Treatment Of Elevated Blood Pressure Research Articles

Blood pressure targets for hypertension in people with chronic renal disease.

Chronic kidney disease (CKD) is an independent risk factor for cardiovascular disease, development of end-stage renal disease, and all-cause mortality. It affects around 10% of the population worldwide. The prevalence of hypertension in people with CKD ranges from 22% in stage 1 to 80% in stage 4. Elevated arterial blood pressure is one of the major independent risk factors for adverse cardiovascular events. Thereby, reducing blood pressure to below standard targets may be beneficial but could also increase the risk of adverse events. The optimal blood pressure target in people with hypertension and CKD remains unknown. Primary: to compare the effects of standard and lower-than-standard blood pressure targets for hypertension in people with chronic kidney disease on mortality and morbidity outcomes. Secondary: to assess the magnitude of reductions in systolic and diastolic blood pressure, the proportion of participants reaching blood pressure targets, and the number of drugs necessary to achieve the assigned target. We used standard, extensive Cochrane search methods. We searched the Cochrane Hypertension Specialized Register, CENTRAL, MEDLINE, Embase, one other database, and two trial registers up to 8 February 2023. We also contacted authors of relevant papers regarding further published and unpublished work. We applied no language restrictions. We included randomized controlled trials (RCTs) in people with hypertension and CKD that provided at least twelve months' follow-up. Eligible interventions compared lower targets for systolic/diastolic blood pressure (130/80 mmHg or lower) to standard targets for blood pressure (140 to 160/90 to 100 mmHg or lower). Participants were adults with CKD and elevated blood pressure documented in a standard way on at least two occasions, or already receiving treatment for elevated blood pressure. We used standard Cochrane methods. Our critical outcomes were: total mortality, total serious adverse events, total cardiovascular events, cardiovascular mortality, and progression to end-stage renal disease. Important outcomes were: participant withdrawals due to adverse effects, and number of participants with a doubling of serum creatinine level or at least a 50% reduction in the glomerular filtration rate (GFR) at the end of the study. We used GRADE to assess the certainty of the evidence for the critical outcomes. This review received no funding. We included six RCTs that contributed data for meta-analysis, involving 7348 participants overall (range 840 to 4733 people per study). The mean follow-up was 3.6 years (range 1.0 to 8.0 years). Three studies were publicly funded, two were privately funded, and one had both public and private funding. All RCTs provided individual participant data. None of the included studies blinded participants or clinicians because of the need to titrate antihypertensive drugs to reach a specific blood pressure target. However, an independent committee blinded to group allocation assessed clinical events in all studies. Critical outcomes. Compared with standard blood pressure targets, lower targets likely result in little to no difference in total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.76 to 1.06; 6 studies, 7348 participants), total serious adverse events (RR 1.01, 95% CI 0.94 to 1.08; 6 studies, 7348 participants), and total cardiovascular events (RR 1.00, 95% CI 0.87 to 1.15; 5 studies, 6508 participants), all with moderate-certainty evidence. Compared with standard blood pressure targets, lower targets may result in little to no difference in cardiovascular mortality (RR 0.90, 95% CI 0.70 to 1.16; 6 studies, 7348 participants) and progression to end-stage renal disease (RR 0.94, 95% CI 0.80 to 1.11; 4 studies, 4788 participants), both with low-certainty evidence. Important outcomes. We found little to no differences in: participant withdrawals due to adverse effects; and the number of participants with a doubling of serum creatinine level, or at least a 50% reduction in GFR at the end of the study. Exploratory outcomes. Compared to the standard blood pressure target groups, participants in the lower target groups achieved lower systolic and diastolic blood pressure values after one year, and required a higher number of antihypertensive drugs at the end of the studies. A higher proportion of participants in the standard blood pressure target groups achieved the targets they were assigned than did participants in the intensive target groups. Compared to a standard blood pressure target, lower blood pressure targets probably result in little to no difference in total mortality, total serious adverse events, and total cardiovascular events, and may result in little to no difference in total cardiovascular mortality or in the progression to end-stage renal disease in people with hypertension and CKD. However, the evidence underpinning these conclusions has several limitations. All studies were open design, blood pressure measurement was performed at a medical office, and there was scant information about adverse events. Future research should include high-quality adverse event data, report results for people with different levels of proteinuria, and consider out-of-office blood pressure monitoring. Several studies are ongoing, and may provide new evidence for this topic in the near future.

