The AHA says ARBs such as Cozaar May Increase Risk of Heart Attack

[Duff Man]

http://www.circ.ahajournals.org/cgi/content/full/114/8/838 <-- The article

The paragraph that stuck out to me:

In the LIFE (Losartan Intervention For Endpoint reduction in hypertension) trial (n=9193),14 losartan treatment was associated with a 5% statistically nonsignificant increase of MI (198/4605 versus 188/4588, unadjusted, or 7% adjusted) compared with atenolol despite a 1.7-mm Hg lower mean pulse pressure and a major reduction in stroke. Candesartan was associated with a 10% statistically nonsignificant increase in fatal plus nonfatal MI (14% for nonfatal MI) in SCOPE (Study on COgnition and Prognosis in Elderly)15 (n=4937) despite a mean 3.2/1.6-mm Hg lower blood pressure than in the control group. In the VALUE trial (n=15 245),13 treatment with valsartan 160 mg was associated with a statistically significant increase (19%; P=0.02) in total MI (fatal and nonfatal MI) compared with amlodipine 10 mg. Importantly, this trial recruited "high-risk" patients with hypertension, 80% of whom had symptomatic vascular disease. A post hoc analysis of serial median matching71 and a division of the follow-up period into consecutive intervals suggested that the MI rate was a reflection of the blood pressure differential of 1.8/1.5 mm Hg in favor of amlodipine, although these analyses have been criticized.72 In VALUE, the predicted odds ratio (OR) for MI was 0.98 for a systolic blood pressure gradient of 2.2 mm Hg compared with the observed 1.19 (P=0.03), which led one expert to conclude, "with regards to myocardial infarction, the results of valsartan-based treatment were worse, or conversely, those of amlodipine-based treatment were better, than predicted from the gradient in the achieved systolic blood pressure."72

and

After adjustment for blood pressure differentials, not only are MI and CV death unaltered with ARBs, but they actually show a tendency to increase, such that compared with the clear benefits seen with ACEIs, the effects seen with ARBs are significantly inferior (Figure 10). It is truly paradoxical that 9 of the 11 key ARB trials showed an excess in rates of MI, an observation that is difficult to discount in clinical practice (Figure 8).

and the graph is damning too:

I reckon it's good reading if you're in to worrying and you can deal with thick jargon. It really is something you should read if you're on an ARB, in my opinion.

In summary, there's some legit data out there that says although ARBs are about as effective as ACE Inhibitors for lowering blood pressure, the mechanism by which they do it may be harmful to some people. It's suggested that ARBs can cause instability and rupture of coronary plaque. It also said some stuff that makes me think it may adversely affect endothelial cells which is probably bad for people with BAV/Aneurysms.

ARBs block the AT1 receptors and turn off a negative feedback mechanism thereby increasing AngII levels and activating the AT2 receptors several times more than would be without the ARB. This makes the body produce more bad stuff and AngII is one of them that probably causes adverse effects, of which not enough is known. The article attempts to explain what kind of bad stuff probably happens because of it.

What's my conclusion? I would stick with an ACE Inhibitor unless I couldn't tolerate their side effects. In my opinion ACE Inhibitors are probably the most protective out of all the BP drugs.

I just switched back to Cozaar so naturally I'm obsessing over the merits of my decision. I've had less heart burn and other small improvements since the switch, but ... at what cost? Hopefully none. Figured I'd share this with my valve family.

 

[tobagotwo]

This is an exellent find, Duff Man.

*caution* soap box rant follows...

The medical industry, including both physicians and drug representatives, has long tried to sell that simply lowered blood pressure (or lowered cholesterol, for that matter) is enough to approve a drug and be allowed to advertise and sell that drug as beneficial. In fact, studies are now showing definitively that it's just not that simple. Expensive drug combinations for touted cholesterol control are being found to be entirely ineffective at preventing heart risks, and others are showing detrimental side effects, such as increased heart attacks, which they are intended to prevent.

Long-term usage in real patients is now showing the price that a patient may pay in reality just to reduce a risk factor that may or may not apply to them. This is something that is rarely discussed with the patient before the compound is prescribed (that would be informed consent). Many blood pressure reduction compounds interact with many bodily chemical exchanges that are not associated with blood pressure, and can have surprisingly damaging, seemingly unrelated effects.

For example, would you be willing to take Atenolol, if it had been pointed out to you that you run the risk of developing lifelong psoriasis from taking it?

Would you be eager to lower your blood pressure with a beta blocker, if it had been explained to you that you run a very real risk of developing diabetes as a side effect? (This is why ACE inhibitors are the first line of blood pressure defense in the UK and Europe, rather than beta blockers.)

Is there anyone reading this who was told of these dangers when they were being prescribed these medications? You would be a rare case indeed, if you had.

It's plain that the effects of diabetes and psoriasis can be linked with heart disease. In fact, you can hear that broadcast on a continuous-loop tape at WalMart, next to the pharmacy. But it's not made plain that drugs used commonly to lower risk factors for heart disease in otherwise healthy patients can cause diabetes and psoriasis where none existed. And most cardiologists feel that placing those risks on their patients is perfectly acceptable, as their interest is only in the blood pressure, and not in the body's other systems.

