Hypertension, Intracranial Pulsatility and Brain Amyloid-beta Accumulation in Older Adults (HIPAC Trial)
Phase: PHASE2
Conditions: Hypertension
Sponsor: University of Texas Southwestern Medical Center

STUDY PROTOCOL AND STATISTICAL ANALYSIS PLAN 
 
 
Official title: Hypertension, intracranial pulsatility and brain Amyloid-
beta Clearance (HIPAC) trial 
 
NCT number: NCT03354143 
IRB approved date: 10-05-21 

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Hypertension, intracranial pulsaƟlity and brain Amyloid-beta Clearance 
(HIPAC) trial 
 
 
Funding Sponsor:  
NaƟonal InsƟtutes on Aging (NIA) 
 
 
 
Protocol Version 1.0 
 
 
October 19, 2017 
 

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SecƟon 1. IntroducƟon 
MounƟng evidence indicates that it is the reducƟon in brain Aβ clearance, rather than its overproducƟon 
which is likely to be the underlying mechanism for late-onset AD (>99% cases in the general 
populaƟon).1, 2 Furthermore, brain Aβ and tau accumulaƟon accelerates age-related cogniƟve decline, 
even in cogniƟvely normal older adults.3-6 The recognized brain Aβ clearance pathways include: 1) 
astrocyte phagocytosis and enzymaƟc degradaƟon of aggregated Aβ;7 2) transportaƟon of soluble Aβ 
from the intersƟƟal ﬂuid (ISF) to CSF with subsequent reabsorpƟon into venous blood and/or the 
cervical lymphaƟc system; 8-11 and 3) direct transportaƟon of Aβ across the blood brain barrier (BBB) into 
the venous blood.2  At present, the relaƟve contribuƟons of these pathways in brain Aβ and tau 
clearance remain unknown. A recent study in young and middle aged subjects suggests that direct 
transport of Aβ across the BBB accounts for ~ 25%, and the CSF reabsorpƟon pathway accounts for 
another ~ 25% of brain Aβ clearance.2 
Importantly, the presence of intracranial pulsaƟlity has been recognized as the driving force for brain Aβ 
and tau clearance through these pathways, and alteraƟons in intracranial pulsaƟlity have been linked to 
the changes in brain Aβ and tau.8, 12 However, whether this mechanism funcƟons similarly in humans 
remains unknown. In this project, we will determine whether changes in intracranial pulsaƟlity alter 
brain Aβ and tau homeostasis in older adults with hypertension.   
Hypertension exacerbates brain atrophy and WMH in older adults.13-15 Recent studies focus on a neural 
network-based approach to detect brain changes in hypertension at an early stage.16-18 For example, 
disrupƟons in brain white mater microstructural integrity and neural network funcƟonal connecƟvity 
were observed prior to the appearance of WMH.16, 18 Furthermore, a “dose-response” relaƟonship 
between elevated SBP and reducƟons in brain white mater integrity has been observed.16 However, 
most of these ﬁndings are from cross-secƟonal studies, and it remains to be determined whether 
intensive BP treatments improve brain white mater integrity and neural network funcƟonal connecƟvity. 
In this project, we will determine the eﬀects of intensive anƟhypertensive treatment on brain white 
mater integrity and neural network funcƟonal connecƟvity, with a focus on the default-mode neural 
network (DMN) and the frontoparietal network (FPN), as  these neural networks are sensiƟve to brain 
vascular damage, Aβ and tau deposiƟon even before morphological changes such as brain atrophy and 
WMH.18-20 To complement these neuroimaging studies, we will use the NIH Toolbox, a well validated test 
batery, to assess neurocogniƟve funcƟon, with a focus on episodic memory and execuƟve funcƟon 

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which are likely to be aﬀected by hypertension and anƟhypertensive treatment.21, 22 Of note, several 
studies have shown that anƟhypertensive treatments may prevent or slow progression of WMH in older 
adults.23, 24 An ongoing RCT also will determine whether intensive reducƟon of 24-hour  SBP has more 
beneﬁts on improving neurocogniƟve funcƟon and reducing WMH in older adults (≥75 yrs.) when 
compared to the standard care.25 These studies complement this project. However, the aims and 
outcome measures as well as the study populaƟon in these studies are diﬀerent from this project. 
 
SecƟon 2. ObjecƟves  
The overarching goal of this project is to test the hypothesis that intensive anƟhypertensive treatment 
alters intracranial pulsaƟlity, which in turn aﬀects brain Aβ and tau protein homeostasis. Furthermore, 
we will determine whether changes in intracranial pulsaƟlity, Aβ and tau are associated with brain white 
mater integrity and neural network funcƟonal connecƟvity. To achieve this goal, we will enroll 120 older 
adults age 55-79. Of those, 40 have normal BP (24- hour BP< 125/75 mmHg) and 80 have high SBP (24- 
hour SBP ≥125mmHg).26 Ambulatory 24- hour BP is used because it is a stronger predictor of 
cerebrovascular disease and cogniƟve decline in older adults than oﬃce BP.25, 27 PaƟents with 
hypertension will be randomized into a 12-month intensive treatment arm (24- hour SBP≤120 ) and a 
control arm of the standard care (24-H SBP≤ 130) (1:1) to accomplish the following aims: 
Aim 1: Determine the eﬀects of hypertension on intracranial pulsaƟlity, CSF Aβ and tau concentraƟon, 
brain white mater integrity and neural network funcƟonal connecƟvity. Hypotheses: Hypertension is 
associated with: 1) augmented central pulsaƟlity, but reduced intracranial pulsaƟlity measured with CINE 
phase-contrast MRI (PC-MRI); 2) reducƟons in CSF soluble Aβ42, but increases in phosphorylated tau and 
total tau; 3) disrupƟons in brain white mater integrity inferred by diﬀusion tensor imaging (DTI), and 
funcƟonal connecƟvity by resƟng-state fMRI (rs-fMRI), with a focus on the default-mode neural network 
(DMN) and the frontoparietal network (FPN).18, 20 We will determine whether group diﬀerences in 
intracranial pulsaƟlity, brain Aβ and tau are associated with white mater integrity and funcƟonal 
connecƟvity.  
Aim 2: Determine the eﬀects of intensive BP reducƟon on intracranial pulsaƟlity, CSF Aβ and tau 
concentraƟon, brain white mater integrity and neural network funcƟonal connecƟvity. Hypotheses: 
compared to standard care, intensive treatment confers more beneﬁts by: 1) reducƟons in central 
pulsaƟlity, but increases in intracranial pulsaƟlity; 2) increases in CSF Aβ42, but reducƟons in 

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phosphorylated tau and total tau; 3) improvement in brain white mater integrity and funcƟonal 
connecƟvity.  
 
SecƟon 3. ParƟcipant SelecƟon 
3.1 Eligibility 
The targeted populaƟon represents otherwise healthy normotensive and hypertensive adults without 
cogniƟve impairment. We will enroll 120 older adults age 55-79. Of those, 40 will have normal BP (24-
hour BP<125/75 mmHg) and 80 have high SBP (24-H SBP ≥125). Individuals with and without 
hypertension will be compared to accomplish Aim 1 to determine the eﬀects of hypertension on 
intracranial pulsaƟlity, brain Aβ and tau, white mater integrity and funcƟonal connecƟvity. AŌer baseline 
measurements, paƟents with hypertension will be randomized into a 12-month intensive treatment arm 
(24- hour SBP≤120) and a control arm of the standard care (24- hour SBP≤130) to accomplish Aim 2 to 
determine the eﬀects of intensive BP reducƟon on intracranial pulsaƟlity, brain Aβ and tau, white mater 
integrity and funcƟonal connecƟvity. Aim 1 and 2 are independent, but highly related to achieve the 
overarching goal of this project 
Table 1. Inclusion and exclusion criteria 
Inclusion Criteria 
1.   Age 55-79, all races/ethniciƟes, and both genders are eligible; 
2.   Mini-mental state exam (MMSE) > 26 to exclude cogniƟve impairment or demenƟa; 
3.   Healthy normotensive subjects (24-hour ambulatory BP<125/75 mmHg without use of 
anƟhypertensive medicaƟon); 
4.   PaƟents with hypertension deﬁned as 24-hour SBP ≥125 mmHg , paƟents on BP medicaƟons are 
eligible; 
5.   PaƟents with hypertension are willing to be randomized into either treatment group and ability 
to return to clinic or laboratory for follow-up visits over 12 months; 
6.   Fluency in English, adequate visual and auditory acuity to allow neuropsychological 
tesƟng; 
7.   Screening laboratory tests and ECG without signiﬁcant abnormaliƟes that might interfere 
with the study; 

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Exclusion Criteria 
1.    History of stroke, transient ischemic atack, traumaƟc brain injury or severe cerebrovascular 
disease by clinical diagnosis or past MRI/CT; 
2.    Diagnosis of AD or other type of demenƟa and neurodegeneraƟve diseases; 
3.    Evidence of severe depression or other DSM-V Axis I psychopathology 
4.    Unstable heart disease based on clinical judgment (heart atack/cardiac arrest, cardiac bypass  
procedures within previous 6 months and congesƟve heart failure), evidence of atrial ﬁbrillaƟon on 
ECG, or other severe medical condiƟons;  
5.    Chronic kidney diseases with GFR < 40 ml/min; 
6.    OrthostaƟc hypotension, deﬁned as standing SBP<100 mmHg for hypertensive medicated 
subjects; 
7.    History of signiﬁcant autoimmune disorders such as systemic lupus erythematosus, rheumatoid 
arthriƟs and polymyalgia rheumaƟca; 
8.    History of drug or alcohol abuse within the last 2 years; 
9.    Diagnosis of uncontrolled diabetes mellitus (fasƟng blood sugar ≥126 mg/dL or A1C >7.5% 
10.  ObstrucƟve sleep apnea; 
11.  Regularly smoking cigarete within the past year; 
12.  Severe obesity with BMI ≥ 45;   
13.  ParƟcipants enrolled in another invesƟgaƟonal drug or device study within the past 2 months; 
14.  CaroƟd stent or sever stenosis (> 50%); 
15.  Pacemaker or other medical device of metal that precludes performing MRI; 
16.  History of B12 deﬁciency or hypothyroidism (stable treatment for at least 3 months is allowable);  
17.  Any condiƟons judged by the study invesƟgators to be either medically inappropriate, or risky for 
parƟcipant or likely to have poor study adherence. 
18. Claustrophobia 
19. Pregnancy 
 
RaƟonale for Exclusion of Certain Study Candidates  
Subjects with uncontrolled diabetes mellitus will be excluded because cerebral autoregulaƟon is likely to 
be impaired in these individuals, which may lead to brain hypo perfusion during intensive lowering of 

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BP.28 Reasons for ineligibility and for non-parƟcipaƟon of eligible candidates will be recorded in the Study 
Screening Log.  
Inclusion of Women and MinoriƟes  
Both women and minoriƟes are included in this study.  However, non-English speaking paƟents will be 
excluded to allow for the implementaƟon and uniformity of neuropsychological tesƟng which requires 
ﬂuency in English. 
 
3.2 Recruitment  
Recruitment of healthy subjects will be conducted mainly by adverƟsement in local newspapers and 
from health fairs and senior centers. We have used these methods successfully to recruit older adults in 
our previous studies. Recruitment for paƟent with hypertension will be conducted mainly through the 
UTSW Medical Center aﬃliated hospital hypertension clinics. Dr. Vongpatanasin is the director of 
hypertension secƟon at the UTSW Medical Center. She has regular contact with other hypotension 
clinicians who will facilitate paƟent recruitment. AddiƟonal recruitment will be conducted via the Texas 
Health Resource (THR) Hospital Systems, which is the largest health care system in the North Texas and 
includes 25 major hospitals in the Dallas-Fort Worth area. Dr. Zhang’s Cerebrovascular Laboratory is 
located at the InsƟtute for Exercise and Environmental Medicine(IEEM), which is aﬃliated with THR. Dr. 
Zhang has established close collaboraƟons with THR clinicians to conduct clinical studies in hypertension 
and other chronic diseases in old adults. The experience learned and methods used for paƟent 
recruitment will be used in this project. AddiƟonally we will use the Research Registry Database within 
UTSW Medical Center, social media adverƟsements, and Craigslist posƟngs.  
Adherence and retenƟon:  BP treatment eﬀects are monitored during each study visit, and via regular 
telephone contact.  ParƟcipants will be asked to return all study medicines and botles (used and 
unused) at each visit to monitor compliance. Every eﬀort will be made to provide a friendly clinic 
environment and to minimize the study burden. Clearly writen instrucƟons for each of follow-up visits 
will be provided and kindly reminded and conﬁrmed with e-mails or phone calls. Time constraints and 
development of medical condiƟons are likely to occur in older adults. Study invesƟgators and staﬀ 
members will work closely with parƟcipants to idenƟfy and resolve problems if they would occur to 
enhance adherence. Our previous year-long longitudinal studies in older adults had a 10-15% of dropout 
rates. We anƟcipate that we will be able to maintain a similarly dropout rate in this project. 

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Study protocols and experiment procedures:  All study protocols and experimental procedures will 
conform to the local InsƟtuƟonal Review Board (IRB) requirements as well as ethical consideraƟons for 
protecƟon of human subjects in clinical studies, and will be approved by the UT Southwestern Medical 
Center and Texas Health Presbyterian Hospital of Dallas IRB. The informaƟon regarding the risks and 
beneﬁts of the study will be explained to the subjects in lay language. All subjects will be volunteers and 
will sign an insƟtuƟonally approved consent form before parƟcipaƟng in any experiments.  All subjects 
will complete a health quesƟonnaire and receive a comprehensive physical examinaƟon, including 12-
lead electrocardiogram prior to parƟcipaƟng in the study. 
 
3.3.2 Informed Consent and Screening Visits 
Overview of study events -  Phone screening: IniƟal phone screen will assess the key inclusion and 
exclusion criteria and willingness and suitability for this study.  In-person screening will include informed 
consent, a physical exam including 12 lead ECG, a comprehensive review of medical history and 
medicaƟon, and further evaluaƟon of inclusion and exclusion criteria. Baseline evaluaƟon consists of 2 or 
3 visits within ~ 6 weeks to complete all measures (Table 1, procedures will be combined as much as 
possible to reduce visit burden). Control subjects will complete only baseline evaluaƟon. AŌer baseline, 
paƟents with hypertension will be randomized to the intervenƟon arms. Follow-up evaluaƟons will be 
performed at 6 and 12 months to track changes in intracranial pulsaƟlity, brain perfusion, structure and 
funcƟon (Table 1). All visits at each follow-up will be completed within a Ɵme window of ± 3 weeks. 
Scheduled in-person and phone checks: Research personnel will meet with the study parƟcipants and/or 
conduct phone assessments to review medicaƟon bi-weekly during the ﬁrst 1-3 months aŌer 
randomizaƟon and monthly aŌerwards during the whole study period to monitor safety and to enhance 
compliance. Similar contacts will be made in the standard care and intensive treatment arms. 

