Hypertension Experts Research Articles

Pulmonary Arterial Hypertension: Diagnostic Considerations

[Editor's note: Editor-in-Chief Victor Tapson, MD, interviewed a select panel of experts in pulmonary hypertension to obtain their review and comments on the new evidence-based clinical practice guidelines of the American College of Chest Physicians. Please see the Editor's Memo for more information.]

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

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.

Unsolved problems in treating hypertension: Rationale for new approaches

Two major problems continue to challenge hypertension experts and clinical practitioners. The first is the apparently simple issue of controlling blood pressure; only one-quarter of hypertensive patients in the United States have blood pressures reduced to less than 140/90 mm Hg. Even those known to be receiving treatment have barely a 50% success rate. Explanations include inadequate commitments by physicians to achieve target blood pressures, but it is also likely that effectively decreasing blood pressure—despite the currently available panoply of antihypertensive agents—is a truly difficult task. The second problem is that despite our success in decreasing stroke incidence, hypertension treatment with traditional agents, largely diuretic-based, has not adequately protected patients against coronary events and renal insufficiency. Such new drug classes as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, and calcium channel blockers exhibit vascular effects that might inhibit atherosclerotic changes and reduce clinical events, but we are still awaiting definitive confirmation of these properties from ongoing clinical outcomes studies in hypertension. Therapy with fixed combinations of antihypertensive drugs is now recognized as a potentially useful approach. Innovative combinations, including ACE inhibitors and calcium channel blockers, can provide enhanced antihypertensive efficacy while avoiding or minimizing adverse metabolic and clinical side effects. These approaches are also convenient and cost-effective. It remains to be learned whether newer drug combinations might exhibit additive cardiovascular protective actions.

Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: A Working Group Report from the National High Blood Pressure Education Program

Background. The "Report of the Second Task Force on Blood Pressure Control in Children—1987" developed normative blood pressure (BP) data for children and adolescents. These normative data are used to classify BP levels. Since 1987, additional BP data in children and adolescents, the use of newer classes of drugs, and the role of primary prevention of hypertension have expanded the body of knowledge regarding the classification and treatment of hypertension in the young. Objective. To report new normative BP data in children and adolescents and to provide additional information regarding the diagnosis, treatment, and prevention of hypertension in children. Methods. A working group was appointed by the director of the National Heart, Lung, and Blood Institute as chair of the National High Blood Pressure Education Program (NHBPEP) Coordinating Committee. Data on children from the 1988 through 1991 National Health and Nutrition Examination Survey III and nine additional national data sets were combined to develop normative BP tables. The working group members produced initial draft documents that were reviewed by NHBPEP Coordinating Committee representatives as well as experts in pediatrics, cardiology, and hypertension. This reiterative process occurred for 12 draft documents. The NHBPEP Coordinating Committee discussed the report, and additional comments were received. Differences of opinion were adjudicated by the chair of the working group. The final report was sent to representatives of the 44 organizations on the NHBPEP Coordinating Committee for vote. It was approved unanimously by the NHBPEP Coordinating Committee on October 2, 1995. Conclusions. This report provides new normative BP tables for children and adolescents, which now include height percentiles, age, and gender. The fifth Korotkoff sound is now used to define diastolic BP in children and adolescents. New charts have been developed to guide practicing clinicians in antihypertensive drug therapy selection. The primary prevention of hypertension in these age groups is discussed. A statement on public health considerations in the treatment of children and adolescents is provided.

Antihypertensive therapy

Investigators of hypertension can be proud of the indisputable successes achieved by antihypertensive therapy and of the correct methodology (randomized controlled trials) by which those successes have been proved. However, hypertension experts should not allow pride to turn into prejudice. Numerous aspects of antihypertensive treatment remain to be clarified. Indeed, that all goals of antihypertensive treatment have been achieved is clear prejudice. Although randomized trials have been essential for establishing the benefits of antihypertensive therapy, claiming that randomized trials are the only valid methodology for providing treatment benefits is another instance in which pride might turn into prejudice. Indeed, there is a large gap between trials and practice, and trials may both overestimate and underestimate the benefits of treatment. Furthermore, event-based trials are not the only valid type of trials, as is often claimed. If the goals of treatment are both to prevent events and avoid or reduce organ damage, then we need both event-based and organ damage-based types of trials. MEASUREMENTS OF SUCCESS: Assessment of the absolute risk and, consequently, calculation of the absolute benefit to be expected from treatment have appropriately been emphasized in recent guidelines for the management of hypertension as instruments to evaluate cost-effectiveness of treatment. However, there is reason for caution against an indiscriminate worship of this concept, because earlier treatment of milder, uncomplicated hypertension is an effective measure by which to prevent development of more severe and complicated hypertension, the treatment of which may be less successful, if success is measured by the residual mortality and morbidity of even well treated patients. BLOOD PRESSURE MEASUREMENTS: Finally, we are still ignorant of the best way to measure blood pressure in order to decide upon initiation and success of treatment. Supporters both of clinic blood pressure measurements and of home or ambulatory blood pressure monitoring have their own prejudices; the problem can only be solved by further research. As in Jane Austen's novel, before the happy end both pride and prejudice must be conquered.

