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Latest & greatest articles for hypertension
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thresholds and treatment targets (see Diabetes section). Consistent with the changes made to section II (Indications for drug therapy for adults with hypertension without compelling indications for specific agents), we have removed the previous guidelines for different BP goals for the elderly. Evidence suggests that older patients with hypertension similarly benefit from intensive BP reduction as younger adults. (53-56) References BloodPressure Lowering Treatment Trialists Collaboration. Bloodpressure (...) in their epidemiological context. Lancet 1990;335:827-38. SHEP Co-operative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;265:3255-64. BloodPressure Lowering Trialists’ Collaboration. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Lancet 2000;356
for thiazide/thiazide-like diuretics for BP control, Grade D for loop diuretics for volume control). Beyond considerations of BP control, doses of ACE inhibitors or ARBs should be titrated to those found to be effective in trials unless adverse effects become manifest (Grade B). An ARB is recommended if ACE inhibitors are not tolerated (Grade A). A combination of hydralazine and isosorbide dinitrate is recommended if ACE inhibitors and ARBs are contraindicated or not tolerated (Grade B). For hypertensive (...) patients whose BP is not controlled, an ARB may be added to an ACE inhibitor and other antihypertensive drug treatment (Grade A). Careful monitoring should be used if combining an ACE inhibitor and an ARB because of potential adverse effects such as hypotension, hyperkalemia, and worsening renal function (Grade C). Additional therapies might also include dihydropyridine CCBs (Grade C). An Angiotensin Receptor-Neprilysin Inhibitor combination should be used in place of an ACE inhibitor or ARB
ischemia, particularly in the setting of intracranial or extracranial arterial occlusion (Grade D; revised wording ). Pharmacological agents and routes of administration should be chosen to avoid precipitous decreases in BP (Grade D). For patients with ischemic stroke who are eligible for thrombolytic therapy, very highBP (>185/110 mm Hg) should be treated concurrently with thrombolysis to reduce the risk of hemorrhagic transformation (Grade B; revised guideline ). Bloodpressure should be lowered (...) with intravenous (IV) nimodipine > 20% was associated with increased risk of death or dependency . CHEP recommends generally, antihypertensive agents should not be administered in the acute phase of both ischemic stroke and ICH. In those patient with extremely highBP (e.g., > 220/110 mm Hg), pressures may be lowered approximately 15% but should not be lowered > 25% of the mean arterial pressure within the first 24 hours of stroke onset. In the Acute Candesartan Cilexetil Therapy in Stroke Survivors (ACCESS
controlled trials of weight loss demonstrate that a reduction in weight is associated with a reduction in bloodpressure in overweight hypertensive patients . For overweight patients, efficacy of weight loss in reducing BP is similar to that of single antihypertensive drug therapy . 3. Weight loss strategies should use a multidisciplinary approach that includes dietary education, increased physical activity, and behavioural intervention (Grade B). Multidisciplinary approaches to weight loss appear (...) increase in bloodpressure (BP), and potential use of the Valsalva manoeuvre during weight training, there are concerns this form of exercise could adversely raiseBP levels, leading to an increased risk of hemorrhagic stroke or subarachnoid hemorrhage. In a meta-analysis of 28 randomized controlled trials examining the effect of resistance training on BP, 33 study groups were pooled (1012 participants in total) . Most of these trials examined dynamic resistance training (30 study groups), largely
). In the absence of Canadian data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions (Grade C). Elevated systolic and diastolic bloodpressure have long been recognized as important modifiable risk factors for the future development of coronary artery disease, stroke and other cardiovascular events . Not unexpectedly, there is increasing interest in focusing antihypertensive therapy toward individuals deemed to have the highest risk (...) blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998;351:1755-62. Tight bloodpressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998;317:703-13.. Estacio RO, Jeffers BW, Gifford N, Schrier RW. Effect of bloodpressure control on diabetic microvascular complications
