Treatment of hypertension in the elderly: effects on blood pressure, heart rate, and physical fitness.

The subjects were 36 hypertensive patients aged 61 to 79 years (mean, 66 years). After a placebo run-in period of one month, each patient was randomly assigned to two months of treatment with 100 mg of metoprolol, 50 mg of captopril, or 25 mg of hydrochlorothiazide plus 2.5 mg of amiloride daily, or placebo. The doses were doubled if diastolic pressure was above 95 mm Hg after one month of treatment. Blood pressure, heart rate, and physical fitness (endurance during a standard cycle ergometer exercise) were measured and side effects assessed after each two-month treatment period. Mean blood pressures were significantly lower after treatment with metoprolol (154/92 mm Hg), captopril (157/92 mm Hg), and hydrochlorothiazide-amiloride (152/91 mm Hg) than after placebo (170/101 mm Hg). Heart rate was significantly lower after treatment with metoprolol (64 beats/minute) than after placebo (77 beats/minute). Exercise endurance was lower after treatment with metoprolol (498 seconds) and hydrochlorothiazide-amiloride (519 seconds) than after placebo (529 seconds) and higher after captopril (541 seconds). More patients reached the target exercise work load after captopril than after the other treatments. No patients withdrew from treatment because of side effects or abnormal laboratory test results. All three active treatments benefited the elderly hypertensive patients and did not lower their physical fitness. Captopril appeared to be more effective than the other two treatments.

24-hour blood pressure control by once-daily administration of irbesartan assessed by ambulatory blood pressure monitoring. Irbesartan Multicenter Investigators' Group.

OBJECTIVES: To compare 24 h ambulatory blood pressure and trough office blood pressure lowerings after 8 weeks of therapy with 75 mg irbesartan once a day, 150 mg irbesartan once a day , and 75 mg irbesartan twice a day versus placebo; and to assess safety and tolerability of irbesartan therapy. DESIGN: Multicenter, double-blind, randomized, placebo-controlled trial. SETTING: Sixteen centers in Italy. PATIENTS: Caucasian patients (n = 215) aged > or = 18 years with seated diastolic blood pressure 95-110 mmHg and ambulatory diastolic blood pressure (ADBP) > or = 85 mmHg. PRIMARY OUTCOME: Mean 24 h ADBP after 8 weeks of irbesartan therapy. RESULTS: Mean changes (value before treatment minus value after treatment) in ADBP for placebo, 75 mg irbesartan once a day, 150 mg irbesartan once a day, and 75 mg irbesartan twice a day were -0.2, -5.4, -7.2, and -7.2 mmHg, respectively; respective changes in ambulatory systolic blood pressure were +1.6, -8.3, -10.5, and -9.7 mmHg. All irbesartan regimens reduced trough office seated diastolic blood pressure and seated systolic blood pressure after 2 and 8 weeks of treatment (all P < 0.01, versus placebo except for seated systolic blood pressure in patients in the 75 mg irbesartan once a day group). Trough: peak ratios were > or = 55% with 150 mg irbesartan once a day. Percentages of patients whose blood pressures were normalized with 150 mg irbesartan once a day (45%) and 75 mg irbesartan twice a day (47%) were greater than those with placebo (14%, P < 0.01) and with 75 mg irbesartan once a day (19%, NS, versus placebo). Adverse events with irbesartan were similar to those with placebo. CONCLUSIONS: All irbesartan regimens significantly reduced mean 24 h ADBP and ambulatory systolic blood pressure, and were well tolerated. Administration of 150 mg irbesartan once a day provided significant reduction of blood pressure for 24 h, equivalent to that obtained with the same daily dose divided into two separate administrations.

Compliance to hypertension guidelines in clinical practice: a multicentre pilot study in Italy.

