Effect of Antihypertensive Treatment on Cardiovascular Events in Elderly Hypertensive Patients: Japan's Benidipine Research on Anti-Hypertensive Effects in the Elderly (J-BRAVE) Treatment of Hypertension in Patients 85 Years of Age or Older: A J-BRAVE Substudy The Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients (JATOS): Protocol, Patient Characteristics, and Blood Pressure during the First 12 Months Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. Protocol for Past BP: a randomised controlled trial of different blood pressure targets for people with a history of stroke of transient ischaemic attack (TIA) in primary care Progress Report on the Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) Study: Status at February 2004 Age-varying association between blood pressure and risk of dementia in those aged 65 and older: a community-based prospective cohort study. Aliskiren and valsartan in stage 2 hypertension: subgroup analysis of a randomized, double-blind study Nitrendipine in older patients with isolated systolic hypertension: second progress report on the SYST-EUR trial. 2015 guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension. South African hypertension guideline 2011. The second progress report on the Hypertension Objective treatment based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) study Relationship between home blood pressure and longitudinal changes in target organ damage in treated hypertensive patients. Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial A multifaceted pharmacist intervention to improve antihypertensive adherence: a cluster-randomized, controlled trial (HAPPy trial). Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes. Rationale and design of the Optimal Macro-Nutrient Intake Heart Trial to Prevent Heart Disease (OMNI-Heart) Linking clinic and home: a randomized, controlled clinical effectiveness trial of real-time, wireless blood pressure monitoring for older patients with kidney disease and hypertension Is a systolic blood pressure target <140 mmHg indicated in all hypertensives? Subgroup analyses of findings from the randomized FEVER trial. Postprandial hypotension predicts all-cause mortality in older, low-level care residents. Swiss Hypertension and Risk Factor Program (SHARP): Cardiovascular risk factors management in patients with type 2 diabetes in Switzerland Home-based self-measurement of blood pressure: a proposal using new reference values (the PURAS study) The Systolic Hypertension in the Elderly Program (SHEP): an intervention trial on isolated systolic hypertension. SHEP Cooperative Research Group.
The achievement rate of blood pressure ( BP ) target and the relationship between on-treatment BP and development of cardiovascular events ( i.e. , stroke , myocardial infa rct ion , and heart failure ) were investigated in a total of 8,897 patients in the Japan 's Benidipine Research on Antihypertensive Effects in the Elderly ( J-BRAVE ) study , a prospect i ve , 3-year observational study of a  calcium channel blocker-based treatment in hypertensive patients aged ≥65 years as a post-marketing  surveillance . Blood pressure decreased significantly from 164.8 ± 14.1/88.2 ± 10.3 mmHg to 137.0 ± 13.5/75.6 ± 9.5 mmHg and the percentage of patients who achieved BP < 140/90 mmHg was 57.2 % after 3 years . The incidence of cardiovascular events was 7.54/1,000 patient-years . Subgroups of patients stratified by on-treatment systolic blood pressure ( SBP ) were analyzed . Baseline BP , body mass index ( BMI ) , the dose of benidipine , the mean number of anti-hypertensive drugs , and the incidence of cardiovascular events were higher in patients with on-treatment SBP ≥160 mmHg than in those with an SBP of < 130 mmHg . In patients aged 65 to 74 years ( n = 5,092 ) and patients aged ≥75 years ( n = 3,805 ) , the percentages of patients who achieved the BP target of < 140/90 mmHg were 57.5 % and 56.6 % after 3 years , respectively , and the incidence of cardiovascular events was higher in patients with on-treatment SBP ≥160 mmHg in both age subgroups . The results of the J-BRAVE study show that on-treatment SBP ≥160 mmHg is associated with a higher incidence of cardiovascular events in elderly hypertensive patients Whether the strict control of blood pressure ( BP ) of patients with hypertension who are aged 85 years or older is beneficial is unclear . The Japan ’s Benidipine Research on Antihypertensive Effects in the Elderly study is a prospect i ve , observational 3-year study to evaluate the safety and effectiveness of treatment with a calcium channel blocker benidipine in 8897 hypertensive patients aged 65 years or older as a post-marketing surveillance . We examined the relationship between the achieved BP and cardiovascular events ( i.e. , stroke , myocardial infa rct ion , and heart failure ) in a subgroup of 415 patients aged 85 years or older ( mean age 88 years ) . BP decreased significantly from 165 ± 14/84 ± 10 mmHg to 130 ± 11/71 ± 10 mmHg during treatment in patients with a treated systolic BP ( SBP ) < 140 mmHg ( n = 230 ) and BP decreased significantly from 169 ± 16/86 ± 12 mmHg to 143 ± 13/75 ± 10 mmHg in those with a treated SBP ≥ 140 mmHg ( n = 185 ) . There was a nonsignificant trend toward a lower rate of cardiovascular events and higher rate of total death in patients with a treated SBP < 140 mmHg . On-treatment SBP ≥ 160 mmHg is tended to associate with a higher incidence of cardiovascular events . There was no significant difference in the incidence of adverse reactions between the controlled BP group ( 3.04 % ) and the less well controlled BP group ( 3.24 % ) . In conclusion , although this study was not powered for definitive conclusion , there was a nonsignificant trend toward a lower rate of cardiovascular events and higher total death in patients aged 85 years or older with a treated SBP < 140 mmHg The benefits of a systolic blood pressure ( BP ) below 150–160 mmHg are well established ; whether a systolic BP of less than 140 mmHg provides additional benefits remains controversial . This study was design ed to