Aggressive BP Lowering Research Articles

Blood Pressure Variability in Acute Stroke: A Narrative Review.

The management of blood pressure variability (BPV) in acute stroke presents a complex challenge with profound implications for patient outcomes. This narrative review examines the role of BPV across various stages of acute stroke care, highlighting its impact on treatment strategies and prognostic considerations. In the prehospital setting, while guidelines lack specific recommendations for BP management, emerging evidence suggests a potential link between BPV and outcomes. Among ischaemic stroke patients who are ineligible for reperfusion therapies, BPV independently influences functional outcomes, emphasising the need for individualised approaches to BP control. During intravenous thrombolysis and endovascular therapy, the intricate interplay between BP levels, recanalisation status, and BPV is evident. Striking a balance between aggressive BP lowering and avoiding hypoperfusion-related complications is essential. Intracerebral haemorrhage management is further complicated by BPV, which emerges as a predictor of mortality and disability, necessitating nuanced BP management strategies. Finally, among patients with acute subarachnoid haemorrhage, increased BPV may be correlated with a rebleeding risk and worse outcomes, emphasizing the need for BPV monitoring in this population. Integration of BPV assessment into clinical practice and research protocols is crucial for refining treatment strategies that are tailored to individual patient needs. Future studies should explore novel interventions targeting BPV modulation to optimise stroke care outcomes.

Effects of blood pressure lowering according to baseline cardiovascular disease: systematic review and meta-analysis of randomized trials

Abstract Background Blood pressure (BP)-lowering is accompanied by reduced cardiovascular (CV) outcomes and death in hypertensive patients. There are no data on the effect of BP lowering in patients with a history of CV disease [i.e., coronary heart disease (CHD), stroke, or heart failure with preserved ejection fraction (HFpEF)]. Purpose To demonstrate the effect of BP-lowering treatment on CV events in patients with different types of baseline CV disease. Methods A systematic review was conducted to identify randomized trials in electronic databases (Pubmed and CENTRAL, search from 1966 to 11/2022) for the effect of BP-lowering treatment against placebo or less aggressive BP reduction on fatal or nonfatal cardiovascular outcomes and all-cause death. Trials or subgroups of trials were identified, including patients with a history of CV disease. We excluded heart failure studies with reduced ejection fraction, acute myocardial infarction, or acute stroke. Risk ratios (RR) were calculated with their 95% confidence interval (CI) under the random-effects model. Results We included 18 BP-lowering treatment trials with 52,359 CHD patients (mean follow-up, 4.2 years; achieved systolic/diastolic BP, 129.2/76.1 mmHg). Despite the fact that mortality outcomes, stroke, and recurrent CHD were not decreased as a result of BP-lowering therapy, the risk of the combined outcome of major CV events (i.e., myocardial infarction, stroke, and heart failure) was reduced by 11% (95% CI, 3-18%) and the risk of recurrent heart failure hospitalization by 28% (95% CI, 18-38%). In addition, we examined 8 trials with 37,866 patients with a history of stroke (mean follow-up, 2.7 years; achieved systolic/diastolic BP, 136.5/79.8 mmHg), in which BP-lowering treatment reduced recurrent stroke by 18% (95% CI, 7-27%) and CV death by 12% (95% CI, 3-21%). Among 5 heart failure trials with 11,597 patients (mean follow-up, 3.4 years; achieved systolic/diastolic BP, 130.8/76.7 mmHg), the combined outcome of major CV events was decreased by 10% (95% CI, 4-16%), and recurrent heart failure hospitalization by 12% (95% CI, 4-19%). Conclusions Maximum CV protection is offered when systolic BP is reduced to levels < 130 mmHg in patients with CHD, to 130-140 mmHg levels in patients with a history of stroke, and to levels of approximately 130 mmHg in patients with heart failure. These findings support the recommendation for more aggressive BP lowering in patients with a history of CHD or optimally treated patients with HFpEF, and for less aggressive BP reduction in post-stroke patients.

Perioperative SBP changes during orthopedic surgery in the elderly: clinical implications.

