RESUMEN
Type 2 diabetes mellitus is a worldwide epidemic with considerable health and economic consequences. Diabetes is an important risk factor for cardiovascular disease, which is the leading cause of death in diabetic patients, and decreasing the incidence of diabetes may potentially reduce the burden of cardiovascular disease. This article discusses the clinical trial evidence for modalities associated with a reduction in the risk of new-onset diabetes, with a focus on the role of antihypertensive agents that block the renin-angiotensin system. Lifestyle interventions and the use of antidiabetic, anti-obesity, and lipid-lowering drugs are also reviewed. An unresolved question is whether decreasing the incidence of new-onset diabetes with non-pharmacologic or pharmacologic intervention will also lower the risk of cardiovascular disease. A large ongoing study is investigating whether the treatment with an oral antidiabetic drug or an angiotensin-receptor blocker will reduce the incidence of new-onset diabetes and cardiovascular disease in patients at high risk for developing diabetes.
Asunto(s)
Antihipertensivos/uso terapéutico , Enfermedades Cardiovasculares/prevención & control , Diabetes Mellitus Tipo 2/terapia , Estilo de Vida , Obesidad/terapia , Antagonistas de Receptores de Angiotensina , Ensayos Clínicos como Asunto , Diabetes Mellitus Tipo 2/complicaciones , Humanos , Obesidad/complicaciones , Sistema Renina-Angiotensina/efectos de los fármacos , Factores de Riesgo , Resultado del TratamientoRESUMEN
Desirable features of antihypertensive agents include efficacy, tolerability, prolonged duration of action and rapid achievement of target blood pressure (BP). Recent studies have examined the relationship between the onset of antihypertensive effect and cardiovascular events. Data from the Valsartan Antihypertensive Long-term Use Evaluation (VALUE), the Study on Cognition and Prognosis in the Elderly (SCOPE), and the Systolic Hypertension in Europe (Syst-Eur) trials support the hypothesis that the time it takes to reach target BP influences cardiovascular outcomes. VALUE, which compared BP-lowering and clinical event rates between patients treated with the angiotensin II receptor blocker (ARB) valsartan or the calcium channel blocker (CCB) amlodipine as well as between those who achieved immediate or delayed BP control, provides the strongest evidence of this to date. Additional data from SCOPE and Syst-Eur suggest that delays of 3 months to 2 years in starting antihypertensive therapy can increase the risk of certain cardiovascular end points, especially stroke. These data suggest that it may be beneficial to examine the efficacy of antihypertensive agents, not only long term, but also at earlier times to assess the onset and impact of early antihypertensive effect. The ARB olmesartan medoxomil (olmesartan) and the CCB amlodipine were compared in a randomized, double-blind, placebo-controlled clinical trial, which demonstrated that the onset of antihypertensive effect of olmesartan is comparable with that of amlodipine. Another study demonstrated that more patients treated with olmesartan achieved target BPs within 2 weeks of treatment compared with the ARBs losartan, valsartan and irbesartan.
Asunto(s)
Bloqueadores del Receptor Tipo 1 de Angiotensina II/uso terapéutico , Antihipertensivos/uso terapéutico , Hipertensión/tratamiento farmacológico , Antihipertensivos/administración & dosificación , Bloqueadores de los Canales de Calcio/administración & dosificación , Bloqueadores de los Canales de Calcio/uso terapéutico , Humanos , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Recent clinical trials indicate that treatment with lipid modifying therapy improves outcomes in patients with ischemic heart disease (IHD) and low levels of high density lipoprotein (HDL) cholesterol. The results of these trials, however, have not been widely implemented in clinical practice. OBJECTIVES: To develop and test an intervention designed to increase the rate of prescription of lipid modifying therapy and to determine the relative effectiveness of three different prompts (progress notes, patient letters, or computer chart reminders). METHODS: The study was conducted in 11 US Department of Veterans Affairs Medical Centers. The effect of the intervention on the proportion of eligible patients receiving lipid modifying therapy was compared between five intervention sites and six matched control sites using a controlled before and after study design. Additionally, 92 providers within the intervention clinics were randomized to receive one of the three prompts. Data were analyzed using logistic regression modeling which incorporated terms to account for the clustered nature of the data. RESULTS: At the intervention sites the prescription rate increased from 8.3% during the pre-intervention period to 39.1% during the intervention (OR = 6.5, 95% CI 5.2 to 8.2, p<0.0001) but remained unchanged at the control sites. The interaction between group (control v intervention) and time period was highly significant (p<0.0001). The adjusted odds of receiving a prescription during the intervention period was 3.1 times higher at the intervention sites than at the control sites (95% CI 2.1 to 4.7). Overall, there was no significant difference in prescription rates among the three prompt groups. However, there was a significant interaction between prompt group and site, indicating that the efficacy of the prompts differed by site. CONCLUSION: An intervention for primary care providers consisting of an educational workshop, opinion leader influence, and prompts substantially increased the prescription rate of lipid modifying therapy.
