Search PubMed⌕ Search

Biomedical subjects

Michael H Alderman

Publications and source records attributed to Michael H Alderman.

14 recordsLinked to original sources
PubMed2003

Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis.

CONTEXT: Establishing relative benefit or harm from specific antihypertensive agents is limited by the complex array of studies that compare treatments. Network meta-analysis combines direct and indirect evidence to better define risk or benefit. OBJECTIVE: To summarize the available clinical trial evidence concerning the safety and efficacy of various antihypertensive therapies used as first-line agents and evaluated in terms of major cardiovascular disease end points and all-cause mortality. DATA SOURCES AND STUDY SELECTION: We used previous meta-analyses, MEDLINE searches, and journal reviews from January 1995 through December 2002. We identified long-term randomized controlled trials that assessed major cardiovascular disease end points as an outcome. Eligible studies included both those with placebo-treated or untreated controls and those with actively treated controls. DATA EXTRACTION: Network meta-analysis was used to combine direct within-trial between-drug comparisons with indirect evidence from the other trials. The indirect comparisons, which preserve the within-trial randomized findings, were constructed from trials that had one treatment in common. DATA SYNTHESIS: Data were combined from 42 clinical trials that included 192 478 patients randomized to 7 major treatment strategies, including placebo. For all outcomes, low-dose diuretics were superior to placebo: coronary heart disease (CHD; RR, 0.79; 95% confidence interval [CI], 0.69-0.92); congestive heart failure (CHF; RR, 0.51; 95% CI, 0.42-0.62); stroke (RR, 0.71; 0.63-0.81); cardiovascular disease events (RR, 0.76; 95% CI, 0.69-0.83); cardiovascular disease mortality (RR, 0.81; 95% CI, 0.73-0.92); and total mortality (RR, 0.90; 95% CI, 0.84-0.96). None of the first-line treatment strategies-beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers (CCBs), alpha-blockers, and angiotensin receptor blockers-was significantly better than low-dose diuretics for any outcome. Compared with CCBs, low-dose diuretics were associated with reduced risks of cardiovascular disease events (RR, 0.94; 95% CI, 0.89-1.00) and CHF (RR, 0.74; 95% CI, 0.67-0.81). Compared with ACE inhibitors, low-dose diuretics were associated with reduced risks of CHF (RR, 0.88; 95% CI, 0.80-0.96), cardiovascular disease events (RR, 0.94; 95% CI, 0.89-1.00), and stroke (RR, 0.86; 0.77-0.97). Compared with beta-blockers, low-dose diuretics were associated with a reduced risk of cardiovascular disease events (RR, 0.89; 95% CI, 0.80-0.98). Compared with alpha-blockers, low-dose diuretics were associated with reduced risks of CHF (RR, 0.51; 95% CI, 0.43-0.60) and cardiovascular disease events (RR, 0.84; 95% CI, 0.75-0.93). Blood pressure changes were similar between comparison treatments. CONCLUSIONS: Low-dose diuretics are the most effective first-line treatment for preventing the occurrence of cardiovascular disease morbidity and mortality. Clinical practice and treatment guidelines should reflect this evidence, and future trials should use low-dose diuretics as the standard for clinically useful comparisons.

Humans↗
PubMed2003

Differential use of coronary revascularization and hospital mortality following acute myocardial infarction.

BACKGROUND: The effect of racial/ethnic disparity in the use of cardiac procedures on short-term outcomes, such as hospital mortality, is limited. We sought to determine the association of revascularization procedures (percutaneous transluminal coronary angioplasty or coronary artery bypass graft) to hospital mortality in non-Hispanic black and white patients and Hispanic patients with acute myocardial infarction. METHODS: Analysis of the New York State Department of Health Statewide Planning and Research Cooperate System (SPARCS) data for 12 555 patients admitted to New York City hospitals with acute myocardial infarction in 1996. Revascularization procedure frequencies and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for hospital mortality were calculated. RESULTS: Whites were older than Hispanics and blacks (mean +/- SD age, 70 +/- 13.3 vs 64 +/- 13.3 and 64 +/- 12.9 years, respectively; P<.001) and more likely to have heart failure (36.3% vs 29.1% and 29.6%, respectively; P<.001). Blacks were least likely to be revascularized compared with Hispanics and whites (15.8% vs 25.8% and 25.2%, respectively; P<.001). Hispanics were more likely to survive than whites (adjusted OR, 0.73 [95% CI, 0.59-0.91]); this difference was not significant for blacks (adjusted OR, 0.83 [95% CI, 0.69-1.00]). Nonrevascularized blacks and Hispanics were more likely to be discharged alive than nonrevascularized whites (OR, 0.80 [95% CI, 0.66-0.98] for blacks; OR, 0.74 [95% CI, 0.59-0.93] for Hispanics). There were no significant racial/ethnic differences in hospital survival among revascularized patients. CONCLUSIONS: Nonclinical and clinical factors appear to account for blacks being least likely to have been revascularized. Despite these differences in revascularization rates, survival was similar for blacks and whites, whereas Hispanics were more likely to survive than whites.

