"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).

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.

THE DESIGN AND ANALYSIS OF EXPERIMENTS. By Oscar Kempthorne. New York, John Wiley and Sons, Inc., 1952. 631 pp. $8.50. This book by a teacher of statistics (as well as a consultant for \"experimenters\") is a comprehensive study of the philosophical background for the statistical design of experiment. It is necessary to have some facility with algebraic notation and manipulation to be able to use the volume intelligently. The problems are presented from the theoretical point of view, without such practical examples as would be helpful for those not acquainted with mathematics. The mathematical justification for the techniques is given. As a somewhat advanced treatment of the design and analysis of experiments, this volume will be interesting and helpful for many who approach statistics theoretically as well as practically. With emphasis on the \"why,\" and with description given broadly, the author relates the subject matter to the general theory of statistics and to the general problem of experimental inference. MARGARET J. ROBERTSON

The Design and Analysis of Experiments

O-30: Predictors of cardiovascular events in 9,194 hypertensive patients with left ventricular hypertrophy. The LIFE study*

Diuretics in the LIFE study. Authors' reply

Small, but well-conducted, clinical trials using statins in hypertensive subjects have indicated that blood pressure lowering may be one of many suggested pleiotrophic effects of statins [1]. However, preliminary results of the large Plaque Hypertension Lipid Lowering Italian Study (PHYLLIS) indicate that this benefit is not seen in welltreated hypertensives [2]. Thus, presently there is no firm evidence that statins contribute to blood pressure reduction in hypertensive patients. However, lowering cholesterol in individuals at high risk for developing cardiovascular disease has been shown to improve outcome [3–10] since there is often a clustering of risk factors including hypertension and concomitant dyslipidemia in such patient groups. Recently, two major trials in hypertensive subjects with additional cardiovascular risk factors have evaluated the potential benefits of statins on cardiovascular outcome. In the American Antihypertensive and Lipid Lowering treatment to prevent Heart Attack Trial (ALLHAT), hypertensive subjects with cholesterol levels above the recommended were included [11], whereas the AngloScandinavian Cardiac Outcomes Trial (ASCOT) excluded subjects with high cholesterol levels [12]. The ALLHAT study, however, was not successful in showing any major benefits of statin as add-on treatment in hypertensives with high risk for coronary heart disease [11]. Most likely, the failure of ALLHAT to demonstrate any positive result was due to the small separation of only approximately 0.5 mmol/l in total cholesterol level between patients randomized to statin vs those randomized to usual care. This failure in achieving the expected difference in cholesterol level could be explained by the high and increasing use of statins in “usual care” of hypertensives with additional cardiovascular risk factors in the USA. Until the ASCOT study results were presented [12], no trial had shown benefit of a statin as add-on treatment in hypertensives and no study had previously been done to evaluate the potential benefits of cholesterol lowering in the primary prevention of coronary heart disease in hypertensive subjects with average and below average levels of serum cholesterol. Of the 19342 hypertensive subjects (aged 40–79 years) initially randomized to one of two antihypertensive treatment strategies in ASCOT, 10305 subjects with total cholesterol levels 6.5 mmol/l were additionally randomized, using a double-blind factorial design, to either atorvastatin 10 mg or placebo [12]. Patients with total cholesterol level 6.5 mmol/l were recommended open statin treatment according to guidelines [11, 12]. Follow-up of the lipid-lowering arm of ASCOT was planned for an average of 5 years, and the primary composite end-point included non-fatal myocardial infarction and fatal coronary heart disease. A number of secondary and tertiary endpoints were pre-specified and included in subgroup analyses. The study was powered ( = 0.90) to detect a 30% reduction in the primary endpoint (p = 0.01) by an intention-to-treat analysis. The lipid arm of the study was stopped prematurely by the Steering Committee after a median follow-up period of 3.3 years, effective October 1, 2002, on the recommendation of the Data Safety Monitoring Board. This recommendation was based on a highly significant 36% reduction in the primary end-point. One hundred events (6.0 per 1000 patient-years) occurred in those randomized to atorvastatin compared with 154 events (9.4 per 1000 patient-years) in those receiving placebo (hazard ratio = 0.64, p = 0.0005). For the primary endpoint, life-table analyses revealed a divergence of the Kaplan–Meier curves already during the first year of follow-up. Several secondary and tertiary endpoints were also significantly reduced – combined fatal and non-fatal stroke by 27% (p = 0.023), total cardiovascular events by 21% (p = 0.0005) and total coronary events by 29% (p = 0.0005). There were 185 deaths (11.1 per 1000 patient-years) in the atorvastatin group and 212 deaths (12.8 per 1000 patient-years) in those receiving placebo (hazard ratio = 0.87, p = 0.165). The impact of atorvastatin on the primary endpoint of ASCOT was homogeneous across all subgroups. Non-cardiovascular mortality and cancer deaths were similar in the two treatment arms of the trial. Atorvastatin lowered total serum cholesterol by of 1.3 mmol/l compared with placebo at 12 months of follow-up. After 3 years of follow-up, the difference between the atorvastatin and placebo arms was 1.1 mmol/ l. This smaller difference was most likely explained by the open use of statin by 9% of those originally allocated placebo, and the 13% of non-statin users who had been randomized to atorvastatin. While it is obvious that the results of the lipid arm in the ALLHAT could not be taken as an evidence for the lack of benefits of pravastatin in hypertensives, the benefits of atorvastatin reported in ASCOT are substantial

In light of ALLHAT and ASCOT: are there benefits of statins as add-on treatment in hypertensives?