We aimed to determine SBP changes during the perioperative period of a scheduled knee surgery under regional anesthesia and the extent of perioperative (in-hospital) white-coat effect. All patients (aged ≥60 years) underwent clinic SBP measurements during both cardiological and anesthesiological visits, while home SBP the week before admission was obtained. Clinic SBP was registered just before surgery, during surgery and reanimation. Ambulatory monitoring was also performed (12 h before surgery to 6-8 h after surgery). One month after discharge, clinic SBP was measured at hypertension unit. Eligible participants (N = 50, mean age 74 ± 7 years, 34% men, 26% with history of cardiovascular disease) had higher SBP during the anesthesiologic than the cardiological evaluation (157 ± 23 vs. 144 ± 18 mmHg, P < 0.001), and the former levels were almost identical to those clinically measured just before surgery. A significant white-coat effect between ambulatory and clinic measurements just before surgery (16.4 ± 21 mmHg, P < 0.001) and between entire ambulatory recording and clinic BP measurements the day before surgery (12.4 ± 16 and 24.8 ± 21 mmHg for cardiologic and anesthesiologic visit, respectively, P < 0.001 for both) was noticed, whereas intraoperatively the white-coat effect faded away. There was a greater SBP decline during surgery in patients aged more than 75 years compared with younger, whereas selective treatment discontinuation (except beta blockers and calcium channel blockers) did not modulate SBP trajectories. The significant white-coat effect observed in scheduled noncardiac surgery is clinically important and the home BP measurement performed before surgery or ABPM, highly reflects the hypertensive burden of the patient. Blood pressure decrease during surgery is quite pronounced especially in patients aged more than 75 years. Aggressive BP lowering should be avoided.

Therapeutic Approach to Hypertension Urgencies and Emergencies in the Emergency Room.

Hypertensive urgencies-emergencies are important and common events. They are defined as a severe elevation in BP, higher than 180/120mmHg, associated or not with the evidence of new or worsening organ damage for emergencies and urgencies respectively. Anamnestic information, physical examination and instrumental evaluation determine the following management that could need oral (for urgencies) or intravenous (for emergencies) anti-hypertensives drugs. The choice of the specific drugs depend on the underlying causes of the crisis, patient's demographics, cardiovascular risk and comorbidities. For emergencies a maximum BP reduction of 20-25% within the first hour and then to 160/110-100 over next 2-6h, is considered appropriate with a further gradual decrease over the next 24-48h to reach normal BP levels. In the case of hypertensive urgencies, a gradual lowering of BP over 24-48h with an oral medication is the best approach and an aggressive BP lowering should be avoided. Subsequent management with particular attention on chronic BP values control is important as the right treatment of the acute phase.

Elderly CAD Patients: Keep Systolic Value Below 140 mm Hg

Elderly hypertensive patients who had coronary artery disease and a baseline systolic blood pressure greater than 150 mm Hg had signifi cantly fewer cardiovascular deaths and strokes if they achieved a systolic pressure of less than 140 mm Hg, compared with similar patients who achieved a systolic pressure of 140-149 mm Hg. The fi ndings were noted in a posthoc analysis of data collected from more than 8,000 patients in an international treatment study. The researchers compared outcomes for patients who achieved these two diff erent levels of systolic pressure as a way to assess the new hypertension treatment goal of a systolic pressure less than 150 mm Hg in patients aged 60 years or older as recommended by the group originally appointed as the Eighth Joint National Committee ( JNC 8) ( JAMA 2014;311:507-20 ). Their fi nding that the patients who achieved the lower systolic pressure level of less than 140 mm Hg had a signifi cantly lower rate of cardiovascular death and stroke as compared with patients whose systolic pressure remained in the 140-149 mm Hg range provided “important information to focus the risk-benefi t discussion for patients who had on-treatment blood pressure in the 140-150 mm Hg range,” wrote Sripal Bangalore, MD, a cardiologist at New York University and his associates in a recently published article ( J Am Coll Cardiol 2014;64:784-93). At least one expert questioned the ability of such a post-hoc analysis to address BP goals in a meaningful way. “To adjudicate between a target of 140 mm Hg and 150 mm Hg it would be necessary to perform a prospective trial in which the population was randomized to these targets,” commented Alan H. Gradman, MD, in an editorial that accompanied the study ( J Am Coll Cardiol 2014;64:794-6). More aggressive BP lowering could result in increased adverse events, he said. Despite these limitations, other experts hailed the new fi nding as important evidence against the recommendations of the former JNC 8 committee. “This study supports the concerns raised by many stakeholders, including the American College of Cardiology [ACC], the American Heart Association [AHA], and a number of the individual members of the JNC 8 panel ( Ann Intern Med 2014;160:499-503 ), about the panel’s 2013 recommendations to raise blood pressure targets in older patients,” said Patrick T. O’Gara, MD, ACC president, and Elliott Antman, MD, AHA president, in a joint written statement released to coincide with the new report’s publication. “This new research suggests that raising the threshold for treatment of hypertension in patients 60 years of age or older with coronary artery disease may be detrimental to the best interest of patients and the public. It Elderly CAD Patients: Keep Systolic Value Below 140 mm Hg

INTERACT2: A Reason for Optimism with Spontaneous Intracerebral Hemorrhage?

