Performance of two metabolic syndrome definitions in the estimation of cardiovascular disease among hypertensive patients.

The authors evaluated the significance of metabolic syndrome (MetS) diagnosis, as defined by the National Cholesterol Education Program (NCEP) and by the International Diabetes Federation (IDF), in the evaluation of cardiovascular risk in hypertensive patients. Among 638 patients, the prevalence of MetS was 54.7% when the IDF criteria were used, compared with 45.5% when the NCEP criteria were used. MetS correlated significantly with the presence of cardiovascular disease (CVD). In patients without type 2 diabetes mellitus (T2DM), only MetS diagnosed using the IDF criteria was associated with the presence of CVD. In those with T2DM, MetS was not associated with CVD, regardless of the criteria used. The diagnosis of MetS, using either set of criteria, was associated with the development of T2DM. We conclude that, in hypertensive patients without diabetes, a diagnosis of MetS according to IDF criteria, but not the NCEP criteria, is useful in identifying individuals with a higher probability of incident CVD. In patients with diabetes, a population already considered at high risk for CVD, a diagnosis of MetS, regardless of the criteria used, has no further impact on prognosis.

Sleep-disordered breathing changes after kidney transplantation: a polysomnographic study.

BACKGROUND: Sleep disorders are common in patients with end-stage renal disease (ESRD) and are not improved by either conventional haemodialysis or peritoneal dialysis. Sleep-disordered breathing (SDB) is associated with cardiovascular disease and contributes to high mortality found in patients with ESRD. Cure of SDB after transplantation has been anecdotally reported. METHODS: Thirty-four non-diabetic patients with ESRD were studied, and clinical, laboratory test and polysomnographic features were determined and compared prior to and after transplantation and between groups with or without SDB, defined as having an apnoea-hypopnoea index (AHI) >or=5. RESULTS: An AHI >or=5 was present in nine patients (26.5%) prior to and seven (21%) after transplantation, and no significant reduction of mean AHI was found between study phases (5.3 +/- 7.3 vs 3.1 +/- 4.5; P > 0.05). Transplantation was associated with a significant improvement in sleep architecture. CONCLUSIONS: Kidney transplantation is associated with an improvement in sleep architecture, but does not cure SDB in all patients.

Diuretic-induced potassium depletion and glucose intolerance are not related to hyperactivity of the renin-angiotensin-aldosterone system in hypertensive patients with the metabolic syndrome.

The metabolic syndrome (MS) has been associated with hyperactivity of the renin-angiotensin-aldosterone system (RAAS). To assess the hypothesis that diuretic therapy in MS patients through further stimulation of RAAS would elicit greater potassium (K) depletion, two groups of hypertensive patients with (MS group [MSG]; n=20) and without (control group [CG]; n=19) MS were studied. Plasma renin activity (PRA), aldosterone (PA), and K levels were determined and an oral glucose tolerance test with plasma insulin determinations for calculation of homeostasis model assessment of insulin resistance (HOMA-IR), sensitivity (ISI), and secretion (HOMA-beta) was performed, both before and 12 weeks after hydrochlorothiazide (HCT; 25 mg/d) therapy. At baseline, higher HOMA IR and HOMA-beta and lower ISI and plasma K were found in the MSG than in the CG, with no differences in PA and PRA between groups. With therapy, PRA increased similarly in both groups while PA increased only in the MSG. However, greater reduction in plasma K occurred in the CG, and the 2 groups reached similar final K values. Impairment in glucose tolerance occurred in both groups, with no change in HOMA-beta in the CG and reduction in the MSG, suggesting that diuretic therapy increases insulin resistance and impairs insulin secretion independent of abdominal obesity. These alterations could not be attributed to hyperactivity of RAAS.

Uric acid as a marker for renal dysfunction in hypertensive women on diuretic and nondiuretic therapy.

