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[beta]-blockers not first line in systolic hypertension. (Cardiovascular Medicine: Select diuretics, calcium channel blockers).

SNOWMASS, COLO. -- [beta]-blockers are not appropriate first-line therapy for elderly patients with isolated systolic hypertension, Dr. John S. Schroeder said at a conference sponsored by the American College of Cardiology.

A surprising number of physicians have mistakenly extrapolated from the well-known guideline in the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI), which highlights diuretics and [beta]-blockers as the initial drugs of choice for uncomplicated hypertension in younger patients.

JNC-VI specifically identifies diuretics and long-acting dihydropyridine calcium channel blockers--not [beta]-blockers--as the initial agents of choice in isolated systolic hypertension in older patients, said Dr. Schroeder, professor of medicine at Stanford (Calif.) University

"[beta]-blockers have never been shown to reduce mortality in patients with coronary or vascular disease unless they have had an MI. If you disagree with that statement, bring me the reference," he said.

The JNC-VI recommendation to initiate therapy with a diuretic or a dihydropyridine calcium channel blocker in patients with isolated systolic hypertension is based upon compelling clinical trial data that show an association with marked reductions in overall mortality cardiovascular events, and stroke.

The Systolic Hypertension-Europe (Syst-Eur) trial, for example, documented a 31% reduction in all cardiovascular end points with calcium channel blocker therapy compared with placebo, during 2 years of follow-up in a randomized study of 4,700 patients over age 60 with isolated systolic hypertension.

In a Syst-Eur substudy of 492 diabetic patients with isolated systolic hypertension, the dihydropyridine calcium channel blocker resulted in a 63% reduction in cardiac events, a 73% decrease in strokes, and a 76% drop in mortality due to cardiovascular disease.

In the 4,736-patient Systolic Hypertension in the Elderly Program (SHEP), a chlorthalidone-based stepped-care regimen for isolated systolic hypertension resulted in a 32% reduction in total major cardiovascular events during 5 years of follow-up.

"If you look at the drugs that are most effective for [inducing regression of] left ventricular hypertrophy, it's the calcium channel blockers and ACE inhibitors. 13blockers are the worst.

"So if you believe that left ventricular hypertrophy is an independent cardiovascular risk factor and reflects blood pressure control, it's another reason not to use [beta]-blockers," the cardiologist said.

In terms of patient adherence--a critical consideration in lifelong management of a silent chronic disease such as hypertension--studies demonstrate that diuretics fare worst in terms of patient compliance and [beta]-blockers are fair.

Calcium channel blockers and ACE inhibitors do best in terms of patient adherence because they have the least bothersome side effects.

But ACE inhibitors cannot be endorsed as a first-line therapy in isolated systolic hypertension because of inadequate data on outcomes. The needed studies are ongoing.

Dr. Schroeder's own treatment strategy in patients with isolated systolic hypertension is to begin with 12.5 mg/day of hydrochlorothiazide. If additional blood pressure lowering is needed, as is usually the case, he then adds 2.5 or 5 mg/day of amlodipine.

If that combination doesn't bring systolic blood pressure down to 140 mm Hg, Dr. Schroeder adds an ACE inhibitor, provided renal function is adequate.
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Author:Jancin, Bruce
Publication:Internal Medicine News
Article Type:Brief Article
Geographic Code:1USA
Date:Apr 1, 2002
Words:515
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