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Recent Developments in the Treatment of Hypertension The Value of Facts 1999.
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Recent Developments in the Recent Developments in the Treatment of HypertensionTreatment of Hypertension
The Value of FactsThe Value of Facts
19991999
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ObjectivesObjectives
• To review recent clinical trial evidence of efficacy To review recent clinical trial evidence of efficacy for antihypertensive agentsfor antihypertensive agents
• To present new data on the treatment of To present new data on the treatment of hypertensive patients with type 2 diabeteshypertensive patients with type 2 diabetes
• To discuss the emerging evidence for use of To discuss the emerging evidence for use of ACE inhibitors in diabetesACE inhibitors in diabetes
• To review recent safety data on antihypertensive To review recent safety data on antihypertensive agentsagents
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Documentation of DrugDocumentation of DrugSafety and EfficacySafety and Efficacy
• Patients, clinicians and the health-care Patients, clinicians and the health-care establishment expect adequate documentationestablishment expect adequate documentation
• A week-long treatment for an acute condition A week-long treatment for an acute condition requires randomized trials that follow patients for requires randomized trials that follow patients for >> 1 week 1 week
• Lifelong treatments are ideally evaluated in lifelong Lifelong treatments are ideally evaluated in lifelong trials, but evaluations in large populations over 4 to trials, but evaluations in large populations over 4 to 5 years are typically accepted5 years are typically accepted..
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Antihypertensive Drugs: DocumentationAntihypertensive Drugs: DocumentationBy the Time of Regulatory ApprovalBy the Time of Regulatory Approval
• BP lowering potential (N = 200-500 patients)BP lowering potential (N = 200-500 patients)
• Common side effects (symptoms)Common side effects (symptoms)
• Any common early drug complications (events)Any common early drug complications (events)
• Major changes in blood chemistryMajor changes in blood chemistry
• Major animal toxicityMajor animal toxicity
KnownKnown
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Antihypertensive Drugs: DocumentationAntihypertensive Drugs: DocumentationBy the Time of Regulatory ApprovalBy the Time of Regulatory Approval
• Effect on major CVD mortality/morbidityEffect on major CVD mortality/morbidity• Optimal dose (risk-benefit balance)Optimal dose (risk-benefit balance)• Uncommon early side effects or clinical Uncommon early side effects or clinical
complicationscomplications• ADRs and complications of long-term drug useADRs and complications of long-term drug use• Efficacy or safety in various subgroupsEfficacy or safety in various subgroups• Effect on pregnancyEffect on pregnancy• Drug interactionsDrug interactions
UnknownUnknown
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Aim of Antihypertensive Aim of Antihypertensive TherapyTherapy
To prevent the cardiovascular complications of To prevent the cardiovascular complications of hypertension -- stroke, acute myocardial infarction, hypertension -- stroke, acute myocardial infarction, congestive heart failure -- not just to lower an congestive heart failure -- not just to lower an elevated blood pressure.elevated blood pressure.
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Eligibility criteria for meta-analysisEligibility criteria for meta-analysis
• Randomized placebo controlled trialsRandomized placebo controlled trials
• Treatment duration of Treatment duration of >> 1 year 1 year
• Assessment of major disease endpointsAssessment of major disease endpoints
• Unconfounded by other therapiesUnconfounded by other therapies
Psaty et al., JAMA 1997Psaty et al., JAMA 1997
