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Context: Although the long-term goal of antihypertensive therapy is to reduce adverse clinical outcomes, the only way to evaluate the efficacy of treatment in an individual is the magnitude of blood pressure (BP) reduction. ACE inhibitors and angiotensin receptor blockers (ARBs) are two drug classes that, by different mechanisms, inhibit the renin-angiotensin- aldosterone system that regulates BP. As these drugs are widely prescribed for hypertension, it is essential to determine and compare their effects on BP, heart rate and tolerability. Objectives: 1) To determine the dose-related effect of ACE inhibitors and ARBs on BP, heart rate and withdrawals due to adverse effects (WDAE), compared with placebo in the treatment of primary hypertension (SBP ≥ 140 mm Hg and/or ≥ DPB 90 mm Hg); and 2) To compare the relative effect on BP, heart rate and WDAE of a) each ACE inhibitor with other ACE inhibitors, b) each ARB with other ARBs, and c) all ACE inhibitors with all ARBs. Methods: Two systematic reviews of published, double-blind, randomized, controlled trials (RCTs) evaluating the BP lowering efficacy of fixed dose monotherapy with an ACE inhibitor or ARB compared with placebo for a duration of 3 to 12 weeks in patients with primary hypertension were conducted. Electronic databases were searched for RCTs and similar trial inclusion criteria and methods of analysis were used in both reviews. Results: Ninety two RCTs evaluated the dose-related BP lowering efficacy of 14 ACE inhibitors in 12 954 participants with a baseline BP of 157.1/101.2 mm Hg. Forty six RCTs evaluated the dose-related BP lowering efficacy of 9 ARBs in 13 451 participants with a baseline BP of 155.6/101.0 mm Hg. The best estimate of the near maximal trough BP reduction for ACE inhibitors and ARBs was -8/-5 mm Hg and -8/-5 mm Hg, respectively. ACE inhibitors and ARBs do not affect heart rate. The evidence for short-term WDAE (tolerability) was incomplete and weak and did not demonstrate a difference between the two classes of drugs. Conclusion: ACE inhibitors and ARBs are not different individually or as drug classes in BP lowering efficacy.

Context: Although the long-term goal of antihypertensive therapy is to reduce adverse clinical outcomes, the only way to evaluate the efficacy of treatment in an individual is the magnitude of blood pressure (BP) reduction. ACE inhibitors and angiotensin receptor blockers (ARBs) are two drug classes that, by different mechanisms, inhibit the renin-angiotensin- aldosterone system that regulates BP. As these drugs are widely prescribed for hypertension, it is essential to determine and compare their effects on BP, heart rate and tolerability. Objectives: 1) To determine the dose-related effect of ACE inhibitors and ARBs on BP, heart rate and withdrawals due to adverse effects (WDAE), compared with placebo in the treatment of primary hypertension (SBP ≥ 140 mm Hg and/or ≥ DPB 90 mm Hg); and 2) To compare the relative effect on BP, heart rate and WDAE of a) each ACE inhibitor with other ACE inhibitors, b) each ARB with other ARBs, and c) all ACE inhibitors with all ARBs. Methods: Two systematic reviews of published, double-blind, randomized, controlled trials (RCTs) evaluating the BP lowering efficacy of fixed dose monotherapy with an ACE inhibitor or ARB compared with placebo for a duration of 3 to 12 weeks in patients with primary hypertension were conducted. Electronic databases were searched for RCTs and similar trial inclusion criteria and methods of analysis were used in both reviews. Results: Ninety two RCTs evaluated the dose-related BP lowering efficacy of 14 ACE inhibitors in 12 954 participants with a baseline BP of 157.1/101.2 mm Hg. Forty six RCTs evaluated the dose-related BP lowering efficacy of 9 ARBs in 13 451 participants with a baseline BP of 155.6/101.0 mm Hg. The best estimate of the near maximal trough BP reduction for ACE inhibitors and ARBs was -8/-5 mm Hg and -8/-5 mm Hg, respectively. ACE inhibitors and ARBs do not affect heart rate. The evidence for short-term WDAE (tolerability) was incomplete and weak and did not demonstrate a difference between the two classes of drugs. Conclusion: ACE inhibitors and ARBs are not different individually or as drug classes in BP lowering efficacy.

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2006. / Härtill 4 uppsatser.

