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).

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

2007 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).

Background End-stage renal disease substantially increases the risks of death, cardiovascular disease, and use of specialized health care, but the effects of less severe kidney dysfunction on these outcomes are less well defined. Methods We estimated the longitudinal glomerular filtration rate (GFR) among 1,120,295 adults within a large, integrated system of health care delivery in whom serum creatinine had been measured between 1996 and 2000 and who had not undergone dialysis or kidney transplantation. We examined the multivariable association between the estimated GFR and the risks of death, cardiovascular events, and hospitalization. Results The median follow-up was 2.84 years, the mean age was 52 years, and 55 percent of the group were women. After adjustment, the risk of death increased as the GFR decreased below 60 ml per minute per 1.73 m2 of body-surface area: the adjusted hazard ratio for death was 1.2 with an estimated GFR of 45 to 59 ml per minute per 1.73 m2 (95 percent confidence interval, 1....

https://www.nejm.org/doi/pdf/10.1056/NEJMoa041031

Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization

Cardiovascular disease represents the leading cause of morbidity and mortality in Western countries, and hypertension-related cardiovascular events affect about 37 million people per year, worldwide. In this perspective, hypertension represents a reference paradigm to illustrate strategies aimed at achieving cardiovascular prevention. Hypertensive patients are at increased risk of experiencing a cardiovascular event during their life-time, and treatment of high blood pressure represents one of the most effective strategies to reduce the global cardiovascular risk of these patients. However, owing to its multifactorial pathophysiology and its frequent association with other relevant risk factors and clinical conditions, such as dyslipidaemia, diabetes mellitus, left ventricular dysfunction and renal impairment, hypertension requires an integrated approach to treatment, including life-style measures, antihypertensive drugs and other therapies (mostly lipid-lowering regimens). Yet worldwide, general practitioners continue to focus their attention on the management of a single risk factor, e.g. blood pressure, rather than on the global cardiovascular risk profile. Modern strategies of cardiovascular prevention should assess the global cardiovascular risk threshold to manage hypertensive patients at high risk, rather than to focus on the high level of a single risk factor, for achieving effective control of cardiovascular risk profile and reducing cardiovascular morbidity and mortality in the general population, as well as in the hypertensive population. In this regard, recent clinical studies have demonstrated that specific antihypertensive classes of drugs, such as those inhibiting the renin-angiotensin system and calcium antagonists, may confer clinical benefits across the spectrum of cardiovascular disease, from patients with conditions predisposing to cardiovascular events, such as left ventricular hypertrophy, microalbuminuria and diabetes mellitus, to patients with coronary artery disease or stroke, congestive heart failure and end-stage renal disease. Data from these studies suggest that the cardiovascular protection achieved by these drugs is, at least in part, independent from the blood pressure-lowering effect.

Treatment of high-risk hypertensive patients: Unresolved issues revised by staging the risk

Hypertension in the Elderly

To come to these conclusions, the authors have used a cross-transplantation model in which they address the question of the impact of renal AT1 receptor on the pathogenesis of hypertension and LVH. Four groups of mice were generated attempting to separate the actions of AT1 receptor pools in the kidney from those in systemic tissues. The authors used genetically matched F1(C57BL/6 129) wild type (WT) mice and F1(C57BL/6 129) mice homozygous for a targeted disruption of the Agtr1a gene locus encoding the AT1aR (AT1aR-KO mice). Hypertension was induced by continuous infusion of angiotensin II. The analysis of blood pressure evolution revealed that only those animals carrying a WT kidney developed hypertension. Animals expressing the receptor in the periphery (KO mice), but not in the transplanted kidney, did not develop hypertension, while those animals expressing the receptor in the transplanted kidney, but not in the periphery, did in a degree similar to that seen in the WT animal. The authors found that the mechanism after the increase in blood pressure during angiotensin II infusion was an increase in

Renal AT 1 receptors and hypertension.

