Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials

Nuts, hypertension and endothelial function

BACKGROUND AND AIMS

High blood pressure (BP) is considered a major risk factor for cardiovascular disease. Among lifestyle factors, diet plays a key role in the prevention and control of high BP. Therefore, it is important to elucidate which dietary components can exert beneficial effects on BP through modulation of endothelial function (EF) or by other mechanisms. In this paper we review the role of nutrients, foods, particularly nuts, and dietary patterns on BP control.

DATA SYNTHESIS

Because nuts are low in sodium and contain significant amounts of mono- and polyunsaturated fatty acids, fiber, minerals such as magnesium, potassium and calcium, and antioxidants, they have been suggested as potentially protective foods against hypertension. Limited evidence from prospective studies and clinical trials suggests that nut consumption has a beneficial effect on both BP and EF. However, BP changes were a secondary outcome in nut feeding trials and no study used ambulatory BP monitoring as the standard for BP measurements.

CONCLUSIONS

Further clinical trials, ideally using ambulatory BP monitoring, are needed to establish the potential protective effect of nut consumption on hypertension and vascular reactivity.

Racial differences in two self-management hypertension interventions

BACKGROUND

Only one half of Americans have their blood pressure controlled, and there are significant racial differences in blood pressure control. The goal of this study was to examine the effectiveness of 2 patient-directed interventions designed to improve blood pressure control within white and non-white subgroups (African Americans, 49%).

METHODS

Post hoc analysis of a 2 by 2 randomized trial with 2-year follow-up in 2 university-affiliated primary care clinics was performed. Within white and non-white patients (n=634), 4 groups were examined: 1) usual care; 2) home blood pressure monitoring (3 times per week); 3) tailored behavioral self-management intervention administered via telephone by a nurse every other month; and 4) a combination of the 2 interventions.

RESULTS

The overall race by time by treatment group effect suggested differential intervention effects on blood pressure over time for whites and non-whites (systolic blood pressure, P=. 08; diastolic blood pressure, P=.01). Estimated trajectories indicated that among the 308 whites, there was no significant effect on blood pressure at 12 or 24 months for any intervention compared with the control group. At 12 months, the non-whites (n=328) in all 3 intervention groups had systolic blood pressure decreases of 5.3 to 5.7 mm Hg compared with usual care (P <.05). At 24 months, in the combined intervention, non-whites had sustained lower systolic blood pressure compared with usual care (7.5 mm Hg; P <.02). A similar pattern was observed for diastolic blood pressure.

CONCLUSION

Combined home blood pressure monitoring and a tailored behavioral phone intervention seem to be particularly effective for improving blood pressure in non-white patients.

Heavy drinking is associated with poor blood pressure control in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

Alcohol intake has been shown to have a J-shaped association with blood pressure (BP). However, this association has not been examined in mixed race populations or in people with diabetes where tighter blood pressure control is recommended. Participants in the REGARDS study who were 45 years or older (n = 30,239) were included. Medical history (including self-reported alcohol intake) was collected by telephone while blood collection and clinical measurements were done during an in-home visit. We defined diabetes as use of medications and/or fasting glucose ≥ 126 mg/dL and hypertension as use of blood pressure lowering medications and/or BP ≥ 140/90 mmHg or BP ≥ 130/80 mmHg in people with diabetes. After adjustment for confounders, heavy drinking was associated with an increased odds of hypertension (OR = 1.59; 95% CI = 1.37, 1.87). Diabetes and gender significantly modified (interaction P < 0.05 for both) the association between alcohol use and hypertension, although heavy drinking remained associated with increased odds of hypertension in sub-group analyses. We did not observe the previously described J-shaped relationship in any sub-group except white females. These data suggest heavy alcohol consumption is associated with poor BP control and that heavy drinkers may want to consider limiting alcohol intake in order to manage hypertension.

Alcohol consumption and metabolic syndrome

Drinking excessive amounts of alcohol regularly for years is toxic to almost every tissue of the body. On the other hand, epidemiological and clinical evidence shows that light-to-moderate drinking is associated with a reduced risk of coronary heart disease, total and ischemic stroke, and mortality. In the past two decades, metabolic syndrome, the combination of obesity, hypertension, dyslipidemia and hyperglycemia, are all also recognized as major cardiovascular risk factors, has given rise to much clinical and research attention, because of its high prevalence in the world. Therefore, it is of interest to evaluate the overall associations of alcohol consumption with the development of metabolic syndrome. Recently, the protective, detrimental or J-shaped associations have been reported between alcohol consumption and metabolic syndrome. This controversy may be due to the complex mechanistic relation between alcohol consumption and each component of metabolic syndrome, and almost all studies have various limitations and problem points. Prospective studies are therefore needed to confirm the association between alcohol consumption and prevalence of metabolic syndrome, and to assess the influence of alcohol drinking patterns and other possible factors, such as smoking, physical activity, socioeconomic status, education, occupation, diet and exercise. This article reviews the relation of alcohol consumption and components of metabolic syndrome, and discusses the epidemiological evidence for alcohol's putative vascular protective effects and plausible underlying biological mechanisms.

Relationship between alcohol consumption and metabolic syndrome in Japanese men with overweight or obesity

SUMMARY

OBJECTIVE

The aim of this study was to determine the relationship of alcohol intake with metabolic syndrome in obese people.

METHODS

Japanese men (35-65 years, n = 7250) who showed high body mass index (25 kg/m(2) or over) were divided into four groups by alcohol intake [non-, light (<22 g ethanol/day), heavy (≥22 and <44 g ethanol/day) and very heavy (≥ 44 g ethanol/day) drinkers]. Odds ratios for metabolic syndrome were calculated after adjustment for age and history of smoking.

RESULTS

Prevalence of metabolic syndrome was significantly higher in very heavy drinkers than in nondrinkers and was significantly lower in light drinkers than in heavy and very heavy drinkers. The odds ratio vs. nondrinkers for metabolic syndrome was significantly low in light drinkers (odds ratio [OR] = 0.84, 95% confidence interval [CI]: 0.71-0.98, p < 0.05), was not significant in heavy drinkers (OR = 1.01, 95% CI: 0.90-1.13), and was significantly high in very heavy drinkers (OR = 1.23, 95% CI: 1.08-1.40, p < 0.01).

CONCLUSIONS

In Japanese men with overweight or obesity, there are significant inverse and positive associations of light and excessive alcohol consumption, respectively, with metabolic syndrome.

Non-pharmacological aspects of blood pressure management: what are the data?

