CHICAGO—The calcium channel blocker verapamil did not show significant increased effectiveness compared to a diuretic and β-blocker in reducing the risk of cardiovascular events in patients with hypertension, according to an article in the April 23/30 issue of the Journal of the American Medical Association (JAMA).

Patients diagnosed as having hypertension are often given a calcium channel blocker to reduce cardiovascular disease risk, but the benefit compared with other drug classes is controversial, according to background information in the article.

Henry R. Black, MD, of Rush-Presbyterian–St Luke's Medical Center, Chicago, Ill, and colleagues conducted a study to determine whether initial therapy with controlled-onset extended release (COER) verapamil is equivalent to atenolol (a β-blocker) or hydrochlorothiazide (a diuretic) in preventing cardiovascular disease. The Controlled Onset Verapamil Investigation of Cardiovascular End Points (CONVINCE) Trial was a double-blind, randomized clinical trial conducted at 661 centers in 15 countries.

A total of 16 602 participants diagnosed as having hypertension and who had 1 or more additional risk factors for cardiovascular disease (such as diabetes or cigarette smoking) were enrolled between September 1996 and December 1998 and followed up until December 31, 2000. The trial included 8179 participants who received 180 mg of COER verapamil and 8297 who received either 50 mg of atenolol or 12.5 mg of hydrochlorothiazide. The primary endpoints were stroke, heart attack, or cardiovascular disease–related death.

After an average follow-up of 3 years, the sponsor closed the study (2 years early, "for commercial reasons") before unblinding the results, according to the authors.

"Systolic and diastolic blood pressure were reduced by 13.6 mm Hg and 7.8 mm Hg for participants assigned to the COER verapamil group and by 13.5 and 7.1 mm Hg for participants assigned to the atenolol or hydrochlorothiazide group. There were 364 primary cardiovascular disease–related events that occurred in the COER verapamil group vs 365 in atenolol or hydrochlorothiazide group," they write. "The treatment regimens showed some minor and statistically nonsignificant differences in the incidence of each component of the primary end point. The incidence of acute [heart attack] was about 18% lower with COER verapamil than with the atenolol or hydrochlorothiazide group; this benefit was offset by a 15% higher risk of stroke."

CHICAGO—Patients with high blood pressure and stage 1 hypertension who make lifestyle changes to lower their blood pressure also reduce the risk of developing cardiovascular disease (CVD), according to an article in the April 23/30 issue of the Journal of the American Medical Association (JAMA).

According to information in the article, high blood pressure (BP) is a risk factor for CVD. Almost 50 million US adults (approximately 25% of the US adult population) have hypertension, defined as a BP of 140/90 millimeters of mercury (mm/Hg) or higher and/or currently use antihypertensive (BP-lowering) medication. Hypertension risk increases with age, and approximately half of all people 60 years or older have hypertension, and the estimated lifetime risk for developing hypertension is 90%. Lifestyle modifications that lower BP are weight loss, reduced salt intake, increased physical activity, limited alcohol consumption, and a balanced diet, especially the Dietary Approaches to Stop Hypertension or DASH diet, which emphasizes eating fruits, vegetables, low-fat dairy products, whole grains, poultry, fish, and nuts and is reduced in fats, red meats, and sweets.

Lawrence J. Appel, MD, MPH, of the John Hopkins Medical Institutions, Baltimore, Md, and colleagues investigated the effectiveness of lifestyle changes on BP.

The researchers studied 810 adults (average age, 50 years; 62% women; 34% African American) with above-optimal BP, including stage 1 hypertension (120-159 mm Hg systolic and 80-95 mm/Hg diastolic) and who were not taking antihypertensive medications. Patients who participated in this randomized trial were enrolled at 4 clinical centers from January 2000 to June 2001, and were randomly assigned to 1 of 3 groups: "established," a behavioral intervention that used established recommendations for lifestyle changes for lowering BP (n=268); "established plus DASH," which also used the DASH diet (n=269); and an "advice-only" comparison group (n=273).

