Treatment and blood pressure control in isolated systolic hypertension vs diastolic hypertension in primary care

Antihypertensive treatment in a general uncontrolled hypertensive population in Belgium and Luxembourg in primary care: Therapeutic inertia and treatment simplification. The SIMPLIFY study

BACKGROUND

Despite effective treatments, blood pressure (BP) control remains suboptimal.

OBJECTIVE

The SIMPLIFY study aimed at identifying key factors related to therapeutic inertia in Belgium and Luxembourg, and evaluating how uncontrolled treated hypertension is managed in primary care.

METHODS

In a 2017 cross-sectional survey, 245 general practitioners (GP) collected routine clinical data from 1,852 consecutive uncontrolled (Office SBP/DBP ≥ 140/90 mmHg) hypertensive adult patients taking at least one antihypertensive drug.

RESULTS

Patients were 64 years old on average, 48% were women, 61% had dyslipidemia, 33% had diabetes mellitus and 22% had established cardiovascular disease. Half of the patients had 2 or more comorbidities. Patients had been treated for hypertension for an average period of 8 years, 40% of patients were in hypertensive stages 2-3, 44% were treated with monotherapy only, 28% with free combinations and 28% with at least one single pill combination (SPC). Therapeutic adherence was rated as 'good' in 62% of patients. AHT treatment was modified in 84% of patients. In the group of patients with stage 2-3 hypertension, treatment remained unchanged in 5%. In the group of patients with stage 1 hypertension, treatment remained unchanged in 23% of patients. Patients treated for longer than 10 years were less likely to undergo treatment change (81%) compared to patients treated for less than 10 years (87%). Patients with 1 or 2 comorbidities were more likely to have their treatment modified (87%) compared to those with no comorbidities (61%) and those with ≥ 3 comorbidities (79%). If treatment was modified, a SPC was introduced in 90% of cases; 91% in stage 1-2 hypertension and 84% in stage 3 hypertension. SPCs were less frequently initiated in patients without comorbidities. Main reasons for the GPs to switch from a free association towards SPC were 'better BP control' (55%), 'better therapeutic compliance' (53%) and 'simplicity for the patient' (50%).

CONCLUSION

The SIMPLIFY study confirms therapeutic inertia in hypertension management. After an average of 8 years hypertension treatment, almost 1 in 2 uncontrolled treated patients are on monotherapy. The key inertia drivers seem to be age, mild grade hypertension, isolated systolic hypertension, longer duration of antihypertensive treatment and better therapeutic adherence. When treatment is updated by the GP, the currently preferred strategy is switching towards SPC based therapy to improve BP control, and enhance therapeutic compliance by simplifying treatment for the patient.

TRIAL REGISTRATION

pharma.be visa number: VI 17/01/20/01 ISRCTN registered study: ISRCTN16199080.

Assessment of Prevalence, Awareness, and Characteristics of Isolated Systolic Hypertension Among Younger and Middle-Aged Adults in China

IMPORTANCE

Isolated systolic hypertension (ISH) is increasing in prevalence among young and middle-aged adults. However, most studies of ISH are limited to older individuals, and a substantial knowledge gap exists regarding younger adults with ISH.

OBJECTIVE

To assess the prevalence, awareness, and characteristics of ISH among younger and middle-aged adults in China.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was performed as part of the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project, which enrolled 3.1 million community residents aged 35 to 75 years from all of the 31 provinces in China between December 15, 2014, and May 15, 2019. The present analysis included only participants younger than 50 years. Data were analyzed from May to November 2019.

MAIN OUTCOMES AND MEASURES

Prevalence and awareness of ISH (defined as systolic blood pressure of 140 mm Hg or higher and diastolic blood pressure of less than 90 mm Hg) and individual characteristics of participants with ISH.

RESULTS

Among 898 929 participants aged 35 to 49 years, the mean (SD) age was 43.8 (3.9) years; 548 657 participants (61.0%) were women, and 235 138 participants (26.2%) had hypertension. Of those with hypertension, 62 819 participants (26.7%; 95% CI, 26.5%-26.9%) had ISH (mean [SD] age, 45.0 [3.5] years; 41 417 women [65.9%]), and 54 463 of those with ISH (86.7%; 95% CI, 86.4%-87.0%) had not received treatment. The prevalence of ISH was higher among individuals who were older, were female, were farmers, resided in the eastern region of China, and had an educational level of primary school or lower. Women and older individuals were more likely to have ISH than to be normotensive or to have other hypertension subtypes. Participants who were obese, currently used alcohol, had diabetes, and experienced previous cardiovascular events were more likely to have other types of hypertension and less likely to have normotension than to have ISH. Among the 54 463 participants with ISH who had not received treatment, only 3682 individuals (6.8%; 95% CI, 6.6%-7.0%) were aware of having hypertension, and awareness rates remained low even among those with systolic blood pressure of 160 mm Hg or higher (7135 individuals [13.1%; 95% CI, 12.4%-13.9%]).

