Prehypertension and cardiovascular morbidity

Sources of differences in estimates of obesity-associated deaths from first National Health and Nutrition Examination Survey (NHANES I) hazard ratios

BACKGROUND

Estimates of obesity-associated deaths in the United States for 1991 were published by Allison et al (JAMA 1999;282:1530-8) and subsequently for 2000 by Mokdad et al (JAMA 2004;291:1238-45). Flegal et al (JAMA 2005;293:1861-7) then published lower estimates of obesity-associated deaths for 2000. All 3 studies incorporated data from the first National Health and Nutrition Examination Survey (NHANES I).

OBJECTIVE

The objective was to clarify the effects of methodologic differences between the 3 studies in estimates of obesity-associated deaths in the US population by using NHANES I hazard ratios.

DESIGN

The earlier reports used imputed smoking data for much of the NHANES I sample rather than the available reported data and applied a method of calculating attributable fractions that did not adjust for the effects of age, sex, and smoking on mortality in the target US population and did not account for effect modification by age. The effects of these and other methodologic factors were examined.

RESULTS

The NHANES I hazard ratios in the earlier reports were too low, probably because of the imputed smoking data. The low hazard ratios obscured the magnitude and direction of the bias arising from the incompletely adjusted attributable fraction method. When corrected hazard ratios were used, the incompletely adjusted attributable fraction method overestimated obesity-associated mortality in the target population by >100,000 deaths.

CONCLUSION

Methodologic sources of bias in the reports by Allison et al and Mokdad et al include the assessment of smoking status in NHANES I and the method of calculating attributable fractions.

Prehypertension is associated with atherosclerosis in Type 2 diabetes

BACKGROUND

Prehypertension is a risk factor for hypertension, diabetes, and cardiovascular diseases. However, the association between prehypertension and atherosclerosis in Type 2 diabetes mellitus (T2DM) has not been evaluated. In the present study, we investigated the impact of prehypertension on atherosclerosis in T2DM.

METHODS

Patients (n=930) with T2DM were recruited for the present study from the outpatient clinic of Shanghai Ruijin Hospital. The intima-media thickness (IMT) of the common carotid artery (CCA) was determined using ultrasound and brachial-ankle pulse wave velocity (baPWV) was determined by volume plethysmography to assess atherosclerosis.

RESULTS

Of the 930 patients with T2DM (mean age of 59 years), 167 were categorized as normotensive, 213 were prehypertensive, and 550 were hypertensive. Diabetic subjects with prehypertension had significantly higher CCA-IMT and baPWV than those with normal blood pressure after adjustment for age and gender. Multiple logistic regression analysis revealed that, compared with normotension, prehypertension was a significant independent determinant of atherosclerosis (for maximum IMT ≥1.1 mm, odds ratio (OR) 2.10 and 95% confidence interval (CI) 1.28-3.44; for baPWV ≥1400 cm/s, OR 3.09 and 95% CI 1.78-5.36).

CONCLUSION

Prehypertension is associated with atherosclerosis independent of conventional cardiovascular risk factors in T2DM patients. We speculate that maintenance of systolic blood pressure <120 mmHg and diastolic blood pressure <80 mmHg may reduce the risk of atherosclerosis in T2DM.

Treating prehypertension: medically sound and economically viable

The 7th Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure provided new guide-lines for the definition and management of hypertension. Notably, a new category-"prehypertension"-was created for intermediate systolic pressures exceeding 120 mmHg, the upper limit of normal, but less than 139 mmHg, the threshold for stage 1 hypertension. The therapeutic consequences of this new classification are not yet clear, but research indicates that prehypertension is an independent risk factor for cardiovascular, cognitive, and renal morbidities as well as diabetes, and statistical data indicate that prehypertension is present in over 30% of US, European, and Asian adults. However, while pharmacotherapy is recommended for hypertension, the use of drugs to control prehypertension is under question. Given the serious health consequences linked with prehypertension, such debates seem misplaced if patient well-being is our priority. While acknowledging the lack of specific randomized controlled trial data on this topic, we suggest that anti-hypertensive therapy be recommended for everyone with prehypertension and address resulting cost-benefit issues.

Metabolic characteristics of prehypertension: role of classification criteria and gender

OBJECTIVE

We tested whether men and women in the European Society of Hypertension (ESH) high normal and normal blood pressure (BP) categories, all included in the the Seventh Joint National Committee (JNC 7) prehypertension group, share similar metabolic characteristics and whether they differ from men and women with optimal BP (<120/80 mmHg).

METHODS

BP (multiple measurements with a standardized automatic device), insulin sensitivity (euglycaemic clamp), oral glucose tolerance test (OGTT), carotid intima-media-thickness (IMT, echo), family history (questionnaire), physical activity (accelerometer), and anthropometrics (bioimpedance) were evaluated in the 1384 healthy European individuals ranging from 30-60 years participating in the multicentre study Relationship between Insulin Sensitivity and Cardiovascular disease (RISC).

RESULTS

BMI and waist-to-hip ratio were higher (both P < 0.05 adjusted for age and recruiting centre) in men and women with high normal (but not normal) BP with respect to optimal BP. Similarly, in women (after adjustment for study centre, age, physical activity, and waist), serum triglycerides and carotid IMT were higher in those with high normal (but not normal) BP; moreover, in this group there was a higher prevalence of glucose-intolerance (21.8 versus 9.7%, P = 0.02) and insulin sensitivity tended to be lower (P = 0.07). Insulin sensitivity and diastolic blood pressure were weakly related variables displaying a nonlinear association with a threshold below the normal BP values and no interaction with family history of hypertension.

CONCLUSION

The JNC 7 category prehypertension identifies a dishomogeneous group of individuals whereas the ESH classification, particularly in women, was more accurate in identifying both the predisease and the healthy phenotype. Insulin resistance is not a major characteristic of the condition of prehypertension.

[Association of blood pressure levels with carotid intima-media thickness and plaques]

OBJECTIVES

The aim of this study was to investigate the association of blood pressure levels with the common carotid artery intima-media thickness (CCA-IMT) and carotid plaques.

METHODS

Data were obtained from 2,635 subjects, aged 50 years and over, who participated in the Community Health Survey (a population-based, cross-sectional study) in Dong-gu, Gwangju city between 2007 and 2008. Participants were categorized into three groups according to blood pressure levels; normotensives (<120/80 mmHg), prehypertensives (120-139/80-89 mmHg), and hypertensives (> or =140/90 mmHg). Prehypertensives were further categorized as low prehypertensives (120-129/80-84 mmHg) and high prehypertensives (130-139/85-89 mmHg). Carotid intima-media thickness and plaques were evaluated with a high-resolution B-mode ultrasound. Statistical analyses were performed using chi-square test, ANOVA, and multiple logistic regression.

