148 results on '"Michael H. Alderman"'
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2. Dietary Sodium: Where Science and Policy Diverge
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Michael H. Alderman
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Health Status ,Population ,Blood Pressure ,Context (language use) ,030204 cardiovascular system & hematology ,Recommended Dietary Allowances ,Risk Assessment ,03 medical and health sciences ,0302 clinical medicine ,Meta-Analysis as Topic ,Risk Factors ,Environmental health ,Internal Medicine ,Humans ,Medicine ,030212 general & internal medicine ,Sodium Chloride, Dietary ,Policy Making ,education ,Health policy ,education.field_of_study ,Evidence-Based Medicine ,business.industry ,Health Policy ,Evidence-based medicine ,Diet, Sodium-Restricted ,Prognosis ,Causality ,Editorial ,Health effect ,Hypertension ,Practice Guidelines as Topic ,Observational study ,business ,Risk assessment ,Risk Reduction Behavior - Abstract
In 2013, an Institute of Medicine (IOM) Committee, after reviewing available evidence, reached conclusions that differed importantly from conventional belief.1 They reported that while harm exists with “excessive” sodium intakes, the term was specifically left undefined. In addition, they concluded, “evidence was insufficient to support (or refute) previous recommendations for population-based efforts to achieve sodium intake levels of less than 2.3 g/day in the general population or most population subgroups.” While recognizing that blood pressure was a strong surrogate for cardiovascular events, IOM nevertheless concluded that the health effect of of dietary sodium should be determined through assessment of evidence directly linking sodium intake to actual health outcomes—and not through intermediate variables such as blood pressure. Since the IOM report, several additional publications linking dietary sodium to health outcomes have confirmed, clarified, and extended its conclusions.2–6 While observational studies can determine associations, they do not establish causality, and can not generally be a basis for therapeutic intervention. The purpose of this review is to critically assess these recent reports in the context of already available evidence, as well as the IOM report, and to suggest policy options consistent with the evidence. Post IoM studIes more...
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- 2014
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3. Stroke outcomes among participants randomized to chlorthalidone, amlodipine or lisinopril in ALLHAT
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Stanley S. Franklin, Barry R. Davis, Jeffrey L. Probstfield, Michael H. Alderman, Sara L. Pressel, Jose-Miguel Yamal, William C. Cushman, David A. Calhoun, Sithiporn Sastrasinh, Gabriel B. Habib, Suzanne Oparil, and Herbert F. Fendley more...
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Male ,medicine.medical_specialty ,medicine.drug_class ,medicine.medical_treatment ,Kaplan-Meier Estimate ,Calcium channel blocker ,Risk Assessment ,Severity of Illness Index ,Drug Administration Schedule ,Article ,Sex Factors ,Double-Blind Method ,Lisinopril ,Cause of Death ,Internal medicine ,Confidence Intervals ,Internal Medicine ,medicine ,Humans ,Amlodipine ,Stroke ,Aged ,Proportional Hazards Models ,Dose-Response Relationship, Drug ,business.industry ,Age Factors ,Chlorthalidone ,Middle Aged ,medicine.disease ,Survival Rate ,Treatment Outcome ,Blood pressure ,Endocrinology ,Hypertension ,ACE inhibitor ,Cardiology ,Female ,Diuretic ,Cardiology and Cardiovascular Medicine ,business ,circulatory and respiratory physiology ,medicine.drug - Abstract
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized, double-blind, practice-based, active-control, comparative effectiveness trial in 33,357 high-risk hypertensive participants. ALLHAT compared cardiovascular disease outcomes in participants initially treated with an angiotensin-converting enzyme inhibitor (lisinopril), a calcium channel blocker (amlodipine), or a thiazide-type diuretic (chlorthalidone). We report stroke outcomes in 1517 participants in-trial and 1596 additional participants during post-trial passive surveillance, for a total follow-up of 8-13 years. Stroke rates were higher with lisinopril (6-year rate/100 = 6.4) than with chlorthalidone (5.8) or amlodipine (5.5) in-trial but not including post-trial (10-year rates/100 = 13.2 [chlorthalidone], 13.1[amlodipine], and 13.7 [lisinopril]). In-trial differences were driven by race (race-by-lisinopril/chlorthalidone interaction P = .005, race-by-amlodipine/lisinopril interaction P = .012) and gender (gender-by-lisinopril/amlodipine interaction P = .041), separately. No treatment differences overall, or by race or gender, were detected over the 10-year period. No differences appeared among treatment groups in adjusted risk of all-cause mortality including post-trial for participants with nonfatal in-trial strokes. Among Blacks and women, lisinopril was less effective in preventing stroke in-trial than either chlorthalidone or amlodipine, even after adjusting for differences in systolic blood pressure. These differences abated by the end of the post-trial period. more...
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- 2014
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4. Pressor Response to Initial Blood Pressure Monotherapy Is Associated With Cardiovascular Mortality
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Michael H. Alderman, Hillel W. Cohen, and Maday C. Gonzalez
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Adult ,Male ,medicine.medical_specialty ,Adrenergic beta-Antagonists ,Angiotensin-Converting Enzyme Inhibitors ,Plasma renin activity ,Prehypertension ,Cohort Studies ,Coronary artery disease ,Internal medicine ,Internal Medicine ,Humans ,Medicine ,Longitudinal Studies ,Prospective Studies ,Diuretics ,Prospective cohort study ,Antihypertensive Agents ,business.industry ,Hazard ratio ,Middle Aged ,Calcium Channel Blockers ,Prognosis ,medicine.disease ,Confidence interval ,Blood pressure ,Cardiovascular Diseases ,Vasoconstriction ,Anesthesia ,Hypertension ,Cardiology ,Aortic pressure ,Female ,business ,circulatory and respiratory physiology - Abstract
Background: A paradoxical pressor systolic response to initial antihypertensive monotherapy has been observed in 8% of hypertensive patients. The long-term consequences of this finding are unknown. Methods: We included 945 hypertensive patients with baseline systolic blood pressure (SBP) ≥140mm Hg. A 4-week washout period free of antihypertensive drugs was allowed for those already on treatment at entry. Mortality outcomes were ascertained from the National Death Index. Subjects were categorized by SBP response into depressor (≥10mm Hg fall), nonresponder, and pressor (≥10mm Hg rise) categories. Results: There were 268 fatalities. Of these, 100 (37%) were from cardiovascular disease (CVD), of which 70 (70%) were due to coronary artery disease (CAD). A pressor response was associated with higher SBP at 1 year compared with the nonresponder or depressor response (141 vs. 136 vs. 136mm Hg). CVD mortality was greater in pressors than depressors (hazard ratio (HR) = 3.0; 95% confidence interval (CI) = 1.4-6.4; P = 0.004], as was CAD (HR = 3.1; 95% CI = 1.4-6.8; P < 0.01) and all-cause mortality (HR = 1.7; 95% CI = 1.1-2.6; P = 0.02), after adjusting for 1-year SBP and other possible confounders. Conclusions: We found the incidence of a pressor response to monotherapy at 3 months was significantly, specifically, and independently associated with higher subsequent cardiovascular mortality. more...
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- 2014
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5. Can We End the Salt Wars With a Randomized Clinical Trial in a Controlled Environment?
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Daniel W. Jones, Paul K. Whelton, Michael H. Alderman, Robert M. Califf, Friedrich C. Luft, David A. McCarron, Eric D. Peterson, and John E. Hall
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medicine.medical_specialty ,MEDLINE ,Disease ,030204 cardiovascular system & hematology ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Internal Medicine ,Humans ,Medicine ,030212 general & internal medicine ,Sodium Chloride, Dietary ,Intensive care medicine ,Stroke ,Randomized Controlled Trials as Topic ,business.industry ,Public health ,Diet, Sodium-Restricted ,Environment, Controlled ,medicine.disease ,Clinical trial ,Blood pressure ,Cardiovascular Diseases ,Observational study ,business - Abstract
The 2013 Institute of Medicine (IOM; now the National Academy of Medicine) Report: Sodium intake in populations recommended that “clinical trials might focus on examining the effects of a range of sodium levels on risk of cardiovascular events, stroke, and mortality among patients in controlled environments.”1 This recommendation was specific in 2 regards. It recommends a cardiovascular outcomes trial of dietary sodium reduction, and it recommends this be done in people in controlled environments. There are important reasons behind these specific recommendations. Despite the large body of data on the relationship between cardiovascular disease and dietary sodium from observational studies and the positive impact on blood pressure in randomized controlled clinical trials and current national guidelines recommending daily sodium intakes of ≤2300 mg/d, mean daily intake for Americans remains in the 3400 to 3500 mg/d range.2 Some scientists have questioned the justification for a reduced intake of dietary sodium.3 This disagreement within the scientific community has been reported in the lay press, leading both clinicians and some in the public to express uncertainty on the issue.4–6 The IOM is not alone in calling for an outcomes clinical trial on dietary sodium. The World Heart Federation, the European Society of Hypertension, and the European Public Health Association joined together to call for a definitive clinical trial of sodium restriction.7 Indeed, for years, leading voices in this area of research have noted the absence of evidence from an outcomes-based clinical trial and advocated for execution of such a trial. The reason this trial has not been accomplished can be seen in the second specificity of the IOM recommendations: that the trial be performed in “patients in controlled environments.” This statement recognizes the … more...
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- 2018
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6. ATTAINED BLOOD PRESSURE LEVELS AND CARDIOVASCULAR EVENTS AND MORTALITY AMONG OLDER WOMEN
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V. Kaminsky, Michael H. Alderman, A. Mcginn, Bernhard Haring, and S. Smoller
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Gerontology ,Blood pressure ,Physiology ,business.industry ,Women's Health Initiative ,Internal Medicine ,Medicine ,Cardiology and Cardiovascular Medicine ,business ,Life study - Abstract
Objective:To examine prospectively the relationship of attained blood pressure levels to cardiovascular events and mortality in older women in the Women's Health Initiative Long Life Study (WHI-LLS).Design and method:Participants in the LLS are 7,875 women who are part of the WHI, who were over 70 y more...
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- 2019
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7. THE HYPERTENSION PARADIGM
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Jean E. Sealey, Jon D. Blumenfeld, Curt D. Furberg, and Michael H. Alderman
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medicine.medical_specialty ,Blood pressure ,Physiology ,business.industry ,Public health ,Internal Medicine ,medicine ,Risk factor ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,business - Abstract
Objective:Belief that a particular blood pressure (BP) can separate ‘hypertension’ from ‘normo-tension’ has transformed a ‘risk factor’ into a treatable condition. An arbitrary blood pressure threshold establishes the diagnosis and standardizes treatment provided by conventional medical caregivers. more...
