Thesis (Ph.D. in Clinical Science) -- University of Colorado Denver, 2007. / Typescript. Includes bibliographical references (leaves 86-91). Free to UCD affiliates. Online version available via ProQuest Digital Dissertations;

INTRODUÇÃO: A hipertensão é um importante problema de saúde pública e os estudos de Custo-Efetividade (C/E) do tratamento antihipertensivo são raros no Brasil. OBJETIVO: Realizar análise farmacoeconômica retrospectiva do tipo C/E do tratamento medicamentoso em hipertensos. MATERIAL E MÉTODOS: Foi analisado o custo (C) dos medicamentos anti-hipertensivos, do número de visitas médicas não programadas e do tratamento dos efeitos adversos e a efetividade (E) medida pela redução média da pressão arterial em mm Hg ao término de estudo sobre eficácia do tratamento Tradicional iniciado com hidroclorotiazida e atenolol comparado ao tratamento Atual iniciado com losartan e anlodipino, administrados aleatoriamente durante 12 meses a hipertensos sem outras doenças concomitantes pertencentes ao estágios 1 e 2 (grupo HT1-2 = 140 menor ou igual PAS < 180 e 90 menor ou igual PAD < 110 mm Hg) e ao estágio 3 (grupo HT3 = PAS > 180 e PAD > 110 mm Hg). RESULTADOS: A razão C/E (R$/mm Hg) no grupo HT1-2 (n = 231) para PAS/PAD dos tratamentos Atual e Tradicional foi de 112,52 ± 395,28 / 181,26 ± 358,91 e 43,05 ± 50,73 / 80,51 ± 108,31 (p < 0,05) ao passo que no grupo HT3 (n = 132) foi de 115,12 ± 254,87 / 108,14 ± 82,56 e 218,59 ± 891,93 / 173,97 ± 447,23 (p > 0,05). CONCLUSÃO: O tratamento Tradicional foi custo-efetivo em relação ao Atual nos hipertensos estágios 1 e 2. Por outro lado, nos hipertensos estágio 3 não houve diferença na razão C/E entre os tratamentos. Estes resultados foram confirmados quando foi utilizado o menor preço de aquisição dos medicamentos e quando foram considerados somente os pacientes que atingiram o controle da pressão arterial ao final do estudo. / INTRODUCTION: Hypertension is an important public health problem and Cost-Effectiveness (C/E) studies of antihypertensive drug treatment are uncommon in Brazil. OBJECTIVE: To perform a cost-effectiveness (C/E) ratio retrospective pharmacoeconomic analysis of drug treatment in hypertensive patients. MATERIAL AND METHODS: Antihypertensive medication cost (C) was analysed, along with the number of non-scheduled medical visits, treatment of adverse effects, and effectiveness (E) based on the average reduction of arterial blood pressure measured in mm Hg at the end of the study comparing the efficacy of a Traditional Treatment with hydrochlorothiazide and atenolol versus Current Treatment using losartan and amlodipine, administered at random for 12 months to hypertensive patients with no other simultaneous diseases and presenting disease stage 1 and 2 (HT1-2 Group = 140 < or = SBP < 180 and < or = 90 DBP < 110mmHg) and stage 3 (HT3 Group = SBP maior or = 180 and DBP > or = 110mmHg). RESULTS: The C/E ratio (R$/mmHg) in the HT1-2 Group (n=231), based on SBP/DBP, for Current and Traditional Treatments was 112.52 ± 395.28 / 181.26 ± 358.91 and 43.05 ± 50.73 / 80.51 ± 18.31 (p < 0.05), while in the HT3 Group (n=132), 115.12 ± 254.87 / 108.14 ± 82.56 and 218.59 ± 891.93 / 173.97 ± 447.23 (p>0.05). CONCLUSION: Traditional treatment was more cost-effective compared to the Current therapy in hypertensive patients with disease stages 1 and 2. On the other hand, in hypertensive patients with disease stage 3 there was no difference in C/E ratio between the treatment regimens. These results were confirmed by using the lowest purchase price of medication and by considering only patients that reached control of their blood pressures at the end of the study.

