-
Canadian Medical Association Journal 04/2012; 184(7):791; author reply 791-2. · 8.22 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Garlic is widely used by patients for its blood pressure lowering effects. A meta-analysis published in 2008 concluded that garlic consumption lowers blood pressure in hypertensive and normotensive patients. Therefore, it is important to review the currently available evidence to determine whether garlic may also have a beneficial role in the reduction of cardiovascular events and mortality rates in patients with hypertension.
To determine whether the use of garlic as monotherapy, in hypertensive patients, lowers the risk of cardiovascular morbidity and mortality compared to placebo.
A systematic search for trials was conducted in the Cochrane Hypertension Group Specialised Register, CENTRAL, MEDLINE, EMBASE, AGRICOLA, AMED, and CINAHL up to November 2011. A hand search of reference lists of identified reviews was conducted. Experts in the area were also contacted to identify trials not found in the electronic search. Clinicaltrials.gov was searched for ongoing trials.
Randomized, placebo-controlled trials of any garlic preparation versus placebo for the treatment of hypertension were included.
Two reviewers independently extracted data and assessed trial quality using the risk of bias tool. Data synthesis and analysis was performed using RevMan 5.
The search identified two randomized controlled trials for inclusion. One trial included 47 hypertensive patients and showed that garlic significantly reduces mean supine systolic blood pressure by 12 mmHg (95% CI 0.56 to 23.44 mmHg, p=0.04) and mean supine diastolic blood pressure by 9 mmHg (95% CI 2.49 to 15.51 mmHg, p=0.007) versus placebo. The authors state that garlic was "free from side effects" and that no serious side effects were reported. There were 3 cases "where a slight smell of garlic was noted."The second trial could not be meta-analysed as they did not report the number of people randomized to each treatment group. They did report that 200 mg of garlic powder given three times daily, in addition to hydrochlorothiazide-triamterene baseline therapy, produced a mean reduction of systolic blood pressure by 10-11 mmHg and of diastolic blood pressure by 6-8 mmHg versus placebo.Neither trial reported clinical outcomes and insufficient data was provided on adverse events.
There is insufficient evidence to determine if garlic provides a therapeutic advantage versus placebo in terms of reducing the risk of mortality and cardiovascular morbidity in patients diagnosed with hypertension. There is also insufficient evidence to determine the difference in withdrawals due to adverse events between patients treated with garlic or placebo.Based on 2 trials in 87 hypertensive patients, it appears that garlic reduces mean supine systolic and diastolic blood pressure by approximately 10-12 mmHg and 6-9 mmHg, respectively, over and above the effect of placebo but the confidence intervals for these effect estimates are not precise and this difference in blood pressure reduction falls within the known variability in blood pressure measurements. This makes it difficult to determine the true impact of garlic on lowering blood pressure.
Cochrane database of systematic reviews (Online) 01/2012; 8:CD007653. · 5.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Hypertension is associated with an increased risk of stroke, myocardial infarction and congestive heart failure. Hydralazine is a direct-acting vasodilator which has been used for the treatment of hypertension since the 1950's. Although it has largely been replaced by newer antihypertensive drugs with more acceptable tolerability profiles, hydralazine is still widely used in developing countries due to its lower cost. A review of its relative effectiveness compared to placebo on surrogate and clinical outcomes is justified.
To quantify the effect of hydralazine compared to placebo in randomized controlled trials (RCTs) on all cause mortality, cardiovascular mortality, serious adverse events, myocardial infarctions, strokes, withdrawals due to adverse effects and blood pressure in patients with primary hypertension.
We searched the following databases: Cochrane Central Register of Controlled Trials (2011, Issue 3), MEDLINE (1948-August 2011), International Pharmaceutical Abstracts (1970-June 2009) and EMBASE (1980-August 2011). Bibliographic citations from retrieved studies were also reviewed. No language restrictions were applied.
We selected RCTs studying the effect of oral hydralazine compared to oral placebo in patients with primary hypertension. We excluded studies of patients with secondary hypertension or gestational hypertension.
Two reviewers independently extracted data and assessed trial quality using the risk of bias tool. Data synthesis and analysis was performed using RevMan 5.
