The detection, treatment and control of high blood pressure in older British adults: cross-sectional findings from the British Women's Heart and Health Study and the British Regional Heart Study Results of the Ontario Survey on the Prevalence and Control of Hypertension Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in Patients Aged 60 Years or Older: The Minority View Implications of the Systolic Hypertension in the Elderly Program: The Systolic Hypertension in the Elderly Program Cooperative Research Group Detection and treatment of hypertension in older individuals. A Risk Score for Predicting Near-Term Incidence of Hypertension: The Framingham Heart Study Double-blind randomised trial of modest salt restriction in older people Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people On-treatment diastolic blood pressure and prognosis in systolic hypertension. Too Old to Benefit from Sports? The Cardiovascular Effects of Exercise Training in Elderly Subjects Treated for Isolated Systolic Hypertension Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension Effects of immediate versus delayed antihypertensive therapy on outcome in the Systolic Hypertension in Europe Trial Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension) Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. Systolic Hypertension in Europe Trial Investigators. Screening for Type 2 Diabetes Mellitus: A Cost-Effectiveness Analysis Pulse pressure as a predictor of stroke Improved Hypertension Management and Control: Results From the Health Survey for England 1998 Hyperuricemia and incident atrial fibrillation in a normotensive elderly population in Taiwan. Pulse pressure and risk of cardiovascular events in the systolic hypertension in the elderly program. Correlates of blood pressure in an urban Zimbabwean population and comparison to other populations of African origin Subgroup and per-protocol analysis of the randomized European Trial on Isolated Systolic Hypertension in the Elderly. 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A LONG-TERM CONTROLLED TRIAL OF SCREENING FOR HYPERTENSION IN GENERAL PRACTICE Have rapid socioeconomic changes influenced awareness of blood pressure in Poland? Pragmatic randomized trial of home visits by a nurse to elderly people with hypertension in Mexico. Compliance to treatment for hypertension in elderly patients: the SHEP pilot study. Systolic Hypertension in the Elderly Program. Antihypertensive therapy in older patients with isolated systolic hypertension: the Syst-Eur experience in general practice Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. A prospective study of glycemia, body size, insulin resistance and the risk of hypertension in Mauritius Smoking and the risk of incident hypertension in middle-aged and older men. Practitioner's Trial on the Efficacy of Antihypertensive Treatment in the Elderly Hypertension (The PATE-Hypertension Study) in Japan. 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The impact of ibuprofen on the efficacy of antihypertensive treatment with hydrochlorothiazide in elderly persons. Impact of the treatment of isolated systolic hypertension on behavioral variables. Results from the systolic hypertension in the elderly program. Systolic Blood Pressure, Diastolic Blood Pressure, and Pulse Pressure as Predictors of Risk for Congestive Heart Failure in the Framingham Heart Study Practitioner's trial on the efficacy of antihypertensive treatment in elderly patients with hypertension II (PATE-hypertension II study) in Japan. The effects of antihypertensive treatment on cognitive function: results from the HOPE study. Postural hypotension and dizziness in a general aged population: a four-year follow-up of the Helsinki Aging Study. The effects of blood pressure reduction in older patients: an overview of five randomized controlled trials in elderly hypertensives. Effects of reduced sodium intake on hypertension control in older individuals: results from the Trial of Nonpharmacologic Interventions in the Elderly (TONE). Immediate and late benefits of treating very elderly people with hypertension: results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial Compliance with pharmacological therapy in hypertension: can we do better, and how? The impact of pay for performance on the control of blood pressure in people with chronic kidney disease stage 3-5. Cardiovascular morbidity and mortality in mild hypertension: the Australian Trial. Home blood pressure as a predictor of future blood pressure stability in borderline hypertension. The Tecumseh Study. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Influence of long-term, low-dose, diuretic-based, antihypertensive therapy on glucose, lipid, uric acid, and potassium levels in older men and women with isolated systolic hypertension: The Systolic Hypertension in the Elderly Program. SHEP Cooperative Research Group. Improving management of hypertension in general practice: a randomised controlled trial of feedback derived from electronic patient data. The role of diastolic blood pressure when treating isolated systolic hypertension. Comparison of the Effects of Antihypertensive Agents on Central Blood Pressure and Arterial Stiffness in Isolated Systolic Hypertension Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial Dogma Disputed: Can Aggressively Lowering Blood Pressure in Hypertensive Patients with Coronary Artery Disease Be Dangerous? Relation between drug treatment and cancer In hypertenslves in the Swedish Trial in Old Patients with Hypertension 2: a 5-year, prospective, randomised, controlled trial Statistical considerations in monitoring the Systolic Hypertension in the Elderly Program (SHEP). Sauna Bathing and Incident Hypertension: A Prospective Cohort Study Nonpharmacologic intervention to reduce blood pressure in older patients with mild hypertension. Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial Prognostic Significance of Serum Creatinine and Uric Acid in Older Chinese Patients With Isolated Systolic Hypertension Systolic Hypertension in the Elderly Program (SHEP): antihypertensive efficacy of chlorthalidone. 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Relationship of Antihypertensive Treatment Regimens and Change in Blood Pressure to Risk for Heart Failure in Hypertensive Patients Randomly Assigned to Doxazosin or Chlorthalidone: Further Analyses from the Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial The Systolic Hypertension in the Elderly Program (SHEP): an intervention trial on isolated systolic hypertension. SHEP Cooperative Research Group. Creatine Kinase Activity Is Associated With Blood Pressure Community-Based Interventions to Promote Blood Pressure Control in a Developing Country Hypotensive therapy in stroke survivors. Influence of gender and age on preventing cardiovascular disease by antihypertensive treatment and acetylsalicylic acid. The HOT study. Hypertension Optimal Treatment. 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Rosiglitazone improves insulin sensitivity and lowers blood pressure in hypertensive patients. Blood pressure and purdue pegboard scores in individuals with hypertension after alternate nostril breathing, breath awareness, and no intervention Influence of diabetes and type of hypertension on response to antihypertensive treatment. Hypertensive men who exercise regularly have lower rate of cardiovascular mortality. Dyslipidemia and an Unfavorable Fatty Acid Profile Predict Left Ventricular Hypertrophy 20 Years Later Effects of regular exercise on blood pressure and left ventricular hypertrophy in African-American men with severe hypertension. Systolic Hypertension in the Elderly: Long‐Term Lacidipine Treatment: Objective, Protocol, and Organization Untreated hypertension among Australian adults: the 1999-2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab).
Among older people , the detection and control of hypertension is particularly important to reduce cardiovascular disease risk . This cross-sectional survey aim ed to describe the detection , treatment and control of hypertension in older British adults . A total of 3059 women and 3007 men aged 60–79 years were r and omly selected from general practice age/sex registers in 24 British towns and examined from 1998 to 2001 . Of these , 52.6 % women and 47.9 % men had at least one indicator of hypertension ( high blood pressure on examination , or taking antihypertensive medication or recalled a doctor diagnosis of high blood pressure ) . Among women , 50 % of those with any indication of hypertension were on treatment and 29 % were well controlled , and among men 45 % were on treatment and 16 % were well controlled . With the exception of alcohol use in men ( adjusted odds ratio 0.67 ( 0.46 , 0.98 ) ) , socioeconomic factors , area of residence and behavioural risk factors were not associated with good control among those with hypertension in either sex . Of those on treatment , 20.7 % of women and 28 % of men were on two classes of antihypertensive medication and 3.5 and 4.9 % , respectively , were on three or more classes of antihypertensive medication . Among those with a doctor diagnosis of hypertension and taking antihypertensive medication , the proportion with well controlled blood pressure did not differ between those on more than one antihypertensive and those on just one in either sex . We conclude that targets of good control are rarely met in older individuals , who would benefit from the associated reduction in cardiovascular disease risk Background : Available information on the prevalence and management of hypertension in the Canadian population date s back to 1986–1992 and probably does not reflect the current status of this major risk factor for cardiovascular disease . We sought to evaluate the current prevalence and management of hypertension among adults in the province of Ontario . Methods : Potential respondents from r and omly selected dwellings within target neighbourhoods in 16 municipalities were contacted at their homes to request participation in the study . For potential respondents who agreed to participate ,  blood pressure  was measured with an automated device . Estimation weights were used to obtain representative estimates of population parameters . Responses were weighted to the total adult population in Ontario of 7 996 653 . Results : From 6436 eligible dwellings , contact was made with 4559 potential participants , of whom 2992 agreed to participate .  Blood pressure measurements were obtained for 2551 of these respondents ( age 20–79 years ) .  Hypertension , defined as systolic blood pressure of 140 mm Hg or more , diastolic blood pressure of 90 mm Hg or more , or treatment with an antihypertensive medication , was identified in 21.3 % of the population overall ( 23.8 % of men and 19.0 % of women ) . Prevalence increased with age , from 3.4 % among participants 20–39 years of age to 51.6 % among those 60–79 years of age . Hypertension was more common among black people and people of South Asian background than among white people ; hypertension was also associated with higher body mass index . Among participants with hypertension , 65.7 % were undergoing treatment with control of hypertension , 14.7 % were undergoing treatment but the hypertension was not controlled , and 19.5 % were not receiving any treatment ( including 13.7 % who were unaware of their hypertension ) . The extent of control of hypertension did not differ significantly by age , sex , ethnic background or comorbidities . Interpretation : In Ontario , the overall prevalence of hypertension is high in the older population but appears not to have increased in recent decades . Hypertension management has improved markedly among all age groups and for both sexes The 2014 Evidence -Based Guideline for the Management of  High Blood Pressure In Adults : Report From the Panel Members Appointed to the Eighth Joint National Committee ( JNC 8) recommends several major changes from the JNC 7 report ( 1 , 2 ) . The 2014 guideline is based on a systematic review of r and omized , controlled trials ( RCTs ) by a multidisciplinary panel using a process informed by Institute of Medicine recommendations for guideline development ( 3 ) . Although there was almost unanimous agreement on nearly all recommendations , a minority of the panel ( the authors of this commentary ) disagreed with the recommendation to increase the target systolic blood pressure ( SBP ) from 140 to 150 mm Hg in persons aged 60 years or older without diabetes mellitus ( DM ) or chronic kidney disease ( CKD ) . This target guides both the initiation of therapy and treatment goals . Although this issue has major clinical and public health implication s , the guideline only briefly summarized the concerns underlying the minority opinion to maintain the target of less than 140 mm Hg . The Institute of Medicine recommendation for guideline development encourages guidelines to provide a description and explanation of any differences of opinion regarding the recommendation ( 3 ) . This summarizes the evidence and rationale underlying the minority opinion to maintain the SBP target of 140 mm Hg or lower in persons aged 60 years or older until there is greater certainty of the risks and benefits of a higher target . First , increasing the target will probably reduce the intensity of antihypertensive treatment in a large population at high risk for cardiovascular disease ( CVD ) ( Table 1 ) . The higher SBP goal would apply to some of the groups at highest cardiovascular risk , such as African Americans , hypertensive patients with multiple CVD risk factors other than DM or CKD , and those with clinical CVD . Second , the evidence supporting increasing the SBP target from 140 to 150 mm Hg in persons aged 60 years or older was insufficient and inconsistent with the evidence supporting the panel 's recommendations for an SBP target of less than 140 mm Hg in persons younger than 60 years and those aged 60 years or older with DM or CKD . Third , the higher SBP goal in individuals aged 60 years or older may reverse the decades-long decline in CVD , especially stroke mortality ( 4 ) . In the absence of definitive evidence defining the optimum SBP target , observational studies and RCT data that the panel did not systematic ally review more strongly support the SBP goal of less than 140 mm Hg , especially in high-risk individuals . Other recent guideline groups review ing similar evidence have recommended a goal of less than 140 mm Hg , particularly in persons aged 80 years or younger ( 59 ) . Table 1 . U.S. Cardiovascular Disease Death Rates for Persons Younger and Older Than 65 y Persons Aged 60 Years or Older With Hypertension and SBP Controlled to 140 mm Hg or Lower More than half of the 72 million persons with hypertension in the United States are aged 60 years or older ( 10 , 11 ) . Among these individuals , the 2014 guideline recommends the SBP goal of 140 mm Hg or lower only for those with DM and those younger than 70 years with CKD ( 2 ) . Although the prevalence of hypertension in this age group ( 65 % to 67 % ) did not change between 1999 and 2010 , the percentage with adequate blood pressure control increased from 27.4 % ( 19992000 ) to 50.5 % ( 20112012 ) , with 82.2 % now receiving antihypertensive medications ( 10 , 12 ) . Data from NHANES ( National Health and Nutrition Examination Survey ) from 2001 to 2008 show that among treated and untreated hypertensive adults aged 60 years or older , median SBPs were 136 mm Hg and 152 mm Hg , respectively ( 13 ) , and SBPs have been decreasing in this age group over the past 5 decades ( Figure ) ( 4 ) . Thus , a target of less than 150 mm Hg would likely increase blood pressures in the treated hypertensive population and would suggest that nearly half of the untreated hypertensive patients in this age range should remain untreated . The large population at high risk for CVD , with most currently at an SBP of 140 mm Hg or lower , creates concern that a higher SBP target will adversely affect public health . Figure . Smoothed weighted frequency distribution , median , and 90th percentile of systolic blood pressure for persons aged 60 to 74 y : United States , 19592010 . Reproduced from Lackl and and colleagues ( 4 ) . NHANES = National Health and Nutrition Examination Survey ; NHES = National Health Examination Survey . High Risk in Persons With the Higher Goal Age substantially increases risk for cardiovascular events ( Table 1 ) , so differences in cardiovascular risk do not justify different targets for patients older and younger than 60 years . The risk range for white and African American men aged 60 years is 9 % to 30 % , depending on risk factor profile . For men of both ethnicities who are aged 70 years or older and have SBP controlled to 140 mm Hg , even without clinical CVD or DM , the 10-year risk exceeds 20 % ( 14 ) . Thus , on the basis of absolute risk , using an age threshold of 60 years to define eligibility for less aggressive treatment lacks consistency . Persons aged 60 to 79 years are at higher risk than those who are younger , even if the younger persons have DM . Insufficient Evidence for Differential Hypertension Treatment Benefit for Patients Older and Younger Than 60 Years The 2014 guideline panel failed to identify evidence of differential benefits or harms of treatment using an SBP goal of 140 mm Hg with an age threshold of 60 years . There is little RCT evidence of risk or benefit in treating persons younger than 60 years to this target , except in those with diastolic hypertension . The guideline indicates that no qualifying evidence was found comparing an SBP less than 140 mm Hg to any other SBP goal for persons younger than 60 years ( 2 ) . However , in persons aged 60 years or older , the SHEP ( Systolic Hypertension in the Elderly Program ) trial showed benefit of treating hypertension to an SBP goal between 140 and 145 mm Hg ( Table 2 ) ( 15 ) . HYVET ( Hypertension in the Very Elderly Trial ) found a benefit of an SBP target of less than 150 mm Hg on health outcomes , including mortality in persons aged 80 years or older ( 16 ) . Patients in the HYVET treatment group achieved an SBP of 144 mm Hg at 2 years compared with 159 mm Hg in the control group , and blood pressures continued to decrease in both groups until the end of the trial . Therefore , HYVET and the SHEP trial provide evidence that reducing SBP to around 140 mm Hg has substantial benefit without major harm in older persons . Thus , the best evidence available for an SBP target around 140 mm Hg , which meets the guideline RCT criteria , is in persons older than 60 years . The lack of benefit seen in 2 Japanese trials in older individuals ( JATOS [ Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients ] [ 17 ] and the VALISH [ Valsartan in Elderly Isolated Systolic Hypertension ] trial [ 18 ] ) was cited by some to rationalize the higher SBP target , but these trials were underpowered ( Table 2 ) . The SHEP trial and HYVET together reported 365 strokes and more than 285 coronary heart disease events , whereas JATOS and the VALISH trial only had a combined total of 125 strokes and 67 coronary heart disease events . In addition , the much larger FEVER ( Felodipine Event Reduction ) trial ( 19 ) did not meet criteria for inclusion in the panel 's deliberation ( Table 2 ) . This trial , which was conducted in a Chinese population ( age range , 50 to 79 years ; mean age , 62 years ) , reported a significant 27 % reduction in its primary outcome , as well as significant reductions in all CVD , total mortality , coronary heart disease , and heart failure in patients treated to an SBP of 137 mm Hg with a thiazide diureticcalcium-channel blocker combination versus 143 mm Hg with a thiazide diuretic plus placebo ( 19 ) . Table 2 . Trials Comparing Different Systolic Blood Pressure Thresholds In addition , generalizability of the Japanese trials to other population s of patients older than 60 years , such as African Americans , is uncertain . African Americans are at highest risk for all complications of hypertension and are historically undertreated . Thus , we believe that recommending less aggressive targets in this or other high-risk population s requires stronger justification than the guideline cites . Three recent guidelines from other countries have concluded that the appropriate cut point for an age-related differential SBP goal is 80 years or older ( 57 ) . We agree that this higher treatment target in frail hypertensive patients aged 80 years or older better reflects existing evidence . Safety and Adverse Event Risk in Hypertensive Patients Aged 60 Years or Older Despite the limited number of end points in JATOS and the VALISH trial , their size and duration provide evidence of safety of the SBP target of less than 140 mm Hg . The VALISH investigators concluded that this target was safe in relatively healthy patients aged 70 years or older with isolated systolic hypertension ( 18 ) . In JATOS , adverse events requiring treatment discontinuation were reported in only 36 patients , with no differences in discontinuation rate between groups ( 17 ) . This evidence and the favorable results at slightly higher blood pressures in the SHEP trial and HYVET provide reassurance of the safety of an SBP goal of less than 140 mm Hg in older , nonfrail persons . Other Trial Evidence of Benefit of Treatment at an SBP of 140 mm Hg or Lower Results of the SPS3 ( Secondary Prevention of Small Subcortical Strokes ) trial indicated that an SBP target of less than 130 mm Hg versus 144 mm Hg in 3020 patients ( mean age , 63 years ) reduced subsequent strokes by 19 % ( P= 0.08 ) and hemorrhagic strokes by nearly 50 % ( P < 0.01 ) ( 20 ) . Of note , the FEVER trial reported a 44 % ( P < 0.001 ) reduction in all strokes in a subgroup analysis of patients older than 65 years ( 17 ) . Finally , 2 meta-analyses & NA ; Several imperatives drive the need to establish the merit of treating isolated systolic hypertension in the elderly . These include its higher prevalence with age , the associated excess cardiovascular risks , and the rapid aging of the population . The Systolic Hypertension in the Elderly Program demonstrated a significant reduction in stroke incidence ( fatal and nonfatal ) ( 36 % , equivalent to preventing 30 strokes per 1,000 participants per 5 years ) . A 27 % reduction in coronary heart disease incidence and a 32 % reduction in all major cardiovascular events were also achieved ( equivalent to the prevention of 16 and 55 events per 1,000 participants per 5 years , respectively ) . These results were associated with a treatment regimen in which the primary agent was low‐dose chlorthalidone . The benefits accrued to all subgroups identified based on baseline age , race and sex , blood pressure , serum cholesterol levels , and electrocardiographic abnormalities . The reduction in coronary disease is consistent with predictions based on prospect i ve epidemiological studies and is concordant with other recent intervention trials . It is a reasonable inference from the Systolic Hypertension in the Elderly Program findings that middle‐aged as well as older people with isolated systolic hypertension , and people with less severe degrees of this condition , particularly when other risk factors are present , would benefit from such therapy . Another reasonable implication of the trial relates to the matter of preferred drug treatment regimens for diastolic hypertension , in middle‐aged as well as older people . A low‐dose diuretic regimen is clearly the initial treatment of choice for most hypertensive patients , based on demonstrated reduction in risk for major cardiovascular events , including coronary heart disease , and its safety , patient acceptance , and low cost . ( Hypertension 1993;21:335‐343 The Hypertension Detection and Follow-up Program screened 34,012 individuals aged 60 - 69 years old in their homes in 14 communities around the United States during 1972 and 1973 . The prevalence of hypertension , defined as diastolic blood pressure greater than or equal to 90 mmHg or on antihypertensive medication , was 42.1 % . After a second clinic screen , 2,376 hypertensives were identified and r and omized into Stepped Care , a special intensive treatment group , or Referred Care , a group referred to their usual medical care sources . These individuals were followed for five years ( until they reached the ages of 65 - 74 years ) . Over the five years , 79.4 % of older individuals remained under active care and 81.4 % of those were at their goal diastolic blood pressure . Side-effects tended to be less frequent in older individuals than in younger ones . Older Stepped Care participants with mild hypertension ( diastolic blood pressure 90 - 104 mmHg ) had a 17.2 % reduction in all-cause mortality over five years compared to Referred Care , which was primarily due to a reduction in deaths attributed to cardiovascular causes . Thus , antihypertensive treatment can be safely and beneficially administered to individuals in this age range with diastolic hypertension , including those with mild hypertension Context Identifying adults with a high probability of developing high blood pressure  could help target nonpharmacologic measures to prevent hypertension . Contribution Using data from the Framingham cohort study , the investigators devised a simple risk score with good performance characteristics that identified adults without diabetes who had low ( < 5 % ) , medium ( 5 % to 10 % ) , or high ( > 10 % ) probability of developing hypertension within 4 years . The risk score included points for age , sex , systolic and diastolic blood pressure , body mass index , parental hypertension , and cigarette smoking . Implication If this risk score is vali date d in additional patient population s , it could help clinicians identify high-risk patients with prehypertension . The Editors In 2003 , the Seventh Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure created a prehypertension category for persons with blood pressures ranging from 120 to 139 mm Hg ( systolic ) or from 80 to 89 mm Hg ( diastolic ) . The committee strongly advocated lifestyle and behavioral modification for individuals with prehypertension ( 1 ) . This new recommendation was based largely on epidemiologic evidence that individuals with nonoptimal blood pressure ( > 120/80 mm Hg ) are at increased risk for progression to overt hypertension ( 1 , 2 ) and that cardiovascular disease risk increases in a grade d fashion beginning at a blood pressure of 115/75 mm Hg , well within the normal range ( 1 , 3 ) . However , this new categorization scheme result ed in 70 million people being considered prehypertensive , a situation that poses a challenge for both physicians and patients . Recent clinical trials have focused on the treatment of persons with prehypertension to determine whether hypertension onset can be delayed . A recent clinical trial demonstrated that individuals with blood pressures of 130 to 139 mm Hg ( systolic ) and 80 to 85 mm Hg ( diastolic ) who were treated for 2 years with c and esartan , an angiotensin II receptor blocker , had a 15 % reduction in the incidence of hypertension over 4 years compared with patients r and omly assigned to placebo ( 4 ) . A clinical trial of lifestyle modification among overweight individuals without hypertension demonstrated that a low-salt diet and regular physical exercise reduced hypertension incidence in the short term and several years after the clinical trial ( 5 , 6 ) . Although these investigations have demonstrated the feasibility and efficacy of preventing hypertension , a strategy that targets all individuals with prehypertension is likely to be associated with substantial medical and economic re sources . Evidence suggests that the risk for progression to hypertension depends on clinical factors , such as baseline blood pressure , age , and body mass index ( 2 ) . An individualized approach of risk stratification and targeted treatment of the nonhypertensive persons who are at greatest risk for progression may be more desirable . We developed a simple risk score that can be used in a physician 's office to estimate the probability that an individual will develop hypertension over 1 to 4 years and to identify the persons who are at the highest risk for hypertension . Such high-risk individuals will probably derive the maximal benefit from nonpharmacologic ( lifestyle-related ) and pharmacologic interventions aim ed at preventing hypertension . Thus , we believe that knowledge of the risk for hypertension will aid patient education and counseling , and it will assist clinical decision making and design of future interventional studies . Supplement . Risk Calculator Methods Sample The Framingham Heart Study is a community-based , prospect i ve cohort study that began in 1948 with the enrollment of 5209 men and women ( whom we refer to as the original cohort ) ( 7 ) . In 1971 , 5124 men and women were enrolled into the Framingham Offspring Study cohort , which included the children of the original cohort and the spouses of the children . Participant examinations for the offspring cohort occurred approximately every 4 years . The design and methods of the Framingham Offspring Study are described elsewhere ( 8) . For our investigation , offspring cohort participants were eligible if they attended 2 consecutive examinations between the second ( 1979 to 1983 ) and seventh examinations ( 1998 to 2001 ) and if both of their parents were in the original cohort ( 8813 person-examinations ) ( Figure 1 ) . Participants were eligible for inclusion at more than 1 heart study examination cycle if they reached the next examination without meeting any exclusion criteria . We excluded participants who had prevalent hypertension ( n= 2542 ) , prevalent cardiovascular disease ( n= 233 ) , or serum creatinine values greater than 177 mol/L ( 2 mg/dL ) ( n= 4 ) ; were younger than age 20 years or older than age 69 years ( n= 77 ) ; had missing covariates ( n= 46 ) ; or had prevalent diabetes mellitus ( n= 97 ) . We excluded persons with diabetes from our analysis because lower cut-points of systolic and diastolic pressure define the target blood pressure goal in these individuals ( 1 ) . After we applied the exclusion criteria , 5814 person-examinations from 1717 unique individuals ( 54 % women ) remained eligible for analysis . All participants provided written informed consent , and the study protocol was approved by the Boston University Medical Center Institutional Review Board . Figure 1 . Number of participants available for evaluation of hypertension incidence at baseline examination and number of participants with incident hypertension at follow-up examination . Assessment of Risk Factors At each Framingham Heart Study examination , participants underwent a medical history and physical examination , anthropometric measurements , and laboratory assessment of vascular risk factors . Blood pressure  was measured on the left arm of seated participants by a physician using a mercury-column sphygmomanometer , a cuff of the appropriate size , and a st and ardized protocol . Participants had rested in a chair for 5 minutes before blood pressure was measured , and the average of 2 readings obtained by a physician was considered the examination blood pressure . Systolic blood pressure of 140 mm Hg or higher , diastolic blood pressure of 90 mm Hg or higher , or use of blood pressurelowering medications defined hypertension . Current smoking was defined as regular cigarette smoking in the year before the examination . Body mass index was calculated as body weight ( in kilograms ) divided by the square of height ( in meters ) . Consumption of more than 7 drinks per week in women and more than 14 drinks per week in men defined moderate alcohol intake ( 1 ) . A fasting blood glucose level of 7.0 mmol/L ( 126 mg/dL ) or more , use of hypoglycemic medications , or both defined diabetes mellitus . Parental hypertension was defined as documented maternal and paternal hypertension at or before the baseline examination at which offspring were eligible for our investigation . Parental hypertension status was ascertained on the basis of blood pressure readings of the original cohort participants by using serial data from examination cycle 3 ( 1952 to 1956 ) through examination 27 ( 2002 to 2004 ) . Prevalent cardiovascular disease was defined as presence of coronary heart disease , stroke , transient ischemic attack , intermittent claudication , or heart failure at any examination . The criteria for diagnosis of these cardiovascular events are described elsewhere ( 9 ) . Statistical Analysis We measured hypertension incidence during the interval between offspring cohort examinations ( median , 3.8 years ) . If a person remained without hypertension at the follow-up examination , he or she remained eligible to contribute to the next 4-year period . A Weibull regression model for interval-censored data ( 10 ) was used because only the interval during which new hypertension developed was available ; the exact date of onset of hypertension between 2 Framingham Heart Study examinations could not be determined . Significant predictors of hypertension incidence were identified by entering c and i date risk factors ( age , sex , body weight , body mass index , physical activity index , diabetes , systolic blood pressure , diastolic blood pressure , moderate alcohol intake , current smoking , and parental occurrence of hypertension [ modeled as 0 , 1 , or 2 parents with hypertension ] ) into a stepwise model . These risk factors have been associated with hypertension in other studies ( 1 ) . Because diastolic blood pressure decreases with age ( 11 ) , we evaluated an interaction term for diastolic blood pressure by age , along with the other c and i date risk factors . We also tested the following additional interaction terms in multivariable models : diastolic blood pressure by sex , systolic blood pressure by sex , body mass index by smoking , parental hypertension by age , parental hypertension by sex , and parental hypertension by body mass index . We developed a risk prediction score from -coefficients for variables associated with hypertension incidence in multivariable Weibull regression models by using