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 Rationale, Design, and Progress of the ENhanced Control of Hypertension ANd Thrombolysis Stroke Study (ENCHANTED) Trial: An International Multicenter 2 × 2 Quasi-Factorial Randomized Controlled Trial of Low- vs. Standard-Dose rt-PA and Early Intensive vs. Guideline-Recommended Blood Pressure Lowerin Effect of Antihypertensive Treatment on Cardiovascular Events in Elderly Hypertensive Patients: Japan's Benidipine Research on Anti-Hypertensive Effects in the Elderly (J-BRAVE) 2015 guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension. Blood Pressure Targets Recommended by Guidelines and Incidence of Cardiovascular and Renal Events in the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) Progress Report on the Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) Study: Status at February 2004 South African hypertension guideline 2011. Swiss Hypertension and Risk Factor Program (SHARP): Cardiovascular risk factors management in patients with type 2 diabetes in Switzerland IMPPACT: Investigation of Medical Professionals and Patients Achieving Control Together. 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 Relationship between home blood pressure and longitudinal changes in target organ damage in treated hypertensive patients. Is a systolic blood pressure target <140 mmHg indicated in all hypertensives? Subgroup analyses of findings from the randomized FEVER trial. The effect of spironolactone, cilazapril and their combination on albuminuria in patients with hypertension and diabetic nephropathy is independent of blood pressure reduction: a randomized controlled study. The second progress report on the Hypertension Objective treatment based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) study Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial Renoprotective Effect and Cost-Effectiveness of Using Benidipine, a Calcium Channel Blocker, to Lower the Dose of Angiotensin Receptor Blocker in Hypertensive Patients with Albumiuria Effects of general practice-based nurse-counselling on ambulatory blood pressure and antihypertensive drug prescription in patients at increased risk of cardiovascular disease Slovak Trial on Cardiovascular Risk Reduction Following National Guidelines with CaDUET® (The STRONG DUET Study) Effects of intensive antihypertensive treatment on Chinese hypertensive patients older than 70 years. Impact of supportive measures on drug adherence in patients with essential hypertension treated with valsartan: the randomized, open-label, parallel group study VALIDATE Treatment of Hypertension in Patients 85 Years of Age or Older: A J-BRAVE Substudy Aliskiren-based stepped-care treatment algorithm provides effective blood pressure control. Barriers to adherence to hypertension guidelines among GPs in southern Sweden: A survey
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 Rationale Controversy exists over the optimal dose of intravenous ( iv ) recombinant tissue plasminogen activator ( rt-PA ) and degree of blood pressure ( BP ) control in acute ischaemic stroke ( AIS ) . Asian studies suggest low-dose ( 0·6 mg/kg ) is more efficacious than st and ard-dose ( 0·9 mg/kg ) iv rt-PA , and guidelines recommend reducing systolic BP to < 185 mmHg before and < 180 mmHg after use of iv rt-PA , despite observational studies indicating better outcomes at much lower ( < 140 mmHg ) systolic BP levels in this patient group . Aims The study aims to assess in thrombolysis-eligible AIS patients whether : ( i ) low-dose ( 0·6 mg/kg body weight ; maximum 60 mg ) iv rt-PA has non-inferior efficacy and lower risk of symptomatic intracerebral haemorrhage ( sICH ) compared to st and ard-dose ( 0·9 mg/kg body weight ; maximum 90 mg ) iv rt-PA ; and ( ii ) early intensive BP lowering ( systolic target 130–140 mmHg ) has superior efficacy and lower risk of any ICH compared to guideline -recommended BP control ( systolic target < 180 mmHg ) . Design The ENhanced Control of Hypertension And Thrombolysis strokE stuDy ( ENCHANTED ) trial is an independent , 2 × 2 quasi-factorial , active-comparison , prospect i ve , r and omized , open blinded endpoint ( PROBE ) , clinical trial that is evaluating Arm [ A ] ‘ rt-PA dose ’ and /or Arm [ B ] ‘ BP control ’ , using central Internet r and omization and data collection in patients fulfilling local criteria for thrombolysis and clinician uncertainty over the study treatments . The treatment arms will be analyzed separately . Study outcomes The primary study outcome in both trial Arms is death or disability according to the modified Rankin scale ( mRS , scores 2–6 ) assessed at 90 days . Secondary outcomes include sICH , any ICH , a shift ( ‘ improvement ’ ) in function across mRS scores , separately on death and disability , early neurological deterioration , recurrent major vascular events , health-related quality of life , length of hospital stay , need for permanent residential care , and health care