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3.3.2.1 Screening Visits 
Screening visits will include: informed consent (also HIPAA & GeneƟc consents), a physical exam, 
baseline ECG, and a review of medical 
history, concomitant medicaƟons and a 
further evaluaƟon of inclusion and exclusion 
criteria. The in-person screening is 
anƟcipated to take a total of 5 hours and 
may require two visits. Up to 3 weeks are 
permited to allow for compleƟon of all screening procedures.  
During screening visits, medical condiƟons not previously known to the subject or study staﬀ may be 
idenƟﬁed. If these condiƟons result in a failure to meet the inclusion and exclusion criteria, those 
individuals will be considered ineligible for the study. Subjects, who are unable to keep commitments to 
the screening or baseline visits due to a change in residence locaƟon, work or family responsibiliƟes or a 
loss of transportaƟon will also be considered as ineligible for the study. 
 
3.3.2.2 Screening Visit 1 (SV1) 
Informed Consent 
The IRB-approved informed consent/HIPAA/geneƟc consent forms will be provided to and discussed with 
the parƟcipants. Opportunity will be given to ask quesƟons, and answers will be provided by the study 
coordinator and/or the invesƟgators or the study physicians. The consent forms signed by the 
parƟcipants will be maintained at the PI’s laboratory at each site. All study procedures will conform to 
ethical consideraƟons as approved by the local InsƟtuƟonal Review Boards (IRB) for Human Subjects. 
 
Inclusion/Exclusion Criteria 
Review to conﬁrm that all inclusion/exclusion criteria are saƟsﬁed. Individuals who meet criteria for 
enrollment and are willing to be followed longitudinally will be oﬀered the opportunity to parƟcipate. 
 
Table 1 Outline of procedures 
Procedure 
Baseline 
6 mo 
12 mo 
Informed consent 
X 
 
 
Neuropsychological tesƟng  
X 
X 
X 
Structural, funcƟonal and CINE PC- MRI  
X 
X 
X 
CSF and Blood sample collecƟon
X
X

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Seated Blood Pressure (BP) 
BP will be measured on the right arm (unless a known history of higher leŌ arm blood pressure) at siƫng 
posiƟon using a standard automated BP device: Welch Allyn Connex® Vital Signs Monitor series 6000. BP 
measurements should be taken aŌer resƟng quietly for > 5 minutes. Three measurements will be 
performed approximately 1 minute apart. The staﬀ should record all BP measurements. For BP 
calculaƟon, the staﬀ should discard the 1st measurement and take the average of measurements 2 and 3.   
 
Standing Blood Pressure/OrthostaƟc hypotension  
AŌer siƫng blood pressure measurements, parƟcipants will be asked to stand up to measure standing 
blood pressure. The staﬀ will take 3 sequenƟal BP measurements immediately aŌer parƟcipant stand. 
ParƟcipants are eligible if there is not a reducƟon in SBP < 100 mmHg based on the 3rd measurement (may 
be rescreened if orthostaƟc hypotension is not accompanied by symptoms of dizziness, pre-syncope or 
syncope). Normotensive subjects whose standing SBP < 100 mmHg will be included based on clinical 
judgement of Dr. Vongpatanasin. Data will be recorded in the Form. 
 
Height, Weight and BMI 
Height and weight as well as body mass index (BMI) will be obtained according to the procedures in the 
MOP. Data will be recorded in the history Form. 
 
Mini-Mental State Exam (MMSE) 
The MMSE will be conducted as part of the screening eligibility criteria to exclude individuals with gross 
demenƟa. 29   
 
Subjects Demographics 
Demographic informaƟon will be collected in the history Form. 
 

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Subject Concussion History 
Subject traumaƟc brain injury (TBI)/concussion history will be obtained in the history Form. 
 
Subject MedicaƟons 
Current and history of medicaƟon will be collected in the history Form. 
 
Subject Health History 
Subject medical history will be collected in the history Form. 
 
Clinical Chemistry  
Blood samples (~ 10 ml) will be collected for hematocrit, hemoglobin A1c, and complete metabolic 
panel. Clinical laboratory tests will be conducted by Quest DiagnosƟcs, serving as a central clinical 
chemistry laboratory.   
 
Physical/Neurological Exam 
A medically qualiﬁed professional will perform a complete physical and neurological exam. Data from 
these exams will be recorded in the HIPAC Trial Screening Visit Form. 
 
Electrocardiogram (ECG) 
A12-lead ECG will be performed and interpreted by Dr. Vongpatanasin to assess the presence of cardiac 
rhythms/atrial ﬁbrillaƟon, ischemic cardiac disease, history of myocardial infarcƟon and/or leŌ 
ventricular hypertrophy.  
 
Urine Specimen  
24-hour urine collecƟon will be collected to measure sodium, phosphate, and magnesium intake.  
 
3.3.3 Baseline Visits 
The baseline visit should be completed in 3-4 visits and all the procedures must be completed within a 6-
week Ɵme period. Neuropsychological tesƟng should not be done the same day as a fasƟng blood draw. 

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The MRI should not be performed with fasƟng; therefore, staﬀ must provide parƟcipants snacks prior to 
iniƟaƟng the MRI if paired with fasƟng blood draw. 
Neuropsychological TesƟng and QuesƟonnaires 
• 
NeurocogniƟve funcƟon will be assessed using the NIH-Toolbox CogniƟon Batery.21, 30, 31  
• 
PaƟent Reported Outcomes of physical and mental health, cogniƟon and health-related QLF will 
be assessed using NIH PROMIS instruments. 
Clinical Chemistry 
FasƟng blood samples will be collected for the measurements of basic metabolic (BMP), lipid panel, 
magnesium level, and phosphorous level. Clinical laboratory tests will be conducted by the Quest 
DiagnosƟcs. 
Symptom Check: Clinical symptoms such as dizziness, headaches or back pain will be documented. 
MagneƟc Resonance Imaging (MRI) 
MRI of brain structure and funcƟon will be performed at baseline and aŌer 1 years or when subjects 
drop out from the study. MRI is a required procedure for all study parƟcipants during the eligible screen 
process and consent.  
Transcranial Doppler (TCD) AutoregulaƟon/Vascular funcƟon 
TCD and/or color coded duplex ultrasonography will be used to assess cerebral autoregulaƟon and 
cardiovascular funcƟon. Non-invasive arterial blood pressure, near infrared spectroscopy (NIRS), 
tonometry and respiratory carbon dioxide (CO2) using capnography will be used to measure changes in 
brain blood ﬂow, Ɵssue oxygenaƟon and arterial sƟﬀness. Cerebral autoregulaƟon and cardiovascular 
funcƟon will be assessed. ParƟcipants will avoid caﬀeine, strenuous exercise, and alcohol 24 hours prior 
to tesƟng. AddiƟonally, they will fast two hours prior to TCD appointment. 
3.4 RandomizaƟon and OrientaƟon Visit (Day 0) 
Hypertensive subjects will be randomized to one of two study arms and straƟﬁed by age and sex using a 
constant blocking factor. RandomizaƟon will be conducted by a staƟsƟcian at UTSW. For treatment 
assignment, research staﬀ will enter subject idenƟﬁcaƟon and straƟﬁcaƟon informaƟon for 
randomizaƟon.  

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3.4.1 Blinded Research Personnel  
Study personnel performing outcome assessments will be blinded to group assignment. The staƟsƟcian 
performing primary data analysis will also be blinded. IntervenƟon staﬀ, site safety oﬃcers, and 
individuals not involved in outcome measures will be considered unblinded in order to address safety 
concerns or adverse events.  
In case of an emergency, Dr. Vongpatanasin will determine if unbinding of a subject’s treatment 
assignment is warranted. Subject safety must always be the ﬁrst consideraƟon in making such a decision. 
If an invesƟgator or site staﬀ performing assessments is unblinded, the subject may remain in the study 
aŌer obtaining approval from the site PI and the reason(s) for making such a decision will be 
documented. 
3.4.2 RandomizaƟon and Study Arms  
Hypertensive subjects will be randomized into one of 2 study arms (The standard care arm and intensive 
treatment arm). BP target for the standard care group is chosen to be 24-hr SBP≤130 mmHg, equivalent 
to a clinic SBP≤140 mmHg.  The 24h SBP target for intensive arm is 24-hr SBP≤120 mmHg, equivalent to a 
clinic SBP≤130 mmHg.  Only authorized staﬀ will access the subject’s randomizaƟon scheme and obtain 
the study arm assignment during the orientaƟon visit. During this visit, the coordinator or designate, will 
provide the parƟcipant with a summary of informaƟon regarding their group assignment and will 
schedule the ﬁrst visit with the intervenƟon staﬀ based on the parƟcipant’s assigned group. The 
OrientaƟon Visit will be considered Day 0 of the study. All other visits will be scheduled from this date 
forward.  
 
SecƟon 4. IntervenƟons/First OrientaƟon Visit 
4.1 Standard Care   
Subjects in the standard care group will receive the same anƟhypertensive drug regimen as the intensive 
BP group in order to minimize potenƟal drug eﬀects on the study outcome. the BP target for the 
standard care group is chosen to be 24-H SBP≤130 mmHg, equivalent to a clinic SBP≤140 mmHg (Figure 
1).25, 26 ParƟcipants in this group may or may not be on treatment with one or more anƟhypertensive 
medicaƟons at the iniƟal visit. ParƟcipants on diﬀerent anƟhypertensive drugs are eligible during 
enrollment. They will be switched to the medicaƟons used in this project aŌer baseline measurement. 

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All clinical visits will be the same for the two groups. We will Ɵtrate anƟhypertensive drugs according to 
the protocol to achieve 24-Hr SBP to ≤130 mmHg (Figure 1). At each visit, parƟcipants will be asked 
about changes in medicaƟons. The study clinician may add, increase or reduce the dose, stop, or change 
anƟhypertensive drugs to reach the goal of lowering 24-Hr  SBP to < 130 mmHg or clinic SBP <140 
mmHg. To minimize subject discomfort during ƟtraƟon of anƟhypertensive medicaƟons, 24-Hr  
ambulatory BP (ABP) will not be obtained during all clinic visits but will be used to verify if the SBP 
reaches goal when clinic SBP is < 140 mmHg, unless parƟcipants are suspected to have signiﬁcantly 
lower out-of-oﬃce BP than clinic BP. 
 
4.2 Intensive Treatment 
We will Ɵtrate anƟhypertensive drugs according to the protocol to achieve 24-H SBP to < 120 mmHg, 
which is equivalent to a clinic SBP<130 mmHg (Figure 1). Calcium channel blocker (CCB, amlodipine) and 
angiotensin II receptor blocker (ARB, losartan) will be used as the ﬁrst line anƟhypertensive to treat 
hypertension; low dose chlorthalidone diureƟc, potassium-sparing diureƟc spironolactone, or doxazosin 
will be added if needed to reach the BP goal.  
The study clinician may add, increase or reduce the dose, stop, or change anƟhypertensive drugs to 
reach the goal of lowering 24-Hr  SBP < 120 mmHg in the interest of parƟcipant safety. To minimize 
subject discomfort during ƟtraƟon of anƟhypertensive medicaƟons, 24-Hr  ambulatory BP (ABP) will not 
be obtained during all clinic visits but will be used to verify if the 24-Hr  SBP reaches goal when clinic SBP 
is < 130 mmHg, unless parƟcipants are suspected to have signiﬁcantly lower out-of-oﬃce BP than clinic 
BP. 
4.2.1  Post RandomizaƟon (day 0) 

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Figure1. Hypertension Treatment Algorithm 
 
1) If 24-Hr SBP is ≥130 mmHg while not on any BP meds, start amlodipine 2.5 mg and losartan 
12.5 mg once daily. 
2) If 24-Hr SBP is ≥130 mmHg while on 1 anƟhypertensive medicaƟon, stop current meds and 
start amlodipine 5 mg and losartan 25 mg once daily. 
3) If 24-Hr SBP is ≥130 mmHg while on 2 or more anƟhypertensive medicaƟons, stop current 
meds and start amlodipine 10 mg and losartan 50 mg once daily.   
 
NOTE: Doses of amlodipine and losartan may change based on a clinical judgment 
 
4) Schedule Subject’s BP and Quest lab test for the 2 week Post RandomizaƟon follow up visit 
(i.e., 2 weeks from starƟng BP medicaƟon ). 
5) Document all informaƟon including visit BP, previous treatment and reason for changing 
medical regimen or drug dosing in the case report form 
 
PaƟent Reminders 
 

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1) Instruct subjects to take their current dose of BP and all other medicaƟons on the day of their 
next visit so that drug dosing can be Ɵtrated accurately at their next visit. 
2)  Instruct subjects to bring pill botles, empty or not, to their next visit. 
 
4.2.2.  2 Weeks Post RandomizaƟon 
Obtain random blood draw for basic metabolic panel and seated/standing BP measurement. 
Blood Pressure Management 
 
1) If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive 
arm), double the dose of amlodipine up to maximal dose of 10 mg daily (e.g., if paƟent is 
taking 2.5 mg daily, increase to 5 mg; if paƟent is taking 5 mg daily, increase to 10 mg). 
2) If subject is taking maximal dose of amlodipine (10 mg) and repeated serum K is < 5.0 and 
serum creaƟnine (Cr) increases by < 25% from baseline (screening) lab results, double the 
dose of losartan up to maximal dose of 100 mg daily,(e.g., if paƟent is taking 25 mg daily, 
increase to 50 mg; if paƟent is taking 50 mg daily, increase to 100 mg).  
3) If clinic SBP is sƟll above target (≥140 mmHg for standard arm and (≥130 mmHg for intensive 
arm) and paƟent is already taking maximal dose of amlodipine (10 mg) plus losartan 100 mg 
daily or serum Cr increases by at least 25% from baseline (screening) lab results while on less 
than maximal dose of losartan, add a THIRD drug from the following choices: 
 
• 
If serum Cr increases by 25% or more from baseline (screening) lab results regardless of 
serum K, add doxazosin 2 mg daily. 
• 
If repeated serum K is ≥ 3.8 and serum Cr increases by < 25%, add Chlorthalidone 12.5 
mg daily. 
• 
If repeated serum K is < 3.8 and serum Cr increases by < 25%, add spironolactone 25 mg 
daily. 
 