methods described elsewhere ( 12 ) . Continuous variables were divided into categories to facilitate risk estimation : Age was divided into 10-year groups ; systolic blood pressure was divided into 5 mm Hg categories beginning with 110 mm Hg and ending with 139 mm Hg ; and diastolic blood pressure was divided into 5 mm Hg categories beginning with 70 mm Hg and ending with 89 mm Hg . Body mass index was classified into 3 levels : less than 25 kg/m2 ( normal ) , 25 to less than 30 kg/m2 ( overweight ) , and 30 kg/m2 or more ( obesity ) . We derived 1- , 2- and 4-year rates of hypertension incidence directly from the Weibull model ( Appendix ) . We chose to assess 4-year risk because examination cycles in the Framingham Offspring Study occurred approximately every 4 years , and we were interested in assessing a short-term risk score for hypertension . We present 1- and 2-year risks for hypertension because we believe that these short-term risk BACKGROUND Stroke is directly related to blood pressure and treatment trials in older hypertensive individuals show a reduction in strokes . However , the majority of strokes occur in normotensive individuals in whom no attempt is made to lower blood pressure . We compared the effects of modest salt restriction on blood pressure in older hypertensive and normotensive people . METHODS 47 untreated elderly people ( 24 men , age range 60 - 78 years ; blood-pressure range 123 - 205 mm Hg systolic and 64 - 112 mm Hg diastolic ) completed a 2-month double-blind r and omised placebo-controlled crossover study of modest salt restriction with slow sodium and placebo to give a salt intake of either 10 g ( equivalent to the normal amount for the UK population ) or 5 g. FINDINGS On the normal salt intake for the UK population , supine blood pressure was 163/90 ( SD 21/10 ) mm Hg with urinary sodium excretion of 177 ( 49 ) mmol/day . With modest sodium restriction , blood pressure fell to 156/87 ( 22/9 ) mm Hg ( p < 0.001/0.004 ) with a urinary sodium excretion of 94 ( 50 ) mmol/day . A reduction in sodium intake of 83 mmol/day was associated with a reduction of 7.2/3.2 mm Hg . There was no significant difference in the blood-pressure fall between 18 normotensive and 29 hypertensive participants ( 8.2/3.9 vs 6.6/2.7 mm Hg ) . INTERPRETATION A modest reduction in salt intake leads to a fall in blood pressure in both normotensive and hypertensive older people similar to that in outcome trials of thiazide-based treatment . Since the majority of strokes in older people occur below the current definition of hypertension , our results have important implication s for the prevention of stroke Summary Background The associations of blood pressure with the different manifestations of incident cardiovascular disease in a contemporary population have not been compared . In this study , we aim ed to analyse the associations of blood pressure with 12 different presentations of cardiovascular disease . Methods We used  linked electronic health records from 1997 to 2010 in the CALIBER ( CArdiovascular research using LInked Bespoke studies and Electronic health Records ) programme to assemble a cohort of 1·25 million patients , 30 years of age or older and initially free from cardiovascular disease , a fifth of whom received blood pressure-lowering treatments . We studied the heterogeneity in the age-specific associations of clinical ly measured blood pressure with 12 acute and chronic cardiovascular diseases , and estimated the lifetime risks ( up to 95 years of age ) and cardiovascular disease-free life-years lost adjusted for other risk factors at index ages 30 , 60 , and 80 years . This study is registered at Clinical Trials.gov , number NCT01164371 . Findings During 5·2 years median follow-up , we recorded 83 098 initial cardiovascular disease presentations . In each age group , the lowest risk for cardiovascular disease was in people with systolic blood pressure of 90–114 mm Hg and diastolic blood pressure of 60–74 mm Hg , with no evidence of a J-shaped increased risk at lower blood pressures . The effect of high blood pressure varied by cardiovascular disease endpoint , from strongly positive to no effect . Associations with high systolic blood pressure were strongest for intracerebral haemorrhage ( hazard ratio 1·44 [ 95 % CI 1·32–1·58 ] ) , subarachnoid haemorrhage ( 1·43 [ 1·25–1·63 ] ) , and stable angina ( 1·41 [ 1·36–1·46 ] ) , and weakest for abdominal aortic aneurysm ( 1·08 [ 1·00–1·17 ] ) . Compared with diastolic blood pressure , raised systolic blood pressure had a greater effect on angina , myocardial infa rct ion , and peripheral arterial disease , whereas raised diastolic blood pressure had a greater effect on abdominal aortic aneurysm than did raised systolic pressure . Pulse pressure associations were inverse for abdominal aortic aneurysm ( HR per 10 mm Hg 0·91 [ 95 % CI 0·86–0·98 ] ) and strongest for peripheral arterial disease ( 1·23 [ 1·20–1·27 ] ) . People with  hypertension ( blood pressure ≥140/90 mm Hg or those receiving blood pressure-lowering drugs ) had a lifetime risk of overall cardiovascular disease at 30 years of age of 63·3 % ( 95 % CI 62·9–63·8 ) compared with 46·1 % ( 45·5–46·8 ) for those with normal blood pressure , and developed cardiovascular disease 5·0 years earlier ( 95 % CI 4·8–5·2 ) . Stable and unstable angina accounted for most ( 43 % ) of the cardiovascular disease-free years of life lost associated with hypertension from index age 30 years , whereas heart failure and stable angina accounted for the largest proportion ( 19 % each ) of years of life lost from index age 80 years . Interpretation The widely held assumptions that blood pressure has strong associations with the occurrence of all cardiovascular diseases across a wide age range , and that diastolic and systolic associations are concordant , are not supported by the findings of this high-resolution study . Despite modern treatments , the lifetime burden of hypertension is substantial . These findings emphasise the need for new  blood pressure-lowering strategies , and will help to inform the design of r and omised trials to assess them . Funding Medical Research Council , National Institute for Health Research , and Wellcome Trust BACKGROUND It has been suggested that low diastolic blood pressure ( BP ) while receiving antihypertensive treatment ( hereinafter called on-treatment BP ) is harmful in older patients with systolic hypertension . We examined the association between on-treatment diastolic BP , mortality , and cardiovascular events in the prospect i ve placebo-controlled Systolic Hypertension in Europe Trial . METHODS Elderly patients with systolic hypertension were r and omized into the double-blind first phase of the trial , after which all patients received active study drugs ( phase 2 ) . We assessed the relationship between outcome and on-treatment diastolic BP by use of multivariate Cox regression analysis during receipt of placebo ( phase 1 ) and during active treatment ( phases 1 and 2 ) . RESULTS Rates of noncardiovascular mortality , cardiovascular mortality , and cardiovascular events were 11.1 , 12.0 , and 29.4 , respectively , per 1000 patient-years with active treatment ( n = 2358 ) and 11.9 , 12.6 , and 39.0 , respectively , with placebo ( n = 2225 ) . Noncardiovascular mortality , but not cardiovascular mortality , increased with low diastolic BP with active treatment ( P < .005 ) and with placebo ( P < .05 ) ; for example , hazard ratios for lower diastolic BP , that is , 65 to 60 mm Hg , were , respectively , 1.15 ( 95 % confidence interval , 1.00 - 1.31 ) and 1.28 ( 95 % confidence interval , 1.03 - 1.59 ) . Low diastolic BP with active treatment was associated with increased risk of cardiovascular events , but only in patients with coronary heart disease at baseline ( P < .02 ; hazard ratio for BP 65 - 60 mm Hg , 1.17 ; 95 % confidence interval , 0.98 - 1.38 ) . CONCLUSIONS These findings support the hypothesis that antihypertensive treatment can be intensified to prevent cardiovascular events when systolic BP is not under control in older patients with systolic hypertension , at least until diastolic BP reaches 55 mm Hg . However , a prudent approach is warranted in patients with concomitant coronary heart disease , in whom diastolic BP should probably not be lowered to less than 70 mm Hg Background : Hypertension in the elderly is commonly characterized by an elevation of pulse pressure . With regard to advanced arteriosclerosis and limited physical fitness , doubt was casted whether elderly patients still achieve relevant cardiovascular benefits by physical exercise . The present work examines the impact of pulse pressure as a footprint of vascular ageing on cardiovascular benefits of endurance training in elderly hypertensives . Methods : 54 patients ≧60 years with systolic 24-hour ambulatory blood pressure ( ABP ) > 140 mm Hg and /or antihypertensive treatment and diastolic ABP ≤90 mm Hg were r and omly assigned  to sedentary activity or a 12-week treadmill exercise program ( target lactate 2.5 ± 0.5 mmol/l ) . Results : Exercise significantly decreased systolic and diastolic ABP by 8.5 ± 8.2 and 5.1 ± 3.7 mm Hg ( p < 0.001 each ) and increased physical performance . Arterial compliance remained unchanged , whereas endothelium-dependent vasodilation – measured by flow-mediated dilation – significantly increased from 5.6 ± 1.7 to 7.9 ± 3.0 % ( p < 0.007 ) . After adjustment for initial systolic ABP , pulse pressure did not affect the change of BP . Conclusion :  The exercise-induced reduction of BP , which is mediated by improved endothelial function , is independent of pulse pressure . Thus , physical exercise is a helpful adjunct to control BP even in old hypertensives with markedly increased arterial stiffness Background Isolated systolic hyprtension occurs in around 8 % of Chinese people aged 60 years or older . In 1988 , the Systolic Hypertension in China ( Syst-China ) Collaborative Group started to investigate whether active treatment could reduce the incidence of stroke and other cardiovascular complications in older patients with isolated systolic hypertension . Methods All patients were initially started on masked placebo . After stratification for centre , sex and previous cardiovascular complications , alternate patients ( n = 1253 ) were assigned nitrendipine at 10–40 mg daily , with the addition of captopril at 12.5–50.0 mg daily or hydrochlorothiazide at 12.5–50.0 mg daily , or both , if a sufficient blood pressure fall was not obtained . In the remaining 1141 control patients , matching placebos were administered similarly . Results At entry , sitting blood pressure averaged 170.5 mmHg systolic and 86.0 mmHg diastolic , age averaged 66.5 years and total serum cholesterol was 5.1 mmol/l . After 2 years of follow-up , sitting systolic and diastolic blood pressures had fallen by 10.9 mmHg and 1.9 mmHg in the placebo group and by 20.0 mmHg and 5.0 mmHg in the active treatment group . The intergroup differences were 9.1 mmHg systolic ( 95 % confidence interval 7.6–10.7 mmHg ) and 3.2 mmHg diastolic ( 95 % confidence interval 2.4–4.0 ) . Active treatment reduced total strokes by 38 % ( from 20.8 to 13.0 endpoints per 1000 patient-years , P = 0.01 ) , all-cause mortality by 39 % ( from 28.4 to 17.4 endpoints per 1000 patient-years , P = 0.003 ) , cardiovascular mortality by 39 % ( from 15.2 to 9.4 endpoints per 1000 patient-years , P = 0.03 ) , stroke mortality by 58 % ( from 6.9 to 2.9 endpoints per 1000 patient-years , P = 0.02 ) , and all fatal and nonfatal cardiovascular endpoints by 37 % ( from 33.3 to 21.4 endpoints per 1000 patient-years , P = 0.004 ) . Conclusions Antihypertensive treatment prevents stroke and other cardiovascular complications in older Chinese patients with isolated systolic hypertension . Treatment of 1000 Chinese patients for 5 years could prevent 55 deaths , 39 strokes or 59 major cardiovascular endpoints Background To assess the impact of immediate versus delayed antihypertensive treatment on the outcome of older patients with isolated systolic hypertension  , we extended the double-blind placebo-controlled Systolic Hypertension in Europe ( Syst-Eur ) trial by an open-label follow-up study lasting 4 years . Methods The Syst-Eur trial included 4695 r and omized patients with minimum age of 60 years and an untreated blood pressure of 160–219 mmHg systolic and below 95 mmHg diastolic . The double-blind trial ended after a median follow-up of 2.0 years ( range 1–97 months ) . Of 4409 patients still alive , 3517 received open-label treatment consisting of nitrendipine ( 10–40 mg daily ) with the possible addition of enalapril ( 5–20 mg daily ) , hydrochlorothiazide ( 12.5–25 mg daily ) , or both add-on drugs .  Non- participants ( n = 892 ) were also followed up . Results Median follow-up increased to 6.1 years . Systolic pressure decreased to below 150 mmHg ( target level ) in 2628 participants ( 75.0 % ) . During the 4-year open-label follow-up , stroke and cardiovascular complications occurred at similar frequencies in patients formerly r and omized to placebo and those continuing active treatment . These rates were similar to those previously observed in the active-treatment group during the double-blind trial . Considering the total follow-up of 4695 r and omized patients , immediate compared with delayed antihypertensive treatment reduced the occurrence of stroke and cardiovascular complications by 28 % ( P = 0.01 ) and 15 % ( P = 0.03 ) , respectively , with a similar tendency for total mortality ( 13 % , P = 0.09 ) . In 492 diabetic patients , the corresponding estimates of long-term benefit ( P < 0.02 ) were 60 , 51 and 38 % , respectively . Conclusions Antihypertensive treatment can achieve blood pressure control in most older patients with isolated systolic hypertension . Immediate compared with delayed treatment prevented 17 strokes or 25 major cardiovascular events per 1000 patients followed up for 6 years . These findings underscore the necessity of early treatment of isolated systolic hypertension Although the benefits of antihypertensive treatment in " young " elderly ( under 70 years ) hypertensive patients are well established , the value of treatment in older patients ( 70 - 84 years ) is less clear . The Swedish Trial in Old Patients with Hypertension ( STOP-Hypertension ) was a prospect i ve , r and omised , double-blind , intervention study set up to compare the effects of active antihypertensive therapy ( three beta-blockers and one diuretic ) and placebo on the frequency of fatal and non-fatal stroke and myocardial infa rct ion and other cardiovascular death in hypertensive Swedish men and women aged 70 - 84 years . We recruited 1627 patients at 116 health centres throughout Sweden , who were willing to participate , and who met the entry criteria of three separate recordings during a 1-month placebo run-in period of systolic blood pressure between 180 and 230 mm Hg with a diastolic pressure of at least 90 mm Hg , or a diastolic pressure between 105 and 120 mm Hg irrespective of the systolic pressure . The total duration of the study was 65 months and the average time in the study was 25 months . 812 patients were r and omly allocated active treatment and 815 placebo . The mean difference in supine blood pressure between the active treatment and placebo groups at the last follow-up before an endpoint , death , or study termination was 19.5/8.1 mm Hg . Compared with placebo , active treatment significantly reduced the number of primary endpoints ( 94 vs 58 ; p = 0.0031 ) and stroke morbidity and mortality ( 53 vs 29 ; p = 0.0081 ) . Although we did not set out to study an effect on total mortality , we also noted a significantly reduced number of deaths in the active treatment group ( 63 vs 36 ; p = 0.0079 ) . The benefits of treatment were discernible up to age 84 years . We conclude that antihypertensive treatment in hypertensive men and women aged 70 - 84 confers highly significant and clinical ly relevant reductions in cardiovascular morbidity and mortality as well as in total mortality BACKGROUND Isolated systolic hypertension occurs in about 15 % of people aged 60 years or older . In 1989 , the European Working Party on High Blood Pressure in the Elderly investigated whether active treatment could reduce cardiovascular complications of isolated systolic hypertension . Fatal and non-fatal stroke combined was the primary endpoint . METHODS All patients ( > 60 years ) were initially started on masked placebo .  At three run-in visits 1 month apart , their average sitting systolic blood pressure was 160 - 219 mm Hg with a diastolic blood pressure lower than 95 mm Hg . After stratification for centre , sex , and previous cardiovascular complications , 4695 patients were r and omly assigned to nitrendipine 10 - 40 mg daily , with the possible addition of enalapril 5 - 20 mg daily and hydrochlorothiazide 12.5 - 25.0 mg daily , or matching placebos . Patients withdrawing from double-blind treatment were still followed up . We compared occurrence of major endpoints by intention to treat . FINDINGS At a median of 2 years ' follow-up , sitting systolic and diastolic blood pressures had fallen by 13 mm Hg and 2 mm Hg in the placebo group ( n = 2297 ) and by 23 mm Hg and 7 mm Hg in the active treatment group ( n = 2398 ) . The between-group differences were systolic 10.1 mm Hg ( 95 % CI 8.8 - 11.4 ) and diastolic , 4.5 mm Hg ( 3.9 - 5.1 ) . Active treatment reduced the total rate of stroke from 13.7 to 7.9 endpoints per 1000 patient-years ( 42 % reduction ; p = 0.003 ) . Non-fatal stroke decreased by 44 % ( p = 0.007 ) . In the active treatment group , all fatal and non-fatal cardiac endpoints , including sudden death , declined by 26 % ( p = 0.03 ) . Non-fatal cardiac endpoints decreased by 33 % ( p = 0.03 ) and all fatal and non-fatal cardiovascular endpoints by 31 % ( p < 0.001 ) . Cardiovascular mortality was slightly lower on active treatment ( -27 % , p = 0.07 ) , but all-cause mortality was not influenced ( -14 % ; p = 0.22 ) . INTERPRETATION Among elderly patients with isolated systolic hypertension , antihypertensive drug treatment starting with nitrendipine reduces the rate of cardiovascular complications . Treatment of 1000 patients for 5 years with this type of regimen may prevent 29 strokes or 53 major cardiovascular endpoints BACKGROUND Recent reports suggest that calcium-channel blockers may be harmful in patients with diabetes and hypertension . We previously reported that antihypertensive treatment with the calcium-channel blocker nitrendipine reduced the risk of cardiovascular events . In this post hoc analysis , we compared the outcome of treatment with nitrendipine in diabetic and nondiabetic patients . METHODS After stratification according to center , sex , and presence or absence of previous cardiovascular complications , 4695 patients ( age , > or = 60 years ) with systolic blood pressure of 160 to 219 mm Hg and diastolic pressure below 95 mm Hg were r and omly assigned to receive active treatment or placebo . Active treatment consisted of nitrendipine ( 10 to 40 mg per day ) with the possible addition or substitution of enalapril ( 5 to 20 mg per day ) or hydrochlorothiazide ( 12.5 to 25 mg per day ) or both , titrated to reduce the systolic blood pressure by at least 20 mm Hg and to less than 150 mm Hg . In the control group , matching placebo tablets were administered similarly . RESULTS At r and omization , 492 patients ( 10.5 percent ) had diabetes . After a median follow-up of two years , the systolic and diastolic blood pressures in the placebo and active-treatment groups differed by 8.6 and 3.9 mm Hg , respectively , among the diabetic patients . Among the 4203 patients without diabetes , systolic and diastolic pressures differed by 10.3 and 4.5 mm Hg , respectively , in the two groups . After adjustment for possible confounders , active treatment was found to have reduced overall mortality by 55 percent ( from 45.1 deaths per 1000 patients to 26.4 deaths per 1000 patients ) , mortality from cardiovascular disease by 76 percent , all cardiovascular events combined by 69 percent , fatal and nonfatal strokes by 73 percent , and all cardiac events combined by 63 percent in the group of patients with diabetes . Among the nondiabetic patients , active treatment decreased all cardiovascular events combined by 26 percent and fatal and nonfatal strokes by 38 percent . In the group of patients receiving active treatment , reductions in overall mortality , mortality from cardiovascular disease , and all cardiovascular events were significantly larger among the diabetic patients than among the nondiabetic patients ( P=0.04 , P=0.02 , and P=0.01 , respectively ) . CONCLUSIONS Nitrendipine-based antihypertensive therapy is particularly beneficial in older patients with diabetes and isolated systolic hypertension . Thus , our findings do not support the hypothesis that the use of long-acting calcium-channel blockers may be harmful in diabetic patients Context In 2003 , the U.S. Preventive Services Task Force recommended screening for type 2 diabetes in adults with hypertension or hyperlipidemia . The economic implication s of this recommendation are unclear . Contribution Diabetes screening for 55-year-old hypertensive persons would cost the U.S. health care system $ 34 375 per quality -adjusted life-year gained . Exp and ing screening to all adults regardless of the presence of hypertension would cost an additional $ 360 966 per quality -adjusted life-year . Implication s The cost-effectiveness of targeting diabetes screening to hypertensive adults older than 55 years of age is similar to the cost-effectiveness of many accepted health care interventions . Universal diabetes screening is far more costly . The Editors Although many adults who meet criteria for type 2 diabetes ( hereafter , diabetes ) have not been identified ( 1 ) , screening for diabetes remains controversial ( 2 - 11 ) . Direct evidence indicates that various treatments to reduce complications are effective among people with clinical ly detected diabetes ( 12 - 14 ) , but no direct evidence tells us the magnitude of any further benefit from starting these treatments earlier , after detection by screening ( 15 ) . In the absence of direct evidence , research ers have applied mathematical models of diabetes progression to the issue of screening . One analysis found that the cost per quality -adjusted life-year ( QALY ) gained by universal diabetes screening was lower for younger than for older people : $ 13 376 at age 25 to 34 years , increasing to $ 116 908 at age 55 to 64 years ( 16 ) . This conclusion followed from the model 's focus on the provision of glycemic control after screening to prevent microvascular complications . The analysis did not consider treatments to reduce the risks for complications of cardiovascular disease ( CVD ) . More recent research suggests that the benefits of CVD risk reduction may be substantial for people with diabetes . The Hypertension Optimal Treatment ( HOT ) trial found that the optimal blood pressure target is lower for people with hypertension and diabetes than for people with hypertension without diabetes ( 14 ) . Other research supports the finding that intensive control of hypertension is beneficial among people with diabetes ( 15 , 17 - 19 ) . Because the benefit may be greater for older people ( at greater risk for CVD ) , the conclusion of the previous analysis , that diabetes screening is most cost-effective among younger people , needs to be reconsidered . We performed a new cost-effectiveness analysis to compare universal diabetes screening ( universal screening ) and diabetes screening targeted to  patients with hypertension ( targeted screening ) . When an up date d version of the model used in the previous analysis that includes benefits from intensive treatment of hypertension was applied , we estimated the incremental cost-effectiveness of these 2 strategies for people in different age groups . Our analysis considers a one-time opportunistic screening for men and women of all races and ethnicities . Methods The Model We used a Markov model of diabetes disease progression to simulate lifetime diabetes-related health care costs and QALYs for people with diabetes ( Appendix Figure 1 ) . Demographic characteristics of the simulated cohort are based on 1997 population estimates projected from the 1990 U.S. Census and data on the distribution of people with diabetes by hypertension , cholesterol level , and smoking status ( 20 ) . As people progress through the simulation model from the onset of diabetes to death , they can develop 5 types of complications : nephropathy , neuropathy , retinopathy , coronary heart disease ( CHD ) , and stroke . People can die of some of these complications or of other causes . The model includes transition probabilities between disease stages on each of the 5 complication paths . The basic model structure has been described previously ( 16 , 21 ) . Key model parameters are presented in the Appendix Tables 1 to 10 . To incorporate screening into the model , we first added a screening module in which some patients with diabetes are identified earlier than they would usually have been in the absence of screening . Second , we made assumptions about the transition probabilities between disease stages from the onset of diabetes to the time of usual clinical diagnosis of diabetes on the basis of the knowledge that progression is relatively slow during this period ( 15 ) . After clinical diagnosis , disease progression depends on the number of years after normal diagnosis . Screening allows for earlier diagnosis , which in turn allows for earlier treatment interventions , such as intensive glycemic control and intensive hypertension control . These interventions decrease the transition probabilities , thereby delaying or preventing progression to diabetes complications . Costs are incurred for screening and diagnostic testing ; st and ard glycemic control and , if the person is hypertensive , st and ard hypertension control ; interventions ( intensive glycemic control and , if the person is hypertensive , intensive hypertension control ) ; and complications over the remaining lifetime of each person with diabetes . The sum of these costs and the model 's estimate of the expected QALYs for each screening strategy are used to calculate the incremental cost-effectiveness ratio of screening relative to no screening . We discounted future costs and QALYs at a 3 % annual rate . Costs are measured in 1997 U.S. dollars . Interventions We assumed that , in the absence of screening , diabetes would be diagnosed 10 years after its onset ( 15 ) . With one-time opportunistic screening , diabetes would be diagnosed on average 5 years after onset and therefore patients would begin treatment 5 years earlier . After diabetes diagnosis , all patients are treated with intensive glycemic control and , if they have hypertension , with intensive hypertension control . With targeted screening , only people with hypertension are screened . Those who screen positive and receive a diagnosis of diabetes begin intensive glycemic control and intensive hypertensive control 5 years earlier than they would in the absence of screening . With universal screening , all people , regardless of hypertension status , are screened . Those who screen positive and receive a diagnosis of diabetes begin intensive glycemic control 5 years earlier than in the absence of screening and begin intensive hypertension control 5 years earlier if they have hypertension . We defined hypertension as a blood pressure of 140/90 mm Hg or higher . We assumed that 19 % of people age 25 to 44 years , 47 % of people age 45 to 64 years , and 60 % of people age 65 to 74 years had hypertension and therefore were included in targeted screening ( 20 ) . Treatment of hypertension is modeled as st and ard ( with a target diastolic blood pressure of 90 mm Hg ) or intensive ( with a target diastolic blood pressure of 80 mm Hg ) , as in the HOT trial ( 14 ) . All persons with hypertension receive st and ard hypertension treatment until they receive a diagnosis of diabetes , after which they receive intensive hypertension treatment . The incremental cost of intensive hypertension control relative to st and ard control is $ 149 per year . In the HOT trial , the relative risk reduction for CHD events ( fatal and nonfatal myocardial infa rct ion ) was 51 % , and the relative risk reduction for stroke was about 30 % . Although neither of these separate relative risk reductions was statistically significant , the relative risk reduction ( 51 % ) for the aggregate outcome of major CVD events was statistically significant ( P = 0.005 ) . We initially modeled the relative risk reduction for CHD events for intensive hypertension control to be 51 % , with no risk reduction for stroke . We conducted a sensitivity analysis that included a 30 % relative risk reduction for stroke on the basis of other studies showing that intensive hypertension control reduces risk among people with diabetes ( 17 , 19 ) . Model estimates of the effects of glycemic control are based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , a 10-year r and omized , controlled trial of intensive versus conventional glycemic control ( 12 ) . On the basis of the UKPDS , the reduction in hemoglobin A1c from intensive glycemic treatment is modeled as slowing the progression of microvascular complications ( 12 ) . The incremental cost of intensive glycemic control ( relative to st and ard control ) ranges from $ 900 to $ 1100 per year , depending on the number of years since diagnosis . Screening and Diagnostic Tests The Figure illustrates the screening and diagnostic testing process and shows where costs are incurred . Figure . Progression of persons screened for diabetes . Appendix Figure 1 . Markov model of diabetes disease progression . LEA CA MI Screening Tests We assume a one-time opportunistic screening during a regularly scheduled physician office visit . The model assumes screening by a fasting capillary blood glucose ( CBG ) test ( 22 ) and an extra 10 minutes over the usual 15 minutes for the physician visit , incurring a cost of $ 24.40 per person screened . Costs for the CBG test are derived from the Medicare Clinical Diagnostic Laboratory Fee Schedule ( 23 ) ; physician visit costs are derived from Relative Values for Physicians ( 24 ) . Table 1 shows prevalence ( from the National Health and Nutrition Examination Survey III data tape ) , CBG sensitivity and specificity values ( 22 ) with exact data points clarified via personal communication ( Rolka DB , 18 January 2002 ) , and the number needed to screen to detect one previously undiagnosed person with diabetes by sex , hypertension status , and age . Table 1 . Number of Screenings and Diagnostic Tests  Needed To Identify One Undiagnosed Diabetes Case Diagnostic Tests All people who screen ( true or false ) positive receive a diagnostic test , the fasting plasma glucose test , which is repeated if the result is positive . Because 2 consecutive elevated fasting plasma glucose test results define diabetes ( 11 ) , we assume The current guidelines for the detection and management of  high blood pressure  depend exclusively on the measurement of  systolic and diastolic blood pressure  , although these are only two specific points on the arterial pressure wave form [ 1,2 ] . However , it may be more appropriate to describe the cardiac cycle as consisting of a pulsatile ( pulse pressure ) and a steady ( mean pressure ) component . Pulse pressure is defined as the difference between systolic and diastolic pressures and primarily reflects the stiffness of large arteries , especially the aorta . Elevated pulse pressure increases the stretch of arteries , induces fatigue and fracture of elastic elements , and accelerates the development of aneurysms , and ultimately their rupture . Similarly , an increased pulse pressure is more likely to contribute to intimal damage , the prelude to atherosclerosis and arterial thrombotic events . Increased pulse pressure has also been associated with thickening of the carotid intima and media [ 3,4 ] . Systolic blood pressure increases across all age groups , whereas diastolic blood pressure increases until the sixth decade of life and then declines thereafter . As a result , pulse pressure increases as age rises , especially in older people as systolic and diastolic blood pressure move in opposite directions . Hence , pulse pressure may become the key blood pressure measure in older individuals and increase in importance as a risk factor for cerebrovascular diseases and death [ 5,6 ] . Several observational studies have found that pulse pressure is an independent predictor of cardiovascular risk in middle aged and older people , in subjects with high blood pressure , in survivors of myocardial infa rct ion and in patients with left ventricular dysfunction [ 7–11 ] . A meta analysis based on individual patient data from three large trials ( Syst-Eur , SystChina and EWPHE [ 12–14 ] ) showed that isolated systolic hypertension and pulse pressure were the major determinants of cardiovascular risk in elderly hypertensives [ 7 ] . A further meta- analysis of individual patient data in control groups of seven r and omized clinical trials ( SHEP , Syst-Eur , MRC 1 , HEP , MRC 2 , EWPHE and STOP ) in the INDANA project [ 8 ] also reported that pulse pressure , rather than mean pressure , was the major risk factor for adverse cardiovascular events . A 10-mmHg increase in pulse pressure at baseline was associated independently with a 6 % rise in total mortality , a 7 % rise in cardiovascular mortality and a 7 % rise in fatal coronary events . A similar rise in fatal stroke was present , although this was statistically nonsignificant due to the limited number of events . However , the relationship between pulse pressure and fatal stroke became significant ( p = 0.04 ) at higher age [ 8 ] . Importantly , pulse pressure calculated from 24 h ambulatory blood pressure recordings is a better predictor of adverse events than if derived from officemeasured blood pressure in older patients with isolated systolic hypertension [ 15 ] A survey in 1994 showed that among the 20 % of the adult English population who were identified as hypertensive , ≈30 % had their blood pressures controlled to < 160 mm Hg systolic and < 95 mm Hg diastolic . The 1998 Health Survey for Engl and data up date the 1994 findings in light of new thresholds and targets for treatment outlined in recent national and international guidelines . This cross-sectional survey is analyzed to describe the prevalence , awareness , treatment , and control of hypertension in a r and om , nationally representative sample of 11 529 English adults ( ≥16 years ) living in noninstitutional households in 1998 and to compare these rates with those from 1994 . In 1998 , 20 % and 37 % of adults were hypertensive according to the old ( systolic ≥160 mm Hg or diastolic ≥95 mm Hg ) and new ( systolic ≥140 mm Hg or diastolic ≥90 mm Hg ) definitions , respectively . Corresponding values in 1994 were 20 % and 38 % . Treatment and control rates among hypertensive adults ( new definition ) improved from 26 % to 32 % and from 6 % to 9 % , respectively , although 60 % of those on treatment received only 1 antihypertensive drug in both years . Among persons with controlled hypertension , 59 % reported having  received nonpharmacological advice  from their physicians in 1998 compared with 30 % in 1994 . Rates of hypertension treatment and control have increased significantly ( P = 0.05 and P < 0.01 , respectively ) since 1994 but remain low by international st and ards . The 1998 data suggest that improved detection , greater use of nonpharmacological measures , and increased use of > 1 antihypertensive agent per patient would produce greater success in achieving target levels . This could lead to major reductions in fatal and nonfatal cardiovascular events BACKGROUND AND AIM Atrial fibrillation ( AF ) is an important cardiovascular disease in the elderly . The association between hyperuricemia and AF is unclear . Therefore , we aim ed to investigate the prospect i ve relationship between uric acid and development of AF in a nationally representative cohort of elderly people . METHODS AND RESULTS A total of 1485 elderly people ( age ≥ 65 yrs ) from the Elderly Nutrition and Health Survey in Taiwan ( 1999 - 2000 ) were without AF on " electrocardiography " at baseline .  