Hypertension affects 29% of US adults and is a significant risk factor for cardiovascular morbidity and mortality. Epidemiological data support contribution of several dietary and other lifestyle-related factors to the development of high blood pressure (BP). Several clinical trials investigated the efficacy of non-pharmacological interventions and lifestyle modifications to reduce BP. Best evidence from randomized controlled trials supports BP-lowering effects of weight loss, the Dietary Approaches to Stop Hypertension (DASH) diet, and dietary sodium (Na(+)) reduction in those with prehypertension, with more pronounced effects in those with hypertension. In hypertensive participants, the effects on BP of DASH combined with low Na(+) alone or with the addition of weight loss were greater than or equal to those of single-drug therapy. Trials where food was provided to participants were more successful in showing a BP-lowering effect. However, clinical studies with long-term follow-up revealed that lifestyle modifications were difficult to maintain. Findings from controlled trials of increased potassium, calcium, or magnesium intake, or reduction in alcohol intake revealed modest BP-lowering effects and are less conclusive. The reported effects of exercise independent of weight loss on BP are inconsistent.

Confirmation of ALDH2 as a Major locus of drinking behavior and of its variants regulating multiple metabolic phenotypes in a Japanese population

BACKGROUND

Normative alcohol use (or drinking behavior) influences the risk of cardiovascular disease in a multi-faceted manner. To identify susceptibility gene variants for drinking behavior, a 2-staged genome-wide association study was performed in a Japanese population.

METHODS AND RESULTS

In the stage-1 scan, 733 cases and 729 controls were genotyped with 456,827 SNP markers. The associated loci without redundancy of linkage disequilibrium were further examined in the stage-2 general population panel comprising 2,794 drinkers (≥ once per week), 1,521 chance drinkers (< once per week), and 1,351 non-drinkers. Along with genome-wide exploration, we aimed to replicate the trait association of a candidate gene SNP previously reported (rs1229984 in ADH1B). A cluster of 12 SNPs on 12q24 were found to significantly (P<5×10(-8)) associate with drinking behavior in stage 1, among which rs671 (a Glu-to-Lys substitution at position 504) in the ALDH2 gene showed the strongest association (odds ratio (OR)=0.16, P=3.6×10(-211) in the joint analysis). The association was also replicated for rs1229984 (OR=1.20, P<3.6×10(-4)). Furthermore, ALDH2 504Lys was associated with several metabolic traits, eg, lower levels of high-density lipoprotein cholesterol and liver enzymes-AST, ALT, and γGTP-by interacting with alcohol intake.

CONCLUSIONS

Our results confirm ALDH2 as a major locus regulating drinking behavior in the Japanese, indicating that the ALDH2 504Lys variant exerts pleiotropic effects on risk factors of cardiovascular disease among drinkers.

Initial clinical encounter with the patient with established hypertension

The initial encounter with the patient with hypertension presents the opportunity to reprogram the trajectory of overall cardiovascular risk in the patient with suspected or established hypertension. The practicing clinician should strive to recognize other important considerations beyond drug prescription and treatment guidelines, such as the patient's level of health literacy, social and economic implications of lifelong drug therapy and health care costs, and readiness for and effectiveness of patient self-management. This should be followed by delivery of patient education that is appropriate for literacy level. Self-monitoring should be a tool to engage patients in active participation. Comprehensive risk stratification should be encouraged in all patients. Careful clinician adherence to established practice guidelines in overall risk assessment and treatment and control of blood pressure to target levels remain crucial.

Lifestyle Intervention Strategies for the Prevention and Treatment of Hypertension: A Review

Hypertension (HTN) is an extraordinarily common progressive cardiovascular syndrome in the United States, afflicting approximately one third of the adult population. HTN is a powerful and unequivocal independent risk factor for cardiovascular and renal diseases, including coronary heart disease, stroke, and renal failure. Despite major advances in the understanding and treatment of HTN over the past several decades, the disease remains the most common primary diagnosis in the United States and is a major public health concern. Adoption of healthy lifestyle modifications has proven to be highly effective in both the prevention of new-onset HTN and in the treatment of those diagnosed with HTN. In view of the continuing epidemic of HTN and blood pressure (BP)—related diseases and the invaluable role of applying nonpharmacological therapy in the prevention and management of HTN, a review of current therapeutic lifestyle strategies appears warranted. This review will define 6 well-established nonpharmacological lifestyle modifications for preventing and managing HTN in addition to 3 novel lifestyle interventions that show promise as effective adjunct strategies for lowering BP. A healthy lifestyle prescription ideally comprising a number of these BP-lowering lifestyle intervention strategies should be dispensed by all primary care physicians for both the prevention and treatment of elevated BP, an action that would have major, positive public health ramifications.

Significance of high HDL cholesterol levels in Japanese men with metabolic syndrome

OBJECTIVE

The objective was to clarify the significance of high high-density lipoprotein cholesterol (HDL-C) levels in the metabolic syndrome (MetS). The evaluation focused on insulin resistance as an indicator of early-stage MetS.

METHODS AND SUBJECTS

Of 2705 men who first underwent an annual health check-up at Tokai University Hachioji Hospital, 2129 men were included in this study, after exclusion of those on medication for hypertension, diabetes or dyslipidemia, and those with a prior history of ischemic heart disease, cerebrovascular disease or chronic renal failure. MetS risk factors include the following five parameters: waist circumference, blood pressure, plasma glucose, triglycerides and HDL-C. The correlations between HDL-C and number of MetS risks with homeostasis model assessment of insulin resistance (HOMA-IR) were analyzed. HOMA-IR, number of risks, habits of smoking, exercise and drinking alcohol, stratified by HDL-C levels, were compared in MetS subjects.

RESULTS

In cases with ≤2 risk factors, the higher the HDL-C, the lower the HOMA-IR. However, with ≥3 risk factors for MetS, the HOMA-IR increased when HDL-C was ≥90 mg/dL. In MetS subjects, the rate of alcohol intake ≥75 g/day was high when HDL-C was ≥90 mg/dL.

CONCLUSION

In MetS subjects with high HDL-C levels, insulin resistance was increased. Therefore, in persons with high HDL-C levels, it is important to monitor the amount of alcohol consumption and reduce alcohol consumption to <75 g/day.

Resistant hypertension in office practice: a clinical approach

Resistant hypertension is defined as blood pressure uncontrolled to guideline levels despite the use of ≥3 antihypertensive medications. When evaluating patients with resistant hypertension, it is important to consider issues such as blood pressure measurement technique, lifestyle, other comorbid conditions and medications, and the white coat effect. To this point, potential contributing factors include obstructive sleep apnea, excess alcohol intake, and use of blood pressure-elevating medications, such as nonsteroidal anti-inflammatory drugs, sympathomimetics, certain anorexic agents, and oral contraceptives. Secondary causes of hypertension are common in patients with resistant hypertension and appropriate screening tests should be performed as suggested by signs, symptoms, and laboratory abnormalities. In this regard, there is increasing evidence that hyperaldosteronism is common in the resistant hypertensive patient group. Pharmacologic therapy in patients with resistant hypertension is centered on drug combinations that have different mechanisms of action, including diuretics, which are essential in maximizing antihypertensive effects. The role of mineralocorticoid receptor antagonists is expanding, especially in patients with the metabolic syndrome, where aldosterone excess is increasingly recognized as an etiology of resistant hypertension. Finally, when appropriate, specialist referral may be necessary to appropriately assess and treat these patients.