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- 2019
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8. Renin-Angiotensin System Blockers May Create More Risk Than Reward for Sodium-Depleted Cardiovascular Patients With High Plasma Renin Levels
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Jean E. Sealey, Michael H. Alderman, Curt D. Furberg, and John H. Laragh
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medicine.medical_specialty ,medicine.drug_class ,business.industry ,Sodium ,Global Health ,Brain natriuretic peptide ,medicine.disease ,Plasma renin activity ,Renin-Angiotensin System ,Survival Rate ,Endocrinology ,Blood pressure ,Cardiovascular Diseases ,Risk Factors ,Internal medicine ,Renin ,Renin–angiotensin system ,Internal Medicine ,medicine ,Natriuretic peptide ,Humans ,Salt intake ,Hyponatremia ,business ,Blood urea nitrogen - Abstract
Background Four recent reports revealed differences in survival rates among treated cardiovascular patients taking renin-angiotensin system–blocking drugs. Patients with higher on-treatment plasma renin activity (PRA) levels died sooner of cardiovascular mortality than those with lower levels. We investigated whether excessive sodium depletion might have induced the higher PRA levels and contributed to the greater morbidity and mortality. Methods Using published data, ranges of PRA, blood pressures, drug usage, and biochemical parameters were compared among various groups of cardiovascular patients. Results We showed (i) that PRA levels are usually medium to low in treated cardiovascular patients, but are sometimes abnormally high, (ii) that excessive sodium depletion can induce such high PRA levels, (iii) that the higher PRA patients exhibited evidence of sodium depletion: lower blood pressures, more frequent natriuretic drug usage, lower N-terminal pro b-type natriuretic peptide (NT-proBNP), and higher blood urea nitrogen and uric acid levels, with similar usage of renin-angiotensin blocking drugs. Conclusions We hypothesize that patients with high on-treatment PRA levels die sooner of cardiovascular events because they are excessively sodiumvolume depleted. Moreover, renin-angiotensin system–blocking drugs may be harmful in such patients because they can functionally interfere with the effects of reactive rises in PRA that are triggered to prevent potentially dangerous falls in blood pressure, increases in plasma potassium, and falls in glomerular filtration rate. Careful liber alization of salt intake and subtraction of natriuretic drugs, sufficient to reduce reactive hyperreninemia without inducing unacceptable increases in blood pressure, might benefit such patients and decrease risk of adverse effects from drugs that block the renin-angiotensin system. more...
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- 2013
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9. Mortality and Morbidity During and After the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
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Barry R. Davis, Michael H. Alderman, Charles E. Ford, Paula T. Einhorn, Lara M. Simpson, L. Julian Haywood, William C. Cushman, Jan Basile, Richard H. Grimm, Linda B. Piller, Jeffrey L. Probstfield, Robert J. Weiss, Paul K. Whelton, Carol Stanford, Jackson T. Wright, Sara L. Pressel, Jeffrey A. Cutler, Bruce P. Hamilton, Suzanne Oparil, Stephen T. Ong, and Henry R. Black more...
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medicine.medical_specialty ,business.industry ,Endocrinology, Diabetes and Metabolism ,Hazard ratio ,Lisinopril ,medicine.disease ,Endocrinology ,Blood pressure ,Internal medicine ,Heart failure ,Internal Medicine ,medicine ,Chlorthalidone ,Amlodipine ,Complications of hypertension ,Cardiology and Cardiovascular Medicine ,business ,Stroke ,medicine.drug - Abstract
A randomized, double-blind, active-controlled, multicenter trial assigned 32,804 participants aged 55 years and older with hypertension and ≥ 1 other coronary heart disease risk factors to receive chlorthalidone (n=15,002), amlodipine (n=8898), or lisinopril (n=8904) for 4 to 8 years, when double-blinded therapy was discontinued. Passive surveillance continued for a total follow-up of 8 to 13 years using national administrative databases to ascertain deaths and hospitalizations. During the post-trial period, fatal outcomes and nonfatal outcomes were available for 98% and 65% of participants, respectively, due to lack of access to administrative databases for the remainder. This paper assesses whether mortality and morbidity differences persisted or new differences developed during the extended follow-up. Primary outcome was cardiovascular mortality and secondary outcomes were mortality, stroke, coronary heart disease, heart failure, cardiovascular disease, and end-stage renal disease. For the post-trial period, data are not available on medications or blood pressure levels. No significant differences (P more...
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- 2011
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10. Enduring Direct Association of Baseline Plasma Renin Activity With All-Cause and Cardiovascular Mortality in Hypertensive Patients
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Michael H. Alderman, Hillel W. Cohen, Maday C. Gonzalez, Jean E. Sealey, and John H. Laragh
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medicine.medical_specialty ,Framingham Risk Score ,business.industry ,Hazard ratio ,medicine.disease ,Plasma renin activity ,Confidence interval ,Coronary artery disease ,Framingham Heart Study ,Blood pressure ,Internal medicine ,Internal Medicine ,medicine ,Cardiology ,cardiovascular diseases ,Myocardial infarction ,business - Abstract
Background Plasma renin activity (PRA) has been associated with cardiovascular disease mortality (CVD) events among hypertensive patients. We now report a long-term follow-up to assess the enduring association of PRA to CVD and all-cause mortality. methodS Participants (3,791) in a systematic hypertension treatment study had entry systolic blood pressure (BP) ≥140 mm Hg and mean age 52. CVD and all-cause mortality was ascertained for mean of 16 years. Pretreatment PRA was analyzed as a continuous variable, and by tertiles. The 10-year Framingham score was similarly examined. Hazard ratios (HRs) were estimated from multivariate Cox proportional hazard models. reSult S There were 804 deaths, and 360 (45%) were CVD. PRA was associated with all-cause mortality and CVD, but not cancer or non-CVD. Although T3 had lower mean baseline and follow-up systolic BP than T1, (146 vs. 152 mm Hg (P < 0.001) and 135 vs. 139 mm Hg (P < 0.001), respectively), T3 had 37% higher all-cause mortality (HR: 1.37, 95% confidence interval (CI): 1.15–1.63, P < 0.001) and 70% higher CVD mortality (HR: 1.70, 95% CI: 1.29–2.23, P < 0.001) after adjustment. The difference between T3 and T1 in mortality from coronary artery disease and myocardial infarction was more pronounced than for all CVD. PRA also significantly improved CVD risk estimation provided by Framingham. concluSionS These findings extend and reinforce previous evidence that pretreatment PRA has a significant, independent, specific, and direct long-term association with CVD mortality. Moreover, PRA adds significantly to risk identified by the Framingham score. more...
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- 2011
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11. Hypertension Control at Physicians' Offices in the United States
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Jing Fang, Janet B. Croft, Carma Ayala, Michael H. Alderman, and Nora L. Keenan
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Adult ,Male ,medicine.medical_specialty ,Blood Pressure ,Internal Medicine ,medicine ,Humans ,Risk factor ,Medical prescription ,Intensive care medicine ,Life Style ,Stroke ,Antihypertensive Agents ,Aged ,business.industry ,Health Policy ,Primary care physician ,Odds ratio ,Physician Office ,Middle Aged ,medicine.disease ,Physicians' Offices ,United States ,Cross-Sectional Studies ,Logistic Models ,Blood pressure ,Health Care Surveys ,Hypertension ,Multivariate Analysis ,Ambulatory ,Emergency medicine ,Female ,business - Abstract
BACKGROUND Uncontrolled hypertension is a common and important risk factor for heart disease and stroke. Nevertheless, the control rate among patients taking prescribed medication and/or therapeutic lifestyle modification has remained about the same for the past several decades. METHODS We analyzed 2003 and 2004 National Ambulatory Medical Care Survey (NAMCS) data to determine hypertension control in the physician offices in the United States. All visits for hypertension with measured blood pressure levels were included in the analyses. Survey weights were applied to obtain national estimates. Characteristics associated with hypertension control status were identified. RESULTS About 176 million hypertension-related office visits occurred (9.7% of total office visits) during 2003 and 2004. Of these, 17, 44, and 62% of visits had blood pressure more...
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- 2008
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12. Sodium, blood pressure, and cardiovascular disease
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Hillel W. Cohen and Michael H. Alderman
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Clinical Trials as Topic ,Inverse Association ,business.industry ,Sodium ,Hazard ratio ,chemistry.chemical_element ,Physiology ,Blood Pressure ,Sodium, Dietary ,medicine.disease ,Cohort Studies ,Stroke ,Blood pressure ,Salt and cardiovascular disease ,chemistry ,Cardiovascular Diseases ,Hypertension ,Aortic pressure ,Humans ,Medicine ,Cardiology and Cardiovascular Medicine ,business ,Cohort study - Abstract
PURPOSE OF REVIEW Persistent recommendations for universal restriction of dietary sodium intake are based on associations of sodium intake with blood pressure. No clinical trial data support an association of sodium intake with mortality and morbidity outcomes, however, while results of observational studies appear heterogeneous. Can these contradictory data be reconciled to inform health policy regarding sodium intake recommendations? RECENT FINDINGS We reported (2006) a statistically significant (P = 0.03) association of sodium intake less than 2.3 g/day with increased cardiovascular disease mortality (hazard ratio 1.37) in a representative sample of the US adult population with an observed baseline mean sodium intake of 2.7 g/day. Others reported (2004) a significant (P < 0.01) higher stroke death among males and borderline significant (P = 0.07) for females, for highest compared with lowest sodium tertile in a community in Japan with mean intake of 5.4 g/day. SUMMARY These results are consistent with earlier studies suggesting that the association of sodium with morbidity and mortality in industrial societies follows a 'J shape' with a direct association at high levels of average intake (over 4 g), an inverse association at lower levels (less than 2 g) and no measurable effect for the widely prevalent intakes in between. more...
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- 2007
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13. Reply to SN Thornton1
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Michael H. Alderman, Janet C. King, Kristin J. Reimers, and David A. McCarron
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medicine.medical_specialty ,Vasopressin ,Sodium ,Population ,Medicine (miscellaneous) ,Physiology ,chemistry.chemical_element ,Blood Pressure ,Recommended Dietary Allowances ,chemistry.chemical_compound ,Internal medicine ,medicine ,Humans ,education ,Letters to the Editor ,education.field_of_study ,Kidney ,Nutrition and Dietetics ,Aldosterone ,business.industry ,Sodium, Dietary ,Congresses as Topic ,Diet, Sodium-Restricted ,medicine.disease ,Angiotensin II ,Blood pressure ,Endocrinology ,medicine.anatomical_structure ,Treatment Outcome ,chemistry ,Hypertension ,business ,Hyponatremia ,Food Science - Abstract
Dear Editor: The comments and concerns expressed by Thornton (1) relate to our recent reviews from the ASN Scientific Sessions at Experimental Biology 2014 symposium regarding sodium intake and health outcomes. His comments appropriately expand the discussion of whether to reduce sodium intakes to low amounts. Our intent with the cited papers was never to exclude critical cofactors such as water. The neural regulation of water and sodium are physiologically interrelated (2), because optimizing both volume and osmolality are essential elements of cardiovascular health. As noted by Thornton, the hormonal response to decreased perfusion invokes angiotensin II, aldosterone, and vasopressin release, all of which have potent vascular actions that potentially increase cardiovascular disease (CVD) risk. Thornton’s argument that overlooking the role of water intake in understanding the association of sodium with health outcomes raises another question as to the safety of a health policy directed at lowering sodium intake across the entire population. Hyponatremia at hospital admission and in free-living populations has been associated with both increased morbidity and mortality (3–6). Those findings are consistent with the proposition that sodium and water intake must be considered in tandem when assessing health outcomes. As opposed to previous hypotheses that comorbidities accounted for an increased risk of death, recent data indicate that the greatest risk appears in those with few comorbid conditions (5, 6). Hyponatremia is the most common electrolyte disturbance in the general population (6). Reduced sodium intake in and of itself can impair the healthy kidney’s ability to excrete excess free water (7). Therefore, a lower sodium diet would promote the development of a reduced serum sodium concentration, or hyponatremia. Although it is typically assumed that with normal kidney function there is a large excess renal capacity to excrete water, what is not generally appreciated is that reduced solute intake impairs the healthy kidney’s capacity to excrete excess water (7). Sodium intake is one of the principle contributors to the renal solute load. Thus, lower sodium intake potentially sets in motion a normal physiologic response that would contribute to the development of hyponatremia in a segment of the general population. If healthy persons lower their sodium intake as recommended by current guidelines, but maintain water consumption that exceeds requirements (as is widely promoted to the general population, especially physically active people), those guidelines may well set the stage for the emergence of hyponatremia even in otherwise healthy people. The hyponatremia-related mortality and morbidity data published to date and the physiology of sodium and water handling by the kidney provide a plausible explanation to account for the increased risk of death from lower sodium intake in healthy, low-risk individuals (8). Furthermore, such a risk would not solely rest on activation of the renin-angiotensin system and aldosterone invoked for those already at risk of CVD. Perhaps the simplest and most important aspect of the issue raised by Thornton is his reminder that water metabolism is linked to sodium. That obvious and accepted physiologic link should serve as a note of caution that there are many “moving parts” associated with reducing sodium intake in the general population. The longstanding assumption that sodium restriction to amounts below that normally consumed in modern societies is safe and effective fails to consider that complex physiology. The old adage that “it is too good to be true” may well apply to the simplistic policy view that sodium restriction lowers blood pressure and therefore reduces CVD risk. more...
