We performed a post hoc analysis of the Systolic Hypertension in the Elderly Program database to assess the incidence of atrial fibrillation in the elderly hypertensive population, its influence on cardiovascular events, and whether antihypertensive treatment can prevent its onset. The Systolic Hypertension in the Elderly Program was a double-blind placebo-controlled trial in 4736 subjects with isolated systolic hypertension aged ≥60 years. Atrial fibrillation was an exclusion criterion from the trial. Participants were randomly assigned to stepped care treatment with chlorthalidone and atenolol (n=2365) or placebo (n=2371). The occurrence of atrial fibrillation and cardiovascular events over 4.7 years as well as the determination of cause of death at 4.7 and 14.3 years were followed. Ninety-eight subjects (2.06%) developed atrial fibrillation over 4.7 years mean follow-up, without significant difference between treated and placebo groups. Atrial fibrillation increased the risk for: total cardiovascular events (RR 1.69; 95% CI 1.21 to 2.36), rapid death (RR 3.29; 95% CI 1.08 to 10.00), total (RR 5.10; 95% CI 3.12 to 8.37) and nonfatal left ventricular failure (RR 5.31; 95% CI 3.09 to 9.13). All-cause and total cardiovascular death were significantly increased in the atrial fibrillation group at 4.7 years (HR 3.44; 95% CI 2.18 to 5.42; HR 2.39; 95% CI 1.05 to 5.43) and 14.3 years follow-up (HR 2.33; 95% CI 1.83 to 2.98; HR 2.21; 95% CI 1.54 to 3.17). Atrial fibrillation increased the risk for total cardiovascular events, rapid death, and left ventricular failure. All-cause mortality and total cardiovascular mortality were significantly increased in hypertensives with atrial fibrillation at 4.7 and 14.3 years follow-up.

No previous study has examined the importance of right ventricular pacing as a risk factor for the development of heart failure (HF) in subjects without a history of HF. A cohort study of patients who underwent initial pacemaker implantation (n = 11,426) was conducted to test the hypothesis that patients with ventricular dyssynchrony created by permanent pacing would develop HF, as shown by new HIF hospitalizations or HF-related deaths, at a higher rate than matched controls. (C) 2005 by Excerpta Medica Inc.

Diuretic-based antihypertensive therapy is associated with the development of diabetes but with improved clinical outcomes. It has been proposed that the duration of clinical trials has been too short to detect the adverse effects of diabetes. We assessed the long-term mortality rate of subjects in the Systolic Hypertension in the Elderly,Program (n = 4,732) who were randomized to stepped-care therapy with 12.5 to 25.0 mg/day of chlorthalidone or matching placebo. If blood pressure remained above the goal, atenolol or matching placebo was added. At a mean follow-up of 14.3 years, cardiovascular (CV) mortality rate was significantly lower in the chlorthalidone group (19%) than in the placebo group (22%; adjusted hazard ratio [HR] 0.854, 95% confidence interval [CI] 0.751 to 0.972). Diabetes at baseline (n 799) was associated with increased CV mortality rate (adjusted HR 1.659, 95% CI 1.413 to 1.949) and total mortality rate (adjusted HR 1.510, 95% CI 1.347 to 1.693). Diabetes that developed during the trial among subjects on placebo (n = 169) was also associated with increased CV adverse outcome (adjusted HR 1.562, 95% CI 1.117 to 2.184) and total Mortality rate (adjusted HR 1.348, 95% CI 1.051 to 1.727). However, diabetes that developed among subjects during diuretic therapy (n = 258) did not have significant associations with CV mortality rate (adjusted HR 1.043, 95% CI 0.745 to 1.459) or total mortality rate (adjusted HZ 1.151, 95% CI 0.925 to 1.433). Diuretic treatment in subjects who had diabetes was strongly associated with lower long-term CV mortality rate (adjusted HR 0.688, 95% CI 0.526 to 0.848) and total mortality rate (adjusted HR 0.805, 95% CI 0.680 to 0.952). Thus, chlorthalidone-based treatment improved long-term outcomes, especially among subjects who had diabetes. Subjects who had diabetes associated with chlorthalidone had no significant increase in CV events and had a better prognosis than did those who had preexisting diabetes. (C)2005 by Excerpta Medica Inc.