Black or African American↗
PubMed2003

ALLHAT and beyond.

Explore the source record for details and available documents.

Antihypertensive Agents↗
PubMed2002

Dissociation of hospitalization and mortality trends for myocardial infarction in the United States from 1988 to 1997.

PURPOSE: Although age-adjusted mortality from myocardial infarction in the United States has declined during the past few decades, changes in the incidence of myocardial infarction are less certain. To address this issue, we evaluated trends in hospitalization for, and in-hospital mortality from, myocardial infarction from 1988 to 1997. METHODS: Hospitalization rates were determined by age and sex using data from the National Hospital Discharge Survey and the Current Population Survey. Comorbid conditions, complications, use of cardiac procedures, and in-hospital mortality were measured. In-hospital mortality was estimated after adjusting for associated risk factors, complications, use of invasive diagnostic and therapeutic procedures, and length of stay. RESULTS: Age-adjusted rates of hospitalization for myocardial infarction were 525 per 100,000 in 1988 and 482 per 100,000 in 1997, with a mean annual decline of 0.8% (P = 0.32). Mortality declined from 58 per 100,000 in 1988 to 40 per 100,000 in 1997, a mean annual decline of 4.2% (P = 0.01). During these 10 years, although the median hospital stay for myocardial infarction decreased from 8 to 5 days, the intensity of hospital care increased, including use of angiography from 20% to 31% (P = 0.04) and revascularization from 16% to 31% (P = 0.004). Age-adjusted in-hospital mortality decreased by nearly half, from 7.6% in 1988 to 3.9% in 1997 (P = 0.006). CONCLUSION: During the past decade, the decline in mortality from myocardial infarction in the United States has not been accompanied by a decline in hospitalization rate. At the same time, there has been a marked increased in the use of cardiac revascularization.

Adult↗
PubMed2002

Impact of dietary sodium on cardiovascular disease morbidity and mortality.

Many public health agencies recommend universal restriction of dietary sodium to 100 mmol/L or less per day. This reflects the belief that because sodium restriction reduces blood pressure, it will therefore also reduce cardiovascular disease morbidity and mortality. Although large (100 mmol/L/24 h) reductions in sodium intake do produce a measurable decline in aggregate blood pressure, there is great heterogeneity in individual response, probably reflecting differing genetic, environmental, and behavioral characteristics. Moreover, sodium depletion has multiple other effects including activation of the renin-angiotensin system and the sympathetic nervous system, and increase in insulin resistance. Since the health effect will be the sum of these multiple good and bad effects of sodium reduction, outcome trials are needed to determine the benefit or harm of alteration in sodium intake. Unfortunately, no clinical trial has addressed the question of whether a lower sodium diet would improve or extend life. The best available data derives from six prospective cohort studies. In sum, the scant available observational data do not rule out the possibility of benefit for some and increased risk for others. Considerable experience--most recently the hormone replacement study--underscores the hazards of extrapolating clinical recommendations from observational data alone. In the absence of any evidence from randomized trials of morbidity and mortality outcomes, and in the face of inconsistent observational studies, a universal recommendation for sodium restriction is unwarranted and inconsistent with the principles of evidence-based medicine.

Blood Pressure↗
PubMed2002

Low sodium diet after DASH: has the situation changed? Dietary Approaches to Stop Hypertension.

The Dietary Approaches to Stop Hypertension (DASH) trial adds to the large body of evidence indicating a direct association of dietary sodium with blood pressure, and showing that rigorous reduction of dietary sodium can reduce blood pressure over a 30-day period by statistically significant amounts. DASH, however, neither addressed nor answered whether a reduction of dietary sodium reduces morbidity and mortality. Data linking baseline sodium to mortality and morbidity outcomes are sparse, with only six known studies. Of these, two showed no association, two showed an inverse association, and two showed a direct association only in obese subsets. No studies have examined outcomes after sodium reduction, and no studies have linked sodium to outcomes or even a blood pressure benefit among treated hypertensives. Universal recommendations for sodium reduction or dietary sodium goals should await evidence that such interventions are both safe and effective as measured by morbidity and mortality outcomes.

Blood Pressure↗
PubMed2002

Hypertension guidelines: criteria that might make them more clinically useful.