IPP-rich milk protein hydrolysate lowers blood pressure in subjects with stage 1 hypertension, a randomized controlled trial

BACKGROUND

Milk derived peptides have been identified as potential antihypertensive agents. The primary objective was to investigate the effectiveness of IPP-rich milk protein hydrolysates (MPH) on reducing blood pressure (BP) as well as to investigate safety parameters and tolerability. The secondary objective was to confirm or falsify ACE inhibition as the mechanism underlying BP reductions by measuring plasma renin activity and angiotensin I and II.

METHODS

We conducted a randomized, placebo-controlled, double blind, crossover study including 70 Caucasian subjects with prehypertension or stage 1 hypertension. Study treatments consisted of daily consumption of two capsules MPH1 (each containing 7.5 mg Isoleucine-Proline-Proline; IPP), MPH2 (each containing 6.6 mg Methionine-Alanine-Proline, 2.3 mg Leucine-Proline-Proline, 1.8 mg IPP), or placebo (containing cellulose) for 4 weeks.

RESULTS

In subjects with stage 1 hypertension, MPH1 lowered systolic BP by 3.8 mm Hg (P = 0.0080) and diastolic BP by 2.3 mm Hg (P = 0.0065) compared with placebo. In prehypertensive subjects, the differences in BP between MPH1 and placebo were not significant. MPH2 did not change BP significantly compared with placebo in stage I hypertensive or prehypertensive subjects. Intake of MPHs was well tolerated and safe. No treatment differences in hematology, clinical laboratory parameters or adverse effects were observed. No significant differences between MPHs and placebo were found in plasma renin activity, or angiotensin I and II.

CONCLUSIONS

MPH1, containing IPP and no minerals, exerts clinically relevant BP lowering effects in subjects with stage 1 hypertension. It may be included in lifestyle changes aiming to prevent or reduce high BP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00471263.

Racial Differences in Barriers to Blood Pressure Control in a Family Practice Setting

Objective: Hypertension prevalence in the African American community is greater than in all other ethnic groups. Cultural perceptions of health and disease introduce barriers to providing effective care. The purpose of this study was to identify racial differences in the perceived causes of hypertension, current behaviors performed to control blood pressure, and perceived barriers to preventing or treating hypertension. Methods: A self-administered survey of patients seen for medical care in a primary care network was conducted. The survey was developed to measure perceptions of hypertension etiology and treatments. Data from African American (n = 69) and Caucasian (n = 218) respondents were used to assess racial differences in perceptions of blood pressure control. Results: About half of respondents knew their current blood pressures. African American patients were significantly less likely to believe that hypertension was caused by a lack of exercise and obesity. Significantly more Caucasians were less likely to report cutting down on table salt and taking prescription medications for blood pressure control. Both African Americans and Caucasians believed that sodium reduction was the most easily changed behavior to control their blood pressure, while both groups identified weight loss as being the most difficult. Conclusion: Racial differences exist in the perceived causes and treatments of high blood pressure, indicating a need for further patient education. When treating and counseling patients, physicians and support staff members must be sensitive to racial diversity and strive to offer culturally relevant solutions, especially for behaviors perceived as most difficult to change.

The impact of lactotripeptides on blood pressure response in stage 1 and stage 2 hypertensives

Nearly 70 million Americans have hypertension, and approximately an equal number have prehypertension. The prevalence of both disorders increases with advancing age and obesity. Many at-risk individuals do not have controlled blood pressure (BP). Lifestyle modification for most persons is the first step in a plan to control these conditions. Non-drug treatments offer an appeal to many patients with modest BP elevation. The authors recently evaluated BP response using 24-hour ambulatory BP monitoring and office BP monitoring of lactotripeptides dosed twice daily in 91 previously treated and treatment-naive patients with stage 1 and stage 2 hypertension. In this population, daytime systolic BP, the primary efficacy end point, significantly decreased (-3.6 mm Hg; P=.013), while placebo did not affect systolic BP (0 mm Hg; P=not significant). Treatment-naive patients exhibited a more robust drop in their daytime systolic BP (-7.6 mm Hg; P=.005) compared with placebo (-3.6 mm Hg; P=not significant). Lactotripeptides may be an effective agent in the management of low-risk and low-grade hypertension and prehypertension.

ASH position paper: dietary approaches to lower blood pressure

A substantial body of evidence has implicated several aspects of diet in the pathogenesis of elevated blood pressure (BP). Well-established risk factors for elevated BP include excess salt intake, low potassium intake, excess weight, high alcohol consumption, and suboptimal dietary pattern. African Americans are especially sensitive to the BP-raising effects of excess salt intake, insufficient potassium intake, and suboptimal diet. In this setting, dietary changes have the potential to substantially reduce racial disparities in BP and its consequences. In view of the age-related rise in BP in both children and adults, the direct, progressive relationship of BP with cardiovascular-renal diseases throughout the usual range of BP, and the worldwide epidemic of BP-related disease, efforts to reduce BP in nonhypertensive as well as hypertensive individuals are warranted. In nonhypertensives, dietary changes can lower BP and delay, if not prevent, hypertension. In uncomplicated stage I hypertension, dietary changes serve as initial treatment before drug therapy. In hypertensive individuals already on drug therapy, lifestyle modifications can further lower BP. The current challenge is designing and implementing effective clinical and public health interventions that lead to sustained dietary changes among individuals and more broadly in the general population.

Dietary patterns and blood pressure among middle-aged and elderly Chinese men in Shanghai

The prevalence of hypertension has increased over the past decade in many developed and developing countries, including China. This increase may be associated with changes in lifestyle, including dietary patterns. We evaluated the association of dietary patterns with blood pressure (BP) by using data from a large, population-based cohort study of middle-aged and elderly Chinese men, the Shanghai Men's Health Study. The present cross-sectional analysis includes 39 252 men who reported no prior history of hypertension, diabetes, CHD, or stroke nor use of antihypertensive drugs at study enrolment. Three dietary patterns, 'vegetable', 'fruit and milk' and 'meat', were derived using factor analysis. The fruit and milk diet was inversely associated with both systolic and diastolic BP (Ptrend < 0.001). The adjusted mean systolic BP was 2.9 mmHg lower (95 % CI - 3.4, - 2.4), and diastolic BP was 1.7 mmHg lower (95 % CI - 2.0, - 1.4) for men in the highest quintile of the 'fruit and milk' pattern compared with men in the lowest quintile. This inverse association was more evident among heavy drinkers; the highest quintile of the 'fruit and milk' pattern was associated with a 4.1 mmHg reduction in systolic BP v. a 2.0 mmHg reduction among non-drinkers (Pinteraction = 0.003) compared to the lowest quintile. The corresponding reductions in diastolic BP were 2.0 v. 1.3 mmHg (Pinteraction = 0.011). The 'fruit and milk' pattern was associated with a lower prevalence of both pre-hypertension and hypertension, and the associations appeared to be stronger among drinkers. Results of the present study suggest an important role for diet in the prevention of hypertension.

