1. Cardiovascular disease is a major cause of death worldwide and hypertension is a growing problem globally.
2. Angiotensin receptor blockers are recommended as first-line treatment for hypertension due to their specific blockade of the renin-angiotensin system and reduced potential for side effects compared to other classes.
3. Studies show that ARBs reduce cardiovascular events more than other blood pressure-lowering regimens and may provide additional benefits such as reduction in left ventricular hypertrophy, prevention of atrial fibrillation recurrence, and improvement of endothelial function markers.
ARBs (Angiotensin receptor blockers) are the most widely used anti hypertensive throughout the world. A solid knowledge related to ARB will make our practice more patients friendly & benefit will be maximum.
ARBs (Angiotensin receptor blockers) are the most widely used anti hypertensive throughout the world. A solid knowledge related to ARB will make our practice more patients friendly & benefit will be maximum.
Catheters are used in a number of processes, such as: cardiovascular, urological, intravenous, oximetry, thermodilution, suction and wound drainage processes, that involve the administration or drainage of fluids from the body. The global market for catheters is vibrant and continually evolving with significant investments to improve the capabilities of existing catheters, improve safety features and identify new medical applications. The growing number of aged people undergoing diagnostic and therapeutic procedures is driving increases in catheter sales. Government regulations also play a key role, mainly in the urological catheter segment, as regulations attempt to promote fewer infections among hospitalized patients through more frequent use of catheterization. This TriMark Publications report provides a detailed analysis of the global market for catheters, including central venous catheters (CVC), peripheral venous catheters (PVC), midline catheters (MC), hemodialysis catheters, pulmonary artery catheters, peripheral artery catheters and umbilical catheters. The study also analyzes almost all of the companies known to be marketing, manufacturing or developing catheter products in the U.S. and worldwide. Detailed tables, charts and figures are included with projected sales data by geographic region for the Americas, EMRA (Europe, the Middle East, Russia, Africa) and Asia-Pacific regions.
The National Corporate Sponsorship Program was established to develop formal alliances that involve Corporate America more closely with BDPA programs, activities and goals. Corporate sponsors not only offer financial support but also participate in programs developed to enhance the technical and professional skills of the community. The investment in BDPA creates positive exposure to a technically diverse membership of African-American Information Technology professionals and students.
The program is designed to offer corporations an opportunity to partner with BDPA to meet corporate goals and objectives for recruiting, employee development, philanthropic endeavors and enhanced image in the African American Community. The program is open to all corporations with a sincere interest in pursuing the vision, mission, objectives and goals of BDPA.
The conceptual and fundamental scope of the program is to:
• Link BDPA strategic initiatives to the objectives of the corporation
• Document mutual understanding, measurements and goals
• Develop plans, assign resources and confirm milestones for viewing progress toward the goals
• Provide a forum to interact with other IT and HR industry leaders and professionals
• Increase exposure opportunities to technically competent and diverse IT professionals and students
• Enhance loyalty in the corporation amongst employees and customers
In order to pull together all the components of a successful program, BDPA partners with corporations, associations and other strategic alliance partners, but by far, corporate support is a major component of BDPA’s success. Sponsoring levels available are listed below and opportunities are detailed in our comprehensive corporate sponsorship portfolio. (2013 Corporate Opportunities Portfolio.pdf)
• Platinum Corporate Sponsor $100,000+
• Gold Corporate Sponsor $50,000+
• Silver Corporate Sponsor $25,000+
• Bronze Corporate Sponsor $10,000+
• Corporate Sponsor $ 5,000+
• Corporate Supporter Less than $5,000
Contact us by email (corpsales@bdpa.org) or phone (301.584-3135) for more details on our corporate sponsorship program.
Spatial analysis of topography and river watershed factors for leptospirosis ...ILRI
Poster by Dyah Ayu Widiasih, Wayan T. Artama, Adi Heru Husodo, Tjut Sugandawaty Djohan and Fred Unger presented at the Ecohealth 2014 conference, Montreal, Canada, 11-15 August 2014.