 
4) If clinic SBP reaches target goal (<140 mmHg for standard arm and <130 mmHg for intensive 
arm), obtain 24-Hr ambulatory BP monitoring to conﬁrm. If 24-Hr SBP does not reach goal (<130 
mmHg for standard arm and < 120 mmHg for intensive arm), use the same protocol for BP 
ƟtraƟon based on corresponding clinic SBP from 1-3. 
 
Electrolyte Management:  
 
1) If serum K is between 5-5.5, stop K supplement (if applicable) and reduce losartan and 
spironolactone by 50%. 

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    Page 16 of 61 
  
2) If K is between 5.5-5.9, hold losartan and spironolactone unƟl K+ <4.8, then consider 
resuming at 50% reduced dose.  
  
Repeat basic metabolic panel in 2 weeks. If needed, increase or add another BP 9medicaƟon to 
control BP (amlodipine 5-10 mg once daily, doxazosin 4-8 mg once daily, hydralazine 25-100 BID 
either alone or in combinaƟon).  
 
3) If serum K is ≥ 6.0mmol/L, subjects should visit emergency department immediately for 
further management to avoid life threatening arrhythmia. 
 
4) If serum Cr increases ≥ 50% from the baseline (screening), hold losartan, spironolactone, 
and chlorthalidone and repeat basic metabolic panel in 2 weeks.  Increase or add other BP 
medicaƟon to control BP, if needed (amlodipine 5-10 mg once daily, doxazosin 4-8 mg once 
daily, hydralazine 25-100 BID, either alone or in combinaƟon). 
 
5) If serum Na is < 132 or K < 3.0, reduce chlorthalidone by 50% (i.e. if paƟent is taking 25 mg 
daily, reduce to 12.5 mg. if paƟent is taking 12.5 mg daily, then stop chlorthalidone). 
 
6) If serum K is between 3.0-3.5, start KCl supplement 40 meq daily and repeat basic metabolic 
panel in 2 weeks. 
 
7) If serum K is between 2.5-2.9, start KCl supplement dose 40 meq BID, stop chlorthalidone 
and any thiazide diureƟcs, and repeat basic metabolic panel in 1 week. 
 
8) If serum K is <2.5 mmol/L, subjects should visit emergency department immediately for 
intravenous K supplement and for further management to avoid life threatening arrhythmia.  
 
The dose of K supplement may be individualized according to clinical judgment. 
 
Management of Low BP/OrthostaƟc Symptoms  
If average seated systolic BP (SBP) < 100 mmHg or the third standing systolic BP is < 90 mmHg or 
orthostaƟc symptoms (dizziness upon standing, near fainƟng, or syncope) are reported, reduce 
doxazosin and/ or losartan by 50%. 
 
Reﬁll anƟhypertensive drugs according to the BP and lab results. Lab results may not be available at the 
Ɵme of visit. However, only Losartan, diureƟcs (chlorthalidone and spironolactone), and potassium 

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    Page 17 of 61 
supplement require lab results before intensiﬁcaƟon for treatment is allowed. Other medicaƟons 
(amlodipine, doxazosin, hydralazine, metoprolol, and guanfacine) may be intensiﬁed without lab results 
if needed. 
 
Subjects should be told that they will be contacted by phone regarding the dose of losartan, diureƟcs or 
potassium pills based on lab tests (serum K and Cr). They may be required to return to pick up new 
botles of losartan, diureƟcs or potassium pills the next day or within the same week their lab results are 
available. However, a BP check is not necessary when subjects return to pick up new medicaƟons. 
 
Glycemic control 
 If plasma glucose is ≥ 140 mg/dL for fasƟng level or ≥ 200 mg/dL for postprandial level, refer subject to 
PCP.  
 
PaƟent Management 
1) Schedule PaƟents to return for 1 month post randomizaƟon follow up visit regardless of BP. 
 
2) Instruct parƟcipant to take current doses of BP and diabeƟc medicaƟons on the day of their 
next visit. 
 
3) Instruct paƟents to bring pill botles, empty or not, back to their next visits. 
 
Visit DocumentaƟon 
In the subject’s study chart, document the following:  
1. 
Current dose of anƟhypertensive medicaƟon and diabeƟc medicaƟons 
2. 
 BP 
3. 
Lab results 
4. 
Previous treatment and the reason for changing medical regimen or drug dosing in the case 
report form 
5. 
Progress note  
6. 
if the criteria for safety alerts listed below have been met. Site clinicians will be noƟﬁed within 
48 hours so that acƟon may be taken. 

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    Page 18 of 61 
• 
Serum sodium <130 mmol/liter  
• 
Serum sodium >150 mmol/liter  
• 
Serum potassium <3.0 mmol/liter  
• 
Serum potassium >5.5 mmol/liter  
• 
OrthostaƟc hypotension (based on the third standing systolic BP of < 90 mmHg either with or 
without dizziness).  
• 
Incident CKD (Increase in serum Cr by at least 50% since the last study lab, usually 3-6 months 
apart). 
• 
Heart rate < 40 bpm or evidence of new AV block or bundle branch block. 
  
7. Research personnel also perform and document pill count of BP meds  to ensure compliance 
in the case report form. 
 
 
4.2.3.  4 Weeks Post RandomizaƟon (Month 1) 
Obtain random blood draw for basic metabolic panel and seated/standing BP measurement. 
Blood Pressure Management 
1) If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive 
arm), double the dose of amlodipine up to maximal dose of 10 mg daily (e.g., if paƟent is 
taking 2.5 mg daily, increase to 5 mg; if paƟent is taking 5 mg daily, increase to 10 mg). 
2) If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive 
arm) and subject is already taking maximal dose of amlodipine (10 mg) and repeated serum K 
is < 5.0 and serum Cr increases by < 25% from baseline (screening) lab results, double the dose 
of losartan up to maximal dose of 100 mg daily. 
(e.g., if subject is taking 25 mg daily, increase to 50 mg; if subject is taking 50 mg daily, increase 
to 100 mg). 
3) If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive 
arm), and subject is already taking maximal dose of amlodipine (10 mg) plus losartan 100 mg 
daily, or serum Cr increases by at least 25% from baseline (screening) lab results while on less 
than maximal dose of losartan, add the THIRD drug from the following choices: 
 
• 
If serum Cr increases by 25% or more from baseline (screening) lab results regardless of 
serum K, add doxazosin 2-4 mg daily. 

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• 
If repeated serum K is ≥ 3.8 and serum Cr increases by < 25% from baseline (screening) 
lab results, add Chlorthalidone 12.5 - 25 mg daily. 
• 
If repeated serum K is < 3.8 and serum Cr increases by < 25% from baseline (screening) 
lab results, add spironolactone 25 mg daily. 
 
4) If clinic SBP reaches target goal (<140 mmHg for standard arm and <130 mmHg for intensive 
arm) and parƟcipant has not had ambulatory BP monitoring during previous visit, obtain 24-Hr 
ambulatory BP monitoring to conﬁrm. If 24-Hr SBP does not reach goal (<130 mmHg for standard 
arm and < 120 mmHg for intensive arm), use the same protocol for BP ƟtraƟon based on 
corresponding clinic SBP from 1-3. 
 
 
 
Electrolyte Management 
Electrolyte management should follow the same principles as above for 2 Weeks  
Post RandomizaƟon.  
 
Management of Low BP/ OrthostaƟc Symptoms 
If average seated systolic BP (SBP) < 100 mmHg or the third standing systolic BP is < 90 mmHg or 
orthostaƟc symptoms (dizziness upon standing, near fainƟng, or syncope) are reported, reduce 
doxazosin and/ or losartan by 50%. 
Reﬁll anƟhypertensive drugs according to the BP and lab results. Lab results may not be available at the 
Ɵme of visit. However, only Losartan, diureƟcs (chlorthalidone and spironolactone), and potassium 
supplement require lab results before intensiﬁcaƟon for treatment is allowed. Other medicaƟons 
(amlodipine, doxazosin, hydralazine, metoprolol, and guanfacine) may be intensiﬁed without lab results 
if needed. 
Subjects should be told that they will be contacted by phone regarding the dose of losartan, diureƟcs or 
potassium pills based on lab tests (serum K and Cr). They may be required to return to pick up new 
botles of losartan, diureƟcs or potassium pills the next day or within the same week their lab results are 
available. However, a BP check is not necessary when subjects return to pick up new medicaƟons. 

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Glycemic Control 
If plasma glucose is ≥ 140 mg/dL for fasƟng level or ≥ 200 mg/dL for postprandial level, refer subject to 
PCP.  
 
PaƟent Management 
1) If BP meds are changed at this visit, schedule ParƟcipant to return for follow up at Week 6 
post randomizaƟon. If BP medicaƟons are not changed, schedule Week 8 visit, regardless of 
BP. 
2) Instruct parƟcipant to take current doses of BP and diabeƟc medicaƟons on the day of their 
next visit, 
3) Instruct paƟents to bring pill botles back to their next visit. 
 
Visit DocumentaƟon 
In the subject’s study chart, document the following:  
1. Current dose of anƟhypertensive medicaƟon and diabeƟc medicaƟons 
2. BP 
3. Lab results 
4. Previous treatment and the reason for changing medical regimen or drug dosing  
5. Progress note.  
6. AE form if the criteria for safety alerts listed below have been met. Site clinicians will be 
noƟﬁed within 48 hours so that acƟon may be taken. 
 
• 
Serum sodium <130 mmol/liter  
• 
Serum sodium >150 mmol/liter  
• 
Serum potassium <3.0 mmol/liter  
• 
Serum potassium >5.5 mmol/liter  
• 
OrthostaƟc hypotension (based on the third standing systolic BP of < 90 mmHg either with or 
without dizziness). 
• 
Incident CKD (Increase in serum Cr by at least 50% since the last study lab, usually 3-6 months 
apart). 
• 
Heart rate < 40 bpm or evidence of new AV block or bundle branch block. 

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    Page 21 of 61 
 
7. Research personnel also perform and document pill count of BP meds  to ensure 
compliance in the case report form. 
 
4.2.4.  6 Weeks Post RandomizaƟon  
Obtain seated/standing BP only if BP medicaƟons are adjusted during the 4-week visit. Obtain a random 
blood draw for basic metabolic panel only if losartan or diureƟcs (chlorthalidone or spironolactone) were 
added or increased at the last visit. 
Blood Pressure Management   
1) If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive 
arm), double the dose of amlodipine up to maximal dose of 10 mg daily (e.g., if paƟent is 
taking 2.5 mg daily, increase to 5 mg; if paƟent is taking 5 mg daily, increase to 10 mg). 
2) If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive 
arm) and subject is already taking maximal dose of amlodipine (10 mg) and repeated serum 
K is < 5.0 and serum Cr increases by < 25% from baseline (screening) lab results, double the 
dose of losartan up to maximal dose of 100 mg daily. 
(e.g., if subject is taking 25 mg daily, increase to 50 mg; if subject is taking 50 mg daily, increase 
to 100 mg). 
3) If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive 
arm) and subject is already taking maximal dose of amlodipine (10 mg) plus losartan 100 mg 
daily, OR serum Cr increases by at least 25% from baseline (screening) lab results while on 
less than maximal dose of losartan, add the THIRD drug from the following choices: 
• 
If serum Cr increases by ≥ 25% from baseline (screening) lab results regardless of serum 
K, add doxazosin 2-4 mg daily. 
• 
If repeated serum K is ≥ 3.8 and serum Cr increases by < 25% from baseline (screening) 
lab results, add Chlorthalidone 12.5 - 25 mg daily. 
• 
If repeated serum K is < 3.8 and serum Cr increases by < 25% from baseline (screening) 
lab results, add spironolactone 25 mg daily 
 
4) If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive 
arm) and paƟent is already taking 3-drug regimen, intensify the THIRD drug by doubling the 
dose (i.e., increase Chlorthalidone to 25 mg daily, add spironolactone 25 mg daily, or 
doxazosin up to 8 mg daily) 
5) If clinic SBP reaches target goal (<140 mmHg for standard arm and <130 mmHg for intensive 
arm) and parƟcipant has not had ambulatory BP monitoring during previous visit, obtain 24-
Hr  ambulatory BP monitoring to conﬁrm. If 24-Hr  SBP does not reach goal (<130 mmHg for 
standard arm and < 120 mmHg for intensive arm), use the same protocol for BP ƟtraƟon based 
on corresponding clinic SBP from 1-3. 

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    Page 22 of 61 
 
Electrolyte Management 
Electrolyte management should follow the same principles as above for 2 Weeks Post RandomizaƟon.  
Management of Low BP/ OrthostaƟc Symptoms  
If average seated systolic BP (SBP) < 100 mmHg or the third standing systolic BP is < 90 mmHg or 
orthostaƟc symptoms (i.e., dizziness upon standing, near fainƟng, or syncope) are reported, reduce 
doxazosin and/ or losartan by 50%. 
 
Reﬁll anƟhypertensive drugs according to the BP and lab results. Lab results may not be available at the 
Ɵme of visit. However, only Losartan, diureƟcs (chlorthalidone and spironolactone), and potassium 
supplement require lab results before intensiﬁcaƟon for treatment is allowed. Other medicaƟons 
(amlodipine, doxazosin, hydralazine, metoprolol, and guanfacine) may be intensiﬁed without lab results 
if needed. 
 
Subjects should be told that they will be contacted by phone regarding the dose of losartan, diureƟcs or 
potassium pills based on lab tests (serum K and Cr). They may be required to return to pick up new 
botles of losartan, diureƟcs or potassium pills the next day or within the same week their lab results are 
available. However, a BP check is not necessary when subjects return to pick up new medicaƟons. 
Glycemic Control  
If plasma glucose is ≥ 140 mg/dL for fasƟng level or ≥ 200 mg/dL for postprandial level, refer subject to 
PCP.  
PaƟent Management 
1) Instruct parƟcipant to take current doses of BP and diabeƟc medicaƟons on the day of their 
next visit, 
 
2) Instruct paƟents to bring pill botles back to their next visit. 
 
 
Visit DocumentaƟon 
In the subject’s study chart, document the following:  
1. Current dose of anƟhypertensive medicaƟon and diabeƟc medicaƟons 

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    Page 23 of 61 
2. BP 
3. Lab results 
4. Previous treatment and the reason for changing medical regimen or drug dosing in case 
report form 
5. Progress note.  
6. AE form if the criteria for safety alerts listed below have been met. Site clinicians will be 
noƟﬁed within 48 hours so that acƟon may be taken. 
 