RESULTS

Prehypertensives had significantly greater maximal CCA-IMT values than normotensives, with a multivariate adjusted odds ratio of 1.78 (95% CI=1.36-2.32) for abnormal CCA-IMT (maximal CCA-IMT > or =1.0 mm), and 1.45 (95% CI=1.19-1.77) for carotid plaques. The multivariate adjusted odds ratio of low prehypertensives was 1.64 (95% CI=1.21-2.21) for abnormal CCA-IMT, and 1.30 (95% CI=1.04-1.63) for carotid plaques compared with normotensives. Subject with hypertension had higher frequency of abnormal CCA-IMT (odds ratio, 2.18; 95% CI=1.49-3.18), and carotid plaques (odds ratio, 1.98; 95% CI=1.46-2.67) compared with normotensives after adjustment for other cardiovascular risk factors.

CONCLUSIONS

Our results indicate that there is a significant increase in the prevalence of carotid atherosclerosis in subjects with prehypertension (even in low prehypertensives) compared with normotensive subjects. Further studies are required to confirm the benefits and role of carotid ultrasonography in persons with prehypertension.

Association between prehypertension and clustering of cardiovascular disease risk factors among Chinese adults

PURPOSE

We aimed to estimate the association between prehypertension (PHT) and clustering of cardiovascular disease (CVD) risk factors among Chinese adults.

METHODS

A cross-sectional survey in a nationally representative sample of 15,540 Chinese adults aged 35-74 years was conducted during 2000-2001.

RESULTS

Overall, 79.4%, 40.0%, and 11.0% of Chinese adults with PHT (120-139/80-89 mm Hg) had >or=1, >or=2, and >or=3 modifiable CVD risk factors (dyslipidemia, impaired fasting glucose/diabetes, cigarette smoking, and overweight/obesity), respectively. The adjusted odds ratio (95% confidence interval, CI) of having >or=1, >or=2, and >or=3 CVD risk factors was 1.41 (1.24-1.61), 1.45 (1.30-1.61), and 1.96 (1.67-2.29), respectively, for adults with PHT compared with those with optimal blood pressure by multivariate models. Moreover, population attributable risk percent of having >or=1, >or=2, and >or=3 CVD risk factors was 16.7%, 18.0%, and 31.9%, respectively, for adults with PHT. Furthermore, among adults with PHT, higher prevalence, adjusted odds ratios, and population attributable risk percent of having >or=1, >or=2, and >or=3 CVD risk factors were more likely to be found among people with high normal blood pressure (130-139/85-89 mm Hg) compared with their counterparts with normal blood pressure (120-129/80-84 mm Hg).

CONCLUSIONS

Clustering of CVD risk factors is common among Chinese adults with PHT, especially with high normal blood pressure. Global lifestyle modification would be a very important nonpharmaceutical therapy to reduce the increasing burden of CVD in China.

Differences in healthy lifestyle characteristics between adults with prehypertension and normal blood pressure

BACKGROUND

Identifying differences in modifiable lifestyle factors between persons with prehypertension and normal blood pressure (BP) can help improve prevention efforts.

METHODS

Data from the 1999-2004 National Health and Nutrition Examination Survey were analyzed (in 2008) for persons aged at least 20 years (n = 11 194). Differences in five healthy lifestyle characteristics were examined by BP status (normal, prehypertension, and hypertension). Additionally, differences in lifestyle characteristics by sex, race/ethnicity, and education among those with prehypertension were analyzed.

RESULTS

Overall, 32.8% of adults had a normal BMI, 75.3% did not smoke, 31.3% were regularly physically active, 57.7% were moderate drinkers or nondrinkers, and 28.1% had a low sodium intake; only 2% had all five characteristics. Almost 40% had a normal BP and 30.3% were prehypertensive. Those with prehypertension were less likely to have a normal BMI than normotensive individuals [adjusted odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.56-0.70], to be regularly active (adjusted OR = 0.85, 95% CI = 0.74-0.98), and to moderately/not drink (adjusted OR = 0.88, 95% CI = 0.80-0.97). Those with prehypertension or hypertension were less likely to have at least three or four healthy lifestyle characteristics compared with those with normal BP. Among 3168 persons with prehypertension, some sex, race/ethnic, and education level differences in the prevalence of healthy lifestyles were observed.

CONCLUSION

Differences in healthy lifestyle factors were observed by BP status, but the prevalence of healthy lifestyle factors is suboptimal among the population as a whole.

Relation of blood pressure components and categories and all-cause, stroke and coronary heart disease mortality in urban Chinese women: a population-based prospective study

OBJECTIVE

To determine whether various levels of blood pressure (BP), particularly normal and high normal BP or prehypertension, predict cardiovascular mortality among urban Chinese women.

METHODS

We evaluated the impact of all measures of BP on total mortality and stroke and coronary heart disease (CHD)-specific mortality in a population-based cohort study, the Shanghai Women's Health Study. Included in this analysis were 68 438 women aged 40-70 years at baseline for whom BP was assessed.

RESULTS

During an average of 5 years of follow-up, we identified 1574 deaths from all causes, 247 from stroke and 91 from CHD. Hypertension and higher levels of individual BP parameters including systolic BP, diastolic BP, pulse pressure, and mean arterial pressure were positively associated with all-cause, stroke, and CHD mortality (Ptrend < 0.05 for all except for DBP and CHD mortality). Prehypertension [adjusted hazard ratio (HRadj) = 1.65; 95% confidence interval, 0.98-2.78], particularly high normal BP (HRadj = 2.34; 95% confidence interval, 1.32-4.12), was associated with an increased risk of mortality from stroke. Hypertension accounted for 9.3% of mortality from all causes, 25.5% of mortality from stroke, and 21.7% mortality from CHD. High normal BP accounted for 10.8% of mortality from stroke. Isolated systolic BP also predicted stroke and mortality from CHD.

CONCLUSION

Hypertension is a significant contributor to mortality, particularly stroke and CHD mortality, among women in Shanghai. High normal BP is associated with high stroke mortality.

Dark chocolate or tomato extract for prehypertension: a randomised controlled trial

Background

Flavanol-rich chocolate and lycopene-rich tomato extract have attracted interest as potential alternative treatment options for hypertension, a known risk factor for cardiovascular morbidity and mortality. Treatment of prehypertension (SBP 120–139/DBP 80–89 mmHg) may forestall progression to hypertension. However, there has been only limited research into non-pharmacological treatment options for prehypertension. We investigated the effect of dark chocolate or tomato extract on blood pressure, and their acceptability as an ongoing treatment option in a prehypertensive population.