Boston University. University Professors Program Senior theses. / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-02

Context: Although the long-term goal of antihypertensive therapy is to reduce adverse clinical outcomes, the only way to evaluate the efficacy of treatment in an individual is the magnitude of blood pressure (BP) reduction. ACE inhibitors and angiotensin receptor blockers (ARBs) are two drug classes that, by different mechanisms, inhibit the renin-angiotensin- aldosterone system that regulates BP. As these drugs are widely prescribed for hypertension, it is essential to determine and compare their effects on BP, heart rate and tolerability. Objectives: 1) To determine the dose-related effect of ACE inhibitors and ARBs on BP, heart rate and withdrawals due to adverse effects (WDAE), compared with placebo in the treatment of primary hypertension (SBP ≥ 140 mm Hg and/or ≥ DPB 90 mm Hg); and 2) To compare the relative effect on BP, heart rate and WDAE of a) each ACE inhibitor with other ACE inhibitors, b) each ARB with other ARBs, and c) all ACE inhibitors with all ARBs. Methods: Two systematic reviews of published, double-blind, randomized, controlled trials (RCTs) evaluating the BP lowering efficacy of fixed dose monotherapy with an ACE inhibitor or ARB compared with placebo for a duration of 3 to 12 weeks in patients with primary hypertension were conducted. Electronic databases were searched for RCTs and similar trial inclusion criteria and methods of analysis were used in both reviews. Results: Ninety two RCTs evaluated the dose-related BP lowering efficacy of 14 ACE inhibitors in 12 954 participants with a baseline BP of 157.1/101.2 mm Hg. Forty six RCTs evaluated the dose-related BP lowering efficacy of 9 ARBs in 13 451 participants with a baseline BP of 155.6/101.0 mm Hg. The best estimate of the near maximal trough BP reduction for ACE inhibitors and ARBs was -8/-5 mm Hg and -8/-5 mm Hg, respectively. ACE inhibitors and ARBs do not affect heart rate. The evidence for short-term WDAE (tolerability) was incomplete and weak and did not demonstrate a difference between the two classes of drugs. Conclusion: ACE inhibitors and ARBs are not different individually or as drug classes in BP lowering efficacy. / Medicine, Faculty of / Anesthesiology, Pharmacology and Therapeutics, Department of / Graduate

Background: Amiodarone (AM) is a widely used anti-arrhythmic medication. Its utility is, however, limited by adverse side effects. The mechanism of amiodarone-induced toxicity (APT) in the lungs is attributed primarily to stimulation of the angiotensin enzyme system leading to lung cell apoptosis and cell death. This mechanism has been demonstrated by in vitro and in vivo experimental animal studies. To date, however, no in vivo human studies have confirmed this mechanism for APT. Purpose: This study was undertaken to determine whether angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) offer a protective effect against APT in humans. Demonstration of a protective effect of an ACE-I or ARB would suggest that stimulation of the angiotensin enzyme system may be a key process in APT. Design: An 8-year retrospective analysis of all patients on AM therapy at the James H. Quillen Veterans Affairs Medical Center was undertaken. Results: A total of 1000 patients on AM were identified. One-hundred-and-seventeen were excluded from the study. Five-hundred-and-twenty-four patients were simultaneously on an ACE-I or ARB. The remaining 359 patients were not. Pulmonary toxicity attributed to AM was identified in five and 14 patients with and without concomitant ACE-I or ARB therapy, respectively. The APT rate for the entire patient sample was 2.2%. APT occurred in 1% of patients on an ACE-I or ARB and in 3.9% of patients not taking an ACE-I or ARB. This observed difference in percentage of APT was statistically significant. Conclusion: The concomitant use of ACE-I or ARB in patients taking AM appears to offer a protective effect against APT. This observation suggests that the stimulation of the angiotensin enzyme system may play an important role in APT in humans.