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Definition of Treatment StrategiesDefinition of Treatment Strategies
• Multiple agents used in most trialsMultiple agents used in most trials• Trials classified by first-line strategyTrials classified by first-line strategy
---- High-dose diuretic therapyHigh-dose diuretic therapy
---- Low-dose diuretic therapyLow-dose diuretic therapy
---- Beta-blocker therapyBeta-blocker therapy• No eligible trials evaluating CCBs or No eligible trials evaluating CCBs or
ACE inhibitorsACE inhibitors
Psaty et al., JAMA 1997Psaty et al., JAMA 1997
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Summary of Eligible Trials (n = 18)Summary of Eligible Trials (n = 18)
Low-dose diureticsLow-dose diuretics 4 4 4,3054,305 5,116 5,116
High-dose diureticsHigh-dose diuretics 1111 7,7687,768 12,07512,075
Beta-blockersBeta-blockers 4 4 6,7366,736 12,14712,147
HDFPHDFP 1 1 5,4845,484 5,455 5,455
TherapyTherapy TrialTrial InterventionIntervention ControlControl
Psaty et al., JAMA 1997Psaty et al., JAMA 1997
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Meta-analysis: AntihypertensivesMeta-analysis: Antihypertensives
EventEvent RRRR 95% CI95% CI
High-dose diureticsHigh-dose diuretics
Psaty et al., JAMA 1997Psaty et al., JAMA 1997
Stroke 0.49 0.39-0.62
CHF 0.17 0.07-0.41
CHD 0.99 0.83-1.18
Total mortality 0.88 0.75-1.03
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Meta-analysis: AntihypertensivesMeta-analysis: Antihypertensives
EventEvent RRRR 95% CI95% CI
Low-dose diureticsLow-dose diuretics
Psaty et al., JAMA 1997Psaty et al., JAMA 1997
Stroke 0.66 0.55-0.78
CHF 0.58 0.44-0.76
CHD 0.72 0.61-0.85
Total mortality 0.90 0.81-0.99
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Meta-analysis: AntihypertensivesMeta-analysis: Antihypertensives
EventEvent RRRR 95% CI95% CI
Beta-blockersBeta-blockers
Psaty et al., JAMA 1997Psaty et al., JAMA 1997
Stroke 0.71 0.59-0.85
CHF 0.58 0.40-0.84
CHD 0.93 0.80-1.09
Total mortality 0.95 0.84-1.07
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Summary of MajorSummary of Major FindingsFindings
• High-dose diuretic and ß-blocker therapies reduced High-dose diuretic and ß-blocker therapies reduced
the incidence of CHF and strokethe incidence of CHF and stroke
• Low-dose diuretic therapy reduced the incidence Low-dose diuretic therapy reduced the incidence
not only of CHF and stroke but also of CHD and not only of CHF and stroke but also of CHD and
total mortalitytotal mortality
• High-dose versus low-dose diuretic comparison High-dose versus low-dose diuretic comparison
was confounded by patient age was confounded by patient age
Psaty et al., JAMA 1997Psaty et al., JAMA 1997
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Syst-Eur -- Nitrendipine in ISHSyst-Eur -- Nitrendipine in ISH
• Randomized, placebo-controlled, 2N = 4,695Randomized, placebo-controlled, 2N = 4,695• Baseline, mean age 70 yrs, BP 174/85 mm HgBaseline, mean age 70 yrs, BP 174/85 mm Hg• Median FU of 2 yrs, BP Median FU of 2 yrs, BP 10/5 mm Hg10/5 mm Hg• Step-up drugs: enalapril (33%), HCTZ (20%)Step-up drugs: enalapril (33%), HCTZ (20%)• 237 randomized patients lost-to-follow-up237 randomized patients lost-to-follow-up• Reduction in stroke:Reduction in stroke: RR 0.58, 95% CI 0.40 - 0.83 RR 0.58, 95% CI 0.40 - 0.83 CHF: CHF: RR 0.71, 95% CI 0.47 - 1.10RR 0.71, 95% CI 0.47 - 1.10
Staessen et al., Lancet 1997Staessen et al., Lancet 1997
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Concerns About Syst-EurConcerns About Syst-Eur
## randomized randomized 4,7364,736 vsvs 4,6954,695# primary events (stroke)# primary events (stroke) 262 262 vsvs 124 124# lost-to-follow-up# lost-to-follow-up 10 10 vsvs 237 237
Case-fatality, stroke (%)Case-fatality, stroke (%) 8.9 8.9 vsvs 27.3 27.3Case-fatality, CHF (%)Case-fatality, CHF (%) 6.4 6.4 vsvs 20.4 20.4
Questions in Syst-Eur:Questions in Syst-Eur: incomplete ascertainment?incomplete ascertainment?level of medical care?level of medical care?generalizable findings?generalizable findings?
