BP Goals Research Articles

Blood pressure goal attainment: comparative efficacy of olmesartan medoxomil, losartan potassium, valsartan, and irbesartan

P-235 Key Words: Olmesartan, Goal Rates, Hypertension

Cardiovascular and renal risk assessment as a guide for treatment in primary hypertension.

BP levels per se may be an unreliable indicator of risk in the individual patient. In fact, the global cardiovascular profile, including the presence and degree of target organ damage, is a better predictor of future events and, therefore, should be used to choose both treatment and BP goals. However, the prevalence of target organ damage and therefore the percentage of patients who are at risk very much depends on the diagnostic techniques used. However, as a result of the high prevalence of hypertension and its financial impact on public health systems, limiting unnecessary and extensive diagnostic tests also should be a priority. The routine search for microalbuminuria may lead to the detection of a significantly greater percentage of patients who are at high risk while contributing the optimization of the cost-effectiveness of diagnostic workup in hypertensive patients.

Secondary Prevention of Renal and Cardiovascular Disease

Australian Aborigines are experiencing an epidemic of renal and cardiovascular disease. In late 1995 we introduced a treatment program into the Tiwi community, which has a three- to fivefold increase in death rates and a recent annual incidence of treated ESRD of 2760 per million. Eligible for treatment were people with hypertension, diabetics with micro or overt albuminuria, and all people with overt albuminuria. Treatment centered around use of perindopril (Coversyl, Servier), with other agents added to reach BP goals; attempts to control glucose and lipid levels; and health education. Thirty percent of the adult population, or 267 people, were enrolled, with a mean follow up of 3.39 yr. Clinical parameters were followed every 6 mo, and rates of terminal endpoints were compared with those of 327 historical controls matched for baseline disease severity, followed in the pretreatment program era. There was a dramatic reduction in BP in the treatment group, which was sustained through 3 yr of treatment. Albuminuria and GFR stabilized or improved. Rates of natural deaths were reduced by an estimated 50% (P = 0.012); renal deaths were reduced by 57% (P = 0.038); and nonrenal deaths by 46% (P = 0.085). Survival benefit was suggested at all levels of overt albuminuria, and regardless of diabetes status, baseline BP, or prior administration of angiotensin converting enzyme inhibitors (ACEI). No significant benefit was apparent among people without overt albuminuria, nor among those with GFR less than 60 ml/min. An estimated 13 renal deaths and 10 nonrenal deaths were prevented, with the number-needed-to-treat to avoid one terminal event of only 11.6. Falling deaths and renal failure in the whole community support these estimates. The program was extremely cost-effective. Programs like this should be introduced to all high-risk communities as a matter of urgency.

Prevention of hypertension and its complications: theoretical basis and guidelines for treatment.

Hypertension is a nutritional-hygienic disease. Long-term caloric intake in excess of energy expenditures, chronic supraphysiological intake of dietary sodium, excessive alcohol consumption, and psychosocial stressors all contribute to the development of hypertension throughout the world. Elevated BP, particularly systolic BP, has been linked to multiple adverse clinical outcomes including stroke, heart failure, myocardial infarction, renal insufficiency/failure, peripheral vascular disease, retinopathy, dementia, and premature mortality. These undesirable clinical outcomes are typically, although not invariably, preceded by pressure-related target-organ injury such as left ventricular hypertrophy, renal insufficiency and proteinuria. The relation of BP and CKD and, in turn, the prevention of CKD or forestalling its progression by hypertension treatment, will be the focus of this manuscript. In hypertensive persons with reduced kidney function and/or proteinuria, lowering BP with multidrug therapy that is inclusive of pharmacologic modulators of the renin-angiotensin-aldosterone-kinin system is an effective strategy to forestall the progressive loss of kidney function. The totality of data support low therapeutic BP targets for persons with proteinuria >1 g/d. Nevertheless, in persons with CKD, even those with proteinuria below the dipstick positive level (approximately 300 mg/d or urine protein to creatinine ratio of 0.22), aggressive BP control also may be warranted because of the high risk of nonrenal cardiovascular disease. Multiple antihypertensive drugs will be required in the vast majority of patients with diabetes and/or reduced kidney function to attain BP goal. Renin-angiotensin system (RAS) modulator therapy is indicated among persons with diabetes mellitus and CKD. Available data support the use of angiotensin receptor blockers in persons with type 2 diabetes and overt nephropathy for preservation of kidney function. Among persons with type I diabetes with or without overt nephropathy, type 2 diabetes without overt nephropathy and in nondiabetic CKD, the available clinical data support the use of angiotensin-converting enzyme inhibitors as the RAS modulator of choice. Low therapeutic target BP levels <130/80 mmHg in persons with type 2 diabetes mellitus also appear warranted based on available data mostly for reducing the risk of nonrenal cardiovascular disease and overall mortality.