compare the 2-year effect of a strict treatment to maintain systolic BP below 140 mmHg ( group A ) and that of a mild treatment to maintain systolic BP at between 140 and below 160 mmHg ( group B ) . The study design followed the Prospect i ve R and omized Open Blinded End-point ( PROBE ) study . The subjects were elderly patients ( 65–85 years old ) who consistently had a systolic BP of 160 mmHg or higher . The baseline drug was efonidipine hydrochloride ( efonidipine ) , a long-acting dihydropiridine calcium antagonist . The primary endpoints were stroke , cardiac disease , vascular disease , and renal failure . After a run-in period of 2 to 4 weeks , 2,165 patients were assigned to group A and 2,155 patients to group B. There were no significant differences between the groups in sex , age , baseline BP , or other cardiovascular risk factors . The systolic BP was 7.2 mmHg lower ( p<0.0001 ) and the diastolic BP 2.4 mmHg lower ( p<0.0001 ) in group A than in group B after 12 months of treatment . As of this interim analysis , primary endpoints have occurred in 87 patients ( stroke in 58 patients , cardiac disease in 27 patients , occlusive arterial disease in 1 patient , and renal failure in 1 patient ) . Five patients have died of stroke and 2 patients of myocardial infa rct ion . The primary -endpoint-related morbidity rate was 20.9/1,000 patient-years , and the mortality rate was 1.7/1,000 patient-years . Currently available results indicate that this study , one of the largest r and omized trials of antihypertensive therapy in elderly patients in Japan , was conducted safely . The final results are expected to provide important and practical information for the management of hypertension in elderly patients OBJECTIVES To investigate the relationships between uncontrolled and controlled hypertension , orthostatic hypotension ( OH ) , and falls in participants of the Maintenance of Balance , Independent Living , Intellect , and Zest in the Elderly of Boston Study ( N=722 , mean age 78.1 ) . DESIGN Prospect i ve population -based study . SETTING Community . PARTICIPANTS Seven hundred twenty-two adults aged 70 and older living within a 5-mile radius of the study headquarters at Hebrew Rehabilitation Center in Boston .  MEASUREMENTS Blood pressure ( BP ) was measured at baseline in the supine position and after 1 and 3 minutes of st and ing .  Systolic OH ( SOH ) and diastolic OH at 1 and 3 minutes were defined as a 20-mmHg decline in systolic BP and a 10-mmHg decline in diastolic BP upon st and ing . Hypertension was defined as BP of 140/90 mmHg or greater or receiving antihypertensive medications ( controlled if BP < 140/90 mmHg and uncontrolled if ≥ 140/90 mmHg ) . Falls data were prospect ively collected using monthly calendars . Fallers were defined as those with at least two falls within 1 year of follow-up . RESULTS OH was highest in participants with uncontrolled hypertension ; SOH at 1 minute was 19 % in participants with uncontrolled hypertension , 5 % in those with controlled hypertension , and 2 % in those without hypertension ( P ≤ .001 ) ) . Participants with SOH at 1 minute and uncontrolled hypertension were at greater risk of falls ( hazard ratio=2.5 , 95 % confidence interval = 1.3 - 5.0 ) than those with uncontrolled hypertension without OH . OH by itself was not associated with falls . CONCLUSION Older adults with uncontrolled hypertension and SOH at 1 minute are at greater risk for falling within 1 year . Hypertension control , with or without OH , is not associated with greater risk of falls in older community-dwelling adults Background Blood pressure ( BP ) lowering in people who have had a stroke or transient ischaemic attack ( TIA ) leads to reduced risk of further stroke . However , it is not clear what the target BP should be , since intensification of therapy may lead to additional adverse effects . PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting , and whether more intensive therapy is associated with adverse effects on quality of life . Methods / Design This is a r and omised controlled trial ( RCT ) in patients with a past history of stroke or TIA . Patients will be r and omised to two groups and will either have their blood pressure ( BP ) lowered intensively to a target of 130 mmHg systolic , ( or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg ) compared to a st and ard group where the BP will be reduced to a target of 140 mmHg systolic . Patients will be managed by their practice at 1 - 3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.610 patients will be recruited from approximately 50 general practice s. The following exclusion criteria will be applied : systolic BP < 125 mmHg at baseline , 3 or more anti-hypertensive agents , orthostatic hypotension , diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness . The primary outcome will be change in systolic BP over twelve months . Secondary outcomes include quality of life , adverse events and cardiovascular events . In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals underst and ing and views of BP management . Discussion The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care , and help determine whether or not further research is required before recommending such targets for this population .Trial Registration IS RCT The Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure ( HOMED-BP ) Study is the first large-scale intervention trial in Japan using a PROBE design to determine an optimal target blood pressure ( BP ) level on the basis of self-measured BP at home and optimal initial antihypertensive medication . The registered patients are r and omized to one of two different BP levels and to initial antihypertensive regimens ( i.e.  ,  calcium antagonist [ Ca-A ] , angiotensin-converting enzyme inhibitor [ ACE-I ] , or angiotensin II receptor antagonist [ ARB ] ) . At the end of February 2004 , 2729 , 1687 , and 971 patients were recruited , r and omized , and followed-up for 12 months or more . Among the 971 patients , mean systolic/diastolic BP levels at r and omization in the Ca-A , ACE-I , and ARB groups were 150/90 , 152/89 , and 151/89 mmHg , respectively . These values reduced after six months of Ca-A- , ACE-I- , and ARB-based treatment ( 133/81 mmHg , 135/80 mmHg , and 134/79 mmHg , respectively ) and further reduced after 12 months ( 131/80 mmHg , 134/79 mmHg , and 132/79 mmHg , respectively ) without any significant differences among groups . In more intensive and less intensive BP-lowering groups , mean systolic/diastolic BP levels at r and omization were 151/90 and 150/89 mmHg , respectively . Although BP levels reduced after 6-month ( 135/80 mmHg and 133/80 mmHg , respectively ) and 12-month treatment ( 133/79 mmHg and 132/80 mmHg , respectively ) in each target group , no significant difference in BP values was observed between groups . These results indicate the necessity of additional interventional strategies to improve the achievement of target BP levels , especially in the more intensive BP-lowering group OBJECTIVES To assess variation in the association between blood pressure ( BP ) and risk for dementia across a spectrum of older ages and to examine BP changes before dementia onset . DESIGN Prospect i ve cohort study . SETTING A large health maintenance organization in Seattle , Washington . PARTICIPANTS A cohort of 2,356 members of a large health maintenance organization aged 65 and older who were initially without dementia . MEASUREMENTS Dementia diagnosis was assessed biennially , and systolic ( SBP ) and diastolic BP ( DBP ) were measured at baseline and at four follow-up assessment s. Cox proportional hazards models were used to estimate hazard ratios ( HRs ) for dementia and Alzheimer 's disease ( AD ) associated with baseline BP in different age groups . RESULTS Within the youngest age group ( 65 - 74 at enrollment ) a greater risk for dementia was found in participants with high SBP ( > or = 160 mmHg ) ( hazard ratio ( HR ) = 1.60 , 95 % confidence interval ( CI ) = 1.01 - 2.55 ) or borderline-high DBP ( 80 - 89 mmHg ) ( HR = 1.59 , 95 % CI = 1.07 - 2.35 ) than for those with normal BP ( SBP < 140 mmHg and DBP < 80 mmHg ) . The dementia risk associated with SBP declined with increasing age ( SBP-by-age interaction , P=.01 ) . SBP declined similarly with aging in subjects who developed dementia and those who did not . Thus , in this sample , the association between SBP and dementia risk was not dependent on when BP was measured in relation to onset of dementia . CONCLUSION High SBP was associated with greater risk of  dementia  in the young elderly ( < 75 ) but not in older subjects . Adequate control of hypertension in early old age may reduce the risk for dementia Introduction Patients with stage 2 hypertension require large absolute reductions in blood pressure ( BP ) to achieve recommended BP goals . Combination therapy with the direct renin inhibitor , aliskiren , and the angiotensin receptor blocker , valsartan , has been shown to produce greater BP reductions than either agent alone in a double-blind study in 1797 hypertensive patients . Methods This post-hoc analysis evaluated the BP-lowering efficacy  of aliskiren in combination with valsartan in a subset of patients ( n=581 ) with stage 2 hypertension ( baseline mean sitting systolic BP [ msSBP ] ≥160 mmHg ) . Patients were r and omized to receive aliskiren/valsartan 150/160 mg , aliskiren 150 mg , valsartan 160 mg , or placebo once daily for 4 weeks followed by 4 weeks at double the initial dose . Mean changes from baseline in msSBP and mean sitting diastolic BP were assessed at week-8 endpoint ( intent-to-treat population ) . Results Aliskiren/valsartan 300/320 mg reduced BP from baseline by 22.5/11.4 mmHg at week-8 endpoint . BP reductions with combination therapy were significantly greater than with aliskiren 300 mg ( 17.3/8.9 mmHg , P<0.05 ) , valsartan 320 mg ( 15.5/8.3 mmHg , P<0.01 ) , or with placebo ( 7.9/3.7 mmHg , P<0.0001 ) . BP control rates ( < 140/90 mmHg ) were also significantly higher ( P<0.05 ) with aliskiren/valsartan 300/320 mg ( 29.8 % ) compared with either aliskiren 300 mg ( 19.0 % ) or valsartan 320 mg ( 13.8 % ) monotherapy , or placebo ( 8.9 % ) . All treatments were generally well tolerated . Conclusion Combination therapy with aliskiren and valsartan provided significantly greater BP reductions  over aliskiren or valsartan monotherapy and is an appropriate option for management of BP in patients with stage 2 hypertension This report from the double-blind placebo-controlled SYST-EUR trial investigated whether modern antihypertensive drugs are suitable for maintaining long-term BP control in older ( > or = 60 years of age ) subjects with isolated systolic hypertension ( SBP 160 - 219 mmHg and DBP < 95 mmHg ) . Active treatment consisted of nitredipine ( 10 - 40 mg/day ) with the possible addition of enalapril ( 5 - 20 mg/day ) and hydrochlorothiazide ( 12.5 - 25 mg/day ) , if necessary to reduce SBP to < 150 mmHg and by > or = 20 mmHg . Matching placebos were used in the control group . This analysis was restricted to 18 months of follow-up . The placebo ( n = 456 ) and active treatment ( n = 485 ) groups had similar characteristics at r and omisation ( sitting pressure 176/85 mmHg ; age 73 years ) .  