Mm Hg In Most Patients Research Articles

Individualization of hypertension treatment: an expert review

Management of hypertension is complex in patients with comorbid conditions and in those who are at high cardiovascular risk. Multiple guidelines recommend different treatment goals and therapeutic approaches for hypertension. In this review, we take an individualized management approach for hypertension with comorbidities mainly diabetes and chronic kidney disease (CKD), coronary artery disease, and for young patients and the elderly. Current evidence indicates a blood pressure goal of <130/80 mmHg for most patients with comorbidities except for the elderly aged >75 years in whom systolic pressure of 130-139 mmHg and diastolic pressure of 70-80 mmHg may be considered. For patients with diabetes and CKD, renin angiotensin aldosterone system (RAAS) inhibitors remain the initial choice of agents whereas in the young or elderly, any class including RAAS inhibitors, calcium channel blockers, and thiazide diuretics may be preferred. Special consideration is necessary for the elderly concerning the possible side effects of each drug class. In the presence of additional risk factors, an individualized approach is necessary to tailor the most effective therapy as per patient needs. Thus, in treating hypertension, a multipronged but individualized approach is necessary to optimize blood pressure control and clinical outcomes in the real-world setting.

A Novel Method for Estimating Right Atrial Pressure With Point-of-Care Ultrasound

Current noninvasive estimation of right atrial pressure (RAP) by either bedside jugular venous pressure exam or inferior vena cava measurement during a comprehensive echocardiogram offers imprecise estimates of actual RAP. We enrolled 41 patients in a prospective, blinded study to validate a novel point-of-care ultrasound method using direct right atrial depth (RAD) measurement and jugular venous ultrasound to estimate RAP. Two subjects were excluded, and 39 were included in the final analysis. A parasternal long-axis view was obtained, and the depth of the noncoronary cusp attachment to the posterior left ventricular outflow tract was recorded as the RAD. This was added to an estimate of the jugular venous pressure obtained during a jugular vein ultrasound to calculate an estimated RAP (RAPUS). The RAPUS was compared to the RAP measurement during right heart catheterization (RAPcath) both as measured and as corrected for where the catheter was zeroed. The correlation coefficient between RAPcath and RAPUS was+0.75; regression R2, 0.56; and bias, -0.49mm Hg (95% CI, -1.42 to+0.43mm Hg), with the limits of agreement -5.56 to+7.24mm Hg and accuracy of 3mm Hg or less in 29 (74%) of the subjects. For the RAPUS corrected for the catheter zero point, the correlation coefficient between RAPcath and RAPUS was+0.72; regression R2, 0.52; and bias, -0.60mm Hg (95% CI, -1.60 to+0.39mm Hg), with the limits of agreement -5.56 to+7.24mm Hg and accuracy of 3mm Hg or less in 26 (67%) of the subjects. This simple ultrasound evaluation of RAD and the right jugular vein correlates well with actual RAP and can accurately estimate RAP within 3mm Hg in most patients. This has the potential to improve our bedside volume status exam, as well as improve the accuracy of RAP estimation during comprehensive echocardiogram.

Starting Antihypertensive Drug Treatment With Combination Therapy

Starting Antihypertensive Drug Treatment With Combination Therapy

A Prospective Noninterventional, Observational Study to Describe the Effectiveness and Safety of Trandolapril and Verapamil Single-Pill Combination in the Management of Patients with Hypertension and Type 2 Diabetes Mellitus: A Harvest TR Study

