***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: CONTEXT Incidence of end-stage renal disease due to hypertension has increased in recent decades , but the optimal strategy for treatment of hypertension to prevent renal failure is unknown , especially among African Americans . OBJECTIVE To compare the effects of an angiotensin-converting enzyme ( ACE ) inhibitor ( ramipril ) , a dihydropyridine calcium channel blocker ( amlodipine ) , and a beta-blocker ( metoprolol ) on hypertensive renal disease progression . DESIGN , SETTING , AND PARTICIPANTS Interim analysis of a r and omized , double-blind , 3 x 2 factorial trial conducted in 1094 African Americans aged 18 to 70 years with hypertensive renal disease ( glomerular filtration rate [ GFR ] of 20 - 65 mL/min per 1.73 m(2 ) ) enrolled between February 1995 and September 1998 . This report compares the ramipril and amlodipine groups following discontinuation of the amlodipine intervention in September 2000 . INTERVENTIONS Participants were r and omly assigned to receive amlodipine , 5 to 10 mg/d ( n = 217 ) , ramipril , 2.5 to 10 mg/d ( n = 436 ) , or metoprolol , 50 to 200 mg/d ( n = 441 ) , with other agents added to achieve 1 of 2 blood pressure goals . MAIN OUTCOME MEASURES The primary outcome measure was the rate of change in GFR ; the main secondary outcome was a composite index of the clinical end points of reduction in GFR of more than 50 % or 25 mL/min per 1.73 m(2 ) , end-stage renal disease , or death . RESULTS Among participants with a urinary protein to creatinine ratio of > 0.22 ( corresponding approximately to proteinuria of more than 300 mg/d ) , the ramipril group had a 36 % ( 2.02 [ SE , 0.74 ] mL/min per 1.73 m(2)/y ) slower mean decline in GFR over 3 years ( P = .006 ) and a 48 % reduced risk of the clinical end points vs the amlodipine group ( 95 % confidence interval [ CI ] , 20%-66 % ) . In the entire cohort , there was no significant difference in mean GFR decline from baseline to 3 years between treatment groups ( P = .38 ) . However , compared with the amlodipine group , after adjustment for baseline covariates the ramipril group had a 38 % reduced risk of clinical end points ( 95 % CI , 13%-56 % ) , a 36 % slower mean decline in GFR after 3 months ( P = .002 ) , and less proteinuria ( P<.001 ) . CONCLUSION Ramipril , compared with amlodipine , retards renal disease progression in patients with hypertensive renal disease and proteinuria and may offer benefit to patients without proteinuria BACKGROUND Patients with hypertension may require a combination of > or = 2 antihypertensive agents to achieve blood pressure ( BP ) control . OBJECTIVE The aim of this study was to determine whether a triple combination of olmesartan medoxomil ( OM ) , amlodipine besylate ( AML ) , and hydrochlorothiazide ( HCTZ ) had a clinical ly significant benefit compared with dual combinations of the individual components in patients with moderate to severe hypertension . METHODS This was a multicenter , r and omized , doubleblind , parallel-group study in which triple combination treatment with OM 40 mg + AML 10 mg + HCTZ 25 mg was compared with dual combinations of the individual components-OM 40 mg/AML 10 mg in fixed-dose combination , OM 40 mg/HCTZ 25 mg in fixed-dose combination , and AML 10 mg + HCTZ 25 mg-in  patients aged > or = 18 years who had a mean seated BP > or = 140/100 mm Hg or > or = 160/90 mm Hg . The study consisted of a 3-week washout period with no study medication and a 12-week double-blind treatment period . In the first 2 weeks of the double-blind treatment period , all patients were r and omized to receive dual combination treatment or placebo . All patients assigned to a dual combination treatment group continued the assigned treatment until week 4 , and all patients assigned to placebo were switched at week 2 to receive 1 of the dual combination treatments until week 4 . At week 4 , patients either continued dual combination treatment or switched to triple combination treatment