Sixth Joint National Committee Research Articles

Blood Pressure and Cardio-Metabolic Risk Profile in Young Saudi Males in a University Setting.

Background and Objectives: The prevalence of cardiovascular diseases (CVDs) poses significant clinical and public health challenges across the world. This study aimed to study the metabolic risk factors and the association with blood pressure alteration. Materials and Methods: This was a cross-sectional study conducted between 2017 and 2018 among 284 male university students in Eastern province, Saudi Arabia. The obesity and cardiovascular measurements were taken using standardized instruments, including blood pressure (BP), mean arterial pressure, body mass index (BMI), body adiposity index (BAI), waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), body fat percentage (BFP), and basal metabolic rate (BMR). Statistical Analysis: Blood pressure was classified according to the United States of America, Sixth Joint National committee (JNC-VI) guidelines. The mean and standard error were calculated for each hypertension group variable. Logistic regression was applied to predict associations. Results: The prevalence of hypertension in the present study was 61.6%., and that of overweight and obesity was 16.5% and 34.9%, respectively. The cut-off values of BMI and WC were 22.23 and 75.24, respectively. Conclusions: The results demonstrated that BMI, WC, WHR, and WHtR significantly predict hypertension and that WC has a greater discrimination capacity than other measures. The findings also emphasize the importance of cardiovascular risk screening for young adults to detect any alterations in blood pressure and thus identify the population that is vulnerable to CVDs at an early stage. The findings highlight the need for health and university policymakers to adopt measures to monitor and control hypertension and obesity at the university level.

0411: Relation between pressure and vascular event among the elderly in Monastir: a population-based study

The sixth Joint National Committee (JNC-VI) classification system of blood pressure emphasizes both systolic blood pressure (SBP) and diastolic blood pressure (DBP) for cardiovascular disease risk assessment. Pulse pressure (PP) = [SBP-DBP], may also be a valuable risk assessment tool. In this study, we examined the association of cardiovascular events with arterial pulse pressure in elderly as well as their correlations within diabetes. A Population based survey supported by WHO and FNUAP, was undertaken in 2008-2009 to investigate health behaviours and health status of elderly living in their home in Monastir. This study was carried out in a representative sample of elderly aged more than 65 years. Standardized techniques were used for blood pressure (BP). Hypertension was defined as BP more than 140/90 mmHg. Diabetes was defined as known diabetics. Regression analyses were used to examine the relationships among pulse pressure age, diabetes and cardiovascular events (myocardial infarction, arteritis and stroke).This project was approved by the research Ethics Committee, CHU F Bourguiba, university of Monastir The study included 598 participants (396 women and 202 men) who were aged ≥65 years. The prevalence of hypertension and diabetes was respectively 52% (n=311) and 27,4% (n= 164). Pulse pressure was more than 65 mmHg for 132 subjects (22%), only 43 subjects without a history of hypertension. The mean of PP is significantly high in hypertensive elderly (52.3 vs 58.4 mmHg), with cardiovascular events (55 vs 58 mmHg), diabetic subjects (53 vs 58 mmHg), with comorbidity (54 vs 58 mmHg) and polymedication (52 vs 57 mmHg). Using pulse pressure (high PP ≥65 mmHg) as dependent variable, the multiple regression analysis reveals the independent influence of diabetes and cardiovascular events on PP. This study has confirmed that subjects with the widest PP have the greatest risk of cardiovascular events. Elderly diabetic patients have a higher PP than non diabetic elderly. These hemodynamic changes may contribute to the increase risk of cardiovascular disease associated with diabetes.

