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).

The development and use of a new scale, the Epworth sleepiness scale (ESS), is described. This is a simple, self-administered questionnaire which is shown to provide a measurement of the subject's general level of daytime sleepiness. One hundred and eighty adults answered the ESS, including 30 normal men and women as controls and 150 patients with a range of sleep disorders. They rated the chances that they would doze off or fall asleep when in eight different situations commonly encountered in daily life. Total ESS scores significantly distinguished normal subjects from patients in various diagnostic groups including obstructive sleep apnea syndrome, narcolepsy and idiopathic hypersomnia. ESS scores were significantly correlated with sleep latency measured during the multiple sleep latency test and during overnight polysomnography. In patients with obstructive sleep apnea syndrome ESS scores were significantly correlated with the respiratory disturbance index and the minimum SaO2 recorded overnight. ESS scores of patients who simply snored did not differ from controls.

A new method for measuring daytime sleepiness: the Epworth sleepiness scale.

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 Limited data have suggested that sleep-disordered breathing, a condition of repeated episodes of apnea and hypopnea during sleep, is prevalent among adults. Data from the Wisconsin Sleep Cohort Study, a longitudinal study of the natural history of cardiopulmonary disorders of sleep, were used to estimate the prevalence of undiagnosed sleep-disordered breathing among adults and address its importance to the public health. Methods A random sample of 602 employed men and women 30 to 60 years old were studied by overnight polysomnography to determine the frequency of episodes of apnea and hypopnea per hour of sleep (the apnea-hypopnea score). We measured the age- and sex-specific prevalence of sleep-disordered breathing in this group using three cutoff points for the apnea-hypopnea score (≥ 5, ≥ 10, and ≥ 15); we used logistic regression to investigate risk factors. Results The estimated prevalence of sleep-disordered breathing, defined as an apnea-hypopnea score of 5 or higher, was 9 percent for w...

The Occurrence of Sleep-Disordered Breathing among Middle-Aged Adults

Genetics wakes up for human sleep

Sleep apnea syndrome: Is it a contributing factor to the sex differential in mortality?

Fourteen right-handed and fourteen left-handed males were wakened from REM and NONREM sleep and tested on the dichotic listening test with verbal stimuli. For right-handers there was a significant right ear advantage (REA) only after REM wakenings, which was equal in magnitude to the REA obtained during waking. Left-handers showed significant REA after both wakening conditions, as well as during waking. These results are interpreted in view of the data suggesting REM-related right hemisphere activation and the role of the right hemisphere in regulating bihemispheric arousal levels.

Differential effects of awakening from REM and NONREM sleep on dichotic listening performance as a function of handedness.

The exact pathophysiology leading to pharyngeal collapse in obstructive sleep apnea (OSA) remains incompletely understood. Recent research have focused on the neurochemical and physiological changes occurring at sleep onset that lead to the loss of muscle activity and diminished reflex pharyngeal control, and a loss of the neuromuscular compensation present during wakefulness, resulting in pharyngeal collapse. Regardless of this physiological arm, it is well documented that patients with OSA suffer from compromised upper airway anatomy. Most studies, using a variety of imaging techniques (CT, MRI, acoustic reflection, cephalometrics), have demonstrated a small pharyngeal airway in apnea patients, with the smallest airway luminal size generally occurring at the level of the velopharynx (behind the soft palate) in both patients and controls (Schwab et al., 1993). The finding of Walsh et al. (2008) from the current issue of the JSR supports these findings as well. Utilizing the novel technology of anatomical optical coherence tomography, they showed that the smallest cross-sectional area in 30 patients with OSA and 10 controls is located at the velopharyngeal level. However, they could not corroborate two previous anatomical findings reported in OSA: the role of airway shape and airway length. Several previous studies have reported an oval shape of the pharyngeal airway in individuals with OSA when compared with controls (i.e. a relatively high anteroposterior ⁄ lateral luminal airway dimension). Furthermore, Leiter (1996) have also suggested a reduced ability of muscles to dilate the pharynx when it is oval in shape. The study by Walsh et al. could not demonstrate differences in the AP ⁄ lateral diameter ratio between patients and controls. The importance of airway shape was also found to be less significant in a recent study examining the potential mechanisms contributing to increase in the prevalence of OSA with increasing age. Malhotra et al. (2006) reported that the ratio of the anteroposterior to lateral dimension became progressively lower with increasing age. Thus, the importance of the oval airway shape as an anatomical predisposing factor in the pathophysiology of OSA remains controversial and unclear. The length of the pharyngeal airway has received only minimal attention so far. It was previously reported that upper airway length (UAL) was greater in normal men compared with women, suggesting that it may play a role in the male predisposition to pharyngeal collapse (Malhotra et al., 2002). Furthermore, using computational modeling, a major impact of UAL on pharyngeal mechanics has been demonstrated (Malhotra et al., 2002). In another recent study of 69 healthy boys and girls who had undergone CT scans of the neck, it has been found that the UAL in prepubertal children is equal between genders. However, following puberty, males were found to have longer upper airways than females (independent of systemic growth), thus potentially explaining why pharyngeal collapse has a strong male predominance in adults but not in children (Ronen et al., 2007). In addition, a longer pharyngeal airway has been shown in postmenopausal as compared with premenopausal women (Malhotra et al., 2006). Thus, the existing data suggest that UAL may at least partially explain the male predisposition to airway collapse that occurs at puberty, and the female predisposition that occurs at menopause. Moreover, data from our own laboratory shows that UAL is greater in patients with OSA than in controls, with a positive significant correlation between the UAL and the severity of OSA (paper under consideration for publication). At least three potential reasons can explain the discrepancy between these previous findings and the findings of the current study by Walsh et al.: methodological differences, statistical limitations, and the patient population studied. While previous studies of UAL were based on MRI or CT scans, the current study utilized a relatively novel technology. The anatomical optical coherence tomography is an endoscopic technique, based on infrared light from an optical probe sliding within a preinserted esophageal catheter. While a CT scan is completed within seconds, this technique takes between 9–12 min (for each pullback scan), and may be affected by swallows, head or tongue movements, and by the topical anesthesia applied prior to catheter insertion. In addition, UAL in the Walsh study was determined as the summation of the velopharyngeal, oropharyngeal, and hypopharyngeal segments, thus extending all the way to below the epiglottis, differently from the previous definition for UAL length (between the rigid bony structures of the airway: hard palate to epiglottis). Also, lack of differences in UAL between OSA and controls is based on only 10 subjects in each group, all of whom are men, while the previous studies reporting the importance for UAL had a substantial gender-related effect and were based on substantially larger groups of subjects (Malhotra et al., 2002, 2006; Ronen et al., 2007). Thus, further studies are required to better understand the role of UAL in obstructive sleep apnea syndrome. Controversies in OSA are further exemplified in the discrepancy between the anatomical findings and therapeutic J. Sleep Res. (2008) 17, 123–124 Editorial