The aim of this study was to investigate the diagnostic approach to recently diagnosed hypertensive patients by primary care physicians in Italy and to find out whether general practitioners manage these patients according to 1999 WHO/ISH guideline recommendations. In total, 228 consecutive patients (117 men and 111 women, mean age 51+/-12 years) with recently diagnosed hypertension (<2 years) referred for the first time to six outpatient hypertension centres throughout Italy were included in the study. The primary care physicians' approach was evaluated during the specialist visit by a specific questionnaire containing detailed questions about diagnostic work-up and treatment made at the time of the first diagnosis of hypertension. At the study visit, 71% of the patients were on treatment with antihypertensive drugs and 18.7% of them had blood pressure (BP) values lower than 140/90 mmHg. A complete clinical and laboratory evaluation according to the minimum work-up suggested by the guidelines had been carried out in only 10% of the patients. A full physical examination had been performed in 60% of the patients, electrocardiogram in 54%, serum total cholesterol in 53%, glucose in 49%, creatinine in 49%, urine analysis in 46%, potassium in 42%, and fundus oculi in 19%. Additional investigations such as ambulatory BP monitoring, echocardiogram, carotid ultrasonogram, and microalbuminuria had been carried out in a minority of patients (21, 18, 9, and 3%, respectively). The impact on hypertension guidelines on patients' management in everyday primary care practice appears marginal. Thus, our findings indicate that the majority of general practitioners manage hypertensive patients according to a simple BP-based approach rather than a more integrated approach based on global risk stratification.

Comparative evaluation of three dosages of slow-release isosorbide dinitrate (60, 80, 100 mg) in chronic angina of the aged.

In a single-blind, placebo-controlled study the acute and chronic antianginal effects of three slow-release (SR) new formulations of isosorbide dinitrate (ISDN 60, 80, 100 mg) have been comparatively evaluated in a group of aged affected by chronic stable effort-induced angina. Compared to placebo, overall the active dose paritetically improved the effort tolerance up to 24 h after the first assumption. In the time course of the trial (2 and 4 weeks) the resting hemodynamic changes induced by the first dose were partially blunted without affecting the exercise related-parameters. Also if plasma levels of ISDN and of its metabolites did not correlate to the degree of physical improvement, the peak increase in effort tolerance was observed under 100 mg treatment. Mild to moderate transient headache was experienced by 50% of actively treated and by 20% of placebo treated patients and no other serious adverse effects have been noted. One may conclude that ISDN in slow-release formulations of 60-100 mg isan effective, safe and well tolerated medication in the management of angina in the aged.

[Cardiac effects of carbamazepine therapy]. / Effetti cardiaci della carbamazepina.

The authors describe the case of an epileptic patient in chronic therapy with carbamazepine, and with plasma concentration of the drug in therapeutical range, who suffers from persistent sinus tachycardia. At the present time the observations available in the literature on cardiac toxicity of carbamazepina concern the appearance of sinus tachycardia as consequence of overdose and of blocks of conduction in elderly with carbamazepine in therapeutical range.

[Controlled clinical study of doxophylline versus aminophylline in the treatment of acute cardiorespiratory insufficiency syndromes]. / Studio clinico controllato doxofillina versus aminofillina nel trattamento delle sindromi da insufficienza acuta cardiorespirtoria.

Twenty patients of both sexes, hospitalized because they were suffering from acute cardiorespiratory syndromes, have been studied in a clinical blind test on unbalanced groups of patients. This research aims to evaluate the therapeutic efficiency and intravenous tolerance of doxophylline. Patients were observed for 24 hours. Signs and symptoms were recorded on a semi-quantitative scale, and the clinical situation, haemogasanalysis, blood pressure, cardiac frequency, and other analytic controls were performed in order to verify the systemic tolerability. We can conclude, in agreement with the literature, that the group treated with doxophylline showed a better reduction in cardiac frequency, while maintaining the same effects on the respiratory apparatus.

Antihypertensive efficacy and influence on physical activity of three different treatments in elderly hypertensive patients.

