Angiotensin-Converting Enzyme Inhibitors and Calcium Channel Blockers for Coronary Heart Disease and Stroke Prevention

Verdecchia, Paolo; Reboldi, Gianpaolo; Angeli, Fabio; Gattobigio, Roberto; Bentivoglio, Maurizio; Thijs, Lutgarde; Staessen, Jan A.; Porcellati, Carlo

doi:10.1161/01.hyp.0000174591.42889.a2

Cited by 291 publications

(182 citation statements)

References 56 publications

Supporting

Mentioning

149

Contrasting

Unclassified

Order By: Relevance

“…In vitro and in vivo studies in animals and humans showed that the blood-pressure-lowering action of indapamide not only involves increased natriuresis but inhibition of the contractile responses of vascular smooth muscle cells to vasopressors and adrenergic stimulation as well. 16,18 Diuretics 21,22 and calcium channel blockers 22,23 probably have a small 5-10% benefit beyond blood pressure lowering in the prevention of stroke. Unlike thiazide diuretics, indapamide, 18,24,25 as well as calcium channel blockers, inhibit the inward current of calcium across cell membranes and reduce intracellular calcium concentrations.…”

Section: Discussionmentioning

confidence: 99%

Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature

et al. 2009

Self Cite

View full text Add to dashboard Cite

We assessed, in a double-blind, placebo-controlled trial, whether lowering blood pressure (BP) prevents the recurrence of stroke in Chinese patients with cerebrovascular disease. Patients were randomized into two groups: 2825 patients received a placebo and 2840 patients received 2.5 mg of indapamide daily. The primary and secondary outcomes were the recurrence of fatal or nonfatal stroke and major fatal and nonfatal cardiovascular events, respectively. The average systolic/diastolic BP at randomization was 153.8/92.8 mm Hg. At median follow-up (2 years), BP was, on an average, 6.8/3.3 mm Hg lower in patients on active treatment. In total, 143 patients on indapamide and 219 patients on placebo had recurrent strokes (hazard ratio for indapamide, 0.69; 95% confidence interval (CI): 0.54-0.89; Po0.001). In addition, 199 patients on indapamide and 258 patients on placebo had a cardiovascular event (hazard ratio, 0.75; 95% CI: 0.89-0.62; P¼0.002). We performed a systematic review of literature that included our new results. Across 10 trials, the odds ratio for the prevention of stroke recurrence by BP lowering was 0.78 (95% CI: 0.68-0.90; P¼0.0007). The pooled odds ratio was 0.63 (95% CI: 0.54-0.73; Po0.0001) for trials involving diuretics as a component of therapy and 0.93 (95% CI: 0.87-1.01; P¼0.086) for trials in which treatment included renin system inhibitors (Po0.0001 for heterogeneity). The weighted correlation between the odds for stroke recurrence and the reduction in systolic BP was À0.57 (P¼0.067). In conclusion, BP lowering by indapamide treatment reduced the recurrence of stroke and the incidence of cardiovascular events in Chinese patients with cerebrovascular disease. Whether prevention of stroke recurrence depends on drug class, degree of BP lowering or both requires further investigation.

show abstract

Section: Discussionmentioning

confidence: 99%

Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature

et al. 2009

Self Cite

View full text Add to dashboard Cite

show abstract

“…As pointed out in the paper, the average systolic BP difference between the CCB group and β-blocker group would have been expected to provide a difference of 4%-8% for coronary events and 11%-14% for strokes, based on previous clinical trials and epidemiologic studies. 2,3 In fact, there was a mean 13% decrease in total coronary end points (95% confidence interval [CI], 4%-21%) and 23% for stroke (95% CI, 11%-34%). This would suggest a benefit beyond BP differences.…”

