Wf Terpstra

Long-term effects of amlodipine and lisinopril on left ventricular mass and diastolic function in elderly, previously untreated hypertensive patients : the ELVERA trial

Objective To compare the effects of a calcium antagonist (amlodipine) and an angiotensin converting enzyme inhibitor (lisinopril) on left ventricular mass and diastolic function in elderly, previously untreated hypertensives. Design A double-blind randomized parallel group trial. Effects of amlodipine and lisinopril on left ventricular mass and diastolic function (E/A Ratio) (The ELVERA trial). Setting Rural northern Netherlands: population screening new diagnosed hypertensive subjects. Patients The study population comprised 166 newly diagnosed hypertensive (aged 60–75) with diastolic blood pressure between 95–115 mmHg and/or systolic blood pressure between 160–220 mmHg. Intervention Patients were randomly allocated to receive 5–10 mg amlodipine or 10–20 mg lisinopril for 2 years. Main outcome measures Prior and after 1 and 2 years of treatment left ventricular mass, indexed by body surface (LVMI) was estimated by 2-D mode echocardiography according to Devereux with use of Penn convention. Early to atrial filling ratio (E/A) was assessed by transmitral flow. Change from baseline of LVMI and E/A ratio was evaluated by repeated measurement analysis of the treatment effect in an intention-to-treat analysis. Results Both amlodipine and lisinopril led to equivalent reduction in systolic and diastolic blood pressure. At the end of the study the amlodipine group led to LVMI decrease by 21.8 g/m ⩽ [95% confidence interval (CI), 18.3–25.3] and E/A ratio increased by 0.08 (95% CI, 0.05–0.11). In the lisinopril group LVMI decreased by 22.4 g/m ⩽ (95%, CI, 19.0–25.8) and E/A ratio increased by 0.07 (95% CI, 0.04–0.10). No statistically significant differences were found in changes in LVMI and E/A ratio between amlodipine and lisinopril. Conclusion A long-term study, the ELVERA trial proves that amlodipine and lisinopril reduce left ventricular mass and improve diastolic function to a similar extent in elderly newly diagnosed hypertensive patients.

Carotid intima-media thickness: influence of drug treatment and clinical implications

With B-mode ultrasound measurements of the intima-media thickness (IMT) of the carotid arterial wall (asymptomatic) atherosclerosis can be detected. In this article several studies are reviewed in which IMT was used as a surrogate endpoint to assess effects of lipid-lowering or antihypertensive drugs on peripheral atherosclerosis, and the clinical implications are discussed. After 1 year of treatment with lipid-lowering drugs an improvement of the blood lipid profile and retarded progression of the carotid IMT was seen. No incontrovertible evidence can be provided for a correlation between induced changes in the carotid and coronary arteries. Carotid IMT appears to be of prognostic value for cardiovascular events. The range of treatment-induced changes in IMT do not support the use of IMT in an individual patient to monitor treatment effects. However, with increased IMT as independent cardiovascular risk factor, IMT measurements are valuable in risk assessment in the individual patient in clinical practice. Looking forward to some ongoing studies, there is so far insufficient evidence that treating hypertension also inhibits progression of the IMT.

Home blood pressure measurement : reproducibility and relationship with left ventricular mass

OBJECTIVE To evaluate the reproducibility and relationship with left ventricular mass index of home blood pressure in comparison with ambulatory and office blood pressures. METHODS We measured home, ambulatory and office blood pressures of 84 previously untreated hypertensive patients, aged 60-74 years, from primary care, at baseline and after 12 weeks, without active intervention in between. Left ventricular mass index was determined echocardiographically during week 12. RESULTS Decreases in systolic and diastolic blood pressures were found after 12 weeks for mean home and office blood pressures (P<0.05), but not for mean ambulatory blood pressure. The coefficients of reproducibility for systolic and diastolic ambulatory blood pressures were 26.4 and 16.0, respectively. Correlation coefficients for correlation of left ventricular mass index to ambulatory blood pressure (0.51 and 0.36) were higher than the correlation coefficients for home (0.31 and 0. 16) and office (0.32 and 0.21) blood pressures, for systolic and diastolic values, respectively. However, we could find no statistically significant difference among the correlation coefficients for all three types of measurements. CONCLUSIONS Home blood pressure was considerably less reproducible than ambulatory blood pressure and no different from office blood pressure in this respect. The relationship with left ventricular mass index appeared to be stronger for ambulatory than it was for home and office blood pressures, although not statistically significant so.

