Appropriate Treatment Of Hypertension Research Articles

Hypertension in Wilms tumor.

Wilms tumor (WT) represents over 90% of all pediatric kidney tumors. Children with WT often present acutely with hypertension which resolves in the short term after nephrectomy. However, WT survivors have increased long-term risk of hypertension, primarily due to decreased nephron mass after nephrectomy, with additional insults from possible exposure to abdominal radiation and nephrotoxic therapies. The diagnosis of hypertension may be improved by ambulatory blood pressure monitoring (ABPM), as several recent single-center studies have shown a substantial proportion of WT survivors with masked hypertension. Current gaps in knowledge include determining which WT patients may benefit from routine screening with ABPM, correlation of casual and ABPM parameters with cardiac abnormalities, and longitudinal assessment of cardiovascular and kidney parameters in relation to appropriate treatment of hypertension. This review aims to summarize the most recent literature on hypertension presentation and management at the time of WT diagnosis as well as the long-term hypertension risk and impact on kidney and cardiovascular outcomes in WT survivors.

Blood Pressure Control and Prescription Pattern of Antihypertensive Drugs in Adherence to the 2020 International Society of Hypertension (ISH) Global Hypertension Practice Guidelines in Saudi Arabia: A Retrospective Study.

Background Hypertension is the leading risk factor for cardiovascular disease and death. Appropriate treatment of hypertension is necessary to reduce mortality. A prescription-based study is one of the most influential and helpful methods to examine physicians' irrational prescribing practices. This study was designed to investigate the antihypertensive prescription of physicians and their adherence to the treatment guidelines, as well as the blood pressure (BP) control rate in a general hospital in the Kingdom of Saudi Arabia. Methodology A retrospective, cross-sectional study was conducted between February 2020 and June 2021 in an outpatient department. Patients diagnosed with hypertension as per the 2020 International Society of Hypertension guidelines and those who received antihypertensive drugs were included. Study data included prescriptions, patient's age, duration of hypertension, comorbidities, BP, drug therapy type, and antihypertensive class. Results Overall, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (67.1%) were the most prescribed agents, followed by dihydropyridine-calcium channel blockers (62.6%), diuretics (26.1%), and β-blockers (10.1%). Comorbid and stage 2 hypertensive patients mainly received combination therapy (51.6%) rather than monotherapy (48.4%). The study revealed an 83.5% prescription adherence to the treatment guidelines. However, non-adherence was encountered in monotherapy, polytherapy, and elderly-treated patient groups. A 66.4% (at target BP in all cases <140/90 mmHg) and 39.3% (at target BP in comorbid patients <130/80 mmHg) rate of BP control was observed. Furthermore, the rate of BP control was significantly associated with prescription adherence (χ2 = 71.316; p < 0.001). Conclusions The degree of prescription adherence and rate of BP control were found to be compatible with other published hypertension studies. However, considerable scope exists for improvement in rational drug utilization and rate of BP control, particularly in high-risk patients. Therefore,treatment guidelines must be followed by clinicians to achieve BP goals and reduce cardiovascular events among the Saudi population.

Management of Hypertension in Fabry Disease.

Fabry disease (FD), a rare X-linked lysosomal storage disorder that depletes alpha-galactosidase A (α-GalA), is caused by mutations in the GLA gene. Diminished α-GalA enzyme activity results in the accumulation of Gb3 and lyso-Gb3. The pathophysiology of hypertension in FD is complex and unclear. The storage of Gb3 in arterial endothelial cells and smooth muscle cells is known to produce vascular injury by increasing oxidative stress and inflammatory cytokines as a primary pathophysiological mechanism. In addition, Fabry nephropathy developed, resulting in a decrease in kidney function and contributing to hypertension. The prevalence of hypertension in patients with FD was between 28.4% and 56%, whereas hypertension in patients with chronic kidney disease ranged between 33% and 79%. A study using 24-hour ambulatory blood pressure monitoring (ABPM) to measure blood pressure (BP) indicated a high prevalence of uncontrolled hypertension in FD. Thus, 24-hour ABPM ought to be considered for FD hypertension assessments. Appropriate treatment of hypertension is believed to reduce mortality in patients with FD caused by kidney disease, cardiovascular disease, and cerebrovascular disease because hypertension significantly impacts organ damage. Up to 70% of FD patients have been reported to have kidney involvement, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prescribed for proteinuria are recommended as first-line therapy with antihypertensive drugs. In conclusion, hypertension should be controlled appropriately, given the different morbidity and mortality caused by significant organ involvement in FD patients.

