Legacy Effect of Delayed Blood Pressure-Lowering Pharmacotherapy in Middle-Aged Individuals Stratified by Absolute Cardiovascular Disease Risk: Protocol for a Systematic Review Lowering blood pressure reduces renal events in type 2 diabetes. Home-based self-measurement of blood pressure: a proposal using new reference values (the PURAS study) Protocol for Past BP: a randomised controlled trial of different blood pressure targets for people with a history of stroke of transient ischaemic attack (TIA) in primary care The Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients (JATOS): Protocol, Patient Characteristics, and Blood Pressure during the First 12 Months Ten-year legacy effects of baseline blood pressure ‘treatment naivety’ in the Second Australian National Blood Pressure study Oat consumption does not affect resting casual and ambulatory 24-h arterial blood pressure in men with high-normal blood pressure to stage I hypertension. Effects of oral magnesium supplementation on insulin sensitivity and blood pressure in normo-magnesemic nondiabetic overweight Korean adults. Control of Blood Pressure and Risk Attenuation: Post Trial Follow-Up of Randomized Groups Community-Based Lifestyle Intervention for Reducing Blood Pressure and Glucose among Middle-Aged and Older Adults in China: A Pilot Study 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). The relationship between nut consumption and blood pressure in an Iranian adult population: Isfahan Healthy Heart Program. Phone-based intervention for blood pressure control among Ghanaian stroke survivors: A pilot randomized controlled trial Effect of Antihypertensive Treatment on Cardiovascular Events in Elderly Hypertensive Patients: Japan's Benidipine Research on Anti-Hypertensive Effects in the Elderly (J-BRAVE) No adverse effect of non-steroidal anti-inflammatory drugs, sulindac and diclofenac sodium, on blood pressure control with a calcium antagonist, nifedipine, in elderly hypertensive patients. A randomised crossover comparison of reserpine and sustained-release nifedipine in hypertension.
Background Many national and international guidelines recommend that the initiation of blood pressure (BP)-lowering drug treatment for the primary prevention of cardiovascular disease ( CVD ) should no longer be based on BP level alone , but on absolute cardiovascular risk . While BP-lowering drug treatment is beneficial in high-risk individuals at any level of elevated BP , clinicians are concerned about legacy effects on patients with low-to-moderate risk and mildly elevated BP who remain “ untreated ” . Objective We aim to investigate the legacy effect of delayed BP-lowering pharmacotherapy in middle-aged individuals ( 45 - 65 years ) with mildly elevated BP ( systolic BP 140 - 159 mmHg and /or diastolic BP 90 - 99 mmHg ) stratified by absolute risk for primary prevention of CVD , but particularly in the low-risk ( < 10 % five-year absolute risk ) group . Methods R and omized trials of BP-lowering therapy versus placebo or pretreated subjects in active comparator studies with posttrial follow-up will be identified using a 2-step process . First , r and omized trials of BP-lowering therapy will be identified by ( 1 ) retrieving the references of trials included in published systematic review s of BP-lowering therapy , ( 2 ) retrieving studies published by the Blood Pressure Lowering Treatment Trialists ’ Collaboration ( BPLTTC ) , and ( 3 ) checking studies referenced in the 1993 World Health Organization/International Society of Hypertension meeting memor and um on BP management . Posttrial follow-up studies will then be identified by forward citation search ing the r and omized trials identified in step 1 through Web of Science . The search will include r and omized controlled trials with at least 1-year in-trial period and a posttrial follow-up phase . Age is the major determinant of absolute cardiovascular risk , so the participants in our review will be restricted to middle-aged adults who are more likely to have a lower cardiovascular risk profile . The primary outcome will be all-cause mortality . Secondary outcomes will include cardiovascular mortality , fatal stroke , fatal myocardial infa rct ion , and death due to heart failure . Results The search es for existing