). Fibromuscular dysplasia primarily affects younger (<40 year old) females. As the prevalence of hypertension below age 40 is relatively low, the presence of hypertension at this age more likely indicates either secondary form of hypertension and/or use of drugs/substances causing highbloodpressure. In this situation, especially in the absence of an obvious contributor to early onset hypertension (such as obesity), testing for renovascular hypertension appears justified, as fibromuscular dysplasia (...) of stenosis (>70% of the lumen area), pressure gradient over the stenosis (> 21 mmHg), lateralization of renal vein plasma renin activity, high arterial resistance index on Doppler ultrasound, delayed contrast accumulation and excretion on intravenous pyelogram, and impaired renal blood flow in response to angiotensin converting enzyme inhibitor on captopril renogram (these last two methods are not indicated for patients with eGFR , 30 ml/min/1.72 m 2 ) . 3. Patients with hypertension and presenting
): Patients with paroxysmal, unexplained, liable, and/or severe (BP ≥180/110 mmHg) sustained hypertension refractory to usual antihypertensive therapy; Patients with hypertension and multiple symptoms suggestive of catecholamine excess (eg, headaches, palpitations, sweating, panic attacks, and pallor); Patients with hypertension triggered by b-blockers, monoamine oxidase inhibitors, micturition, or changes in abdominal pressure, surgery, or anesthesia; Patients with incidentally discovered adrenal mass (...) , and/or verapamil should be used for bloodpressure control while testing since they have minimal interference with biochemical testing (but this may not be possible depending on the risk and clinical situation). The ratio should be measured in patients that have been ambulatory for at least 2 hours using morning specimens drawn after sitting for at least 15 min . The value of these ratios appears to be primarily in defining a subpopulation with a high rate of confirmed primary aldosteronism (29% to 93
on ambulatory bloodpressure monitoring. J Hypertens 2013;31:1731-1768. Ohkubo T, Imai Y, Tsuji I, etal. Reference values for 24-hour ambulatory bloodpressure monitoring based on a prognostic criterion: the Ohasama Study. Hypertension 1998;32:255-9. O’Brien E, Sheridan J, O’Malley K. Dippers and non-dippers. Lancet 1988;ii:397. Ohkubo T, Hozawa A, Yamaguchi J, Kikuya M, Ohmori K, Michimata M, et al. Prognostic significance of the nocturnal decline in bloodpressure in subjects with and without high 24-hour (...) in the diagnosis of hypertension (Grade C). Ambulatory BP monitoring should be considered when an office-induced increase in BP is suspected in treated patients with: BP that is not below target despite receiving appropriate chronic antihypertensive therapy (Grade C); Symptoms suggestive of hypotension (Grade C); or Fluctuating office BP readings (Grade D). Ambulatory BP monitoring upper arm devices that have been validated independently using established protocols must be used (see ) (Grade D). Therapy
); Blood chemistry (potassium, sodium, and creatinine) (Grade D); Fasting blood glucose and/or glycated hemoglobin (A1c) (Grade D); Serum total cholesterol, low-density lipoprotein, high-density lipoprotein (HDL), non-HDL cholesterol, and triglycerides (Grade D); lipids may be drawn fasting or non-fasting (Grade C). Standard 12-lead electrocardiography (Grade C). Assess urinary albumin excretion in patients with diabetes (Grade D). All treated hypertensive patients should be monitored according (...) M, Omvik P, Hua TA, Julius S. Impact of new-onset diabetes mellitus on cardiac outcomes in the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial population. Hypertension 2007;50:467-73. The DREAM Trial Investigators. Effect of ramipril on the incidence of diabetes. N Engl J Med 2006;355:1551-62. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor
(SMBP) is useful for the diagnosis of sustained hypertension, white coat hypertension and masked hypertension. As white coat hypertension (i.e., elevated office bloodpressure and normal out-of-office bloodpressure findings) is associated with a better cardiovascular prognosis compared with those with elevatedBP at the office and in non-office settings its identification is not only important to guide therapeutic decision-making, but it relies on comparing an office bloodpressure reading (...) the incidence of cardiovascular events in patients with controlled hypertension (hazard ratio [HR], 1.18, 95% confidence interval [CI], 0.67-2.10) . The existing data strongly suggest that levels of bloodpressure at home are lower than those in the office , with home values above 135/85 mm Hg considered elevated . 2. The use of home BP monitoring on a regular basis should be considered for patients with hypertension, particularly those with: i. Diabetes mellitus (Grade D); ii. CKD (Grade C); iii. Suspected