Risk factors promoting hypertensive crises: evidence from a longitudinal study

BACKGROUND

Current knowledge about risk factors promoting hypertensive crisis originates from retrospective data. Therefore, potential risk factors of hypertensive crisis were assessed in a prospective longitudinal study.

METHODS

Eighty-nine patients of the medical outpatient unit at the University Hospital of Bern (Bern, Switzerland) with previously diagnosed hypertension participated in this study. At baseline, 33 potential risk factors were assessed. All patients were followed-up for the outcome of hypertensive crisis. Cox regression models were used to detect relationships between risk factors and hypertensive crisis (defined as acute rise of systolic blood pressure (BP) > or =200 mm Hg and/or diastolic BP > or =120 mm Hg).

RESULTS

The mean duration of follow-up was 1.6 +/- 0.3 years (range 1.0-2.4 years). Four patients (4.5%) were lost to follow-up. Thirteen patients (15.3%) experienced hypertensive crisis during follow-up. Several potential risk factors were significantly associated with hypertensive crisis: female sex, higher grades of obesity, the presence of a hypertensive or coronary heart disease, the presence of a somatoform disorder, a higher number of antihypertensive drugs, and nonadherence to medication. As measured by the hazard ratio, nonadherence was the most important factor associated with hypertensive crisis (hazard ratio 5.88, 95% confidence interval 1.59-21.77, P < 0.01).

CONCLUSIONS

This study identified several potential risk factors of hypertensive crisis. Results of this study are consistent with the hypothesis that improvement of medical adherence in antihypertensive therapy would help to prevent hypertensive crises. However, larger studies are needed to assess potential confounding, other risk factors and the possibility of interaction between predictors.

Prehypertension: detection, evaluation, and management

Prehypertension was defined as a discrete category in 1993. There is evidence to support active management of this entity given the increased risk of hypertension, cardiovascular disease, heart failure, and stroke. There have been few comprehensive summaries on the management of this population. Therefore, this article summarizes the latest guidelines and studies on the detection, evaluation, and management of prehypertension.

History of antihypertensive therapy influences the relationships of alcohol with blood pressure and pulse pressure in older men

BACKGROUND

Blood pressure is known to be higher in heavy drinkers than in nondrinkers. The aim of this study was to determine whether the alcohol-blood pressure relationship is modified by therapy for hypertension in the elderly.

METHODS

Men aged > or = 65 years (n = 1,396) with or without current history of antihypertensive therapy were divided into four groups by alcohol intake (non-, light (<22 g ethanol/day), heavy (> or = 22 and <44 g ethanol/day), and very heavy (> or = 44 g ethanol/day) drinkers). Blood pressure and pulse pressure were compared among the groups.

RESULTS

Systolic blood pressure and pulse pressure were significantly higher in subjects receiving antihypertensive therapy than in subjects not receiving antihypertensive therapy, whereas diastolic blood pressure was not different between the two groups. In multivariate analysis with adjustment for age, smoking history, and body mass index (BMI), systolic and diastolic blood pressure and pulse pressure in the group not receiving antihypertensive therapy were significantly higher in heavy and very heavy drinkers than in nondrinkers, whereas in the group receiving antihypertensive therapy, systolic and diastolic blood pressure and pulse pressure were not different between each drinker group and the nondrinker group.

CONCLUSIONS

Alcohol intake was associated with blood pressure and pulse pressure in older men not receiving therapy for hypertension but not in those receiving antihypertensive therapy. The indicated possibility that changes in drinking do not have a substantial impact on blood pressure among treated hypertensives should be examined in longitudinal studies and preferably in clinical trials.

Arterial hypertension in the elderly of Bridgetown, Barbados: prevalence and associated factors

OBJECTIVE

To determine the prevalence of and investigate factors associated with hypertension among elderly Barbadians.

METHOD

This was a cross-sectional, population-based household survey. A total of 1,508 persons aged 60 and older were examined. The occurrence of hypertension was assessed by the following question: "Do you take any medication for high blood pressure?"

RESULTS

The prevalence of hypertension was 29.9% in men and 45.9% in women. Multivariable analysis (the hierarchical model) showed that alcohol consumption, arthritis, heart attack, and self-reported health presented, in women, an association with hypertension (p < .05). Obesity and diabetes were associated with hypertension in both genders.

DISCUSSION

Sociodemographic variables, sedentary lifestyles, and smoking did not have a noticeable role in the chosen model for the determination of hypertension. Obesity was an especially noteworthy risk factor due to its high prevalence as well as the possibility of the latter being altered through intervention.

Comparison of the Framingham Heart Study hypertension model with blood pressure alone in the prediction of risk of hypertension: the Multi-Ethnic Study of Atherosclerosis

A prediction model, developed in the Framingham Heart Study (FHS), has been proposed for use in estimating a given individual's risk of hypertension. We compared this model with systolic blood pressure (SBP) alone and age-specific diastolic blood pressure categories for the prediction of hypertension. Participants in the Multi-Ethnic Study of Atherosclerosis, without hypertension or diabetes mellitus (n=3013), were followed for the incidence of hypertension (SBP > or =140 mm Hg and/or diastolic blood pressure > or =90 mm Hg and/or the initiation of antihypertensive medication). The predicted probability of developing hypertension among 4 adjacent study examinations, with a median of 1.6 years between examinations, was determined. The mean (SD) age of participants was 58.5 (9.7) years, and 53% were women. During follow-up, 849 incident cases of hypertension occurred. The c statistic for the FHS model was 0.788 (95% CI: 0.773 to 0.804) compared with 0.768 (95% CI: 0.751 to 0.785; P=0.096 compared with the FHS model) for SBP alone and 0.699 (95% CI: 0.681 to 0.717; P<0.001 compared with the FHS model) for age-specific diastolic blood pressure categories. The relative integrated discrimination improvement index for the FHS model versus SBP alone was 10.0% (95% CI: -1.7% to 22.7%) and versus age-specific diastolic blood pressure categories was 146.0% (95% CI: 116.0% to 181.0%). Using the FHS model, there were significant differences between observed and predicted hypertension risks (Hosmer-Lemeshow goodness of fit: P<0.001); recalibrated and best-fit models produced a better model fit (P=0.064 and 0.245, respectively). In this multiethnic cohort of US adults, the FHS model was not substantially better than SBP alone for predicting hypertension.