SHEPSHEP Syst-EurSyst-Eur
Pahor et al., Lancet 1998Pahor et al., Lancet 1998
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Captopril Prevention Project (CAPPP)Captopril Prevention Project (CAPPP)
DesignDesign Randomized, openRandomized, open
PopulationPopulation 10,985 hypertensives, aged 25-10,985 hypertensives, aged 25-66 years, with DBP 66 years, with DBP >> 100 mm Hg 100 mm Hg
InterventionIntervention Captopril (50-100 mg) Captopril (50-100 mg) vsvs clinician’s clinician’s choice of a diuretic or a ß-blocker; choice of a diuretic or a ß-blocker; diuretic or the other class as step-updiuretic or the other class as step-up
Follow-upFollow-up Average of 6.1 yearsAverage of 6.1 years
Hansson et al., Lancet 1999Hansson et al., Lancet 1999
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Stroke, MI, CV deathStroke
0.33 0.5 1 2Relative Risk
MIDeath
CaptoprilCaptoprilbetterbetter
ConventionalConventionaltreatm. bettertreatm. better
Captopril Prevention Project - CAPPPCaptopril Prevention Project - CAPPP
Diabetes
OutcomeOutcome
Hansson et al., Lancet 1999Hansson et al., Lancet 1999
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Limitations of CAPPPLimitations of CAPPP
• Captopril only given once or twice per dayCaptopril only given once or twice per day
• Flawed randomization process (envelopes)Flawed randomization process (envelopes)
• Baseline difference on BP unlikely explained Baseline difference on BP unlikely explained by chanceby chance
• Potential differential evaluation of incident Potential differential evaluation of incident diabetes in the 2 groups due to lack of blindingdiabetes in the 2 groups due to lack of blinding
Cutler, Lancet 1999Cutler, Lancet 1999
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Antihypertensive Treatment Antihypertensive Treatment in Type 2 Diabetesin Type 2 Diabetes
1.1. Active treatment Active treatment vsvs control (placebo) control (placebo)
2.2. More tight More tight vsvs less tight BP control less tight BP control
3.3. Comparisons of active treatmentsComparisons of active treatments
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SHEP - CV Event Rate in ISHSHEP - CV Event Rate in ISH by Diabetes Statusby Diabetes Status
Curb et al., JAMA 1996Curb et al., JAMA 1996
Annualcardiovascular
event rate(%)
No diabetes Diabetes0
1
2
3
4
5
6
7
Active treatment
RR .66, 95%CI .55-.79
RR .66, 95%CI .46-.94Placebo
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Syst-Eur -- Diabetic CohortSyst-Eur -- Diabetic CohortN
o. o
f N
o. o
f E
vent
sE
vent
s
Tuomilento et al., NEJM 1999Tuomilento et al., NEJM 1999
MortalityMortality Stroke Stroke Cardiac Events Cardiac Events
NitrendipineNitrendipinePlaceboPlacebo
0
5
10
15
20
25
302626
1616 1515
55
1515
NSNSp=0.02p=0.02
77
NSNS
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UK Prospective Diabetes StudyUK Prospective Diabetes Study150/85 vs 180/105 mmHg BP Target
EndpointEndpoint RR RR 95% CI95% CI
Any endpoint 0.76 0.62-0.92Diabetes death 0.68 0.49-0.94Any death 0.82 0.63-1.08MI 0.79 0.59-1.07Stroke 0.56 0.35-0.89PAD 0.51 0.19-1.37Microvascular dis. 0.63 0.44-0.89n = 758 vs 390 UKPDS Group, BMJ 1998UKPDS Group, BMJ 1998
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HOT - Rate of Major CV Events HOT - Rate of Major CV Events According to Randomized GroupsAccording to Randomized Groups
BP goalmmHg
p for trend0.005
p for trend 0.5
Hansson et al., Lancet 1998Hansson et al., Lancet 1998
0
5
10
15
20
25
30
All n=18790 Diabetic n=1501
Rat
e/10
00 p
erso
n-y
ears
<90
<85
<80
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FACET ABCD
UKPDS CAPPP
MIDAS
Comparative Trials in Hypertensives Comparative Trials in Hypertensives with Type 2 Diabetes or Impaired with Type 2 Diabetes or Impaired
Glucose MetabolismGlucose Metabolism
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FACET - Fosinopril versus Amlodipine FACET - Fosinopril versus Amlodipine Cardiovascular Events TrialCardiovascular Events Trial
DesignDesign Prospective randomized trial
PatientsPatients Hypertension and type 2 diabetes
Sample sizeSample size 380 patients
Intervention Intervention Fosinopril / amlodipine open label
OutcomesOutcomes - Primary: serum lipids
- Secondary: CV events, BP
Follow-upFollow-up 2.5 to 3.5 years
Tatti et al., Diabetes Care 1998Tatti et al., Diabetes Care 1998
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Tatti et al., Diabetes Care 1998Tatti et al., Diabetes Care 1998