SBP fell ( P < 0.001 ) on average 10 mmHg more on active treatment than on placebo and DBP 4 mmHg more . Fewer patients remained on monotherapy in the placebo than in the active treatment group ( P < 0.001 ) ; on placebo the second and third line medications were started earlier ( P < 0.001 ) . Nitrendipine tablets were discontinued in nine patients on placebo and in 29 patients assigned to active treatment ( P < 0.001 ) . In conclusion , a significant BP reduction can be achieved and maintained in older patients with isolated systolic hypertension treated with a calcium antagonist ( associated with a converting-enzyme inhibitor and a thiazide , where necessary ) . Whether this BP reduction results in a clinical ly meaningful decrease of cardiovascular complications is under investigation It has been almost 5 years since the publication of the 2010 hypertension guidelines of the Taiwan Society of Cardiology ( TSOC ) . There is new evidence regarding the management of hypertension , including r and omized controlled trials , non-r and omized trials , post-hoc analyses , subgroup analyses , retrospective studies , cohort studies , and registries . More recently , the European Society of Hypertension ( ESH ) and the European Society of Cardiology ( ESC ) published joint hypertension guidelines in 2013 . The panel members who were appointed to the Eighth Joint National Committee ( JNC ) also published the 2014 JNC report . Blood pressure ( BP ) targets have been changed ; in particular , such targets have been loosened in high risk patients . The Executive Board members of TSOC and the Taiwan Hypertension Society ( THS ) aim ed to review up date d information about the management of hypertension to publish an up date d hypertension guideline in Taiwan . We recognized that hypertension is the most important risk factor for global disease burden . Management of hypertension is especially important in Asia where the prevalence rate grows faster than other parts of the world . In most countries in East Asia , stroke surpassed coronary heart disease ( CHD ) in causing premature death . A diagnostic algorithm was proposed , emphasizing the importance of home BP monitoring  and ambulatory BP monitoring  for better detection of night time hypertension , early morning hypertension , white-coat hypertension , and masked hypertension . We disagreed with the ESH/ESH joint hypertension guidelines suggestion to loosen BP targets to < 140/90 mmHg for all patients . We strongly disagree with the suggestion by the 2014 JNC report to raise the BP target to < 150/90 mmHg for patients between 60 - 80 years of age . For patients with diabetes , CHD , chronic kidney disease who have proteinuria , and those who are receiving antithrombotic therapy for stroke prevention , we propose BP targets of < 130/80 mmHg in our guidelines . BP targets are < 140/90 mmHg for all other patient groups , except for patients ≥80 years of age in whom a BP target of < 150/90 mmHg would be optimal . For the management of hypertension , we proposed a treatment algorithm , starting with life style modification ( LSM ) including S-ABCDE ( Sodium restriction , Alcohol limitation , Body weight reduction , Cigarette smoke cessation , Diet adaptation , and Exercise adoption ) . We emphasized a low-salt strategy instead of a no-salt strategy , and that excessively aggressive sodium restriction to < 2.0 gram/day may be harmful . When drug therapy is considered , a strategy called " PROCEED " was suggested ( Previous experience , Risk factors , Organ damage , Contraindications or unfavorable conditions , Expert 's or doctor 's judgment , Expenses or cost , and Delivery and compliance issue ) . To predict drug effects in lowering BP , we proposed the " Rule of 10 " and " Rule of 5 " . With a st and ard dose of any one of the 5 major classes of anti-hypertensive agents , one can anticipate approximately a 10-mmHg decrease in systolic BP ( SBP ) ( Rule of 10 ) and a 5-mmHg decrease in diastolic BP ( DBP ) ( Rule of 5 ) . When doses of the same drug are doubled , there is only a 2-mmHg incremental decrease in SBP and a 1-mmHg incremental decrease in DBP . Preferably , when 2 drugs with different mechanisms are to be taken together , the decrease in BP is the sum of the decrease of the individual agents ( approximately 20 mmHg in SBP and 10 mmHg in DBP ) . Early combination therapy , especially single-pill combination ( SPC ) , is recommended . When patient 's initial treatment can not get BP to targeted goals , we have proposed an adjustment algorithm , " AT GOALs " ( Adherence , Timing of administration , Greater doses , Other classes of drugs , Alternative combination or SPC , and LSM + Laboratory tests ) . Treatment of hypertension in special conditions , including treatment of resistant hypertension , hypertension in women , and perioperative management of hypertension , were also mentioned . The TSOC/THS hypertension guidelines provide the most up date d information available in the management of hypertension . The guidelines are not m and atory , and members of the task force fully realize that treatment of hypertension should be individualized to address each patient 's circumstances . Ultimately , the decision of the physician decision remains of the utmost importance in hypertension management OUTCOMES Extensive data from r and omised controlled trials have shown the benefit of treating hypertension . The target blood pressure ( BP ) for antihypertensive management is systolic < 140 mmHg and diastolic < 90 mmHg with minimal or no drug side-effects ; however , stricter BP control is required for patients with end-organ damage , co-existing risk factors and co-morbidity , e.g. diabetes mellitus . The reduction of BP in the elderly and in those with severe hypertension should be achieved gradually over 1 month . Co-existent risk factors should also be controlled . BENEFITS Benefits of management include reduced risks of stroke , cardiac failure , chronic kidney disease and coronary heart disease . RECOMMENDATIONS The correct BP measurement procedure is described , and evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated . The total cardiovascular disease risk profile should be determined for all patients to inform management strategies . Lifestyle modification and patient education are cornerstones in the management of every patient . Major indications , pre caution s and contra-indications to each recommended antihypertensive drug are listed . Combination therapy should be considered ab initio if the BP is ≥ 20/10 mmHg . First-line drug therapy for uncomplicated hypertension includes low-dose thiazide-like diuretics , calcium channel blockers ( CCBs ) or angiotensin-converting enzyme inhibitors ( ACE-Is ) ( or ARBs - angiotensin II receptor blockers ) . If the target BP is not obtained , a second antihypertensive should be added from the aforementioned list . If the target BP is still not met , the third remaining antihypertensive