Methods

Our trial consisted of two phases: a randomised controlled three-group-parallel trial over 12 weeks (phase 1) followed by a crossover of the two active treatment arms over an additional 12-week period (phase 2). Group 1 received a 50 g daily dose of dark chocolate with 70% cocoa containing 750 mg polyphenols, group 2 were allocated one tomato extract capsule containing 15 mg lycopene per day, and group 3 received one placebo capsule daily over 8 weeks followed by a 4-week washout period. In phase 2 the active treatment groups were crossed over to receive the alternative treatment. Median blood pressure, weight, and abdominal circumference were measured 4-weekly, and other characteristics including physical activity, general health, energy, mood, and acceptability of treatment were assessed by questionnaire at 0, 8 and 20 weeks. We analysed changes over time using a linear mixed model, and one time point differences using Kruskal-Wallis, Fisher's-Exact, or t-tests.

Results

Thirty-six prehypertensive healthy adult volunteers completed the 6-month trial. Blood pressure changes over time within groups and between groups were not significant and independent of treatment. Weight and other characteristics did not change significantly during the trial. However, a marked difference in acceptability between the two treatment forms (chocolate or capsule) was revealed (p < 0.0001). Half of the participants allocated to the chocolate treatment found it hard to eat 50 g of dark chocolate every day and 20% considered it an unacceptable long-term treatment option, whereas all participants found it easy and acceptable to take a capsule each day for blood pressure.

Conclusion

Our study did not find a blood pressure lowering effect of dark chocolate or tomato extract in a prehypertensive population. Practicability of chocolate as a long-term treatment option may be limited.

Trial registration

Identifier: ACTRN12609000047291

Hypertension: reflections on risks and prognostication

Framingham Heart Study cardiovascular disease prospective population epidemiologic research has played an important role in the evolution of modern cohort study design and the advancement of preventive cardiology. To date no single essential factor has been identified; multiple interrelated factors are promoting increased risk for development of CHD. Elevated blood pressure has emerged as a prominent member of cardiovascular risk factors. The study's documentation of a strong link of blood pressure to development of cardiovascular events stimulated the pharmaceutical industry to develop medications for controlling blood pressure and, in turn, national campaigns to combat hypertension and its adverse vascular outlook.

Prevalence of prehypertension and associated risk factors in a rural Taiwanese adult population

BACKGROUND

The Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure has recently introduced the prehypertension category of blood pressure status that needs monitoring and intervention. This study aimed to assess the prevalence of prehypertension and its associated risks in rural Taiwan.

METHODS

From community-based cross-sectional data of 6204 adults (2650 men and 3554 women) who received general health examination in the Chi-Shan district in rural Taiwan, collected between 2002 and 2007, we analyzed and compared the blood pressure and demographic, metabolic, and behavior characteristics of prehypertensive and normotensive subjects. Multiple logistic regression methods were used to identify risk factors for prehypertension.

RESULTS

Within the study population, 3354 had hypertension, 1875 had prehypertension, and 975 had normal blood pressure. The prehypertensive subjects were older, had higher body mass index (BMI), and had higher blood glucose, total cholesterol, triglycerides, and uric acid levels than did the normotensive group. Multivariate logistic regression analysis revealed that BMI was the strongest predictor of prehypertension in both men and women (OR=1.102, 95% CI=1.054-1.152, P<0.001; and OR=1.121, 95% CI=1.085-1.159, P<0.001, respectively).

CONCLUSIONS

The prevalence of prehypertension is high among adults in rural Taiwan and it was associated with many risk factors for further hypertension and cardiovascular disease. Early lifestyle modifications, such as healthy diet, optimal weight control, and exercise are recommended interventions.

Prehypertension: should we be treating with pharmacologic therapy?

Prehypertension, defined by Seventh Joint National Committee (JNC 7) as a blood pressure (BP) 120-139/80-89 mm Hg, was controversial. Approximately 31-37% of US adults are prehypertensive, and approximately 12-14% have BP of 130-139/85-89 mm Hg or ;Stage 2' prehypertension, is associated with approximately 3-fold greater likelihood of developing hypertension and roughly twice the cardiovascular events than BP <120/80 mm Hg. Lifestyle change is the only intervention recommended for most prehypertensives. When fully implemented, lifestyle changes lower BP and prevent cardiovascular events, but evidence for community-wide effectiveness is limited. The Trial of Preventing Hypertension (TROPHY) documented that angiotensin receptor blockade safely lowers BP and prevents and/or delays hypertension in Stage 2 prehypertensives. Prehypertensives with diabetes or nephropathy are at high risk and should receive antihypertensive treatment according to JNC 7. Epidemiological data suggest that the number needed to treat to prevent a cardiovascular event in these at-risk Stage 2 prehypertensives is similar to Stage 1 hypertensives when both groups have one or more concomitant risk factors. Clinical trials are urgently needed to address this question. In the absence of clinical trials data, we believe it is prudent for the concerned clinician to consider initiating antihypertensive pharmacotherapy in selected Stage 2 prehypertensive patients at significant absolute risk for progression to hypertension and cardiovascular events.

Capillary rarefaction in treated and untreated hypertensive subjects

This study aimed to determine if capillary rarefaction is detectable and associated with endothelial dysfunction in persons with mild systolic blood pressure (SBP) elevation. Capillary density and endothelial function were quantified for 150 nondiabetic participants, grouped by blood pressure (BP) as normotensive, untreated high BP, and treated high BP. Structural capillary rarefaction measures were not different between the three groups. Functional capillary rarefaction measures were significantly lower in both high BP groups compared to normotensives, and correlated inversely with endothelial function. The study findings indicate that the hypertensive vascular pathologic process is already underway at modest levels of blood pressure elevation.

High blood pressure--when should employees be sent home from work?

This article explores guidelines for hypertension and why individuals do not control their hypertension.

Prehypertension: risk stratification and management considerations

Approximately 37% of US adults are prehypertensive; about 31 million have blood pressures in the range of 130-139/85-89 mm Hg. These stage 2 prehypertensives have threefold greater risk for developing hypertension and twofold higher risk for cardiovascular events than normotensives. Lifestyle changes only are recommended for most prehypertensives, but evidence for community-wide effectiveness is limited. Projected numbers needed to treat to prevent a cardiovascular event are similar for stage 2 prehypertension and stage 1 hypertension when both groups are matched for concomitant risk factors. However, no clinical trials document that pharmacotherapy reduces cardiovascular events in stage 2 prehypertension. The Trial of Preventing Hypertension demonstrated that angiotensin receptor blockade safely lowers blood pressure and prevents or delays progression to hypertension in stage 2 prehypertensives. We believe it is reasonable for clinicians to identify stage 2 prehypertensives at high absolute risk for progression to hypertension and cardiovascular events, and to treat them with a renin-angiotensin system blocker when lifestyle changes alone are ineffective.