Cardiovascular Events in FACET
Stroke AMI
Rateper 100
person-years
0
12
3
4
5
101413
27
10
4
p=.03
40
The figures at top of the bars indicate the number of events
Any majorCV event
Hospit.Angina
Fosinopril n=189
Amlodipine n=191
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ABCD TrialABCD Trial
DesignDesign Double-blind randomized trialEnalapril vs nisoldipineIntensive vs moderate BP control
PatientsPatients Type 2 diabetes, a normotensiveand a hypertensive group
OutcomesOutcomes - Primary: renal function - Secondary: CV events, BP
Follow-upFollow-up 5 years
Estacio et al., NEJM 1998Estacio et al., NEJM 1998
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Nisoldipine Enalapril
10
12
14
Intensive Moderate
Nu
mb
er
of
Pa
tie
nts
4
1
1312
0
2
4
6
8
ABCD TrialABCD TrialRisk of Myocardial Infarction -Risk of Myocardial Infarction -
Intensive and Moderate GroupsIntensive and Moderate Groups
Estacio et al., NEJM 1998Estacio et al., NEJM 1998
P= 0.03 P= 0.002P= 0.002
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1015202530354045
Nu
mb
er
of
Pat
ien
ts
NisoldipineNisoldipine EnalaprilEnalapril
5 5
20
43
2522
05
Non-Fatal MI's All MI's All CV Events
ABCD TrialABCD TrialCardiovascular DiseaseCardiovascular Disease
Estacio et al., NEJM 1998Estacio et al., NEJM 1998
P= 0.001 P= 0.001
P= 0.002
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ABCD TrialABCD Trial
• The independent Data Safety Monitoring Committee recommended early termination of the hypertensive arm because of the 5-fold increase in risk of fatal and non-fatal AMI in the nisoldipine group compared to the enalapril group
• Those receiving the calcium antagonist were reassigned to the ACE inhibitor
Estacio et al., NEJM 1998Estacio et al., NEJM 1998
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UK Prospective Diabetes StudyUK Prospective Diabetes StudyDesignDesign Randomized trial comparing (a) Randomized trial comparing (a)
lessless tight tight vsvs tight BP control and (b) two tight BP control and (b) two forms of tight control forms of tight control
PatientsPatients Hypertensives with type 2 diabetesHypertensives with type 2 diabetes
InterventionIntervention Furosemide-based Furosemide-based vsvs captopril- or captopril- or atenolol-basedatenolol-based
OutcomesOutcomes Fatal and nonfatal CV eventsFatal and nonfatal CV events
Follow-upFollow-up 8.4 years8.4 years
UKPDS Group, BMJ 1998UKPDS Group, BMJ 1998
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UK Prospective Diabetes StudyUK Prospective Diabetes Study
EndpointEndpoint RR RR 95% CI95% CIAny endpointAny endpoint 1.101.10 0.86-1.410.86-1.41Diabetes deathDiabetes death 1.271.27 0.82-1.970.82-1.97Any deathAny death 1.141.14 0.81-1.610.81-1.61MIMI 1.201.20 0.82-1.760.82-1.76StrokeStroke 1.121.12 0.59-2.120.59-2.12PADPAD 1.481.48 0.35-6.190.35-6.19Microvascular dis. Microvascular dis. 1.291.29 0.80-2.100.80-2.10
n = 400 vs 358 UKPDS Group, BMJ 1998UKPDS Group, BMJ 1998
Captopril vs Atenolol (reference group)Captopril vs Atenolol (reference group)
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Stroke, MI, CV death
Stroke
0.33 0.5 1 2Relative Risk
MIDeath
Captoprilbetter
Conventionaltreatm. better
CAPPP - patients with diabetesCAPPP - patients with diabetesOutcome
Hansson et al., Lancet 1999Hansson et al., Lancet 1999
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MIDAS TrialMIDAS Trial• 883 hypertensive patients randomized to 883 hypertensive patients randomized to
isradipine or HCTZ and followed for 3 yearsisradipine or HCTZ and followed for 3 years
• No difference in carotid intimal medial thickness, No difference in carotid intimal medial thickness, the primary outcomethe primary outcome
• Increased risk of major CV events by 78% Increased risk of major CV events by 78% (p=0.07) and all CV events and procedures by (p=0.07) and all CV events and procedures by 63% (p=0.02) in the isradipine group63% (p=0.02) in the isradipine group
Borhani et al., JAMA 1996Borhani et al., JAMA 1996
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MIDAS Trial - Relative Risk of CV MIDAS Trial - Relative Risk of CV Events for Isradipine versus HCTZEvents for Isradipine versus HCTZ
*p<.05
Byington et al., Diabetes Care 1998Byington et al., Diabetes Care 1998
HbA1c %
RR
Serum insulin U/ml
1.81
1.16
2.71*
1.25
3.22*
0
1
2
3
4
All <6.7 6.7+ <9.8 9.8+
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Blood Pressure Changes in FACET
mmHg
*p .05 amlodipine vs fosinopril.