CONCLUSIONS AND RELEVANCE

In this study, ISH was identified in 1 of 4 young and middle-aged adults with hypertension in China, most of whom remained unaware of having hypertension. These results highlight the increasing need for better guidance regarding the management of ISH in this population.

Short term effects of cocoa consumption on blood pressure

Hypertension, defined as diastolic pressure ≥ 90 mmHg and systolic pressure ≥ 140 mmHg, is a major cause of morbidity and mortality among black populations globally. Several studies have shown that prolonged consumption of cocoa or cocoa containing products leads to decreased blood pressure (BP) in hypertensives. In this study, we investigated the flavonoid content of the top selling cocoa/cocoa based products in Trinidad and Tobago and attempted to determine if consumption of cocoa had any immediate impact on blood pressure levels. The flavonoid content of three 100% cocoa powder products and four cocoa based formulas was measured using a modified Folin-Ciocalteu procedure. The brand with the highest flavonoid content, 372 gallic acid equivalents, was selected to evaluate the short-term impact of cocoa consumption on blood pressure. Thirty-six participants comprising nineteen hypertensives and seventeen persons with normal blood pressure had their blood pressure recorded on three separate days using ambulatory blood pressure monitors; the blood pressure was recorded every half hour for eight hours. On the first day, the participants received no intervention but on the second and third days, they received either the intervention (5 g cocoa in 125 ml water) or a placebo, in any order. Statistical analysis conducted using t-test statistic and a 95% confidence interval revealed that whether participants regularly took antihypertensive medication or not, a single intervention of cocoa induced decreases in both the diastolic and systolic BPs that were significant (p = 0.0001). Mean decreases of between 8 mmHg and 18 mmHg were observed.

Lack of adherence to hypertension treatment guidelines among GPs in southern Sweden-a case report-based survey

BACKGROUND

General practitioners (GPs) often fail to correctly adhere to guidelines for the treatment of hypertension. The reasons for this are unclear, but could be related to lack of knowledge in assessing individual patients' cardiovascular disease risk. Our aim was to investigate how GPs in southern Sweden adhere to clinical guidelines for the treatment of hypertension when major cardiovascular risk factors are taken into consideration.

METHOD

A questionnaire with five genuine cases of hypertension with different cardiovascular risk profiles was sent to a random sample of GPs in southern Sweden (n=109) in order to investigate the attitude towards blood pressure (BP) treatment when major cardiovascular risk factors were present.

RESULTS

In general, GPs who responded tended to focus on the absolute target BP rather than assessing the entire cardiovascular risk factor profile. Thus, cases with the highest risk of cardiovascular disease were not treated accordingly. However, there was also a tendency to overtreat the lowest risk individuals. Furthermore, the BP levels for initiating pharmacological treatment varied widely (systolic BP 140-210 mmHg). ACE inhibitors (70%) were the most common first choice of pharmacological treatment.

CONCLUSION

In this study, GPs in Southern Sweden were suggesting, for different cases, either under- or overtreatment in relation to current guidelines for treatment of hypertension. On reason may be that they failed to correctly assess individual cardiovascular risk factor profiles.

Global cardiovascular risk associated with hypertension and extent of treatment and control according to risk group

BACKGROUND

Hypertension (HTN) confers increased cardiovascular disease (CVD) risk; however, the variation in risk and how treatment and control rates may differ according to extent of risk needs clarification. We examined CVD risk distribution and treatment and control patterns according to risk group.

METHODS

We estimated 10-year Framingham global risk in 1,509 U.S. persons aged ≥30 years from the National Health and Nutrition Examination Survey (NHANES) 2005-2006 with HTN and the proportion of subjects in low (<10%), intermediate (10-20%), and high (>20%) risk groups, or with pre-existing CVD, or who otherwise had high cardiometabolic risk according to European Society of Hypertension (ESH) criteria (diabetes (DM), metabolic syndrome (MetS), stage 3 HTN, or 3 additional CVD risk factors). We also examined HTN treatment and control rates by risk group.