Maintaining regular blood pressure control usually requires multidrug regimens rather than monotherapy. The objective of this study was to describe the effectiveness and safety of an angiotensin-converting enzyme inhibitor and a nondihydropyridine calcium channel blocker in a single-tablet combination in patients with hypertension, a heart rate higher than 70 beats/min, and type 2 diabetes mellitus (T2DM). This study was conducted in Turkey as a prospective, noninterventional, observational study. At 22 clinical sites, the data of 200 patients with hypertension were used for efficacy analysis; however, 262 patients received at least one dose of trandolapril/verapamil fixed-dose combination at two dose strengths. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate, PR interval, glycated haemoglobin (HbA1c), and albumin/creatinine ratios were recorded during 8 weeks of treatment. With treatment, the mean (±SD) SBP that was recorded as 162.8 (±14.642) mm Hg at baseline was reduced to 131.7 ± 11.1 mm Hg at week 8 (p < 0.05). Similarly, the mean DBP was reduced from 93.76 ± 9.16 mm Hg to 77.6 ± 7.6 mm Hg (p < 0.001). Following 8 weeks of treatment, SBP and DBP values were reduced below 140 mm Hg and 90 mm Hg in most patients (81.5%), respectively. The mean heart rate as evaluated using electrocardiography measurements was reduced to 78.25 beats/min at week 8 as compared with baseline during trandolapril/verapamil single-pill combination treatment (p < 0.001). Treatment with trandolapril and verapamil was well tolerated over 8 weeks with no unexpected safety signals. In conclusion, the single-pill combination of trandolapril and verapamil was considered effective in reducing and controlling blood pressure in patients with hypertension and T2DM. There was a significant improvement in HbA1c and ACR levels in a smaller subgroup of the patient cohort. The trandolapril/verapamil combination was evaluated as being safe and well-tolerated following a treatment period of 8 weeks. This trial was registered with NCT02298556.

Aortic Aneurysm: DIAGNOSIS, MANAGEMENT, EXERCISE TESTING, AND TRAINING.

Some patients who participate in cardiac rehabilitation have aortic abnormalities, including abdominal and thoracic aneurysm (AAA and TAA, respectively). There is scant guidance on implementing exercise training in these individuals. This article reviews the epidemiology, diagnostic process, medical issues, and the available exercise training literature, and provides recommendations for performing regular exercise. Patients with aortic abnormalities are at risk for enlargement, aneurysm development, dissection, and rupture. During exercise, individuals with large aneurysms may be at greater risk of an adverse event. The available literature suggests little increased risk of complications when training at low and moderate intensities in those with an AAA, and exercise may be protective for aneurysm expansion. There is little exercise data for TAA, but the available literature suggests training at lower intensities and avoidance of excessive increases of blood pressure. When exercise testing and training are performed, the intensity should be controlled to avoid complications. It is prudent to keep systolic blood pressure <180 mm Hg in most patients and <160 mm Hg in those at greater risk of dissection or rupture (eg, women and larger sized aneurysm) during aerobic training. During resistance training, patients should avoid sudden excessive blood pressure increases (ie, avoid the Valsalva maneuver), and keep intensity below 40-50% of the 1-repetition maximum. Existing data suggest these patients may improve functional capacity and reduce the rate of aneurysm expansion. Most patients with AAA can safely perform exercise training when conservative guidelines are followed. Additional research is needed to fully determine whether exercise is protective against aneurysm expansion, and the effects of exercise in those who have had surgical repair. More research is necessary to provide specific recommendations for those with a TAA.

Dlaczego warto stosować walsartan i jego skojarzenia u pacjentów z nadciśnieniem tętniczym?

The most recent guidelines for the treatment of arterial hypertension have set blood pressure targets of below 130/80 mm Hg in most patients, recommending a single-pill combination (SPC) consisting of two drugs for treatment initiation. In addition to its strong antihypertensive effect, the use of valsartan is associated with a reduction in metabolic risk and in the incidence of hypertension-mediated organ damage and cardiovascular events. Valsartan is the only angiotensin receptor blocker of choice both in patients with hypertension and concomitant coronary artery disease, and in patients with heart failure. The combination of valsartan with amlodipine or hydrochlorothiazide is associated with a proven stronger hypotensive effect due to the synergistic effect of both molecules on the one hand, and a reduction in the frequency of side effects (such as peripheral oedema with amlodipine monotherapy or hypokalemia with hydrochlorothiazide monotherapy) on the other.

