Fixed-dose Hypotensive Combination — differencesses and similarities. New Possibilities in the Choice of the First Line Hypertension Treatments

Obniżeia podwyższonego ciśnienia tętniczego metodami farmakologicznymi zmniejsza zdecydowanie chorobliwość i śmiertelność. Jednak systematyczne, przewlekłe leczenie nadciśnienia tętniczego i uzyskanie docelowych wartości ciśnienia jest trudnym zadaniem w praktyce lekarskiej. Kontrola nadciśnienia tętniczego w różnych krajach waha ię miedzy 6% a 27%. Większość leków stosowanych w monoterapii charakteryzuje się podobną skutecznością hipotensyjną sięgającą 50%. Inną metodą leczenia nadciśnienia w przeciwieństwie do monoterapii jest stosowanie kombinacji dwóch leków o różnym mechanizmie działania. Kombinacja trwałego połączenia małych dawek leków może być zastosowana do rozpoczęcia leczenia nadciśnienia tętniczego. Ostatni raport JNC VI, eksperci WHO/ISH oraz PTNT zalecają w tym celu stosowanie kombinacji małych dawek leków, szczególnie z niewielką dawką diuretyku. Korzyści ze stosowania kombinacji małych dawek leków, działających addytywnie lub synergistycznie z minimalizacją działąń niepożądanych, wynikają z możliwości ujawienia różnych mechanizmów obniżenia ciśnienia.Redusing blood pressure by pharmacological means clearsly reduces cardiovascular morbidity and mortality rate. However, keeping patiens on treatment and treating to a goal blood pressure are difficult in practice, and only 6% to 27% of hypertensive patients are controlled in different countries. The majority of antihypertensive drugs administered as monotherapy have similar overall efficacy close to 50%. An alternative strategy to monotherapy is therefore to prescribe two drugs with diffirent modes of action. Lowdose, fixed combination therapy can be used in place of monotherapy as initial hypertension treatment. The recent JNC VI Report, WHO/ISH and PTNT guidelines recommends the use of combination therapy, especially with low-dose diuretics in hypotensive therapy initation. The advantage of this approach is that low doses of drugs that act by different mechanisms may have additive or synergistic effects on blood pressure with minimal-dose-dependent adverse effects

J-curve - myth or reality?