Effect of the DASH Diet on Pre- and Stage 1 Hypertensive Individuals in a Free-Living Environment

BACKGROUND

Dietary Approaches to Stop Hypertension (DASH) has been shown to successfully reduce systolic (SBP) and diastolic blood pressure (DBP) when evaluated in clinically controlled environments but there is a lack of information regarding the efficacy of the original DASH diet when it is applied in a free-living environment.

PURPOSE

To provide descriptive data as to the changes in blood pressure individuals could expect to achieve when following the DASH diet in a free-living environment for 4-weeks with no additional behavioral modifications.

METHODS

Twenty, pre- and stage 1 hypertensive participants were randomly split into 2 groups; DASH (males N = 5, females N = 5, age = 38.5 ± 10.8) and control (males N = 7, females N = 3, age = 38.1 ± 11.1). The DASH group was instructed on how to follow the DASH diet on their own for 4-weeks while the control group continued their normal diet. SBP, DBP, body weight, 3-day food diaries and physical activity recall questionnaire data were collected pre and post intervention using a traditional person-to-person instructional technique.

RESULTS

Two-way ANOVA demonstrated that there was a significant group (DASH, control) by time (pre, post) interaction for SBP (P = 0.003) and no significant effects for DBP. The interaction was due to a significant reduction (P < 0.001) in SBP in the DASH group (pre: 141.3 ± 11.3 mmHg vs. post: 130.7 ± 9.1 mmHg) over the course of the intervention with no change in SBP in the control group (pre: 133.5 ± 6.6 mmHg vs. post: 131.9 ± 8.9 mmHg). Pearson's correlation analyses revealed that changes in potential moderators of blood pressure including body weight, BMI, sodium intake and total kilocalories were each not associated with changes in SBP (r ≤ 0.14, P ≥ 0.5) or DBP (r ≤ 0.10, P ≥ 0.6) pre- to post-treatment. Chi-square demonstrated no significant differences in the number of participants per group (n = 4 DASH, n = 1 control) who indicated increasing physical activity during the intervention.

CONCLUSION

DASH diet followed in a free-living environment significantly reduced SBP but not DBP. However, the changes in SBP and DBP were very similar to those noted in controlled clinical feeding evaluations of the DASH diet. Presently, none of the potential moderators of blood pressure that were assessed were independently associated with the observed changes in blood pressure which may be due to our small sample size or the possibility that it is the combined change in multiple factors that lead to reductions in blood pressure when following the DASH diet.

Recommendations for global hypertension monitoring and prevention

In recent years, cardiovascular diseases (CVDs) have been recognized as the most common cause of death in the world, accounting for 30% of all mortality, with a growing burden in developing countries. In 2000, it was estimated that 26% of the world's adult population (972 million individuals) had prevalent hypertension, a key risk factor for CVD, and this number is expected to increase to 29% (1.56 billion) by 2025. CVDs place a heavy burden on society and overall economic activity; they are ranked third in disability-adjusted life years lost. We now have a comprehensive understanding of the basic lifestyle modifications that decrease risk of hypertension and its associated sequelae, however, and it is clear that only modest lifestyle changes would be required to produce small reductions in population averages that would have a large impact, given the multitude of adverse outcomes attributable to high blood pressure. Hypertension therefore is an important public health issue. Considerably more research and standardization of surveillance methods are required to realize the existing opportunities to reduce the global burden of CVDs.

Hypertension awareness, treatment, and control in adults with CKD: results from the Chronic Renal Insufficiency Cohort (CRIC) Study

BACKGROUND

A low rate of blood pressure control has been reported in patients with chronic kidney disease (CKD). These data were derived from population-based samples with a low rate of CKD awareness.

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

Data from the baseline visit of the Chronic Renal Insufficiency Cohort (CRIC) Study (n = 3,612) were analyzed. Participants with an estimated glomerular filtration rate of 20-70 mL/min/1.73 m(2) were identified from physician offices and review of laboratory databases.

OUTCOMES

Prevalence and awareness of hypertension, treatment patterns, control rates, and factors associated with hypertension control.

MEASUREMENTS

Following a standardized protocol, blood pressure was measured 3 times by trained staff, and hypertension was defined as systolic blood pressure > or =140 mm Hg and/or diastolic blood pressure > or =90 mm Hg and/or self-reported antihypertensive medication use. Patients' awareness and treatment of hypertension were defined using self-report, and 2 levels of hypertension control were evaluated: systolic/diastolic blood pressure <140/90 and <130/80 mm Hg.

RESULTS

The prevalence of hypertension was 85.7%, and 98.9% of CRIC participants were aware of this diagnosis and 98.3% were treated with medications, whereas 67.1% and 46.1% had hypertension controlled to <140/90 and <130/80 mm Hg, respectively. Of CRIC participants with hypertension, 15%, 25%, 26%, and 32% were using 1, 2, 3, and > or =4 antihypertensive medications, respectively. After multivariable adjustment, older patients, blacks, and those with higher urinary albumin excretion were less likely, whereas participants using angiotensin-converting enzyme inhibitors and angiotensin receptor blockers were more likely to have controlled their hypertension to <140/90 and <130/80 mm Hg.

LIMITATIONS

Data were derived from a single study visit.

CONCLUSIONS

Despite almost universal hypertension awareness and treatment in this cohort of patients with CKD, rates of hypertension control were suboptimal.

Lifestyle behaviors and receipt of preventive health care services among hypertensive Americans aged 45 years or older in 2007

OBJECTIVE.: The aim of the study was to explore opportunities for more effective interventions on lifestyle modifications among hypertensives. METHODS.: Using 2007 data from the Behavioral Risk Factor Surveillance System from the United States, we assessed the prevalence of various lifestyle behaviors and receipt of preventive health care services among US adults aged 45 years or older based on hypertension and treatment status (n=218,228). RESULTS.: Compared with nonhypertensives, hypertensives were significantly less likely to engage in recommended levels of physical activity and to be more obese regardless of treatment status. Compared to nonhypertensives, hypertensives on medical treatment were less likely to consume five or more servings of fruit and vegetables per day, be current smokers, and binge drinkers. Hypertensives not on medical treatment were more likely to be current smokers, binge and heavy drinkers. Hypertensives on medical treatment were more likely to have routine health checkup, have blood cholesterol checkup within previous 5 years and have a flu shot within the previous year than hypertensives not on treatment. CONCLUSION.: Different patterns of lifestyle behaviors and use of preventive health care services were found based on treatment status among hypertensives. Intervention programs should be tailored accordingly to achieve optimal outcome on lifestyle modification.