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- 2015
14. Clinical Events in High-Risk Hypertensive Patients Randomly Assigned to Calcium Channel Blocker Versus Angiotensin-Converting Enzyme Inhibitor in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
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Michael H. Alderman, William C. Cushman, Henry R. Black, Barry R. Davis, Richard A. Dart, Chuke Nwachuku, Steven A. Atlas, Paul K. Whelton, Richard H. Grimm, Jan Basile, James V. Felicetta, Aloysius B. Cuyjet, Udho Thadani, Lara M. Simpson, Syed Z. A. Jafri, Frans H. H. Leenen, L. Julian Haywood, Michael A. Proschan, and Jackson T. Wright more...
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Blood Glucose ,Male ,Risk ,medicine.medical_specialty ,medicine.drug_class ,Cardiac Output, Low ,Myocardial Infarction ,Black People ,Angiotensin-Converting Enzyme Inhibitors ,Blood Pressure ,Coronary Disease ,Calcium channel blocker ,law.invention ,Randomized controlled trial ,Lisinopril ,law ,Internal medicine ,Internal Medicine ,medicine ,Humans ,Amlodipine ,Angioedema ,Sex Distribution ,Hypolipidemic Agents ,biology ,business.industry ,Incidence ,Angiotensin-converting enzyme ,Middle Aged ,Calcium Channel Blockers ,medicine.disease ,Blood pressure ,Cardiovascular Diseases ,Heart failure ,Hypertension ,ACE inhibitor ,Cardiology ,biology.protein ,Female ,Hypertrophy, Left Ventricular ,Gastrointestinal Hemorrhage ,business ,Glomerular Filtration Rate ,medicine.drug - Abstract
The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) provides a unique opportunity to compare the long-term relative safety and efficacy of angiotensin-converting enzyme inhibitor and calcium channel blocker–initiated therapy in older hypertensive individuals. Patients were randomized to amlodipine (n=9048) or lisinopril (n=9054). The primary outcome was combined fatal coronary heart disease or nonfatal myocardial infarction, analyzed by intention-to-treat. Secondary outcomes included all-cause mortality, stroke, combined cardiovascular disease (CVD), end-stage renal disease (ESRD), cancer, and gastrointestinal bleeding. Mean follow-up was 4.9 years. Blood pressure control was similar in nonblacks, but not in blacks. No significant differences were found between treatment groups for the primary outcome, all-cause mortality, ESRD, or cancer. Stroke rates were higher on lisinopril in blacks (RR=1.51, 95% CI 1.22 to 1.86) but not in nonblacks (RR=1.07, 95% CI 0.89 to 1.28), and in women (RR=1.45, 95% CI 1.17 to 1.79), but not in men (RR=1.10, 95% CI 0.92 to 1.31). Rates of combined CVD were higher (RR=1.06, 95% CI 1.00 to 1.12) because of higher rates for strokes, peripheral arterial disease, and angina, which were partly offset by lower rates for heart failure (RR=0.87, 95% CI 0.78 to 0.96) on lisinopril compared with amlodipine. Gastrointestinal bleeds and angioedema were higher on lisinopril. Patients with and without baseline coronary heart disease showed similar outcome patterns. We conclude that in hypertensive patients, the risks for coronary events are similar, but for stroke, combined CVD, gastrointestinal bleeding, and angioedema are higher and for heart failure are lower for lisinopril-based compared with amlodipine-based therapy. Some, but not all, of these differences may be explained by less effective blood pressure control in the lisinopril arm. more...
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- 2006
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15. Evidence Relating Dietary Sodium to Cardiovascular Disease
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Michael H. Alderman
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medicine.medical_specialty ,Nutrition and Dietetics ,Chemistry ,Sodium ,Medicine (miscellaneous) ,Hemodynamics ,chemistry.chemical_element ,Blood Pressure ,Sodium, Dietary ,Disease ,medicine.disease ,law.invention ,Insulin resistance ,Endocrinology ,Blood pressure ,Randomized controlled trial ,Cardiovascular Diseases ,law ,Internal medicine ,medicine ,Humans ,Observational study ,Salt intake - Abstract
The expectation that dietary sodium intake might influence cardiovascular disease occurrence has been based upon its impact on blood pressure (BP). Solid experimental data confirms the ability of large (75-100 mmols/24 hours) changes in dietary sodium to reduce pressure by, on average, mid-low single digits. However, there is substantial inter-individual variation in BP response. In addition, sodium restriction generates other, sometimes undesirable effects, including increased insulin resistance, activation of the renin-angiotensin system, and increased sympathetic nerve activity. The health effects of salt restriction are, therefore, the sum of these recognized, and probably other unrecognized, intermediate effects. Ideally, salt restriction would be tested in a randomized clinical trial. In its absence, there are 9 observational studies linking baseline sodium intake, estimated by either 24 hour urine or dietary intake, to morbidity and mortality. The results have been inconsistent. The only study in hypertensive patients, there was an inverse relation of sodium to cardiovascular outcome. In a Japanese study, stroke incidence was increased among males with the highest salt intake. Two studies found a direct relation of sodium intake to cardiovascular mortality in an obese minority of the group studied. Taken together, these results suggest, not surprisingly given the genetic, behavioral, and environmental variety of humankind, that heterogeneity best describes the relation of sodium intake to cardiovascular morbidity and mortality. In short, the available data provides no support for any universal recommendation of a particular level of dietary sodium. more...
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- 2006
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16. Renal dysfunction and ischemic heart disease mortality in a hypertensive population
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Hillel W. Cohen, Michael H. Alderman, and Susan M. Hailpern
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Adult ,Male ,medicine.medical_specialty ,Heart disease ,Physiology ,Population ,Myocardial Ischemia ,Renal function ,Blood Pressure ,urologic and male genital diseases ,National Death Index ,Internal medicine ,Internal Medicine ,medicine ,Humans ,Prospective cohort study ,education ,Occupational Health ,Aged ,Proportional Hazards Models ,Analysis of Variance ,education.field_of_study ,business.industry ,Hazard ratio ,Middle Aged ,medicine.disease ,Health Surveys ,Surgery ,Survival Rate ,Hypertension ,Cohort ,Cardiology ,Female ,Kidney Diseases ,New York City ,Cardiology and Cardiovascular Medicine ,business ,Glomerular Filtration Rate ,Kidney disease - Abstract
Objective While recent studies indicate that renal dysfunction may be predictive of all-cause mortality and cardiovascular disease (CVD) outcomes in hypertensive individuals, there has been little attention to the specific association of ischemic heart disease (IHD) mortality and renal function. This study examines the relationship between IHD mortality and baseline glomerular filtration rate (GFR) (estimated by the Cockcroft and Gault formula) among treated hypertensive subjects. Design A prospective cohort study of participants in a worksite-based antihypertensive treatment program in New York City (1981–1999). Patients We studied 9929 subjects who had at least 6 months follow-up (mean 9.6 years) with a baseline serum creatinine. Main outcome measures IHD death outcomes (n = 343) ascertained from the National Death Index. Results Multivariate Cox proportional hazard models were constructed adjusting for known cardiovascular risk factors. Mean GFR of the cohort was 91.6 ml/min per 1.73 m2. Those with lower GFR were more likely to be older, female, White, report a history of cardiovascular disease, have higher cholesterol and blood urea nitrogen values, and lower hemoglobin and body mass index than those with highest GFR. After adjustment for known cardiovascular risk factors, the risk of IHD death increased progressively as the GFR decreased. Hazard ratio for IHD mortality for each 10-unit reduction of estimated GFR below the normal threshold of ≥ 90 ml/min per 1.73 m2 was 1.33 (95% confidence interval 1.17, 1.50; P Conclusions The results of this study suggest an independent inverse association between estimated GFR and IHD mortality among treated hypertensive individuals. more...
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- 2005
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17. Exercise and Cardiovascular Outcomes by Hypertensive Status: NHANES I Epidemiological Follow-up Study, 1971–1992
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Jing Fang, Judith Wylie-Rosett, and Michael H. Alderman
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Adult ,Male ,medicine.medical_specialty ,National Health and Nutrition Examination Survey ,Population ,Blood Pressure ,Physical exercise ,Prehypertension ,Risk Factors ,Internal medicine ,Internal Medicine ,medicine ,Humans ,education ,Exercise ,Aged ,Proportional Hazards Models ,Retrospective Studies ,education.field_of_study ,Proportional hazards model ,business.industry ,Incidence ,Mortality rate ,Incidence (epidemiology) ,Middle Aged ,United States ,Survival Rate ,Blood pressure ,Cardiovascular Diseases ,Hypertension ,Physical therapy ,Female ,business ,Follow-Up Studies - Abstract
A favorable effect of exercise on cardiovascular longevity has been repeatedly demonstrated in the general population. The association of exercise and cardiovascular disease (CVD) outcome among persons with different blood pressure (BP) status is less well known.We examined the epidemiologic follow-up of the First National Health and Nutrition Examination Survey (NHANES I) (1971-1992). Of 14,407 participants, 9791 subjects aged 25 to 74 years met inclusion criteria. All cause, CVD, and non-CVD mortality rates, as well as CVD incidence rates were determined. The associations of levels of exercise and outcomes by BP status were examined. Age- and gender-adjusted rates, as well as Cox proportional hazard models were determined.During 17 years of follow-up, there were 3069 deaths, 1465 of which were CVD. In addition, 2808 subjects had incident CVD events. Overall, CVD incidence and mortality rates increased as BP rose. The association of exercise with CVD events differed by BP status (normal, prehypertension, and hypertension). Age- and gender-adjusted CVD mortality rate per 1000 person-years for least, moderate, and most exercise were 5.0, 3.6, and 2.4 among normotensive subjects (P.05), 6.3, 4.7, and 5.2 among prehypertensive subjects (P.05), and 11.8, 9.8, and 8.7 among hypertensive subjects (P.01), respectively. In fact, exercise was a significant independent predictor of reduced CVD event only among hypertensive subjects, after adjusting for other CVD risk factors. Among prehypertensive and normotensive subjects, where events were fewer, those who exercise more vigorously also had lower mortality, but these differences did not reach statistical significance.This study, consistent with previous observational data, demonstrates that increased exercise is associated with decreased CVD event. Interestingly, this effect is most robust among hypertensive subjects, whereas for prehypertensive and normotensive subjects, a significant benefit of exercise on CVD outcome, perhaps because of lack of power, was not found. more...
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- 2005
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18. Is High Pulse Pressure a Marker of Preclinical Cardiovascular Disease?