Prevalence and risk factors of prehypertension among Chinese adults

PURPOSE

We aimed to estimate the prevalence of prehypertension and to identify its risk factors among Chinese adults.

METHODS

A cross-sectional survey in a nationally representative sample of 15,540 Chinese adults aged 35 to 74 years was conducted during 2000 and 2001. Body weight, height, waist circumference, and blood pressure were measured by trained observers.

RESULTS

Overall, 21.9% of Chinese adults had prehypertension. The prevalences were 25.7% and 18.0% in men and in women, respectively. The prevalences of prehypertension were higher among residents in northern China compared with their counterparts in southern China. The prehypertensive group had higher levels of blood glucose, total cholesterol, low-density lipoprotein cholesterol, and triglycerides, higher body mass index, and lower levels of high-density lipoprotein cholesterol than did the normotensive group. Of note, prehypertension was high among men and women who were overweight, as well as with central obesity (38.4% and 27.8%, respectively, for overweight and 37.8% and 25.9%, respectively, for central obesity). Multivariate analysis revealed that increased body mass index, waist circumference, and rural and northern residence were associated with prehypertension. High odds ratios of prehypertension were found in overweight and central obese adults.

CONCLUSION

The fact that a large proportion of Chinese adults have prehypertension, a major precursor of hypertension, warrants more efforts to implement national programs of prevention and control of hypertension and excessive weight, especially in rural and northern China, to reduce the societal burden of hypertension in China.

Effect of comprehensive therapeutic lifestyle changes on prehypertension

Although national clinical guidelines promulgate therapeutic lifestyle changes (TLC) as a cornerstone in the management of prehypertension, there is a perceived ineffectiveness of TLC in the real world. In this study of 2,478 ethnically diverse (African Americans n = 448, Caucasians n = 1,881) men (n = 666) and women (n = 1,812) with prehypertension and no known atherosclerotic cardiovascular disease, diabetes mellitus, or chronic kidney disease, we evaluated the clinical effectiveness of TLC in normalizing blood pressure (BP) without antihypertensive medications. Subjects were evaluated at baseline and after an average of 6 months of participation in a community-based program of TLC. TLC included exercise training, nutrition, weight management, stress management, and smoking cessation interventions. Baseline BP (125 +/- 8/79 +/- 3 mm Hg) decreased by 6 +/- 12/3 +/- 3 mm Hg (p <or=0.001), with 952 subjects (38.4%) normalizing their BP (p <or=0.001). In subjects with a baseline systolic BP of 120 to 139 mm Hg (n = 2,082), systolic BP decreased by 7 +/- 12 mm Hg (p <or=0.001). In subjects with a baseline diastolic BP of 80 to 89 mm Hg (n = 1,504), diastolic BP decreased by 6 +/- 3 mm Hg (p <or=0.001). There were no racial differences in the magnitude of reduction in BP; however, women had greater BP reductions than men (p <or=0.001). Also, subjects with a baseline body mass index (BMI) <30 kg/m(2) had a greater reduction in BP than those with a BMI >or=30 kg/m(2). In conclusion, the present study adds to previous research by reporting on the effectiveness, rather than the efficacy, of TLC when administered in a real-world, community-based setting.

Prehypertension and hypertension in a primary care practice

OBJECTIVE

To assess the prevalence of prehypertension and the prevalence and treatment of hypertension in a family practice population.

DESIGN

Cross-sectional study.

SETTING

An academic family practice unit.

PARTICIPANTS

Practice patients aged 30 to 80 years who had visited the clinic at least once during the 2 years before the study and had at least 1 blood pressure (BP) measurement recorded on their charts during that time period.

MAIN OUTCOME MEASURES

Most recent BP recorded on the chart; presence or absence of a diagnosis of hypertension recorded on the chart; number and class of prescribed antihypertensive medications.

RESULTS

Of the 1388 patients who met the inclusion criteria, 389 had a diagnosis of hypertension. Of the 999 who did not have a diagnosis of hypertension, 306 (30.6%) met the criteria for prehypertension used in this study (systolic BP of 130 to 139 mm Hg or diastolic BP of 85 to 89 mm Hg). Men and older patients (60 to 80 years of age) were more likely to have prehypertension than other patients were. Of the patients with hypertension, 254 (65%) had achieved a BP level of < 140/90 mm Hg. The majority of hypertensive patients were prescribed 1 or 2 medications. Only 4.5% were using more than 2 different medications.

CONCLUSION

A large proportion of a family practice's patients need close surveillance of BP because of the prevalence of prehypertension. Despite the improvement in the management of hypertension, only 65% of hypertensive patients had achieved the recommended target BP. Family physicians could be treating their hypertensive patients more aggressively with medications; only 4.4% of patients were using more than 2 different antihypertensive medications, despite 35% not being at target. Hypertension surveillance and treatment to achieve target BP levels continue to be important issues in primary care.

Association between protein bound sialic acid and high sensitivity C-reactive protein in prehypertension: a possible indication of underlying cardiovascular risk

The global burden posed by cardiovascular disease due to a rising incidence of known risk factors like essential hypertension underlines an urgent need to identify other potential risk factors like dyslipidemia, elevated levels of high-sensitivity CRP (hsCRP), Apo-B, and sialic acid in prehypertensive subjects. This study sought to examine the possible alteration in the levels of hsCRP, plasma protein bound sialic acid, and other lipid risk factors and the possible interactions among these parameters in prehypertensive subjects. Forty prehypertensive and 34 normotensive male subjects were enrolled in the study. Lipid profile, hsCRP, Apo-B, sialic acid, and lipid risk ratios were estimated in both the groups. There was no significant difference between fasting glucose and BMI in either group. The levels of total cholesterol, triglycerides, direct LDL-cholesterol, non-HDL cholesterol, and Apo-B were significantly increased in prehypertensive subjects compared with controls. The risk ratios calculated as direct LDL-cholesterol/Apo-B, total cholesterol/HDL-cholesterol, non-HDL-cholesterol/HDL-cholesterol were significantly elevated in prehypertensive subjects. There was also a significant increase in hsCRP and protein bound sialic acid in prehypertensive subjects in comparison with normotensive subjects. Correlation analysis revealed a significant association between the protein bound sialic acid with hsCRP, LDL cholesterol, and LDL-C/Apo-B. The findings of the present study suggest that in prehypertension, there is an association between protein bound sialic acid and hsCRP that reflects the clustering of cardiovascular risk factors in these subjects.