Stratification and Assessment of Risk Factors of Chronic Kidney Disease in Hospitalized Patients

Chronic kidney disease (CKD) has become a global public health concern. The adverse outcome of CKD are high in number in developing countries due to scarcity of facilities for renal replacement therapy and high cost of services for management of ESRD. It is one of the leading cause of hospital deaths. CKD is strongly associated with diabetes, hypertension, glomerulonephritis and elevated lipids. Therefore, identifying the preventable risk factors, pathophysiological mechanisms and stratification of CKD helps in decreasing and slowing its progression. This study was conducted for the staging of chronic kidney disease (CKD) and assessment of the risk factors with CKD in hospitalized patients of Dhaka Medical College Hospital in collaboration with Medicine and Nephrology department. This was a cross sectional observational study where 125 patients having chronic kidney diseases (CKD) were diagnosed on the basis of history, clinical examinations and investigations, who had fulfill the inclusion and exclusion criteria admitted in the department of medicine and department of nephrology from January to December 2016. Sampling method was purposive sampling. A specifically designed questionnaire were used to get the personal and medical history data. Blood and urine samples were collected and data was analyzed using SPSS (22.00). Out of 125 patients, no Stage-1 patient was found, remaining were Stage- 2 CKD 7.2%, Stage- 3 CKD 63.2%, Stage- 4 CKD was 25.6%, and Stage- 5 CKD was 4%. Among 125 participants, 52.0% had glomerulonephritis (GN), 31.2% had diabetes mellitus (DM) and 9.6% had hypertension (HTN). Mean age was 48.41 (±13.99) years, mean body weight was 50.61 (±10.73) Kg, mean BMI was 22.9 (±1.69), male female ratio was 3.6:1. Age group 51 to 60 years were suffering more. The association between CKD and other risk factors including obesity and overweight, use of tobacco, diabetes and hypertension were highly significant. The commonest risk factors for CKD like DM and HTN are also alarmingly high and obviously adding to the existing burden of CKD. Early detection of the risk factors of CKD, early referral to nephrologist, appropriate treatment of hypertension, DM, GN and other risk factors, life style modification with specific emphasis on reduction in salt intake, physical exercise, and abstinence from smoking would retard progression of kidney disease to an advanced stage. Bangladesh Med J. 2020 May; 49(2) : 19-24

P4482Antihypertensive drugs in experimental NAFLD as the first step to the establishment of criteria for choosing appropriate treatment of hypertension in NAFLD carriers

Abstract Background/Introduction Hypertension is highly prevalent in NAFLD patients (39%). NAFLD has been independently associated with an increased risk of arterial hypertension in observational studies and emerge as the most frequent cause of chronic hepatic disease in adults. Therefore, we can deduce that treating hypertension in NAFLD carriers will be often necessary. However, there are no established criteria for choosing the most appropriate drug therapy for hypertension in patients with NAFLD, and the basic research may be the first step to the development of these criteria. Purpose We aimed to evaluate the effects of the renin-angiotensin system blockade with angiotensin-converting enzyme inhibitor ramipril and angiotensin 2 type 1 receptor antagonist olmesartan, used preventively, in NAFLD induced in rabbits fed hypercholesterolemic diet. Antihypertensive drugs in experimental NAFLD as the first step to the establishment of criteria for choosing appropriate treatment of hypertension in NAFLD carriers. Methods Olmesartan study: Thirty-four rabbits were divided into three groups (control, untreated and olmesartan). The untreated and olmesartan group were fed a hypercholesterolemic diet. Animals from olmesartan group were treated with olmesartan 1mg/kg/day. Ramipril study: Twenty-nine rabbits were divided into three groups (normal, placebo, and ramipril). The placebo and ramipril groups were fed a hypercholesterolemic diet. The groups were orally administered 0.35 mg/kg/day of ramipril, and an equivalent volume of vehicle was administered to the placebo group. In both studies, at the end of the 8th week, all rabbits underwent segmental hepatic resection and were euthanised. Blood samples were collected to determine glucose, creatinine, total cholesterol, triglycerides, high-density lipoprotein cholesterol, and aminotransferase levels at baseline and euthanasia. Haematoxylin and eosin and Gomori trichrome stained slides were analysed based on the histological scoring system for NAFLD. Results The comparison between two groups (olmesartan with untreated group and ramipril with placebo) showed that ramipril and olmesartan significantly diminished the development of steatosis (p&lt;0.013, p=0.032), lobular inflammation (p&lt;0.001, p=0.006), and fibrosis (p=0.015, p=0.02). Based on NAFLD activity score, olmesartan and ramipril significantly reduced the development of nonalcoholic steatohepatitis (p&lt;0.001, p=0.003). Conclusion(s) The preventive use of olmesartan and ramipril attenuates the development of hepatic steatosis, lobular inflammation and fibrosis in hypercholesterolemic rabbits. These results can serve as the basis to the establishment of criteria for choosing the most appropriate drug therapy for hypertension in NAFLD carriers.