The notion that it's appropriate for any specialty to feel that their piece of the human pie is so overwhelmingly important that it's acceptable to endanger other aspects of their patients' health needs to pass out of the system. Patients should be properly informed of the risks of their treatment. Maybe patients should have a primary pharmacist as well a primary physician, to keep tabs on what ill effects may be occurring.

How many times have you been put on a prescription, and told by your physician that they would "monitor" how well it worked for you. And if you went back to complain about a side effect you were having, how often were you told to just keep taking it and see if you could adjust to it, rather than any attempt being made to try something different? Even if there were FDA-required warnings on the drug that you should immediately report the specific side effect you were having to your doctor, did the doctor do anything to change the prescription, or even look into it? Generally, the answer is no. Most of us have had this happen to us at least once.

While these drugs can have useful, even life-saving benefits for many patients, their risks should be discussed with patients before being prescribed, and complaints from patients to their doctors should be treated with the concern the FDA intended when they put warnings on them. These should never be looked upon as so overwhelingly important that it's okay to risk other portions of the patients' health without informing the patient of those risks, just to use them.

Something to think about.

Best wishes,

 

[DavesMom]

Excellent find, Duff Man, and excellent post, Bob.

I was put on Coreg last spring due to keep my BP down since I have an aneurysm. In June I met with my cardio's assistant to ask about getting off it because of terrible fatigue. I was assured by both my cardio and her assistant that this was the best drug for me. The fatigue has improved somewhat, so that's the good news.

I have since read that Coreg can cause diabetes. Was I informed of this? No, even though my cardio is well aware of the fact that I have a congenital condition that gives me a 50% greater chance than the general population of developing it. Frankly, I was on no BP med for a year after the aneurysm was discovered and there was no increase in the size of the aneurysm, so a part of me wonders why bother with the Coreg? I still get high readings at times, even with it. I have an appointment with her in a couple of months and this will definitely be discussed. I will even print out the article to take.

This same congenital condition also causes decreased bone density. And guess what? After a bone density test came back bad, my neurologist said that the med I'm on for complex partial seizures can be detrimental to bone density. Great - so I'm taking a bone density medicine thanks in part to my seizure med.

Some of this boils down to the plain old fear that doctors can instill in patients. Do I go off Coreg and risk an aortic dissection? Do I go off my seizure med and risk having them worsen? Grrrrr.....

Anyway, sorry for my own lengthy semi-rant! Great posts from both of you.

Cheers,
Michelle

 

[Duff Man]

Bob, I agree with your sentiments about MDs wanton disregard for our informed consent with prescription medications. I honestly believe though that they simply don't KNOW the stuff they should know to inform a patient of the risks of the drugs they prescribe. I do think that their pride perpetuates their ignorance to some extent.

I too developed a hideous, painful rash on my face within a year of starting Atenolol. I went to the doctor convinced that Atenolol was causing the rash, to which he said "That's really weird. Really, weird. I've been practicing for 35 years and I've never heard of it." He then referred me to a dermatologist hahahaha. I'm thinking "OH OK BUDDY, you've been practicing for 35 years, therefor the hideous rash on my face couldn't be caused by huge chemistry changes in my body due to the medicine you prescribed me." I've since managed to pinpoint that it is in fact the beta blockers, but I still take them and manage to keep the rash in check with creams and stuff. I also switched to bystolic (a very cardio specific betablocker said to be "Novel"), and I think that helped too.

While I think that the beta blockers do serious things to my face, I also believe they've saved my life. With my rapid resting heart rate and just about malignantly high blood pressure, I think I would've been a goner without it. The alternative medications I've tried had side effects that were even more unbearable than the weird rashes and fatigue.

I think it's important for me to point out that although there are side effects both known and unkonwn to every drug, we shouln't automatically discount the importance of taking the drug. Beta blockers are still a very necessary, albeit fairly ugly and primitive drug.

Michelle(DavesMom), just so you know, this article from the AHA is talking about Angiotensin REceptor Blockers, and not beta blockers. Coreg is a beta blocker that is NON-selective. Non-selective beta-blockers are thought to have more inherent side effects such as fatigue and respiratory issues than their selective counterparts. There may be benefits to Coreg that the doctor believes appropriate for you, but you should know there are more selective alternatives.

Wikipedia.org at one time had an awesome chart with more beta blockers that showed their selectivity, but I can't find it right now.

 

[CThrock]

I have been on Cozaar for two years now and never had a problem. I don't trust any of those ARB or FDA, you just don't know what to believe anymore. It also helps with my kidney function. Good reading information though.

 

[DavesMom]

Thanks for the clarification about Coreg, Duff Man. I know it's a beta blocker but for some reason I equated beta blockers with ARBs.

I am still upset about Coreg increasing my risk of diabetes, so I will talk to my cardio about the alternatives.

Thanks again!

Cheers,
Michelle