Mubashar A Choudry MD | Effects of statin or usual care on outcomesMubashar A Choudry MD
Here, Dr. Mubashar A Choudry MD is explaining about effects of statin or usual care on outcomes. Dr. Mubashar Choudry is a respected cardiologist in Washington.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
2. Not all ARBs looks
after your patient
heart as well as
his mind
3. Cardiovascular Disease: A Worldwide Epidemic
World Health Organization Burden of Disease Estimates 2002.
0 5 10 15 20 25 30 35 40 45 50
CVDs
Infectious/parasitic diseases
Malignant neoplasms
Respiratory infections
Respiratory diseases
Unintentional injuries
Perinatal conditions
Digestive diseases
Intentional injuries
Neuropsychiatric conditions
Diabetes mellitus
Cause of death
Worldwide
Developed world
CVD is responsible for one third of all deaths worldwide and almost half of all
deaths in the developed world
4. Contribution of Risk Factors to Burden of
Disease Mortality*
*Based on The World Health Report 2003.*Based on The World Health Report 2003.
Yach et al.Yach et al. JAMAJAMA. 2004;291:2616-2622.. 2004;291:2616-2622.
0 5 10 15 20
Percentage of Mortality Attributable to Risk Factors
DevelopingDeveloping
countriescountries
DevelopedDeveloped
countriescountries
Blood pressureBlood pressure
TobaccoTobacco
UnderweightUnderweight
AlcoholAlcohol
CholesterolCholesterol
Unsafe sexUnsafe sex
OverweightOverweight
Unsafe water, sanitation,Unsafe water, sanitation,
hygienehygiene
Low fruit and vegetableLow fruit and vegetable
intakeintake
Indoor smoke from solid fuelsIndoor smoke from solid fuels
Physical inactivityPhysical inactivity
5. Hypertension: A Growing Problem
Prevalence (%)
United StatesUnited States77
EgyptEgypt99
JapanJapan88
ItalyItaly77
SwedenSweden77
EnglandEngland77
SpainSpain77
FinlandFinland77
GermanyGermany77
00 1010 2020 3030 4040 5050
TaiwanTaiwan99
CanadaCanada77
South KoreaSouth Korea99
*Defined as systolic/diastolic blood pressure*Defined as systolic/diastolic blood pressure ≥≥140/90, (140/90, (≥≥160/95 for Taiwan)160/95 for Taiwan) or receiving treatment.or receiving treatment.
††
South Korea is defined as men, aged 30 to 59.South Korea is defined as men, aged 30 to 59.
7. Wolf-Maier et al.7. Wolf-Maier et al. JAMAJAMA. 2003;289:2363-2369; 8. Data on file. Pfizer Inc, New York, NY;. 2003;289:2363-2369; 8. Data on file. Pfizer Inc, New York, NY;
9.9. WHO Collaborating Centre on Surveillance of Cardiovascular Disease Web site. Available at: www.cvdinfobase.ca. Accessed February 22, 2005.WHO Collaborating Centre on Surveillance of Cardiovascular Disease Web site. Available at: www.cvdinfobase.ca. Accessed February 22, 2005.
6. Lewington et al. Lancet 2002 ; 360 : 1903–13.
CARDIOVASCULAR MORTALITY DOUBLES FOR EVERY
INCREMENT IN SBP/DBP OF 20/10 mm Hg
7. Meta-analysis of 61 prospective, observational studies
1 million adults
12.7 million person-years
BENEFITS OF BP DECREASE
Lewington S, et al. Lancet. 2002;360:1903-1913.
