"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 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

ABCD
: Appropriate Blood pressure Control in Diabetes
ABI
: ankle–brachial index
ABPM
: ambulatory blood pressure monitoring
ACCESS
: Acute Candesartan Cilexetil Therapy in Stroke Survival
ACCOMPLISH
: Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension
ACCORD
: Action to Control Cardiovascular Risk in Diabetes
ACE
: angiotensin-converting enzyme
ACTIVE I
: Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events
ADVANCE
: Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation
AHEAD
: Action for HEAlth in Diabetes
ALLHAT
: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart ATtack
ALTITUDE
: ALiskiren Trial In Type 2 Diabetes Using Cardio-renal Endpoints
ANTIPAF
: ANgioTensin II Antagonist In Paroxysmal Atrial Fibrillation
APOLLO
: A Randomized Controlled Trial of Aliskiren in the Prevention of Major Cardiovascular Events in Elderly People
ARB
: angiotensin receptor blocker
ARIC
: Atherosclerosis Risk In Communities
ARR
: aldosterone renin ratio
ASCOT
: Anglo-Scandinavian Cardiac Outcomes Trial
ASCOT-LLA
: Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm
ASTRAL
: Angioplasty and STenting for Renal Artery Lesions
A-V
: atrioventricular
BB
: beta-blocker
BMI
: body mass index
BP
: blood pressure
BSA
: body surface area
CA
: calcium antagonist
CABG
: coronary artery bypass graft
CAPPP
: CAPtopril Prevention Project
CAPRAF
: CAndesartan in the Prevention of Relapsing Atrial Fibrillation
CHD
: coronary heart disease
CHHIPS
: Controlling Hypertension and Hypertension Immediately Post-Stroke
CKD
: chronic kidney disease
CKD-EPI
: Chronic Kidney Disease—EPIdemiology collaboration
CONVINCE
: Controlled ONset Verapamil INvestigation of CV Endpoints
CT
: computed tomography
CV
: cardiovascular
CVD
: cardiovascular disease
D
: diuretic
DASH
: Dietary Approaches to Stop Hypertension
DBP
: diastolic blood pressure
DCCT
: Diabetes Control and Complications Study
DIRECT
: DIabetic REtinopathy Candesartan Trials
DM
: diabetes mellitus
DPP-4
: dipeptidyl peptidase 4
EAS
: European Atherosclerosis Society
EASD
: European Association for the Study of Diabetes
ECG
: electrocardiogram
EF
: ejection fraction
eGFR
: estimated glomerular filtration rate
ELSA
: European Lacidipine Study on Atherosclerosis
ESC
: European Society of Cardiology
ESH
: European Society of Hypertension
ESRD
: end-stage renal disease
EXPLOR
: Amlodipine–Valsartan Combination Decreases Central Systolic Blood Pressure more Effectively than the Amlodipine–Atenolol Combination
FDA
: U.S. Food and Drug Administration
FEVER
: Felodipine EVent Reduction study
GISSI-AF
: Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Atrial Fibrillation
HbA1c
: glycated haemoglobin
HBPM
: home blood pressure monitoring
HOPE
: Heart Outcomes Prevention Evaluation
HOT
: Hypertension Optimal Treatment
HRT
: hormone replacement therapy
HT
: hypertension
HYVET
: HYpertension in the Very Elderly Trial
IMT
: intima-media thickness
I-PRESERVE
: Irbesartan in Heart Failure with Preserved Systolic Function
INTERHEART
: Effect of Potentially Modifiable Risk Factors associated with Myocardial Infarction in 52 Countries
INVEST
: INternational VErapamil SR/T Trandolapril
ISH
: Isolated systolic hypertension
JNC
: Joint National Committee
JUPITER
: Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin
LAVi
: left atrial volume index
LIFE
: Losartan Intervention For Endpoint Reduction in Hypertensives
LV
: left ventricle/left ventricular
LVH
: left ventricular hypertrophy
LVM
: left ventricular mass
MDRD
: Modification of Diet in Renal Disease
MRFIT
: Multiple Risk Factor Intervention Trial
MRI
: magnetic resonance imaging
NORDIL
: The Nordic Diltiazem Intervention study
OC
: oral contraceptive
OD
: organ damage
ONTARGET
: ONgoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial
PAD
: peripheral artery disease
PATHS
: Prevention And Treatment of Hypertension Study
PCI
: percutaneous coronary intervention
PPAR
: peroxisome proliferator-activated receptor
PREVEND
: Prevention of REnal and Vascular ENdstage Disease
PROFESS
: Prevention Regimen for Effectively Avoiding Secondary Strokes
PROGRESS
: Perindopril Protection Against Recurrent Stroke Study
PWV
: pulse wave velocity
QALY
: Quality adjusted life years
RAA
: renin-angiotensin-aldosterone
RAS
: renin-angiotensin system
RCT
: randomized controlled trials
RF
: risk factor
ROADMAP
: Randomized Olmesartan And Diabetes MicroAlbuminuria Prevention
SBP
: systolic blood pressure
SCAST
: Angiotensin-Receptor Blocker Candesartan for Treatment of Acute STroke
SCOPE
: Study on COgnition and Prognosis in the Elderly
SCORE
: Systematic COronary Risk Evaluation
SHEP
: Systolic Hypertension in the Elderly Program
STOP
: Swedish Trials in Old Patients with Hypertension
STOP-2
: The second Swedish Trial in Old Patients with Hypertension
SYSTCHINA
: SYSTolic Hypertension in the Elderly: Chinese trial
SYSTEUR
: SYSTolic Hypertension in Europe
TIA
: transient ischaemic attack
TOHP
: Trials Of Hypertension Prevention
TRANSCEND
: Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease
UKPDS
: United Kingdom Prospective Diabetes Study
VADT
: Veterans' Affairs Diabetes Trial
VALUE
: Valsartan Antihypertensive Long-term Use Evaluation
WHO
: World Health Organization