costs . Results Following launch of the trial in February 2012 , the study has recruited more than 2500 patients across a global network of approximately 100 sites in 15 countries . The required sample sizes are 3300 for Arm [ A ] and 2300 for Arm [ B ] , which will provide > 90 % power to detect non-inferiority of low-dose iv rt-PA and superiority of intensive BP lowering on the primary clinical outcome , respectively . Conclusions Low-dose iv rt-PA and early intensive BP lowering could provide more affordable and safer use of thrombolysis treatment for patients with AIS worldwide 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 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 Background — Hypertension treatment guidelines recommend that blood pressure ( BP ) be lowered to < 140/90 mm Hg , but that a reduction to < 130/80 mm Hg be adopted in patients at high cardiovascular ( CV ) risk . We investigated the CV and renal benefits associated with these BP targets in the high-CV-risk population of the Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial ( ONTARGET ) . Methods and Results — Patients were divided into 4 groups according to the proportion of in-treatment visits before the occurrence of an event ( < 25%–>75 % ) in which BP was reduced to < 140/90 or < 130/80 mm Hg . After adjustment for demographic and clinical variables , a progressive increase in the proportion of visits in which BP was reduced to < 140/90 or < 130/80 mm Hg was associated with a progressive reduction in the risk of stroke , new onset of microalbuminuria or macroalbuminuria , and return to normoalbuminuria in albuminuric patients . An increased frequency of BP control to either target did not have any consistent effect on the adjusted risk of myocardial infa rct ion and heart failure . The adjusted risk of CV events was reduced by increasing the frequency of BP control to < 140/90 mm Hg , but not to < 130/80 mm Hg . Similar findings were obtained for the achievement of the BP target in the visit preceding a CV event . Conclusion — The more frequent achievement of the BP targets recommended by guidelines led to cerebrovascular and renal protection , but did not increase cardiac protection . Overall , CV protection was favorably affected by the less tight but not by the tighter BP target . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00153101 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 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 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 OBJECTIVE To determine whether home blood pressure monitoring ( HBPM ) led to physician-initiated medication titration and improved achievement of target BP levels compared with st and ard , office-based management . METHODS Physicians were r and omly assigned to a treatment group or a control group . Patients in the control group were monitored by their physician and were drug-adjusted according to the usual approach . In the treatment group , patients were given home BP monitors ( UA-767P [ A&D Medical/Life source , USA ] ) , and drug dosing was adjusted according to HBPM readings and protocol . Long-acting diltiazem ( 240 mg/day ) was added at baseline , which was adjusted as necessary ( other medications were added if more than 360 mg/day of diltiazem was required ) . A final BP measurement was taken in the office after six weeks . RESULTS Nineteen physicians were r and omly assigned to the office BP monitoring group and 34 were assigned to the HBPM group . Of the 270 subjects recruited , 97 were in the office BP monitoring group and 173 were in the HBPM group . From baseline to the final visit , there was a statistically significant time by group interaction with lower BP in the HBPM group ( P=0.034 for both systolic BP and diastolic BP ) . BP fell from 159/91+/-11/10 mmHg at baseline in the HBPM group to 138/80+/-13/8 mmHg on the final visit , and from 160/88+/-14/10 mmHg to 141/78+/-10/9 mmHg in the control group . CONCLUSIONS BP was lowered significantly in both groups , and to a statistically greater degree in the HBPM group . The Hawthorne effect might have led to altered care by the physicians with improvement in BP control in both groups 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 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 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 OBJECTIVE The effect of spironolactone , cilazapril and their combination on albuminuria was examined in a r and omized prospect i ve study in female patients with diabetes and hypertension . PATIENTS AND METHODS Sixty female diabetic patients aged 45 - 70 years with blood pressure ( BP ) 140 - 180/90 - 110 mmHg , serum creatinine ( sCr ) < or = 160 micro mol/l , HbA(1c ) < or = 10 % , and albuminuria were treated by atenolol 12.5 - 75 mg/d and hydrochlorothiazide 6.25 - 25 mg/d . Titration-to-target helped to reach BP values < or = 135/85 mmHg in 46 patients after 12 weeks . These patients were r and omized to