8. Effect of antihypertensive therapy on all
CV events: Comparison of more or less
intensive BP control
Relative risk (95% CIs)
1.0 1.25
More
intensive BP
control better
Less
intensive BP
control
better
0.5
Stroke
Coronary heart disease
Heart failure
Major CV events
CV death
Total mortality
BPLTTC Lancet 2003
9. Benefits of Lowering BP
Average Percent ReductionAverage Percent Reduction
Stroke incidenceStroke incidence 35–40%35–40%
Myocardial infarctionMyocardial infarction 20–25%20–25%
Heart failureHeart failure 50%50%
10. SBP-Associated Risks: MRFIT
Adapted from Neaton JD et al. Arch Intern Med. 1992;152:56-64.
SBP versus DBP in Risk of CHD Mortality
Diastolic BP
(mm Hg)
Systolic BP
(mm Hg)
CHD Death Rate
100+
90–99
80–89
75–79
70–74
<70 <120
120–139
140–159
160+
48.3
20.6
10.3
11.8
8.8
8.5
9.2
23.8
16.9
13.9
12.8
12.6
11.8
31.0
25.5
24.6 25.3
25.2
24.9
37.4
34.7
43.8
38.1
80.6
11. Pulse Pressure
• Increase in pulse pressure (PP) indicates
greater stiffness in large conduit arteries,
primarily the thoracic aorta.
• PP may be a better marker of increased
CV risk than either systolic BP or diastolic
BP alone in older persons.
PP = SBP – DBPPP = SBP – DBP
14. Rationale for Use of ARB’s in Hypertension
• Specific blockade of the renin-angiotensin-
aldosterone system provides:
– More complete blockade of BP response to angiotensin
II (specific for ATII receptor blockade)
– Reduced potential for target organ damage
– Reduced potential for bradykinin “cough”
– Best tolerability (specific for ATII receptor blockade)
– Some studies suggest a reduced risk of vascular events
compared with other BP lowering regimens
Guidelines recognize the additive positive effect of ARBs in hypertensives with:
• Type 2 diabetes
• End-organ disease, particularly that affecting the kidney
15. RR (95% CI)
Favors
ARB
Favors
Other
0.5 1.0 2.0
Relative risk
0.79 (0.69,0.90)Stroke
0.96 (0.85,1.09)CHD
Heart failure 0.84 (0.72,0.97)
Major CV events 0.90 (0.83,0.96)
CV death 0.96 (0.85,1.08)
Total mortality 0.94 (0.86,1.02)
Outcome
BP
difference
(mmHg)
-2/-1
-2/-1
-2/-1
-2/-1
-2/-1
-2/-1
Angiotensin Receptor Antagonists Reduce RiskAngiotensin Receptor Antagonists Reduce Risk
of Vascular Events And Total Mortalityof Vascular Events And Total Mortality
BPLTTC Lancet 2003; 362: 1527-35
Based on analysis of data from the SCOPE, IDNT, RENAAL and LIFE trials
17. ARBs significantly increased probability
of maintaining sinus rhythm
0
20
40
60
80
100
Probability
of maintaining
sinus rhythm (%)
ARB
+ amiodarone
Madrid A et al. Circulation
p = 0.008 vs. amiodarone
Amiodarone
85%
63%
159 patients with persistent atrial fibrillation were randomized159 patients with persistent atrial fibrillation were randomized
to either amiodarone or amiodarone + ARBto either amiodarone or amiodarone + ARB
Results are taken at 2-month follow-up visitResults are taken at 2-month follow-up visit
19. ESH/ESC Guidelines
“A blocker of the renin-
angiotensin system should be
a regular component of
combination treatment and
the one preferred when
monotherapy is sufficient”
22. Change in mean SBP and DBP from baseline after 8 weeks