Hypertension control with angiotensin II receptor blockers: strategies utilizing titration and combination

Recommended BP goals must be achieved to provide hypertensive patients with maximal protection from CV disease. Less than one third of hypertensive patients achieve goal BP, and so remain at significant risk for CV disease. Angiotensin II receptor blockers (ARBs) provide antihypertensive efficacy similar to that of other antihypertensive classes, but have better patient acceptance. In integrated analyses of controlled clinical trials, olmesartan medoxomil, the newest ARB, demonstrated 24-h BP control with dose-related efficacy and a tolerability profile similar to that of placebo. Titration from the starting 20-mg/d dose to the maximum 40-mg/d dose resulted in an incremental reduction in BP of 5.7/4.7 mm Hg, with no increase in adverse events. In head-to-head comparative trials, olmesartan medoxomil has been shown to provide antihypertensive efficacy equal to that of amlodipine besylate and atenolol, and to compare favorably with other leading ARBs. Olmesartan medoxomil was also studied in combination with hydrochlorothiazide (HCTZ), resulting in placebo-subtracted BP reductions of up to 24/14 mm Hg. A 24-wk study assessed BP control rates achieved with an olmesartan medoxomil-based treatment algorithm. Patients were initiated on olmesartan medoxomil 20 mg once daily. At subsequent 4-wk intervals, treatment was modified for subjects with BP >130/85 mm Hg: olmesartan medoxomil could be titrated to 40 mg/d; HCTZ (12.5-25 mg) could be added; and, finally, amlodipine (5-10 mg) could be added. Utilizing this algorithm, >90% of patients achieved a BP goal of ≤140/90 mm Hg, and approximately 88% achieved a more aggressive goal of ≤130/85 mm Hg. Reductions in mean systolic and diastolic BP were 33.7 mm Hg and 18.2 mm Hg, respectively. The development and use of such drug algorithms may be an important contribution to improving BP control.

BP results from the SPS3 pilot study

Small Sub-cortical Strokes (S3) comprise about 27% of brain infarctions and are present in 20% of patients >65 years; 150,000 symptomatic S3 occur each year. They are the commonest cause of vascular dementia and 80% of patients also have hypertension. It is not known what the optimal BP target is, to prevent recurrence of S3. SPS3 is a new 5-year NIH-funded study to determine whether SBP should be treated to 130–149mmHg, or to <130mmHg, and whether aspirin should be given alone, or with clopidogrel to prevent S3 recurrence and vascular dementia. We here describe the results, in a pilot study, of BP titration, in 66 symptomatic S3 patients, over up to 18 months, to these goal BP’s. JNCVI guidelines were generally followed. Mean age was 58y, 53% were male, mean time from stroke to study entry was 109 days, entry BP averaged 160/87mmHg on an average of 1.6 BP meds. Medication compliance was excellent in 41 and 34% (goal 130–149mmHg and <130mmHg respectively), good in 41 and 44% and poor in 15 and 19%, at the final visit. Adverse effects were seen in 65 and 50% but were generally very mild prompting medication change in 3% of each group. Median blood pressures were 141/75 and 129/70mmHg at the most recent visit, both within target. 24hr BP monitoring was done in 33pts: 6 increased nocturnal BP by 1–10%, 16 dipped by 0–9%, 1 by 10–20% and 1 by > 20%. This Pilot study shows we can, using a “Hypertension Expert”, control BP at widely separated target levels in these hard-to-treat patients who have shown, by having an S3, their poor prior BP control.

