Baby Boomers make up one of the fastest growing population segments in the United States, with a person turning 50 years of age every 7 seconds. Along with this aging population comes an increase in disease prevalence. Four diseases that have a higher prevalence in this population—chronic obstructive pulmonary disease (COPD), stroke, benign prostatic hyperplasia (BPH), and hypertension—were discussed in detail at a continuing education symposium that took place at the 32nd Annual American Society of Consultant Pharmacists Meeting in Chicago, November 2001.

Diastolic dysfunction is increasingly recognized as a cause of congestive heart failure. Meta-analyses of earlier studies of this disorder suggest that 40%–50% of patients with the congestive heart failure syndrome have preserved left ventricular systolic function, with current estimates ranging up to 74%. Among patients ≥65 years of age with congestive heart failure, 55% of all subjects and 67% of women had normal systolic function. Histopathologic evaluation reveals a maladaptive remodeling of the interstitium associated with aging, resulting in an increase in interstitial collagen content. The interstitium normally plays a critical role in the generation of early diastolic suction. When there is a significant enough increase in myocardial collagen volume fraction, with its increased viscoelastic burden, this normal early diastolic suction is compromised and diastolic pressures increase. Left ventricular diastolic dysfunction ensues. Neurohumoral abnormalities associated with diastolic dysfunction include activation of the renin-angiotensin-aldosterone system, including increased elaboration of myocardial aldosterone. This excess of aldosterone appears to play a major role in the development of myocardial fibrosis. Recent observations in animal models and humans have demonstrated regression of interstitial collagen volume fraction in response to inhibition of the renin-angiotensin-aldosterone system by angiotensin-converting enzyme inhibitors and aldosterone inhibition, with improvement in diastolic function. Therapeutic implications of these observations suggest targeting the maladaptive remodeling of the interstitium via inhibition of the renin-angiotensin-aldosterone system.

Fasting glucose (FG) levels increase in older adults with hypertension regardless of whether they are treated with chlorthalidone, amlodipine, or lisinopril, according to the results of an analysis from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) reported in the November 13 issue of the Archives of Internal Medicine. Although the risk of developing FG levels higher than 125 mg/dL was modestly greater with chlorthalidone, there was no conclusive or consistent evidence that this diuretic-associated increase in risk for diabetes increased the risk for clinical events.

Physical examination revealed an elderly, obese Hispanic woman. Electrocardiogram and Holter monitor indicated a supraventricular arrhythmia; an echocardiogram showed decreased left ventricular compliance and left ventricular hypertrophy. Doppler imaging revealed 25% to 30% stenosis of the carotid arteries. A chemistry panel, complete blood count, and urinalysis were within normal limit; however, lipid panel abnormalities included elevations of total cholesterol (312 mg/dL) and low-density lipoprotein cholesterol (216 mg/dL).

The goal of this activity is to teach the latest Effectiveness Report comparative data on angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for treating essential hypertension.Upon completion of this activity, participants will be able to: 1. Determine whether angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) differ in outcomes, quality of life, or treatment rates in adult patients with essential hypertension. 2. Identify any significant differences in adverse effects between ACEIs and ARBs. 3. Discuss whether there are any subgroups of patients who might tolerate one class of these antihypertensives over the other.

October 2007 issue of The CME

The American Heart Association scientific statement on the treatment of hypertension in the prevention and management of ischemic heart disease was published recently. The main recommendations were as follows: (1) For most adults with hypertension, the blood pressure (BP) goal is <140/90 mm Hg but should be <130/90 mm Hg in patients with diabetes mellitus, chronic kidney disease, known coronary artery disease (CAD), CAD equivalents (carotid artery disease, abdominal aortic aneurism, and peripheral vascular disease), or 10-year Framingham risk score of ≥10%. For those with left ventricular dysfunction, the recommended BP target is <120/80 mm Hg. (2) For primary CAD prevention, any effective antihypertensive drug or combination is indicated, but preference is given to angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), and thiazide diuretics. (3) For the management of hypertension in patients with established CAD (stable or unstable angina, non–ST-segment elevation myocardial infarction, ST-segment elevation myocardial infarction), β-blockers and ACE inhibitors (or ARBs) are the basis of treatment. If further BP lowering is needed, a thiazide diuretic and/or a dihydropyridine CCB (not verapamil or diltiazem) can be added. If a β-blocker is contraindicated or not tolerated, diltiazem or verapamil can be substituted. (4) If there is left ventricular dysfunction, recommended therapy consists of an ACE inhibitor or ARB, a β-blocker, and either a thiazide or loop diuretic. In patients with more severe heart failure, an aldosterone antagonist and hydralazine/isosorbide dinitrate (in black patients) should be considered. (J Clin Hypertens. 2007;9:790–795) ©2007 Le Jacq

The guidelines offer the best available and most balanced recommendations for the management of hypertension.

A substantial body of evidence strongly supports the concept that multiple dietary factors affect blood pressure (BP). Well-established dietary modifications that lower BP are reduced salt intake, weight loss, and moderation of alcohol consumption (among those who drink). Of substantial public health relevance are findings related to blacks and older individuals. Specifically, blacks are especially sensitive to the BP-lowering effects of reduced salt intake, increased potassium intake, and the DASH diet. Furthermore, it is well documented that older individuals, a group at high risk for BP-related cardiovascular and renal diseases, can make and sustain dietary changes.

This is an evidence-based approach to the prevention and management of hypertension. The report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan.

This statement from the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute (NHLBI) is intended to provide up-to-date guidance for professionals on the diagnosis and management of the metabolic syndrome in adults.