Fixed combinations in modern hypertension treatment algorithms

Modern appropriate treatment of hypertension involves the use of combination antihypertensive therapy. According to updated version of European Society of Cardiology 2018 guidelines, renin-angiotensin-aldosterone system blockers must be used as first-line drugs, including in combination with hydrochlorothiazide. This article presents the algorithms for the management of patients with uncomplicated and asymptomatic (with target lesions) arterial hypertension. It also described the management of patients with concomitant cardiovascular, cerebrovascular, renal pathology and diabetes mellitus, and use of fixed combination of candesartan and hydrochlorothiazide. The article presents research data that confirmed not only the high antihypertensive efficacy of this combination, but also demonstrated its neutral metabolic profile, organ-protective effects, the ability to use in patients with chronic kidney disease, chronic heart failure, prior stroke, as well as high tolerability and treatment adherence.

The role of a captopril renal scintigraphy in examination of children with hypertension: A case report

Introduction. Secondary hypertension is a relatively common form of hypertension in childhood with renovascular hypertension being responsible for 5%?10% of all arterial hypertensions in children. An early diagnosis of renovascular hypertension is important when considering an appropriate treatment of hypertension that may prevent or slow further progression of kidney damage. To validate the usefulness of a captopril renal scintigraphy in hypertensive children, we report a case of a 16-year-old female patient with a history of hypertension as a result of fibromuscular dysplasia. Case report. The patient was asymptomatic with elevated blood pressure revealed by a routine physical examination. Laboratory tests showed the increased levels of plasma renin activity with the normal levels of aldosteron. The renal ultrasound was normal. The Doppler of the renal arteries showed no significant differences of resistive index. A renal captopril scintigraphy was performed, including two day study protocol, the baseline study followed by another captopril study several days later. The scintigraphy showed the abnormal baseline and captopril renogram curve of the right kidney with significant cortical retention of radiotracer after angiotensin-converting enzyme inhibition. Following the captopril scintigraphy a renovasography was obtained confirming the presence of a 2 mm long circular narrowing of the right renal artery. It was immediately treated resulting in a significant expansion of the lumen. Conclusion. The captopril renal scintigraphy allows non-invasive functional testing in a selected group of hypertensive children, which can either confirm or rule out the existence of hemodynamically significant renal artery stenosis.

Hypertension in Athletes and Active Populations.

Hypertension continues to be the most common cardiovascular disorder in the USA and worldwide. While generally considered a disorder of aging individuals, hypertension is more prevalent in athletes and the active population than is generally appreciated. The timely detection, diagnosis, and appropriate treatment of hypertension in athletes must focus on both adequately managing the disorder and ensuring safe participation in sport while not compromising exercise capacity. This publication focuses on appropriately diagnosing hypertension, treating hypertension in the athletic population, and suggesting follow-up and participation guidelines for athletes.

Hypertension Management in Diabetic Kidney Disease.

IN BRIEF Hypertension is prevalent in most individuals with diabetic kidney disease (DKD). Failure to treat hypertension appropriately in this subgroup of patients results in an increased risk of cardiovascular morbidity and mortality, as well as a faster progression of kidney disease. The current guidance for appropriate treatment of hypertension in this high-risk population provides an opportunity to improve both kidney and cardiovascular outcomes. This review discusses the current state of evidence-based hypertension management in patients with DKD.