elevation (i.e., white coat effect) and is associated with a lower prevalence of masked hypertension . On the basis of the above evidence the CHEP Recommendations Task Force endorsed the use of AOBP for office bloodpressure measurement in 2011 . Several studies have shown that mean AOBP readings are comparable to daytime ambulatory BP readings, therefore a mean AOBP of SBP ≥135 mm Hg or DBP ≥85 mm Hg is considered high. Three cross-sectional studies demonstrating high correlations between AOBP levels (...) professionals who have been specifically trained to measure BP accurately should assess BP in all adult patients at all appropriate visits to determine cardiovascular risk and monitor antihypertensive treatment (Grade D). Use of standardized measurement techniques and validated equipment for all methods (automated office bloodpressure (AOBP), non-AOBP, home bloodpressure monitoring, and ambulatory bloodpressure monitoring) is recommended (Grade D; see , , ). Measurement using electronic (oscillometric
to 2.3) and women (hazard ratio 1.8; 95% CI 1.0 to 3.1) with high normal BP than in subjects with BP levels lower than 120/80 mm Hg . Those older than 65 years of age with high normal BP levels had the highest risk of progression to hypertension and development of cardiovascular disease. In this group, the crude incidence rate of cardiovascular events per 1000 patient years was 20 in women and 28 in men . These data indicate that patients with high normal bloodpressure have (a) a higher risk (...) of progression to overt hypertension; and (b) a worse prognosis than patients with optimal bloodpressure levels. Therefore, although antihypertensive therapy is not recommended, close surveillance in the form of annual bloodpressure checks is recommended. 3. If the visit 1 mean OBPM or AOBP is high (see thresholds outlined in ), a history and physical examination should be performed and, if clinically indicated, diagnostic tests to search for target organ damage (Supplemental ) and associated
therapy3090 8.21 Perioperative management of hypertension3090 9 Managing concomitant cardiovascular disease risk3091 9.1 Statins and lipid-lowering drugs3091 9.2 Antiplatelet therapy and anticoagulant therapy3091 9.3. Glucose-lowering drugs and blood pressure3092 10 Patient follow-up3092 10.1 Follow-up of hypertensive patients3092 10.2 Follow-up of subjects with high–normal bloodpressure and white-coat hypertension3092 10.3 Elevatedbloodpressure at control visits3093 10.4 Improvement in bloodpressure (...) discussion of hypertension diagnostic thresholds) and provides the basis for the recommendation that the classification of BP and definition of hypertension remain unchanged from previous ESH/ESC Guidelines ( Table ). , , Table 3 Classification of office bloodpressure and definitions of hypertension grade Category Systolic (mmHg) Diastolic (mmHg) Optimal <120 and <80 Normal 120–129 and/or 80–84 High normal 130–139 and/or 85–89 Grade 1 hypertension 140–159 and/or 90–99 Grade 2 hypertension 160–179
Long-term mortality after bloodpressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomised factorial trial. In patients with hypertension, the long-term cardiovascular and all-cause mortality effects of different bloodpressure-lowering regimens and lipid-lowering treatment are not well documented, particularly in clinical trial settings. The Anglo-Scandinavian (...) Cardiac Outcomes Trial (ASCOT) Legacy Study reports mortality outcomes after 16 years of follow-up of the UK participants in the original ASCOT trial.ASCOT was a multicentre randomised trial with a 2 × 2 factorial design. UK-based patients with hypertension were followed up for all-cause and cardiovascular mortality for a median of 15·7 years (IQR 9·7-16·4 years). At baseline, all patients enrolled into the bloodpressure-lowering arm (BPLA) of ASCOT were randomly assigned to receive either amlodipine
2018LancetControlled trial quality: predicted high
Metformin added to bosentan therapy in patients with pulmonary arterial hypertension associated with congenital heart defects: a pilot study Pulmonary arterial hypertension (PAH) is a common complication of a congenital heart defect (CHD). Recent studies suggest metformin may be a potential drug to improve cardiac function in PAH. A pilot study was conducted to investigate the efficacy of short-term treatment with a combination regimen consisting of bosentan and metformin in PAH-CHD patients