Predictors of one year blood pressure control and treatment resistance in the value trial

The Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) Trial is testing the hypothesis that for the same level of BP control, the AT1-receptor blocker valsartan reduces serious cardiac events by 15% compared to the CCB amlodipine. VALUE is a double-blind, randomized, in 31 countries, prospective trial of 15314 previously treated (92%) or untreated hypertensives, 42.4% women, mean age 67.2 yrs, BMI 28.6 kg/m2, coronary heart disease (CHD) in 45.8%, high cholesterol in 32.9%, type-2 diabetes mellitus (DM) in 31.7% and 24.0% smokers. The primary endpoint is expected in 1450 pts. in 2-3 yrs. The aim of this analysis is to identify predictors of 1-year BP control and resistance to treatment in the VALUE population. BP decreased from 154.7/87.6 at randomization to 141.3/80.9 mmHg at 12 months and control rate <140/90 mmHg improved from 21.4 to 54.6%. Responsive (n=4328) achieved goal BP on monotherapy and resistant (n=1091) remained >160 and/or >100 mmHg at the highest drug titration step (step 5). Characteristics are shown in the accompanying table. The odds of being controlled were up 23% in pts. with controlled SBP at baseline, decreased by 3% per mmHg rise in baseline pulse pressure (PP) and 2% per year of age, were 23% less in DM, 25% higher in USA, 85% higher in Asians, 25% higher in CHD and 34% higher in smokers. In the “best” model, pts. not in USA (RR 1.58, p<0.0001), Oriental (RR 0.49, p<0.0004) and PP (3% per mmHg rise, RR 1.03, p<0.0001) predicted resistance. Thus, overall the 1-year blood pressure control in VALUE is comparable to the best previously reported in large hypertension outcome trials. Geographical origin and pulse pressure at baseline most strongly predicted resistance to drug therapy.

Focus: Hypertension in the Aged Population

The treatment of the elderly hypertensive patients has reduced the incidence of strokes, cardiovascular events, and cardiovascular morbidity. Regrettably, few hypertensive patients over 80 years of age are being treated, and those who are, are not being treated effectively. Hypertension, at any age, should be treated with a goal of BP <140/90 mmHg, as set by the Joint National Committee on Hypertension. This message should be spread throughout the medical community.

Goal BP in hospital located hypertension units

BP<140/90 mm Hg is considered a good control in treated essential hypertensives (EH). However in EH with a higher risk a lower level of BP (<130/85) should be achieved. The aim of this study was to investigate both the baseline cardiovascular risk, assessed according the WHO/ISH 99 criteria,and the level of BP control (mercury sphygmomanometer and OMRON 705 CP) after the first year of follow-up,in 3527 EH hypertensives (age 58.6 y, BMI 29.5 kg/m2; 50.6% males) followed in 47 HU in Spain. At baseline 2755 (78.2%) EH had high or very high risk, 1174 (33.2%) with > 3 associated risk factors, TOD and/or diabetes, and 1507 (42.1%) with associated cardiovascular complications, and only 772 EH (21.8%) presented with low and medium risk. A conventional goal BP (<140/90) was attained in 1481 EH (42.1%). However, a more estrict control (BP<130/85) was attained only in 496 (18.5%) out of those needing that goal according the guidelines. Results were similar with either method of BP determination. In the hospital located HU most of the patients presented with high or very high cardiovascular risk and their goal BP should be < 130/85 mmHg. With this criteria BP control in HU is as poor as that seen in population based studies.

Lower BP goal preferable for hypertension in diabetes

Lower BP goal preferable for hypertension in diabetes

Antihypertensive drug therapy in the third millennium: are there benefits beyond blood pressure?

