Then there is also the consideration of co-morbid conditions. There is a category of compelling indications in this last series of recommendations. For example, diabetics with proteinuria. There’s a strong indication for using ACE inhibitors. For patients who have also the co-morbid condition of heart failure, consider ACE inhibitors and diuretics. Isolated systolic hypertension, especially in older patients, diuretics and probably long-acting dihydropyridine calcium channel blockers. Those patients who have experienced myocardial infarction, you heard about the benefit of beta-blockers, especially those without the ISA, or intrinsic sympathomimetic activity, and then the ACE inhibitors especially in those post-MI patients with systolic dysfunction.
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Now in the last year, year or two, we have seen one new beta-blocker enter the arena and that is cheap Coreg, curvediol. It’s a non-selective beta-blocker and it’s indicated for both hypertension and congestive heart failure. This is pretty remarkable when you think about five or six years ago we all stood back and said, “Um, beta-blocker? Congestive heart failure? I don’t think that’s a healthy combination and we don’t want to do that.” But with the non-selectivity, that kind of opens the door for the use here. It seems to also be beneficial in ischemic and non-ischemic heart failure, however it’s still a beta-blocker and it will lower heart rate so it’s probably best to avoid it in those patients with significant underlying bradycardia. Unfortunately, it is also a b.i.d. drug and that may lower compliance a little bit.
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In the ACE arena we’ve seen the appearance of the ACE II inhibitors and the most recent one is Diovan, which is valsartan. It’s similar to the losartan, which was the first entry, and that was Cozaar. The valsartan seemed to be very similar in efficacy to the other ACE inhibitors but there seems to be less causative effect to that dry, hacking cough, and the valsartan seems to be more efficacious in all comers as far as gender, race, sex. Some of the ACE I blockers did not seem to be very effective in black patients. In addition, this valsartan is priced competitively with the other ACE inhibitors. I personally think that this is going to be a very interesting drug category to watch. Right now it’s a little bit different from ACE I inhibitors, but it’s once a day, it seems to cause less side effects and I’ll be very interested to see if in the next two or three years if the ACE II class doesn’t in fact sort of replace the ACE I class.
In the calcium channel blocker classification, we have a new subgroup of calcium channel blockers, the tetralol group. Right now there’s only one that we are using and that’s the Posicor. It’s recommended for both high blood pressure and angina and it has the interesting effect that it may also slow heart rate. Some of the early calcium channel blockers had the reflex tachycardia and we don’t seem to see that with the Posicor. Unfortunately it is also subject to the interaction that you heard about earlier with the statin drugs as it is metabolized through the cytochrome P450 enzyme channel.