Zasadniczym celem terapii hipotensyjnej u pacjentów z nadciśnieniem tętniczym jest redukcja ciśnienia tętniczego i zapobieganie powikłaniom układu sercowo-naczyniowego związanym z nadciśnieniem. Mimo znacznych postępów w terapii hipotensyjnej nadal w praktyce klinicznej trudne jest osiągnięcie celu terapeutycznego, a pacjenci z nadciśnieniem tętniczym stanowią grupę zwiększonego ryzyka zawału serca lub zgonu z przyczyn sercowo-naczyniowych. Słuszne więc wydawać się może twierdzenie, iż bardziej intensywna terapia hipotensyjna przyniesie więcej korzyści w tej grupie pacjentów. Z drugiej jednak strony istnieje teoria sugerująca, że nadmierne obniżenie ciśnienia tętniczego poniżej pewnego poziomu może zwiększyć ryzyko powikłań sercowo-naczyniowych, a zależność ta przyjmuje charakterystyczny kształt krzywej J. Dyskusja na temat istnienia krzywej J trwa już od około 25 lat i nadal wzbudza wiele wątpliwości, które zapoczątkowali swoimi pracami Stewart i Cruickshank w latach 70. i 80 XX wieku. Jednak mimo krytyki badań sugerujących możliwość szkodliwego działania nadmiernego obniżenia ciśnienia tętniczego podczas terapii hipotensyjnej, problem krzywej J pozostawał i nadal pozostaje nierozwiązany. Pod koniec lat 80. oraz w latach 90. przeprowadzono więc badania prospektywne, których celem było ostateczne wyjaśnienie teorii krzywej J i wskazanie, do jakich wartości należy obniżać ciśnienie tętnicze, aby uzyskać maksymalne korzyści z leczenia hipotensyjnego. Badaniem, które miało wyjaśnić ostatecznie problem istnienia krzywej J, było badanie HOT. Jednak jego autorom nie udało się uzyskać odpowiedzi dotyczącej tego problemu. Kolejnych argumentów potwierdzających istnienie krzywej J dostarczyła zwolennikom tej teorii analiza wyników badania INVEST, przedstawiona przez Franza Messerliego na tegorocznym kongresie ACC. Podsumowując wyniki wielu badań, a w szczególności wyniki ostatniej analizy badania INVEST, uzasadniony wydaje się wniosek, że nadmierne obniżanie DBP wśród pacjentów z nadciśnieniem tętniczym obciążonych chorobą wieńcową może zwiększyć ryzyko zawału serca.Fundamental purpose of therapy in hypertensive patients is reduction of blood pressure and prevention of cardiovascular morbidity and mortality associated with hypertension. Despite many achievements in hypotensive therapy hypertensive patients are still at increased risk of cardiovascular morbidity and mortality. Reasonable is affirmation that intensive therapy will bring more benefits in this group of patients. However there is J curve theory suggesting, that excessive drop of blood pressure, below certain level can increase cardiovascular risk, especially in hypertensive patients with coronary heart disease. Discussion about existence of J curve relationship has lasted for near 25 years, still raising many doubts, which have been initiated by Steward and Cruickshank publications. Despite numerous criticism of research suggesting harmful capability of excessive blood pressure reduction, J curve relationship still remains unsolved. Prospective studies in the late ‘80 and in ‘90 which were conducted to give final explanation of J curve theory and supply answers how far in clinical practice we should lower blood pressure to achieve maximal benefit of hypotensive thrapy. HOT study was the research everybody hoped will explain J curve problem. However, authors did not reach the answer concerning J curve relationship between blood pressure reduction and cardiovascular risk. Analysis of results of INVEST study has supplied apologists of this theory next arguments confirming J curve existence which were presented by Franz Messerli on this years Congress of American Society of Cardiology. So after analysis of many clinical trials especially INVEST study the conclusion that excessive blood pressure reduction among hypertensive patients with coronary heart disease may increase risk of myocardial infarction seems to be reasonable

Morning and afternoon serum cortisol level in patients with post-myocardial infarction depression

Background: Post-myocardial depression is a highly prevalent condition which worsens the course and prognosis of coronary artery disease. One possible pathogenetic factor is dysregulation of the hypothalamic-pituitary-adrenal axis, resulting in cortisol profile disturbances. Methods: Thirty seven patients hospitalized due to a first myocardial infarction (MI) were enrolled in this study. The Beck Depression Inventory (BDI) was used to rate the severity of their depressive symptoms. Morning and afternoon serum cortisol samples were taken on the fifth day of the MI. Results: Depression, defined as BDI ≥ 10, was present in 34.4% of the patients. A statistically significant difference was observed between the mean morning and the evening plasma concentrations in patients with depression compared to the no-depression group: F (1.29) = 5.0405, p = 0.0328. Conclusions: Patients with depressive symptoms directly after MI have a flattened diurnal serum cortisol profile. This is particularly expressed in patients with longer lasting symptoms

Exercise stress test and comparison of ST change with cardiac nucleotide catabolite production in patients with coronary artery disease