Orientador: Cláudio Chrysostomo Werneck / Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Biologia / Made available in DSpace on 2018-08-23T04:57:03Z (GMT). No. of bitstreams: 1 Nery-Diez_AnaClaudiaCoelho_D.pdf: 21192177 bytes, checksum: 572bd54be1e7496c1fd325e94812ecc1 (MD5) Previous issue date: 2013 / Resumo: As mutações no gene da fibrilina-1, presente na fibra elástica, estão relacionadas à síndrome de Marfan, doença genética autossômica dominante. Acredita-se que a maioria dos seus sintomas esteja relacionada a uma hiper-ativação do fator TGF-?. Quando camundongos modelo para síndrome são tratados com losartan apresentam uma melhora significativa nos sinais clínicos. Assim, neste estudo, investigamos o papel de fibrilina-1 na análise de trombose arterial em modelos de camundongos para a síndrome de Marfan (Fbn1mg?/+). Foram analisados a formação de trombos, os níveis de plaquetas, APTT, PT e TT, agregação e adesão plaquetária, parâmetros hemodinâmicos, níveis de TGF-?, atividade das MMPs, bem como a morfologia das plaquetas, das fibras elásticas e dos trombos. Foi observado que os animais Fbn1mg?/+ necessitam de cerca de 120±21,07 minutos para formarem o trombo, enquanto os animais selvagens precisam de 58±7,16 minutos. Mas, quando os animais Fbn1mg?/+ foram tratados com anti-hipertensivos losartan e captopril, ocorreu uma recuperação no tempo de formação do trombo, com redução de 57,5% e 67,5% no tempo, respectivamente. Além disso, constatou-se que os animais Fbn1mg?/+ apresentam um aumento na atividade das MMPs e TGF-? ativos, quando tratados com os anti-hipertensivos, houve uma diminuição apenas na atividade das MMPs. Ademais, não foi verificada diferença significativa entre todos os outros parâmetros analisados. Este estudo sugere que, de alguma forma, as drogas interferem na remodelação da matriz elástica, devido a uma diminuição da atividade das metaloproteinases de matriz e, consequentemente, leva á recuperação na formação do trombo / Abstract: Recent works show that an increased activation of the TGF-? is associated with most of the symptoms of the Marfan syndrome. Studies using mouse models of Marfan treated with losartan have been shown to prevent the degradation of the elastic matrix. Other investigators suggest that the metalloproteinases and the noncanonical ERK signaling are involved in the breakdown of the elastic fiber, which results in the aneurysm. In this study we investigated the role of fibrillin-1 in the arterial thrombosis model using mouse models of Marfan. We analyzed thrombus formation, platelet levels, APTT, PT and TT time, hemodynamic parameter, TGF-? levels, MMP activity as well as platelets, elastic fibers morphology and thrombus. This study demonstrated that Fbn1mg?/+ mice take about 120±21,07 minutes for the thrombus to be formed when compared with wild type, 58±7,16. When these Fbn1mg?/+ mice were treated with antihypertensive losartan and captopril the time taken for the thrombus formation was reduced in 57,5% and 67,5%, respectively. The activity of metalloproteinases and activity TGF-? was increased in the Fbn1mg?/+, however no significant difference between the hemodynamic parameters, levels of totals TGF-?, morphological platelets, elastic fiber and thrombus were observed. Finally, the results suggested that fibrillin-1 interferes with this process and antihypertensive affect the physiology of Fbn1mg?/+ mice. This study suggested that somehow drugs interfere with elastic matrix remodeling due to a decrease in the activity of matrix metalloproteinases which results in the recovery time of thrombus formation / Doutorado / Bioquimica / Doutora em Biologia Funcional e Molecular

Made available in DSpace on 2015-07-22T20:49:12Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-03-31. Added 1 bitstream(s) on 2015-08-11T03:25:40Z : No. of bitstreams: 1 Publico-063.pdf: 1283927 bytes, checksum: 89787a2a88db59b03f60213385f6b0ba (MD5) / Nosso laboratório mostrou que um único gene codifica um precursor protêico, cujo processamento gera o peptídeo natriurético tipo C (CNP) e uma variedade de peptídeos ricos em prolina, conhecidos como peptideos potenciadores da bradicinina ou BPPs. Com pequenas diferenças, esse precursor é expresso na glândula do veneno e na região neuro-endócrina do cérebro da Bothrops jararaca. Todos os produtos desse