Novel blood pressure targets in patients with high-normal levels and grade 1 hypertension: Room for monotherapy?

The 2018 European and 2017 American guidelines recommend to start antihypertensive treatment with combinations of two or more drugs in most hypertensive patients, as a consequence of the suggested more ambitious blood pressure (BP) targets (systolic BP between 130 and 120 mmHg in most patients, diastolic BP between 80 and 70 mmHg).Monotherapy, however, is still suggested as first choice in some specific classes of patients.In this article, we analyze the subgroups of hypertensive patients that should properly started and even maintained on monotherapy, with a focus on subjects with BP in the high-normal range or grade 1 hypertension, young adults with estimated low cardiovascular risk, women during pregnancy or menopause, elderly patients aged >80 years or with frailty parameters.Altogether, these subgroups cover a relatively large proportion of patients with hypertension. Thus, we conclude that, despite the upgrowing role of combination therapy, there is still ample room for the approach with monotherapy in clinical management of hypertension.

What's new in the ESC 2018 guidelines for arterial hypertension : The ten most important messages.

SummaryThe new guidelines on hypertension of the European Society of Cardiology (ESC) 2018 have refined the treatment cut-offs and therapy decisions in adults. This review highlights important recommendations of the guidelines and also on the situation of hypertension in Austria. The general treatment targets of blood pressure have been lowered to at least 130/80 mmHg for most patients. The definition of hypertension is specified as a repeated systolic blood pressure in the office of ≥140 and or diastolic BP ≥90 mmHg. For home blood pressure monitoring, an average value of ≥135/85 mmHg is now defined as hypertension. Ambulatory 24h-blood pressure measurement is recommended for diagnosis of hypertension and to demask lack of nocturnal blood pressure dipping. Whether drug treatment should be initiated immediately or after a delay with lifestyle intervention is focused on the individual high or low cardiovascular risk of the patients and the degree of hypertension. For most patients a combination therapy with single pill is now recommended as initial therapy for hypertension from the start. The salt consumption should be reduced in the majority of patients. The new guidelines have clarified the treatment of hypertension in different comorbidities.

Management of arterial hypertension

Arterial hypertension has ahigh prevalence and is amajor risk factor for the development of cardiovascular diseases. It is amajor contributor to worldwide morbidity and mortality and hence poses ahuge socioeconomic burden. Despite great progress in perception, diagnosis and treatment of hypertension, blood pressure control is inadequate in less than half of the hypertensive patients (<140/90 mm Hg). The diagnosis of arterial hypertension starts in most patients with the conventional office blood pressure measurement. Out-of-office blood pressure measurement is an important adjunct, especially to unmask white-coat hypertension. To reach the right target blood pressure many effective antihypertensive drugs are available. By how much the blood pressure should be lowered is currently amatter of controversy. The 2013 European and the identical German national guidelines recommend atarget blood pressure of <140/90 mm Hg for most patients. The recent SPRINT study revealed that some patients may benefit from an even lower blood pressure. This CME-article summarizes recent developments in the management of arterial hypertension and provides tips for daily practice based on these aims.

Is It Time to Reappraise Blood Pressure Thresholds and Targets? A Statement From the International Society of Hypertension-A Global Perspective.