The search strategy did not yield any randomized controlled trials comparing hydralazine to placebo for inclusion in this review. There is insufficient evidence to conclude on the effects of hydralazine versus placebo on mortality, morbidity, withdrawals due to adverse effects, serious adverse events, or systolic and diastolic blood pressure. Some of the adverse effects related to hydralazine that have been reported in the literature include reflex tachycardia, hemolytic anemia, vasculitis, glomerulonephritis, and a lupus-like syndrome.
Hydralazine may reduce blood pressure when compared to placebo in patients with primary hypertension, however this data is based on before and after studies, not RCTs. Furthermore, its effect on clinical outcomes remains uncertain.
Cochrane database of systematic reviews (Online) 01/2011; · 5.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Spironolactone is an aldosterone antagonist, considered fourth line therapy for hypertension in patients already treated with multiple medications.
Primary: to determine the effect of spironolactone on patient mortality, morbidity, and to quantify the magnitude of blood pressure lowering effect of spironolactone monotherapy.Secondary: to determine the prevalence of adverse reactions observed with spironolactone monotherapy and to determine if there is a blood-pressure lowering dose response with spironolactone.
We searched the following databases: Cochrane Central Register of Controlled Trials (3rd Quarter 2009), MEDLINE (2005 - Sept. 2009), and EMBASE (2007 - Sept. 2009). References from retrieved studies were reviewed to identify any studies missed in the initial search. No language restrictions were applied.
We selected RCTs studying patients with primary hypertension. We excluded studies of patients with secondary or gestational hypertension, and studies where patients were receiving multiple antihypertensives.
Two reviewers independently reviewed the search results for studies meeting our criteria. Three reviewers extracted data and assessed trial quality using a standardized data extraction form. Data synthesis and analysis was performed using RevMan 5.
Meta-analysis of the 5 cross-over studies found a reduction in SBP of 20.09 mmHg (95%CI:16.58-23.06,p<0.00001) and a 6.75 mmHg (95%CI:4.8-8.69,p<0.00001) reduction in DBP. These results were statistically significant and there was no evidence of heterogeneity between the studies. There may be a dose response effect with spironolactone up to 50 mg/day, but the confidence intervals around the mean end-of-study blood pressure for doses ranging 25-500 mg/day all overlapped. In other words, it appears that doses >50mg/day do not produce further reductions in either SBP or DBP. One cross-over study found that spironolactone 25 mg/day did not statistically significantly change SBP or DBP compared to placebo, SBP: -9.9 (95%CI:-21.15,1.35); DBP -2.34 (95%CI:-7.92,3.06).
From the limited available evidence, spironolactone appears to lower blood pressure compared to placebo to a similar degree in patients with primary (essential) hypertension when doses of 100-500 mg/day are given. A dose of 25 mg/day did not statistically significantly reduce systolic or diastolic blood pressure, compared to placebo. Given the lack of a dose-response, coupled with a possible increased risk in adverse events with higher doses, doses of 25 to 100 mg/day are reasonable. There is no evidence of the effect of spironolactone on clinical outcomes in hypertensive patients.
Cochrane database of systematic reviews (Online) 01/2010; · 5.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Hypertension is associated with an increased risk of stroke, myocardial infarction and congestive heart failure. Hydralazine is a direct-acting vasodilator which has been used for the treatment of hypertension since the 1950's. Although it has largely been replaced by newer antihypertensive drugs with more acceptable tolerability profiles, hydralazine is still widely used in developing countries due to its lower cost. A review of its relative effectiveness compared to placebo on surrogate and clinical outcomes is justified.
To quantify the effect of hydralazine compared to placebo in randomized controlled trials (RCTs) on all cause mortality, cardiovascular mortality, serious adverse events, myocardial infarctions, strokes, withdrawals due to adverse effects and blood pressure in patients with primary hypertension.
We searched the following databases: Cochrane Central Register of Controlled Trials (to Second Quarter 2009), MEDLINE (2005-June 2009), International Pharmaceutical Abstracts (1970-June 2009) and EMBASE (2007-June 2009). Bibliographic citations from retrieved studies were also reviewed. No language restrictions were applied.
We selected RCTs studying the effect of oral hydralazine compared to oral placebo in patients with primary hypertension. We excluded studies of patients with secondary hypertension or gestational hypertension.
Two reviewers independently extracted data and assessed trial quality using the risk of bias tool. Data synthesis and analysis was performed using RevMan 5.