Design and rationale for a randomized, open-label, parallel clinical trial evaluating major adverse cardiovascular events (pharmacological treatment versus diet control) in patients with high-normal blood pressure: the PRINT-TAHA9 trial

BackgroundThe distinction between normal and high blood pressure remains a debated topic, with varying guidelines on when to start medication. Contemporary guidelines advocate for the initiation of antihypertensive therapy in individuals who present with high-normal blood pressure, particularly those exhibiting elevated 10-year atherosclerotic cardiovascular disease (ASCVD) risk scores. Despite these recommendations, there is a notable lack of direct evidence supporting the efficacy of treating high-normal blood pressure to prevent major adverse cardiovascular events (MACE).MethodsThe PRINT-TAHA9 trial, a unicentric, randomized, open-label, controlled, parallel clinical study, seeks to explore the effects of intensive blood pressure control on MACE in participants with high-normal blood pressure. We will enroll 1620 adults aged 18 years and above with a systolic blood pressure range of 130–140 mmHg, diastolic blood pressure under 90 mmHg, and atherosclerotic cardiovascular disease (ASCVD) risk score exceeding 7.5%. The study will be executed in five distinct phases, with each phase enrolling between 300 and 400 participants. Participants will be randomly assigned to either the treatment group receiving antihypertensive medication (amlodipine/valsartan) and a low-salt/low-fat diet or to the control group receiving a similar diet. Follow-up visits are scheduled every 6 months over a 3-year period to monitor blood pressure, evaluate medication adherence, document any adverse events, and adjust the intervention as necessary. Cox proportional hazards regression analysis will be employed to examine the disparities between the two arms.DiscussionDespite guidelines promoting early treatment of elevated blood pressure, the debate continues due to insufficient evidence that such interventions significantly reduce the occurrence of MACE. This trial seeks to address this critical evidence gap.Trial registrationThe PRINT-TAHA9 trial was registered in October 2019 with the Iranian Registry of Clinical Trials (IRCT.ir) under the registration number IRCT20191002044961N1. https://irct.behdasht.gov.ir/trial/43092.

Preventive Cardiovascular Measures in Children with Elevated Blood Pressure.

Cardiovascular diseases are the leading cause of morbidity and mortality in developed countries and are becoming increasingly significant in developing nations. Many cardiovascular risk factors originate early in life, even prenatally. Elevated blood pressure and hypertension are gaining attention in paediatrics due to their rising prevalence and impact on early cardiovascular risk in adulthood. Along with non-modifiable risk factors for hypertension, several modifiable factors can be addressed through primordial and primary prevention, emphasising lifestyle modifications. When these measures fail and elevated blood pressure develops, early detection is crucial (secondary prevention). Regular blood pressure measurement, a simple and non-invasive procedure, should be a standard practice in paediatric clinical settings. Diagnosing elevated blood pressure and hypertension should adhere to recommended guidelines. Lifestyle modifications are the first-line therapy for primary hypertension in children; if a secondary cause is identified, targeted treatment can be implemented, but a healthy lifestyle remains essential. The early detection and treatment of high-risk blood pressure enable timely interventions to prevent complications (tertiary prevention). Collectively, these preventive measures aim to reduce the incidence of cardiovascular disease in adulthood. Furthermore, quaternary prevention seeks to avoid unnecessary or harmful medical interventions including unwarranted examinations and pharmacotherapy. This underscores the importance of accurate diagnosis and treatment of elevated blood pressure and hypertension and emphasises the need for primordial and primary prevention to minimise unnecessary clinical interventions.

Emergency Department Treatment of Elevated Blood Pressure in the Headache Patient

Emergency Department Treatment of Elevated Blood Pressure in the Headache Patient

Efficacy of acupuncture for hypertension in the elderly: a systematic review and meta-analysis.