processamento têm como característica comum sua ação sob o sistema cardiovascular, levando à redução da pressão arterial e da frequência cardíaca. Esse fato intrigante levou-nos a questionar se esses diferentes peptídeos teriam mecanismo de ação semelhante. Surpreendentemente, esse trabalho mostrou que a resposta é negativa embora ainda não possamos explicar detalhadamente como cada um desses peptídeos atua no complexo mecanismo responsável pelo tônus vascular e pela frequência cardíaca. Historicamente, a demonstração de que os peptídeos potenciadores da bradicinina da Bothrops jararaca (Bj-BPPs) eram inibidores naturais da enzima conversora de angiotensina (ECA) teve ampla repercussão médica. Essa inibição parecia explicar a forte ação anti-hipertensiva desses peptídeos, dai servirem de modelo estrutural para o desenvolvimento de um inibidor sítio-dirigido, o Captopril, medicamento mundialmente utilizado para o tratamento da hipertensão arterial sistêmica humana. Contudo, recentes evidências experimentais sugerem que a atividade anti-hipertensiva dos Bj-BPPs não está relacionada somente com a inibição da ECA. Nosso grupo demonstrou para o Bj-BPP-10c que sua ação anti-hipertensiva se deve à ativação da geração de L-arginina, essencial para produção de óxido nítrico, potente vasodilatador, bem como pela regulação do barorreflexo arterial e pela sinalização de cálcio intracelular, ações que contribuem para a produção de NO em células endoteliais e neurais. Outros Bj-BPPs derivados do mesmo precursor foram aqui analizados. Demonstramos que o mecanismo de ação do Bj-BPP-5a envolve receptores B2 da bradicinina, o receptor muscarínico do subtipo M1 e a produção de NO. Curiosamente, o Bj-BPP-9a que serviu de modelo para a síntese do Captopril, parece atuar predominantemente como um clássico inibidor da ECA. O Bj-BPP-11e deve ter ação num receptor de membrana, assim explicando seus efeitos sobre parâmetros cardiovasculares. O mecanismo de ação do Bj-BPP-12b poderia ser explicado pela potenciação da BK e/ou pela inbição da ECA e do Bj-BPP-13a por ação em receptor muscarínico do subtipo M3 e sobre a ASS. Adicionalmente, o presente trabalho mostrou, pela primeira vez na área de toxinologia, que toxinas de serpentes já se valem do recurso bem conhecido na geração de hormônio-peptídeos em mamíferos, isto é, utilizam o processamento de uma poliproteina para gerarem peptídeos de ação sinérgica. / Our laboratory has shown that one gene codes for the protein precursor that yields the natriuretic peptide type C (CNP) after having been processed, along with a variety of proline-rich peptides, known as bradykinin-potentiating peptides or BPPs. Showing little differences, this precursor is expressed in the venom gland and the neuroendocrine region of the Bothrops jararaca brain. All processing products have in common that they act on the cardiovascular system, lowering arterial blood pressure and heart frequency. This intriguing fact led us to question whether the different peptides display similar mechanisms of action. Surprisingly, the present study showed that the answer is negative, although we cannot, at the present time, explain in full detail how each peptide acts in the complex mechanism, responsible for vascular tonus and cardiac frequency. Historically, the demonstration that the Bradykinin-Potentiating Peptides from Bothrops jararaca (Bj-BPPs) were natural inhibitors of the angiotensin converting enzyme (ACE) had a wide medical impact. In fact, this inhibition seemed to fully explain the strong anti-hypertensive action of these peptides, therefore being employed as structural models for the development of a site-directed inhibitor, Captopril, a drug used worldwide for the treatment of systemic human arterial hypertension. Recent experimental evidences, however, suggest that the anti-hypertensive activity of the Bj-BPPs is not due exclusively to the inhibition of the ACE. Our group demonstrated that the antihypertensive action of Bj-BPP-10c, for instance, is due to the activation of L-arginine generation, which is essential for NO production, a potent vasodilator. Moreover, it also regulates the arterial baroreflex and intracellular calcium signaling, which contribute to NO production in endothelial and neuronal cells. In the present work we studied the mechanism of action of other Bj-BPPs