Two self-management interventions to improve hypertension control: a randomized trial

BACKGROUND

Fewer than 40% of persons with hypertension in the United States have adequate blood pressure (BP) control.

OBJECTIVE

To compare 2 self-management interventions for improving BP control among hypertensive patients.

DESIGN

A 2 x 2 randomized trial, stratified by enrollment site and patient health literacy status, with 2-year follow-up. (ClinicalTrials.gov registration number: NCT00123058).

SETTING

2 university-affiliated primary care clinics.

PATIENTS

636 hypertensive patients.

INTERVENTION

A centralized, blinded, and stratified randomization algorithm was used to randomly assign eligible patients to receive usual care, a behavioral intervention (bimonthly tailored, nurse-administered telephone intervention targeting hypertension-related behaviors), home BP monitoring 3 times weekly, or the behavioral intervention plus home BP monitoring.

MEASUREMENTS

The primary outcome was BP control at 6-month intervals over 24 months.

RESULTS

475 patients (75%) completed the 24-month BP follow-up. At 24 months, improvements in the proportion of patients with BP control relative to the usual care group were 4.3% (95% CI, -4.5% to 12.9%) in the behavioral intervention group, 7.6% (CI, -1.9% to 17.0%) in the home BP monitoring group, and 11.0% (CI, 1.9%, 19.8%) in the combined intervention group. Relative to usual care, the 24-month difference in systolic BP was 0.6 mm Hg (CI, -2.2 to 3.4 mm Hg) for the behavioral intervention group, -0.6 mm Hg (CI, -3.6 to 2.3 mm Hg) for the BP monitoring group, and -3.9 mm Hg (CI, -6.9 to -0.9 mm Hg) for the combined intervention group; patterns were similar for diastolic BP.

LIMITATION

Changes in medication use and diet were monitored only in intervention participants; 24-month outcome data were missing for 25% of participants, BP control was adequate at baseline in 73% of participants, and the study setting was an academic health center.

CONCLUSION

Combined home BP monitoring and tailored behavioral telephone intervention improved BP control, systolic BP, and diastolic BP at 24 months relative to usual care. .

ASH Position Paper: Dietary approaches to lower blood pressure

A substantial body of evidence has implicated several aspects of diet in the pathogenesis of elevated blood pressure (BP). Well-established risk factors for elevated BP include excess salt intake, low potassium intake, excess weight, high alcohol consumption, and suboptimal dietary pattern. African Americans are especially sensitive to the BP-raising effects of excess salt intake, insufficient potassium intake, and suboptimal diet. In this setting, dietary changes have the potential to substantially reduce racial disparities in BP and its consequences. In view of the age-related rise in BP in both children and adults, the direct, progressive relationship of BP with cardiovascular-renal diseases throughout the usual range of BP, and the worldwide epidemic of BP-related disease, efforts to reduce BP in nonhypertensive as well as hypertensive individuals are warranted. In nonhypertensives, dietary changes can lower BP and delay, if not prevent, hypertension. In uncomplicated stage I hypertension, dietary changes serve as initial treatment before drug therapy. In hypertensive individuals already on drug therapy, lifestyle modifications can further lower BP. The current challenge is designing and implementing effective clinical and public health interventions that lead to sustained dietary changes among individuals and more broadly in the general population.

Relation of alcohol consumption and coronary heart disease in hypertensive male physicians (from the Physicians' Health Study)

Alcohol has diverse effects on the cardiovascular system. Moderate drinking is associated with a decreased risk of cardiovascular disease, yet increasing amounts of alcohol consumption are known to increase blood pressure. These opposing effects have led to interest in the effect of moderate alcohol consumption on the risk of coronary heart disease (CHD) in patients with hypertension. To test the hypothesis that moderate alcohol consumption decreases the risk of myocardial infarction (MI) in patients with hypertension, we used data on 5,164 participants in the Physicians' Health Study who were apparently healthy and free of CHD at baseline. Incident MI was ascertained by annual follow-up questionnaires and validated through review of medical records. Cox proportional hazard model was used to compute multivariable-adjusted hazard ratios with corresponding 95% confidence intervals. From 1982 to 2008, 623 cases of MI occurred. Compared to subjects consuming <1 drink per week, hazard ratios for MI were 1.05 (95% confidence interval 0.85 to 1.28), 0.78 (95% confidence interval 0.64 to 0.97), and 0.57 (95% confidence interval 0.35 to 0.95) for alcohol consumption of 1 to 4, 5 to 7, and >8 drinks per week adjusted for age, body mass index, smoking, exercise, diabetes, multivitamin use, vegetable intake, breakfast cereal intake, and cholesterol (p for trend <0.0022). Similar inferences could be made for the secondary outcomes of angina pectoris and any CHD (which included MI, angina pectoris, and previous revascularization). In conclusion, our data demonstrated an inverse relation between moderate alcohol consumption and CHD in hypertensive men.

Knowledge, perceptions and practices of lifestyle-modification measures among adult hypertensives in Nigeria

Hypertension remains the most rapidly rising cardiovascular disease in Africa. This study was designed to evaluate the perception, knowledge and practices of Nigerian hypertensive patients regarding hypertension and lifestyle modification measures. Consecutive hypertensive patients attending the cardiac clinics of the University of Nigeria Teaching Hospital, Enugu, Nigeria, were recruited. A pre-tested structured interviewer-administered questionnaire was used to collect data. Questions were categorised to elicit patients' demographic characteristics, knowledge, perception and practice of various lifestyle-modification measures. chi(2) tests were performed. More than half (54.2%) of the 260 respondents had no formal, or just primary, education. About 25% were no longer taking their antihypertensive medication. Fifty per cent of the patients thought that hypertension was caused by stress. Most knew about the lifestyle measures through health personnel. More than 50% adopted the lifestyle-modification measures once they became aware of their effects. This study has shown a poor level of perception of hypertension and awareness of the lifestyle-modification measures through the mass media, but a high level of willingness to adopt the lifestyle measures. Concerted strategies are required to change the perception of hypertension and increase the awareness of the lifestyle-modification measures in this part of the world.

