Effect of treatment of isolated systolic hypertension on left ventricular mass

Compelling therapy of LVH: straight (and not-so-straight) inferences from evidence

We have read with interest the Korean Society of Hypertension guidelines for the management of hypertension and congratulate the Society for an extensive review of literature while drafting the guidelines. The guidelines indicate preferring ACE-I and CCB over diuretics in patients with left ventricle hypertrophy. However, in landmark head-to-head comparison trials, the thiazide-like diuretic chlorthalidone has been shown to be superior to ACE-I and CCB in decreasing left ventricle mass and preventing heart failure in hypertensive patients. Also, we put forth the paradoxical finding that mere regression of LVH may not always translate into reduction in risk of HF; and that the pleiotropic effects of chlorthalidone may be the explanation behind its beneficial action in HF.

Stress Reduction in the Prevention of Left Ventricular Hypertrophy: A Randomized Controlled Trial of Transcendental Meditation and Health Education in Hypertensive African Americans

Background

African Americans have disproportionately high rates of cardiovascular disease (CVD). Left ventricular hypertrophy (LVH) is an independent risk factor for CVD and may contribute to this disparity. Psychological stress contributes to LVH in African Americans and other populations.

Objective

This study evaluated the effects of stress reduction with the Transcendental Meditation (TM) technique on preventing LVH in African American adults with hypertension.

Setting

Martin Luther King Hospital - Charles R. Drew University of Medicine and Science, Los Angeles, CA.

Method

In this trial, 85 African American adults (average 52.8 years) were randomly assigned to either TM program or health education (HE) control group and completed posttesting. Participants were tested at baseline and after six months for left ventricular mass index (LVMI) by M-mode echocardiography, blood pressure, psychosocial stress and behavioral factors. Change in outcomes was analyzed between groups by ANCOVA and within groups by paired t-test.

Results

The TM group had significantly lower LVMI compared with the HE group (-7.55gm/m², 95% CI -14.78 to -.34 gm/m², P=.040). Both interventions showed significant within group reductions in BP, (SBP/DBP changes for TM: -5/ -3 mm Hg, and for HE: -7/-6 mm Hg, P=.028 to <.001) although between group changes were not significant. In addition, both groups showed significant reductions in anger (P=.002 to .001). There were no other changes in lifestyle factors.

Conclusions

These findings indicate that stress reduction with TM was effective in preventing LVMI progression and thus may prevent LVH and associated CVD in high-risk African American patients.

Hydrochlorothiazide and alternative diuretics versus renin-angiotensin system inhibitors for the regression of left ventricular hypertrophy: a head-to-head meta-analysis

BACKGROUND

Found in 36-41% of hypertension, elevated left ventricular mass (LVM) independently predicts cardiovascular events and total mortality. Conversely, drug-induced regression of LVM predicts improved outcomes. Previous studies have favored renin-angiotensin system inhibitors (RASIs) over other antihypertensives for reducing LVM but ignored differences among thiazide-type diuretics. From evidence regarding potency, cardiovascular events, and electrolytes, we hypothesized a priori that 'CHIP' diuretics [CHlorthalidone, Indapamide and Potassium-sparing Diuretic/hydrochlorothiazide (PSD/HCTZ)] would rival RASIs for reducing LVM.

METHOD AND RESULTS

Systematic review yielded 12 relevant double-blind randomized trials. CHIPs were more closely associated with reduced LVM than HCTZ (P = 0.004), indicating that RASIs must be compared with each diuretic separately. Publication bias favoring RASIs was corrected by cumulative analysis. For reducing LVM, HCTZ tended to be less effective than RASIs. However, the following surpassed RASIs: chlorthalidone Hedge's G: -0.37 (95% CI -0.72 to -0.02), P = 0.036; indapamide -0.20 (-0.39 to -0.01), P = 0.035; all CHIPs combined (with 61% of patients in one trial) -0.25 (-0.41to -0.09), P = 0.002. Statistical significance (P < 0.05) did not depend on any one trial. CHIPs reduction in LVM was 37% greater than that from RASIs. CHIPs superiority tended to increase with trial duration, from a negligible effect at 0.5 year to a maximal effect at 0.9-1.0 years: -0.26 (-0.43 to -0.09), P = 0.003. Fifty-eight percent of patients had information on echocardiographic components of LVM: relative to RASIs, CHIPs significantly reduced end-diastolic LV internal dimension (EDLVID): -0.18 (-0.36 to -0.00), P = 0.046. Strength of evidence favoring CHIPs over RASIs was at least moderate.

