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[The best of arterial hypertension in 1999]
1Service de cardiologie, Hôpital de la Croix-Rousse, Lyon.
Insights
ACE inhibitors, like ramipril, are valuable in preventing vascular events, including strokes. Antihypertensive therapy effectively reduces hypertension and left ventricular hypertrophy (LVH), contributing to decreased cardiovascular mortality.
Area of Science:
- Cardiology
- Hypertension Research
- Epidemiology
Context:
- Concerns about ACE inhibitor safety regarding cerebrovascular events were raised by the CAPP trial.
- The HOPE trial provided reassurance regarding the efficacy of ACE inhibitors in preventing vascular events, including cerebrovascular accidents.
- The Framingham study offers long-term data on hypertension, left ventricular hypertrophy (LVH), and antihypertensive therapy.
Purpose:
- To evaluate the safety and efficacy of ACE inhibitors in preventing cerebrovascular events.
- To analyze the impact of antihypertensive therapy on LVH and its association with cardiovascular mortality.
- To highlight current recommendations for hypertension management and the importance of individualized risk assessment.
Summary:
- The HOPE trial demonstrated that ramipril, an ACE inhibitor, is beneficial in preventing vascular events, including cerebrovascular accidents, alleviating concerns from earlier studies.
- Long-term data from the Framingham study suggest antihypertensive therapy contributes to the regression of LVH and a significant decrease in cardiovascular mortality.
- Current WHO and IHS guidelines recommend strict blood pressure targets (<130/85 mmHg) and individualized risk assessment for hypertension management, emphasizing the need for better patient control.
Impact:
- ACE inhibitors are confirmed as effective agents for vascular event prevention, particularly in reducing cerebrovascular accidents.
- Antihypertensive therapy plays a crucial role in managing LVH and reducing overall cardiovascular mortality.
- Stricter adherence to hypertension treatment guidelines and personalized risk assessment are essential for improving patient outcomes and public health.
Abstract:
THE RELIEF OF THE RESULTS OF THE HOPE TRIAL WITH RESPECT TO THE INCIDENCE OF CEREBROVASCULAR EVENT UNDER ACE INHIBITOR THERAPY: In 1998, the CAPP trial had raised a serious concern about whether captopril therapy increased the risk of cerebrovascular accidents. When compared with betablocker therapy (+/- diuretics) in 11,000 hypertensives, there was a very worrying number of excess cerebrovascular accidents in the captopril group (+25%) (with no difference in the number of cerebrovascular accidents overall). There were several reasons which led to believe that the captopril was not the causal factor. But a doubt remained. In 1999, the results of the HOPE trial with ramipril, though not primarily for a hypertensive population, provided reassurance beyond the investigators' hopes concerning the value of ACE inhibitors in the prevention of vascular events, including cerebrovascular accidents. THE FRAMINGHAM EXPERIENCE OF LVH AND THE TREATMENT OF HYPERTENSION: The Framingham study reported unique data concerning the effects of antihypertensive therapy on LVH in 10,333 subjects of 45 to 74 years of age followed up for 40 years (1950-1989). As the incidence of antihypertensive therapy increased during the observation period, that of hypertension and LVH decreased in parallel. Although these data were retrospective, they are compatible with a causal relationship between the treatment and regression of LVH. This could explain up to 50% of the decrease in cardiovascular mortality observed in the United States during this period. The Framingham study so reposition, in an epidemiological context, the considerable benefits of antihypertensive therapy and of the regression of the associated LVH. THE SEVERITY OF THE WHO AND IHS RECOMMENDATIONS: Less than 130/85: this is the target value of the blood pressure in adults under antihypertensive therapy according to WHO and IHS. In patients with diabetes or renal failure with proteinuria > 1 g/j, the target is even lower. These recommendations incite physicians to beware of any laxness in the treatment of hypertension. The most recent epidemiological data from France indicates that only a minority of the hypertensive patients under treatment are well controlled and that this advice is probably not superfluous. Moreover, in the decision to treat hypertension (drug therapy or not), these recommendations underline the evaluation of the individual risk of the subject on the basis of associated risk factors, target organ complications and previous history of vascular events.