Baseline 1 2 3
Follow-up time (years)
Fosinopril Amlodipine
60
80
100
120
140
160
180 Systolic
Diastolic
*
Tatti et al., Diabetes Care 1998Tatti et al., Diabetes Care 1998
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The Appropriate Blood Pressure The Appropriate Blood Pressure Control in Diabetes (ABCD) TrialControl in Diabetes (ABCD) Trial
Adapted from Estacio RO et al., NEJM 1998Adapted from Estacio RO et al., NEJM 1998
Intensive-Treatment Group
70
90
110
130
150
0 6 12 18 24 30 36 42 48 54 60
Month
No. of patients 237 189 199 176 166 137
Nisoldipine
EnalaprilSystolic
DiastolicBlo
od
Pre
ssu
re
(m
m H
g)
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Systolic Blood Pressure Reduction Systolic Blood Pressure Reduction and Cardiovascular Events in FACET and Cardiovascular Events in FACET
Amlodipine
p<.05p<.01
Fosinopril
Pahor et al., J Cardiovasc Pharmacol 1998Pahor et al., J Cardiovasc Pharmacol 1998
-20-23
-20
-32-35
-30
-25
-20
-15
-10
-5
0
mm
Hg No events
Events
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One-year Diastolic BP Reduction and Cardiovascular Events in MIDAS
Isradipine
p=.03
HCTZ
p=.01
Byington et al., Byington et al., Diabetes CareDiabetes Care 1998 1998
-20
-15
-10
-5
0
mm
Hg No events
Events
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Comparative Trials of Comparative Trials of Antihypertensive Agents in DiabetesAntihypertensive Agents in Diabetes
• Blood pressure alone is not a sufficient marker of drug Blood pressure alone is not a sufficient marker of drug efficacyefficacy
• Pronounced reductions may be harmful in diabeticsPronounced reductions may be harmful in diabetics• Health benefits may differ among antihypertensive agentsHealth benefits may differ among antihypertensive agents• ACE inhibitors appear to be most beneficial; calcium ACE inhibitors appear to be most beneficial; calcium
antagonists least beneficialantagonists least beneficial
Demonstrate that:Demonstrate that:
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Other Benefits of ACE Other Benefits of ACE Inhibitors in DiabetesInhibitors in Diabetes
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0
10
20
30
40
50
60
70
BaselineBaseline 6 months6 months 12 months12 months
Lisinopril (10-20mg o.d)Lisinopril (10-20mg o.d)
Nifedipine (20-40 mg b.d)Nifedipine (20-40 mg b.d)
BRILLIANTBRILLIANTUrinary Albumin ExcretionUrinary Albumin Excretion
Uri
na
ry a
lbu
min
exc
reti
on
Uri
na
ry a
lbu
min
exc
reti
on
(mic
rog
/min
)(m
icro
g/m
in)
**
*p=0.0006*p=0.0006
Agardh et al., J Human Hypertens 1996Agardh et al., J Human Hypertens 1996
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ACE Inhibitors and Microvascular ACE Inhibitors and Microvascular Disease in Diabetic PatientsDisease in Diabetic Patients
• ACEIs delay the development and progression of diabetic ACEIs delay the development and progression of diabetic nephropathy*nephropathy*
• ACEIs markedly slow progression of retinopathy**ACEIs markedly slow progression of retinopathy**
• ACEIs appear to improve peripheral neuropathy*** ACEIs appear to improve peripheral neuropathy***
* Ahmad et al., Diabetes Care 1997* Ahmad et al., Diabetes Care 1997 * Maschio et al., NEJM 1996* Maschio et al., NEJM 1996 ** Chaturvedi et al., Lancet 1998** Chaturvedi et al., Lancet 1998*** Malik et al., Lancet 1998*** Malik et al., Lancet 1998
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Short-term mortality benefit of ACE Short-term mortality benefit of ACE Inhibitors in Diabetic Patients with Inhibitors in Diabetic Patients with
Acute MIAcute MI%%
of ptsof pts
LisinoprilLisinopril ControlControl
NIDDNIDD IDDIDDZuanetti & Latini, J Diabetes Complications 1997Zuanetti & Latini, J Diabetes Complications 1997
0
5
10
15
20
25
810.6 11.8
21.1
LisinoprilLisinopril ControlControl