Hypertension has now developed into a major public health problem worldwide. Under the existing antihypertensive drug treatment paradigm, problems such as decreasing drug resistance and increasing drug side effects can occur for elderly patients. Acupuncture, a core technique in the non-pharmacological treatment of Chinese medicine, plays an important role in the treatment of elevated blood pressure. This study aimed to systematically evaluate the effect of acupuncture alone or in combination with antihypertensive drugs on the efficiency of reducing blood pressure and controlling blood pressure in elderly patients with hypertension. Articles of randomized controlled trials of acupuncture for hypertension in the elderly published before November 2022 were searched in 7 databases. The methodological quality of the literature was evaluated using the Cochrane Risk of Bias Assessment Tool. The primary outcome was the efficiency rate of blood pressure reduction, and the secondary outcome was the change in blood pressure after treatment. This study conducted a systematic review and meta-analysis of 12 randomized controlled trials with a total of 1,466 subjects. Among the primary outcome-efficiency rate, acupuncture-only treatment (RR = 1.11, 95% CI: 1.03-1.20, P < 0.01) and acupuncture combined with antihypertensive drug treatment (RR = 1.18, 95% CI: 1.06-1.31, P < 0.01) were significantly different compared with drugs-only treatment. Among the secondary outcomes, SBP (MD: -4.85, 95% CI: -10.39 to -0.69, P = 0.09) and DBP (MD: -1.45, 95% CI: -5.35 to 2.45, P = 0.47) show no significant difference between acupuncture-only treatment and drug-only treatment. Compared to drugs-only treatment, acupuncture plus drugs has more significant efficiency in lowering SBP (MD: -9.81, 95% CI: -13.56 to -6.06, P < 0.01) and DBP (MD: -7.04, 95% CI: -10.83 to -3.24, P < 0.01). For elderly patients with hypertension, acupuncture-only treatment has the same efficiency and antihypertensive effect compared to drug therapy and acupuncture plus drugs outperforms drugs-only treatment. If the patients receive therapy with less frequency per week and longer duration, there will be a more obvious antihypertensive effect. Due to the methodological defects in the included study and the limited sample size of this paper, more well-designed randomized controlled trials are needed for verification. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022376407, PROSPERO (CRD42022376407).

Abstract 16549: Longitudinal Associations of Accelerometer-Based Sedentary Time and Physical Activity With Blood Pressure Progression From Childhood Through Young Adulthood: A 13-year Mediation and Isotemporal Substitution Study of 2513 Children

Introduction: Randomized controlled trials in the young population concluded that moderate-to-vigorous physical activity (MVPA) was ineffective in lowering blood pressure (BP). The associations of cumulative sedentary time (ST), light physical activity (LPA), and MVPA with BP from ages 11 - 24 years, the isotemporal substitution of ST with LPA or MVPA, and the mediation path through which movement behaviour exact their impact on BP was examined. Hypothesis: Increased ST would be associated with increased BP while cumulative LPA and MVPA would be associated with decreased BP. Methods: Altogether 2513 children (61% female) from the Avon Longitudinal Study of Parents and Children birth cohort, UK who had data on at least one time-point measure of accelerometer-based movement behaviour across the follow-up and complete BP measures at ages 11, 15, and 24 years clinic visits were studied. MVPA was categorized into ≥60mins/day or less according to WHO’s PA guidelines. Longitudinal associations and isotemporal substitutions were examined with generalized linear-mixed effect models whereas the mediation path was examined using structural equation models, adjusting for cardiometabolic and other lifestyle factors. Results: After full adjustment, a 1-minute cumulative ST from ages 11-24 years was positively associated with increased systolic BP (0.009 mmHg [95% CI 0.007 - 0.011]; p&lt;0.001), and diastolic BP. A 1-minute cumulative LPA was associated with decreased systolic BP (-0.007 mmHg [-0.009 - -0.004]; p&lt;0.001), but not diastolic BP. Persistent MVPA of ≥60mins/day was not associated with reduced systolic BP but paradoxically associated with increased diastolic BP (0.007 mmHg [0.002 - 0.013]; p=0.008). The longitudinal replacement of 10 minutes of ST with equal time in LPA during childhood, adolescence, and young adulthood cumulatively decreased systolic BP by -3 mmHg and diastolic BP by -2 mmHg during the 13-year follow-up period. Replacing 10 minutes of ST with 10 minutes of MVPA had no statistically significant effect. The positive association of ST with BP was fully mediated by lean mass (93% mediation). Conclusions: Future guidelines may emphasize the importance of early LPA intervention from childhood for the prevention and treatment of elevated BP.