Hyperuricemia is a common finding in hypertensive patients, especially among those who are on diuretic therapy. However, its clinical relevance regarding cardiovascular and chronic kidney disease (CKD) has not clearly been established. The authors assessed whether, in a population of 385 hypertensive women categorized according to diuretic therapy, the stratification in quartiles by uric acid levels would identify a gradient of changes in renal function and in risk factors for cardiovascular disease. The following were evaluated: serum uric acid, glycemia, total and fractional cholesterol, triglycerides, apolipoprotein (Apo) B, Apo A-I, and C-reactive protein. Renal function was assessed by serum creatinine, albuminuria, and estimated glomerular filtration rate (eGFR) by the Modification of Diet in Renal Disease equation, whereas cardiovascular risk was estimated through the Framingham score. A total of 246 women were on diuretic therapy; 139 were taking other antihypertensive medications. There was a reduction in eGFR parallel to the increase in uric acid levels, regardless of diuretic use and without a concomitant increase in albuminuria. In both groups, higher uric acid levels translated into an increase in metabolic syndrome components, in markers of insulin resistance, triglyceride / high-density lipoprotein levels, and Apo B/Apo A-I ratios, as well as in Framingham scores. Hyperuricemia was associated with an increase in inflammatory markers only in patients on diuretic therapy. In a binary logistic regression, hyperuricemia (uric acid >6.0 mg/ dL) was independently associated with CKD (eGFR <60 mL/ min / 1.73 m(2)) (odds ratio, 2.63; 95% confidence interval, 1.61-4.3; P<.001). In hypertensive women, the presence of hyperuricemia indicated a substantial degree of kidney dysfunction as well as a greater cardiovascular risk profile.

Hyperglycemia and nocturnal systolic blood pressure are associated with left ventricular hypertrophy and diastolic dysfunction in hypertensive diabetic patients.

BACKGROUND: The aim of this study was to determine if hypertensive type 2 diabetic patients, when compared to patients with essential hypertension have an increased left ventricular mass index (LVMI) and a worse diastolic function, and if this fact would be related to 24-h pressoric levels changes. METHODS: Ninety-one hypertensive patients with type 2 diabetes mellitus (DM) (group-1 [G1]), 59 essential hypertensive patients (group-2 [G2]) and 26 healthy controls (group-3 [G3]) were submitted to 24-h Ambulatory Blood Pressure Monitoring (ABPM) and echocardiography (ECHO) with Doppler. We calculated an average of fasting blood glucose (AFBG) values of G1 from the previous 4.2 years and a glycemic control index (GCI) (percentual of FBG above 200 mg/dl). RESULTS: G1 and G2 did not differ on average of diurnal systolic and diastolic BP. However, G1 presented worse diastolic function and a higher average of nocturnal systolic BP (NSBP) and LVMI (NSBP = 132 +/- 18 vs 124 +/- 14 mmHg; P < 0.05 and LVMI = 103 +/- 27 vs 89 +/- 17 g/m2; P < 0.05, respectively). In G1, LVMI correlated with NSBP (r = 0.37; P < 0.001) and GCI (r = 0.29; P < 0.05) while NSBP correlated with GCI (r = 0.27; P < 0.05) and AFBG (r = 0.30; P < 0.01). When G1 was divided in tertiles according to NSBP, the subgroup with NSBP> or =140 mmHg showed a higher risk of LVH. Diabetics with NSBP> or =140 mmHg and AFBG>165 mg/dl showed an additional risk of LVH (P < 0.05; odds ratio = 11). In multivariate regression, both GCI and NSBP were independent predictors of LVMI in G1. CONCLUSION: This study suggests that hyperglycemia and higher NSBP levels should be responsible for an increased prevalence of LVH in hypertensive patients with Type 2 DM.

Efficacy, safety and tolerability of sildenafil in Brazilian hypertensive patients on multiple antihypertensive drugs.