of treatment with eprosartan (600mg/day) or placebo in
patients with mild-to-moderate hypertension
Eprosartan vs Placebo in Mild-to-Moderate HTN
-26
-17.1
-12.6 -13.5
-50
-45
-40
-35
-30
-25
-20
-15
-10
-5
0
mmHg
SBP
MBP
DBP
PP
23. Sega. Blood Press 1999;8:114
ReductioninsitSBP(mmHg)
p=0.025
–29.1
–21.2
–15
–25
–20
–30
0
–5
–10
ReductioninstaSBP(mmHg)
p=0.032
–27.8
–20.0
–15
–25
–20
–30
0
–5
–10
Eprosartan
Enalapril
Eprosartan reduces sitSBP and staSBP in
patients with severe hypertension
24. Argenziano & Trimarco. Curr Med Res Opin 1999;15:9
<65 years
(n=201)
≥65 years
(n=63)
0
–2
–4
–6
–8
–10
–12
–14
–16
–18
–20
MeanchangefrombaselineinsitSBP(mmHg)
Eprosartan has similar efficacy in young
and elderly patients
0
–2
–4
–6
–8
–10
–12
–14
–16
–18
–20
<65 years
(n=201)
≥65 years
(n=63)
MeanchangefrombaselineinsitDBP(mmHg)
25. Puig et al. J Hypertens 1999;17:1033
ReductioninsitBP(mmHg)
–18
–15
–12
–9
–6
–3
0
Diastolic Systolic
–12.4
–9.6
–12.7
–10.9
0
20
40
60
80
Responserate(%)
73
53
100
Eprosartan
Losartan
Eprosartan is more effective than losartan
in mild hypertension
26. PULSE PRESSURE REDUCTION
Robles NR, et al. Int J Clin Pract 2005;59(4):478-484
Reduction in mean pulse pressure, arterial pressure, SBP and DBP in
a 16-week open-label study (n=566)
27. Teveten effect on fibrinolytic/hemostatic
variables: Comparative study to losartan
In conclusion, the results indicate
that 6-month monotherapy with an
angiotensin II type 1 receptor blocker,
eprosartan, is associated with a more
favorable modification of hemostatic
& fibrinolytic status than with
losartan
Drugs Exp Clin Res. 2004;30(3):125-32
28. Effect of Teveten on cytoplasmic free calcium
mobilization, platelet activation, and
microparticle formation in hypertension
CONCLUSIONS: Teveten
significantly reduces blood
pressure and normalizes
undesirable changes in platelet
function
Am J Hypertens. 2004 Sep;17(9):757-63.
29.
30. CEREBROVASCULAR RISK EPIDEMIOLOGY
Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and
stroke statistics—2009 update: a report from the American Heart Association Statistics
Committee and Stroke Statistics Subcommittee.Circulation 2009;119:e21–181.
CVD is the 3rd
leading cause of death in the U.S. and the first
cause of long-term major disability
There are 795,000 incident strokes in the U.S. each year
8–12% of individuals die within the first 30 days of their initial
stroke
Patients who survive the initial attack face an increased risk of
subsequent vascular events and stroke (21.5%)
The consequences of stroke are socioeconomic
Therefore, in light of this disease burden, prevention of initial
and recurrent stroke is a major priority for healthcare providers
31. STROKE IS MORE FREQUENT THAN AMI
Gentil, A et al. J Neurol Neurosurg Psychiatry 2009;80:1006-1011C
40. POST STROKE TRIAL
ACCESS: candesartan, post acute STROKE, positive
but pilot study
SCAST: candesartan, negative.
PROFESS: telmisartan, post stroke negative
MOSES: eprosartan, post stroke only positive trial with
an active comparator, benefits beyond simple BP
reduction.
