Case 2
Andrew Solomon, Julia Anstey, Liora Wittner, Priti Dutta in Clinical Cases, 2021
This chapter presents a case study of a 60-year-old businessman, collapsed at home and was brought into the emergency department by ambulance. He had been working from home, when his wife heard a thud and rushed into the room to find that he had collapsed and was unconscious. His past medical history includes obesity, hypertension and high cholesterol, for which he takes atorvastatin, amlodipine and ramipril. He had a previous deep-vein thrombosis 4 years ago. Careful clinical judgement must be used as the optimal agent will depend on the haemodynamic stability of the patient, presence of risk factors and comorbidities and anticipated need for later procedures or thrombolysis. The chapter illustrates the complicated, progressive problems that will be seen while practicing as a doctor with detailed diagrams and diagnostic imagery to aid understanding. It also shows, with timepoints, how differential diagnoses may change as more information becomes available and new symptoms arise.
Write short notes on the mode of action of drugs that lower blood pressure
Nathaniel Knox Cartwright, Petros Carvounis in Short Answer Questions for the MRCOphth Part 1, 2018
Elevated blood pressure (BP) accelerates microvascular and macrovascular disease. Antihypertensive agents are widely prescribed. They include: β -blockers (e.g. atenolol): – the precise antihypertensive action of β -blockers is poorly understood – reduce cardiac output, alter baroreflex sensitivity and block peripheral adrenoreceptors – it is possible that their antihypertensive effect is central α -blockers (e.g. prazosin): – reduce BP by blocking post-synaptic α -receptors, causing vasodilatation calcium channel blockers (e.g. nifedipine): – act by blocking calcium influx through the slow transmembrane calcium channels – dihydropyridine calcium channel blockers such as nifedipine cause vasodilatation alone; non-dihydropyridine calcium channel blockers such as verapamil are also negative ionotropes angiotensin-converting enzyme (ACE) inhibitors (e.g. ramipril): – block the conversion of angiotensin I to angiotensin II – reduction in angiotensin II levels leads to reduced salt and water retention and vasodilatation – particularly useful in diabetic patients in whom they may protect against nephropathy angiotensin II antagonists (e.g. losartan): – used in those intolerant of ACE inhibitors, these drugs directly inhibit angiotensin II – actions are identical to ACE inhibitors nitrates (e.g. glyceryl trinitrate): – reduce blood pressure through a direct vasodilatating action on smooth muscle central-acting antihypertensives (e.g. methyldopa): – mode of action is uncertain.
The benefits of treating hypertension in the elderly
Norman M Kaplan in Hypertension in the Elderly: Pocketbook, 1999
The four RCTs comparing ACEIs against placebo involved patients whose primary problem was coronary disease and not hypertension. The largest by far, the Heart Outcomes Prevention Evaluation (HOPE) trial (2000), included 4355 hypertensive patients, but most were on other antihypertensive drugs and the average blood pressure of the entire 9297 patient population at entry into the trial was only 139/79 mmHg. Despite only a 3/1 mmHg further lowering of BP, significant reductions in all major end-points were seen in those given the ACEI ramipril.
Type 2 diabetes-induced cardiovascular complications: comparative evaluation of spironolactone, atenolol, metoprolol, ramipril and perindopril
Published in Clinical and Experimental Hypertension, 2014
Bhoomika M. Patel, Shraddha V. Bhadada
The present study was carried out to study the effect of spironolactone, atenolol, metoprolol, ramipril and perindopril on cardiovascular complications in neonatal model of diabetes in rats, induced by administering 90 mg/kg streptozotocin (STZ), i.p. in 2-day-old rats. Our data suggest that spironolactone, metoprolol and perindopril prevent not only the STZ-induced metabolic abnormalities but also cardiovascular complications as evident from the reduction in cholesterol, triglyceride and decrease in cardiac hypertrophy which are the initial symptoms of congestive heart failure. Metoprolol and perindopril appears to be beneficial agents as compared to atenolol and ramipril.
Impact of amlodipine or ramipril treatment on left ventricular mass and carotid intima-media thickness in nondiabetic hemodialysis patients
Published in Renal Failure, 2010
Rahmi Yilmaz, Bulent Altun, Serkan Kahraman, Necla Ozer, Devrim Akinci, Cetin Turgan
Objective: Left ventricular hypertrophy (LVH) and atherosclerosis are frequently observed in uremic patients and they have appeared as an independent predictor of cardiovascular morbidity and mortality. The aim of this study was to compare the effects of ramipril and amlodipine on left ventricular mass index (LVMI) and carotid intima-media thickness (CIMT) in nondiabetic hypertensive hemodialysis patients. Methods: A total of 112 hemodialysis (HD) patients were included in this study. Patients were randomly allocated to receive ramipril or amlodipine for 1 year. Blood pressure (BP) measurements, LVMI, and CIMT were assessed at baseline and 6-month intervals. Biochemical parameters and inflammatory markers were also determined at the initiation and during the study period. Results: Similar BP decrease was observed in treatment groups. During follow-up, LVMI and CIMT progressed likewise in both treatment groups despite BP control. However, subgrouping analyses due to the pattern of left ventricular geometry showed that LVMI in patients with eccentric LVH increased, whereas LVMI decreased in subjects with concentric LVH under antihypertensive treatment. Discussion: BP control with ramipril or amlodipine could not provide adequate protection for development or progression of atherosclerosis and eccentric type of LVH in nondiabetic HD patients.
Economic evaluation of ramipril in the treatment of patients at high risk for cardiovascular events
Published in Journal of Medical Economics, 2000
Martin E. Backhouse, Anke Richter, Louise Gaffney
SUMMARY Cardiovascular disease (CVD) is a primary cause of death and morbidity in the United Kingdom (UK). Recently, the Heart Outcomes Prevention Evaluation (HOPE) trial demonstrated significant survival and morbidity benefits associated with ramipril use in the treatment of patients at high risk for cardiovascular events. The purpose of this paper is to assess whether and to what extent, these clinical benefits might translate into economic benefits from the perspective of the UK NHS. Using trial data and a decision-analytic model, our base case estimate of cost-effectiveness is £4,406 per life-year saved (undiscounted) and £5,544 per life-year saved (discounted). The extreme values of our sensitivity analyses ranged from a best case of £2,814 per life-year saved (undiscounted) to a worst case of £10,291 per life-year saved (undiscounted). Our base case estimate of cost-effectiveness suggests that treating patients at high risk for CVD events with ramipril is likely to be a good investment of NHS resources.
Related Knowledge Centers
- Ace Inhibitor
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- Revascularization
- Stroke
- Hypertension
- Heart Failure
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