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Giovanni de Simone, Richard B. Devereux, Michael H. Alderman, Maurizio Galderisi, Oreste de Divitiis, and Mary J. Roman
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Adult ,Male ,medicine.medical_specialty ,Brachial Artery ,Heart Ventricles ,Blood Pressure ,Asymptomatic ,Predictive Value of Tests ,Internal medicine ,medicine.artery ,Heart rate ,Internal Medicine ,Humans ,Medicine ,Brachial artery ,business.industry ,Stroke Volume ,Stroke volume ,Middle Aged ,Pulse pressure ,medicine.anatomical_structure ,Blood pressure ,Endocrinology ,Cardiovascular Diseases ,Echocardiography ,Case-Control Studies ,Hypertension ,Vascular resistance ,Cardiology ,Female ,Vascular Resistance ,medicine.symptom ,business ,Body mass index - Abstract
This study tests the hypothesis that high brachial pulse pressure might constitute preclinical cardiovascular disease, rather than a risk factor. We studied 1250 subjects (472 nonobese normotensive [63 mm Hg, and peripheral resistance high when >90th percentile of normal distribution. Among hypertensive subjects, 34% had high resistance; among them, 33% had high brachial pulse pressure, as opposed to 147 of 516 patients (28.5%) with normal resistance ( P =not significant). After adjusting for age, sex, race, body mass index, heart rate, and center, left ventricular (LV) internal dimension and mass were lower with high resistance, and higher when brachial pulse pressure was high. PP/SV was 36% higher with high resistance than with normal resistance, and higher when brachial pulse pressure was high (all P more...
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- 2005
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19. The IOM Report Fails To Detect Evidence to Support Dietary Sodium Guidelines
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Michael H. Alderman and Hillel W. Cohen
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National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division ,medicine.medical_specialty ,business.industry ,Sodium ,Alternative medicine ,MEDLINE ,Blood Pressure ,Sodium, Dietary ,Recommended Dietary Allowances ,Disease control ,United States ,Sodium intake ,Harm ,Dietary Sodium ,Family medicine ,Environmental health ,Credibility ,Internal Medicine ,medicine ,Humans ,New York City ,Observational study ,Centers for Disease Control and Prevention, U.S ,business - Abstract
The recent Institute of Medicine (IOM) report “Sodium intake in populations: Assessment of Evidence”1 has provided critical information concerning the dietary sodium guidelines currently recommended by agencies of the US government.2 The American Journal of Hypertension has assembled a set of commentaries providing the range of official and independent views addressing how the IOM report will (or should) influence dietary sodium policy and practice.3–7 Our purpose is to provide a concise and comprehensive assessment of how things stand in the immediate aftermath of the IOM report. Our hope is that these manuscripts will further inform what promises to be a lively public and scientific debate about the implications of the IOM report. The balanced review and analysis has the credibility to make this report a paradigm shifting publication. The hypothesis from which sodium guidelines emerged i.e., that because reduced sodium intake lowered blood pressure, it would inevitably prevent cardiovascular morbidity and mortality – has failed to find support in the IOM report. The Committee found that the modest blood pressure effect is not a certain surrogate for health outcomes associated with sodium intake. Instead, the Committee’s case rested upon evidence of actual health consequences associated with reducing sodium intake from the current average of 3,400 mgs/day, to 5,000 mgs) of sodium to all lower intake levels. Third, based upon the large body of mostly observational data reported over the past 8 years, it found that a possibility of harm existed at the lower ( more...
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- 2013
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20. [Untitled]
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Michael H. Alderman, Luis M. Ruilope, Curt D. Furberg, Rodney Jackson, John B. Kostis, Bruce M. Psaty, Massimo Volpe, and John H. Laragh
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medicine.medical_specialty ,business.industry ,medicine.drug_class ,Elevated bp ,Case-control study ,medicine.disease ,Surgery ,Blood pressure ,Diabetes mellitus ,Internal Medicine ,medicine ,Disease risk ,Risk factor ,Intensive care medicine ,business ,Antihypertensive drug ,Risk assessment - Abstract
Background Most current clinical guidelines focus primarily on the management of individual cardiovascular risk factors, such as high blood pressure (BP), hypercholesterolemia, or diabetes. A more appropriate clinical approach to reducing cardiovascular disease risk would be based on a comprehensive evaluation of risk profile, and accurate stratification of global (absolute) risk in individual patients. We propose that global risk should be used as the main determinant of whom to treat, how to treat, and how much to treat. Methods In this article we use a series of case studies to demonstrate the implications of replacing the traditional “single risk factor-based” approach to managing hypertension by one based on global risk assessment. In some situations patients with mildly elevated BP levels would not be recommended for antihypertensive drug treatment whereas others with lower BP would be treated, depending upon the entire risk profile. Conclusion We propose to replace the single risk factor-based approach with the assessment of global cardiovascular risk, both in the clinical management of individual patients and in guidelines. more...
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- 2004
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21. Cardiovascular risk reduction in hypertensive black patients with left ventricular hypertrophy
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Sverre E. Kjeldsen, Gareth Beevers, Michael H. Alderman, Katherine E. Harris, Otelio S. Randall, Stevo Julius, Richard B. Devereux, Jonathan M. Edelman, Björn Dahlöf, Janice G. Douglas, Shawna D. Nesbitt, and Jackson T. Wright more...
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medicine.medical_specialty ,business.industry ,Hazard ratio ,Atenolol ,medicine.disease ,Left ventricular hypertrophy ,Losartan ,Blood pressure ,Internal medicine ,medicine ,Cardiology ,cardiovascular diseases ,Myocardial infarction ,Risk factor ,business ,Cardiology and Cardiovascular Medicine ,Stroke ,circulatory and respiratory physiology ,medicine.drug - Abstract
OBJECTIVES We report on a subanalysis of the effects of losartan and atenolol on cardiovascular events in black patients in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study. BACKGROUND The LIFE study compared losartan-based to atenolol-based therapy in 9,193 hypertensive patients with left ventricular hypertrophy (LVH). Overall, the risk of the primary composite end point (cardiovascular death, stroke, myocardial infarction) was reduced by 13% (p = 0.021) with losartan, with similar blood pressure (BP) reduction in both treatment groups. There was a suggestion of interaction between ethnic background and treatment (p = 0.057). METHODS Exploratory analyses were performed that placed LIFE study patients into black (n = 533) and non-black (n = 8,660) categories, overall, and in the U.S. (African American [n = 523]; non-black [n = 1,184]). RESULTS A significant interaction existed between the dichotomized groups (black/non-black) and treatment (p = 0.005); a test for qualitative interaction was also significant (p = 0.016). The hazard ratio (losartan relative to atenolol) for the primary end point favored atenolol in black patients (1.666 [95% confidence interval (CI) 1.043 to 2.661]; p = 0.033) and favored losartan in non-blacks (0.829 [95% CI 0.733 to 0.938]; p = 0.003). In black patients, BP reduction was similar in both groups, and regression of electrocardiographic-LVH was greater with losartan. CONCLUSIONS Results of the subanalysis are sufficient to generate the hypothesis that black patients with hypertension and LVH might not respond as favorably to losartan-based treatment as non-black patients with respect to cardiovascular outcomes, and do not support a recommendation for losartan as a first-line treatment for this purpose. The subanalysis is limited by the relatively small number of events. more...
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- 2004
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22. Dietary Sodium and Cardiovascular Health in Hypertensive Patients
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Michael H. Alderman
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medicine.medical_specialty ,education.field_of_study ,business.industry ,Sodium ,Population ,chemistry.chemical_element ,Hemodynamics ,Physiology ,General Medicine ,Diet, Sodium-Restricted ,Clinical trial ,Excretion ,Blood pressure ,Endocrinology ,chemistry ,Cardiovascular Diseases ,Nephrology ,Health effect ,Internal medicine ,Hypertension ,Humans ,Medicine ,Observational study ,business ,education - Abstract
Salt and BP have been linked for more than a century. Recent data indicate that, given free access to sodium, in most populations, intake is between 100 and 200 mmol/d, although individual variation is wide. There is good evidence that individual differences are influenced by genetics, environment, and behavior. There is also solid clinical trial data suggesting that substantial reduction in sodium intake (75 to 100 mmol/d) will, on average, lower diastolic pressure by approximately 1 mmHg and systolic by approximately 3 to 5 mmHg. In addition, there is good evidence that sodium restriction is accompanied by other hemodynamic and nonhemodynamic effects. The health effect of sodium restriction can be assessed only by outcome study in humans. The best available evidence in this regard derives from observational study. The several available studies in the general population are inconsistent and demonstrate heterogeneity across subgroups in the relation of sodium intake to cardiovascular morbidity and mortality. Only a single study has been reported in hypertensive patients that links baseline sodium, measured by 24-h urinary excretion, and subsequent cardiovascular outcomes. In that study, controlling for other risk factors, there was a significant, independent, inverse association of urinary sodium excretion and coronary morbidity and mortality. Indeed, an increase of 66 mmol/24 h was associated with a 36% reduction in events. Taken together, these data provide no support for the notion that either normotensive or hypertensive individuals should routinely decrease (or increase) dietary sodium intake. more...
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- 2004
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23. Original Papers
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Chuke Nwachuku, Robert J. Weiss, William C. Cushman, Sandra M. Walsh, Michael H. Alderman, Karen L. Margolis, Joanne Holland, Barry R. Davis, Linda B. Piller, Charles E. Ford, Henry R. Black, Bruce P. Hamilton, Vasilios Papademetriou, Jeffrey L. Probstfield, Richard H. Grimm, Judy Bettencourt, Jackson T. Wright, and Jeffrey A. Cutler more...
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medicine.medical_specialty ,education.field_of_study ,business.industry ,medicine.drug_class ,Endocrinology, Diabetes and Metabolism ,Population ,Lisinopril ,law.invention ,Clinical trial ,Blood pressure ,Randomized controlled trial ,law ,Internal medicine ,Internal Medicine ,medicine ,Physical therapy ,Chlorthalidone ,Amlodipine ,Cardiology and Cardiovascular Medicine ,business ,Antihypertensive drug ,education ,medicine.drug - Abstract
Context Blood pressure control ( 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 ( Main outcome measures The outcome measures for this report are systolic and diastolic blood pressure, the proportion of participants achieving blood pressure control ( 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 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 more...
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- 2002
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24. Low sodium diet after DASH: Has the situation changed?
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Hillel W. Cohen and Michael H. Alderman
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Nephrology ,medicine.medical_specialty ,business.industry ,Sodium ,food.diet ,Psychological intervention ,chemistry.chemical_element ,Low sodium diet ,Surgery ,Dietary Sodium ,Blood pressure ,food ,chemistry ,Internal medicine ,Dash ,Internal Medicine ,medicine ,business ,Sodium reduction - Abstract
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. more...
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- 2002
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25. Salt, blood pressure and health: a cautionary tale
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Michael H. Alderman
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education.field_of_study ,medicine.medical_specialty ,Epidemiology ,business.industry ,Sodium ,Dietary intake ,Population ,chemistry.chemical_element ,Blood volume ,General Medicine ,Surgery ,Dietary Sodium ,Blood pressure ,chemistry ,Environmental health ,medicine ,Salt intake ,education ,business ,Developed country - Abstract
By virtue of its central role in maintaining intravascular and extracellular volume, sodium is essential to human survival. Taste, habit, environment, genes, and behaviour probably all influence sodium intake. In view of the heterogeneity that characterizes humankind, it is remarkable that the vast majority of the world’s citizens, everywhere, given free access to salt, consume between 100 and 200 mmol of sodium per 24 hours. 1 Despite this uniformity of sodium intake across all dietary, cultural, environmental, and hereditary circumstances, and the fact that life spans that are steadily increasing worldwide, many authorities now contend that current salt intake is too high by half. Advocates of universal restriction of sodium intake to ,100 mmol/24-h base their case on the belief that this will produce a population-wide reduction of blood pressure which, in turn, will reduce cardiovascular morbidity and mortality. There is even stronger enthusiasm for strict control of sodium intake for hypertensive people. Indeed, these dogma are often preached with a fervour usually associated with religious zealotry. I will argue here that the available data provides insufficient evidence to justify any universal target for sodium intake for either the whole population or for its hypertensive subset. The Link of Salt to Blood Pressure Recognition of the strong, continuous, independent, and significant relationship of blood pressure to the occurrence of cerebral, cardiac, and renal disease, provided the reasonable stimulus for seeking safe, simple, and effective means for reducing blood pressure on a population-wide basis. Dietary intake of sodium, or salt, both because of its ubiquity in the human diet, and its centrality in determining blood volume, presented an obvious opportunity to intervene on blood pressure. The first indication that differences in dietary sodium might explain variation in blood pressure came from cross-cultural studies. In unacculturated societies, blood pressures tended to be lower, and did not appear to rise with age. This contrasted sharply with the age-related rise in pressure and high levels of ‘hypertension’ common in most industrialized nations. Sodium intake, among many other factors, was found to differ between ‘developed’ and ‘undeveloped’ communities. In fact, people confined to an economy of hunting and gathering, with little access to salt, had daily intakes of sodium often limited to 20‐40 mmol sodium. 2 more...