spironolactone 100 mg/d or cilazapril 5 mg/d for 24 weeks . Then both groups received spironolactone 50 mg/d and cilazapril 2.5 mg/d for 24 weeks . BP was stabilized by tapering the dose of the initial agents . Urinary albumin/creatinine ratio ( ACR ) , BP , K(+ ) . sCr and HbA(1c ) were assessed at baseline and at weeks 12 , 16 , 36 and 60 . RESULTS The average BP at week 12 was 128 + /- 4/81 + /- 3 mmHg and remained constant , in both groups , throughout the study . ACR declined on spironolactone from a median value ( range ) of 452 ( 124 - 1571 ) to 216 ( 64 - 875 ) mg/g ( P = 0.001 ) , and on cilazapril to 302 ( 90 - 975 ) mg/g ( P = 0.001 ) . The difference between spironolactone and cilazapril was significant ( P = 0.002 ) . Combined treatment result ed in a further modest decline in ACR . Serum creatinine was unaltered by spironolactone and rose slightly ( 121 to 126 micro mol/l , P = 0.02 ) on cilazapril . CONCLUSION At the doses tested , spironolactone was superior to cilazapril in reducing albuminuria . Combined administration was more effective than either drug alone . These effects were independent of BP values . Hyperkalaemia was the main side-effect 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 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 In hypertensive patients with chronic renal disease ,  angiotensin receptor blockers ( ARBs ) are among the first-line drugs , and calcium channel blockers ( CCBs ) are recommended as a second line . We examined the effects of two therapeutic strategies using ARBs and benidipine , a CCB , on blood pressure ( BP ) , urinary albumin excretion ( UAE ) , and cost-effectiveness in hypertensive patients with albuminuria . Patients whose BP was 140/90 mmHg or higher despite treatment with low- or medium-dose ARBs were assigned r and omly to two groups . In Group A ( n=14 ) , the ARB dose was maximized and then benidipine was added until BP targets were reached ( < 130/85 mmHg ) . In Group B ( n=18 ) , benidipine was administered first and then the ARB dose was increased until BP targets were reached . The BP targets were achieved by ARB alone in 36 % of Group A patients and by the addition of benidipine in 83 % of Group B patients . Finally , BP decreased in each group , reaching the targets in 93 % of Group A patients and 94 % of Group B patients after a 4-month therapeutic period . UAE was decreased in both groups after a 4-month therapeutic period compared to the allocation period ( −33±6 % in Group A , −31±6 % in Group B ; p<0.001 , respectively ) . The monthly drug cost was higher ( 11,426±880 vs. 8,955±410 yen , p=0.012 ) and the cost-effectiveness of antihypertensive treatment was lower ( p=0.003 ) in Group A than in Group B. We conclude that the addition of benidipine to low- or medium-dose ARB is , in light of the renal protection and the cost-effectiveness of this approach , a useful therapeutic strategy for controlling BP in hypertensive patients with albuminuria Lifestyle programmes delivered by academic nurse-counsellors in a primary care setting lowered blood pressure ( BP ) among at-risk patients . We examined whether the programmes could be successfully implemented by nurses employed in Australian general practice s. In a r and omised controlled trial , 212 of 591 eligible 20–75-year olds with hypertension , Type II diabetes or coronary disease from seven practice s volunteered . Patients were r and omised to : a ‘ Low ’ group with one face-to-face individual counselling session , then monthly telephone contacts for 1 year ( n=69 ) ; a ‘ High ’ group with individual face-to-face counselling up to 1 h monthly for 1 year ( n=74 ) or a control group receiving usual care only ( n=69 ) , and were evaluated at baseline and 12 and 18 months later ; 164 individuals completed the study . Patients ' usual doctors continued to prescribe in all groups . Changes in 24 h ambulatory BP did not differ significantly between groups at 12 months ( Low , −2±2/1±1 mmHg ; High , + 4±2/1± 1 mmHg ; usual care , + 1±2/1±1 mmHg ) or 18 months ( −2±2/2±1 mmHg ; −4±2/3±2 mmHg ; −1±2/2± 1 mmHg , respectively ) . Antihypertensive drugs prescribed decreased by 12 months in 33 % of the High , 5 % of the Low and 13 % of the control groups ( P=0.008 ) and by 36 , 7 and 16 % at 18 months ( P=0.018 ) . After 18 months , targets for BP control were not met in about 60 % of patients and almost 50 % had clinic BP above 140/90 mmHg . Year-long interaction with nurse-counsellors may influence longer-term antihypertensive drug prescription , possibly by improving compliance . Suboptimal BP control suggests that continuing physician education on BP targets is needed Introduction The efficacy and safety of single-pill amlodipine/atorvastatin for reducing blood pressure ( BP ) , low-density lipoprotein cholesterol ( LDLC ) , and predicted 10-year cardiovascular ( CV ) risk have been demonstrated in low CV risk countries . The Slovak Trial on Cardiovascular Risk Reduction Following