41. Primary endpoint:
Total mortality plus total number of
cardiovascular and cerebrovascular events
Secondary endpoints:
Change in mental capacity and functional status
(Barthel Index and Rankin Scale)
Individual elements of the combined primary
endpoint
Mean follow-up:
2.5 years
42. 29 in total:
14 withdrew consent prior
to first intake of study drug
1 without known vital status
14 lost for follow-up monitoring
24 in total:
10 withdrew consent prior to
first intake of study drug
2 without known vital status
12 lost for follow-up monitoring
1,405 patients eligible for randomization
710 assigned to
eprosartan-based
regimen
695 assigned to
nitrendipine-based
regimen
681 available for intention-
to-treat analyses
671 available for intention-
to-treat analyses
47. Blood pressure Blood pressure
Riskofcoronaryheartdisease
Nitrendipine
Nitrendipine
Teveten
Teveten
-25%vs
CCB
-31%vs CCB
)1st time occurrence(
Risk of Stroke and CHD – MOSES StudyRisk of Stroke and CHD – MOSES Study
Benefits beyond BP LoweringBenefits beyond BP Lowering
Riskofcerebrovascularevents
48. Adverse Remodeling of the VasculatureAdverse Remodeling of the Vasculature
Alpha-1
vasoconstriction
Ang II
Doxazosin
Prazosin
Eprosartan
NE
Eprosartan
(ARBs)
Vasoconstriction
Vasoconstriction
Media hypertrophy
Collagen deposition
Dual mechanism of
action
49. CONCLUSIONS
Cerebrovascular health protection is cardiovascular
prevention
Prevention is primary, secondary prevention of stroke but
also dementia and global cardiovascular protection
Evidence based approach:
Eprosartan
Efficient in BP reduction
Specific and dual mode of action
Prevention of cardiovascular and cerebrovascular
Health
Editor's Notes
The World Health Report identified the contribution of selected risk factors to mortality worldwide in developing and developed countries. Blood pressure (BP) levels higher than optimal account for the largest percentage of mortality worldwide followed by tobacco use. Cholesterol higher than a level considered optimal is the fifth largest contributor to mortality worldwide. It is important to note that higher than optimal BP, tobacco use, and higher than optimal cholesterol are major contributors to mortality in both developing and developed countries. Risk factors such as underweight, unsafe sex, unsafe water, poor sanitation, and hygiene are overwhelmingly contributors to mortality in the developing world.
The World Health Report identified the contribution of selected risk factors to mortality worldwide in developing and developed countries. Blood pressure (BP) levels higher than optimal account for the largest percentage of mortality worldwide followed by tobacco use. Cholesterol higher than a level considered optimal is the fifth largest contributor to mortality worldwide. It is important to note that higher than optimal BP, tobacco use, and higher than optimal cholesterol are major contributors to mortality in both developing and developed countries. Risk factors such as underweight, unsafe sex, unsafe water, poor sanitation, and hygiene are overwhelmingly contributors to mortality in the developing world.
The World Health Report identified the contribution of selected risk factors to mortality worldwide in developing and developed countries. Blood pressure (BP) levels higher than optimal account for the largest percentage of mortality worldwide followed by tobacco use. Cholesterol higher than a level considered optimal is the fifth largest contributor to mortality worldwide. It is important to note that higher than optimal BP, tobacco use, and higher than optimal cholesterol are major contributors to mortality in both developing and developed countries. Risk factors such as underweight, unsafe sex, unsafe water, poor sanitation, and hygiene are overwhelmingly contributors to mortality in the developing world.
The data from placebo-controlled trials clearly supports the benefits of treating hypertension but it should be appreciated that most (but not all) of the trials focussed upon diuretics as initial therapy. Based on their positive outcomes it was no longer considered to be ethical to perform placebo control trials. Thus for the last 10 years trials have compared alternative antihypertensive strategies using different classes of antihypertensive drugs. The philosophy underlying these trials was based upon the fact that treatment of hypertensive patients should not only consist of a reduction in blood pressure but should also focus on the effects of therapy on associated risk factors and metabolic abnormalities some of which might be deleteriously effected by the therapy itself. The question as to whether particular advantages exist for certain types of antihypertensive agent has not unequivocally been answered. However, the Blood Pressure Lowering Treatment Trialists Collaboration meta-analysis (1) clearly indicated that more intensive blood pressure lowering was associated with improvements in cardiovascular outcome, including heart failure (although heart failure did not attain statistical significance).
(1) BPLTTC. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet 2003;362:1527-35.