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- 2002
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26. Myocardial function and geometry in hypertensive subjects with low levels of afterload
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Michael J. Koren, Gerard P. Aurigemma, Mary J. Roman, Richard B. Devereux, Michael J. O’Grady, Michael H. Alderman, John H. Laragh, and Giovanni de Simone
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Male ,Heart disease ,Systole ,Hemodynamics ,Blood Pressure ,Geometry ,Ventricular Function, Left ,Muscle hypertrophy ,Electrocardiography ,Ventricular Dysfunction, Left ,Afterload ,Humans ,Medicine ,Endocardium ,Analysis of Variance ,medicine.diagnostic_test ,business.industry ,Middle Aged ,medicine.disease ,Myocardial Contraction ,Blood pressure ,Echocardiography ,Hypertension ,Female ,Hypertrophy, Left Ventricular ,Cardiology and Cardiovascular Medicine ,business ,Algorithms - Abstract
Background It has been hypothesized that the level of end-systolic wall stress (σ m ) is a feedback signal that regulates the level of hypertrophy. Thus, low levels of σ m may signify inappropriate hypertrophy. Methods To characterize left ventricular (LV) structure and systolic function in hypertensive subjects with low levels of σ m , we studied 763 patients. LV function was studied by midwall stress-shortening analysis. Partition values for σ m were derived from a separate group of normal subjects, and the study population was divided into low stress (group I, n=136), high stress (group III, n=157), and intermediate stress group II (n = 470). LV chamber and myocardial function were characterized by relating shortening at the endocardium and at the midwall, respectively, to stress. Results As expected, group III patients had the highest values for systolic blood pressure and LV cavity size but the lowest values for wall thickness and relative wall thickness. Surprisingly, however, there were no significant differences among stress groups with regard to age or body mass index. Contrary to the hypothesis that low levels of stress are indicative of excessive hypertrophy, there were no significant differences among the 3 groups with regard to LV mass or any form of LV mass index. Furthermore, despite lower mean values for afterload, group I patients had significantly lower values for midwall shortening, and this finding was indicative of reduced myocardial function; stress-shortening plots demonstrated that 28% of group I patients fell below 95% CI compared with 10% of group II and only 5% of group III patients. Conclusions Hypertensive subjects with low values for σ m have more concentric LV geometry (higher relative wall thickness) and, on average, reduced myocardial function. (Am Heart J 2002;143:546-51.) more...
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- 2002
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27. Design of the omapatrilat in persons with enhanced risk of atherosclerotic events (OPERA) trial
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Michael H. Alderman, John M. Flack, Björn Dahlöf, John B. Kostis, Henry R. Black, Pierre-François Plouin, Michael Murphy, Daniel Levy, Michael A. Weber, G. Mancia, Stuart M. Cobbe, Luis M. Ruilope, Colin I. Johnston, R. Kolloch, Robert Wolf, Pierre Larochelle, and Ian Ford more...
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Male ,medicine.medical_specialty ,Arteriosclerosis ,Pyridines ,Thiazepines ,law.invention ,Placebos ,Double-Blind Method ,Randomized controlled trial ,Risk Factors ,law ,Diabetes mellitus ,Internal medicine ,Internal Medicine ,Clinical endpoint ,Humans ,Medicine ,Protease Inhibitors ,Myocardial infarction ,business.industry ,Vascular disease ,Middle Aged ,medicine.disease ,Blood pressure ,Research Design ,Heart failure ,Hypertension ,Cardiology ,Female ,Omapatrilat ,business ,medicine.drug - Abstract
The Omapatrilat in Persons with Enhanced Risk of Atherosclerotic events (OPERA) trial is a large clinical trial of omapatrilat, a vasopeptidase inhibitor, in patients with stage 1 isolated systolic hypertension (ISH). OPERA is the first study to examine whether effective antihypertensive treatment can provide survival and clinical end point benefits in older persons with this common condition. This 5-year multinational, randomized, double-blind, parallel-group, placebo-controlled, forced-titration study will be conducted in approximately 12,600 subjects randomized by approximately 1100 study centers worldwide over a recruitment period of approximately 2 years. The primary objective of OPERA is to determine whether treatment with once-daily omapatrilat (target dose 40 mg) will reduce cardiovascular (CV) morbidity and mortality in older (> or = 65 years) men and women with enhanced risk for atherosclerotic events due to stage 1 ISH plus other risk factors for which currently there is no evidence-based requirement for treatment. Blood pressure inclusion criteria are systolic blood pressure (SBP) 140 to 159 mm Hg (SBP 125 to 139 mm Hg in diabetic individuals) and diastolic blood pressure (DBP) more...
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- 2002
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28. Response to 'Salt Intake and Mortality'
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Niels Graudal and Michael H. Alderman
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education.field_of_study ,medicine.medical_specialty ,business.industry ,Sodium ,Public health ,Population ,chemistry.chemical_element ,Blood Pressure ,Diet, Sodium-Restricted ,Response to Letter to Editor ,Odds ,Blood pressure ,chemistry ,Hypertension ,Internal Medicine ,Medicine ,Humans ,Salt intake ,Sodium Chloride, Dietary ,business ,education ,Demography ,Cohort study ,Low sodium - Abstract
To the Editor: He and Macgregor (H&M) have often supported a meta-analysis,1 which included 13 of the 25 “flawed” studies included in our analysis.2 This may reflect an inverse logic, namely that the quality of the studies depends on the conclusion of the analysis. In contrast, we do not consider the inherent obstacles of population studies as flaws, but as challenges. The paper to which H&M refer3 was a response to Institute of Medicine’s conclusions,4 which were at odds with the established AHA position, but was not available before our’s2 had gone to press. Still, we did address the methodological problems associated with cohort studies and the imprecise estimations of the usual sodium intake.2 In spite of this imprecision, a significant signal (association of low sodium intake with increased mortality) was detected. It is certainly possible that this signal would have been stronger had the sodium measurements been more precise. The probably provisional, but still inappropriate editorial retraction of Taylor’s Cochrane review on a weak foundation is irrelevant to our report. It was cited because it was the sole source of mortality data from the Trial of Nonpharmacologic Interventions in the Elderly study, which is not in question.5 Our analysis on renin and aldosterone6 does not depend on extreme results, as it shows similar results, when we limit the analysis to studies that randomized patients to usual intake (100–225 mmol) or to a level below 100 mmol. Our results indicate what might be the full consequences of the governmental sodium reduction recommendations in normotensive subjects with a mean blood pressure corresponding to the general population (120/70).6 This is in contrast to the copy meta-analysis of H&M,7 which includes almost entirely study populations of high blood pressure not relevant to public health recommendations. For instance, 9 of 12 study populations in the “normotensive” analysis are borderline-hypertensive populations, who were reduced to an average sodium intake level of 1,920mg (84 mmol). At this higher sodium level, the likelihood of a hormonal effect is reduced, and therefore does not address the issue of whether sodium intake should be reduced to 1,200mg (52 mmol)—the position endorsed by H&M.7 This illustrates that conflicts of interest (COIs) are not necessarily financial, but also could be intellectual. Concerning significant financial COIs, the American Medical Association has defined this to be a fee exceeding 5,000 US$ and received within 12 months of disclosure.8 Neither of the present authors have ever fulfilled these criteria. The “totality” of evidence suggests that reducing sodium from levels above 4,945mg/d may be beneficial. Furthermore, there is evidence that sodium reduction below 2,495mg/d is associated with increased mortality, and this evidence is substantial2 and increasing.9 Thus, intake of sodium, just like every other essential nutrient, bears a “J”- or “U”-shaped relation to health outcomes with an optimal range approximating 2,495–4,945mg/d. more...
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- 2014
29. Assessing the Associations of Sodium Intake With Long-Term All-Cause and Cardiovascular Mortality in a Hypertensive Cohort
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Pamela Singer, Hillel W. Cohen, and Michael H. Alderman
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Adult ,Male ,medicine.medical_specialty ,Sodium ,chemistry.chemical_element ,Insulin resistance ,Internal medicine ,Epidemiology ,Internal Medicine ,Medicine ,Humans ,Myocardial infarction ,Risk factor ,Adverse effect ,business.industry ,Middle Aged ,medicine.disease ,Blood pressure ,Endocrinology ,chemistry ,Cohort ,Hypertension ,Original Article ,Female ,New York City ,business ,Follow-Up Studies - Abstract
Hypertension affects approximately 30% of all US adults1 and is the leading risk factor for cardiovascular morbidity and mortality.2 Although antihypertensive medication is the mainstay of blood pressure (BP) control, dietary sodium restriction has been widely recommended as a public health measure for both prevention and treatment of hypertension.3 Sodium restriction has been found to lower mean BP,4–6 with a recent Cochrane review indicating an average systolic BP (SBP) reduction of 3.5% in hypertensive patients when sodium intake was reduced by 125 mmol/day.7 At the same time, controversy exists on whether this sodium–BP effect actually translates to cardioprevention because intensive sodium restriction may have adverse effects on insulin resistance, triglycerides, and sympathetic nervous system activation.7,8 Studies directly examining the association between sodium intake and cardiovascular outcomes have produced conflicting results, with some finding a direct association, some showing an inverse or J-shaped curve, and others finding no relation to cardiovascular disease mortality. The lack of a consistent association is highlighted by the recent Institute of Medicine report,9 which concluded that the available data preclude a recommendation to restrict sodium to more...
- Published
- 2014
30. Response to 'Article on sodium intake should include ethnic disclaimer'
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Niels Graudal and Michael H. Alderman
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medicine.medical_specialty ,business.industry ,Disclaimer ,Ethnic group ,Blood Pressure ,Diet, Sodium-Restricted ,Sodium intake ,Endocrinology ,Internal medicine ,Family medicine ,Hypertension ,Internal Medicine ,medicine ,Humans ,Sodium Chloride, Dietary ,business - Published
- 2014
31. Health outcomes associated with calcium antagonists compared with other first-line antihypertensive therapies: a meta-analysis of randomised controlled trials
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Bruce M. Psaty, Michael H. Alderman, William B. Applegate, Marco Pahor, Jeff D. Williamson, Chiara Cavazzini, and Curt D. Furberg
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Male ,medicine.medical_specialty ,Systole ,Myocardial Infarction ,Blood Pressure ,Coronary Disease ,Pharmacology ,Placebo ,Diastole ,Internal medicine ,medicine ,Humans ,Myocardial infarction ,Stroke ,Antihypertensive Agents ,Aged ,Randomized Controlled Trials as Topic ,Heart Failure ,business.industry ,General Medicine ,Odds ratio ,Middle Aged ,Calcium Channel Blockers ,medicine.disease ,Treatment Outcome ,Blood pressure ,Meta-analysis ,Heart failure ,Hypertension ,Female ,Observational study ,business - Abstract
Summary Background Several observational studies and individual randomised trials in hypertension have suggested that, compared with other drugs, calcium antagonists may be associated with a higher risk of coronary events, despite similar blood-pressure control. The aim of this meta-analysis was to compare the effects of calcium antagonists and other antihypertensive drugs on major cardiovascular events. Methods We undertook a meta-analysis of trials in hypertension that assessed cardiovascular events and included at least 100 patients, who were randomly assigned intermediate-acting or long-acting calcium antagonists or other antihypertensive drugs and who were followed up for at least 2 years. Findings The nine eligible trials included 27 743 participants. Calcium antagonists and other drugs achieved similar control of both systolic and diastolic blood pressure. Compared with patients assigned diuretics, β-blockers, angiotensin-converting-enzyme inhibitors, or clonidine (n=15 044), those assigned calcium antagonists (n=12 699) had a significantly higher risk of acute myocardial infarction (odds ratio 1·26 [95% Cl 1·11–1·43], p=0·0003), congestive heart failure (1·25 [1·07–1·46], p=0·005), and major cardiovascular events (1·10 [1·02–1·18], p=0·018). The treatment differences were within the play of chance for the outcomes of stroke (0·90 [0·80–1·02], p=0·10) and all-cause mortality (1·03 [0·94–1·13], p=0·54). Interpretation In randomised controlled trials, the large available database suggests that calcium antagonists are inferior to other types of antihypertensive drugs as first-line agents in reducing the risks of several major complications of hypertension. On the basis of these data, the longer-acting calcium antagonists cannot be recommended as first-line therapy for hypertension. more...