Oxidative stress in prehypertension: rationale for antioxidant clinical trials

Prehypertension has been recently described as an independent category of blood pressure. Mounting evidence suggests that blood pressure in the prehypertensive range is associated with an increased risk of developing hypertension and cardiovascular disease. Several reports have assigned a critical role for oxidative stress in these disease processes. This review focuses on the clinical and experimental studies done in prehypertension and hypertension within the context of oxidative stress. This article also provides insights into why diverse therapeutic interventions, which have in common the ability to reduce oxidative stress, can impede or delay the onset of hypertension in prehypertension subjects.

Prehypertension: What is the Current Status?

Cardiovascular disease (CVD) risk is a continuum across blood pressure. The term prehypertension was introduced because it is now recognized that blood pressure readings between what is deemed optimal and hypertension is associated with increased CVD risk. The prevalence of prehypertension is high and the progression to hypertension is also high. Prehypertension is also commonly associated with other CVD risk factors namely dyslipidaemia, dysgylcaemia and overweight/ obesity. Eighty-five percent of prehypertensives have one other or more CVD risk factor compared to normotensives. A recent study has shown a reduction in the development of hypertension from prehypertension with the use of an angiotensin receptor blocker. Unfortunately to date, the impact of treatment of prehypertension on CVD outcome is still unknown except in those with high CVD risk like diabetes or established CVD. However this does not mean nothing can be done for those with prehypertension. The aim of managing prehypertension is to lower the BP, prevent progression to hypertension and to prevent BP related CVD deaths. Lifestyle changes can reduce BP and this by itself can lower CVD risk. Until more evidence about other modalities of treatment become available this is a sensible and cost-effective way to manage prehypertension.

Comparison of cardiovascular risk factors between prehypertension and hypertension in a Mongolian population, Inner Mongolia, China

BACKGROUND

There is little knowledge on comparisons of cardiovascular risk factors between prehypertension and hypertension in Mongolian populations, Inner Mongolia, China.

METHODS AND RESULTS

A total of 2,589 Mongolians aged 20 years and over were recruited as study participants. Demographic data, lifestyle factors, family history of hypertension, blood pressure measurements, physical examination and blood samples were obtained and analyzed for all individuals. Prehypertensives and hypertensives accounted for 38.39% and 37.39%, respectively, in all participants. Multivariate logistic regression using proportional odds model showed that hypertension was significantly associated with age (odds ratio was 5.79, 8.84, 30.05 and 32.28 for age 40-, 50-, 60- and 70-, respectively), family history of hypertension (7.12), alcohol drinking (2.03), overweight (4.69) and hyperlipidemia (3.49), and prehypertension significantly associated with age (3.65 for age 70-84), hyperlipidemia (1.80) in males. In females, hypertension was significantly associated with age (8.58, 14.40, 33.00, 63.67 for age 40-, 50-, 60- and 70-, respectively), family history of hypertension (5.65), overweight (3.16) and high C-reactive protein (> or = 10.356 mg/L), and prehypertension significantly associated with age (1.72, 2.00, 2.74 and 6.67 for age 40-, 50-, 60- and 70-, respectively) and overweight (1.68).

CONCLUSIONS

Prevalence of some cardiovascular risk factors and number of risk factors in hypertensives were higher than that in prehypertensives.

Prehypertension during young adulthood and coronary calcium later in life

BACKGROUND

High blood pressure in middle age is a well-established risk factor for cardiovascular disease, but the consequences of low-level elevations during young adulthood are unknown.

OBJECTIVE

To measure the association between prehypertension exposure before age 35 years and coronary calcium later in life.

DESIGN

Prospective cohort study.

SETTING

Four communities in the United States.

PARTICIPANTS

Black and white men and women age 18 to 30 years recruited for the CARDIA (Coronary Artery Risk Development in Young Adults) Study in 1985 through 1986 who were without hypertension before age 35 years.

MEASUREMENTS

Blood pressure trajectories for each participant were estimated by using measurements from 7 examinations over the course of 20 years. Cumulative exposure to blood pressure in the prehypertension range (systolic blood pressure of 120 to 139 mm Hg, or diastolic blood pressure of 80 to 89 mm Hg) from age 20 to 35 years was calculated in units of mm Hg-years (similar to pack-years of tobacco exposure) and related to the presence of coronary calcium measured at each participant's last examination (mean age, 44 years [SD, 4]).

RESULTS

Among 3560 participants, the 635 (18%) who developed prehypertension before age 35 years were more often black, male, overweight, and of lower socioeconomic status. Exposure to prehypertension before age 35 years, especially systolic prehypertension, showed a graded association with coronary calcium later in life (coronary calcium prevalence of 15%, 24%, and 38% for 0, 1 to 30, and >30 mm Hg-years of exposure, respectively; P < 0.001). This association remained strong after adjustment for blood pressure elevation after age 35 years and other coronary risk factors and participant characteristics.

LIMITATION

Coronary calcium, although a strong predictor of future coronary heart disease, is not a clinical outcome.

CONCLUSION

Prehypertension during young adulthood is common and is associated with coronary atherosclerosis 20 years later. Keeping systolic pressure below 120 mm Hg before age 35 years may provide important health benefits later in life.

Prevention of cardiovascular events by treating hypertension in older adults: an evidence-based approach

Hypertension in older adults is not well controlled in clinical practice. Isolated systolic hypertension is often more difficult to manage. A systematic PubMed search was conducted to look for evidence showing benefits of lowering blood pressure (BP) in older hypertensive adults. Lowering BP in these individuals significantly reduces the risk of coronary artery disease, stroke, and cardiovascular and all-cause mortality. Based on trial evidence, a low-dose diuretic should be considered the most appropriate first-step treatment for preventing cardiovascular morbidity and mortality. Therapy with >1 medication is often necessary to reduce BP in these patients. There is unequivocal evidence that cardiovascular events can be prevented in older adults, even those older than 80 years, by treating hypertension.

Reduction in blood pressure with statins: results from the UCSD Statin Study, a randomized trial

BACKGROUND

Some studies have suggested reductions in blood pressure (BP)with statin treatment, particularly in persons with hypertension. Randomized trial evidence is limited.