Background: Uridine (Ur) and hypoxanthine (Hx) are the major end products of ischemic nucleotide breakdown in the human heart. Hypoxanthine is further metabolized to uric acid (UA). The aim of the study was the evaluation of whether changes in nucleotide concentrations during exercise correlate with electrocardiography (ECG) changes, and the severity of coronary artery disease (CAD). Methods: Twenty-nine males with CAD and 11 controls without CAD (mean age 56.1 vs. 51.45) were subjected to treadmill exercise. The test was considered positive if ECG showed more then 1 mm ST segment depression. Venous blood samples taken before and 10 minut after the exercise were analysed by high performance liquid chromatography. Results: Twenty-two out of 29 patients with CAD and 6 of 11 in the control group had abnormal exercise stress tests according to ECG criteria only. Mean &#8710;Ur was positive in the CAD group and negative in the control group (0.45 SEM &#177; 0.09 &#181;M/L vs. -0.43 SEM &#177; 0.21 &#181;M/L, p < 0.0001). &#8710;UA was positive in the CAD group (15.31 SEM &#177; 5.52 &#181;M/L) and negative in the control group (15.31 SEM &#177; 5.52 &#181;M/L vs. -48.18 SEM &#177; 13,8 &#181;M/L, p < 0.00001); Hx increased in both groups, and the change was not significantly different. Correlations of CAD-index with ST depression, &#8710;Ur and &#8710;UA, were: r = 0.43 (p < 0.005), r = 0.62 (p < 0.001), and r = 0.39 (p < 0.01), respectively. Sensitivity of any increase of uridine was superior to 1.5 mm ST depression during exercise. Conclusions: Blood Ur and UA concentration changes during exercise correlate with severity of CAD. We observed slightly greater accuracy of uridine change in comparison to ST changes, thus being a possible new tool in diagnosis of CAD. (Cardiol J 2007; 14: 573-579)

Oral hygiene levels and oral cavity pro-health behaviours of patients with cardiovascular diseases

Introduction. Studies in the relationships between periodontal diseases and cardiovascular diseases are one of the main research areas in contemporary periodontology. The data published in recent years indicate periodontitis as one of the potential risk factors for coronary heart disease (CHD) and myocardial infarction (MI). Thus the population with cardiovascular diseases is recommended as a target for dental prophylaxis and pro-health educational programmes. Aim of the study. The aim of this study was the assessment of oral hygiene levels and dental pro-health behaviours among patients with CHD and MI. Material and methods. The study encompassed 86 individuals with MI (group 1), and 84 persons with stable CHD (group 2). The control group comprised 50 persons without cardiovascular diseases. Clinical examinations of oral hygiene level using API, gingivitis level using mSBI, and an individual questionnaire regarding dental pro-health behaviours and oral hygiene maintenance methods were performed. Results. Low oral hygiene levels were observed in the examined groups (mean API value: 68.72%, 68.44%, and 60% respectively). Data from the questionnaires revealed a lack of proper periodontal prophylaxis. Gum bleeding was not considered as a pathological symptom, about 60% of patients never participated in oral hygiene training, and the frequency of dental control check-ups and professional hygiene procedures was too low. Only a few percent of patients cleaned interdental spaces. Conclusions. The results obtained indicate a low level of dental pro-health behaviours and could support recommendations regarding the necessity of educational, prophylactic and treatment programmes for patients with CHD / MI – performed by dentists / periodontologists and cardiologists togethe

The Polish MacNew heart disease heath-related quality of life questionnaire: A validation study

Background: The MacNew health-related quality of life questionnaire was designed to assess feelings about how heart disease affects their daily physical, emotional and social functioning in patients with 1 of the 3 major coronary artery diagnoses, stable coronary artery disease (CAD) with angina, ST-elevation myocardial infarction (STEMI), and ischemic heart failure (HF). The aim of this study was to determine the reliability and validity of the Polish version of the MacNew in patients with CAD. Methods: Patients with CAD completed a self-report sociodemographic and clinical ques­tionnaire: the MacNew, the Short-Form 36 Health Survey, and HADS at baseline; 10% of the patients completed each questionnaire 2 weeks later. Results: We studied patients with stable CAD with angina (n = 115), with STEMI (n = 112), and with ischemic HF (n = 105). Internal consistency reliability was demonstrated with Cronbach’s a from 0.86 to 0.95 for the MacNew global scale and subscales. The original 3-factor structure was confirmed for the Polish version of the MacNew explaining 53.5% of the variance. Convergent validity of similar MacNew and SF-36 subscales was confirmed in the total group and in each diagnosis. Discriminant validity with the SF-36 health transition was fully confirmed in the total group and in patients with HF and partially confirmed in patients with stable CAD with angina or myocardial infarction. Conclusions: The Polish MacNew health-related quality of life questionnaire can be recommended in patients with stable CAD with angina, myocardial infarction and HF