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2869.2008.00668.x

Upper airway in obstructive sleep apnea--controversies continue.

gressional Record Vol. 155 (2009): pp. 62–64. 3. Board on Health Care Services. Crossing the quality chasm: a new health system for the 21st Century (accessed October 30, 2011). Available at http://iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-HealthSystem-for-the-21st-Century.aspx 4. ECRI Institute. Comparative Effectiveness Resource Center (accessed October 30, 2011). https://www.ecri.org/Search/Pages/SearchResults. aspx?k1⁄4comparative%20effectiveness%20legislation Accessed September 4, 2011. 5. Congress of the United States Congressional Budget Office. A CBO Paper: Research on the comparative effectiveness of medical treatments. December 2007. 6. Patient Protection and Affordable Care Act. Title III, Subtitle F, Section 3501, and Title VI, Subtitle D, Section 6301 and 6302. Congressional Record, Vol. 156 (2010): pp. 390–392 and pp. 609–625. 7. Board on Health Care Services. Comparative effectiveness research priorities (accessed October 30, 2011). Available from: http://www.iom. edu/Reports/2009/ComparativeEffectivenessResearchPriorities.aspx 8. HSR Information Central. Comparative Effectiveness Research (accessed October 30, 2011). Available from: http://www.nlm.nih.gov/hsrinfo/cer.html 9. Iglehart JK. Prioritizing comparative-effectiveness research—IOM recommendations. N Engl J Med 2009;361:4. 10. Patient-Centered Outcomes Research Institute. Areas of Interest for the Pilot Projects Grants Program (accessed October 30, 2011). Available from www.pcori.org/funding-opportunities/pcori-funding-announcementpilot-project-grants/areas-of-interest-for-the-pilot-project-grantsprogram/ 11. Luce BR, Kramer JM, Goodman SN, Connor JT, Tunis S, Whicher D, Schwartz JS. Rethinking randomized clinical trials for comparative effectiveness research: The need for transformational change. Ann Intern Med 2009;151:206–209. 12. Trikalinos TA, Siebert U, Lau J. Decision-analytic modeling to evaluate benefits and harms of medical tests—uses and limitations. Med Decis Making 2009;29:E22–E29. 13. Frick KD. How comparative effectiveness research feeds into costbenefit analysis. Virtual Mentor 2011;13:248–250. 14. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458–1465. 15. Salinas GD, Williamson JC, Kalhan R, Thomashaw B, Scheckermann JL, Walsh J, Abdolrasulnia M, Foster JA. Barriers to adherence to chronic obstructive pulmonary disease guidelines by primary care physicians. Int J Chron Obs Pulm Dis 2011;6:171–179.

Peretz Lavie

Papers

Genetics wakes up for human sleep

Sleep apnea syndrome: Is it a contributing factor to the sex differential in mortality?

Differential effects of awakening from REM and NONREM sleep on dichotic listening performance as a function of handedness.

Upper airway in obstructive sleep apnea--controversies continue.

Obstructive Sleep Apnea and Hypertension: How Strong Is the Association?