CONCLUSION

In these novel results in patients with hypertension, CHIPs surpassed RASIs for reducing LVM and EDLVID.

Electrocardiographic measures of left ventricular hypertrophy in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial

Left ventricular hypertrophy (LVH) predicts cardiovascular risk in hypertensive patients. We analyzed baseline/follow-up electrocardiographies in 26,376 Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial participants randomized to amlodipine (A), lisinopril (L), or chlorthalidone (C). Prevalent/incident LVH was examined using continuous and categorical classifications of Cornell voltage. At 2 and 4 years, prevalence of LVH in the C group (5.57%; 6.14%) was not statistically different from A group (2 years: 5.47%; P = .806, 4 years: 6.54%; P = .857) or L group (2 years: 5.64%; P = .857, 4 years: 6.50%; P = .430). Incident LVH followed similarly, with no difference at 2 years for C (2.99%) compared to A (2.57%; P = .173) or L (3.16%; P = .605) and at 4 years (C = 3.52%, A = 3.29%, L = 3.71%; P = .521 C vs. A, P = .618 C vs. L). Mean Cornell voltage decreased comparably across treatment groups (Δ baseline, 2 years = +3 to -27 μV, analysis of variance P = .8612; 4 years = +10 to -17 μV, analysis of variance P = .9692). We conclude that risk reductions associated with C treatment in secondary end points of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial cannot be attributed to differential improvements in electrocardiography LVH.

Renal revascularization in Takayasu arteritis–induced renal artery stenosis

PURPOSE

This study was undertaken to define the long-term effects of renal revascularization on blood pressure, and renal and cardiac function in patients with Takayasu arteritis-induced renal artery stenosis (TARAS).

METHODS

Twenty-seven patients (25 women; mean age, 27 years) with TARAS underwent intervention. Primary, primary assisted, and secondary patency rates were determined, and the late effects on blood pressure, renal and cardiac function, and survival were analyzed.

RESULTS

All patients had hypertension (mean blood pressure, 167/99 mm Hg; 2.5 antihypertensive medications per patient). Mean estimated glomerular filtration rate in patients not receiving hemodialysis was 76 mL/min, and in five patients serum creatinine concentration was greater than 1.5 mg/dL. Three patients were hemodialysis-dependent, and two had intractable congestive heart failure. Forty interventions were performed, including 32 aortorenal bypass procedures, two repeat implantations, four nephrectomies, and two transluminal angioplasty procedures. Postoperative morbidity was 19%. There were no deaths. During follow-up (mean, 68 months), three graft stenoses, all due to intimal hyperplasia, and three graft occlusions occurred. Two of three graft stenoses were successfully revised. At 1, 3, and 5 years of follow-up, primary patency was 87%, 79%, and 79%, respectively; primary assisted patency was 93%, 89%, 89%, respectively; and secondary patency was 93%, 89%, and 89%, respectively. Intervention resulted in a decrease in blood pressure to a mean of 132/79 mm Hg (P<.0001), and the need for antihypertensive medications was reduced to one per patient (P<.01). Mean glomerular filtration rate increased to 88 mL/min (P<.005), and two patients no longer required hemodialysis. Congestive heart failure resolved in both patients, and did not recur. There were three deaths during follow-up, with 5-year and 10-year actuarial survival of 96% and 80%, respectively.