agent should be used . In black patients  either thiazide-like diuretics or CCBs can be used initially , because response rates are better than with ACE-Is or β-blockers . In treating resistant hypertension , a central ly acting drug , vasodilator , α-blocker , spironolactone or β-locker should be added . This guideline includes management of specific situations , i.e. hypertensive emergency and urgency , severe hypertension with target organ damage , hypertension in diabetes mellitus , resistant hypertension , fixed drug combinations , new trials in hypertension , and interactions of antihypertensive agents with other drugs . VALIDITY The guideline was developed by the Southern African Hypertension Society Background The Hypertension Objective treatment based on Measurement by Electrical Devices of Blood Pressure ( HOMED-BP ) study is a large-scale intervention trial to determine both optimal target blood pressure ( BP ) on the basis of self-measured BP at home , and optimal initial antihypertensive medication . Objective To investigate the quality of r and omization at the end of March 2003 , and BP-controlled conditions during initial 6 months . Methods We evaluated the number of patients r and omized by the end of March 2003 , and BP changes during the initial 6 months based on intention-to-treat analysis . Results By the end of March 2003 , a total of 1086 patients ( 12 % of a planned r and omization of 9000 patients ) had been r and omized . Among 653 patients who had been followed for ≥6 months after r and omization  , mean systolic/diastolic BPs at r and omization in the calcium antagonist , angiotensin-converting enzyme and angiotensin II receptor blocker groups were 149/89 , 150/89 and 149/88 mmHg , respectively . Blood pressures were reduced after 3 months ( 137/83 , 139/82 and 136/82 mmHg , respectively ) , and further reduced after 6 months ( 134/81 , 135/80 and 133/80 mmHg , respectively ) , with no significant differences identified between groups . In more- and less-intensive BP-lowering groups , mean systolic/diastolic BPs at r and omization were 149/88 and 150/89 mmHg , respectively . Although BPs were reduced after treatment for 3 months ( 137/83 and 137/82 mmHg , respectively ) and 6 months ( 134/80 and 135/80 mmHg , respectively ) in each target group , significant differences were still not observed between groups . Conclusions Good quality of r and omization was observed at the end of March 2003 , but rate of achievement for target BPs was insufficient Cross-sectional studies have shown that home blood pressure ( BP ) correlates with hypertensive target organ damage better than clinic BP . However , there have been few longitudinal studies regarding the predictive value of home BP on the changes in organ damage in treated hypertensive patients .  Clinic and home BP  over a 12-month period ,  antihypertensive medication use , echocardiographic and electrocardiographic results , and serum creatinine and urinary protein levels  were examined in 209 treated hypertensive patients in 1993 . These patients were prospect ively followed for 5 years . The patients were divided into 4 subgroups according to hypertension control as follows : good control ( < 140/90 mmHg for clinic BP , < 135/85 mmHg for home BP ) , improved , worsened , and poor control . The average clinic BP was 147.0+/-14.9/87.0+/-7.6 mmHg ( mean+/-SD ) in 1993 and 146.0+/-13.7/84.1+/-7.5 mmHg in 1998 . The average home BP was 136.8+/-10.4/84.3+/-7.6 mmHg in 1993 and 136.1+/-9.7/81.2+/-7.7 mmHg in 1998 . The left ventricular mass index ( LVMI ) positively correlated with both home systolic BP and clinic systolic BP in 1998 but not in 1993 . The correlation tended to be closer for home BP than for clinic BP . LVMI did not change in patients with good or improved home systolic BP , while it increased in those with poor or worsened home systolic BP . The relationship between changes in LVMI and clinic BP was not significant . In conclusion , Home BP was more effective than clinic BP as a predictor of changes in left ventricular hypertrophy in treated hypertensive patients .  Home BP should be controlled to below 135/85 mmHg to prevent cardiac hypertrophy Objective To explore the likely optimum blood pressure ( BP ) level for patients with a history of cerebrovascular disease . Methods The Perindopril Protection Against Recurrent Stroke Study ( PROGRESS ) was a r and omized , placebo-controlled trial that established the beneficial effects of BP lowering in 6105 patients with cerebrovascular disease . The present study comprises two series of post hoc analyses . The first was design ed to investigate the effects of r and omized treatment on recurrent stroke by baseline BP levels , and the second was a corresponding observational analysis investigating the association between achieved follow-up BP levels and recurrent stroke risk . Results Analyses of the r and omized treatment comparisons showed that BP lowering with combination therapy produced similar risk reductions in each of four subgroups defined by baseline BP of less than 120 , 120–139 , 140–159 , and 160 mmHg or greater ( P homogeneity = 0.5 ) . The effects of single-drug therapy were also comparable across these subgroups ( P homogeneity = 0.2 ) , but consistently greater benefits were observed with combination compared to single-drug therapy . The analyses of achieved follow-up BP showed that the lowest risk of recurrence was among the one-quarter of participants with the lowest follow-up BP levels ( median 112/72 mmHg ) , and that risks rose progressively with higher follow-up BP levels . Minor side-effects were progressively more common at lower BP levels ( P homogeneity = 0.04 ) , but there was no excess of serious complications ( all P homogeneity > 0.2 ) . Conclusion These analyses provide no evidence of a J-curve relationship between BP level and stroke risk among patients with cerebrovascular disease , and identify no patient group among whom more intensive BP lowering would not be expected to produce greater risk reductions WHAT IS KNOWN AND OBJECTIVES About half