General health maintenance in IBD

Patients with inflammatory bowel disease (IBD) often rely on their gastroenterologist for healthcare maintenance. In addition, the gastroenterologist also provides guidance to the patient's primary care physician on a broad range of issues such as vaccinations, osteoporosis screening, and cancer/dysplasia surveillance. Appropriate vaccinations should be administered to patients with IBD, particularly those likely to receive immunosuppression. Live virus vaccines are not appropriate for patients on immunosuppressive therapy, and therefore should be anticipated and given prior to initiating immunosuppression. Screening for osteoporosis is based on a combination of individual risk factors, but a history of prolonged (>3 months) steroid use over 10 mg is reason enough to obtain dual-energy x-ray absorptiometry scanning. Smoking cessation also falls within the realm of the gastroenterologist, as current smoking has a negative impact on Crohn's disease and cessation can be related to exacerbation in ulcerative colitis. Cancer screening includes not only colorectal cancer, but discussion regarding cervical dysplasia, skin cancer, and prostate cancer. Other primary care issues include hypertension and cholesterol monitoring, depression, and ocular health. A comprehensive understanding of all of the issues that can affect a patient with IBD throughout their life cycle is important, as it can impact their natural history, medication decisions, and overall outcomes.

Lifestyle Modifications for Its Prevention and Management

Therapeutic lifestyle changes (TLC) are important for the prevention and management of, as well as adjuncts to, pharmacotherapy of hypertension. This article reviews relevant TLC and their effects on blood pressure (BP) levels, with emphasis on exercise and dietary habits. Regular, moderate-intensity (40%-70% of heart rate reserve) aerobic exercise training for 30 to 60 minutes, 3 to 5 times per week, can lower systolic and diastolic BP levels, with a greater reduction observed in patients with hypertension compared with those with normal BP levels. A diet rich in fruits, vegetables, and whole grains, with a moderate intake of fat-free or low-fat dairy products, and low in saturated and total fat, sodium, and alcohol, such as the Dietary Approaches to Stop Hypertension eating pattern, also significantly reduces BP levels. A TLC program including regular exercise and dietary modifications along with weight management appears to result in a greater BP reduction than either intervention alone. TLC can also significantly reduce other risk factors for cardiovascular disease commonly accompanying hypertension. Multiple mechanisms appear to contribute to BP reduction by dietary intervention (reduced weight, sodium, and alcohol and increased calcium, potassium, and magnesium). For exercise, these include improvements in arterial endothelial function and compliance, left ventricular structure and function, and perhaps vascular blood supply with increased cardiorespiratory endurance. The available evidence is robust in support of TLC for management of elevated BP and for the primary prevention of hypertension, supporting the recommendations by the Joint National Committee Seventh Report on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Alcohol consumption and risk of cardiovascular disease and death in women: potential mediating mechanisms

BACKGROUND

Although an association between moderate alcohol consumption and decreased cardiovascular disease (CVD) and death has been reported, limited data are available on potential mediating mechanisms. We examined the association between alcohol and CVD and death in 26 399 women and estimated the proportion of reduced risk of CVD/death explained by a series of intermediate factors.

METHODS AND RESULTS

Alcohol consumption was self-reported at baseline, and CVD events and deaths were ascertained via follow-up questionnaires and medical records. Baseline levels of hemoglobin A1c, inflammatory markers, hemostatic factors, and lipids were measured. Blood pressure and hypercholesterolemia and treatment for lipids were self-reported. During a mean follow up of 12.2 years, 1039 CVD events and 785 deaths (153 CVD deaths) occurred. There was a J-shaped relation between alcohol consumption and incident CVD and total and CVD deaths in a multivariable model. Compared with abstainers, alcohol intake of 5 to 14.9 g/d was associated with 26%, 35%, and 51% lower risk of CVD, total death, and CVD death, respectively, in a multivariable model. For CVD risk reduction, lipids made the largest contribution to the lower risk of CVD (28.7%), followed by hemoglobin A1c/diabetes (25.3%), inflammatory/hemostatic factors (5%), and blood pressure factors (4.6%). All these mediating factors together explained 86.3%, 18.7%, and 21.8% of the observed lower risk of CVD, total death, and CVD death, respectively.

CONCLUSIONS

These data suggest that alcohol effects on lipids and insulin sensitivity may account for a large proportion of the lower risk of CVD/death observed with moderate drinking under the assumption that the alcohol-CVD association is causal.

The impact of a population-based multi-factorial lifestyle intervention on alcohol intake: the Inter99 study

PURPOSE

To investigate the effect of screening and five years of multi-factorial lifestyle intervention on changes in alcohol intake in a general population.

METHODS

The study was a pre-randomized intervention study on lifestyle, Inter99 (1999-2006), Copenhagen, Denmark. Participants in the intervention group (n=6 091) had at baseline a medical health examination and a face-to-face lifestyle counselling. Individuals at high risk of ischemic heart disease were repeatedly offered both individual and group-based counselling. The control group (n=3 324) was followed by questionnaires. Alcohol intake was measured by questionnaires. Changes were analysed by multilevel analyses.

RESULTS

Binge drinking decreased both in men and women at three and five-year follow-ups (men: five-year: net-change:-0.13; p=0.03; women: five-year: net-change:-0.08; p=0.04). Furthermore, in women the ratio between wine and total alcohol was increased compared with the control group at five-year follow-up (net-change: 0.04; p<0.01). In men with a high intake of alcohol (>21 drinks per week) the effect on total alcohol intake was maintained at five-year follow-up (net-change: -3.7; p=0.01). No significant effects were found in women on total alcohol intake.

CONCLUSION

Multi-factorial lifestyle intervention, including low intensity alcohol intervention, improved long-term alcohol habits in a general population.

Diet and lifestyle risk factors associated with incident hypertension in women

CONTEXT

Hypertension is an important preventable risk factor for death among women. While several modifiable risk factors have been identified, their combined risk and distribution in the population have not been assessed.

OBJECTIVE

To estimate the hypothetical fraction of hypertension incidence associated with dietary and lifestyle factors in women.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of 83,882 adult women aged 27 to 44 years in the second Nurses' Health Study who did not have hypertension, cardiovascular disease, diabetes, or cancer in 1991, and who had normal reported blood pressure (defined as systolic blood pressure of < or = 120 mm Hg and diastolic blood pressure of < or = 80 mm Hg), with follow-up for incident hypertension for 14 years through 2005. Six modifiable lifestyle and dietary factors for hypertension were identified. The 6 low-risk factors for hypertension were a body mass index (BMI) of less than 25, a daily mean of 30 minutes of vigorous exercise, a high score on the Dietary Approaches to Stop Hypertension (DASH) diet based on responses to a food frequency questionnaire, modest alcohol intake up to 10 g/d, use of nonnarcotic analgesics less than once per week, and intake of 400 microg/d or more of supplemental folic acid. The association between combinations of 3 (normal BMI, daily vigorous exercise, and DASH-style diet), 4 (3 low-risk factors plus modest alcohol intake), 5 (4 low-risk factors plus avoidance of nonnarcotic analgesics), and 6 (folic acid supplementation > or = 400 microg/d) low-risk factors and the risk of developing hypertension was analyzed.