CONCLUSIONS

Renal revascularization to treat TARAS is durable, has a salutary effect on blood pressure, and enhances long-term renal and cardiac function. This response establishes renal revascularization as a successful and durable intervention for TARAS, and a benchmark to which other therapies should be compared.

Trials in isolated systolic hypertension: an update

Isolated systolic hypertension (ISH) has proved to be a powerful predisposing factor for cardiovascular diseases in the elderly. Recent placebo-controlled interventional trials such as the Systolic Hypertension in the Elderly Program, the Systolic Hypertension in Europe, and the Systolic Hypertension in China showed that the lowering of systolic blood pressure using a diuretic- or a calcium antagonist-based treatment is associated with a decrease in cardiovascular events. Antihypertensive therapy was found especially effective in preventing stroke in the elderly with ISH. A slowing in the progression of dementia was observed in patients randomized to a calcium antagonist-based treatment. Patients at high cardiovascular risk such as those with diabetes benefited the most from treatment. In another trial performed in patients with left ventricular hypertrophy (Losartan Intervention For Endpoint Reduction), a subset of patients had ISH. In those patients, an angiotensin II antagonist-based treatment was superior to a b-blocker-based treatment in preventing cardiovascular complications. The experience accumulated in patients with ISH showed that combination therapy is often required to control blood pressure. Overall, the evidence available today indicates that pharmacologic treatment of ISH markedly improves the outcome of elderly patients.

Trials in isolated systolic hypertension: an update

Isolated systolic hypertension (ISH) has proved to be a powerful predisposing factor for cardiovascular diseases in the elderly. Recent placebo-controlled interventional trials such as the Systolic Hypertension in the Elderly Program (SHEP), the Systolic Hypertension in Europe (Syst-Eur), and the Systolic Hypertension in China (Syst-China) showed that the lowering of systolic blood pressure using a diuretic- or a calcium antagonist-based treatment is associated with a decrease in cardiovascular events. Antihypertensive therapy was found especially effective in preventing stroke in the elderly with ISH. A slowing in the progression of dementia was observed in patients randomized to a calcium antagonist-based treatment. Patients at high cardiovascular risk such as those with diabetes benefited the most from treatment. In another trial performed in patients with left ventricular hypertrophy (Losartan Intervention For Endpoint Reduction ), a subset of patients had ISH. In those patients, an angiotensin II antagonist-based treatment was superior to a b-blocker-based treatment in preventing cardiovascular complications. The experience accumulated in patients with ISH showed that combination therapy is often required to control blood pressure. Overall, the evidence available today indicates that pharmacologic treatment of ISH markedly improves the outcome of elderly patients.

A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension

PURPOSE

Antihypertensive medications have different effects on left ventricular mass. We conducted a meta-analysis of double-blind trials that measured the effects of antihypertensive therapy on left ventricular mass.

METHODS

Medical databases and review articles were screened for double-blind, randomized controlled trials (through September 2002) that reported the effects of diuretics, beta-blockers, calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin II receptor antagonists on echocardiographic left ventricular mass in essential hypertension. Treatment arms of the same drug class, weighted for the number of patients, were combined. Analysis of covariance was performed to detect differences among drug classes in effects on left ventricular structure.

RESULTS

Eighty trials with 146 active treatment arms (n = 3767 patients) and 17 placebo arms (n = 346 patients) were identified. Adjusted for treatment duration and change in diastolic blood pressure, there was a significant difference (P = 0.004) among medication classes: left ventricular mass index decreased by 13% with angiotensin II receptor antagonists (95% confidence interval [CI]: 8% to 18%), by 11% with calcium antagonists (95% CI: 9% to 13%), by 10% with ACE inhibitors (95% CI: 8% to 12%), by 8% with diuretics (95% CI: 5% to 10%), and by 6% with beta-blockers (95% CI: 3% to 8%). In pairwise comparisons, angiotensin II receptor antagonists, calcium antagonists, and ACE inhibitors were more effective at reducing left ventricular mass than were beta-blockers (all P <0.05 with Bonferroni correction).