Microalbuminuria is Related to Marked End Organ Damage in Previously Untreated, Elderly Hypertensive Patients

We wondered whether, in an elderly hypertensive population in a primary prevention setting, free from diabetes mellitus and clinical atherosclerosis, differences between end organ damage and microalbuminuria (MA) could be found using a lower level of urinary albumin excretion than that of classically defined MA. From a population survey of 173 previously untreated hypertensive patients (4 2 blood pressure systolic S 160 and h 220 mmHg, and/or diastolic S 95 and h 115 mmHg), mean age 67 - 4 years, were screened for MA (defined as albumin excretion between 20 and 300 mg/24 h). End organ damage was determined by B-mode ultrasound scanning echocardiography. Out of 173 hypertensives, 14 showed MA (8%). These hypertensives had a significantly higher intima media thickness (IMT; 1.01 - 0.21 vs 0.88 - 0.6 mm, p < 0.05) and increased left ventricular mass index (118 - 31 vs 103 - 22 g/m 2 , p < 0.05) than hypertensives without MA. Linear regression analysis showed that MA, age, male gender and diastolic blood pressure were independently related to IMT, while systolic blood pressure, male gender and body mass index were independently related to left ventricular mass. Even using lower levels of urinary albumin excretion rate, patients with MA had significantly higher IMT and increased left ventricular mass. Moreover, MA was independently related to IMT in these elderly hypertensives. These results suggest that the threshold value for MA should be reconsidered in hypertension.

Effects of nifedipine on carotid and femoral arterial wall thickness in previously untreated hypertensive patients

Background: Experimental and clinical evidence suggests that calcium-channel blockers may retard the atherosclerotic process after long-term treatment. Whether these effects exist after intermediate-term treatment in hypertensive patients is mainly unknown. Objective: To determine the 26-week effects of the long-acting calcium-channel blocker nifedipine on intima media thickness (IMT) in newly found hypertensive patients. Design: Open-label study with blinded end-point analysis. Methods: From a population survey, 131 previously untreated mild hypertensives (4× systolic blood pressure between 160 and 220 mmHg and/or diastolic blood pressure between 95 and 115 mmHg) were included. Patients were treated with long-acting nifedipine 30-60 mg targeted to reach a predetermined drop in blood pressure. Prior to and after 26 weeks of treatment, IMT was measured by ultrasonography in the carotid and femoral artery. The combined mean maximal far wall IMT was used as primary endpoint. Change from baseline was evaluated by paired t-test in an intention-to-treat analysis. Results: The mean maximal far wall IMT at baseline was 1.03 ± 0.23 mm, and decreased by 0.078 mm (95% confidence interval, CI 0.044-0.111) after treatment. Regression analysis, including baseline IMT and changes of blood pressure, showed that reduction of IMT was mostly influenced by baseline IMT (p < 0.001; model R [Formula: See Text] = 0.11). Conclusion: Our observations show that 26 weeks of nifedipine treatment inhibits IMT progression in these newly found hypertensive patients. This effect was mostly seen in arterial walls with highest IMT before treatment, suggesting that patients with highest cardiovascular risk benefit most of antihypertensive treatment.

Silent ST depression and cardiovascular end-organ damage in newly found, older hypertensives

In hypertension, both reduced vascular supply and increased cardiac demand contribute to the development of (silent) myocardial ischemia. Our aim was to determine the prevalence of ST-segment depression and to analyze contributing factors in asymptomatic, previously untreated, older hypertensives. From a population survey, in 184 patients with mild hypertension (4 times systolic blood pressure >/=160 mm Hg and/or diastolic blood pressure >/=95 mm Hg), 60 to 75 years of age, cardiovascular end-organ damage was measured. Episodes of ST-segment depression were measured by 48-hour ambulatory Holter monitoring and were observed in 21 hypertensives (12%). They showed a significantly higher combined far-wall intima-media thickness of carotid and femoral arteries and more arterial plaques as measured by B-mode ultrasound compared with hypertensives without ST depression (0.00098+/-0.00021 versus 0.00088+/-0.00016 mm and 5.2+/-3.7 versus 3.7+/-2.8 plaques, P<0.05, respectively), whereas left ventricular mass index was not different (111+/-18 versus 104+/-24 g/m(2); P=0.18, respectively). In hypertensives with transient ST-segment depression, a significant relation was found between left ventricular mass and ischemic burden (r=0.51, P=0.02). Approximately 1 of 8 unselected and previously untreated older hypertensives show asymptomatic ST-segment depression, suggestive of silent myocardial ischemia. These data suggest that vascular factors mainly determine the occurrence of ischemic ST-segment depression and cardiac factors determine the ischemic burden in older hypertensives.

Gender-related differences in left ventricular structural and functional responses to hypertension

Gender-related differences in left ventricular structural and functional responses to hypertension