The Renin Academy was launched during the first week of September in Stockholm, at the European Society of Cardiology (ESC) annual congress The Academy aims to encourage understanding of the renin-angiotensin-aldosterone system (RAAS) and to raise awareness of the benefits of optimising RAAS suppression

https://journals.sagepub.com/doi/pdf/10.3317/jraas.2005.009

The Launch of the Renin Academy

Arterial hypertension continues to be the leading cause of death worldwide1,2 and, unfortunately, remains uncontrolled in a significant percentage of hypertensive patients who do not attain the blood pressure (BP) goal that most guidelines recommend (o140/90 mmHg). A lively debate began after the publication of the Systolic Blood Pressure Intervention Trial (SPRINT),3 in which a goal of 120 mmHg was reported to be adequate in a portion of the hypertensive population. This has intensified the lack of adequate BP control, as the results of SPRINT cannot be applied to all hypertensive populations. In populations not included in SPRINT but in which stroke is particularly prevalent, such as the Asian population, a trial similar to SPRINT must be conducted before the recommendations suggested by SPRINT3 are accepted and included in the hypertension guidelines, as has been done in countries such as Canada.4 It is clear by the acceptance of values below 140/90 as the goal of BP control that a great deal of works remains, even in those countries that exhibit the highest rates of good BP control. This is particularly true if we take into account that, in the uncontrolled population, comorbidities such as diabetes, chronic kidney disease and obesity are particularly prevalent and make BP control more difficult and increasingly important in terms of global cardiovascular risk.5 In addition to the need to consider the adequate implementation of lifestyle changes—particularly adequate sodium and potassium intake, control of body mass index, and increasing physical activity—the adequate use of drug combinations is also pertinent, and the triple combination of a renin-angiotensin blocker (RASB), calcium antagonist and diuretic is considered in most guidelines to be the best triple combination.6 This has also been demonstrated in a Japanese hypertensive population with the use of a combination of an angiotensin receptor blocker, a calcium channel blocker and a diuretic.7 In this issue of the journal, Supasyndh et al.8 describe the efficacy and safety of the combination of sacubitril and valsartan for the control of BP over a 1-year follow-up period. These data are among the most important yet published on this new combination, which unfortunately does not seem as though it will be available in the near future for the treatment of hypertension. The sacubitril/valsartan combination was up-titrated if it needed to be 400 mg QD and, subsequently, amlodipine followed by hydrochlorothiazide could be used. The overall control of systolic BP was 90.6%, whereas it was 87.6 for diastolic BP. Additionally, 66.9% of patients remained on sacubitril/ valsartan monotherapy until the study ended. These results expand upon the initial data that were obtained with different doses of sacubitril/ valsartan9 and in the treatment of severe hypertension.10 They also show that twothirds of patients with mild to moderate hypertension attain good control with this new monotherapy and that a diuretic is the best drug to add to complete a triad of therapy that aligns with the previous results of studies in Japanese hypertensives.7 Interestingly, the capacity of sacubitril/valsartan to control BP has been successfully tested in patients with chronic kidney disease, a frequent and dangerous comorbidity in arterial hypertension.11 Such positive results can only be explained by the capacity of sacubitril/valsartan to simultaneously counteract different mechanisms that facilitate the development of high BP, such as angiotensin II and aldosterone, while promoting natriuretic peptides and natriuresis.12,13 The impressive effects of this combination on heart failure with reduced ejection fraction demonstrated in the Prospective Comparison of ARNI (angiotensin receptor neprilysin inhibitor) with ACEI (angiotensin-converting enzyme inhibitor) to Determine the Impact on Global Mortality and Morbidity in Heart Failure Trial (PARADIGM-HF)14 remind us that the excellent initial results obtained with ACE in this clinical entity continued on with great success for arterial hypertension, renal disease and cardiovascular risk.15 Can these results be replicated? The initial results in the context of arterial hypertension are sufficiently positive to consider the need for an indication of sacubitril/valsartan for arterial hypertension.16 Additional studies are required in the areas of arterial hypertension, chronic kidney disease and high cardiovascular risk. An indication for arterial hypertension would be of great value in facilitating the control of the world’s 2017–0029 number one killer.

Luis M. Ruilope

Papers

Treatment of high-risk hypertensive patients: Unresolved issues revised by staging the risk

Hypertension in the Elderly

Renal AT 1 receptors and hypertension.

The Launch of the Renin Academy

Sacubitril/valsartan in the treatment of arterial hypertension: an unaccomplished promise?