Antihypertensive and Lipid-Lowering Medication Adherence in Young Adults With Youth-Onset Type 2 Diabetes

Youth-onset type 2 diabetes is associated with early development of chronic complications. Treatment of elevated blood pressure (BP), nephropathy, and dyslipidemia are critical to reduce morbidity. Data are needed on adherence to BP- and lipid-lowering medications in young adults with youth-onset diabetes. To assess adherence and factors associated with adherence to BP- and lipid-lowering medications in young adults with youth-onset type 2 diabetes and diagnoses of hypertension, nephropathy, or dyslipidemia. This cohort study measured medication adherence with 3 monthly unannounced pill counts at 2 time points 1 year apart during iCount, conducted during the last years (2017-2019) of the observational phase of the Treatment Options for Type 2 Diabetes in Adolescents and Youth study. Psychosocial factors associated with medication adherence were examined. Participants included individuals with youth-onset type 2 diabetes with hypertension, nephropathy, or dyslipidemia receiving diabetes care in their communities. Data were analyzed from September 2022 to September 2023. The main outcome was BP- and lipid-lowering medication adherence, with low adherence defined as using less than 80% of pills and high adherence, at least 80% of pills. Psychosocial factors were measured using the Beliefs about Medicines Questionnaire and Material Needs Insecurities Survey. Of 381 participants in iCount, 243 participants (mean [SD] age, 26.12 [2.51] years; 159 [65.43%] women) with hypertension, nephropathy, or dyslipidemia were included in analysis. Among 196 participants with hypertension or nephropathy, 157 (80.1%) had low adherence. Participants with low adherence, compared with those with high adherence, were younger (mean [SD] age, 25.99 [2.41] vs 27.26 [2.41] years; P = .005), had higher glycated hemoglobin A1c (mean [SD], 10.33% [2.66 percentage points] vs 8.85% [2.39 percentage points]; P = .001), shorter diabetes duration (mean [SD], 12.32 [1.49] vs 12.90 [1.46] years; P = .03), and less education (eg, 17 participants [10.83%] vs 0 participants with no high school diploma; P = .004). Of 146 participants with dyslipidemia, 137 (93.8%) had low adherence and only 9 participants (6.2%) had high adherence. Of 103 participants with low adherence to BP-lowering medications and using oral hypoglycemic agents, 83 (80.58%) had low adherence to oral hypoglycemic agents. Beliefs that medications are necessary were higher for participants with high adherence to BP-lowering medications than those with low adherence in unadjusted analyses (mean [SD] necessity score, 16.87 [6.78] vs 13.89 [9.15]; P = .03). In adjusted multivariable analyses of participants with hypertension or nephropathy, having at least 1 unmet social need (odds ratio [OR], 0.20; 95% CI, 0.05-0.65; P = .04) and medication concerns (OR, 0.63; 95% CI, 0.40-0.96; P = .01) were associated with worse medication adherence 1 year follow-up. Diabetes distress, self-efficacy, depressive and anxiety symptoms, and self-management support were not associated with 1-year medication adherence. These findings suggest that adherence to BP- and lipid-lowering medications was very poor in this cohort. To improve medication adherence and prevent early vascular events, approaches that identify and address medication concerns and unmet social needs are needed.

346 Stroke Risk After Emergency Department Treatment of Elevated Blood Pressure in Transient Ischemic Attack

346 Stroke Risk After Emergency Department Treatment of Elevated Blood Pressure in Transient Ischemic Attack

Effect of Self‐Reported Anxiety Levels on Blood Pressure Responses to Slow Breathing

Anxiety, an emotion involved in the development and presentation of anxiety disorders, is linked to elevated blood pressure (BP) which may contribute to the increased cardiovascular disease risk observed in individuals diagnosed with anxiety disorders. Slow breathing (SB), defined as a respiration rate below 10bpm, has been implemented successfully to reduce BP in several clinical populations. However, to the best of our knowledge, the efficacy of SB has yet to be investigated in individuals with anxiety. Therefore, the purpose of this study was to compare BP responses to an acute bout of SB between individuals with moderate to severe anxiety and individuals with no or mild levels of anxiety. We hypothesized that individuals with moderate/severe anxiety levels would exhibit greater SB‐induced decreases in BP compared to individuals with no/mild anxiety levels. We assessed 14 young (18‐25 years old) lean (body mass index &lt; 24.9kg/m2) non‐smoking individuals with moderate/severe anxiety levels (n=7), as well as age‐ and body mass index‐matched individuals with no/mild anxiety levels during 15‐mins of rest and during 15‐mins of device‐guided SB (RESPeRATE). Anxiety levels were assessed using the Hospital Anxiety and Depression Scale, in which participants with a score of at least 8 were categorized as having a moderate/severe anxiety score (ANX) and individuals with scores less than 8 were classified as having no/mild anxiety levels (CTRL). Respiratory patterns were monitored via respitrace strain gauge. Beat‐by‐beat BP was measured using finger photoplethysmography calibrated to values obtained from manual sphygmomanometry. Respiratory and systolic BP (SBP) data were extracted averaged across 5‐mins of steady state rest and during the final 5‐mins of SB; differences between ANX and CTRL were evaluated using unpaired t‐tests. Despite similar resting SBP between ANX and CTRL (111.28 ± 11.40 vs 109.39 ± 7.05mmHg; p=0.75), the SBP response to SB differed between ANX and CTRL (‐2.18 ± 4.84 vs 3.57 ± 4.47mmHg; p=0.04). In fact, ANX experienced a clinically meaningful SB‐induced reduction in BP (defined as a change greater than or equal to 2 mmHg) that was absent in CTRL. Interestingly, resting respiration rates were higher in ANX than CTRL (13.33 ± 4.07 vs 7.74 ± 2.18bpm; p&lt;0.01), and reductions in respiration rate during SB were greater in ANX than CTRL (‐9.27 ± 3.74 vs ‐2.66 ± 2.19bpm; p&lt;0.01). Taken together, in a young and relatively healthy cohort of individuals with a range of self‐reported anxiety levels, it appears that SB is effective in lowering SBP in individuals with moderate or high levels of anxiety but has no effect in individuals reporting no or low levels of anxiety. Thus, SB may be an effective intervention to reduce BP in individuals with high anxiety levels, which may have long‐term implications in the treatment of elevated BP and reduction of cardiovascular disease risk in individuals diagnosed with anxiety disorders.