systematic review s and BPLTTC studies were piloted and modified . The study is expected to be completed before June 2018 . Conclusions The findings of this study will contribute to the body of knowledge concerning the beneficial , neutral , or harmful effects of delayed BP-lowering drug treatment on the primary prevention of CVD in patients with mildly elevated BP and low-to-moderate CVD risk . Trial Registration PROSPERO International Prospect i ve Register of Systematic Review s : CRD42017058414 ; https://www.crd.york.ac.uk/ PROSPERO /display_record.asp?ID = CRD42017058414 ( Archived by WebCite ® at http://www.webcitation.org/6t6sa8O2Q BP is an important determinant of kidney disease among patients with diabetes . The recommended thresholds to initiate treatment to lower BP are 130/80 and 125/75 mmHg for people with diabetes and nephropathy , respectively . We sought to determine the effects of lowering BP below these currently recommended thresholds on renal outcomes among 11,140 patients who had type 2 diabetes and participated in the Action in Diabetes and Vascular disease : preterAx and diamicroN-MR Controlled Evaluation ( ADVANCE ) study . Patients were r and omly assigned to fixed combination perindopril-indapamide or placebo , regardless of their BP at entry . During a mean follow-up of 4.3 yr , active treatment reduced the risk for renal events by 21 % ( P < 0.0001 ) , which was driven by reduced risks for developing microalbuminuria and macroalbuminuria ( both P < 0.003 ) . Effects of active treatment were consistent across subgroups defined by baseline systolic or diastolic BP . Lower systolic BP levels during follow-up , even to < 110 mmHg , was associated with progressively lower rates of renal events . In conclusion , BP-lowering treatment with perindopril-indapamide administered routinely to individuals with type 2 diabetes provides important renoprotection , even among those with initial BP < 120/70 mmHg . We could not identify a BP threshold below which renal benefit is lost Objectives To establish reference values for blood pressure by means of self-measurement of blood pressure ( BP ) conducted at home . Design Descriptive study of the distribution of self-measured BP at home and its correspondence with clinic-based measurements of BP . Methods The aim of this study is to define the home BP levels that correspond to clinic BP thresholds 140/90 mmHg ( hypertension ) and 130/85 mmHg ( normality ) . The sample consisting of 1411 r and omly selected adults stratified by age and gender . A pre-calibrated electronic device ( Omron 705CP ) was used for BP and heart rate ( HR ) measurements  and a trained nurse performed clinic-based sphygmomanometer measurements . The same nurse provided tutorials for the subjects on how to obtain 12  self-measured BP values at home using the Omron device in a single day . Results Of the 1184 volunteers that attended the appointment , 195 were known as hypertensives and were excluded from the study . The average age of the remaining 989 subjects ( 50.4 % females ) was 44.3 years .  Clinic BP values were significantly higher than self-measured BP at home regardless of age and gender . Both had good correlations ( systolic BP , r=0.84 and diastolic BP , r=0.77 ) . Using linear regression , the self-measured BP at home hypertension threshold would be 131/82 mmHg and the limit of normality 123/78 mmHg . Using corresponding percentiles , these values would be 134/85 and 124/80 mmHg , respectively . Conclusions The self-measured BP at home values found in this study , when defining hypertension , are lower than values currently accepted ( 135/85 mmHg ) . Long-term studies are necessary to confirm these results Background Blood pressure ( BP ) lowering in people who have had a stroke or transient ischaemic attack ( TIA ) leads to reduced risk of further stroke . However , it is not clear what the target BP should be , since intensification of therapy may lead to additional adverse effects . PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting , and whether more intensive therapy is associated with adverse effects on quality of life . Methods / Design This is a r and omised controlled trial ( RCT ) in patients with a past history of stroke or TIA . Patients will be r and omised to two