CONCLUSIONS

Antihypertensive drug classes have different effects on left ventricular mass reduction. Whether a greater reduction of left ventricular mass results in better clinical outcomes remains to be determined.

Left ventricular regional variations in myosin isoform shift in Dahl salt-sensitive hypertensive rats

To evaluate the effects of chronic pressure overload on different parts of the left ventricle (LV), we examined a myosin isoform shift from V1 to V3 as a biochemical marker of LV hypertrophy in Dahl salt-sensitive (DS) rats. Six-week-old DS rats were fed an 8% (high salt, HS; n = 24) or a 0.3% (low salt, LS; n = 12) NaCl diet. After 2 or 4 weeks, the hearts were dissected and the LVs were separated into four parts (the base and mid-portion of the interventricular septum (IVS), and the base and mid-portion of the LV free wall) for isomyosin analysis. The myosin isoform shift was analyzed by pyrophosphate gel electrophoresis. Both blood pressure and LV/body weight ratio were clearly increased in the HS group. The myosin isoform shift from V1 to V3, which was measured as a decrease in the percentage of V1 isomyosin, was demonstrated only in the base of LV, with significant predominance in the IVS at 2 weeks and in all four parts at 4 weeks in the HS group. In the LS group, a myosin isoform shift was demonstrated only in the basal portion of the LV at 4 weeks. We concluded that, in rats with salt-induced hypertension, the myosin isoform shift from V1 to V3 starts at the base of the LV, and particularly at the base of the IVS, and then spreads across the entire LV. These results suggest that pressure overload from hypertension may be strongest at the base of the IVS, and that LV hypertrophy may originate at the IVS base.

High blood pressure in the geriatric population: treatment considerations

Increases in blood pressure (BP), particularly systolic BP, have traditionally been considered to be a normal or "physiologic" component of the aging process. However, it is now clear that elevated BP, particularly systolic BP, represents a pathophysiologic manifestation of altered cardiovascular physiology and structure, ultimately manifesting as increased cardiovascular morbidity and mortality (myocardial infarction, stroke, and total cardiovascular death rates). More than one half of the population aged 65 or older have hypertension, defined as BP > or = 140/90 mm Hg. Framingham data indicate that the risk of coronary heart disease increases with lower diastolic BP at any level of systolic BP > or = 120 mm Hg, thus further stressing the importance of pressure-induced arterial vascular compliance changes and introducing pulse pressure as an important predictor of cardiovascular risk. Geriatric hypertension is generally of a salt-sensitive nature and often associated with impaired baroreflex function. Reduction in sodium intake is important and effective in older patients, and should be initiated before or together with drug therapy. Encouraging data from clinical trials now strongly support the aggressive anti-hypertensive treatment of elderly patients. A recent meta-analysis of eight outcome trials evaluating the risks of treated and untreated isolated systolic hypertension has demonstrated a 30% reduction in combined fatal and nonfatal stroke, a 26% reduction in fatal and nonfatal cardiovascular events, and a 13% reduction in total mortality. Those drugs effective in younger patients also appear effective in the elderly; low-dose thiazides (alone or in combination with potassium sparing agents), beta blockers, long-acting dihydropyridine calcium antagonists, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers all have demonstrated efficacy. In selecting an agent, it is important to consider comorbid disease states, and to recognize the potential of all nonsteroidal anti-inflammatory drugs, whether conventional or cyclooxygenase-2 specific, to increase BP or interfere with other antihypertensive agents. In general, the elderly should be treated to target BP levels identical to those suggested for younger patients, although a more gradual reduction to target, perhaps with an intermediate BP goal of < 160 mm Hg, may be advisable.