The first Intensive Blood Pressure Reduction in Acute Intracerebral Hemorrhage Trial (INTERACT1) study found that early intensive BP lowering seemed to attenuate haematoma growth when compared with a more conservative guideline based policy. Clinicians were therefore waiting with anticipation for the results of INTERACT2, in which 2839 patients with spontaneous ICH and a systolic BP between 150 and 220 mmHg were randomly assigned to receive intensive anti-hypertensive therapy with a systolic target of <140 mmHg within one hour, or a standard guideline recommended treatment of <180 mmHg. INTERACT2 failed to show a significant reduction in the rate of the primary outcome of death or major disability [modified Rankin scale score (mRS) of 3-6], with early intensive BP lowering. However, in the key secondary endpoint of an ordinal analysis of the distribution of mRS scores, there was a significant favorable shift in those patients with aggressive therapy. There were also more patients who were normal or near normal (mRS of 0-1) at 90 days. Reassuringly, there were no differences in the rate of death or numbers of serious adverse events between the two groups. INTERACT2 has shown that a strategy of early and aggressive BP lowering is safe in a wide range of clinical settings, and is probably effective. The Antihypertensive Treatment of Acute Cerebral Haemorrhage (ATACH) II trial, which is using similar BP targets to INTERACT, should shed further light on the benefit of early aggressive BP lowering in patients with spontaneous ICH.

Abstract TP39: Delayed CT "Swirl Sign" Predicts Outcome in Intracerebral Hemorrhage.

BACKGROUND: “Swirl sign” on an initial CT scan indicates ongoing hemorrhage in a hematoma and has been associated with increased mortality. OBJECTIVE: To assess CT swirl sign(CTSS) for predicting outcome in acute primary intracerebral hemorrhage. METHODS: Acute ICH patients within 24 hours of symptom onset were recruited. Baseline Non contrast and contrast enhanced CT scan and CT angiography of the brain was done. Follow up CT(FU CT) scan was done 24 hours from baseline.Hematoma volume(HV), CT spot and swirl sign were assessed. All patients were managed as per standard guidelines. Outcome assessment with modified rankin scale(mRS) was carried out at 1 month and 3 months RESULTS: 25 patients were recruited.Mean age was 52.44+11.35years,72% males, time from symptom onset ranged from 180-990 mins (mean-499 mins), GCS range 7-15 ,NIHSS range 6-33 (Mean 19.76), Mean systolic, diastolic and mean arterial pressures at baseline were 186.40 ,108.72 and 134.32 mm Hg. 10 (40%) had hematoma expansion (HE; &gt; 33% increase in hematoma volume on FU CT). Mortality was 36% (9). Prevalence of CT spot sign was 4% . CTSS at baseline and follow-up was 24% (6)and 32%(8) respectively. 87.5% with delayed CTSS had a poor outcome (mRS&gt;2). Delayed CTSS was associated with increased early mortality (1 month) (p = 0.005) and poor outcome at 3 months (p=0.03). CONCLUSION: Delayed CT Swirl sign (&gt;24 hours) is a predictor of mortality and outcomes in acute primary supratentorial intracerebral hemorrhage. It may serve as a marker for aggressive BP lowering even in patients presenting after 6-8 hours