The classic outcome trials in hypertension, most of which used diuretics and b-blocking agents as first-line antihypertensive agents, have shown that antihypertensive drug treatment greatly reduces the risk of stroke, heart failure, and left ventricular hypertrophy (LVH). However, it is less successful in preventing fatal and nonfatal coronary heart disease (CHD) [1]. In the Framingham Heart Study, increased rates of use of antihypertensive medications, from 2.3% to 24.6% among men and from 5.7% to 27.7% among women, were associated with reduced prevalence of hypertension (blood pressure [BP]>160/100 mm Hg). Reductions were from 18.5% to 9.2% among men and from 28.0% to 7.7% among women. The prevalence of electrocardiographic evidence of LVH, an index of target organ damage, was reduced from 4.5% to 2.5% among men and from 3.6% to 1.1% among women. These findings suggest that the increasing use of antihypertensive medication may in part explain the major decline in mortality from cardiovascular disease observed in the United States since the late 1960s. Yet, despite these effective treatments, many important questions remain, some of which have been addressed by recently completed and ongoing clinical trials: • Are the newer classes of drugs, such as the calciumchannel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin-II type-1 receptor blockers (ARBs), or a-adrenergic blockers (ABs) superior to diuretics or b-blockers in preventing cardiovascular disease and events? • Do specific classes of antihypertensive drugs, over and above their blood pressure–lowering effects, benefit specific subgroups of hypertensive patients? • What is the appropriate BP goal in various patient groups? • Are specific antihypertensive drugs indicated in special groups of patients, such as the very elderly (>80 years), normotensive persons at high cardiovascular risk, patients with type 2 diabetes, patients with stage 1 hypertension, or hypertensive patients of African-American extraction?

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 …

Detection, treatment, and control of adult hypertension in Northwest Indiana

Recent data from the third National Health and Nutrition Examination Survey (NHANES-IIIB) suggest that detection and treatment of hypertension is improving, but only 27.4% of American hypertensives achieved controlled blood pressure ([BP] < 140 and < 90 mm Hg). Our objective was to assess the degree of BP control in a group of steelworkers and their families whose health care is financed by a large corporation. A random sample of 792 adults (age > 18 years, average 55 ± 1 years, 50.4% male) was selected from a roster of patients who were known (from claims data) to have visited a physician in 1995 to 1996. Office charts were reviewed by trained nurses, who abstracted dates of 4095 visits, 3352 BP readings, and 3331 prescribed medications. Filled prescriptions were identified from 54,689 claims submitted for pharmacy services. Hypertension, defined (per NHANES) as more than one BP reading of 140/90 or higher, or taking antihypertensive medication, was found in 437 (55%). At least one antihypertensive medication was prescribed for 386 (88%) of the hypertensives; only 10 failed to have any prescription for antihypertensive medications filled. Controlled hypertension, as defined by Healthcare Employer Data Information Sheet (HEDIS) 3.0 (average BP < 140 and < 90 mm Hg in the office during a yearlong period of observation), was observed in 189 patients (43% of total sample, or 50% of the 382 with at least one recorded BP measurement). These data suggest that in this population, insured by a jointly run employer-union health benefits plan, Healthy People 2000’s BP goal—at least 50% of hypertensives having BP under control by the turn of the century—may be achieved ahead of schedule.

Doxazosin GITS Compared with Doxazosin Standard and Placebo in Patients with Mild Hypertension

Doxazosin, an effective treatment for mild-to-moderate hypertension and benign prostatic hyperplasia, in its standard formulation requires a multiple-step titration regimen to minimize the potential for first-dose effects. A new controlled-release gastrointestinal therapeutic system (GITS) formulation of doxazosin was developed to enhance the pharmacokinetic profile, significantly reducing serum peak-to-trough ratios, thereby minimizing the need for titration. We assessed the efficacy and tolerability of doxazosin GITS compared with doxazosin standard and placebo in a prospective, randomized, double-blind, parallel-group, dose-titration, multicenter study of 392 patients with mild hypertension (blood pressure [BP] < or = 180/95-105 mmHg). Patients were randomized to doxazosin GITS, doxazosin standard, or placebo in 2:2:1 manner. The primary outcome measure was the proportion of patients in the per-protocol analysis (PPA) who achieved goal BP response (sitting BP < or = 90 mmg or 10 mmHg decrease from baseline at 24 h postdose at the final evaluable visit). Goal BP response in the intention-to-treat (ITT) population and prespecified BP and/or heart rate changes in the PPA and/or ITT population were also analyzed. Tolerability was assessed throughout the study. Doxazosin GITS and doxazosin standard produced comparable goal BP responses superior to that of placebo, with 92 of 156 patients (59.0%) on doxazosin GITS and 86 of 152 patients (56.6%) on doxazosin standard in the PPA population achieving goal BP response 24 hours postdose on the final visit, compared with 25 of 70 patients (35.7%) on placebo. Both active treatments produced mean significant BP reductions compared with baseline and placebo (p < 0.001). The most commonly reported side effects were headache, dizziness, and asthenia. No syncope was reported in the doxazosin GITS group; two cases were observed in the doxazosin standard group and one case in the placebo group. Doxazosin GITS was well tolerated and as effective as doxazosin standard in patients with mild hypertension, producing well-tolerated, comparable BP reductions with minimal need for titration. Both active treatments were clinically and statistically superior to placebo.