Reproducibility of left ventricular mass measurement using a half-Fourier black-blood single-shot fast spin-echo sequence within a single breath hold: comparison with a conventional multiple breath-hold segmented gradient echo technique in patients

PURPOSE

To compare the reproducibility of left ventricular (LV) mass measurements using a black-blood half-Fourier single-shot fast spin-echo (SSFSE) and a segmented gradient echo magnetic resonance (MR) pulse sequence.

MATERIAL AND METHODS

Breath-hold SSFSE and segmented gradient echo cardiac MR examinations were performed twice in 32 patients and manual detection of the LV endocardium and epicardium was applied by two blinded reviewers. The SSFSE pulse sequence allowed whole-heart coverage in a single breath hold, while multiple breath holds were required using the segmented gradient echo sequence. Spatial presaturation slabs were used with the SSFSE pulse sequence to reduce the field of view (FOV) and thereby achieve higher spatial resolution.

RESULTS

Intraclass correlation coefficients were higher with the SSFSE pulse sequence than with the segmented gradient echo pulse sequence: intraobserver reproducibility reached 0.999 vs. 0.991; interobserver reproducibility: 0.997 vs. 0.981; and interstudy reproducibility: 0.998 vs. 0.936. These higher levels of reproducibility were confirmed on Bland and Altman plots.

CONCLUSION

LV mass measurements can be assessed more reproducibly with the single breath-hold SSFSE technique than with the standard multiple breath-hold segmented gradient echo method.

Similar effects of isolated systolic and combined hypertension on left ventricular geometry and function: the LIFE Study

Echocardiograms of 143 patients with isolated systolic hypertension were compared to 808 patients with combined (systolic and diastolic) hypertension. All patients met electrocardiographic criteria for left ventricular hypertrophy and were evaluated off medication. Patients with isolated systolic hypertension were older, shorter, weighed less, and were mostly women, but body mass index (BMI) was similar in both groups. Systolic blood pressure (SBP) was 172 mm Hg in isolated systolic hypertension, 174 mm Hg in combined (P = not significant). Diastolic blood pressure was 83 and 101 mm Hg, respectively (P < .001). Despite having mean arterial pressure 12 mm Hg lower than patients with combined hypertension, the group with isolated systolic hypertension had equally severe abnormalities of left ventricular mass, left ventricular geometric patterns, and measures of systolic and diastolic function. Peripheral resistance was lower and pulse pressure/stroke volume ratio (arterial stiffness index) was higher and the isovolumic relaxation time shorter in isolated systolic hypertension. Multiple regression analyses identified age, height, BMI, stress-corrected mid wall shortening, stroke volume, male gender, and systolic or mean blood pressure (but not isolated systolic hypertension) as independent correlates of left ventricular mass. Relative wall thickness was independently associated with isolated systolic hypertension (P = .001) in addition to mean pressure and other covariates. The present results add support to the concept that systolic blood pressure (SBP) is a stronger determinant than diastolic pressure of cardiac target organ damage in hypertension.

Measurement of left ventricular dimensions and function in patients with dilated cardiomyopathy

Studies on medical therapy in heart failure are focused on changes of left ventricular (LV) dimensions and function. These changes may be small, requiring a large study group. We measured LV parameters (LV volumes, LV ejection fraction (LV-EF), and left ventricular mass (LVM)) with two-dimensional echocardiography (2D-echo) and magnetic resonance imaging (MRI) in 50 patients. Based on the difference between the measurements, we determined the variance of the results and calculated the sample sizes needed to detect changes of baseline values. For the calculated and measured parameters we found significant differences between the two techniques: LV-EF and LVM were higher in 2D-echo, and LV dimensions were comparable. The sample size to detect relevant changes from baseline with MRI was significantly (P < 0.01) smaller than in 2D-echo. We conclude that MRI is superior in clinical studies on left ventricular dimensional and functional changes, since measurements are more reproducible and the required sample size is substantially smaller, thereby reducing costs.

