HYT-hypertension in Turkey: a cross-sectional survey on blood pressure control with calcium channel blockers alone or combined with other antihypertensive drugs.

INTRODUCTION: Although improved during the past few years, high blood pressure control still remains an unmet goal of antihypertensive drug treatment. Among different antihypertensive agents, calcium channel blockers (CCBs), either as monotherapy or in combination with other drugs are recommended by several guidelines for initiation and maintenance of antihypertensive treatment. AIM: The HYT-HYperTension survey, carried out in Turkey was aimed to assess (a) blood pressure control in hypertensive patients under treatment with dihydropyridine CCBs, either as monotherapy or in combination with other drugs and (b) the prevalence of blood pressure control in subgroups of patients with cardiovascular risk factors (previous cardiovascular disease, diabetes, renal disease, isolated systolic hypertension, visceral obesity, overweight, current smoking habit). METHODS: More than 7000 hypertensive patients (60.0 % men, mean age 61.2 ± 11.5 years), routinely visited by either a specialist or a non-specialist physician in the Primary Care Units of 26 cities across Turkey, were enrolled in the survey. Only patients treated with dihydropyridine-type CCBs, as mono- or combination therapy were included in the study, whereas individuals treated with non-dihydropyridine-type CCBs or with other drug classes (as monotherapy or combination therapy), were excluded. Demographic data (age, gender, height, weight, waist circumference, current smoker habit), clinical data and drug treatments were collected at each visit. Blood pressure was measured with a semiautomatic device (Omron-M6) with the patient in sitting position and after at least 5 min of rest. Measurements were repeated three times, at intervals of 5 min each other. RESULTS: In the overall survey population blood pressure control (blood pressure <140/90 mmHg) was achieved in 31.7 % of patients and the average systolic and diastolic blood pressure was 145.3/88.2 mmHg. Prevalence of patients treated with dihydropyridine-type CCBs, either as monotherapy or combined with other drugs, was superimposable (51.6 vs 48.4 %, P = NS). Dihydropyridine-type CCBs were more frequently combined with drugs acting on the renin-angiotensin-aldosterone system (86.4 %), particularly with ACE-inhibitors (34.1 %) and angiotensin II receptor antagonists (52.3 %), while in 13.6 % of patients CCBs were combined with diuretics and/or beta-blockers. Diabetes mellitus was detected in 22.7 % of patients, obesity in 41.5 % and history of cardiovascular disease in 23.0 % (coronary artery disease in 19.2 % and stroke in 3.8 %). Blood pressure control was more difficult to be achieved in complicated hypertension, particularly when cigarette smoking, obesity, overweight, visceral obesity and renal disease were associated with hypertension. CONCLUSIONS: Taken together these findings provide evidence that dihydropyridine-type CCBs, particularly when combined with ACE-inhibitors or angiotensin II receptors blockers, allow to achieve a blood pressure control better than the one reported in the same geographic area by other treatment strategies based on different combinations of diuretics, beta-blockers, ACE-inhibitors, angiotensin II receptors blockers and calcium channel blockers.

Investigation of flow-mediated dilation response in normal coronary angiographic patients.

Normal findings from coronary angiography do not always show normal endothelial functions. An impaired flow-mediated dilation (FMD) can be a useful marker of the presence of endothelial dysfunction. Hypertension, left ventricular hypertrophy, hypercholesterolemia, and vasospastic angina pectoris can negatively affect FMD response. FMD responses of normal subjects and patients with coronary artery pathology were compared in a prospective cross-sectional study. Patients were divided into 3 groups. Group I patients had a positive exercise stress test and angiographically normal coronary arteries. Group II patients had angiographically significant coronary artery stenosis and stable angina pectoris. Group III had normal results from an exercise stress test and no chest pain. It was concluded that flow-mediated dilation response cannot predict coronary angiographic results. Patients with normal findings from coronary angiography may have impaired endothelial functions.

A Randomised Comparison of the Effects of Nebivolol and Atenolol with and without Chlorthalidone on the Sexual Function of Hypertensive Men.