The SPRINT (Systolic Blood Pressure Intervention Trial) findings,1 together with the publication of other major studies within the last year addressing how low blood pressure should be targeted to prevent cardiovascular events in patients with hypertension,2–4 support what we have known for a long time that: (1) blood pressure >115/75 mm Hg is associated with increased risk of cardiovascular disease and stroke, (2) blood pressure lowering is associated with reduced morbidity and mortality, (3) antihypertensive drugs reduce the incidence of hypertension-associated events, and (4) prevention of cardiovascular morbidity is largely related to blood pressure lowering per se, although other effects of the drugs used contribute to this benefit. The questions that are now posed, particularly in response to an editorial commentary by the Editors of this Journal,5 are the following: What is the threshold at which antihypertensive treatment should be initiated? and what target blood pressure should we strive for to achieve maximum benefit in patients with hypertension? SPRINT and other recent meta-analyses and trials provide new data that allow us to sharpen and refine recommendations for blood pressure targets in people with hypertension.1–4 Here, we will briefly address the questions in the worldwide context of hypertension. In hypertensive patients without diabetes mellitus, previous stroke or polycystic kidney disease, SPRINT has provided strong evidence that targeting systolic blood pressure of <120 mm Hg (as measured by an automated measurement protocol in the office)1 provides significantly stronger protection from cardiovascular events and death than the traditionally accepted target of <140 mm Hg. This study was conducted in a hypertensive patient cohort of intermediate-to-high cardiovascular risk. It should be highlighted that the target of 120 mm Hg in SPRINT was based on blood pressure readings using a defined protocol with an office automated device, where blood pressure …

Management of Different Subtypes of Primary Angle Closure with Phacoemulsification and Viscogoniosynechialysis

ABSTRACTPurpose: To retrospectively assess the effectiveness of combined phacoemulsification with viscogoniosynechialysis for patients with different subtypes of primary angle closure (PAC). Methods: Forty-three eyes of 37 patients diagnosed with PAC (12 eyes), PAC with glaucoma (PACG, 20 eyes), and acute PAC (11 eyes) were treated with phacoemulsification and viscogoniosynechialysis between November 2010 and October 2012. Main outcome measures were anterior chamber depth (ACD), intraocular pressure (IOP), the number of IOP-lowering medication, extent of peripheral anterior synechia (PAS), and visual acuity preoperatively and one month postoperatively. Results: All operations were successfully accomplished and no intra-operative complications were observed. The ACD, IOP, PAS, and visual acuity were all significantly improved postoperatively, especially in the acute PAC group, which resulted in few glaucoma drugs being needed. The IOP was decreased into equal or less than 21 mmHg in most patients postoperatively, except four patients had IOP slightly higher than 21 mmHg. However, they were restored to normal spontaneously or by medication at last follow-up. The extent of PAS was all reduced to less than 90 or 180°, with the visual acuity restored to more than 0.1. Conclusions: Combined phacoemulsification with viscogoniosynechialysis seems to be an effective surgical procedure in the treatment of various subtypes of PAC.

Is the lower blood pressure target for patients with chronic kidney disease supported by evidence?

Major guidelines recommend a blood pressure (BP) target of less than 130/80 mmHg for patients with chronic kidney disease (CKD) even though the optimal BP target in this population is unclear. This review summarizes the evidence on BP target in CKD and highlights recent pertinent publications. Clinical trials in CKD have not definitively shown that setting a BP target that is lower than the standard target of less than 140/90 mmHg provides additional benefit for important clinical outcomes. However, subgroup analyses from the recently published posttrial cohort of the African-American Study of kidney disease and a systematic review of BP target trials in CKD suggest that lower than the standard BP target may be beneficial in patients with proteinuria level of more than 300 or 1000 mg/day. Evidence supports a BP target of less than 140/90 mmHg in most patients with CKD. A lower target may be chosen in CKD patients with proteinuria after individualized risk-benefit assessment. Treatment to a lower target may require greater vigilance to monitor for and avoid possible symptoms and adverse events from hypotension.

Cerebral Autoregulation and Acute Ischemic Stroke

Cerebral autoregulation tightly controls blood flow to the brain by coupling cerebral metabolic demand to cerebral perfusion. In the setting of acute brain injury, such as that caused by ischemic stroke, the continued precise control of cerebral blood flow (CBF) is vital to prevent further injury. Chronic as well as acute elevations in blood pressure are frequently associated with stroke, therefore, understanding the physiological response of the brain to the treatment of hypertension is clinically important. Physiological data obtained in patients with acute ischemic stroke provide no clear evidence that there are alterations in the intrinsic autoregulatory capacity of cerebral blood vessels, except perhaps in infarcted tissue. While it is likely safe to modestly reduce blood pressure by 10-15 mm Hg in most patients with acute ischemic stroke, to date, there are no controlled trial data to indicate that reducing blood pressure is beneficial. There may be subgroups, such as those with persistent large vessel occlusion, large infarcts with edema causing increased intracranial pressure or local mass effect, or chronic hypertension, in which blood pressure reduction may lead to impaired cerebral perfusion in noninfarcted tissue.