222: Relation between pulse pressure and vascular event among the elderly in Monastir: a population-based study

The sixth Joint National Committee (JNC-VI) classification system of blood pressure emphasizes both systolic blood pressure (SBP) and diastolic blood pressure (DBP) for cardiovascular disease risk assessment. Pulse pressure (PP)=[SBP - DBP], may also be a valuable risk assessment tool. In this study, we examined the association of cardiovascular events with arterial pulse pressure in elderly as well as their correlations within diabetes. A Population based survey supported by WHO and FNUAP, was undertaken in 2008-2009 to investigate health behaviours and health status of elderly living in their home in Monastir. This study was carried out in a representative sample of elderly aged more than 65 years. Standardized techniques were used for blood pressure (BP). Hypertension was defined as BP more than 140/90 mmHg. Diabetes was defined as known diabetics. Regression analyses were used to examine the relationships among pulse pressure age, diabetes and cardiovascular events (myocardial infarction, arteritis and stroke) This project was approved by the research Ethics Committee, CHU F Bourguiba, university of Monastir The study included 598 participants (396 women and 202 men) who were aged ≥65 years. The prevalence of hypertension and diabetes was respectively 52% (n=311) and 27,4% (n= 164). Pulse pressure was more than 65 mmHg for 132 subjects (22%), only 43 subjects without a history of hypertension. The mean of PP is significantly high in hypertensive elderly (52.3 vs 58.4 mmHg), with cardiovascular events (55 vs 58 mmHg), diabetic subjects (53 vs 58 mmHg), with comorbidity (54 vs 58 mmHg) and polymedication (52 vs 57 mmHg). Using pulse pressure (high PP ≥65 mmHg) as dependent variable, the multiple regression analysis reveals the independent influence of diabetes and cardiovascular events on PP. This study has confirmed that subjects with the widest PP have the greatest risk of cardiovascular events. Elderly diabetic patients have a higher PP than non diabetic elderly. These hemodynamic changes may contribute to the increase risk of cardiovascular disease associated with diabetes.

Aging, Blood Pressure, and Heart Failure

See related article, pp 895–901 Although systolic blood pressure (BP; SBP) is the best predictor of future cardiovascular disease (CVD) risk for the majority of the older hypertensive population, there is much that can be learned from simultaneously assessing diastolic BP (DBP) and its relation to levels of SBP.1 After 50 years of age, SBP increases disproportionately to DBP, and after 60 years of age DBP falls, resulting in a widening of the pulse pressure (PP).1 Indeed, a previous Framingham Heart Study report revealed an age-related gradual shift from DBP below 50 years of age to SBP and PP at older ages as predictors of coronary heart disease risk.2 Furthermore, with the age-related rise in SBP and fall in DBP, isolated SBP (ISH), accompanied by a wide PP, becomes the most common form of hypertension from middle-aged onward3 and is associated with increased CVD risk in general4 and overt heart failure in particular.5 ### The Role of Low DBP as a Predictor of CVD Risk With Aging In Framingham Heart Study participants who were free of CVD and not receiving BP-lowering therapy, SBP and DBP (or mean arterial pressure and PP) in combination produced a model that was superior to any single BP component alone in predicting total CVD events (coronary heart disease, heart failure, and stroke)6; of the 4 BP components, only DBP was nonlinear and showed a J-shaped curve of CVD risk that could be related to a rise in PP and/or a fall in DBP, and these findings were independent of antihypertensive therapy. Furthermore, when CVD events were stratified by DBP <70 mm Hg versus ≥70 to 89 mm Hg to evaluate risk according to the Sixth Joint National Committee classification, those individuals with DBP <70 mm Hg had an increased cardiovascular event rate (Table).6 Importantly, data from the …

Obesity Paradox in Patients with Hypertension and Coronary Artery Disease

Purpose An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known. Methods A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66 ± 9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m 2 (thin), 20 to 25 kg/m 2 (normal weight), 25 to 30 kg/m 2 (overweight), 30 to 35 kg/m 2 (class I obesity), and 35 kg/m 2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke. Results With patients of normal weight (BMI 20 to <25 kg/m 2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P <.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P <.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5 ± 21.9 mm Hg/−9.8 ± 12.4 mm Hg vs −20.7 ± 23.1 mm Hg /−10.6 ± 12.5 mm Hg, P <.001). Conclusion In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.