RESULTS

From Framingham risk assessment, 24% of subjects were low risk, 21% intermediate risk, 23% high risk, and 32% had CVD. An additional 39% of low and 51% of intermediate risk subjects were at high or very high risk based on European criteria, for a total of 80% classified high risk or with CVD by either criterion. Treatment rates across Framingham risk groups ranged from 58 to 75%. HTN control rates were over 80% for lower risk persons, but under 50% for higher risk subjects.

CONCLUSIONS

There is a wide variation in CVD risk in persons with HTN with control rates still suboptimal in higher risk subjects. Future guidelines should consider risk stratification combining shorter and longer-term risk assessment to best identify those who have the greatest CVD risk.

Is patient-perceived severity of a geriatric condition related to better quality of care?

BACKGROUND

Care for falls and urinary incontinence (UI) among older patients is inadequate. One possible explanation is that physicians provide less recommended care to patients who are not as concerned about their falls and UI.

OBJECTIVE

To test whether patient-reported severity for 2 geriatric conditions, falls, and UI, is associated with quality of care.

RESEARCH DESIGN

Prospective cohort study of elders with falls and/or fear of falling (n = 384) and UI (n = 163).

SUBJECTS

Participants in the Assessing Care of Vulnerable Elders-2 Study (2002-2003), which evaluated an intervention to improve the care for falls and UI among older (age, ≥ 75) ambulatory care patients with falls/fear of falling or UI.

MEASURES

Falls Efficacy Scale (FES) and the Incontinence Quality of Life surveys measured at baseline, quality of care measured by a 13-month medical record abstraction.

RESULTS

There was a small difference in falls quality scores across the range of FES, with greater patient-perceived falls severity associated with better odds of passing falls quality indicators (OR: 1.11 [95% CI: 1.02-1.21] per 10-point increment in FES). Greater patient-perceived UI severity (Incontinence Quality of Life score) was not associated with better quality of UI care.

CONCLUSIONS

Although older persons with greater patient-perceived falls severity receive modestly better quality of care, those with more distressing incontinence do not. For both conditions, however, even the most symptomatic patients received less than half of recommended care. Low patient-perceived severity of condition is not the basis of poor care for falls and UI.

Effectiveness of a protocol-based strategy for achieving better blood pressure control in general practice

BACKGROUND

There continues be a problem with the proportion of treated hypertension patients who are actually at recommended blood pressure targets.

OBJECTIVE

Is an intensive protocol-based strategy for achieving blood pressure control effective in family practice and will family physicians and their hypertensive patients adhere to such a protocol.

METHODS

Design of the study is a cluster randomized controlled trial at the Centre for Studies in Primary Care, Queen's University, Kingston, Ontario. Participants were 19 family physicians and 156 (98 intervention group and 58 control group) of their patients in and around the Kingston area. Patients were eligible if they had a diagnosis of hypertension and had not yet achieved their target blood pressure. Patients in the intervention group were managed according to a protocol that involved seeing their family doctor every 2 weeks over a 16-week period and having their antihypertensive medication regimen adjusted at each visit if target was not achieved. This was compared to usual care. Main outcomes were primary effectiveness outcome measured at 12 months was the differences in blood pressure between baseline and 12 months in the two groups. Secondary effectiveness outcomes included rates of achieving BP target and compliance with protocol by physicians and patients. Adherence outcomes were assessed by determining the number of visits made during the 16-week intervention period and the increase in the number of drugs being used.

RESULTS

Of the patients enrolled, 72 (74%) from the intervention group and 41 (71%) in the control group were available for analysis. Improvement between baseline and 12-month follow-up was significantly better for the intervention group than the control for diastolic mean daytime BP on 24 hours ambulatory blood pressure monitoring (4.5 mmHg reduction versus 0.5 mmHg reduction) and for both systolic (14.7 mmHg reduction versus 2.7 mmHg reduction) and diastolic (7.4 mmHg reduction versus 0.6 mmHg increase) blood pressure on BpTRU. Of the 98 patients in the intervention, 80% attended four or more of the eight visits and 25% attended all eight visits; physicians increased the number or dosage of drugs the patient was taking in 52% of the visits. Conclusions. An intensive, protocol-based, management approach to achieving blood pressure control in hypertensive patients in family practice is effective and works even when there is flexibility built into the algorithm to allow family physicians to use their judgement in individual patients.