METHODS

We performed a randomized, double-blind, placebo-controlled trial with equal allocation to simvastatin, 20 mg; pravastatin sodium,40 mg; or placebo for 6 months. Nine hundred seventy-three men and women without known cardiovascular disease or diabetes mellitus, with low-density lipoprotein cholesterol screening levels of 115 to 190 mg/dL, had assessment of systolic and diastolic BP (SBP and DBP, respectively). Blood pressure values were compared for placebo vs statins by intention-to-treat (ITT) analysis. Additional analyses were performed that (1) were confined to subjects with neither high baseline BP (SBP>140 mm Hg or DBP>90 mm Hg) nor receiving BP medications, to exclude groups in whom BP medications or medication changes may have influenced results, and (2) separately evaluated simvastatin and pravastatin (vs placebo). The time course of BP changes after statin initiation and the effect of stopping statins on BP were examined.

RESULTS

Statins modestly but significantly reduced BP relative to placebo,by 2.2 mm Hg for SBP (P=.02) and 2.4 mm Hg for DBP (P<.001) in ITT analysis. Blood pressure reductions ranged from 2.4 to 2.8 mm Hg for both SBP and DBP with both simvastatin and pravastatin, in those subjects with full follow-up, and without potential for influence by BP medications (ie, neither receiving nor meriting BP medications).

CONCLUSIONS

Reductions in SBP and DBP occurred with hydrophilic and lipophilic statins and extended to normotensive subjects. These modest effects may contribute to the reduced risk of stroke and cardiovascular events reported on statins. Trial Registration clinicaltrials.gov Identifier: NCT00330980.

Nationwide survey of prevalence and risk factors of prehypertension and hypertension in Iranian adults

OBJECTIVE

The aim of this study was to estimate the prevalence and risk factors of prehypertension (Pre-HTN) and hypertension (HTN) among the adult population of Iran.

METHODS

A nationwide cross-sectional survey was conducted from December 2004 to February 2005. The selection was conducted by stratified probability cluster sampling through household family members in Iran. Blood pressure (BP) and associated risk factors of 35 048 men and 34 674 women aged 25-65 years (mean 44.1 years) were measured.

RESULTS

The prevalence of Pre-HTN was 59.6% in men and 44.5% in women; and 19.8% of men and 26.9% of women were hypertensive, according to Joint National Committee 7 criteria. Pre-HTN was more common among men whereas HTN was more common among women. Multivariate analysis revealed that age, overweight, obesity, abdominal obesity and high cholesterol were strongly associated with Pre-HTN in both genders. In women, low educational attainment, residence in an urban area and high blood glucose were also associated with Pre-HTN. Age, low educational attainment, overweight, obesity, abdominal obesity and high cholesterol and blood glucose were strongly associated with HTN in both genders.

CONCLUSION

Pre-HTN and HTN appear to be quiet common in Iran and were associated with obesity. More men than women present with Pre-HTN, whereas more women than men present with HTN. Prevention and treatment strategies are urgently needed to address the health burden of Pre-HTN and HTN and to prevent prehypertensive people from developing HTN and cardiovascular disease.

Prevalence of prehypertension and associated cardiovascular risk profiles among prediabetic Omani adults

Background

The importance of prediabetes and prehypertension has been demonstrated in several studies especially for primary prevention of CVD. A recent community based cross-sectional study revealed that 40.9 percent Omani adults are prediabetics. This study was undertaken to estimate the prevalence of prehypertension and associated cardiovascular risk profiles in prediabetics. To best of our knowledge, this is the first report on this subject.

Methods

The study included 327 confirmed pre-diabetic Omani adults, who were analysed for their demographic, metabolic and behavioral characteristics. These characteristics were compared between the three different blood pressure groups to determine the CVD risk factors. Univariate and step-wise multiple logistic regression methods were used to carry out the analysis of the data.

Results

In this study, the prevalence of prehypertension was 54.1 percent. Males were at higher risk of developing prehypertension as compared to females (OR = 2.30, 95% CI: 1.21, 4.38; P < 0.01). The individuals with higher BMI have two fold more risk of developing prehypertension (OR = 2.25, 95% CI: 1.26, 4.02; P < 0.01). The increased level of OGT enhanced the risk of developing prehypertension (OR = 1.26, 95% CI: 1.06, 1.50; P < 0.01).

Conclusion

A high prevalence of prehypertension (54.1%) exists in this study population. The major determinants of prehypertension in these prediabetic subjects were male gender, increasing dysglycemia and BMI. Appropriate intervention strategies have been suggested.

High blood pressure and cardiovascular disease mortality risk among U.S. adults: the third National Health and Nutrition Examination Survey mortality follow-up study

PURPOSE

We sought to examine whether prehypertension is associated with increased cardiovascular disease (CVD) mortality risk and whether the association of blood pressure with CVD outcome is modified by social demographics or hypertension treatment and control.

METHODS

Data from the Third National Health and Nutrition Examination Survey and mortality follow-up through 2000 were used to estimate the relative risk of death from CVD associated with hypertension and prehypertension, after adjusting for confounding and modifying factors.

RESULTS

Compared with normotension, the relative risks of CVD mortality were 1.23 (95% confidence interval [95% CI] 0.85-1.79, p=0.26) for prehypertension, 1.64 (95% CI 1.11-2.41, p=0.01) for hypertension, 1.74 (95% CI 1.28-2.49, p=0.007) for uncontrolled hypertension, and 1.15 (95% CI 0.79-1.80, p=0.53) for controlled hypertension. Hypertensive adults <65 years and non-Hispanic blacks had a 3.86-fold and a 4.65-fold increased CVD mortality risk respectively. Age, gender, and race/ethnicity stratified analyses showed no associations between prehypertension and CVD mortality. However, blood pressure at a high range of prehypertension (130-139/84-89 mmHg) was associated with increased risk of CVD mortality (hazard ratio 1.41, p<0.05) relative to blood pressure less than 120/80 mmHg.

CONCLUSIONS

This study supports a strong, significant, and independent association of elevated blood pressure with CVD mortality risk. Hypertension continued to greatly increase CVD morality risk, particularly among persons <65 years and non-Hispanic blacks. Treatment and control of hypertension eliminated the excess CVD mortality risk observed among the hypertension population.

Cardiorespiratory fitness influences the blood pressure response to experimental weight gain

OBJECTIVE

We tested the hypothesis that with similar weight gain the increase in blood pressure (BP) would be smaller in men with higher cardiorespiratory fitness (HCRF) than in men with lower cardiorespiratory fitness (LCRF).

RESEARCH METHODS AND PROCEDURES

Thirteen men (age = 23 +/- 1, BMI = 24 +/- 1) were overfed by approximately 1000 kcal/d over approximately 8 weeks to achieve a 5-kg weight gain. Resting BP and 24-hour ambulatory BP, body composition, and fat distribution were measured.