groups and will either have their blood pressure ( BP ) lowered intensively to a target of 130 mmHg systolic , ( or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg ) compared to a st and ard group where the BP will be reduced to a target of 140 mmHg systolic . Patients will be managed by their practice at 1 - 3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.610 patients will be recruited from approximately 50 general practice s. The following exclusion criteria will be applied : systolic BP < 125 mmHg at baseline , 3 or more anti-hypertensive agents , orthostatic hypotension , diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness . The primary outcome will be change in systolic BP over twelve months . Secondary outcomes include quality of life , adverse events and cardiovascular events . In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals underst and ing and views of BP management . Discussion The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care , and help determine whether or not further research is required before recommending such targets for this population .Trial Registration IS RCT The benefits of a systolic blood pressure ( BP ) below 150–160 mmHg are well established ; whether a systolic BP of less than 140 mmHg provides additional benefits remains controversial . This study was design ed to compare the 2-year effect of a strict treatment to maintain systolic BP below 140 mmHg ( group A ) and that of a mild treatment to maintain systolic BP at between 140 and below 160 mmHg ( group B ) . The study design followed the Prospect i ve R and omized Open Blinded End-point ( PROBE ) study . The subjects were elderly patients ( 65–85 years old ) who consistently had a systolic BP of 160 mmHg or higher . The baseline drug was efonidipine hydrochloride ( efonidipine ) , a long-acting dihydropiridine calcium antagonist . The primary endpoints were stroke , cardiac disease , vascular disease , and renal failure . After a run-in period of 2 to 4 weeks , 2,165 patients were assigned to group A and 2,155 patients to group B. There were no significant differences between the groups in sex , age , baseline BP , or other cardiovascular risk factors . The systolic BP was 7.2 mmHg lower ( p<0.0001 ) and the diastolic BP 2.4 mmHg lower ( p<0.0001 ) in group A than in group B after 12 months of treatment . As of this interim analysis , primary endpoints have occurred in 87 patients ( stroke in 58 patients , cardiac disease in 27 patients , occlusive arterial disease in 1 patient , and renal failure in 1 patient ) . Five patients have died of stroke and 2 patients of myocardial infa rct ion . The primary -endpoint-related morbidity rate was 20.9/1,000 patient-years , and the mortality rate was 1.7/1,000 patient-years . Currently available results indicate that this study , one of the largest r and omized trials of antihypertensive therapy in elderly patients in Japan , was conducted safely . The final results are expected to provide important and practical information for the management of hypertension in elderly patients Objectives : Current blood pressure ( BP ) management guidelines recommend that treatment thresholds for BP be based on absolute cardiovascular disease ( CVD ) risk rather than on elevated BP levels alone . Clinicians are concerned that delayed pharmacotherapy in individuals with high BP , but low CVD risk , may increase long-term CVD events . To investigate this , we examined differences in CVD events within the Second Australian National BP study ( ANBP2 ) for those previously on pharmacotherapy and those who were not , as well as fatal events in the 6-year post-trial period . Methods : Population consisted of ANBP2 participants without a prior CVD event . Adjusted Cox-regression hazard models were used to assess the effects of prior BP pharmacotherapy use on cardiovascular endpoints within ANBP2 . An extended 6-year follow-up analysis for cardiovascular and all-cause mortality was also conducted . Results : We found a higher in-trial CVD and all-cause mortality rate and incidence of new-onset diabetes for those on previous treatment versus those who were treatment-naive . We investigated whether this was an effect of the in-trial protocol , but this did not explain the observed differences . No