Predictive value of night-time heart rate for cardiovascular events in hypertension. The ABP-International study

Background - Data from prospective cohort studies regarding the association between ambulatory heart rate (HR) and cardiovascular events (CVE) are conflicting. Methods - To investigate whether ambulatory HR predicts CVE in hypertension, we performed 24-hour ambulatory blood pressure and HR monitoring in 7600 hypertensive patients aged 52 ± 16 years from Italy, U.S.A., Japan, and Australia, included in the ‘ABP-International’ registry. All were untreated at baseline examination. Standardized hazard ratios for ambulatory HRs were computed, stratifying for cohort, and adjusting for age, gender, blood pressure, smoking, diabetes, serum total cholesterol and serum creatinine. Results - During a median follow-up of 5.0 years there were 639 fatal and nonfatal CVE. In a multivariable Cox model, night-time HR predicted fatal combined with nonfatal CVE more closely than 24 h HR (p = 0.007 and = 0.03, respectively). Daytime HR and the night:day HR ratio were not associated with CVE (p = 0.07 and = 0.18, respectively). The hazard ratio of the fatal combined with nonfatal CVE for a 10-beats/min increment of the night-time HR was 1.13 (95% CI, 1.04–1.22). This relationship remained significant when subjects taking beta-blockers during the follow-up (hazard ratio, 1.15; 95% CI, 1.05–1.25) or subjects who had an event within 5 years after enrollment (hazard ratio, 1.23; 95% CI, 1.05–1.45) were excluded from analysis. Conclusions - At variance with previous data obtained from general populations, ambulatory HR added to the risk stratification for fatal combined with nonfatal CVE in the hypertensive patients from the ABP-International study. Night-time HR was a better predictor of CVE than daytime HR

Candesartan and hydrochlorothiazide in isolated systolic hypertension

Aim: We investigated the efficacy and safety of daily candesartan 8/16 mg and hydrochlorothiazide 12.5 mg as monotherapy and in combination in older patients with systolic hypertension. Methods: The study used a double-blind randomized placebo-controlle

Candesartan and hydrochlorothiazide in isolated systolic hypertension

Aim: We investigated the efficacy and safety of daily candesartan 8/16 mg and hydrochlorothiazide 12.5 mg as monotherapy and in combination in older patients with systolic hypertension. Methods: The study used a double-blind randomized placebo-controlled crossover design. Treatment phases were of 6 weeks duration. For inclusion, patients were aged 55-84 years with sitting systolic blood pressure (SBP) 160-210 mmHg and diastolic blood pressure (DBP) \u3c95 mmHg. Nineteen patients (11 male, eight female, median age 68 years) completed the study. Major findings: Compared with the placebo phase, clinic and ambulatory SBP was significantly reduced with both dose-adjusted candesartan and fixed-dose hydrochlorothiazide as monotherapy, the effect of candesartan being greater than that of hydrochlorothiazide. In combination, the effects of the two drugs were additive. Both drugs were well tolerated either as monotherapy or in combination. Conclusion: Both candesartan and a low dose of hydrochlorothiazide are effective and well-tolerated antihypertensive agents in isolated systolic hypertension with additive effects in combination. Candesartan was more effective than hydrochlorothiazide, although it is possible that dose adjustment only of candesartan could have enhanced its relative effectiveness

Candesartan and hydrochlorothiazide in isolated systolic hypertension

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Predictive performance of echocardiographic parameters for cardiovascular events among elderly treated hypertensive patients

BACKGROUND: Hypertension leads to cardiac structural and functional changes, commonly assessed by echocardiography. In this study, we assessed the predictive performance of different echocardiographic parameters including left ventricular hypertrophy (LVH) on future cardiovascular outcomes in elderly hypertensive patients without heart failure. METHODS: Data from LVH substudy of the Second Australian National Blood Pressure trial were used. Echocardiograms were performed at entry into the study. Cardiovascular outcomes were identified over short term (median 4.2 years) and long term (median 10.9 years). LVH was defined using threshold values of LV mass (LVM) indexed to either body surface area (BSA) or height2.7: >115/95g/m2 (LVH-BSA115/95) or ≥49/45g/m2.7 (LVH-ht49/45) in males/females, respectively, and ≥125g/m2 (LVH-BSA125) or ≥51g/m2.7 (LVH-ht51) for both sexes. RESULTS: In the 666 participants aged ≥65 years in this analysis, LVH prevalence at baseline was 33%–70% depending on definition; and after adjusting for potential risk factors, only LVH-BSA115/95 predicted both short- and long-term cardiovascular outcomes. Participants having LVH-BSA115/95 (69%) at baseline had twice the risk of having any first cardiovascular event over the short term (hazard ratio, 95% confidence interval: 2.00, 1.12–3.57, P = 0.02) and any fatal cardiovascular events (2.11, 1.21–3.68, P = 0.01) over the longer term. Among other echocardiographic parameters, LVM and LVM indexed to either BSA or height2.7 predicted cardiovascular events over both short and longer term. CONCLUSIONS: In elderly treated hypertensive patients without heart failure, determining LVH by echocardiography is highly dependent on the methodology adopted. LVH-BSA115/95 is a reliable predictor of future cardiovascular outcomes in the elderly

Country report: Australia

Introduction\ud The last 10 years has been an interesting time for Australian medical education despite reduced funding.\ud \ud Workforce\ud There are five main workforce trends: a rural/urban maldistribution, a need for more specialists, public hospital staffing difficulties, increasing female practitioners and under-representation of indigenous practitioners.\ud \ud Issues facing the Deans\ud Lack of resources is a problem facing Deans, with pressure for clinical service in teaching hospitals. Entrepreneurial activities have been undertaken including the enrolment of overseas students. Medical schools have also responded to important government initiatives.\ud \ud Developments in medical education\ud Australia's 11 medical schools have undergone significant reform in the last decade. There is a mix of four (graduate), five and six year courses.\ud \ud Australia's new medical school\ud James Cook University opened the first medical school in northern Australia in 2000. The School admits students from rural, northern Australian and indigenous backgrounds. It has a strong regional mission.\ud \ud Rural and community-based education\ud Government funding to address the maldistribution of the workforce has led to the establishment of rural clubs, Departments of Rural Health and community-based programs.\ud \ud The first two postgraduate years\ud There have been recent moves to improve education in the two years following graduation. This includes the initiation of national projects in curriculum and assessment.\ud \ud Postgraduate and continuing medical education\ud Postgraduate programs in Australia are being reformed to build on the changes in undergraduate education. CME is also under review.\ud \ud Conclusion\ud Australian medical educators should build on the recent reforms and take on some of the new directions in medical education