until week 12 . The primary end point was the change in seated diastolic BP ( SeDBP ) from baseline to week 12 ; SeDBP reduction of > or = 2 mm Hg was considered a clinical ly significant benefit . Secondary efficacy end points included the change in seated systolic BP ( SeSBP ) at week 12 and the percentages of patients achieving BP targets of < 140/90 mm Hg , < 120/80 mm Hg , SeSBP < 140 mm Hg , and SeDBP < 90 mm Hg at week 12 . The tolerability of the treatments was also evaluated based on adverse events ( AEs ) , clinical laboratory evaluations ( chemistry , hematology , and urinalysis ) , physical examinations , and 12-lead ECGs . RESULTS The 2492 r and omized patients ( 52.9 % male , 66.8 % white , 30.4 % black ) had a mean ( SD ) age of 55.1 ( 10.9 ) years and a mean weight of 96.0 ( 22.9 ) kg . Diabetes was present in 15.5 % of the population , chronic cardiovascular disease in 9.1 % , and chronic kidney disease in 4.1 % . At baseline , the mean SeBP was 168.5/100.9 mm Hg . At week 12 , triple combination treatment was associated with significantly greater least squares mean reductions in SeBP compared with the dual combinations ( SeDBP : -21.8 vs -15.1 to -18.0 mm Hg , respectively [ P < 0.001 ] ; SeSBP : -37.1 vs -27.5 to -30.0 mm Hg [ P < 0.001 ] ) . A significantly higher proportion of patients receiving triple combination treatment reached BP targets compared with the dual combinations at week 12 ( P < 0.001 ) . The proportions of patients reaching the BP target of < 140/90 mm Hg at week 12 was 69.9 % in the triple combination treatment group and 52.9 % , 53.4 % , and 41.1 % in the treatment groups receiving OM 40 mg/AML 10 mg , OM 40 mg/HCTZ 25 mg , and AML 10 mg + HCTZ 25 mg , respectively ( P < 0.001 , triple combination vs each dual combination ) . The incidence of treatment-emergent AEs ( TEAEs ) was 58.4 % for triple combination treatment and 51.7 % to 58.9 % for the dual combinations ; most TEAEs were mild or moderate in severity . The most common TEAEs in the triple combination treatment group were dizziness ( 9.9 % ) , peripheral edema ( 7.7 % ) , and headache ( 6.4 % ) . In total , 52 patients ( 2.3 % ) discontinued the study due to TEAEs-6 ( 1.0 % ) in the OM 40 mg/AML 10 mg group , 12 ( 2.1 % ) in the OM 40 mg/HCTZ 25 mg group , 11 ( 2.0 % ) in the AML 10 mg + HCTZ 25 mg group , and 23 ( 4.0 % ) in the OM 40 mg + AML 10 mg + HCTZ 25 mg group . Thirty-two patients (1.4%)-4 ( 0.7 % ) , 5 ( 0.9 % ) , 5 ( 0.9 % ) , and 18 ( 3.1 % ) in the respective treatment groups-discontinued the study due to drug-related TEAEs . CONCLUSIONS In these adult patients with moderate to severe hypertension , triple combination treatment with OM 40 mg + AML 10 mg + HCTZ 25 mg was associated with significant BP reductions compared with dual combinations of the individual components . All treatments were generally well tolerated . Clinical Trials . gov identifier : NCT00649389 The Losartan Intervention For Endpoint ( LIFE ) reduction in hypertension study is a double-blind , prospect i ve , parallel group study design ed to compare the effects of losartan with those of atenolol on the reduction of cardiovascular morbidity and mortality . A total of 9194 patients with hypertension and ECG left ventricular hypertrophy ( LVH ) by Cornell voltage- duration product and /or Sokolow-Lyon voltage criteria were enrolled in the study , with baseline clinical and ECG data available in 8785 patients ( 54 % women ; mean age , 67±7 years ) . ECG LVH by Cornell voltage- duration product criteria was present in 5791 patients ( 65.9 % ) and by Sokolow-Lyon voltage in 2025 patients ( 23.1 % ) . Compared with patients without ECG LVH by Cornell voltage- duration product criteria , patients with ECG LVH by this method were older ; more obese ; more likely to be female , white , and to have never smoked ; more likely to be diabetic and have angina ; and had slightly higher systolic , diastolic , and pulse blood pressures . In contrast , patients with ECG LVH by Sokolow-Lyon criteria were