Blood pressure goal in chronic kidney disease: what is the evidence?

Most guidelines recommend that seated clinic blood pressure (BP) be targeted to less than 130/80 mmHg in patients with chronic kidney disease (CKD). The evidence underlying these recommendations is the subject of this review. The best evidence to target a certain level of BP in patients with CKD comes from randomized trials. Only three trials have prospectively examined the level to which BP should be lowered. These trials conducted exclusively among patients with CKD have demonstrated that compared to a less aggressive BP goal, a BP goal of less than 130/80 mmHg neither saves lives nor protects the kidney or the cardiovascular system. It is reasonable to achieve a goal of less than 140/90 mmHg in most patients with CKD. More aggressive lowering is not firmly supported by current data. Since BP control is important, hypertension therapy should be individualized. Individualization through home BP measurements to diagnose, monitor and treat hypertension appears to be an attractive option.

Reducing Cardiovascular Events and End-Organ Damage in Patients with Hypertension: New Considerations

Hypertension treatment should focus on achieving blood pressure (BP) of < 140/90 mm Hg in most patients and < 130/80 mm Hg in patients with diabetes. Lifestyle modifications play a central role in therapy and should be the first line of treatment in all patients. However, long-term lifestyle changes are rarely achieved and pharmacotherapy is required. The selection of an optimal regimen for each patient will depend on comorbid conditions. Most patients will require combination therapy with ≥ 2 antihypertensive agents to control their BP. The most useful combinations employ drugs from different classes with complementary mechanisms of action, producing additive or synergistic BP reduction with minimal adverse events.

Initial Assessment, Surveillance, and Management of Blood Pressure in Patients Receiving Vascular Endothelial Growth Factor Signaling Pathway Inhibitors

Hypertension is a mechanism-based toxic effect of drugs that inhibit the vascular endothelial growth factor signaling pathway (VSP). Substantial evidence exists for managing hypertension as a chronic condition, but there are few prospectively collected data on managing acute hypertension caused by VSP inhibitors. The Investigational Drug Steering Committee of the National Cancer Institute convened an interdisciplinary cardiovascular toxicities expert panel to evaluate this problem, to make recommendations to the Cancer Therapy Evaluation Program on further study, and to structure an approach for safe management by treating physicians. The panel reviewed: the published literature on blood pressure (BP), hypertension, and specific VSP inhibitors; abstracts from major meetings; shared experience with the development of VSP inhibitors; and established principles of hypertension care. The panel generated a consensus report including the recommendations on clinical concerns summarized here. To support the greatest possible number of patients to receive VSP inhibitors safely and effectively, the panel had four recommendations: 1) conduct and document a formal risk assessment for potential cardiovascular complications, 2) recognize that preexisting hypertension will be common in cancer patients and should be identified and addressed before initiation of VSP inhibitor therapy, 3) actively monitor BP throughout treatment with more frequent assessments during the first cycle of treatment, and 4) manage BP with a goal of less than 140/90 mmHg for most patients (and to lower, prespecified goals in patients with specific preexisting cardiovascular risk factors). Proper agent selection, dosing, and scheduling of follow-up should enable maintaining VSP inhibition while avoiding the complications associated with excessive or prolonged elevation in BP.