Asunto(s)
Prescripciones de Medicamentos , Hipolipemiantes/uso terapéutico , Isquemia Miocárdica/tratamiento farmacológico , Anciano , HDL-Colesterol/sangre , Estudios de Cohortes , Interpretación Estadística de Datos , Femenino , Educación en Salud , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/sangre , Médicos de Familia , Pautas de la Práctica en Medicina , Sistemas Recordatorios , Proyectos de Investigación , Tamaño de la Muestra , MuestreoAsunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Aspirina/uso terapéutico , Infarto del Miocardio/tratamiento farmacológico , Disfunción Ventricular Izquierda/tratamiento farmacológico , Interacciones Farmacológicas , Quimioterapia Combinada , Humanos , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Inhibidores de Agregación Plaquetaria , Resultado del Tratamiento , Disfunción Ventricular Izquierda/complicacionesAsunto(s)
Antihipertensivos/uso terapéutico , Población Negra , Hidroclorotiazida/uso terapéutico , Hipertensión/tratamiento farmacológico , Tetrazoles/uso terapéutico , Valina/análogos & derivados , Valina/uso terapéutico , Humanos , Hipertensión/etnología , Proyectos Piloto , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Cloruro de Sodio Dietético , ValsartánAsunto(s)
Antagonistas Adrenérgicos beta/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Población Negra , Bloqueadores de los Canales de Calcio/uso terapéutico , Hipertensión/tratamiento farmacológico , Ramipril/uso terapéutico , Insuficiencia Renal/tratamiento farmacológico , Amlodipino/uso terapéutico , Humanos , Hipertensión/etnología , Metoprolol/uso terapéutico , Insuficiencia Renal/etnologíaAsunto(s)
Enfermedad Coronaria/prevención & control , Hipercolesterolemia/terapia , Guías de Práctica Clínica como Asunto , Educación en Salud , Humanos , Hipercolesterolemia/complicaciones , Hipercolesterolemia/prevención & control , Hipertensión/complicaciones , Factores de Riesgo , Estados UnidosAsunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Población Negra , Enalapril/uso terapéutico , Disfunción Ventricular Izquierda/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Factores de Confusión Epidemiológicos , Humanos , Disfunción Ventricular Izquierda/etnologíaAsunto(s)
Presión Sanguínea/efectos de los fármacos , Presión Sanguínea/fisiología , Hipertensión/diagnóstico , Hipertensión/mortalidad , Cloruro de Sodio Dietético , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Hipertensión/fisiopatología , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVE: Hypertension (HTN) is a major risk factor for cardiovascular disease (CVD) in the setting of diabetes. There is no consensus on how best to treat hypertension among those with diabetes. Here we describe the characteristics of a cohort of hypertensive adults with diabetes who are part of a large prospective blood pressure study. This study will help clarify the treatment of HTN in the setting of diabetes. RESEARCH DESIGN AND METHODS: The Antihypertensive and Lipid-Lowering high-risk hypertensive participants, ages > or = 55 years, designed to determine whether the incidence of fatal and nonfatal coronary heart disease (CHD) and combined cardiovascular events (fatal and nonfatal CHD, revascularization surgery, angina pectoris, congestive heart failure, and stroke) differs between diuretic (chlorthalidone) treatment and three alternative antihypertensive therapies: a calcium channel blocker (amlodipine), an ACE inhibitor (lisinopril), and an alpha-adrenergic blocker (doxazosin). The planned follow-up is an average of 6 years, to be completed March 2002. RESULTS: There are 15,297 diabetic individuals in the ALLHAT study (36.0% of the entire cohort). Of these individuals, 50.2% are male, 39.4% are African-American, and 17.7% are Hispanic. Demographic and laboratory characteristics of the cohort are similar to those of other studies of the U.S. elderly population with HTN. The sample size has 42 and 93% confidence, treatments for the two study outcomes. CONCLUSIONS: The diabetic cohort in ALLHAT wil be able to provide valuable information about the treatment of hypertension in older diabetic patients at risk for incident CVD.