MRFIT showed that SBP is a stronger predictor of CHD mortality than DBP in men of all age groups except those 35 to 39 years of age. This study examined the relative risk of CHD mortality as a function of SBP and DBP in 353,340 screened men who were followed for an average of 12 years. A strong, graded relationship was evident between SBP at every level &gt;110 mm Hg and death due to CHD. Differences in CHD-related mortality at various DBP levels were relatively small.24
Results from MRFIT strongly support the conclusion that SBP is a better indicator of increased CHD risk than DBP. This conclusion prompted the recent recommendation by the Coordinating Committee, National High Blood Pressure Education Program, National Heart, Lung, and Blood Institute, that SBP should “…become the principal clinical end point for the detection, evaluation, and treatment of hypertension, especially in middle-aged and older Americans.”26
Hypertension is a widespread disease responsible for a considerable health care burden.
Suboptimal treatment and control of hypertension is common.
Blockade of the renin-angiotensin-aldosterone system with ARBs offers advantages over ACE inhibitors
More complete blockade of BP response to angiotensin II (specific for ATII receptor blockade)
Reduced potential for target organ damage
Reduced potential for bradykinin “cough” improves tolerability (specific for ATII receptor blockade).
Some studies suggest a reduced risk of vascular events compared with other BP lowering regimens.
Guidelines recommend use of ARBs for hypertensive patients with end-organ disease affecting the heart and the kidney.
The Blood Pressure Lowering Treatment Trialists&apos; Collaboration showed that ARBs reduce the risk of vascular events such as stroke, coronary heart disease, heart failure, major cardiovascular events, cardiovascular death and total mortality when compared to other treatment regimens (placebo or other active treatment).1
Whether this benefit is due to greater blood pressure lowering (mean 2/1 mmHg) is not known.
Reference
Blood Pressure Lowering Treatment Trialists&apos; Collaboration. Lancet 2003;362: 1527–35.
GLB.IRB.06.12.01
What about the effects of antihypertensive drugs on LVH regression ?
According to a meta-analysis of 80 randomized double-blind studies, angiotensin II antagonists were more effective than other classes of drugs in inducing decrease of LV mass. However, meta-analyses should be considered as hypothesis-generating rather than as definitive truth because of (a) potential methodological differences across different studies and, (b) the possibility that negative studies may go missed because unpublished or published in remote journals.
However, at least two important studies supported these results:
References:
Klingbeil AU et al. Am J Med 2003; 115:41-46.
Easterbrook PJ, Berlin JA, Gopalan R, Matthews DR. Publication bias in clinical research. Lancet 1991; 337: 867-872.
By intention-to-treat analysis, the recurrence rate was lower in the amiodarone + irbesartan group. Kaplan-Meier analysis demonstrated a 2-month probability for maintaining sinus rhythm of 85% for irbesartan + amiodarone-treated patients compared with 63% for those taking amiodarone alone (p=0.008).
Eprosartan reduces sitSBP and standing SBP in patients with severe hypertension
A total of 118 patients with severe hypertension were randomized to eprosartan (200–400mg BID) or enalapril (10–40mg OD) in this10-week, multicentre, double-blind, parallel-group study designed to compare the antihypertensive efficacy of eprosartan with enalapril. Severe hypertension was defined as DBP 115mmHg and 125mmHg.
Eprosartan was significantly (p=0.025) more effective than enalapril in reducing sitSBP, with a fall of 29.1mmHg recorded for eprosartan-treated patients, compared with 21.2mmHg for enalapril. In addition, eprosartan was significantly (p=0.032) more effective than enalapril in reducing standing SBP (staSBP) (27.8mmHg for the eprosartan group compared with 20mmHg for the enalapril group). In addition, reductions from baseline in sitDBP of 20.1mmHg and 16.2mmHg for eprosartan and enalapril, respectively, were achieved (p=0.136).