### 1.1 Principles

The 2013 guidelines on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology …

/pdf/2013-esh-esc-guidelines-for-the-management-of-arterial-4ydvs5ifsx.pdf

2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).

https://caltcm.memberclicks.net/assets/documents/acc_aha_chf_2013_guidelines.pdf

2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

The metabolic syndrome has received increased attention in the past few years. This statement from the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute (NHLBI) is intended to provide up-to-date guidance for professionals on the diagnosis and management of the metabolic syndrome in adults.

The metabolic syndrome is a constellation of interrelated risk factors of metabolic origin— metabolic risk factors —that appear to directly promote the development of atherosclerotic cardiovascular disease (ASCVD).1 Patients with the metabolic syndrome also are at increased risk for developing type 2 diabetes mellitus. Another set of conditions, the underlying risk factors , give rise to the metabolic risk factors. In the past few years, several expert groups have attempted to set forth simple diagnostic criteria to be used in clinical practice to identify patients who manifest the multiple components of the metabolic syndrome. These criteria have varied somewhat in specific elements, but in general they include a combination of both underlying and metabolic risk factors.

The most widely recognized of the metabolic risk factors are atherogenic dyslipidemia, elevated blood pressure, and elevated plasma glucose. Individuals with these characteristics commonly manifest a prothrombotic state and a pro-inflammatory state as well. Atherogenic dyslipidemia consists of an aggregation of lipoprotein abnormalities including elevated serum triglyceride and apolipoprotein B (apoB), increased small LDL particles, and a reduced level of HDL cholesterol (HDL-C). The metabolic syndrome is often referred to as if it were a discrete entity with a single cause. Available data suggest that it truly is a syndrome, ie, a grouping of ASCVD risk factors, but one that probably has more than one cause. Regardless of cause, the syndrome identifies individuals at an elevated risk for ASCVD. The magnitude of the increased risk can vary according to which components of the syndrome are …

https://www.lipidcenter.com/pdf/metabolic.pdf

Diagnosis and Management of the Metabolic Syndrome An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement

Objective: Hypertension is very common and inadequately controlled among the elderly. Ambulatory blood pressure (ABP) measurement has a better predictive value than office blood pressure (BP) measurement. In a substudy of the VALVET trial, we examined the effect of combined valsartan/hydrochlorothiazide (V/HCTZ), or V or HCTZ alone on 24-h mean ABP in elderly subjects with systolic hypertension. Methods: Three hundred eighty-four subjects >=70 years old with mean sitting systolic BP >150 and =<200 mmHg were randomized to receive V/HCTZ 160/12.5 mg (n = 24), HCTZ 12.5 mg (n = 26), or V 160 mg (n = 31) for 4 weeks. At Week 4, subjects not achieving <140/90 mmHg received optional titration with V/HCTZ (160/12.5 mg in HCTZ and V groups; 320/12.5 mg in V/HCTZ group) up to a maximum dose of V/HCTZ 320/25 mg by Week 12. Results: Baseline ASBP/ADBP values ± SD were 141.1 ± 10.7/76.5 ± 9.3, 142.2 ± 9.3/78.7 ± 7.5, and 142.2 ± 10.6/78.3 ± 8.2 mmHg in the V/HCTZ, HCTZ, and V groups, respectively. At Week 4, reductions from baseline in 24-h mean ASBP and ADBP were greater in subjects initiating V/HCTZ than HCTZ or V alone (Table). At Week 16, differences were observed between V/HCTZ and HCTZ groups only. These results were largely consistent for nighttime vs daytime, and last-4-hours dosing analyses. Adverse events were similar across all groups; the most common being dizziness, fatigue, and headache. Conclusions: In conclusion, 4 weeks of initial combination therapy resulted in a greater BP reduction from baseline vs monotherapy, demonstrating enhanced efficacy of V/HCTZ in elderly patients. Figure 1. No caption available.