of all patients taking antihypertensives discontinue treatment by 12 months . There is potential for substantial health gains at both individual and population levels through improved treatment adherence . The objective was to evaluate a community pharmacist intervention to improve adherence with antihypertensive medicines with a view to improving blood pressure ( BP ) control . METHODS DESIGN prospect i ve , non-blinded , cluster-r and omized , controlled trial . PARTICIPANTS adults with primary hypertension who obtained antihypertensives in the previous 6 months . Patients with poor refill adherence were preferentially identified with the help of a purpose -built software application . INTERVENTION package comprising BP monitor ; training on BP self-monitoring ; motivational interviewing ; medication use review ; prescription refill reminders . FOLLOW-UP six months . PRIMARY OUTCOME change in proportion self-reporting medication adherence . Secondary outcome : BP changes . RESULTS Participants ( n = 395 ; intervention - 207 ; control - 188 ) had a mean age of 66.7 years ; 51.1 % were males . The proportion of adherent participants increased in both groups but was not significantly different between groups [ 57·2 % to 63·6 % ( control ) vs. 60·0 % to 73·5 % ( intervention ) , P = 0·23 ] . The mean reduction in systolic BP was significantly greater in the intervention group ( 10·0 mmHg vs. 4·6 mmHg ; P = 0·05 ) . The proportion of patients who were non-adherent at baseline and adherent at 6 months was 22·6 % ( 95%CI 5·1 - 40·0 % ) higher in the intervention group ( 61·8 % vs. 39·2 % , P = 0·007 ) . Among participants with baseline  BP above target , reduction of systolic BP was significantly greater in the intervention group [ by 7·2 mmHg ( 95%CI 1·6 - 12·8 mmHg ) ; ( P = 0·01 ) ] . Among participants non-adherent at baseline and above target BP , the proportion reporting adherence at 6 months was significantly greater in the intervention group [ 56·8 % vs. 35·9 % , P = 0·039 ) . WHAT IS NEW AND CONCLUSION This community pharmacist intervention result ed in improved adherence to antihypertensive medication and reduced systolic BP OBJECTIVE To compare the effectiveness of a nurse-led hypertension clinic with conventional community care in general practice in the management of uncontrolled hypertension in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS We studied 120 men and women outpatient attendees ( 61 % non-Caucasian ) with type 2 diabetes and a seated blood pressure ( BP ) > or=140/80 mmHg . All patients were being treated for hypertension , and 71 % had increased urinary albumin excretion ( UAE ) . Patients were allocated to either a nurse-led hypertension clinic or conventional primary care . The primary outcome measure was a change in systolic BP . Secondary outcome measures were total cholesterol , HDL cholesterol , total triglycerides , HbA(1c ) , UAE , serum creatinine , and changes in absolute stroke and coronary heart disease ( CHD ) risk scores . RESULTS The mean ( 95 % CI ) difference in the decrement of systolic BP was 12.6 mmHg ( 5.9 - 19.3 ) ( P = 0.000 ) in favor of the nurse-led group , whose patients were three times more likely to a reach target systolic BP < 140 mmHg compared with conventional care ( P = 0.003 ) . A significant fall in 10-year CHD ( P = 0.004 ) and stroke risk ( P = 0.000 ) scores occurred only in the nurse-led group . There were no significant differences in the reduction of diastolic BP or any of the other secondary outcome measures at 6 months . CONCLUSIONS Compared with conventional care , a nurse-led hypertension clinic is a more effective intervention for patients with type 2 diabetes and uncontrolled hypertension . A target systolic BP < 140 mmHg is more readily achieved and may be associated with significant reductions in 10-year cardiovascular disease risk scores Background The DASH ( Dietary Approaches to Stop Hypertension ) diet is a carbohydrate-rich , reduced-fat diet that lowers blood pressure ( BP ) and LDL-cholesterol . Whether partial replacement of some carbohydrate ( C ) with either protein ( P ) or unsaturated fat ( U ) can further improve these and other cardiovascular ( CVD ) risk factors is unknown . Methods OmniHeart is a r and omized , three-period , crossover feeding study design ed to compare the effects on BP and blood lipids of a carbohydrate-rich diet ( CARB , similar to the DASH diet ) with a diet rich in protein ( PROT , predominantly from nonmeat sources ) and a diet rich in unsaturated fat ( UNSAT , predominantly monounsaturated ) . Throughout feeding ( run in and the three intervention periods ) , participants are provided with all of their meals that meet the nutrient profile of their assigned diet . Calorie intake is adjusted to maintain weight . The target sample size is 160 ( 50 % African-American ) . Participants are adults , aged 30 or older , with prehypertension or Stage 1 hypertension ( systolic BP 120–159 or diastolic BP 80–99 mmHg ) . The primary outcome variables are systolic BP and LDL-cholesterol . Secondary outcomes are diastolic BP , HDL-cholesterol , and triglycerides . Other outcome variables are total cholesterol , apolipoproteins VLDL-apoB , VLDL-apoCIII , apolipoprotein B , non-HDL cholesterol , and lipoprotein(a ) , and insulin resistance , as measured by Homeostasis Model Assessment ( HOMA ) . Conclusions OMNI-Heart should advance our fundamental knowledge of the effects of diet on both traditional and emerging risk factors , and , in the process , guide policy makers , health care providers and the general public on the relative benefits of carbohydrate , protein , and unsaturated fat as a means to reduce CVD risk Objective Older adults with chronic kidney disease have a high rate of uncontrolled hypertension . Home monitoring of  blood pressure ( BP ) is an integral part of management , but requires that patients bring records to clinic visits . Telemonitoring interventions , however , have not targeted older , less technologically-skilled population s. Methods Veterans with stage 3 or greater chronic kidney