Sega R. Efficacy and safety of eprosartan in patients with severe hypertension Blood Press 1999; 8: 114–121
Figure reproduced with permission
Eprosartan has similar efficacy in young and elderly patients
When data from a large-scale study (&gt;500 patients) were analysed according to age, it was found that eprosartan proved to be effective regardless of patient’s age. Target reductions in sitDBP to either &lt;90mmHg or 90–100mmHg with a decrease of &gt;10mmHg from baseline were very similar in those under and over 65 years of age (13.2 and 13.9mmHg, respectively). The change from baseline in sitSBP also showed no significant difference between the two populations, with mean reductions of 16.2mmHg and 18.9mmHg for those under and over 65 years, respectively.
Argenziano L, Trimarco B. Effect of eprosartan and enalapril in the treatment of elderly hypertensive patients: subgroup analysis of a 26-week, double-blind, multicentre study. Curr Med Res Opin 1999; 15: 9–14
Figure reproduced with permission
Eprosartan is more effective than losartan in mild hypertension
A 4-week study was carried out to compare the effects of eprosartan (600mg OD) and losartan (50mg OD) on BP in 60 patients with mild to moderate hypertension (Puig et al, 1999). BP measurements were taken at baseline, at 2 weeks and at the end of the study. Significant reductions in BP were observed for both eprosartan and losartan. Mean reductions in DBP were 12.4 and 9.6mmHg for eprosartan and losartan, respectively, with reductions of 12.7 and 10.9mmHg in SBP. The response rate (sitDBP &lt;90mmHg or a decrease of ³10mmHg from baseline) was 73% for eprosartan versus 53% for losartan.
Puig JG, Mateos AF, Buno A, Ortega R, Rodriguez F, Dal-Re R. Effect of eprosartan and losartan on uric acid metabolism in patients with essential hypertension. J Hypertens 1999; 17: 1033–1039
Robles et al (2005) reported the results of a 16-week open-label study in the primary care setting, which assessed the effect of eprosartan 600mg/day on pulse pressure in patients with mild-to-moderate hypertension. Results were evaluable in 566 patients at the end of the study period.
There were statistically significant reductions in mean blood pressure (-26/-13 mmHg), mean pulse pressure (-13 mmHg) and mean arterial pressure (-17.4 mmHg), all p&lt;0.0001 compared with pretreatment baseline. As in the de la Sierra study, there was a statistically significant reduction in the ratio of pulse pressure/mean arterial pressure from 61% to 59%.
Relative risk estimates stroke for a blood pressure reduction of 10 mm Hg systolic or 5 mm Hg diastolic in the blood pressure difference trials and in epidemiological cohort studies.
Relative risk estimates of stroke in 46 drug comparison trials comparing each of the five classes of blood pressure lowering drug with any other class of drug.
20,332 pts aged more than 50 years (75 % hypertension) who recently had an ischemic stroke (within 120 days median 15 days) were randomly assigned to receive telmisartan or placebo
The combined primary endpoint was a composite of total mortality plus the total number of cardiovascular and cerebrovascular events, including all recurrent events.
Cerebral complications were defined as intracerebral haemorrhage, recurrence of stroke, TIAs or PRIND. Cardiovascular complications were defined as any cardiovascular event, including MI and new heart failure.
Pre-defined secondary endpoints were the single components of the combined primary endpoint, as well as an assessment of functional status and cognitive function assessed by the mini mental state examination (MMSE), Barthel Index,and Rankin Scale.
Mean follow-up of patients in the study was 2.5 years.
A total of 1,405 patients were eligible for randomization, of whom 710 were assigned an eprosartan-based regimen and 695 a nitrendipine-based regimen.
At the study end, 681 in the eprosartan and 671 in the nitrendipine groups, respectively, were eligible for analysis.
SYSTOLIC AND DIASTOLIC BLOOD PRESSURE AMONG PATIENTS ASSIGNED EPROSARTAN OR NITRENDIPINE
PRIMARY ENDPOINTS (TOTAL OCCURRENCE INCLUDING RECURRENT EVENTS)