Cardiovascular disease prevention depends on reduction of risk factors, including hypertension. Guidelines designed to improve management of hypertension are widely available. Their purpose is to assemble the available data from basic biomedical science, epidemiology, and clinical science in an accessible form with which physicians and patients can make reasoned decisions for individual cases. However, guidelines have been neither widely accepted, nor effectively implemented. We recommend a strategy for guideline preparation designed to yield a product more user friendly, accessible, and effective. Guideline recommendations and the evidence used to make them should be based on an explicit grading system. Relevant clinical as well as nonclinical factors must be considered. Moreover, because the goal of antihypertensive therapy is to prevent cardiovascular events, and the likelihood of such events is determined by multifactor or absolute risk assessment, risk, rather than level of blood pressure (BP), should determine the need for therapy. Similarly, the benefit of therapy must be assessed by reduction in cardiovascular disease morbidity and mortality.

Humans↗
PubMed2002

Uric acid and cardiovascular risk.

Uric acid has long been associated with cardiovascular disease. Most epidemiological evidence suggests a significant, graded, independent and specific association between the level of serum uric acid and cardiovascular morbidity and mortality. This is particularly robust among persons at high cardiovascular risk, including those with hypertension, diabetes and congestive heart failure. Although several potential mechanisms have been identified to explain this association, as yet there is no evidence that uric acid bears a causal or reversible relationship to vascular disease.

Animals↗
PubMed2000

Debate: Does it matter how you lower blood pressure?

Whether it matters how pressure is lowered has been debated since antihypertensive drugs proved to prevent cardiovascular events. However, in clinical trials, while the stroke benefit predicted by a given difference in blood pressure was achieved, the results for myocardial infarction were roughly half that expected. This suggested that adverse drug effects of diuretics and beta-blockers might have detracted from their hypotensive effects. Trials with newer antihypertensive classes have revealed superior effects on outcomes associated with converting enzyme inhibitor use, and that alpha-blockers are less cardioprotective than diuretics. These studies establish that simple blood pressure reduction is an inadequate guide to therapy. The challenge now will be to determine the optimal therapy for each hypertensive patient.

Journal Article↗
PubMedDate not supplied

Success and predictors of blood pressure control in diverse North American settings: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT).

CONTEXT: Blood pressure control (<140/90 mm Hg) rates for hypertension fall far short of the US national goal of 50% or more. Achievable control rates in varied practice settings and geographic regions and factors that predict improved blood pressure control are not well identified. OBJECTIVE: To determine the success and predictors of blood pressure control in a large hypertension trial involving a multiethnic population in diverse practice settings. DESIGN: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial is a randomized, double-blind, active-controlled clinical trial with a mean follow-up of 4.9 years. Participant enrollment began in February 1994 and follow-up was completed in March 2002. SETTING: A total of 623 centers in the United States, Canada, and the Caribbean. PARTICIPANTS: A total of 33,357 participants (aged > or =55 years) with hypertension and at least one other coronary heart disease risk factor. INTERVENTIONS: Participants were randomly assigned to receive (double-blind) chlorthalidone, 12.5-25 mg/d (n=15,255), amlodipine 2.5-10 mg/d (n=9048), or lisinopril 10-40 mg/d (n=9054) after other medication was discontinued. Doses were increased within these ranges and additional drugs from other classes were added as needed to achieve blood pressure control (<140/90 mm Hg). MAIN OUTCOME MEASURES: The outcome measures for this report are systolic and diastolic blood pressure, the proportion of participants achieving blood pressure control (<140/90 mm Hg), and the number of drugs required to achieve control in all three groups combined. RESULTS: Mean age was 67 years, 47% were women, 35% black, 36% diabetic; 90% were on antihypertensive drug treatment at entry. At the first of two pre-randomization visits, blood pressure was <140/90 mm Hg in only 27.4% of participants. After 5 years of follow-up, the percent controlled improved to 66%. Systolic blood pressure was <140 mm Hg in 67% of participants, diastolic blood pressure was <90 mm Hg in 92%, the mean number of drugs prescribed was 2.0+/-1.0, and the percent on > or =2 drugs was 63%. Blood pressure control varied by geographic regions, practice settings, and demographic and clinical characteristics of participants. CONCLUSIONS: These data demonstrate that blood pressure may be controlled in two thirds of a multiethnic hypertensive population in diverse practice settings. Systolic blood pressure is more difficult to control than diastolic blood pressure, and at least two antihypertensive medications are required for most patients to achieve blood pressure control. It is likely that the majority of people with hypertension could achieve a blood pressure <140/90 mm Hg with the antihypertensive medications available today.

Aged↗