Ischemic Brain Injury After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the second most common cause of stroke and accounts for 8% to 15% of strokes in Western societies with an estimated incidence of 10 to 25 per 100 000 persons.1–3 Despite advances in the field of stroke and neurocritical care,4 the 30-day mortality has not changed significantly over the past 20 years.3 Indeed, ICH has the highest rates of dependence or death among stroke types and proven treatments are lacking. Clinical trials aimed at limiting hemorrhage growth, procoagulant agents for hemostasis,5 and surgical evacuation6 have not translated into improved clinical outcomes. Antihypertensive therapy for the purpose of reducing hematoma growth has been a mainstay of acute management. Guidelines recommend maintaining mean arterial pressure <130 mm Hg during the acute phase7; however, controversies exist given the lack of randomized clinical trial data and uncertainties about the rapidity and target level of blood pressure (BP)-lowering. Recent Phase 2 clinical trials evaluating acute BP control have shown promise in reducing hematoma expansion with an adequate safety profile and Phase 3 trials are underway.8,9 Besides hematoma growth, other pathophysiological processes occur in the setting of ICH and may serve as potential therapeutic targets. In the acute period after ICH, a rapid rise in intracranial pressure (ICP) from an expanding hematoma may reduce cerebral perfusion pressure. In this setting, interventions aimed at BP-lowering and hemostasis may theoretically induce thrombosis or exacerbate brain ischemia, particularly in patients with pre-existing cerebrovascular disease. A recent publication suggests that aggressive BP-lowering may actually cause acute brain ischemia and worsen outcomes after ICH.10 In this review, we outline the data on secondary acute ischemic injury after ICH, review the prevalence of remote ischemic lesions and risk factors associated with their occurrence, explore potential …

Abstract 2710: Aggressive Blood Pressure Lowering in Acute Intracerebral Hemorrhage is Associated with Perihematomal Hypoperfusion and Ischemia

Introduction Optimal blood pressure control following acute ICH remains controversial. Blood pressure reduction may limit hematoma expansion, but may also cause hypoperfusion and further damage in the perihematomal region. We examined the relationship between the extent and speed of systolic blood pressure (SBP) lowering and perihematomal perfusion and ischemia. Methods Consecutive prospectively enrolled ICH patients with an MRI within 24 hours of symptom onset were included. Hourly SBPs were recorded from hospital presentation to MRI acquisition. Aggressive BP lowering was defined as: ≥30% reduction from baseline and at least one BP drop of ≥35mmHg/h. Hematoma volume was considered large if ≥30cc. FLAIR, GRE and perfusion weighted images were co-registered. T max maps were generated using RApid processing of PerfusIon and Diffusion (RAPID) software. The perihematomal region was defined by outlining the perihematomal edema on FLAIR images and subtracting the inner surface of blood products on the GRE generating a perihematomal rim. Statistical analyses were done using MATLAB. Results Twenty-seven patients were included (age: 62.7±17.9years; ICH volume: 26±26cc). Six of 27 (22%) patients experienced aggressive SBP lowering. Numbers reported: mean(IQR). The aggressiveness of SBP reduction was similar in large versus small hematomas: the percentage drop in SBP was 26% (10-33) vs. 21% (13-28), and the highest SBP drop was 43mmHg/h (29-56) versus 46mmHg/h (31-51), p=0.61 and p=0.92, respectively. Patients with SBP drops ≥35mmHg/h tended to have delayed bolus arrival (high T max ), 6.1s (4.8-7.7) versus 5.3s (3.5-5.6) (p=0.06), as did patients with SBP drops ≥30%,T max values 7.3s (6.2-8.6) versus 5.3s (3.6-6.2) (p=0.014). The effect was magnified in patients with a large (≥30%) and fast (≥35mmHg/h) drop in SBP, despite hematoma volumes being equivalent (p=0.01, Figure1 ). Five of 6 patients with aggressive SBP lowering had a T max &gt;6s. Conversely, 7 out of 8 patients with modest SBP reduction had a T max ≤6s ( Figure2 ). Out of 11 patients with T max &gt;6s, 8 had DWI lesions (73%) versus 4 of 16 (25%) with T max ≤6s (p=0.02). Conclusions: Aggressive SBP lowering in acute ICH is associated with high T max values in the perihematomal region irrespective of hematoma volume. High T max values in turn are associated with DWI lesions.

Effects of Intensive Blood Pressure Control in the Management of Patients With Type 2 Diabetes Mellitus in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial

To appreciate the importance of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial,1 one needs to remember that the systolic blood pressure (BP) target currently recommended by major guidelines for diabetic patients, that is, 130 mm Hg, except in the Appropriate Blood Pressure Control in Diabetes Study (ABCD) normotensive trial,7 which consisted of only a few hundred patients and had changes in creatinine clearance as the primary end point. Thus, ACCORD represents the only large-scale randomized trial that provides information on what happens to the cardiovascular risk of diabetic patients when SBP is reduced to 130 mm Hg as a result of randomization to the usual (rather than the tight) BP control treatment strategy. Thus, the message from ACCORD to guidelines and clinical practice is that in diabetic patients it is not necessary to adopt …