Section: Discussionmentioning

confidence: 99%

ASCOT‐Blood Pressure Trial (ASCOT‐BPLA) and HOPE‐TOO

Liebson

2006

Preventive Cardiology

View full text Add to dashboard Cite

Summary.A total of 19,257 hypertensive patients aged 40-79 years old with at least three other cardiovascular (CV) risk factors were assigned either to the calcium channel blocker (CCB) amlodipine, 5-10 mg, adding the angiotensin-converting enzyme inhibitor (ACEI) perindopril, 4-8 mg, as required; or the β blocker atenolol, 50-100 mg, adding the diuretic bendroflumethiazide, 1.25-2.5 mg, and potassium as required. The primary end point was nonfatal myocardial infarction (MI) and fatal coronary heart disease, using intention-to-treat analysis. The study was stopped prematurely after 5.5 years' median follow-up because the data and safety monitoring indicated that the amlodipine-based group had significantly better outcomes in secondary end points. Although fewer individuals in the amlodipine group reached the primary end point (429 vs. 474), the results were not significant (adjusted relative risk [RR], 0.90; 95% confidence interval [CI], 0.79-1.02). As indicated, however, the amlodipine-based group had significantly lower secondary end points of all-cause mortality, total CV events and procedures, fatal and nonfatal stroke, and incidence of diabetes. After adjustment for coronary and stroke findings by multivariate analysis, residual differences were no longer significant.Rationale. The study compared newer antihypertensive regimens (CCB and ACEI) vs. the β blocker and diuretic because at the time of the study inception, there were limited data on the relative effects of these newer agents, and because earlier hypertension trials showed less than the expected decrease in coronary heart disease events with the earlier agents and the newer agents do not have the metabolic side effects that presumably might have adversely affected coronary heart disease outcomes with the former. It was also understood that at least two agents were needed to achieve blood pressure (BP) targets, and the most common combinations used at the time were diuretics and β blockers, primarily thiazides and atenolol. Despite evidence that CCBs and ACEIs were effective in BP control in limited studies, safety and cost issues were of concern at the time. For example, some observational data had brought into question the safety of dihydropyridine CCBs.Study Design. The patients were recruited between 1998 and 2000. Patients were evaluated at clinical centers in the United Kingdom, Ireland, and the Scandinavian countries. BP had to be at least 160 mm Hg systolic or 90 mm Hg diastolic if previously untreated, or 140 mm Hg systolic or 90 mm Hg diastolic, if treated. The three additional risk factors were included from the following list: left ventricular hypertrophy on echocardiography or electrocardiography (ECG); other specified ECG abnormalities; type 2 diabetes; peripheral arterial disease; previous stroke or transient ischemic attack; male sex; age 55 years or older; microalbuminuria or proteinuria; smoking; total cholesterol/high-density lipoprotein (HDL) cholesterol ratio of 6 or higher; or family history of premature coronary artery disease...

show abstract

“…25 Furthermore, metaregression analyses have suggested that, at a projected absence of any blood pressure reduction by treatment, ACE inhibitors retained a substantial ability to reduce the incidence of heart failure and coronary heart disease, whereas neither ACE inhibitors and angiotensin II receptor blockers retained the ability to reduce stroke, the protection against which appeared thus to be strictly blood pressuredependent. [34][35][36][37] Comparison between the cardioprotective effects of an ACE inhibitor and an angiotensin II receptor antagonist-based treatment has been recently evaluated in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET), 38 which, together with the Telmisartan Randomised AssessmeNT Study in ACE INtolerant subjects with cardiovascular Disease (TRASCEND), 39 represents the largest trial ever performed in the field of cardiovascular protection. The results of ONTARGET trial unequivocally show that telmisartan has the same efficacy, in terms of cardiovascular protection (reduction in myocardial infarction, stroke and hospitalization for congestive heart failure ( Figure 3), of ramipril, although guaranteeing a better tolerability profile (Figure 4).…”

Section: Angiotensin II Receptor Blockers Versus Ace Inhibitors On Hamentioning

confidence: 99%

Protective effects of renin–angiotensin blockade beyond blood pressure control

et al. 2009

View full text Add to dashboard Cite

Angiotensin-Converting Enzyme Inhibitors and Calcium Channel Blockers for Coronary Heart Disease and Stroke Prevention

Cited by 291 publications

References 56 publications

Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature

Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature

ASCOT‐Blood Pressure Trial (ASCOT‐BPLA) and HOPE‐TOO

Protective effects of renin–angiotensin blockade beyond blood pressure control

Contact Info

Product

Resources

About