p <0.05p <0.05
p <0.05p <0.05
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Safety DocumentationSafety Documentation
• More than 100,000 person-years desiredMore than 100,000 person-years desired
• Safety problems common across indicationsSafety problems common across indications
• Extensive safety documentation for diuretics, Extensive safety documentation for diuretics, beta-blockers and ACE inhibitorsbeta-blockers and ACE inhibitors
• Inadequate documentation of long-term safety Inadequate documentation of long-term safety for calcium antagonists, alpha-blockers, for calcium antagonists, alpha-blockers, angiotension II blockersangiotension II blockers
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Safety Documentation for Slow-ReleaseSafety Documentation for Slow-ReleaseCAs in HypertensionCAs in Hypertension
Adalat CCAdalat CC 31 31 10 10Procardia XLProcardia XL 56 56 36 36PlendilPlendil 39 39 14 14NorvascNorvasc 269 269 158 158CardeneCardene 53 53 22 22Cardizem SRCardizem SR 138 138 115 115Dilacor XRDilacor XR 24 24 7 7IsoptinIsoptin 1 1 1 1VerelanVerelan 5 5 2 2
TotalTotal 616 (x = 68)616 (x = 68) 365 (x = 41)365 (x = 41)
DrugsDrugs ActiveActive ControlControlPerson-yearsPerson-years
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Risk of Primary Cardiac ArrestRisk of Primary Cardiac Arrest
ß-blockerß-blocker 1.01.0 referencereferenceThiazide, 100 mgThiazide, 100 mg NoNo 2.42.4 0.7-8.80.7-8.8Thiazide, 50 mgThiazide, 50 mg NoNo 1.11.1 0.5-2.50.5-2.5Thiazide, 25 mgThiazide, 25 mg NoNo 0.70.7 0.2-2.50.2-2.5Thiazide, 50 mgThiazide, 50 mg YesYes 0.50.5 0.1-2.20.1-2.2Thiazide, 25 mgThiazide, 25 mg YesYes 0.30.3 0.1-1.00.1-1.0
TherapyTherapy K-sparing RR K-sparing RR 95% CI 95% CI
Siscovick et al., N Engl J Med 1994Siscovick et al., N Engl J Med 1994
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CCBs in HypertensionCCBs in HypertensionPotential Serious Adverse EventsPotential Serious Adverse Events
• Coronary eventsCoronary events• Bleeding (GI and surgical)Bleeding (GI and surgical)• Cancer (blocking apoptosis)Cancer (blocking apoptosis)• Cerebral white matter lesions (MRI)Cerebral white matter lesions (MRI)• OthersOthers
• Strong association to drug dose and duration of Strong association to drug dose and duration of exposure support causationexposure support causation
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CAs safety - Non Randomized CAs safety - Non Randomized Studies and Meta-analysisStudies and Meta-analysis
CAs10
54
6
2
5
10 0
0
2
4
6
8
10
12
CVD, death Bleeding Cancer
Nu
mb
er
of r
ep
ort
s
increase risk
neutral
reduce risk
Pahor et al., (to be published)Pahor et al., (to be published)
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Hypertensive EmergenciesHypertensive Emergencies• IR nifedipine widely used in hypertensive emergencies and IR nifedipine widely used in hypertensive emergencies and
even moderately elevated BP in asymptomatic patientseven moderately elevated BP in asymptomatic patients• Never approved by the FDA for this indication; complete Never approved by the FDA for this indication; complete
lack of outcome datalack of outcome data• Unpredictable BP fall associated with stroke, acute MI, Unpredictable BP fall associated with stroke, acute MI,
severe hypotension and deathsevere hypotension and death• ““Routine use of IR nifedipine in hypertensive emergencies Routine use of IR nifedipine in hypertensive emergencies
and pseudoemergencies should be abandoned”and pseudoemergencies should be abandoned”
Grossman et al., JAMA 1996Grossman et al., JAMA 1996
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Hypertension Optimal Hypertension Optimal Treatment Trial (HOT)Treatment Trial (HOT)
18,790 hypertensives randomized to three DBP goals: < 90, < 85 and < 80 mm Hg.