Guidelines on treatment of hypertension in the elderly, 1995--a tentative plan for comprehensive research projects on aging and health-- Members of the Research Group for "Guidelines on Treatment of Hypertension in the Elderly", Comprehensive Research Projects on Aging and Health, the Ministry of Health and Welfare of Japan

We propose the following guidelines for treatment of hypertension in the elderly. 1. Indications for Treatment. 1) Age: Lifestyle modification is recommended for patients aged 85 years and older. Antihypertensive therapy should be limited to patients in whom the merit of the treatment is obvious. 2) Blood pressure: Systolic BP > 160 mmHg, diastolic BP > 90 approximately 10 mmHg. Systolic BP < age + 100 mmHg for those aged 70 years and older. Patients with mild hypertension (140-160/ 90-95 mmHg) associated with cardiovascular disease should be considered for antihypertensive drug therapy. 2. Goal of Therapy for BP: The goal BP in elderly patients is higher than that in younger patients (BP reduction of 10-20 mmHg for systolic BP and 5-10 mmHg for diastolic BP). In general, 140-160/< 90 mmHg is recommended as the goal. However, lowering the BP below 150/85 should be done with caution. 3. Rate of Lowering BP: Start with half the usual dose, observe at the same dose for at least four weeks, and reach the target BP over two months. Increasing the dose of antihypertensive drugs should be done very slowly. 4. Lifestyle Modification: 1) Dietary modification: (1) Reduction of sodium intake is highly effective in elderly patients due to their high salt-sensitivity. NaCl intake of less than 10 g/day is recommended. Serum Na+ should be occasionally measured. (2) Potassium supplementation is recommended, but with caution in patients with renal insufficiency. (3) Sufficient intake of calcium and magnesium is recommended. (4) Reduce saturated fatty acids. Intake of fish is recommended. (2) Regular physical activity: Recommended exercise for patients aged 60 years and older: peak heart rate 110/minute, for 30-40 minutes a day, 3-5 days a week. (3) Weight reduction. (4) Moderation of alcohol intake, smoking cessation. 5. Pharmacologic Treatment: 1) Initial drug therapy. First choice: Long-acting (once or twice a day) Ca antagonists or ACE inhibitors. Second choice: Thiazide diuretics (combined with potassium-sparing diuretic). 2) Combination therapy. (1) For patients without complications, either of the following is recommended. i) Ca antagoinst + ACE inhibitor, ii) ACE inhibitor + Ca antagonist (or low-dose diuretics), iii) diuretic + Ca antagonist (or ACE inhibitor), iv) beta-blockers, alpha 1-blockers, alpha + beta blockers can be used according to the patho-physiological state of the patient. (2) For patients with complications. Drug(s) should be selected according to each complication. 3) Relatively contraindicated drugs. beta-Blockers and alpha 1-blockers are relatively contraindicated in elderly patients with hypertension in Japan. Centrally acting agents such as reserpine, methyldopa and clonidine are also relatively contraindicated beta-Blockers are contraindicated in patients with congestive heart failure, arteriosclerosis obliterans, chronic obstructive pulmonary disease, diabetes mellitus (or glucose intolerance), or bradycardia. These conditions are often present in elderly subjects. Elderly subjects are susceptible to alpha 1-blocker-induced orthostatic hypotension, since their baroreceptor reflex is diminished. Orthostatic hypotension may cause falls and bone fractures in the elderly.