Effect of valsartan, hydrochlorothiazide, and its combination on 24-hour ambulatory blood pressure response in elderly individuals with systolic hypertension: a valvet substudy: pp.27.96

Age is the most powerful of risk factors and is related continuously to systolic BP and cardiovascular disease risk. Yet current guidelines have dichotomized age groups around a cutoff value of 55-60 years and some guidelines now suggest that age should affect diagnostic thresholds and drug choices. These choices are not supported directly by scientific evidence but are based on expert opinion, the value of which is uncertain. This initial topic of the new Controversies in Hypertension series highlights important differences among current U.S., European, and Canadian practice guidelines, then moves on to editorial commentaries with different perspectives.

Should age determine hypertension management? Recommendations from current guidelines.

Objective: Low rates of blood pressure (BP) control in the elderly are partly attributable to clinicians’ reluctance to initiate combination therapy. The 16-week Valsartan in the Very Elderly Trial (VALVET) investigated the efficacy and tolerability of initial single-pill combination therapy with valsartan (V) and hydrochlorothiazide (HCTZ) vs the individual components at similar doses. Methods: After a 3–14 day washout, subjects >=70 years of age (mean age: 77.5 years, sitting systolic BP [SBP]: 150–200 mmHg) were randomized to V/HCTZ 160/12.5 mg (n = 128), HCTZ 12.5 mg (n = 128), or V 160 mg (n = 128). Subjects not achieving BP goal <140/90 mmHg in any of the 3 groups could receive an optional titration up to a maximum dose of V/HCTZ 320/25 mg from Week 4 until Week 12: subjects in the V and HCTZ arms electively received V/HCTZ 160/12.5 mg at Week 4, 320/12.5 mg at Week 8, and the maximum dose 320/25 mg at Week 12. Results: Mean baseline clinic BP was 165/85 mmHg. At Week 2, there were greater SBP reductions from baseline in subjects assigned initially to the combination V/HCTZ (−18.6 mmHg) compared with those assigned to HCTZ (−13.0 mmHg, p < 0.005), or V (−10.8 mmHg, p < 0.001). Similar BP differences were maintained until the end of study, by which time 65% of subjects initiated on HCTZ and 78% initiated on V required combination therapy. Median time to BP control was lower with V/HCTZ (4 weeks) than with HCTZ (8 weeks, p < 0.05) or V (12 weeks, p < 0.0001). At Week 16, 52.0%, 49.5%, and 36.6% of subjects in the V/HCTZ, HCTZ, and V arms, respectively, achieved goal BP. Adverse events were similar across the 3 treatment groups; the most common events being dizziness, fatigue, and headache. Conclusion: Initiation of treatment with V/HCTZ lowered BP more effectively, controlled a higher proportion of individuals, reduced the time necessary to reach BP target, and was equally well tolerated compared with monotherapy with either component.

Efficacy and tolerability of combined angiotensin receptor blocker+diuretic therapy vs component monotherapies in elderly individuals with systolic hypertension:results from valvet: pp.27.93

Chapter 15 – Assessment of Hypertensive Target Organ Damage

An arterial pulse contour can be defined by its amplitude and timing landmarks. We studied the effects of aging and hypertension on central blood pressure landmarks in a reference cohort of normotensive and hypertensive individuals (treated and untreated (n1⁄4376, age 16-90) designed to mimic the NHANES III cohort. Each participant had standard cuff BP (oscillometry, Omron CP705) and radial artery tonometry (Sphygmocor) after >5 min sitting. In a subset (n1⁄463), supine heart-femoral pulse wave velocity (hfPWV, Colin VP 1000) and systemic vascular resistance (SVR, impedance cardiography, Bio-Z) were also measured. Variables were inter-correlated (Pearson) and the group was dichotomized at age 55 for landmark comparisons (ttests) and ensemble wave averaging. Mean age of the younger (Y) group (n1⁄4213) was 33 years; the older (O) group (n1⁄4163) was 66 years. Figure 1 demonstrates the ensemble waveforms and landmarks for Y (gray line) and O (black line), with timing (Y long vertical lines, O short verticals) and pressure (vertical intersections for Y, filled dots for O) landmarks. Mean timing values for each landmark deviated by only a few msec between Y and O, with T2/P2 always occurring in late systole. P2 amplitude was most strongly correlated with age and P2 differed most between Y and O groups (highest T-statistic). Amplitude at each pressure landmark correlated with age, brachial BP, hfPWV and SVR, with the highest values occurring in late systole (P2). Further, the amplitude of the first diastolic peak (DT1/DP1) was not greater in Y than O absolutely or relative to other pressure landmarks. A very similar

Joseph L. Izzo

Papers

Effect of valsartan, hydrochlorothiazide, and its combination on 24-hour ambulatory blood pressure response in elderly individuals with systolic hypertension: a valvet substudy: pp.27.96

Should age determine hypertension management? Recommendations from current guidelines.

Efficacy and tolerability of combined angiotensin receptor blocker+diuretic therapy vs component monotherapies in elderly individuals with systolic hypertension:results from valvet: pp.27.93

Chapter 15 – Assessment of Hypertensive Target Organ Damage

Effects of aging and blood pressure on timing and amplitude of central pulse contour landmarks