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- 2000
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32. Salt, Blood Pressure, and Human Health
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Michael H. Alderman
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Adult ,medicine.medical_specialty ,Health Status ,Sodium ,Population ,chemistry.chemical_element ,Physiology ,Hemodynamics ,Blood Pressure ,Risk Factors ,Outcome Assessment, Health Care ,Renin–angiotensin system ,Epidemiology ,Internal Medicine ,medicine ,Humans ,Obesity ,education ,Randomized Controlled Trials as Topic ,education.field_of_study ,business.industry ,Public health ,Sodium, Dietary ,Diet, Sodium-Restricted ,Surgery ,Blood pressure ,chemistry ,Circulatory system ,business - Abstract
Abstract —The positive relation of sodium intake and blood pressure, first recognized a century ago, has been well established in ecological, epidemiological, and experimental human studies. Equally well established is the association of increasing blood pressure and cardiovascular morbidity and mortality. Indeed, the pharmacological capacity to reduce blood pressure has produced one of the great public health accomplishments of the 20th century. These two facts—the positive relation of blood pressure to strokes and heat attacks and the positive association of sodium intake to blood pressure—underlie the hypothesis that a reduction in sodium intake, by virtue of its hypotensive effect, might prevent strokes and heart attacks. Moreover, even if the effect on blood pressure were in the range of a 1- to 2-mm Hg decline in blood pressure for every 75- to 100-mmol difference in sodium intake, the impact of such a change, applied to the whole population, would be enormous. The problem with this appealing possibility is that a reduction in salt consumption of this magnitude has other—and sometimes adverse—health consequences. The question, therefore, is whether the beneficial hypotensive effects of sodium restriction will outweigh its hazards. Unfortunately, few data link sodium intake to health outcomes, and that which is available is inconsistent. Without knowledge of the sum of the multiple effects of a reduced sodium diet, no single universal prescription for sodium intake can be scientifically justified. more...
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- 2000
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33. Dietary Potassium Intake and Stroke Mortality
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Jing Fang, Michael H. Alderman, and Shantha Madhavan
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Adult ,Male ,medicine.medical_specialty ,National Health and Nutrition Examination Survey ,Potassium ,Physiology ,chemistry.chemical_element ,Age Distribution ,Surveys and Questionnaires ,Internal medicine ,Epidemiology ,medicine ,Humans ,Sex Distribution ,Risk factor ,Stroke ,Aged ,Proportional Hazards Models ,Advanced and Specialized Nursing ,Proportional hazards model ,business.industry ,Potassium, Dietary ,Middle Aged ,medicine.disease ,Health Surveys ,Dietary Potassium ,Endocrinology ,Blood pressure ,chemistry ,Female ,Neurology (clinical) ,Energy Intake ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
Background and Purpose —An inverse relationship of dietary potassium to stroke mortality in a small community has been previously reported. To further assess this association in a larger sample, we examined data from the first National Health and Nutrition Examination Survey (NHANES I) Epidemiological Follow-up Study. Methods —We analyzed baseline data during 1971–1975 and follow-up through 1992. Dietary potassium intake, determined by 24-hour dietary recall at baseline, was available for 9866 subjects. Stroke mortality was recorded through 1992 follow-up. Results —Mean age and dietary potassium at baseline were 55 years and 2084 mg/d; blacks reported significantly lower potassium intake than whites (1606 versus 2178 mg/24 h). During an average of 16.7 years of follow-up, there were 304 stroke deaths. For men, stratified by tertile of dietary potassium intake, age-adjusted stroke mortality rates per 1000 person-years for the lowest dietary potassium group were significantly higher than for the highest intake group, for both whites (1.94 versus 1.17; relative risk, 1.66; 95% CI, 1.32 to 2.14) and blacks (5.08 versus 1.19; relative risk, 4.27; 95% CI , 1.88 to 9.19). For women, there was no significant difference in stroke mortality between similar levels of potassium intake for either whites (1.61 versus 1.42; relative risk, 1.13; 95% CI, 0.84 to 1.66) or blacks (2.46 versus 3.04; relative risk, 0.80; 95% CI, 0.21 to 2.01). After stratification by hypertensive status, stroke mortality rates were significantly different by tertile of dietary potassium only for hypertensive men. There was no stroke mortality difference by potassium intake among hypertensive women or nonhypertensive men and women. Multivariate analysis, in which we controlled for caloric intake and other baseline cardiovascular risk factors, revealed that only among black men and hypertensive men was lower dietary potassium intake a predictor of stroke mortality. Conclusions —The previous finding of an association of increasing dietary potassium intake with decreasing stroke mortality has been detected only among black men and hypertensive men in this study. more...
- Published
- 2000
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34. Diabetes and Cardiovascular Events in Hypertensive Patients
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Michael H. Alderman, Hillel W. Cohen, and Shantha Madhavan
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Adult ,Blood Glucose ,Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Blood sugar ,Cohort Studies ,Diabetes Complications ,Risk Factors ,Diabetes mellitus ,Internal medicine ,Diabetes Mellitus ,Internal Medicine ,medicine ,Humans ,Risk factor ,Diuretics ,Antihypertensive Agents ,business.industry ,Incidence (epidemiology) ,Racial Groups ,Smoking ,Hazard ratio ,Infant, Newborn ,Middle Aged ,medicine.disease ,Confidence interval ,Cholesterol ,Endocrinology ,Blood pressure ,Cardiovascular Diseases ,Hypertension ,Multivariate Analysis ,Female ,Diuretic ,business ,Follow-Up Studies - Abstract
Abstract —To determine the relation of self-reported history of diabetes as well as baseline and in-treatment blood sugar to subsequent cardiovascular disease (CVD) in treated hypertensive patients, we assessed the experience of 6886 participants in a systematic treatment program. The presence or absence of a history of diabetes was known for all patients, who were then stratified into 3 groups according to blood sugar at baseline and in treatment (P =0.004) and rare users (13.25, P =0.008). These data affirm that the coincidence of diabetes and hypertension is common, that evidence of diabetes substantially increases CVD risk, that self-reported history is a more powerful predictor of CVD events than any measure of blood sugar, and that CVD increases in hypertensive diuretic users who develop hyperglycemia even when blood pressure is well controlled. more...
- Published
- 1999
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35. Can we Stratify Risk to Guide Therapy Presented at WHO-ISH Meeting. September 29, 1998. Fukuoka, Japan
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Michael H. Alderman
- Subjects
medicine.medical_specialty ,Physiology ,business.industry ,Conventional treatment ,Specific risk ,General Medicine ,Disease ,medicine.disease ,Target organ damage ,Blood pressure ,Diabetes mellitus ,Internal Medicine ,medicine ,Observational study ,In patient ,Intensive care medicine ,business - Abstract
The relation of blood pressure to cardiovascular (CVD) disease is direct, continuous, and independent. Nevertheless, blood pressure alone is a poor predictor of CVD events. In fact, the totality of factors, including smoking, cholesterol, diabetes, target organ damage, and existing cardiovascular disease, together, permit discrimination of persons with similar blood pressure into subgroups with event expectations that might differ by more than twenty-fold. Thus, absolute CVD risk, rather than level of blood pressure, should determine the need for antihypertensive treatment. In addition, conventional treatment, even when effective, prevents only 25% of expected events. Observational study of long term treated patients provides the basis for pre-treatment stratification of CVD risk in patients who will maintain “normal” blood pressure in treatment. This stratification scheme makes it possible to modulate the intensity of therapy to match the potential for CVD prevention. Finally, specific risk factors, infl... more...
- Published
- 1999
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36. Salt and blood pressure in children
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Michael H. Alderman
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medicine.medical_specialty ,business.industry ,Blood Pressure ,Feeding Behavior ,Kidney ,stomatognathic diseases ,Endocrinology ,Dietary Sodium ,Blood pressure ,Creatinine ,Internal medicine ,Epidemiology ,Internal Medicine ,medicine ,Humans ,Sodium Chloride, Dietary ,Child ,business - Abstract
The relationship of dietary sodium to blood pressure in adults is well established by substantial epidemiological and clinical data,1, 2 as well as various pathophysiological studies.3, 4 Not surprisingly, considerably less is known about the relationship in children. more...
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- 2007
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37. JNC V revisited: Standard of care or individualized treatment for hypertension?
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Michael H. Alderman
- Subjects
Male ,medicine.medical_specialty ,Standard of care ,Myocardial Infarction ,Individualized treatment ,Disease ,Risk Assessment ,Pharmacotherapy ,Risk Factors ,Renin ,medicine ,Humans ,Risk factor ,Intensive care medicine ,Antihypertensive Agents ,Blood pressure level ,business.industry ,Incidence ,Absolute risk reduction ,Prognosis ,Surgery ,Cerebrovascular Disorders ,Blood pressure ,Cardiovascular Diseases ,Hypertension ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
The fifth report of the National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V) has weathered the test of time fairly well. The significant new dimensions of the 1992 document included (1) a new classification system reflecting the recognition that risk from hypertension does not arise at a specific blood pressure level but is continuous, (2) an expanded list of agents suitable for antihypertensive therapy, (3) recognition of the significance of systolic blood pressure as a risk factor, particularly isolated systolic blood pressure in the elderly, (4) identification of diuretics and β-blockers as agents of first use, and (5) recognition that, in addition to level of blood pressure, absolute risk for cardiovascular disease events should influence the nature of therapy. Concern for matching therapeutic efforts with actual risk of disease and potential for benefit has grown. Some have recommended that drug therapy be reserved for those whose absolute risk of a CVD event is above an arbitrary threshold. The next JNC report is likely to be more precise in linking treatment recommendations to the actual level of risk, as well as level of blood pressure, particularly within the broad range of levels where, in JNC V, the decision to treat was left to individual judgment. (Am Heart J 1998;135:S8-S15.) more...