Asunto(s)
Antihipertensivos/uso terapéutico , Colesterol en la Dieta , Enfermedad Coronaria/prevención & control , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Hipercolesterolemia/dietoterapia , Hipercolesterolemia/tratamiento farmacológico , Hipertensión/tratamiento farmacológico , Infarto del Miocardio/prevención & control , Pravastatina/uso terapéutico , Antagonistas Adrenérgicos alfa/uso terapéutico , Adulto , Anciano , Amlodipino/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Presión Sanguínea , Bloqueadores de los Canales de Calcio/uso terapéutico , Estudios de Cohortes , Enfermedad Coronaria/epidemiología , Enfermedad Coronaria/mortalidad , Método Doble Ciego , Doxazosina/uso terapéutico , Etnicidad , Femenino , Humanos , Hipercolesterolemia/complicaciones , Hipertensión/complicaciones , Lisinopril/uso terapéutico , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Infarto del Miocardio/mortalidad , Grupos Raciales , Factores de Riesgo , Estados UnidosRESUMEN
Diuretics and beta-blockers are presently recommended as first-line therapy for the treatment of uncomplicated hypertension. JNC VII will probably consider ACE inhibitors worthy of this recommendation. In those at high risk for CHD or CHF, the initial use of an alpha-blocker or calcium antagonist will be recommended with caution. In those with systolic hypertension, who remain at increased risk of stroke, the initial use of CCB therapy continues to be supported by trial-based evidence. A diuretic, based on outcome-based trials, should be included in most regimens to lower the risk of ischemic stroke. Since most patients will require two or more drugs to control their blood pressure, the initial agent chosen will assume less importance for the practicing physician.
Asunto(s)
Hipertensión/dietoterapia , Hipertensión/tratamiento farmacológico , Antihipertensivos/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Presión Sanguínea/fisiología , Conducta Alimentaria/fisiología , Humanos , Hipertensión/fisiopatología , Estilo de VidaAsunto(s)
Antihipertensivos/uso terapéutico , Hipertensión/prevención & control , Cooperación del Paciente , Adulto , Antihipertensivos/administración & dosificación , Antihipertensivos/efectos adversos , Antihipertensivos/economía , Presión Sanguínea/efectos de los fármacos , Esquema de Medicación , Combinación de Medicamentos , Costos de los Medicamentos , Humanos , Hipertensión/tratamiento farmacológico , Masculino , SístoleAsunto(s)
Metabolismo Basal/fisiología , Ciclo Menstrual/fisiología , Femenino , Humanos , Factores de TiempoRESUMEN
Ca absorption is regulated by 1,25(OH)2D, and serum values vary inversely with Ca intake. In sarcoidosis, 1,25(OH)2D is produced by alveolar macrophages in response to gamma-interferon, and patients may develop hypercalcemia after prolonged exposure to sunlight and increased dermal production of vitamin D3. To determine if increased Ca intake suppresses serum 1,25(OH)2D in normocalcemic patients and to identify those at risk, 17 normal subjects and 11 patients were studied on a metabolic ward for two and one-half days while receiving first 400 and then 1,000 mg/d of Ca. On the low Ca intake, serum angiotensin-converting enzyme (ACE), an index of disease activity, was higher in only three of the patients than in the controls, mean serum 1,25(OH)2D was higher in the patients, and mean serum total Ca, serum Ca++, and urinary Ca were not different in the two groups. On the higher Ca intake, mean urinary Ca increased in both groups, but mean serum 1,25(OH)2D was suppressed only in the normal subjects. Thus, 1,25(OH)2D production is abnormally regulated, indicating that (a) normocalcemic patients with sarcoidosis are at risk for developing abnormal Ca metabolism, and (b) a better index of disease activity is provided by the oral Ca suppression test than by serum ACE.