Health plan starts P4P program for community pharmacies

Health plan starts P4P program for community pharmacies

Rationale and design of the NAGOYA HEART Study: Comparison between valsartan and amlodipine regarding morbidity and mortality in patients with hypertension and glucose intolerance

Inhibitors of the renin angiotensin system are recommended as the first-line medications for diabetic hypertensive patients. However, there is less evidence supporting this recommendation especially among East Asians, a population with a unique distribution of cardiovascular disease compared to the Western population. The NAGOYA HEART Study is a prospective randomized open-label blinded-endpoint study to compare an angiotensin II receptor blocker, valsartan, and a calcium channel blocker, amlodipine, regarding their efficacies on cardiovascular morbidity and mortality in Japanese hypertensive patients with glucose intolerance. Of 1168 eligible patients, we enrolled 1150 patients from October 2004 to January 2009. The participants will be followed for more than a median follow-up period of 3 years. The primary composite endpoint includes myocardial infarction, stroke, coronary revascularization, and admission due to congestive heart failure or sudden cardiac death. Any of these events are adjudicated by an independent committee under blinded information regarding the treatment arm. Secondary endpoints include all-cause mortality, changes in glucose tolerance status, kidney function, left ventricular structure measured by echocardiogram, and incident atrial fibrillation/flutter. The study was registered at ClinicalTrials.gov NCT00129233. The NAGOYA HEART Study will provide us with a relevant insight for appropriate treatment of hypertension with glucose intolerance.

Diabetic Cardiomyopathy and Anesthesia

Diabetic Cardiomyopathy and Anesthesia

Hypertension in black Americans as a special population: Why so special?

Studies have shown that appropriate treatment of hypertension will reduce cardiovascular, renal, and cerebrovascular morbidity and mortality for all patients. Because hypertension has a multifaceted nature the disorder presents with unique features in prevalence, morbidity, and mortality among ethnic groups. Blacks, Hispanics, and Native Americans have been identified as special populations at risk for unique experiences with hypertension. Among these special populations, black Americans present unique issues in etiology, pathophysiology, severity, and response to treatment. This article reviews the varied aspects of hypertension detection, treatment, and control as they relate to the special population of black Americans.

Strategies to prevent eclampsia in a developing country: I. Reorganization of maternity services

Objective: To determine whether changes in primary and secondary care service delivery could prevent antenatal eclampsia. Method: One intervention (St. Catherine) and two control (St Ann, Manchester) parishes were chosen. The health system in St. Catherine was restructured. Primary antenatal clinics had clear instructions for referring patients to a high-risk antenatal clinic or to hospital. Guidelines were provided to high-risk clinics and the antenatal ward for appropriate treatment of hypertension and preeclampsia when induction of labor should occur. Antenatal eclampsia incidence was monitored before and during the intervention and compared with control parishes (no intervention). Each eclampsia case was investigated to identify inadequacies in the system. Results: The process resulted in better identification of women at risk. Antenatal eclampsia incidence dropped dramatically as care improved. Compared with control areas, by completion of the study, the rate was significantly lower than at the start: OR 0.19 (95% CI: 0.13–0. 27; p<0.001 trend). Antenatal admissions for hypertensive disorders declined significantly, and the number of bed days halved. Conclusion: Reorganization of maternal care can have major public health benefits and cost savings; however, women need to be alerted to recognise and act upon signs of impending eclampsia.

From Hypertension to Heart Failure

The prevalence of heart failure is increasing in modern societies. Hypertension is a major contributor to the development of heart failure, whether through the development of left ventricular hypertrophy and diastolic dysfunction or by promoting atherosclerosis and myocardial infarction, which eventually leads to systolic dysfunction and left ventricular dysfunction. Effective therapy for hypertension can prevent more than 50% of heart failure events. Most studies done in the last three decades have used b blockers with diuretics as the modality of therapy. These agents have been shown to effectively prevent the development of heart failure. More recent comparative studies have shown that use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are also effective in preventing heart failure. Calcium channel blockers, however, seem to be less effective in preventing development of heart failure in patients with hypertension. It needs to be emphasized that the most important variable in preventing heart failure is the appropriate treatment of hypertension.

Use of antihypertensive drug therapy in older persons in an academic nursing home.

