Antihypertensive Efficacy and Safety of Lacidipine in the Treatment of Patients with Mild to Moderate Essential Hypertension - Multi-Center Study POL-LACY

Wstęp Lacydypina jest długodziałającym antagonistą wapnia z grupy pochodnych dihydropirydynowych i charakteryzuje się łagodnym początkiem działania hipotensyjnego i trwającym 24 h efektem hipotensyjnym. W badaniach z użyciem tego leku potwierdzono jej skuteczność hipotensyjną, a także korzystny wpływ na układ sercowo-naczyniowy. Celem wieloośrodkowego badania POL-LACY była ocena skuteczności hipotensyjnej oraz tolerancji lacydypiny podawanej raz dziennie w zakresie dawek 2&#8211;6 mg chorym z łagodnym i umiarkowanym nadciśnieniem tętniczym pierwotnym. Materiał i metody Otwarte badanie o charakterze otwartym przeprowadzono w 37 ośrodkach w Polsce, włączając do niego 470 chorych z łagodnym i umiarkowanym nadciśnieniem tętniczym pierwotnym. Badanie składało się z dwóch faz. W trakcie 7-dniowego okresu kwalifikacyjnego u chorych odstawiano stosowane wcześniej leki hipotensyjne oraz wykonywano badania laboratoryjne. W trakcie 8-tygodniowego okresu aktywnego leczenia chorzy otrzymywali lacydypinę w początkowej dawce dobowej 4 mg lub 2 mg u chorych powyżej 65 rż. pacjenci podawanej raz dziennie z możliwością zwiększenia dawki do 6 lub 4 mg na dobę u osób, u których nie uzyskano normalizacji ciśnienia po 4 tygodniach leczenia. Normalizację ciśnienia definiowano jako skurczowe ciśnienie tętnicze (SBP) o wartości < 140 mm Hg i rozkurczowe ciśnienie tętnicze (DBP) wynoszące < 90 mm Hg. W czasie leczenia chorzy odbyli 2 wizyty kontrolne, po 4 i po 8 tygodniach, w trakcie których dokonywano oceny osiągniętego efektu hipotensyjnego oraz tolerancji leczenia. Wyniki Badanie ukończyło 446 chorych (255 M, 191 K; średnia wieku 52 &plusmn; 13 lat). Pod koniec badania 9,9% chorych leczono dawką 2 mg, 72,9% chorych - dawką 4 mg, a 17,3% chorych - dawką 6 mg lacydypiny. Po 8 tygodniach leczenia tym preparatem w badanej grupie uzyskano znamienne obniżenie SBP o 23 mm Hg (p < 0,0001) i DBP o 15 mm Hg (p < 0,0001) w pozycji siedzącej. Uzyskany efekty hipotensyjny nie zależał od płci, wieku i wskaźnika masy ciała (BMI). Pełną normalizację wartości ciśnienia uzyskano u 71% chorych. W czasie badania stwierdzono istotne obniżenie średnich wartości ciśnienia tętna o 8 mm Hg (p < 0,0001). Lacydypina była dobrze tolerowana przez chorych, działania niepożądane wystąpiły u 21% z nich. Wnioski Lacydypina (Lacipil) stosowana w monoterapii charakteryzuje się wysoką skutecznością hipotensyjną u chorych z łagodnym i umiarkowanym nadciśnieniem tętniczym pierwotnym. Efekt hipotensyjny nie zależy od wieku i płci pacjentów. Preparat cechuje korzystny wpływ na wartości ciśnienia tętna uważanego za niezależny czynnik ryzyka powikłań sercowo-naczyniowych. Uzyskane wyniki wskazują na dobrą tolerancję leku przez chorych z nadciśnieniem tętniczym. Badanie wskazuje na przydatność leku w monoterapii nadciśnienia tętniczego.Background Lacidipine is an orally administered calcium channel blocker of the dihydropyridine class, which shows selectivity for vascular smooth muscle and has a long duration of action. The aim of multi-center study POL-LACY was to establish antihypertensive effect and safety of lacidipine given once a day 2 to 6 mg in patient with mild to moderate hypertension. Material and methods The study was an open, multi-centre study in 37 Polish medical centers. 470 patients with mild to moderate hypertension were included into the study. 7 days qualification period was followed by 8 weeks of active treatment. During qualification period antihypertensive treatment was withdrawn and patients underwent clinical evaluation. In the phase of active treatment patients were treated with lacidipine (Lacipil&reg;, GlaxoSmithKline Pharmaceuticals) starting from dose of 4 mg or 2 mg in patients older than 65 years. The dose could be tritated up to 6 or 4 mg if there was no normalization of BP level after 4 weeks of treatment. Normalization of BP was defined as systolic BP < 140 mm Hg and diastolic BP < 90 mm Hg. During phase of active treatment, after 4 and 8 weeks, efficacy and safety of treatment was evaluated. Results 446 patients completed the study (255 M, 191 F; mean age 52 &plusmn; 13 years). The mean baseline BP value was 157/98 mm Hg. At the end of the study 9,9% of patients were treated with 2 mg, 72,9% of patients with 4 mg and 17,3% of patients with 6 mg of lacidipine. After 8 weeks lacidipine decreased significantly systolic BP by 23 mm Hg (p < 0,0001) and diastolic BP by 15 mm Hg (p < 0,0001) in the sitting position. Antihypertensive effect of lacidipine was not influenced by sex, age and BMI. Full normalization of BP was achieved in 71% of patients. Pulse pressure was significantly reduced by 8 mm Hg (p < 0,0001). Lacidipine was well tolerated, 21% of patients experienced adverse events. Conclusions Lacidipine is a highly effective drug in the monotherapy of mild to moderate essential hypertension. Antihypertensive effect of lacidipine is not influenced by age, sex and BMI. Lacidipine has a positive effect on pulse pressure. Lacidipine is well tolerated by patients. In conclusion, presented data point at the lacidipine as a useful drug in monotherapy of essential hypertension