Incident AF events ( International Classification of Diseases , Ninth Revision , Clinical Modification , ICD-9-CM : 427.31 ) were identified using data from the National Health Insurance Data set . Hyperuricemia was defined as levels of uric acid > 7.0 mg/dL in men and 6.0 mg/dL in women . A Cox proportional hazards model was used to evaluate the association between hyperuricemia and incident AF . The follow-up period was from 1999 to 2000 to 2008 . During the follow-up period ( median : 9.16 yrs ) , 90 AF events occurred ( 44 in men and 46 in women ) . Older age , elevated systolic blood pressure , being an ex-smoker , and high uric acid were positively associated with incident AF . Hyperuricemia was positively associated with incident AF in normotensive ( age-adjusted hazard ratio ( HR ) : 2.65 and 95 % confidence intervals : 1.05 - 6.69 ) , but not in ( 1.20:0.74 - 1.94 ) hypertensive individuals ( systolic blood pressure ≥130 or diastolic blood pressure ≥85 or using hypertensive medicine ) . A significant association between hyperuricemia and AF ( 3.78 ; 1.24 - 11.59 ) remained after adjusting for other potential confounders among normotensive older persons . CONCLUSION Hyperuricemia is associated with the development of AF in elderly people with normal blood pressure Pulse pressure has been related to higher risk of cardiovascular events in older persons . Isolated systolic hypertension is common among the elderly and is accompanied by elevated pulse pressure . Treatment of isolated systolic hypertension may further increase pulse pressure if diastolic pressure is lowered to a greater extent than systolic pressure . Little is known regarding pulse pressure as a predictor of cardiovascular outcomes in elderly persons with isolated systolic hypertension , and the influence of treatment on the pulse pressure effect . We assessed the relation between pulse pressure , measured throughout the follow-up period , and the incidence of coronary heart disease ( CHD ) , heart failure ( HF ) , and stroke in 4,632 participants in the Systolic Hypertension in the Elderly Program , a 5-year r and omized , placebo-controlled clinical trial of treatment of isolated systolic hypertension in older adults . In the treatment group , a 10-mm Hg increase in pulse pressure was associated with a statistically significant 32 % increase in risk of HF and a 24 % increase in risk of stroke after controlling for systolic blood pressure and other known risk factors , as well as with a 23 % increase in risk of HF and a 19 % increase in risk of stroke after controlling for diastolic blood pressure and other risk factors . Pulse pressure was not significantly associated with HF or stroke in the placebo group , nor with incidence of CHD in either the placebo or treatment group . These results suggest that pulse pressure is a useful marker of risk for HF and stroke among older adults being treated for isolated systolic hypertension We have evaluated the relationship between systolic blood pressure ( SBP ) and age , body mass index ( BMI ) , waist circumference , sodium to potassium ratio ( Na/K ) , and tobacco use in an urban African population . We conducted a r and om , population -based , cross-sectional survey of people 25 years and older in Marondera , Zimbabwe , with over-sampling in older age groups ( n = 775 ) , using a method comparable to that used in International Collaborative Study on Hypertension in Blacks ( ICSHIB ) . The age-adjusted prevalences of hypertension in Marondera ( SBP ⩾140/DBP ⩾90/antihypertensive medication ) were 30 % for women and 21 % for men . The average BMI was 26.3 kg/m2 for women and 21.4 kg/m2 for men . The prevalence of hypertension had a steep association with age and in women ranged from 15 % ( 25–34 years ) to 63 % ( 55 years and over ) and in men from 9 % to 47 % . No tobacco use in women and greater Na/K ratio in spot urines in men were significantly associated with an increased SBP . In both men and women the levels of hypertension and SBP were strongly positively associated with BMI , although the relationship appeared to plateau in women with a BMI greater than ⩾25 kg/m2 . At a given BMI , men and women had similar SBPs and prevalences of hypertension . There is a very high prevalence of hypertension among urban Zimbabweans , particularly among women . Under the assumption the studies are comparable , the prevalence of hypertension in Zimbabwean women ( 41 % ) and men ( 26 % ) after age adjustment to the ICSHIB population s , appeared higher than almost all of the ICSHIB population s , including those with higher average body mass indexes BACKGROUND In 1989 , the European Working Party on High Blood Pressure in the Elderly started the double-blind , placebo-controlled , Systolic Hypertension in Europe Trial to test the hypothesis that antihypertensive drug treatment would reduce the incidence of fatal and nonfatal stroke in older patients with isolated systolic hypertension . This report addresses whether the benefit of antihypertensive treatment varied according to sex , previous cardiovascular complications , age , initial blood pressure ( BP ) , and smoking or drinking habits in an intention-to-treat analysis and explores whether the morbidity and mortality results were consistent in a per- protocol analysis . METHODS After stratification for center , sex , and cardiovascular complications , 4695 patients 60 years of age or older with a systolic BP of 160 to 219 mm Hg and diastolic BP less than 95 mm Hg were r and omized . Active treatment consisted of nitrendipine ( 10 - 40 mg/d ) , with the possible addition of enalapril maleate ( 5 - 20 mg/d ) and /or hydrochlorothiazide ( 12.5 - 25 mg/d ) , titrated or combined to reduce the sitting systolic BP by at least 20 mm Hg , to below 150 mm Hg . In the control group , matching placebo tablets were employed similarly . RESULTS In the intention-to-treat analysis , male sex , previous cardiovascular complications , older age , higher systolic BP , and smoking at r and omization were positively and independently correlated with cardiovascular risk . Furthermore , for total ( P = .009 ) and cardiovascular ( P = .09 ) mortality , the benefit of antihypertensive drug treatment weakened with advancing age ; for total mortality ( P = .05 ) , the benefit increased with higher systolic BP at entry , while for fatal and nonfatal stroke ( P = .01 ) , it was most evident in nonsmokers ( 92.5 % of all patients ) . In the per protocol analysis , active treatment reduced total mortality by 24 % ( P = .05 ) , reduced all fatal and nonfatal cardiovascular end points by 32 % ( P<.001 ) , reduced all strokes by 44 % ( P = .004 ) , reduced nonfatal strokes by 48 % ( P = .005 ) , and reduced all cardiac end points , including sudden death , by 26 % ( P = .05 ) . CONCLUSIONS In elderly patients with isolated systolic hypertension , stepwise antihypertensive drug treatment , starting with the dihydropyridine calcium channel blocker nitrendipine , improves prognosis . The per- protocol analysis suggested that treating 1000 patients for 5 years would prevent 24 deaths , 54 major cardiovascular end points , 29 strokes , or 25 cardiac end points . The effects of antihypertensive drug treatment on total and cardiovascular mortality may be attenuated in very old patients Abstract : The 2014 Evidence -Based Guideline for the Management of  High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee ( JNC 8) was recently published . This guideline recommended that older adults ( ≥60 years ) without diabetes or chronic kidney disease with systolic blood pressure ( SBP ) ≥150 mm Hg or diastolic blood pressure ( DBP ) ≥90 mm Hg be initiated on antihypertensive medication with a treatment goal SBP/DBP < 150/90 mm Hg . In contrast , the previous 3 JNC guidelines recommended treatment for these individuals be initiated at SBP/DBP ≥140/90 mm Hg with goal SBP/DBP < 140/90 mm Hg . In this article , we review r and omized trials of antihypertensive medication and observational data on SBP and DBP with cardiovascular outcomes among older adults , possible explanations underlying the different findings from these r and omized trials and observational studies , and contemporary antihypertensive treatment patterns among older U.S. adults . In closing , we highlight future research needs related to hypertension and outcomes among older adults BACKGROUND With few exceptions , tools used to estimate cardiovascular disease ( CVD ) risk in those without prior events are based mainly on data from middle-aged subjects . Given the ever increasing number of older people , many with hypertension , a risk score relevant to this group is warranted . Our aim was to develop a cardiovascular risk equation suitable for risk prediction in elderly , hypertensive population s. METHODS We utilized  cardiovascular end point data from 4.1 years median follow-up in 5,426 hypertensive subjects without previous CVD from the Second Australian National Blood Pressure Study ( ANBP2 ) . Our risk model , based on Cox regression , was developed using 75 % of subjects without evident CVD ( n = 4,072 ) , r and omly selected and stratified by age and gender , and internally vali date d using the remaining 25 % . The model was also externally vali date d against the Dubbo Study data set . RESULTS The final model included sex , age , physical activity in the 2 weeks prior to entry into study , family history , use of anticoagulants , central ly acting antihypertensive agents or diabetes medication , and an interaction term for sex and diabetes medication . The C-statistic was 0.65 ( 0.62 - 0.67 ) for our predictive model on the model development data set and 0.62 ( 0.57 - 0.67 ) on the internal validation data set . The Dubbo Data C-statistic for CVD was 0.68 ( 95 % CI 0.65 - 0.71 ) . CONCLUSIONS All models performed similarly . Because of greater ease of implementation , we recommend that existing algorithms be extended into older age groups BACKGROUND Systolic hypertension increases the risk of dementia in elderly people . The vascular dementia project , set up in the framework of the double-blind placebo-controlled Systolic Hypertension in Europe ( Syst-Eur ) trial , investigated whether antihypertensive drug treatment could reduce the incidence of dementia . METHODS Eligible patients had no dementia , were at least 60 years old , and had a blood pressure when seated of 160 - 219 mm Hg systolic and below 95 mm Hg diastolic . Active treatment consisted of nitrendipine ( 10 - 40 mg/day ) with the possible addition of enalapril ( 5 - 20 mg/day ) , hydrochlorothiazide ( 12.5 - 25 mg/day ) , or both drugs , titrated or combined to reduce the systolic blood pressure by at least 20 mm Hg to reach a value below 150 mm Hg . Cognitive function was assessed by the mini mental state examination ( MMSE ) . If the MMSE score was 23 or less , diagnostic tests for dementia were done ( DSM-III-R criteria ) . The cause of dementia was established by the modified ischaemic score with brain imaging or the Hachinski score . FINDINGS Median follow-up by intention to treat was 2.0 years . Compared with placebo ( n=1180 ) , active treatment ( n=1238 ) reduced the incidence of dementia by 50 % from 7.7 to 3.8 cases per 1000 patient-years ( 21 vs 11 patients , p=0.05 ) . The median MMSE score at r and omisation was 29 in both treatment groups . At the last available assessment , systolic and diastolic blood pressure were , respectively , 8.3 mm Hg and 3.8 mm Hg lower ( p<0.001 ) in the active-treatment group , but on average the MMSE scores did not change in either group . In the control patients , however , the MMSE decreased ( p=0.04 ) with decreasing diastolic blood pressure , whereas in the active-treatment group MMSE scores improved slightly ( p=0.01 ) with greater reduction in diastolic blood pressure ( p=0.002 for between-group difference ) . INTERPRETATION In elderly people with isolated systolic hypertension , antihypertensive treatment was associated with a lower incidence of dementia . If 1000 hypertensive patients were treated with antihypertensive drugs for 5 years 19 cases of dementia might be prevented Background Sub-Saharan Africa is facing rapidly increasing prevalences of cardiovascular disease , obesity , diabetes and hypertension . Previous and ongoing undernutrition among pregnant women may contribute to this development as suggested by epidemiological studies from high income countries linking undernutrition in fetal life with increased burden of non-communicable diseases in later life . We undertook to study the risks for hypertension , glucose intolerance and overweight  forty years after fetal exposure to famine afflicted Biafra during the Nigerian civil war ( 1967–1970 ) . Methods and Findings Cohort study performed in June 27–July 31 , 2009 in Enugu , Nigeria . Adults ( n = 1,339 ) born before ( 1965–67 ) , during ( 1968–January 1970 ) , or after ( 1971–73 ) the years of famine were included . Blood pressure ( BP ) , r and om plasma glucose ( p-glucose ) and anthropometrics , as well as prevalence of hypertension ( BP>140/90 mmHg ) , impaired glucose tolerance ( IGT ; p-glucose 7.8–11.0 mmol/l ) , diabetes ( DM ; p-glucose ≥11.1 mmol/l ) , or overweight ( BMI > 25 kg/m2 ) were compared between the three groups . Fetal-infant exposure to famine was associated with elevated systolic ( + 7 mmHg ; p<0.001 ) and diastolic ( + 5 mmHg ; p<0.001 ) BP , increased p-glucose ( + 0.3 mmol/L ; p<0.05 ) and waist circumference ( + 3 cm , p<0.001 ) , increased risk of systolic hypertension ( adjusted OR 2.87 ; 95 % CI 1.90–4.34 ) , IGT ( OR 1.65 ; 95 % CI 1.02–2.69 ) and overweight ( OR 1.41 ; 95 % CI 1.03–1.93 ) as compared to people born after the famine . Limitations of this study include the lack of birth weight data and the inability to separate effects of fetal and infant famine . Conclusions Fetal and infant undernutrition is associated with significantly increased risk of hypertension and impaired glucose tolerance in 40-year-old Nigerians . Prevention of undernutrition during pregnancy and in infancy should therefore be given high priority in health , education , and economic agendas Hypertension is associated with cognitive impairment in older adults . The Hypertensive Old People in Edinburgh ( HOPE ) study reported improved scores in two psychometric tests in those subjects with the greatest fall in diastolic blood pressure during a 24-week r and omised , double-blind trial of captopril versus bendrofluazide in 81 elderly hypertensive people with mild cognitive impairment . Three hundred and eighty-seven of the original sample of 603 older people with and without hypertension and /or cognitive impairment from which the trial sub sample was drawn were available for adequate psychometric testing 4 years later . Blood pressure was related prospect ively to Raven 's Progressive Matrices ( RPM ) , a measure of fluid intelligence , but not memory differences . RPM scores were obtained at baseline , 6 weeks , 12 weeks and at the end of the r and omised controlled trial . For subjects on captopril mean scores at each time point adjusted for blood pressure change were 27.6 ( 95 % CI 25.5 - 29.6 ) , 27.2 ( 95 % CI 25.1 - 29.2 ) , 28.4 ( 95 % CI 26.6 - 30.3 ) and 28.9 ( 95 % CI 26.9 - 30.9 ) , and for bendrofluazide 27.1 ( 95 % CI 25.1 - 29.0 ) , 28.9 ( 95 % CI 26.9 - 30.9 ) , 28.9 ( 95 % CI 27.2 - 30.7 ) and 28.7 ( 95 % CI 26.8 - 30.6 ) . There was a significant improvement in scores for those on bendrofluazide compared with captopril at week 6 ( F=8.10 , p=0.006 , partial eta2=0.11 ) . There were no significant effects for either drug or blood pressure at any time point for tests of memory . Future trials of the effects of antihypertensive therapy on cognition should focus more on outcomes other than memory . Early differential effects of therapeutic agents may not be maintained CONTEXT Heart failure is often preceded by isolated systolic hypertension , but the effectiveness of antihypertensive treatment in preventing heart failure is not known . OBJECTIVE To assess the effect of diuretic-based antihypertensive stepped-care treatment on the occurrence of heart failure in older persons with isolated systolic hypertension . DESIGN Analysis of data from a multicenter , r and omized , double-blind , placebo-controlled clinical trial . PARTICIPANTS A total of 4736 persons aged 60 years and older with systolic blood pressure between 160 and 219 mm Hg and diastolic blood pressure below 90 mm Hg who participated in the Systolic Hypertension in the Elderly Program ( SHEP ) . INTERVENTION Stepped-care antihypertensive drug therapy , in which the step 1 drug is chlorthalidone ( 12.5 - 25 mg ) or matching placebo , and the step 2 drug is atenolol ( 25 - 50 mg ) or matching placebo . MAIN OUTCOME MEASURES Fatal and nonfatal heart failure . RESULTS During an average of 4.5 years of follow-up , fatal or nonfatal heart failure occurred in 55 of 2365 patients r and omized to active therapy and 105 of the 2371 patients r and omized to placebo ( relative risk [ RR ] , 0.51 ; 95 % confidence interval [ CI ] , 0.37 - 0.71 ; P<.001 ; number needed to treat to prevent 1 event [ NNT ] , 48 ) . Among patients with a history of or electrocardiographic evidence of prior myocardial infa rct ion ( MI ) , the RR was 0.19 ( 95 % CI , 0.06 - 0.53 ; P=.002 ; NNT , 15 ) . Older patients , men , and those with higher systolic blood pressure or a history of or electrocardiographic evidence of MI at baseline had higher risk of developing heart failure . CONCLUSION In older persons with isolated systolic hypertension , stepped-care treatment based on low-dose chlorthalidone exerted a strong protective effect in preventing heart failure . Among patients with prior MI , an 80 % risk reduction was observed BACKGROUND Our underst and ing of the growing population of very old patients ( aged > or=80 years ) with coronary artery disease and hypertension is limited , particularly the relationship between blood pressure and adverse outcomes . METHODS This was a secondary analysis of the INternational VErapamil SR-Tr and olapril STudy ( INVEST ) , which involved 22,576 clinical ly stable hypertensive coronary artery disease patients aged > or=50 years . The patients were grouped by age in 10-year increments ( aged > or=80 , n=2180 ; 70-<80 , n=6126 ; 60-<70 , n=7602 ; < 60 , n=6668 ) . Patients were r and omized to either verapamil SR- or atenolol-based treatment strategies , and primary outcome was first occurrence of all-cause death , nonfatal myocardial infa rct ion , or nonfatal stroke . RESULTS At baseline , increasing age was associated with higher systolic blood pressure , lower diastolic blood pressure , and wider pulse pressure ( P < .001 ) . Treatment decreased systolic , diastolic , and pulse pressure for each age group . However , the very old retained the widest pulse pressure and the highest proportion ( 23.6 % ) with primary outcome . The adjusted hazard ratio for primary outcomes showed a J-shaped relationship among each age group with on-treatment systolic and diastolic pressures . The systolic pressure at the hazard ratio nadir increased with increasing age , highest for the very old ( 140 mm Hg ) . However , diastolic pressure at the hazard ratio nadir was only somewhat lower for the very old ( 70 mm Hg ) . Results were independent of treatment strategy . CONCLUSION Optimal management of hypertension in very old coronary artery disease patients may involve targeting specific systolic and diastolic blood pressures that are higher and somewhat lower , respectively , compared with other age groups Background The goal of the present study was to assess the effect of antihypertensive therapy on clinic ( CBP ) and ambulatory ( ABP ) blood pressures , on ECG voltages , and on the incidence of stroke and cardiovascular events in older patients with sustained and nonsustained systolic hypertension . Methods and Results Patients who were ≥60 years old , with systolic CBP of 160 to 219 mm Hg and diastolic CBP of < 95 mm Hg , were r and omized into the double-blind placebo-controlled Systolic Hypertension in Europe ( Syst-Eur ) Trial . Treatment consisted of nitrendipine , with the possible addition of enalapril , hydrochlorothiazide , or both .  Patients enrolled in the Ambulatory Blood Pressure Monitoring Side Project were classified according to daytime systolic ABP into 1 of 3 subgroups : nonsustained hypertension ( < 140 mm Hg ) , mild sustained hypertension ( 140 to 159 mm Hg ) , and moderate sustained hypertension ( ≥160 mm Hg ) . At baseline , patients with nonsustained hypertension had smaller ECG voltages ( P < 0.001 ) and , during follow-up , a lower incidence of stroke ( P < 0.05 ) and of cardiovascular complications ( P = 0.01 ) than other groups . Active treatment reduced ABP and CBP in patients with sustained hypertension but only CBP in patients with nonsustained hypertension ( P < 0.001 ) . The influence of active treatment on ECG voltages ( P < 0.05 ) and on the incidence of stroke ( P < 0.05 ) and cardiovascular events ( P = 0.06 ) was more favorable than that of placebo only in patients with moderate sustained hypertension . Conclusions Patients with sustained hypertension had higher ECG voltages and rates of cardiovascular complications than did patients with nonsustained hypertension . The favorable effects of active treatment on these outcomes were only statistically significant in patients with moderate sustained hypertension OBJECTIVE To study the effect of a community-based walking intervention on  blood pressure among older people . METHOD The study design was a r and omized controlled trial conducted in a rural area of Taiwan between October 2002 and June 2003 . A total of 202 participants aged 60 years and over with mild to moderate hypertension was recruited . Participants r and omized to the intervention group ( n=102 ) received a six-month community-based walking intervention based on self-efficacy theory . A public health nurse provided both face-to-face and telephone support design ed to assist participants to increase their walking .  Control group participants ( n=100 ) received usual primary health care .  Primary outcome was change in systolic blood pressure and secondary outcomes were exercise self-efficacy , self-reported walking and diastolic blood pressure . RESULTS At six-month follow-up the mean change in systolic blood pressure was a decrease of 15.4 mmHg and 8.4 mmHg in the intervention and control group , respectively . The difference in mean change between the two groups was -7.0 mmHg ( 95 % CI , -11.5 to -2.5 mmHg , p=0.002 ) . Improvement in exercise self-efficacy scores was greater among intervention group participants ( mean difference 1.23 , 95 % CI , 0.5 to 2.0 , p=0.001 ) . Intervention group participants were more likely to report walking more ( p<0.0005 ) but no differences were observed in diastolic blood pressure ( p=0.19 ) . CONCLUSIONS Among hypertensive older people , a six-month community-based walking intervention was effective in increasing their exercise self-efficacy and reducing systolic blood pressure A controlled trial was undertaken to evaluate the practical consequences of screening in general practice . Of 2420 people aged 40 - 64 years examined in 1967 - 68 , 191 ( 7.9 % ) had previously been told , at some time , that they had raised blood-pressure , other than during pregnancy . However , only 77 ( 3 - 2 % ) had any record of current antihypertensive treatment .  Screening result ed in a further 50 persons ( 2 - 1 % ) being newly diagnosed as hypertensive in 1967 - 68 and a further 9 in 1969 - 70 . Antihypertensive treatment was given to 21 of these immediately following diagnosis , while the treatment was adjusted in 23 of those already known to be hypertensive . In 1972 - 73 the blood-pressures of the screening population were directly compared with the control group . No significant differences in the distributions of their blood-pressure levels were observed . Over 95 % of the new hypertensives discovered by the screening process in the control group in 1972 - 73 had visited their general practitioners for some reason during the previous five years . This suggests that " case-finding " by general practitioners would be more cost-effective than setting up separate blood-pressure screening clinics . However , the results of this study indicate that we need to know more about how raised blood-pressure can be successfully controlled over a long time , before any mass screening programmes can be actively encouraged The aim of our study was to evaluate changes in awareness of blood pressure during transition into a market economy in Pol and . Thus , in 1994 , we conducted a cross-sectional survey based on a question naire interview on a sample of 2080 men ( M ) and women ( F ) aged 18 years and over . The subjects were selected from a Polish population by stratified and cluster r and om sampling with quotas by the Center for Social Research in Sopot . They were asked if they were aware of blood pressure . The results were analysed according to age , sex , education level , income and place of living . In September 1997 we carried out the same investigation on a new group of 1664 adults . In addition to the question naire , the blood pressure ( three recordings at home ) measurements were completed . The interviewers were well-trained medical students . Awareness of blood pressure has declined ( P < 0.001 ) from 71 % in 1994 to 65.5 % in 1997 . The highest decrease in awareness of blood pressure was observed among less educated people , as well as among people living in smaller cities and villages . The overall prevalence of hypertension was 25.9 % by ‘ older ’ WHO criteria ( BP ⩾160/95 mm Hg or taking antihypertensive medication ) and 44.5 % by JNC VI criteria ( BP ⩾140/90 mm Hg or taking antihypertensive medication ) . Forty-six percent of hypertensive subjects classified by JNC VI criteria were previously known to be hypertensives and 54 % were newly detected ( F : 39 % , M : 69 % ) . Low awareness of blood pressure in Pol and is the crucial factor of insufficient detectability of hypertension . Decline of awareness of blood pressure being the most significant among people representing lower social status , emphasises the need for urgent preventive measures BACKGROUND In Mexico , hypertension is a major cause of disability and death in the elderly , but the most effective way to promote behaviour change in old people is unknown . Low re source interventions that are effective in normal healthcare setting s are urgently needed . We report the results of a r and omized trial of nurse-provided health and lifestyle advice during home visits to elderly people with hypertension in Mexico City . METHODS Subjects were 718 people with hypertension aged > or = 60 years , who were residents of Mexico City and were registered with the Family Medicine Clinics of the Mexican Institute of Social Security ( IMSS ) . A r and omized controlled trial was carried out in which the intervention group was offered nurse visits over 6 months with blood pressure checks and negotiated lifestyle changes . The control group continued to receive usual care . RESULTS After 6 months , 36.5 % of the intervention versus 6.8 % of the control group had a blood pressure of < 160/90 mmHg . The difference in the mean change in systolic blood pressure was 3.31 mmHg ( P = 0.03 , 95 % CI : 6.32 , 0.29 ) and the same difference in diastolic blood pressure was 3.67 mmHg ( P = 0.00 , 95 % CI : 5.22 , 2.12 ) . Weight and sodium excretion fell more in the intervention group , but the difference was not significant . CONCLUSIONS Nurse home visits are effective in reducing blood pressure in hypertensive patients aged > or = 60 years Assessing the compliance of people over 60 years of age and older with an antihypertensive treatment regimen was a major objective of the Systolic Hypertension in the Elderly Program ( SHEP ) pilot study . The study r and omized 551 men and women over the age of 60 ( mean age = 72 years ) to a stepped care treatment that included chlorthalidone or placebo in a double-blind trial . Three measures of compliance to treatment protocol --pill count , self-report , and a urine chlorthalidone assay -- all indicated high levels of compliance in 80 to 90 % of participants at 3 months and 1 year after r and omization . Pill-taking compliance was similar in the active and placebo groups , although the rate of discontinuance from study medications at 1 year was higher in the placebo than in the active group . Compliance was high in all age categories , including those over age 80 . These data suggest that elderly patients can achieve high levels of compliance with antihypertensive medications Background and objective . This interim report from the Syst-Eur trial investigated the level of blood pressure control achieved during the double-blind period in patients followed in general practice s. Methods . In the Syst-Eur trial elderly patients ( 60 years or older ) with isolated systolic hypertension were r and omized to either active or placebo treatment . Active treatment consisted of nitrendipine combined with enalapril and /or hydrochlorothiazide to reduce systolic pressure to Results . This analysis was restricted to patients of general practitioners who had been followed for at least 12 months . The placebo ( N = 204 ) and active treatment ( N = 217 ) groups had similar characteristics at r and omization . At one year , the difference in sitting pressure between the two treatment groups was 10 mmHg systolic and 4 mmHg diastolic . Fewer patients remained on monotherapy in the placebo than in the active treatment group and on placebo the second and third line medications were started earlier . Nitrendipine tablets were discontinued in 10 patients on placebo and in 21 patients assigned to active treatment ( P Conclusions . A significant blood pressure reduction can be achieved and maintained in older patients with isolated systolic hypertension followed by general practitioners . Whether this blood pressure reduction results in a clinical ly meaningful decrease of cardiovascular complications is under investigation . Keywords . Antihypertensive treatment , general practice , isolated systolic hypertension , r and omized clinical trial CONTEXT The long-term risk for developing hypertension is best described by the lifetime risk statistic . The lifetime risk for hypertension and trends in this risk over time are unknown . OBJECTIVES To estimate the residual lifetime risk for hypertension in older US adults and to evaluate temporal trends in this risk . DESIGN , SETTING , AND PARTICIPANTS  Community-based prospect i ve cohort study of 1298 participants from the Framingham Heart Study who were aged 55 to 65 years and free of hypertension at baseline ( 1976 - 1998 ) . MAIN OUTCOME MEASURES Residual lifetime risk ( lifetime cumulative incidence not adjusted for competing causes of mortality ) for hypertension , defined as blood pressure of 140/90 mm Hg or greater or use of antihypertensive medications . RESULTS The residual lifetime risks for developing hypertension and stage 1 high blood pressure or higher ( greater-than-or-equal to 140/90 mm Hg regardless of treatment ) were 90 % in both 55- and 65-year-old participants . The lifetime probability of receiving antihypertensive medication was 60 % . The risk for hypertension remained unchanged for women , but it was approximately 60 % higher for men in the contemporary 1976 - 1998 period compared with an earlier 1952 - 1975 period . In contrast , the residual lifetime risk for stage 2 high blood pressure or higher ( greater-than-or-equal to 160/100 mm Hg regardless of treatment ) was considerably lower in both sexes in the recent period ( 35%-57 % in 1952 - 1975 vs 35%-44 % in 1976 - 1998 ) , likely due to a marked increase in treatment of individuals with substantially elevated blood pressure . CONCLUSION The residual lifetime risk for hypertension for middle-aged and elderly individuals is 90 % , indicating a huge public health burden . Although the decline in lifetime risk for stage 2 high blood pressure or higher represents a major achievement , efforts should be directed at the primary prevention of hypertension Objective To estimate the associations between new-onset hypertension and glycemia , insulin resistance , and overall and regional adiposity in a prospect i ve study conducted in Mauritius . Research design and methods Three thous and five hundred and eighty-one adults without hypertension , pregnancy , or known diabetes at baseline ( 1987 ) were followed for incident hypertension in 1992 and 1998 , ( systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg or antihypertensive medication treatment ) . Other measurements  included fasting plasma glucose and 2-h plasma glucose after a 75-g oral glucose load , fasting insulin , BMI , waist circumference , smoking , alcohol use , exercise , and demographic information .  