The search strategy did not yield any randomized controlled trials comparing hydralazine to placebo for inclusion in this review. There is insufficient evidence to conclude on the effects of hydralazine versus placebo on mortality, morbidity, withdrawals due to adverse effects, serious adverse events, or systolic and diastolic blood pressure. Some of the adverse effects related to hydralazine that have been reported in the literature include reflex tachycardia, hemolytic anemia, vasculitis, glomerulonephritis, and a lupus-like syndrome.
Hydralazine may reduce blood pressure when compared to placebo in patients with primary hypertension, however this data is based on before and after studies, not RCTs. Furthermore, its effect on clinical outcomes remains uncertain.
Cochrane database of systematic reviews (Online) 01/2010; · 5.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Intradialytic parenteral nutrition (IDPN) is widely used to treat malnourished hemodialysis (HD) patients. However, the benefits of this treatment are unknown. Moderate protein-energy malnutrition (PEM) is thought to affect 15% to 43% of maintenance HD patients, and is independently associated with mortality in this population. This study systematically reviews the current literature, to assess whether IDPN improves survival, quality of life, or nutritional status in those receiving maintenance HD.
Two investigators undertook a formal systematic review of the literature, using the following key search words: intradialytic parenteral nutrition or intradialytic total parenteral nutrition plus any combination of renal dialysis or kidney-failure or chronic kidney disease and parenteral nutrition or intravenous nutrition or intravenous feeding.
The search identified three suitable randomized, controlled trials, only one of which investigated hard clinical endpoints. There were insufficient data to undertake a meta-analysis.
The evidence from clinical studies is insufficient to demonstrate either a net benefit or a net harm associated with the providing IDPN to malnourished HD patients. We recommend that any patient in whom IDPN was deemed necessary be entered into a clinical trial or registry, to record hard clinical outcomes associated with the use of this treatment.
Journal of Renal Nutrition 09/2009; 20(1):1-7. · 1.57 Impact Factor
-
Annals of Pharmacotherapy 03/2009; 43(2):391-2; author reply 392-3. · 2.13 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Wegener's granulomatosis (WG) is a necrotizing small-vessel vasculitis that can affect any organ in the body but mainly affects the upper and lower respiratory tract, the kidneys, joints, skin and eyes. The current mainstay of remission induction therapy is systemic corticosteroids in combination with oral daily cyclophosphamide (CYC) which induces remission in 75% to 100% of cases. Although standard therapy is effective in inducing partial or complete remission, 50% of complete remissions are followed by at least one relapse.
To determine if intravenous immunoglobulin (IVIg) adjuvant therapy provides a therapeutic advantage over and above treatment with systemic corticosteroids in combination with immunosuppressants for the treatment of WG.
The Cochrane Peripheral Vascular Diseases (PVD) Group searched their Trials Register (last searched 8 May) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched 2009, Issue 2). We searched MEDLINE (1966 to May 2009) and EMBASE (1980 to May 2009).
Randomized controlled trials (RCTs), or quasi RCTs, or randomized cross-over trials. Participants had to be adults with a confirmed diagnosis of WG.
Two authors independently extracted data and assessed trial quality. Relative risk was used to analyze dichotomous variables, and mean difference (MD) was used to analyze continuous variables.
We included one RCT with 34 participants who were randomly assigned to receive IVIg or placebo once daily in addition to azathioprine and prednisolone for remission maintenance. There were no significant differences between adjuvant IVIg and adjuvant placebo in mortality, serious adverse events, time to relapse, open-label rescue therapy, and infection rates. The fall in disease activity score, derived from patient-reported symptoms, was slightly greater in the IVIg group than in the placebo group at one month (MD 2.30; 95% Confidence interval (CI) 1.12 to 3.48, P < 0.01) and three months (MD 1.80; 95% CI 0.35 to 3.25, P = 0.01). There was a significant increase in total adverse events in the IVIg group (relative risk (RR) 3.50; 95% CI 1.44 to 8.48, P < 0.01).
There is insufficient evidence from one RCT that IVIg adjuvant therapy provides a therapeutic advantage compared with the combination of steroids and immunosuppressants for patients with WG. Given the high cost of IVIg (one dose at 2g/kg for a 70kg patient = $8,400), it should be limited to treat WG in the context of a well conducted RCT powered to detect patient-relevant outcomes.
