"The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure" provides a new guideline
for hypertension prevention and management. The following are the key messages(1) In persons older than 50 years, systolic blood pressure (BP) of
more than 140 mm Hg is a much more important cardiovascular disease
(CVD) risk factor than diastolic BP; (2) The risk of CVD, beginning at 115/75
mm Hg, doubles with each increment of 20/10 mm Hg; individuals who are normotensive
at 55 years of age have a 90% lifetime risk for developing hypertension; (3)
Individuals with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80
to 89 mm Hg should be considered as prehypertensive and require health-promoting
lifestyle modifications to prevent CVD; (4) Thiazide-type diuretics should
be used in drug treatment for most patients with uncomplicated hypertension,
either alone or combined with drugs from other classes. Certain high-risk
conditions are compelling indications for the initial use of other antihypertensive
drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor
blockers, β-blockers, calcium channel blockers); (5) Most patients with
hypertension will require 2 or more antihypertensive medications to achieve
goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes
or chronic kidney disease); (6) If BP is more than 20/10 mm Hg above goal
BP, consideration should be given to initiating therapy with 2 agents, 1 of
which usually should be a thiazide-type diuretic; and (7) The most effective
therapy prescribed by the most careful clinician will control hypertension
only if patients are motivated. Motivation improves when patients have positive
experiences with and trust in the clinician. Empathy builds trust and is a
potent motivator. Finally, in presenting these guidelines, the committee recognizes
that the responsible physician's judgment remains paramount.

https://jamanetwork.com/journals/jama/articlepdf/196589/JSC30096.pdf

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

The Cochrane Handbook for Systematic Reviews of Interventions is the official document that describes in detail the process of preparing and maintaining Cochrane systematic reviews on the effects of healthcare interventions.

/pdf/cochrane-handbook-for-systematic-reviews-of-interventions-1xbdy6uvru.pdf

Cochrane Handbook for Systematic Reviews of Interventions

Atherosclerosis is an inflammatory disease. Because high plasma concentrations of cholesterol, in particular those of low-density lipoprotein (LDL) cholesterol, are one of the principal risk factors for atherosclerosis,1 the process of atherogenesis has been considered by many to consist largely of the accumulation of lipids within the artery wall; however, it is much more than that. Despite changes in lifestyle and the use of new pharmacologic approaches to lower plasma cholesterol concentrations,2,3 cardiovascular disease continues to be the principal cause of death in the United States, Europe, and much of Asia.4,5 In fact, the lesions of atherosclerosis represent . . .

https://www.nejm.org/doi/pdf/10.1056/NEJM199901143400207

Atherosclerosis — An Inflammatory Disease

Context Little is known about lifetime prevalence or age of onset of DSM-IV disorders. Objective To estimate lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the recently completed National Comorbidity Survey Replication. Design and Setting Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview. Participants Nine thousand two hundred eighty-two English-speaking respondents aged 18 years and older. Main Outcome Measures Lifetime DSM-IV anxiety, mood, impulse-control, and substance use disorders. Results Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse-control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%. Median age of onset is much earlier for anxiety (11 years) and impulse-control (11 years) disorders than for substance use (20 years) and mood (30 years) disorders. Half of all lifetime cases start by age 14 years and three fourths by age 24 years. Later onsets are mostly of comorbid conditions, with estimated lifetime risk of any disorder at age 75 years (50.8%) only slightly higher than observed lifetime prevalence (46.4%). Lifetime prevalence estimates are higher in recent cohorts than in earlier cohorts and have fairly stable intercohort differences across the life course that vary in substantively plausible ways among sociodemographic subgroups. Conclusions About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence. Interventions aimed at prevention or early treatment need to focus on youth.