Insulin sensitivity was estimated by the computerized homeostasis model assessment ( HOMA2 ) program . Results In multivariable logistic models that included age , gender , ethnicity , alcohol use , exercise , education , systolic blood pressure , diastolic blood pressure , homeostasis model assessment , fasting plasma glucose , 2-h plasma glucose , BMI , and waist circumference , the independent predictors of incident hypertension by time of follow-up were ( odds ratio for a 1 SD increase ; 95 % confidence interval ) : 1992 – age ( 1.73 ; 1.47–2.03 ) , Creole ethnicity ( 1.42 ; 1.04–1.94 ) , 2-h plasma glucose ( 1.26 ; 1.04–1.51 ) ; 1998 – age ( 1.60 ; 1.40–1.83 ) and BMI ( 1.33 ; 1.05–1.69 ) . Also , systolic blood pressure and diastolic blood pressure significantly predicted hypertension at both time points . Conclusion Risk factor patterns depended on duration of follow-up . Over 5 years , hypertension was related to 2-h plasma glucose but not to measures of body size or homeostasis model assessment , while over 11 years , incident hypertension was related to BMI but not waist circumference , 2-h plasma glucose , or homeostasis model assessment . These findings support a more important role for 2-h plasma glucose and overall adiposity than waist circumference , fasting plasma glucose , or insulin resistance in the development of hypertension in Mauritius BACKGROUND Cigarette smoking is a known risk factor for cardiovascular disease ( CVD ) , but its relationship to the development of hypertension is unclear . Previous epidemiological studies have shown inconsistent results , having demonstrated inverse and positive associations between cigarette smoking and the development of hypertension . METHODS We analyzed 13,529 male participants from the Physicians ' Health Study free of baseline hypertension and CVD who provided information about smoking status . Smoking status was categorized as never , past , or current < 20 cigarettes/day , or current > or = 20 cigarettes/day .  Incident hypertension was defined as either the initiation of antihypertensive treatment , self-reported systolic blood pressure ( BP ) > or = 140 mm Hg , or diastolic BP > or = 90 mm Hg . RESULTS Over a median follow-up of 14.5 years , 4,904 men developed hypertension .  We modeled the risk of developing hypertension by baseline smoking status adjusting for known risk factors for hypertension or CVD . In a fully adjusted Cox proportional hazards model , we found that compared with never smokers , past smokers and current smokers had corresponding relative risks ( RRs ) of 1.08 and 1.15 of developing hypertension . The risk for smokers did not appear to differ based on number of cigarettes smoked daily . Further , the RR of hypertension was higher for men with normal vs. prehypertensive levels of systolic ( SBP ) or diastolic BP ( DBP ) . CONCLUSIONS This prospect i ve cohort data suggests that cigarette smoking may be a modest but important risk factor for the development of hypertension Patients aged 60 years and older with essential hypertension were treated with an angiotensin-converting enzyme inhibitor ( ACE-I ) , delapril ( Adecut ) or a long-acting calcium (Ca)-antagonist , manidipine ( Calslot ) for 3 years . The incidences of cardiovascular events as well as drug-related side effects were compared between the two groups to investigate whether both classes of antihypertensive drugs are beneficial in elderly hypertensive patients . There were no significant differences in characteristics of patients between the two intervention groups , except for slightly lower blood pressure ( P = .08 ) in the Ca-antagonist group at the initiation of the study . There were no significant differences in total death between the two groups . Cardiovascular events ( both fatal and nonfatal ) were noted in 34 of 699 patients ( 22.5/1000 patient-years ) in the ACE-I group and 50 of 1049 patients ( 19.7/1000 patient-years ) in the Ca-antagonist group , with no significant difference found between the two groups . The correlation between cardiovascular incidence and the blood pressure attained during treatment showed a J-shaped phenomenon and suggests that an excessive reduction less than 120 mm Hg in systolic blood pressure ( SBP ) is unnecessary and may be harmful in certain cases . Side effects were more frequent in the ACE-I group than in the Ca-antagonist group ( P = .01 ) . Cough was the major adverse event , occurring in 5.0 % of patients in the ACE-I group . In conclusion , the study indicates that both ACE-I ( delapril ) and Ca-antagonist ( manidipine ) were equally beneficial for reducing cardiovascular morbidity and mortality in elderly hypertensive patients . However , tolerability of ACE-I was lower due to the adverse event of coughing BACKGROUND In 1988 , the Systolic Hypertension in China ( Syst-China ) Collaborative Group initiated the placebo-controlled Syst-China trial to investigate whether antihypertensive drug treatment could reduce the incidence of fatal and nonfatal stroke in older Chinese patients with isolated systolic hypertension . OBJECTIVES To explore ( 1 ) whether the benefits of active treatment were evenly distributed across 4 strata , prospect ively defined according to sex and previous cardiovascular complications , and ( 2 ) whether the morbidity and mortality results were influenced by age , level of systolic or diastolic blood pressure ( BP ) , smoking or drinking habits , or diabetes mellitus at enrollment . METHODS Eligible patients had to be 60 years or older with a sitting systolic BP of 160 to 219 mm Hg and diastolic BP less than 95 mm Hg . After stratification for center , sex , and previous cardiovascular complications , 1253 patients were assigned to active treatment starting with nitrendipine ( 10 - 40 mg/d ) , with the possible addition of captopril ( 12.5 - 50.0 mg/d ) , and /or hydrochlorothiazide ( 12.5 - 50 mg/d ) . In the 1141 control patients , matching placebos were used similarly . RESULTS Male sex , previous cardiovascular complications , older age , higher systolic BP or lower diastolic BP , living in northern China , smoking , and diabetes mellitus significantly and independently increased the risk of 1 or more of the following end points : total or cardiovascular mortality , all fatal and nonfatal cardiovascular end points , all strokes , and all cardiac end points . In the placebo-control group diabetes raised the risk of all end points 2- to 3-fold ( P < or = .05 ) . However , active treatment reduced the excess risk associated with diabetes to a nonsignificant level ( P values ranging from .12-.86 ) except for cardiovascular mortality ( P = .04 ) . Cox regression with adjustments applied for significant covariates suggested that active treatment may reduce total mortality more ( P = .06 ) in women and stroke more ( P = .07 ) in men and that it may provide better protection against cardiac end points in nonsmokers than smokers ( P = .04 ) . Otherwise , the benefits of active treatment were equally manifest , regardless of the enrollment characteristics of the patients , and regardless of whether active treatment consisted of only nitrendipine or of nitrendipine associated with other active drugs . CONCLUSIONS In elderly Chinese patients with isolated systolic hypertension , stepwise antihypertensive drug treatment , starting with the dihydropyridine calcium channel blocker nitrendipine , improved prognosis . The benefit was particularly evident in diabetic patients ; for cardiac end points it tended to be larger in nonsmokers . Otherwise , the benefit of active treatment was not significantly influenced by the characteristics of the patients at enrollment in the trial OBJECTIVE To assess the ability of antihypertensive drug treatment to reduce the risk of nonfatal and fatal ( total ) stroke in isolated systolic hypertension . DESIGN Multicenter , r and omized , double-blind , placebo-controlled . SETTING Community-based ambulatory population in tertiary care centers . PARTICIPANTS 4736 persons ( 1.06 % ) from 447,921 screenees aged 60 years and above were r and omized ( 2365 to active treatment , 2371 to placebo ) . Systolic blood pressure ranged from 160 to 219 mm Hg and diastolic blood pressure was less than 90 mm Hg . Of the participants , 3161 were not receiving antihypertensive medication at initial contact , and 1575 were . The average systolic blood pressure was 170 mm Hg ; average diastolic blood pressure , 77 mm Hg . The mean age was 72 years , 57 % were women , and 14 % were black . INTERVENTIONS -- Participants were stratified by clinical center and by antihypertensive medication status at initial contact . For step 1 of the trial , dose 1 was chlorthalidone , 12.5 mg/d , or matching placebo ; dose 2 was 25 mg/d . For step 2 , dose 1 was atenolol , 25 mg/d , or matching placebo ; dose 2 was 50 mg/d . MAIN OUTCOME MEASURES Primary . Nonfatal and fatal ( total ) stroke . Secondary . Cardiovascular and coronary morbidity and mortality , all-cause mortality , and quality of life measures . RESULTS Average follow-up was 4.5 years . The 5-year average systolic blood pressure was 155 mm Hg for the placebo group and 143 mm Hg for the active treatment group , and the 5-year average diastolic blood pressure was 72 and 68 mm Hg , respectively . The 5-year incidence of total stroke was 5.2 per 100 participants for active treatment and 8.2 per 100 for placebo . The relative risk by proportional hazards regression analysis was 0.64 ( P = .0003 ) . For the secondary end point of clinical nonfatal myocardial infa rct ion plus coronary death , the relative risk was 0.73 . Major cardiovascular events were reduced ( relative risk , 0.68 ) . For deaths from all causes , the relative risk was 0.87 . CONCLUSION In persons aged 60 years and over with isolated systolic hypertension , antihypertensive stepped-care drug treatment with low-dose chlorthalidone as step 1 medication reduced the incidence of total stroke by 36 % , with 5-year absolute benefit of 30 events per 1000 participants . Major cardiovascular events were reduced , with 5-year absolute benefit of 55 events per 1000 This study examined the blood pressure ( BP ) control and number of drugs prescribed for a sample of hypertensive patients from 18 practice s in Northeast Engl and . Out of a total of 35,379 registered patients aged 40 - 69 years , 2995 ( 8.5 % ) were on treatment for hypertension . Data was abstract ed from the practice records of a r and om sample of 691 patients . Using British Hypertension Society st and ards , BP control was optimal for systolic pressure ( less than 160 mm Hg ) in 469 ( 68 % ) , and for diastolic pressure ( less than 90 mm Hg ) in 345 ( 50 % ) , but only 269 ( 39 % ) had optimally controlled systolic and diastolic pressures . Sixty-one per cent were taking one drug and 39 % two or more ; 82 % of patients aged 40 - 49 years but only 61 % of those aged 60 - 69 years had optimally controlled systolic pressures . Forty-three per cent of the 40 to 49-year-old group and 56 % of the 60 to 69-year-old group had optimally controlled diastolic pressures . A strong inverse relationship was found between age and systolic BP control but there was no association between age and diastolic pressure or the number of drugs being prescribed . Sub-optimal BP control is a major problem and remedial strategies should stress the greater gain from treating older patients IMPORTANCE Observational data link low 25-hydroxyvitamin D levels to both prevalent blood pressure and incident hypertension . No clinical trial has yet examined the effect of vitamin D supplementation in isolated systolic hypertension , the most common pattern of hypertension in older people . OBJECTIVE To test whether high-dose , intermittent cholecalciferol supplementation lowers blood pressure in older patients with isolated systolic hypertension . DESIGN Parallel group , double-blind , placebo-controlled  r and omized trial . SETTING Primary care clinics and hospital clinics . PARTICIPANTS Patients 70 years and older with isolated systolic hypertension ( supine systolic blood pressure > 140 mm Hg and supine diastolic blood pressure < 90 mm Hg ) and baseline 25-hydroxyvitamin D levels less than 30 ng/mL were r and omized into the trial from June 1 , 2009 , through May 31 , 2011 . INTERVENTIONS A total of 100,000 U of oral cholecalciferol or matching placebo every 3 months for 1 year . MAIN OUTCOMES AND MEASURES Difference in office blood pressure , 24-hour blood pressure , arterial stiffness , endothelial function , cholesterol level , insulin resistance , and b-type natriuretic peptide level during 12 months . RESULTS A total of 159 participants were r and omized ( mean age , 77 years ) .  Mean baseline office systolic blood pressure was 163/78 mm Hg . Mean baseline 25-hydroxyvitamin D level was 18 ng/mL. 25-Hydroxyvitamin D levels increased in the treatment group compared with the placebo group ( + 8 ng/mL at 1 year , P < .001 ) . No significant treatment effect was seen for mean ( 95 % CI ) office blood pressure ( −1 [ −6 to 4]/−2 [ −4 to 1 ] mm Hg at 3 months and 1 [ −2 to 4]/0 [ −2 to 2 ] mm Hg overall treatment effect ) . No significant treatment effect was evident for any of the secondary outcomes ( 24-hour blood pressure , arterial stiffness , endothelial function , cholesterol level , glucose level , and walking distance ) . There was no excess of adverse events in the treatment group , and the total number of falls was nonsignificantly lower in the group receiving vitamin D ( 36 vs 46 , P = .24 ) . CONCLUSIONS AND RELEVANCE Vitamin D supplementation did not improve blood pressure or markers of vascular health in older patients with isolated systolic hypertension . TRIAL REGISTRATION is rct n.org Identifier : IS RCT N92186858 OBJECTIVE To provide up date d , evidence -based recommendations for the therapy of hypertension in adults . OPTIONS For patients with hypertension , a number of antihypertensive agents may control blood pressure . R and omized trials evaluating first-line therapy with thiazides , beta-adrenergic antagonists , angiotensin-converting enzyme inhibitors , calcium channel blockers , alpha-blockers , central ly acting agents or angiotensin II receptor antagonists were review ed . OUTCOMES The health outcomes that were considered were changes in blood pressure , cardiovascular morbidity , and cardiovascular and /or all-cause mortality rates . Economic outcomes were not considered due to insufficient evidence . EVIDENCE MEDLINE was search ed for the period March 1999 to October 2001 to identify studies not included in the 2000 revision of the Canadian Recommendations for the Management of Hypertension . Reference lists were scanned , experts were polled , and the personal files of the subgroup members and authors were used to identify other published studies . All relevant articles were review ed and appraised , using prespecified levels of evidence , by content experts and method ological experts . VALUES A high value was placed on the avoidance of cardiovascular morbidity and mortality . BENEFITS , HARMS AND COSTS Various antihypertensive agents reduce the blood pressure of patients with sustained hypertension . In certain setting s , and for specific classes of drugs , blood-pressure lowering has been associated with reduced cardiovascular morbidity and /or mortality . RECOMMENDATIONS The present document contains detailed recommendations pertaining to treatment thresholds , target blood pressures , and choice of agents in various setting s in patients with hypertension . The main changes from the 2000 Recommendations are the addition of a section on the treatment of hypertension in patients with diabetes mellitus , the amalgamation of the previous sections on treatment of hypertension in the young and old into one section , increased emphasis on the role of combination therapies over repeated trials of single agents and expansion of the section on the treatment of hypertension after stroke . Implicit in the recommendations for therapy is the principle that treatment for an individual patient should take into consideration global cardiovascular risk , the presence and /or absence of target organ damage , and comorbidities . VALIDATION All recommendations were grade d according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group . Individuals with potential conflicts of interest relative to any specific recommendation were excluded from voting on that recommendation . Only those recommendations achieving high levels of consensus are reported here . These guidelines will continue to be up date d annually 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 Hypertension is increasingly common with advancing age and a risk factor for all kinds of cardiovascular complications . Moreover , cardiovascular disease is a major cause of morbidity and mortality in the elderly . The Swedish Trial in Old Patients with Hypertension ( STOP-Hypertension ) was set up by the Swedish Hypertension Society to investigate the value of antihypertensive treatment in the elderly . In this placebo controlled r and omised prospect i ve study 1,627 men and women aged 70 - 84 years with a supine blood pressure > or = 180/105 mmHg ( and /or ) but not isolated systolic hypertension participated . Three beta-blockers and one diuretic were used as blood pressure lowering agents and the average follow-up in the study was 25 months ( 3,390 patient-years ) . Administration of active antihypertensive therapy , reduced supine blood pressure from 195/102 mmHg to 167/87 mmHg at longest follow-up in comparison with placebo . A majority of the patients needed combined treatment to reach the goal blood pressure ( 160/95 mmHg ) . Associated with a fall in blood pressure were significant reductions in all cardiovascular primary endpoints ( -40 % , p = 0.0031 ) , in fatal and non-fatal stroke ( -47 % , p = 0.0081 ) and in total mortality ( -43 % , p = 0.0079 ) . In addition to the substantial effects on primary endpoints active treatment also showed clinical ly relevant effects on secondary endpoints ( e.g. heart failure ) . The impact on cardiovascular morbidity and mortality with antihypertensive treatment in this elderly cohort was greater than previously seen in middle-aged hypertensive patients , with maintained tolerability and a favourable cost-effectiveness ratio . Finally , women benefited from treatment at least as much as men Hypertensive emergencies , and to a certain extent their treatment , contribute to morbidity and mortality in elderly patients . We studied 22 hospitalized patients , aged 70 - 90 years , all of whom had moderate essential hypertensive . During acute hypertension , mean systolic and diastolic blood pressure rose to 230 + /- 24 and 120 + /- 22 mmHg , respectively . Symptoms of reduced tissue perfusion/oxygenation and /or organ failure occurred , forcing us to begin antihypertensive therapy . We administered 50 mg of the angiotensin converting enzyme ( ACE ) inhibitor captopril sublingually , and within 15 min , systolic blood pressure decreased by an average 60 + /- 16 mmHg and diastolic blood pressure by an average 25 + /- 14 mmHg . There was no significant change in the heart rate . In addition , we treated 22 comparable patients with 10 mg nifedipine sublingually and observed , in four cases , a greater fall in blood pressure ( up to 90 mmHg ) together with tachycardia . These results show the beneficial effects of captopril in the treatment of hypertensive emergencies in elderly patients . The absence of dangerous side effects indicates that ACE inhibitors can be used as first-choice drugs for the treatment of acute hypertensive crises , even in old age BACKGROUND Nonsteroidal antiinflammatory drugs ( NSAIDs ) may alter blood pressure through their inhibitory effects on prostagl and in bio synthesis . Such potential hypertensive effects of NSAIDs have not been adequately examined in the elderly , who are the largest group of NSAID users . METHODS We performed a r and omized , double-blind , two-period crossover trial of ibuprofen ( 1800 mg per day ) vs placebo treatment in patients older than 60 years of age with hypertension controlled with hydrochlorothiazide .  While continuing their usual thiazide dosage , subjects were r and omized to a 4-week treatment period ( ibuprofen or placebo ) followed by a 2-week placebo wash-out period and a second 4-week treatment period with the alternative therapy .  Supine and st and ing systolic and diastolic blood pressures were measured weekly . RESULTS Of 25 r and omized subjects , 22 completed the study protocol ( mean age = 73 + /- 6.7 years ) .  Supine systolic blood pressure and st and ing systolic blood pressure were increased significantly with ibuprofen treatment , compared with placebo .  Mean supine systolic blood pressures were 143.8 + /- 21.0 and 139.6 + /- 15.9 mmHg on ibuprofen and placebo , respectively ( p = .004 ) . Mean st and ing systolic blood pressures were 148.1 + /- 19.9 and 143.4 + /- 17.9 mmHg on ibuprofen and placebo , respectively ( p = .002 ) . CONCLUSION We conclude that 1800 mg per day of ibuprofen does induce a significant increase in systolic blood pressure in older hypertensive patients treated with hydrochlorothiazide . NSAID therapy may negatively impact the control of hypertension in elderly patients BACKGROUND Little information has been published on the impact of antihypertensive medications on quality of life in older persons . Particular concern has existed that lowering systolic blood pressure in older persons might have adverse consequences on cognition , mood , or leisure activities . METHODS A multicenter double-blind r and omized controlled trial was conducted over an average of 5 years ' followup involving 16 academic clinical trial clinics . Participants consisted of 4736 persons ( 1.06 % ) selected from 447,921 screenees aged 60 years and older . Systolic blood pressure at baseline ranged from 160 to 219 mm Hg , while diastolic blood pressure was less than 90 mm Hg . Participants were r and omized to active antihypertensive drug therapy  or matching placebo . Active treatment consisted of 12.5 to 25 mg of chlorthalidone for step 1 , while step 2 consisted of 25 to 50 mg of atenolol . If atenolol was contraindicated , 0.05 to 0.10 mg of reserpine could be used for the second-step drug . The impact of drug treatment on measures of cognitive , emotional , and physical function and leisure activities was assessed . RESULTS Our analyses demonstrate that active treatment of isolated systolic hypertension in the Systolic Hypertension in the Elderly Program cohort had no measured negative effects and , for some measures , a slight positive effect on cognitive , physical , and leisure function . The positive findings in favor of the treatment group were small . There was no effect on measures related to emotional state . Measures of cognitive and emotional function were stable in both groups for the duration of the study . Both treatment groups showed a modest trend toward deterioration of some measures of physical and leisure function over the study period . CONCLUSIONS The overall study cohort exhibited decline over time in activities of daily living , particularly the more strenuous ones , and some decline in certain leisure activities . However , mood , cognitive function , basic self-care , and moderate leisure activity were remarkably stable for both the active and the placebo groups throughout the entire study . Results of this study support the inference that medical treatment of isolated systolic hypertension does not cause deterioration in measures of cognition , emotional state , physical function , or leisure activities Context Hypertension is a recognized risk factor for the development of congestive heart failure ( CHF ) . By measuring blood pressure , however , we have not yet been able to underst and the significance of pulse pressure as a contributor to CHF in middle-aged men and women . Contribution Using data from the Framingham Heart Study , the authors found that although elevations of systolic , diastolic , and pulse pressure were all related to the risk for CHF , the relation was strongest for systolic and pulse pressure . Caution s Underst and ing the relationships between systolic , diastolic , and pulse pressure and risk for CHF is helpful ; however , they do not help determine the increased risk faced by a person with systolic hypertension who also has increased pulse pressure . The Editors Hypertension is the most common risk factor for congestive heart failure ( CHF ) . It confers a twofold risk for the occurrence of CHF and also carries the highest population attributable risk among all risk factors for CHF ( 1 , 2 ) . Placebo-controlled clinical trials in patients with hypertension have demonstrated a consistent reduction in risk for CHF attributable to the lowering of elevated blood pressure ( 3 - 6 ) . The causal role of hypertension in the pathogenesis of CHF underscores the need to identify high-risk patients because early treatment may prevent or delay the occurrence of CHF ( 2 , 7 ) . The prognostic significance of systolic and diastolic blood pressure in CHF has been reported . However , blood pressure may also be divided into two other components : steady ( mean arterial pressure ) and pulsatile ( pulse arterial pressure ) ( 8 - 10 ) . Pulse pressure , a simple correlate of conduit vessel stiffness , is associated with left ventricular hypertrophy ( 11 ) . Increased pulse pressure has also been implicated in the development and progression of large-vessel atherosclerosis and small-vessel disease ( 12 - 14 ) . Accumulating evidence indicates that pulse pressure ( defined as the difference between systolic and diastolic blood pressure ) may be an important predictor of cardiovascular events ( 15 - 18 ) . Pulse pressure predicts the risk for CHF in elderly persons ( 19 , 20 ) ; however , the association of pulse pressure with CHF in middle-aged men and women has not been examined . The Framingham Heart Study provides an opportunity to examine the long-term associations of systolic , diastolic , and pulse pressure with the new onset of  CHF in middle-aged and elderly men and women .  Blood pressure and traditional risk factors have been measured repeatedly at serial examinations in this community-based cohort with long-term follow-up . We examined systolic blood pressure , diastolic blood pressure , and pulse pressure as predictors of risk for CHF in the Framingham Heart Study . Methods The Framingham Heart Study , which began in 1948 , has followed 5209 participants ( 28 to 62 years of age at entry to the study ) as part of a prospect i ve epidemiologic study of cardiovascular disease . Enrollment criteria and study design have been published previously ( 21 ) . Biennial follow-up visits included a medical history , physical examination , blood pressure measurements , 12-lead electrocardiography , and laboratory tests . Eligibility requirements for inclusion in our study were as follows : Participants had to be free of coronary heart disease and CHF and not be receiving antihypertensive therapy at Framingham Heart Study clinic baseline examinations 10 , 11 , or 12 ( 1968 to 1973 ) . Participants were followed for onset of CHF through mid-1994 . We obtained data for selected risk factors from the baseline examination . Methods for assessing risk factors have been published previously ( 21 , 22 ) . Risk factors , including age , sex , cigarette smoking , heart rate , antihypertensive medication use , and total and high-density lipoprotein cholesterol levels , were assessed .  Sitting systolic and diastolic blood pressure were measured twice by the examining physician ( using a mercury column sphygmomanometer ) and averaged . We used body mass index ( kg/m2 ) as a measure of obesity . Participants were categorized as smokers if they smoked cigarettes regularly within the 1-year period before the baseline examination . Electrocardiography revealed left ventricular hypertrophy when increased voltage was associated with major ST-T repolarization changes ( strain pattern ) ( 22 ) . Diabetes mellitus was defined on the basis of a fasting blood glucose level greater than 7.77 mmol/L ( > 140 mg/dL ) , two r and om nonfasting blood glucose levels greater than 11.10 mmol/L ( > 200 mg/dL ) , or the use of insulin or an oral hypoglycemic agent . Diagnostic criteria for CHF have been described previously ( 21 , 22 ) . At each clinic examination , a history of interim hospitalizations and symptoms of CHF were obtained . Outside medical records of participants who did not attend an examination were evaluated for incident CHF . All suspected interim events were review ed by a panel of three physicians who evaluated relevant Framingham Heart Study clinic notes , outside physician reports , and hospitalization records . Congestive heart failure was diagnosed when at least two major or one major and two minor criteria were present . Minor criteria were considered only if their presence could not be attributed to another disease process . Major criteria were paroxysmal nocturnal dyspnea , pulmonary rales , distended jugular veins , enlarging heart size on chest radiography , acute pulmonary edema , hepatojugular reflux , third heart sound , jugular venous pressure of 16 cm or greater , and weight loss of 4.5 kg or greater in response to diuresis . Major criteria also included pulmonary edema , visceral congestion , or cardiomegaly on autopsy . Minor criteria were bilateral ankle edema , nocturnal cough , shortness of breath on ordinary exertion , hepatomegaly , pleural effusion , decrease in vital capacity by one third from the previous maximum recorded value , and heart rate of 120 beats/min or more . Statistical Analysis We used multivariable Cox proportional-hazards regression models to examine the relations of systolic , diastolic , and pulse pressure with CHF . After accounting for age and sex and using a P value less than 0.15 as the selection criterion , we determined covariates by stepwise selection from the following list : body mass index , diabetes , smoking status , total cholesterol level , high-density lipoprotein ( HDL ) cholesterol level , totalHDL cholesterol ratio , left ventricular hypertrophy , and heart rate . Only total cholesterol level and totalHDL cholesterol ratio did not enter the model . After accounting for relevant covariates , we used Cox proportional-hazards models to obtain hazard ratio estimates with 95 % CIs for st and ardized values of systolic , diastolic , and pulse pressure . These estimates were obtained individually and pairwise by using SAS software ( SAS Institute , Inc. , Cary , North Carolina ) ( 23 ) . We repeated analyses for participants stratified according to hypertension status and sex . Because blood pressure and age are correlated , we conducted separate analyses for participants younger than 60 years of age and 60 years of age and older . To examine constancy of effects over time , follow-up was divided into early and late periods ( < 10 years , 10 years ) , and hazard ratios were calculated separately for early and late follow-up . In addition , we analyzed blood pressure as a time-varying covariate and assessed the effect of antihypertensive treatment after the baseline blood pressure measurements . We used the KaplanMeier method to plot age- and sex-st and ardized cumulative incidence rates for CHF as a function of pulse pressure tertile at baseline . Descriptive data are presented as percentages or means ( SD ) . A P value less than 0.05 was considered statistically significant . Role of the Funding Sources The funding sources had no role in the design , conduct , analyses , and reporting of the study or in the decision to su bmi t the manuscript for publication . Results A total of 894 men and 1146 women , age 50 to 79 years , fulfilled criteria for inclusion in our study . Table 1 presents baseline clinical characteristics for these persons . During 35 497 person-years of follow-up ( mean , 17.4 years [ range , 0.06 to 24 years ] ) , CHF developed in 234 ( 11.8 % ) persons . Myocardial infa rct ion preceded CHF in 59 ( 25 % ) persons . Table 1 . Baseline Clinical Characteristics of the Study Participants Increments of 1 SD in systolic pressure , pulse pressure , and diastolic pressure were associated with hazard ratios for congestive failure of 1.56 , 1.55 , and 1.24 , respectively , after adjustment for age , sex , smoking , left ventricular hypertrophy , body mass index , diabetes mellitus , HDL cholesterol level , and heart rate ( Table 2 ) . When blood pressure tertiles were used , similar associations were observed among various components of blood pressure and CHF . No threshold effect or J-shaped association was documented ( Table 2 ) . The cumulative incidence of CHF according to tertiles of baseline pulse pressure is plotted in the Figure . Table 2 . Risk FactorAdjusted Association of Blood Pressure with Congestive Heart Failure Figure . Cumulative incidence of congestive heart failure according to pulse pressure tertiles at the baseline examination . The joint influences of different blood pressure components were also examined , with adjustment for the covariates mentioned previously . Of note , correlations among the blood pressure variables ranged from modest to very high ( r = 0.20 for diastolic and pulse pressure , r = 0.65 for diastolic and systolic pressure , and r = 0.88 for systolic and pulse pressure ) . Diastolic pressure was not significant ( hazard ratio , 1.12 [ CI , 0.98 to 1.29 ] ) in conjunction with pulse pressure ( hazard ratio , 1.51 [ CI , 1.33 to 1.72 ] ) . Likewise , diastolic pressure was not significant ( hazard ratio , 0.86 [ CI , 0.72 to 1.03 ] ) in conjunction with systolic pressure ( hazard ratio , 1.71 [ CI , 1.45 to 2.01 ] ) , but joint estimates were less stable than those obtained for individual pressure variables . Finally AIM Reduction of elevated blood pressure ( BP ) has been an important treatment goal in elderly hypertensive patients . However , it has been reported that an excessive reduction of systolic BP to less than 120mmHg might be harmful in such patients . We investigated whether this was the case in a study which assessed long-term antihypertensive efficacy , tolerability and impact on cardiovascular/cerebrovascular ( CV ) morbidity/mortality in a large cohort of Japanese patients . METHODS This study was performed at general practitioners ' offices nationwide with a target sample size of 1500 patients . Hypertensive patients aged 60years or more who achieved successful BP control with c and esartan monotherapy , and who tolerated the treatment for at least 8weeks , were enrolled into the study and followed for 3years . RESULTS BP was maintained below the target level of 140/90mmHg over the 3-year period . The incidence of CV events during the study period was 20.4/1000person-years . Investigation of the relationship between BP and the incidence of CV events revealed that patients with higher BP generally had a higher incidence of events . However , very elderly patients ( ≥75years ) with a systolic BP ( SBP ) of less than 120mmHg also had a higher incidence of CV events compared with those with an SBP of 120 - 139mmHg . CONCLUSION This study demonstrated that treatment with c and esartan maintained long-term control of BP in elderly hypertensive patients without serious adverse events . CV events demonstrated a J-curve relationship with SBP in patients aged 75years or older , which suggests that excessive BP reductions might be harmful for very elderly patients OBJECTIVES Hypertension is associated with impaired cognition , but it is unclear whether this impairment is reversible . We sought to evaluate the effect of blood pressure reduction on cognition . DESIGN A r and omized , double-blind trial . SETTING A single center , with assessment s in subjects ' domiciles . PARTICIPANTS Community-screened subjects more than 69 years of age who had median diastolic pressures > 99 mm Hg and systolic pressures > 159 mm Hg or diastolic > 85 mm Hg and systolic > 179 mm Hg with Mini-Mental State Examination scores of 20 to 28 . Subjects had not previously received antihypertensive treatment . INTERVENTION Captopril 12.5 mg twice daily or bendrofluazide 2.5 mg daily for 24 weeks , preceded by a 2-week placebo phase . MEASUREMENTS Cognition was evaluated by a psychometric test battery comprising Immediate and Delayed Logical Memory , Paired Associates recall , Raven 's Progressive Matrices , Halstead Reitan Trail Making A , and the Anomalous Sentences Repetition Test . RESULTS Eighty-one subjects ( 28 male , 53 female ) were treated ( 41 captopril , 40 bendrofluazide ) . At entry , mean age was 76.1 years ( range 70 - 84 ) , mean blood pressure was 191 ( 160 - 230 ) mm Hg systolic , 101 ( 88 - 110 ) mm Hg diastolic , and mean MMSE score 26.1 . A total of 69 subjects completed the trial . The 25th , 50th , and 75th percentiles of the difference between pretreatment and Week 24 blood pressures wer 15 mm Hg , 35 mm Hg , and 50 mm Hg ( systolic ) and 5 mm Hg , 10 mm Hg , and 19 mm Hg ( diastolic ) . There were no significant differences in any psychometric test between captopril and bendrofluazide . The 19 subjects in the quartile that lowered their diastolic blood pressure most ( > or = 19 mm Hg ) had improved scores on Anomalous Sentences ( P = .012 ) and Paired Associates ( P = .044 ) compared to the 19 subjects in the least blood pressure responsive quartile ( fall < or = 5 mm Hg)s . CONCLUSION The treatment of hypertension is not hazardous to cognitive function in older people with pre-existing cognitive impairment . Long-term adequate blood pressure control may reverse cognitive impairment associated with pre-existing hypertension OBJECTIVE To evaluate the frequency , risk factors , and prognostic significance s of  postural hypotension ( PH ) and dizziness  on  postural testing  ( DPT ) . DESIGN A prospect i ve cohort study . SETTING General community , The Helsinki ( Finl and ) Aging Study . SUBJECTS Persons of three age cohorts ( 75 , 80 , and 85 years , n = 569 ) were chosen r and omly and followed for 4 years . MEASURES  Postal question naires , structured interview , extensive clinical and laboratory examinations , blood pressure ( BP ) changes in a postural test using different definitions for PH , history of dizziness , dizziness on testing postural blood pressure reactions ( DPT )  , and date of death during a 4-year follow-up . RESULTS The frequency of a fall in systolic blood pressure greater than 20 mm Hg or a fall in diastolic pressure greater than 10 mm Hg ( PH-I ) was 30.3 % . Both criteria occurred simultaneously ( PH-II ) in 7.5 % , and if dizziness on postural testing ( DPT ) was an additional symptom ( PH-III ) , the prevalence was 2.6 % . The overall prevalence of DPT was 19.7 % . PH-I , PH-II , and DPT were also frequent among the healthy aged ( 26.6 % , 6.6 % , and 17.3 % , respectively ) . The postural change in BP correlated inversely with the initial supine BP levels ( systolic r = -.149 , P < .001 and diastolic r = -.218 , P < .001 ) , but in persons with isolated systolic hypertension PH was rather less frequent ( 21.9 % and 2.3 % ) . DPT was more common in the subjects with heart failure ( 26.3 % , P < .05 ) , impaired exercise tolerance ( NYHA III-IV ) ( 33.7 % , P < .05 ) , and PH-II ( 37.2 % , P < .05 ) compared with the healthy controls ( 17.3 % ) . The 1-year mortality was higher in subjects with than without DPT ( 7.1 % vs 4.8 % , P < .05 ) , but the difference was not significant after controlling for age and gender . PH-I , PH-II , and PH-III were not significantly related to 4-year mortality . CONCLUSIONS In this study of older people in Helsinki , Finl and , asymptomatic hypotensive postural BP reactions and DPT were found frequently among healthy older people , and they tended to be increased in people with some diseases . Neither PH nor DPT were of prognostic significance for mortality in this population Direct evidence about the effects of antihypertensive treatment on vascular disease in older patients is available from five r and omized trials conducted exclusively in patients over the age of 60 years . These trials involved a total of 12,483 individuals with systolic or diastolic hypertension ( mean age = 72 years , mean entry blood pressure = 181/88 mmHg ) . Over an average follow-up period of 4.7 years , a 15/6 mmHg difference in blood pressure between study and control groups was achieved . Among those patients assigned active treatment , stroke incidence was reduced by 34 % SD6 and coronary heart disease incidence was reduced by 19 % SD7 . These proportional reductions were of similar size to those observed in trials in predominantly younger patients . However , the absolute benefits observed in older patients were more than twice as great as those observed in younger patients . The results suggest that over 10 years , treatment would prevent at least one major vascular event among every 10 elderly patients at similar risk to those enrolled in the trials BACKGROUND Few trials have evaluated the effects of reduced sodium intake in older individuals , and no trial has examined the effects in relevant subgroups such as African Americans . PATIENTS AND METHODS The effects of sodium reduction on blood pressure ( BP ) and hypertension control were evaluated in 681 patients with hypertension , aged 60 to 80 years , r and omly assigned to a reduced sodium intervention or control group .  Participants ( 47 % women , 23 % African Americans ) had systolic BP less than 145 mm Hg and diastolic BP less than 85 mm Hg while taking 1 antihypertensive medication . Three months after the start of intervention , medication was withdrawn . The primary end point was occurrence of an average systolic BP of 150 mm Hg or more , an average diastolic BP of 90 mm Hg or more , the resumption of medication , or a cardiovascular event during follow-up ( mean , 27.8 months ) . RESULTS Compared with control , mean urinary sodium excretion was 40 mmol/d less in the reduced sodium intervention group ( P<.001 ) ; significant reductions in sodium excretion occurred in subgroups defined by sex , race , age , and obesity . Prior to medication withdrawal , mean reductions in systolic and diastolic BPs from the reduced sodium intervention , net of control , were 4.3 mm Hg ( P<.001 ) and 2.0 mm Hg ( P = .001 ) . During follow-up , an end point occurred in 59 % of reduced sodium and 73 % of control group participants ( relative hazard ratio = 0.68 , P<.001 ) . In African Americans , the corresponding relative hazard ratio was 0.56 ( P = .005 ) ; results were similar in other subgroups . In dose-response analyses , end points were progressively less frequent with greater sodium reduction ( P for trend = .002 ) . CONCLUSION A reduced sodium intake is a broadly effective , nonpharmacologic therapy that can lower BP and control hypertension in older individuals Objective To assess if very elderly people with hypertension obtain early benefit from antihypertensive treatment . Design One year open label active treatment extension of r and omised controlled trial ( Hypertension in the Very Elderly Trial ( HYVET ) ) . Setting Hospital and general practice based centres mainly in eastern and western Europe , China , and Tunisia . Participants People on double blind treatment at the end of HYVET were eligible to enter the extension . Interventions Participants on active blood pressure lowering treatment continued taking active drug ; those on placebo were given active blood pressure lowering treatment . The treatment regimen was as used in the main trial — indapamide SR 1.5 mg ( plus perindopril 2 - 4 mg if required)—with the same target blood pressure of less than 150/80 mm Hg . Main outcome measures The primary outcome was all stroke ; other outcomes included total mortality , cardiovascular mortality , and cardiovascular events . Results Of 1882 people eligible for entry to the extension , 1712 ( 91 % ) agreed to participate . During the extension period , 1682 patient years were accrued . By six months , the difference in blood pressure between the two groups was 1.2/0.7 mm Hg . Comparing people previously treated with active drug and those previously on placebo , no significant differences were seen for stroke ( n=13 ; hazard ratio 1.92 , 95 % confidence interval 0.59 to 6.22 ) or cardiovascular events ( n=25 ; 0.78 , 0.36 to 1.72 ) . Differences were seen for total mortality ( 47 deaths ; hazard ratio 0.48 , 0.26 to 0.87 ; P=0.02 ) and cardiovascular mortality ( 11 deaths ; 0.19 , 0.04 to 0.87 ; P=0.03 ) . Conclusion Very elderly patients with hypertension may gain immediate benefit from treatment . Sustained differences in reductions of total mortality and cardiovascular mortality reinforce the benefits and support the need for early and long term treatment . Trial registration Clinical trials NCT00122811 Noncompliance with treatment has long been the plague of the national health-care system . Each year it is estimated that noncompliance with medication costs the UK economy billions of pounds , as a result of preventable hospital admissions and loss of productivity due to illness . In addition , noncompliance has been identified as the predominant reason for the failure of medical therapy and disease progression . Compliance has been defined as ‘ the extent to which a person ’s behaviour coincides with medical care or advice ’ . In the management of hypertension , figures from the United States suggest that noncompliance with medication may be as high as 50–80 % , with compliance decreasing rapidly over time . Based on the current definition of hypertension ( blood pressure ( BP ) of X140/90 mm Hg ) , the 1998 Health Survey for Engl and revealed that 42 % and 33 % of adult ( X16 years ) men and women , respectively , were hypertensive . Fewer than 10 % of all UK hypertensive patients currently achieve the recommended target BP of o140/90 mmHg , despite the well-known risks associated with hypertension and the overwhelming evidence from numerous clinical trials of the benefits of antihypertensive medication . A recent study , based on a meta- analysis of 61 prospect i ve BP studies , calculated that if all hypertensive patients in the UK reduced their systolic BP to o140 mmHg , approximately 21 400 stroke deaths , 41 400 ischaemic heart disease ( IHD ) deaths , and 125 600 events ( nonfatal stroke or IHD ) could be prevented each year . Why then , in the face of such overwhelming evidence of the benefits of BP reduction , are less than one in 10 people in the UK achieving adequate control of their BP ? Various explanations have been proffered to explain why such a large percentage of patients have resistant hypertension , including secondary hypertension and endogenous resistance to treatment . However , the main reason for inadequate control of BP is poor compliance with the treatment regimen , both pharmacological and behavioural ( eg , weight reduction , sodium intake restriction , and exercise ) . Underst and ing the reasons for patient noncompliance with antihypertensive medication is essential if BP is to be more effectively managed . Table 1 presents some possible factors contributing to noncompliance with medication regimens . Much of the earlier research focused on identifying patient characteristics of noncomplaint individuals and the complexity of the medication regimen . BP control typically requires more than one antihypertensive medication and the frequency of dosing may vary . The complexity of the drug regimen effects compliance ; compliance among hypertensive patients improves considerably when drugs are prescribed just once a day . In addition , many patients experience unpleasant side effects from their medication that may be unacceptable in a largely asymptomatic disease . This is often reported as one of the main reasons for nonor partial compliance . However , more recent studies have focused on patient ’s decisions and the complex relationship between the patient and physician as possible mediating factors for compliance . Patients often make rational decisions about the benefits of medication compared to the risks before they decide whether or not to comply with treatment . Several studies , some qualitative , have investigated how hypertensive patients balance these concerns with their reasons for taking such medication . The majority of patients ( 80 % ) also express general concerns about taking medication ; previous bad experiences , perceptions that drugs are unnatural or unsafe and are best avoided , and that drugs signify ill health . With regard to Received/accepted 03 February 2004 ; published online 18 March 2004 Correspondence : Dr D Lane , University Department of Medicine , City Hospital , Dudley Road , Birmingham B18 7QH , UK . E-mail : deirdre.lane@swbh.nhs.uk Journal of Human Hypertension ( 2004 ) 18 , 595–597 & 2004 Nature Publishing Group All rights reserved 0950 - 9240/04 $ BACKGROUND The implementation of national estimated glomerular filatration rate reporting and the inclusion of renal-specific indicators in a primary care pay for performance ( P4P ) system since April 2006 has promoted identification and better management of risk factors related to chronic kidney disease ( CKD ) . In the UK , the P4P framework is known as the Quality and Outcomes Framework ( QOF ) . One of the key targets for intervention in primary care was hypertension . It is clear that hypertension is a major predictor of development and progression of CKD ; thus , targeting better blood pressure control is likely to have a positive impact on outcomes in CKD . The aim of this study was to evaluate the effectiveness of renal indicators outlined in P4P on the management of hypertension in primary care . To estimate the cost implication s of the result ing changes in prescribing patterns of antihypertensive medication following introduction of such indicators . METHODS We performed a prospect i ve cohort study using a large primary care data base . This cohort was taken from a data base collated as part of a clinical decision support system used to assist the management of CKD in primary care . We investigated a total population of 90 250 individuals on general practitioner ( GP ) registers with a valid serum creatinine estimation in the 6-year study period . A total of 10 040 patients had confirmed stage 3 - 5 CKD in the 2 years pre-QOF and formed the study cohort . Patients were studied over three time periods , pre-QOF ( 1 April 2004 to 31 March 2006 ) , 2 years post-QOF ( 1 April 2006 to 31 March 2008 ) and finally the two subsequent years ( 1 April 2008 to 31 March 2010 ) . The mean systolic and diastolic blood pressures ( BP ) together with antihypertensive medication were analysed over the three time periods . Cost calculation was based on 2009 British National Formulary list prices for antihypertensives . RESULTS The mean age of the cohort at the start of the study period was 64.8 years , 55 % were female . In those patients with stage 3 - 5 CKD 83.9 % were hypertensive , defined by a pre-P4P BP of > 140/85 or currently taking antihypertensive medication . The proportion of patients with CKD 3 - 5 attaining the BP target of 145/80 increased from 41.5 % in the pre-QOF period to 50.0 % in the post-QOF period . This increase was even more marked for those with hypertension in the pre-QOF period ( 28.8 - 45.1 % ) . In the hypertensive patients , mean BP fell from 146/79 mmHg to 140/76 in the first 2 years post-P4P [ P < 0.01 , analysis of variance ( ANOVA ) ] . This BP reduction was sustained in the last 2 years of the study , 139/75 ( P < 0.01 , ANOVA ) . The proportion of hypertensive patients taking angiotensin-converting enzyme inhibitors or angiotensin blockers  increased , this was also sustained in the third time period . An increase in the prescribing of diuretics , calcium channel blockers and β-blockers  was also observed . The additional cost of increased prescribing was calculated to be € 25.00 per hypertensive patient based on GP prescription data . CONCLUSIONS Population BP control has improved since the introduction of P4P renal indicators , and this improvement has been sustained . This was associated with a significant increase in the use of antihypertensive medication , result ing in increased prescription cost . Longer-term follow-up will establish whether or not this translates to improved outcomes in terms of progression of CKD , cardiovascular disease and patient mortality The Australian Therapeutic Trial in Mild Hypertension was a controlled trial in which mildly hypertensive patients , aged between 35 and 65 years ( diastolic blood pressure 95 - 109 ) were r and omly assigned to take antihypertensive drugs or matched placebos  for periods of up to 6 years . The overall data showed that the treated group had a lower incidence of both death and of nonfatal cardiovascular events . The differences in the incidence of noncardiovascular deaths did not differ significantly between the two groups . Univariate analysis of possible prognostic factors at the time of entry into the study showed a higher incidence of trial endpoints -- mostly events due to ischemic heart disease and cerebrovascular disease -- in older subjects , men , cigarette smokers and those with higher systolic blood pressures , and in thinner subjects than in others . There was a lower incidence of these events in actively treated persons than in control subjects at each level of incidence of each covariate measured . Treatment benefit was greatest in persons with lower systolic blood pressures and lower serum cholesterol levels . Multivariate regression analyses confirmed that the incidence of trial endpoints increased with age and with systolic blood pressures . There was a higher incidence in smokers than in nonsmokers , especially in those with low body weights . Treatment benefited thin smokers most , and the effects of treatment seemed to be reduced in those with higher serum cholesterol levels . There was a substantial fall in blood pressure in many of the placebo group We evaluated time-related blood pressure trends in the Tecumseh study participants , none of whom received antihypertensive treatment .  At baseline the  blood pressures  were measured in the field clinic and by self measurement at home ( twice daily for 7 days ) . After a mean of 3.2 + /- 0.42 years , the clinic and home pressure readings were repeated . Nine hundred forty-six subjects had clinic and home blood pressure readings at baseline . Of these 735 ( 380 men , 355 women ; average age , 32 years ) also completed the second examination . Blood pressure , morphometric data , and biochemical measures at the first examination were used as predictors of future clinic blood pressures .  Five hundred ninety-six subjects were normotensive on both examinations ( 81 % ) . Of 79 subjects ( 10.7 % ) with clinic hypertension ( > 140 mg Hg systolic or 90 mm Hg diastolic ) at baseline , 38 remained hypertensive ( " sustained hypertension " ) and 41 became normotensive ( " transient hypertension " ) after 3 years . Another 60 normotensives at baseline ( 10.4 % ) became hypertensive on second examination ( " de novo hypertensives " ; incidence ; 8.1 % ) . The home blood pressure readings on both examinations were reproducible . The three hypertensive groups had elevated home blood pressure , were overweight , had dyslipidemia , and higher insulin values . Only the home blood pressure proved predictive of subsequent blood pressure trends . A home blood pressure of 128 and 83 mm Hg or higher detected " sustained " hypertension with a 48 % sensitivity and 93 % specificity . Readings of 120 and 80 mm Hg or lower predicted future normotension with a 45 % sensitivity and a 91 % specificity . We conclude that self determination of the blood pressure at home is useful in the management of borderline hypertension . An algorithm for the management of these patients is proposed Since the 1950s carotid endarterectomy has been performed in patients with symptomatic carotid artery stenosis , based on suggestive but inconclusive evidence for its effectiveness . Only during the last 5 years have r and omized studies clarified the indications for surgery . In preparing this report , panel members used the same rules of evidence used in the previous report1 2 ( Table ⇓ ) . View this table : Table 1 . Levels of Evidence and Grading of Recommendations Few studies have analyzed control of risk factors in a r and omized , prospect i ve manner following carotid endarterectomy . However , a wealth of data are available regarding the general relationship between risk factor control and stroke risk . These data provide some guidance for the care of endarterectomy patients . # # # Hypertension Hypertension is the most powerful , prevalent , and treatable risk factor for stroke.3 Both systolic and diastolic blood pressure are independently related to stroke incidence . Isolated systolic hypertension , which is common in the elderly , also considerably increases risk of stroke . Reduction of elevated blood pressure significantly lowers risk of stroke . Meta-analyses of r and omized trials found that an average reduction in diastolic blood pressure of 6 mm Hg produces a 42 % reduction in stroke incidence.3 4 Treatment of isolated systolic hypertension in people older than 60 years also reduces stroke incidence by 36 % without an excessive number of side effects such as depression or dementia.5 Long-term care of patients after endarterectomy should include careful control of hypertension ( Grade A recommendation for treatment of hypertension in general ; Grade C recommendation for postendarterectomy care ) . Perioperative treatment of hypertension  after carotid endarterectomy represents a special situation . Poor control of blood pressure after endarterectomy increases risk of cerebral hyperperfusion syndrome.6 7 8 9 This complication is characterized by unilateral headache , seizures , and occasionally altered mental status or focal neurological signs . Neuroimaging may show intracerebral hemorrhages10 11 12 or white BACKGROUND Previous studies often of short duration have raised concerns that antihypertensive therapy with diuretics and beta-blockers adversely alters levels of other cardiovascular disease risk factors . METHODS The Systolic Hypertension in the Elderly Program was a community-based , multicenter , r and omized , double-blind , placebo-controlled clinical trial of treatment of isolated systolic hypertension in men and women aged 60 years and older . This retrospective analysis evaluated development of diabetes mellitus in all 4736 participants in the Systolic Hypertension in the Elderly Program , including changes in serum chemistry test results in a subgroup for 3 years . Patients were r and omized to receive placebo or treatment with active drugs , with the dose increased in stepwise fashion if blood pressure control goals were not attained : step 1 , 12.5 mg of chlorthalidone or 25.0 mg of chlorthalidone ; and step 2 , the addition of 25 mg of atenolol or 50 mg of atenolol or reserpine or matching placebo . RESULTS After 3 years , the active treatment group had a 13/4 mm Hg greater reduction in systolic and diastolic blood pressure than the placebo group ( both groups , P<.001 ) . New cases of diabetes were reported by 8.6 % of the participants in the active treatment group and 7.5 % of the participants in the placebo group ( P=.25 ) . Small effects of active treatment compared with placebo were observed with fasting levels of glucose ( + 0.20 mmol/L [ + 3.6 mg/dL ] ; P<.01 ) , total cholesterol ( + 0.09 mmol/L [ + 3.5 mg/dL ] ; P<.01 ) , high-density lipoprotein cholesterol ( -0.02 mmol/L [ -0.77 mg/dL ] ; P<.01 ) and creatinine ( + 2.8 micromol/L [ + 0.03 mg/dL ] ; P<.001 ) . Larger effects were seen with fasting levels of triglycerides ( + 0.9 mmol/L [ + 17 mg/dL ] ; P<.001 ) , uric acid ( + 35 micromol/L [ + .06 mg/dL ] ; P<.001 ) , and potassium ( -0.3 mmol/L ; P<.001 ) . No evidence was found for a subgroup at higher risk of risk factor changes with active treatment . CONCLUSIONS Antihypertensive therapy with low-dose chlorthalidone ( supplemented if necessary ) for isolated systolic hypertension lowers blood pressure and its cardiovascular disease complications and has relatively mild effects on other cardiovascular disease risk factor levels BACKGROUND Although absolute risk of death associated with raised blood pressure increases with age , the benefits of treatment are greater in older patients . However , fewer patients in this group are identified , treated , and controlled . AIM To evaluate the impact of the provision of different levels of feedback on identification , treatment , and control of older patients with hypertension . DESIGN OF STUDY R and omised controlled trial . SETTING Fifty-two Scottish general practice s. METHOD Practice s were r and omly allocated to either control ( n = 19 ) , audit only feedback ( n = 16 ) , or audit plus risk feedback , prioritising patients by absolute risk ( n = 17 ) . Electronic data were extracted from practice computer systems annually from 1999 to 2001 and used to develop feedback . Data were collected for 30 345 patients aged 65 - 79 years . RESULTS The majority of known patients with hypertension in each group had an initial blood pressure recorded ( control = 89.6 % ; audit = 80.4 % ; risk = 96.1 % ) and this increased over the study period ( control = 92.3 % ; audit = 86.0 % ; risk = 96.6 % ) . Initially , more than 80 % of patients in each group were treated but many were uncontrolled ( blood pressure > /=160/ > /=90 mmHg ) ( control = 41.5 % ; audit = 41.3 % ; risk = 36.1 % ) . The numbers of untreated and uncontrolled patients in each group reduced ( control = 32.3 % ; audit = 38.3 % ; risk = 32.6 % ) . There was some evidence of a significant difference in mean systolic pressure between the audit plus risk and audit only groups : ( 149.6 versus 152.7 mmHg ; P = 0.019 ) and of significantly greater control in the audit plus risk group compared with the other groups 49.4 % ( versus audit only = 35.4 % ; versus control = 46.5 % ; odds ratio = 1.72 [ 95 % confidence interval = 1.09 to 2.70 ] ; P = 0.019 ) . CONCLUSIONS Levels of identification , treatment , and control improved in each group . Although there were still significant numbers of patients with uncontrolled hypertension , there is some evidence to suggest that providing patient-specific feedback may have a positive impact on identification and management of hypertension in older people and produce an increase in control OBJECTIVE To assess the role of treated diastolic blood pressure ( DBP ) level in stroke , coronary heart disease ( CHD ) , and cardiovascular disease ( CVD ) in patients with isolated systolic hypertension ( ISH ) . DESIGN An analysis of the 4736 participants in the Systolic Hypertension in the Elderly Program ( SHEP ) was undertaken . The SHEP was a r and omized multicenter double-blind outpatient clinical trial of the impact of treating ISH in men and women aged 60 years and older . MAIN OUTCOME MEASURES Cox proportional hazards regression analysis , with DBP and systolic blood pressure ( SBP ) as time-dependent covariables . RESULTS After adjustment for the baseline risk factors of race ( black vs other ) , sex , use of antihypertensive medication before the study , a composite variable ( diabetes , previous heart attack , or stroke ) , age , and smoking history ( ever vs never ) and adjustment for the SBP as a time-dependent variable , we found , for the active treatment group only , that a decrease of 5 mm Hg in DBP increased the risk for stroke ( relative risk , [ RR ] , 1.14 ; 95 % confidence interval [ CI ] , 1.05 - 1.22 ) , for CHD ( RR , 1.08 ; 95 % CI , 1.00 - 1.16 ) , and for CVD ( RR , 1.11 ; 95 % CI , 1.05 - 1.16 ) . CONCLUSIONS Some patients with ISH may be treated to a level that uncovers sub clinical disease , and some may be overtreated . Further studies need to determine whether excessively low DBP can be prevented by more careful titration of antihypertensive therapy while maintaining SBP control . It is reassuring that patients receiving treatment for ISH never perform worse than patients receiving placebo in terms of CVD events Isolated systolic hypertension is an important risk factor for cardiovascular disease and results primarily from elastic artery stiffening . Although various drug therapies are used to lower peripheral blood pressure ( BP ) in patients with isolated systolic hypertension , the effects of the 4 major classes of antihypertensive agents on central BP , pulse pressure ( PP ) amplification , and arterial stiffness in this condition are not clear . Fifty-nine patients over the age of 60 years with untreated isolated systolic hypertension ( systolic BP ≥140 mm Hg and diastolic BP ≤90 mm Hg ) were r and omly assigned to receive 1 of the following 4 antihypertensive agents : perindopril , atenolol , lercanidipine , or bendrofluazide  . BP was measured using a mercury sphygmomanometer , and augmentation index and carotid-femoral ( aortic ) pulse wave velocity were measured at baseline , after 2 weeks of placebo therapy , and at the end of 10 weeks of active therapy . Peripheral systolic BP and peripheral PP were reduced similarly after treatment with all 4 classes of drug . However , central PP was only reduced significantly by perindopril , lercanidipine , and bendrofluazide , whereas atenolol had no effect . Lercanidipine reduced the augmentation index , whereas atenolol increased it . Aortic pulse wave velocity was not changed by any of the drugs . In summary , despite similar reductions in peripheral systolic and PPs with the 4 classes of drug , changes in central pressure and augmentation index varied . Because central PP and increased wave reflections are considered important risk factors in patients with isolated systolic hypertension , the choice of therapy may be influenced by these findings in the future Background : First Nations people with diabetes mellitus and hypertension are at greater risk of renal and cardiovascular complications than are non-native patients because of barriers to health care services . We conducted this r and omized controlled trial to assess whether a community-based treatment strategy implemented by home care nurses would be effective in controlling hypertension in First Nations people with existing hypertension and type 2 diabetes . Methods : We compared 2 community-based strategies for controlling hypertension in First Nations people with existing hypertension and diabetes . In the intervention group , a home care nurse followed a predefined treatment algorithm of pharmacologic antihypertensive therapy . In the control group , treatment decisions were made by each subject 's primary care physician . The primary outcome measure was the difference between the 2 groups in the change in systolic blood pressure after 12 months . Secondary outcome measures were the change in diastolic blood pressure over time , the change in urine albumin status and the incidence of adverse events . Results : Both groups experienced a significant reduction in systolic blood pressure by the final visit ( by 24.0 [ st and ard deviation ( SD ) 13.5 ] mm Hg in the intervention group and by 17.0 [ SD 18.6 ] mm Hg in the control group ) ; p < 0.001 in each case ) . However , the difference between the 2 groups in this change was not significant . Patients in the intervention group had a larger decrease in diastolic blood pressure over time than did those in the control group ( by 11.6 [ SD 10.6 ] mm Hg v. 6.8 [ SD 11.1 ] mm Hg respectively ; p = 0.05 ) . The groups did not differ significantly in terms of changes in urine albumin excretion or incidence of adverse events . Interpretation : High rates of blood pressure control in the community were achieved in both groups in the DREAM 3 study . The addition of a home care nurse to implement a treatment strategy for blood pressure control was more effective in lowering diastolic than systolic blood pressure compared with home care visits for blood pressure monitoring alone and follow-up treatment by a family physician Context Experts debate the consequences of excessive lowering of diastolic pressure in patients with hypertension and coronary artery disease . Contribution This report is a secondary analysis of data from a large trial of 2 antihypertensive drug regimens in patients with known coronary artery disease . The authors found a J-shaped relationship between diastolic blood pressure and all-cause death and myocardial infa rct ion , with the increased risk occurring at diastolic blood pressures below 70 to 80 mm Hg , that is , the lower the diastolic pressure , the higher the risk . Caution s The study examined associations between blood pressure and outcomes ; it could not prove that the antihypertensive therapy that lowered diastolic pressure too much caused the adverse outcomes . The Editors For 2 decades , the hypertension literature has been haunted by the phenomenon of a paradoxical increase in morbidity and mortality with an excessive decrease in blood pressure ( J-curve ) . Indeed , several reports have shown that low diastolic pressure is associated with an increased risk for coronary heart disease and related mortality in older adults and in patients taking antihypertensive medications ( 1 - 13 ) . After doing a review and meta- analysis of pertinent studies , Farnett and colleagues ( 14 ) concluded that although there was no consistent J-shaped relationship between stroke and systolic or diastolic pressure , there was a consistent J-shaped relationship for cardiac events and diastolic pressure . These authors stated that this dichotomy in the relationship between diastolic pressure and target organ disease may leave a clinician with the uncomfortable choice of whether to prevent stroke or renal disease at the expense of coronary heart disease . These findings were at variance with the generally accepted dogma formulated by the sixth report of the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure ( JNC VI ) ( 15 ) , which stated that the relationship between pressure and risk was strong , continuous , independent , predictive and etiologically significant . Within the past decade , the phenomenon of a J-curve has been studied in several large trials of normotensive and hypertensive patients ( 16 - 30 ) . Not surprisingly , arguments regarding whether a J-curve could be clinical ly significant have become somewhat contentious . That is , some rely on evidence that on-treatment diastolic pressure below 70 mm Hg does not increase risk for cardiovascular disease and thus deny an impairment of vital organ perfusion within the usual values achievable by antihypertensive treatment . Others , however , consider the J-curve a more real possibility , particularly for the heart . In contrast to other organs , the heart is perfused mostly during diastole and thus could be more vulnerable to diastolic pressure reduction . If a J-curve did exist , it should be most evident in patients with limited coronary perfusion , in other words , in those with manifest coronary artery disease ( CAD ) . Optimal blood pressure in patients with hypertension and CAD remains controversial because few r and omized clinical trials have been done in this population ( 31 , 32 ) . The International Verapamil-Tr and olapril Study ( INVEST ) ( 33 ) , a r and omized trial , evaluated more than 22000 patients with CAD and hypertension . This patient profile , together with unprecedented levels of blood pressure control , provided a unique opportunity to critically investigate the hypothesis that the risk for CAD would increase with an excessive decrease in diastolic pressure . Methods Study Design and Intervention The INVEST design , methods , and principal results have been previously published ( 33 ) . The trial used an open design with blinded end point assessment . In brief , clinical ly stable patients with CAD and hypertension were r and omly assigned to a verapamil sustained-releasebased or atenolol-based strategy .  