Use of Steroid Profiling Combined With Machine Learning for Identification and Subtype Classification in Primary Aldosteronism

Importance: Most patients with primary aldosteronism, a major cause of secondary hypertension, are not identified or appropriately treated because of difficulties in diagnosis and subtype classification. Applications of artificial intelligence combined with mass spectrometry–based steroid profiling could address this problem. Objective: To assess whether plasma steroid profiling combined with machine learning might facilitate diagnosis and treatment stratification of primary aldosteronism, particularly for patients with unilateral adenomas due to pathogenic KCNJ5 sequence variants. Design, Setting, and Participants: This diagnostic study was conducted at multiple tertiary care referral centers. Steroid profiles were measured from June 2013 to March 2017 in 462 patients tested for primary aldosteronism and 201 patients with hypertension. Data analyses were performed from September 2018 to August 2019. Main Outcomes and Measures: The aldosterone to renin ratio and saline infusion tests were used to diagnose primary aldosteronism. Subtyping was done by adrenal venous sampling and follow-up of patients who underwent adrenalectomy. Statistical tests and machine-learning algorithms were applied to plasma steroid profiles. Areas under receiver operating characteristic curves, sensitivity, specificity, and other diagnostic performance measures were calculated. Results: Primary aldosteronism was confirmed in 273 patients (165 men [60%]; mean [SD] age, 51 [10] years), including 134 with bilateral disease and 139 with unilateral adenomas (58 with and 81 without somatic KCNJ5 sequence variants). Plasma steroid profiles varied according to disease subtype and were particularly distinctive in patients with adenomas due to KCNJ5 variants, who showed better rates of biochemical cure after adrenalectomy than other patients. Among patients tested for primary aldosteronism, a selection of 8 steroids in combination with the aldosterone to renin ratio showed improved effectiveness for diagnosis over either strategy alone. In contrast, the steroid profile alone showed superior performance over the aldosterone to renin ratio for identifying unilateral disease, particularly adenomas due to KCNJ5 variants. Among 632 patients included in the analysis, machine learning–designed combinatorial marker profiles of 7 steroids alone both predicted primary aldosteronism in 1 step and subtyped patients with unilateral adenomas due to KCNJ5 variants at diagnostic sensitivities of 69% (95% CI, 68%-71%) and 85% (95% CI, 81%-88%), respectively, and at specificities of 94% (95% CI, 93%-94%) and 97% (95% CI, 97%-98%), respectively. The validation series yielded comparable diagnostic performance. Conclusions and Relevance: Machine learning–designed combinatorial plasma steroid profiles may facilitate both screening for primary aldosteronism and identification of patients with unilateral adenomas due to pathogenic KCNJ5 variants, who are most likely to show benefit from surgical intervention

Pheochromocytoma and paraganglioma: Clinical feature based disease probability in relation to catecholamine biochemistry and reason for disease suspicion