To determine the prevalence of hypertension and the appropriate treatment of hypertension in older persons in an academic nursing home. The charts of all persons aged > or = 59 years currently residing in a nursing home affiliated with Westchester Medical Center/New York Medical College were analyzed by two geriatrics fellows according to a protocol designed by one of the authors (W.S.A.). An academic nursing home affiliated with Westchester Medical Center/New York Medical College. The study population included 96 men and 159 women, mean age 77 +/- 9 years (range, 59-100 years). Hypertension was present in 129 of 255 persons (51%). Clinical cardiovascular disease or target organ damage or diabetes mellitus was present in 121 of 129 persons (94%) with hypertension. Hypertension was poorly controlled in 21 of 129 persons (16%). Of 129 persons with hypertension, 70 (54%) were treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers, 61 persons (47%) with beta blockers, 43 persons (33%) with diuretics, 36 persons (28%) with calcium channel blockers, 5 persons (4%) with alpha blockers, and 5 persons (4%) with other antihypertensive drugs. Of 54 persons with hypertension and diabetes mellitus, 37 persons (69%) were treated with ACE inhibitors or angiotensin II type 1 receptor blockers. Of 58 persons with hypertension and coronary artery disease, 33 persons (57%) were treated with ACE inhibitors or angiotensin II type 1 receptor blockers, 31 persons (53%) with beta blockers, 20 persons (34%) with diuretics, 18 persons (31%) with calcium channel blockers, 2 persons (4%) with alpha blockers, and 4 persons (7%) with other antihypertensive drugs. Of 31 persons with hypertension and heart failure, only 5 persons (16%) had measurement of left ventricular ejection fraction. Of 31 persons with hypertension and heart failure, 30 persons (97%) were treated with diuretics, 21 persons (68%) with ACE inhibitors or angiotensin II type 1 receptor blockers, 18 persons (58%) with beta blockers, and 8 persons (26%) with calcium channel blockers. Of older persons with hypertension in an academic nursing home, 16% had poor control of their hypertension. There was overuse of calcium channel blockers and alpha blockers and underuse of diuretics, beta blockers, and ACE inhibitors in treating hypertension. Physician education needs to be intensified to provide better medical care of older persons with hypertension through the use of optimal doses of drugs found to be effective and safe by evidence-based studies.

Use of Antihypertensive Drug Therapy in Older Persons in an Academic Nursing Home

Objectives To determine the prevalence of hypertension and the appropriate treatment of hypertension in older persons in an academic nursing home. Design The charts of all persons aged ≥ 59 years currently residing in a nursing home affiliated with Westchester Medical Center/New York Medical College were analyzed by two geriatrics fellows according to a protocol designed by one of the authors (W.S.A.). Setting An academic nursing home affiliated with Westchester Medical Center/New York Medical College. Participants The study population included 96 men and 159 women, mean age 77 ± 9 years (range, 59–100 years). Results Hypertension was present in 129 of 255 persons (51%). Clinical cardiovascular disease or target organ damage or diabetes mellitus was present in 121 of 129 persons (94%) with hypertension. Hypertension was poorly controlled in 21 of 129 persons (16%). Of 129 persons with hypertension, 70 (54%) were treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers, 61 persons (47%) with beta blockers, 43 persons (33%) with diuretics, 36 persons (28%) with calcium channel blockers, 5 persons (4%) with alpha blockers, and 5 persons (4%) with other antihypertensive drugs. Of 54 persons with hypertension and diabetes mellitus, 37 persons (69%) were treated with ACE inhibitors or angiotensin II type 1 receptor blockers. Of 58 persons with hypertension and coronary artery disease, 33 persons (57%) were treated with ACE inhibitors or angiotensin II type 1 receptor blockers, 31 persons (53%) with beta blockers, 20 persons (34%) with diuretics, 18 persons (31%) with calcium channel blockers, 2 persons (4%) with alpha blockers, and 4 persons (7%) with other antihypertensive drugs. Of 31 persons with hypertension and heart failure, only 5 persons (16%) had measurement of left ventricular ejection fraction. Of 31 persons with hypertension and heart failure, 30 persons (97%) were treated with diuretics, 21 persons (68%) with ACE inhibitors or angiotensin II type 1 receptor blockers, 18 persons (58%) with beta blockers, and 8 persons (26%) with calcium channel blockers. Conclusions Of older persons with hypertension in an academic nursing home, 16% had poor control of their hypertension. There was overuse of calcium channel blockers and alpha blockers and underuse of diuretics, beta blockers, and ACE inhibitors in treating hypertension. Physician education needs to be intensified to provide better medical care of older persons with hypertension through the use of optimal doses of drugs found to be effective and safe by evidence-based studies.