OBJECTIVE: To evaluate the efficacy, safety and tolerability of sildenafil among Brazilian patients with hypertension treated with combinations of anti-hypertensive drugs. MATERIALS AND METHODS: One hundred twenty hypertensive men aged 30 to 81 years old under treatment with 2 or more anti-hypertensive drugs and with erectile dysfunction (ED) lasting for at least 6 months were enrolled at 7 research centers in Brazil. Patients were randomized to receive treatment with either sildenafil or placebo taken 1 hour before sexual intercourse (initial dose of 50 mg, adjusted to 25 mg or 100 mg according to efficacy and toxicity). During the following 8 weeks, patients were evaluated regarding vital signs, adverse events, therapeutic efficacy, satisfaction with treatment and use of concurrent medications. RESULTS: The primary evaluation of efficacy, which was based on responses to questions 3 and 4 of the International Index of Erectile Function, showed significant differences regarding treatment with sildenafil (p = 0.0002 and p < 0.0001, respectively). In the assessment of global efficacy, 87% of the patients treated with sildenafil reported improved erections, as compared with 37% of patients given placebos (p < 0.0001). The other secondary evaluations supported the results favoring sildenafil. The most frequent adverse events among patients treated with sildenafil were headaches (11.4%), vasodilation (11.4%) and dyspepsia (6.5%). There were no significant changes in blood pressure measurements in both groups. CONCLUSION: Sildenafil is efficacious and safe for the treatment of hypertensive patients with ED who receive concurrent combinations of anti-hypertensive drugs.

Efficacy, safety and tolerability of sildenafil in Brazilian hypertensive patients on multiple antihypertensive drugs

OBJECTIVE: To evaluate the efficacy, safety and tolerability of sildenafil among Brazilian patients with hypertension treated with combinations of anti-hypertensive drugs. MATERIALS AND METHODS: One hundred twenty hypertensive men aged 30 to 81 years old under treatment with 2 or more anti-hypertensive drugs and with erectile dysfunction (ED) lasting for at least 6 months were enrolled at 7 research centers in Brazil. Patients were randomized to receive treatment with either sildenafil or placebo taken 1 hour before sexual intercourse (initial dose of 50 mg, adjusted to 25 mg or 100 mg according to efficacy and toxicity). During the following 8 weeks, patients were evaluated regarding vital signs, adverse events, therapeutic efficacy, satisfaction with treatment and use of concurrent medications. RESULTS: The primary evaluation of efficacy, which was based on responses to questions 3 and 4 of the International Index of Erectile Function, showed significant differences regarding treatment with sildenafil (p = 0.0002 and p < 0.0001, respectively). In the assessment of global efficacy, 87 percent of the patients treated with sildenafil reported improved erections, as compared with 37 percent of patients given placebos (p < 0.0001). The other secondary evaluations supported the results favoring sildenafil. The most frequent adverse events among patients treated with sildenafil were headaches (11.4 percent), vasodilation (11.4 percent) and dyspepsia (6.5 percent). There were no significant changes in blood pressure measurements in both groups. CONCLUSION: Sildenafil is efficacious and safe for the treatment of hypertensive patients with ED who receive concurrent combinations of anti-hypertensive drugs.

The risk of developing end-stage renal disease in patients with type 2 diabetes and nephropathy: the RENAAL study.

BACKGROUND: Diabetic nephropathy has become the single most important cause of end-stage renal disease (ESRD) worldwide. Strategies to slow the rate of loss of renal function in these patients have been developed. We examined the risk factors that predict loss of kidney function (doubling of serum creatinine) or ESRD (dialysis or transplantation) in patients with type 2 diabetes in whom blood pressure was controlled. METHODS: We evaluated risk factors for doubling of serum creatinine or the development of ESRD in the Reduction of End Points in NIDDM with the Angiotensin II Receptor Antagonist Losartan (RENAAL) study, which included 1513 patients with type 2 diabetes and nephropathy. RESULTS: Univariate analyses demonstrated a group of 23 risk factors that significantly predicted doubling of serum creatinine or ESRD. From these univariate analyses, a multivariate model was developed that demonstrated four independent risk factors: proteinuria, serum creatinine, serum albumin, and hemoglobin level. Proteinuria was the strongest and most consistent risk factor. The multivariate risk model was derived from only the placebo group and was similar to that derived for the total population, suggesting that the risk predictors for progression of kidney disease were independent of therapy. CONCLUSION: After control of blood pressure in type 2 diabetic patients with nephropathy, proteinuria, degree of renal failure, serum albumin, and hemoglobin level are independent risk factors that predict renal outcomes. The level of proteinuria proved to be the most important risk for progressive kidney injury in these diabetic patients.

The role of angiotensin II antagonism in type 2 diabetes mellitus: a review of renoprotection studies.