National Guidelines with CaDUET ® ( amlodipine besylate/atorvastatin calcium ; Pfizer , Morrisville , PA , USA ; STRONG DUET ) study evaluated its clinical utility in Slovakia , one of the highest CV risk regions in Europe . Methods This was a two-phase study involving 100 outpatient cardiologist and internist departments in Slovakia . Phase 1 assessed BP control and CV risk profiles in adults with treated hypertension , and phase 2 was an open-label , multicenter , observational study . In the phase 2 study , patients with treated but uncontrolled hypertension and three or more coronary heart disease risk factors received single-pill amlodipine/atorvastatin ( 5/10 or 10/10 mg ) for 12 weeks . Major outcomes were the percentage of patients achieving target BP ( ≤140/90 mmHg ) and /or LDL-C ( ≤3 mmol/L ) and reductions in predicted 10-year CV risk . Results Of the 4,672 phase 1 patients , 80.8 % had uncontrolled hypertension and 61.4 % had dyslipidemia . Of the 1,406 phase 2 patients , 90.3 % of patients achieved target BP at week 12 , 66.3 % achieved target LDL-C , and 60.7 % achieved both . The mean 10-year CV risk was reduced by 49 % ( P < 0.0001 ) ; treatment was well-tolerated and safe . ConclusionS ingle-pill amlodipine/atorvastatin was associated with significant improvements in BP , LDL-C target attainment , and 10-year CV risk in patients with uncontrolled hypertension in Slovakia . The treatment was well-tolerated and safe . Use of single-pill amlodipine/atorvastatin in high CV-risk countries could lead to significant improvements in CV risk management This study was performed to investigate whether intensive antihypertensive treatment with achieved blood pressure ( BP ) ≤140/90 mm Hg , as compared with st and ard treatment with achieved BP ≤150/90 mm Hg , could further improve cardiovascular outcomes in Chinese hypertensive patients older than 70 years . A total of 724 participants were r and omly assigned to intensive or st and ard antihypertensive treatment . After a mean follow-up of 4 years , the mean achieved BP was 135.7/76.2 mm Hg in the intensive treatment group and 149.7/82.1 mm Hg in the st and ard treatment group . The visit-to-visit variability in systolic BP and diastolic BP was lower in the intensive group than that in the st and ard group . Intensive antihypertensive treatment , compared with the st and ard treatment , decreased total and cardiovascular mortality by 41.7 % and 50.3 % , respectively , and reduced fatal/nonfatal stroke by 42.0 % and heart failure death by 62.7 % . Cox regression analysis indicated that the mean systolic BP ( P=.020 ; 95 % confidence interval , 1.006 - 1.069 ) and the st and ard deviation of systolic BP ( P=.033 ; 95 % confidence interval , 1.006 - 1.151 ) were risk factors for cardiovascular endpoint events . Intensive antihypertensive treatment with achieved 136/76 mm Hg was beneficial for Chinese hypertensive patients older than 70 years . Long-term visit-to-visit variability in systolic BP was positively associated with the incidence of cardiovascular events Objective The majority of treated hypertensive patients do not achieve target blood pressure ( BP ) levels of less than 140/90 mmHg . One key reason is inadequate adherence with the prescribed drug regimen . Dosing regimens are either not executed as prescribed ( noncompliance ) or patients stop taking the medication ( nonpersistence ) . It has been demonstrated that adherence with angiotensin receptor antagonists such as valsartan is high due to the tolerability profile of this drug class . The present study was design ed to evaluate whether drug adherence could further be improved by the use of supportive measures . Design and methods Twenty-eight centers were r and omized to provide pharmacological treatment with or without a set of supportive measures ( e.g. structured physician – patient interaction , printed information about hypertension , reminder stickers , 24 h timer , and home BP measurement device ) . Two hundred and two patients with grade 1 hypertension ( BP at baseline 149.8 ± 6.2/93.9 ± 4.4 mmHg ) who were either newly diagnosed or who had not been treated for at least 1 year were included in this trial . All patients entered the 34-week treatment phase  with valsartan 160 mg daily . Titration to valsartan 160 mg/hydrochlorothiazide 12.5 mg was allowed if necessary . Drug adherence was assessed by electronic monitors ( Medication Event Monitoring System ) . Results Patients treated with a valsartan-based therapy receiving supportive measures as compared with the st and ard care group demonstrated an initially higher level of adherence with a maximum absolute difference of 7.8 % ( P = 0.041 ) . This difference did not persist over the observation period but faded with time . In parallel , execution of the dosing regimen ( compliance ) was also improved in the intervention group during the early months of treatment but this effect also disappeared by the end of the observation