disease and uncontrolled hypertension were r and omized to a novel telemonitoring device pairing a Bluetooth-enabled BP cuff with an Internet-enabled hub , which wirelessly transmitted readings ( n=28 ) , or usual care ( n=15 ) . Home recordings were review ed weekly and telemonitoring participants were contacted if BP was above goal . The prespecified primary endpoints were improved data exchange and device acceptability . Secondary endpoint was BP change . Results Forty-three participants ( average age 68 years , 75 % white ) completed the 6-month study . Average start-of- study BP was 147/78 mmHg . Those in the intervention arm had a median of 29 ( IQR 22 , 53 ) transmitted BP readings per month , with 78 % continuing to use the device regularly , whereas only 20 % of those in the usual care group brought readings to in-person visits . The median number of telephone contacts triggered by the wireless monitoring was 2 ( IQR 1 , 4 ) per patient . Both groups had a significant improvement in systolic BP ( P<0.05 , for both changes ) ; systolic BP fell a median of 13 mmHg in monitored participants compared with 8.5 mmHg in usual care participants ( P for comparison 0.31 ) . Conclusion This low-cost wireless monitoring strategy led to greater sharing of data between patients and clinic and produced a trend toward improvements in BP control over usual care at 6 months AIMS Major guidelines recommend lowering systolic blood pressure ( SBP ) to < 140 mmHg in all hypertensives , but evidence is missing whether this is beneficial in ( i ) uncomplicated hypertensives , ( ii ) grade 1 hypertensives , and ( iii ) elderly hypertensives . Providing this missing evidence is important to justify efforts and costs of aggressive therapy in all hypertensives . METHODS AND RESULTS Felodipine Event Reduction ( FEVER ) was a double-blind , r and omized trial on 9711 Chinese hypertensives , in whom cardiovascular outcomes  were significantly reduced by more intense therapy ( low-dose hydrochlorothiazide and low-dose felodipine ) achieving a mean of 138 mmHg SBP compared with less-intense therapy ( low-dose hydrochlorothiazide and placebo ) achieving a mean of 142 mmHg . FEVER included older and younger patients , and patients with and without diabetes or cardiovascular disease . In the analyses here reported , Cox regression models assessed outcome differences between more and less-intense treatments in groups of patients with different baseline characteristics . Significant reductions in stroke were found in uncomplicated hypertensives ( -39 % , P = 0.002 ) , in hypertensives with r and omization SBP < 153 mmHg ( -29 % , P = 0.03 ) , and in elderly hypertensives ( -44 % , P < 0.001 ) , when their SBP was lowered by more intense treatment . Significant reductions ( between -29 and -47 % , P = 0.02 to < 0.001 ) were also found in all cardiovascular events and all deaths . Achieving mean SBP values < 140 mmHg by adding a small dose of a generic drug prevented 2.1 ( uncomplicated hypertensives ) and 5.2 ( elderly ) cardiovascular events every 100 patients treated for 3.3 years . CONCLUSIONS These analyses provide strong support , missing so far , to guidelines recommending goal SBP < 140 mmHg in uncomplicated hypertensives , individuals with moderately elevated BP and elderly hypertensives OBJECTIVES To evaluate which indices of blood pressure ( BP ) homeostasis are the strongest predictors of mortality in older low-level-care residents in long-term health facilities . DESIGN Prospect i ve cohort study . SETTING Eight long-term healthcare facilities in Canberra , Australia . PARTICIPANTS A total of 179 r and omly selected semi-independent residents aged 65 and older ( mean age+/-st and ard deviation 83.2+/-7.0 ; 80 % women ) . MEASUREMENTS Baseline BP levels taken while lying , after st and ing for 1 and 3 minutes , and sitting before and 1 hour after meal intake were recorded , as well as demographic information , chronic medical conditions , medications , and all-cause mortality during follow-up . Postpr and ial hypotension ( PPH ) was defined as a fall in systolic BP ( SBP ) of 20 mmHg or more 1 hour postmeal while sitting .  Orthostatic hypotension ( OH ) was defined as a fall in SBP of 20 mmHg or more or in diastolic BP ( DBP ) of 10 mmHg or more within 3 minutes of st and ing from a supine position . Hypertension was defined as BP greater than 160/90 mmHg at commencement of the study . Mean arterial pressure ( MAP ) and pulse pressure ( PP ) were calculated . RESULTS At baseline , 47 % of participants had hypertension , 38 % PPH , and 23 % OH ; PP was 70 mmHg or greater in 54 % , and DBP was 65 mmHg or lower in 6 % . Over 4.7 years , 97 ( 54 % ) participants died . Those who died were significantly older and more likely to have PPH ( 47 % vs 28 % ) and atrial fibrillation ( 35 % vs 17 % ) and a significantly greater decrease in BP after meal intake . Mortality rates in those with and without PPH were 145.0 and 98.5 per 1,000 person-years , respectively . Using multivariate Cox proportional hazards models after adjustment for age , sex , presence of atrial fibrillation , Parkinson 's disease , and use of diuretics , PPH was the only BP parameter that significantly and independently predicted 4.7-year all-cause mortality ( relative risk (RR)=1.79 ; 95 % confidence interval (CI)=1.19 - 2.68 ; P=.005 ) . Further adjustment for the presence of OH , hypertension , low resting BP , coronary artery disease , cerebrovascular disease , congestive heart failure , history of syncope , cognitive impairment , cancer , diabetes mellitus , chronic obstructive pulmonary disease , and history of smoking did not reveal any new statistically significant associations . There was a dose-response relationship between postpr and ial fall in SBP and mortality rates . Absolute postpr and ial SBP of 120 mmHg or less was also significantly associated with total mortality ( RR=1.69 , 95 % CI=1.04 - 2.78 ; P=.04 ) . Low DBP was also associated with increased mortality ( RR=1.10 , 95 % CI=1.01 - 1.13 ; P=.03 ) , although this association became nonsignificant