Abstract 90: Meta-analysis Of Early Treatment Of Hypertension In Acute Ischemic Stroke And Functional Outcome

Introduction: Elevation in blood pressure (BP) in the early period following acute ischemic stroke (AIS) is frequent and likely due to a physiologic response to neurologic insult, damage to specific structures, and failure of cerebral autoregulation. It remains unclear whether early treatment of elevated BP after AIS influences clinical outcome in these patients. This meta-analysis aimed to investigate if treatment of sustained elevations in BP in the early period following AIS leads to a reduced risk of poor functional outcome. Method: Systematic review identifying randomized-controlled, double-blinded trials of AIS patients between 1994-2020 comparing those who receive anti-hypertensive medications within 72 hours of symptom-onset to those who do not receive medication. The primary outcome was poor functional outcome (defined by mRS &gt; 2 at 90 days). Results were pooled using inverse variance random effects meta-analyses. Conclusions accounted for the magnitude of effect, precision, and risk of bias in the studies using the modified GRADE process of the American Academy of Neurology (AAN). Results: Ten randomized-controlled double-blinded studies totaling 15762 AIS patients met inclusion criteria. Baseline patient characteristics were without significant confounders. Mean symptom-onset to treatment time was 3-72 hours. The duration of treatment ranged from 3-90 days. Antihypertensive medications used included calcium-channel blockers, angiotensin receptor blockers, ACE-inhibitors, nitrates, and diuretics. Overall, poor functional outcome occurred in 32.4% of patients. There was no statistical difference in poor functional outcome in patients treated with antihypertensive medications within 72 hours of symptom-onset vs no treatment (OR=1.05, CI 95% 0.93-1.18). Conclusion: For the early period following AIS, treatment of sustained elevations in BP does not reduce the risk of mRS &gt; 2 at 90 days. Confidence in the evidence is strong, anchored by selection of large randomized-controlled, double-blinded trials. Limitations include variable BP medications, initial stroke severities, and AIS mechanisms.

Understanding Barriers to Adherence to Optimal Treatment of Elevated Blood Pressure and Hypertension—Insights From Primary Care

Understanding Barriers to Adherence to Optimal Treatment of Elevated Blood Pressure and Hypertension—Insights From Primary Care

Suboptimal blood pressure control and associated risk for cardiovascular mortality among stroke survivors in China