A Lower Blood Pressure Goal in Patients Without Diabetes Lessens the Occurrence of Left Ventricular Hypertrophy

A LOWER BLOOD PRESSURE GOAL IN PATIENTS WITHOUT DIABETES LESSENS THE OCCURRENCE OF LEFT VENTRICULAR HYPERTROPHY The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends a blood pressure (BP) goal of <140 ⁄90 mm Hg in most patients with hypertension and a goal of <130 ⁄80 mm Hg in patients with diabetes or chronic kidney disease. A recent scientific statement from the American Heart Association suggested adding patients with known coronary artery disease, carotid disease, peripheral artery disease, an abdominal aortic aneurysm, left ventricular dysfunction, or a calculated 10-year Framingham risk score of at least 10% to the group of patients with a BP goal of <130 ⁄80 mm Hg. These recommendations were made despite a lack of level I clinical trial evidence for benefit of more intensive treatment of BP in those patient populations. These recommendations are largely aimed at reducing the incidence of hard cardiovascular events such as myocardial infarction (MI), stroke, or heart failure. In patients with hypertension, left ventricular hypertrophy (LVH) is a major independent risk factor for stroke, MI, sudden cardiac death, and cardiovascular mortality. Yet, neither JNC 7 nor the American Heart Association (AHA) Scientific Statement specify a more aggressive BP goal in patients with LVH, and prevention of LVH is not emphasized in current guidelines. Whether more aggressive BP lowering would effectively reduce the incidence of LVH was recently tested in the Studio Italiano Sugli Effetti Cardiovascolari del Controllo della Pressione Arteriosa Sistolica (Cardio-Sis) trial. In this open-label, industry-supported trial conducted between February 2005 and February 2007, Italian researchers enrolled 1111 Italian hypertensive nondiabetic patients (93% of those screened). Inclusion criteria included age 55 years or older, a baseline systolic BP of 150 mm Hg, use of antihypertensive therapy for at least 12 weeks, and at least 1 additional risk factor (cigarette smoking, dyslipidemia, family history of premature cardiovascular disease, previous transient ischemic attack or stroke, or established coronary or peripheral artery disease). Patients were excluded if they had a history of diabetes, renal dysfunction, valvular heart disease, liver disease, atrial fibrillation, substance abuse, or a limited life expectancy. Eligible participants entered a run-in phase to make sure that at two visits 7 to 14 days apart their systolic BP on their present antihypertensive regimen was 150 mm Hg. They were then randomized in a 1:1 ratio to receive antihypertensive drug treatment to achieve either usual systolic BP control (<140 mm Hg) (n=553) or tight systolic BP control (130 mm Hg) (n=558). They were followed up every 4 months for 2 years. At baseline and at 1 and 2 years, patients had a 12-lead electrocardiogram (ECG) and laboratory blood tests performed. Treatment was open-label, with all classes of antihypertensive drugs available. Intensification or down-titration of treatment was permitted in order to achieve the specified BP goals. Drug classes were evenly distributed at baseline, except in the usualcontrol group where more patients were taking a diuretic and fewer were taking an angiotensin receptor blocker (ARB). The primary study outFrom the Division of General Internal Medicine ⁄ Division of Cardiology, University of Nevada School of Medicine; the Risk Reduction Center, Saint Mary’s Regional Medical Center, Reno, NV; the Primary Care Service Line, Ralph H. Johnson VA Medical Center, and the Division of General Internal, Medicine ⁄Geriatrics, Medical University of South Carolina, Charleston, SC Address for correspondence: Michael J. Bloch, MD, Risk Reduction Center, Saint Mary’s Regional Medical Center, 645 North Arlington Street, Suite 460, Reno, NV 89503 E-mail: mbloch@aol.com

Is it Time for a Cardiovascular Primary Prevention Trial in the Elderly?