period . In contrast , persistence in the two groups slowly but continuously separated over time . Estimated absolute difference in persistence at the end of the 34-weeks study between the two groups was 7.6 % ( 95.9 vs. 88.3 % ) reflecting a 66 % lower hazard of discontinuation in the intervention group ( P = 0.073 ) . BP control improved more in patients with the supportive measures . Conclusion Drug adherence improved initially with the use of supportive measures . However , this effect faded with time mainly because of the short-lived improvement in the quality of execution ( compliance ) achieved . In contrast , a longer lasting effect of the chosen supportive measures on persistence could be demonstrated , which , however , at least under the conditions of the present study , did not translate into a persistent improvement of medication adherence 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 AIMS Recent guidelines for the management of hypertension recommend an individualised stepped-care treatment approach in mild-to-moderate hypertensive patients , to achieve blood pressure ( BP ) goals . This study evaluated the probability of patients achieving BP targets  with an  aliskiren-based stepped-care treatment regimen . METHODS This was a 24-week , open-label , non-comparator study design that included six sequential 4-week treatment periods in patients with mild-to-moderate hypertension . Over the potential 24 weeks of active treatment , incremental therapy included the following add-on therapies at 4-week intervals : aliskiren 150 - 300 mg once daily , hydrochlorothiazide ( HCTZ ) 12.5 - 25 mg once daily , and finally amlodipine 5 - 10 mg once daily , as needed to achieve target BP . Subjects achieving BP targets following any given 4 weeks of therapy were considered study completers , while subjects not achieving their clinical BP target entered into the next step of incremental therapy . The primary efficacy end-point was the estimated cumulative probability of patients achieving BP target . RESULTS Of 256 patients treated , 232 ( 90.6 % ) completed the study .  Baseline mean sitting BP was 155.7/91.7 mmHg . At study end-point , the estimated cumulative probability of reaching BP target was 86.12 % . The stepped-care treatment regimen was well tolerated at the maximal recommended doses of all the individual complimentary therapies . CONCLUSION An aliskiren-based stepped-care treatment regimen that subsequently included both HCTZ and amlodipine is effective in achieving BP goals in approximately 90 % of patients with mild-to-moderate hypertension Objective . To evaluate barriers to adherence to hypertension guidelines among publicly employed general practitioners ( GPs ) . Design . Question naire-based survey distributed to GPs in 24 r and omly selected primary care centres in the Region of Skåne in southern Sweden . Subjects . A total of 109 GPs received a self-administered question naire and 90 of them responded . Main outcome measures . Use of risk assessment programmes . Reasons to postpone or abstain from  pharmacological treatment  for the management of hypertension . Results . Reported managing of high blood pressure ( BP ) varied . In all , 53 % ( 95 % CI 42–64 % ) of the GPs used  risk assessment programmes and nine out of 10 acknowledged blood pressure target levels . Only one in 10 did not inform the patients about these levels . The range for immediate initiating pharmacological treatment was a systolic BP 140–220 ( median 170 ) mmHg and diastolic BP 90–110 ( median 100 ) mmHg . One-third ( 32 % ; 95 % CI 22–42 % ) of the GPs postponed or abstained from pharmacological treatment of hypertension due to a patient 's advanced age . No statistically significant associations were observed between GPs ’ gender , professional experience ( i.e. in terms of specialist family medicine and by number of years in practice ) , and specific reasons to postpone or abstain from pharmacological treatment of hypertension . Conclusion . These data suggest that GPs accept higher blood pressure levels than recommended in clinical guidelines . Old age of the patient seems to be an important barrier among GPs when considering pharmacological treatment for the management of hypertension
Treating patients to lower than st and ard BP targets , < /=140 - 160/90 - 100 mmHg , does not reduce mortality or morbidity .
BACKGROUND When treating elevated blood pressure , doctors need to know what blood pressure ( BP ) target they should try to achieve .
The st and ard of clinical practice for some time has been < /= 140 - 160/ 90 - 100 mmHg .
New guidelines are recommending BP targets lower than this st and ard .
It is not known whether attempting to achieve targets lower than the st and ard reduces mortality and morbidity .
OBJECTIVES To determine if lower BP targets ( < /= 135/85 mmHg ) are associated with reduction in mortality and morbidity as compared with st and ard BP targets ( < /= 140 - 160/ 90 - 100 mmHg ) .