Unmet needs in hypertension Cakmak, Hüseyin Altuğ; Arslan, Eren; Erdine, Serap
Türk Kardiyoloji Derneği arşivi
37 Suppl 7
Journal Article
Recenzirano
Hypertension is considered one of the world's most important health problems. Approximately one billion people are affected in the world. Almost for 50 years, effective medical treatment in reducing ...blood pressure are among the tools of cardiovascular medical treatment. However, control rates of hypertension is not at an acceptable level. One of the main causes of the difficulty to take hypertension under control is that this disease is a chronic disease. Control of hypertension and the goal of optimum blood pressure is of crucial importance because of the association between arterial hypertension and organ damage in terms of cardiac, vascular and renal functions. An important part of research on hypertension has concentrated on renin angiotensin system (RAS), as a basic mechanism in regulating acute and chronic blood pressure. Today, what is expected from new antihypertensive drugs and direct renin inhibitors in particular is to provide significantly more effective blood pressure control as well as preventing target organ damage, by acting on the RAS which has an important role in the etiology of hypertension.
The following is a brief statement of the 2003 European Society of Hypertension (ESH)-European Society of Cardiology (ESC) guidelines for the management of arterial hypertension. The continuous ...relationship between the level of blood pressure and cardiovascular risk makes the definition of hypertension arbitrary. Since risk factors cluster in hypertensive individuals, risk stratification should be made and decision about the management should not be based on blood pressure alone, but also according to the presence or absence of other risk factors, target organ damage, diabetes, and cardiovascular or renal damage, as well as on other aspects of the patient's personal, medical and social situation. Blood pressure values measured in the doctor's office or the clinic should commonly be used as reference. Ambulatory blood pressure monitoring may have clinical value, when considerable variability of office blood pressure is found over the same or different visits, high office blood pressure is measured in subjects otherwise at low global cardiovascular risk, there is marked discrepancy between blood pressure values measured in the office and at home, resistance to drug treatment is suspected, or research is involved. Secondary hypertension should always be investigated. The primary goal of treatment of patient with high blood pressure is to achieve the maximum reduction in long-term total risk of cardiovascular morbidity and mortality. This requires treatment of all the reversible factors identified, including smoking, dislipidemia, or diabetes, and the appropriate management of associated clinical conditions, as well as treatment of the raised blood pressure per se. On the basis of current evidence from trials, it can be recommended that blood pressure, both systolic and diastolic, be intensively lowered at least below 140/90 mmHg and to definitely lower values, if tolerated, in all hypertensive patients, and below 130/80 mmHg in diabetics. Lifestyle measures should be instituted whenever appropriate in all patients, including subjects with high normal blood pressure and patients who require drug treatment. The purpose is to lower blood pressure and to control other risk factors and clinical conditions present. In most, if not all, hypertensive patients, therapy should be started gradually, and target blood pressure achieved progressively through several weeks. To reach target blood pressure, it is likely that a large proportion of patients will require combination therapy with more than one agent. The main benefits of antihypertensive therapy are due to lowering of blood pressure per se. There is also evidence that specific drug classes may differ in some effect or in special groups of patients. The choice of drugs will be influenced by many factors, including previous experience of the patient with antihypertensive agents, cost of drugs, risk profile, presence or absence of target organ damage, clinical cardiovascular or renal disease or diabetes, patient's preference.
The CRUCIAL trial was designed to compare the relative reduction in calculated Framingham coronary heart disease risk when a multiple risk factor intervention strategy, based on single-pill ...amlodipine besylate/atorvastatin calcium, was compared with a usual-care strategy. Eligible patients had treated or untreated hypertension, ≥ 3 additional cardiovascular risk factors, and baseline total cholesterol ≤ 6.5 mmol/L, but no coronary heart disease. The CRUCIAL trial was a 12-month, international, multicenter, prospective, stratified, cluster-randomized, parallel-design, open-label trial conducted in 20 countries in Asia, the Middle East, Europe, and Latin America. We anticipate the results of this study will be available in mid to late 2010. In this article we report the rationale for and design of the CRUCIAL trial and discuss how the challenges in the design and conduct of this cluster-randomized trial were addressed. The cluster-randomized trial design, with the investigator as the unit of randomization, was chosen to minimize contamination between the trial arms. The intent of the study was to compare the new therapeutic strategy with customary treatment practices, so no recommendation was made regarding the choice of antihypertensive or lipid-lowering drugs in the usual-care arm. It was considered that if the investigator managed both arms of the trial it would be difficult to prevent crossover of treatment strategies. Patients were enrolled in the study before the investigators were randomized to avoid selection bias. Investigators were randomized in a 1:1 ratio within each country to explicitly balance the treatment arms with respect to potential confounding factors. The cluster effect was taken into account in the sample size calculation. The findings from the CRUCIAL trial have the potential to inform current thinking on how to effectively reduce the cardiovascular risk of patients with hypertension and additional risk factors but only modestly elevated total cholesterol.