BACKGROUND: Diabetic nephropathy is the leading cause of end-stage renal disease (ESRD) in Western and Asian countries. Effective antihypertensive therapy reduces the rate of decline in renal function and postpones ESRD in patients with diabetic nephropathy. OBJECTIVE: This review presents evidence from studies on how blood pressure control, plasma glucose control, and the presence of proteinuria determine outcomes in diabetic patients. The role of angiotensin II (All) in the development of diabetic nephropathy and the reno- and cardiobeneficial effects of AII antagonism in patients with type 2 diabetes mellitus (DM-2) and diabetic nephropathy also are addressed. METHODS: Articles included in this review were found using a MEDLINE search for studies published from 1991 to 2001 and including the search terms diabetic nephropathy, type 2 diabetes mellitus, microalbuminuria, proteinuria, angiotensin receptor blockade, angiotensin-converting enzyme inhibition, and cardiovascular disease. Articles reporting new data, new mechanisms, major clinical trials, and our own data were included. RESULTS: Recently, the Reduction of Endpoints in NIDDM (non-insulin-dependent diabetes mellitus) with the Angiotensin II Antagonist Losartan (RENAAL) trial provided sufficient data to conclude that the blockade of the All AT1 receptor with losartan confers renoprotection in patients with DM-2 and nephropathy. Similar results were obtained with irbesartan in the Irbesartan Diabetic Nephropathy Trial (IDNT) and the Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria study (IRMA 2). The results of RENAAL indicate that the renoprotective effects of losartan were attributable to effects beyond blood pressure control. In addition to the favorable impact of the All blockade on blood pressure and renal hemodynamics, the blockade of the growth-promoting, profibrotic, nonhemodynamic actions of AII also may be important for renoprotection. Intensive blood pressure control also confers cardiovascular protection in pa- tients with DM-2. Some studies suggest that the blockade of the renin-angiotensin system confers superior cardioprotective effects in patients with DM-2. The RENAAL study also showed cardioprotection with losartan, with an important reduction in the risk for first hospitalization for heart failure. CONCLUSION: Evidence supports the importance of an effective blockade of AII action for both reno- and cardioprotection in patients with DM-2.

Tratamento de diabetes e hipertensäo no paciente obeso / Treating diabetes and hypertension in the obese patient

A obesidade é um fator de risco independente para doença coronariana. A resistência à insulina associada à obesidade contribui para o desenvolvimento de dislipidemia, hipertensäo arterial e diabetes tipo 2. A coexistência de hipertensäo e diabetes aumenta o risco para complicaçöes micro e macrovasculares, predispondo os indivíduos à insuficiência cardíaca congestiva, doença coronariana e cerebrovascular, insuficiência arterial periférica, nefropatia e retinopatia. Em pacientes diabéticos obesos a reduçäo do peso, bem como o uso de metiformina, melhoram a sensibilidade à insulina, o controle da glicemia e da pressäo arterial. O tratamento anti-hipertensivo em diabéticos reduz a mortalidade cardiovascular e retarda o declínio da funçäo glomerular. Deve-se considerar os efeitos dos agentes anti-hipertensivos sobre a sensibilidade à insulina e o perfil lipídico. Diuréticos e b-bloqueadores podem reduzir a sensibilidade à insulina, enquanto bloqueadores de canais de cálcio säo metabolicamente neutros e os TECA aumentam a sensibilidade à insulina, além de conferir proteçäo adicional cardiovascular e renal para diabéticos. O bloqueio da angiotensina II tem mostrado benefícios semelhantes.

Role of vasopressin in 24-hour blood pressure regulation in diabetic patients with autonomic neuropathy.