OBJECTIVE Hypertension and symptoms of catecholamine excess are features of pheochromocytomas and paragangliomas (PPGLs). This prospective observational cohort study assessed whether differences in presenting features in patients tested for PPGLs might assist establishing likelihood of disease. DESIGN AND METHODS Patients were tested for PPGLs because of signs and symptoms, an incidental mass on imaging or routine surveillance due to previous history or hereditary risk. Patients with (n=245) compared to without (n=1820) PPGLs were identified on follow-up. Differences in presenting features were then examined to assess probability of disease and relationships to catecholamine excess. RESULTS Hyperhidrosis, palpitations, pallor, tremor and nausea were 30-90% more prevalent (P<0.001) among patients with than without PPGLs, whereas headache, flushing and other symptoms showed little or no differences. Although heart rates were higher (P<0.0001) in patients with than without PPGLs, blood pressures were not higher and were positively correlated to body mass index (BMI), which was lower (P<0.0001) in patients with than without PPGLs. From these differences in clinical features, a score system was established that indicated a 5.8-fold higher probability of PPGLs in patients with high than low scores. Higher scores among patients with PPGLs were associated, independently of tumor size, with higher biochemical indices of catecholamine excess. CONCLUSIONS This study identifies a complex of five signs and symptoms combined with lower BMI and elevated heart rate as key features in patients with PPGLs. Prevalences of these features, which reflect variable tumoral catecholamine production, may be used to triage patients according to likelihood of disease

Determinants of disease-specific survival in patients with and without metastatic pheochromocytoma and paraganglioma

BACKGROUND: Pheochromocytomas and paragangliomas (PPGLs) have a heterogeneous prognosis, the basis of which remains unclear. We, therefore, assessed disease-specific survival (DSS) and potential predictors of progressive disease in patients with PPGLs and head/neck paragangliomas (HNPGLs) according to the presence or absence of metastases. METHODS: This retrospective study included 582 patients with PPGLs and 57 with HNPGLs. DSS was assessed according to age, location and size of tumours, recurrent/metastatic disease, genetics, plasma metanephrines and methoxytyramine. RESULTS: Among all patients with PPGLs, multivariable analysis indicated that apart from older age (HR = 5.4, CI = 2.93-10.29, P < 0.0001) and presence of metastases (HR = 4.8, CI = 2.41-9.94, P < 0.0001), shorter DSS was also associated with extra-adrenal tumour location (HR = 2.6, CI = 1.32-5.23, P = 0.0007) and higher plasma methoxytyramine (HR = 1.8, CI = 1.11-2.85, P = 0.0170) and normetanephrine (HR = 1.8, CI = 1.12-2.91, P = 0.0160). Among patients with HNPGLs, those with metastases presented with longer DSS compared to patients with metastatic PPGLs (33.4 versus 20.2 years, P < 0.0001) and only plasma methoxytyramine (HR = 13, CI = 1.35-148, P = 0.0380) was an independent predictor of DSS. For patients with metastatic PPGLs, multivariable analysis revealed that apart from older age (HR = 6.2, CI = 3.20-12.20, P < 0.0001), shorter DSS was associated with the presence of synchronous metastases (HR = 4.9, CI = 2.78-8.80, P < 0.0001), higher plasma methoxytyramine (HR = 2.4, CI = 1.44-4.14, P = 0.0010) and extensive metastatic burden (HR = 2.1, CI = 1.07-3.79, P = 0.0290). CONCLUSIONS: DSS among patients with PPGLs/HNPGLs relates to several presentations of the disease that may provide prognostic markers. In particular, the independent associations of higher methoxytyramine with shorter DSS in patients with HNPGLs and metastatic PPGLs suggest the utility of this biomarker to guide individualized management and follow-up strategies in affected patients

Prediction of metastatic pheochromocytoma and paraganglioma: a machine learning modelling study using data from a cross-sectional cohort

BACKGROUND Pheochromocytomas and paragangliomas have up to a 20% rate of metastatic disease that cannot be reliably predicted. This study prospectively assessed whether the dopamine metabolite, methoxytyramine, might predict metastatic disease, whether predictions might be improved using machine learning models that incorporate other features, and how machine learning-based predictions compare with predictions made by specialists in the field. METHODS In this machine learning modelling study, we used cross-sectional cohort data from the PMT trial, based in Germany, Poland, and the Netherlands, to prospectively examine the utility of methoxytyramine to predict metastatic disease in 267 patients with pheochromocytoma or paraganglioma and positive biochemical test results at initial screening. Another retrospective dataset of 493 patients with these tumors enrolled under clinical protocols at National Institutes of Health (00-CH-0093) and the Netherlands (PRESCRIPT trial) was used to train and validate machine learning models according to selections of additional features. The best performing machine learning models were then externally validated using data for all patients in the PMT trial. For comparison, 12 specialists provided predictions of metastatic disease using data from the training and external validation datasets. FINDINGS Prospective predictions indicated that plasma methoxytyramine could identify metastatic disease at sensitivities of 52% and specificities of 85%. The best performing machine learning model was based on an ensemble tree classifier algorithm that used nine features: plasma methoxytyramine, metanephrine, normetanephrine, age, sex, previous history of pheochromocytoma or paraganglioma, location and size of primary tumours, and presence of multifocal disease. This model had an area under the receiver operating characteristic curve of 0·942 (95% CI 0·894-0·969) that was larger (p<0·0001) than that of the best performing specialist before (0·815, 0·778-0·853) and after (0·812, 0·781-0·854) provision of SDHB variant data. Sensitivity for prediction of metastatic disease in the external validation cohort reached 83% at a specificity of 92%. INTERPRETATION Although methoxytyramine has some utility for prediction of metastatic pheochromocytomas and paragangliomas, sensitivity is limited. Predictive value is considerably enhanced with machine learning models that incorporate our nine recommended features. Our final model provides a preoperative approach to predict metastases in patients with pheochromocytomas and paragangliomas, and thereby guide individualised patient management and follow-up. FUNDING Deutsche Forschungsgemeinschaft