Antihypertensive efficacy and tolerability of different drug regimens in isolated systolic hypertension in the elderly

The pharmacological treatment, mainly based on diuretics, of isolated systolic hypertension (ISH) has recently been shown to reduce the risk of stroke and coronary heart disease in the elderly. The purpose of this study was to compare the antihypertensive effect and tolerability of different drug regimens in elderly subjects with ISH (systolic blood pressure--SBP-- > or = 160 mmHg and diastolic blood pressure--DBP-- < 90 mmHg). A multicentre, randomized, controlled open trial was planned in the general practice setting. Four widely used treatment schedules were tested: hydrochlorothiazide 25 mg plus amiloride 2.5 mg (H+Am), nifedipine slow release 20 mg (N), atenolol 50 mg (At) and atenolol 25 mg plus chlorthalidone 6.25 mg (At+C). After a baseline evaluation, 308 patients (76.3% female, mean age 75.3 +/- 7.1 years) were randomized and followed up for 6 months. After 3 months the drug dosage was doubled if the systolic blood pressure goal (SBP < 160 mmHg and SBP reduction of at least 20 mmHg) had not been reached. Ninety-four subjects (30.5%) presented contraindications to beta-blockers. At the 3rd- and 6th-month visits all treatment groups, except At, showed a significant reduction in SBP compared to the control group; DBP showed no significant reduction in any group at any time. At the end of the follow-up the percentage of hypertensives who had reached the BP goal was 14.6% in the control group, 52.9% in H+Am, 54.8% in N, 28.6% in At and 52.2% in At+C.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolated Systolic Hypertension: New Answers, More Questions

Isolated Systolic Hypertension: New Answers, More Questions

Treatment of Mild-to-Moderate Hypertension

In a multicenter study, 61 patients, 18-70 years of age, with mild-to-moderate hypertension [diastolic blood pressure (DBP) 95/114] completed a 28-week treatment. After initial placebo washout, patients were randomly allocated either to diltiazem or hydrochlorothiazide/triamterene. At the end of 12 weeks, the patients continued on the same medication if their goal blood pressure achieved (DBP less than 90; or 10 mm Hg below baseline). If not, the alternate agent was added (either diltiazem + hydrochlorothiazide/triamterene or hydrochlorothiazide/triamterene + diltiazem). At the end of 28 weeks, the intent-to-treat analysis showed that 90% on diltiazem alone, 73.7% on hydrochlorothiazide/triamterene alone, 71.4% on (diltiazem + hydrochlorothiazide/triamterene), and 57.1% on (hydrochlorothiazide/triamterene + diltiazem) achieved goal BP. End point mean values of BP and heart rate after adjusting for sex, baseline values, age, and weight showed no significant difference between groups. Forty-six percent on hydrochlorothiazide/triamterene alone and 24% on diltiazem alone reported one or more adverse events, possibly related to study medication. Patients with diltiazem as the first choice had better BP control than those on hydrochlorothiazide/triamterene alone (81.5% vs. 69.7%). Furthermore, among non-goal achievers at week 12, there was a greater response in the group when hydrochlorothiazide/triamterene was added to diltiazem than when diltiazem was added to hydrochlorothiazide/triamterene. This study suggests that in mild-to-moderate hypertension, diltiazem is better than hydrochlorothiazide/triamterene as first line therapy.

Assessment of intravenous fenoldopam mesylate in the management of severe systemic hypertension

To evaluate the acute BP response to iv fenoldopam mesylate (FNP), 14 patients with severe hypertension (diastolic BP 120 to 170 mm Hg) were studied in an open-label trial. Initial infusion rate of FNP was 0.1 microgram/kg.min. Titration to diastolic BP goal (95 to 110 mm Hg) was followed by a constant infusion phase (greater than or equal to 6 h), a detitration phase (2 h), and a postinfusion phase. FNP reduced BP by 27/29 mm Hg (p less than .001) with no significant effect on heart rate. Maintenance of the BP effect was noted through the 6 h of constant rate infusion. Mild, transient vasodilating-associated adverse effects were noted with FNP. We conclude that FNP is an effective, well-tolerated iv antihypertensive agent for acute BP reduction in a severely hypertensive population.

Is there a lower limit of goal BP?

Is there a lower limit of goal BP?