Coronary artery disease (CAD) is the leading cause of mortality worldwide and atrial fibrillation (AF) is a prevalent arrhythmia associated with increased risk of mortality and morbidity. Despite improved outcome in both diseases, there is a need to further describe the prevalence, outcome and management of CAD in patients with concomitant AF. AF was a common finding among patients with MI, with 16% having new-onset, paroxysmal or chronic AF. Patients post-MI with concomitant AF, regardless of subtype, were at increased risk of composite cardiovascular outcome of mortality, MI or ischemic stroke, including mortality and ischemic stroke alone. No major difference in outcome was observed between AF subtypes. At discharge, an oral anticoagulant was prescribed to 27% of the patients with MI and AF undergoing percutaneous coronary intervention (PCI). Aspirin or clopidogrel plus warfarin versus dual antiplatelet therapy with aspirin plus clopidogrel were associated with similar 0-90-day and lower 91-365-day risk of cardiovascular outcome, without increased risk of major bleeding events. Triple therapy with aspirin, clopidogrel plus warfarin versus dual antiplatelet therapy was associated with non-significant lower risk of cardiovascular outcome, but with increased risk of bleeding events. Treatment with renin-angiotensin system (RAS) inhibitors post-MI was associated with lower risk of all-cause and cardiovascular mortality in patients with and without congestive heart failure and/or AF. However, RAS inhibition in patients without AF was not associated with lower risk of new-onset AF. Approximately 1 in 3 patients undergoing isolated coronary artery bypass grafting (CABG) had pre- or postoperative AF. Patients with AF, regardless of subtype, were at higher risk of all-cause mortality, cardiovascular mortality and congestive heart failure. Furthermore, postoperative AF was associated with higher risk of recurrent AF. In conclusion, AF was a common finding in the setting of MI and CABG. AF, irrespectively if in the setting of MI or CABG was associated with higher risk of ischemic events and mortality. Also, postoperative AF was associated with recurrent AF. Oral anticoagulants post-MI and PCI in patients with AF was underutilized, however, optimal antithrombotic therapy is still unknown. RAS inhibition post-MI seems beneficial, however, it was not associated with lower incidence of new-onset AF.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-03-24T14:56:20Z No. of bitstreams: 1 josemarcosgirardi.pdf: 1287766 bytes, checksum: 075ed2df1583d07329df989c3ebc4738 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-03-27T17:36:27Z (GMT) No. of bitstreams: 1 josemarcosgirardi.pdf: 1287766 bytes, checksum: 075ed2df1583d07329df989c3ebc4738 (MD5) / Made available in DSpace on 2017-03-27T17:36:27Z (GMT). No. of bitstreams: 1 josemarcosgirardi.pdf: 1287766 bytes, checksum: 075ed2df1583d07329df989c3ebc4738 (MD5) Previous issue date: 2011-06-09 / Alterações no remodelamento miocárdico, vascular, inflamatório, proteinúria e inflamação glomerular em ratos deficientes de óxido nítrico (NO), tratados com olmesartana medoxomila (OLM) e/ou rosuvastatina cálcica (ROS) foram estudadas após 28 dias com o objetivo de avaliar o impacto destes fármacos. Veículo (G1), Lnitro-arginina-metil-éster (L-NAME) 30mg/kg/dia (G2), OLM 5mg/kg/dia (G3), ROS 20mg/kg/dia (G4), OLM 0,5mg/kg/dia (G5), ROS 2mg/kg/dia (G6), OLM 0,5+ROS 2mg/kg/dia (G7), OLM 5+ROS 20mg/kg/dia (G8) administrados oralmente a ratos Wistar. Pressão sistólica (PS) mensurada semanalmente. Análises hematológica, bioquímica {colesterol total (CT), triglicérides (Tg), aminotransferases (AMT), fosfatase alcalina (FA), creatinina (Cr), nitrito/nitrato (NOx), Interleucina-6 (IL-6), Fator de Necrose Tumoral-alfa (TNF-α)}, urinária: {relação albumina/creatinina (RACU)}. Cortes de ventrículo esquerdo, aorta, rins (hematoxilina/eosina e Masson), analisados morfometricamente: análise transversa de cardiomiócitos (ATC), relação média e íntima sobre o lúmen arterial (MILA), fibrose perivascular de arteríolas intramiocárdicas (FPAI). Macrófagos glomerulares (MG) analisados por imunohistoquímica. L-NAME elevou a PS, ATC, MILA, FPVAI, IL-6, MG (p < 0,0001), TNFα, RACU, reduziu NOx (p < 0,01). OLM reduziu PS (p < 0,001), TNF-α (p < 0,05), IL6, ATC, MILA, FPVAIM (p < 0,0001), MG (p < 0,01), RACU (G3) (p < 0,05). ROS elevou NOx (G6), reduziu TNF-α, RACU (G4) (p< 0,05), IL-6, ATC, MILA (G4), FPAI (p < 0,0001), MG (p < 0,001). ROS potencializou efeito de OLM sobre a RACU. OLM e ROS exercem efeitos benéficos no remodelamento miocárdico, vascular, inflamatório e renal em ratos deficientes de NO. Efeitos pleiotrópicos de ROS independentes da PS e CT, mediados por suas propriedades antioxidantes / Changes in myocardial remodeling, vascular inflammation, proteinuria, and glomerular inflammation in nitric oxide (NO)-deficient rats, treated with olmesartan medoxomil (OLM) and / or rosuvastatin calcium (ROS) were studied after 28 days in order to assess the impact of these drugs. Vehicle (G1), nitro-L-arginine methyl ester (L-NAME) 30mg/kg/dia (G2), OLM 5mg/kg/day (G3), ROS 20mg/kg/day (G4), OLM 0,5mg/kg/day (G5), ROS 2mg/kg/day (G6), OLM 0.5+ROS 2mg/kg/day (G7), OLM 5+ROS 20mg/kg/day (G8) orally administered to Wistar rats. Systolic pressure (SBP) measured weekly. Haematological, biochemical {total cholesterol (TC), triglycerides (Tg), aminotransferase (AMT), alkaline phosphatase (ALP), creatinine (Cr), nitrite / nitrate (NOx), Interleukin-6 (IL-6), Tumor Necrosis Factor-alpha (TNFα)}, urinary {albumin / creatinine ratio (UACR)}. Cuts from the left ventricle, aorta, kidneys (hematoxylin / eosin and Masson) were morphometrically analyzed: crosssectional area of cardiomyocytes (Acmy), intima-media thickness on the arterial lumen (IMT), perivascular fibrosis of intramyocardial arterioles ratio (PFR). Glomerular macrophages (GM) were analyzed by immunohistochemistry. L-NAME increased the SBP, Acmy, IMT, PFR, IL-6, GM (p <0.0001), TNF-α, UACR reduced NOx (p <0.01). OLM reduced SBP (p <0.001), TNF-α (p <0.05), IL-6, Acmy, IMT, PFR (p <0.0001), GM (p <0.01), UACR (G3) (p <0.05). ROS increased NOx (G6), reduced TNF-α, UACR (G4) (p <0.05), IL-6, Acmy, IMT (G4), PFR (p <0.0001), GM (p <0.001). ROS potentiated the effect of OLM on UACR. OLM and ROS exert beneficial effects on myocardial, vascular, inflammatory and renal remodeling in nitric oxide deficient rats. The pleiotropic effects of ROS were independent of SBP and TC, mediated by its antioxidant properties.