Optimal antihypertensive therapy for prevention and treatment of left ventricular hypertrophy

Left ventricular hypertrophy (LVH) is considered an adaptation to a pressure load on the left ventricle and is common in hypertensive patients. The condition is a profound risk factor for cardiovascular events, greater than and independent of blood pressure. It is now recognized in hypertension management guidelines as an indication for more stringent blood pressure control. All of the first-line antihypertensive agents have been shown to variably regress LVH, but no definitive evidence yet shows that one agent is superior to others in decreasing risk independent of blood pressure control. Although some evidence suggests that reduction of LVH is associated with improved prognosis independent of blood pressure control, relative efficacy of drug classes in this regard has yet to be demonstrated. At present, recommendations for optimal therapy in hypertensive patients with LVH must rest on the presence of underlying cardiac and noncardiac conditions, with the understanding that the major classes of antihypertensive agents will probably decrease LVH.

Predictors of congestive heart failure in the elderly: the Cardiovascular Health Study

OBJECTIVES

We sought to characterize the predictors of incident congestive heart failure (CHF), as determined by central adjudication, in a community-based elderly population.

BACKGROUND

The elderly constitute a growing proportion of patients admitted to the hospital with CHF, and CHF is a leading source of morbidity and mortality in this group. Elderly patients differ from younger individuals diagnosed with CHF in terms of biologic characteristics.

METHODS

We analyzed data from the Cardiovascular Health Study, a prospective population-based study of 5,888 elderly people >65 years old (average 73 +/- 5, range 65 to 100) at four locations. Multiple laboratory measures of cardiovascular structure and function, blood chemistries and functional assessments were obtained.

RESULTS

During an average follow-up of 5.5 years (median 6.3), 597 participants developed incident CHF (rate 19.3/1,000 person-years). The incidence of CHF increased progressively across age groups and was greater in men than in women. On multivariate analysis, other independent predictors included prevalent coronary heart disease, stroke or transient ischemic attack at baseline, diabetes, systolic blood pressure (BP), forced expiratory volume 1 s, creatinine >1.4 mg/dl, C-reactive protein, ankle-arm index <0.9, atrial fibrillation, electrocardiographic (ECG) left ventricular (LV) mass, ECG ST-T segment abnormality, internal carotid artery wall thickness and decreased LV systolic function. Population-attributable risk, determined from predictors of risk and prevalence, was relatively high for prevalent coronary heart disease (13.1%), systolic BP > or =140 mm Hg (12.8%) and a high level of C-reactive protein (9.7%), but was low for subnormal LV function (4.1%) and atrial fibrillation (2.2%).

CONCLUSIONS

The incidence of CHF is high in the elderly and is related mainly to age, gender, clinical and subclinical coronary heart disease, systolic BP and inflammation. Despite the high relative risk of subnormal systolic LV function and atrial fibrillation, the actual population risk of these for CHF is small because of their relatively low prevalence in community-dwelling elderly people.

Left Ventricular Hypertrophy

The presence of left ventricular hypertrophy (LVH) as a treatable entity is of particular importance in patients with primary hypertension. Because LVH is associated with a strong risk of adverse clinical events (eg, heart failure, ischemic events, and cardiovascular death) and because evidence from retrospective studies suggests that regression of LVH, along with a decrease in blood pressure, may help modify these outcomes, the use of antihypertensive agents that have been shown to promote regression of LVH has been recommended. These include diuretics, beta-blockers (except those with intrinsic sympathomimetic activity ), angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, peripheral alpha(1)-blockers, and central alpha(2)-stimulators. Agents to be avoided include direct arterial vasodilators (eg, hydralazine and minoxidil), which have strong sympathetic stimulating properties and tend to maintain LVH despite lowering blood pressure. The use of ACE inhibitors is increasing. Unfortunately, the cost of these agents is higher than that of some other classes of agents, such as diuretics, which show excellent evidence of regression of hypertrophy. African-American and elderly persons, in particular, may benefit from diuretics for treatment of hypertension as well as reduction of left ventricular (LV) mass. Beta-blockers should be considered in the elderly, especially those with greatly thickened LV walls and small chamber sizes, factors associated with hyperdynamic systolic performance, systolic midcavity obliteration, and diastolic relaxation abnormalities on echocardiography. Calcium channel blockers may also be useful in patients with LVH who have normal systolic performance and diastolic compliance abnormalities. The purpose of serial echocardiographic studies in patients already being treated for hypertension is to ensure that LV geometry has not worsened and that function is unchanged or improved (especially with respect to previously noted diastolic Doppler inflow abnormalities). Considerable changes in estimated LV mass (>60 g on serial intrapatient evaluation) are needed before the clinician can conclude with confidence that LV mass has decreased. More specific definitive recommendations based on the outcomes of current large-scale clinical trials are awaited.