Patients with previous myocardial infa rct ion ( MI ) within 3 months of enrollment or class IV or V congestive heart failure were excluded .  Blood pressure goals were based on JNC VI ( systolic pressure < 140 mm Hg and diastolic pressure < 90 mm Hg or systolic pressure < 130 mm Hg and diastolic pressure < 85 mm Hg in patients with diabetes or renal impairment ) ( 15 ) . The addition of tr and olapril or hydrochlorothiazide was recommended when necessary to achieve blood pressure goals . Tr and olapril was also recommended for patients with heart failure , diabetes , or renal impairment . Documented CAD was defined as any of the following : remote ( 3 months before enrollment ) confirmed MI , coronary angiography showing more than 50 % narrowing of at least 1 major coronary artery , diagnosis of classic angina pectoris , or concordant abnormalities on 2 different signals ( electrocardiography , echocardiography , or radionuclide scans ) from stress test findings concordant for ischemia ( for example , ST-segment depression or perfusion defects on radionuclide scanning or wall-motion abnormalities on echocardiography or radionuclide scanning ) . Patient Monitoring and Follow-up Protocol visits were scheduled every 6 weeks for the first 6 months and then biannually until 2 years after the last patient was enrolled . Patients were assessed for response to treatment , symptoms , treatment adherence , and adverse effects at each visit and at the end of the study as detailed elsewhere ( 33 ) . Patient follow-up was complete when we received a final assessment form through the online data system or a death report . The Internet-based electronic data collection method used in INVEST did not accept the entry until all required fields were complete . Blood pressure  was measured by using a st and ard mercury sphygmomanometer with an appropriately sized cuff applied to the upper nondominant arm at heart level . By auscultation at the brachial artery , systolic pressure was recorded at the first Korotkoff sound and diastolic pressure was recorded at the disappearance of the fifth Korotkoff sound . Blood pressure was measured twice , at least 2 minutes apart , and the measurements were averaged . Study Outcomes The primary outcome was the first occurrence of all-cause death , nonfatal MI , or nonfatal stroke by intention-to-treat analysis . The MI and stroke definitions are detailed elsewhere ( 34 ) . These 3 components individually were the main secondary outcomes . For this analysis , additional outcomes included fatal and nonfatal MI , fatal and nonfatal stroke , and average on-treatment blood pressure before outcome or censoring . Ascertainment and blinded adjudication of outcomes were described previously ( 32 ) . Follow-up data were available for 22008 ( 97.5 % ) patients . Statistical Analysis The main conclusions of INVEST were that the 2 treatment strategies were equivalent with respect to the primary outcome , main secondary outcomes , and on-treatment systolic and diastolic pressures . Thus , data for all enrolled patients were combined and included in these analyses following the intention-to-treat principle . A P value of 0.05 or less was considered statistically significant . Patients without a primary outcome event were censored at their latest follow-up visit . Average follow-up systolic and diastolic pressures were calculated for each patient by using all post-baseline results , up to the date of primary outcome or censoring . The baseline value was substituted for patients with no post-baseline data ( n= 1154 ) . In this exploratory analysis , the proportions of patients were pooled by 10 mm Hg strata of average follow-up systolic pressure , and the distribution of primary outcome event rate was evaluated to determine whether the relationship was linear . A similar presentation was prepared for diastolic pressure . Because the frequency distributions seemed consistent with a quadratic curve , a quadratic Cox proportional hazards model was formed for the time to primary outcome for each blood pressure variable , with factors for blood pressure and blood pressure squared . Similarly , the relationship between each 10 mm Hg stratum of average systolic pressure and diastolic pressure and all-cause death , fatal and nonfatal MI , and fatal and nonfatal stroke was evaluated . For the time to primary outcome , a second model was fitted , adjusting for the following baseline covariates : age ( 10-year increments ) , sex , race and ethnicity ( white , Asian , black , Hispanic , multiracial , or other ) , previous MI , heart failure ( classes I to III ) , body mass index in increments of 5 kg/m2 , U.S. residency , renal impairment , peripheral vascular disease , left ventricular hypertrophy , smoking history , coronary revascularization , dyslipidemia , stroke or transient ischemic attack , angina pectoris , arrhythmia , diabetes , cancer , aspirin use , and average systolic pressure or diastolic pressure and systolic pressure squared or diastolic pressure squared . To identify clinical ly relevant interactions between the J-shaped curve and baseline diastolic pressure , demographic characteristics , and comorbid conditions for the primary outcome , a 2-step procedure was used . First , baseline covariates were tested individually by adding the variable and 2 interaction terms ( variablediastolic pressure and variable[diastolic pressure squared ] ) to the Cox proportional hazards model . Variables included were age older than 70 years , sex , previous MI , heart failure ( classes I to III ) , previous stroke or transient ischemic attack , diabetes , cancer , renal impairment , hypercholesterolemia , peripheral vascular disease , smoking history , U.S. residency , body mass index greater than 29 kg/m2 ( mean baseline body mass index ) , and diastolic pressure greater than 86 mm Hg ( mean baseline diastolic pressure ) . The change in log likelihood was used to assess the significance of simultaneously adding the 2 interaction terms . The second step in identifying clinical ly relevant interactions between the J-shaped curve and baseline covariates was to plot the hazard ratios for the primary outcome versus diastolic pressure in the BACKGROUND Is cancer related to hypertension and blood pressure ? Do antihypertensive drugs promote cancer ? Do antihypertensive drugs protect against cancer ? We previously analysed the frequency of  cardiovascular mortality and morbidity in elderly people who participated in the Swedish Trial in Old Patients with Hypertension 2 ( STOP-Hypertension-2 ) . We have also looked at the frequency of cancer in these patients . METHODS We r and omly assigned 6614 elderly patients with hypertension ( mean age 76 years , median time of follow-up 5.3 years ) to one of three treatment strategies : conventional drugs ( diuretics or b-blockers ) , calcium antagonists , or ACE inhibitors . We matched the patients to the Swedish Cancer Registry and compared our findings with expected values based on age , sex , and calendar-year-specific reference frequencies for the general Swedish population . We also compared the number of cancers between the three treatment groups . FINDINGS At baseline , 607 ( 9 % ) patients had previous malignant disease . Diagnoses were closely similar to the distribution of cancer types that might be seen in elderly patients . During follow-up , there were 625 new cases of cancer in 590 patients . The frequency of cancer did not differ significantly between the treatment strategies , including all cancers and those at individual sites . The st and ardised incidence ratios ( SIRs ) for all cancers were also close to unity : 0.92 ( 95 % CI 0.80 - 1.06 ) for conventional drugs , 0.96 ( 0.83 - 1.10 ) for calcium antagonists , and 0.99 ( 0.86 - 1.13 ) for ACE inhibitors . INTERPRETATIONS No difference in cancer risk was seen between patients r and omly assigned to conventional drugs , calcium antagonists , or ACE inhibitors . Thus , the general message to the practising physician is that more attention should be given to getting the blood pressure down than to the risk of cancer The Systolic Hypertension in the Elderly Program ( SHEP ) , a r and omized , double-masked , placebo-controlled trial of 4736 persons , was design ed to assess the efficacy of antihypertensive drug treatment to reduce the risk of fatal and nonfatal strokes among people age 60 and over with isolated systolic hypertension . The statistical method used in interim monitoring of results was conditional power ( or stochastic curtailment ) . The findings did not become conclusive until near the completion of the trial , and therefore SHEP was continued to its scheduled closing date . The trial demonstrated a 36 % reduction in the incidence of stroke in the active treatment group ( P = .0003 ) . In addition to evaluating overall efficacy of treatment , the monitoring process considered such other issues as nonstroke outcomes , lag time between first report of stroke and final confirmation of stroke diagnosis , consistency of results across subgroups , and completeness of follow-up . The purpose of this article is to review these factors with primary emphasis on the statistical aspects BACKGROUND Sauna bathing is associated with reduced  cardiovascular risk  , but the mechanisms underlying this beneficial effect are not entirely understood . We aim ed to assess the relationship between sauna bathing and risk of incident hypertension . METHODS Frequency of sauna bathing was ascertained using question naires in the Kuopio Ischemic Heart Disease Study , a prospect i ve cohort study conducted in Eastern Finl and that comprised a population -based sample of 1,621 men aged 42 to 60 years without hypertension at baseline . The incidence of hypertension was defined as a physician diagnosis of hypertension , systolic blood pressure ( SBP ) > 140 mm Hg , diastolic blood pressure > 90 mm Hg , or use of antihypertensive medication . RESULTS During a median follow-up of 24.7 years , 251 incident cases ( 15.5 % ) were recorded . In Cox regression analysis adjusted for baseline age , smoking , body mass index , and SBP ; compared to participants reporting 1 sauna session per week , the hazard ratio for incident hypertension in participants reporting 2 to 3 sessions and 4 to 7 sessions was 0.76 ( 95 % confidence interval : 0.57 - 1.02 ) and 0.54 ( 0.32 - 0.91 ) , respectively . The corresponding hazard ratios were similar after further adjustment for glucose , creatinine , alcohol consumption , heart rate , family history of hypertension , socioeconomic status , and cardiorespiratory fitness : 0.83 ( 95 % confidence interval : 0.59 - 1.18 ) and 0.53 ( 0.28 - 0.98 ) , respectively . CONCLUSIONS Regular sauna bathing is associated with reduced risk of hypertension , which may be a mechanism underlying the decreased cardiovascular risk associated with sauna use . Further epidemiological and experimental studies could help eluci date the effects of sauna bathing on cardiovascular function BACKGROUND Although nonpharmacologic interventions are widely recommended in the therapy of high blood pressure in older adults , surprisingly little data exist to confirm the efficacy of these interventions in older persons . METHODS We conducted a r and omized , controlled clinical trial in persons aged 60 to 85 years with a diastolic blood pressure of 85 to 100 mm Hg . The experimental arm was a nonpharmacologic intervention combining weight reduction , sodium restriction , and increased physical activity . The nonpharmacologic intervention consisted of eight weekly group and two individual sessions during the intensive phase , followed by four monthly group sessions during the maintenance phase . The control group received no treatment during the study .  Blood pressure was assessed by certified technicians ( blinded to group assignment ) using r and om zero sphygmomanometers . RESULTS Of 56 participants r and omized , 47 completed the entire 6-month trial ( 21 in the intervention group and 26 in the control group ) . Attendance at the intervention sessions was excellent . The intervention group lost more weight ( -2.1 kg ) over 6 months than the control group ( + 0.3 kg ) . Trends for decreasing 24-hour urine sodium excretion in both the intervention and control groups , with greater trend in the intervention group , were not statistically significant . The intervention group experienced more reduction in systolic and diastolic blood pressure than did the control group ( mean differences between groups at 6 months , 4.2/4.9 mm Hg , respectively ) . CONCLUSIONS Our data indicate that a nonpharmacologic intervention will lower systolic and diastolic blood pressure levels in older people with borderline or mild elevations of diastolic blood pressure BACKGROUND Observational epidemiological studies have shown a positive association between hypertension and risk of incident dementia ; however , the effects of antihypertensive therapy on cognitive function in controlled trials have been conflicting , and meta-analyses of the trials have not provided clear evidence of whether antihypertensive treatment reduces dementia incidence . The Hypertension in the Very Elderly trial ( HYVET ) was design ed to assess the risks and benefits of treatment of hypertension in elderly patients and included an assessment of cognitive function . METHODS Patients with hypertension ( systolic pressure 160 - 200 mm Hg ; diastolic pressure < 110 mm Hg ) who were aged 80 years or older were enrolled in this double-blind , placebo-controlled trial . Participants were r and omly assigned to receive 1.5 mg slow release indapamide , with the option of 2 - 4 mg perindopril , or placebo . The target systolic blood pressure was 150 mm Hg ; the target diastolic blood pressure was 80 mm Hg . Participants had no clinical diagnosis of dementia at baseline , and cognitive function was assessed at baseline and annually with the mini-mental state examination ( MMSE ) . Possible cases of incident dementia ( a fall in the MMSE score to < 24 points or a drop of three points in 1 year ) were assessed by st and ard diagnostic criteria and expert review . The trial was stopped in 2007 at the second interim analysis after treatment result ed in a reduction in stroke and total mortality . Analysis was by intention to treat . The trial is registered with Clinical Trials.gov , number NCT00122811 . FINDINGS 3336 HYVET participants had at least one follow-up assessment ( mean 2.2 years ) and were included : 1687 participants were r and omly assigned to the treatment group and 1649 to the placebo group . Only five reports of adverse effects were attributed to the medication : three in the placebo group and two in the treatment group . The mean decrease in systolic blood pressure between the treatment and placebo groups at 2 years was systolic -15 mm Hg , p<0.0001 ; and diastolic -5.9 mm Hg , p<0.0001 . There were 263 incident cases of dementia . The rates of incident dementia were 38 per 1000 patient-years in the placebo group and 33 per 1000 patient-years in the treatment group . There was no significant difference between treatment and placebo groups ( hazard ratio [ HR ] 0.86 , 95 % CI 0.67 - 1.09 ) ; however , when these data were combined in a meta- analysis with other placebo-controlled trials of antihypertensive treatment , the combined risk ratio favoured treatment ( HR 0.87 , 0.76 - 1.00 , p=0.045 ) . INTERPRETATION Antihypertensive treatment  in elderly patients does not statistically reduce incidence of dementia . This negative finding might have been due to the short follow-up , owing to the early termination of the trial , or the modest effect of treatment . Nevertheless , the HYVET findings , when included in a meta- analysis , might support antihypertensive treatment to reduce incident dementia We examined the relation of serum creatinine and uric acid to  mortality and cardiovascular disease in older ( aged ≥60 years ) Chinese patients with isolated systolic hypertension ( systolic/diastolic blood pressure ≥160/<95 mmHg ) . We used Cox regression to correlate outcome with baseline serum creatinine and uric acid measured in 1880 and 1873 , respectively , of the 2394 patients enrolled in the placebo-controlled Systolic Hypertension in China ( Syst-China ) Trial . Median follow-up was 3 years . In multiple Cox regression analysis with adjustment for gender , age , active treatment , and other significant covariates , serum creatinine was significantly associated with a worse prognosis . The relative hazard rates ( 95 % CIs ) associated with a 20-&mgr;mol/L increase in serum creatinine for all-cause , cardiovascular , and stroke mortality were 1.16 ( 1.05 to 1.27 , P = 0.003 ) , 1.15 ( 1.01 to 1.31 , P = 0.03 ) , and 1.37 ( 1.13 to 1.65 , P = 0.001 ) , respectively . In a similar analysis , which also accounted for serum creatinine , serum uric acid was also significantly and independently associated with excess mortality of cardiovascular disease and stroke . The relative hazard rates associated with a 50-&mgr;mol/L increase of serum uric acid were 1.14 ( 1.02 to 1.27 , P = 0.02 ) for cardiovascular mortality and 1.34 ( 1.14 to 1.57 , P < 0.001 ) for fatal stroke . In conclusion , in older Chinese patients with isolated systolic hypertension , serum creatinine and serum uric acid were predictors of mortality The Systolic Hypertension in the Elderly Program ( SHEP ) is a r and omized , blinded test of the efficacy of antihypertensive drug treatment . In a large feasibility trial , 551 men and women who had isolated systolic hypertension and were at least 60 years old received chlorthalidone ( 25 to 50 mg/day ) or matching placebo as the step I drug . After 1 year , 83 % of the chlorthalidone group and 80 % of the placebo group were still taking SHEP medications . Of those still taking chlorthalidone , 88 % had reached goal blood pressure ( BP ) without requiring a step II drug , and most had responded to the lower dose ( 25 mg/day ) . The BP response was similar in all age , sex and race subgroups , with an overall mean difference between r and omized groups of 17 mm Hg for systolic BP ( p less than 0.001 ) and 6 mm Hg for diastolic BP ( p less than 0.001 ) . The only common adverse effects were asymptomatic changes in the serum levels of potassium ( 0.5 mEq/liter lower in the chlorthalidone group , p less than 0.001 ) , uric acid ( 0.9 mg/dl higher , p less than 0.001 ) and creatinine ( 0.08 mg/dl higher , p = 0.02 ) . This study indicates that chlorthalidone is effective for lowering BP in elderly patients with systolic hypertension and sets the stage for a larger trial of the effects of such treatment on the incidence of cardiovascular disease Background We conducted an Internet-based r and omized trial comparing three valence framing presentations of the benefits of antihypertensive medication in preventing cardiovascular disease ( CVD ) for people with newly diagnosed hypertension to determine which framing presentation result ed in choices most consistent with participants ' values . Methods and Findings In this second in a series of televised trials in cooperation with the Norwegian Broadcasting Company , adult volunteers rated the relative importance of the consequences of taking antihypertensive medication using visual analogue scales ( VAS ) . Participants viewed information ( or no information ) to which they were r and omized and decided whether or not to take medication . We compared positive framing over 10 years ( the number escaping CVD per 1000 ) ; negative framing over 10 years ( the number that will have CVD ) and negative framing per year over 10 years of the effects of antihypertensive medication on the 10-year risk for CVD for a 40 year-old man with newly diagnosed hypertension without other risk factors . Finally , all participants were shown all presentations and detailed patient information about hypertension and were asked to decide again . We calculated a relative importance score ( RIS ) by subtracting the VAS-scores for the undesirable consequences of antihypertensive medication from the VAS-score for the benefit of CVD risk reduction . We used logistic regression to determine the association between participants ' RIS and their choice . 1,528 participants completed the study . The statistically significant differences between the groups in the likelihood of choosing to take antihypertensive medication in relation to different values ( RIS ) increased as the RIS increased . Positively framed information lead to decisions most consistent with those made by everyone for the second , more fully informed decision . There was a statistically significant decrease in deciding to take antihypertensives on the second decision , both within groups and overall . Conclusions For decisions about taking antihypertensive medication for people with a relatively low baseline risk of CVD ( 70 per 1000 over 10 years ) , both positive and negative framing result ed in significantly more people deciding to take medication compared to what participants decided after being shown all three of the presentations . Trial Registration International St and ard R and omised Controlled Trial Number Register IS RCT N The European Working Party on High blood pressure in the Elderly ( EWPHE ) trial was a double-blind r and omized placebo-controlled trial of antihypertensive treatment in patients over the age of 60 years . Entry criteria included both a sitting diastolic blood pressure on placebo treatment in the range of 90 - 119 mmHg and a systolic blood pressure in the range of 160 - 239 mmHg . Eight-hundred and forty patients were r and omly assigned either to active treatment ( hydrochlorothiazide + triamterene ) or a matching placebo . If blood pressure remained elevated methyldopa was added to the active regimen and matching placebo to the placebo regimen . Before r and omization , the patients were stratified in eight strata according to sex , age groups between 60 and 69 years or 70 years and over , and the presence or absence of cardiovascular complications of hypertension . Both the intention-to-treat and ' on r and omized treatment ' analyses suggested a benefit from active treatment in men and women . Formal statistical significance was achieved for male cardiovascular mortality ( intention-to-treat analyses ) and for cardiovascular events in females . Although the event rates were greater for patients with previous cardiovascular events and patients over the age of 70 years , the percentage reduction in cardiovascular events was similar in these groups to those without complications and in patients between 60 and 69 years of age . However , little benefit from treatment could be demonstrated in patients over the age of 80 years . The presence or absence of smoking had no influence on response to treatment in these elderly patients The Swedish trial in old patients with hypertension ( STOP-Hypertension ) is a multicentre , r and omized , double-blind study of beta-blockers/diuretics versus placebo in old hypertensives . Primary end-points are stroke and myocardial infa rct ion ( fatal and non-fatal ) as well as other cardiovascular mortality . To evaluate the logistics of STOP-Hypertension , a pilot study was carried out . All patients aged 70 - 84 years in 31 centres were consecutively registered in a log-book . Altogether 4668 patients were screened : 41.5 % had previously been treated for hypertension and 13.5 % had blood pressures greater than or equal to 180/105 mmHg . Thus , 55 % were ' hypertensive ' . In all , 465 patients ( 18 % of the ' hypertensive ' patients ) started a 3-month washout period ( previously treated , n = 396 ) or a 4-week run-in period ( previously untreated , n = 69 ) period . The most frequent reasons for not starting the run-in/washout were other indications for treatment with beta-blockers/diuretics ( 13 % ) , unwillingness to participate ( 8 % ) or isolated systolic hypertension ( 4 % ) . The pilot study was evaluated after 1 year : 89 patients ( 1.9 % ) had been r and omized , 66 patients ( 1.4 % ) were still in the run-in/washout period and the majority of the remaining patients were not r and omized because they had not reached the inclusion blood pressure ( greater than or equal to 180 mmHg systolic and /or greater than or equal to 105 mmHg diastolic ) following withdrawal of their antihypertensive medication . During the run-in/washout period there were few serious clinical events : one case of myocardial infa rct ion , three patients had strokes ( two fatal ) , 10 developed congestive heart failure , three tachyarrhythmia and two pneumonia ( one fatal ) . ( ABSTRACT TRUNCATED AT 250 WORDS BACKGROUND It is expected that the treatment of hypertension in patients with renal disease decreases the risk of cardiovascular events , but the evidence in these patients is lacking . OBJECTIVE To assess the effect of diuretic-based treatment on cardiovascular events in patients with isolated systolic hypertension and renal dysfunction . METHODS A total of 4336 persons aged 60 years and older with systolic blood pressures of 160 mm Hg and higher and diastolic blood pressures of less than 90 mm Hg were r and omly assigned to receive either placebo or chlorthalidone ( 12.5 - 25.0 mg/d ) , with the addition of atenolol ( 25 - 50 mg/d ) or reserpine ( 0.05 - 0.10 mg/d ) if needed , and observed for 5 years . The risk of first-occurring cardiovascular events , including stroke , transient ischemic attack , myocardial infa rct ion , heart failure , coronary artery bypass surgery , angioplasty , aneurysm , endarterectomy , sudden death , or rapid death , was stratified according to baseline serum creatinine levels ( 35.4 - 84.0 , 84.1 - 101.6 , 101.7 - 119.3 , and 119.4 - 212.2 micromol/L [ 0.4 - 0.9 , 1.0 - 1.1 , 1.2 - 1.3 , and 1.4 - 2.4 mg/dL ] ) . RESULTS Systolic blood pressure reduction was not affected by baseline serum creatinine levels . Active treatment did not affect the risk of serum creatinine levels becoming elevated during follow-up . The risk of hypokalemia with active treatment decreased significantly with increasing baseline serum creatinine levels . In the 4 baseline serum creatinine groups , the relative risk ( 95 % confidence interval ) of cardiovascular events developing with active treatment was 0.73 ( 0.54 - 0.97 ) , 0.63 ( 0.49 - 0.82 ) , 0.62 ( 0.44 - 0.87 ) , and 0.59 ( 0.38 - 0.91 ) . The results were similar for the outcomes of stroke or coronary artery events and in analyses stratified by sex or age . CONCLUSION Diuretic-based treatment of patients with isolated systolic hypertension prevents the development of cardiovascular events in older persons with mild renal dysfunction CONTEXT Nonpharmacologic interventions are frequently recommended for treatment of hypertension in the elderly , but there is a paucity of evidence from r and omized controlled trials in support of this recommendation . OBJECTIVE To determine whether weight loss or reduced sodium intake is effective in the treatment of older persons with hypertension . DESIGN R and omized controlled trial . PARTICIPANTS A total of 975 [ corrected ] men and women aged 60 to 80 years with systolic blood pressure lower than 145 mm Hg and diastolic blood pressure lower than 85 mm Hg while receiving treatment with a single antihypertensive medication . SETTING Four academic health centers . INTERVENTION The 585 obese participants were r and omized to  reduced sodium intake , weight loss , both , or usual care , and the 390 nonobese participants were r and omized to reduced sodium intake or usual care . Withdrawal of antihypertensive medication was attempted after 3 months of intervention . MAIN OUTCOME MEASURE Diagnosis of high blood pressure at 1 or more follow-up visits , or treatment with antihypertensive medication , or a cardiovascular event during follow-up ( range , 15 - 36 months ; median , 29 months ) . RESULTS The combined outcome measure was less frequent among those assigned vs not assigned to reduced sodium intake ( relative hazard ratio , 0.69 ; 95 % confidence interval [ CI ] , 0.59 - 0.81 ; P<.001 ) and , in obese participants , among those assigned vs not assigned to weight loss ( relative hazard ratio , 0.70 ; 95 % CI , 0.57 - 0.87 ; P<.001 ) . Relative to usual care , hazard ratios among the obese participants were 0.60 ( 95 % CI , 0.45 - 0.80 ; P<.001 ) for reduced sodium intake alone , 0.64 ( 95 % CI , 0.49 - 0.85 ; P=.002 ) for weight loss alone , and 0.47 ( 95 % CI , 0.35 - 0.64 ; P<.001 ) for  reduced sodium intake and weight loss combined . The frequency of cardiovascular events during follow-up was similar in each of the 6 treatment groups . CONCLUSION Reduced sodium intake and weight loss constitute a feasible , effective , and safe nonpharmacologic therapy of hypertension in older persons OBJECTIVE To provide up date d , evidence -based recommendations for the prevention and management of hypertension in adults . OPTIONS AND OUTCOMES For lifestyle and pharmacological interventions , evidence was review ed from r and omized controlled trials and systematic review s of trials . Changes in cardiovascular morbidity and mortality were the primary outcomes of interest . However , for lifestyle interventions , blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field . For treatment of patients with kidney disease , the progression of kidney dysfunction was also accepted as a clinical ly relevant primary outcome . EVIDENCE A Cochrane collaboration librarian conducted an independent MEDLINE search from 2005 to August 2006 to up date the 2006 Canadian Hypertension Education Program recommendations . In addition , reference lists were scanned and experts were contacted to identify additional published studies . All relevant articles were review ed and appraised independently by both content and method ological experts using prespecified levels of evidence . RECOMMENDATIONS Dietary lifestyle modifications for prevention of hypertension , in addition to a well-balanced diet , include a dietary sodium intake of less than 100 mmol/day . In hypertensive patients , the dietary sodium intake should be limited to 65 mmol/day to 100 mmol/day . Other lifestyle modifications for both normotensive and hypertensive patients include : performing 30 min to 60 min of aerobic exercise four to seven days per week ; maintaining a healthy body weight ( body mass index of 18.5 kg/m2 to 24.9 kg/m2 ) and waist circumference ( less than 102 cm in men and less than 88 cm in women ) ; limiting alcohol consumption to no more than 14 units per week in men or nine units per week in women ; following a diet reduced in saturated fat and cholesterol , and one that emphasizes fruits , vegetables and low-fat dairy products , dietary and soluble fibre , whole grains and protein from plant sources ; and considering stress management in selected individuals with hypertension . For the pharmacological management of hypertension , treatment thresholds and targets should take into account each individual 's global atherosclerotic risk , target organ damage and any comorbid conditions : blood pressure should be lowered to lower than 140/90 mmHg in all patients and lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease . Most patients require more than one agent to achieve these blood pressure targets . In adults without compelling indications for other agents , initial therapy should include thiazide diuretics ; other agents appropriate for first-line therapy for diastolic and /or systolic hypertension include angiotensin-converting enzyme ( ACE ) inhibitors ( except in black patients ) , long-acting calcium channel blockers ( CCBs ) , angiotensin receptor blockers ( ARBs ) or beta-blockers ( in those younger than 60 years of age ) . First-line therapy for isolated systolic hypertension includes long-acting dihydropyridine CCBs or ARBs . Certain comorbid conditions provide compelling indications for first-line use of other agents : in patients with angina , recent myocardial infa rct ion , or heart failure , beta-blockers and ACE inhibitors are recommended as first-line therapy ; in patients with cerebrovascular disease , an ACE inhibitor plus diuretic combination is preferred ; in patients with nondiabetic chronic kidney disease , ACE inhibitors are recommended ; and in patients with diabetes mellitus , ACE inhibitors or ARBs ( or , in patients without albuminuria , thiazides or dihydropyridine CCBs ) are appropriate first-line therapies . All hypertensive patients with dyslipidemia should be treated using the thresholds , targets and agents outlined in the Canadian Cardiovascular Society position statement ( recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease ) . Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy . Once blood pressure is controlled , acetylsalicylic acid therapy should be considered . VALIDATION All recommendations were grade d according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence -Based Recommendations Task Force . All recommendations reported here achieved at least 95 % consensus . These guidelines will continue to be up date d annually Objective : Our aim was to compare the effect of lacidipine and chlorthalidone on cardiovascular outcome as a primary parameter and blood pressure as a secondary in elderly patients with isolated systolic hypertension in a prospect i ve study with an open design . Methods : 1882 males and females out patients ≥60 years were r and omly assigned to the administration of  chlorthalidone 12.5 mg o.d . or lacidipine 4 mg o.d . Patients were recruited if sitting systolic blood pressure was ≥160 mmHg with a diastolic blood pressure equal or lower than 95 mmHg .  Primary endpoint was a composite of cardiovascular and cerebrovascular events . Results : At r and omization mean systolic blood pressure was 178.1 mmHg in the lacidipine and 178.2 mmHg in the chlorthalidone group , the corresponding mean diastolic values being 86.9 and 86.8 mmHg . In both lacidipine and chlorthalidone groups treatment caused a significant ( p < 0.001 ) and marked systolic blood pressure reduction which was maintained throughout the treatment period with a significant ( p < 0.001 ) and steady although less marked reduction in diastolic blood pressure as well . At the end of treatment period ( median 32 months ) , the reduction was 36.8/8.1 mmHg ( systolic/diastolic ) in the chlorthalidone and 38.4/7.9 mmHg in the lacidipine group , the final on treatment blood pressures being 142.0/79.2 and 143.2/79.5 mmHg , respectively . Treatments were similarly effective in males and females and in age groups between 60 and 69 years ( n = 763 ) , 70 and 79 years ( n = 744 ) and ≥80 years ( n = 375 ) . Similar reductions were obtained in a subgroup of patients ( n = 209 ) followed in double-blind fashion for 1 year . The overall incidence of the primary endpoints was 9.3 % with no significant between-group difference . Total mortality was also similar between groups . Conclusions : In elderly patients with isolated systolic hypertension , administration of lacidipine or chlorthalidone markedly reduced systolic blood pressure with no difference in the incidence of cardiovascular events and total mortality Objective To investigate the associations of diastolic blood pressure ( DBP ) and systolic blood pressure ( SBP ) with the risk of coronary heart disease , sudden cardiac and all-cause death in elderly men . Design A cohort study . Setting The Dutch town of Zutphen . Subjects Eight hundred and eighty-five r and omly selected men , aged 64 - 84 years . Main outcome measures Relative risks adjusted for age , body mass index , total and high-density lipoprotein cholesterol , cigarette smoking , alcohol consumption , use of blood pressure-lowering medications without a specific indication for hypertension , and the physician who measured the blood pressure . Results Neither DBP nor SBP was associated significantly with the incidence of a first coronary heart disease event and no clear associations were observed with mortality from coronary heart disease . However , positive associations with sudden cardiac death were observed . The adjusted relative risk for men with definite isolated systolic hypertension was 9.20 . The risk of dying from coronary heart disease not recorded additionally as sudden death was highest in men at the lower end of the DBP and SBP distributions and in men using antihypertensives . DBP and SBP were positively associated with all-cause mortality when possible comorbidity at the time of the blood pressure measurement was accounted for . Overall , the highest risk for all endpoints was observed in men on antihypertensive medication , who formed a distinct group with a clustering of cardiovascular risk factors . Conclusion Elevated DBP and SBP , and especially isolated systolic hypertension , are important predictors of sudden cardiac death in elderly men . The highest risk of nonsudden coronary heart disease mortality was found at the lower end of the blood pressure distributions and among men on antihypertensive medication Abstract Objective : To establish whether initiation of treatment with diuretic or β blocker is associated over 54 months with change in cognitive function . Design : A cognitive sub study , nested within a r and omised , placebo controlled , single blind trial . Setting : 226 general practice s from the Medical Research Council 's general practice research framework . Subjects : A subset of 2584 subjects sequentially recruited from among the 4396 participants aged 65 - 74 in the trial of treatment of hypertension in older adults . The 4396 subjects were r and omised to receive diuretic , β blocker , or placebo . Subjects had mean systolic pressures of 160 - 209 mm Hg and mean diastolic pressures < 115 mm Hg during an eight week run in . Outcome measures : The rate of change in paired associate learning test ( PALT ) and trail making test part A ( TMT ) scores ( administered at entry and at 1 , 9 , 21 , and 54 months ) over time . Results : There was no difference in the mean learning test coefficients ( rate of change of score over time ) between the three treatments : diuretic -0.31 ( 95 % confidence interval -0.23 to -0.39 ) , β blocker -0.33 ( -0.25 to -0.41 ) , placebo -0.30 , ( -0.24 to -0.36 ) . There was also no difference in the mean trail making coefficients ( rate of change in time taken to complete over time ) between the three groups : diuretic -2.73 ( 95 % confidence interval -3.57 to -1.88 ) , β blocker -2.08 ( -3.29 to -0.87 ) , placebo -3.01 , ( -3.69 to -2.32 ) . A less conservative protocol analysis confirmed this negative finding . Conclusion : Treating moderate hypertension in older people is unlikely to influence , for better or for worse , subsequent cognitive function . Key messages Key messages Studies have shown that treating hypertension in older adults reduces cardiovascular mortality and morbidity Treating moderate hypertension with either diuretic or β blocker does not seem to influence cognitive function Concerns about damaging cognition should not deter doctors from treating hypertension in older patients Age should no longer be a factor in the decision to initiate antihypertensive BACKGROUND After the double-blind , placebo-controlled Systolic Hypertension in Europe ( Syst-Eur ) trial ended in February 1997 , r and omized patients were offered active study medication for a further period of observation . OBJECTIVE To refine the estimates of the long-term effects of antihypertensive therapy on the incidence of dementia . METHODS Eligible patients had no dementia and were at least 60 years old . Their systolic blood pressure at entry was 160 to 219 mm Hg , with diastolic blood pressure below 95 mm Hg .  Antihypertensive therapy was started immediately after r and omization in the active treatment group , but only after termination of the double-blind trial in the control patients . Treatment consisted of nitrendipine ( 10 - 40 mg/d ) , with the possible addition of enalapril maleate ( 5 - 20 mg/d ) , hydrochlorothiazide ( 12.5 - 25 mg/d ) , or both add-on drugs . RESULTS Median follow-up increased from 2.0 years in the double-blind trial to 3.9 years overall . The incidence of dementia doubled from 32 to 64 cases , 41 of whom had Alzheimer disease . Throughout follow-up , systolic/diastolic blood pressure was 7.0/3.2 mm Hg higher in the 1417 control patients than in the 1485 subjects r and omized to active treatment . At the last examination , the blood pressure difference was still 4.2/2.9 mm Hg ; 48.1 % , 26.4 % , and 11.4 % of the control patients were taking nitrendipine , enalapril , and /or hydrochlorothiazide , whereas in the active treatment group these proportions were 70.2 % , 35.4 % , and 18.4 % , respectively . Compared with the controls , long-term antihypertensive therapy reduced the risk of dementia by 55 % , from 7.4 to 3.3 cases per 1000 patient-years ( 43 vs 21 cases , P<.001 ) . After adjustment for sex , age , education , and entry blood pressure , the relative hazard rate associated with the use of nitrendipine was 0.38 ( 95 % confidence interval , 0.23 - 0.64 ; P<.001 ) . Treatment of 1000 patients for 5 years can prevent 20 cases of dementia ( 95 % confidence interval , 7 - 33 ) . CONCLUSION The extended follow-up of Syst-Eur patients reinforces the evidence that blood pressure-lowering therapy initiated with a long-acting dihydropyridine protects against dementia in older patients with systolic hypertension Background and Objectives : Older adults ' adherence to antihypertensive medications is far lower than what is considered necessary for clinical effectiveness , despite the risks for adverse cardiovascular events from uncontrolled blood pressure ( BP ) in the elderly . This pilot study tested a novel 8-week behavioral feedback intervention to improve antihypertensive medication adherence ( MA ) and BP control among older adults on existing treatment for hypertension . Methods : Adults 60 years old , or older taking at least 1 antihypertensive medication were r and omized to receive the nurse-delivered adherence intervention or usual care . Medication adherence was monitored continuously using electronic monitoring for 20 weeks . Intervention-group participants received biweekly MA and BP feedback , habit counseling , medication and disease education , a medication instruction card , and were given an electronic medication bottle cap with a digital display that provided daily adherence feedback during the 8-week intervention . Blood pressure was measured by a nurse at 12 and 20 weeks after r and omization . Adherence and BP outcomes were described using descriptive statistics and analyzed for between- and within-group differences using Mann-Whitney U tests . Results : Fifteen participants ( median age , 71 years ; 73 % female ) were eligible for r and omization . Participants took an average of 5.8 prescription medications and 2.93 over-the-counter medications per day . A nonsignificant difference was noted in baseline MA between groups . At the end of the intervention , the treatment group had better antihypertensive MA than did the control group ( median MA : 100 % vs 27.3 % , U = 5.00 , P = .013 ) . Systolic BP improved slightly in the intervention group during the study and was significantly different at week 12 ( median systolic BP : 130 vs 152 mm Hg ; U = 4.50 , P = .008 ) . Diastolic BP was largely unchanged over the course of the study . Conclusion : The results indicate that the intervention had a positive effect on MA . Additional testing is needed to further evaluate the intervention and its effect on adherence behavior and BP control Univariate and multivariate analyses have been made of the relationship of systolic and diastolic blood-pressure measured at study entry to subsequent 14-year mortality among 1233 White males originally age 40 - 59 in 1958 from the Chicago Peoples Gas Company prospect i ve study . With age , serum-cholesterol , and cigarettes per day controlled , both elevated systolic and electaed diastolic blood-pressure in 1958 were found to be strongly related to subsequent mortality from cancer in the men of this study . The possibility that this finding was due either to an association between antihypertensive medication in general , and cancer , or to an association was found that could explain the excess cancer mortality among those with elevated blood-pressure in 1958 , either with medication in general , or with reserpine and rauwolfia in particular . These findings thus pose the question , is high blood-pressure associated with an increased risk of death due to cancer Context Previously published results of this r and omized , double-blind trial showed that hypertensive patients treated with doxazosin rather than chlorthalidone more often developed heart failure . Did differences in blood pressure control or treatment with other drugs explain these findings ? Contribution This analysis shows that the slightly worse blood pressure control achieved with doxazosin did not explain higher risks for heart failure . Risks with doxazosin versus chlorthalidone were highest among patients who received monotherapy ( relative risk , 3.10 ) and lowest among patients who received stepped care with additional drugs ( relative risk , 1.42 ) . Implication s Increased risks for heart failure with doxazosin versus chlorthalidone are attenuated but not eliminated when additional antihypertensive drugs are used . The Editors The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial ( ALLHAT ) , a r and omized , double-blind , multicenter clinical trial including 42 418 participants at 623 clinical sites , is design ed to determine whether treatment begun with a calcium-channel blocker ( amlodipine ) , an angiotensin-converting enzyme inhibitor ( lisinopril ) , or an -adrenergic blocker ( doxazosin ) compared to treatment with a diuretic ( chlorthalidone ) reduces the incidence of fatal coronary heart disease or nonfatal myocardial infa rct ion in high-risk patients with hypertension ( 1 ) . Secondary end points are all-cause mortality , stroke , and other cardiovascular events . A lipid-lowering trial in a subset of 10 356 participants is design ed to determine whether decreasing cholesterol levels with a hydroxymethyl glutamyl coenzyme A reductase inhibitor ( pravastatin ) compared with usual care reduces all-cause mortality in older , moderately hypercholesterolemic patients . In January 2000 , the doxazosin arm of the trial was discontinued ( 2 ) because major cardiovascular disease ( relative risk , 1.25 [ 95 % CI , 1.17 to 1.33 ] ; P < 0.001 ) , especially heart failure ( relative risk , 2.04 [ 95 % CI , 1.79 to 2.32 ] ; P < 0.001 ) , was significantly increased compared with the chlorthalidone arm . Equally important , a low probability existed that doxazosin would show benefit over chlorthalidone for the primary end point by the scheduled study end , given the lack of difference ( relative risk , 1.02 [ 95 % CI , 0.90 to 1.17 ] ; P > 0.2 ] at that time . These intention-to-treat analyses compared patients assigned to chlorthalidone with patients assigned to doxazosin . In this article , we analyze how treatment changes may have affected the comparison of doxazosin with chlorthalidone in terms of heart failure . Our major objectives are to ascertain to what extent the relative risk with doxazosin versus chlorthalidone depends on 1 ) whether the assigned drugs were used as monotherapy or in combination with other agents and 2 ) the difference in decreases in systolic and diastolic blood pressure . Methods Study Design The rationale and design of ALLHAT are described in detail elsewhere ( 1 ) . In brief , eligible participants were men and women 55 years of age or older who had systolic or diastolic hypertension ( 140/90 mm Hg or hypertension controlled with medication ) plus at least one additional risk factor for coronary heart disease events . The risk factors included previous ( > 6 months ) myocardial infa rct ion or stroke , left ventricular hypertrophy on electrocardiography or echocardiography , history of type 2 diabetes , current cigarette smoking , and a low high-density lipoprotein cholesterol level . Persons with a history of hospitalized or treated symptomatic heart failure or a known ejection fraction less than 0.35 were excluded . Unless the drug regimen required tapering for safety , participants who had been taking antihypertensive medications continued to do so until the day of r and omization , at which point they stopped taking all previous medications . On the day after r and omization , treatment with the study drug was initiated . Enrollment occurred from February 1994 through January 1998 . The original reported number of 42 448 participants and 625 sites changed because 30 patients with poor documentation of informed consent were excluded ( 2 ) . Participants were assigned by a computer-generated r and omization schedule in a ratio of 1.7:1 to receive chlorthalidone or doxazosin . R and omization was stratified by center and blocked over time to maintain the ratio . All participants gave written informed consent , and all centers obtained institutional review board approval . Ascertainment of Outcomes At each clinic visit , occurrence of study end points was assessed by the clinical investigator . A hospital discharge summary was required for each hospitalized study outcome , and a death certificate was required for each death . ALLHAT defined symptomatic heart failure as clear-cut signs or symptoms of left or right ventricular dysfunction that can not be attributed to other causes . A patient had to have at least one symptom ( paroxysmal nocturnal dyspnea , dyspnea at rest , New York Heart Association class III dyspnea or other symptoms [ on less than ordinary exertion ] , or orthopnea ) and one sign ( rales , ankle edema , tachycardia , cardiomegaly or characteristic pulmonary pattern on chest radiography , S3 gallop , or jugular venous distention ) ( 3 ) . Symptoms and signs were determined by the clinic investigator through patient history , chart review , or consultation with the treating physician , but such data were not collected central ly . A one-time sample of 24 hospitalized or fatal heart failure events was review ed in a blinded manner by the ALLHAT Endpoints Subcommittee ; 20 of 24 ( 83 % ) were deemed to have complete data for a definitive diagnosis . Of the 20 cases , the agreement rate between the subcommittee and the clinic investigators was 90 % ( 18 of 20 ) and similar in both treatment groups . Details on the validity of diagnosis of heart failure will be provided in a future report . Measurement and Treatment of Blood Pressure The ALLHAT protocol specified a stepped-care treatment program for hypertension . Trained observers using st and ardized techniques measured blood pressures during the trial ( 1 , 2 ) . All blood pressures were calculated as the average of two measurements obtained with a 30-second interval between them . The blood pressure goal in all four study arms was less than 140/90 mm Hg . This level was to be achieved with the lowest possible dose of blinded first-line drug , with addition of second- and third-line open-label therapy as needed after reaching the maximal dose of first-line drug . Chlorthalidone and doxazosin were to be taken once daily in the morning . By design , doses were selected to achieve equivalent blood pressure control in the treatment groups . The first , second , and third dosage levels were 12.5 mg/d , 12.5 mg/d ( sham titration ) , and 25 mg/d , respectively , for chlorthalidone and 2 mg/d , 4 mg/d , and 8 mg/d for doxazosin . Double-blinded 1-mg and 12.5-mg doses of doxazosin and chlorthalidone , respectively , were used for the first week to minimize the frequency of postural hypotension associated with doxazosin . The identity of drugs was masked at each dosage level , but dosage level was not . After r and omization , patients were seen for dose titration as needed at 1 and 3 months per the protocol , but they could return more often until target blood pressure was reached . Subsequently , required visits occurred at 3-month intervals during the first year and at 4-month intervals thereafter . Open-label second-step drugs were added as needed and tolerated . These agents were reserpine ( 0.05 to 0.2 mg/d ) , clonidine ( 0.1 to 0.3 mg twice daily ) , and atenolol ( 25 to 100 mg/d ) . The choice of second-step drug was at the discretion of the treating clinician-investigator . The third-step agent was hydralazine ( 25 to 100 mg twice daily ) . Details of these therapies are provided elsewhere ( 1 ) . Investigators could choose to prescribe open-label antihypertensive drugs other than those provided by the study . However , use of the drug classes under study thiazide diuretics , calcium antagonists , angiotensin-converting enzyme inhibitors , and -adrenergic blockerswas strongly discouraged to avoid dilution of treatment comparisons . When clinical conditions other than uncontrolled hypertension ( for example , angina or heart failure ) were present , drugs from any study class could be used . If a step 1 drug was specifically required for blood pressure control while blinded drug treatment was continued , the step 1 drug could be added as open-label therapy but the dose could not exceed one half the maximum recommended by the Fifth Joint National Committee ( 4 ) . In most such cases , unblinding the patient or the investigator to treatment assignment was not necessary . ( Overall , < 1 % of drug identities were provided to either participant or investigator . ) Any of nine possible open-label drug typesdiuretic , calcium-channel blocker , angiotensin-converting enzyme inhibitor , -adrenergic blocker , atenolol , reserpine , clonidine , hydralazine , and other antihypertensive drug ( which could include nonatenolol -blockers , although drug name was not logged)could be recorded at each visit . Because diuretics , angiotensin-converting enzyme inhibitors , and -blockers are beneficial in preventing or treating heart failure , we call these antihypertensive heart failure drugs . Data on  antihypertensive drug use before study enrollment were collected , but not by drug class . Statistical Analysis Data were analyzed for use of additional drugs according to participants ' r and omized treatment assignments and regardless of continuation of blinded study treatment . The outcomes all heart failure ( treated outside hospital , hospitalized , or fatal ) and hospitalized or fatal heart failure were examined by treatment group for the entire cohort . The time to event for the previously published as-r and omized analyses was the interval from r and omization to first diagnosis of heart failure for patients who had an outcome , or from r and omization to 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 Background — We previously hypothesized that high activity of creatine kinase , the central regulatory enzyme of energy metabolism , facilitates the development of high blood pressure . Creatine kinase rapidly provides adenosine triphosphate to highly energy-dem and ing processes , including cardiovascular contraction , and antagonizes nitric oxide – mediated functions . Relatively high activity of the enzyme , particularly in resistance arteries , is thought to enhance pressor responses and increase blood pressure . Tissue creatine kinase activity is reported to be high in black people , a population subgroup with greater hypertension risk ; the proposed effects of high creatine kinase activity , however , are not “ race dependent . ” We therefore assessed whether creatine kinase is associated with blood pressure in a multiethnic population . Methods and Results — We analyzed a stratified r and om sample of the population of Amsterdam , the Netherl and s , consisting of 1444 citizens ( 503 white European , 292 South Asian , 580 black , and 69 of other ethnicity ) aged 34 to 60 years . We used linear regression analysis to investigate the association between blood pressure and normal serum creatine kinase after rest , as a substitute measure of tissue activity . Creatine kinase was independently associated with blood pressure , with an increase in systolic and diastolic pressure , respectively , of 8.0 ( 95 % CI , 3.3 to 12.7 ) and 4.7 ( 95 % CI , 1.9 to 7.5 ) mm Hg per log creatine kinase increase after adjustment for age , sex , body mass index , and ethnicity . Conclusions — Creatine kinase is associated with blood pressure . Further studies are needed to explore the nature of this association , including how variation in cardiovascular creatine kinase activity may affect pressor responses Context Physician education and community-based interventions to educate people with hypertension may improve hypertension care in re source -poor setting s. Contribution Among 1341 patients living in 12 communities in Pakistan that were r and omly assigned to general practitioner education , home health visits by trained lay workers , both , or neither , patients in communities assigned to both interventions had the greatest improvements in systolic blood pressure ( 10.8 mm Hg ) after 2 years . Improvements were similar in all other groups ( about 5 mm Hg ) . Caution Twenty-two percent of patients were lost to follow-up . Implication Home visits by trained lay workers plus physician education deserves further study as a way to improve hypertension control in re source -poor setting s. The Editors Cardiovascular disease has , in just a few decades , become the leading cause of death in adults worldwide , accounting for 1 in 5 deaths . Hypertension confers the highest attributable risk for death and disease associated with cardiovascular disease ( 1 , 2 ) . Despite the demonstrated benefits of effective drug treatment ( 3 , 4 ) and the existence of many clinical practice guidelines ( 5 ) , hypertension prevention , treatment , and control rates remain suboptimal worldwide ( 6 ) . The situation is particularly acute in developing countries , such as Pakistan , India , and China , where hypertension has reached epidemic proportionsaffecting more than 20 % of the adult population (7)yet control rates are less than 6 % ( 8) . Poor health literacy and unhealthy lifestyles , compounded by lack of awareness of hypertension ( 7 ) , are part of the cause . In addition , the health systems in these countries are often dysfunctional : More than 80 % of the expenditure for chronic disease care is out-of-pocket ; private care general practitioners ( GPs ) , who primarily treat acute conditions , are the front-line service providers ; and national programs for preventing and controlling hypertension are inadequate . Serious deficiencies in management of hypertension also have been identified in the knowledge and practice of health care providers . ( 9 ) However , evidence for public health interventions to improve hypertension control rates through patient or physician education in Indo-Asian countries is lacking . We conducted the COBRA-1 ( Control of Blood Pressure and Risk Attenuation-1 ) trial in Karachi , Pakistan , to test the effectiveness of 2 community-based strategies : family-based home health education ( HHE ) , delivered by trained community health workers , to improve population -level health literacy and behaviors , and hypertension management training for GPs . We tested the effect of these interventions , alone and in combination , on blood pressure in adults with hypertension . We hypothesized that HHE would be more effective than no education , that the specially trained GPs would provide more effective care than that usually received in Karachi , and that the combined interventions would provide additional benefit . Methods Study Design and Setting We performed a cluster r and omized , controlled trial with a 22 factorial design to determine the effect of  family-based HHE and special training for GPs  on blood pressure in adults 40 years or older with hypertension . We used a cluster approach because our objective was to assess the effectiveness of both HHE and GP training as health system interventions at a population level , and an individual approach would be prone to contamination of interventions and biased outcomes ( 10 ) . The Aga Khan University Ethics Review Committee granted ethical approval . The sampling frame is described elsewhere ( 11 ) . In brief , we used a multistage r and om sampling technique to select 12 of 4200 low- to middle-income , geographic census-based clusters ( mean household monthly income , $ 70 ; about 250 households in each cluster ) in Karachi , the most populous city in Pakistan ( about 16 million inhabitants ) . We ensured at least a 10-km distance between clusters to minimize the risk for contamination by the intervention . Participants Persons 40 years or older who resided in the 12 clusters and had known hypertension or consistently elevated blood pressure on 2 separate visits ( mean of 2 of past 3 measurements of systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg ) were eligible for inclusion . We excluded pregnant women , persons who could not give informed consent , and bed-bound persons . R and omization and Intervention We used computer-generated codes to r and omly assign 3 clusters each to the following groups : HHE alone , GP alone , HHE and GP combined , and no intervention . Home Health Education We trained 6 community health workers ( 1 for each cluster ) over 6 weeks in methods for using behavior-changing communication strategies to convey st and ardized health education messages to all households in clusters assigned to receive HHE . The education status of the workers we employed was consistent with the requirements of the government-sponsored Lady Health Workers Programme of Pakistan ( 8 or preferably 10 years of schooling ) ( 12 ) . Salary scales and assigned workload were similarly consistent . The health messages included information on the deleterious effects of hypertension and nonpharmacologic interventions for preventing and controlling hypertension and cardiovascular disease , as well as advice on the importance of engaging in moderate physical activity ; maintaining normal body weight ; reducing salt intake ; consuming a diet rich in fruit , vegetables , and low-fat dairy products ; reducing intake of saturated and total fat ( including suggestions on sample recipes for culturally acceptable and economically feasible food products ) ; and smoking cessation ( Appendix 1 ) . The importance of achieving blood pressure targets and adhering to medication and physician follow-up was emphasized . The first HHE session , lasting 90 minutes , was held at a time when all members of the household could be present . Follow-up reinforcement visits of 30 minutes were made every 3 months . Appendix 1 . Training Manual for Community Health Workers General Practitioner Education We invited all GPs in the 6 study areas assigned to this intervention to receive training , with the aim of training at least two thirds of the GPs in each area . We considered this proportion to be feasible both for future uptake of the strategy and for assessing the effectiveness of training . Training was a 1-day session that focused on st and ard treatment algorithms for the stepped-care management of hypertension , which were based on the seventh report of the Joint National Committee ( 3 ) and the Fourth Working Party of the British Hypertension Society guidelines ( 4 ) and modified for the Indo-Asian population ( Appendix 2 ) . The course included components on nonpharmacologic ( diet , exercise , weight loss , and smoking cessation ) and pharmacologic interventions , prescription of low-cost and appropriate generic drugs , preferential use of single-dose drug regimens , scheduled follow-up visits guided by blood pressure , the stepped-care approach for titrating drugs to achieve target blood pressure , and satisfactory consultation sessions for patients , with explanations of treatment and use of appropriate communication strategies . For managing persons with known hypertension , GPs were advised to review medication and blood pressure ; simplify regimens ; and aim to return to a regimen that was in line , as reasonably as possible , with that recommended for those with newly diagnosed hypertension . The recommended target blood pressure was < 140/90 mm Hg for all patients . Although this diverges from