difference in CVD or all-cause mortality at 10 years was observed between ‘ treatment-naive ’ and ‘ previous treatment ’ groups . Conclusion : We found no long-term adverse mortality associated with treatment naivety of elevated BP in an elderly hypertensive cohort , but this finding is likely to be confounded as seen by the lower in-trial mortality in the ‘ treatment-naive ’ group . Legacy effects need to be explored in r and omized trials of middle-aged population s where the clinical concern lies The results of epidemiologic studies suggest that increased intake of dietary fiber is associated with lower levels of arterial blood pressure ( BP ) . However , there is little information available addressing the possibility that increased oat consumption may reduce arterial BP in individuals with elevated arterial BP . To test this hypothesis , middle-aged and older men ( n = 36 ; body mass index , 25 - 35 kg/m(2 ) ; aged 50 - 75 y ) with elevated BP ( systolic BP 130 - 159 mmHg and /or diastolic BP 85 - 99 mmHg ) were r and omly assigned to consume an additional 14 g/d of dietary fiber in the form of oat ( 5.5 g beta-glucan , n = 18 ) or wheat cereals ( no beta-glucan , n = 18 ) for 12 wk . Casual resting arterial BP was measured at baseline and after 4 , 8 and 12 wk of intervention . The 24-h ambulatory arterial BP was measured at baseline and after 12 wk of intervention . There were no differences in casual resting or 24-h ambulatory BP at baseline in the two groups . Casual systolic BP ( SBP ) did not change as a result of the 12-wk intervention in the oat ( 138 plus minus 2 vs. 135 plus minus 3 mmHg ) or wheat ( 142 plus minus 2 vs. 140 plus minus 3 mmHg ) groups , respectively ( all P > 0.05 ) . Casual diastolic BP ( DBP ) also did not change in the oat ( 89 plus minus 2 vs. 88 plus minus 2 mmHg ) or wheat ( 90 plus minus 2 vs. 91 plus minus 2 mmHg ) group during this period ( all P > 0.05 ) . Further , 24-h , daytime and nighttime SBP and DBP did not decrease with the intervention . Therefore , the results of the present study suggest that any cardioprotective benefit of regular oat consumption may not be conferred via an arterial BP-lowering effect BACKGROUND AND AIM Little is known about the effect of magnesium on insulin sensitivity and BP in healthy individuals . Therefore , we investigated whether magnesium could improve insulin sensitivity and blood pressure ( BP ) in normo-magnesemic nondiabetic overweight adults . METHODS AND RESULTS In a double-blinded , placebo-controlled , r and omized trial , a total of 155 participants ( BMI > or = 23 kg/m(2 ) ) received either 12.3 mmol ( 300 mg ) of elemental magnesium in the form of magnesium oxide ( n=75 ) or placebo ( n=80 ) each day for 12 weeks , constituting the intent-to-treat population . A repeated- measures ANOVA was used to evaluate the between-group changes in variables during the study . The baseline characteristics between the intervention and control groups were similar . There were no significant differences between the groups in the pattern of change of the homeostasis model assessment insulin resistance index , BP over time during the 12-week study . In subgroup analysis , magnesium supplementation ( n=8 , 27 , and 24 , respectively ) lowered BP much more than placebo ( n=16 , 29 , and 25 , respectively ) in those subjects whose systolic BP > or = 140 mmHg , diastolic BP 80 - 90 mmHg , and diastolic BP > or = 90 mmHg at the start of the study ( P=0.016 , 0.043 , and 0.023 , respectively ) ; in comparison , those subjects whose initial BP reading was low at baseline did not show a change in BP . No significant adverse events related to magnesium supplementation were recorded . CONCLUSIONS These results suggested that magnesium supplementation does not reduce BP and enhance insulin sensitivity in normo-magnesemic nondiabetic overweight people . However , it appears that magnesium supplementation may lower BP in healthy adults with higher BP Background Evidence on long term effectiveness of public health strategies for lowering blood pressure ( BP ) is scarce . In the Control of Blood Pressure and Risk Attenuation ( COBRA ) Trial , a 2 x 2 factorial , cluster r and omized controlled trial , the combined home health education ( HHE ) and trained general practitioner ( GP ) intervention delivered over 2 years was more effective than no intervention ( usual care ) in lowering systolic BP among adults with hypertension in urban Pakistan . However , it was not clear whether the effect would be sustained after the cessation of intervention . We conducted 7 years follow-up inclusive of 5 years of post intervention period of COBRA trial participants to assess the effectiveness of the interventions on BP during extended follow-up . Methods A total of 1341 individuals 40 years or older with hypertension ( systolic BP 140 mm Hg or greater , diastolic BP 90 mm Hg or greater , or already receiving treatment ) were followed by trained research staff masked to r and omization status .  BP was measured thrice with a calibrated automated device ( Omron HEM-737 IntelliSense ) in the sitting position after 5 minutes of rest . BP measurements were repeated after two weeks . Generalized estimating equations ( GEE ) were used to analyze the primary outcome of change in systolic BP from baseline to 7- year follow-up . The multivariable model was adjusted for clustering , age at baseline , sex , baseline systolic and diastolic BP , and presence of diabetes . Findings After 7 years of follow-up , systolic BP levels among those r and omised to combined HHE plus trained GP intervention were significantly lower ( 2.1 [ 4.1–0.1 ] mm Hg ) compared to those r and omised to usual care , ( P = 0.04 ) . Participants receiving the combined intervention compared to usual care had a greater reduction in LDL-cholesterol ( 2.7 [ 4.8 to 0.6 ] mg/dl . Conclusions The benefit in systolic BP reduction observed in the original cohort assigned to the combined intervention was attenuated but still evident at 7- year follow-up . These findings highlight the potential for scaling-up simple strategies for cardiovascular risk reduction in low- and middle- income countries . Trial Registration Clinical Trials.gov Although evidence suggests that lifestyle interventions can reduce blood pressure ( BP ) and glucose levels , there is little information about the feasibility of such interventions when implemented in community setting s. This study evaluated the effectiveness of a community-based lifestyle intervention on BP and glucose in the middle-aged and older Chinese population . By using a cluster r and omisation approach , 474 participants from two communities were assigned to the intervention group which received intensive health education and behavioural intervention , or the control group which received conventional education . Linear mixed models were used to compare between-group differences on change in BP and fasting glucose after 6 , 12 and 24 months . At the 12-month follow-up , the intervention group experienced significantly reductions in systolic BP ( −4.9 vs. 2.4 mmHg ; mean difference [ MD ] −7.3 mmHg ; p < 0.001 ) , diastolic BP ( −1.9 vs. 1.9 mmHg ; MD −3.8 mmHg ; p < 0.001 ) and fasting glucose ( −0.59 vs. 0.08 mmol/L ; MD −0.67 mmol/L ; p < 0.001 ) . These differences were sustained at the 24-month follow-up . With only two communities , it was not possible to adjust for potential clustering by site . This approach of lifestyle interventions conducted through primary care services may be a potential solution for combating hypertension and diabetes in a re source -limited country context in China 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 AND AIMS Few studies outside of Western countries have evaluated the relationship between consumption of nuts and blood pressure ( BP ) . This study aim ed to investigate the relationship between nut consumption and blood pressure in an Iranian adult population . METHODS AND RESULTS We performed a cross-sectional investigation among 9660 r and omly selected Iranian adults , sample d to represent three large Iranian regions , using data collected in the Isfahan Healthy Heart Program in 2007 . The frequency of nut consumption was assessed by a food frequency question naire  . Systolic and diastolic BPs ( SBP and DBP ) were measured in duplicate by trained personnel using a st and ard protocol . Multiple linear and logistic regressions were applied to assess the relationship between nut intake and BP levels and the presence of hypertension as SBP ≥ 140 mmHg , and /or a DBP ≥ 