Changes in Antihypertensive Prescribing During US Outpatient Visits for Uncomplicated Hypertension Between 1993 and 2004

Monitoring national patterns of antihypertensive drug therapy is essential to assessing adherence to treatment guidelines and the impact of major scientific publications on physician prescribing. We analyzed data from 2 US National Ambulatory Care Surveys to examine trends between 1993 and 2004 in the prescription of antihypertensive drug classes for uncomplicated hypertension and the association between thiazide and beta-blocker prescribing and physician and patient characteristics. Diuretic prescriptions remained level through 2001 (39%; 95% CI: 34% to 44%) but increased to 53% (48% to 58%) in 2003, largely because of a 72% increase in thiazide prescriptions in the first quarter of 2003 (50%; 95% CI: 40% to 59%). However, these increases did not sustain in 2004. Beta-blocker prescriptions increased modestly from 1993 (24%; 95% CI: 19% to 29%) to 2004 (33%; 95% CI: 28% to 39%). Prescription of calcium channel blockers and angiotensin-converting enzyme inhibitors declined significantly following the sixth Joint National Committee report, but both subsequently rebounded to prereport levels. Prescription of angiotensin II receptor blockers increased continuously from 1% in 1995 to 23% by 2004. Polytherapy prescriptions, particularly those involving > or = 3 drug classes, became increasingly prevalent, accounting for 60% of antihypertensive drug visits by 2004. Prescriptions of thiazides and beta-blockers were both more likely in 1998-2004 (versus 1993-1997). Blacks, women, and hospital outpatients were more likely to receive thiazides. Also, cardiologists were more likely to prescribe beta-blockers. Evidence-based guidelines for antihypertensive drug therapy do impact physician prescribing, but the impact seems to be short lived. Future interventions are imperative for promoting long-term adherence to published guidelines.

Antihypertensive Medication Use Among US Adults With Hypertension

High blood pressure can be controlled through existing antihypertensive drug therapy. This study examined trends in prescribed antihypertensive medication use among US adults with hypertension and compared drug utilization patterns with recommendations of the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Persons aged > or =18 years from the National Health and Nutrition Examination Surveys were identified as hypertensive on the basis of either a blood pressure > or =140/90 mm Hg or self-reported current treatment for hypertension with a prescription medication. In 1999-2002, 62.9% of US hypertensive adults took a prescription antihypertensive medication compared with 57.3% during 1988-1994 (P<0.01). Men had the greatest increase in antihypertensive medication use (47.5%, 1988-1994 versus 57.9%, 1999-2002 [P<0.001]). In both surveys, antihypertensive medication use increased with age, was lower among men than among women, and was lower among Mexican Americans than among non-Hispanic whites and blacks. Multiple antihypertensive drug use increased from 29.1% to 35.8% (P<0.001). Polytherapy with a calcium channel blocker, beta-blocker, or angiotensin-converting enzyme inhibitor significantly increased by 30%, 42%, and 68%, respectively, whereas monotherapy with a diuretic or beta-blocker significantly decreased. For hypertensives with diabetes, congestive heart failure, or a prior heart attack, the utilization patterns closely followed the Sixth Joint National Committee guideline recommendations. Antihypertensive medication use and multiple antihypertensive medication use among US hypertensive adults increased over the past 10 years, but disparities by sociodemographic factors continue to exist.

The Need for Evidence in Hypertension Management: Historical Perspective

The Task Force of the National Heart, Lung and Blood institute issued the first standardized, algorithmic approach to treating hypertension in 1973.1 The concept of a stepped-care approach was born at that time. Their initial recommendation for antihypertensive drug therapy was diuretics. Subsequent Joint National Committee (JNC) Reports on Detection, Evaluation, and Treatment of High Blood Pressure recommended that initial drug therapy be either a diuretic or beta-adrenergic blocker, and then either of these two drugs, and then a calcium channel blocker (CCB) or an angiotensin-converting enzyme inhibitor (ACE-inhibitors). The JNC-V then recommended any of the four classes or an α-β-blocker as initial therapy, but diuretics and b-blockers were preferable. That diuretics or β-blockers should be the initial drug for non-complicated hypertensive patient was also the recommendation of the Sixth Joint National committee report.2–7 Safety issues that arose after introduction ACE inhibitors and CCBs have since been mostly resolved. Drug treatment thresholds varied among the US, Canadian, British and WHO/ISH recommendations despite the fact that all were based on the same set of data. The concept of “the lower the blood pressure the better without causing symptoms” was the rule until the J-curve hypothesis emerged and generated a long debate. Now the current evidence supports the old concept, at least for some conditions such as hypertension in diabetic patients or in those with nephrotic-range proteinuria. Despite the repeated recommendations that thiazide-diuretics are preferred as the initial agent in hypertension treatment, many clinicians ignore these guidelines. This practice has added a signficant cost to hypertension treatment worldwide.