• 
Serum sodium <130 mmol/liter  
• 
Serum sodium >150 mmol/liter  
• 
Serum potassium <3.0 mmol/liter  
• 
Serum potassium >5.5 mmol/liter  
• 
OrthostaƟc hypotension (based on the third standing systolic BP of < 90 mmHg either with or 
without dizziness). 
• 
Incident CKD (Increase in serum Cr by at least 50% since the last study lab, usually 3-6 months 
apart). 
• 
Heart rate < 40 bpm or evidence of new AV block or bundle branch block. 
  
7. Research personnel also perform pill count of BP meds  to ensure compliance and 
document on the case report form. 
 
4.2.5.  8 Weeks Post RandomizaƟon (Month 2) & Month 3, 6, 9, and 12  
1) Obtain random BMP regardless of previous test results. BMP should be obtained at 2, 3, 6, 9, and 12 
months and as needed when BP meds are adjusted. 24-Hr  ABP should be obtained as soon as clinic BP 
reaches goal, 6 months and 12 months. 
2) Obtain seated and standing BP even if BP was well-controlled at previous visits. 
BP Management 
1) If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive arm) 
and paƟent is already taking maximal dose of amlodipine of 10 mg plus losartan 100 mg daily, or 
serum Cr increases by at least 25% from baseline (screening) lab while on less than maximal dose of 
losartan, add a THIRD drug. Choices of third drugs are: 

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    Page 24 of 61 
• 
If serum Cr increases by ≥ 25% from baseline (screening) lab results regardless of serum 
K, add doxazosin 2 mg daily. 
• 
If repeated serum K is ≥ 3.8 and serum Cr increases by < 25% from baseline (screening) 
lab results, add Chlorthalidone 12.5 mg daily. 
• 
If repeated serum K is < 3.8 and serum Cr increases by < 25% from baseline (screening) 
lab results, add spironolactone 25 mg daily 
 
2)  If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive arm) and 
paƟent is already taking 3-drug regimen, intensify the THIRD drug by doubling the dose (i.e. increase 
Chlorthalidone to 25 mg daily, add spironolactone to 25 mg daily, or doxazosin up to 8 mg daily). 
3)  If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive arm) and 
paƟent is already taking 3-drug regimen at the maximal tolerated dose, add the fourth drug from the 
list of third-line drugs that paƟents have not taken (i.e., combined spironolactone with 
chlorthalidone or doxazosin, depending on serum K and Cr).  
4)  If clinic SBP is sƟll above target (≥140 mmHg for standard arm and ≥130 mmHg for intensive arm) 
despite adding addiƟonal drugs from the list of third-line drugs (spironolactone or chlorthalidone or 
doxazosin), consider adding more drugs from the alternaƟve Fourth- and FiŌh-line drug below: 
• 
Metoprolol XL 25-100 mg daily only if HR ≥65 beats/min 
• 
Guanfacine 1-2 mg at bedƟme 
• 
Hydralazine 25-100 mg BID 
 
5)  If BP goal cannot be achieved with 5 drug regimen, make sure that paƟent:  
 
1. Is truly adherent to treatment as more than 50% of paƟents with resistant hypertension 
are non-adherent to at least 1 drug prescribed in clinical pracƟce. 
2. Follows low sodium diet of <1,500 mg/day which could result in as much as 15-20 mmHg 
reducƟon in BP in resistant hypertension. See Sodium secƟon. 
3. Avoids concomitant medicaƟons that may either reduce anƟhypertensive drug eﬃcacy 
(e.g., NSAID) or directly increase BP (e.g., glucocorƟcoids, nasal decongestant or 
sympathomimeƟc drugs). See SecƟon 9.9 Concomitant MedicaƟons. 
 
A decision will be made whether to exclude the subject from the study and refer for follow up with 
his/her regular healthcare provider. 

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    Page 25 of 61 
  
Electrolyte Management 
Electrolyte management should follow the same principles as above for 2 Weeks Post RandomizaƟon.  
 
Management of Low BP/ OrthostaƟc Symptoms  
If average seated systolic BP (SBP) < 100 mmHg or the third standing systolic   BP is < 90 mmHg or 
orthostaƟc symptoms (i.e., dizziness upon standing, near fainƟng, or syncope) are reported, reduce 
doxazosin and/ or losartan by 50%. 
Reﬁll anƟhypertensive drugs according to the BP and lab results. Lab results may not be available at the 
Ɵme of visit. However, only Losartan, diureƟcs (chlorthalidone and spironolactone), and potassium 
supplement require lab results before intensiﬁcaƟon is allowed. Other medicaƟons (amlodipine, 
doxazosin, hydralazine, metoprolol, and guanfacine) may be intensiﬁed without lab results if needed. 
Subjects should be told that they will be contacted by phone regarding the dose of losartan, diureƟcs or 
potassium pills based on lab tests (serum K and Cr). They may be required to return to pick up new 
botles of losartan, diureƟcs or potassium pills the next day or within the same week their lab results are 
available. However, a BP check is not necessary when subjects return to pick up new medicaƟons. 
 
Glycemic Control 
If plasma glucose is ≥ 140 mg/dL for fasƟng level or ≥ 200 or above mg/dL for postprandial level, instruct 
subject to visit his/her PCP. 
 
PaƟent Management  
1) Instruct parƟcipants to take current doses of BP and diabeƟc medicaƟons on the day of their 
next visit, 
2) Instruct subjects to bring pill botles back to their next visit. 
3) Schedule subjects to return for week 8, and at 3, 6, 9, and 12 month visit, regardless of BP.  

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    Page 26 of 61 
4) During these visits, obtain a basic metabolic panel, if any diureƟcs (Chlorthalidone or 
spironolactone) have been added to the regimen or the dose of diureƟcs or losartan have 
been increased. Complete a case report form to document the lab check visit. 
 
Visit DocumentaƟon 
In the subject’s study chart, document the following:  
1. Current dose of anƟhypertensive medicaƟon and diabeƟc medicaƟons 
2. BP 
3. Lab results 
4. Previous treatment and the reason for changing medical regimen or drug dosing in the 
case report form. 
5. Progress note  
6. AE form if the criteria for safety alerts listed below have been met. Site clinicians will be 
noƟﬁed within 48 hours so that acƟon may be taken. 
 
• 
Serum sodium <130 mmol/liter  
• 
Serum sodium >150 mmol/liter  
• 
Serum potassium <3.0 mmol/liter  
• 
Serum potassium >5.5 mmol/liter  
• 
OrthostaƟc hypotension (based on the third standing systolic BP of < 90 mmHg 
either with or without dizziness). 
• 
Incident CKD (Increase in serum Cr by at least 50% since the last study lab, 
usually 3-6 months apart). 
• 
Heart rate < 40 bpm or evidence of new AV block or bundle branch block. 
  
7. Research personnel also perform pill counts of BP meds to ensure compliance and 
document on the pill count in case report form. 
 
4.2.6.  12 Months Post RandomizaƟon   
1) Obtain seated and standing BP even if BP has been well controlled at previous visits.  
2) Obtain fasƟng blood draw aŌer an overnight fast (9-12 hours) for Complete Metabolic Panel and 
24-Hr  ABP. 
 
BP, Electrolyte Management, Glycemic Control 

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    Page 27 of 61 
BP, electrolyte management, and glycemic control should follow procedures described in 8 Weeks Post 
RandomizaƟon (Month 2) & Month 3, 6, 9, and 12.  
Use the AE form to document addiƟonal informaƟon regarding AST and ALT from complete metabolic 
panel IF: 
Measure 
Alert Value 
Serum sodium 
< =130 or >150 mEq/L 
Serum potassium 
<3.5 or >5.0 mEq/L 
Serum creaƟnine 
Increase by at least 50% since the last study lab (usually 6 
months apart). 
Serum AST 
Increase by at least 2-fold since the last study lab 
Serum ALT 
Increase by at least 2-fold since the last study lab 
CK  
Increase by at least 5-fold since the screening lab, with or 
without muscle symptoms 
Heart rate 
<40 beats/min (bpm)  
OrthostaƟc Hypotension 
The third standing systolic BP is < 90 mmHg    
    
4.3  Milepost Visits  
“Clinical inerƟa” in hypertension management, where clinicians fail to intensify therapy despite paƟents 
not being at goal BP, has been observed in both clinical pracƟce and clinical trial seƫngs. For this reason, 
“Milepost Visits” were used in the intensive BP group in the ACCORD and SPRINT trials to assist in 
reaching goal SBP. For all parƟcipants Milepost Visit date will be assigned at 6 months. 
Between these dates, anƟhypertensive medicaƟons should be adjusted and/or addiƟonal 
anƟhypertensive medicaƟons should be added within the recommended dose range to achieve the 
target BP. However, once a milepost date has been reached and the parƟcipant’s 24-SBP is not under 
target goal, the invesƟgator is required to add to the exisƟng regimen another anƟhypertensive drug 
from a drug class diﬀerent from what is being taken, unless there are compelling reasons to wait. The 
parƟcipant should be seen monthly unƟl the clinic SBP reaches goal. 

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    Page 28 of 61 
If the invesƟgator believes that the addition of another drug may potentially be harmful to the 
participant, the requirement may be waived. This excepƟon must be jusƟﬁed and documented on the 
case report form and reviewed by Dr. Vongpatanasin.  
 
4.5  Diastolic Blood Pressure Treatment  
The primary BP goal is SBP < 130. Once the SBP goal is achieved, the anƟhypertensive regimen should be 
intensiﬁed to achieve 24-Hr  DBP < 80 mmHg for standard arm and < 70 mmHg for intensive arm. If clinic 
DBP remains ≥ 95 mmHg at a single visit or ≥ 90 mmHg at two successive visits, anƟhypertensive 
treatment should be intensiﬁed. The visit intervals and decisions for ƟtraƟon (other than the BP levels) 
will be similar to those used for the SBP goal.  
 
4.6  Drug Dispensing 
All study medicaƟons dispensed to parƟcipants will be labeled with the medicaƟon, study and 
parƟcipant’s name, strength and quanƟty, direcƟons for use, and authorized prescriber’s name. An 
emergency study-related phone number for study drug informaƟon will also appear on the label. All 
parƟcipants are to be counseled verbally on medicaƟon administraƟon. Writen instrucƟons will also be 
provided. 
ParƟcipants will receive a 30-day medicaƟon supply at each regular visit during the ﬁrst  3 months aŌer 
randomizaƟon. AŌer  3 months, a 90-day supply may be provided to reduce unnecessary visits to the 
study sites. MedicaƟon may be dispensed in the intervening periods between visits in case of 
emergency, loss, or schedule change. A tracking record is maintained for all dispensing acƟons. It is 
recommended that the number of authorized dispensing personnel be limited to assure proper 
adherence to established accountability and dispensing procedures. 
 
4.7  Drug Storage and Disposal 
Clinical Sites are responsible for destroying expired drug and documenƟng destrucƟon. 
4.8  Concomitant MedicaƟons  

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CombinaƟons of RAS blockers (ACE inhibitor, ARB, and/or renin inhibitor) are strongly discouraged in 
HIPAC, based on lack of beneﬁt and adverse outcomes seen in several large randomized controlled trials. 
The use of 2 nodal blockers (beta blocker and a non-dihydropyridine calcium channel blocker) is strongly 
discouraged. AddiƟve reducƟons in heart rate, cardiac conducƟon, and cardiac contracƟlity may occur 
when non-dihydropyridine calcium channel blockers (e.g., verapamil or dilƟazem) are used 
concomitantly with beta blockers. While this combinaƟon may be useful and eﬀecƟve in some situaƟons, 
potenƟally serious cardiovascular adverse eﬀects such as congesƟve heart failure, heart block, severe 
bradycardia, ventricular asystole, and sinus arrest have been reported. If a non-dihydropyridine CCB 
(e.g., dilƟazem) is to be used, it should not be combined with a beta-blocker. 
An HIPAC parƟcipant who cannot achieve SBP at target goal despite maximal doses of ﬁrst to ﬁŌh line 
drug therapy outlined may require Minoxidil to achieve target BP. Since Minoxidil is a potent vasodilator, 
parƟcipants not receiving adequate doses of a diureƟc (usually a loop diureƟc with or without a thiazide 
diureƟc) will face a substanƟal risk of ﬂuid overload. Therefore, whenever a parƟcipant is prescribed 
Minoxidil, addiƟonal therapy with either chlorthalidone or a loop diureƟc is strongly encouraged. 
Although the diureƟc dose requirement may vary from paƟent to paƟent, most paƟents on Minoxidil will 
require at least 12.5mg/day chlorthalidone or loop diureƟc equivalent to furosemide 40 mg/day 
(usually BID unless prescribed with a thiazide diureƟc). ParƟcipants on Minoxidil doses above 20 mg/day 
will require even higher diureƟc doses and the need for a combinaƟon of a thiazide and loop diureƟc is 
not uncommon. ParƟcipants prescribed Minoxidil without also receiving chlorthalidone or a loop diureƟc 
will receive email alerts and messages similar to those described above for discouraged combinaƟons. 
The use of simvastaƟn with calcium channel blockers including amlodipine, verapamil, and dilƟazem 
should be avoided due to increased risk of muscle damage (htp://Safety Oﬃcer 
.fda.gov/Drugs/DrugSafety/ucm256581.htm). Similarly, simvastaƟn should not be used at the dose of 80 
mg because of increased risk of myopathy. SimvastaƟn should not be used in HIPAC. 
Some prescripƟon or over-the-counter drugs (as shown in the following list) may reduce 
anƟhypertensive eﬃcacy of BP medicaƟons or directly increase BP. The use of these drugs should be 
discouraged or minimized as much as possible. 
• 
NSAIDS : Ibuprofen (motrin, advil), naproxen (alleve), meloxicam (mobic), high dose aspirin. 

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• 
SympathomimeƟcs, including nasal decongestants and ADHD drugs: midodrine, droxidopa, 
pseudoephedrine, ephedrine, methamphetamine, methylphenidate (Ritalin), 
dexmethamphetamine 
• 
Immunosuppressive drug: cyclosporin 
• 
GlucocorƟcoids: prednisone, dexamethasone (solumedrol), medrol dose pak 
• 
Drugs to increase red blood cells: ErythropoieƟn, DarbepoieƟn 
• 
MineralocorƟcoids: ﬂudrocorƟsone 
• 
Oral ContracepƟves 
• 
Herbal supplement: St. John's Wort 
 
4.9  MedicaƟon Adherence  
ParƟcipants will be asked to return study medicaƟon botles, used and unused, at each visit; pill counts 
will be performed to monitor compliance. The percentage of pills taken/dispensed will be used to 
document drug adherence. HIPAC will strive to achieve a goal >80% treatment adherence. PotenƟal 
eﬀects of intervenƟon adherence on study outcome measures will be assessed as secondary data 
analysis.  
Monthly phone or in-person follow-up and three month clinic visits to monitor study safety and 
compliance will be conducted with all parƟcipants in order to maintain the same level of study contact 
across all study arms.  
 