90 mmHg and /or current use of at least one type of anti-hypertensive medication . Those with nut consumption ≥4 times/week showed less mean of BPs and hypertension prevalence , compared to those who consumed nuts < 1 times/week ( p < 0.001 ) . Compared to no consumption , consuming nuts ≥4 times/week was associated with a 34 % lower prevalence of hypertension ( multivariate odds ratio ( OR ) = 0.66 ; confidence interval ( CI ) = 0.51 - 0.87 ; p for trend = 0.009 ) . CONCLUSIONS More frequent nut consumption is associated with lower BP and lower risk of hypertension among Iranian adults Background The potential of mobile-health ( mHealth ) technology for the management of hypertension among stroke survivors in Africa remains unexplored . We assessed whether an mHealth technology-enabled , nurse-guided intervention initiated among stroke patients within one month of symptom onset is effective in improving their blood pressure ( BP ) control . Methods A two-arm pilot cluster r and omized controlled trial involving 60 stroke survivors , ≥18 years , with BP ≥140/90 mmHg at screening/enrollment visit at a medical center in Ghana . Participants in the intervention arm ( n = 30 ) received a Blue-toothed BP device and smartphone with an App for monitoring BP measurements and medication intake under nurse guidance for three months after which intervention was withdrawn . Control arm ( n = 30 ) received usual care . Primary outcome measure was proportion with clinic BP < 140/90 mmHg at month 9 ; secondary outcomes included medication adherence . Findings Mean ± SD age was 55 ± 13 years , 65 % males . Two participants on intervention and three in control group were lost to follow-up . At month 9 , proportion on the intervention versus controls with BP < 140/90 mmHg was 14/30 ( 46.7 % ) versus 12/30 ( 40.0 % ) , p = 0.79 by intention-to-treat ; systolic BP < 140 mmHg was 22/30 ( 73.3 % ) versus 13/30 ( 43.3 % ) , p = 0.035 . Mean ± SD medication possession ratio was 0.95 ± 0.16 on intervention versus 0.98 ± 0.24 in the control arm , p = 0.56 . Interpretation We demonstrate feasibility and signal of improvement in BP control  among stroke survivors in a re source -limited setting via an mHealth intervention . Larger scale studies are warranted . Trial registration NCT02568137 . Registered on 13 July 2015 at Clinical Trials.gov The achievement rate of blood pressure ( BP ) target and the relationship between on-treatment BP and development of cardiovascular events ( i.e. , stroke , myocardial infa rct ion , and heart failure ) were investigated in a total of 8,897 patients in the Japan 's Benidipine Research on Antihypertensive Effects in the Elderly ( J-BRAVE ) study , a prospect i ve , 3-year observational study of a  calcium channel blocker-based treatment in hypertensive patients aged ≥65 years as a post-marketing  surveillance . Blood pressure decreased significantly from 164.8 ± 14.1/88.2 ± 10.3 mmHg to 137.0 ± 13.5/75.6 ± 9.5 mmHg and the percentage of patients who achieved BP < 140/90 mmHg was 57.2 % after 3 years . The incidence of cardiovascular events was 7.54/1,000 patient-years . Subgroups of patients stratified by on-treatment systolic blood pressure ( SBP ) were analyzed . Baseline BP , body mass index ( BMI ) , the dose of benidipine , the mean number of anti-hypertensive drugs , and the incidence of cardiovascular events were higher in patients with on-treatment SBP ≥160 mmHg than in those with an SBP of < 130 mmHg . In patients aged 65 to 74 years ( n = 5,092 ) and patients aged ≥75 years ( n = 3,805 ) , the percentages of patients who achieved the BP target of < 140/90 mmHg were 57.5 % and 56.6 % after 3 years , respectively , and the incidence of cardiovascular events was higher in patients with on-treatment SBP ≥160 mmHg in both age subgroups . The results of the J-BRAVE study show that on-treatment SBP ≥160 mmHg is associated with a higher incidence of cardiovascular events in elderly hypertensive patients Effect of non-steroidal anti-inflammatory drug ( NSAID ) on blood pressure ( BP ) control was evaluated in elderly hypertensive patients treated with calcium antagonist .  