En France, le syndrome coronaire aigu (SCA) représente environ 100 000 hospitalisations par an. Il est recommandé, en prévention secondaire du SCA, un traitement combinant quatre classes médicamenteuses : bêtabloquants, antiagrégants plaquettaires, statines, et inhibiteurs de l’enzyme de conversion ou antagonistes des récepteurs à l’angiotensine II(combinaison BASI). L’objectif de ce travail était l’étude, en situation réelle de soin et en population générale, de l’utilisation et de l’effectivité de la combinaison thérapeutique recommandée en prévention secondaire du SCA. Nous avons d’abord exploré le potentiel représenté par les bases de données médicoadministratives françaises pour cette évaluation. Nous avons ensuite étudié l’utilisation de la combinaison BASI : 42 % des patients étaient traités par la combinaison BASI en post-SCA et 57 % d’entre eux étaient encore traités à deux ans ; la persistance au traitement était plus faible chez les patients âgés, chez ceux ayant d’autres co-morbidités et chez ceux ayant eu un SCA de nature autre qu’un infarctus du myocarde.Nous avons enfin étudié l’effectivité de la combinaison BASI : la combinaison BASI était la combinaison thérapeutique la plus effective à long terme après un SCA chez les patients avec antécédent d’insuffisance cardiaque ; chez les patients sans antécédent de ce type la combinaison sans bêtabloquants n’était pas associée à une augmentation du risque.Ces résultats permettent de reconsidérer l’intérêt à long terme de l’ensemble de la combinaison BASI en post-SCA chez tous les patients et mettent en avant la nécessité de renforcer les stratégies d’éducation thérapeutique. / Acute coronary syndrome (ACS) causes approximately 100,000 hospitalisations per year in France. In secondary prevention of ACS, guidelines advocate pharmacological treatment combining four drug classes: beta-blockers, antiplatelet agents, statins and angiotensin converting enzyme inhibitors or angiotensin receptor blockers (recommended combination).The aim of this work was to study, in real life and among the general population, the use and the effectiveness of the recommended combination for secondary prevention of ACS.Firstly, we explored the potential represented by the French claims databases in this context. Secondly, we studied the use of the recommended combination: 42% of patients were treated with the recommended combination in post-ACS and 57% of them were still treated two years after; persistence to combination was lower in older patients, in those with other comorbidities and those who had an ACS different of myocardial infarction. Thirdly, we studied the effectiveness of the recommended combination: the recommended combination was the most effective combination therapy at long-term in post-ACS patients with history of heart failure; in patients without such history the combination without betablockers was not associated with an increased risk. These results could help reconsidering the long-term interest of the full recommended combination in all ACS patients and highlight the need to strengthen patient education strategies.