Augmented Cardiopulmonary Baroreflex Sensitivity in Intradialytic Hypertension End-stage renal disease (ESRD) patients with a paradoxical increase in bloodpressure (BP) during hemodialysis (HD), termed intradialytic hypertension (ID-HTN), are at significantly increased risk for mortality and adverse cardiovascular events. ID-HTN affects up to 15% of all HD patients, and the pathophysiologic mechanisms remain unknown. We hypothesized that ESRD patients prone to ID-HTN have heightened volume (...) -sensitive cardiopulmonary baroreflex sensitivity (BRS) that leads to exaggerated increases in sympathetic nervous system (SNS) activation during HD.We studied ESRD patients on maintenance HD with ID-HTN (n = 10) and without ID-HTN (controls, n = 12) on an interdialytic day, 24 to 30 hours after their last HD session. We measured continuous muscle sympathetic nerve activity (MSNA), beat-to-beat arterial BP, and electrocardiography (ECG) at baseline, and during graded lower body negative pressure (LBNP
Metabolic Reprogramming in the Heart and Lung in a Murine Model of Pulmonary Arterial Hypertension A significant glycolytic shift in the cells of the pulmonary vasculature and right ventricle during pulmonary arterial hypertension (PAH) has been recently described. Due to the late complications and devastating course of any variant of this disease, there is a great need for animal models that reproduce potential metabolic reprograming of PAH. Our objective is to study, in situ, the metabolic
Fixed Low-Dose Triple Combination Antihypertensive Medication vs Usual Care for BloodPressure Control in Patients With Mild to Moderate Hypertension in Sri Lanka: A Randomized Clinical Trial. Poorly controlled hypertension is a leading global public health problem requiring new treatment strategies.To assess whether a low-dose triple combination antihypertensive medication would achieve better bloodpressure (BP) control vs usual care.Randomized, open-label trial of a low-dose triple BP (...) therapy vs usual care for adults with hypertension (systolic BP >140 mm Hg and/or diastolic BP >90 mm Hg; or in patients with diabetes or chronic kidney disease: >130 mm Hg and/or >80 mm Hg) requiring initiation (untreated patients) or escalation (patients receiving monotherapy) of antihypertensive therapy. Patients were enrolled from 11 urban hospital clinics in Sri Lanka from February 2016 to May 2017; follow-up ended in October 2017.A once-daily fixed-dose triple combination pill (20 mg
What Should Be the Target BloodPressure for This Older Patient With Hypertension?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Hypertension is prevalent and the most important risk factor for cardiovascular disease. Controversy exists regarding the optimum threshold above which to begin antihypertensive therapy and the optimum target bloodpressure once medication is begun. This controversy is particularly true for older patients, who may be more likely to benefit from (...) treatment because of their higher risk for cardiovascular events, but may also be more at risk for adverse effects of treatment. Two guidelines published in 2017 address this issue. The American College of Physicians/American Academy of Family Physicians guideline recommends initiating antihypertensive therapy for older patients (aged 60 years or older) if systolic bloodpressure is 150 mm Hg or higher and to treat to the same target. They recommend a lower threshold for starting treatment and a lower
Jessup , Mikhail Kosiborod , Allison M. Pritchett , Kumudha Ramasubbu , Clive Rosendorff , Clyde Yancy 2016 3. Hypertension - not diabetic Hypertension - not diabetic - NICE CKS Clinical Knowledge Summaries Share Hypertension - not diabetic - Summary Hypertension is persistently raised arterial bloodpressure (BP). It is one of several risk factors for diseases such as heart failure, myocardial infarction, stroke, and chronic kidney disease. Hypertension should be suspected if clinic systolic BP (...) antihypertensive drug classes are used as the first-line drug, to quantify the bloodpressure lowering effect and the rate of withdrawal due to adverse drug effects, compared to placebo or no treatment. SEARCH METHODS: The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to November 2017 2018 14. Calcium supplementation commencing before or early in pregnancy, or food fortification with calcium, for preventing hypertensivedisorders of pregnancy