How can we improve the effectiveness of treatment in elderly hypertensives?

Despite evidence for the benefits of treating hypertension in old age, only a small number of elderly patients have adequate blood pressure control. The reasons are complex and include a combination of factors related to physician, patient adherence to therapy and properties of the antihypertensive drugs. Substantial gaps have been documented between the development and dissemination of recommendations and their implementation in practice. Older patients are more likely to have difficulty with medication adherence. Better compliance achievement among the elderly patients should include a complex strategy. Moreover, physician information strategies must be improved.

Health-related quality of life and blood pressure control in hypertensive patients with and without complications

INTRODUCTION

The goal of antihypertensive treatment is to reduce blood pressure without interfering in health-related quality of life (HRQL) OBJECTIVE: This study aimed to assess the influence of hypertension control upon HRQL in hypertensive patients with and without complications.

MATERIALS AND METHODS

Seventy-seven hypertensive outpatients (71% women, 58% white, 60% with elementary school level education, average age 54 +/- 8 years) were observed during a 12-month special care program (phase 1: clinical visits every two months, donation of all antihypertensive medications, meetings with a multidisciplinary team, and active telephone calls) and three years of standard care (phase 2: clinical visits every four months, medication provided by the drugstore of the hospital with a two-hour wait and a possible lack of medication, no meetings with a multidisciplinary team or active telephone calls). The patient HRQL was assessed using Bulpitt and Fletcher's Specific Questionnaire, as well as the SF-36 scores. Hypertensive patients were divided into "with complications" (n=37, diastolic blood pressure great than 110 mm Hg for patients with or without treatment, with clinically evident target-organ or other associated illness) and "without complications" (n=40). The variables studied were quality of life, blood pressure control, hypertension gravity, and demographic characteristics.

RESULTS

In hypertensive patients with and without complications, both the systolic and diastolic blood pressure were significantly higher (p<0.05) in phase 2 of observation (143+/-18/84+/-11 and 144+/-21/93+/-11 mm Hg for patients with and without complications, respectively) relative to phase 1 (128+/-17/75+/-13 and 128+/-15/83+/-11 mm Hg). The proportion of patients with controlled blood pressure (defined as a blood pressure less than 140/90 mm Hg) decreased from 70% to 49% in the "with complications" group and from 78% to 50% in the "without complications" group during phase 2 of observation. The patients with complications showed a decrease in bodily pain, vitality, and mental health component summary scores in both phases. In phase 2, the patients without complications had significantly better HRQL scores compared to complicated patients using both the Bulpitt and Fletcher's Questionnaire and the SF-36 assessment of physical capacity, bodily pain, and vitality domain summary scores. With regards to hypertension control, there was a significant decrease from phase 1 to phase 2 in the vitality component summary scores and an increase in the emotional aspect component summary scores assessed by the SF-36, whereas Bulpitt and Fletcher's Questionnaire showed no differences in these scores.

CONCLUSION

Special care programs with multidisciplinary activities, individualized and personalized assistance, easy access to pharmacological treatment, frequent meetings, and active telephone calls for hypertensive patients significantly increase blood pressure control but do not interfere with the HRQL.

Prevalence of isolated uncontrolled systolic blood pressure among treated hypertensive patients in primary care in Belgium: results of the I-inSYST survey

OBJECTIVE

To evaluate the prevalence of isolated uncontrolled systolic blood pressure (on-treatment isolated systolic hypertension) in treated hypertensive patients and identify the characteristics and treatment strategy in these patients.

METHODS

Prospective cross-sectional survey in primary care. Participating physicians enrolled more than 13 consecutive treated hypertensive patients. Patients were considered to have isolated systolic hypertension when systolic blood pressure was at least 140 mmHg and diastolic blood pressure was less than 90 mmHg.

RESULTS

On-treatment isolated systolic hypertension occurred in 28% of evaluable patients (n = 11562) and in 36% of uncontrolled patients (n = 9080). Among the isolated systolic hypertension and among other uncontrolled patients, 53% and 47%, respectively, used more than one antihypertensive drug class. beta-Blockers were the most frequently prescribed antihypertensive drugs. Patients with isolated uncontrolled systolic blood pressure were more frequently treated with diuretics (43 vs. 39%) and angiotensin II receptor antagonists (23 vs. 17%). Despite blood pressure being under control in only 21% of the patients, hypertension treatment was not changed in 46% of patients with isolated uncontrolled systolic blood presssure vs. 14% of patients with both uncontrolled systolic and diastolic blood pressure.

