9: The Minions in Hypertension!

02/27/22 • 6 min

You probably recognize the minions. Those tiny yellow characters featured in three motion pictures. I personally love them. Capsule-like small creatures with wide eyes, blue overalls and peculiar cheerful funny laughs and squawks. And I share with them their love for bananas!Kevin, Stuart, Dave and Bob are four of the most familiar minions. Individually they are small but each one has a special talent and when they work together they can create marvelous tools and solve the most difficult problems for the film’s main character.Speaking of difficult problems, hypertension is one problem that affects billions of people. Most of us, if we live to our eighties, will become hypertensive. And the control rates are poor in the developed countries. The traditional treatment is based on giving one drug in the standard dose or combining two of those two also in standard doses to lower the blood pressure.But, how about combining four (mini doses) minions of antihypertensives in one pill! Would that pill do better than a standard dose of a single good antihypertensive?This question was tackled by a trial called QUARTET trial was presented at the ESC Congress last August then published in the Lancet last September.The trial was a multicentre, double-blind randomised, trial of 571 Australian adults with hypertension, who were untreated or receiving monotherapy. Patients were randomly assigned to either quadpill or a mono therapy. The quad pill (contained 4 medications, each in one fourth of the standard dose; irbesartan 37·5 mg instead of 150, amlodipine at 1·25 mg not 5, indapamide at 0·625 mg not 2.5, and bisoprolol at 2·5 mg not 10 or even 5) or an indistinguishable monotherapy control (irbesartan 150 mg). If blood pressure was not at target, additional medications could be added in both groups. The researchers looked at BP control, safety and tolerability a 12 weeks then 12 months. And guess who won?SBP was about 7mmHg lower in the quadpil (allow me to call it the minion group) and control rates were 30% higher compared to the monotherapy group without difference in adverse events. The better BP control was sustained at one year with minions. Significantly less patients in the minion group) required additional BP medications compared to the mono therapy groupI consider this one of the key research papers in hypertension. I can think of several future implications of this conceptNumber 1: This is a further step in combination therapies for HTN. Not just two as recommended in many guidelines. With four mini doses, multiple pathophysiologic pathways tackled in one pill; sympathetic , RAS, sodium overload, vasoconstriction in small doses with less adverse effects. This can overcome physicians inertia and improve patients adherence to treatment.Number 2: Polypill is revived. Expect to see trials combining not just several BP medications, but also with statins and aspirin. NEJM trial on polypill in socioeconomic classes, cheap, more compliance, better BP and LDL reduction.Number 3: I expect the idea may be adopted by the pharma to manufacture different doses and different combinations not only triple combinations as we currently haveNumber 4: Boost to personalized medicine. Think of the tens of permutations that could come from different doses of four medications. Maybe in the future, the local pharmacist can add tailor your minion pill combinations; more beta blocker for the young, less diuretics for an elderly...etc

Previous Episode

8: Mercury, Seafood and Your Heart

Seafood is a classic heart-healthy food. It is part of the Mediterranean diet that can lower blood pressure. Fish consumption was shown in several studies to lower the risk of death in patients with coronary artery disease. Seafoods are traditionally low in saturated fats, rich in iron, iodine and in omega-3 fatty acids. But also seafoods contain Methyl mercury which is produced by microorganisms in water and soil, and accumulates in fish. Recently, many people choose to limit their seafood consumption because of fear of mercury exposure from seafood. Excessive mercury may adversely affect the nervous system in infants and pregnant ladies and lactating mothers should avoid exposure to mercury because of its effects on the fetus. So what should we do? Consume fish and seafood to get the benefits on the CV system or reduce or intake to avoid exposure to mercury?https://www.fda.gov/food/consumers/advice-about-eating-fish

Next Episode

10: Salt and Hypertension. Expert Interview.

https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-22/salt-and-hypertension-current-viewsWhen you hear the word “salt” What’s the first thing that comes to the mind White crystals that give food its taste, pickles, potatoe chips, snacks, high blood pressure and low blood pressure...Whatever came across your mind, we must admit that salt is deeply rooted in our culture. In the roman times, it was called the white gold. A famous roman saying “Trust no one unless you have eaten much salt with him”. We say we have eaten bread and salt so we will remain faithful forever.But when it comes to medicine, many questions need to be answered. What’s the relation between salt and hypertension or hypotension? How much salt do we need to take to stay healthy? Which foods have high salt content and which foods are free of salt? Hello and welcome. My name is Hussien Heshmat, professor of cardiology, and this is my Cardio Buzz my weekly podcast where we provide updates on cardiology news, research, conferences, and products. These questions on salt were answered in a recent review article in the European society of cardiology E journal of clinical practice. I am placing a link to that nice and comprehensive review. And I am glad to interview today Prof Ghada Sayed, associate professor of cardiology at Cairo University, my colleague for almost 20 years. Dr Ghada has done lots of research on hypertension epidemiology including salt surveys, she shared in writing Egyptian hypertension guidelines in 2014, she moderate specialized hypertension clinics in Egypt, and she is also of course the author of the ESC review on salt and hypertension.