found in the above mentioned precursor. We showed that the mechanism of action of Bj-BPP-5a involves bradykinin B2 receptor, the muscarinic receptor, subtype M1, and NO production. Bj-BPP-11e probably acts on a membrane receptor, thereby explaining its effects on cardiovascular parameters. The mechanism of action of Bj-BPP-12b might be explained by Bk potentiation and/or by ACE inhibition and Bj- BPP-13a action on by muscarinic receptor subtype M3 and the ASS. Interestingly, Bj-BPP-9a, which was the model molecule for the synthesis of Captopril, seems to act predominantly as a classic ACE inhibitor. Beside the pharmacological interest, our work also revealed, for the first time, that snake toxins also employ the well-known strategy in hormone-peptide generation, that is, they use the processing of a polyprotein to generate peptides which display a synergistic action. / TEDE / BV UNIFESP: Teses e dissertações

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Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Le traitement antihypertenseur (TAH) réduit le risque cardiovasculaire (RCV). Son efficacité est établie à partir de nombreux essais et méta-analyses conduits sur différentes populations. L’effet du TAH suit en moyenne un modèle multiplicatif différent d’une classe médicamenteuse à l’autre et non constant dans le temps. Pour progresser vers une prescription personnalisée du TAH, nous avons suivi 3 objectifs: 1) La modélisation statistique de l’effet du TAH sur le risque d’accidents vasculaires cérébraux (AVC) et d’infarctus (IDM) dans différents sous-groupes de patients, selon le temps et la classe médicamenteuse. 2) La méta-analyse de l’effet du TAH sur le risque d’AVC, d’IDM et de mortalité après 80 ans, situation de prescription fréquente. 3) La mise en place, conduite et coordination de l’essai clinique IDEAL, randomisé en plan croisé et double insu dont l’objectif est d’étudier l’influence des caractéristiques individuelles sur la réponse pressionnelle à 2 classes de TAH. Les 2 premiers travaux ont été réalisés sur la base INDANA, méta-analyse sur données individuelles des essais évaluant le TAH contre placebo. Ils suggèrent sans être définitivement convaincants que la réduction du bénéfice au cours du temps sur le risque d’infarctus est plus nette chez la femme et sous bêtabloquants. Chez les patients très âgés le TAH reste efficace pour réduire le RCV, mais notre analyse de l’absence de réduction de la mortalité nous conduit à recommander d’éviter toute intensification du TAH à cet âge. L’essai IDEAL a inclus 124 patients chez lesquels la régression à la moyenne et l’évolution sous placebo expliquent une baisse de pression de même ordre que le TAH. / Antihypertensive treatment (AHT) reduces cardiovascular risk (CVR). Its efficacy is well established from numerous clinical trials and meta-analysis conducted in several populations. The AHT effect follows on average a multiplicative model. This model is different from one drug class to another, and is not constant during follow-up.In order to progress towards a personalized prescription of AHT, we followed 3 objectives: 1) The statistical modelling of AHT effect on stroke (ST) and myocardial infarction (MI) in different sub-groups of patients,depending on time of follow-up and first line drug class. 2) The meta-analysis of AHT effect on the risk of stroke,MI and total mortality in patients ages 80 years and older in whom AHT is frequently prescribed. 3) The set-up,conduct and coordination of the IDEAL study, a cross-over randomized double blind clinical trial in order to assess the influence of individual characteristics on blood pressure (BP) response to two AHT drug classes. The first two analyses were performed on the INDANA database, an individual patient data meta-analysis from trials that evaluated the effect of AHT against placebo. These analyses suggest that the decreased benefit of AHT over timeon MI prevention was mostly apparent in women and with first line beta-blocker. Treatment remained efficient invery old patients in reducing CVR, but the lack of mortality reduction led us not to recommend AHT intensificationin this age group. The IDEAL study included 124 patients for which the regression to the mean and the evolution under placebo phenomena explained a BP reduction similar to the one under AHT.