Abstract Background Elevated blood pressure (BP) is associated with substantial morbidity and mortality in stroke survivors. China has approximately 7.5 million stroke survivors, and accounts for one third of stroke mortality worldwide, but little is known about the prevalence and management of elevated BP as well as its effect on cardiovascular death at the national level. Purpose We aim to describe the prevalence and treatment of elevated BP and assess the cardiovascular mortality attributable to elevated BP among stroke survivors in China. Methods Based on 3 million participants aged 35–75 years from all 31 provinces in mainland China recruited from September 2014 through August 2019, we assessed the prevalence and treatment of elevated BP (systolic BP ≥140mmHg or diastolic BP ≥90mmHg) among those with self-reported stroke. Cardiovascular death was recorded before December 31st 2019. The age- and sex- specific population attributable fractions of cardiovascular death from elevated BP were estimated based on hazard ratios derived by Cox regression analysis. Results Among 91,628 stroke survivors, the mean (SD) age was 62 (8) years, 49% were male sex. The median (IQR) stroke duration was 4 (2,7) years. 61.3% of the individuals had elevated BP, and the prevalence increased with age (from 47.6% at 35–44 years of age to 64.7% at 65–75 years of age) and was slightly higher in rural area (63.2%) than urban area (58.8%). 32.7% of the overall population were treated, and 23.4% of those with elevated BP were treated. Among stroke survivors, elevated BP accounted for 26% of cardiovascular death at 35–75 years of age, and about one third at 35–54 years of age. The age- and sex- specific results were shown in the Table. Conclusions In this nationwide cohort of stroke survivors from China, over 60% had elevated BP, and about one third were treated. Elevated BP was associated with particularly substantial cardiovascular mortality for young and middle-aged stroke survivors. National strategies targeting elevated BP are required to improve the prognosis of stroke survivors in China. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Key Research and Development Program from the Ministry of Science and Technology of China Age- and sex-specific HRs and PAFs

Physical Activity as a Critical Component of First-Line Treatment for Elevated Blood Pressure or Cholesterol: Who, What, and How?: A Scientific Statement From the American Heart Association.

Current guidelines published by the American Heart Association and the American College of Cardiology broadly recommend lifestyle approaches to prevent and treat elevated blood pressure and cholesterol. For patients with mildly or moderately elevated blood pressure and blood cholesterol, lifestyle-only approaches are the first line of therapy. The purpose of this scientific statement is to: (1) highlight the mild-moderate-risk patient groups indicated for lifestyle-only treatment for elevated blood pressure or cholesterol; (2) describe recommendations, average effects, and additional considerations when prescribing lifestyle treatment with physical activity; and (3) provide guidance and resources for clinicians to assess, prescribe, counsel, and refer to support increased physical activity in their patients. An estimated 21% and 28% to 37% of US adults, respectively, have mild-moderate-risk blood pressure and cholesterol and should receive lifestyle-only as first-line treatment. Of the recommended lifestyle changes, increasing physical activity has extensive benefits, including improving both blood pressure and blood cholesterol, that are comparable, superior, or complementary to other healthy lifestyle changes. Physical activity assessment and prescription are an excellent lifestyle behavior treatment option for all patients, including for the large population of mild-moderate-risk patients with elevated blood pressure and blood cholesterol.

The Story of Intracerebral Hemorrhage: From Recalcitrant to Treatable Disease.

This invited special report is based on an award presentation at the World Stroke Organization/European Stroke Organization Conference in November of 2020 outlining progress in the acute management of intracerebral hemorrhage (ICH) over the past 35 years. ICH is the second most common and the deadliest type of stroke for which there is no scientifically proven medical or surgical treatment. Prospective studies from the 1990s onward have demonstrated that most growth of spontaneous ICH occurs within the first 2 to 3 hours and that growth of ICH and resulting volumes of ICH and intraventricular hemorrhage are modifiable factors that can improve outcome. Trials focusing on early treatment of elevated blood pressure have suggested a target systolic blood pressure of 140 mm Hg, but none of the trials were positive by their primary end point. Hemostatic agents to decrease bleeding in spontaneous ICH have included desmopressin, tranexamic acid, and rFVIIa (recombinant factor VIIa) without clear benefit, and platelet infusions which were associated with harm. Hemostatic agents delivered within the first several hours have the greatest impact on growth of ICH and potentially on outcome. No large Phase III surgical ICH trial has been positive by primary end point, but pooled analyses suggest that earlier ICH removal is more likely to be beneficial. Recent trials emphasize maximization of clot removal and minimizing brain injury from the surgical approach. The future of ICH therapy must focus on delivery of medical and surgical therapies as soon as possible if we are to improve outcomes.

Blood pressure targets in adults with hypertension.