Use of Antihypertensive Drug Therapy in Older Persons in an Academic Nursing Home

Objectives To determine the prevalence of hypertension and the appropriate treatment of hypertension in older persons in an academic nursing home. Design The charts of all persons aged ≥ 59 years currently residing in a nursing home affiliated with Westchester Medical Center/New York Medical College were analyzed by two geriatrics fellows according to a protocol designed by one of the authors (W.S.A.). Setting An academic nursing home affiliated with Westchester Medical Center/New York Medical College. Participants The study population included 96 men and 159 women, mean age 77 ± 9 years (range, 59–100 years). Results Hypertension was present in 129 of 255 persons (51%). Clinical cardiovascular disease or target organ damage or diabetes mellitus was present in 121 of 129 persons (94%) with hypertension. Hypertension was poorly controlled in 21 of 129 persons (16%). Of 129 persons with hypertension, 70 (54%) were treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers, 61 persons (47%) with beta blockers, 43 persons (33%) with diuretics, 36 persons (28%) with calcium channel blockers, 5 persons (4%) with alpha blockers, and 5 persons (4%) with other antihypertensive drugs. Of 54 persons with hypertension and diabetes mellitus, 37 persons (69%) were treated with ACE inhibitors or angiotensin II type 1 receptor blockers. Of 58 persons with hypertension and coronary artery disease, 33 persons (57%) were treated with ACE inhibitors or angiotensin II type 1 receptor blockers, 31 persons (53%) with beta blockers, 20 persons (34%) with diuretics, 18 persons (31%) with calcium channel blockers, 2 persons (4%) with alpha blockers, and 4 persons (7%) with other antihypertensive drugs. Of 31 persons with hypertension and heart failure, only 5 persons (16%) had measurement of left ventricular ejection fraction. Of 31 persons with hypertension and heart failure, 30 persons (97%) were treated with diuretics, 21 persons (68%) with ACE inhibitors or angiotensin II type 1 receptor blockers, 18 persons (58%) with beta blockers, and 8 persons (26%) with calcium channel blockers. Conclusions Of older persons with hypertension in an academic nursing home, 16% had poor control of their hypertension. There was overuse of calcium channel blockers and alpha blockers and underuse of diuretics, beta blockers, and ACE inhibitors in treating hypertension. Physician education needs to be intensified to provide better medical care of older persons with hypertension through the use of optimal doses of drugs found to be effective and safe by evidence-based studies. To determine the prevalence of hypertension and the appropriate treatment of hypertension in older persons in an academic nursing home. The charts of all persons aged ≥ 59 years currently residing in a nursing home affiliated with Westchester Medical Center/New York Medical College were analyzed by two geriatrics fellows according to a protocol designed by one of the authors (W.S.A.). An academic nursing home affiliated with Westchester Medical Center/New York Medical College. The study population included 96 men and 159 women, mean age 77 ± 9 years (range, 59–100 years). Hypertension was present in 129 of 255 persons (51%). Clinical cardiovascular disease or target organ damage or diabetes mellitus was present in 121 of 129 persons (94%) with hypertension. Hypertension was poorly controlled in 21 of 129 persons (16%). Of 129 persons with hypertension, 70 (54%) were treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers, 61 persons (47%) with beta blockers, 43 persons (33%) with diuretics, 36 persons (28%) with calcium channel blockers, 5 persons (4%) with alpha blockers, and 5 persons (4%) with other antihypertensive drugs. Of 54 persons with hypertension and diabetes mellitus, 37 persons (69%) were treated with ACE inhibitors or angiotensin II type 1 receptor blockers. Of 58 persons with hypertension and coronary artery disease, 33 persons (57%) were treated with ACE inhibitors or angiotensin II type 1 receptor blockers, 31 persons (53%) with beta blockers, 20 persons (34%) with diuretics, 18 persons (31%) with calcium channel blockers, 2 persons (4%) with alpha blockers, and 4 persons (7%) with other antihypertensive drugs. Of 31 persons with hypertension and heart failure, only 5 persons (16%) had measurement of left ventricular ejection fraction. Of 31 persons with hypertension and heart failure, 30 persons (97%) were treated with diuretics, 21 persons (68%) with ACE inhibitors or angiotensin II type 1 receptor blockers, 18 persons (58%) with beta blockers, and 8 persons (26%) with calcium channel blockers. Of older persons with hypertension in an academic nursing home, 16% had poor control of their hypertension. There was overuse of calcium channel blockers and alpha blockers and underuse of diuretics, beta blockers, and ACE inhibitors in treating hypertension. Physician education needs to be intensified to provide better medical care of older persons with hypertension through the use of optimal doses of drugs found to be effective and safe by evidence-based studies.