To evaluate the role of vasopressin (AVP) on blood pressure (BP) in diabetic patients with autonomic neuropathy (AN), 10 patients were studied on a fixed sodium and potassium diet. On days 4 and 7, a 24-h BP monitoring, as well as blood and urine samples for sodium, potassium, creatinine, and osmolality determinations were obtained for every 4-h period; either placebo or an AVP-V1-antagonist (d(CH2)5Tyr(me)AVP; 0.5 mg; AVPi) were given iv at 1 PM. On placebo, systolic BP (SBP) showed a progressive elevation during the day, declining after 12 PM (8 AM to 12 AM 122+/-9; 12 AM to 4 PM 125+/-11; 4 PM to 8 PM 134+/-14; 8 PM to 12 PM 136+/-14; 12 PM to 8 AM 131+/-17 mm Hg). On AVPi this rise in SBP was blunted: 8 AM to 12 AM 125+/-122; 12 AM to 4 PM 121+/-21; 4 PM to 8 PM 126+/-16; 8 PM to 12 PM 129+/-14; 12 PM to 8 AM 124+/-12 mm Hg. Creatinine clearance and diureses were greater during the night, both with placebo and AVPi. Plasma osmolality did not change on either day, although serum sodium decreased after AVPi, reaching the lowest values at 4 PM to 8 PM period (137+/-4.7 v 131+/-3.8 mEq/L; P < .05). With placebo, fractional excretion of sodium (FENa) increased from 0.43%+/-0.32% during 12 h of orthostasis to 0.92%+/-1.05% during 12 h of recumbency (P < .02). With AVPi, the FENa on orthostasis did not differ from that with placebo, although BP values were lower and did not increase with recumbency (0.58+/-0.57 v 0.73%+/-0.49%; NS). In conclusion, our results show that in diabetic patients with AN, vasopressin participates in BP control by stimulating vascular and renal V1 receptors, which results in vasoconstriction and sodium reabsorption.

Estudo multicêntrico nacional para avaliação da eficácia e tolerabilidade da nifedipina oros em hipertensão arterial leve a moderada / Multicenter National Study for the evaluation of the efficacy and tolerance of nifedipine oral release osmotic system in mild to moderate hypertension

PURPOSE--Evaluation of the efficacy and tolerability of nifedipine oros in patients with mild to moderate essential hypertension without major target organ damage and the anti-hypertensive effect along the 24 hours. METHODS--Two hundred and three patients were studied. After two weeks placebo running period single dose of nifedipine oros (30 mg/day) was administered for 8 weeks. At the end of the 4th week, the non-responders (diastolic blood pressure > 90 mmHg or reduction in diastolic pressure < 10 mmHg), had the dosage increased to 60 mg/day. Laboratory tests and 24h blood pressure monitoring (60 patients) were performed at the beginning and at the end of the study. RESULTS--One hundred and ninety one patients completed the study. Fifty nine percent were considered responders at the end of the 4th week with nifedipine oros 30 mg/day and 41 needed dosage increment to 60 mg/day. At the end of the 8th week, all patients were considered responders to nifedipine oros. The blood pressure control extended throughout the 24h of the day. The most common adverse events were edema (14.6) and headache (12.4). Good and very good tolerability were informed by 85 of the patients. CONCLUSION--Nifedipine oros was able to control blood pressure efficaciously along the 24h period without important side effects. The possibility of once day dosage, increases the patient adherence to anti-hypertensive therapy.

A lovastatina no tratamento da hipercolesterolemia em portadores de diabete näo dependente de insulina / Lovastatin for the Treatment of Hypercholesterolemia in Non-insulin Dependent Diabetic Patients