https://www.ph.ucla.edu/epi/faculty/detels/PH150/Kessler_DSMIV_AGP2009.pdf

Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication

The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

The peripheral vascular response to severe exercise in eight dogs with heart failure produced by tricuspid avulsion and progressive pulmonary stenosis was compared to the response determined in eight control dogs. After full recovery from implantation of Doppler flow probes and miniature pressure gauges, measurements of arterial blood pressure and blood flow were telemetered from untethered dogs running behind a mobile recording vehicle at speeds of 10-25 mph over distances averaging 1 mile. Severe exercise in control dogs increased heart rate from 78 to 281 beats/min and mean arterial blood pressure from 93 to 134 mm Hg. Iliac blood flow rose from 151 to 897 ml/min, but mesenteric and renal blood flows did not change significantly. Iliac vascular resistance decreased from 0.64 to 0.15 mm Hg/ml min-1, but mesenteric vascular resistance increased from 0.31 to 0.47 mm Hg/ml min-1 and renal vascular resistance increased from 0.49 to 0.75 mm Hg/ml min-1. Severe exercise in dogs with heart failure increased heart rate from 102 to 274 beats/min, but mean arterial blood pressure only increased from 100 to 107 mm Hg. Iliac blood flow rose from 96 to 360 ml/min, whereas mesenteric blood flow decreased from 237 to 89 ml/min and renal blood flow decreased from 226 to 79 ml/min. Iliac vascular resistance decreased from 1.09 to 0.34 mm Hg/ml min-1, but mesenteric vascular resistance increased from 0.49 to 1.31 mm Hg/ml min-1 and renal vascular resistance increased from 0.47 to 1.81 mm Hg/ml min-1. Thus, in heart failure a distinctly abnormal peripheral vascular response to severe exercise occurs, characterized by a very small elevation in mean arterial blood pressure and intense visceral vasoconstriction resulting in diversion of visceral blood flows.

Effects of Experimentally Produced Heart Failure on the Peripheral Vascular Response to Severe Exercise in Conscious Dogs

The present study was undertaken to define the O2 requirements of electrical activation of the heart. Thirteen isolated canine hearts were perfused with whole blood from which calcium had been removed with an exchange resin and to which the disodium salt of ethylenediaminetetraacetic acid had been added. Spontaneous depolarizations were suppressed by raising the plasma potassium to an average concentration of 7.5 mEq/liter, and the right ventricle was stimulated electrically at controlled frequencies. Although the stimuli produced propagated depolarizations, neither high-sensitivity strain gauge arches sutured to both ventricles, nor careful visual observation, showed any evidence of associated contractile activity. Ten of the hearts were studied with repetitive single stimuli applied in the conventional fashion, while the remaining three hearts were subjected to paired electrical stimulation. Changes of myocardial O2 consumption (MV·O2) were measured at a constant coronary blood flow and arterial O2 content by determining changes of venous O2 content from a continuous recording of venous PO2. Increases of the frequency of depolarization were uniformly accompanied by small increases of MV·O2, averaging 0.40 ± 0.04 (SEM) µliter/activation/100 g. The increases were of the same order of magnitude in the hearts subjected to paired electrical stimulation as in the hearts studied with single stimulation, suggesting that the altered frequency and rhythm of depolarization in paired electrical stimulation cannot account for the marked increase of MV·O2 which this intervention produces in the intact heart. It is concluded that the amount of O2 required for electrical activation of the heart is less than 1% of the total O2 consumption of the normally working heart.

Oxygen Cost of Electrical Activation of the Heart

Myocardial ischemia (second of three parts).

The effects of autonomic innervation and of myocardial catecholamine stores on the action of ouabain on myocardial contractile force, the functional refractory period of the A-V conduction system, and on the dose required to produce multiple ventricular premature contractions were determined in pentoharbital anesthetized, open-chest dogs. The mean increment in contractile force produced by ouabain in groups of dogs which had been vagotomized, reserpine-pre-treated, acutely cardiac denervated, and chronically cardiac denervated, was not significantly different from the mean change produced by ouabain in the control dogs. Similarly, the mean cumulative doses of ouabain required to produce multiple ventricular premature contractions did not differ significantly among the five groups of animals. The mean prolongation in AVFRP produced by a cumulative dose of 42 µg/kg ouabain was 46 milliseconds in the control dogs, 21 milliseconds in the vagotomized dogs, and 10 milliseconds in the chronically cardiac denervated dogs. These results indicate that the inotropic and arrhythmic doses of ouabain are independent of autonomic innervation and myocardial catecholamine stores, but that a major portion of the prolongation of the functional refractory period of the atrioventricular conduction system produced by ouabain is dependent upon intact autonomic innervation. However, by studying dogs after chronic cardiac denervation and myocardial catecholamine depletion, it was shown that there is a significant though small direct effect of this glycoside on the functional refractory period of the A-V conduction system. Since the magnitude of the prolongation of the AVFRP produced by ouabain was inversely proportional to the AVFRP existing prior to the infusion of the glycoside, the possibility was considered that the state of cardiac innervation modified the effects of ouabain on atrioventricular conduction by affecting the resting level of the AVFRP.

Eugene Braunwald

Papers

Effects of Experimentally Produced Heart Failure on the Peripheral Vascular Response to Severe Exercise in Conscious Dogs

Oxygen Cost of Electrical Activation of the Heart

Myocardial ischemia (second of three parts).

Studies on digitalis. viii. effect of autonomic innervation and of myocardial catecholamine stores upon the cardiac action of ouabain

Letters to the editor Reply