CONCLUSION

In Belgium, the prevalence of on-treatment isolated systolic hypertension in treated hypertensive patients, was 28%. The goal blood pressure was likely not reached in most patients due to inadequate treatment. The overall control rate was worse for systolic than for diastolic blood pressure. Furthermore, antihypertensive treatment was less frequently adapted in patients with isolated uncontrolled systolic blood pressure than in those patients with both uncontrolled systolic and diastolic blood pressure.

Aim, design and methods of the ‘reasons for not intensifying antihypertensive treatment’ (RIAT): an international registry in essential hypertension

Failure of physicians to adhere to hypertension guidelines may partly account for the failure to achieve blood pressure (BP) goals in clinical practice. The aim of this trial is a comprehensive description of the approach of physicians in the management of high BP among primary care patients. It will primarily assess what are the Reasons for not Intensifying an Antihypertensive Treatment (RIAT), when predefined individual BP goals are not achieved. Open intervention survey was conducted in 17 countries in Latin America, Eastern Europe, Africa and Asia in family practices, government and private clinics. The registry is based on a three-step epidemiological design. Step one shall identify guidelines and recommendations taken as reference in each country for the management of hypertension. Step two will assess the variance between individual targets defined by physicians in their practice compared to guidelines and recommendations. Step three is a prospective registry where physicians collect patient data at baseline; determine individual target BP values. Several follow-up visits are proposed to monitor achievement of these targets. Step three of RIAT aims at providing responses to several key objectives. Recruitment is under way aiming at enrolling 33,000 patients. To identify, what is the BP targeted according to the risk factor profile and what are the reasons for not modifying an antihypertensive treatment when BP goals are not reached, and to analyse the type of antihypertensive drugs prescribed according to compelling indications and to assess the percentage of patients reaching target figures.

Structure and function of CLCA proteins

CLCA proteins were discovered in bovine trachea and named for a calcium-dependent chloride conductance found in trachea and in other secretory epithelial tissues. At least four closely located gene loci in the mouse and the human code for independent isoforms of CLCA proteins. Full-length CLCA proteins have an unprocessed mass ratio of approximately 100 kDa. Three of the four human loci code for the synthesis of membrane-associated proteins. CLCA proteins affect chloride conductance, epithelial secretion, cell-cell adhesion, apoptosis, cell cycle control, mucus production in asthma, and blood pressure. There is a structural and probable functional divergence between CLCA isoforms containing or not containing beta4-integrin binding domains. Cell cycle control and tumor metastasis are affected by isoforms with the binding domains. These isoforms are expressed prominently in smooth muscle, in some endothelial cells, in the central nervous system, and also in secretory epithelial cells. The isoform with disrupted beta4-integrin binding (hCLCA1, pCLCA1, mCLCA3) alters epithelial mucus secretion and ion transport processes. It is preferentially expressed in secretory epithelial tissues including trachea and small intestine. Chloride conductance is affected by the expression of several CLCA proteins. However, the dependence of the resulting electrical signature on the expression system rather than the CLCA protein suggests that these proteins are not independent Ca2+-dependent chloride channels, but may contribute to the activity of chloride channels formed by, or in conjunction with, other proteins.

Detection and treatment of hypertension in general health-care practice: a patient-based study

The aim of this study was to describe the pattern of blood pressure (BP) distribution in a multiethnic primary care practice in relation to sociodemographic characteristics, lifestyle and risk factors. Another aim was to analyse the quality of diagnosis and effectiveness of hypertension (HT) treatment. In all, 470 adult patients (> or =16 years old) who visited the Jordbro Health Centre (JHC), Haninge Municipality, participated in this study. A general questionnaire with questions about sociodemographic characteristics, lifestyle, health status and chronic disease was used. Medical records: information on consultations with the general practitioner and prescriptions were collected from the medical records for the year 2001. Furthermore, a medical examination was performed: this consisted of weight, height, systolic (SBP) and diastolic (DBP) blood pressure, and laboratory analyses including fasting blood glucose, serum cholesterol, serum triglycerides, electrocardiogram and spirometry. Out of 464 patients, 114 (24.6%) reported HT. Among the HT patients, 93 (81.6%) had SBP > or =140 mmHg and 52 (45.6%) DBP > or =90 mmHg. Among the nonhypertensive patients (n=350), 120 (34.3%) had SBP > or =140 mmHg and 50 (14.3%) DBP > or =90 mmHg. Furthermore, there are some patients with high BP who are unknown or undetected. HT treatment among this population is unsatisfactory and greater efforts are required to identify people with high BP and to ensure that they are managed according to the best available evidence.