4.10 Assessment of OrthostaƟc Hypotension (OH), Measurement of Standing Blood Pressure  
Standing BP will be measured at screening, and all subsequent visits, using the same BP device that is 
used to measure seated BP. AŌer seated BP measurements, parƟcipants will be asked to stand. 
Beginning when their feet touch the ﬂoor, BP will be taken one minute later in the same arm used for the 
seated measurements. ParƟcipants will be asked aŌer the standing BP measurements if they had any 
symptoms of orthostaƟc hypotension during the standing BP measurement.  
ParƟcipants with standing SBP <100 mm Hg will not be eligible for randomizaƟon (may be rescreened if 
corrected). However, the detecƟon of asymptomaƟc orthostaƟc hypotension, i.e., orthostaƟc 
hypotension unaccompanied by orthostaƟc symptoms of dizziness, presyncope or syncope will not 

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inﬂuence the anƟhypertensive drug treatment algorithm. SymptomaƟc orthostaƟc hypotension will be 
managed as follows. 
DeﬁniƟon  
OrthostaƟc hypotension (OH) is usually deﬁned as a decline of systolic blood pressure (SBP) ≥20 mmHg 
or a decline of diastolic BP ≥10 mmHg that occurs within 3 minutes aŌer moving from a supine or seated 
to a standing posiƟon.  
Symptoms  
OH may be asymptomaƟc or may be accompanied by dizziness, lightheadedness, feeling faint, or 
syncope. Generally, asymptomaƟc OH should not change adherence to the HIPAC protocol, although 
medicaƟon classes may be adjusted to conƟnue appropriate  BP control while minimizing postural 
hypotension (see below Management of OH).  
Predisposing CondiƟons  
In epidemiologic studies OH is more likely to occur in older individuals with high SBP. Diabetes mellitus 
and other autonomic neuropathies, volume depleƟon, varicose veins, alcoholism, and certain 
medicaƟons are also associated with OH.  
Note: Occasionally, hypotension occurs if a paƟent previously nonadherent to prescribed medicaƟons 
begins taking the medicaƟons. Because BP typically declines aŌer a meal due to splanchnic blood 
pooling, standing BP should not be measured within 90 minutes aŌer a meal if possible.  
Predisposing MedicaƟons  
Some classes of medicaƟons are more likely to cause OH than others. The most frequent oﬀenders 
currently in use are alpha-blocking drugs, such as prazosin, terazosin, or doxazosin, and central alpha 
agonists, such as clonidine, methyldopa or guanfacine. Although beta-blockers are perhaps the least 
likely anƟhypertensive class to cause OH, one of the most common adverse eﬀects of combined alpha-
beta blockers, such as labetalol or carvedilol, is OH or dizziness, primarily because of the alpha-blocking 
component of these drugs. Rarely, beta-blockers may cause OH because of severe bradycardia (e.g., 
heart rate <40-50 beats/min) and inability to increase heart rate/cardiac output in upright posture, 
especially if other drugs or condiƟons have lowered BP excessively. Occasionally, reserpine, nitrates, or 

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calcium channel blockers may contribute to or cause OH. Certain psychotropic drugs, most notably 
phenothiazines, can also cause OH.  
Thiazide diureƟcs rarely cause OH, unless the paƟent is signiﬁcantly volume depleted or another agent is 
added to a diureƟc that may cause ﬁrst-dose hypotension (e.g., a short-acƟng ACE inhibitor like captopril 
or a short-acƟng alpha blocker like prazosin). High dose loop diureƟcs, such as furosemide, or 
combinaƟons of diureƟcs may lead to excessive volume depleƟon and hypotension, with or without OH.  
Management of OH 
PaƟents with poor oral intake, dehydraƟon from any cause, GI or renal causes for excessive ﬂuid loss, or 
hemorrhage, may need to have their diureƟc or other anƟhypertensive medicaƟons stopped temporarily 
unƟl the volume-depleƟon is corrected. If a parƟcipant with symptomaƟc OH has no obvious cause of 
excessive volume depleƟon, the medicaƟon regimen should be reviewed. Psychotropic drugs may need 
to be reduced in dose or changed to alternaƟve agents (many newer ones are equally eﬀecƟve without 
hypotensive eﬀects). If the paƟent is on an alpha-blocker, alpha-beta blocker, or central alpha agonist, 
the dose should be reduced or the potenƟally oﬀending agent disconƟnued. If necessary for BP control, 
that drug should be replaced with another class of anƟhypertensive that is less likely to cause 
symptomaƟc OH. If the parƟcipant requires an alpha-blocker for BPH/bladder outlet obstrucƟve 
symptoms, a more selecƟve alpha-blocker (e.g., tamsulosin) may be considered.  
PaƟents with symptomaƟc OH should eat small meals and avoid standing up rapidly aŌer eaƟng. Such 
individuals should avoid hot showers and other excessive heat exposure. An increase in sodium intake 
may be considered in paƟents without hypertension or heart failure. In individuals with large varicose 
veins, ﬁted elasƟc hose or compression stockings may reduce venous pooling in the legs. In refractory 
cases of symptomaƟc OH, drug therapy with vasoconstrictors such as midodrine or dihydroergotamine 
or with mineralcorƟcoids may be considered. This is unlikely to be needed in HIPAC.  
ImplicaƟons for protocol  
The presence of orthostaƟc hypotension, parƟcularly if asymptomaƟc, should not be considered as an 
exclusion from the study, parƟcularly since some studies indicate that control of hypertension can lead 
to improvement in orthostaƟc hypotension. Likewise, decisions regarding up-ƟtraƟon toward protocol 
blood pressure targets should be made primarily on the basis of the seated blood pressure 
measurements. OrthostaƟc hypotension should also not preclude up-ƟtraƟon toward blood pressure 
targets. When symptomaƟc, it is suggested that iniƟal eﬀorts described above should be directed toward 

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idenƟﬁcaƟon of other causes (e.g., psychotropic drugs, recent meal ingesƟon) and preferenƟal use of 
hypertension medicaƟon classes that have less predilecƟon to orthostaƟc hypotension.  
 
4.11  Dietary / Lifestyle ModiﬁcaƟon  
Dietary modiﬁcaƟons are recommended based both on blood pressure control and prevenƟon of CVD 
risk factors. The main focus of nutriƟon intervenƟon for HIPAC parƟcipants without chronic kidney 
disease will be the DASH Diet recommendaƟon. PaƟents with stage 3 or greater kidney disease will 
receive alternate dietary instrucƟon. RecommendaƟons will also be made for alcohol intake.  
DASH Diet 
The DASH diet is an eaƟng plan that is low in saturated fat, cholesterol, and total fat. It emphasizes fruits, 
vegetables, fat-free or low-fat milk and milk products, and includes whole grain products, ﬁsh, poultry 
and nuts. Red meat, sweets, added sugars and sugar-containing beverages are reduced on the DASH 
eaƟng plan. The DASH diet is rich in potassium, magnesium and calcium as well as protein and ﬁber.  
HIPAC parƟcipants who do not have chronic kidney disease should be introduced to the DASH diet by 
study coordinators. Each parƟcipant will receive a copy of the DASH diet recommendaƟon prepared 
especially for HIPAC parƟcipants at the study enrollment. Study coordinators should review the table 
that provides the number of daily servings for the DASH eaƟng plan with study parƟcipants. 
Diet for Chronic Kidney Disease  
The DASH diet is high in nutrients and foods which can be detrimental to parƟcipants with chronic 
kidney disease. ParƟcipants meeƟng the criteria for chronic kidney disease should instead be counseled 
on a prudent renal diet and provided with the NaƟonal Kidney FoundaƟon educaƟonal material (see 
htp://Safety Oﬃcer .kidney.org/atoz/index.cfm). Speciﬁcally, paƟents with chronic kidney disease 
should be counseled to limit foods that are high in phosphorus. They may also need to limit their 
potassium intake and their intake of protein. Protein-rich foods include red meat, poultry, ﬁsh and other 
seafood, eggs, dairy product and vegetables and grains. 
Reduced Sodium Diet 
Dietary sodium intake should be reduced to less than 1500 mg/day for the HIPAC study populaƟon.  

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High sodium foods should be avoided, including chips, nuts, lunch meats, most canned foods, most fast 
foods, pickles and olives. Instead of adding salt to foods for ﬂavor, encourage trying pepper, lemon juice, 
mustard, garlic, spices, herbs and salt subsƟtutes. ParƟcipants with chronic kidney disease should be 
counseled to discuss use of salt subsƟtutes with their health care provider or clinical nutriƟonist before 
using. Many of these products subsƟtute potassium for sodium. Increased potassium intake is not 
recommended for paƟents with CKD. Emphasize choosing more fresh foods - vegetables, fruits, grains, 
meats, and minimally processed foods. Encourage more home preparaƟon of foods and reading food 
labels to help make lower sodium choices. Examples of diet high in sodium are shown in the table below 
which should be avoided or minimized. 
4.12 Study Drug Supply and Dispensing 
4.12.1 Drug Dispensing 
Drugs will be labeled and idenƟﬁed with the study name, parƟcipant’s name, medicaƟon name, strength 
and quanƟty, direcƟons for use, and authorized prescriber’s name. An emergency study-related phone 
number for study drug informaƟon will also appear on the label. All parƟcipants are to be counseled 
verbally on medicaƟon administraƟon. Writen instrucƟons will also be provided. 
ParƟcipants will receive a 30-90 day medicaƟon supply during each regular visit (the amount of drug 
dispensing will be site speciﬁc). MedicaƟon dispensing may occur in the intervening periods between 
visits in case of emergency, loss, or schedule changes. A tracking mechanism is maintained for all 
dispensing acƟons. It is recommended that authorized dispensing personnel be limited in number to 
assure proper adherence with established accountability and dispensing procedures. 
 
4.12.2 Drug Storage 
Research personnel is responsible for storing the study drug supplies in a locked, secure area with 
limited access. Manufacturer recommendaƟons and local policies for drug storage must be followed. 
 
4.12.3 Drug Disposal 
Research personnel is responsible for destroying expired drug and documenƟng destrucƟon. 
 

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4.13 IntervenƟon Compliance and Adherence Monitoring  
The randomizaƟon procedures will be explained fully to the parƟcipants during enrollment and their 
understanding and willingness to be randomized into one of the 2 study arms will be conﬁrmed. 
ParƟcipants will be encouraged to stay with the intervenƟons they have received. Any changes in the 
health-related behavior or medicaƟon, which may impact study outcome, will be reviewed, discussed 
and documented during regular study visits.   
Treatment eﬀects of BP will be monitored at each study visit. ParƟcipants will be asked to return study 
anƟhypertensive drug botles, used and unused, at each visit; pill counts will be performed to monitor 
compliance. The percentage of pills taken/dispensed will be used to document drug adherence. PotenƟal 
eﬀects of intervenƟon adherence on study outcome measures will be assessed as secondary data 
analysis.  
Monthly phone or in-person follow-up and three month clinic visits to monitor study safety and 
compliance will be conducted with all parƟcipants in order to maintain a same level of study contact 
across the study arms. At each visit, parƟcipants will be asked about any changes in their medicaƟons 
and health to monitor and record potenƟal inﬂuences on study outcome measures.  
 
4.14 RetenƟon Strategies 
Every eﬀort will be made to provide a friendly clinic environment for study visits, to foster personal 
relaƟonships between study staﬀ and parƟcipants, and to minimize study burden. Clearly writen 
instrucƟons for follow-up visits will be provided and reminder calls will be made before each study visit.  
 
 
SecƟon 5. Outcome Measurements and Follow-Up 
Post-randomizaƟon follow-up schedules for outcome measurements and safety monitoring are 
summarized in Table 1. ParƟcipants will be monitored and interviewed during monthly phone or in-
person visits and clinic visits at 6, 9, 12, months for all study arms.  All follow-up visits will be completed 
within a Ɵme window of ± 2 weeks. Vital signs, physical exam and laboratory tests will be performed if 
suggested by clinical symptoms to ensure safety. 
5.1 Measurement of NeurocogniƟve FuncƟon  

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Lowering BP in older adults may slow cogniƟve decline in episodic memory and processing speed.14, 33 
We will use NIH-Toolbox to assess changes in neurocogniƟve funcƟon which includes: Episodic memory 
with the Picture Sequence Memory Test; working memory with the List SorƟng Working Memory Test; 
execuƟve funcƟon and AtenƟon with the Flanker Inhibitory Control and AtenƟon, and Dimensional 
Change Card Sort Tests; processing speed with the Patern Comparison Processing Speed Test.21 A 
composite z score will be obtained by conversion of individual test scores to the standardized z scores, 
then averaged to assess changes in global cogniƟon.34 Domain speciﬁc z scores will be used to assess 
changes in speciﬁc cogniƟve funcƟon associated with hypertension and anƟhypertensive treatment. 
Heath-related quality of life will be measured using the NIH PROMIS, a set of highly reliable, precise 
instruments to assess paƟent-reported health status for physical, mental, and social well-being .   
Measurement of neurocogniƟve funcƟon will be performed at Baseline, 6, and 12 months. 
 