- Published
- 1998
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38. Urinary sodium excretion and myocardial infarction in hypertensive patients: a prospective cohort study
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Shantha Madhavan, J E Sealey, Michael H. Alderman, John H. Laragh, and Hillel W. Cohen
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Male ,medicine.medical_specialty ,Sodium ,Urinary system ,Myocardial Infarction ,Medicine (miscellaneous) ,chemistry.chemical_element ,Left ventricular hypertrophy ,Gastroenterology ,Plasma renin activity ,Cohort Studies ,Excretion ,chemistry.chemical_compound ,Sex Factors ,Internal medicine ,Humans ,Medicine ,Prospective Studies ,Myocardial infarction ,Creatinine ,Nutrition and Dietetics ,business.industry ,Incidence ,Middle Aged ,medicine.disease ,Cerebrovascular Disorders ,Blood pressure ,Endocrinology ,chemistry ,Cardiovascular Diseases ,Hypertension ,Female ,business ,Follow-Up Studies - Abstract
Reduced-sodium diets are frequently recommended for hypertensive patients. To determine the relation of sodium intake to subsequent cardiovascular disease, 24-h urinary excretion of sodium, potassium, and creatinine and plasma renin activity (PRA) were measured in 2937 mildly and moderately hypertensive patients unmedicated for > or = 3-4 wk. Morbidity and mortality in these treated subjects were ascertained. Subjects were stratified by sex-specific quartiles of urinary sodium excretion; race, cardiovascular status, and blood pressure before and during treatment were similar for each stratum. Patients with lower urinary sodium excretion were thinner, excreted less potassium, and had higher PRA. During an average 3.8-y follow-up, 55 myocardial infarctions (MIs) occurred. Incidence of MIs and urinary sodium excretion were inversely associated in the total population and in males but not in females. In males, age- and race-adjusted MI incidence in the lowest compared with the highest quartile of urinary sodium excretion was 11.5 compared with 2.5 (RR: 4.3; 95% CI: 1.7, 10.6). No association was observed between mortality from causes other than cardiovascular disease (n = 11) and urinary sodium excretion. There was a significant linear trend in proportions of MI by quartile of urinary sodium excretion, with a breakpoint after the lowest quartile. In Cox multivariate analysis, the logarithm of PRA, age, systolic blood pressure, and cholesterol as continuous variables, as well as left ventricular hypertrophy and smoking, had a direct association and urinary sodium excretion an inverse, independent association (P = 0.036) with incidence of MI. more...
- Published
- 1997
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39. Plasma Renin Activity: A Risk Factor for Myocardial Infarction in Hypertensive Patients
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Shantha Madhavan, Jean E. Sealey, Michael H. Alderman, John H. Laragh, Wee Lock Ooi, and Hillel W. Cohen
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Male ,medicine.medical_specialty ,Myocardial Infarction ,Black People ,Left ventricular hypertrophy ,Plasma renin activity ,Gastroenterology ,White People ,Urine sodium ,Risk Factors ,Internal medicine ,Renin ,Blood plasma ,Internal Medicine ,Humans ,Medicine ,Myocardial infarction ,Risk factor ,business.industry ,Incidence (epidemiology) ,Middle Aged ,medicine.disease ,Endocrinology ,Blood pressure ,Hypertension ,Female ,business - Abstract
To determine whether pretreatment plasma renin activity (PRA), without accompanying 24-h urine sodium, can predict myocardial infarction (MI), the PRA levels of 2,902 hypertensive patients [white (38%), male (65%), median age 55 years], with mean entry blood pressure (BP) of 150/97 mm Hg were examined. During an average 3.6 years follow-up (87%or = 9 months), there were 55 MIs, 21 strokes, and 16 other cardiovascular disease (CVD) deaths. Classification of PRA levels into 3 renin strata [high (H) PRAor = 4.5 (n = 354), normal (N) 0.75 to 4.49 (n = 1,622), and low (L)0.75 (n = 926) ng/mL/h] yielded subgroups that did not differ in LVH (9% v 11%) or smoking prevalence (26% v 25%) but high versus low PRA subjects included more aged55 years (64% v 53%); white (49% v 25%); men (79% v 52%); cholesterolor = 6.3 mmol/L (33% v 25%); all P values.01. MI rates per 1,000/year were H: 9.3, N: 5.5, L: 2.5 (H v L, RR = 3.8, 95% CI: 1.7 to 8.4). A similar relationship was seen with total CVD (H: 12.5, N: 9.3, L: 5.2; RR = 2.4, 95% CI: 1.3 to 4.5) and all-cause mortality (H: 7.0, N: 6.2, L: 2.5; RR = 2.8, 95% CI: 1.2 to 6.8) but not CVA (H: 1.6, N: 2.0, L: 1.9). In a Cox survival analysis only renin, age, sex, smoking, LVH, and cholesterol were significantly (P.02) related to MI occurrence. There was, for every 2 unit increase in PRA, an overall 25% increase in MI incidence. Among hypertensive subjects, PRA level (without urine sodium), is independently and directly associated with the incidence of MI. more...
- Published
- 1997
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40. The Limitations of Transferring Evidence from Clinical Trials to the Care of Individual Patients
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Michael H. Alderman
- Subjects
medicine.medical_specialty ,Blinding ,business.industry ,Confounding ,Alternative medicine ,Surgery ,Clinical trial ,Blood pressure ,Pharmacotherapy ,Intervention (counseling) ,Epidemiology ,Internal Medicine ,medicine ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,business - Abstract
The randomised clinical trial has, justifiably, become the premier research technique by which the efficacy and, to a lesser extent, safety of hypertensive therapy are established. Through blinding and randomisation, the influence of potentially confounding factors is minimised. In these circumstances, a comparison of outcomes with an identical control group permits an assessment of the impact of the intervention. Useful as this strategy has been in establishing a scientific basis for blood pressure reduction, the process has limitations — particularly in the comparison of different antihypertensive drugs. It may not always be appropriate to apply the result of a clinical trial to the individual patient. Since most participants in these trials do not experience an endpoint, the effect of the intervention probably will not be experienced by most patients who fit the entry criteria of the study. Moreover, the risk of cardiovascular events is unevenly distributed among trial participants even though they have similar blood pressures and, thus, the potential for actual benefit likewise varies depending upon absolute cardiovascular risk. Finally, unrecognised mechanistic differences may produce different results, particularly when comparing mechanistically different drugs, among patients heterogeneous in terms of pathophysiology of blood pressure control. For these reasons, and others, it is likely that the net results of a trial mask substantial outcome differences hidden within the overall study group. In short, the average result may not apply to many patients, even when they meet the criteria for participation in the study. This is not an argument against clinical trials but rather a recognition that clinical practice must not be guided exclusively by epidemiological data but, in addition, by all the information that derives from pathophysiology and pharmacology. more...
- Published
- 2005
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41. Is there a link between the circulating renin-angiotensin system and coronary disease? A buoyant view
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Michael H. Alderman
- Subjects
medicine.medical_specialty ,Myocardial ischemia ,Myocardial Infarction ,Myocardial Ischemia ,Reviews ,Angiotensin-Converting Enzyme Inhibitors ,Cardiomegaly ,Coronary disease ,Cohort Studies ,Renin-Angiotensin System ,Dogs ,Recurrence ,Internal medicine ,Renin ,Renin–angiotensin system ,Animals ,Humans ,Medicine ,Prospective Studies ,Myocardial infarction ,business.industry ,medicine.disease ,Coronary heart disease ,Rats ,Endocrinology ,Blood pressure ,Hypertension ,Rabbits ,Cardiology and Cardiovascular Medicine ,business - Published
- 1996
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42. Influence of Obesity on Left Ventricular Midwall Mechanics in Arterial Hypertension
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Antonello Ganau, Gian Francesco Mureddu, Michael H. Alderman, Franco Contaldo, John H. Laragh, Richard B. Devereux, Giovanni de Simone, and Mary J. Roman
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Adult ,Male ,Overweight ,Ventricular Function, Left ,Body Mass Index ,Cohort Studies ,Ventricular Dysfunction, Left ,Predictive Value of Tests ,Reference Values ,Ventricule gauche ,Internal Medicine ,medicine ,Humans ,Obesity ,Ventricular function ,business.industry ,Nutritional status ,Mechanics ,Middle Aged ,medicine.disease ,Blood pressure ,Echocardiography ,Hypertension ,Female ,medicine.symptom ,business ,Body mass index - Abstract
The evaluation of the effect of obesity on left ventricular systolic performance may differ in relation to the method used to measure left ventricular function and to the type of study population. Whether obesity worsens left ventricular midwall mechanics in arterial hypertension has never been investigated. Accordingly, we assessed echocardiographic left ventricular midwall shortening–circumferential end-systolic stress relations in 156 normotensive and normal-weight (reference) adults, 94 normotensive and overweight (1985 National Institutes of Health partition values) to obese (body mass index >30 kg/m 2 ) adults, 263 hypertensive and normal-weight adults, and 224 hypertensive and overweight-to-obese adults. There was an inverse relation of midwall shortening to circumferential end-systolic stress in all groups (all P R =.31, P more...
- Published
- 1996
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43. Blood pressure J-curve: is it cause or effect?
- Author
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Michael H. Alderman
- Subjects
Clinical Trials as Topic ,medicine.medical_specialty ,business.industry ,Models, Cardiovascular ,Myocardial Infarction ,Blood Pressure ,Disease ,medicine.disease ,Coronary artery disease ,Clinical trial ,Blood pressure ,Nephrology ,Internal medicine ,Hypertension ,Epidemiology ,Internal Medicine ,medicine ,Cardiology ,Humans ,Myocardial infarction ,business ,Prospective cohort study ,Stroke - Abstract
Clinical trials have demonstrated that antihypertensive therapy leads to the prevention of stroke, consistent with that predicted by epidemiological data. In contrast, in the same studies, the reduction in coronary artery disease events has been substantially less than predicted. Many possible explanations have been proposed to account for this shortfall in the reduction of disease produced by antihypertensive therapy. One suggestion has been that too great a fall in diastolic pressure during treatment actually increases the risk of myocardial infarction. A substantial body of data taken from clinical trials has consistently demonstrated a J-shaped association of diastolic pressure and coronary events. Some studies suggest that this J-shaped association is limited to those with coronary disease, and that the J-phenomenon is the result rather than the cause of atherosclerotic disease of the aorta. A prospective study is underway to resolve this issue. Meanwhile, the cautious physician is advised to seek a moderate decline in diastolic pressure to a level greater than 80 mmHg. more...
- Published
- 1996
- Full Text
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44. Antihypertensive drug therapy The effect of JNC criteria on prescribing patterns and patient status through the first year
- Author
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Hillel W. Cohen, Michael H. Alderman, and Shantha Madhavan
- Subjects
Blood Glucose ,Male ,Drug ,medicine.medical_specialty ,Patient Dropouts ,medicine.drug_class ,media_common.quotation_subject ,medicine.medical_treatment ,Blood Pressure ,Guidelines as Topic ,Pharmacology ,Drug Prescriptions ,Internal medicine ,Internal Medicine ,medicine ,Humans ,Medical prescription ,Antihypertensive drug ,Antihypertensive Agents ,media_common ,Analysis of Variance ,Chemotherapy ,biology ,business.industry ,Outcome measures ,Angiotensin-converting enzyme ,Middle Aged ,Clinical trial ,Cholesterol ,Treatment Outcome ,Blood pressure ,Hypertension ,biology.protein ,Patient Compliance ,Female ,New York City ,business - Abstract
This study was designed to evaluate the impact of the protocol-driven antihypertensive therapy on outcomes guided by the Joint National Committee (JNC) on Detection, Evaluation, and Treatment of high blood pressure. In a systematic hypertension control program for union employees conducted in New York City, untreated patients who began treatment on monotherapy guided by JNC recommendations during three representative periods: I-pre-JNC IV (1986-1987); II-post-JNC IV (1990-1991); and III (JNC V)-period of application of what were later published as JNC-V guidelines (1992) were observed during 1 year of treatment. A total of 550 presumably untreated patients were prescribed either diuretics, beta-blockers, calcium channel blockers, or angiotensin converting enzyme inhibitors. There were 231 in period I, 213 in II, and 106 in III. The patient composition over time became more predominantly female and Hispanic (I to III: 28% to 34%, and 35% to 45%, respectively). The main outcome measures were type of drug first prescribed and the outcomes at the end of 1 year-changes in blood pressure, clinical chemistry measures and therapy, and clinic attendance are dropout rate. The pattern of first drug prescription changed from 85% to 90% of patients given diuretics or beta-blockers in I to 90% begun on calcium channel blockers or angiotensin converting enzyme inhibitors in II and finally, to an even distribution of drugs in III. Blood pressure response was similar across the three periods, 135/89 mm Hg (I), 138/89 (II), and 140/89 (III). Proportion of patients remaining on their initial drug in each period was fairly similar (60%, 67%, and 69%). Scheduled clinic visits fell significantly from 7.4 visits in I, 6.9 in II, and 6.4 in III (I upsilon III P = .004). Dropouts diminished significantly from 17% in I, to 10% in II, and 9% in III (I upsilon II or III P = .045). Modest positive changes in cholesterol and fasting blood sugar level occurred over time. In this general community setting, dramatic shifts in the choice of initial drug based upon application of JNC guidelines had little discernable impact on short term patient outcomes. more...