slightly younger ; less obese ; more likely to be male , black , and current smokers ; less likely to have diabetes ; more likely to have angina and a history of cerebrovascular disease ; and had higher systolic and pulse blood pressure but slightly lower diastolic blood pressure than patients without ECG LVH by this method . By use of multivariate logistic regression analyses , presence of ECG LVH by Cornell voltage- duration product criteria was predominantly associated with higher body mass index , increased age , and female gender , whereas presence of ECG LVH by Sokolow-Lyon voltage criteria was predominantly related to lower body mass index , male gender , and black race . Thus , hypertensive patients who meet Cornell product and Sokolow-Lyon voltage criteria are associated with different , but potentially equally adverse , risk factor profiles CONTEXT Few cardiovascular outcome data are available for blacks with hypertension treated with angiotensin-converting enzyme ( ACE ) inhibitors or calcium channel blockers ( CCBs ) . OBJECTIVE To determine whether an ACE inhibitor or CCB is superior to a thiazide-type diuretic in reducing cardiovascular disease ( CVD ) incidence in racial subgroups . DESIGN , SETTING , AND PARTICIPANTS Prespecified subgroup analysis of ALLHAT , a r and omized , double-blind , active-controlled , clinical outcome trial conducted between February 1994 and March 2002 in 33,357 hypertensive US and Canadian patients aged 55 years or older ( 35 % black ) with at least 1 other cardiovascular risk factor . INTERVENTIONS Antihypertensive regimens initiated with a CCB ( amlodipine ) or an ACE inhibitor ( lisinopril ) vs a thiazide-type diuretic ( chlorthalidone ) . Other medications were added to achieve goal blood pressures ( BPs ) less than 140/90 mm Hg . MAIN OUTCOME MEASURES The primary outcome was combined fatal coronary heart disease ( CHD ) or nonfatal myocardial infa rct ion ( MI ) , analyzed by intention-to-treat . Secondary outcomes included all-cause mortality , stroke , combined CVD ( CHD death , nonfatal MI , stroke , angina , coronary revascularization , heart failure [ HF ] , or peripheral vascular disease ) , and end-stage renal disease . RESULTS No significant difference was found between treatment groups for the primary CHD outcome in either racial subgroup . For amlodipine vs chlorthalidone only , HF was the only prespecified clinical outcome that differed significantly ( overall : relative risk [ RR ] , 1.37 ; 95 % confidence interval [ CI ] , 1.24 - 1.51 ; blacks : RR , 1.46 ; 95 % CI , 1.24 - 1.73 ; nonblacks : RR , 1.32 ; 95 % CI , 1.17 - 1.49 ; P<.001 for each comparison ) with no difference in treatment effects by race ( P = .38 for interaction ) . For lisinopril vs chlorthalidone , results differed by race for systolic BP ( greater decrease in blacks with chlorthalidone ) , stroke , and combined CVD outcomes ( P<.001 , P = .01 , and P = .04 , respectively , for interactions ) . In blacks and nonblacks , respectively , the RRs for stroke were 1.40 ( 95 % CI , 1.17 - 1.68 ) and 1.00 ( 95 % CI , 0.85 - 1.17 ) and for combined CVD were 1. 
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Aside from the well-known blood pressure efficacy of calcium channel blockers and diuretics , with lesser effect of ACE inhibitors and beta-blockers , nebivolol was not more effective than placebo in reducing systolic blood pressure levels .
In conclusion , in patients of African ethnicity , treatment initiated with ACE inhibitor or angiotensin II receptor blocker monotherapy was associated with adverse cardiovascular outcomes .
We found no evidence of different efficacy of antihypertensive drugs in South Asians , but there is a need for trials with morbidity and mortality outcomes .
Screening for cardiovascular risk at a younger age , treating hypertension at lower thresholds , and new delivery models to find , treat and follow hypertensives in the community may help reduce the excess cardiovascular mortality in these high-risk groups