This is the first update of this review first published in 2009. When treating elevated blood pressure, doctors usually try to achieve a blood pressure target. That target is the blood pressure value below which the optimal clinical benefit is supposedly obtained. "The lower the better" approach that guided the treatment of elevated blood pressure for many years was challenged during the last decade due to lack of evidence from randomised trials supporting that strategy. For that reason, the standard blood pressure target in clinical practice during the last years has been less than 140/90 mm Hg for the general population of patients with elevated blood pressure. However, new trials published in recent years have reintroduced the idea of trying to achieve lower blood pressure targets. Therefore, it is important to know whether the benefits outweigh harms when attempting to achieve targets lower than the standard target. The primary objective was to determine if lower blood pressure targets (any target less than or equal to 135/85 mm Hg) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (less than or equal to 140/ 90 mm Hg) for the treatment of patients with chronic arterial hypertension. The secondary objectives were: to determine if there is a change in mean achieved systolic blood pressure (SBP) and diastolic blood pressure (DBP associated with "lower targets" as compared with "standard targets" in patients with chronic arterial hypertension; and to determine if there is a change in withdrawals due to adverse events with "lower targets" as compared with "standard targets", in patients with elevated blood pressure. The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up toMay 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 4), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. Randomised controlled trials (RCTs) comparing patients allocated to lower or to standard blood pressure targets (see above). Two review authors (JAA, VL) independently assessed the included trials and extracted data. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure, end stage renal disease, and other serious adverse events. Secondary outcomes were achieved mean SBP and DBP, withdrawals due to adverse effects, and mean number of antihypertensive drugs used. We assessed the risk of bias of each trial using the Cochrane risk of bias tool and the certainty of the evidence using the GRADE approach. MAIN RESULTS: This update includes 11 RCTs involving 38,688 participants with a mean follow-up of 3.7 years. This represents 7new RCTs compared with the original version. At baseline the mean weighted age was 63.1 years and the mean weighted blood pressure was 155/91 mm Hg. Lower targets do not reduce total mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.86 to 1.05; 11 trials, 38,688 participants; high-certainty evidence) and do not reduce total serious adverse events (RR 1.04, 95% CI 0.99 to 1.08; 6 trials, 18,165 participants; moderate-certainty evidence). This means that the benefits of lower targets do not outweigh the harms as compared to standard blood pressure targets. Lower targets may reduce myocardial infarction (RR 0.84, 95% CI 0.73 to 0.96; 6 trials, 18,938 participants,absolute risk reduction (ARR) 0.4%, number needed to treat to benefit (NNTB) 250 over 3.7 years) and congestive heart failure (RR 0.75, 95% CI 0.60 to 0.92; 5 trials, 15,859 participants,ARR 0.6%, NNTB167 over 3.7 years) (low-certainty for both outcomes). Reduction in myocardial infarction and congestive heart failure was not reflected in total serious adverse events. This may be due to an increase in other serious adverse events (RR 1.44, 95% CI 1.32 to 1.59; 6 trials. 18,938 participants,absolute risk increase (ARI) 3%, number needed to treat to harm (NNTH) 33 over four years) (low-certainty evidence). Participants assigned to a "lower" target received one additional antihypertensive medication and achieved a significantly lower mean SBP (122.8 mm Hg versus 135.0 mm Hg,and a lower mean DBP (82.0 mm Hg versus 85.2 mm Hg,than those assigned to "standard target". For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets. The results of this review are primarily applicable to older people with moderate to high cardiovascular risk. They may not be applicable to other populations.

Blood pressure after PREeclampsia/HELLP by SELF monitoring (BP-PRESELF): rationale and design of a multicenter randomized controlled trial

BackgroundHypertensive disorders of pregnancy (HDP), such as preeclampsia (PE) or the Hemolysis Elevated Liver enzymes and Low Platelets (HELLP) syndrome are associated with elevated cardiovascular disease (CVD) risks, but standardized prevention guidelines after such pregnancies are lacking. Hypertension is the first emerging risk factor after PE/HELLP pregnancies and is a major risk factor for CVD. Hypertension before the age of 55 years may lead to various manifestations of end-organ damage at relatively young age. Therefore, timely treatment of elevated blood pressure is mandatory, but many of these high-risk women have long-term undetected and untreated hypertension before adequate treatment is initiated.AimThe aim of our study is to assess whether home blood pressure monitoring (HBPM) in women with a previous PE/HELLP pregnancy is a valuable tool for the early detection of hypertension.MethodsWomen with a history of both early and late PE/HELLP syndrome aged 40–60 years are invited to participate. Patients with a history of CVD, known hypertension and/or use of antihypertensive medication are excluded. Women are randomized between HPBM or ‘usual care’. The primary outcome is feasibility and usability of HBPM after 1 year of follow-up.Secondary outcomes will be the effectiveness of HPBM to detect hypertension, the efficacy of BP treatment, quality of life, health-related symptoms, work ability, and life-style behaviour.The results of this study will provide better strategies for timely detection and prevention of hypertension in women after PE/HELLP.Trial registrationClinicalTrials.gov, NCT03228082. Registered June 15, 2017.