5.2 MagneƟc Resonance Imaging (MRI) 
The MRI methods used in HIPAC trial have been used in our previous studies,35-38 which have 
demonstrated strong to excellent test-retest reproducibility, i.e., the intersession coeﬃcient of variaƟon 
for PC-MRI CBF and CSF ﬂow is ~ 7% and 5%, respecƟvely;39, 40 DTI metrics, ~ 3%;41  and the intra-class 
correlaƟons for DMN funcƟonal connecƟvity is ~ 0.7.42 We also have extensive experience in CSF 
sampling and ELISA study of Aβ, tau and inﬂammatory cytokines in older adults.32 Blood and CSF 
sampling, processing and storage and analyses will follow the standard protocols of NIA Biospecimen 
Best PracƟce Guidelines ). The NIH Toolbox is a sensiƟve and well validated test batery for cogniƟve 
assessment; the test-retest reproducibility, measured as the intraclass correlaƟon coeﬃcient for episodic 
memory, atenƟon and execuƟve funcƟon, which are the focus of this project, ranges from ~ 0.77 to ~ 
0.94.21 Thus, we are conﬁdent about the accuracy and reliability of the methods used for the outcome 
measures proposed in this project. 
1) Measurement of intracranial pulsaƟlity using CINE PC MRI  We will use the velocity-encoded  CINE PC 
MRI to measure intracranial pulsaƟlity .38, 43, 44 2) QuanƟﬁcaƟon of the arterial pressure-CBF coupling 
relaƟonship We will use high temporal resoluƟon TCD to measure CBF velocity waveforms at the MCA, 
and applanaƟon tonometry to measure changes in central arterial pressure at the ICA.45 ApplanaƟon 
tonometry also will be used to assess central arterial sƟﬀness by measuring the caroƟd-femoral pulse 
wave velocity (PWV).35 Fourier spectral analysis will be used to esƟmate cerebrovascular 

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resistance/impedance.45 Mean blood pressure and CBF velocity will be used to esƟmate cerebrovascular 
resistance index (CVRI=BP/CBFV). In addiƟon, we will use 2D color-coded duplex ultrasonography to 
measure volumetric CBF from the ICA and the vertebral artery (VA) to calculate total CBF and 
cerebrovascular resistance (CVR=BP/CBF).46 3) QuanƟﬁcaƟon of the CBF-brain Ɵssue and CBF-CSF 
coupling relaƟonship  CollecƟng CINE PC MRI data in sync with the cardiac cycle, we will measure 
pulsaƟle oscillaƟons of CBF at the ICA, brain Ɵssue volume, local brain Ɵssue movements, and CSF 
dynamic ﬂow at the aqueduct of Sylvius within a whole cardiac cycle4) Measurement of brain volume, 
T2 FLAIR WMH and perfusion  i) 3D T1-weighted MagneƟzaƟon-Prepared-Rapid-AcquisiƟon-of-
Gradient-Echo (3D MPRAGE) sequence (4 min 48 sec) will be used to measure brain volume ii) T2 FLAIR 
sequence (4 min 12 sec) will be used to measure WMH volume.  iii)  Pseudo-conƟnuous arterial spin 
labeling (3D PCASL) sequence  will be used to measure regional CBF.5) Measurement of brain white 
mater microstructural integrity and neural network funcƟonal connecƟvity  i) Diﬀusion tensor imaging 
(DTI) ) and rs-fMRI will be used   to measure  neural network funcƟonal connecƟvity.   
 
5.3 Clinical Chemistry 
5.3.2 Clinical Chemistry 
For all study arms, fasting serum and whole blood will be collected for CMP, lipid profile, 
hemoglobin A1C and analyzed by Quest Diagnostics at Baseline,  6, and 12 months. 
BMP also will be performed at the 2 and 4 weeks during the first month, then at the 2, 3, 
and 9 months or as needed based on clinical judgment/medication adjustment during 
the trial. 
 
5.4 Concomitant MedicaƟons 
All concomitant medicaƟon taken during the study must be recorded during each study visit. InformaƟon 
regarding parƟcipants’ concomitant non-study medicaƟon therapy is collected and documented at 
baseline and then reviewed and revised at each follow-up visit.  Appropriate sources for obtaining this 
informaƟon include parƟcipant (or signiﬁcant other) report, current pharmacy acƟon proﬁles, and 
veriﬁcaƟon of medicaƟons documented in the medical record.   
 

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5.5 DisconƟnuaƟons 
5.5.1 DisconƟnuaƟon of Subjects 
Subjects may be disconƟnued from the intervenƟon, but remain in the study, or may be withdrawn from 
the study by the invesƟgator for any of the following reasons : 
1)  Persistently low eGFR of < 15 ml/min/1.73 m2 or serum K+ > 5.5mmol/L that does not 
respond to anƟhypertensive dose reducƟon or adjustment.  
2) Systolic BP equal or greater than 180mmHg and/or diastolic BP equal or greater than 110 
mmHg.  
3) ComorbidiƟes that make conƟnued parƟcipaƟon in the study medically inappropriate or 
impossible. 
4)  Signiﬁcant cogniƟve decline deﬁned as a decrease in MMSE by 3 points and/or clinical 
manifestaƟon of confusion, disorientaƟon, problems with judgment or  bizarre behavior that 
may impair subject’s safety and/or ability to parƟcipate in the study. 
 
5) Subjects may withdraw their consent at any Ɵme by noƟfying study staﬀ. 
 
Any subject who withdraws or is disconƟnued will be referred to their treaƟng physician/PCP for 
follow-up during reducƟon or disconƟnuaƟon of staƟns or anƟhypertensive in order to monitor 
and resolve any drug-related abnormaliƟes. Subjects who withdraw or disconƟnue due to 
signiﬁcant cogniƟve decline will be evaluated by the site PI or clinician to determine whether 
demenƟa or other diseases are present. Previous cogniƟve test results will be reviewed and 
Clinical DemenƟa RaƟng (CDR) scale will be used to assist clinical judgment. Subjects who 
disconƟnue from the study early will be encouraged to have an early terminaƟon visit at the 
Ɵme of disconƟnuaƟon so that study staﬀ can perform as many outcome measures as possible if 
judged clinically safe for parƟcipants.  
 

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5.5.2 Temporary DisconƟnuaƟons 
AnƟhypertensive drugs may be temporarily disconƟnued if parƟcipants develop low BP (<90/60 mmHg) 
and renal dysfuncƟon (eGFR reduced by > 50%) related to severe dehydraƟon, nausea, vomiƟng, 
diarrhea, reduced oral intake, or febrile illness that may incidentally occur during the trial. BP treatment 
may be restarted aŌer side eﬀects are reduced and it is judged clinically safe to restart study medicaƟon. 
5.5.3 DisconƟnuaƟon of the Study   
The study may be disconƟnued by the IRB, SO, NIH or other government agencies as part of their duƟes 
to ensure the protecƟon of research parƟcipants. In addiƟon, DSMB may require an interim safety data 
analysis based on the overall safety proﬁle and AE or SAEs monitoring to make recommendaƟons to the 
NIH and the PIs concerning disconƟnuaƟon of the study if the adverse eﬀects during the study period 
exceed what would be expected under the study treatments (BP reducƟon) in older adults when 
compared with similar trials reported previously. 
 
 
 
SecƟon 6. Safety Monitoring and ReporƟng 
6.1 IntroducƟon 
All anƟhypertensive agents in the study have been approved by the Food and Drug AdministraƟon (FDA) 
and have been rouƟnely prescribed for lowering BP and blood lipid level in older adults. PaƟent safety 
will be monitored carefully beginning from the enrollment and throughout the whole study. Each 
parƟcipaƟng invesƟgator has primary responsibility for the safety of parƟcipants under his/her care. In 
addiƟon, an independent HIPAC Safety Oﬃcer (SO) will monitor the study safety and any potenƟal 
treatment-related adverse events (AEs) and serious adverse events (SAEs) to protect the safety of study 
parƟcipants. 
 
6.2 Safety Monitoring 

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Several safety issues related to the side eﬀects of anƟhypertensive agents may be a concern (discussed 
below). PotenƟal side eﬀects of anƟhypertensive drugs will be reviewed and discussed with parƟcipants 
during the enrollment. ParƟcipants will be asked to inform the study clinician or staﬀ immediately if side 
eﬀects occur and persist. ParƟcipants will be monitored and interviewed during each of the follow-up 
visits to ensure that any symptoms are addressed early and properly.  
AnƟhypertensive medicaƟon 
PotenƟal adverse eﬀects of the blood pressure drugs used in HIPAC have been well documented.  For 
example, electrolyte abnormaliƟes (hyponatremia or hypokalemia are known to be associated with 
thiazide diureƟcs; hyperkalemia and short-term decline in GFR with losartan, hyperkalemia with 
spironolactone; as well as bradycardia with beta blockers). ParƟcipants will be monitored rouƟnely with 
interviews, vital signs, targeted physical examinaƟon and regular laboratory tests to ensure safety (see 
Figure 1, Table 2).  In addiƟon, site clinicians may also obtain lab tests and/or ECG if safety is a concern at 
non-scheduled intervals. Clinical alerts are generated when the safety parameters exceed the established 
thresholds (see Table 2).  Expected events associated BP drugs will not be considered as SAEs unless they 
meet the criteria for a SAE. 
 
Table 2 Clinical Safety Alerts  
Measure 
Alert Value 
Serum K+ 
> 5.0 mmol/L 
Serum K+ and Na+ 
K+ < 3.5 or Na < 130 mmol/L  
Heart rate 
ResƟng HR < 40 beats/min (bpm) 
ECG 
Evidence of AV or new bundle branch block 
SBP 
Standing SBP < 90 mmHg or seated SBP < 100 mmHg  
 
6.3 ProtecƟon Against Risk 

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Risk associated with anƟhypertensive medicaƟons: All anƟhypertensive medicaƟons used in the study 
are approved by the FDA. The side eﬀects and risks are not more than the expected risk in the clinical 
seƫng. However, we plan to modify treatment in response to safety concerns as below: 
 
If serum K+ > 5.0 mmol/L: 
1. If serum K+ is between 5-5.5, stop K supplement (if applicable) and reduce losartan and spironolactone 
by 50%. 
2. If K+ is between 5.5-5.9, hold losartan and spironolactone unƟl K+ < 4.8, then consider resuming at 50% 
reduced dose. Repeat BMP in 2 weeks. Increase or add other BP medicaƟon to control BP if needed 
(amlodipine 5-10 mg once daily, doxazosin 4-8 mg once daily, hydralazine 25-100 BID either alone or in 
combinaƟon). 
3. If serum K+ is  ≥  6.0 mmol/L, paƟents should visit emergency department immediately for further 
management to avoid life threatening arrhythmia. 
4. Increase or add Amlodipine, Doxazosin, hydralazine, chlorthalidone to control BP, if needed.  
5. Recheck BP and BMP 1-2 weeks aŌer drug adjustment.  
 
 
If serum K+ < 3.5 or serum Na+ < 130 mmol/L:  
1. Reduce chlorthalidone dose by 50%. 
2. Increase or add other BP medicaƟon to control BP, if needed. 
3. If serum K+ is between 3.0-3.5, subjects will receive KCl supplement 40 meq daily and BMP will be 
repeated in 2 weeks. 
4. If serum K+ is between 2.5-2.9, subjects will receive KCl supplement 40 meq bid, stop chlorthalidone 
and any thiazide diureƟcs, and BMP will be repeated in 1 week.  
5. If serum K+ is < 2.5 mmol/L, paƟents will be asked to visit emergency department immediately for 
intravenous K supplement for further management to avoid life threatening arrhythmia. 
6. Recheck BP and BMP in 1-2 weeks aŌer drug adjustment.  
 
HR < 40 bpm or evidence of AV or new bundle block: 
1. Reduce the dose of Beta Blockers by 50%.  
2. Increase or add other anƟhypertensive drugs to control BP, if needed. 
3. Recheck BP aŌer drug adjustment.  

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Standing SBP < 90 mmHg or seated SBP <100 mmHg:  
1. Reduce the dose of Doxazosin, or amlodipine, or diureƟcs or Losartan by 50 %. 
2. Recheck seated and standing BP 2 weeks aŌer drug adjustment. If the standing BP conƟnues to be 
<90, disconƟnue Doxazosin, or other anƟhypertensive drugs, as needed.  
 
MagneƟc Resonance Imaging 
MRI is a safe procedure, used rouƟnely in the clinical evaluaƟon of brain disorders. There are no known 
risks from exposure of older adults to 3T magneƟc ﬁelds that will be used in this study. Claustrophobia 
occurs occasionally in the MRI scanner, but there are no known long-term adverse eﬀects. Usually, 
conversaƟon and reassurance will remove such anxieƟes. If subjects experience severe anxiety during 
MRI, they will be free to end the session at any Ɵme. However, metallic objects are hazardous in MRI 
environment because they can interact and be atracted to the scanner. As a result, each subject will be 
screened with a standard MRI safety form before each MRI scan to rule out potenƟal safety hazards. A 
parƟcipant who is wearing a pacemaker, neurosƟmulator, or any other implanted device will not be 
allowed to parƟcipate in MRI. All metallic objects (keys, watches, and the like) will be removed from the 
researchers and subjects before the MRI experiment begins. 
 
The risk of MRI to pregnant women and unborn babies is not known. For this reason, women who are 
pregnant are not allowed to enter the scanner environment. Thus female parƟcipants will be asked to ﬁll 
out the pregnancy screening form. We will provide a pregnancy test to each female parƟcipant who is 
unsure if she is pregnant. If parƟcipants have a posiƟve pregnancy test, or are not sure whether they are 
pregnant, but don’t want to take the pregnant test, they will not be able to parƟcipate in this study. 
 
Phlebotomy Venous catheters are placed for blood sampling  
There is a small (<5%) risk of superﬁcial thrombus at the inserƟon site, and a smaller risk (<2%) of 
bleeding or infecƟon. To make the blood draw procedure safe and easy for the parƟcipants, only trained 
and experienced Phlebotomist/Nurses will be delegated to perform venipuncture. All measures will be 
taken to ensure infecƟon prevenƟon. 

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QuesƟonnaire administraƟon and neuropsychological tesƟng  
Every eﬀort will be made by the invesƟgators to minimize the possible risks of psychological and/or 
physiological discomfort of parƟcipants during either interviews or studies by reassurance of the subjects 
and by oﬀering rest breaks if needed or required.  ParƟcipants can skip any quesƟon that they do not 
wish to answer and any test that they do not want to perform. 
 
Loss of ConﬁdenƟality 
The data obtained from this project will be used exclusively for the purpose of the research and will not 
be idenƟﬁable to individual subjects when published. All informaƟon obtained that can be idenƟﬁed 
with an individual subject will remain conﬁdenƟal and will be disclosed only with a subject’s permission.  
We will retain whatever blood and cerebral spinal ﬂuid are leŌ over aŌer all the analyses are complete in 
case other tests become available that might be useful to explain the eﬀects of aging on the brain. The 
samples will be kept in the freezer in the Stowe lab at UTSW. All samples will be labeled and coded, with 
each subject’s personal informaƟon de-idenƟﬁed. Only the study invesƟgators will have access to these 
samples. All data collected will be coded with an experiment and subject speciﬁc code to maintain 
conﬁdenƟality. Only the members of the research team will be able to access to this coding informaƟon. 
All samples will be kept unƟl the end of the study then de-idenƟﬁed for future research.  
 
Other Risks 
UnanƟcipated problems or side eﬀects of BP lowering drugs that are unknown at this Ɵme may be 
possible. The invesƟgators will make every eﬀort to minimize potenƟal risks of parƟcipants experiencing 
either psychological or physiological discomforts during either interviews or studies by oﬀering 
reassurance and rest breaks if needed. All study procedures and protocols will be approved by the local 
IRB and HIPAC Safety Oﬃcer (SO). 
 