in multivariate analysis . CONCLUSION In older low-level-care residents , PPH is an independent predictor of all-cause mortality with no added predictive value explained by other BP indices : OH , hypertension , PP , MAP The prevalence of hypertension in type 2 diabetics is high , though there is no published data for Switzerl and . This prospect i ve cohort survey determined the frequency of type 2 diabetes mellitus associated with hypertension from medical practitioners in Switzerl and , and collected data on the diagnostic and therapeutic work‐up for cardiovascular risk patients . The Swiss Hypertension And Risk Factor Program ( SHARP ) is a two‐part survey : The first part , I‐SHARP , was a survey among 1040 Swiss physicians to assess what are the target blood pressure ( BP ) values and preferred treatment for their patients . The second part , SHARP , collected data from 20,956 patients treated on any of 5 consecutive days from 188 participating physicians . In I‐SHARP , target BP⩽135/85 mmHg , as recommended by the Swiss Society of Hypertension , was the goal for 25 % of physicians for hypertensives , and for 60 % for hypertensive diabetics ; values > 140/90 mmHg were targeted by 19 % for hypertensives , respectively 9 % for hypertensive diabetics . In SHARP , 30 % of the 20,956 patients enrolled were hypertensive ( as defined by the doctors ) and 10 % were diabetic ( 67 % of whom were also hypertensive ) . Six per cent of known hypertensive patients and 4 % of known hypertensive diabetics did not receive any antihypertensive treatment . Diabetes was not treated pharmacologically in 20 % of diabetics . Proteinuria was not screened for in 45 % of known hypertensives and in 29 % of known hypertensive diabetics . In Switzerl and , most physicians set target BP levels higher than recommended in published guidelines . In this country with easy access to medical care , high medical density and few financial constraints , appropriate detection and treatment for cardiovascular risk factors remain highly problematic Objectives To establish reference values for blood pressure by means of self-measurement of blood pressure ( BP ) conducted at home . Design Descriptive study of the distribution of self-measured BP at home and its correspondence with clinic-based measurements of BP . Methods The aim of this study is to define the home BP levels that correspond to clinic BP thresholds 140/90 mmHg ( hypertension ) and 130/85 mmHg ( normality ) . The sample consisting of 1411 r and omly selected adults stratified by age and gender . A pre-calibrated electronic device ( Omron 705CP ) was used for BP and heart rate ( HR ) measurements  and a trained nurse performed clinic-based sphygmomanometer measurements . The same nurse provided tutorials for the subjects on how to obtain 12  self-measured BP values at home using the Omron device in a single day . Results Of the 1184 volunteers that attended the appointment , 195 were known as hypertensives and were excluded from the study . The average age of the remaining 989 subjects ( 50.4 % females ) was 44.3 years .  Clinic BP values were significantly higher than self-measured BP at home regardless of age and gender . Both had good correlations ( systolic BP , r=0.84 and diastolic BP , r=0.77 ) . Using linear regression , the self-measured BP at home hypertension threshold would be 131/82 mmHg and the limit of normality 123/78 mmHg . Using corresponding percentiles , these values would be 134/85 and 124/80 mmHg , respectively . Conclusions The self-measured BP at home values found in this study , when defining hypertension , are lower than values currently accepted ( 135/85 mmHg ) . Long-term studies are necessary to confirm these results The Systolic Hypertension in the Elderly Program ( SHEP ) is a r and omized double-blind placebo-controlled trial to determine if antihypertensive treatment of isolated systolic hypertension ( ISH ) [ systolic blood pressure ( SBP ) greater than or equal to 160 mmHg , diastolic blood pressure ( DBP ) less than 90 mmHg ] reduces the 5 year incidence of fatal and nonfatal stroke . Between March 1 , 1985 and January 15 , 1988 , 4736 persons ( target 4800 ) with ISH , age 60 years and over , were enrolled . Potential participants met blood pressure ( BP ) and age criteria . Those on antihypertensive medication prior to enrollment without documented diastolic hypertension had their medication tapered and discontinued , and then met BP criteria ( 33 % of cohort ) . Stepped-care therapy with chlorthalidone and atenolol ( alternative , reserpine ) or matching placebos was initiated as first and second steps . At baseline the trial population was 43.1 % male , 56.9 % female ; 13.9 % black , 86.1 % non-black . Also , the mean age was 71.6 years ; the mean SBP was 170.3 mmHg and the mean DBP was 76.6 mmHg ; 59.8 % had codeable resting electrocardiographic abnormalities .  The trial is now in follow-up phase with scheduled termination in 1991
However , the 95 % confidence intervals of these outcomes suggest the lower BP target is probably not worse , and might offer a clinical ly important benefit .
AUTHORS ' CONCLUSIONS At the present time there is insufficient evidence to know whether a higher BP target ( less than150 to 160/95 to 105 mmHg ) or a lower BP target ( less than 140/90 mmHg ) is better for older adults with high BP .
BACKGROUND Eight out of 10 major antihypertensive trials in older adults attempted to achieve a target systolic blood pressure ( BP ) less than 160 mmHg .
Collectively these trials demonstrated benefit for treatment , as compared to no treatment , for an older adult with BP greater than 160 mmHg .
However an even lower BP target of less than 140 mmHg is commonly applied to all age groups .
At the present time it is not known whether a lower or higher BP target is associated with better cardiovascular outcomes in older adults .
OBJECTIVES To assess the effects of a higher ( less than 150 to 160/95 to 105 mmHg ) BP target compared to the lower BP target of less than 140/90 mmHg in hypertensive adults 65 years of age or older .