Hypertension in children in sub-Saharan Africa: primordial prevention is crucial

Hypertension in children in sub-Saharan Africa: primordial prevention is crucial

60. Blood pressure after PREeclampsia/HELLP by SELF monitoring (BP-PRESELF): Rationale and design of a multicenter randomized controlled trial

Background Hypertensive pregnancy disorders (HPD) such as preeclampsia (PE) or the hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome are associated with an elevated cardiovascular disease (CVD) risk. Standardized prevention guidelines after pregnancy in these high-risk women are lacking. Hypertension is the first emerging risk factor after PE/HELLP pregnancies and is acknowledged as a major risk factor for CVD. Premature hypertension leads to various manifestations of end-organ damage at young age. Timely treatment of elevated blood pressure is mandatory, despite many of these women have long-term undetected and untreated hypertension before adequate treatment is initiated. Hypothesis The aim of our study is to assess whether home blood pressure monitoring (HBPM) in women with a previous pregnancy with PE/HELLP is a valuable tool for early detection of hypertension. Methods Women with a history of PE/HELLP syndrome (both early and late) aged 40–60 years are invited to participate. They are randomized between HPBM or ‘usual care’. Patients with a history of CVD, known hypertension and/or use of antihypertensive medication are excluded. The primary outcome is to evaluate feasibility and usability of HBPM after 1 year of follow-up. Secondary outcomes will be to assess the effectiveness of blood pressure (BP) home monitoring to detect hypertension, the efficacy of BP treatment, quality of life (QoL), health-related symptoms, work ability and life-style behaviour. Discussion The results of this study will provide information for optimal preventive strategies to detect hypertension in women after PE/HELLP.

Prevention: Saving lives: the importance of having Resolve.

Cardiovascular disease is the world's leading cause of death, with a disproportionate burden in low-income and middle-income countries. The Resolve initiative — eliminating artificial trans fats, reducing dietary sodium, and improving treatment of elevated blood pressure — is a substantial step in the right direction, but more combined efforts will be required.

Abstract P183: Visit to Visit Variability in Diastolic Blood Pressure Predicts Incident Cardiovascular Disease Events in Middle-aged Adults

Introduction: visit-to-visit variability (VVV) in blood pressure (BP) relates to risk for cardiovascular disease (CVD) in clinical studies. It is unknown if VVV in systolic or in diastolic BP predicts incidents CVD in community-based middle-aged adults. Methods: The study sample comprised 1817 Framingham Heart Study (FHS) offspring cohort participants free of clinical CVD at the sixth examination (1995-1998) cycle who had attended examination cycles three, four and five at four year intervals. Exclusion criteria include medication treatment for elevated BP at any of the four examinations. We defined VVV in systolic and diastolic BP as the standard deviation of BP values across the four examinations. Incident CVD events were identified through physician panel review of medical records with follow-up through December 31, 2013. We used proportional hazards regression models to test associations of between VVV in systolic and diastolic BP and CVD risk adjusting for age, sex, body-mass-index, mean systolic and diastolic BP, total cholesterol, HDL cholesterol, medication treatment for hyperlipidemia, fasting blood sugar, diabetes, and cigarette smoking. Results: During follow up (average 16.2 years), 276 (15.2%) participants developed CVD. Mean and standard deviation values of VVV in systolic and diastolic BP were 8.09±4.48 and 5.38±2.5, respectively. Each standard deviation increase in diastolic BP VVV was associated with a hazards ratio (HR) of 1.08 (95% confidence interval [CI] 1.03-1.14) for incident CVD. The HR of systolic BP VVV was 1.03 (95% CI 1.00-1.06). Including both variables gave an HR of 1.01 (95% CI 0.98-1.04) for VVV in systolic BP and 1.08 (95% CI 1.03-1.13) for VVV in diastolic BP. There were significant linear trends in CVD risk according to quartiles of VVV in systolic and diastolic BP. Participants in the highest quartile of VVV in systolic BP had a HR of 1.68 (95% CI 1.13-2.50) for incident CVD; those with highest quartile of VVV in diastolic BP had a HR of 1.66 (95% CI 1.17--2.35). Conclusion: Visit-to-visit variability in BP predicts CVD risk in middle-aged adults.