Calcium-Channel Blockers No Better Than Diuretics for Treating Hypertension

Diuretics are just as effective as calcium-channel blockers, alpha-blockers or angiotensin-converting enzymes (ACE) inhibitors when treating hypertension among patients with metabolic syndrome, according to a report in the Archives of Internal Medicine.

Metabolic syndrome is defined as hypertension with at least two of the following factors: high glyceride levels, diabetes, a body mass index (BMI) of at least 30, and low levels of "good cholesterol." Patients with metabolic syndrome are at high risk for complications of cardiovascular disease.

While some alpha-blockers, ACE inhibitors and calcium channel blockers have more favorable short-term effects on blood glucose or blood cholesterol levels, they have been promoted over beta-blockers and diuretics to treat patients with metabolic syndrome.

Researchers at Case Western Reserve University, Cleveland, analyzed data from the Antihypertensive and Lipid- Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). 42,418 hypertension patients with at least one other risk factor for heart disease were randomly picked to take either a diuretic (chlorthalidone -15,255 patients), a calcium channel blocker (doxazosin mesylate – 9,061 patients), or an ACE inhibitor (lisinopril – 9,054 patients).

Other drugs could be added if necessary to control blood pressure, and patients were checked for an average of 4.9 years for all drugs administered except the alpha-blocker. Followup of this drug was discontinued after 3.2 years, because increased rates of cardiovascular disease were noted, including nearly twice the rate of heart failure, compared with the group taking diuretics. A total of 23,077 ALLHAT participants (54.4%) met criteria for metabolic syndrome.

"No differences were noted among the four treatment groups, regardless of race or metabolic syndrome status for the primary end point (non-fatal myocardial infarction [heart attack] and fatal coronary heart disease)," the authors write.

Among patients with the metabolic syndrome (7,327 black and 15,750 white patients), the calcium channel blocker, ACE inhibitor and alpha-blocker had higher rates of heart failure compared with the diuretic; the ACE inhibitor and the alpha-blocker also had an increased risk of combined cardiovascular disease.

"The lack of benefit of the agents with the most favorable metabolic profile (i.e., ACE inhibitors and alpha-blockers) was especially marked in the black participants with metabolic syndrome," the authors write. "The magnitude of the excess risk of end-stage renal disease (70 percent), heart failure (49 percent) and stroke (37 percent) and the increased risk of combined cardiovascular disease and combined coronary heart disease strongly argue against the preference of ACE inhibitors over diuretics as the initial therapy in black patients with metabolic syndrome. Similar higher risk was noted for those randomized to the alpha-blocker vs. the diuretic."

"These findings fail to provide support for the selection of alpha-blockers, ACE inhibitors, or calcium channel blockers over thiazide-type diuretics to prevent cardiovascular or renal outcomes in patients with metabolic syndrome, despite their more favorable metabolic profiles," the authors conclude.

This study was supported by a contract from the National Heart, Lung, and Blood Institute and by Pfizer Inc. (ALLHAT).

Source: Arch Intern Med. 2008;168[2]:207-217.

Increased Risk for Heart Disease in Women May Be Linked to Calcium in Coronary Arteries

Some 5% of women rated as low-risk for heart disease show indications of advanced coronary artery calcium, and may be at risk for cardiovascular problems, according to a report in Archives of Internal Medicine.

The standard method for assessing a person’s risk of developing coronary heart disease in the next 10 years is the Framingham risk score, which measures age, cholesterol and blood pressure levels, smoking habits and diabetes. Americans are considered low-risk if their risk is estimated at less than 10% in 10 years, and high risk if the risk is 20% or more in 10 years.

Approximately 95% of American women aged less than 70 are considered low-risk. “Nevertheless”, write the authors, “most women will ultimately die of heart disease, suggesting that the Framingham risk score alone does not adequately identify women in ways that would be useful for targeted preventive interventions”.

Susna G. Lakoski, M.D., M.S., of the Wake Forest School of Medicine, Winston-Salem, N.C., and colleagues measured 3,601 women aged 45 to 84, in 2000. Computed tomographic (CT) chest scans determined scores for coronary artery calcium. High scores pointed to considerable amounts of calcium deposits. Participants were interviewed by telephone every 9 to 12 months about any subsequent cardiovascular diagnoses and hospital admissions.

2,684 (90%) of women were assessed as low-risk by the Framingham score. 32% had detectable calcium in their coronary arteries, while during an average of 3.75 years, 24 of the low-risk women had heart attacks or heart pain, and 34% had a cardiovascular disease event such as heart attacks, stroke or death.

“Compared with women with no detectable coronary artery calcium, low-risk women with a coronary artery calcium score greater than zero were at increased risk for coronary heart disease and cardiovascular disease events,” the authors write. In addition, almost 5 percent of the low-risk women had advanced coronary artery calcium, defined as a score of 300 or greater. These women had a 6.7 percent risk of a heart event and 8.6 percent risk of a cardiovascular event over the 3.75-year follow-up.

The authors believe that these data provide new information on cardiovascular disease risk and the evaluation and treatment of it in middle-aged and older women. They also maintain that women with coronary artery calcium are at potentially higher risk that A Framingham risk score would suggest. Further studies with longer follow-up periods will be required to determine whether women should be screened for coronary artery calcium, or treated more aggressively for heart disease risk factors.

Source: Arch Intern Med. 2007;167(22):2399-2401

Simple and Cost Effective Treatment of Calcific Shoulder Tendinitis

A simple and cost effective way of treating calcium tendinitis of the shoulder was revealed by Spanish researchers,led by Dr. Del Cura, publishing in the American Journal of Roentgenology.

Calcium tendinitis presents as small calcium deposits (1 – 2 cm) on the rotator cuff of the shoulder in individuals over 35 years old. Often painful, some resolve spontaneously, but others persist and become disabling.

Traditional treatment involves shockwave therapy to the shoulder, and in worst case scenarios, surgery.

Dr. del Cura’s treatments, in contrast to surgery, are relatively non-invasive, and involve percutaneous needle lavage (with lidocaine or saline solution) guided by sonography.

In a study of 67 shoulders, 91% were "substantially or completely improved." Of note is that "transitory" recurrences were observed 15 weeks after treatment in 44% of shoulders that had previously improved.

Source: American Journal of Roentgenology (AJR 2007; 189:W128-W134)