RESULTS

Cardiorespiratory fitness (CRF) was higher in the HCRF group compared with the LCRF group (49.9 +/- 1.2 vs. 38.1 +/- 1.4 mL/kg per minute, p < 0.001). At baseline, body weight was similar in the HCRF and LCRF groups, whereas the HCRF group displayed lower levels of total body fat (13.0 +/- 1.7 vs. 16.9 +/- 1.3 kg, p = 0.049) and abdominal visceral fat (49 +/- 6 vs. 80 +/- 14 cm2, p = 0.032). Resting BP and 24-hour ambulatory BP were similar in the two groups at baseline. After weight gain, body weight increased approximately 5 kg (p < 0.05) in both groups; the changes in body composition and regional fat distribution were similar. As hypothesized, the increases in resting systolic (1 +/- 2 vs. 7 +/- 2 mm Hg; p = 0.008) and diastolic (-1 +/- 4 vs. 5 +/- 1 mm Hg; p = 0.005) BP were smaller in the HCRF group. CRF was correlated with the increases in resting systolic (r = -0.64; p = 0.009) and diastolic BP (r = -0.80; p < 0.001). Furthermore, the relationship between CRF and BP remained significant after adjusting for the changes in the proportion of total abdominal fat gained as visceral fat.

DISCUSSION

These findings suggest that higher levels of CRF are associated with a smaller increase in BP with weight gain, independently of changes in abdominal visceral fat.

Prehypertension

Prehypertension--blood pressure between 120-139/80-89 mmHg--is a major public health concern. The condition is very prevalent (especially in obese young people), is often associated with other cardiovascular risk factors and independently increases the risk of hypertension and subsequent cardiovascular events. In the general population, prehypertension can be lowered, but not often reliably, by lifestyle modifications. Drug therapy for prehypertension is not yet recommended, except for individuals with diabetes, chronic kidney disease, and perhaps known coronary artery disease, because of short-term cost considerations and unproven long-term benefits. Ongoing research will probably identify which individuals with blood pressures in the prehypertensive range, but with no serious comorbidities, would benefit from treatment. In this Review, we attempt to summarize the recently published data concerning the epidemiology, attendant risks and potential treatment options for this important and growing public-health problem.

Psychosocial factors and progression from prehypertension to hypertension or coronary heart disease

PURPOSE

This study explored the influence of trait anger and long-term psychological stress on progression to hypertension and incident coronary heart disease (CHD) in persons with prehypertension.

METHODS

A secondary data analysis was performed using the Atherosclerosis Risk in Communities (ARIC) study, a cohort of men and women aged 45 to 64 years at enrollment. Participants with blood pressures in the prehypertension range at the second visit conducted between 1990 and 1992, free of heart disease or stroke, and observed through the end of the ARIC study (1996-1998) were included (N = 2,334). The main outcomes were progression from prehypertension to hypertension and prehypertension to CHD or CHD death.

RESULTS

After adjusting for various covariates, high levels of trait anger, compared with low/moderate levels (odds ratio [OR] 1.53; 95% confidence interval [CI], 1.05-2.24), were associated with progression from prehypertension to hypertension. After stratifying on sex, trait anger was predictive for men only (OR 1.71; 95% CI 1.04-2.83). In survival analysis, trait anger was associated with progression to CHD for men (hazard ratio [HR] 1.92; 95% CI, 1.07-3.54). Long-term psychological stress was also associated with risk of incident CHD (HR 1.68; 95% CI 1.18-2.40).

CONCLUSIONS

High levels of trait anger in middle-aged prehypertensive men were associated with increased risk of progressing to hypertension and incident CHD. Long-term stress was also associated with increased risk of incident CHD in both men and women.

Risk of progression to hypertension in a low-income Mexican population with prehypertension and normal blood pressure

BACKGROUND

Blood pressure (BP) levels below the prehypertensive category may be associated with the risk of developing hypertension. We estimated the incidence rates of hypertension in a low-income Mexican population according to several subcategories of baseline BP within normal and prehypertensive categories.

METHODS

In total, 1572 nonhypertensive men (n = 632) and nonpregnant women (n = 940), aged 35 to 64 years at baseline, were followed for a median of 5.8 years. Hypertension was defined as systolic blood pressure (SBP) >or=140 mm Hg, diastolic blood pressure (DBP) >or=90 mm Hg, or a self-reported physician's diagnosis with antihypertensive medications.

RESULTS

During follow-up, 267 subjects developed hypertension, of whom 83 were men and 184 were women. The age-adjusted incidence rate was higher in women (37.1 per 1000 person-years) than in men (23.7 per 1000 person-years). There was a significant association between BP levels at baseline and incidence of hypertension, even within the normal category. For the upper levels of normal SBP (110 to 119 mm Hg), the hazards ratio (HR) was 2.43 (95% confidence interval [CI], 1.50 to 3.93) in women and 2.44 (95% CI, 1.05 to 5.69) in men, compared with SBP <110 mm Hg. For the upper levels of normal DBP (70 to 79 mm Hg), the HR was 2.33 (95% CI, 1.65 to 3.31) in women and 1.80 (95% CI, 0.92 to 3.52) in men, compared with DBP <70 mm Hg, after adjustment for recognized predictors.

CONCLUSIONS

A high risk for the incidence of hypertension was associated with levels of BP, even within the normal category. This information could help define a population at high risk of progression to hypertension, to establish preventive measures.

The prevalence of erectile dysfunction among hypertensive and prehypertensive men aged 25-40 years

INTRODUCTION

Erectile dysfunction (ED) and hypertension (HTN) are common and associated among men aged 40-70 years. Data on the prevalence of ED among younger hypertensive and prehypertensive men are limited.

AIM

To study the prevalence of ED in a large-scale population of hypertensive and prehypertensive men aged 25-40 years.

MAIN OUTCOME MEASURES

ED severity, systolic blood pressures (SBPs), diastolic blood pressures (DBPs), and mean arterial blood pressures (MAPs).

METHODS

Israel Defense Force personnel, aged 25 years and older, go through routine health checks at the Staff Periodic Health Examination Center (SPEC) every 3-5 years, including measuring blood pressure and completing the Sexual Health Inventory for Men (SHIM) questionnaire in order to detect HTN and ED, respectively, and assess its severity. Pre-HTN was defined as SBP 120-139 mm Hg or DBP 80-89 mm Hg. HTN was defined as SBP >/or140 mm Hg and/or DBP >or=90 mm Hg.