Felodipine-metoprolol combination tablet: maintained health-related quality of life in the presence of substantial blood pressure reduction.

BACKGROUND: Most treated hypertensive patients do not achieve adequate blood pressure (BP) control. Initiating therapy with two drugs has been suggested when BP is &amp;gt;20/10 mm Hg above goal. To ensure patients' compliance, such treatment needs to be well tolerated and must not compromise health-related quality of life (HRQL). The primary objective of this study was to compare the effects on HRQL of initiating treatment with felodipine + metoprolol (F+M) fixed combination tablets, or enalapril (E), or placebo (P). METHODS: A total of 947 patients of both sexes with primary hypertension (diastolic BP 95 to 110 mm Hg), aged 20 to 70 years, participated in this randomized, double-blind, parallel group, 12-week, multicenter trial. Treatment was initiated with F+M 5 + 50 mg, or E 10 mg, or P. Doses were doubled after 4 or 8 weeks if diastolic BP was &amp;gt;90 mm Hg. The HRQL was measured at baseline and at the last visit using two validated questionnaires: the Psychological General Well-being Index (PGWB) and the Subjective Symptom Assessment Profile (SSA-P). Office BP was measured at trough, that is, 24 h after the previous dose. RESULTS: The HRQL was high at baseline and generally well maintained during the study. For example, the mean (SD) PGWB total score was 104 (16) at baseline and 105 (16) at 12 weeks in all three treatment groups. The BP reductions after F+M (18/14 mm Hg) and E (12/9 mm Hg) were significantly greater than after P (7/7 mm Hg), and the reduction after F+M was significantly greater than after E. CONCLUSIONS: The HRQL is maintained in the presence of substantial BP reduction during antihypertensive treatment with F+M fixed combination tablets

Prediction of metastatic pheochromocytoma and paraganglioma:a machine learning modelling study using data from a cross-sectional cohort

BACKGROUND: Pheochromocytomas and paragangliomas have up to a 20% rate of metastatic disease that cannot be reliably predicted. This study prospectively assessed whether the dopamine metabolite, methoxytyramine, might predict metastatic disease, whether predictions might be improved using machine learning models that incorporate other features, and how machine learning-based predictions compare with predictions made by specialists in the field.METHODS: In this machine learning modelling study, we used cross-sectional cohort data from the PMT trial, based in Germany, Poland, and the Netherlands, to prospectively examine the utility of methoxytyramine to predict metastatic disease in 267 patients with pheochromocytoma or paraganglioma and positive biochemical test results at initial screening. Another retrospective dataset of 493 patients with these tumors enrolled under clinical protocols at National Institutes of Health (00-CH-0093) and the Netherlands (PRESCRIPT trial) was used to train and validate machine learning models according to selections of additional features. The best performing machine learning models were then externally validated using data for all patients in the PMT trial. For comparison, 12 specialists provided predictions of metastatic disease using data from the training and external validation datasets.FINDINGS: Prospective predictions indicated that plasma methoxytyramine could identify metastatic disease at sensitivities of 52% and specificities of 85%. The best performing machine learning model was based on an ensemble tree classifier algorithm that used nine features: plasma methoxytyramine, metanephrine, normetanephrine, age, sex, previous history of pheochromocytoma or paraganglioma, location and size of primary tumours, and presence of multifocal disease. This model had an area under the receiver operating characteristic curve of 0·942 (95% CI 0·894-0·969) that was larger (p&lt;0·0001) than that of the best performing specialist before (0·815, 0·778-0·853) and after (0·812, 0·781-0·854) provision of SDHB variant data. Sensitivity for prediction of metastatic disease in the external validation cohort reached 83% at a specificity of 92%.INTERPRETATION: Although methoxytyramine has some utility for prediction of metastatic pheochromocytomas and paragangliomas, sensitivity is limited. Predictive value is considerably enhanced with machine learning models that incorporate our nine recommended features. Our final model provides a preoperative approach to predict metastases in patients with pheochromocytomas and paragangliomas, and thereby guide individualised patient management and follow-up.FUNDING: Deutsche Forschungsgemeinschaft.</p