Does optimal or normal blood pressure in the office rule out ambulatory hypertension?

According to the recommendations of the Sixth Joint National Committee, subjects with office blood pressure (BP) < 140/90 mm Hg are subdivided into groups with high normal BP (130–139 or 85–89 mm Hg), normal BP (< 130/85 mm Hg), and optimal BP (<120/80 mm Hg) based on their risk of cardiovascular disease. Recently, it has been demonstrated that subjects with normal office BP (< 140/90 mm Hg) but ambulatory hypertension (daytime BP ≥ 135/85) have an increased risk of cardiovascular disease. The aim of this study was to find out how many subjects with optimal and normal office blood pressure actually had ambulatory hypertension. Our study population consisted of a random sample of 1700 men and women, age 41–72 years, without major cardiovascular diseases. At baseline, office BP, ambulatory BP, and other risk factors were recorded. In total, 32 subjects with optimal office BP had ambulatory hypertension, and 94 subjects with normal office BP had ambulatory hypertension. Compared with the 1018 subjects with normal ambulatory BP (daytime BP < 135/85), these subjects were younger: mean age 47.9, 51.0, and 53.1 years, respectively. After a mean period of 9.5 years, 156 combined endpoints (cardiovascular death, ischemic heart disease, or stroke) were recorded. The absolute risk of the combined endpoint was 9.4% in subjects with optimal office BP but ambulatory hypertension, 8.3% in subjects with normal office BP but ambulatory hypertension, and 5.6% in subjects with ambulatory normotension (daytime BP < 135/85). In conclusion, optimal and normal office BP does not rule our ambulatory hypertension and an increased risk of cardiovascular disease.

Generalizability of guidelines and physicians' adherence. Case study on the Sixth Joint National Commitee's guidelines on hypertension.

BackgroundClinical practice guidelines (CPG) are thought to be an effective tool in improving efficiency and outcomes of clinical practice. Physicians' adherence to guidelines is reported to be poor. We evaluated the relationship between generalizability of guidelines on hypertension and physicians' adherence to guidelines' recommendations for pharmacological treatment.MethodsWe used the Sixth Joint National Committee's (JNC VI) guidelines on hypertension to evaluate our hypothesis. We evaluated the evidence from controlled clinical trials on which the JNC VI bases its recommendation, and compared the population enrolled in those trials with the American hypertensive population. Data on this population came from the National Health and Nutritional Examination Survey III.ResultsTwenty-three percent of the NHANES population had a diagnosis of hypertension, 11% had hypertension requiring drug treatment according to the JNC VI. Only half of the population requiring treatment would have been enrolled in at least two trials. Rate of adherence to CPG was 69%. We found a weak association between generalizability and physicians' adherence to guidelines. Baseline risk was the major determinant of the decision to treat.ConclusionJNC VI guidelines may not be generalizable to their target population. We found a relatively poor adherence rate to these guidelines. Failing of completely taking into account the clinical characteristics of the patients may be partly responsible for this lack of adherence.

Blood pressure, antihypertensive therapy and risk for renal injury in African-Americans.