RESULTS

During 2001-2004, an overall of 11,252 men, aged 25-40 years, reported to the SPEC, and 5,860 (52.1%) men filled out the SHIM questionnaire. Among responders to the SHIM questionnaire, 1,278 (21.8%) men had low scores (<or=21), suggesting ED. Overall, 3021 (51.6%) men had pre-HTN and 557 (9.5%) men had HTN. The prevalence of ED was similar among men with HTN, men with pre-HTN, and men with normal blood pressure: 22.9% vs. 21.3% vs. 22.3%, respectively. In addition, SBPs, DBPs, and MAPs were not associated with the SHIM scores among all men.

CONCLUSIONS

The prevalence of ED is not increased among hypertensive and prehypertensive men compared with normotensive men aged 25-40 years. Moreover, higher blood pressures are not associated with worse erections among all men in this age group. Apparently, it takes years for HTN to cause ED.

Prehypertension and Insulin Resistance in a Nationally Representative Adult Population

Prehypertension is associated with increased risk of cardiovascular disease and progression to hypertension. Insulin resistance (IR) is also related to cardiovascular risk. It is unknown whether individuals with prehypertension also have higher IR. The purpose of this study was to examine the association between prehypertension and IR. The National Health and Nutrition Examination Survey 1999-2002 was used to determine odds of IR by fasting insulin level >12.2 microU/mL or homeostasis model assessment (HOMA) > or = 2.6 among nondiabetic adults aged 20 to 80 years across blood pressure categories. Compared with normotensives, odds of IR were over 60% higher for prehypertensive individuals by both IR measures: fasting insulin (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12-2.48) and HOMA (OR, 1.67; 95% CI, 1.22-2.30). After stratifying by sex, IR was associated with prehypertension in only men for both IR measures. In conclusion, prehypertension is associated with higher IR in men, which may confer additional cardiovascular disease risk.

Surrogate markers of insulin resistance in assessing individuals with new categories “prehypertension” and “prediabetes”

BACKGROUND

There are few data on the impact of insulin resistance on the recently defined categories of prehypertension (PHT) and prediabetes (PDM). The aim of this study was to examine associations of surrogate markers of insulin resistance with PHT/PDM.

METHODS

Subjects included 554 individuals who underwent a 75-g oral glucose tolerance test (OGTT). They were classified into four groups using a severity score for high blood pressure and glucose tolerance. Insulin resistance was measured using the homeostasis model assessment of insulin resistance (HOMA-R) and three surrogate markers obtained from 75-g OGTT values (ISI-composite, Stumvoll index, and OGIS index).

RESULTS

HOMA-R increased significantly, but the other three surrogate indices decreased with increasing severity score. Of these markers, the OGIS index was mostly associated with prevalent PHT/PDM and the odds ratio for insulin resistance was 3.61 (95% CI 1.68-7.76, p=0.001) for subjects with either PHT or PDM and 29.98 (12.81-70.18, p<0.001) for subjects with both PHT and PDM.

CONCLUSIONS

PHT and PDM frequently coexist in relatively lean Japanese subjects. Decreased insulin sensitivity may contribute to the underlying status of PHT/PDM. Among the surrogate markers of insulin resistance, the OGIS index is the most sensitive for assessment of PHT/PDM status.

Exercise capacity and blood pressure associations with left ventricular mass in prehypertensive individuals

Prehypertensive individuals are at increased risk for developing hypertension and cardiovascular disease compared with those with normal blood pressure. Early compromises in left ventricular structure may explain part of the increased risk. We assessed echocardiographic and exercise parameters in prehypertensive individuals (n=790) to determine associations between exercise blood pressure and left ventricular structure. The exercise systolic blood pressure at 5 metabolic equivalents (METs) and the change in blood pressure from rest to 5 METs were the strongest predictors of left ventricular hypertrophy. We identified the systolic blood pressure of 150 mm Hg at the exercise levels of 5 METs as the threshold for left ventricular hypertrophy. There was a 4-fold increase in the likelihood for left ventricular hypertrophy for every 10-mm Hg increment in systolic blood pressure beyond this threshold (OR: 1.15; 95% CI: 1.12 to 1.18). There was also a 42% reduction in the risk for left ventricular hypertrophy for every 1 MET increase in the workload (OR: 0.58; P<0.001). When compared with low-fit, moderate, and high-fit individuals exhibited significantly lower systolic blood pressure at an exercise workload of 5 METs (155+/-14 versus 146+/-10 versus 144+/-10; P<0.05), lower left ventricular mass index (48+/-12 versus 41+/-10 versus 41+/-9; P<0.05), and prevalence of left ventricular hypertrophy (48.3% versus 18.7% versus 21.6%; P<0.001). This suggests that moderate improvements in cardiorespiratory fitness achieved by moderate intensity physical activity can improve hemodynamics and cardiac performance in prehypertensive individuals and reduce the work of the left ventricle, ultimately resulting in lower left ventricular mass.

Expanding the definition of hypertension to incorporate global cardiovascular risk

Recent epidemiologic analyses have changed the way that hypertension is viewed. Cardiovascular risk has been found to be elevated at levels of blood pressure previously believed to be normal and not imparting additional risk. Furthermore, the approach to hypertension has been shifted from viewing and treating it in isolation to a more comprehensive approach that incorporates a focus on global cardiovascular risk and the risk factors commonly associated with having an elevated blood pressure. However, control rates not only for hypertension but also for associated risk factors, such as hyperlipidemia and diabetes, remain abysmal, providing an even greater challenge to providers of care. To change this alarming trend, physicians must become aggressive in using the available armamentarium of lifestyle modifications and drugs in treating hypertension and other risk factors that increase the burden of atherosclerosis.

Prehypertension and risk of cardiovascular disease

Epidemiologic data have established a continuous relationship between vascular risk and blood pressure that extends down to levels as low as 115/75 mmHg, emphasizing the lack of a critical threshold value that defines 'high' blood pressure. Acknowledging the graded and continuous nature of the relations of blood pressure to vascular risk, the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VII) introduced the new category 'prehypertension' to describe people with a systolic blood pressure between 120 and 139 mmHg and/or a diastolic blood pressure between 80 and 89 mmHg. It is estimated that 31% of the US population (70 million) has prehypertension. The risk of cardiovascular disease within this large prehypertensive population is not uniform, however, and increases with a rising concomitant burden of other vascular risk factors. Accordingly, a strategy of estimating global cardiovascular risk (by applying standardized risk prediction algorithms) and adjusting the intensity of blood pressure lowering (and reduction of other risk factors) to the absolute risk of cardiovascular disease is desirable in prehypertensive individuals. Adopting a healthier lifestyle, as recommended by JNC VII, is a critical component of the therapeutic approach to prehypertension.