The antihypertensive efficacy and subjective and physical tolerability of three different pharmacological treatments (metoprolol, captopril and the combination of hydrochlorothiazide + amiloride) were compared with placebo in 36 elderly hypertensives (aged 61-79 years), according to a Latin-square double-blind design. The placebo and the active treatments were administered for 2 months. Seated blood pressure was significantly reduced by all the pharmacological treatments compared with placebo, but only metoprolol significantly reduced the heart rate. No haematological or biochemical changes were observed during the study. Physical fitness, evaluated as endurance in a standard cycle ergometer exercise test, was slightly decreased after the treatment with metoprolol and the diuretic combination and slightly improved after treatment with captopril. Subjective tolerability, evaluated by a check-list of symptoms, was better during the active therapies, and in particular during the captopril treatment, than during the placebo treatment. Our results indicate that all three active treatment regimens significantly reduce blood pressure in elderly hypertensives and that captopril appears slightly better tolerated physically and subjectively.

General anaesthesia in a patient affected by Brugada syndrome.

This case report describes an asymptomatic patient with positive familiar anamnesis of Brugada syndrome (BrS) who elected to undergo surgery. The anaesthesiological technique using propofol, fentanyl, atracurium, air/oxygen did not induce any electrocardiographic alteration during the operation; the intraoperation use of a biphasic defibrillator was critical here. The cerebral state index and adhesive plaques connected with a biphasic defibrillator having PM capabilities allowed us to monitor the operation and continually assess the patient's cardiac stability. Afterwards, the patient was transferred to the intensive care unit and was monitored for 24 hours. This anesthesiological technique was performed in place of ARL, which the patient refused.

[Electrophysiological evaluation of ventricular tachycardia by right and left ventricle endocardial mapping (author's transl)]. / Rilievi elettrofisiologici nelle tachicardie ventricolari con il mappaggio endoventricolare destro e sinistro.

Eight patients with ventricular tachycardia (VT) have been studied by unipolar recordings of 7 endocardial points of the left ventricle (LV) and 6 endocardial points of the right ventricle (RV) in order to record if possible: 1) where the VT arose; 2) a continuous electrical activity during the sistodiastolic phase of the intracardiac ECG [late potentials (LP)], suggesting the reciprocating mechanism of VT. All the patients underwent cardiac catheterization with left and/or right ventriculography. A coronary arteriography was performed in four cases. Four patients had no evidence of heart disease; one patient had aortic stenosis; one patient had two vessels coronary disease and extensive ipo-akinesis of the LV; two patients had dyskinetic areas of the RV. In all the cases it was possible to identify where the VT arose by means of recordings during spontaneous VT episodes (the sites of origin of the VTs were stated in the points where the intracardiac QRS began with an intrinsic deflection), or by means of asyncronous ventricular stimulation (the sites of origin of the VTs were stated in the points where the ventricular stimulation reproduced a surface ECG similar to the one recorded during spontaneous VT). The fact that the site of origin of the VT is never in the same point of the earliest endocardial activation during sinus rhythm and the fact that this site is located in a zone with rich terminations of the conduction system, suggest the reciprocating VT may develop in a circuit, with both conduction and myocardial tissue.

A single blind comparison of dihydroergotoxine mesilate and clonidine for treatment of hypertensive emergencies.

The effectiveness and safety of dihydroergotoxine mesylate (DHT) and clonidine (CLO) as acute antihypertensive treatments were studied in a single-blind randomized controlled study of 28 patients hospitalized after abrupt increases in mean blood pressure (MAP) to more than 150 mmHg, with concomitant symptoms related to hypertensive status (16 patients). Intravenous infusion of 1.5 mg DHT significantly reduced both systolic (SBP) and diastolic (DBP) blood pressure from 227 +/- 2/128 +/- 2 mmHg to 160 +/- 4/94 +/- 2 mmHg by 1 hour after the onset of infusion (p less than 0.01). In patients given CLO, BP values fell from 221 +/- 3/123 +/- 3 mmHg to 166 +/- 5/95 +/- 3 mmHg after 150 minutes. After that BP values did not change significantly up to 6 hours after both treatments. One hour after the onset of infusion, mean heart-rate (HR) had decreased by 15 beats/min in the DHT group and by 10 beats/min in the CLO-group. Twenty-one per cent of the patients given DHT and 78% of the patients given CLO complained of mild or moderate side-effects. The results of this study showed that DHT is an effective and well tolerated agent for the treatment of hypertensive emergencies and can be used safely even when continuous monitoring of blood pressure cannot be carried out.