African-Americans are more likely than Caucasians to develop hypertension-related end-stage renal disease. Elevations in blood pressure levels clearly potentiate pre-existing renal disease and also contribute to kidney injury independently of other primary renal diseases in this cohort. Until recently, data relevant to a full examination of the issue of blood pressure levels and end-stage renal disease in African-Americans have largely been from post-hoc analyses of clinical trials or from small, prospective, short-term studies. The most recent United States Renal Data Systems data show hypertension as the primary cause of end-stage renal disease in African-Americans until 1997, diabetes now being the most prevalent etiology. Data from post-hoc analyses of the Modification of Diet in Renal Disease study demonstrated that African-Americans with a mean arterial pressure above 98 mmHg had a higher risk of end-stage renal disease than Caucasians. The African-American Study of Kidney Disease tested the hypothesis that a blood pressure well below the usual recommended level will further reduce renal disease progression in African-Americans. The study concluded that a blood pressure lower than that needed to reduce cardiovascular events, as defined by the Sixth Joint National Committee Report on the Detection, Evaluation and Treatment of High Blood Pressure, i.e. 135-140/80-85 mmHg, will not further slow renal disease progression in African-Americans with hypertensive nephrosclerosis. Moreover, a regimen of blood pressure lowering anchored on angiotensin-converting enzyme inhibitors, antihypertensive agents that are touted as ineffective in African-Americans, was more effective than one based on either beta-blockers or dihydropyridine calcium-channel blockers in slowing the progression of renal injury. Systolic blood pressure reduction in the range 130-139 mmHg is appropriate to reduce risk of nephropathy progression and cardiovascular risk in African-Americans with hypertensive nephrosclerosis. Moreover, a regimen that is initiated with an angiotensin-converting enzyme inhibitor should be the antihypertensive treatment of choice in African-Americans with kidney disease.

Goal-oriented hypertension management: translating clinical trials to practice.

Several clinical trials using a blood pressure (BP) treatment algorithm focused on a predetermined goal have achieved better control rates than those of national survey data. These trials reached the Sixth Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI) diastolic blood pressure (DBP) goal of <90 mm Hg in >90% of volunteers and systolic blood pressure (SBP) goal of <140 mm Hg in >60% of volunteers. We evaluated BP control of 437 consecutive patients after at least one year of follow up in a specialist clinic which employed "goal-oriented management," ie, treating to a specific BP goal without a formal drug treatment algorithm, to determine whether JNC VI goals could be achieved. Overall, 276 (63%) patients achieved SBP goal, with 376 (86%) at DBP goal and 358 (59%) at both goals. Only 23% of patients were on monotherapy, with 34% requiring 2 drugs and 37% requiring 3 or more medications. There was no substantial difference in BP control rates among age, gender, and ethnicity subgroups. However, in the 20% of patients who were diabetic, only 52% had a BP of <140 mm Hg and <90 mm Hg, whereas fewer (22% and 15%, respectively) achieved the more stringent goals of JNC VI and the American Diabetic Association (ADA)/National Kidney Foundation (NKF). Goal-oriented management achieved dramatically better control rates than what is reported. Although DBP control was easy to achieve, achieving SBP goal still remained difficult. Employing goal-oriented management can translate BP control results achieved in clinical trials into outpatient practice.

Incidence of new coronary events in older persons with prior myocardial infarction and serum low-density lipoprotein cholesterol ≥125 mg/dl treated with statins versus no lipid-lowering drug