Achieved mean DBP: 85.2, 83.2 and 81.1 mm Hg. No difference in incidence of major CV events:
9.9, 10.0 and 9.3/1,000 pt. years. Post-hoc analysis suggested benefit of lower DBP
among diabetics. Offset by increase in events among non-diabetics. .
Hansson et al., Lancet 1998Hansson et al., Lancet 1998
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Interpretation of HOT ResultsInterpretation of HOT ResultsMRFITMRFIT 5.8 mm Hg lower DBP associated with lower stroke 5.8 mm Hg lower DBP associated with lower stroke
(44%) and CHD (25%) risks(44%) and CHD (25%) risks
HDFPHDFP Mean 5.4 mm Hg reduction in DBP translated into Mean 5.4 mm Hg reduction in DBP translated into 17% mortality and 35% stroke benefit17% mortality and 35% stroke benefit
HOTHOT Mean 4.0 mm Hg reduction in DBP between Mean 4.0 mm Hg reduction in DBP between << 90 90 and and << 80 target groups translated into a 7% lower 80 target groups translated into a 7% lower CV event rate (N.S.)CV event rate (N.S.)
ExplanationsExplanations (1) Null hypothesis true (unlikely)(1) Null hypothesis true (unlikely)
(2) Higher doses of felodipine (2) Higher doses of felodipine increased CV event increased CV event
offsetting offsetting benefit of BP lowering itself benefit of BP lowering itself (likely(likely) )
(3) Insufficient power(3) Insufficient power
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Antihypertensive and Lipid Antihypertensive and Lipid Lowering Treatment to Prevent Lowering Treatment to Prevent
Heart Attack Trial (ALLHAT)Heart Attack Trial (ALLHAT)DesignDesign Randomized, double-blind clinical Randomized, double-blind clinical
trialtrial
PatientsPatients 42,451 hypertensives; 15,290 diabetics42,451 hypertensives; 15,290 diabetics
InterventionIntervention Lisinopril, amlodipine and doxazosinLisinopril, amlodipine and doxazosincompared to chlorthalidone compared to chlorthalidone Same BP goal -- 140/90 mm HgSame BP goal -- 140/90 mm Hg
EndpointsEndpoints Fatal and nonfatal CV eventsFatal and nonfatal CV events
Follow-upFollow-up Approximately 6 yearsApproximately 6 years
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ConclusionsConclusions• ACEIs appear to convey similar antihypertensive benefits as ACEIs appear to convey similar antihypertensive benefits as
the established first-line agents low-dose diuretics and beta-the established first-line agents low-dose diuretics and beta-blockersblockers
• ACEIs are the antihypertensive drugs of choice in ACEIs are the antihypertensive drugs of choice in hypertensives with type 2 diabeteshypertensives with type 2 diabetes
• ACEIs are recommended in diabetic patients with nephropathy ACEIs are recommended in diabetic patients with nephropathy and myocardial infarctionand myocardial infarction
• CCBs should be 4th-line agents in diabeticsCCBs should be 4th-line agents in diabetics
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Ordering of Slide SetOrdering of Slide Set
If you wish to order an electronic copyIf you wish to order an electronic copyof this slide set, “Recent Developments inof this slide set, “Recent Developments inthe Treatment of Hypertension,” pleasethe Treatment of Hypertension,” pleasecontact Ms. Sarah Hutchens, Wake Forestcontact Ms. Sarah Hutchens, Wake ForestUniversity School of Medicine at:University School of Medicine at:
[email protected]@rc.phs.wfubmc.edu
The slide set is in PowerPoint Version 4.0.The slide set is in PowerPoint Version 4.0.