BACKGROUND AND OBJECTIVE: Erectile dysfunction, which is common in men with hypertension, has been reported as a common adverse effect of many antihypertensive drug classes, including beta-blockers and diuretics. Atenolol and nebivolol are both beta(1)-selective blockers, but nebivolol is a new-generation compound with nitric oxide-mediated vasodilating activity. The aim of the study was to compare the effects of nebivolol and atenolol +/- chlorthalidone on the sexual function of hypertensive men. METHODS: A total of 131 male patients (mean age 47.3 +/- 4.6 years) with newly diagnosed hypertension were included in the study. All the patients were married and had not previously experienced any erectile dysfunction. After a 4-week placebo run-in period, patients were randomised to receive 12 weeks' therapy with nebivolol 5 mg/day (n = 43), atenolol 50 mg/day (n = 44), or atenolol 50 mg/day + chlorthalidone 12.5 mg/day (n = 44), according to a double-blind design. After 4 weeks of treatment, drug dosage could be doubled in patients not responding to therapy. Erectile function (instances of successful intercourse/month) was assessed by means of a questionnaire at the end of the placebo run-in period (baseline) and at the end of double-blind treatment. Blood pressure was also assessed at these times. RESULTS: At the end of the 12-week, double-blind treatment period, the mean number of episodes of satisfactory sexual intercourse per month was significantly decreased from baseline in the groups receiving atenolol (from 7.0 to 3.7; p < 0.01) and atenolol + chlorthalidone (from 6.4 to 2.8; p < 0.01). In contrast, the mean number of episodes of satisfactory sexual intercourse per month remained constant in the group of patients receiving nebivolol (6.4 during the baseline assessment and 6.0 during the last month of treatment). Blood pressure and heart rate were significantly decreased from baseline in all treatment groups. CONCLUSION: Increased release of nitric oxide associated with nebivolol may counteract the detrimental effect of beta-blockade on penile erection, thereby allowing maintenance of sexual activity in previously untreated hypertensive men compared with a significant decrease observed in the sexual activity of men receiving atenolol-based treatment.

The effect of combination therapy on regression of left ventricular hypertrophy in cases with hypertension.

OBJECTIVE: Up to this date, it is well shown that several antihypertensive drugs have different regressive effect on left ventricular hypertrophy (LVH). However, there are different studies regarding the effect of antihypertensive combination therapies on regression of LVH. In this study, 2 different combinations ACE-I plus calcium channel blocker and ACE-I plus diuretic were compared in cases with hypertension whose BPs were not controlled by ACE-I alone. METHODS: Forty patients with mild to moderate hypertension were included in this study. The treatment was continued for 6 months in the Faculty of Medicine at Ege University, Turkey, between January and December 2003. Adequate response with lisinopril 20 mg/daily failed to be achieved in all patients. Patients divided into 2 groups. There were no differences between the groups in patients' age, blood pressure (BP) and other clinical and laboratory range. First group patients received lisinopril 20 mg + nifedipine GITS 30 mg and second group patients received lisinopril 20 mg + hydrochlorothiazide 25 mg. The treatment was continued for 6 months. Blood pressure were measured every 2 weeks, echocardiographic findings, and blood and urinary analysis were performed before and at the end of treatment. RESULTS: Systolic and diastolic BP decreased significantly in both groups and no significant difference regarding BP was found between the 2 groups. Left ventricular mass index also decreased significantly in both groups. However, in the first group left ventricular mass index decreased more compared to the second group. CONCLUSION: The effect of combination therapies with angiotensin converting enzyme inhibitor (ACE-I) plus diuretic and ACE-I plus calcium channel blocker on systolic and diastolic BP are similar. However, when LVH is present, regressive effect of the combination of ACE-I plus calcium channel blocker is superior to the combination of ACE-I plus diuretic.

Left ventricular hypertrophy and endothelial functions in patients with essential hypertension.

OBJECTIVE: In this study, we used a non-invasive method in patients with essential hypertension and without any overt clinical evidence of atherosclerosis to investigate the role of left ventricular hypertrophy (LVH) in endothelial functions. METHODS: We assessed endothelial function in 32 hypertensive patients with LVH (group 1), 28 hypertensive patients without LVH (group 2) and 29 normotensive subjects (control group). Flow-mediated (endothelium-dependent) and nitrate induced (endothelium-independent) dilatation of the brachial artery was evaluated in all groups. RESULTS: Flow-mediated dilatation was considerably higher in the control group than in group 1 and 2 (13.98 +/- 2.92%, 4.67 +/- 1.09% and 7.02 +/- 1.79% respectively, p < 0.001). In addition, endothelium-dependent dilatation was significantly lower in group 1 than in group 2 (p < 0.001), whereas nitrate induced changes were similar in all groups. CONCLUSION: Vascular endothelial functions are impaired in hypertensive patients. There may be heterogeneity of endothelial dysfunction among patients with hypertension. Presence of LVH has an additional negative effect on endothelial function in hypertensive patients.

Elevated serum CA 125 levels in mitral stenotic patients with heart failure.

BACKGROUND: Elevated tumor marker levels have been reported in heart failure patients with left ventricular (LV) systolic dysfunction and enlargement. The levels of several tumor markers, including CA 125, CA 19-9, CA 15-3 and CEA, in rheumatic mitral stenotic patients were compared to the control group. MATERIALS AND METHODS: Tumor markers were measured in 60 mitral stenotic patients and in 30 normal subjects who served as the control group. Mitral stenotic patients were classified into two categories of cardiac dysfunction based on the classification of the New York Heart Association (NYHA). Group I consisted of 31 patients in NYHA class 3-4 and group II of 29 patients in NYHA class 1-2. Echocardiographic examinations and invasive hemodynamic monitoring were performed in all patients. RESULTS: Group I patients had decreased mitral valve area (p = 0.004) and higher left atrial diameter (p = 0.003) than group II patients. Right atrial, mean pulmonary artery and pulmonary capillary wedge pressures and transmitral gradient were higher in group I than in group II (p = 0.010, 0.0001, 0.0001 and 0.0001, respectively). CA 125 levels were statistically higher in mitral stenotic patient groups than in the control group (p < 0.0001). No statistically significant differences were shown for the other tumor markers. Group I patients had higher CA 125 levels compared to group II (p < 0.0001). CONCLUSION: Elevated CA 125 levels may be due to venous congestion and activation of peritoneal mesothelium or increased signal peptides.