Guidelines for the treatment of hypertension: an American view

REPORT OF FIFTH JOINT NATIONAL COMMITTEE: The 1993 report of the Fifth Joint National Committee presents the position of most United States hypertension experts. CRITICISMS: Sharp criticisms have been voiced on two of the major points of the fifth report of the Joint National Committee, the threshold for therapy and the choice of initial therapy. In addition, there is continued uncertainty about the appropriate goal for therapy.

Textbook of Hypertension

Ed J D Swales Blackwell Scientific, £129.50, pp 1328 ISBN 0 632 03527 7 The second edition of Sir George Pickering's singole author treatise, High Blood Pressure, published in 1968, comprised 717 pages including approximately 1760 references. Such have been the pace and breadth of research in hypertension over the past 25 years that in this first edition of Textbook of Hypertension John Swales has enlisted the help of 84 international experts in hypertension to contribute over 1300 pages and 10000 references, many from 1994. In an age when it is increasingly difficult to keep abreast of advances in a single disease, let alone a whole specialty, this authoritative text will be welcomed by researchers and …

Modern Strategies to Prevent Coronary Sequelae and Stroke in Hypertensive Patients Differ From the JNC V Consensus Guidelines

In recent years, government agencies of many countries have established consensus guidelines for the evaluation and treatment of hypertension. Once published, guidelines tend to be perceived as directives by a variety of health care providers. Unfortunately, these guidelines often do not reflect the practices of most hypertension experts. This report summarizes the opinions of seven hypertension experts concerning the impact of "official" guidelines on clinical practice. In addition, the individual therapeutic recommendations of these panel members are summarized. Their different treatment strategies reflect the diversity of first rate treatment plans that aim to reduce the cardiovascular sequelae in individual patients with essential hypertension. Most importantly, not one of these seven treatment strategies followed the "preferred" treatment of the U.S. guidelines, which recommend diuretics and beta-blockers as first-line therapy. The present authors approach the treatment of hypertension as a means to reduce cardiovascular events. Thus, reduction of blood pressure is not the most important therapeutic endpoint. The panel believes that whereas many different drugs can produce effective blood pressure reduction, the modern primary goal of antihypertensive drug therapy is to select a regimen most likely to prolong the quality and duration of life. In real terms, this means that the primary goal of treatment is the prevention of the major vascular sequelae of hypertension (heart attack, ventricular remodeling, hypertrophy, heart failure, and stroke) that shorten useful life. There are a number of effective hypertensive treatments, which can be selected based on individual patient requirements. However, many consensus guidelines do not allow the flexibility required to optimize individual patient treatment. As a result, health care providers should not feel compelled to regard the preferences of "official" guidelines as the best, modern, state-of-the-art therapy for an individual patient. All seven experts who are deeply involved in the daily care of patients preferred drugs other than beta-blockers and diuretics (the Joint National Committee [JNC] choices) for first-line therapy of hypertension.

African Lineage, Hypertension Linked

NO TEARS were shed by members of the Council for High Blood Pressure Research as hypertension experts reported new findings about salt and water in the human body at this year's fall conference in Chicago, Ill. Many expressed their "excitement" about the possibility of finding evidence for the etiology of hypertension directly in men and women, rather than being limited to extrapolating from studies on rats that may or may not be totally applicable. Clarence E. Grim, MD, director of the Hypertension Research Center at the Charles R. Drew University of Medicine and Science, Los Angeles, Calif (a facility affiliated with the UCLA School of Medicine), used mitochondrial DNA analysis to extend an ongoing study of high blood pressure among blacks in the western hemisphere. <h3>Unusual in Africa</h3> Among present-day Africans living on their own continent, hypertension is unusual. Grim says a study he conducted in a Nigerian village revealed