6.4 Safety ReporƟng 

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6.4.1 Adverse Events and Serious Adverse Events 
Adverse Event (AE) 
Any untoward or unfavorable medical occurrence in a human study parƟcipant, including any abnormal 
sign (e.g. abnormal physical exam or laboratory ﬁnding), symptom, or disease, temporally associated 
with the parƟcipants’ involvement in the research, whether or not considered related to parƟcipaƟon in 
the research. 
 
Serious Adverse Event (SAE) 
Any adverse event that:  
• 
Results in death  
• 
Is life threatening, or places the parƟcipant at immediate risk of death from the event as it 
occurred  
• 
Requires or prolongs hospitalizaƟon  
• 
Causes persistent or signiﬁcant disability or incapacity  
• 
Results in congenital anomalies or birth defects 
• 
Is another condiƟon which invesƟgators judge to represent signiﬁcant hazards  
 
ParƟcipants will be queried for AEs and SAEs at regular phone and clinic visits. InformaƟon on SAEs may 
also be reported to study staﬀ by parƟcipants at any Ɵme between visits. 
 
6.4.2 AE ReporƟng 
All AEs, expected or unexpected, are collected on an Adverse Event Form . All AEs experienced by the 
parƟcipant during the Ɵme frame of the study (e.g. screening, baseline, follow-up visits or close-out), 
under a speciﬁc condiƟon and locaƟon will be reported. The reporƟng Ɵme frame and procedures will 
meet the requirements of the local IRB, HIPAC SO and NIA. 
 
6.4.3 SAE ReporƟng 
SAEs will be reported to the UT Southwestern Medical Center and Texas Health Presbyterian Hospital 
Dallas InsƟtuƟonal Review Boards as soon as the event is known. All SAEs will be recorded by research 
personnel and forwarded to the Drs. Zhang and Vongpatanasin within 48 hours of knowledge of the 
event. The PI will noƟfy the Safety Oﬃcer and NIA Program Oﬃcer within 24 hours of the event being 

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reported. The SO and NIA will receive noƟﬁcaƟon about all SAEs within 72 hours of when the event is 
known and reported by study staﬀ. The reporƟng Ɵme frame and procedures to the local IRBs will follow 
the guidelines of the local IRB. SAEs will be collected and reported from screening to the end of the 
study follow-up period for an individual parƟcipant. SAEs will be followed unƟl resoluƟon, stabilizaƟon, 
or unƟl it is determined that study parƟcipaƟon is not the cause. If a parƟcipant is seen in the ER and 
within seven days is admited to the hospital for a procedure related to that ER visit, a separate SAE does 
not need to be completed. The original SAE for the ER visit should be edited to reﬂect the ER visit and 
the hospitalizaƟon.  
Drs. Zhang and Vongpatanasin will be responsible for Ɵmely reporƟng to the NIH and the SO and provide 
reports of SAEs for review by the SO either by e-mail or at their meeƟngs. 
 
The expedited report will be followed by a detailed, writen SAE report as soon as possible. Follow up 
informaƟon may be required and asked directly by the SO, or NIA Program Oﬃcer or his/her 
representaƟve.  
 
6.4 Data and Safety Monitoring Plan (DSMP) 
According to the NIH  guidelines, the Safety Oﬃcer is an independent individual who performs data and 
safety monitoring acƟviƟes in low-risk, single site clinical studies. The Safety Oﬃcer advises the NIH 
Program Director and Principal InvesƟgator (PI) regarding parƟcipant safety, scienƟﬁc integrity and 
ethical conduct of a study. The Principal InvesƟgator typically proposes an independent Safety Oﬃcer, 
usually a physician, with relevant study and disease speciﬁc experƟse, and submits the individual's name 
for review and approval by the NIH Program Oﬃcer. 
Safety Oﬃcer (SO) will receive the manual of operaƟng procedures, which typically contains the study 
protocol and safety monitoring plan, before study enrollment begins. 
 To remain objecƟve, SO will maintain independence from the study.  Accordingly, SO will not be directly 
involved in the conduct of the study and should not have scienƟﬁc, proprietary, ﬁnancial or other 
interests that may aﬀect independent decision-making. 

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At predetermined intervals, the study staƟsƟcian will prepare adverse event reports to be reviewed by 
SO.  The adverse events are reported in aggregate as requested.  Serious adverse events are generally 
reported as they occur. The safety monitoring plan should specify how data are to be presented.  In 
addiƟon, the safety monitoring plan should specify the process for reporƟng safety concerns among the 
InsƟtuƟonal Review Board, the Safety Oﬃcer and the NIH Program Oﬃcer.  
SO will provide independent safety monitoring in a Ɵmely fashion to assure paƟent safety and study 
quality. 
At the beginning of the trial, SO will review the manual of operaƟng procedures, containing the study 
protocol, study forms, and safety monitoring plan, for scope and comprehensiveness. The monitoring 
plan should delineate data preparaƟon funcƟons, the review process, and the role of the Safety Oﬃcer. 
The monitoring plan also speciﬁes the contents and format of the reports, their frequency, and triggers 
for ad hoc reviews. Stopping rules, if appropriate, should outline the condiƟons under which a study may 
be stopped prematurely. The Safety Oﬃcer may suggest modiﬁcaƟons to the protocol, the monitoring 
plan and the reports that will rouƟnely be prepared by the study staƟsƟcian.  
The primary focus of the Safety Oﬃcer’s monitoring acƟvity is parƟcipant safety.  The Safety Oﬃcer 
reviews adverse event reports prepared by the study staƟsƟcian.  
Serious adverse events are generally reviewed as they occur. The Safety Oﬃcer will noƟfy the NIA if a 
patern of events occurs and will suggest prevenƟon measures. 
For unexpected and/or related serious adverse events, SO  will contact the NIH  Program representaƟve. 
In addiƟon, the Safety Oﬃcer may request individual paƟent records, including laboratory data, clinical 
records, and other study related data, to evaluate these events against the known safety proﬁle of the 
study treatment and the disease. The Safety Oﬃcer may recommend acƟons including parƟal or 
complete unblinding, and/or modifying or terminaƟng the study.  
In addiƟon to safety monitoring, the Safety Oﬃcer may review enrollment data, demographic 
informaƟon, retenƟon status, and other reports prepared by the study staƟsƟcian that describe study 
performance and progress.  SO will provide a report to NIH  that describes study safety, progress and 
performance and provides recommendaƟons regarding safe conƟnuaƟon or early terminaƟon of the 
trial. 

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 The monitoring plan may require SO to evaluate the general performance of the study, including 
periodic assessment of parƟcipant recruitment, accrual and retenƟon, protocol adherence, and data 
quality and Ɵmeliness.  SO may also review any interim analyses to ensure that once the objecƟves of 
the study are met, outcome diﬀerences are detected or stopping rule thresholds are reached, the study 
will conclude. 
 ConﬁdenƟality must be maintained throughout all phases of the trial, including monitoring, preparaƟon 
of interim results, review, and response to monitoring recommendaƟons.  Thus, SO will not receive 
paƟent idenƟﬁers, will maintain study conﬁdenƟality and will not share data. 
AŌer review and evaluaƟon of the speciﬁed periodic reports prepared by the staƟsƟcian, SO will prepare 
a summary cover leter for submission to the NIA. The leter provides comments on the report, discusses 
any concerns or suggesƟons for change, and recommends to NIA conƟnuaƟon or cessaƟon of the trial. 
  
SecƟon7. Sample Size and StaƟsƟcal Methods 
Aim 1: Determine the eﬀects of hypertension on intracranial pulsaƟlity, CSF Aβ and tau, white mater 
integrity and neural network funcƟonal connecƟvity. Hypotheses: Hypertension is associated with: 1) 
augmented central pulsaƟlity, but reduced intracranial pulsaƟlity; 2) reducƟons in CSF soluble Aβ42, but 
increases in phosphorylated tau and total tau; 3) disrupƟons in brain white mater integrity and 
funcƟonal connecƟvity. 
RaƟonale and anƟcipated results  We anƟcipate that central pulsaƟlity is increased, while intracranial 
pulsaƟlity is reduced in paƟents with hypertension, which are associated with increases in 
cerebrovascular impedance and/or reducƟons in brain Ɵssue compliance.47, 48 We anƟcipate that CSF 
Aβ42 is reduced, but total tau and phosphorylated tau are increased in hypertension, suggesƟng impact 
of intracranial pulsaƟlity on brain Aβ and tau homeostasis via reducƟons in glymphaƟc Aβ and tau 
clearance.9, 10 We expect that brain white mater integrity in the regions related to the episodic memory 
and execuƟve funcƟon is reduced in hypertension, which is associated with reducƟons in DMN and FPN 
connecƟvity. We focus on a neural network approach to assess the impact of hypertension on brain 
structure and funcƟon because it is likely to detect early brain changes.16, 18, 22, 36 Gray mater atrophy, 
white mater lesions, and execuƟve dysfuncƟon are observed in older adults with hypertension, and are 
likely inﬂuenced by age and severity of hypertension.15 We do not propose to use PET amyloid imaging to 
assess brain Aβ burden because it is expensive, and only measures the amount of aggregated ﬁbrillary 

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Aβ in the cerebral cortex (extracellular plaques), which manifested only in about one-third of cogniƟvely 
normal older adults.5, 49 Conversely, CSF soluble Aβ and tau are reliable biomarkers of brain aging and AD, 
and reﬂect a steady-state homeostasis (or a metabolic equilibrium) between the producƟon and 
clearance of brain Aβ and tau which may change in response to modiﬁable risk factors such as lowering 
BP, thus suitable for the purpose of this project.50, 51 
StaƟsƟcal analysis and sample size jusƟﬁcaƟon DescripƟve analysis will be performed where we 
summarize conƟnuous variables by mean and standard deviaƟon, and categorical variables by counts 
and percentages. Appropriate transformaƟon will be performed when necessary so that the normality 
assumpƟon is not violated. Comparisons between groups will be performed using two-sample T test or 
Chi-square test. The nonparametric Wilcoxon–Mann–Whitney test and Fisher’s exact test will be 
employed when necessary. We report staƟsƟcal signiﬁcance for a p-value of <0.05 for the primary 
outcome measure of group diﬀerences in the magnitude of intracranial pulsaƟlity. Due to the 
exploratory nature of the proposed study, no adjustments for mulƟple comparisons are planned a priori 
for other outcome measures. Adjustments for mulƟple comparisons for neuroimaging data analysis will 
be performed using the established methods.36, 37 As a secondary data analysis, we propose to conduct 
mediaƟon analysis to assess whether the eﬀects of hypertension on brain Aβ and tau, neural network 
structure and funcƟon are mediated by alteraƟons in intracranial pulsaƟlity. Speciﬁcally, to establish that 
the eﬀect of X (diﬀerences in BP) on the outcome Y (e.g., brain neural network structure or funcƟon) is 
mediated by M (intracranial pulsaƟlity), the following four steps need to be saƟsﬁed: 1) The eﬀect of X 
on Y must be signiﬁcant; 2) The eﬀect of X on M much be signiﬁcant; 3) The eﬀect of M on Y controlling 
for X must be signiﬁcant; 4) the eﬀect of X on Y adjusted for M should be smaller than that observed in 
the step 1. We will use linear models, and the diﬀerence-in-coeﬃcients tests will be performed.52 Sample 
size and power analysis are based on group diﬀerences in the magnitude of intracranial pulsaƟlity, that 
is, measurements of pulsaƟle oscillaƟons in brain Ɵssue volume and regional brain Ɵssue movements 
(local pixel displacement). Previous studies and our pilot data indicate that the magnitude of pulsaƟle 
oscillaƟons in total brain Ɵssue volume during a cardiac cycle is about 0.80 ± 0.15 ml, while the local 
brain Ɵssue movement at the edge of the lateral ventricle is about 0.165 ± 0.042 mm in all three spaƟal 
direcƟons.38, 43, 44 With a total of 120 subjects (40 normotensive and 80 hypertensive), a two-sample T 
test can detect a mean diﬀerence of 0.083 ml of changes in brain Ɵssue volume between the two groups 
with 80% power and 5% two-sided type I error. In addiƟon, a mean diﬀerence of 0.023 mm of local brain 
Ɵssue movement can be detected between the two groups with 80% power and 5% two-sided type I 
error.53 All staƟsƟcal analysis will be performed using SAS 9.3 (SAS InsƟtute, Cary, NC). 

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PotenƟal problems  We do not anƟcipant major problems in the proposed MRI and TCD studies because 
the proposed procedures have been used in our previous studies.35-37, 45 However, the magnitudes of 
pulsaƟle oscillaƟons in brain Ɵssue movement and CSF in a cardiac cycle are relaƟvely small (Fig 3), thus 
robust velocity post-processing procedures are essenƟal to improve the accuracy and reliability of these 
measurements. The procedures for velocity post-processing have been developed by Dr. Zhu (Co-PI of 
this project) and their accuracy and reliability are demonstrated in previous studies.38, 54, 55 EssenƟally, to 
reduce the possibility of a spaƟally dependent oﬀset velocity due to eddy currents or head moƟon, the 
velocity at each pixel locaƟon will be corrected by subtracƟon of the Ɵme-average “velocity” of a nearby 
solid brain Ɵssue “background” within a 29 mm × 29 mm region having the interested pixel at its 
center.38, 44, 56 In calculaƟon of the velocity of the brain Ɵssue, the velocity at each pixel locaƟon will be 
corrected by a subtracƟon of the Ɵme-average “velocity” of the pixel itself obtained over a full cardiac 
cycle. This approach is based on the fact that brain Ɵssue is unlikely to accumulate a net displacement 
over a cardiac cycle.38, 44, 56 The CINE PC-MRI also assumes that blood ﬂow, CSF ﬂow and brain moƟon 
paterns remain relaƟvely constant and are in sync with the cardiac cycle. Following this assumpƟon, we 
will collect PC-MRI data at the second half of the scan session aŌer the subjects are accustomed to the 
MRI environment and relaxing music will be provided to reduce potenƟal discomfort. rs-fMRI 
connecƟvity may be inﬂuenced by the data pre-processing methods to remove vascular contaminaƟon 
that is not related to neuronal acƟvity.37, 57 The most controversial debate on the pre-processing steps is 
the global signal removal strategy.57 Our team is acƟvely working on a beter understanding of the 
impact of global signal removal on fMRI connecƟvity, and has developed more un-biased noise-removal 
techniques.37 rs-fMRI reproducibility is also important to quanƟfy the within-subject modiﬁcaƟon of the 
DMN and FPN. To improve the reproducibility, we propose to collect a relaƟvely long but sƟll durable 12-
minutes of rs-fMRI dataset. We have considered that CSF samples may not be obtained from all study 
parƟcipants. We plan to use an educaƟon video as well as other materials provided by the Alzheimer's 
Disease CooperaƟve Study to improve parƟcipant’s understanding of LP procedures and to increase 
enrollment. Based on our own experience and other trials, CSF samples are likely to be obtained from 
about 50-60% of study parƟcipants.32, 58 We will use consent to LP as an inclusion criteria if the 
enrollment target is below the expected values when we have about 50% of parƟcipants being enrolled 
in the project. Finally, we acknowledge that we cannot measure directly brain Aβ and tau clearance 
through the glymphaƟc system. CSF soluble Aβ and tau reﬂect a steady-state homeostasis between the 
producƟon and clearance of Aβ and tau which ulƟmately inﬂuences brain aging and AD.2, 50 Thus, an 
associaƟon between intracranial pulsaƟlity and CSF Aβ and tau only suggest, but cannot prove a causal 

