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Showing papers by "Henry R. Black published in 1997"


Journal ArticleDOI
16 Jul 1997-JAMA
TL;DR: In older persons with isolated systolic hypertension, stepped-care treatment based on low-dose chlorthalidone exerted a strong protective effect in preventing heart failure, and among patients with prior MI, an 80% risk reduction was observed.
Abstract: Context. —Heart failure is often preceded by isolated systolic hypertension, but the effectiveness of antihypertensive treatment in preventing heart failure is not known. Objective. —To assess the effect of diuretic-based antihypertensive stepped-care treatment on the occurrence of heart failure in older persons with isolated systolic hypertension. Design. —Analysis of data from a multicenter, randomized, double-blind, placebo-controlled clinical trial. Participants. —A total of 4736 persons aged 60 years and older with systolic blood pressure between 160 and 219 mm Hg and diastolic blood pressure below 90 mm Hg who participated in the Systolic Hypertension in the Elderly Program (SHEP). Intervention. —Stepped-care antihypertensive drug therapy, in which the step 1 drug is chlorthalidone (12.5-25 mg) or matching placebo, and the step 2 drug is atenolol (25-50 mg) or matching placebo. Main Outcome Measures. —Fatal and nonfatal heart failure. Results. —During an average of 4.5 years of follow-up, fatal or nonfatal heart failure occurred in 55 of 2365 patients randomized to active therapy and 105 of the 2371 patients randomized to placebo (relative risk [RR], 0.51; 95% confidence interval [CI], 0.37-0.71;P Conclusion. —In older persons with isolated systolic hypertension, stepped-care treatment based on low-dose chlorthalidone exerted a strong protective effect in preventing heart failure. Among patients with prior MI, an 80% risk reduction was observed.

659 citations


Journal ArticleDOI
TL;DR: Low-dose diuretic-based (chlorthalidone) treatment is effective in preventing major CVD events, cerebral and cardiac, in both non-insulin-treated diabetic and nondiabetic older patients with ISH, with few adverse effects.
Abstract: OBJECTIVE To assess the effect of low-dose, diuretic-based antihypertensive treatment on major cardiovascular disease (CVD) event rates in older, non-insulin-treated diabetic patients with isolated systolic hypertension (ISH), compared with nondiabetic patients. DESIGN Double-blind, randomized, placebo-controlled trial: the Systolic Hypertension in the Elderly Program (SHEP). SETTING Multiple clinical and support centers in the United States. PARTICIPANTS A total of 4736 men and women aged 60 years and older at baseline with ISH (systolic blood pressure [BP], > or = 160 mm Hg; diastolic BP, <90 mm Hg) at baseline, 583 non-insulin-dependent diabetic patients and 4149 nondiabetic patients (4 additional patients not so classifiable were randomized but not included in these analyses). Diabetes mellitus defined as physician diagnosis, taking oral hypoglycemic drugs, fasting glucose level of 7.8 mmol/L or more (> or = 140 mg/dL), or any combination of these characteristics. INTERVENTION The active treatment group received a low dose of chlorthalidone (12.5-25.0 mg/d) with a step-up to atenolol (25.0-50.0 mg/d) or reserpine (0.05-0.10 mg/d) if needed. The placebo group received placebo and any active antihypertensive drugs prescribed by patient's private physician for persistently high BP. MAIN OUTCOME MEASURES The 5-year rates of major CVD events, nonfatal plus fatal stroke, nonfatal myocardial infarction (MI) and fatal coronary heart disease (CHD), major CHD events, and all-cause mortality. RESULTS The SHEP antihypertensive drug regimen lowered BP of both diabetic and nondiabetic patients, with few adverse effects. For both diabetic and nondiabetic patients, all outcome rates were lower for participants randomized to the active treatment group than for those randomized to the placebo group. Thus, 5-year major CVD rate was lower by 34% for active treatment compared with placebo, both for diabetic patients (95% confidence interval [CI], 6%-54%) and nondiabetic patients (95% CI, 21%-45%). Absolute risk reduction with active treatment compared with placebo was twice as great for diabetic vs nondiabetic patients (101/1000 vs 51/1000 randomized participants at the 5-year follow-up), reflecting the higher risk of diabetic patients. CONCLUSION Low-dose diuretic-based (chlorthalidone) treatment is effective in preventing major CVD events, cerebral and cardiac, in both non-insulin-treated diabetic and nondiabetic older patients with ISH.