O lder persons with hypercholesterolemia or increased serum low-density lipoprotein (LDL) or low serum high-density lipoprotein (HDL) cholesterol levels are at increased risk for new coronary events. Older persons with coronary artery disease (CAD) and elevated serum LDL cholesterol treated with simvastatin or pravastatin had a significant reduction in new coronary events. We are reporting data from an observational study investigating the effects of statins on the incidence of new coronary events in older men and women with prior myocardial infarction and a serum LDL cholesterol 125 mg/dl followed prospectively for the incidence of new coronary events. • • • Four hundred eighty-eight men and 922 women, mean age 81 9 years (range 60 to 100), with prior myocardial infarction and a serum LDL cholesterol 125 mg/dl treated with a statin or with no lipidlowering drug were followed prospectively in a longterm health care facility for the incidence of new coronary events. Persons were considered to have prior myocardial infarction if they had a documented clinical history of myocardial infarction or electrocardiographic evidence of Q-wave myocardial infarction. New coronary events were diagnosed if the person developed nonfatal or fatal myocardial infarction or sudden coronary death as previously described. Systemic hypertension was diagnosed according to the criteria of the Sixth Joint National Committee Report on the Detection, Evaluation, and Treatment of Hypertension. All persons with hypertension were treated with antihypertensive therapy. Diabetes mellitus was diagnosed according to the American Diabetes Association’s new criteria. Measurements of fasting serum lipids were obtained in all persons after a 12to 14-hour overnight fast at baseline, after 1 month of therapy, and every 6 months during the study. A serum LDL cholesterol 125 mg/dl was considered elevated. A serum HDL cholesterol 35 mg/dl was considered decreased. A serum triglyceride level 190 mg/dl was considered increased. A person was considered obese if the body mass index was 30 kg/m. The full-time staff physicians involved in the study treated 679 of 1,410 persons (48%) with a statin and 731 (52%) with no lipid-lowering drug. The attitude of different physicians toward treating hypercholesterolemia in older persons with prior myocardial infarction determined whether statins were prescribed. Persons were followed until the time of a new coronary event, death, or cutoff date analysis of data. Follow-up was 36 21 months (range 1 to 133). Chi-square tests were used to analyze dichotomous variables and Student’s t tests for continuous variables (Tables 1 to 4). Table 5 lists the prognostic variables for new coronary events and their regression coefficients in the stepwise Cox regression model. The Cochran-Armitage test was used to examine if there was a trend in the reduction of new coronary events in persons treated with statins as the last level of serum LDL cholesterol decreased (Table 6). Table 1 lists baseline characteristics of those treated with statins versus no lipid-lowering drugs and lists levels of statistical significance. Table 2 lists the baseline and last follow-up serum lipids in persons treated with statins versus no lipid-lowering drugs and lists levels of statistical significance. Table 3 shows the incidence of new coronary events in persons treated with statins versus no lipid-lowering drugs and lists the level of statistical significance. Table 5 shows the prognostic variables for new coronary events and their regression coefficients in the stepwise Cox regression model. Table 4 shows the incidence of new coronary events in persons treated with statins versus no lipid-lowering drugs for the age groups of 60 to 70, 71 to 80, 81 to 90, and 91 to 100 years, and lists levels of statistical significance. Table 6 shows the incidence of new coronary events in persons treated with statins From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York; and the Division of Clinical Epidemiology, University of Texas Medical School at Houston, Houston, Texas. Dr. Aronow’s address is: Department of Medicine, Westchester Medical Center/New York Medical College, 23 Pebble Way, New Rochelle, New York 10804. Manuscript received July 30, 2001; revised manuscript received and accepted September 4, 2001. TABLE 1 Baseline Characteristics of Persons With Prior Myocardial Infarction and Elevated Serum LDL Cholesterol Treated With Statins Versus No Lipid-Lowering Drug

Cardiovascular risk assessment using pulse pressure in the first national health and nutrition examination survey (NHANES I).

Increased stiffness of the conduit arteries has been associated with increased risk of death and cardiovascular death in a number of populations. None of these populations, however, are fully representative of the US population. The cohort examined in the First National Health and Nutrition Examination Survey (NHANES I) that was free of overt cardiovascular disease was selected to be representative of the US population. We assessed and quantified the increased risk of death associated with elevated pulse pressure in this population. A cohort of 5771 subjects from NHANES I was used to determine the value of adding pulse pressure to standard cardiovascular disease risk factors for assessment of the risk of death during a mean follow-up period of 16.5 years. Analyses were performed by use of the SUDAAN statistical package for performing Cox proportional regression, logistic regression, and other standard methods in complex, weighted samples. Pulse pressure increased with increasing age, body mass index, cholesterol level, and mean arterial pressure. With increasing pulse pressure, the percentage of cigarette smokers decreased and the percentage of diabetics increased. Despite these associations with known risk factors, pulse pressure was independently predictive of an increased risk of death from cardiovascular disease, coronary heart disease, and all-cause mortality. It provides independent prognostic information beyond that provided by known risk factors that were evaluated in this study, including the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure hypertension classification. A 10 mm Hg increase in pulse pressure in persons 25 to 45 of age was associated with a 26% increase in risk of cardiovascular death (95% confidence interval [CI], 5 to 50) and with an 10% increase (95% CI, 2 to 19) in persons 46 to 77 years of age. In a cohort designed to be representative of the US population, elevated pulse pressure has been shown to provide independent prognostic information. This variable may be a marker for the extent of vascular disease and may contribute to the occurrence of clinical events.