Six hour ambulation after elective coronary angioplasty and stenting with 7F guiding catheters ald low dose heparin.

BACKGROUND: Early ambulation after coronary angioplasty may reduce in-hospital stay and add to the patient's comfort. This approach, however, may increase the risk of insertion site related complications, such as arterial bleeding, haematoma, pseudoaneurysm, and the need for surgical repair. AIM: To evaluate the feasibility and safety of ambulation of patients six hours after elective coronary angioplasty or stenting, or both. METHODS: Coronary angioplasty and stenting were performed using 7F guiding catheters via the femoral or brachial approach. The first dose of heparin 5000 IU was given immediately after insertion of the arterial sheath and the second dose heparin 2500 IU was given 90 minutes later. There were no angiographic exclusion criteria. The arterial sheath was removed immediately after the procedure. Haemostasis was achieved by manual compression and maintained with a compression bandage. Early ambulation was attempted after six hours of supine bed rest following removal of the bandage. The incidence of bleeding at ambulation requiring compression and additional bed rest, and insertion site complications documented 48 hours after the procedure, were analysed. RESULTS: 326 patients (290 femoral, 36 brachial route) were included. Stent implantation was performed in 267 patients (82%). The mean+/-SD time to haemostasis was 14+/-4 minutes. Bleeding at ambulation occurred in 7 (2.14%) patients, and major haematomas were seen in 8 (2.45%) patients during 48-hour follow up. All were seen in patients in whom the femoral route was used and who were treated conservatively. There were no late bleeding or vascular complications. CONCLUSIONS: Ambulation six hours after elective balloon angioplasty or stent implantation with 7F guiding catheters using femoral or brachial route and low dose heparin is feasible and safe, with a low incidence of insertion site complications. This early ambulation protocol shortens hospital stay.

Comparison of candesartan and felodipine alone and combined in the treatment of hypertension: a single-center, double-blind, randomized, crossover trial.

BACKGROUND: In the past decade, many studies have indicated that the combination of low doses of different classes of antihypertensive agents may be more efficacious than monotherapy while minimizing the likelihood of dose-dependent adverse effects (AEs). OBJECTIVE: The aim of this study was to determine whether combination therapy with lower doses of candesartan and a calcium antagonist, felodipine, would be more effective and tolerable in controlling mild to moderate hypertension compared with either drug used alone. METHODS: In this 18-week, single-center, double-blind, crossover study, patients with mild to moderate essential hypertension were randomized to 1 of 2 treatment groups after a 2-week placebo washout period. Patients in group 1 received candesartan 16 mg once daily and patients in group 2 received felodipine 5 mg once daily, for 6 weeks. All patients then received half-dose combination therapy (candesartan 8 mg plus felodipine 2.5 mg, once daily) for 6 weeks. Finally, patients received 6 weeks of monotherapy with the alternate medication (group 1 received felodipine 5 mg once daily and group 2 received candesartan 16 mg once daily). RESULTS: Thirty patients (18 men, 12 women; mean [SD] age, 54.0 [4.9] years; range, 39-62 years) were included in the study. During both monotherapy periods, candesartan and felodipine significantly reduced blood pressure (BP) (both P<0.001). BP further decreased with combination therapy (P<0.001 in both groups). Overall, 90.0% (27/30) of the patients achieved the target BP at the end of combination therapy. The incidence of AEs was similar with combination therapy compared with either monotherapy. CONCLUSIONS: In this study population, candesartan and felodipine had additive effects when used in combination, even at low doses, in the treatment of hypertension. Therefore, the combination of candesartan and felodipine is an effective alternative to that of candesartan and hydrochlorothiazide.

[Hypertension and endothelial dysfunction]. / Hipertansiyon ve endotel fonksiyon bozuklugu.

Endothelium; effective in vascular tonus, blood tension, blood flow and coagulation system is the biggest endocrine organ with 1800 gr. weight in human body. The endothelium releases nitric oxide, which maintains vascular integrity. In endothelial dysfunction the balance between releasing vasodilatatory and vasoconstrictory factors is changed. In the presence of essential hypertension defection in endothelium-dependent vasodilation and increasing sensitivity to vasoconstrictors could increase vascular resistance. Although some beneficial results with angiotensin converting enzyme inhibitors, carvedilol, angiotensin-II and endothelin receptor antagonists were reported in patients with endothelial dysfunction the effectiveness of these drugs is still debate. Also the decreasing of arterial pressure was not always shown to be parallel to the restoration of endothelial dysfunction. In the future according to genetic studies, the increased use of nitric oxide releasing genes therapy will have a more effective role in regression of endothelial dysfunction.