179 citations


Journal ArticleDOI
TL;DR: Valsartan provides a new antihypertensive agent with comparable efficacy to lisinopril and appears to be associated with a reduced incidence of cough.
Abstract: Objective: To compare the efficacy, safety and tolerability of valsartan to an angiotensin-converting enzyme (ACE) inhibitor, lisinopril, and placebo in patients with mild-to-moderate essential hypertension.Design: A total of 734 men and women were randomised in this multicentre, double-blind, optional titration, parallel group trial. Volunteers received valsartan 80 mg (n = 364), lisinopril 10 mg (n = 187) or placebo (n = 183) daily for 4 weeks, with subsequent titration of dose depending on response to treatment (valsartan 80 mg titrated to valsartan 160 mg once daily or valsartan 80 mg twice daily, lisinopril 10 mg titrated to lisonopril 20 mg once daily). Patients were assessed at 4, 8 and 12 weeks.Main outcome measures: The primary variable was change from baseline in mean sitting diastolic blood pressure (SDBP). Other efficacy variables included sitting systolic blood pressure (SSBP) and percentage of ‘successful’ responders (SDBP <90 mm hg or ⩾10 mm hg reduction from baseline).Results: All active treatment groups were shown to demonstrate significant reductions in SDBP compared to placebo at endpoint of therapy (least mean square reduction from baseline: valsartan 80/160 mg: −5.25 mm Hg (CI −7.17, −3.34, P < 0.001); valsartan 80/80 mg twice daily: −5.63 mm hg (ci −7.51,−3.75, P < 0.001); lisinopril 10/20 mg: −6.93 mm hg, (ci −8.81, −5.05, P < 0.001). there were no statistically significant differences between the active treatment groups at endpoint of therapy. in patients requiring titration to a higher dose (placebo n = 142, valsartan 80/80 twice daily n = 124, valsartan 80/160 n = 114, lisinopril 10/20 n = 120), there were no significant treatment differences between valsartan 160 mg given as a single daily dose or as 80 mg twice daily (P = 0.658). Both valsartan and lisinopril produced similarly high percentages of ‘successful’ responders at endpoint of therapy. A somewhat higher frequency of drug related cough was observed in lisinopril treated patients (8%) compared to valsartan (1.1%) or placebo (0.5%).Conclusions: Valsartan 80 mg daily, with titration to 160 mg daily as required, provides similar antihypertensive efficacy to lisinopril 10 mg daily with titration to 20 mg daily. Valsartan provides a new antihypertensive agent with comparable efficacy to lisinopril and appears to be associated with a reduced incidence of cough.

124 citations


Journal Article
TL;DR: The handbook covers many aspects of cardiovascular disease in the elderly and focuses on common problems, including heart failure, atrial fibrillation and isolated systolic hypertension.
Abstract: It reflects current UK and international guidelines and provides key evidence based references. Wherever possible, published guidelines are incorporated to ensure the book reflects current recommended management. It indicates where practice differs from that of younger adults, and provides guidance on the ethical and clinical dilemmas particular to the elderly. The handbook covers many aspects of cardiovascular disease in the elderly and focuses on common problems, including heart failure, atrial fibrillation and isolated systolic hypertension.

7 citations


Journal ArticleDOI
TL;DR: Two novel systems of classifying hypertension have recently been proposed, incorporating most of the desirable attributes of the simpler (and widely used) methods of “staging” blood pressure, but adding a subscript to indicate the presence or absence of complications or other risk factors present in a given patient.
Abstract: Classification schemes for hypertension are helpful in defining the condition, quantitating risk, estimating prognosis, and guiding management. Most "classic" systems classify hypertension based on the blood pressure level, according to "relative risk" (the proportional likelihood of cardiovascular events occurring as blood pressure--either systolic, diastolic, or both--rises). Several recent systems are based on "absolute risk," and quantify the risk for adverse events related to other cardiovascular risk factors besides hypertension. Classification schemes based on the pattern of blood pressure elevation, extent of damage to target organs from hypertension, and laboratory evaluations have also been suggested, but are, of necessity, more complicated than systems based simply on the blood pressure readings. Two novel systems of classifying hypertension have recently been proposed, incorporating most of the desirable attributes of the simpler (and widely used) methods of "staging" blood pressure, but adding a subscript to indicate the presence ("c") or absence ("u") of complications or other risk factors present in a given patient. This system also uses a subscript "e" to indicate the presence of a widened pulse pressure (more common in the elderly); such patients are more likely to benefit from hypertension treatment. A complete medical history and physical examination and a few inexpensive laboratory tests provide essentially all the information needed to classify an individual as "complicated" or "uncomplicated." This system also provides a guide to treatment, because drug therapy should be used sooner in those with complicated hypertension. Implementation of this system is likely to be enhanced if compensation for health care providers were higher when treating the higher stages of hypertension, especially an elderly patient with complicated hypertension, compared with a younger person with uncomplicated hypertension.

6 citations


Journal Article
TL;DR: In this article, the benefit from treatment of either systolic or diastolic hypertension in this group is much greater than in younger hypertensives, and a clear benefit from treating elevated blood pressure has been demonstrated by several clinical trials.
Abstract: Cardiovascular disease is still the most common cause of morbidity and mortality in the elderly and hypertension is a significant risk factor for CVD such as stroke, myocardial infarction, and chronic renal disease. Fortunately, hypertension is readily treatable. A clear benefit from treating elevated blood pressure has been demonstrated by several clinical trials. In fact, benefit from treatment of either systolic or diastolic hypertension in this group is much greater than in younger hypertensives. Understanding physiologic and socioeconomic changes with age is an essential part of treatment and will allow for individualized treatment suitable for the elderly. Life-syle modification is a good starting point to control high blood pressure but should not be enforced unrealistically in this group. Once pharmacologic therapy is decided upon it should be started with a lower dose than usual and should be slowly titrated. Monotherapies and combination therapies are available for treatment of hypertension. All clinicians who take care of the geriatric population should be aware of the benefit of antihypertensive therapy since this is one of the most rewarding aspects of preventive medicine.

3 citations