Objetivo - Avaliar os efeitos da lovastatina como agente capaz de corrigir as anormalidade do perfil lipídico do plasma em pacientes diabéticos näo dependentes de insulina (NIDDM) e portadores de hipercolesterolemia. Métodos - Foram estudados 20 pacientes NIDDM nos quais se diagnosticou hipercolesterolemia, definida como a ocorrência de níveis de LDL-colesterol superiores a 160mg/dl, em pacientes do sexo feminino, e acima de 130mg/dl em pacientes do sexo masculino, ou em mulheres portadoras de qualquer outro fator de risco para doença coronariana. Dos 20 pacientes incluídos, 18 eram hipertensos que foram admintidos no estudo após terem substituído a terapêutica com ß-bloqueadores ou diurêticos por inibidores da enzima conversora ou bloqueadores dos canais de cálcio. O tratamento consistiu na administraçäo de lovastatina por um período de 24 semanas. A dose diária inicial de 20mg era elevada para 40mg, após 6 semanas de uso da droga, caso os níveis de LDL-colesterol se mantivessem acima de 130mg/dl. Resultados - A lovastatina na dose diária de 20mg (9 pacientes) ou 40mg (11 pacientes), reduziu os níveis séricos de LDL-colesterol e do colesterol total em 30// e 21// respectivamente, enquanto os níveis de HDL-colesterol e triglicérides permaneceram inalterados. A medicaçäo foi bem tolerada e nenhum paciente apresentou alteraçöes nos níveis séricos das transaminases ou bilirrubinas. Em 9 dos pacientes estudados houve elevaçäo dos níveis séricos da fosfatase alcalina, sendo que a média do grupo todo se elevou de 109 ñ 59 para 188 ñ 60mµ (p < 0,05), sendo esta a única alteraçäo laboratorial observada, näo associada a qualquer manifestaçäo clínica. Conclusäo - Em NIDDM a lovastatina se mostrou eficiente para promover reduçöes nos níveis séricos do colesterol total e do LDL-colesterol. Embora se desconheça o real significado da elevaçäo nos níveis séricos da fosfatase alcalina, recomendamos, nessa condiçäo, a suspensäo da terapia com essa droga

Purpose- To evaluate the effects of lovastatin as an hypocholesterolemic agent in non-insulin dependent diabetic (NIDDM) patients with high cholesterol plasma levels. Methods - Twenty NIDDM patients were included in this study. Hypercholesterolemia was defined as LDL cholesterol plasma levels above 160mg/dl in female patients and above 130mg/dl in male patients or in women presenting any other risk factor for cardiovascular disease. From the 20 patients included, 18 had also high levels of arterial blood pressure. They were evaluated for admission in the study after they have substituted the antihypertensive medication for at least 6 weeks, from bblockers or diuretics to angiotensin converting enzyme inhibitors or calcium channel blockers. Lovastatin was administered in a initial daily dose of 20mg to all patients for 6 weeks. After this period this dose was increased to 40mg in 11 patients with LDL-cholesterol levels above 130mg/dl. All patients were treated for a total period of 24 weeks. Results - Lovastatin therapy for 24 weeks reduced LDL-cholesterol and total cholesterol plasma levels in 30% and 21°/, respectively, while no changes in HDL cholesterol or triglycerides plasma levels wereobserved. The medication was well tolerated and no changes in bilirrubins or transaminases plasma levels were detected. In 9 patients the serum levels of alkaline phosphatase showed an elevation and the mean level of all group increased from 109±59 to 188±60mm/ml (p< 0.05). This was an isolated abnormality without any other clinical manifestation. Conclusion - Lovastatin in NIDDM showed to be an efficient agent to reduce high levels of LDL-cholesterol and total cholesterol. However, the importance of the abnormality observed in serum alkaline phosphatase levels deserves further investigation. In this condition we recommend discontinuation of lovastatin therapy

Captopril na hipertensão arterial leve e moderada resistente a diurético: valor preditivo da eficácia através do teste agudo do captopril / Captopril in mild and moderate arterial hypertension diuretic resistant: acute captopril test to predict treatment efficacy