No / Although guidelines indicate when patients are eligible for antihypertensives and statins, little is known about whether general practitioners (GPs) follow this guidance. To determine the factors influencing GPs decisions to prescribe cardiovascular prevention drugs. DESIGN OF STUDY: Secondary analysis of data collected on patients whose cardiovascular risk factors were measured as part of a controlled study comparing nurse-led risk assessment (four practices) with GP-led risk assessment (two practices). SETTING: Six general practices in the West Midlands, England. PATIENTS: Five hundred patients: 297 assessed by the project nurse, 203 assessed by their GP. MEASUREMENTS: Cardiovascular risk factor data and whether statins or antihypertensives were prescribed. Multivariable logistic regression models investigated the relationship between prescription of preventive treatments and cardiovascular risk factors. RESULTS: Among patients assessed by their GP, statin prescribing was significantly associated only with a total cholesterol concentration >/= 7 mmol/L and antihypertensive prescribing only with blood pressure >/= 160/100 mm Hg. Patients prescribed an antihypertensive by their GP were five times more likely to be prescribed a statin. Among patients assessed by the project nurse, statin prescribing was significantly associated with age, sex, and all major cardiovascular risk factors. Antihypertensive prescribing was associated with blood pressures >/= 140/90 mm Hg and with 10-year cardiovascular risk. LIMITATIONS: Generalizability is limited, as this is a small analysis in the context of a specific cardiovascular prevention program. CONCLUSIONS: GP prescribing of preventive treatments appears to be largely determined by elevation of a single risk factor. When patients were assessed by the project nurse, prescribing was much more consistent with established guidelines.

Yes / This study investigated the relationship of ethnicity to the differences between blood pressure (BP) measured in a clinic setting and by ambulatory blood pressure monitoring (ABPM) in individuals with a previous diagnosis of hypertension (HT) and without a previous diagnosis of hypertension (NHT). A cross-sectional comparison of BP measurement was performed in 770 participants (white British (WB, 39%), South Asian (SA, 31%), and African Caribbean (AC, 30%)) in 28 primary care clinics in West Midlands, United Kingdom. Mean differences between daytime ABPM, standardized clinic (mean of 3 occasions), casual clinic (first reading on first occasion), and last routine BP taken at the general practitioner practice were compared in HT and NHT individuals. Daytime systolic and diastolic ABPM readings were similar to standardized clinic BP (systolic: 128 (SE 0.9) vs. 125 (SE 0.9) mm Hg (NHT) and 132 (SE 0.7) vs. 131 (SE 0.7) mm Hg (HT)) and were not associated with ethnicity to a clinically important extent. When BP was taken less carefully, differences emerged: casual clinic readings were higher than ABPM, particularly in the HT group where the systolic differences approached clinical relevance (131 (SE 1.2) vs. 129 (SE 1.0) mm Hg (NHT) and 139 (SE 0.9) vs. 133 (SE 0.7) mm Hg (HT)) and were larger in SA and AC hypertensive individuals (136 (SE 1.5) vs. 133 (SE 1.2) mm Hg (WB), 141 (SE 1.7) vs. 133 (SE 1.4) mm Hg (SA), and 142 (SE 1.6) vs. 134 (SE 1.3) mm Hg (AC); mean differences: 3 (0-7), P = 0.03 and 4 (1-7), P = 0.01, respectively). Differences were also observed for the last practice reading in SA and ACs. BP differences between ethnic groups where BP is carefully measured on multiple occasions are small and unlikely to alter clinical management. When BP is measured casually on a single occasion or in routine care, differences appear that could approach clinical relevance.