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relaƟonship. Despite these limits, ﬁndings from this project will provide signiﬁcant new insights into the 
eﬀects of hypertension and anƟhypertensive treatment on intracranial pulsaƟlity, AD biomarkers, brain 
neural network structure and funcƟon.                
Aim 2: Determine the eﬀects of anƟhypertensive treatments on intracranial pulsaƟlity, CSF Aβ and tau, 
brain white mater integrity and neural network funcƟonal connecƟvity. Hypotheses: compared to 
standard care, intensive treatment confers more beneﬁts by: 1) reducƟons in central pulsaƟlity, but 
increases intracranial pulsaƟlity; 2) increases in CSF Aβ42, but reducƟons in phosphorylated tau and total 
tau; 3) improvement in brain white mater integrity and funcƟonal connecƟvity.  
RaƟonale and anƟcipated results The primary outcome measures of Aim 2 are BP treatment induced 
changes in intracranial pulsaƟlity, CSF Aβ and tau. We anƟcipate that cerebrovascular 
resistance/impedance is reduced, and brain Ɵssue compliance is improved aŌer BP lowering, and these 
changes in turn increase global as well as regional intracranial pulsaƟlity.47, 48 We anƟcipate 
anƟhypertensive treatment alters central and/or intracranial pulsaƟlity as well as the dynamic 
relaƟonships between them. An important strength of this project is that we will be able to assess 
whether and to what extent each of the systemic and cerebrovascular factors contribute to the changes 
in intracranial pulsaƟlity. Recent studies including our own work have demonstrated that increases in 
SBP and PBP are associated with increases in brain Aβ burden and elevated CSF tau in older adults, 
suggesƟng a potenƟal link between hypertension and AD pathology.4, 5, 49 We anƟcipate that compared 
to the baseline, CSF Aβ42 level will be higher, and total and phosphorylated tau level will be lower aŌer 
anƟhypertensive treatment, and that larger changes are conferred by intensive BP lowering when 
compared to the standard care.50 We will determine whether changes in CSF Aβ42 and tau are associated 
with changes in intracranial pulsaƟlity, suggesƟng improvement in brain Aβ and tau clearance through 
the glymphaƟc system.8, 12 Furthermore, we anƟcipant that brain white mater integrity in the regions 
related to the episodic memory and execuƟve funcƟon, DMN and FPN funcƟonal connecƟvity is 
improved aŌer intensive BP treatment and that these improvements are associated with improvement in 
global and domain speciﬁc neurocogniƟve funcƟon. We expect that the eﬀects of BP treatment on brain 
white mater integrity, neural network structure and funcƟon are related to the magnitude of BP 
lowering. We have considered that although the presence of intracranial pulsaƟlity is criƟcal for brain Aβ 
and tau clearance,10, 59 changes in intracranial pulsaƟlity may have direct eﬀects on brain perfusion and 
brain neural network structure and funcƟon through either Aβ and tau dependent or independent 
mechanisms.3, 15, 60, 61 We will measure regional brain perfusion using ASL and conduct mulƟvariable 

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    Page 51 of 61 
linear regression and mediaƟon analysis to determine whether changes in intracranial pulsaƟlity are 
related to changes in brain white mater integrity and funcƟonal connecƟvity aŌer adjusƟng for their 
eﬀects on CSF Aβ and tau concentraƟon.    
StaƟsƟcal analysis and sample size jusƟﬁcaƟon Based on the measurements at baseline, 6 months, and 
12 months, we will construct linear mixed models to detect the diﬀerences in the rate of changes of 
outcome measures between the intensive treatment and the standard care group. The models include 
subject random eﬀects to account for the correlaƟons among the measurements. The generalized 
esƟmaƟon equaƟon (GEE) approach will be employed to make inference about the models.53 In addiƟon, 
we will conduct mediaƟon analysis to assess whether the eﬀects of BP lowering on CSF Aβ and tau 
concentraƟons, white mater microstructural integrity and neural network funcƟonal connecƟvity are 
mediated by changes in intracranial pulsaƟlity. The causal-steps approach will be employed for the 
mediaƟon analysis,62 and linear models and the diﬀerence-in-coeﬃcients tests will be performed.52 We 
will build mulƟvariate regression models to assess the associaƟon between the magnitude of BP 
reducƟons and changes in intracranial pulsaƟlity. The outcome and predictor variables will be the within-
subject changes in intracranial pulsaƟlity and BP at one year from the baseline, respecƟvely. The 
regression model will control for other confounding variables including intervenƟon, age, sex, BP 
medicaƟon and central arterial sƟﬀness. The ﬁnal model will be determined based on step-wise variable 
selecƟon as well as clinical consideraƟons. Sample size for the comparison of the slope of the magnitude 
of pulsaƟle oscillaƟons in brain Ɵssue volume or regional brain Ɵssue movement between the treatment 
groups: We conducted power analysis based on the GEE sample size approach developed for the test of 
slopes using longitudinal measurements.63, 64 Based on a previous study, we assume an equal standard 
deviaƟon of 0.15 ml for the two groups.43 At a 5% two-sided type I error and 80% power, by enrolling 40 
paƟents in each group, we can detect a diﬀerence of 0.11 ml/year in the slope between the two groups. 
This calculaƟon assumes a compound symmetric correlaƟon structure, a moderate within-subject 
correlaƟon of 0.25, and a dropout rate of 10% over the 1 year study period. We have also assessed the 
impact of within-subject correlaƟon on power analysis. For example, when the within-subject correlaƟon 
changes from 0.1 to 0.5, the diﬀerence in the slopes that can be detected ranges from 0.1 to 0.13 
ml/year. Sample size for the comparison of changes in CSF at one year from baseline between the 
treatment groups: Assuming that a minimum of 50% of paƟents (that is, 20 paƟents from each group) 
will contribute to both baseline and 12-month measurements. A previous ADNI study in normal older 
adults suggests that the standard deviaƟon of annualized change in CSF Aβ42 is ~ 0.84 pg/ml.58 With 20 
paƟents from each group, using a two-sample T test, we can detect a change of 0.67 pg/ml of CSF Aβ42 

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    Page 52 of 61 
between the two treatment groups with a power of 80% and a one-sided type I error of 5%. Sample size 
for the comparison of brain white mater integrity and neural network funcƟonal connecƟvity: we will 
compare changes in DTI metrics to assess brain white mater integrity at 1 year from the baseline 
between the treatment groups, assuming a dropout rate of 10% from each group. A previous study in 
middle-aged and older adults suggests that the standard deviaƟon of annualized change in global 
fracƟonal anisotropy (FA) based on TBSS analysis is about 0.003.65 With 36 paƟents from each group, 
using a two-sample T test, we can detect a change of 0.002 of FA in the intensive treatment group 
compared with the standard care group with a power of 80% and a two-sided type I error of 5%. 
Similarly, assuming the standard deviaƟon of annualized change in the global DMN funcƟonal 
connecƟvity is about 0.11 using a two-sample T test,66 we can detect a change of 0.074 of funcƟonal 
connecƟvity between the two groups with a power of 80% and a two-sided type I error of 5%.   
 
SecƟon8. Risk/Beneﬁt Assessment 
To the study subjects: Occasionally, an unknown condiƟon that might require medical atenƟon (such as 
a brain tumor, hypertension and diabetes) could be discovered during a careful history and physical 
exam, and with MRI scan. In addiƟon, being followed clinically by the study physician and nurse 
pracƟƟoner, and parƟcipaƟng in the proposed intervenƟon of intensive reducƟon of blood pressure are 
likely to be beneﬁcial for the parƟcipants to improve cardiovascular and brain health.  
To others with similar problems: This project will study the impact of hypertension and intensive 
anƟhypertensive treatment on brain structure and funcƟon. The new knowledge obtained will provide 
mechanisƟc understanding of eﬀects of hypertension and anƟhypertensive treatments on brain health in 
older adults. 
To society in general More than 60% of older adults age ≥ 60 have hypertension which is an important 
risk factor for age-related cogniƟve decline and Alzheimer's disease. Understanding of the underlying 
mechanisms by which hypertension leads to brain damage and potenƟal beneﬁts of anƟhypertensive 
treatments on brain structure and funcƟon is fundamentally important for developing eﬀecƟve 
intervenƟons to prevent age-related cogniƟve decline and demenƟa - one of the signiﬁcant challenges 
we are facing with the aging populaƟon. The relaƟvely minor risks, associated with the potenƟal beneﬁts 
to the individuals and society in general reﬂect a favorable risk/beneﬁt raƟo. 
8.1  IMPORTANCE OF THE KNOWLEDGE TO BE GAINED 

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    Page 53 of 61 
We are facing one of the most signiﬁcant challenges of the 21st century in how to maintain brain health 
in older adults. A mechanisƟc understanding of the role of biomechanical forces (i.e., central and 
intracranial pulsaƟlity) in brain Aβ and tau protein homeostasis in older adults with hypertension is 
potenƟally important for developing novel biomarkers and eﬀecƟve intervenƟons to prevent or slow 
age-related cogniƟve decline and demenƟa.  
 

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    Page 54 of 61 
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resting-state fMRI over thirty days. J Neurotrauma. 2015;32:327-41. 
 
 
 

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Table1. Screening, Baseline and Follow-up Schedule Events for All Study Arms 
Procedures 
Phone-
Screeni
ng 
In-
perso
n 
Scree
ning 
Baseline (3 visits) 
Day 0 
IntervenƟon  
Close out 
  
(12 Month) 
Visit ID 
PS 
SV1 
BL1 
BL2 
BL3 
Day0 
wk2 
wk
4 
wk6 
wk8  
M3 
M6 
M9 
FU1 
FU2 
FU3 
Visit Windows  
  
  
± 2 wks 
± 2 
wks 
± 2 
wks 
Day 0 ± 2 
wks 
± 2 
wks 
  
  
± 2 
wks 
  
  
± 2 
wks 
± 1 
wks 
± 1 
wks 
± 1 
wks 
Estimated Hours 
30mins 
5hr 
2.5hrs 
3.5hr
s 
1.5hr
s 
2hrs 
4hrs 
2hr
s 
2hrs 
2hrs 
4hrs 
4hr
s 
4hrs 
5hrs 
3.5hr
s 
1.5
hrs 
Phone Screen 
QuesƟonnaire/Eligi
bility 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Informed consent/ 
HIPAA  
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Inclusion/Exclusion 
Criteria Review 
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Seated/Standing 
Clinic BP 
  
X 
  
  
  
  
X 
X 
X 
X 
X 
X 
X 
X 
  
  
24-h Ambulatory 
BP* 
  
X 
  
  
  
  
X  
X 
X 
 X 
X 
X 
  
X  
  
  
MMSE 
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Height/ Weight 
/BMI 
  
X 
  
  
  
  
X  
  
  
X 
  
  
X 
 X 
  
  
Subject 
Demographics 
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Subject Family 
History 
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Subject 
MedicaƟons 
  
X 
  
  
  
  
X  
  
  
 X 
  
  
 X 
 X 
X 
  
Subject Health 
History 
  
X 
  
  
  
  
  
  
  
  
  
  
  
X 
  
  
Physical/Neurologi
cal Exam  
  
X 
  
  
  
  
  
  
  
X 
  
  
  
 X 
  
  
ECG 
  
X 
  
  
  
  
  
  
  
  
  
  
  
X 
  
  
NeurocogniƟve 
funcƟon  (NIH-
TB)/NIH PROMIS 
  
  
X 
  
  
  
  
  
  
  
  
X 
  
  
X 
  
Phosphorous and 
Magnesium 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Basic Metabolic 
Panel (BMP)✝ 
  
 
  
X  
  
  
X 
X 
X 
X 
X 
  
X 
  
  
  
Complete 
Metabolic Panel 
(CMP), Hgb A1C, 
Hematocrit 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

STU102017-029, Zhang, FormA3-ResearchProtocol, Mod_21, 10-05-21 (1) 
Version 1.0 
 
    Page 61 of 61 
Complete 
Metabolic Panel 
(CMP), HgbA1C 
  
 
  
  
  
  
  
  
  
X 
  
  
  
X 
  
  
24 Hour Urine 
CollecƟon 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
Plasma, serum and 
whole blood long-
term storage 
(FasƟng), Lipid 
Panel (FasƟng) 
  
 
  
 X 
  
  
  
  
  
  
  
  
  
X 
  
  
MRI  
  
  
  
  
X 
  
  
  
  
  
  
  
  
  
  
X 
TCD 
AutoregulaƟon/Vas
cular funcƟon  
  
  
X 
  
  
  
  
  
  
  
  
X 
  
  
  
X 
RandomizaƟon 
  
  
  
  
  
X 
  
  
  
  
  
  
  
  
  
  
IntervenƟon 
OrientaƟon 
  
  
  
  
  
X 
  
  
  
  
  
  
  
  
  
  
BP MedicaƟon 
TitraƟon 
  
  
  
  
  
  
X 
X 
X 
X 
X 
X 
X 
  
  
  
Treatment 
MedicaƟon 
Compliance 
  
  
  
  
  
  
X 
X 
X 
X 
X 
X 
X 
X 
X  
X  
Adverse Event 
Assessment 
  
  
  
  
  
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
* 24-h ABP will be performed during week 2-10 when clinic BP reaches goal, and during wk 12 or M3 (unless 24-h ABP 
already reaches goal between wk 2-10), M6, and 12 
  
  
  
  
  
✝ BMP will be performed at wk 2, and prn only when diureƟcs, ACEI, or ARB are added to regimen or the 
doses of these drugs are increased. 
 
 
 
 
 
 
 
** LP will be performed only in subjects who agree 
to this part of the study 
 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline Visit Procedures can be done at diﬀerent order with some restricƟons: MRI cannot be fasƟng, must give snacks 
prior to MRI if paired with fasƟng blood draw