Safety and Tolerability of Fixed-Dose Irbesartan/Hydrochlorothiazide for Rapid Control of Severe Hypertension

This prospective, double-blind, multicenter trial compared the safety and tolerability of irbesartan/hydrochlorothiazide (HCTZ) fixed-dose combination therapy with irbesartan monotherapy in patients with severe hypertension (seated diastolic blood pressure (SeDBP) ≥110 mm Hg, mean BP 172/113 mm Hg at baseline). Patients were randomized 2:1 to 7 weeks' irbesartan/HCTZ 150/12.5 mg to 300/25 mg (n = 468) or irbesartan 150 mg to 300 mg (n = 227). The incidence of treatment-related adverse events (AEs) was similar with combination and monotherapy (11.3% and 10.1%), and most AEs were mild-to-moderate. The combined incidence of prespecified AEs was lower with irbesartan/HCTZ than with irbesartan (8.8% vs. 11.5%). There were no treatment-related serious AEs or deaths. At week 5, more patients achieved SeDBP < 90 mm Hg compared to irbesartan (47% vs. 33%; P = 0.0005). Despite more rapid and aggressive BP lowering, initial fixed-dose irbesartan/HCTZ demonstrated a comparable AE profile to irbesartan monotherapy in patients with severe hypertension.

The ADVANCE Trial

Patients with type 2 diabetes mellitus exhibit a marked increase in cardiovascular and renal risk. A number of interventional trials have shown that these patients benefit greatly from aggressive BP lowering, especially when the drug regimen comprises an inhibitor of the renin-angiotensin system. The results of the placebo-controlled ADVANCE (Action in Diabetes and Vascular disease: PreterAx and DiamicroN MR Controlled Evaluation) trial, conducted in patients with type 2 diabetes, are exemplary in this respect. The systematic use of a fixed-dose combination containing the ACE inhibitor perindopril and the diuretic indapamide afforded substantial protection against cardiovascular mortality and myocardial infarction, while providing important renoprotection, reducing the development of micro- and macroalbuminuria, and allowing regression of nephropathy. The beneficial effects were obtained regardless of baseline BP and whether or not the patients were receiving antihypertensive therapy.

Prompt, aggressive BP lowering in high-risk patients.

Various populations with hypertension have been singled out by current treatment guidelines as requiring more specific treatment. These include patients with stage 2 hypertension, black patients, and patients with coexistent diabetes mellitus and coronary heart disease. Hypertension in these groups is often associated with higher risk of cardiovascular morbidity and mortality. This article reviews current knowledge regarding hypertension in high-risk patient populations, with a particular focus on the importance of prompt, aggressive treatment to lower blood pressure and prevent cardiovascular disease progression. Such treatment includes the early use of multiple-drug therapy with agents that have complementary blood pressure-lowering mechanisms and provide protection from target organ damage. While 2- or 3-drug antihypertensive therapy in these high-risk groups has typically included a diuretic, other combinations of agents may be indicated. Evidence suggests that therapy with a calcium channel blocker and an inhibitor of the renin-angiotensin system is one effective strategy for lowering blood pressure and improving outcomes in these populations.