recent guidelines for special subgroups ( such as diabetic persons or those with end-organ damage ) , we reasoned that we needed to keep the intervention , guidelines , and targets simple for both patients and practitioners in a setting where blood pressure control rates are less than 3 % ( 7 ) . The training sessions for GPs used a case-based curriculum and were interactive . We provided a certificate of training at the end of the course . Appendix 2 . Training Manual for General Practitioner All study participants were advised to consult a local GP . If participants in the clusters r and omly assigned to a trained GP group did not already have a preferred GP , we gave them a list of trained GPs in their cluster from which to choose . However , it remained the participant 's choice whether they attended a physician on the list . We did not provide for medications or fee-for-health care services . Participants were blinded to intervention status ( training of GP ) . Neither the patients nor the GPs received reimbursement for participation . Screening and Recruitment All households in each cluster were visited , and we obtained informed consent for screening from all adults 40 years and older , whose blood pressure was then measured 3 times with a calibrated automated device ( Omron HEM-737 IntelliSense ; Omron Healthcare , Vernon Hills , Illinois ) in the sitting position after 5 minutes of rest . Those with known hypertension were invited to participate . Those with elevated blood pressure who were not receiving antihypertensive medication were visited again for remeasurement of blood pressure 1 to 4 weeks after the initial visit . If mean blood pressure remained elevated , these persons were also invited to participate . A routine physical examination was performed , and the following information was collected : smoking status , food frequency , and physical activity by question naire , the latter by using the international physical activity question naire ; blood pressure , measured as described above ; anthropometric characteristics ( height , weight , and waist and hip circumferences ) ; and fasting blood glucose level ( Synchron Cx-7/Delta , Beckman Coulter , Fullerton , California ) and lipid profile ( Hitachi-912 , Roche , Basel , Switzerl and ) ( 11 ) . Follow-up Procedures Trained outcomes assessors ( who were not part of and had no relationship with the community health worker team ) evaluated Abstract A prospect i ve r and omised controlled trial of hypotensive therapy in 97 hypertensive patients surviving an ischaemic-type stroke was started in 1964 and terminated 4 years later . The patients were under 80 years of age , consecutively admitted to one hospital and the control and treated groups compared well for age , sex , and severity of hypertension . The drugs used were methyldopa , bethanidine or debrisoquine combined with restriction of salt intake , weight reduction , and thiazide diuretics , and the results were analysed with regard to survival and recurrence rates . Hypertension was defined as diastolic if this pressure was 110 mm . Hg or above , and as systolic if this pressure was over 160 mm . Hg with the diastolic below 110 mm . Hg . The mortality-rate at the end of a 2 to 5 year followup was 26 % in the treated group and 46 % in the untreated , and the non-fatal recurrence-rate 14 % in the treated and 23 % in the controls . Good smooth control was essential to success , untreated patients doing better than those whose control was unsatisfactory . In patients aged over 65 treatment of systolic hypertension was of no benefit , although the diastolic hypertensives improved marginally with treatment . As age increased this effect was progressively less apparent but the figures are probably too small to mean anything . In this series significant improvement occurred in treated hypertensive patients who had survived a stroke if they were aged 65 or below , but not if they were older OBJECTIVE We have assessed the influence of gender and age on the main outcome results of the Hypertension Optimal Treatment ( HOT ) study . DESIGN AND INTERVENTIONS The aims of the HOT study were to study the relationship between three levels of target office diastolic blood pressure ( BP ) ( < or = 90 , < or = 85 or < or = 80 mmHg ) and  cardiovascular ( CV ) events in hypertensive patients , and to examine the effects of 75 mg acetylsalicylic acid ( ASA ) daily versus placebo . SETTING Outpatient clinical trial in 26 countries . PATIENTS A total of 18790 patients ( mean age 61.5 years , range 50 - 80 ) were r and omized and followed for an average of 3.8 years until 71051 patient-years and 683 events had occurred . MAIN OUTCOME MEASURES CV death , myocardial infa rct ion ( MI ) and stroke . RESULTS There were significantly fewer MIs in those in the lower diastolic BP target groups ( 3.0 versus 1.2 and 1.7 MIs/1000 patient-years , P for trend = 0.034 ) in women ( n = 8883 ) , whereas the similar but smaller trend ( 4.1 versus 4.1 and 3.4 MIs/1000 patient-years ) was not statistically significant in men nor in the subgroup analysis of younger and older subjects . The effect of ASA on preventing MI was not influenced by age < 65 years ( P= 0.02 ) or age > or = 65 years ( P = 0.04 ) but was influenced by gender ( P = 0.38 in women and P = 0.001 in men , lowered by 42 % corresponding to a reduction from 5.0 to 2.9 MIs/1000 patient-years ) . CONCLUSIONS The data of this HOT study sub- analysis suggest somewhat differentiated optimal gender- and age-dependent effects of anti-hypertensive and anti-platelet therapies ; lowering of diastolic BP to about 80 mmHg in hypertensive women and , in addition , the administration of 75 mg of ASA to well-treated hypertensive men appear to effectively reduce the most common cardiovascular complication , i.e. myocardial infa rct ion , in patients with essential hypertension The Systolic Hypertension in Europe ( Syst-Eur ) trial proved that blood pressure ( BP ) lowering therapy starting with nitrendipine reduces the risk of cardiovascular complications in older ( ⩾60 years ) patients with isolated systolic hypertension ( systolic BP ⩾160 mm Hg and diastolic BP < 95 mm hg ) . after the completion of the syst-eur trial on 14 february 1997 , 3506 consenting patients ( 93.0 % of those eligible ) were enrolled in phase 2 of the syst-eur trial . this open follow-up study aims to confirm the safety of long-term antihypertensive therapy based on a dihydropyridine . to lower the sitting systolic bp below 150 mm hg ( target bp ) , the first-line agent nitrendipine ( 10–40 mg/day ) may be associated with enalapril ( 5–20 mg/day ) , hydrochlorothiazide ( 12.5–25 mg/day ) , both add-on study drugs , or if required any other antihypertensive agent . on 1 november 1998 , 3248 patients were still being followed , 86 patients had proceeded to non-supervised follow-up , and 43 had died . the median follow-up in syst-eur 2 was 14.3 months . at the last available visit , systolic/diastolic bp in the patients formerly r and omised to placebo ( n = 1682 ) or active treatment ( n = 1824 ) , had decreased by 13.2/5.2 mm Hg and by 4.6/1.6 mm Hg , respectively , so that the between-group BP difference was 1.7 mm Hg systolic ( 95 % Cl : 0.8 to 2.6 mm Hg ; P < 0.001 ) and 0.9 mm hg diastolic ( 95 % cl : 0.4 to 1.5 mm mm hg ; P < 0.001 ) . at the beginning of syst-eur 2 , the goal bp was reached by 25.4 % and 50.6 % of the former placebo and active-treatment groups ; at the last visit these proportions were 55.9 % and 63.1 % , respectively . at that moment , 45.9 % of the patients were on monotherapy with nitrendipine , 29.3 % took nitrendipine in combination with other study drugs . until the end of 2001 , bp control of the syst-eur 2 patients will be further improved . cardiovascular complications and adverse events , such as cancer or gastro-intestinal bleeding , will be monitored and vali date d by blinded experts OBJECTIVE To study whether the cardiovascular preventive effect of antihypertensive therapy can be explained solely by the reduction in office blood pressure , and to what extent the risk of stroke and cardiac events is associated with in- study diastolic blood pressure ( DBP ) and systolic blood pressure ( SBP ) . DESIGN The Swedish Trial in Old Patients with Hypertension ( STOP-Hypertension ) was a prospect i ve , r and omized , double-blind , multicentre trial comparing active antihypertensive treatment with placebo in patients aged 70 - 84 years . The study group comprised 1,627 elderly patients ( mean blood pressure 195/102 mm Hg ; mean age 75.7 , SD 3.7 ; 63 % females ) . The average follow-up was 25 months ( range 6 - 65 months ) . No patient was lost to follow-up . METHOD We applied a Poisson model taking current age , sex , treatment , DBP and SBP into account for all patients in the study . The constants of the model were estimated by the maximum likelihood method . RESULTS The risk of stroke was significantly lower ( 42 % , p = 0.0402 ) for a patient on active therapy than for a patient on placebo having the same blood pressure level , age , and sex . There was a corresponding , non-significant , reduction in cardiac events of 21 % . In the whole study group the risk of stroke increased by 3 % per mmHg ( p = 0.0247 ) with increasing diastolic blood pressure for a given systolic pressure . The corresponding value for cardiac events was 2 % per mmHg ( p = 0.0376 ) . CONCLUSION In STOP-Hypertension we found a substantial risk reduction in stroke in actively treated patients , which was not solely explained by the blood pressure reduction obtained by treatment with beta-blockers and a potassium-sparing diuretic combination CONTEXT Blood pressure control ( < 140/90 mm Hg ) rates for hypertension fall far short of the US national goal of 50 % or more . Achievable control rates in varied practice setting s and geographic regions and factors that predict improved blood pressure control are not well identified . OBJECTIVE To determine the success and predictors of blood pressure control in a large hypertension trial involving a multiethnic population in diverse practice setting s. DESIGN The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial is a r and omized , double-blind , active-controlled clinical trial with a mean follow-up of 4.9 years . Participant enrollment began in February 1994 and follow-up was completed in March 2002 . SETTING A total of 623 centers in the United States , Canada , and the Caribbean . PARTICIPANTS A total of 33,357 participants ( aged > or = 55 years ) with hypertension and at least one other coronary heart disease risk factor . INTERVENTIONS Participants were r and omly assigned to receive ( double-blind ) chlorthalidone , 12.5 - 25 mg/d ( n=15,255 ) , amlodipine 2.5 - 10 mg/d ( n=9048 ) , or lisinopril 10 - 40 mg/d ( n=9054 ) after other medication was discontinued . Doses were increased within these ranges and additional drugs from other classes were added as needed to achieve blood pressure control ( < 140/90 mm Hg ) . MAIN OUTCOME MEASURES The outcome measures for this report are systolic and diastolic blood pressure , the proportion of participants achieving blood pressure control ( < 140/90 mm Hg ) , and the number of drugs required to achieve control in all three groups combined . RESULTS Mean age was 67 years , 47 % were women , 35 % black , 36 % diabetic ; 90 % were on antihypertensive drug treatment at entry . At the first of two pre-r and omization visits , blood pressure was < 140/90 mm Hg in only 27.4 % of participants . After 5 years of follow-up , the percent controlled improved to 66 % . Systolic blood pressure was < 140 mm Hg in 67 % of participants , diastolic blood pressure was < 90 mm Hg in 92 % , the mean number of drugs prescribed was 2.0+/-1.0 , and the percent on > or = 2 drugs was 63 % . Blood pressure control varied by geographic regions , practice setting s , and demographic and clinical characteristics of participants . CONCLUSIONS These data demonstrate that blood pressure may be controlled in two thirds of a multiethnic hypertensive population in diverse practice setting s. Systolic blood pressure is more difficult to control than diastolic blood pressure , and at least two antihypertensive medications are required for most patients to achieve blood pressure control . It is likely that the majority of people with hypertension could achieve a blood pressure < 140/90 mm Hg with the antihypertensive medications available today Hypertension is the most common condition seen in primary care and leads to myocardial infa rct ion , stroke , renal failure , and death if not detected early and treated appropriately . Patients want to be assured that blood pressure ( BP ) treatment will reduce their disease burden , while clinicians want guidance on hypertension management using the best scientific evidence . This report takes a rigorous , evidence -based approach to recommend treatment thresholds , goals , and medications in the management of hypertension in adults . Evidence was drawn from r and omized controlled trials , which represent the gold st and ard for determining efficacy and effectiveness . Evidence quality and recommendations were grade d based on their effect on important outcomes . There is strong evidence to support treating hypertensive persons aged 60 years or older to a  BP goal  of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg ; however , there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal , or in those younger than 30 years for a diastolic goal , so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion . The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease ( CKD ) as for the general hypertensive population younger than 60 years . There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor , angiotensin receptor blocker , calcium channel blocker , or thiazide-type diuretic in the nonblack hypertensive population , including those with diabetes . In the black hypertensive population , including those with diabetes , a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy . There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes . Although this guideline provides evidence -based recommendations for the management of high BP and should meet the clinical needs of most patients , these recommendations are not a substitute for clinical judgment , and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient BACKGROUND Good blood pressure ( BP ) control reduces the risk of complications in people with type 2 diabetes , yet many do not achieve this . Guidelines for managing hypertension recommend increasing antihypertensive medications until control is achieved , but the effect of such recommendations in routine primary care is unknown . AIM To evaluate the effectiveness of a BP treatment algorithm in primary care patients with type 2 diabetes . DESIGN OF STUDY A cluster r and omised controlled trial of 1534 patients with type 2 diabetes . SETTING Forty-two practice s in Nottingham , UK . METHOD Practice s were r and omised to continue usual care or to use a treatment algorithm design ed so that practice nurses and GPs would increase antihypertensive treatment in steps until the target of 140/80 mmHg was reached . Participants were assessed by a clinical interview and case note review at recruitment and at 1 year . The primary outcome measure was the proportion of participants achieving target BP at 1 year . RESULTS At 1 year there was no difference between the proportions of participants with well controlled BP in the intervention and control arms ( 36.6 % versus 34.3 % ; P = 0.27 ) . Mean systolic and diastolic blood pressures were identical in the two arms ( 143/78 mmHg ) . There was some evidence that participants in the intervention arm were more likely to be receiving higher doses of their antihypertensive drugs , although there was no significant difference in the number of different antihypertensive drugs prescribed . Participants in the intervention arm had a higher rate of primary care BP-related consultations over 12 months than those receiving usual care ( rate ratio = 1.55 , 95 % confidence interval [ CI ] = 1.26 to 1.88 , P<0.001 ) . CONCLUSION Despite increased monitoring and possibly higher doses of medication there was no improvement in blood pressure control . Improvements achieved by specialist nurse-led clinics in secondary care may not translate to people with type 2 diabetes in primary care setting IMPORTANCE Hypertension is a major public health problem in sub-Saharan Africa , but the lack of affordable treatment and the poor quality of health care compromise antihypertensive treatment coverage and outcomes . OBJECTIVE To report the effect of a community-based health insurance ( CBHI ) program on blood pressure in adults with hypertension in rural Nigeria . DESIGN , SETTING , AND PARTICIPANTS We compared changes in outcomes from baseline ( 2009 ) between the  CBHI program  area and a control area in 2011 through consecutive household surveys . Households were selected from a stratified r and om sample of geographic areas . Among 3023 community-dwelling adults , all nonpregnant adults ( aged ≥18 years ) with hypertension at baseline were eligible for this study . INTERVENTION Voluntary CBHI covering primary and secondary health care and quality improvement of health care facilities . MAIN OUTCOMES AND MEASURES The difference in change in blood pressure from baseline between the program and the control areas in 2011 , which was estimated using difference-in-differences regression analysis . RESULTS Of 1500 eligible households , 1450 ( 96.7 % ) participated , including 564 adults with hypertension at baseline ( 313 in the program area and 251 in the control area ) . Longitudinal data were available for 413 adults ( 73.2 % ) ( 237 in the program area and 176 in the control area ) . Baseline blood pressure in respondents with hypertension who had incomplete data did not differ between areas . Insurance coverage in the hypertensive population increased from 0 % to 40.1 % in the program area ( n = 237 ) and remained less than 1 % in the control area ( n = 176 ) from 2009 to 2011 . Systolic blood pressure decreased by 10.41 ( 95 % CI , -13.28 to -7.54 ) mm Hg in the program area , constituting a 5.24 ( -9.46 to -1.02)-mm Hg greater reduction compared with the control area ( P = .02 ) , where systolic blood pressure decreased by 5.17 ( -8.29 to -2.05 ) mm Hg . Diastolic blood pressure decreased by 4.27 ( 95 % CI , -5.74 to -2.80 ) mm Hg in the program area , a 2.16 ( -4.27 to -0.05)-mm Hg greater reduction compared with the control area , where diastolic blood pressure decreased by 2.11 ( -3.80 to -0.42 ) mm Hg ( P = .04 ) . CONCLUSIONS AND RELEVANCE Increased access to and improved quality of health care through a CBHI program was associated with a significant decrease in blood pressure in a hypertensive population in rural Nigeria .  Community-based health insurance programs should be included in strategies to combat cardiovascular disease in sub-Saharan Africa OBJECTIVE To examine the effect of rosiglitazone on insulin resistance and blood pressure in patients with essential hypertension , classified based on abnormalities of their renin-angiotensin system . RESEARCH DESIGN AND METHODS A total of 24 hypertensive nondiabetic patients ( age 58 + /- 6 years , BMI 30 + /- 5 kg/m2 ) were studied before and after rosiglitazone treatment . After 2 weeks off antihypertensive medication , subjects received a euglycemic-hyperinsulinemic clamp ( 40 mU. m(-2 ) . min(-1 ) ) with 6,6-[2H2]glucose infusion , ambulatory blood pressure monitoring , and blood tests for cardiovascular risk factors . Subjects were then placed on rosiglitazone ( 4 mg orally b.i.d . ) and their usual antihypertensive medications ( but not ACE inhibitors ) for 16 weeks , and baseline tests were repeated . RESULTS There was no change in fasting plasma glucose ( 83 + /- 2 vs. 82 + /- 2 mg/dl , P = 0.60 ) , but fasting insulin decreased ( 16.1 + /- 1.4 vs. 12.5 + /- 0.9 micro U/ml , P < 0.01 ) . Total glucose disposal during the clamp increased ( 5.0 + /- 0.4 vs. 5.9 + /- 0.5 mg . kg(-1 ) . min(-1 ) , P < 0.001 ) , with no change in suppression of hepatic glucose output . There were significant decreases in mean 24-h systolic ( 138 + /- 2 vs. 134 + /- 2 mmHg , P < 0.02 ) and diastolic ( 85 + /- 2 vs. 80 + /- 2 mmHg , P < 0.0001 ) blood pressure , and the decline in systolic blood pressure was correlated with the improvement in insulin sensitivity ( r = 0.59 , P < 0.005 ) . Triglycerides ( 135 + /- 16 vs. 89 + /- 8 mg/dl , P < 0.01 ) , LDL cholesterol ( 129 + /- 6 vs. 122 + /- 8 mg/dl , P = 0.18 ) , and HDL cholesterol ( 51 + /- 3 vs. 46 + /- 3 mg/dl , P < 0.02 ) all decreased , with no change in the LDL-to-HDL ratio . Plasminogen activator inhibitor-1 and C-reactive protein also declined significantly . CONCLUSIONS Rosiglitazone treatment of nondiabetic hypertensive patients improves insulin sensitivity , reduces systolic and diastolic blood pressure , and induces favorable changes in markers of cardiovascular risk . Insulin sensitizers may provide cardiovascular benefits when used in the treatment of patients with hypertension Background Previously alternate nostril yoga breathing ( anuloma-viloma pranayama ) was shown to reduce the  blood pressure ( BP ) in people with hypertension . An elevated BP has been associated with poor performance in certain tasks requiring attention and co-ordination . The Purdue pegboard task assesses manual dexterity and eye-h and co-ordination . Material / Methods In the present study there were ninety participants with essential hypertension . Their ages ranged from 20 to 59 years ( group average age ±S.D. , 49.7±9.5 years ; sixty males ) . Participants were r and omized as three groups , with thirty participants in each group . One group practice d alternate nostril yoga breathing for 10 minutes , the second group practice d breath awareness for the same duration and the third group was given a control intervention ( i.e. , reading a magazine with neutral content ) . Assessment s were taken before and after the interventions for participants of the three groups . Assessment s included the blood pressure and performance in the Purdue pegboard task . Data were analyzed with a repeated measures ANOVA and post-hoc analyses were Bonferroni adjusted . Results Following alternate nostril breathing ( ANYB ) there was a significant decrease in systolic and diastolic blood pressure ( p<0.001 and p<0.05 ) , and an improvement in Purdue pegboard task scores for both h and s ( p<0.05 ) , and for the right h and ( p<.001 ) . Breath awareness ( the control session ) also showed a significant decrease in systolic blood pressure ( p<0.05 ) . The right h and scores improved in the group reading a magazine ( p<0.05 ) . Conclusions The results suggest that the immediate effect of ANYB is to reduce the BP while improving the performing in a task requiring attention , bimanual dexterity and visuo-motor co-ordination The aim of our investigation was to determine whether the presence of additional risk factors or type of hypertension ( diastolic or isolated systolic ) influences blood pressure ( BP ) response to treatment . The International Nifedipine GITS Study : Intervention as a Goal in Hypertension Treatment ( INSIGHT ) study is a double-blinded outcome comparison of calcium channel blockade with diuretics in high-risk patients aged 55 to 80 years . Dynamic r and omization between nifedipine once daily and hydrochlorothiazide/amiloride was performed to ensure that approximately equal numbers of patients in the 2 groups had each of the major cardiovascular risk factors . Patients with isolated systolic hypertension were also separately r and omized . Atenolol or enalapril was the m and atory second-line drug . In 5669 patients who completed the 18-week titration , BP fell from 172+/-15/99+/-9 mm Hg ( mean+/-SD ) while receiving placebo to 139+/-12/82+/-7 mm Hg . Twenty-six percent of patients required 2 drugs , and 4 % required 3 drugs . Patients with diabetes were the most resistant to treatment , requiring second and third drugs 40 % and 100 % more frequently than patients without diabetes and achieving marginally the highest final BP , for any risk group , of 141+/-13/82+/-8 mm Hg . Age , smoking , gender , hypercholesterolemia , left ventricular hypertrophy , and existing atherosclerosis had little ( < 1 mm Hg ) or no influence on BP at the end of titration , but all except smoking slightly reduced the initial response of either systolic or diastolic BP . Patients with isolated systolic hypertension were slightly more responsive than average to treatment . Our findings suggest that in patients at high absolute risk of cardiovascular complications from hypertension , the risk factors themselves do not prevent the recommended BP targets from being achieved BACKGROUND Regular exercise has been associated in prospect i ve studies with reduced incidence of  cardiovascular disease ( CVD ) and death  . OBJECTIVE To assess in a cohort study whether there is a similar protective effect of regular exercise among hypertensive individuals . DESIGN Population -based prospect i ve cohort study . Spare time physical activity was assessed by structured interview . SETTING Malmo , Sweden . PARTICIPANTS Healthy men ( n = 642 ) born in 1914 . A baseline examination took place in 1969 - 1970 . MAIN OUTCOME MEASURES All-cause and cardiovascular mortality rates during 25 years of follow-up in relation to blood pressure and other risk factors for atherosclerosis . RESULTS One-hundred ( 16 % ) men reported vigorous spare time physical activity . In this group , 31 had hypertension ( blood pressure > 160/95 mm Hg or treatment for hypertension ) , 47 were smokers and 39 had hyperlipidaemia . Among the 173 men with hypertension , vigorous physical activity was associated with markedly reduced rates of all-cause ( 17.3 versus 40.0 deaths per 1000 person-years ) and cardiovascular mortality ( 6.3 versus 21.0 deaths per 1000 person-years ) . The risk reductions associated with exercise remained statistically significant after adjustment for smoking , systolic blood pressure and antihypertensive therapy . The relative risk was 0.43 ( confidence interval 0.22 - 0.82 ) for total mortality and 0.33 ( confidence interval 0.11 -0.94 ) for CVD mortality . CONCLUSION People who regularly perform physical activity constitute a heterogeneous group with regard to their exposure to known cardiovascular risk factors . Our results support the view that regular physical activity is associated with a reduced incidence of cardiovascular disease and death and suggest that this protective effect may be enhanced among hypertensive individuals Background —Left ventricular hypertrophy ( LVH ) is a common risk factor for cardiovascular mortality . Causes other than hypertension have not previously been investigated longitudinally . The aim of the present study was to determine hemodynamic , metabolic , and psychosocial predictors at 50 years of age for the prevalence of echocardiographic LVH and geometric subtypes at age 70 by use of a large sample of men from the general population followed up for 20 years . Methods and Results —In 1970 to 1973 , all men born from 1920 to 1924 and residing in Uppsala County , Sweden , were invited to participate in a health survey aim ed at identifying risk factors for cardiovascular disease . At a reinvestigation 20 years later , echocardiographic left ventricular mass index was determined in 475 subjects . A 1-SD increase in body mass index , systolic or diastolic blood pressure , fasting LDL/HDL cholesterol , serum triglycerides , or the serum cholesterol ester proportion of several saturated fatty acids or oleic acid at age 50 significantly increased the odds of having LVH at age 70 by 27 % to 41 % , whereas an increase in linoleic acid proportion was protective . Almost all metabolic predictors were independent of ischemic heart disease , valvular disease , and use of antihypertensive medication at age 70 . Conclusions —Dyslipidemia and indices of a low dietary intake of linoleic acid and high intake of saturated and monounsaturated fats , as well as hypertension and obesity , at age 50 predicted the prevalence of LVH 20 years later in this prospect i ve longitudinal cohort study , thereby suggesting that lipids may be important in the origin of LVH BACKGROUND The prevalence of hypertension and its cardiovascular complications is higher in African Americans than in whites . Interventions to control blood pressure in this population are particularly important . Regular exercise lowers blood pressure in patients with mild-to-moderate hypertension , but its effects in patients with severe hypertension have not been studied . We examined the effects of moderately intense exercise on blood pressure and left ventricular hypertrophy in African-American men with severe hypertension . METHODS We r and omly assigned 46 men 35 to 76 years of age to exercise plus antihypertensive medication ( 23 men ) or antihypertensive medication alone ( 23 men ) . A total of 18 men in the exercise group completed 16 weeks of exercise , and 14 completed 32 weeks of exercise , which was performed three times per week at 60 to 80 percent of the maximal heart rate . RESULTS After 16 weeks , mean ( + /- SD ) diastolic blood pressure had decreased from 88 + /- 7 to 83 + /- 8 mm Hg in the patients who exercised , whereas it had increased slightly , from 88 + /- 6 to 90 + /- 7 mm Hg , in those who did not exercise ( P = 0.002 ) . Diastolic blood pressure remained significantly lower after 32 weeks of exercise , even with substantial reductions in the dose of antihypertensive medication . In addition , the thickness of the interventricular septum ( P = 0.03 ) , the left ventricular mass ( P = 0.02 ) , and the mass index ( P = 0.04 ) had decreased significantly after 16 weeks in the patients who exercised , whereas there was no significant change in the nonexercisers . CONCLUSIONS Regular exercise reduced blood pressure and left ventricular hypertrophy in African-American men with severe hypertension & NA ; Isolated systolic hypertension ( ISH ) is a definite risk factor for cardiovascular complications ( i.e. , cardiac failure , coronary artery disease , and stroke ) independent of diastolic elevation . The prevalence of ISH is estimated to be approximately 15‐20 % in the population above the age of 60 years , and increases with advancing age . The Systolic Hypertension in the Elderly ( SHELL ) study is planned to evaluate the efficacy and tolerability of lacidipine , matched with the diuretic chlorthalidone , in treatment of ISH in elderly hypertensive patients ( EHP ) . One hundred fifteen Italian centers will participate in the study . Fifty centers are associated with the Società Italiana di Geriatria Ospedaliera and 65 centers are departments of internal medicine or outpatient clinics for management of hypertension . A total of 4,800 patients will be enrolled in the trial . Two subprojects will consist of periodical echocardiographic evaluation and 24‐h ambulatory blood pressure monitoring . The primary end point of the SHELL study is the incidence of cardiovascular and cerebrovascular events in EHP with ISH , treated with either lacidipine or chlorthalidone . In particular , the SHELL trial is intended to determine whether lacidipine treatment will significantly reduce fatal myocardial events and total cardiovascular mortality OBJECTIVE To measure the prevalence of untreated hypertension in Australian adults , and examine the associations with clinical and lifestyle factors . DESIGN AusDiab , a cross-sectional survey conducted between May 1999 and December 2000 , involved participants from 42 r and omly selected census districts throughout Australia . PARTICIPANTS Of 20 347 eligible people aged > or= 25 years who completed a household interview , 11 247 attended a physical examination  ( response rate , 55 % ) . MAIN OUTCOME MEASURES The prevalence of hypertension ( blood pressure > or= 140/90 mmHg or self-reported use of antihypertensive drugs ) and its treatment ; associations of clinical and lifestyle factors with the treatment of hypertension ; and adequacy of treatment for primary and secondary prevention of cardiovascular disease . RESULTS The prevalence of hypertension was 28.6 per 100 ( 95 % CI , 25.0 - 32.3 ) , and the prevalence of untreated hypertension was 15.2 per 100 ( 95 % CI , 13.2 - 17.2 ) . Of those with untreated hypertension , 80.8 % ( 95 % CI , 74.7%-85.0 % ) had had a  blood pressure check within the preceding 12 months . At least one modifiable lifestyle factor was present in 71.7 % ( 95 % CI , 68.5%-74.8 % ) of participants with untreated hypertension . Although lower risk clinical characteristics of younger age and lack of hyperlipidaemia were independently associated with untreated hypertension , 53.5 % warranted treatment based on current cardiovascular disease prevention guidelines and multivariable absolute risk assessment . CONCLUSIONS Considerable scope remains for reducing the burden of cardiovascular disease through lifestyle modification and rational treatment of hypertension
The reduction in cardiovascular mortality and morbidity was primarily due to a reduction in cerebrovascular mortality and morbidity .
AUTHORS ' CONCLUSIONS Treating healthy adults 60 years or older with moderate to severe systolic and /or diastolic hypertension with antihypertensive drug therapy reduced all-cause mortality , cardiovascular mortality and morbidity , cerebrovascular mortality and morbidity , and coronary heart disease mortality and morbidity .
Most evidence of benefit pertains to a primary prevention population using a thiazide as first-line treatment
BACKGROUND This is the second substantive up date of this review .
It was originally published in 1998 and was previously up date d in 2009 .
Elevated blood pressure ( known as ' hypertension ' ) increases with age - most rapidly over age 60 .
Systolic hypertension is more strongly associated with cardiovascular disease than is diastolic hypertension , and it occurs more commonly in older people .
It is important to know the benefits and harms of antihypertensive treatment for hypertension in this age group , as well as separately for people 60 to 79 years old and people 80 years or older .