Blood Pressure Reduction and Cardiovascular Prevention: An Update Including the 2003-2004 Secondary Prevention Trials

In a meta-analysis published in June 2003, we reported that new and old classes of antihypertensive drugs had similar long-term efficacy and safety. Furthermore, we observed that in clinical trials in hypertensive or high-risk patients gradients in systolic blood pressure (SBP) accounted for most differences in outcome. To test whether our previous conclusions would hold, we updated our quantitative overview with new information from clinical trials published before 2005. To compare new and old antihypertensive drugs, we computed pooled odds ratios from stratified 2 x 2 contingency tables. In a meta-regression analysis, we correlated these odds ratios with corresponding between-group differences in SBP. We then contrasted observed odds ratios with those predicted from gradients in SBP. The main finding of our overview was that reduction in SBP largely explained cardiovascular outcomes in the recently published actively controlled trials in hypertensive patients and in placebo-controlled secondary prevention trials. The published results suggested that dihydropyridine calcium-channel blockers might offer a selective benefit in the prevention of stroke and inhibitors of the renin-angiotensin system in the prevention of heart failure. For prevention of myocardial infarction, the published results were more equivocal, because of the benefit of amlodipine over placebo or valsartan in 2 trials, whereas other placebo-controlled trials of calcium-channel blockers or angiotensin converting enzyme inhibitors did not substantiate the expected benefit with regard to cardiac outcomes. In conclusion, the hypothesis that new antihypertensive drugs might influence cardiovascular prognosis over and beyond their antihypertensive effect remains unproven. Our overview emphasizes the need of tight blood pressure control, but does not allow determining to what extent blood pressure must be lowered for optimal cardiovascular prevention.

Prevalence, pathophysiology and treatment of isolated systolic hypertension in the elderly

Isolated systolic hypertension is the predominant type of hypertension in the elderly and is associated with cardiovascular complications such as stroke, coronary heart disease and heart failure. In this review, the role of arterial stiffness, endothelial function, atherosclerosis and oxidative stress in the pathogenesis of isolated systolic hypertension is extensively discussed. Placebo-controlled intervention trials such as the Systolic Hypertension in Europe Trial and the Systolic Hypertension in the Elderly Program have clearly shown that pharmacological treatment of isolated systolic hypertension improves outcome in the elderly. Nevertheless, isolated systolic hypertension remains the major subtype of untreated and uncontrolled hypertension.

Do we need drug therapy to manage mild hypertension in the elderly?

Mild hypertension (grade 1 or stage 1 hypertension) is defined as a systolic blood pressure of 140-159 mm Hg or a diastolic pressure of 90-99 mm Hg. According to current guidelines, patients with mild hypertension can be at low, medium, high or very high risk depending on the presence of other risk factors, target organ damage and associated cardiovascular or renal conditions. Guidelines recommend prompt initiation of antihypertensive treatment in patients at very high risk because of associated clinical conditions and this recommendation is strongly supported by the literature. Also patients at high risk must be treated without much delay, but it should be mentioned that the evidence is stronger for patients who are at high risk because of diabetes mellitus, than for patients at high risk because of left ventricular hypertrophy or the accumulation of >or = 3 other risk factors. Patients at low and medium risk should be followed up and given advice on nonpharmacological measures and treatment should only be initiated in cases of persistently elevated blood pressure. However, this advice is based on indirect evidence and is currently not supported by randomised controlled trials. A survey on treatment of hypertension and implementation of World Health Organization/International Society of Hypertension (WHO/ISH) guidelines in primary care revealed that, respectively, only 20% and 33% of elderly men with mild hypertension at medium and high risk were treated with antihypertensive drugs and that this prevalence amounted to 67% in patients at very high risk; the prevalence was higher in patients with higher levels of blood pressure in each risk category.