Cardiovascular disease (CVD) due to atherosclerosis of the arterial vessel wall and to thrombosis is the foremost cause of premature mortality and of disability-adjusted life years (DALYs) in Europe, ...and is also increasingly common in developing countries.1 In the European Union, the economic cost of CVD represents annually E192 billion1 in direct and indirect healthcare costs. The main clinical entities are coronary artery disease (CAD), ischaemic stroke, and peripheral arterial disease (PAD). The causes of these CVDs are multifactorial. Some of these factors relate to lifestyles, such as tobacco smoking, lack of physical activity, and dietary habits, and are thus modifiable. Other risk factors are also modifiable, such as elevated blood pressure, type 2 diabetes, and dyslipidaemias, or non-modifiable, such as age and male gender. These guidelines deal with the management of dyslipidaemias as an essential and integral part of CVD prevention. Prevention and treatment of dyslipidaemias should always be considered within the broader framework of CVD prevention, which is addressed in guidelines of the Joint European Societies’ Task forces on CVD prevention in clinical practice.2 – 5 The latest version of these guidelines was published in 20075; an update will become available in 2012. These Joint ESC/European Atherosclerosis Society (EAS) guidelines on the management of dyslipidaemias are complementary to the guidelines on CVD prevention in clinical practice and address not only physicians e.g. general practitioners (GPs) and cardiologists interested in CVD prevention, but also specialists from lipid clinics or metabolic units who are dealing with dyslipidaemias that are more difficult to classify and treat.
The aim of the present study is to determine and correlate adiponectin, homocysteine, nitric oxide, and ADP-induced platelet aggregation levels in untreated patients with essential hypertension and ...healthy individuals. A total of 36 individuals, 23 untreated patients with essential hypertension and 13 healthy individuals, were included in the scope of this study. Enzyme-linked immunosorbent assay (ELISA) was used to determine the serum adiponectin and TNF-α levels. The levels of serum homocysteine were measured by using competitive chemiluminescent enzyme immunoassay. Serum concentrations of hsCRP were measured by the Nephelometer. Plasma nitrite, nitrate, and total nitric oxide (NOx) levels were determined by colorimetric method. Homocysteine and hsCRP levels in patients with essential hypertension were found to be significantly higher than those in the control group (
P
= 0.02,
P
= 0.001, respectively). The avarage platelet aggregation levels in patient group were higher than control group, but there were no statistically significant differences between them (
P
> 0.05). In addition, in patients with essential hypertension adiponectin and nitrite levels are significantly lower than control group (
P
< 0.001,
P
= 0.045, respectively). We have also found significant correlations between nitrite-platelet aggregation amplitude, nitrite-platelet aggregation slope, nitrite-adiponectin, homocysteine-platelet aggregation amplitude, and sistolic blood pressure-platelet aggregation amplitude levels (
r
= −0.844;
P
< 0.001,
r
= −0.680;
P
= 0.011,
r
= 0.454;
P
= 0.05,
r
= 0.414;
P
= 0.05,
r
= 0.442;
P
= 0.035, respectively). Increased homocysteine and decreased adiponectin serum levels in patients with essential hypertension correlate well with changes in ADP-induced conventional platelet aggregation. This association may potentially contribute to future thrombus formation and higher risks for cardiovascular events in hypertensive patients.
ESC/EAS Guidelines for the Management of Dyslipidaemias Reiner, Željko; Catapano, Alberico L; De Backer, Guy ...
Revista portuguesa de cardiologia (English ed.),
2013, January 2013, 2013-01-00, Letnik:
32, Številka:
1
Journal Article
ESC/EAS Guidelines for the Management of Dyslipidaemias Reiner, Željko; Catapano, Alberico L; De Backer, Guy ...
Revista portuguesa de cardiologia (English ed.),
2013, January 2013, 2013-01-00, Letnik:
32, Številka:
1
Journal Article
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