are empiric. As medications are added, the resulting polypharmacy may be complex, inefficient and poorly tolerated, resulting in low treatment adherence rates. The selection of antihypertensive drug therapy based on hemodynamic mechanisms is not new but became practical with the availability of noninvasive hemodynamic parameters using impedance cardiography. Individualized therapy based on hormonal or hemodynamic measurements can effectively control hypertension as shown in several small clinical trials. Hemodynamic measurements are obtained quickly, painlessly and can be used in a serial fashion to guide treatment adjustments. Current limitations relate to availability of the measurement device and personnel trained in its use, reimbursement for the measurements, expertise in interpretation of the measurements and systems to adjust medication and repeat measurements in a serial fashion until targets are attained. The potential utility of this approach increases with greater complexity of the medication regimen. Further studies are indicated and may advance options for individualized treatment of hypertensive patients.
Topics: Antihypertensive Agents; Blood Pressure; Drug Therapy, Combination; Hemodynamics; Humans; Hypertension; Precision Medicine
PubMed: 24806735
DOI: 10.1007/s11906-014-0451-y -
Hypertension (Dallas, Tex. : 1979) Jan 2024
Review
Topics: Humans; Hypertension; Cardiovascular Diseases; Antihypertensive Agents; Blood Pressure
PubMed: 37795644
DOI: 10.1161/HYPERTENSIONAHA.123.21725 -
Vascular Health and Risk Management 2011In patients with hypertension, 24-hour blood pressure control is the major therapeutic goal. The number of daily doses is one characteristic of an antihypertensive agent... (Review)
Review
In patients with hypertension, 24-hour blood pressure control is the major therapeutic goal. The number of daily doses is one characteristic of an antihypertensive agent that may affect the adequacy of 24-hour control. One measure of therapeutic coverage is the 24-hour trough-to-peak ratio, which determines the suitability of an agent for once-daily administration. The closer an agent is to a 100% trough-to-peak ratio, the more uniform the 24-hour coverage and therefore blood pressure control. High trough-to-peak ratio, long-acting antihypertensive medications lower blood pressure more gradually, which reduces the likelihood of adverse events attributable to abrupt drug action that occurs with shorter-acting agents. In hypertension, the natural diurnal variation of blood pressure may be altered, including elevated nighttime pressures. An optimal once-daily hypertension therapy would not only lower blood pressure but also normalize any blunted circadian variations in blood pressure. The benefits of once-daily agents with sustained therapeutic coverage may also be explained, in part, by increased patient adherence to simpler regimens as well as lower loss of blood pressure control during virtually inevitable intermittent noncompliance. Studies have demonstrated that once-daily antihypertensive agents have the highest adherence compared with twice-daily or multiple daily doses, including greater adherence to the prescribed timing of doses.
Topics: Adrenergic beta-Antagonists; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Aorta; Brachial Artery; Calcium Channel Blockers; Cardiovascular Diseases; Clinical Trials as Topic; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Chronotherapy; Drug Therapy, Combination; Humans; Hypertension; Medication Adherence
PubMed: 22241952
DOI: 10.2147/VHRM.S17207 -
Journal of the American College of... Dec 1989Hypertension is a major public health problem amendable to treatment. Numerous large scale clinical trials have demonstrated that effective, sustained control of... (Review)
Review
Hypertension is a major public health problem amendable to treatment. Numerous large scale clinical trials have demonstrated that effective, sustained control of elevated arterial pressure to a level below 140/90 mm Hg results in reduced cardiovascular morbidity and mortality. Over the past 4 decades antihypertensive drug therapy has evolved from a stepwise, but physiologically rational, selection of agents to specific programs tailored to individualized therapy for specific clinical situations. This evolution has taken place because of a greater understanding of the pathophysiology of hypertensive diseases, the development of new classes of antihypertensive agents that attack specific pressor mechanisms, and the ability to wed these concepts into a rational and specific therapeutic program. Thus, with the currently available spectrum of antihypertensive therapy, we are now able to select treatment for special patient populations utilizing a single agent and, therefore, we can protect the heart, brain and kidneys and maintain organ function without exacerbating associated diseases. These benefits are clear-cut and have resulted in many millions of patients becoming the beneficiaries of this transfer of careful, painstaking and purposeful investigative experiences into clinical practice.
Topics: Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Calcium Channel Blockers; Diuretics; Humans; Hypertension; Sympatholytics; Vasodilator Agents
PubMed: 2685075
DOI: 10.1016/0735-1097(89)90002-8