Statins have been shown conclusively to reduce the risk of cardiovascular events in subjects with clinical cardiovascular disease or diabetes aged 65 to 80 years of age. However, few data are available for primary prevention of cardiovascular disease in those aged > or =70 years. A moderate-dose statin was of little benefit in a population aged 70 to 82 years when given for 3 years in the setting of suboptimally treated blood pressure. More evidence supports the use of blood pressure-lowering medications, but few data are available regarding the appropriate blood pressure target and most effective agents in the elderly. Some evidence also suggests that the elderly could experience higher mortality with antihypertensive treatment. These findings, along with greater safety concerns and an increasing number of competing risks and medical conditions with advancing age, make it imperative to carefully evaluate the risk/benefit balance from treating hypercholesterolemia and hypertension in persons aged > or =70 years. We propose a 5-year 2x2 factorial trial of primary prevention in the elderly that will (1) evaluate whether statin therapy will reduce the risk of cardiovascular events when added to the treatment of hypertension to achieve a blood pressure <140/90 mm Hg in most patients and (2) determine the most appropriate blood pressure regimen for the prevention of cardiovascular and renal events.

Management of older hypertensive patients: is there a difference in approach?

Hypertension is the most common reason Americans visit a physician. Recent analyses from the Framingham Heart Study and others have shown that there will be 70 million hypertensive Americans by the year 2020 and that the overwhelming majority of hypertensives will be 65 years of age or older (what we used to call elderly). The lifetime risk of Americans who live to age 85 years of becoming hypertensive is approximately 90% for both men and women. These individuals, even if they develop an elevated blood pressure late in life, are at significantly increased risk of the many medical complications attributable to hypertension (coronary artery disease, strokes, heart failure, chronic renal disease, and more). Older hypertensives are more likely to have an elevated systolic blood pressure and a low diastolic blood pressure, both of which are related to a loss of article compliance and have an increase in left ventricular mass and a decrease in peripheral resistance. We now have a substantial body of evidence from well done clinical trials that older hypertensives benefit as much or more than younger patients from antihypertensive therapy, so there is no longer any justification for withholding medication from any hypertensive patient whose competing risk or other medical problems are not a contraindication to treatment. These same studies, and practice-based analyses, have shown that the major barrier to reaching blood pressure goal is our failure to reduce systolic blood pressure to <140 mm Hg in most patients and to <130 mm Hg in diabetics and those with renal failure. The basis for all antihypertensive therapy, especially in older people, is thiazide diuretics with either angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, or calcium entry blockers as appropriate add-on treatment. The choice of the second agent depends on other factors, such as comorbidity, lifestyle, and affordability. We must be more aggressive in getting the message out that older hypertensives benefit from treatment and we must overcome the clinical inertia that seems to be a factor in the decision of many physicians not to treat an older patient. No older person should suffer a preventable, life-threatening event or become confined to a wheel chair if attention to lifestyle issues and a few pills a day could avoid that outcome.

Diamox((R)) challenge test to decide indications for cerebrospinal fluid shunting in normal pressure hydrocephalus.

The indications for cerebrospinal fluid (CSF) shunting in patients with normal pressure hydrocephalus (NPH) have not been established. Establishment of clear-cut indications for this procedure is essential to ensure cost-effective, and safe treatment. We report the usefulness of the Diamox((R)) challenge test in evaluating indications for CSF shunting in patients with NPH. Pre- and post-operative responses in cerebral blood flow (CBF) and intracranial pressure (ICP) to intravenous administration of Diamox((R)) 1000mg (Diamox((R)) administration) were analysed in 41 patients with NPH who were treated by ventriculoperitoneal (VP) shunt with a programmable valve and an on-off valve. The preoperative response of ICP to Diamox((R)) administration was more than 10 mmHg in most patients in whom the shunt was effective (shunt effective group), however, it was less than 10 mmHg in most patients in whom the shunt was ineffective (shunt non-effective group). Furthermore, the postoperative response of ICP to Diamox((R)) administration decreased to less than 10 mmHg in most patients in the shunt effective group. The increases in CBF in response to Diamox((R)) administration were similar in the two groups both before and after placement of the VP shunt. Patients in whom ICP increased by more than 10 mmHg in response to Diamox((R)) administration were regarded to have poor CSF circulation and to thus be candidates for CSF shunting. The Diamox((R)) challenge test is a simple, safe procedure, useful in evaluating the response to treatment.