MAIN OUTCOME MEASURES

Adjusted hazard ratios for incident self-reported hypertension and population attributable risks (PARs).

RESULTS

A total of 12,319 incident cases of hypertension were reported. All 6 modifiable risk factors were independently associated with the risk of developing hypertension during follow-up after also adjusting for age, race, family history of hypertension, smoking status, and use of oral contraceptives. For women who had all 6 low-risk factors (0.3% of the population), the hazard ratio for incident hypertension was 0.22 (95% confidence interval [CI], 0.10-0.51); the hypothetical PAR was 78% (95% CI, 49%-90%) for women who lacked these low-risk factors. The corresponding hypothetical absolute incidence rate difference (ARD) was 8.37 cases per 1000 person-years. The PARs were 72% (95% CI, 57%-82%; ARD, 7.76 cases per 1000 person-years) for 5 low-risk factors (0.8% of the population), 58% (95% CI, 46%-67%; ARD, 6.28 cases per 1000 person-years) for 4 low-risk factors (1.6% of the population), and 53% (95% CI, 45%-60%; ARD, 6.02 cases per 1000 person-years) for 3 low-risk factors (3.1% of the population). Body mass index alone was the most powerful predictor of hypertension, with a BMI of 25 or greater having an adjusted PAR of 40% (95% CI, 38%-41%) compared with a BMI of less than 25.

CONCLUSIONS

Adherence to low-risk dietary and lifestyle factors was associated with a significantly lower incidence of self-reported hypertension. Adopting low-risk dietary and lifestyle factors has the potential to prevent a large proportion of new-onset hypertension occurring among young women.

Associations of alcohol consumption with blood pressure and serum lipids in Japanese female smokers and nonsmokers

BACKGROUND

Alcohol intake and smoking have been reported to influence atherosclerotic progression.

OBJECTIVE

The purpose of this study was to determine whether the associations of alcohol intake with blood pressure (BP) and serum lipid concentrations are modified by smoking in Japanese women.

METHODS

Eligible subjects were healthy female Japanese workers aged 35 to <55 years who had received periodic health examinations at workplaces in Yamagata Prefecture in Japan. Subjects were classified as smokers or nonsmokers and subclassified into 3 subgroups based on average daily reported alcohol intake: nondrinkers, light drinkers (<15 g/d), and heavy drinkers (>-15 g/d). The means of each variable (systolic and diastolic BP [SBP and DBP, respectively] and serum concentrations of total cholesterol [TC], low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], and triglycerides) were compared among the 2 groups of smoking history and 3 subgroups of alcohol intake after adjusting for age and body mass index.

RESULTS

A total of 16,805 healthy women were enrolled (14,695 nonsmokers, 2110 smokers). In smokers, SBP was significantly higher in heavy drinkers than in nondrinkers, and DBP was significantly higher in light drinkers and heavy drinkers than in nondrinkers (all, P < 0.01). In nonsmokers, SBP was not significantly higher in light drinkers and heavy drinkers versus nondrinkers, and the difference in DBP between heavy drinkers and nondrinkers was significant (P < 0.01), but that between light drinkers and nondrinkers was not. In smokers but not in nonsmokers, serum TC concentration was significantly lower in heavy drinkers than in nondrinkers. In smokers and nonsmokers, LDL-C was significantly lower in light and heavy drinkers than in nondrinkers (all, P < 0.01), and serum HDL-C was significantly higher in light and heavy drinkers than in nondrinkers (all, P < 0.01). The differences in mean LDL-C between light and heavy drinkers versus nondrinkers were numerically greater in smokers than in nonsmokers.

CONCLUSION

In this sample of women in Japan, serum LDL-C concentration was significantly lower in drinkers than in nondrinkers, and smoking might increase this association between alcohol intake and lowered LDL-C.

Arterial Hypertension and Stroke Prevention: An Update

High blood pressure (BP) is the most important modifiable risk factor for stroke and other vascular diseases. Evidence from randomized controlled trials supports the use of antihypertensive drugs to lower blood pressure for stroke prevention. There is some evidence that specific classes of antihypertensive drugs have different effects and/or their pharmacological actions differ in patient subgroups. This review evaluates the development of antihypertensive therapies and the latest studies of arterial hypertension and stroke prevention: HOPE trial (ramipril versus placebo), ALLHAT trial (CCB or/ and Angiotensin-Conventing enzyme Inhibitors (ACE-Is) versus diuretic), LIFE trial (losartan versus atenolol), and PROGRESS trial (perindopril or/and indapamide versus placebo). Despite the results of these relevant clinical trails, some aspects still remain unresolved. Future clinical trials on hypertension and stroke prevention should answer the following questions: Does lowering BP reduce stroke risk due to specific drug effect or class effect? Are angiotensin II receptor blockers (ARBs) better than ACE-Is? Should ACE-Is and ARBs be considered routinely for either high-risk stroke patients or patients with history of stroke or transient ischemic attack, irrespective of blood pressure? What is the role of lifestyle in BP control?

Health behaviour patterns in relation to hypertension: the English Longitudinal Study of Ageing

OBJECTIVE

Clinical guidelines emphasize that hypertensive individuals should be encouraged to maintain healthy lifestyles with respect to smoking, physical activity, alcohol consumption and diet. We assessed health behaviours in a large sample of older hypertensive individuals, and tested whether medication for hypertension leads to compensatory increases in cardiovascular risk behaviours.

METHODS

Analysis of wave 1 of the English Longitudinal Study of Ageing, involving 5231 men and 6292 women aged at least 50 years. We analysed the prevalence of smoking, heavy drinking, sedentary behaviour and vigorous physical activity in relation to self-reported hypertension, controlling for age, sex, socioeconomic status, comorbidity (coronary heart disease, diabetes, arthritis), impairments of mobility, activities of daily living and depression.

RESULTS

The prevalence of self-reported hypertension was 37.8%, and 77% of hypertensive participants were prescribed medication. Hypertensive participants were less likely to smoke than normotensive ones (14.8 vs. 19.7%), with reduced odds of smoking [odds ratio (OR) 0.72, 95% confidence intervals (CI) 0.56-0.83] after adjusting for covariates. Hypertensive individuals were more likely to be heavy drinkers (OR 1.34, CI 1.10-1.62), to be sedentary (OR 1.14, CI 1.02-1.27), and not engage in vigorous physical activity (OR 0.84, CI 0.75-0.94). There was no evidence for risk compensation in medicated hypertensive individuals compared with unmedicated ones.

CONCLUSION

Smoking rates are low among hypertensive individuals, but the patterns of alcohol consumption and physical activity are suboptimal. Compensatory increases in risky behaviours appear not to be present in medicated individuals. There is considerable scope for advice and counselling to older hypertensive individuals to improve patterns of health behaviour.