Cochrane database of systematic reviews (Online) 02/2009; · 5.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Hypertension is associated with an increased risk of stroke, myocardial infarction and congestive heart failure. Methyldopa is a centrally acting antihypertensive agent, which was commonly used in the 1970's and 80's for blood pressure control. Its use at present has largely been replaced by antihypertensive drug classes with less side effects, but it is still used in developing countries due to its low cost. A review of its relative effectiveness compared to placebo on surrogate and clinical outcomes is justified.
To quantify the effect of methyldopa compared to placebo in randomized controlled trials (RCTs) on all cause mortality, cardiovascular mortality, serious adverse events, myocardial infarctions, strokes, withdrawals due to adverse effects and blood pressure in patients with primary hypertension.
We searched the following databases: Cochrane Central Register of Controlled Trials (1960-June 2009), MEDLINE (2005-June 2009), and EMBASE (2007-June 2009). Bibliographic citations from retrieved studies were also reviewed. No language restrictions were applied.
We selected RCTs studying patients with primary hypertension. We excluded studies of patients with secondary hypertension or gestational hypertension.
Two reviewers independently extracted data and assessed trial quality using the risk of bias tool. Data synthesis and analysis was performed using RevMan 5. Data for blood pressure were combined using the generic inverse variance method.
Twelve trials (N=595) met the inclusion criteria for this review. None of these studies evaluated the effects of methyldopa compared to placebo on mortality and morbidity outcomes. Data for withdrawals due to adverse effects were not reported in a way that permitted meaningful meta-analysis. Data from six of the twelve trials (N=231) were combined to evaluate the blood pressure lowering effects of methyldopa compared to placebo. This meta-analysis shows that methyldopa at doses ranging from 500-2250 mg daily lowers systolic and diastolic blood pressure by a mean of 13 (95%CI 6-20) / 8 (95% CI 4-13) mmHg. Overall, the risk of bias was considered moderate.
Methyldopa lowers blood pressure to varying degrees compared to placebo for patients with primary hypertension. Its effect on clinical outcomes, however, remains uncertain.
Cochrane database of systematic reviews (Online) 01/2009; · 5.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Elevated blood pressure (known as hypertension) increases with age, and most rapidly over age 60. Systolic hypertension is more strongly associated with cardiovascular disease than diastolic hypertension, and occurs more commonly in older people. It is important to know the benefits and harms of antihypertensive treatment of hypertension in this age group.
To quantify antihypertensive drug effect on overall mortality, cardiovascular mortality and morbidity and withdrawal due to adverse effects in people 60 years and older with mild to moderate systolic or diastolic hypertension.
Updated search of electronic database of EMBASE, CENTRAL, MEDLINE until Dec 2008; previous search of two Japanese databases (1973-1995) and WHO-ISH Collaboration register (August 1997); references from reviews, trials and previously published meta-analyses; and experts.
Randomized controlled trials of at least one year duration in hypertensive elders (at least 60 years old) comparing antihypertensive drug therapy with placebo or no treatment and providing morbidity and mortality data.
Outcomes assessed were total mortality (including cardiovascular, coronary heart disease and cerebrovascular mortality); total cardiovascular morbidity and mortality (representing combined coronary heart disease and cerebrovascular morbidity and mortality); and withdrawal due to adverse events.
Fifteen trials (24,055 subjects >/= 60 years) with moderate to severe hypertension were identified. These trials mostly evaluated first-line thiazide diuretic therapy for a mean duration of treatment of 4.5 years. Treatment reduced total mortality, RR 0.90 (0.84, 0.97); event rates per 1000 participants reduced from 116 to 104. Treatment also reduced total cardiovascular morbidity and mortality, RR 0.72 (0.68, 0.77); event rates per 1000 participants reduced from 149 to 106. In the three trials restricted to persons with isolated systolic hypertension the benefit was similar. In very elderly patients >/= 80 years the reduction in total cardiovascular mortality and morbidity was similar RR 0.75 [0.65, 0.87] however, there was no reduction in total mortality, RR 1.01 [0.90, 1.13]. Withdrawals due to adverse effects were increased with treatment, RR 1.71 [1.45, 2.00].
Treating healthy persons (60 years or older) with moderate to severe systolic and/or diastolic hypertension reduces all cause mortality and cardiovascular morbidity and mortality. The decrease in all cause mortality was limited to persons 60 to 80 years of age.
Cochrane database of systematic reviews (Online) 01/2009; · 5.72 Impact Factor