Objetivo - Estabelecer se a resposta aguda ao captopril pode ser aplicada como teste preditivo de eficácia a longo prazo, no tratamento da hipertensäo arterial de pacientes que näo obtiveram o controle pressórico com diurético. Métodos - Foram estudados 120 pacientes portadores de hipertensäo arterial leve e moderada, näo controlada com 100 mg de hidroclorotiazida. Determinaram-se as variaçöes da pressäo arterial sistólica (PAS), diastólica (PAD) e média durante a administraçäo aguda e crônica do captopril. Procurou-se correlacionar o percentual de queda destas pressöes, obtidas ao final do tratamento, com aquelas obtidas com o teste de captopril, aplicando-se a funçäo discriminante linear (FDL) e o teste do Qui-quadrado com índices preditivos de tratamento. Previamente à aplicaçäo destes testes, subdividiram-se os pacientes em dois grupos de acordo com o percentual de queda da pressäo arterial média )PAM) em grupo de mau desempenho (G1) ou bom desempenho (G2) caso a PAM, respectivamente, apresentasse queda menor ou igual/maior a 159% ao final do tratamento com a associaçäo do diurético e captopril. Resultados - Os autores médios da pressäo arterial durante o período placebo foram 168 ñ 2/109 ñ 1 mmHg. Apos o uso do diurético e a associaçäo com captopril os valores da pressäo arterial foram 151 ñ 1/101 ñ 1 e 137 ñ 1/90 ñ 1 mmHg, respectivamente, valores significativamente diferentes entre si (p < 0,05). A normalizaçäo dos valores pressóricos foi observada em 58% dos pacientes. A FDL calculada apresenta a seguinte equaçäo: FDL = 7,92 queda % PAS + 1,21 queda % PAD. O valor médio para FDL de G1 foi de 192 e para G2 de 361. O valor 276 representa o ponto médio de separaçäo dos dois grupos. Aplicando-se a FDL e o qui-quadrado, as percentagens de acerto para G1 foram, repectivamente, de 80% e 47%. Para o grupo G2, de bom desempenho, a FDL e o qui-quadrado estäo de acordo, respectivamente, em 72 e 77%. Conclusäo - O emprego da funçäo discriminante linear e do qui-quadrado sugerem que o teste do captopril pode ser metodologia auxiliar para selecionar pacientes que näo foram controlados com diuréticos, e que iräo ter benefício com a adiçäo de um inibidor da enzima conversora ao tratamento

Purpose - To evaluate if acute blood pressure response with captopril can be applied as a predictive test of treatment efficacy in hypertensive patients uncontrolled with large dose of diuretics. Methods - Mild and moderate 120 uncontrolled hypertensive patients treated with hydrochlorothiacide 100 mg, were submitted to captopril (25 mg) test. The systolic (SBP) and diastolic (DBP) blood pressure acute and chronic responses were correlated and the linear discriminate function (LDF) and qui-square were applied to test the treatment efficacy. Previously two groups (G) patients were obtained as bad responders (G1) and good responders (G2) respectively, if the mean arterial pressure fall less or equal/more than 15% at the end of the associated treatment with diuretic and captopril. Results - Mean arterial pressure values during placebo were 168 ± 2/109 ± 1 mmHg. This values after diuretic and associated captopril treatment were, respectively, 151 ± 1/ 101 ± 1 and 137 ± 1/90 ± 1 mmHg, all signif cant different (p < 0.05). Blood pressure normalization was obtained in 58% of patients. The calculated LDF formula were: LDF = 7.92 ­ % SBP ± 1.21 D % DBP. The G1 LDF mean value was 192 and 361 to G2. The value 276 represents the separation medium point between both groups. As far the distance from the separation medium point for a calculated LDF for a calculated LDF for a problematic patient, as more will be the probability for this patient to belong to tLis group. LDF and qui-square classified correctly, respectively, 80% and 47% of patients in G1. To G2 good re ponders patients, LDF and qui-square agreed, respectively, in 72 and 77%. Conclusion - The results obtained suggest that captopril test, could be useful as an auxiliary methodology to select hypertensive patients, uncontrolled with diuretic treatment, which might benefit with the association of converting enzyme inhibitors drugs

Captopril na hipertensão arterial leve e moderada resistente a diureticoterapia: estudo multicêntrico / Captopril for the treatment of mild to moderate hypertension diuretic resistant multicenter study