Findings Support Aggressive BP Lowering

Findings Support Aggressive BP Lowering

Managing blood pressure in type 2 diabetes mellitus

Patients with type 2 diabetes exist in a state of accelerated cardiovascular risk. Indeed, as outlined in the accompanying paper1 it is prudent to consider the level of risk as being on a par with that of patients with established cardiovascular disease. Despite the general decline in cardiovascular mortality in the Western world there is evidence to suggest that this has not been so for diabetics2. The reasons for this discrepancy are unclear but it may, in part, reflect a different approach to the management of risk factors? There has never been a randomised, placebo controlled, trial of the treatment of hypertension amongst diabetic patients. Our information on the undoubted benefits of treatment has therefore come solely from sub-group analysis of large intervention trials or from studies comparing different degrees of BP control. Such evidence has however convinced most physicians and perhaps the main message to be taken from the recently published UKPDS3 is that aggressive BP lowering in hypertensive diabetic patients confers more health gain than does the more conventional reduction of plasma glucose. These and other published data1 have established, beyond reasonable doubt, that we should treat blood pressure at lower levels and with more vigour in high risk individuals such as diabetic patients. We still do not know how low we should go and it is being increasingly argued that treatment of ‘normotension’ might confer benefit (the risks are linearly related to the level of BP with no threshold). Realistically there would have to be a level of BP which would be too low but both HOT4 and UKPDS3 imply that we have yet to find it. I would submit that we do not yet know the best combination of drugs to use (remember that most patients will require multiple therapy). Dr. McKnight's paper1 indicates that we have positive evidence for treatment regimens based upon thiazide diuretics, dihydropyridine calcium channel blockers (CCB), β blockers and ACE inhibitors and there are suggestions that ACE inhibitors might be better than CCBs. Such comparative studies are bedevilled by small numbers and even the statement in UKPDS3 that β blockers are equivalent to ACE inhibitors should be treated cautiously: the study did not have sufficient power to detect a difference. I believe, however, that we will see an increasing use of a thiazide/ACE inhibitor combination as a baseline for diabetic patients. Is it simply an effect on BP that conveys benefit? It has long been believed by many that ACE inhibitors might have a peculiar advantage (over and above their effects on BP) in protecting patients from vascular disease. This belief is based on much animal evidence of harm induced by activation of the renin/angiotensin/aldosterone axis in a variety of experimental models. Early treatment trials of heart failure with ACE inhibitors revealed ‘non-significant’ reductions in the rate of subsequent myocardial infarctions. ACE inhibitors are probably better than other antihypertensive treatments at retarding the decline in renal function in type I diabetic patients, even when BP is not lowered5. Anecdotally, most doctors appear to believe that this class of drugs is special and now they can start to say ‘I told you so!’ Publication of the HOPE trial6 has established that diabetic patients over the age of 55 who have one other cardiovascular risk factor (hypertension, elevated total cholesterol, low HDL cholesterol, cigarette smoking or documented microalbuminuria) benefit from treatment with an ACE inhibitor. The study demonstrated a 25% reduction in the combined risk of myocardial infarction, stroke and cardiovascular death in patients receiving Ramipril (10 mg/day) for 4.5 years compared with a placebo group. This benefit was observed with only a 3 mm Hg difference in SBP between the groups over the lifetime of the trial. At most only 40% of the benefits seen could be explained on the basis of the BP effect. It will be a long time before the dust settles on the discussion of this major trial but it will have an impact on our treatment of cardiovascular risk in patients with type 2 diabetes. Indeed, if this study is accepted then there is a strong argument for documenting the presence of microalbuminuria in our patients with type 2 diabetes so as to further stratify risk1. The treatment of diabetes rightly involves an attempt to modify the abnormal glucose metabolism but we do our patients a major disservice if we do not address total cardiovascular risk. This is going to mean the likelihood of two or three antihypertensive agents, lipid-lowering therapy and aspirin, on top of what is needed for glucose control. I await with interest the comments of health economists regarding the cost effectiveness of such interventions!

Essential hypertension : part II: treatment.

The goal of antihypertensive treatment is to reduce overall CVD risk and thus its morbidity and mortality rates. In any given patient, the decision to begin treatment is governed by the risk of CVD, which is determined by the magnitude of the BP elevation and the presence or absence of target organ disease and/or additional CVD risk factors. Recent consensus committees, including JNC VI and the World Health Organization–International Society of Hypertension (WHO-ISH) Guidelines Subcommittee, have modified traditional treatment recommendations in several important ways3,35 : (1) Criteria for initiation of treatment now take into consideration total cardiovascular risk rather than BP alone, such that treatment is now recommended for persons whose BP is in the normal range but still bear a heavy burden of CVD risk factors or established CVD. (2) Systolic BP is recognized as an important target for treatment, particularly in older persons, because it is an even more important determinant of CVD risk than diastolic BP. (3) More aggressive BP goals are recommended for hypertensive patients with comorbid conditions such as diabetes mellitus or renal insufficiency. (4) The importance of tailoring the choice of antihypertensive drug treatment to the patient’s individual profile of concomitant CVD risk factors/comorbid conditions is emphasized. (5) The role of simultaneous reduction of multiple CVD risk factors in improving prognosis in hypertensive patients is stressed. (6) Home and ambulatory BP measurement has been recommended because of its value in guiding therapy and enhancing adherence to treatment. (7) Greater reliance on evidence-based medicine (ie, results of randomized controlled trials with CVD outcomes) in making treatment decisions has been endorsed. JNC VI has arrived at an empirical classification that stratifies hypertensive patients into risk groups for therapeutic decisions (Table 4⇓). Risk group A includes patients who do not have clinical CVD, target …