- Published
- 1996
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45. Absolute Cardiovascular Risk: The Basis for Deciding to Treat
- Author
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Michael H. Alderman
- Subjects
Male ,Risk ,medicine.medical_specialty ,Population ,Blood Pressure ,Disease ,Risk Factors ,medicine ,Humans ,Risk factor ,education ,Intensive care medicine ,Antihypertensive Agents ,education.field_of_study ,business.industry ,Absolute risk reduction ,Middle Aged ,Hypotensive therapy ,Surgery ,Blood pressure ,Cardiovascular Diseases ,Nephrology ,Relative risk ,Hypertension ,Female ,Raised blood pressure ,business - Abstract
It has been convincingly demonstrated that a raised blood pressure is a risk factor for cardiovascular disease and that its reduction saves lives. It seems logical to suggest that the whole population's blood pressure distribution should be displaced downwards, since the reduction of blood pressure by only a few millimeters of mercury, if easily and safely achieved, would produce more disease prevention than could be attained by any other conceivable clinical strategy. Physicians already have powerful tools to lower blood pressure in individual patients, but must make challenging decisions as to when and how to use them. Blood pressure level is a reflection of relative risk and one of many risk factors that determine absolute risk. Reduction of blood pressure therefore does not cure cardiovascular disease, but reduces the risk of developing disease. The need for hypotensive therapy should be determined by absolute risk and the opportunity for successful prevention, rather than by a threshold level of blood pressure. The task of the physician is to assist the patient in assessing the balance between the potential for benefit and the burden of intervention, and to provide the best possible care to implement the therapeutic choice that is made. more...
- Published
- 1996
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46. Quantifying Cardiovascular Risk in Hypertension
- Author
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Michael H. Alderman
- Subjects
medicine.medical_specialty ,Blood pressure ,business.industry ,medicine ,Rationality ,General Medicine ,Disease ,Risk factor (computing) ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,business - Abstract
The facts are that blood pressure is a risk factor for cardiovascular disease and that its reduction saves lives. The question now is how best to translate that knowledge into practice. The goal of this article is to suggest a strategy for quantifying risk in hypertensive patients as a means to determine the potential value of therapy and thus to give more rationality to the decision to treat than is afforded by absolute reliance on level of pressure alone. more...
- Published
- 1995
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47. The effects of vitamin D repletion on endothelial function and inflammation in patients with coronary artery disease
- Author
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Seth I. Sokol, Jill P. Crandall, Yiting Yu, Mimi Kim, Alok Gupta, Michael H. Alderman, Vankeepuram S. Srinivas, George Tellides, and Amir H. Lebastchi
- Subjects
Adult ,Male ,medicine.medical_specialty ,Endothelium ,Hyperemia ,Coronary Artery Disease ,Placebo ,Gastroenterology ,vitamin D deficiency ,Double-Blind Method ,Internal medicine ,medicine ,Vitamin D and neurology ,Humans ,Vitamin D ,Reactive hyperemia ,Aged ,Inflammation ,business.industry ,Middle Aged ,medicine.disease ,Intercellular adhesion molecule ,Vitamin D Deficiency ,Ergocalciferol ,medicine.anatomical_structure ,Blood pressure ,Immunology ,Dietary Supplements ,Female ,Endothelium, Vascular ,Cardiology and Cardiovascular Medicine ,business ,Cell Adhesion Molecules ,Biomarkers ,medicine.drug - Abstract
Adequate vitamin D levels may promote cardiovascular health by improving endothelial function and down-regulating inflammation. The objective of this pilot trial was to investigate the effects of vitamin D repletion on endothelial function and inflammation in patients with coronary artery disease (CAD). Using a double-blind placebo wait-list control design, 90 subjects with CAD and vitamin D deficiency (< 20 ng/ml) were randomized 1:1 to 50,000 IU of oral ergocalciferol or placebo weekly for 12 weeks. Endothelial function (reactive hyperemia peripheral arterial tonometry, RH-PAT), circulating adhesion molecules, and pro-inflammatory cytokines were measured at baseline and 12 weeks. The median increase in serum 25-vitamin D from baseline was 26 ± 17 ng/ml in the active group and 4 ± 8 ng/ml in the placebo group (between-group difference = 22 ng/ml, p < 0.001). The median within-subject change in RH-PAT score was 0.13 ± 0.73 with active treatment and −0.04 ± 0.63 with placebo (between-group difference = 0.17, p = 0.44). Within-group and between-group differences in intercellular adhesion molecule levels were greater with placebo (between-group difference = 6 ng/ml, p = 0.048). Vascular cell adhesion molecule levels decreased in both groups by a similar magnitude (median difference between groups = 8.5 ng/ml, p = 0.79). There was no difference between groups in magnitude of reduction in interleukin (IL)-12 (−8.6 ng/ml, p = 0.72) and interferon-gamma (0.52 ng/ml, p = 0.88). No significant differences in blood pressure, e-selectin, high-sensitivity c-reactive protein, IL-6 or the chemokine CXCL-10 were found with treatment. In conclusion, repleting vitamin D levels in subjects with CAD failed to demonstrate any benefits on surrogate markers of cardiovascular health. These results question the role of vitamin D supplementation in modifying cardiovascular disease. more...
- Published
- 2012
48. Mortality and morbidity during and after the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
- Author
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William C, Cushman, Barry R, Davis, Sara L, Pressel, Jeffrey A, Cutler, Paula T, Einhorn, Charles E, Ford, Suzanne, Oparil, Jeffrey L, Probstfield, Paul K, Whelton, Jackson T, Wright, Michael H, Alderman, Jan N, Basile, Henry R, Black, Richard H, Grimm, Bruce P, Hamilton, L Julian, Haywood, Stephen T, Ong, Linda B, Piller, Lara M, Simpson, Carol, Stanford, and Robert J, Weiss more...
- Subjects
Male ,Racial Groups ,Blood Pressure ,Hyperlipidemias ,Health Status Disparities ,Middle Aged ,Lipid Metabolism ,United States ,Article ,Outcome and Process Assessment, Health Care ,Double-Blind Method ,Population Surveillance ,Hypertension ,Humans ,Female ,Acute Coronary Syndrome ,Mortality ,Antihypertensive Agents ,Aged ,Follow-Up Studies ,Hypolipidemic Agents - Abstract
A randomized, double-blind, active-controlled, multicenter trial assigned 32,804 participants aged 55 years and older with hypertension and ≥ 1 other coronary heart disease risk factors to receive chlorthalidone (n=15,002), amlodipine (n=8898), or lisinopril (n=8904) for 4 to 8 years, when double-blinded therapy was discontinued. Passive surveillance continued for a total follow-up of 8 to 13 years using national administrative databases to ascertain deaths and hospitalizations. During the post-trial period, fatal outcomes and nonfatal outcomes were available for 98% and 65% of participants, respectively, due to lack of access to administrative databases for the remainder. This paper assesses whether mortality and morbidity differences persisted or new differences developed during the extended follow-up. Primary outcome was cardiovascular mortality and secondary outcomes were mortality, stroke, coronary heart disease, heart failure, cardiovascular disease, and end-stage renal disease. For the post-trial period, data are not available on medications or blood pressure levels. No significant differences (P.05) appeared in cardiovascular mortality for amlodipine (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.93-1.06) or lisinopril (HR, 0.97; CI, 0.90-1.03), each compared with chlorthalidone. The only significant differences in secondary outcomes were for heart failure, which was higher with amlodipine (HR, 1.12; CI, 1.02-1.22), and stroke mortality, which was higher with lisinopril (HR, 1.20; CI, 1.01-1.41), each compared with chlorthalidone. Similar to the previously reported in-trial result, there was a significant treatment-by-race interaction for cardiovascular disease for lisinopril vs chlorthalidone. Black participants had higher risk than non-black participants taking lisinopril compared with chlorthalidone. After accounting for multiple comparisons, none of these results were significant. These findings suggest that neither calcium channel blockers nor angiotensin-converting enzyme inhibitors are superior to diuretics for the long-term prevention of major cardiovascular complications of hypertension. more...
- Published
- 2012
49. A New Paradigm for Blood Pressure Management
- Author
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Michael H. Alderman
- Subjects
Male ,Blood pressure management ,medicine.medical_specialty ,business.industry ,Blood Pressure ,General Medicine ,Middle Aged ,Blood pressure ,Cardiovascular Diseases ,Reference Values ,Risk Factors ,Reference values ,Hypertension ,medicine ,Humans ,Intensive care medicine ,business ,Antihypertensive Agents ,Aged - Published
- 1994
- Full Text
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50. Relation of obesity and gender to left ventricular hypertrophy in normotensive and hypertensive adults
- Author
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Mary J. Roman, Michael H. Alderman, G. De Simone, John H. Laragh, and Richard B. Devereux
- Subjects
Adult ,Male ,medicine.medical_specialty ,Heart disease ,Population ,Left ventricular hypertrophy ,Muscle hypertrophy ,Sex Factors ,Ventricular hypertrophy ,Internal medicine ,Internal Medicine ,medicine ,Humans ,Obesity ,education ,Aged ,Body surface area ,education.field_of_study ,business.industry ,Body Weight ,Middle Aged ,medicine.disease ,Endocrinology ,Blood pressure ,Hypertension ,Cardiology ,Regression Analysis ,Female ,Hypertrophy, Left Ventricular ,business - Abstract
Although it is recognized that both hypertension and obesity are associated with increased left ventricular mass, the relative impacts of obesity, arterial hypertension, and gender on the prevalence of ventricular hypertrophy remain uncertain. Accordingly, echocardiographic left ventricular mass normalized for height to the power of the allometric or growth relation between ventricular mass and height was compared in 164 normotensive subjects (85 men [24 obese] and 79 women [28 obese], aged 45 +/- 12 years) and 475 hypertensive patients (325 men [126 obese] and 150 women [85 obese], aged 54 +/- 10 years) from an adult employed population. Gender-specific upper normal limits were used to identify ventricular hypertrophy. Left ventricular mass/height 2.7 was higher in obese than normal-weight normotensive subjects (P < .004) independently of the level of blood pressure and identified a higher prevalence of hypertrophy (mainly eccentric) in obese than in normal-weight normotensive subjects (14% versus 5%, P < .04), a difference that was not detected by left ventricular mass/body surface area. Left ventricular mass/height identified hypertrophy in 52% of obese and 30% of normal-weight hypertensive patients (P < .0001) because of higher prevalences in obese than normal-weight patients of both eccentric (34% versus 20%) and concentric ventricular hypertrophy (18% versus 10%). The increase in left ventricular mass was independent of blood pressure values in obese normotensive women (but not men), and the prevalence of supranormal left ventricular mass/height 2.7 was even higher in hypertensive obese women (58%) than men (49%).(ABSTRACT TRUNCATED AT 250 WORDS) more...
- Published
- 1994
- Full Text
- View/download PDF
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