The study was based on a r and omized , crossover design to compare the effect of an NSAID , sulindac , with that of another NSAID , diclofenac sodium , in the hypertension treatment . The study was completed in six elderly female subjects ( the average age : 66 + /- 3 year ) whose systolic BP and diastolic BP were more than 160 mmHg and more than 95 mmHg , respectively . When BP was controlled by nifedipine ( 20 mg x 2 per day in slow releasing form ) within normal limits , sulindac ( 100 mg x 3 per day ) or diclofenac sodium ( 25 mg x 3 per day ) was administered for a week . After one week-washout period , the other NSAID was substituted . Plasma and urinary variables were measured on the final day of each study period . The average systolic BP and diastolic BP and the entry of study were 167 + /- 5 mmHg and 93 + /- 5 mmHg , respectively . Nifedipine significantly decreased the systolic BP to 140 + /- 4 mmHg ( p less than 0.02 ) and the diastolic BP to 84 + /- 4 mmHg ( p less than 0.05 ) . Addition of either sulindac or diclofenac sodium did not affect BP , whereas urinary PGE2 excretion and plasma renin activity were significantly inhibited . Plasma creatinine and electrolyte concentration were not changed by the NSAIDs . The results indicate that either sulindac or diclofenac sodium does not interfere with control of hypertension by a calcium antagonist , nifedipine in in elderly hypertensive patients . ( ABSTRACT TRUNCATED AT 250 WORDS OBJECTIVE To compare the effectiveness of the combination of hydrochlorothiazide ( HCT ) plus sustained-release nifedipine with the combination of HCT plus reserpine in lowering  high blood pressure ( BP )  unresponsive to HCT monotherapy . DESIGN An open , r and omised crossover drug trial . SETTING Out patients ' clinic in Parirenyatwa Hospital , Harare , a tertiary referral centre . SUBJECTS 32 Black patients of both sexes with newly diagnosed or previously treated hypertension aged between 21 and 65 years who had a BP > 140/95 after receiving HCT 25 mg daily for four weeks were studied . INTERVENTION Patients were kept on HCT 25 mg daily and were r and omised to receive either reserpine 0.25 mg daily or nifedipine ( Adalat Retard ) 20 mg bd for four weeks . This was followed by a two week washout period during which patients received HCT 25 mg daily only . After the washout period patients were crossed over to the alternative treatment for four weeks . Patients were kept on HCT 25 mg daily throughout the trial . MAIN OUTCOME MEASURES The main outcome measure was the fall in BP which was taken as the difference between the BP at baseline and the BP at the end of each treatment period . Both systolic blood pressure ( SBP ) and diastolic blood pressure ( DBP ) measurements were taken . RESULTS Both second line drugs were effective in lowering SBP and DBP and there was no significant difference between them . Nifedipine reduced SBP by 18.9 mmHg ( 95 % CI 12.1 to 25.7 ) and DBP by 9.6 mmHg ( 95 % CI 7.2 to 12.0 ) . Reserpine reduced SBP by 15.9 mmHg ( 95 % CI 8.4 to 23.4 ) and DBP by 11.1 mmHg ( 95 % CI 7.5 to 14.6 ) . However , only two patients attained the target DBP of < or = 90 mmHg after each active treatment period . CONCLUSION AND RECOMMENDATIONS Since both agents were equally effective in reducing both SBP and DBP and reserpine is much cheaper than nifedipine , it is recommended that for a developing country like Zimbabwe , the combination of HCT and reserpine at the above doses should be used as the first step to treat mild to moderate hypertension without evidence of end organ damage . However , further trials should compare BP lowering effects as well as end organ protection offered by the trial drugs
The effects of delayed BP lowering treatment on long-term all-cause and CVD mortality did not vary with baseline risk of CVD .
The review showed no clinical ly adverse ‘ legacy effect ’ on mortality or major CVD event from not treating middle-aged adults at a systolic BP threshold of 140 mmHg or over .
Although these studies are non-r and omised post-hoc analyses , they may allay concerns that early treatment of elevated systolic BP is necessary to prevent CVD events in primary prevention population
To investigate if there is evidence for a ‘ legacy effect ’ for blood pressure ( BP ) lowering treatment , that is , worse health outcomes from not initiating drug treatment at a systolic BP threshold of 140 mmHg in middle-age adults .