Abstract 1449: Racial Differences in Incident Heart Failure Among Hypertensive Patients During Antihypertensive Therapy: The LIFE Study

Despite major efforts to improve detection, treatment and follow-up, inadequate management of risk patients remains one of the leading causes of excess cardiovascular morbidity and mortality worldwide (1). In order to come to grips with this situation, there is clearly an urgent need to improve identification, quantification and management of cardiovascular risk in the hypertensive population. Inadequate risk assessment leads to serious underestimation of the risk level in many patients and poor quantification of total cardiovascular risk will have serious consequences for the choice of appropriate treatment. Hypertension remains an area of medicine where major improvements can be made, since in spite of intense clinical and research, goal blood pressure levels are rarely achieved (2). The decision to initiate antihypertensive treatment is based on clinical, ambulatory or home assessment of systolic and diastolic blood pressure as well as additional risk factors in order to calculate the level of total cardiovascular risk. The evident goal is to achieve maximum reduction in the long-term total risk of cardiovascular morbidity and mortality at the expense of minimal adverse effects and costs. This requires a focused and optimized management of all the reversible risk factors identified, including smoking, dyslipidemia, abdominal obesity or diabetes, as well as appropriate management of associated clinical conditions. Recent randomized trials demonstrate that irrespective of what mode of blood pressure lowering, reduction of blood pressure to v140 and v90 mmHg, markedly and costeffectively reduces cardiovascular morbid and fatal events as compared to those remaining even moderately above these values (3). However, in spite of overwhelming evidence of the benefits of treatment, primary hypertension still remains underdiagnosed and under-treated, resulting in an excess of strokes and heart attacks that are potentially preventable (2). Several evidence-based guidelines offer guidance on appropriate blood pressure targets. Current evidence based on analyses of randomized trials, provide evidence that a value of at least v140/ 90 mmHg should be the blood pressure target in the whole hypertensive population. Still, however, the level to which blood pressure should be reduced to achieve maximum benefit remains to be settled. It is obvious that in diabetic patients as well as in patients at increased risk, the target systolic as well as diastolic blood pressures should be even lower, although this remains poorly implemented in the everyday clinical setting (4). Thus, it is increasingly evident, that reality does not match ambition, theory and guidelines (2). Despite widespread use of multidrug combination treatments, even in the setting of clinical outcome trials, the achieved average systolic blood pressure has remained above 140 mmHg (5), with control rates of most 60–70% of the recruited and treated patient population. More importantly, in diabetic patients on-treatment average values v130 mmHg are rarely obtained, resulting in blood pressure control being achieved in at most 30% of the patients. Clearly, reaching the recommended target blood pressures are difficult and should be the focus for increased efforts, both in terms of research and clinical management. In patients where initial blood pressures are high, the difficulties are even greater. Commonly, combination of two or more antihypertensive drugs has been the most widely used treatment strategy to obtain appropriate blood pressure lowering and to reach predetermined diastolic and systolic blood pressure goals. Notably, in the recent ASCOT trial on high-risk hypertensive patients, two or more antihypertensive drugs had to given to about 9/10 patients in order to reduce blood pressure v140/90 mmHg (6). Moreover, additional trial evidence show that, even for the same or even a greater use of combination treatment in diabetic patients, achieved systolic blood pressure generally remains higher than in non-diabetics (5). Therefore, in the future it is evident that physicians involved in the management of hypertensive patients have to recognize that combination treatments will have to be implemented earlier in the course of hypertension management. Combinations, based on a calcium antagonist and an ACE inhibitor, are clearly effective and well tolerated. Fixed-dose Blood Pressure. 2007; 16(Suppl 1): 4–5

Sverre E. Kjeldsen

Papers

O-30: Predictors of cardiovascular events in 9,194 hypertensive patients with left ventricular hypertrophy. The LIFE study*

Diuretics in the LIFE study. Authors' reply

In light of ALLHAT and ASCOT: are there benefits of statins as add-on treatment in hypertensives?

Abstract 1449: Racial Differences in Incident Heart Failure Among Hypertensive Patients During Antihypertensive Therapy: The LIFE Study

There is a need for more aggressive implementation of combination strategies to control hypertensive risk.