The renin-angiotensin-aldosterone system plays a major role in the development and progression of heart failure. The review by Jamali et al of major outcome trials explores the rationale for and clinical experience with the use of angiotensin-converting enzyme inhibitors and angiotensin receptor antagonist, alone or in combination, in patients with heart failure.
Ziegler et al questioned 2500 individuals about whether or not they wished to be told about medication-induced adverse effects. The desire for maximum information was positively correlated with lower educational levels and previous experience with adverse effects.
Sodium reduction is widely advocated to reduce blood pressure and control hypertension in the elderly, but empiric evidence on its efficacy is scarce. In this article by Appel et al on a large, randomized trial of a diverse group of individuals with hypertension aged 60 to 80 years, those who made the greatest reduction in sodium intake also were the most likely to have controlled blood pressure, many without medication. Reduced sodium intake is a broadly effective nonpharmacologic therapy to lower blood pressure and control hypertension in older individuals.
Lowering serum homocysteine with folic acid purportedly reduces mortality from ischemic heart disease, although direct evidence of this has not yet been confirmed in clinical trials.
The minimum dose of folic acid needed to effect the maximum reduction in serum homomocysteine is not established. The placebo-controlled, randomized trial by Wald and colleagues documents 151 patients with ischemic heart disease were who randomized to 1 of 5 doses of folic acid or placebo.
They found that homocysteine levels decreased with increased intake of folic acid; the maximum effect was seen in those taking doses of up to 0.8 mg daily. Based on these results and the established association between homocysteine levels and ischemic heart disease, mortality from heart disease could be reduced by 15% with this therapy. Since the current US government–mandated level of fortification is 0.14 mg of folic acid per 100 g of cereal grain, approximately 0.1 mg/d, substantial increases in this amount are needed to realize the full potential benefits of folic acid intake in reducing ischemic heart disease.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2001;161(5):639. doi:10.1001/archinte.161.5.639