Patient-reported adherence to guidelines of the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

To compare antihypertensive drug compliance with treatment guidelines established by the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI), and to identify patient adherence to antihypertensive drugs and factors affecting prescribing patterns. Patients filling antihypertensive drug prescriptions in metropolitan New York area pharmacies were enrolled. Pharmacy externs collected patient-reported demographics, medical and drug histories, and blood pressure measurements. Compliance with JNC VI guidelines was assessed. Eight hundred twenty-one patients from 102 pharmacies participated. Blood pressure was controlled in 61% of patients at the time of the study. The most prescribed class of antihypertensive agents was angiotensin-converting enzyme inhibitors, followed by diuretics and beta-blockers. Over the study period, compliance with JNC VI guidelines decreased significantly from 85% to 64% (p<0.05). Thirty-seven percent of patients reported consistent adherence to their antihypertensive regimens. Patients' education level was the only factor found to correlate positively with the appropriateness of antihypertensive agents prescribed. Compliance with JNC VI guidelines decreased over time, and patient adherence to drug therapy was suboptimal. Continuing-education efforts to reinforce optimal blood pressure management are necessary.

The urgent need to improve hypertension care.

Hypertension is the most prevalent health problem among adult primary care patients, but its recognition and treatment are suboptimal. Although there is ample evidence from several large-scale randomized, controlled studies that treatment of hypertension reduces morbidity and mortality, current management of hypertension is characterized by underdiagnosis, misdiagnosis, undertreatment, overtreatment, and misuse of medications. As a result, roughly 75% of the estimated 50 million adults with hypertension in the United States are at increased risk for vascular complications. Optimal therapy requires careful attention to patients' age, sex, race, diet, exercise, tobacco use, comorbid conditions, choice of antihypertensive drug treatment, compliance with treatment, and achievement of blood pressure control. Other issues that deserve scrutiny are accuracy of the initial diagnosis, self-monitoring of blood pressure, and the advisability of attempting reduction of dosage or possible withdrawal from administration of antihypertensive drug treatment in patients whose blood pressures have been controlled for 1 year or more. Physicians' knowledge and use of the Sixth Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure report are deficient. Several responses to this current crisis in care of hypertensive patients are reviewed, including computer-aided management, medical chart audit, academic detailing, and a nurse case manager using prepared algorithms in consultation with the physician.

Combination Agents as a Means of Improving Adherence and Other Aspects of the Sixth Joint National Committee Report

Combination Agents as a Means of Improving Adherence and Other Aspects of the Sixth Joint National Committee Report

Combination Agents as a Means of Improving Adherence and Other Aspects of the Sixth Joint National Committee Report

Combination Agents as a Means of Improving Adherence and Other Aspects of the Sixth Joint National Committee Report

Hypertension in elderly patients: treatment reduces mortality, but is underused.

Recently published clinical trials provide compelling evidence of the effectiveness of antihypertensive therapy to reduce cardiovascular mortality. The Sixth Joint National Committee on Detection, Evaluation, and Treatment of Hypertension emphasizes that hypertension is undertreated in this country: only approximately one fourth of hypertensive persons have their blood pressure controlled to the current recommended level of less than 140/90 mm Hg. The point is especially pertinent to elderly patients, most of whom have hypertension. Moreover, most elderly hypertensive persons have systolic hypertension, which has an even stronger association with risk than does diastolic pressure. Current recommendations are reviewed.

Will better-tolerated antihypertensive agents improve blood pressure control?: JNC VI revisited

Although we have incontrovertible evidence for the benefits of treating hypertension, only a minority of Americans with this disorder have blood pressure readings at the levels currently recommended by the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Recent trials have shown that if physicians set a goal, they can regularly reduce blood pressure to suggested levels using standard therapy. The barriers to reaching that goal in practice can be overcome if well-tolerated agents are used, if the importance of adherence to the regimen is emphasized and effectively conveyed, and if practitioners utilize the services of hypertension specialists should a goal not be reached. The availability of newer agents that are virtually free of side effects and the clear understanding of the value of aggressively managing hypertension make it imperative that all clinicians understand how to most effectively use the many tools available.