Potential new cardiovascular risk factors: left ventricular hypertrophy, homocysteine, lipoprotein(a), triglycerides, oxidative stress, and fibrinogen

The 1996 Bethesda Conference acknowledged left ventricular hypertrophy, hyperhomocysteinemia, lipoprotein(a) excess, hypertriglyceridemia, oxidative stress, and hyperfibrinogenemia as possible new cardiac risk factors. This review summarizes the current literature that supports these conditions as cardiac risk factors. Left ventricular hypertrophy is an independent risk factor for vascular disease. Improvement or progression of left ventricular hypertrophy influences subsequent cardiovascular complications. Clinical trials are under way to assess the potential benefit of decreasing homocysteine levels. The role of lipoprotein(a) excess in vascular disease is controversial. The atherogenic potential of lipoprotein(a) seems to be neutralized by effective reduction of low-density lipoprotein cholesterol levels. Increasing evidence supports an independent role of hypertriglyceridemia in cardiovascular disease and a possible clinical benefit from decreasing triglyceride levels. Among antioxidant micronutrients, supplementation with vitamin E has been shown to be beneficial in primary and secondary prevention studies. Data supporting the use of other antioxidants are much weaker. Preliminary evidence suggests that reducing fibrinogen levels in patients with high baseline levels and coronary disease may be beneficial. Despite the potential relation between new risk factors and cardiovascular disease, routine clinical application of these conditions as cardiovascular risk factors would be premature. Evidence is needed that these conditions extend prognostic ability beyond conventional risk factors and that modification of these conditions can reduce the risk for cardiovascular events.

A review of the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Hypertension is a major modifiable risk factor for cardiovascular diseases. After decades of improvement, population surveys demonstrate disturbing downward trends in the rates of awareness, treatment, and control of this disorder in recent years. Over this same time period, there has been a slight increase in the incidence of strokes, and a steady rise in the incidence of end-stage renal disease and the prevalence of congestive heart failure, conditions in which hypertension plays a prominent role. Results of recent studies support the possibility that lifestyle modifications may be effective for prevention of hypertension. Treatment of established hypertension involves lifestyle modifications and drug therapies designed to control blood pressure and reduce overall cardiovascular risk. Both threshold blood pressure levels for initiating drug therapy and goal blood pressure levels with treatment are individually determined based on the presence or absence of additional cardiovascular risk factors and hypertension target organ injury or clinical cardiovascular disease. Recent clinical trials support the value of lower goal blood pressures for patients with diabetes, heart failure, and renal disease. The presence or absence of comorbid conditions often determines specific drug choices. Diuretics and beta-blockers remain the drugs of choice in uncomplicated hypertension. Additional studies confirm the benefits of treating isolated systolic hypertension in the elderly. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure provides a practical, evidence-based resource to help health care providers meet the public health challenges of preventing and controlling hypertension.

Hypertension in the elderly

The decade of the 1990s has clarified the perspective on treating hypertension in the elderly and provided a wealth of evidence to assist in the treatment of elevated blood pressure in older persons. Despite this wealth of information, important questions remain about treatment of hypertension in the elderly.