African lineage, hypertension linked

NO TEARS were shed by members of the Council for High Blood Pressure Research as hypertension experts reported new findings about salt and water in the human body at this year's fall conference in Chicago, Ill. Many expressed their "excitement" about the possibility of finding evidence for the etiology of hypertension directly in men and women, rather than being limited to extrapolating from studies on rats that may or may not be totally applicable. Clarence E. Grim, MD, director of the Hypertension Research Center at the Charles R. Drew University of Medicine and Science, Los Angeles, Calif (a facility affiliated with the UCLA School of Medicine), used mitochondrial DNA analysis to extend an ongoing study of high blood pressure among blacks in the western hemisphere. <h3>Unusual in Africa</h3> Among present-day Africans living on their own continent, hypertension is unusual. Grim says a study he conducted in a Nigerian village revealed

What goes up must come down, but hypertension experts worldwide differ about ways, means

What goes up must come down, but hypertension experts worldwide differ about ways, means

Predictive values of routine blood pressure measurements in screening for hypertension.

There presently is no consensus regarding criteria for hypertension screening or case finding. Blood pressure variability results in differential ascertainment, depending upon the number of screening visits, the number of measurements per visit, and the method used in reducing the data obtained to an underlying measure of blood pressure status. To develop screening rules, the authors have computed the predictive values of blood pressure measurements for particular age-, race-, and sex-specific groups. Predictive value computations require estimates of between- and within-visit variability and of prevalence. Estimates of variability were calculated from data obtained at a worksite or a community blood pressure program from 991 persons, aged 30-69 years and not currently on antihypertensive medications, who were screened over two to five visits, one week apart. Estimates of prevalence were obtained from the screening of 158,955 adults by the Hypertension Detection and Follow-Up Program. Predictive values are presented for particular age-, race-, and sex-specific groups over a wide range of diastolic blood pressures, and are used to identify appropriate screening rules that minimize misclassification with the fewest possible blood pressure measurements. The results of a questionnaire sent to 30 hypertension experts indicated that the median acceptable predictive values for making screening decisions were 80% for predictive value positive and 77.5% for predictive value negative. When these criteria were adopted, 81%, 90%, and 93% of the subgroup of 901 persons with at least three visits from the above screened population were identified as having or not having true diastolic blood pressure greater than or equal to 90 mmHg after one, two, and three visits, respectively. The status of the remaining 7% remained uncertain after three visits.

Therapy for Mild Hypertension

PUBLICATION in this journal of the results of the Multiple Risk Factor Intervention Trial (MRFIT)¹should bring about a reassessment of the current widespread and routine use of drug treatment for most people with mild hypertension, defined as a diastolic BP between 90 and 104 mm Hg. Such patients make up about 75% of the hypertensive population, a total of at least 30 million Americans. Most American practitioners are now responding to the admonishments of hypertension experts and pharmaceutical advertisements that the "HDFP (Hypertension Detection and Follow-up Program) findings justify early and aggressive management of mild hypertension." Even before the HDFP²or any other data in support of the value of such therapy for mild hypertension were available, 92% of the physicians in New York State who responded to a questionnaire indicated they routinely gave antihypertensive drug therapy to patients with diastolic BPs between 90 and 104 mm

Therapy for mild hypertension. Toward a more balanced view

PUBLICATION in this journal of the results of the Multiple Risk Factor Intervention Trial (MRFIT)¹should bring about a reassessment of the current widespread and routine use of drug treatment for most people with mild hypertension, defined as a diastolic BP between 90 and 104 mm Hg. Such patients make up about 75% of the hypertensive population, a total of at least 30 million Americans. Most American practitioners are now responding to the admonishments of hypertension experts and pharmaceutical advertisements that the "HDFP (Hypertension Detection and Follow-up Program) findings justify early and aggressive management of mild hypertension." Even before the HDFP²or any other data in support of the value of such therapy for mild hypertension were available, 92% of the physicians in New York State who responded to a questionnaire indicated they routinely gave antihypertensive drug therapy to patients with diastolic BPs between 90 and 104 mm

Antihypertensive Medication in the Elderly

To the Editor.— The article by Ray Gifford, Jr, MD, Isolated Systolic Hypertension in the Elderly: Some Controversial Issues (1982;247:781) describes various aspects of systolic hypertension in sufficient detail, but contains unrealistically simple conclusions, particularly with reference to the therapy. Few would agree with Dr Gifford's assertion that it is a misconception that elderly patients are not able to tolerate antihypertensive medication. Indeed, many physicians would attest that the opposite is true. It is less difficult to talk and write about hypertension in the elderly, but in the real world, clinical circumstances and experiences are a different story. Many hypertension experts would no doubt agree on the potential harm of systolic hypertension and the possible benefits of therapy, but, as Dr Gifford points out, we do not know what the goal should be when the treatment is planned. Both methyldopa and clonidine hydrochloride, particularly the latter drug, can cause