Objetivo - Avaliar o efeito antihipertensivo do captopril para o tratamento de hipertensäo arterial leve e moderada resistente a diurético-terapia. Métodos - Hipertensos leves e moderados, sem, ou que tiveram a medicaçäo antihipertensiva suspensa por sete dias, foram tratados com 50 mg de hidroclorotiazida por duas semanas. Os pacientes que obtiveram normalizaçäo pressórica (pressäo arterial diastólica * 90 mmHg) foram excluídos, e nos demais, a dose do diurético foi aumentada para 100 mg; por mais três semanas. Nos hipertensos em que este tratamento näo teve sucesso para normalizar a pressäo arterial (n = 120), captopril, na dose de 25 a 50 mg/dia, em duas tomadas diárias, foi introduzido durante nove semanas. Após este período, a um subgrupo (n = 74) de pacientes a dose necessária de captopril foi administrada com o diurético em uma única tomada, por mais três semanas adicionais. A avaliaçäo clínica foi realizada previamente ao diurético, a cada duas semanas após sua introduçäo e a cada três, durante o captopril Os exames laboratoriais foram analisados antes do diurético, antes da introduçäo do captopril e ao final de 12 semanas do tratamento combinado. Resultados - A pressäo arterial supina no período placebo que foi de 168 ñ 2 / 109 ñ 1 mmHg apresentou um decréscimo significante com o tratamento diurético para 151 ñ 1 / 101 ñ 1 mmHg e uma queda adicional para 137 ñ 1 / 90 ñ 1 mmHg com a associaçäo do captopril na dose média de 44 ñ 1 mg. Na 12ª semana de tratamento quando o paciente estava medicado com dose única diária há 3 semanas a pressäo arterial foi de 137 ñ 2 / 90 ñ 1 mmHg. Obteve-se normalizaçäo pressórica em 58% dos pacientes com o captopril em duas tomadas e em 63% com dose única. Obteve-se normalizaçäo pressórica em 63% dos pacientes näo brancos e em 56% dos pacientes com idade superior a 45 anos. Houve alteraçäo significante dos níveis plasmáticos de potássio com o diurético que näo reverteu com a associaçäo de captopril. Conclusäo - O captopril em baixa dose administrado uma ou duas vezes ao dia causou queda pressórica adicional em pacientes portadores de hipertensäo arterial e moderada resistente a diureticoterapia

Purpose - To evaluate the antihypertensive effect of captopril in mild and moderate hypertensive patients uncontrolled with diuretics. Methods - Low dose of captoprzl (25 to 50 mg) bid were associated during 9 weeks in 120 patients previously treated with 100 mg of hydrochlorothiazid e. A subgroup of patients (74) were followed additionally for 3 weeks with the same dose of the drugs administered as a single dose. The patients were clinically evaluated after two weeks placebo, and each three weeks of active drugs. Blood pressure normalization were considered when diastolic arterial pressure was < 90 mmHg. Laboratory tests were measured before diuretic, before captopril and at the end of combined twelve weeks treatment. Results - After 15 days washout, the baseline supine arterial pressure, 168 + 2/109 + 1 mmHg decrease significantly-with diuretic to 151 + 1 / 101 + 1 mmHg and the drop wasfurther increased with captopril b.i.d., with a mean dose of 44 + 1 mg, to 137+ 1/90 + 1 mmHg. Blood pressure normalization was obtained in 58% patients with captopril b.i.d. and in 63% as single dose. Blood pressure normalization was achieved in 63% of non-white patients and in 56% patients over 45 years old. Plasmatic potassium decreased significantly with diuretic and did not recovered when captopril was associated. Conclusion - Our results indicate that the addition of low dose of captopril twice or once a day may result in a marked additional blood pressure reduction in cases of insuficient control by the diuretic alone

Efeitos anti-hipertensivo e metabólicos a longo prazo de dozes baixas de clortalidona em pacientes de dois grupos etários com hipertensäo leve e moderada / A long-term study of the antihypertensive and metabolic effects of low doses of chlorthalidone en two groups of age with mild and moderate hypertensives

Estudamos durante um ano os efeitos anti-hipertensivo e metabólicos de doses baixas de clortalidona (25mg/dia) em 30 pacientes portadores de hipertensao arterial leve e moderada. Quinze pacientes eram maiores de 60 anos (média das idades = 66,1 anos) e 15 pacientes eram menores de 60 anos (média das idades = 48,4 anos). Observamos reduçao persistente dos níveis pressóricos em ambos os grupos de pacientes (queda na pressao sistólica de 20 a 28mmHg e na pressao diastólica de 11 a 16 mmHg) e efeitos colaterais metabólicos menos intensos se comparados àqueles induzidos pelas doses habitualmente utilizadas de tiazídicos. Calculamos também a relaçao risco/benefício em relaçao às variáveis reduçao pressórica e aumento do colesterol. Concluimos que o uso de clortalidona em doses baixas é efetivo e seguro no tratamento da hipertensoo leve e moderada, especialmente nos pacientes mais idosos.