The researchers found that both of the behavioral interventions significantly reduced weight, increased fitness levels, and lowered sodium intake. The established plus DASH intervention also increased fruit, vegetable and dairy intake. From baseline to 6 months, the mean reduction in systolic BP (the top number in blood pressure) were 6.6 mm Hg in the advice-only group, 10.5 mm Hg in the established group, and 11.1 mm Hg in the established plus DASH diet group.

Compared with the 38% prevalence of hypertension at the beginning of the study, the prevalence at 6 months was 26% in the advice only group, 17% in the established group, and 12% in the established plus DASH group. The prevalence of optimal BP (<120 mm/Hg systolic, and <80 mm/Hg diastolic) was 19% in the advice-only group, 30% in the established group, and 35% in the established plus DASH group.

"In summary, our trial results demonstrate the feasibility of comprehensive behavioral interventions and their beneficial effects on BP and hypertension control," write the authors. "Benefits extend to both nonhypertensive individuals at risk for developing hypertension and hypertensive individuals who are not receiving medication therapy."

CHICAGO—A survey of forensic physicians in Mexico indicates that detainees experience torture and ill treatment, according to an article in the April 23/30 issue of the Journal of the American Medical Association (JAMA).

According to background information in the article, torture and ill treatment of detainees commonly occur in more than half of the world's countries and have devastating physical, psychological, and social health consequences. In response to this problem, physicians and other health professionals worldwide are playing crucial roles in efforts to investigate and document medical evidence, treat torture survivors, prevent torture, and oppose any form of physician involvement in torture. International and Mexican human rights organizations have documented torture of detainees (ie, those held and indicted but not sentenced) in all 31 states and the Federal District of Mexico, but little is known about the attitudes and experiences of forensic physicians who examine detainees.

Michele Heisler, MD, MPA, of the Physicians for Human Rights, Boston, Mass, and colleagues assessed forensic physicians' experiences with and attitudes toward torture and ill treatment of detainees in Mexico examined in the previous year. With the support of the Mexican Office of the Federal Attorney General, as part of a larger initiative to implement governmental reforms to eradicate torture in Mexico, an anonymous survey designed to assess correspondence of physician practices and attitudes with international standards on forensic investigation and documentation of torture was distributed to all federal forensic physicians (n=115) and a convenience sample of state forensic physicians (n=99) in Mexico in 2002.

The researchers wanted to determine estimates of the numbers of federal detainees medically evaluated and numbers of cases of suspected, alleged, and documented torture or ill treatment among federal detainees; factors interfering with documentation of forensic evidence; physicians' attitudes toward torture; measures that would help them document torture; and recommendations for reform.

Survey responses were received from 93 (81%) federal and 91 (92%) state forensic physicians. "Forty-nine percent of federal physicians and 58% of state physicians reported that torture is a severe problem for detainees in Mexico. Federal physicians estimated that they had conducted 26 445 to 30 650 or more medical evaluations of the 13 000 federal detainees in the past year and that between 1658 and 4850 of these detainees had alleged torture; these physicians also estimated that they had documented evidence of torture in a range of 285 to 1090 cases," they write.

Among the federal forensic physicians responding to this survey, 40% "had suspected torture and/or ill treatment of detainees examined during the previous year, 64% had examined detainees who alleged these practices had occurred, and 49% had documented forensic evidence of torture among these detainees. Respondents reported that lack of photographic equipment and services (58%), inadequate monitoring and accuracy of medical examinations (36%), inadequate documentation of torture (29%), limitations in their training (28%), fear of reprisals for documenting torture (23%), and fear of coercion by police officials (18%) are factors that interfere with documentation of torture and ill treatment of detainees. Respondents further reported the need for additional training (98%), standardized protocols and documentation procedures for use in cases of alleged or suspected torture and/or ill treatment (81%), and monitoring to ensure the quality and accuracy of medical evaluations (95%)," the researchers add.

MAKING DIET AND EXERCISE LIFESTYLE CHANGES CONCURRENTLY CAN DRAMATICALLY IMPROVE BLOOD PRESSURE