Prognosis of diastolic and systolic orthostatic hypotension in older persons.

Orthostatic hypotension (OH) predicts mortality in hypertensive persons with diabetes mellitus, but no increase in mortality has been found among random samples of home-dwelling persons with OH. We examined the risks of nonvascular and vascular deaths according to different definitions of OH among home-dwelling elderly persons. The study population consisted of all persons aged 70 years or older living in 5 rural municipalities (N=969), of whom 833 (86%) participated. Orthostatic tests were successfully carried out in 792 persons by nurse examiners. Orthostatic hypotension was defined as a systolic blood pressure (BP) drop of 20 mm Hg or more or a diastolic BP drop of 10 mm Hg or more 1 minute or 3 minutes after standing up. Nonvascular and vascular deaths during the follow-up period were recorded. Data on diseases, symptoms, medications, the results of clinical examinations and tests, functional ability, and health behavior were collected at the beginning of the follow-up period. Of the sample, 30% had OH: the prevalence of systolic OH 1 minute and 3 minutes after standing up was 22% and 19%, respectively; that of diastolic OH 1 minute and 3 minutes after standing up was 6% for each. No differences in the occurrence of nonvascular deaths were found according to any of these definitions. By Cox multivariate regression analysis, the hazard ratio of vascular death associated with a diastolic BP reduction of 1 mm Hg 1 minute after standing up was 1.02 (P=.03), adjusted for systolic BP postural changes at 1 and 3 minutes and a diastolic BP change at 3 minutes. Adjusted for other significant factors associated with vascular death, the hazard ratio for vascular death associated with diastolic OH 1 minute after standing up was 2.04 (95% confidence interval, 1.01-4.15). The corresponding hazard ratio for systolic OH 3 minutes after standing up was 1.69 (95% confidence interval, 1.02-2.80). Using a cutoff point of 7 mm Hg or greater for a diastolic BP change 1 minute after standing up, the hazard ratio for vascular death was highest: 2.20 (95% confidence interval, 1.23-3.93). By logistic regression analysis, the baseline associates of diastolic OH 1 minute after standing up were dizziness when turning the neck (odds ratio [OR], 2.44), the use of a calcium antagonist (OR, 2.31), the use of a diuretic medication (OR, 2.29), a high systolic BP (OR, 2.23), and a low body mass index (OR, 2.26). The baseline associates of systolic OH 3 minutes after standing up were male sex (OR, 1.52), diabetes mellitus (OR, 1.92), a high systolic BP (OR, 2.91), and a low body mass index (OR, 1.68). The presence of diastolic OH 1 minute and systolic OH 3 minutes after standing up predict vascular death in older persons. They differ from each other in their prevalence and in several associates, suggesting different pathophysiologic backgrounds. Clinicians should prescribe vasodilating and volume-depleting medications with caution for elderly persons with diastolic OH 1 minute after standing up. Appropriate treatment of hypertension might be the best means to manage the different types of OH with poor vascular prognoses.

ANTIHYPERTENSIVE DRUGS IN THE ELDERLY

Elderly are the most rapidly growing segment of the population. The appropriate treatment of hypertension in these individuals should involve consideration of age-related changes in hemody-namics, presence of coexistent diseases, pharmacokinetics of different medications, drug-drug interactions, and cost-effectiveness. It may be helpful to follow reasonable guidelines in managing hypertension in the elderly population.